Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're exploring why when to refer matters, advancing outcomes with AHN's Interventional Cardiology and Cath Lab.

Joining me is Dr. Aashish Dua. He's the Medical Director of the Cardiac Cath Lab at Forbes Hospital. Dr. Dua, thank you so much for joining us today. And when we think of advanced interventional capabilities across the full spectrum of cardiac disease, tell us a little bit about AHN's Interventional Cardiology program that manages both coronary and structural heart disease, including complex procedures such as intracardiac closures, valve interventions, and advanced angioplasty techniques.

Dr. Aashish Dua: Yes. Thanks, Melanie, for having me. We have a full gamut of procedures that we offer at Allegheny Health Network through the parent hospital at Allegheny General and through our hospital at Forbes and have built a nice connection with all our local networks. So, what we are trying to offer here is the full gamut of care, right from the cardiac world to the peripheral world.

And as you know, in the last 10 to 15 years, there has been a lot of advances in structural heart programs as well as in the cardiac innovation. So, we are trying to adopt all the recent technology in trying to do complex procedures including TAVRs, mitral valve clips, along with the pulmonary embolism treatment, as well as treatment of patients who have shock and who need to be urgently managed to help and improve quality and quantity of life.

So, we are able to offer that with the help of our referring hospitals as well as with good connections and good teamwork from our parent and coronary healthcare system from Allegheny General. So, I would say that we have definitely grown in that area over the last five to six years and have developed a fair level of confidence as well as capabilities to manage these complex patients.

Melanie Cole, MS: Well, thank you for that. And we're going to talk about some of those capabilities in complex patients. Before we do, when is it important to refer patients earlier for improved outcomes? Speak to other physicians now about why it's so important to refer earlier and what you're looking for from them.

Dr. Aashish Dua: So, just to give you an example, one of the bigger areas of research and also an area where a lot of work is being done is in the aortic valve disease patients. So just to give you an example, those folks that actually in the past were treated surgically, as we all know, a lot of centers in the country are now treating them transfemorally with TAVR procedures.

We all know that patients who start to develop symptoms, their quality of life is affected. But more importantly, they also can die suddenly. So if you do recognize patients who have aortic valve disease and are managing them and following them, the patient who's not physically very active and not able to express their symptoms, they need some kind of testing or referral early on so that we can recognize when that downward spiral will start.

And if you don't refer in time, unfortunately, some of these folks, by the time we try to take care of them, it's too late in the game and the ejection fraction has decreased significantly and the risks and mortality go up from the procedure itself. Most of the times, we are able to offer surgery in these folks, in the younger folks. But in the older patients who are infirm or who are not able to get out and have other comorbidities, TAVR is a very good procedure. And the earlier it's done in capable hands has shown improved outcomes, improved survival in this very high-risk cohort of patients.

And also, this applies to cardiac disease as well. If you're not able to take care of these patients in a timely fashion, you are basically risking myocardial infarctions and worsening quality of life, as well as drop in their ejection fractions, which again will translate into increased hospitalization and more mortality and more morbidity for these patients.

So, I think just giving an example, early referral will start the process, may not need a procedure done, but the monitoring phase is extremely important and close observation and close contact with these patients is extremely important to make sure they don't fall off.

Melanie Cole, MS: Well, you made some great points there, Dr. Dua. And with state-of-the-art cath lab enabling minimally invasive high-acuity care, as I understand it, the cath lab supports drug-coated balloon angioplasty, carotid stenting, pulmonary interventions, and advanced circulatory support. I think you touched on that. Tell us how the exciting new technology reduces that need for open surgery, improves those recovery times, and what excites you the most about some of that new technology?

Dr. Aashish Dua: Yes. So, I think that if I was to date back, I think, our journey towards these high-end procedures started right around COVID times. And if you remember at that time, we had a lot of patients coming, who were very sick, either from pulmonary emboli or respiratory failure and shock, who required circulatory support along with advanced treatment.

So because of the need for beds, trying to get these patients treated in a timely fashion, we were able to expand our service line to take care of these high-end procedures. And pulmonary embolism comes to the forefront. Patients with shock comes to the forefront. We were already doing carotid work, peripheral work already in our patients. But because of doing high complexity of care in these very sick patients, we found other issues, peripheral vascular disease, carotid disease, that we had to take care of to get the patient healthy again. So, I think it was a halo effect.

And as a result, one procedure, which was done for the patient to help them feel better, unfortunately, they had disease elsewhere as well. So, we need to take care of the whole patient, not just take care of one problem. So after COVID, our expertise in all these areas has significantly increased our comfort level, our staff's comfort in doing these patients, the nursing, the techs, the physicians. All of us have actually adopted this early on and now are able to take care of these patients without having any hesitation.

So, all these things that you mentioned have grown dramatically over the last three to four years. And unfortunately, I don't want to thank COVID for that, but it allowed us to delve into areas where we were not comfortable in maybe before 2020 or so.

Melanie Cole, MS: And Dr. Dua, in that answer, you just mentioned colleagues and learning. And as AHN delivers coordinated care across cardiology, cardiac surgery, and the subspecialties involved, tell us how referring physicians benefit from that clear communication, streamlined referrals, and shared patient management.

I'd like you to tell us about your team-based approach and collaboration and the importance of that multidisciplinary care model for these referring physicians, because that's where they get that reassurance that their patients are really getting that great collaborative care

Dr. Aashish Dua: Yeah. That's an excellent point you raised, and I think that's where our team-based approach comes in. And we have this model in which we have the patient as a central figure. And every caregiver around him is basically focused on delivering that care, whether it be an interventional cardiologist, radiology, CT surgery, vascular surgery, and/or the referring physician. That's also one of the main points where we actually want to make sure that we have what we call shared decision-making. Because not always do you need a procedure done, not always do you need an advanced surgical procedure or a very complex procedure done, but it's important to involve that patient. And when we do the shared decision-making, we are communicating actively with the referring doctors, with our partners in various specialties, and coming up with the best care.

