Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

Daniel Lobell: (00:24)
Hello, and welcome to the Doctorpedia podcast. I’m your host Daniel Lobell. Today I’m on the line and I’m honored to be speaking with Dr. Thomas Waggoner. How are you Dr. Waggoner?

Dr. Thomas Waggoner: (00:34)
Excellent, Daniel, thanks for having me on.

Daniel Lobell: (00:36)
I got to hear a little bit during the sound check about what you were having for breakfast, and it was a very healthy sounding breakfast. And then we went into lunch and dinner and maybe they weren’t as healthy, but they also sounded like pretty nutritious, balanced meals. As you are a cardiologist and you deal with people with heart conditions, is what you’re eating a very conscious part of your life?

Dr. Thomas Waggoner: (01:07)
Absolutely. It’s a real pleasure to be on again, and we’re excited to come live from Tucson here regarding this podcast. I believe that breakfast is the most important meal of the day hands down. So I usually do something healthy, granola, protein bar, egg whites, something very healthy. But as I get busy with my procedures throughout the course of the day, I tend to let down the guard a little bit and end up eating chocolate chip cookies for lunch. And by dinner time, it’s the most savory food I can find because I’m so hungry after a long day of cases. So the Peruvian place was definitely spot on for a night like tonight.

Daniel Lobell: (01:41)
I’m curious to hear you tell us more about how important the link is between what we eat and what’s going on with our heart. We all know that it’s not good for your heart to be overweight, but is there more to it than that?

Dr. Thomas Waggoner: (01:58)
Absolutely. A healthy diet goes a long way, but also being active. Aerobic exercise is really a mainstay. We hear it all the time. It’s like preaching to the choir to a lot of folks who are very active. There are really three aspects to it. One is your diet, two is the amount of aerobic exercise or cardio exercise that you get and the third one is genetics. About half of that is genetics and we have a hard time modifying those things, but things that are modifiable like diet and lifestyle really go a long way.

Daniel Lobell: (02:29)
I am somebody who has always struggled with their weight and I’ll gain weight, I’ll lose weight. And I’ve been actually warned that losing weight quickly can be bad for your heart. Is there any merit to that?

Dr. Thomas Waggoner: (02:41)
We believe so. There’s not a lot of large randomized trials. In cardiology, we’re very trial heavy. If we’re going to do a device or procedure in your heart, we want to make sure we’re doing the right thing. So most trials are very well vetted with data to back them up. There’s not a lot of data regarding rapidly losing weight and what it does to heart muscle. We do know that it can change the strength and the dimension of the muscle. It can shrink down and expand up like what we call an athlete’s heart, for example, if you’re a really know high volume runner. Long-term, there can be some side effects of that. They’re just not well studied in our literature.

Daniel Lobell: (03:18)
So you brought up cardiovascular disease. I read a book a while back called, “How not to die.” Have you ever heard of it?

Dr. Thomas Waggoner: (03:31)
No. I have not.

Daniel Lobell: (03:33)
It’s a good title. Dr. Michael Greger wrote it, and he said that moving to a plant-based diet is the only diet that’s proven to be able to reverse heart disease. Have you heard anything about that?

Dr. Thomas Waggoner: (03:48)
We know from some minimal longitudinal data that there is some merit to that. It’s hard to sell it to the community at large, but I think there’s been some merit with Mediterranean diet, high protein diets with no carbs. So we don’t know a lot about long-term data. We do know though that moderation is key. So moderation with a very active cardio-heavy lifestyle will pay dividends in preventing that plaque from building up in the heart arteries and on the valves. I’m a valve specialist. So in terms of your diet and lifestyle, that can definitely help to delay some of the deterioration of heart valves as you grow into your seventh or eighth decade in life.

Daniel Lobell: (04:38)
Is there any time when it’s too late for us? Is there a certain age where you go, “Look, my heart is what it is at this point. There’s no making it any better. Maybe I can just not make it worse,” or can it get better at any point?

Dr. Thomas Waggoner: (04:58)
[Laughs.] It’s a good question. In my opinion, it’s never too late. So if you’re still waking up and walking, talking, breathing, it’s never too late to modify something that’s modifiable.

Daniel Lobell: (05:06)
I was wondering what it looks like in there. You never get a reading on it and it’s the scariest thing in the world, because I think heart disease and heart attacks account for a high percentage of deaths, maybe the most or second most – you would probably know better than me, but it’s up there, right?

Dr. Thomas Waggoner: (05:26)
It is. It teeters between first and second place for full mortality in the US over the last many years. Moving into the broader scope of things in terms of heart disease, there’s heart disease, which generally implies coronary artery disease or blockages or plaque that accumulates in your vessels that feed the muscle. So the muscle pumps through the four heart chambers, the blood gets re-oxygenated from the lungs and the heart pumps it out. The first blood that gets pumped out of the heart crosses the aortic valve and goes into the aorta. The first vessels that come off the aorta actually go back to feed the muscle itself, so about 10% of the cardiac output or greater, and go back to the muscle to feed the muscle with oxygenated blood. And so when those arteries themselves get filled up with plaque, the muscle weakens, and you have heart disease. So you want to stay active and stay healthy. Valve disease also can at least be set at bay when you have lower blood pressure and avoid a high sodium diet. If you have valves that leech or valves that are stenotic, you want to prevent those from deteriorating more. So I think diet and lifestyle can go a long way.

