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Bifurcations: EPISODE 3 – TAP TECHNIQUE

As the summer holidays wind down to the final few days, many of us are heading back to the routine of work, school and home.  With the end of summer, my Bifurcation Series comes to a close as well. The final episode is the TAP technique.

Operators find this to be the least cumbersome of all the 2-stent strategies. Many resort to it during emergencies as the access to the main branch (MB) is maintained throughout the procedure. The steps are fewer which ensures expeditious coverage of both vessels followed by the conventional optimization steps including kissing and proximal optimization with a non-compliant balloon. Similar to culotte, this strategy allows operators to start with a provisional strategy and convert to TAP should the need arise. In addition, there is minimal stent overlap. This technique is considered a modification of what was formally known as T-stenting. The primary limitation of the original T-stenting was missing the ostium of the side branch (SB). This geographic miss is what prompted many operators to perform minimal protrusion to mitigate in-stent restenosis at that missed segment. Hence the name TAP, T and small protrusion, was coined. Although this technique has been adopted worldwide, there are no large randomized trials with long term outcome data to reference. There are some published data; however, that are worth reviewing.

 

Study TAP strategy Patients (n) Unprotected
left main stem
Follow-up
duration
TVR Definite stent
thrombosis
Burzotta et al’ Bail-out TAP in provisional 73 37.0% 9 months 6.8% 1.40%
Al Rashdan
et al7
Systematic TAP 156 10.3  % 36 months
(range 24-48 months)
5.3% 0.06%
Burzotta et a1 Bail-out TAP in
provisional procedures
19 5.0% 12 months 5.3% none
Naganuma et al Bail-out TAP (type B dissection or
TlMI <3 or stenosis >50% in the SB)
95 18.9% 36 months 9.7% none
ARTEMIS
study10
Bail-out TAP (type B dissection or
TlMI <3 or stenosis >75% in the SB)
71 26.8% 12 months 8.5% none
 SB:side branch;TVR: target vessel revascularisation

 

Burzotta et al, 2007

The modification of the T-stenting was first described in 2007 by Burzotta et al.1 It was evaluated in vitro and in two independent series of patients undergoing elective drug-eluting stent (DES) implantation on a bifurcation lesion. In vitro testing demonstrated perfect coverage of the bifurcation with minimal stent’s struts overlap at the proximal segment of SB ostium with a single layer stent struts. Sirolimus, paclitaxel, or zotarolimus DES were deployed in 73 patients (67% with Medina 1,1,1 lesions and 44% of unprotected distal left main disease) using the TAP technique. The procedural success was achieved in all cases. At 9 months the clinically-driven target vessel revascularization (TVR) was 6.8%. Since this was a pilot study, the investigators recommended larger outcome trials to further evaluate this technique. No comparison arm was available in this initial trial.

 

Al-Rashdan et al, 2009

In 2009 Al-Rashdan et al published their series of 156 consecutive patients who underwent TAP stenting.2 This was a single center study that resulted in a 99% procedural success rate and a major adverse cardiac events (MACE) free survival rate of 88% at 36 months average follow up. The TVR rate was 5.3%. Although to date this represents the largest cohort of TAP cases, the results are limited to a single center with no randomization which precludes further conclusions.

 

Burzotta et al, 2009

In 2009, Burzotta’s group prospectively enrolled 266 consecutive patients requiring treatment of a bifurcation lesion.3 The MB was treated with a DES and TAP was reserved as a bailout strategy. Only 19 of the total required a bailout 2-stent strategy. Nine percent of the total had unprotected left main disease. At one year, the MACE rate was 8.2%. A non-hierarchical analysis revealed a 0.4% cardiac death, 4.1% MI, 4.5% TVR and 2 of the total had probable stent thrombosis (ST).  Given the small number of bailout 2-stent strategy arm, this study only demonstrates safety.

 

Naganuma et al, 2013

Naganuma et al retrospectively analyzed data of all patients who underwent TAP technique with DES between July 2005 and January 2012.4 A total of 95 patients were enrolled. Angiographic procedural success was achieved in all cases. A true bifurcation was found in 78.9% of those enrolled. The 3-year MACE, cardiac death or myocardial infarction, TVR and target lesion revascularization (TLR) rates were 12.9%, 3.1%, 9.7%, and 5.1%, respectively. No ST was observed in this cohort. Once again, the investigators recommend larger trials to make solid recommendations.

Naganuma et al, JACC Cardiovasc Interv. 2013;6:554-61.

Naganuma et al, JACC Cardiovasc Interv. 2013;6:554-61.

 

ARTEMIS Study 2014

The ARTEMIS study was published in 2014.5 It evaluated the mid-term angiographic results of TAP as the bailout strategy in symptomatic patients who were treated with one-stent strategy (DES of the MB) and kissing balloon inflation of the SB who subsequently developed impingement of the branch. TAP was performed if residual diameter stenosis of SB was ≥75%, presence of ≥type B dissection or flow impairment of the SB occurred. A total of 71 patients were enrolled with a MEDINA classification 1,1,1 lesions occurring in 60% of the total. At 9 months, restenosis was occurred in 12.5% of the total. Late lumen loss in the MB and SB was 0.22 ± 0.19 and 0.34 ± 0.37 mm, respectively.

 

Dzavik et al, 2014

In 2014, there was much hype revolving around bioresorbable technology. Dzavik et al performed in vitro bifurcation stenting employing different modalities on synthetic arterial models.6 The everolimus-eluting bioresorbable vascular scaffold (Abbott Vascular, Santa Clara, California) (BVS) was used. A low-pressure final kissing balloon inflation was performed to complete the procedures. The results demonstrated that a single-stent technique optimally opened the SB without deforming the BVS in the MB. T or TAP-stenting covered the SB ostium completely. Culotte and crush with 2 BVS stents was successful; however, disruption was reported after the low pressure kissing inflation in one case. Investigators concluded that it was feasible to perform bifurcation stenting with BVS in large caliber vessels. They also recommended that a provisional strategy as the default. TAP or T-stenting with a metal DES is preferable. As the overall in vivo outcome data for BVS remains cautionary at best, the use of BVS outside clinical trials is not recommended whether for focal type A lesions or complex bifurcations.

The technique itself is illustrated below. As mentioned earlier, it is one of the simpler 2-stent strategies. Like other strategies, appropriate sizing, positioning and optimization ultimately dictate the final angiographic and clinical outcomes. Intracoronary imaging facilitates these crucial steps. Yet, as with all interventions, judgment is the cornerstone of any successful procedure. When appropriate, and based on both Syntax score and clinical scores, surgical revascularization should be considered. When one opts for percutaneous revascularization, the indication for the procedure, its potential risks and complexity should be shared with the patient. For operators, judging the significance of the SB, the angle of the bifurcation, the size of both vessels and the need for mechanical circulatory support is valuable. Finally, complex bifurcation stenting is not for everyone. When appropriate, such complex procedures should be referred to expert operators for the best outcomes.

