Episode 3: Stanford’s Dr. Ingela Schnittger Defines the Myocardial Bridge. (part 1 of 2 episodes)

SPEAKER_01 0:00

Myocardial bridging is very common. Depending on the tool that you use to study the heart, it's at least 20 to 25% of all people out there will have some degree of myocardial bridging. But it's a wide variability in the severity of the bridging.

SPEAKER_00 0:21

Is it possible then that many of these blocked coronary arteries resulting in sudden cardiac arrest could be as a result of a bridge that's been unrecognized?

SPEAKER_01 0:34

Yes.

SPEAKER_00 0:44

Welcome to Imperfect Heart, a place for you to join me, Jeff Holden, in conversations, discussions, and dialogue about our hearts and the impact myocardial bridges have on them. We'll talk with healthcare professionals, those in related fields that support our condition, and others just like us with stories of their myocardial bridge experiences. It's my intention for this content to inform, educate, entertain, and even motivate or inspire you in your personal journey on dealing with a myocardial bridge. Most importantly is to have you leave each episode with hope, knowing you're not alone and that what you're experiencing is real. My guest today is somebody many of you on the Facebook page for myocardial bridges will recognize. Her academic and medical accomplishments are varied and numerous. She may very well be the most outspoken advocate for all of us with myocardial bridges and is most certainly a large contributor to the fact that unroofing surgery is now being done in more and more hospitals around the country, around the globe. She received both her bachelor's and doctorate degrees in medicine from Karolinska Institute in Stockholm, Sweden. She received a special fellowship in cardiovascular medicine at Stanford University in 1976. After several other residencies, both in Sweden and in the United States, she returned to residency in internal medicine at Stanford University School of Medicine. In 1980, she did her fellowship in cardiovascular medicine again with Stanford, where she currently practices as professor of cardiovascular medicine. She has passed numerous boards, received many research grants, has held multiple academic and non-academic positions with Stanford, participated on national committees and task forces with emphasis on echocardiography and cardiology, has been published in over ten scientific journals, has spoken or appeared on many broadcast outlets, including the BBC, and has been recognized as one of the best doctors in America among many other awards. She's written and published over 130 peer-reviewed articles. She's also responsible for the myocardial bridge research team at Stanford University, where they have published 16 full peer-reviewed manuscripts, four case reports, two review articles, and many abstracts on myocardial bridges. Without her efforts, many of us would not be where we are today, myself included. It is with great pleasure and a very humble heart, imperfect, but humble, that I introduce a true pioneer in the field of cardiology, Dr. Ingla Schnitker. Dr. Schnitker, thank you for affording me the opportunity to spend a little time with you to talk about myocardial bridges. You are an icon in the field and a beacon of hope for so many that are still working to get proper diagnosis of their symptoms and or working to find a surgeon to perform their unroofing. Welcome to Imperfect Heart.

SPEAKER_01 3:52

Thank you. Thank you for inviting me.

SPEAKER_00 3:55

Could you please share what it was that caused you to begin down this path of learning about myocardial bridges?

SPEAKER_01 4:03

I know. It's curious. I was asked to be a medical expert in the legal case where a young man had exercise-induced chest pain. He had a treadmill test that was normal. His primary care doctor reassured him. And he, however, continued to have exercise-induced chest pain. And one day, while he was running on a treadmill in a commercial gym, he had a sudden cardiac arrest. He was resuscitated, but turned out to be brain dead. And the autopsy showed a myocardial bridge with a plaque upstream from the bridge that had ruptured and formed a clot around it. And he had an acute heart attack followed by an arrhythmia that caused the heart to stand still. And I was supposed to be the expert on the defendant's side, but the plaintiff's attorney who gave who took my deposition, he knew everything about myocardial bridges, and I knew nothing. It was embarrassing. And it came to really pique my interest. What is this myocardial bridge? And why is it that it wasn't diagnosed and got me started?

SPEAKER_00 5:32

Isn't it interesting that the legal and medical fields come together as they do so often? And in this case, for the greater good.

SPEAKER_01 5:42

Yeah.

SPEAKER_00 5:43

What then led you to the research at Stanford and formalizing this into a myocardial bridge team?

