The State of Care: At the Heart of It

By Christine Yu | Portraits by Jörg Meyer

In the spring of 2020, at the height of the pandemic, Columbia’s cardiologists faced a dilemma. Not only were physicians pulled off their service and into COVID-19 hospital units, members of the advanced heart failure and transplant cardiology team needed to figure out how to continue to care for their patients. “We realized we had to do something right now,” says cardiologist Kelly Axsom, MD. 

So they created a centralized, multidisciplinary team. Any patient with a device capable of monitoring patients—such as a weight scale, blood pressure cuff, or CardioMEMS unit that tracks pressure in the pulmonary artery—was pulled into a remote monitoring program. The program started with 90 patients in April 2020.

The devices allowed doctors to see when something changed, like blood pressure that was too high or too low or atypical changes in weight. They also worked seamlessly with the electronic medical records system to treat patients immediately and adjust medication dosages without an office visit. 

Since its inception, the program has served over 1,000 patients with heart failure from across the New York metropolitan area. “Patients can’t stop raving about how excellent the care is, how much better they feel, how quality of life has improved being in a program like this,” says Dr. Axsom, who leads the centralized team. 

Chronic heart failure affects more than 6 million Americans and doesn’t exist in isolation. Patients often have multiple medical problems in addition to heart failure, making it a complex condition to treat. It’s deadly too. “It’s worse than having metastatic cancer, especially if you’ve had a hospitalization for heart failure,” says Dr. Axsom. Heart failure costs an estimated $30 billion each year in treatment, medication, and lost working days.

Columbia serves one of the largest heart failure and cardiac transplant patient populations in the country and is committed to changing the trajectory for these patients. The remote monitoring program is just one example of an evolving suite of diagnostic and treatment options to help physicians identify patients early and get them the care they need. It’s part of Columbia’s ongoing commitment to ensure that all heart failure patients get the best quality of care and live longer and better lives.

Proactive Management

A major constraint to the treatment of heart failure patients is the capacity of specialists. Not enough specialists are available to care for these patients.

Historically, doctors have relied on patients to tell them when they felt unwell, so doctors may miss opportunities to intervene early. Symptoms ebb and flow and the debilitating symptoms that patients report can be a late sign of decompensation. 

“There are physiological changes that happen about a month prior to someone feeling sick enough that they end up in the emergency room or need an IV dose of diuretics,” Dr. Axsom says. “If we can prevent those symptoms, we can probably prolong the life of these patients and the viability of their hearts.”

It also takes time to get patients on the right pharmacological therapy. With patient visits scheduled every three to six months, it can take a year or more to get a patient on the maximal tolerated dosage in a safe manner. However, remote treatment can reach the goal in three to six months.

Treating patients outside of the clinic and asynchronously increases the heart failure team’s capacity. Using remote monitoring devices and standardized care protocols, the program proactively observes and treats patients between visits to prevent decompensation. The devices flag changes in a patient’s status, even if they are not experiencing symptoms, potentially catching problems early. Patients can message the team any time of day with questions or concerns. 

Dr. Axsom describes the remote monitoring program as “checking in with a purpose.” Patients are contacted if they require ongoing attention, had an event that resulted in hospitalization, or are referred by their provider. The program has between 350 to 400 active patients.

Remote monitoring has improved quality of life for patients too. For instance, the team noticed that one patient’s numbers spiked every Sunday. It turned out that Sunday was family dinner, an important tradition. Instead of telling the patient to abstain from the meal, the team advised the patient to adjust the medication beforehand to avoid an episode the next day that might require medical attention. “It’s not to take away people’s joy,” Dr. Axsom says.

Patients in this program have experienced an 81% reduction in heart failure hospitalization and a 64% reduction in other hospitalizations. 

Life Extension Options

While medication and programs like remote monitoring can improve the health and quality of life of heart failure patients, some people eventually stop responding to treatment and may qualify for a heart transplant or heart pump, such as a left ventricular assist device (LVAD).

LVADs haven’t always had the best public image. In many cases, these surgically implanted pumps have been considered a temporary fix until a donor heart becomes available. Plus, early versions were bulky, noisy machines that weren’t durable. They were associated with high rates of stroke, bleeding, and clotting. Patients had to exchange their pumps because of clots, which meant an additional surgery and hospital stay.