Animations/illustrations courtesy of Graphic Designer Dania Al-Shaibi

Email: dn.alshaibi@gmail.com

 

 

References:

  1. Burzotta F, Gwon HC, Hahn JY, Romagnoli E, Choi JH, Trani C, Colombo A. Modified T-stenting with intentional protrusion of the side-branch stent within the main vessel stent to ensure ostial coverage and facilitate final kissing balloon: the T-stenting and small protrusion technique (TAP-stenting). Report of bench testing and first clinical Italian-Korean two-centre experience. Catheter Cardiovasc Interv.2007;70:75-82.
  2. Al Rashdan I, Amin H. Carina modification T stenting, a new bifurcation stenting technique: clinical and angiographic data from the first 156 consecutive patients. Catheter Cardiovasc Interv.2009;74:683-90.
  3. Burzotta F, Sgueglia GA, Trani C, Talarico GP, Coroleu SF, Giubilato S, Niccoli G, Giammarinaro M, Porto I, Leone AM, Mongiardo R, Mazzari MA, Schiavoni G, Crea F. Provisional TAP-stenting strategy to treat bifurcated lesions with drug-eluting stents: one-year clinical results of a prospective registry. J Invasive Cardiol.2009;21:532-7.
  4. Naganuma T, Latib A, Basavarajaiah S, Chieffo A, Figini F, Carlino M, Montorfano M, Godino C, Ferrarello S, Hasegawa T, Kawaguchi M, Nakamura S, Colombo A. The long-term clinical outcome of T-stenting and small protrusion technique for coronary bifurcation lesions. JACC Cardiovasc Interv. 2013;6:554-61.
  5. Jim MH, Wu EB, Fung RC, Ng AK, Yiu KH, Siu CW, Ho HH. Angiographic result of T-stenting with small protrusion using drug-eluting stents in the management of ischemic side branch: the ARTEMIS study. Heart Vessels.2014 Mar 14.
  6. Dzavik V, Colombo A. The absorb bioresorbable vascular scaffold in coronary bifurcations: insights from bench testing. JACC Cardiovasc Interv.2014;7:81-8.

 

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Learning to Lead in New Ways

Last November, I attended Career Advancement and Leadership Skills for Women in Healthcare, an illuminating conference that changed my approaches to my personal and professional development.

Led by Drs. Julie Silver and Saurabha Bhatnagar, this Harvard Medical School women’s leadership course delivers evidence-based strategies, skills development, and education to help women across health professions assume and succeed in leadership positions. Executive leaders from my institution have written about the critical need for health systems to support emerging physician leaders and to nurture them at each stage of professional advancement. Considering these organizational priorities, I thought that this course would effectively combine education with skills development in a unique environment and would provide strategic and cultural alignment with my own interests in leadership.

The course itself spanned two and a half days with a mix of daily morning plenary sessions, afternoon small group breakout sessions, and evening networking opportunities. From the outset, the tone of the conference was unlike that of any I had previously attended. There was a sense of genuine camaraderie in the rooms, despite the huge number of attendees largely from different clinical, research, and administrative backgrounds. Interpersonal interactions were built on a mutual understanding of the obstacles of underrepresentation and inequity. I noticed how openly women discussed successes and failures, asked questions, and negotiated when surrounded by a supportive group with shared experiences. As one of the few trainees in attendance, I felt especially empowered through hearing about the career trajectories of these successful women leaders.

The first day of the conference focused on identifying your mission and vision, recognizing your leadership potential and style, and learning strategic planning. Here are five of my top takeaways from day 1:

5 takeaways from day 1

The second day focused on refining your oral and written communication skills. Here are five of my top takeaways from day 2:

key takeaways from day 2

In the last session of the conference, Dr. Silver delivered an impassioned call to action for us to take our newly developed skills back to our institutions to share with others and to advance our own careers. After I returned home, I created my own customized plan for career development using the course principles. I also led an abbreviated career advancement and leadership skills workshop for my institution’s Women in Cardiology group, sharing the highlights of what I had learned with my resident, fellow, and faculty colleagues.

For more content from the conference, check out the #SheLeadsHealthcare hashtag on Twitter and this year’s conference project, the #BeEthical campaign.

This year’s course is scheduled for November 14-16, 2019 in Boston, Massachusetts. If you work in health care and are interested in developing your leadership skills, I strongly recommend investing in your personal and professional development through a course like this or another similar experience.

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Balancing versus Integration of Motherhood and Your Career as a Female Cardiologist

Balancing versus Integration of Motherhood and Your Career as a Female Cardiologist

As we recently closed the academic year last month, I attended our graduating fellows’ dinner and I was reminded of the continued challenges of motherhood for many female cardiologists.  This reminder came in the form of a conversation I had with one of our Interventional Cardiology fellows who was completing her Interventional fellowship and we were discussing the challenges of being a mother and navigating a career in Cardiology. I gave her some pearls of wisdom from my own experiences that I have had so far in my career and am still learning myself.

These conversations took me back thirteen years ago when I started my fellowship as a general cardiology fellow and was entering into my ninth month of pregnancy. I still remember walking into the cardiology conference room on the first day of fellowship orientation and feeling all the doubts and fears of wondering if I would make it through those three years. Although I had completed my Internal Medicine residency and had garnered the recognition from my attendings and colleagues as a Chief Resident, my confidence was shaken as a young soon to be mother entering this challenging field. There are many pearls of wisdom I have learnt or have been taught along the way. In this month’s blog I will be discussing a few of these pearls of wisdom.

Before discussing these pearls I will delve into the statistics with regards to females and our experience in the Cardiology field.

 

Statistics on Gender gaps in Cardiology  and its Challenges for Mothers

Unfortunately there is still a scarcity of females in the Cardiology field.  Females represent only 13 % of Cardiologists in the United States (US)1. Female representation is even lower in the procedural fields of Cardiology such as Interventional Cardiology where only approximately 8% of interventional cardiologists are females and only 6% of electrophysiologists are females1. Among Cardiologists in the US, 72 percent of female cardiologists are mothers and 86 percent of male cardiologists are fathers. It is important to note that most of these fathers (57%) have a spouse who provides child care at home while only 13% of these mothers have similar support1. This poses a significant challenge for mothers in the field of Cardiology as most often there are long work hours in addition to overnight call particularly during fellowship training. There is also a significant lack of scheduling flexibility during these training years and also in practice. These challenges often result in reliance on extended family members, colleagues,  or hired help to assist with child care.

Another challenge in our field is the concern with regards to radiation exposure particularly during procedural rotations and for proderural specialties such as Interventional Cardiology, Electrophysiology as well as the emerging field of Structural Cardiac Imaging. This poses challenges for mothers who are considering pregnancy or who are pregnant.

Generally, the Cardiology field is perceived as a very difficult field with long and grueling work hours. This perception along with the very unfortunate fact that it is still a male predominant field with potential gender bias and discrimination has resulted in many very talented females avoiding this field altogether.

