Thank you, Dr. Sethi. That was really a fantastic talk. So I'll invite the panelists to come on at this point, but I'll work a little bit backwards. So Dr. Sethi, this is actually tagging back onto your last couple of slides. You know, not every institution has PERT teams available. And when you think about these more complex PE patients and then adding pregnancy on top of that, I was just curious to see your thoughts in terms of, you know, the thresholds to transfer pregnant women who present with PE. Of course, not all of them need to be transferred and clearly some are quite low risk. Perhaps some of those intermediate patients concerning the complexity, what are your thoughts on transferring those patients, at least for some further specialized evaluation? Yeah, we have a low threshold to transfer, especially those who have risk factors like pregnancy. We're really going to look for that. That patient evaluation slide that I have can be done in every hospital. So having that data on what their troponin is, what their BNP is, what their RV may look like on echo, if that's available to you. And then quite frankly, if you're concerned, we're very receptive to evaluating that patient in our institution. And I would say that the hub and spoke model of pairing with an institution and developing that relationship with a center that can fill in the gaps of what your institution may not have is the best way to form that collateral relationship. Because now when you're calling somebody that you know or that knows you, the conversation goes so much smoother, right? And it just facilitates the care for those patients. So I think there's a lot of ways to go about it. And I'd encourage for those centers that don't have PE teams to develop them. PERT Consortium has a lot of resources in this, and I'm happy to facilitate or link anybody to those things. Yeah, I think a lot of those things are sort of overarching in a lot of what we discuss in Cardio OB. Centers are very good at discussing valve disease and cardiogenic shock, and models have developed all that. But then you add this sort of extra layer of dealing with a pregnant woman, and it sort of ups the ante. So thank you for your thoughts. I'm going to bring in Dr. Barron, who has extensive knowledge and expertise in valve disease and valve interventions. And I'm curious on your thoughts on Dr. Sintek's talk on both mitral and aortic valve disease, and particularly with bicuspid patients. You know, in sort of the TAVR territory, you know, we're creeping more and more into the bicuspid space. And so it's a very different population clearly here, different than our standard, you know, 70, 80-year-olds that were thinking about TAVR. And so the decision-making process in regards to, you know, how to assess these patients, the contemporary role of balloony or valvuloplasty, which as Dr. Sintek said, is usually not something we're really keen on doing, but still has a preserved niche in this area. So curious on your, you know, thoughts on sort of management and transcatheter management of AS in pregnancy. Well, first of all, I just want to say these are absolutely fabulous presentations, and I really want to thank you, Dr. Park, for helping to organize this. It's definitely a topic that I think needs to be discussed more. It's certainly something that I think a lot of interventionists fear, i.e. getting that pregnant patient on the table, what do we do? And so I think having these types of educational seminars is incredible. I think within, you know, when we start to think about bicuspid disease in patients who are pregnant, I think there's a couple things to think about. One of the things I really do look at is the shared decision-making process. Where is the patient in regards to their pregnancy? So are we talking about someone who's saying, hey, I have disease that needs to be treated now, but I'm looking to become pregnant, or I'm thinking I will become pregnant sometime in the next 10 years. How does that affect the choice of valve, the choice of procedure? Is the patient pregnant currently? What stage of their pregnancy are they in? Are they in their first trimester when there's a whole lot of embryological development going on, and how is that going to affect what we're going to do? Or in the third case, a third part of their pregnancy where these fluid shifts that can come with severe aortic stenosis can certainly bring on complications during delivery, but also you're worried a little bit less about the fetus with the terms of at least as far as radiation exposure. And so I think the importance of having a shared decision-making process with the patient becomes, while it's important in any patient situation, certainly in the AS field, I think in these situations becomes just absolutely incredibly top of the line of what we absolutely need to do. From my standpoint, I actually have also done a couple of alveoloplasties in these types of patients. It's actually probably the most common valvuloplasty that I've done at this point prior to my, other than prior to my fellowship, for exactly that reason. We're not looking for a long-term fix. We're looking for something that we can get in, get out, get the patient through the pregnancy, and we'll figure out the long-term term, the long-term fix. I absolutely agree with Dr. Syntag. We're not looking for the perfect result. I often just try to take that gradient down, whether it's mitral or aortic, and not cause a substantial amount of regurgitation, just enough to get us through those fluid shifts that come with delivery, the hemodynamic instability that can come. We'll deal with everything else afterwards, but let's just kind of get you through this very specific period of time. And remember that these are absolutely complex patients that we need to be thinking about everything involved with them. Yeah. So Dr. Syntag, I'm curious what, I don't think you include this in your talks, but in the cases that you showed, how you went about the sizing of your balloons, because in these cases, I think that to your point about trying to minimize any secondary untoward effects and inducing either raging AI or mitral regurgitation, I call it sort of minimalistic BAV. So I'm curious your kind of logistical thoughts on that. Yeah. And those are good points by Dr. Barron too. And perhaps I should have made that a little bit more clear. A lot of what I was discussing as sort of acute problems during pregnancy, the whole issue of what to do with valvular heart disease kind of before, that's like a whole different discussion, I think, to have. And certainly, I would draw people's attention to the fact that TAVR is only approved for 65 or older. And so a lot of these patients probably shouldn't be talking about TAVR when they're younger as a treatment strategy to kind of get them through. But to kind of go back to your question about sort of how we do it. So the mitral valvuloplasty, the Inouye balloon kit is based upon the patient's size and they have different balloon sizes. And then you insert a certain volume in that balloon. You actually test it. There's these cool little calipers that come with it and you test it to make sure it's the size that you want it to be. So that's just based upon the patient size. And I would advise going smaller at first. You can always make it bigger, right? But