Episode 38: Meetup Session Live With Dr. Kofidis on Myocardial Bridge Scarring and More.

SPEAKER_03 0:18

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. I'm excited to share with you the recordings from the first Imperfect Heart Myocardial Bridge live meetup that we had on Saturday, September 14th, 2024. The first session, our guest was none other than somebody we're all very familiar with, our cardiovascular surgeon friend in Greece, Dr. Theodoros Kofitis. He's now the director, first cardiac surgery department at Hygia Hospital. Let's get started.

SPEAKER_04 1:39

I'm very delighted to see you all.

SPEAKER_03 1:42

As we are, as we are you, you get ready for some questions. Absolutely. Dr. Kofitis, maybe just tell us a little bit about the new hospital. You've moved to Hygia now.

SPEAKER_04 1:54

Yeah. Well, I'm very delighted to see you all. So until about two months ago, I was the head of department of a university in Singapore, National University of Singapore, and a professor at the university there. I decided to move back to Greece with my family. I'm a native of Greece, having trained in Germany, Switzerland, and the United States. That was very long ago. And upon my arrival in Greece, I actually asked this JCI accredited hospital to do significant renovations, which they did. It uh looks like a spaceship now. It's really very well equipped. And we're in the process of renovating, and the operation theater will open on the 17th, with the first myocardial bridge patient coming in on the 19th to be operated on the 20th. She will uh be one of the first patients to be operated in our uh top-notch operation theaters here. Well, back in Greece now, after 37 years of uh living, training, and practicing away from home, so to speak. So now I'm closer to that group of patients and many others who seek my help in the in the West. Okay, at your disposal for questions, discussion, how can I help?

SPEAKER_01 3:28

First, I want to just say thank you for being with us. Appreciate it. I found out I had a myocardial bridge 18 years ago and have had symptoms quite a bit with activity, riding a bike, uh hiking, pretty much any activity. So I my question is do I seek help on how that artery is doing after all these years with having symptoms?

SPEAKER_04 3:55

Absolutely. What's your good name, madam?

SPEAKER_01 3:58

Jane.

SPEAKER_04 3:58

Jane. Very good to meet you, Jane. Well, nobody should live with symptoms for such a long period of time. Okay, so may I ask back, have you been treated for those symptoms and is myocardial bridge definitely diagnosed or not yet?

SPEAKER_01 4:19

Yes. I went in for a cardiac cath. They thought I had blockage because of an echo test they did. Came back, showed, I think, a lack of blood flow. Okay. So they did the cardiac cath instead there was a marticardio bridge with a kink with a big kink. Yeah. They did not tell me how bad the bridge was at all. And they just sent me to cardiac rehab.

unknown 4:45

Yeah.

SPEAKER_01 4:45

That was eight years ago.

SPEAKER_04 4:47

Well, you see, your story pretty much reflects the typical story of myocardial breach patients. Oftentimes they're not taken seriously. This disease entity is not being recognized by many heart experts around the world. And often it is difficult to objectify the symptoms and the diagnosis. So what you're saying doesn't surprise me. If there is a myocardial breach, you've been treated with medications more than six months. The recommendation, the international recommendation is to seek the help of a surgeon. Now, after excluding all other possible causes of myocardial of chest pain, such as esophageal pain, lung or spine-related diseases, and other causes of possible chest pain, one should proceed to treat the myocardial bridge on the base of symptomatic relief. Look, if any condition causes the patient to experience these ease, then we consider it a disease. Meaning to say that we must do something to relieve you of your symptoms. Even sometimes the myocardial breach looks controversial on some people's eyes or in certain stance. Nobody should live with persistent pain over a lengthy period of time. And the means we have in our quiver nowadays allow us to provide solutions in a customized surgical fashion for many of those patients.

SPEAKER_01 6:32

Thank you so much. Appreciate it.

SPEAKER_04 6:35

My pleasure.

SPEAKER_00 6:36

Hi, Dr. Cofetis. I'm Linda Cunningham. I'm a uh physician and internist, and I was diagnosed with myocardial bridge officially in 2016 on an angiogram that I had uh when I got chest pain after exercising rather moderately. It was it was blown off. The guy, the cardiologist said, never gonna bother you. Take a toperol if you need it. I eventually, I had surgery a year ago and it's made a world of difference to me. One of the things that I've been hearing about is scarring after surgery causing recurrent symptoms. And I wanted to know what your feeling about that was. Does the myocardium rescar? Do any of us have recurrent symptoms because of scarring after surgery?

