we'll go ahead and switch over to our first speaker, who I will introduce. Dr. Anna Bortnick is an associate professor and program director for the Interventional Cardiology Fellowship at Montessori Medical Center. She, excuse me, and also the Albert Einstein College of Medicine in Bronx, New York. She's the co-founder and co-director of the Maternal Fetal Medicine Cardiology Joint Program. Dr. Bortnick, thank you so much for your time. Thank you, Dr. Park for the invitation. It's really terrific to be here and thank you to Sky for taking an interest in a challenging and difficult topic and one you don't think about until it comes to your door. So today we're gonna talk about intervention and cardiopstetric team care. I'm gonna talk to you a little bit about the model that we have and maybe these are some points that you could take home to your program. These are my disclosures. So the goal of my portion of this discussion is really to talk about the interdisciplinary team management of pregnant patients who come to the cardiac catheterization laboratory. I wanna talk today about three important points. First, who's on the team and what are the logistics of team care? And then how does this team approach actually optimize the outcomes? And then how can we use this as an opportunity to engage women in lifelong cardiovascular care because it really shouldn't end when we close the case. I wanna give you a little bit of background on where I am and what my population looks like. I am in a borough of New York City. We serve a population of 1.4 million people in our borough and we have a high proportion of individuals who are living in poverty in the Bronx, almost greater than 23%. We have a very high proportion of individuals who I self-identify as black, African-American or Hispanic Latino. We also have a large immigrant population coming from all over the world, largely from Spanish-speaking Caribbean, Dominican Republic, Puerto Rico, but also from West Africa, Bangladesh and Albania. We also unfortunately have a high proportion of individuals who have late or no prenatal care as compared to other surrounding neighborhoods and that's greater than 7%. So when we think about the challenge of a cardiac intervention, we have to think about a very busy New York intersection. And that intersection is one of pathophysiology, high clinical need, depressed or disadvantaged socioeconomics and therapeutics, which some of which we don't completely have established. So when we have our approach and we think about what we do in our neighborhood in the context of our population, you know, who's on our team and who am I gonna look to for support and help? And you know, what has happened over the past seven years since we established our program is that there's some core members of the team and then there's some ad hoc members of the team. And the core members of the team come from cardiology, MFM, OB anesthesia and nursing on both sides. And then at times we have other individuals join us. So, you know, people from heart failure, from the nephrology group, patient safety, social work. So it depends on the needs of the patient a little bit. But if I'm thinking about the invasive management of a pregnant patient reporting to the cath lab, I'm gonna think about having these different components, you know, critical care, CT surgery, imaging. I'm gonna have my nurses on both sides, my MFM colleagues and my anesthesia folks. And what are the logistics? You know, time will drive the amount of preparation that you can do. If you wanna try to put all these individuals in a room together, it will take more time. But if you have a moment, if it's elective, maybe even if it's urgent, you can still try to gather some of those core members of the team. And I think the minimum would be the interventional cardiology, the MFM or OB, and the OB anesthesia, and the nursing on both sides. So we have a monthly multidisciplinary meeting in our CCU location. And we have, you know, the following people present. So we have representation from MFM, labor and delivery nursing, from the NICU, anesthesia, OB anesthesia, cardiology, CCU nursing, from adult congenital heart disease, because we often have these individuals, and then our trainees. We involve and educate cardiology fellows also our MFM trainees. And, you know, we publish how our team works. Essentially in the meeting, the maternal fetal medicine group will present the patient, their concerns, and what they think about the approach to labor and the postpartum management. On the cardiology side, we try to talk about the pathophysiology, reviewing the cardiac studies like the echocardiogram, if there are other imaging. And then we talk about our perspective on the safe management of labor and postpartum. And then our neonatologist sometimes will get involved and the approach to the baby. Our LND nurses and our CCU nurses will talk about whether there needs to be continuous cardiac monitoring, telemetry, or where that patient should deliver, whether it's the CCU or LND. And then, you know, all of our anesthesia plan, whether it's general anesthesia or, you know, spinal or regional. So we have kind of a comprehensive team meeting. And we have a form that we fill out. And, you know, these components get posted into the chart so that there's no lack of communication between members of the group. And even if this person presented in the middle of the night, you would know, you know, enough about their plan that you could, you know, carry the care forward in a kind of more seamless way. And, you know, that's the point of having this tool. And so we use this for, you know, our interdisciplinary monthly team meeting for every patient. And that way, the communication is standardized. We've reviewed everything. And it's in a checklist type format, which we know is really good for standardization of care. And this is what that documentation might look like in the chart. So those points from the sheet get posted into Epic, which is what we're using at our site. So the American Heart Association has talked about cardio-obstetric team and who the members of the team should be. And what they advise is that they should be a cardiologist, the high-risk obstetrician, the anesthesiologist, and the neonatologist. But they also mention a geneticist, an