Dr. Haythe: Cardiovascular disease is considered the number one cause of maternal mortality.
Erin Welsh: Dr. Jennifer Haythe is a cardiologist specializing in heart failure, as well as the director of the Adult Pulmonary Hypertension Center and director of the Cardio-Obstetrics Program at NewYork-Presbyterian and Columbia.
Dr. Haythe: Many women are having children much older. As a result, women have a higher risk of having risk factors for heart disease if they're having a baby when they're 35 or 40 or 50, compared to when they're 22.
Erin Welsh: Because of this shift in maternal age, there are more pregnant patients at risk for cardiovascular disease than ever before. On top of that, pregnant patients who have preexisting heart disease are especially high risk for negative outcomes. One of these rare, but extremely dangerous conditions is pulmonary hypertension.
Dr. Haythe: The pressures in the lungs are very high, and a lot of these women have right heart failure as a result because the right side of the heart just can't pump against such a high pressure. Couple that with pregnancy and the delivery after pregnancy, and you develop acute right heart failure, and they can go into cardiac arrest very, very easily. And the mortality is quoted somewhere between 30 and 70%.
Erin Welsh: But Dr. Haythe and her team have developed a unique multidisciplinary approach to treat these high-risk patients, some of whom have been told that they should avoid pregnancy because it might be too risky for them.
The strategy combines the expertise of NewYork-Presbyterian's world-renowned Adult Pulmonary Hypertension Center with cutting-edge research and coordinated treatment in the Cardio-Obstetrics Program, one of the few of its kind in the US. Through this unique approach, Dr. Haythe and her team are creating a pathway to help an increasing population of high-risk patients with pulmonary hypertension and other cardiovascular diseases achieve safe and successful pregnancies.
Dr. Haythe: This program really lights me up because I feel like there's nothing more satisfying than having a woman who is, you know, already feeling vulnerable being pregnant, and then on top of it to have a complicated cardiovascular disease. You know, someone told them they could never have a baby, and then we tell them, "That's not true. You can." So that's been really, really satisfying.
Erin Welsh: I'm Erin Welsh, and this is Advances in Care.
Today, I'll speak with Dr. Jennifer Haythe about the pioneering multidisciplinary care and innovative research she and her team are pursuing to change the odds for pregnant patients with high-risk cardiovascular diseases.
Erin Welsh: Dr. Haythe, thanks for joining me today. It's great to have you here.
Dr. Haythe: Thank you so much for inviting me to speak to you today.
Erin Welsh: To get us started, can you tell me more about the Adult Pulmonary Hypertension Center? I know it's one of the first programs of its kind in the country.
Dr. Haythe: So pulmonary hypertension is an interesting disease. It's sort of somewhere between cardiology and pulmonology, and here at Columbia, it has traditionally been under the umbrella of cardiology. But what's so great about our program is that we have a really incredible collaboration with our pulmonary colleagues. We have one of the largest cardiac and lung transplant programs in the country. We also have a shock team that can provide ECMO and state-of-the-art advanced care to patients who are really sick, waiting for transplant, or as a bridge to recovery. We collaborate well together, and all of these things allow these patients who are really complex, and we can make sure we stay on top of it.
Erin Welsh: And as you mentioned, you're seeing a diversity of patients with many different complex conditions. How does your team use all of their specialized skills and expertise to approach these different cases?
Dr. Haythe: So pulmonary hypertension is a disease that can be caused by many different underlying, uh, illnesses. And so we have, you know, cutting-edge treatment and physicians at the top of their fields who do research, who take care of the sickest patients, and we can call upon them to facilitate the care. One of the interesting causes of pulmonary hypertension is a condition called chronic thromboembolic pulmonary hypertension, which is a type of pulmonary hypertension driven by blood clots in the lungs. And interestingly, that is one of the few or only curable forms of pulmonary hypertension if the patient is a candidate for a surgery called a pulmonary endarterectomy surgery where the surgeon literally goes in and carves out this sort of old clot tissue and opens up all those blood vessels again. It is a very complicated, delicate procedure that requires a lot of skill and experience.
Erin Welsh: Hmm.
Dr. Haythe: And so there aren't that many surgeons that can do it and have enough volume of patients to make them, you know, considered to be the best of the best, right? Because this is not, you know, aortic valve surgery that happens, you know, multiple times a week. And we are really fortunate to have Dr. Koji Takeda here, who performs that surgery. In fact, twice a month, we have a meeting with Cornell and Columbia physicians of many different cardiology backgrounds, and we review these cases prior to sending them for surgery.
Erin Welsh: I mean, that is such a great example of this multidisciplinary approach in action, and that's so important for taking care of specialized populations who are at risk for pulmonary hypertension, like your high-risk pregnant patients. Can you tell me a bit more about how cardiovascular diseases like pulmonary hypertension affect those patients?