The way we're going to take care of this patient, which takes priority, how are we going to go about it, that all is held in meetings. We have Wednesday meetings dedicated towards TAVR. We have Thursday meetings dedicated towards our Watchman procedures. So that way, we are actually able to collaborate with the referring doctors, give them information. And then, once we have taken care of the patient, hand it back to them, and then continue to maintain that close communication loop.

So if something happens post-procedure, we are easily approachable and are able to take care of any complications that may arise. So, I think that patient being the central figure helps us make those communication with them and the family. And all the subspecialties that we have at our disposal, we can have open lines of communication and try to go through and sift through all the complex issues and come up with a plan A and plan B, and so to say, and then kind of work our way through that.

Melanie Cole, MS: Yeah, that's really such a comprehensive approach. And Dr. Dua, we mentioned some of those technologies, and with all the exciting access to novel technologies and emerging therapies, tell us how the program is incorporating leading-edge innovations like AI and next-generation device therapies. How do patients gain access to these kinds of treatments that are not widely available in all the markets?

Dr. Aashish Dua: So, I think the great thing about this is that I think patients are now getting more involved in their care than ever before. As you know, with all the models that they have at their disposal, with Claude and ChatGPT and everything, they do their own research, which is great. Because in fact, when they come to us, they are really as informed, some of them, and some of their family members are informed about this, and they have asked some tough questions.

And I think we as providers have to be ready with those answers. So, AI has definitely allowed physicians as well as patients to be more involved in their care, and they're able to ask some intelligent questions, as well as that shared decision-making becomes a central point. And it basically allows us to go into areas where the patient will say, "Well, I read about this, and is there a possibility?" And we have to sometimes go back to the drawing board and reanalyze what the situation is and figure out the best strategy for this patient.

Now, a lot of research is done at Allegheny General. As you know, most of the papers that are coming out are mostly based on that. So, I think the key is to try to figure out how we can incorporate AI into our everyday approach. But as I said, because the patient is as involved as the provider, I think now it's tough to basically not be able to answer those tough questions that we have.

Melanie Cole, MS: Tell us a little bit, Dr. Dua, how the cath lab supports these advanced interventions. We've only touched on those, and including ECMO and the percutaneous ventricular assist devices. There's so much. So when you speak about referral and earlier is better and better outcomes, speak about referral for emergent conditions versus electively.

Dr. Aashish Dua: So, we have a great shock team now. Shock team and PE teams are available at our institution in which we are able to recognize a patient who's come into the emergency room who's impendingly getting worse. And now, we've incorporated that into a model, in which we are able to cannulate these patients early on, but after having a discussion with a shock team approach at Allegheny General.

And as a result, because of that, we are able to not just transfer the very sick patient who may not even make it to the quaternary healthcare system, but by early cannulation, stabilization, taking care of the acute issues here, and then transferring the patient if the need arises, has worked out very well for our institution because we are now able to offer that early support to these patients.

And I think that comes from the days with COVID when we had experience with cannulation in some of the sickest of the patients who actually were having difficulty with their respiratory and cardiovascular systems. So by doing so, we were able to put them on ECMO, put them on advanced support and stabilize them. And even patients who actually were actively arresting, we were able to get them salvaged because of that.

So by doing so, we are able to now offer care in our community, and patients can, without any hesitation, come into the emergency room, know that they will get top-notch care and not be transferred somewhere in which their condition may not allow them to and are at least able to offer high level of care and basically stabilize them in the local hospital. And if we do need to transfer them for transplant evaluation or advanced VAD therapies, then we have a great referral system based with Allegheny, and we have a nice bridge that we can get over there and take care of those issues too.

So by doing so, we are again offering patients care in the community itself, which is what our intentions are to provide high level of care locally.

Melanie Cole, MS: You've given us some great information, Dr. Dua, today, a lot to think about. It's such an exciting time in your field. And as we wrap up, as we recognize the growing complexity of patients, which you have discussed here today, and procedures at your facilities, tell us about your patient-centered approach with shared decision-making in patient care with that collaboration between AGH and Forbes. Kind of summarize it all for us with what you would like the key takeaways for other providers to be from our discussion today.

Dr. Aashish Dua: So, I would like to say that the referring providers need to be reassured that when we do get a patient in our facility, we have a very open-ended approach where our patient comes first. And whatever needs to be done in our institution with all these specialties that we have at our disposal, the team-based approach, they can be reassured that we will take excellent care of these patients.

And also, the communication lines between our quaternary and tertiary healthcare systems is always open, and we always are communicating back and forth about our complicated patients. So, there is always expertise available at multiple levels and multiple layers that we can go into to take care of any patient.

So, I would say we haven't no hesitation in accepting any patients who are coming through our doors and able to give them the top-notch care that we can. And again, because of the model that we have created, I think that has allowed us to continue to perform at a high level and have good outcomes, which is what, at the end of the day, is to make the patients feel safe as well as give them top-notch care.

And I don't think the providers who are referring to us need to be concerned about that their patients are not going to get that top-level care because we make extra emphasis on that, and we make sure that these patients are well taken care of.

Melanie Cole, MS: Beautifully said. Thank you so much, Dr. Dua, for joining us today and sharing your incredible expertise and telling us about what you do every day. So, thank you again. And to learn more or to refer your patient to Dr. Dua, please call 844-MD-REFER, or you can visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.