SPEAKER_01 5:51

Well, I'm a specialist in cardiac ultrasound, also called echocardiography. And so I interpret echocardiograms and have done so for 40 years. And so one day I'm sitting in the lab and I'm reviewing a file of a 35-year-old man who came to the lab for chest pain and had an exercise echocardiogram. And as I was looking at the pictures, I was struck by an abnormal motion of one of the walls of the heart. And I asked myself, hmm, because he reminded me of my legal case. So I asked myself, could this be a pattern of motion in a person with a myocardial bridge? Well, it turned out that he soon thereafter did have an invasive androgram that did show a myocardial bridge. And this then started my interest in trying to study this condition. So I wanted to do invasive andrograms on patients that had this pattern. And of course, I had to team up with colleagues of mine, specifically Dr. Tremel, who's an invasive cardiologist. And she and a team of fellows helped us get started on investigating the bridges in the cath lab. And then we realized we needed intravascular ultrasound. So then we engaged our very superb intravascular ultrasound laboratory, and then eventually led to involving a cardiac surgery. So that's how we formed a team. And because the myocardial ridges are much more complicated than just meets the eye, so you need input from different specialties. And I should also say that we were working with the radiologist who did the CT scans, and they learned from us, and we learned from them what constitutes a significant myocardial bridge. So that's how we came to form a whole team. And personally, I think it's important to have this team approach because there are aspects of a bridge that a even a cardiologist isn't gonna know all the intricacies in evaluating the bridges.

SPEAKER_00 8:26

It's interesting. I can't help but think back again to the gentleman on the treadmill that started this cause for research. A myocardial bridge, in essence, killed him. It caused the heart attack.

SPEAKER_01 8:39

Yes.

SPEAKER_00 8:40

And yet so many times and so frequently, we're told it's benign.

SPEAKER_01 8:44

Well, it's interesting because, as you probably know, myocardial bridging is very common. Depending on the tool that you use to study the heart, it's at least 20 to 25% of all people out there will have some degree of myocardial bridging. But it's a wide variability in the severity of the bridging, the length, the depth, how hard the band compresses the vessel, how many side branches are jailed in the tunneled segment, how hard the band presses on the heart, we have shown is correlated to the plaque buildup, then you form a plaque, then that becomes a problem. So there's so many aspects, and that makes it very challenging to sort out what bridge is likely to cause symptoms, and what kind of situation should we worry about, the heart attack situation. Okay. So there are several pieces to this which makes it it's not just one shoe fits all.

SPEAKER_00 10:01

And Dr. Tremble did my provocative test to identify the symptom and cause and what was happening. So thank you for hiring her. I'm very, very happy about that. As you were in the process of the research part of it, you then went to actual mechanical repair. And how did that develop? How long ago was it that you started the team at Stanford? And then at what point did you decide, hey, we can actually do repair as well? We can do the surgery on these things as well as diagnosing and understanding.

SPEAKER_01 10:37

Well, it wasn't quite so simple to say, okay, we just built a team and then we go from there. It was really sort of things that developed, right? We learn with every little project we do. But we had a surgeon involved basically pretty quickly after we started to diagnose the bridges as significant from a circulatory problem, a circulatory aspect. So, in order to get a surgeon engaged, and in the beginning we had a couple of surgeons, but in the last eight years or so, we've had one single surgeon that does all the surgeries. But they want to have some reassurance that the bridge is actually causing a circulatory problem. Since bridges are common, and many of them do not cause a circulatory problem. So you, the surgeon, understandably, were tentative in doing open heart surgery. You know, it's not a walk in the park, it's a major surgery. And you don't want to harm anybody. Do no harm is the number one ethnic concept we had. So the surgeons wanted to have confirmation that there was a circulatory problem, and it was challenging to prove a circulatory problem because everything that had been done up to that point was to study circulatory problems in fixed blockages, fixed coronary, coronary arteries disease, fixed blockages. But the bridge is a very dynamic, dynamic situation. So if you study the bridge at rest, a patient on the table in the cat and ab sedated, slow heart rate, you may find nothing. So we had to move to the concept of studying a bridge under the circumstances that are real life experience, such as exercising. And it could be just walking up a flight of stairs, but a situation where you're moving. Okay. So that was the first sort of obstacle. But as we were able to prove that with a new measurement tool, we got surgeons on board.

SPEAKER_00 13:06

Why do you think that there's still such a lack of understanding about the symptoms of bridges when now you've got what 10, 12 years of history surgery, correction, diagnosis, yet it still seems to be vague in the cardiology community?