advanced practice nurse, a social worker, and an ethicist. I would say that we've never had a geneticist or an ethicist on our team. And we use a slightly different composition. And I think it has to be more tailored to what problem is kind of presenting to your door and what that patient really needs. So I think you should use maybe a more tailored approach. You know, some of these components I think are required. And I think the additional providers are a little bit flexible. So what are some logistics for team care in the cath lab? I want to give you some examples. But here's just a broad overview of a sequence, right? So you want to have your C-section, your intubation trays available, depending on the acuity and the risk of the patient. Again, if you have more time, you can gather more items. But you want to have your cath lab team, your L&D nursing, your OBGYN or MFM physicians, your anesthesiologists. Those are the kind of people that you need to engage. And in a pre-procedural timeout and conversation about how things are going to go. We do fetal monitoring pre-procedure. We have to consider proper positioning, how you're going to shield the patient, kind of slightly tilting them left lateral position to avoid compression of the IVC during the case while they're laying flat. You know, a detailed timeout, reviewing CPR plans, particularly because the cath lab team is not going to remember how to resuscitate a pregnant patient. They're not going to remember how you have to shift the uterus. They're not going to remember all of the components they may not be familiar with, whether the standard drugs are the same doses or not, whether they can defibrillate the patient in the same way. So you just want to review the CPR plan, go over it one more time, reassure everybody, same doses, same defibrillation plan. We're just going to shift the uterus over even more if we need to. In terms of the procedure itself, we're going to think about collimating the fluoroscopy, reducing the intensity, staying off of synag, just doing fluorosave, using very small catheters, going from the radial approach, which has less bleeding and has a mortality benefit and less fluoroscopy of the gorine. And then we do fetal monitoring post-procedure. So I want to give you an example of three cases where you can see who the team is and how to improve the outcome of that patient. So we had a 21-year-old woman with cardiomegaly diagnosed since age 14 without a clear radiology. And this goes to problems with primary prevention and access to cardiovascular care. She also had some other comorbidities like Von Willebrand's disease. She had a dilated pulmonary artery on a chest X-ray and mild shortness of breath and was referred to MFM cardiology. And to be honest, she only got an echocardiogram because she was there. And that TTE showed that she had moderate RV dilatation and severe pulmonary hypertension. What a find. Because this is the kind of patient who has very, very high mortality risk in pregnancy. Okay, so that's her RV. So, you know, it's working, it's a little bit big, but, you know, it's going. Let's see if I can get to the next. There's her TR. So she was admitted for IV prostacyclin and eventual delivery. And, you know, she had frank hematemesis. It was very scary. So we had placed a right heart cath. You know, we had done a right heart cath in the lab. And, you know, you can do this without fluoroscopy, right? You can just, you know, do it looking at your hemodynamic screen. And what we noted, she had a very low right atrial pressure and all the other pressures had kind of normalized with the prostacyclin. But, you know, I called the MFM and I said, she looks like she's dry, you know? I don't know if it's bleeding, what's going on, but it was really hard to put in this PA cath. So it turned out she had superimposed preeclampsia with elevated LFTs. So she had an emergency C-section delivery in the main OR. And look at all the people who had to come. You see, this is her team. So that's what it took to deliver this patient. She now is on her second pregnancy, but now she's on sildenafil. She has her team from day one. And so we have a plan for her and she's done very well so far. She's going to be delivered in July. So this was the all hands on deck team for this patient in addition to our CT surgery, CHF, ECMO colleagues. And that's her. We just did an interview with local news and she gave her perspective on her experience. And her message was, make sure you see your doctor and share your symptoms. But your doctor has to be educated and think that if you're a pregnant patient with a symptom or an abnormal vital sign, we need to screen you. So I'll give you another example. 34 year old woman, immigrant, non-English speaking, actually not in our borough, outside of our regional care. And the father of the baby is incarcerated. She's 34 weeks pregnant. She was referred from an outside physician who happened to know me from fellowship because her insurance didn't cover her where she was. And they had detected that she had mitral stenosis. So she was referred for evasive treatment. So she came to the clinic the next day and we listened to her, got an echo, admitted her. And she underwent mitral balloon valvuloplasty the following day after that. So that's her valve. And she got to advanced pregnancy with that valve. That's her gradient. So we proceeded with the procedure to do mitral balloon valvuloplasty. She was well advanced into her pregnancy. She actually came in and she was already dilated. So it was urgent. And we crossed the septum and we noticed that. So what is that? That's thrombus. And if I can emphasize the teaching point from here is you have to be absolutely sure you're well anticoagulated immediately, upfront, before you cross, because the patient is hypercoagulable, they're pregnant. And we sat, we waited, the anticoagulation kind of dealt with that. And the patient did great. But that's a little point that these patients are hypercoagulable. So before you put a lot of instruments in, make sure you've anticoagulated and you know your ACT is high. And that was the reduction in her gradient. We had a very nice result. And her MS was reduced and her mitral regurgitation fortunately remained moderate. She was treated with steroids. She was a