As mothers in Cardiology we are pulled in 2 different directions, one direction with regards to our patient care and professional duties and responsibilities and the other direction with regards to our duties and responsibilities as a mother. While this seems daunting, there are several actions that can be taken to mitigate these challenges so that we can feel fulfilled both as a mother and as a Cardiologist.

 

Pearls of Wisdom

Build Your Support System- Your “Village”

Regardless of whether you are in training or in practice as a Mother in Cardiology, one thing will remain true throughout your career, you will need to create and build your “village” of support. This village of support will be a necessity particularly with regards to child care during long days and long nights at work. This village of support involves your spouse, extended family members, your colleagues and/or hired help.  This is a must, you will not be able to do this all on your own as much as we may have that “superwoman” mentality. Once you have created and built this village of support you should show your appreciation for each member of this village. This appreciation will go a long way especially when they may have to be called upon in the middle of the night or on weekends to provide child care when you have patient care duties to attend to.

 

Focus on Quality rather than Quantity of time with our Children:

Time with our children is precious, therefore focusing on making that time quality time is what is most important and will be the most memorable. Therefore, on weekends or days when you are away from work spending time with your children doing activities that are engaging, meaningful and fun is important.

 

Time Management

Planning your time both at work and at home with your children is a key factor. A family calendar is very useful in planning and managing time with your kids to ensure that there are no work scheduling conflicts. The weekend is a good time to reset, recover and plan for the week ahead. This may mean that meal plans are created for the week and food may need to be prepped ahead on the weekends so that preparing dinner in the week can be less daunting. This also applies to lunches for the children in the week.Grocery shopping should also be planned to alleviate that additional stress of getting this done in the week. Grocery delivery services may also be useful in this regard. Time for household chores should also be planned and if you are able to outsource some of these tasks to your spouse, older aged children, extended family members or hired help this is recommended.

Time management is also important at work to minimize any unnecessary distractions or interruptions so that we can perform our patient care duties in a safe and time efficient manner. Taking work home should be minimized as this often robs us of precious time that should be spent with our children and has the potential to result in professional burnout.

Time management is also vital with regards to professional activities such as board exam preparation and research activities. My advice is to start planning for these early in your training to give yourself enough lead time to be well prepared for the exam and with regards to research, enough lead time to complete your research activity during your training. As a fellow and even as a practicing cardiologist, a study guide should be created early so that you spend some time each day studying for board exams if applicable and reading the medical literature to keep yourself up to date in the field. Audio files are very useful especially during your commute to and from work as this will readily facilitate board exam preparation and even keeping up with the medical literature.

 

Prioritization

Making a “to do” list and prioritizing this list is important. You cannot do it all at the same time. There are times that less valuable activities with regards to motherhood or with regards to your profession may have to be placed on the “back burner” and revisited at another time when you may be available. There are times when these less valuable activities may even have to be deferred.

 

Finding Your “Me Time” is Important.

It is important to find the time to recharge and take care of yourself. Self care involves small things from finding the time at work to eat healthfully and rehydrate throughout the day. Self care also involves making the time to participate in an activity that takes you away from the throws of the day. This activity may be a hobby such as arts and crafts, gardening, playing an instrument, playing a sport or exercising.  Making the time to exercise is also vital to maintain not only your health but to maintain your physical and mental endurance. Getting adequate sleep is another important part of self care as sleep deprivation results in increased risk of professional burnout and not being able to function at your best throughout  the day. The emphasis is on making this time as often times it is far easier to have an excuse of not having the time to do these activities and it may create guilt as a mother. However, it is important to remember that if you are not happy and energized then this may be reflected at work and at home and in the long run will likely lead to a lack of fulfillment as a mother and as a cardiologist.

If you are feeling overwhelmed, it is important to seek assistance with your responsibilities if possible. Sometimes this assistance may have to be hired help. There are many services in the market that assist not only in child care but also provides assistance with other responsibilities such as professional cleaning services and laundry service. There are also tutoring services available to assist  school  aged children to not only ensure that they are completing assignments but to also ensure that they are keeping up with the school syllabus throughout the school year.

 

Finding a Mentor

Finding a mentor is important as this person not only provides guidance with regards to your career but could also be an advocate for you during your fellowship training. Developing and maintaining this mentorship relationship is invaluable and may evolve as you progress in your career. Having more than one mentor is often recommended as no one mentor will be able to provide guidance on every aspect of your career. For more ideas on the value of mentorship in Cardiology see my earlier blog on this topic.2

 

Negotiate for A Flexible Work Schedule

If it is possible it can be useful if a flexible schedule could be negotiated with your fellowship program director. An example of this would be allowing for time off for maternity leave after delivery of your child with the understanding that your fellowship completion date would be delayed to ensure that the 36 months of fellowship training is completed. Another example is re-arranging the fellowship rotation schedule to avoid exposure to radiation during cardiac cath rotations in your pregnancy. Therefore, during the pregnancy period rotations could be limited to those outside of the cardiac catheterization lab.

As a practicing cardiologist there may be more flexibility for negotiating with your practice group if in private practice or the Cardiology Chair if you are working in a hospital based academic setting to allow for an extended maternity leave  or to have the ability to go part time during the pregnancy. There are unique challenges to these arrangements in a relative value unit (RVU) based productivity model. However, it is useful to try to negotiate for these arrangements to ensure that you have the time that you need to take care of your child after the delivery as those moments are precious and also to ensure that you are able to have the greatest chance for a healthy pregnancy with regards to a reasonable work schedule.

 

Change the things you can and accept the things you cannot change

As a working mother in a demanding job as a Cardiologist it is important to remember that you cannot do it all and you are not perfect. This is a struggle for most of us to remember as many of us are high achieving women. However, as mothers and as physicians we should strive to do our best for our children and the best for our patients with the understanding that there are times the outcome may not be what we hoped for. During these moments we have to realize that we are also human and we can only be expected to change the things we can and accept the things that we cannot change.

 

Work-Life Integration vs. Work Life Balance

Over the last 5 to 10 years the term “work life integration” has been seen as a more realistic goal for working mothers rather than “work life balance” as the latter is seen as more of a myth and a rather unrealistic goal for many. The boundaries between your professional life and your personal life is often blurred especially in a demanding field such as Cardiology. This is even more true in today’s practice environment with electronic medical records and constant connectivity between emails and texts. It is most desirable to unplug when we are away from work, however this is not always possible. We also have to embrace the fact we are working mothers in a demanding field that we can find fulfilling but is sometimes daunting. This means that achieving a balance between your professional life and your personal life is often impossible and many times we may have to incorporate the two roles in a more adaptive work-life integration model. This may mean that there are times you may have to take the kids along with you to a scientific medical meeting and this could be made possible particularly if your spouse or family member is able to attend with you to take care of the children while you are attending the sessions at the meeting. This integration of both of your roles allow for a happier situation both for yourself as a mother not having to spend a prolonged time away from your children  and a happy situation for the children who often see this as vacation time with you. In fact several cardiology professional meetings have made accommodations for nursing mothers with areas designated at the meeting for nursing. This has a far reaching and positive impact for female cardiologists as this encourages attendance to these meetings even if nursing.