Daniel Lobell: (06:35)
Yeah. You brought up plaque and that’s exactly what got me thinking about it. That, and my friend who passed away from a heart attack while he was biking. He was relatively young, in his fifties. And he pushed himself to do a big bike ride, which we all think is really healthy. And then I guess he pushed his heart too far and he passed away recently. So that’s got me thinking about it a lot and the word plaque, because I was at the dentist this week, I got a cleaning on my teeth. And she said, “You have to watch out for plaque.” And I thought, “Man, you can’t even know if you have plaque in your heart.” At least you go to the dentist every now and then, and they tell you about the plaque on your teeth. But how would you know?

Dr. Thomas Waggoner: (07:22)
Yeah, you can’t actually. There are different ways or different scans or stress tests. You can determine if you have plaque, from a basic cat scan of the heart, you can determine if there’s calcified plaque, there’s also soft or thrombus laden plaque, which is a little bit different, it’s softer and can break off and cause an acute heart attack. We can do a chemical stress test to determine if the plaque that’s there is clinically significant. And then finally we can do an invasive angiogram. We put a catheter directly in those arteries and take a picture to see if that plaque is causing a problem, if it’s obstructive in blocking blood flow. So there are different ways to definitely check for plaque with different modalities, both what we call invasive, which are catheter-based and non-invasive, which are usually screening tests, with stress tests or scans.

Daniel Lobell: (08:09)
It’s not as common as going for a cleaning at the dentist though. [Laughs.]

Dr. Thomas Waggoner: (08:13)
[Laughs.] No, it’s definitely not that type of walk in the park, although depends on how good your teeth are.

Daniel Lobell: (08:21)
I was also told that there’s a link between dental issues or gum disease and heart conditions.

Dr. Thomas Waggoner: (08:29)
Yeah, poor dental hygiene correlates with heart disease, both plaque buildup, as well as infections of heart valve, which can be very, very serious where bacteria in your mouth can get into your bloodstream and then sit on a heart valve leaflet and eat away that leaflet and cause an infection that causes endocarditis. And that can be very serious.

Daniel Lobell: (08:49)
We have to watch out for plaque, wherever it is. [Laughs.]

Dr. Thomas Waggoner: (08:52)
[Laughs.] Exactly.

Daniel Lobell: (08:54)
So I jumped right in with all these questions and I didn’t actually get to address with you my friend, who had passed away sadly from a heart attack. How do we know if we’re exercising too much and what are some signs we should look for? Like if I was able to go back and tell my friend before he went for that big bike ride, “Watch out for this.”

Dr. Thomas Waggoner: (09:19)
Yeah, that’s tough. Again, my deepest condolences for your friend. If you’re someone who’s not that active, before you launch into a very rigorous exercise regimen, I would definitely see your cardiologist. You may want to start with the simple treadmill stress test where you walk on a treadmill, so we can determine if you’re in a good enough capacity from a cardiac standpoint, to start something very vigorous and have that prior to becoming a marathon runner overnight.

Daniel Lobell: (09:48)
Well, okay. That’s good advice. So a stress test, I have to put that on the list, make sure to get that done. I can’t believe it never even occurred to me to do these things. I usually start these interviews at the beginning when I go back to your childhood and we didn’t get a chance to do that. So let’s do it now. I know you said you’re in Tucson, Arizona. Is that where you grew up?

Dr. Thomas Waggoner: (10:19)
No, I grew up outside of Columbus, Ohio. I grew up in the Midwest. I’m a rabid fan of the Ohio State Buckeyes. I trained on the East Coast from Maine, New York, New Jersey outside of Philadelphia and all the way down to Florida and then came out to Tucson, Arizona about six years ago and joined a practice called Pima Heart. And now we’re the second largest cardiovascular practice privately held on the West Coast. So it’s a pretty busy program, a very robust structural heart program. So I’m at Tucson Medical Centers where I’m based as director of structural heart and director of cardiothoracic research. And what we do daily is really transcatheter heart valve interventions, which means if someone has a bad valve, as you were just alluding to earlier in the conversation, if they have a leaky heart valve or a valve that doesn’t want to open well, called a stenotic valve, we can replace those and repair those through catheters in your groin, we access the femoral vein or artery and go into the heart and actually repair valves daily and keep these patients from undergoing major open heart surgery and get them home usually the same day or the next day. So it’s cutting edge stuff. And we’re excited to offer Southern Arizona and the greater Southwest these opportunities.

Daniel Lobell: (11:32)
You said it was cutting edge. How long has this been common or available for people to do?

Dr. Thomas Waggoner: (11:39)
So at major centers, the first transcatheter valve was approved by the USFDA in 2012, we started doing them about six years ago and now have really grown this kind of hub and spoke model where we have one major center which is Tucson Medical Center. We bring all of our complex cases to that one center, really a center of excellence. It’s a 600 plus bed hospital. And now it’s becoming a semi teaching hospital where we have residents and fellows and interns and students and we offer patients newer technologies. We have a whole segment of new device technology through clinical research studies, where, for example, if you have a heart valve that can’t be treated surgically and you have to have a catheter-based valve, instead of driving to Mayo Clinic or flying to Cleveland Clinic, we can now offer a lot of those same devices through our clinical research center at TMC and Pima Heart.

Daniel Lobell: (12:30)
Amazing. Well, if you thought your heart and your groin were connected before … [Laughs]

Dr. Thomas Waggoner: (12:40)
[Laughs.] Now they indeed are for catheter-based treatments. And it’s minimally invasive. It started during Covid where we were discharging folks home the same day, in fact, after new heart valve. And now that COVID is beginning to become less of an issue, we still are realizing we can discharge a lot of these patients home within 24 hours of a brand new heart valve or heart valve repair. So it’s pretty phenomenal. I think COVID has really helped push and become the impetus for us, understanding how to run a program, to get patients safe and out of the hospital in an expeditious manner, but a safe manner. And seeing them for follow up within a day or two.