SPEAKER_04 7:22

Well, we cannot exclude that scarring can cause rhythmosis. Indeed, in rare occasions, it may cause it. In my quite significance, I had perhaps two patients who came back with the notion of scarring without that being confirmed. You can only know if you reopen the patient and remove the scarring. So, however, angiographic tests have shown a nicely open and dilated and unobstructed arc. We have a term, I'm sure you know, Lim, there is nothing that there isn't there in medicine. So it is quite possible, but in both cases, I've seen it in conjunction or in the context of autoimmune disease, eusenophilia, Crohn's disease, and multi-allergic predisposition. So some people tend to scar a lot and some people don't. There are no clear guidelines or statistics for us to be able to tell the patient what's the risk of scarring. I would say rather very, very rare. And we do have means to try and mitigate the risk of scarring during the first operation.

SPEAKER_00 8:41

Second question I had was about endothelial dysfunction. I was told on my angiogram right before surgery that I had severe diffuse endothelial dysfunction with acetylcholine infusion. And Dr. Schnitter, the cardiologist at Stanford, told me that I would eventually get better to stay on a good diet, to stay on the beta blocker. What are your thoughts about endothelial dysfunction and how we can deal with that? And it does it eventually go away.

SPEAKER_04 9:10

Well, the treatment for endothelial dysfunction is obviously medical. You don't go in and operate an endothelial dysfunction. However, I have seen it in many, many myocardial bridge cases in the context of the myocardial breed. And I've seen a lot of other findings, both anatomical as functional, as you mentioned, in the context of myocardial bridge. For example, a pre-bridge or post-bridge kinking. Those arteries are diving, and then in their course of coming up to the surface, they may have a kink. Sometimes the kink causes more trouble than the myocardial bridge itself. Now, back to the endothelial dysfunction. We all have an external plexus that means a meshwork of little nerves on the surface of our coronary arteries that regulate endothelian function and smooth muscle function. One of the substances that is being secreted to regulate that function is acetyl choline. And in many patients with vasospasm, endothelial dysfunction, but also in the context of myocardial breach, that acetyl choline regulation mechanism is dysfunctional. It doesn't work anymore. And it's causing the opposite, so-called paradox effect, which means spasm. Now, in my practice, in my approach, whether the patient qualifies for median stenotomy or endoscopic or robotic procedure, I make sure to dissect and unruff not only the visible area of the bridge. And this is what I recommend to all my colleagues, but far beyond that, above and below. What this does in my theory, based on literature search we have done, but also on my patient's experience posto-operatively, is you by unroofing the full length of the LED, you basically dissect this external plexus or disrupt this paradox function on the surface. And many patients experience relief. So by we call it our expression in Greece is one shot, two birds down. So that means by dissecting the surface of the uh unloofing the bridge, but going far beyond the actual bridge, you may disrupt this process of uh paradox effect in vasospasm. It is a speculation rather than uh scientific evidence because it just doesn't exist as myocardial bridge patients and in the vasospasm, uh so-called CAS patients, coronary artery spasm patients, are quite rare. But I just think it all the time because when I unroof the myocardial bridge and go beyond that, and I make sure to provide as good as possible a quality assurance. That means colorful, top-like, Doppler studies of the vessel before and after in the operation theater, you can often see how the vessel dilates nicely. It's not only unroofed and comes to the surface, it dilates and becomes a much bigger tube. So coronary regulation continues to be important for the myocardial diffusion of the patient. But if you look at the symptoms postoperatively, we do have quite a high rate of symptomatic relief, partial or total, mostly the second one.

SPEAKER_02 12:48

I'm gonna piggyback the exact same questions with a little extension. I had my surgery done at the University of Chicago with Dr. Balkey two joons ago, so about a year and a half. Yeah. My symptoms were incredibly severe to the point where I'd walk 50 yards and I'd have to rest for five minutes. So he unroofed my entire LED with a lateral. We got to watch the videos, brilliant. It was a lot deeper than the scandal test showed us initially. Um, we're very, very pleased with the surgery. Now it's been a few months. I've been having extreme endothelial dysfunction, a lot of spasms. Um, and recently I do generic cartasm. So my question is have you noticed some medications responding to endothelial dysfunction better than others?