 

Conclusion

Being a female cardiologist and a mother, I consider to be a blessing. Our children often look up to us as positive role models as we navigate through a challenging and demanding Cardiology field to take care of our patients while also being able to take care of our children and provide the best life possible for them. I also believe that being a mother teaches us many skills that we often even subconsciously apply to our  jobs as physicians to make us better listeners to our patients and better communicators with our patients. Being a mother also makes us more efficient with our time and more productive at work3. Our children also learn the values of hard work, dedication, compassion and empathy from our role as a Cardiologist. Embracing our roles of motherhood and a practicing female cardiologist can be fulfilling as we have the privilege of having a meaningful positive impact on the health of our patients while taking the best care of our children and “yes” we can have the best of both worlds.

 

References:

  1. Lewis SJ, Mehta LS, Douglas PS, Gulati M, Limacher MC, Poppas A, Walsh MN, Rzeszut AK, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council. Changes in the Professional Lives of Cardiologists Over 2 Decades.J Am Coll Cardiol. 2017 Jan 31;69(4):452-462. doi: 10.1016/j.jacc.2016.11.027. Epub 2016 Dec 21. Review.
  2. Bullock-Palmer RP. The Invaluable Importance of Mentorship Throughout Your Career as a Female Cardiologist. American Heart Association Early Career blog site. February 25, 2019. https://earlycareervoice.professional.heart.org/the-invaluable-importance-of-mentorship-throughout-your-career-as-a-female-cardiologist/
  3. Krapf M, Ursprung HW, and Zimmermann C. Parenthood and Productivity of Highly Skilled Labor: Evidence from the Groves of Academe January 11, 2014
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Anxiety, Food Security, & Beyoncé: Addressing Young Women’s Cardiovascular Health

What can you do to address gender disparities in health and health care? In my last post, I suggested working to identify your own bias by increasing your awareness. I’m walking this path, too. A few years ago, I made a concerted effort to diversity my reading habits after I noticed that a huge percentage of the work I was consuming was produced by white men. I spent a year choosing to read only books by women and people of color instead. I learned that it was not hard to do this, but it required that I pay attention. I read a lot of wonderful work that I might have otherwise overlooked, and I was exposed to much more diverse viewpoints. I continue to seek out broad representation, and I suggest a similar approach to reading scientific literature.

Start by paying attention to 1) study populations, and 2) authorship. Are you reading articles about (and by) underrepresented populations? In cardiovascular health, this includes women, who remain underrepresented in clinical trials (estimates as low as 34% of participants in trials supporting drugs for some CV conditions1), clinical practice (just 20% of cardiology fellow are women2), and academia (check out the #nomanels hashtag on Twitter).

Clearly, we need more cardiovascular research by and about women. In this post, I want to highlight some exciting research by and about women.

Evidence of the pervasive male bias: we've programmed our machines to assume patients are male.

Evidence of the pervasive male bias: we’ve programmed our machines to assume patients are male.

At the recent American Heart Association EPI/Lifestyle conference, a woman-led team from Boston Children’s Hospital presented their work on perceptions of cardiovascular risk among adolescent and young adult (AYA) women. The team recognized that young women didn’t seem particularly informed about or interested in their heart health. Based on this clinical insight, they designed a study to identify barriers to awareness and preventive behaviors among AYA women. I spoke with Courtney Brown, an early-career professional herself and the first author of the abstract3, who explained the team’s findings. First, noted Brown, AYA women have a low baseline knowledge of their cardiovascular risk— lower than expected. They also face competing demands to focusing on their cardiovascular health, such as limited time and financial resources. One key finding was the role of mental health concerns like depression and anxiety: it’s hard to care about something that might happen to you in thirty years when you’re worried about getting through your next few days. Some participants also noted that eating healthy seems too expensive, and sometimes healthy food just isn’t available. These barriers to healthy behaviors are real! Yet behaviors established in young adulthood tend to persist as we age, so AYA women are at a crucial time in their lives for their heart health.

A key point for intervention development, says Brown, is that lifestyle behaviors (including exercise and high-quality nutrition) that are good for mood are also good for heart health. So while cardiovascular health may not be this group’s priority, they will likely benefit from risk-reducing behaviors in multiple ways.

Delivering the message in the setting of competing demands is tricky— and important.  When asked what might facilitate their adoption of heart-healthy behaviors, participants in the study indicated that family was their biggest influence, followed by their health care providers and celebrities (favorites were Drake, the Kardashians, and Beyoncé). They also talked about using Facebook, Snapchat, and Instagram to get information and communicate. This is rich data, and it suggests that a “meet them where they’re at” approach is likely to be successful. “We’d love for more people to take up this work— we have more steps to take,” Brown says. “We’d love to create and test materials.” It’s encouraging to see rigorous science targeting the needs of a group that’s often overlooked in cardiovascular research. As the body of evidence grows, perhaps some of the disparities in women’s cardiovascular health will fade.

There are also some great lessons here from a methodological standpoint. This study utilized mixed methods, including online focus groups. Courtney Brown, the researcher from the AYA study, stressed that the qualitative component of the work is highly valuable because it can help researchers develop interventions that will effectively reach the population of interest. “It lets us dig deeper into responses to find out what the unique barriers are and how to reach this population, not just what to tell them”, she says. When so much of existing clinical practice is based on research that excluded women, this approach is very relevant. In a climate where the RCT is king and the p-value determines whether or not a finding is considered significant, qualitative work is often undervalued, but these kinds of studies are crucial in understanding the needs, values, and preferences of patient populations— especially those, such as young women, that have been previously understudied and undertreated.

 

Have you read (or authored!) any great women’s health studies lately? Try to add some to your reading list!

 

References:

  1. Scott, P, Unger, E., Jenkins, M. Southworth, M., McDowell, T., Geller, R., Elahi, M. Temple, R., & Woodcock, J. (2018). Participation of women in clinical trials supporting FDA approval of cardiovascular drugs. Journal of the American College of Cardiology, 71(18), 1960-9.
  2. Lau, E. & Wood, M. (2018). How to we attract and retain women in cardiology? Clinical Cardiology, 41(2), 264-268.
  3. Brown, C., Revette, A., de Ferranti, S., Liu, J., Stamoulis, C., & Gooding, H. (2019). Heart Healthy Behaviors in Young Women: What Prevents Teens from Going Red? Abstract presented at American Heart Association Epidemiology, Prevention, Lifestyle & Cardiometabolic Health Scientific Sessions, Houston, TX.

 

 

Who is writing what you're reading? Look at the great mix of people on the AHA early career blogging team!