Daniel Lobell: (13:15)
That’s a nice silver lining from COVID.

Dr. Thomas Waggoner: (13:18)
It really is, one of the few silver linings.

Daniel Lobell: (13:21)
What makes somebody a good candidate for this?

Dr. Thomas Waggoner: (13:24)
It really depends on quite a few factors. We have a whole team that evaluates folks, but generally, if they have a bad heart valve, they will go to their general cardiologist and the cardiologist will say, “Hey, I hear a murmur on exam with my stethoscope. I’ll get an echocardiogram,” which is a sonogram of the heart. And then they’ll determine that they have a bad valve, either a leaky valve or a stenotic valve, then they’ll refer to a specialist like myself who’s a structural heart interventionist. That means I can do these heart valves through catheters and tubes, minimally invasively. It was approved initially for folks that were high risk for surgery that were too sick to undergo major, open chest surgery. Now the FDA has approved it for all comers. So anybody who is even low risk can be approved for a catheter-based approach. So in terms of who’s a good candidate, most folks now are candidates for these catheter-based procedures, which is a big win for our community because they can literally go home the same day or the next day, and not be in the hospital in ICU for five to seven days.

Daniel Lobell: (14:20)
That’s amazing. That’s really incredible. It seems like a game changer.

Dr. Thomas Waggoner: (14:25)
It really has been, and a lot of it’s based on our research devices as well. So as a lot of new device technology companies have emerged with smaller valves, with more durable valves, with procedures to help mitigate bleeding disorders. If you have to take a blood thinners, there are procedures called WATCHMANs and appendage closers that can block off clots and prevent clots from leaving the heart. So it’s really been transformative in this community and largely speaking in the US at structural heart centers, centers of excellence that can treat these valves through catheter-based approaches. And I think it really bodes well for our patient population: We’re in Arizona, a lot of folks here are retired but they’re still very active at the age of 65 or 66. They still want to go out and they want to hike and bike and climb and travel and RV, and they’re thankful that they can continue to do that without having a long protracted recovery.

Daniel Lobell: (15:22)
So if you keep a clot from leaving the heart, what does it do? It just hangs out in there.

Dr. Thomas Waggoner: (15:27)
So that particular device is called a WATCHMAN device. You put a little plug in this chamber called the left atrial appendage. So the heart has four major chambers, but there’s a little side pocket, one on the atrium called appendages. Just like your appendix in your stomach, you don’t need it, it’s a vestigial organ, meaning it’s something that’s just a remnant of embryology. But the problem is when you have a cardiac arrhythmia called atrial fibrillation, clots can form on that little chamber and then break off and embolize to the brain. So we put a little cork on that and block it off and put a door on that closet so those clots cannot exit the heart and they stay in that little chamber, solidify and get absorbed by the body.

Daniel Lobell: (16:01)
I have a friend who has that. I wonder if he’d be a good candidate. He’s in his sixties and he’s had it for years. And he winds up going to the hospital all the time when he has an episode with it.

Dr. Thomas Waggoner: (16:14)
Yeah, absolutely. So it’s interesting – that device commercially is only approved for people that are deemed high risk. However, we are doing a clinical research trial. We are now able to offer anybody with AFib a device called a WATCHMAN in a trial called Champion AFib. So that’s a trial for low-risk WATCHMAN candidates. So he very well may be a candidate.

Daniel Lobell: (16:37)
Wow. All right. Well, that’s something I’ll have to pass on to him. How do you like Arizona? I love Tucson Arizona. I used to go there as a kid when my grandparents would rent a place in the summers.

Dr. Thomas Waggoner: (16:48)
I love Tucson. I love Arizona in general, coming from the East Coast. I love the dry heat. At this time of year from October until Memorial day, it’s 75 degrees and sunny every day without a cloud in the sky, the most beautiful sunsets and sunrises you can imagine. You can go up to Mount Lemmon during January and February, there’ll be snow capped mountains on the Catalina range. It’s almost 10,000 feet and interestingly, it’s one of the few places in the world where you have saguaro cactus growing next to ponderosa pines side-by-side. It’s amazing.

Daniel Lobell: (17:21)
What are the other places?

Dr. Thomas Waggoner: (17:24)
I believe they grow in a place in Asia near Mongolia but in the US I think that’s the only place that has cactus and pines growing side by side in a collegial environment. It’s amazing. You drive up this mountain that’s almost 10,000 feet and you can see all four climates, summer, winter, fall all in one, and a little bit of spring driving up the highway.

Daniel Lobell: (17:47)
Truly, Arizona is a magical place, but it does get pretty intense in the summertime with that heat.

Dr. Thomas Waggoner: (17:54)
Oh, absolutely. During June, July and August in Tucson, half the population leaves and they go up north into the woods, the white mountains, or Flagstaff Sedona, or even further up north, or they go to California, they go to the beaches.

Daniel Lobell: (18:06)
I was there in Scottsdale two years ago in the summer and you get heat headaches, it’s so hot.

Dr. Thomas Waggoner: (18:12)
[Laughs.] Yeah, you do, you can boil an egg on a hood of a car. No question about it.

Daniel Lobell: (18:18)
[Laughs.] It’s an advantage if you don’t want to use up your gas bill or whatever.

Dr. Thomas Waggoner: (18:22)
Yeah.