SPEAKER_04 13:41

I would say in the bivolo response better than metoprolol, but which one of the bivolo.

SPEAKER_02 13:49

Okay.

SPEAKER_04 13:50

But for every patient, the pattern of medicational response is different. Unfortunately, our uh today's healthcare and medicine has not reached the stage of uh individualized care yet, personalized medicine or personalized surgery. You see, a patient goes to the doctor with high blood pressure, and we try the first, the same two, three things. But how do we know that the organism of that specific patient has a better response on this or a better response on that? Unfortunately, only empirically. As medicine progresses, genetic tests will be done, metabolic and proteinomic tests will be done in future, those treatments will be much more, much more personalized. What I mean is that your blood, genetic, whatever profile will be examined, and then we will know upfront which medication is best for you. Nowadays it's still in theory. Try and error.

SPEAKER_02 14:52

Okay. And on piggybacking again, I have been having symptoms once again. Where I'll get pale a little weak, nowhere near what it was. But I had a year where I didn't have any symptoms. I was going back to the gym. It was amazing. And within the last month or so, it's been reoccurring. What would you theoretically attribute that to? Scarring.

SPEAKER_04 15:15

Okay, again, not based on scientific evidence. I would say obviously some of the dysfunction is recurring, perhaps because a certain anatomical aspect of the dysfunction is coming back or regrowing. Uh whether this is substance release, nerve regrowth from the surface, from the adventitial side, I can't tell you. But obviously, something takes time to grow back and re-excite the same effect. Okay. Thank you. Rather than scar.

SPEAKER_03 15:49

So, Dr. Kofidas, I have a question. Uh first a comment. Thank you for what you're doing for us and raising the awareness of myocardial bridges globally. The recurrence, I think all of us that have been unroofed fear that this is going to come back. And we're seeing through the face group group more and more people saying, I was unroofed a year or two or three ago, and now symptoms are coming back. And if I heard you correctly, it is possible that some of that nerve from the surgery, as it heals, it recurs the symptoms?

SPEAKER_04 16:37

Yes, that's my hypothesis. As I said, there are no public there is no published evidence on that. Uh we did a very thorough literature research at the very beginning of our practice, and it indicates eventually there are nerves on the adventitial side that trigger the release of acetylcholine that may cause this. Uh, it may be other mechanisms which have not been studied yet. Uh, I'm sure that a couple of surgeons around the world who are capable to unruff a myocardial bridge, withdraw from doing that, refrain from doing that, because they may have experienced discouraging results after some time. Thankfully, in our practice, as I said, is very, very rare. But I I think what we ought to do, we surgeons, doctors, cardiologists, is form a group just as you did, put our data together and look at the uh post-operative aspects falling and roofing. What we managed to do, and I'm happy for that, code triggered by your initiative, Chef, all of you, and a little bit my participation, as many other doctors around the world, we created awareness. People start recognizing this entity as a disease and are more aggressive and decisive in treating it. That's a step forward. But what needs to happen next, it put our data together, eventually send you all quality of life or postoperative questionnaires, and we do have specific ones for decades now in the domain of heart surgery. Then we put those all together and share or publish scientifically. I'm curious to see what all surgical groups around the world have to say.

SPEAKER_03 18:28

And if I can ask another question, because you've been performing the surgery for some time now, a lot of surgeons have their own best practice. Many are just starting, they recognize the condition, but they may not have a pattern of what they think is best to do. In your opinion, what's the best way to unroof a bridge artery?