you can't untake it away, as they say. So that way. The TAVR or the aortic valve valvuloplasty, you know, there's a lot of different ways of doing that. You know, we used to look at the echo and kind of look at the two-dimensional figures and know roughly their size and kind of pick a smaller balloon, 18, 20 millimeters, something like that would be on the small side. You could potentially get a, you know, a CT scan and work it up for TAVR and figure out exactly what the size is and figure that out too. But I'm not sure that would necessarily, I don't know if I would say that would be a good risk of radiation for the mom. You know, I think that might be a little bit of overkill for that. So I would probably rely on the echo and I would use, you know, kind of a smaller balloon again too. And you can always upsize again too. What we're really looking for when you're doing a valvuloplasty is to reduce the gradient by about 50%. And if you do that, you've done a very good job. I think trying to get more aggressive than that, you're probably going to lead to some issues and some problems. Yeah. Great. Great comments. So I'm going to engage Dr. Ahmed here and talk a little bit kind of in reference to Dr. Loomir's talk about cardiogenic shock. And you know, this is, I think a really exciting expanding sub area within cardiology. And I'm curious about your thoughts about use of balloon pumps in pregnancy. I know that this has come up in our institution. And, you know, I think that nowadays perhaps with some of the technology we have, we sometimes, I don't want to say forget, but perhaps, you know, don't think about balloon pumps as much. And I know we've done some discussions about logistical things and balloon pumps in pregnant patients. So if you want to share your thoughts on that. Yeah, I think that, you know, one of the important things to keep in mind when you're talking about treating somebody's shock syndrome with device therapy is that the etiology of the shock probably should be factored in, right? AMI cardiogenic shock is different than somebody who has chronic systolic heart failure and goes into cardiogenic shock. And although, you know, this is, you know, I happen to be right now in Boston at the ICHLT meeting. So this is kind of heresy to suggest that we continue to use balloon pumps, but they're actually, you know, and people will say, well, there's no data balloon pumps do anything. In fact, be told there's no data that impellers do anything either in regards to cardiogenic shock in terms of trial data. We know separately from registry data, of course, but in terms of trial data, bigger, better devices have not led to better outcomes. And it tells us that, you know, the data that we have that shock teams improve outcomes. It's not really about the device. It's about the approach to multidisciplinary care and identifying these patients earlier. And if you identify the patients earlier and you have real-time collaborative consensus-based decision-making, those patients will do better regardless of what device you put in them. Having said that, there is data that would suggest that patients who have chronic systolic heart failure are balloon pump super responders. David Barron's group published that. David Barron was, of course, one of the folks who put together the sky shock stages. And so, you know, I think there still is a role for a balloon pump. And importantly, you know, when you're thinking about shock teams, you have to leverage the resources at your institution. And so, does your institution have interventionalists who are skilled at large-bore access? Some places don't have that. If you don't have a structural heart program, you may not have the luxury of having an interventionalist on call every night who is, you know, able to do large-bore access and manage any complications of that access. And so, a balloon pump is still something that, you know, most, you know, even, you know, non-interventionalists can place. And so, I think instead of telling everybody that there's a particular device to use, we need to have more emphasis on the team approach, real-time collaborative assessment, identifying the patient sooner, and then leveraging whatever resources you have at your institution to deliver the best care you can at your institution. Yeah, really important comments. As you say, you know, all the resources vary at different places, and we have to keep in mind what we actually have access to and what can actually be done safely. So, tagging off of that a little bit, Dr. Ludmere, I'll ask you, you know, you showed some data how, you know, early MCS is helpful, again, not expansive data, but in pregnant patients. And I'm curious in your thoughts about, you know, hesitancy, I think, to a lot of points about treating pregnant women in general. You know, you present the same case of a woman who's not pregnant. They probably received therapy earlier, as opposed to there's hesitancy in regards to risk and whatnot. And so, you know, perhaps what your experiences or thoughts on sort of getting over those hurdles of treating these women appropriately and in a timely fashion. And really, it's important, you know, not just for maternal outcomes, but also for fetal outcomes as well. Yeah, thank you, Dr. Parkin. Thank you, Dr. Ahmed, for those important comments. I think, again, it goes back to the team approach. It's having the collaboration, everyone sitting down together, or virtually, if needed, to make that decision. I think this has been highlighted by multiple speakers this evening, that we're addressing the mom sometimes first. Of course, always taking into consideration the fetus, but really doing what's best to manage that type of shock at a particular time. And I think it's certainly scary when we're taking care of pregnant women, but we always have to pause and think about what would we do if this person were not pregnant. So for us, you know, we're lucky we can deploy and get someone on ECMO anytime, 24-7. And we have a policy, if we get paged for anything on the labor floor, we deploy the team immediately. So we are actually more aggressive with MCS and often don't think twice. And we kind of make the conversation much shorter, because we know that time is of the essence. These patients are younger, and as I showed, for the most part, the outcomes are better compared to the average cardiogenic shock patient. Yeah, really, I think kind of a nice summary to the theme of the evening in terms of interdisciplinary care, and also perhaps de-stigmatizing a little bit our approach to pregnant women versus non-pregnant women in conditions where a lot of us have experience and expertise in managing patients. And then how should we translate that to the pregnant women? So I really want to thank all of our speakers and panelists this evening. I think this hopefully was very informative on topics I know in my own realm that don't seem to converge very often in terms of interventions and pregnancy, but really just appreciate everyone sharing their expertise and knowledge. And again, the session will be available for CME credit on Sky and also recorded if anybody would like to share with their colleagues. So thank you again very much, everyone. Have a good evening. Thanks.

cardiovascular conditions

pregnant women

specialized evaluation

collaboration

valve disease