Who is writing what you’re reading? Look at the great mix of people on the AHA early career blogging team!

 

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Women’s History Month: Cardiology Edition

Somehow it’s already March, which means it’s Women’s History Month, so I wanted to take this opportunity to highlight some of the many amazing cardiologists and researchers (who also happen to be women) who have shaped our field.

Last month, I wrote about the importance of science outreach, especially with regard to promoting science and cardiology to young girls and women, because women still make up around only a third of scientific researchers and only around 13% of cardiologists are women. To learn more, Renee P. Bullock-Palmer’s most recent blog is a great resource.

This month I wanted to highlight some of the women who paved the way for the rest of us.


Now, unsurprisingly, simple Google searches for things like “scientists who shaped cardiology” or “most famous cardiologists” provide results that are pretty male and pale. There weren’t that many pieces that included women in their lists of cardiologists/researchers, and there were only a handful of sources I found that focused specifically on women. Lucky for you, I’ve collected what I found here! I’m also going to highlight several of the brilliant women who shaped our field – this is by no means an exhaustive list of amazing women in cardiology (or their accomplishments) because there are too many to fit on one list.

 

Maude Abbott, MD was a Canadian physician who invented an international classification system for congenital heart disease in the 1930’s. Her work the Atlas of Congenital Heart Disease became the definitive reference guide on the subject.

 

Helen B. Taussig, MD, FACC is widely regarded as the Founder of Pediatric Cardiology. In the 1940’s she developed the operation to correct the congenital heart defect that causes “blue baby” syndrome. She received the Medal of Freedom from President Lyndon B. Johnson and was the first female president of the American Heart Association.

 

Myra Adele Logan, MD was the first woman (and only the 9th person!) to operate on a human heart in 1943.

 

Marie Maynard Daly, PhD was first African American woman to obtain a PhD in chemistry in the United States, whose research in the 1950’s was invaluable in demonstrating the relationship between high cholesterol levels and heart attacks.

 

Celia Mary Oakley, MD was one of the first women cardiologists in the United Kingdom and was part of the team that coined the term hypertrophic cardiomyopathy in the late 1950’s.

 

Sharon A. Hunt, MD was just one of seven women in her 1967 medical school class and she went on to revolutionize the field of heart transplantation by working to improve survival rates by identifying and treating rejection and determining how to reduce the side effects of the drugs.

 

Nanette Kass Wenger, MD, was among the first cardiologists to focus on heart disease in women, and to evaluate the different risk factors and manifestations of the condition, specifically coronary artery disease, in women and men. I was lucky enough to talk with her about her work at AHA Sessions 2018, which I wrote about here. You can also follow her on twitter @NanetteWenger.

 

Christine Seidman, MD, is a researcher who transformed the field of cardiovascular genetics with her research that uncovered the genetic basis of many human cardiovascular disorders, including cardiomyopathy, heart failure and even congenital heart malformations.

 

Elizabeth O. Ofili, MD, MPH, FACC is a clinical scientist who led the effort to implement the landmark African American Heart Failure Trial (AHEFT), whose findings improved the practice guidelines for the treatment of heart failure in African Americans. She also became the first woman president of the Association of Black Cardiologists in 2000.

 

Ileana Piña, MD, MPH, FACC is a nationally renowned cardiologist known for her work in heart failure and improving patient rehabilitation outcomes. Her work has also upturned preconceived notions about women in the medical community and she works tirelessly to get more women into clinical trials.

 

Rong Tian, MD, PhD is a leader in the field of cardiac metabolism whose work has been translated to clinical trials. Among her many contributions, she was the first to demonstrate that AMP-activated protein kinase (AMPK) acted to remodel cardiac energy metabolism, which critically informed the heart failure field. You can also follow her on twitter @Rongtian2.

 

I want to note, that these cardiologists and researchers are not important just because they are women – they are talented scientists and cardiologists who happen to also be women. But pieces like this are important because representation matters. It’s important for everyone, especially young girls and women, to see that it’s possible not just to be successful in this field, but also to revolutionize it.

 

Helpful sources & suggested reading:

 

 

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The Invaluable Importance of Mentorship Throughout Your Career as a Female Cardiologist

Featuring an Interview with Dr. Stacey Rosen recipient of the American Heart Association (AHA) 2018 “Women in Cardiology Mentoring Award”

 

Lack of Females in the Cardiology Field

Over 36% percent of Internal Medicine residents are females. Despite this fact, females account for less than 20% of the Adult Cardiologist workforce in the United States and account of less than 10% of Interventional Cardiologists in the United States1. Recruitment and retention of many talented female cardiologists remain a constant challenge and is due to a variety of reasons. Some of these reasons include the thought that cardiology is a grueling field that does not allow for work life balance and is often inhospitable for females desiring to start a family. There is also difficulty in retaining females in the field due to increased gender discrimination in the field1. In fact the Professional Life Survey conducted by the American College of Cardiology had reported that many female cardiologists in the field report a high level of career satisfaction which has not changed over the last 20 years1. However, there are many challenges that have remained the same for female cardiologists over the last 2 decades, such as gender discrimination, the need to arrange for paid or unpaid childcare, being single and not having any children1. In addition, there has been aging of the workforce and there are increasingly more female cardiologists practicing in an academic and/or hospital employed setting rather than in private practiceand therefore having less autonomy over their work schedule and environment.

 

Need for Effective Mentorship For Female Cardiologists and the American Heart Association Women in Cardiology Mentoring Award

 

There is an ever increasing need to not only recruit more females in the field of Cardiology, but to also retain many talented female cardiologists in the field. Finding a good mentor and fostering good mentorship is invaluable for many females throughout their career in Cardiology. The Women in Cardiology Committee of the American Heart Association (AHA) values the importance of good mentorship and as such bestows the Women in Cardiology Mentor Award that is sponsored by the AHA Council on Clinical Cardiology to Cardiologists who have been recognised as having an outstanding record of effectively mentoring and supporting female cardiologists. Dr. Stacey E. Rosen,  Endowed Chair and Vice President for the Katz Institute for Women’s Health at Northwell Health, Partners Council Professor of Women’s Health at Hofstra North Shore-LIJ School of Medicine at Hofstra University and Professor of Cardiology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is the recipient of the 2018 AHA Women in Cardiology Mentoring Award. She has mentored and supported numerous female cardiologists, and in the following interview, I had the honor of discussing the following questions with Dr. Rosen.

Courtney could we add a hyperlink to the AHA WIC mentor award nomination site?

 

What attracted you to the field of Cardiology?

Dr. Rosen: “I am the first member of my family to become a doctor. I am the daughter of educators and while in high school , I volunteered at Memorial Sloan Kettering in the pediatric child-life center. I thought that the medical field would allow me to pursue various professional options including clinical care, education, advocacy and research. I felt one could never be bored in medicine! As a student in the 6-year medical program at Boston University, we dissected a bovine heart and I was so amazed by the “simplicity” of the structure. Nothing else seemed intriguing after that – my only important decision was between pediatric cardiology and adult cardiology.”