Daniel Lobell: (18:23)
So what made you decide you wanted to become a doctor and what age were you?

Dr. Thomas Waggoner: (18:28)
I was just thinking about that question earlier today. I would pin it on a couple of things. I’d say the first phase was realizing I wanted to help people and that goes back to my high school years when my second oldest brother, Andy, had non-Hodgkin’s lymphoma. And he had it three times, has battled and has since survived. And now he has a family, I have a nephew who is doing well. So that was the first pivotal moment in my life where I said, “You know what? I love helping people. And I would love to do it from a medical standpoint.” I love the science. I love the ability to help someone out who’s in need and it feels like they’re helpless.

Dr. Thomas Waggoner: (19:10)
Then I go to college and I say, “Okay. I like biology. I like the sciences. Let’s go to med school.” I get into med school and then go through residency. And I wanted to be a surgeon. I love using my hands. I wanted to be a general surgeon and sew things together. I love that aspect of it: using my hands and the tactile feedback and fixing things. Then I found cardiology, I did an elective in cardiology, and I said, “This is it.” I love the physiology and I love doing procedures. And then even better, what’s called structural heart cardiology, which is the most advanced training you can get for catheter-based cardiac interventions, aside from opening your chest. So you have thoracic surgeons who do open heart procedures, and then you have structural intervention cardiologists, who do those procedures, but through catheter-based, minimally invasive, which is really the future. So that’s been the timeline of my decisions that has ended with me having a medical degree and seven medical boards beyond that. So it’s really been a phenomenal ride. And I think number one is being motivated by the success of helping others.

Daniel Lobell: (20:14)
Beautiful that it came through your brother as well.

Dr. Thomas Waggoner: (20:17)
It really was looking back and now he’s in his mid forties and he has a son, my nephew, who is a phenomenal football player back in Ohio. And it’s been a really big roller coaster, particularly for him and his family, but the last five or six years it’s really settled down and it’s been a blessing.

Daniel Lobell: (20:33)
Amazing. I saw in my notes that you have done the first transcaval TAVR – what is that?

Dr. Thomas Waggoner: (20:47)
We’ve done quite a few procedural firsts, actually. So we’ve done the first percutaneous axillary TAVR in Tucson. We’ve done the first transcaval TAVR in Tucson, and we’ve done the first one of the early trans-carotids. So what that means is how do you get a valve in the heart? All roads lead to Rome, which avenue do you take? So for example, when we do a transcatheter heart valve, we have to replace the aortic valve and there are different routes in the body. Usually we use the groin, as we’ve mentioned earlier, the femoral artery, either the right side or the left side. Now we can also use the axillary or your shoulder arteries. So you can access and put the valve into your shoulder arteries, as well as your neck or your carotid arteries. Then additionally, we can go through the vein in the groin, into the vena cava, puncture into the aorta, and then put the valve in the aorta that way. So now we have seven access pathways to Rome to get that valve home. Those have really been born out by the fact that we’ve understood in our space that a catheter-based valve, no matter how you get it into the body, usually is safer with less morbidity and risk than opening the chest up.

Daniel Lobell: (21:56)
So would you say that opening the chest up is the riskiest way?

Dr. Thomas Waggoner: (22:01)
Generally speaking, yes.

Daniel Lobell: (22:03)
What are some of the complications that you guys have faced in doing this? And did you overcome certain things and what was learned along the way?

Dr. Thomas Waggoner: (22:11)
Absolutely. So, in terms of complications, obviously there can be vascular injury when you’re going through the vessels or veins, whether it’s in the groin or the shoulders of the carotid, those are usually relatively low, less than 5%. You can cause heart attacks when you’re putting the valve in, cause some of that plaque to break off and causing a heart attack during the procedure, that’s less than 1%, strokes also less than 1%. To bring that even lower we’ve enrolled ourselves (with the help of a sponsor) in this trial called PROTECTED TAVR. So TAVR is a transcatheter aortic valve replacement. That’s what we’re discussing now. PROTECTED TAVR is a large randomized clinical trial, actually one of the largest structural clinical trials in the world currently enrolling. During this transcatheter valve implantation, we put a filter up from the wrist vessel into your carotid arteries, believe it or not, and it can catch plaque. So we’re working on your heart valve. We don’t break off plaque on the aortic valve and have it embolize to the brain and cause a stroke. For this trial, we were the top global enrollers this past summer out of about 200 sites between the US, Canada, UK, Spain, and Australia. So we’re very proud of that, being the top global enrollers in one of the larger structural clinical trials in the world.

Daniel Lobell: (23:24)
Can you guys clean the plaque out yet like the dentist does? Can you put a little suction thing? Get all the plaque out?

Dr. Thomas Waggoner: (23:32)
[Laughs.] That’s for sure the golden answer to a lot of stuff in cardiology, yes and no. We don’t have a magic pill, but we have tools to help either remove the plaque with what’s called rotational atherectomy, which is a robotic drone outs. We have balloons that are part of our new device technology where we can take a balloon that causes impulses like lithotripsy, for example. So if you have a kidney stone, you go get lithotripsy to break it up, because it’s stuck in what’s called your ureter. So we have that same technology now on balloons for heart arteries, as well as for vessels in the periphery. So we can do what’s called shockwave, which is a lithotripsy technique, which is high pitch sonographic impulses that cause the calcium to breakup. So we do have different tools to remove calcium. Unfortunately, we have no magic pill to clear out the plaque completely like Draino would in a clogged up drain.

Daniel Lobell: (24:26)
What is the MitraClip?