Dr. Haythe: The thing about pregnancy is that it is a stress test for cardiovascular disease. And if you have something wrong with your heart, once you get to that point and then you deliver the baby and the placenta is delivered and all that blood volume and is pushed back into the bloodstream-
Erin Welsh: Mm-hmm
Dr. Haythe: ... women who have heart problems can't actually sometimes manage that. Very important to remember that pregnancy's not just done 'cause you had your baby, right? You're, it takes a woman, like, six months to-
Erin Welsh: Yeah
Dr. Haythe: ... really get back to normal. [laughs]
Erin Welsh: It's really like a fourth and fifth trimester. [laughs]
Dr. Haythe: Yeah, exactly, and maybe, like, the rest of your life, by the way.
Erin Welsh: Yeah. [laughs]
Dr. Haythe: 'Cause, like, my kids just went to college, and I'm still, like, worrying about them.
Erin Welsh: Of course.
Dr. Haythe: So it never goes away.
Erin Welsh: Of course. The eternal trimester. Yeah.
Dr. Haythe: The eternal trimester, right. That's a good book. We should write that.
Erin Welsh: Yeah, okay. I'm down. [laughs]
Dr. Haythe: Okay. [laughs]
Erin Welsh: And yeah, I mean, it's so important, though, to not discount the postpartum period because I know that there are some cardiovascular issues that can develop after delivery. What are some of those conditions?
Dr. Haythe: So, we have something called the hypertensive disorders of pregnancy. So, in pregnancy, women can have had high blood pressure that's chronic, and they keep that through pregnancy. You could develop gestational high blood pressure in pregnancy, and then there's preeclampsia. And if it's not treated with delivery, ultimately, it can lead to eclampsia and seizures and then death. Preeclampsia is very serious, and sometimes women don't develop preeclampsia until after they deliver. So they may deliver, go home, and suddenly they feel like they have a horrible headache. You know, their legs are swollen. They go back to the emergency room, and their blood pressure is 200 over 100, and they've never had that before in their life. So, that needs to be managed, obviously, by the OBs, and cardiology can come in and help as well. Another postpartum condition is postpartum cardiomyopathy. Some percentage of women can develop a heart failure syndrome after delivery or within the f- last four weeks of pregnancy-
Erin Welsh: Mm
Dr. Haythe: ... where a woman's heart function goes down, and they can… it can range from mild with no symptoms to severe, needing a heart transplant or even dying. So, that is something that we treat very aggressively, and we w- we wanna know about it because if we know, we can really get ahead of it.
Erin Welsh: Right. And I imagine that being able to spot these issues and then have the right team provide follow-up care is a large part of what's improving outcomes in the cardio-obstetrics program.
Dr. Haythe: That's exactly right. Our job is to try to manage all of those complicated problems and get them through a safe delivery, and the only way we can really do that effectively, which I feel very proud that we have, is it's a multidisciplinary approach, right? So we need OB anesthesia, cardiac anesthesia, cardiac surgery, the ECMO team, neonatology, the pediatric ICU, the neonatal ICU, the cardiac ICU. So all of these teams can come together at any moment.
Erin Welsh: And I imagine that having all this expertise on hand really kick-starts innovation. For example, with a disease like peripartum cardiomyopathy, where mortality is, of course, very high and treatment options are quite slim-
Dr. Haythe: That's right
Erin Welsh: .. can you tell me more about that condition and the work that your team is doing to try to find new treatments for it?
Dr. Haythe: Peripartum cardiomyopathy has always been something that you learn about in medical school and in training, and you… everyone's seen it happen, and it can be pretty upsetting. And so finding a, a cause or a treatment is, is something that we've all been, you know, wondering about for many, many years. We are part of a study called the REBIRTH Study, which is a national, multicenter, randomized, placebo-controlled study of the use of bromocriptine in treatment of peripartum cardiomyopathy. Bromocriptine's a drug that's been around for a very long time. It blocks prolactin, which is what's released by the pituitary to make women breastfeed. There's some thought that cleavage particles from prolactin are potentially, I'm not sure if I would say the cause of peripartum cardiomyopathy, but exacerbate or may be one of the contributing factors. And so we are actively enrolling patients into this large study because smaller studies have shown that bromocriptine seems to work. There's a lot of potential new research after this study to see what comes of it.
Erin Welsh: Right. So I mean, so far we've, we've mostly been talking about cardio-obstetrics in the abstract, like from a clinical perspective. But I can imagine that it is incredibly rewarding to work with these patients during such an intense period of their lives, and I was wondering if you could share any patient stories that kind of illustrate the power of this multidisciplinary approach.
Dr. Haythe: Oh my, like so many. I have a recent one. She has a form of pulmonary hypertension, which is very v- what we call vasoresponsive. So, while very high initially, with simpler medications, we're able to get her pulmonary pressures much lower. Okay. So very, still very reactive pulmonary vascular bed. Really wanted a baby, got pregnant. She really wanted to have the baby, was committed to it. So what we decided to do was during her second trimester, we started her on an infusion of treprostinil, which is a drug, Remodulin, that we use to treat pulmonary hypertension. It's a continuous, a 24/7 infusion. You administer it subcutaneously. Um, brought her into the hospital, got her started on it, sent her home with the subcutaneous pump so that we had her on the drug, that everything was set up, and that we could increase it more easily and readily as her pressures increased.