Who were the inspirational persons that influenced this decision?

Dr. Rosen: “The Division of Cardiology at Boston University School of Medicine in the 1980’s – and ever since – was extraordinary. The faculty at Boston City Hospital (BCH) demonstrated commitment and passion for those in the underserved neighborhoods near BCH and the faculty at University Hospital were national respected clinicians , investigators and educators.”

Who were your mentors in Cardiology and how did they contribute to the advancement of your career?

Dr. Rosen: I completed Internal Medicine residency and a chief resident year at Montefiore Medical Center in the Bronx, and was privileged to work with an impressive Division of Cardiology. Hildrud S. Mueller, MD and James Scheuer , MD taught me the importance of rigor and attention to detail in both clinical work and research. I presented my first oral presentation with John Fisher, MD – the recently retired division chief – and learned to perform a complete and thorough cardiac exam with Mark Menegus, MD.

As a fellow at Cornell – New York Hospital, Mary Roman, MD, Peter Okin, MD, Paul Kligfiled, MD, and Richard Devereux, MD fostered my fascination with imaging and non-invasive cardiology. Doppler physics was replacing hemodynamic assessment in the cardiac catheterization lab and I was hooked!

Finally, my first faculty position was at Mount Sinai Medical Center. Working in the echo lab with Martin Goldman, MD was an extraordinary opportunity. He inspired me to view echocardiography as a critical tool to enhance optimal patient care and helped me to develop the skills to become a lab director in my next position.

You have mentored many colleagues in the Cardiology field and have been valued by many as a great mentor, which led to your selection for the 2018 AHA Women in Cardiology Mentorship Award. What are the factors that mentees should consider when selecting a mentor?

Dr. Rosen:Mentees should consider several critical factors:

  • Compatibility – Choose someone with whom you are compatible but not someone who is a “mini me“ of yourself. You do want a mentor who will challenge you, be comfortable providing feedback, and teach you to internalize and utilize feedback to advance your goals.
  • Trust – You want a mentor whom you can trust – you will likely be sharing important and perhaps confidential conversations. It is also critical to know that you must earn a sense of trust from your mentor.
  • Expertise – Your mentor does not have to have the most senior titles or positions, but should have the requisite expertise to help you advance your career and help navigate challenges.
  • Willingness – A great mentor is one who is devoted to helping you develop a vision and is delighted to share knowledge and wisdom. It should be someone who is a good listener and has sufficient time to commit to the relationship.

 

Would you recommend having more than one mentor?

Dr. Rosen:  “Absolutely! But do remember that the mentee needs to commit sufficient time to each relationship in order to optimize the value of the partnership

 

How can mentees truly harness the power of strong mentorship?

Dr. Rosen:First – choose your mentor wisely and respect the relationship. Meet with individuals who you think may be good mentors and ask questions that will help you make a decision and get advice from friends and colleagues. Networking is often the key to identifying good choices.

Second – do the work and always respect the relationship! Discuss the goals and expectations of the partnership, as well as the process for communication, meetings and feedback. Be respectful of your mentor’s time and build trust immediately.

 

What are the differences between mentorship and sponsorship?

Dr. Rosen: Simply put – mentors advise you, while sponsors advance your career. A mentor is someone who can offer support, guidance and feedback, and allow you to develop your personal vision. A sponsor is earned – not chosen. A sponsor connects us to opportunities and advocates for our career advancement. It has been said that women are over-mentored and under-sponsored.

 

 

How has the experience of being a great mentor for so many colleagues contributed to your own career and personal growth?

Dr. Rosen: My late father was a middle school principal and my mother is a retired school teacher who taught in an underserved community in Brooklyn, NY. I learned from them the deep satisfaction one gets from teaching and advancing someone’s skills and abilities. I am also so grateful to MY mentors and get great satisfaction from “paying it forward.”  I am certain that I have learned as much from my mentors as they have learned from me!

What have been the 3 most rewarding experiences you have had throughout your career?

Dr. Rosen: As the director of the fellowship program at Northwell, I have had the privilege to work with dozens of trainees. I have helped impact their professional success and hopefully, the joy they find from practicing cardiology.

As chief of cardiology at Long Island Jewish Medical Center, I was able to rebuild a division that had weathered a hospital merger. Together with my colleagues, we completely revamped the division.

As a lifelong advocate for women’s heart health, I get enormous pride seeing the impact we have had on women’s health through improved clinical care, advances in gender-specific investigation and through advocacy and changes in policy. I know that our work is not done and that we still need to continue to advance women’s heart health agenda.

How has the field of Cardiology evolved over the duration of your career with regards to gender diversity and inclusivity of women in Cardiology?

Dr. Rosen: Unfortunately, our field has not advanced sufficiently when it comes to gender diversity and inclusion in Cardiology. Currently, fewer than 25% of cardiology fellows are female and fewer than 15% of board-certified cardiologists are women. Now that women are 50% of medical school graduates, the importance of developing a strategic approach to this lack of diversity is critical, or we will see a true talent drain in the near future. The good news is that both the American Heart Association and the American College of Cardiology have focused on lessening this disparity by better understanding the barriers facing female cardiologists and by making changes that will encourage young women to choose Cardiology.

What advice would you give to females considering a career in Cardiology?

Dr. Rosen: I can honestly think of no better choice! As clinicians, we can develop long-term longitudinal relationships and have an enormous impact on health and longevity. I believe that cardiology combines the best features of primary care and subspecialty medicine. As investigators, we can have a lasting impact on individuals and communities. Cardiology is also a field that is perfect for those who enjoy advocacy and advancing health policy improvements. I urge women NOT to eliminate Cardiology as a possibility because of concern about the challenges. Find the area of the field that you love, without fear or compromise, and then make decisions that will allow you to fulfill your vision of work – life integration.

References:

  1. Lewis SJ, Mehta LS, Douglas PS, et al. Changes in the Professional Lives of
    Cardiologists Over 2 Decades on behalf of the American College of Cardiology Women in Cardiology Leadership Council. J Am Coll Cardiol 2017

 

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Women In Cardiology & The 2:00am Leadership

The Women In Cardiology (WIC) community has grown in recent years and has represented professional women in many ways. Tangible accomplishments include advocacy for more women on panels (#NoManels), curbing harassment (#MeToo), opening leadership opportunities and much more. Many have recruited men into the campaign for women (#HeForShe). Guidance into what men can do has also been emphasized, for example, speaking up when a committee lacks diversity and lending an early career woman a research opportunity. But, have we given women enough guidance? I fear not. Allow me to display examples where women have failed other women. It’s a collection that I’ve discussed over the course of the last several months in WIC workshops across the globe.

 

Time: 2:00 am

Place: Cathlab

Setting: STEMI & shock

Woman interventional cardiologist (IC) calls the on-call anesthetist (a fellow woman) to provide deep anesthesia because “I need to cardiovert this patient who had primary PCI and now in AF with RVR and is hemodynamically unstable”.