Dr. Thomas Waggoner: (24:29)
A MitraClip is a minimally invasive way to treat your mitral valve regurgitation. It’s a catheter-based mitral valve repair system that goes into your femoral vein. We then feed it up the vena cava. From there, it goes into the mitral valve and it brings the two leaflets together and puts like a clip or staple in the middle to help reduce the leakiness of that valve. It’s a mitral valve system that’s minimally invasive.

Daniel Lobell: (24:52)
Wow. All of this is just like mind blowing for me. I didn’t know any of this was going on.

Dr. Thomas Waggoner: (24:59)
It’s amazing. Last year, we were the second busiest MitraClip program in the country last year out of hundreds of hospitals that do it.

Daniel Lobell: (25:07)
Who was number one?

Dr. Thomas Waggoner: (25:09)
Cedars-Sinai in LA. It’s like the Mecca of cardiology in the country, in the world really for transcatheter heart valve interventions.

Dr. Thomas Waggoner: (25:19)
So our model down here is called the Cedars of the Southwest. So that’s what we’ve been coined by some of the sponsors. We’re honored and humbled if people are calling us the Cedars of the Southwest, that’s a win for us, for sure.

Daniel Lobell: (25:37)
It’s got a ring to it. Southwest Cedars.

Dr. Thomas Waggoner: (25:38)
I thought so too.

Daniel Lobell: (25:42)
What is the iSLEEVE sheath?

Dr. Thomas Waggoner: (25:46)
The iSLEEVE sheath is an introducer sheath that we use for our transcatheter heart valves. There’s many different – there’s the eSheath, the iSheath, the pSheath. These are just sheaths that we use to put into the femoral vessels or shoulder vessels to put our transcatheter heart valve through that type of sheath. So we did one of the first of those in Arizona a couple of years ago.

Daniel Lobell: (26:10)
I guess I should ask what a sheath is.

Dr. Thomas Waggoner: (26:12)
So a sheath is a tube that you use. So you access the vessel with a needle. Once you access the vessel, you put a wire through the needle into the vessel, you back the needle out. Then you put this sheath in and it’s a little tube that helps support that vessel opening. So then you can access the vessel routinely with catheters and valves. So it’s like the conduit to get into the vessel.

Daniel Lobell: (26:34)
So it’s like replacement tubing or reinforcing.

Dr. Thomas Waggoner: (26:37)
Yeah, it’s like PVC piping made as a conduit so we can keep that vessel open and access the vessel repeatedly. Instead of putting a needle in multiple times, we put the needle in once, access the vessel and then put a little tube in there called a sheath to help keep that vessel access available as we do our procedures.

Daniel Lobell: (26:55)
Do you think that in the next decade, we are going to get to the point where we can eliminate heart attacks and/or strokes?

Dr. Thomas Waggoner: (27:04)
Probably not in the next decade, but I would say in the decade after that, it’s likely there will be technology, probably a genetic base, that we will be able to get to that point.

Daniel Lobell: (27:15)
Amazing. So all we have to do out here as non-doctors is live another 20 years, and then we should be fine. [Laughs.]

Dr. Thomas Waggoner: (27:27)
[Laughs.] Sometimes you have to run first in order to understand how to walk better. I think we’ve done that over the last many years in cardiology.

Daniel Lobell: (27:35)
There’s so much that you just mentioned that you guys are actually doing already. What are you most excited about that’s in the works? What’s left in development right now?

Dr. Thomas Waggoner: (27:48)
Yeah. So a couple of things: One of them is a device called Millipede, which sounds like the insect but it’s this device that’s a repair system for the mitral valve, a little bit different than the MitraClip. The MitraClip is a repair system where we bring the leaflets together, a millipede (and I love the name) is a device that brings the frame together. So imagine you have a door that’s leaky, but the problem’s not the door. The door is fine. It’s actually the doorframe that’s expanded out and dilated. So we’re hoping in this clinical trial that using this device, we will be able to cinch down and tighten down the doorframe around a healthy door. We have ways now to replace the door and the door jam in one system, a new valve, we have ways to repair the door. But now we potentially have a way to repair the doorframe. So, at Pima Heart in Tucson Medical Center, we’re one of 10 sites selected in the world to be involved in this clinical research trial using millipede.

Daniel Lobell: (28:44)
Amazing. And I liked the name too, although it is almost creepy though to tell a patient that we’re just going to do a little millipede type of a procedure on you. [Laughs.]

Dr. Thomas Waggoner: (28:56)
And you’re not sure whether that is a mitral intervention or some insect I have to clean off my windshield? [Laughs.]

Daniel Lobell: (29:05)
Like maybe I’ll stay away from the millipedes. What are some of the big challenges that you face when you have patients that come in that need some of these procedures?

Dr. Thomas Waggoner: (29:17)
I think some of the biggest challenges is getting insurance companies to approve that. We’ve run into a lot of roadblocks with all the authorization for insurance companies to do these procedures. We have patients that are in dire need of them, like the WATCHMAN, which would get you off a blood thinner if you’re stuck with AFib, these new transcatheter valve interventions, insurance companies block it at paying those and covering those prior authorizations. So that has definitely been a bit of a headache. Having bed space during COVID was definitely challenging. We had a lot of patients that were just waiting for a room to have it done due to the overflow of patients. I think our physicians at TMC have done a phenomenal job, partners at Pima Heart, really just battling through the Covid crisis and pandemic and have really emerged learning a lot. I think we have better coping skills, better patient management skills and better resource utilization management skills. I think it was eye-opening for a lot of folks, there was some lost attrition due to physician fatigue and burnout, but those have been the biggest barriers. And I think we’re beginning to see the light of day and realizing, “Hey, you know, we survived this and it made us stronger.”