SPEAKER_01 13:26

Yes, I I agree with you. And I think first and foremost, as I mentioned, you you have to use different tools to prove that there is a circulatory problem. Okay, you have to study the artery during induced stress that we do in the CAT lab. And secondly, I think that, as you know, a majority of the patients that have a significant myocardial bridge do have endothelial dysfunction. What is endothelial dysfunction? Well, the lining of the vessel is made up of special cells called endothelial cells. And in order for the blood vessel to stay healthy and stay open all the time, those endothelial cells have to be healthy. They produce nitric oxide, they produce endothelium one that keeps the vessel open. When you bang on that vessel every minute, every second, you traumatize the endothelial lining and you have a tendency to develop spasm. Why is that important? Well, because the spasm is random. It comes at rest. It can wake a person up at night. It comes with emotional stress, it comes with physical stress too. But the problem here is that the patient, the person afflicted by this condition, had just discomfort with effort and at rest. If you go to a doctor and say you have chest pain, they're gonna say, okay, let's see, do you have any risk factors for coronary arter disease? Maybe this is scared, whatever. Maybe you end up saying, okay, well, it's pretty typical pain from the heart. But when you say either pain watching a movie or talking to your partner or spouse or kid, then the doctor is gonna say, uh-uh, this is not typical. You're probably just a little stressed, you're you're a little bit, you know, anxious, this is not heart disease. That's a problem. So then people get discarded. So it's it's I think the symptomatology with pain, both with effort and rest, as well as it being very common condition, challenging to sort out which bridges are causing problem. And in order to study that, you have to understand that this is a dynamic situation, and you have to apply different diagnostic tools.

SPEAKER_00 16:21

And I can certainly concur with the at-rest, because most of my spasms occurred initially at rest.

SPEAKER_01 16:29

Yeah.

SPEAKER_00 16:29

And I had my myocardial infarction, which it's so hard to say I had a heart attack, but I had that heart attack in the morning coming out of bed.

SPEAKER_01 16:40

Yeah.

SPEAKER_00 16:40

So nothing to do with stress or exercise. As a matter of fact, when I exercised, it was better.

SPEAKER_01 16:45

Right.

SPEAKER_00 16:46

I never had the symptoms under heavy exercise.

SPEAKER_01 16:50

So there's variability in the symptom, but I think that if you're, I mean, when you go to the doctor with chest pain, whatever doctor, primary care, internal medicine, cardiologist, and you say you have chest pain, it's incumbent upon the doctor to go through the differential list, right? But to discard the patient that's, ah, it's musculoskeletal. Uh-huh. Muscular pain is painful to touch. When you press on the chest, it hurts. Heart pain does not hurt from the surface. If the pain is coming from the heart, you cannot elicit the pain by pushing on the muscle. So, you know, there's a number of ways you can narrow down the potential differential diagnosis because, of course, chest pain. I mean, every patient that walks through my office door has chest pain of some sort or another. And so it's a common problem, right? So we need to do better in in asking questions that might lead you down the road of, oh, could this be a myocardial bridge?

SPEAKER_00 18:01

Is there one gold standard that identifies the fact that yes, this is a myocardial bridge with enough severity to cause symptoms?

SPEAKER_01 18:12

Well, I think that the most reliable non-invasive test is the CT scan. And we have shown that you if you do a careful CT scan with controlled heart rate, you want the heart rate to be 60 or less, otherwise you get fussy pictures when the heart moves. So you do a good CT scan, and from the CT scan, you can measure the length and you can estimate the depth. And we have developed a myocardial bridge muscle mass index. It's basically a number, and if that number hits a certain threshold, we have compared that to invasive studies. So then we can say, okay, if your muscle mass index is X, it's a very high likelihood that you have a circulatory problem in your brain. So I would say I would recommend, you know, after you do stress testing, which I can come back to, which could be positive or negative, I would say the next step is a CT scan. But then you have to have a radiologist, uh-huh, that's going to read it. Because I even have radiologists at Stanford who don't always read the bridge because they are so in the mode of thinking, it's so common, it's a normal variant, we don't need to, we don't need to bother. So I've had to say to my radiology colleagues, I only want Dr. X, Y, and C to read them because if I order a CT scan and if somebody else orders a CT scan where the question is just pain, please pay attention.