SPEAKER_04 18:56

Well, I guess in the context of my former comments, uh it becomes clear. So for me, the long-term result is much more important than the approach. Whether this is a six-centimeter cut or an eight-centimeter cut or a full stenotomy or a bodic access, all this is secondary to me. The most important thing is to unroof properly. And I think I mentioned in my uh first dialogue with you, Jeff, that my involvement in this group and in the treatment of this disease has been somewhat, how to say, uh, surprising or uh unexpected. Many years ago, more than 10 years ago, I was called to be an independent expert in court, which involved a patient and obviously a surgeon. And uh so uh in my due uh diligence and preparation for this court case, I studied a lot and I spoke to many people and practitioners around the world. And I realized that a mistake that occurs often is just going for the bridge, for that one, two centimeters of the bridge, rather than unroofing the full length of an extended length of the arch. So this is what I do, obviously. Uh I don't just unroof, I go beyond. I want to make sure to reduce the possibility of altospasm afterward. Second, if the bridge extends to the first diagonal and beyond, usually we often see a true atherosclerotic uh narrowing over that spot. As if it was a coronary artery disease, the traditional coronary artery disease. Unruf zone part as well. Okay? All the way down to the distal aspect of the heart of the artery, it should be unruffed properly. Then look at the other uh coronary arteries as part of the surgery. Now, intramuscular course of the coronary artery doesn't equal myocardial bridge. So I wouldn't recommend we go around and, you know, cut all the muscle over all arteries, big and small on the surface of the heart. It's nonsense. You know, I know patients coming out of the first surgery, re-experiencing symptoms and saying, okay, my doctor should have unruited that little branch of that little artery. I'm a bit skeptical about that. I do take it seriously, but I'm skeptical about that. Now, another aspect of any treatment is quality control. That's very important to me. In my practice, other than the diagnostic procedures, which may be IFFR, DFFR, CTA with 3D reconstruction. Of course, I surround myself with cardiologists here in Athens who are at the top in their domain and provide. Me beautifully magnified 3D aspects of the artery in uh in all directions, a proper uh IFFR or angiography at least, in order to see exactly the squeeze where the location of the squeeze, the systolic squeeze. And then, of course, intra-operatively, we use uh high frequency ultrasound, which provides a color-coded blood flow signal through the artery and also gives us the exact anatomical appearance on the artery on the ultrasound. You can, most of the times, all of the times actually, you can see the difference before the before and after, between the before and after. So this quality assurance is critical to me and it's measurable. So now, as of the surgical approach, in my case, as you know, I'm a specialized minimally invasive heart set. I don't enjoy opening with stenum opening. My practice is largely minimal invasive, even though median stenotomy has to be performed in certain patients. My approach is an endoscopic approach. That means a small cut under the left nipple, and then the manual approach. Even though I was trained to do robotic surgery, not to the extent, I'm not practicing it to the extent that uh some balcony practices it. A friend, very respected surgeon across the world. But I feel more comfortable to do it, you know, with this almost the same size incision from the side with my my hands, with uh manual instruments, not the robotic instruments. Because when unroofing the myocardial bridge, I get much better. I need the tactile feedback, Jeff. I need the tactile feeling when I touch the surface of uh the vessel. And and if I have to deal with complications, bleedings, uh, extension of the initially planned surgery, meaning looking at other arteries, going further up, I feel more comfortable in doing that with tactile feeling and the sensibility of my hands rather with telemanipulated metal instruments. Now, if you talk to a religious robotic surgeon, he would refute that. But in the end of the day, it's not about one centimeter more or less of a cut. It's about the end result for the patient.

SPEAKER_03 24:28

I do want to ask another question as technology increases. What are we seeing in the mapping and the ability to read the compression through AI?

SPEAKER_04 24:44

AI has not yet entered field profession. There are certain new photon CT scanners and dual tube CT scanners who partially based on AI calibration. I'm consulting for some of those companies, and therefore I have the privilege of knowing how they work. They can provide higher resolution, irrespective of the heart rate, because when you do a CT scan and the heart beats too fast, you may have to deal with inaccuracies. But at the same time, Jeff, they measure flow. And I'm looking forward to a wide establishment of such devices. So I'm sure we're gonna have uh a better assess. Now, look, in order to apply AI, you need huge patient cohorts to validate, to calibrate the algorithm in order for this algorithm to be used in the next diagnostic patient. There are not as many myocardial patients around the world as at least not that many who have been captured by proper statistics.

SPEAKER_03 26:00

If one in four of the population has a myocardial bridge of some sort, yet the consensus is one percent or less than one percent presents symptomatically. Could that really be that all you're hearing about is the one percent that says something's wrong, yet many more people are walking around afflicted by the condition?