Daniel Lobell: (30:32)
What about with respect to the doctor-patient relationship? Is there a lot of hesitancy when you have people come in needing these newer procedures and if there is, how do you handle that?

Dr. Thomas Waggoner: (30:44)
I think it’s been very well received from our population. I think that they’re very interested in learning about devices that are minimally invasive, that they can have done and go home within 24 hours. I think that’s been a big selling point. You know, if you’re going to have something done, it’s going to repair your valve or treat you, make you feel better, if you can have it done and not have a long projected recovery. I think in the COVID area, that’s been very important, not only for physicians, but also the patients saying, “I don’t want to be in a hospital and be in a bed for for seven, eight days, maybe the patient behind, beside me as COVID and doesn’t know it, or he has a disease that I may contract.” So I think there’s been some trepidation from patients about having hospital-based procedures. We have moved some of our catheterizations, our cardiac stent procedures, to our outpatient surgery centers. I think that’s been helpful, but our main valve procedures are still done at the hospitals and will continue to be for many years. I think patients are generally open to new device technology. It’s going to make them feel better, improve their quality of life, and keep them out of the hospital.

Daniel Lobell: (31:49)
Okay. Well, that makes sense. What do you do to earn the trust of your patients when you’re talking to them? What do you think are the most important things there?

Dr. Thomas Waggoner: (31:58)
I would say there’s three things. One is that you have to be very candid with them. I don’t beat around the bush. I’m very frank and I say, “This is your disease state. These are the ways to treat it. These are the ways I would recommend treating it. This is our final consideration for how I would personally treat it if it was a family member of mine.” So I think if you’re very honest with your patients, and very candid about what their disease state is, and you want to be very gentle about introducing disease states to a patient, they’re essentially labeled that, it’s filed like that on their medical record, but you also don’t want to be too conservative.

Dr. Thomas Waggoner: (32:38)
So if have a bad heart valve, you always stick to the data. If you have a bad aortic valve and you’re symptomatic, we know your mortality is not good. 60% of folks won’t be around in one to two years, if they have a bad aortic valve and they are symptomatic from it. So if you are very candid with the data, with what their clinical disease state is and the therapy options, most patients are very trusting of that. I’ve been to physicians before and I’m the type of person that wants to know everything, like, “Just lay it out and give it to me straight.” And I think people respect that and are willing to proceed if they understand what exactly their disease state is.

Daniel Lobell: (33:23)
Yeah. I’m trying to imagine a doctor who doesn’t give it to them straight. It’s almost like Woody Allen coming up in my head, “There’s something wrong.”

Dr. Thomas Waggoner: (33:31)
[Laughs.]

Daniel Lobell: (33:31)
[Laughs.] So you said three things. I’m trying to see if I clocked them all. One of them was being upfront.

Dr. Thomas Waggoner: (33:45)
Yeah. So being upfront, giving them a well-defined disease state and the therapeutic options. So people want to know, “What do I have? How’s it treated? And what’s the best way to treat it?” So those are the three things you want to convey.

Daniel Lobell: (33:59)
Okay. So you had them all in one.

Daniel Lobell: (34:10)
Well, let’s shift gears into the online house space a little bit. This interview is being conducted on behalf of Doctorpedia and I’m proud to be part of Doctorpedia and you yourself are part of Doctorpedia. So it’s a loaded question, but I’m going to ask you anyway. What do you think about the online health space and do you discourage or encourage people to go online before coming to see you?

Dr. Thomas Waggoner: (34:36)
Daniel, I love loaded questions. I like to shoot them down. So as we move forward with things like new device technology, we move into the online digital world of medicine. It’s here to stay. I think Covid again has been the impetus for that. That’s another silver lining. So just a little backstory here: before I could not call a patient and talk to them and bill for that. If I was going to speak to a patient and I called them and we were on the phone for 20, 30 minutes, I used to do that out of our own dime. As physicians, we did that because we cared about our patients. Now with COVID, the insurance will reimburse us a little bit of money for that.

Dr. Thomas Waggoner: (35:18)
So that’s helpful. And physicians in the past always did this. We would call our patients at the end of the da and say, “Hey, how are you doing? Are you feeling okay?” But now with COVID, insurance companies and the government said, “Hey, you know, physicians probably should get something for this 30 minute phone call or whatever it is.” So that’s been nice and I think it has set the stage for this to continue. So now physicians are able to reach patients. Using that kind of platform, I can call my patients who are in New Mexico or in Utah. I have patients that come from Washington State. I have patients that come from out of the country to have procedures done with us. So now I can reach out to them and call them and make sure I’m connected with them. And on a more personal level, as we move through this field of digital medicine, if they’re able to log online or reach me online or follow up with me online, I think that is something that’s only going to continue to grow as the world gets smaller through a digital source. And I think medicine has been lacking in this, and I think COVID has really moved this to the forefront.

Daniel Lobell: (36:22)
Do you personally engage with any apps for your own health?

Dr. Thomas Waggoner: (36:27)
I really haven’t right now, but it’s really gotten me to think, with Doctorpedia, moving forward, there are lots of ways to help people stay healthy, to be treated and to set up appointments with their cardiologist or their primary care physician or a subspecialist. And to keep up to date, for example with clinical trials, you can do a little app search for what the latest clinical trials are to treat your disease state. If there’s something new, what does the latest data show? What do clinical trials suggest is the best method and technique to treat a heart valve for plaque buildup? So I think it’s here to stay.