SPEAKER_00 20:01

So it actually is a specific look that they get experience from doing more and more and more, obviously. Right, right, right. Well, certainly you've got to be extremely proud of the accomplishments to date and ongoing. What do you think needs to be done to get more of the data that you're coming up with and providing into the hands of cardiologists around the world so that we can help more people with this?

SPEAKER_01 20:29

Well, I I do think that the condition, the subject, is getting some traction. And I think it's multifactorial. I think we have published a good deal. There's actually more publications from abroad than from American institutions, sadly to say. So I think that there is an increasing awareness in the cardiology medicine community. But I also think that you know your work and of Facebook is also helping people to gain more understanding. And I think we get a lot of referrals from across the country and sometimes from abroad. And when I asked the person, the patient, how did you come to Stanford? They would say, Well, I struggled for many years. I eventually got the diagnosis that I have a myocardial bridge, but I was told that don't worry, it's not causing your symptoms. But then I go online and I find out that it could be a problem. So sometimes it's the patient that is pushing for more consultation, more second opinion. Sometimes it's the cardiologist that's saying, Ooh, I see that you have a myocardial bridge. I don't know if It's causing you a symptom. I don't know enough about it, but let's send you to another institution for a second opinion. So there's two ways that they come. And I think that is sort of increasing. In the beginning, when we started our work, most of my patients were local. But now most of my patients are from out of state. And they come because they understand that they may have a problem. Or their doctor, I would say, admits or acknowledged that they may have a problem. So I think I think it's happening. It's still, you know, sort of tentative in some people's mind. But I I think I think we're making progress.

SPEAKER_00 22:45

Oh, I would definitely say you're making progress. And the recognition of Stanford as the leader in the diagnosis and the process of remedy to the extent that it can be remedied is world renowned. Especially from the uh the Facebook page and how people recognize it. I even had a gentleman from India email me and ask me, what do you know about Stanford? What can you tell me? Because he can't find a doctor in India to do the surgery.

SPEAKER_03 23:12

Yeah. Yeah.

SPEAKER_00 23:14

So it's something to be uh extremely complimented on. And again, I think anybody listening to the show is also aware of the work that you're doing there. So thank you, thank you, thank you. Keep going.

SPEAKER_01 23:29

Sure. I think we've, you know, gone forward slowly and cautiously. I think I feel sort of very sorry for a surgeon that is just approached by a patient who says, I have a myocardial bridge, can you fix it? Because my surgeon, he would not take a patient to surgery unless the team says this is a problem. We have studied this individual. There's a high likelihood that he or she will improve with surgery. We need to make sure there's no other major issues. We do very careful mapping of the bridges to let the surgeon know exactly where the bridge start, where does it end, how long is it? My surgeon, he even takes out a measurement in the operating room after he has dissected, free the bridge, and he measures and he says, okay, Ingela, I have 31 millimeters. Is that good enough? And then look at the ibis members. Yeah, that's good enough. You did good, you can stop now. Because you know what? I mean, even I, as a cardiologist, have learned a lot going to the operating room. And you would think that if you open up the breastbone and you look at the heart, that it would be absolutely obvious where the bridge is. Uh-uh. No, no. Because it can be covered in fat, it can be covered in the pericardium. And so you need to know exactly the location, how long it is, what your landmarks is. From the CT scan, we learn if it goes very deep, if it goes into the right ventricle, we have to go on pump before. So we decide on pump, off pump, mini thoraconomy, sternotomy, all pre-operative evaluation so that the surgery can be done with a complete dissection of the whole bridge. Sometimes there are two bridges. You have to do both, okay? And that it's safe. We haven't lost anybody, no, you know, aneurysms of the heart, strokes or heart attacks, because you very, very, very carefully do the evaluation before the patient goes to surgery. So I feel very, very sorry for the surgeon who's asked to just, oh, I have a bridge. Can you take care of it? No.

SPEAKER_00 26:14

You mentioned something I think is really key, and I know it was something that I asked that same surgeon who performed my surgery. I said, How many people didn't make it off the table?

unknown 26:26

Yeah.

SPEAKER_00 26:26

And he looks at me and he says, none. Everybody did.

SPEAKER_01 26:31

Yeah.

SPEAKER_00 26:31

And I said, Okay, I I feel pretty good about it then. I'm not, I'm not as concerned.