SPEAKER_04 26:32

Very good question. And it has a logical answer, I believe. First of all, we should separate myocardial breach from intramyocardial course of the coronary. I would be very skeptical to accept the 25%. I think 25% of patients, and even more, may have an intramyocardial course of their coronary artery. We see it in the obtuse margin of the so-called OM or circumflex branches of the artery. We also see it in the course of the LED. Oftentimes the LED dives under is, you know, a bridge of muscle. Sometimes, as I said, in the circumflex territory on the left side of the heart, I see big branches, smaller branches being covered by muscle. But that doesn't equal myocardial bridge. Myocardial bridge, and you see, even the definition of the myocardial bridge is often difficult. It's not just the anatomical feature of muscle covering the artery, is the capacity of that muscle to constrict, to squeeze in certain ways that it compromises the vessel, often comes with a kink of the artery, as we mentioned before, and equally often it can present with the visospad. So myocardial bridge is not equal intramyocardial course of the core. But I do agree with you that many more patients are walking around with true myocardial bridges than we will ever know. I'm glad for this. And that's where the notion by the choreologist comes who tells you, you know, not serious. Go on, you know, uh with your life. There are so many patients out there they don't even have symptoms. Well, let's look at those first who do have symptoms and take them seriously.

SPEAKER_02 28:32

So it's more of a question of the anatomical bridgings. I know they say that, you know, a quarter or a third of people who have bridges most are not affected by it. But over the years, with the bridge and just how it's lined out, like a plumbing, you get a lot of regurgitation. So those same patients, in theory to me, would collect plaque in those areas and potentially die of coronary artery disease. Is that something that long term we're losing a lot of people in their 60s for coronary artery disease, and they're just calling it coronary artery disease when the real problem is actually the bridge?

SPEAKER_04 29:10

Okay. Very good question. And I do agree with you. It's a well described phenomenon that patients with a myocardial breach do have a tendency to form more aggressive and earlier coronary artery disease. That's true. Okay. But coronary artery disease is a very common and frequent phenomenon, unfortunately, will affect a large portion of a male and female nowadays population around the world, and is not necessarily associated with myocardial bridge. Only the smallest portion of coronary artery disease patients have a myocardial bridge or arteries that are covered by muscle and intramyocardial pores. So coronary artery disease is the well-described entity. Having said that, people with myocardial bridges are reported to have a tendency to build up coronary artery disease faster than the average population and to a more extensive uh degree.

SPEAKER_03 30:14

And you're explaining that from coronary artery disease. What about plaque buildup that narrows to the point of occlusion? The patient may get unroofed, but not bypassed. And that I understand is a condition as well.

SPEAKER_04 30:31

Yeah. No, the plaque buildup in the context of myocardial bridging is mine. Okay, those plaque buildups nowhere close to what we see in traditional coronary artery disease. We're looking at maybe 20%, 30%, something like that. Functionally, a narrowing of 20, 30, 40, 50% even, doesn't cause dynamic consequences. That means lack of blood supply, distal to it after the blockage. Coronary artery disease causes serious, very high degree stenosis and pulp buildup. And it does so not only in one vessel, oftentimes, but everywhere. That's why we call it two vessel disease, three vessel disease, and their branches. So what I see just before the breach is usually only a slight buildup, which definitely doesn't cause a true coronary artery disease kind of stenosis. Therefore, a bypass is not warranted in most of the patients who suffer from myocardial breach. You'd be surprised to know that for a coronary artery disease blockage to cause ischemia, that means undersupply of the muscle, distal to it, the blockage must really be above 70% or so in different aspects when the scanner goes around you and checks in different directions.

SPEAKER_03 32:08

You're actually making me feel very special because I am that patient that had the above 70% and required the bypass. And I did have you know, ischemia, I had a heart attack. So I'm in that very, very less than 1% range.

SPEAKER_02 32:26

On the rare chance that we were able to make it out to Greece, could we come and visit your facility and take a look at it?