little bit early. Four days later, vaginal delivery in the unit. She was already almost in labor. With a vacuum assist, she did very well. And she had LND and CCU nursing working together. And what happens when you have a team like this is they start to get to know each other. So that is helpful for communication. So now I know the LND nurses and they know me and they know the CCU people. They have people that they know they can call and that they will respond if they have a problem. So that was the team for that case. So here's the last case. We have a 28-year-old woman with insulin-dependent type 2 diabetes since age 15, uncontrolled. Again, problems with primary prevention leading to advanced heart disease, diagnosed in pregnancy because of hemodynamic stress. She's hypertensive. She has retinopathy, nephrotic syndrome, anasarca, is actively smoking. And she presented at 15 weeks. Interestingly, she had called EMS because she was having worsened facial edema. She wasn't having a chest symptom. But when she got into the ambulance, she had acute onset of chest pain and then it resolved. And her EKG had anterior T-wave inversion and she had a mildly elevated troponin. So she meets criteria for NSTEMI. And she had a normal LVF without regional wall motion abnormality. So this is a dilemma. Are you gonna take this patient to the cath lab or are you gonna sit and treat medically and see how things go? So we had an ad hoc interdisciplinary team meeting. We had nephrology. We had a person who had a very deep experience with pregnant women, pregnant patients from representing internal medicine knowledge and critical care. And then our MFM interventional cardiology, myself and my colleague. And what we thought of was the following. If she wasn't pregnant, we would take her to the lab. She has all these risk factors. She has a diagnosis. She has the criteria for an MI. Are we gonna sit on this and see how it goes or should we absolutely look? And we looked. So I went radial, and what we found is that she had a stenosis in her middle ID that was severe. And to this day, I can't tell you for sure that it's not a SCAD, because you can have focal SCAD. But I didn't wanna put any kind of imaging down there. I didn't really wanna manipulate this vessel more than I had to. And I looked at the patient and the context of the patient. So this is a woman who's young by age, but not biologically. And it is plausible that this is an atherosclerotic lesion. We've had 24-year-olds show up with MIs in our neighborhood, okay, because we have a very high-risk population. And so we decided to treat this and we stented that middle ID. Let me see if I can show you the result. Okay, so we can have a lot of conversation about how you would manage this patient. I think later on, where there's gonna be some discussion of this, but this is what we chose to do. And she was discharged to rehab. She eventually had spontaneous abortion very early on in her pregnancy. And we think related to the comorbidities. So the all-hands-on-deck team here were the following. And the key points, you know, is that the team is dictated by the patient and what they need and what the procedure is. And that the core members really should be from that MFM and the cardiology group that deals with these kinds of patients, if you have that kind of program. And then your flex people should be probably from structural heart, CCU, heart failure, and EP. And what's really interesting is that in the past seven years, we've had several of our L&D nurses involved in this care actually transfer to the CCU. So can you imagine, now we have these like cross-trained nurses, you know, who've seen everything and there's no better team than that, right? Where people are talking to each other and they're learning from each other. And that's the point of having this kind of combined program because the time when this kind of patient will come to you, you'll be ready and you'll have all of that care kind of streamlined and no one's gonna be scared. So that's the point, right? Know who to call, what's the mechanism for the inpatient discussion and the outpatient appointments? Because this is not one and done, this is the beginning of a lifetime of cardiovascular care. When you have programs like this, you start to raise the awareness of cardiac disease, risk factors and management in young women, you impact the future workforce because you're gonna teach your trainees, you're gonna teach other physicians, teach the community, you impact nursing care, you spark new research because you know new things from talking to other people. And it really aligns well with our foundation and NIH missions. And you're gonna disseminate all of this experience that you've learned at regional, national and international meetings. And you can educate the public via media and have your patients talk about their experience to educate other women in the community. So the last point is that, why are we doing this at the time of catheterization? Why isn't this being treated upfront? And when I asked the patients, how come your subaortic membrane was never diagnosed or treated? And then they tell me, my parents were incarcerated, I was raised by my grandmother and I had asthma during gym class, so I just sat on the bench and nobody asked me to get a doctor's note. So I came to the emergency room and they told me to see a cardiologist but they never set up the appointment for me. So that's the kind of problem that women in our communities have and that's the kind of barrier to care and then they come in late when they're pregnant when that's stress. So, we have to now shift this earlier. So we've been working with other teams and we've even been working with reproductive endocrinology and fertility to screen their patients for whether it's appropriate for them to undergo those treatments. So I wanna thank you all. This is our team. We're showing MFMs how to look at echoes. We have a GYN table in our cardiac clinic and we like to disseminate knowledge through our seminars and our research and I just wanna thank our big team because it takes a lot of people to do this work and to study it and I thank you all for your attention.

Dr. Anna Bortnick

interdisciplinary team management

pregnant patients

cardiac catheterization laboratory

team care