SPEAKER_01 26:36

Yeah. You know, this is this is not some superficial little surgery. It's it's major. And you, as a doctor, wants to instill the confidence in the person, in the patient, that they'll do well, they'll improve, and it's it's a reasonable approach, right?

SPEAKER_00 27:01

Mm-hmm. And that was actually my second question. The first one was, how many of these have you done? And he looks at me with a little smile and he goes, Over the course of the last year, more than anybody else in the world.

SPEAKER_03 27:12

Yeah.

SPEAKER_00 27:12

And I said, Oh. Okay. I almost felt like I insulted him, but how would you know? And I think the significance of that is while you when you hear something like that, you say, Wow, more than anybody else in the world, that's gotta be a lot. And at that point in time, it was 200 over a 10-year period. And I thought, Yeah, well, there's not a whole lot of this being done in the United States, is there?

SPEAKER_01 27:35

Right.

SPEAKER_00 27:36

So in some of the research that I've seen, it's been estimated that roughly 25% or more of the population could be walking around with a myocardial bridge.

unknown 27:46

Right.

SPEAKER_00 27:47

And it could even be postulated that the cause of many of these blocked coronary arteries resulting in sudden cardiac arrest could be as a result of a bridge that's unrecognized. Is that fair to say?

SPEAKER_01 28:02

Yes. It's very interesting. Uh sudden cardiac arrest is not a disease in itself. It's an event, right? And it's caused by a ventricular arrhythmia. So the heart starts to go very, very fast and almost just fibrillating, and it goes so fast that it actually doesn't mechanically pump any blood out of the heart. So a cardiac arrest can be caused by a number of different conditions. Myocardial bridge is one of them. And then there's two aspects of the bridge. Number one is a plaque that everybody that I have studied in the CAT lab has a plaque, small or medium, or large. And it's always in the same position. And it's regardless if you have any risk factors for plaque. The form plaque because of the turbulence in front of the tunneled segment. So you could either, like my legal patient, have plaque plaque rupture and acute 100% occlusion, a heart attack, and an arrhythmia. Or you can have repetitive chest pain episodes that choke the circulation in the bridge and causes fibrosis, scar, and edema, swelling. So there are autopsy studies where people have looked at patients or people that died in the cardiac arrest. Some of them, of course, do not have a bridge, but then there's a cohort that has a bridge. And in those patients, they have found scar tissue and edema in the area subtended by the area that is confined in the bridge. And that structure is a trigger for ventricular arrhythmia. So you can have an acute heart attack, you choke the circulation 100%, you trigger arrhythmia, you can have a buildup of scar and edema inside the heart wall, the septum that triggers the arrhythmia. So it's it's tricky because you can look at autopsy studies, you can look at retrospectively cohorts of people that died in a cardiac arrest. And there are bridges there. But of course, there's several other conditions. But when it comes to the bridges, you have to look for them. Because if the pathologist isn't thinking bridge, he's not going to find the bridge. He's going to look for hypertrophic cardiomyopathy, he's going to look for, you know, dilated cardiomyopathy, he's going to look for valvular heart disease, et cetera, et cetera. But there's clearly bridges in that forehorn. Some of them triggered by an acute heart attack, some of them triggered by just the scar tissue, edema, that, especially with effort, I mean, you hear about football players, you know, basketball players, marathon runners that just drop. And if they have a if they have a bridge and nothing else, it does it could be either on the concept of just a D mascar or acute plaque plaque rupture. I mean, I have one case, one patient that ran the San Francisco marathon, got chest pain, got to a local hospital. The doctor there knew how to study with an angiogram, and he had a plaque plaque rupture, and the clock flew down the LED, and he had a heart attack, and he had a bridge, and he was saved.

SPEAKER_00 32:08

I want to dance and I want to scream and I want to shake people because what you just said in that description is exactly why I stress to say sooner better than later.

SPEAKER_03 32:19

Yeah.

SPEAKER_00 32:20

Because that plaque is only going to get worse over time.

SPEAKER_01 32:24

Yeah.

SPEAKER_00 32:24

And the longer you wait, I mean, it was 60, 65 years for me, which means I had the ability for that plaque to build.

SPEAKER_01 32:32

Yeah.

SPEAKER_00 32:32

And I didn't have any other conditions that would suggest that I have an issue. So that was just a wonderful, wonderful description for anybody to understand how this happens.