Daniel Lobell: (37:06)
Yeah. I’m excited that you’re working with Doctorpedia. What is the capacity in which you’re working with Doctorpedia? How can people find what you’re doing?

Dr. Thomas Waggoner: (37:15)
So we have just started working with Doctorpedia and we are excited to be joining the team and we’re looking forward to growing this. There’ll be many avenues to get connected. I think starting at the Doctorpedia homepage would be the best source at this point.

Daniel Lobell: (37:32)
What are some of your hopes of what you intend to bring?

Dr. Thomas Waggoner: (37:37)
I want to reach patients weekly, you could potentially have a podcast like this, or just a newsflash: What are the latest devices in cardiology that look like they have promise, that are going to treat patients well, that have good outcomes and replace the old standard of care, more pragmatic approaches that can work. But I think as things grow, we get better by modifying the corners and trimming the margins and making things more seamless and better for the patients with better outcomes. If you put the patient first, everything else will fall into place. And we want to make sure that our patients are up to speed with what the newest technologies are.

Daniel Lobell: (38:21)
Oh, I love that. And I would listen to that podcast even though thank God, I think I have a healthy heart. I say I think because I don’t have like a cleaning, like the dentist, but I like to think I have a healthy heart. A lot of the things you said today are really fascinating and eye-opening to me, because I had no idea that these things were going on. And I imagine that people who are dealing with heart issues would absolutely tune in for that.

Dr. Thomas Waggoner: (38:51)
Absolutely. Just think about setting heart valve procedure, which is what I specialize in on the side – If you just look at heart plaque, so 50% of people that present with a heart attack, that’s their first diagnosis of heart disease or plaque buildup. Think about that. Half of the heart attacks that come into our ER’s, that’s the first time they’re diagnosed with heart disease.

Daniel Lobell: (39:13)
That’s what I was alluding to earlier. There should be something that we can do to find an indicator before it’s already at that point. I don’t think there are too many routine heart checkups that I’ve heard of.

Dr. Thomas Waggoner: (39:31)
There aren’t – it’s based on your risk profile and your other co-morbidities, if you have high blood pressure, cholesterol, diabetes, a history of heart disease, are you a smoker? Those are the big screening risk factors where we, as cardiologists, say, “Well, you have these, you check off those, you’re at high risk for heart disease. And you can look up what’s called your Framingham score, which is a score that suggests your risk of having cardiovascular heart disease over the next 10 and 20 years. So we have ways that we can risk stratify you. That’s the most important thing that I think we need to educate patients about – risk stratification and understanding, “At your age and with your comorbidities, what is your risk of having heart disease and having a heart attack in the next 10 years?”

Daniel Lobell: (40:11)
I feel like this whole thing is run by actuaries [Laughs] or at least they’re snooping in on it.

Dr. Thomas Waggoner: (40:18)
[Laughs.]

Daniel Lobell: (40:18)
But that sounds like something that I would like to do. And I think other people should do as well. Can you say the name of that test again?

Dr. Thomas Waggoner: (40:27)
Yeah. So you can do what’s called your Framingham (as in Framingham, Massachusetts) heart score. That’s your risk of having cardiovascular disease and symptoms from that over a 10 year period. And that’s just one way, there are many ways: We can do stress testing, cat scans, ultrasounds, there’s many ways to risk stratify patients, based on what their comorbidities are and what their risks are from their other organ systems.

Daniel Lobell: (40:56)
I wonder if Framingham has an app, like Credit Karma.

Dr. Thomas Waggoner: (40:59)
There are actually some apps out there regarding your cardiovascular risk in the scoring system. Absolutely.

Daniel Lobell: (41:05)
I’ll have to look into that. What is the biggest compliment that a patient could give you?

Dr. Thomas Waggoner: (41:12)
I think the biggest thing is saying, “Thank you for saving my life,” that’s the ultimate. When somebody comes in with a massive heart attack and they’re dying on the procedure table and we open up their blockage, I think that’s the most rewarding thing, and I can say, “You know what, I’m so glad I was able to help you.” We’ve been on both sides of that outcome and it’s very rewarding. That’s why, when you’re doing a heart valve intervention or a transcatheter procedure in the patients in their sickest condition and they’re unwell, I’ll see them in clinic and follow up. But the most gratifying thing is getting their card saying, “Dr. Waggoner, thank you. I can see my son again, I can see my grandchild again at the next holiday, the next Christmas or Thanksgiving or wherever the holiday we did.” That’s the most rewarding thing, knowing that you can help that patient out to see their family and be with their loved ones at very important times in their lives.

Daniel Lobell: (42:06)
It’s beautiful. Have you personally been through any health scares yourself that have let you really feel what it’s like on the other side of the table?

Dr. Thomas Waggoner: (42:15)
The last one I had was when I was 17, I got into a car accident and got 75 stitches in my forehead. I think that the universe taught me my lesson. And I’ve been so appreciative for every second after that during the last many, many years. It was actually our homecoming night in football. I was driving home to change, to come back to the homecoming high school dance and got into a car accident and hit a tree and hit my head on the windshield and got 75 stitches in my forehead. So a nice little beauty mark for everybody; those moments that remind you of a great deal of what life really is and how precious it can be and how quickly it can be taken from you. I think health is something that we can never take for granted.

Daniel Lobell: (42:59)
I pray that you never have any more health scares. I wasn’t hoping you had them, but the fact that you had that one means that you have been on the patient side of things and you know what it’s like to be in that vulnerable state.