Erin Welsh: Right.
Dr. Haythe: Towards the end of her pregnancy, her pressure started to go higher. I started to get nervous. We brought her in, and we actually wired her for ECMO just in case. She had a beautiful delivery and did very well. Brought to the ICU after. Her pulmonary pressures came down nicely. We increased her medical therapy pretty aggressively. And now we're in the process of actually taking away that continuous therapy-
Erin Welsh: Uh-huh
Dr. Haythe: ... um, having replaced it with other drugs, and she has this adorable baby now.
Erin Welsh: Oh.
Dr. Haythe: But it was stressful. I mean, it, it was stressful.
Erin Welsh: Yeah, and but I mean, but also, how, how reassuring to have someone like you in their corner, like, "We, we've got the-"
Dr. Haythe: Yeah
Erin Welsh: ... "team here. We've got everyone, everyone that we need, everything that we need."
Dr. Haythe: Yes.
Erin Welsh: "We have plan B, C, D, E," you know, all the way down the line.
Dr. Haythe: Yeah, yeah.
Erin Welsh: [laughs]
Dr. Haythe: I have to say, like, watching a baby be born is still beyond incredible. Even all these years and all this training later, it's just like, "Oh my God," [laughs] you know?
Erin Welsh: Never gets old, yeah.
Dr. Haythe: Never gets old.
Erin Welsh: Yeah. That's, that's incredible. I mean, I think stories like this just really highlight that meaningful change is driven by innovation and a willingness to work across disciplines. Just taking a step back and considering how far this field has come, not just in cardio-obstetrics, but in pulmonary hypertension overall, I, I'm curious of your thoughts on how the environment within NewYork-Presbyterian and Columbia has supported or enriched your work in cardiology and cardio-obstetrics.
Dr. Haythe: I mean, NewYork-Presbyterian really has a commitment to allowing doctors and providers the room to be creative, be cutting edge, and innovative, and I feel that it's, it, it is unique to our hospital that, that there is a culture of collaboration, of pushing the boundaries, of trying new things and being given the freedom to do that with an incredible support team of nurses and PAs and our profusionists. It just, it takes a village. It really does. It sounds corny, but it does. It just does.
Erin Welsh: [laughs]
Dr. Haythe: And without it, you can't achieve these kinds of things over and over and over again.
Erin Welsh: Yeah, and it's also, it, it really inspires hope for what future developments might bring. And in that vein, can you tell me about the New York City Maternal Mortality Review Board that you're a part of and what the committee's mission is?
Dr. Haythe: Right. So the committee's a multidisciplinary group of community members, OB, EMTs, cardiologists, emergency room doctors, and then we have a medical examiner, and they've been tasked with looking at all maternal deaths within each year. And they really do an incredible job of extracting the medical data from whatever they can find of their entire pregnancy and try to piece together, you know, why did this woman die? What could we have done differently? What is our recommendation to the city and the state about h- what kinds of resources could be applied where that would help minimize the risk of this happening?
Erin Welsh: That sounds like a difficult meeting, but also this really unique opportunity to change outcomes.
Dr. Haythe: Yes, definitely. I feel like that is their mission, and it does feel gratifying to see those kinds of changes be enacted.
Erin Welsh: Yeah. Well, and I mean, just, just chatting with you so far, I can hear your passion for this-
Dr. Haythe: Mm-hmm
Erin Welsh: ... subject shine through so much, and I, I wanna ask you to imagine yourself in the field of cardio-obstetrics, you know, 10 or 20 years into the future.
Dr. Haythe: Mm, mm.
Erin Welsh: What do you think you would most want to look back on and say, "I contributed to that change"?
Dr. Haythe: I think if we could come up with a real treatment and understanding of peripartum cardiomyopathy so that not only could we treat it to save women's lives so that they didn't need to get a heart transplant or an LVAD pump, but then that they could go on and have another baby if they wanted to and not have that taken away from them, that feels really, you know, special. I would say the other thing would be that I have somehow contributed to creating a mindset of, you know, how to identify and look out for heart disease in women so that more people are aware, that the medical society algorithms are really clear and help people diagnose these things everywhere and not just at a major tertiary care medical center.
Erin Welsh: I love that. I mean, integrating prevention, treatment, awareness, and access to really just expand care. Well, this has been such an inspirational conversation, truly. I wanna thank you so much for taking the time to chat with me.
Dr. Haythe: Well, thank you for talking to us about this. This is so great that you're highlighting these really interesting areas of medicine.
Erin Welsh: Thanks so much to Dr. Jennifer Haith for speaking with me today about the impactful work she's doing to achieve better outcomes for pregnant patients with high-risk cardiovascular disease.
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Erin Welsh: I'm Erin Welsh. Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.