SPEAKER_01 32:45

Yeah, and it's interesting because there is a group in Japan that has actually looked at autopsy studies in patients with bridges and acute heart attacks. And it turns out that the plaque in the bridge patients is more vulnerable to plaque rupture and clot formation than the plaque in the same position in another person who doesn't have a bridge. So these plaques are vulnerable to fissure and rupture and adhere clot. And so, therefore, anybody that has a significant bridge should be considered for baby aspirin.

SPEAKER_00 33:31

And also, yes, yes, I take it every day now.

SPEAKER_01 33:37

And also, of course, reviewing any any existing, you know, risk factors for plaque buildup, most often it could be cholesterol because that could be quiescent and the person doesn't know. Diabetes is a risk factor, but people often know that they have diabetes. So we treat the cholesterol, we we treat with baby aspirin. If a person has symptoms and also preferably some you know, diagnosis of the severity of the bridge.

SPEAKER_00 34:12

And I had the good fortune of also a bypass just to really be safe and get around that you know obstruction.

SPEAKER_01 34:19

You had a you had a bypass as well, but that's tricky. It's tricky because, yes, in your case, your plaque was deemed to be partially occluding the vessel.

SPEAKER_00 34:39

Yes.

SPEAKER_01 34:40

And so you had two problems. You had a plaque that was partially occluding the vessel, and then you had a bridge that was partially occluding. Then it's legit to do bypass pass unroofing. But please do not bypass a plaque that has not been proven flow limiting, because if you do that, the bypass will close. But you were fortunate to have a very, very, very careful evaluation that showed that your plaque was significant enough that it encroaches on the lumen. See, what happens with these plaque buildups in the bridges is that the vessel enlarges eccentric. So the plaque doesn't encroach on the lumen until very, very late. So it it causes a half-mone area of math which changes the size and the shape of the vessel. And that's why it goes unrecognized forever in a day. Those plaques don't show up on a CT scan unless they're calcified. Most of them are not calcified.

SPEAKER_02 35:51

Right.

SPEAKER_01 35:52

They only show up on an intravascular ultrasound. They don't show up on a coronary endeagram unless they start to encroach on the lumen. But they can still be there, they can still be potentially dangerous. So it's tricky. It's very, very tricky. And you should never, ever, ever bypass a plaque that isn't flow limiting. You were very, very, very carefully evaluated, and they found that your plaque was limiting the blood flow through that area.

SPEAKER_00 36:26

You know, the goal of the podcast, Dr. Schnitger, is to inform and educate as well as to give some hope to those listening that there are solutions and there are doctors and there are cures for the symptoms in some cases. Could you walk us through what you would suggest as a proper diagnosis and course of action? Once I'm aware that I've got this pain, I know it's not fleeting, it's not emotionally originated, it's pretty sure it's something material. And I may even have gotten the diagnosis that it is, but it it isn't a bridge. I mean, it hasn't been diagnosed as a bridge. What steps would you suggest for somebody in that situation? Yeah, the first step, second, and then obviously conclusion. I'm going to step in for a moment as I'm sure you're likely finding that Dr. Schnitker is taking us on a journey we all wished we could have found on our own, but weren't able. There's a lot to reflect on, digest, and unpack. I'm sure you're also applying much of what you've heard so far to your own personal situation and finding it possibly a bit overwhelming. I get that. For those of you that didn't want to take a break, don't. You can load up the second part of the conversation with Dr. Schnitter where things get a little more detailed and clinical. This is exactly what many of us were looking for before our unroofing procedures, and what I'm sure many of you will find to be the most valuable in your journey to minimize the symptoms from your myocardial bridge. I made this episode into two parts specifically for that reason. If you need that break, here it is. If not, simply hit play on part two and get ready to hear some incredibly valuable information. Thank you for listening to Imperfect Heart. It's my hope that this information help in some way to improve your situation or will help you better understand this condition. More importantly, that it gives you hope through stories that there is help and you most certainly are not alone. If you've been diagnosed with a myocardial bridge, please be sure to join the private Facebook group, Myocardial Bridge Support Group. For more information about our program or to reach me directly, visit the website, myimperfectheart.com. If you like what you heard today, please give a positive review, thumbs up, high five, whatever your app likes. And be sure to share with everyone important to you so they understand what it is you're dealing with. Please subscribe as well. Welcome each day with gratitude and positivity. Imperfect Heart is a production of Hear Me Now Studio.