Focus on K2P Faculty: Dr. Michelle Kittleson
MD, PhD, FACC, FAHA, FHFSA
Dr. Michelle Kittleson serves as faculty for K2P’s CurrentMD Cardiology, where she has a 4-video series on advanced heart failure and cardiac transplantation.
Dr. Kittleson is the Director of Postgraduate Education in Heart Failure and Transplantation, Director of Heart Failure Research, and Professor of Medicine at the Smidt Heart Institute at Cedars-Sinai in Los Angeles, CA. She is also on the Board of Directors for Cedars-Sinai, Co-Course Director for Smidt Heart Institute Cardiology Grand Rounds, and Co-chair of the Cedars-Sinai Medical Group Peer Review and Credentialing Committee.
Dr. Kittleson is the author of over 60 peer-reviewed publications in heart failure and transplantation as well as review articles, editorials, and book chapters. She participates in educational efforts on a national scale, including chairing the writing group for the 2020 American Heart Association Scientific Statement on Cardiac Amyloidosis, and sitting on writing committees for the American College of Cardiology/American Heart Association 2020 Hypertrophic Cardiomyopathy Guidelines and 2021 Heart Failure Guidelines. She has medical narrative essays published in the New England Journal of Medicine, Annals of Internal Medicine, and JAMA Cardiology, as well as poems in JAMA and the Annals of Internal Medicine.
We sat down with Dr. Kittleson to ask a few questions…
What would you like learners to take from your four talks on advanced heart failure and heart transplantation?
The world of advanced heart failure is relatively small and specialized, but the most important thing learners should know is when to identify a patient who’s heading down that slippery slope of advanced heart failure. Because if you can identify a patient at the right time, then you can implement life-saving therapies before it’s too late and they’re no longer a candidate. So, the most important thing is to know who is sick enough to require advanced heart failure therapies. The second would be if they are sick enough, are they a heart transplant candidate? And then once they have a heart transplant, what are the most important high yield facts you need to know and how to best tailor and optimize immunosuppression, and what are the highest yield complications that need to be monitored and managed?
How likely are non-transplant specialists to be managing immunosuppression or other transplant complications?
I think for a general cardiologist, it’s important to really identify those patients who may be heading towards advanced heart failure because as a heart failure transplant cardiologist, I’m only as good as the patients who are sent to me if they’re sent to me at the right time. But the second point I would make is that even though general cardiologists rarely will be the point people for managing immunosuppression, they may still see these patients on a regular basis and it’s important for them to be mindful of potential complications like nephrotoxicity, malignancy, infection risk. So, if there are signs or symptoms of those potential complications, they can route those patients back in a timely fashion to the heart transplant cardiologist.
Where do you think we’re going to be in the treatment of advanced heart failure in 10 years?
Wouldn’t it be amazing if there was much less advanced heart failure to begin within the next 10 years because of the incredible advances in guideline-directed medical therapy for heart failure with reduced ejection fraction? So, if the combination of an angiotensin receptor-neprylisin inhibitor, evidence-based beta-blocker, mineralocorticoid antagonist, and SGLT2 inhibitors rendered the work of advanced heart failure obsolete? Or if therapies for cardiac amyloidosis, for example, are so highly effective that patients don’t progress? That would be the first hope 10 years from now–that there would be far fewer patients who need these therapies.
I’d say the next hope is if patients reach that point of advanced heart failure, that we’re so able to optimize their comorbidities, that we widen the pool of eligible candidates for heart transplantation, and that we’ll also be able to extend the pool of possible donors through advances such as accepting hearts for farther distances using the Organ Care System, which is an ex vivo perfusion platform to minimize ischemic time. Or that we’ll be able to use more hearts with donation after circulatory death, as opposed to the current standard of donation after brain death, or by expanding the donor pool using hearts with hepatitis C, which is now really the standard in many programs.
What’s been the greatest advance in the field over the last five years. I know there have been several big ones, but can you pick what you think is the one that’s most exciting?
I don’t think you can talk about heart transplantation without talking about the gene-edited pig heart transplanted into an adult earlier this year at the University of Maryland. Unfortunately, the patient didn’t live very long, but it was such an important proof of concept. We are hamstrung in the world of heart transplantation by the limited supply of donor hearts and I think this gives us a lot of hope for the future.
What was the greatest advice you were given by a mentor that still holds true today?
My most amazing medical school mentor told me that medicine is not about memorization. Medicine is about reasoning and understanding first principles. So you will never memorize a list of differential diagnoses. You need to understand pathophysiology, which will then lead you to understand etiology, which will then allow you to make a differential diagnosis. And every time I become overwhelmed with medical knowledge, I remember that and try to go back to first principles to understand where my patient is and where they’re going.
What career would you have chosen if you hadn’t chosen to become a physician?
I don’t know if anyone’s ever asked me that question! I bet this is the first time someone has given this answer, but I think I would’ve either been a hairdresser because listen, I loved my Barbies and I loved doing their hair. That or a writer of romance novels.
Your #kittlesonrules on Twitter are fantastic. How did that start and what’s been the response to it?
I’m actually not much of a social media person but on rounds every day, I often pontificate to the residents and fellows. One day, a fellow suggested that I should be putting this stuff on Twitter and he showed me how to set up an account. So then my rule became, if I’m going to say it to a trainee on rounds, then I’m going to put it on Twitter.
I have only one goal, which is to hopefully help people become better doctors. I often get fantastic feedback, random emails or messages from people saying, “Wow, that tip today was perfect: I applied it to a patient and patient care was improved.”