Anesthetist: Okay the patient is asleep, but does he really need cardioversion?

IC: Yes.

IC calls to technician: 200 Joules.

Anesthetist: No. It should be 100 Joules according to the AHA algorithm.

With an unstable patient on the table, is this the time to be questioning a colleague’s judgment in front of her staff? I fear using “patient advocacy” as an excuse to lecture a qualified cardiologist on the management of arrhythmias is inappropriate. Many electrophysiologists have reservations about the very conservative algorithm. 2:00 am in the cathlab is hardly the time or place for such a discourse. Perhaps at a more suitable time, a scientific discussion can educate everyone on the indications of cardioversion for AF. Why is this incident reckless and detrimental on many levels?

  1. It undermines a colleague in front of her staff to whom she has to prove herself every day.
  2. It doesn’t help a patient who is unstable. Every failed shock reduces the chance for the next shock to work.
  3. It portrays an image of two professional women “bickering” over a crashing patient.

 

Time: 2:00 am

Place: Email

Setting: Clinic Schedule

Cardiologist (a woman) fires off an email to the Chief of Staff expressing disillusion with the “disruptive” clinic schedule that was planned by her immediate section head (a woman). Why is this incident reckless and detrimental on many levels?

  1. It undermines the leadership of the section head, a woman nonetheless.
  2. It negatively impacts the relationship between colleagues (2 women).

Wouldn’t it have been more constructive if she spoke to her head first and made her recommendations? The worst part of this whole story is that the immediate section head did not design the clinic schedule. It was the Chief of Staff. The “backstabbing” backfired and the notion was that this cardiologist is not a team player. It would have been wiser and more respectable to go through the appropriate channels with suggestions for improvements. Why is this incident reckless and detrimental on so many levels?

  1. It doesn’t build team spirit or trust. It does the exact opposite.
  2. It damages future prospects for both women in the workplace. It leaves the impression that the head cannot inspire or lead and the other woman is not a trustworthy team player (late night backstabbing email).
  3. On a larger scale, it suggests men can be more professional even when competitive.

 

Time: 2:00 am

Place: International Teleconference

Setting: Planning of a Scientific Activity

A woman participant claims ownership of an idea that belongs to the chair of one of the subcommittees (a woman) and bypasses her. The worst part of this story is the director of this scientific activity (also a woman) allows her to do so. She does not empower the head of the subcommittee by channeling all projects/decisions through her. She does not acknowledge the other participants. Instead, this woman’s name is placed first in all communications. Why is this incident reckless and detrimental on so many levels?

  1. It proves that women can do other women more injustice by stripping them of credit and authority.
  2. It projects an image that women leaders lack fair leadership suggesting that it’s no better (perhaps worse) than men’s leadership.
  3. It casts doubt on the efficiency of the various WIC programs in providing leadership training and addressing such inconsistencies.

 

The purpose of this month’s blog is not to be critical of women. To the contrary, there have been many women exhibiting true leadership and effecting concrete changes. Now we find lactation areas at major meetings, opportunities for women to serve as proctors and live transmission operators, and emphasis on diversity in training programs and the workplace. I do believe we have to build on that momentum. The purpose of this blog is to allow for some self-reflection on our part as women in the field. Whether we like it or not we are held to higher standards. Any deviation by one woman is considered a setback for all and any success story of one woman is a stride forward for all. It is not a fair world and prejudice/inconsistencies are noted on all fronts. I am a catheterization laboratory director and have been for a couple of years now. Every single day I have to prove I’m capable and reliable. Every single day, and no matter how much time has passed, I still need to assert my authority and earn respect from men and women. I know that when men are given leadership opportunities, the respect and authority are automatic until proven otherwise. For a woman, it gets exhausting after a while…and that’s why we have more work to do & more self-reflection can only help.

 

Not references for this blog, but worthwhile data for WIC:

  1. O’Sullivan S. Women in medicine: deeds not words. Lancet. 2018;392(10152)1002-1003.
  2. Mehran R. Women’s Voices in Cardiology: An Uncomfortable Silence. JAMA Cardiol.2018;3(8):676–677. doi:10.1001/jamacardio.2018.1289
  3. Breaking the Catheterization Laboratory Ceiling. JACC 2017;69(21)2668-2271.
  4. Lautenberger DM, Dandar VM, Raezer CL, Sloane RA. 2013–2014 The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership. Washington, DC: Association of American Medical Colleges, 2014.
  5. Prasad M. Gender in cardiology: work yet to be done. J Am Coll Cardiol 2016;67:3016–9.
  6. Wang TY, Grines C, Ortega R, et al. Women in interventional cardiology: update in percutaneous coronary intervention practice patterns and outcomes of female operators from the National Cardiovascular Data Registry. Catheter Cardiovasc Interv 2016;87:663–8.
  7. Carr PL, Gunn CM, Kaplan SA, Raj A, Freund KM. Inadequate progress for women in academic medicine: findings from the National Faculty Study. J Womens Health 2015;24:190–9.
  8. Lewis SJ, Mehta LS, Douglas PS, et al., for the American College of Cardiology Women in Cardiology Leadership Council. Changes in the professional lives of cardiologists over 2 decades. J Am Coll Cardiol 2017;69:452–62.
  9. Bates C, Gordon L, Travis E, et al. Striving for gender equity in academic medicine careers. Acad Med 2016;91:1050–2.
  10. Marchant A, Bhattacharya A, Carnes M. Can the language of tenure criteria influence women’s academic advancement? J Womens Health (Larchmt) 2007;16:998–1003.
  11. Hlatky MA, Shaw LJ. Women in cardiology: very few, different work, different pay. J Am Coll Cardiol 2016;67:542–4.

 

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Participating in Science Outreach is a Win-Win For Everyone

Last month I wrote about the January is for Advocacy AHA initiative and discussed the importance of physicians and scientists getting involved in science advocacy. Since I mentioned I wanted this New Year’s resolution to stick, I am continuing this theme for February because there are so many different ways to get involved with our communities and advocate for change.

One way I personally enjoy engaging with my community is by participating in science outreach activities. Now, the best part about this type of extra-curricular community engagement is that it comes in a variety of different forms, whether it be judging a local science fair, visiting an elementary classroom to talk about your science and do an experiment (my favorite is isolating DNA from strawberries with them), or even Skyping with a classroom of students through the fantastic Skype A Scientist program (you don’t even have to leave work!).

Before I highlight a fantastic cardiology outreach program that just recently happened, I want to take a moment to discuss why science outreach programs are so critical for our both our local and scientific communities. We are all busy, so finding time to fit something like this into our schedules feels like a scary game of Tetris. However, science and particularly the cardiology field, has diversity/inclusivity issues that need attention. Even though this is an issue that some may feel like has “been addressed,” women still make up around only a third of scientific researchers across the world. While this varies across disciplines, only around 13% of cardiologists are women – even though roughly 50% of medical students are women. All of these numbers are even lower for people of color.