SPEAKER_04 32:33

Well, I would say don't call it rare. Look, I did my part. I came 11,000 miles to the west from Singapore. You're gonna manage the 6,000 miles from the United States. Okay, that's number one. On a light-hearted note. Greece is a wonderful location. It's culturally, gastronomically, historically, geographically. The best. I mean, look, the Mediterranean climate is known to be the best in the world. A bit like South like California, I would say. Okay? So that's number one. I came to this hospital specifically because it's JCI accredited, and it's an American-funded hospital. The professionals in these hospitals usually have trained in the United States, Germany, UK, uh in top centers in the world. And uh, well, one of the reasons I'm here is to contribute to these centers, you know, climbing up uh the international ranking. Now, this aside, Athens can be and will be in the near future a magnet for international surgical cardiological patients. People come here, they can experience a totally different patient journey. No waiting times. One-tenth of the treatment costs, or one-fifth of the treatment costs compared to the United States. Top of the notch treatment and professional. So Greece is not a developing country. Greece is first world, as we say. We are here to help. We follow international guidelines. The hospital is a JCI accredited hospital, and whoever comes will live certainly with a unique experience. It's a beautiful experience. And with today's, in today's age and technology, everything is possible. Look, we are sitting here as if we were in the same room, and connections are wonderful. I mean, there are direct flights from New York, if I'm not mistaken, but even if not, you can fly from your location, Chicago, Frankfurt, Chicago, UK, whatever, London, and then take a short flight to Athens. Usually, a patient should book about two weeks of stay in Greece. The rehabilitation opportunities, of course, are magnificent. You can enjoy beautiful hospitality, excellent hotels, and overall a unique experience, I believe.

SPEAKER_03 35:05

So you just took care of the Visitors Bureau for Athens, Greece, which we appreciate.

SPEAKER_04 35:11

Absolutely. Absolutely. In fact, on the 23rd of October, we're inaugurating Greece's first international heart surgery center in Athens, which aims at extroversion, reaching out to the world and inviting the world to enjoy top-notch surgery, top-notch technologies and solutions personalized for every patient. 23rd of October, we will have American, European, Asian professors raining down on Greece to take part of that inauguration ceremony.

SPEAKER_01 35:45

I have a question. Do you have any idea how much it costs to come have surgery there?

SPEAKER_04 35:51

Absolutely, I do. I mean, usually we don't talk about money on public forums. But I can assure you of this. My return to Greece comes is associated with the drop in the price, of course, because earlier I had to fly in from Singapore for hotels and car rentals and such things. But now I'm permanent here. The price has dropped. Number one. Number two, the usual fees by the hospital is somewhere around 30 to 40,000 uh euros right now, which is a ridiculous amount compared to, let's say, the average US facility. It's ridiculously low. So now, of course, the next step would be as we gather steam and as we gather experience with US patients, ideally, and this is something that I will pursue, sit down with the insurances in the United States and offer US patients with such alternative solutions. As I mentioned before, please consider the facility, the single rule, the no waiting time, lack of waiting time whatsoever, and much, much lesser fees. Now, these fees are subject to change, of course, subject to international patient numbers, agreement with insurances or not, and so forth. But they are nowhere close, as you know, to American fees.

SPEAKER_01 37:22

Thank you.

SPEAKER_04 37:24

We shall certainly be happy to see you here in Greece.

SPEAKER_03 37:28

Well, Dr. Cofides, it's morning for us. So we're greeting each other with good morning. We will say goodnight to you. Thank you so much for your support.

SPEAKER_04 37:41

Thank you for your hospitality. I hope it was helpful.

SPEAKER_03 37:44

It absolutely was.

SPEAKER_04 37:46

Please reach out. I hope you all do well and you never need a heart surgeon. But if you do, we in Athens will be at your disposal.

SPEAKER_03 37:54

Well, medical tourism abounds, so I think you'll see some more patients as a result.

SPEAKER_04 38:00

Happy to help.

SPEAKER_03 38:01

Thank you.

SPEAKER_04 38:02

Thank you. Take care.

SPEAKER_03 38:04

Thank you for listening to Imperfect Heart. It's my hope that this information helped 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. The views and opinions expressed in this program are solely those of the host and the guest and are not intended to provide, nor are they a suitable substitute for professional care by a doctor, therapist, mental health professional, or other qualified medical professional.