Dr. Thomas Waggoner: (43:20)
Absolutely. And that’s the best way to describe it. It’s a very vulnerable state, probably your most vulnerable state, and you’re relying on another human being and their judgments and their clinical skills to take care of you. And I think that the patient’s level of trust in the doctor-patient relationship is something that is cherished, and is something that we, as physicians, hold very dear.

Daniel Lobell: (43:41)
What do you wish your patients knew coming in to see you?

Dr. Thomas Waggoner: (43:49)
That they have many options to treat heart valves and heart disease. And it’s not just always an open procedure – that they can be educated that as we move into the 21st and 22nd centuries and going forward, minimally invasive heart interventions are here to stay. And I want them to be aware of all the opportunities they could potentially have to be treated in a minimalist fashion.

Daniel Lobell: (44:13)
Do you still go out there and play football these days?

Dr. Thomas Waggoner: (44:18)
I’ll throw a pigskin around here and there. I love Saturday morning college games. If I’m not working, I definitely haven’t the game on and then NFL on Sunday. So if there’s a weekend I’m around and not working, I love watching football, whether it’s college or NFL. As a rabid Buckeyes fan, on Saturdays I’m committed for three hours to something and that’s usually the Buckeyes game.

Daniel Lobell: (44:43)
What other things do you do for fun?

Dr. Thomas Waggoner: (44:46)
I like to snowboard, I like to wakeboard, wakesurf. It’s funny, Arizona is one of the busiest states in the country with a wakeboarding circuit, which is where you surf behind a boat, on something like a surfboard, without a rope or a tether. So that’s something that I’ve done a few times and really enjoyed.

Daniel Lobell: (45:10)
That sounds fun. A little risky, but I guess that you have to have a little risk to have reward. If you get into too much trouble, you know how to protect the heart at least, and you know the people, you’ve got connections. Do you feel most secure in your specialty, like if you, God forbid, had any kind of issues, would you think, “I hope they’re heart issues,” or as someone who works on hearts, would you say “I hope they’re not heart issues?”

Dr. Thomas Waggoner: (45:44)
I would say you never want to hope it’s the heart. I mean, you generally want to hope it’s something else, but if it was the heart, the most optimal thing to have as a cardiologist would be to have heart disease. Because you’re the example, right? So you want to be the prime example. I think that’d be the least optimal thing to have. I would hope it’d be a joint issue or something else.

Daniel Lobell: (46:13)
Yeah. Well, hopefully you have none of it, but at least you know that if you had a heart issue, you would be like, “I got this.”

Dr. Thomas Waggoner: (46:22)
It depends on which one, there’s a whole host of them. But knowing what you know, as a cardiologist, generally you’d hope that it’s a non-cardiac issue.

Daniel Lobell: (46:33)
What are your greatest joys in life?

Dr. Thomas Waggoner: (46:35)
My kids, absolutely. I have two daughters and those trump the successes, taking care of patients – those are number one and two for sure.

Daniel Lobell: (46:46)
Sure. Absolutely. How old are your kids?

Dr. Thomas Waggoner: (46:50)
Six and ten.

Daniel Lobell: (46:51)
So they’re still little kids.

Dr. Thomas Waggoner: (46:53)
Oh yeah. They’re so much fun.

Daniel Lobell: (46:56)
My daughter’s two.

Dr. Thomas Waggoner: (46:56)
Oh, so there you go. So very young, a very fun age. Two to ten is the most memorable time in childhood and we’re blessed to have kids that age and to watch them grow.

Daniel Lobell: (47:10)
I love being a dad too. It’s just the most fun thing ever. And at every stage people say, “Oh, this is a good stage.” They’re all great stages to me so far. I just enjoy all of it so much.

Dr. Thomas Waggoner: (47:24)
I totally agree with you. It seems like every stage is the greatest stage until you get to the next stage and then you think, “Oh no. This is the greatest stage.”

Daniel Lobell: (47:31)
[Laughs.] It’s a really fun ride the whole way through.

Dr. Thomas Waggoner: (47:34)
Professionally, my greatest joy has really been the development of our two fellowships. So we have what’s called a structural heart fellowship, which is basically training to become a structural interventionist, which is what I do. And there’s only 40 of those programs in the country. So we’re very privileged and honored to have a prestigious program like this. We also have a cardiovascular research fellow, for which we’re very thankful. And I think starting those two programs has been the most rewarding for me professionally speaking.

Daniel Lobell: (48:08)
It’s pretty impressive.

Dr. Thomas Waggoner: (48:09)
Thank you very much. We’re trying to do great things here in Tucson, and then I’m reminded that we are now being coined the Cedars of the Southwest. So we’ll run with that.

Daniel Lobell: (48:19)
Well, I wish you much continued success. I want to ask you this last question to round off the interview, and that is, “If you could give one piece of advice to the listeners out there on something they can do to stay healthy, what would it be?”

Dr. Thomas Waggoner: (48:31)
I would say that our heart health is the most important. I’ve been teaching our fellows that sometimes you have to run first to understand how to walk better, meaning if you’re going to go out there, push yourself into it, work hard. Don’t try to run a marathon, but always be proactive in acting with your health – both your cardiac health and your mental health – to keep pushing forward in life. And I think that’ll take you a long way.

Daniel Lobell: (49:00)
So push it hard and then slow it down.

Dr. Thomas Waggoner: (49:02)
Exactly.

Daniel Lobell: (49:03)
Thank you so much, doctor.

Dr. Thomas Waggoner: (49:04)
It’s been a pleasure.

Daniel Lobell: (49:08)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

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