While I understand that these issues are insanely complex and speak to the need of a re-vamp of how our scientific and medical institutions are structured, we need to continue to flame the excitement for science in students of every background, gender and race. The easiest way to do this is by getting involved and not just in your neighborhood, but also underserved communities. I highlighted a variety of ways to get involved in science outreach in last month’s post. The STEM ecosystem is a particularly good resource for getting in contact with underserved communities you may have not been aware of before.

I mentioned before that I completely understand that getting involved or organizing a science outreach event feels overwhelming. However, working with other colleagues within your network who are also passionate about this issue is the key to really making an impact. Just like with everything else in science, you don’t have to do this alone!

This is exactly the approach Dr. Kathryn Berlacher and Diana Rodgers took to organize their recent She Looks Like A Cardiologist event last month in Pittsburgh. Both women took their passion for increasing the diversity in cardiology into creating a fantastic event where 28 female high school students interested in becoming cardiologists got to meet with local women in cardiology. The day was filled with a mix of lectures, group discussions and some simulation, as well as one-on-one lunch with paired mentors. The best part of this event is that it’s not over – the organizers didn’t want this to be a “one and done” day, so every girl got paired with one of the mentors who will help answer college application questions, advise on jobs and summer experiences, and just be a resource for them in the future. You can find a great breakdown of the day on Dr. Berlacher’s twitter page (@KBerlacher). Seeing this event on Twitter is actually what inspired me to write this blog post and I emailed Dr. Berlacher right away to talk about it. I asked her if she thinks outreach activities are valued within our field and I loved her response:

Definitely – many of my colleagues do it and love it. Almost all of my fellows do it. The fellows who came on Saturday raved about the event afterwards, saying they thought it was going to be a great event for the high school girls, but at the end of the day they felt inspired and invigorated too.  Things like this (and all our other volunteering), keeps us grounded and really provides perspective. I honestly think it’s a great way to bond – AND to combat burnout in the field, which is another hot topic. If you feel valued and feel that what you’re doing is making a difference, then you’re much less likely to get burnt out at your job.”

I hope this event inspires you to get involved in science outreach within your community as much as it inspired me. Here’s to seeing many more events like this in the future.

 

 

 

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Women & TAVR: “I Don’t Want Any Procedure”

Round 1…

Patient’s son-in-law: “My mother has been turned down for surgery. They tell me her mortality rate at 2 years is high since she had fluids collecting in her lungs. They told me to ask you about catheterization.”

Me: “Yes, she does have a tight aortic valve and did develop heart failure. She is also very high risk for surgery. Percutaneous or catheter-based replacement may be an option. She will need a CT Scan first to determine if she is suitable for that treatment.”

The patient’s son-in-law asked me only one question, but a number of questions rushed through my head.

When is a good time to give the patient a contrast load after her recent admission with pulmonary edema? How safe is contrast given her borderline renal dysfunction and recent pulmonary edema? What is the outcome of trans-catheter aortic valve replacement (TAVR) in women?

I realized that there were no concrete answers. Irrespective of risk of contrast induced nephropathy, she needs the CT Angiogram. Irrespective of the timing, she remains high risk for recurrent pulmonary edema with or without the 50-60 cc of contrast given during the CT scan. Irrespective of her gender, TAVR maybe her only option. So, the CT scan was done with a small amount of contrast & her renal function remained unchanged and she did not develop pulmonary edema. She had borderline parameters with a short distance from the aortic valve annulus to left main, significant calcification into her LVOT, small tortuous and calcified common iliac arteries bilaterally. She was not an “ideal” candidate.

 

Round 2…

 

Me: “You are at a higher risk of coronary occlusion. We can place an undeployed stent preemptively in the coronary artery. Your risk of requiring a pacemaker is high and we’ve notified our electrophysiologist. Your risk of rupture is high, so we plan to use a self-expanding valve. We may need to use an alternative access like your armpit artery.”

Patient: “I don’t want any procedure.”

Patient’s son-in-law: “Is there anything else that we can do that is less risky?”

Me: “Palliative balloon valvuloplasty, but the gradient will increase again in 6-12 months.”

Patient: “I don’t want any procedure.”

Patient’s son (in-law): “Can we repeat this valvuloplasty every 6 months if need be?”

Patient: “I don’t want procedure.”

*Awkward silence.*

Me: “She does not want any procedure. It is time you and I listen to her.”

 

This patient was referred to me by a colleague from another hospital. She had no sons of her own but had her son-in-law to accompany her. She was a small, frail, soft spoken, elderly lady. She was also grateful for the care she received. We immediately had the surgeons evaluate her. While the surgeons were examining her, I did a quick literature review:

Data from Vancouver demonstrated that the mortality rate at 30 days after TAVR was 6.5% in women and 11.2% in men after accounting for other variables.1 This advantage for the female gender was maintained at 1 year as confirmed by the PARTNER Trial sub-analysis. Whether this was due to worse surgical outcomes in women or an advantage of TAVR in women was further explored by Humphries et al. Although vascular complications were higher in women, the overall survival rate at 2 years was 72.1% for women and 61.7% for men. Real world international registry and the first WIN TAVR registry further confirmed that high risk women had low 30-day and one-year mortality and stroke rates.2-4

Naturally, I picked up the conversation where the surgeons left off. In retrospect, even as a woman interventional cardiologist, was I dismissive of my patient’s own preference? Do we have a tendency to ignore female patients’ wishes more than men? Do we have a tendency to ignore elderly patients’ wishes more than younger ones? Or do we find it difficult to resolve to hospice care even before exhausting all options? It may be a combination of all of these. I don’t normally dismiss my patients’ wishes, but this time, I was clearly not listening. Maybe I listened to my colleague (a physician) and maybe I just grew attached to this soft spoken grateful woman…and I couldn’t resign myself to writing hospice care for her. Women..men..no matter, we make imperfect choices at times driven by our humanity. May that imperfection continue to drive us to care.

 

References:

1. Humphries KH, Toggweiler S, Rodés-Cabau J, et al. Sex differences in mortality after transcatheter aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol 2012;60:882–6.

2. Williams M, et al. Sex-related differences in outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis: Insights from the PARTNER Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol. 2014 Apr 22;63(15):1522-8.

3. Chieffo A, et al. 1-Year Clinical Outcomes in Women After Transcatheter Aortic Valve Replacement: Results From the First WIN-TAVI Registry. JACC Cardiovasc Interv. 2018 Jan 8;11(1):1-12.

4. Chieffo A, et al. Acute and 30-Day Outcomes in Women After TAVR: Results From the WIN-TAVI (Women’s INternational Transcatheter Aortic Valve Implantation) Real-World Registry. JACC Cardiovasc Interv. 2016 Aug 8;9(15): 1589-600.