The LVAD field has made major advances over the past 20 years. Modern heart pumps are much smaller and more durable and are no longer implanted just as a bridge to transplantation. They can extend a patient’s life with survival rates on par with heart transplant recipients. “This is great news for patients. It’s yet another option that can save the life of a heart failure patient,” says Paolo Colombo, MD, medical director of the mechanical circulatory support program.

The current heart pump available—HeartMate 3—is a fully magnetically levitated centrifugal continuous flow LVAD. The pump accelerates and decelerates every two seconds, essentially shaking the blood in the pump and preventing clots from forming. Columbia was one of the first institutions to make HeartMate 3 available to patients as part of the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) clinical trial.  

The trial—Columbia enrolled the largest number of participants—randomized patients to receive either the old HeartMate II or the new HeartMate 3 to compare outcomes. The results, published in the New England Journal of Medicine, found significant improvements in HeartMate 3 patients. At two years, the survival rate was 80%, the stroke rate fell below 10%, and pump clotting was only 1%. Most recent MOMENTUM 3 data show that the survival at five years was 58.4% with fewer complications compared with HeartMate II. Columbia results are even better with a survival rate in patients who received HeartMate 3 of 88% at two years and 70% at five years. Complications are also less at Columbia compared with the MOMENTUM 3 results. “Not only were we leaders in testing this new device, if you look at the results of our program in isolation, we were able to do much better than what was published, despite the fact that our center implanted the device in much sicker patients than reported in the trial,” says Dr. Colombo.

He believes that part of the reason Columbia’s patients fared better is the team charged with caring for them. “We have a very organized, well-oiled system,” he says, one that spans multiple disciplines and specialties. The team is in constant communication. Pre- and post-surgery huddles allow the team to review the case in detail and make a plan. Well-defined protocols are followed if complications occur during and after hospitalization. 

With results like this, LVADs are no longer just a stopgap. “My patients with LVAD play full rounds of golf and travel everywhere. Their quality of life has totally changed. They get back the energy that they didn’t have before,” Dr. Axsom says. “It’s not perfect but we’ve come a long way.” 

Multidisciplinary Model

The strong results achieved by the remote monitoring program, the LVAD team, and other cardiology programs all hinge on a multidisciplinary model of clinical care to treat complex conditions. “The ability to collaborate and innovate, in a way it’s like you’re an artist. You’re able to push the science because you have so many different experts in their respective fields working together,” says Erika Berman Rosenzweig, MD, director of adult and pediatric pulmonary hypertension comprehensive care at NewYork-Presbyterian/Columbia. 

Pulmonary hypertension affects the blood vessels in the lungs. As pressure increases, it puts strain on the right side of the heart. If untreated, it can lead to right heart failure. When Dr. Berman Rosenzweig started in the field in the 1990s, a diagnosis of pulmonary hypertension was considered fatal: no cure and significant morbidity and mortality. Still, Dr. Berman Rosenzweig says, “I don’t ever want to tell a patient I can’t help them. My team and I create solutions so that I never have to say we don’t have anything to offer.”

Columbia’s Pulmonary Hypertension Comprehensive Care Center is one of the largest programs of its kind in the country and among the first to be accredited by the Pulmonary Hypertension Association in both adult and pediatric pulmonary hypertension. It serves patients of all ages, from newborn to adult, and treats all forms of pulmonary hypertension, ranging from idiopathic pulmonary hypertension to secondary forms of the disease caused by other underlying conditions. 

The center began under the leadership of the late Robyn Barst, MD. Her work ignited an important period of drug discovery for the condition. When Dr. Berman Rosenzweig became the center’s director in 2008, she continued Dr. Barst’s legacy and commitment to improved patient outcomes. Dr. Berman Rosenzweig realized patients needed more than just medication and began to build a multidisciplinary team. “It was very important to me to have these collaborations and to be able to offer every patient every option, whether it was surgical, medical, or interventional,” she says.

The center has been at the forefront of clinical trials that have led to new FDA-approved drugs, genetic discovery, multiomics research to understand the underlying fingerprints associated with pulmonary hypertension, and specialized surgeries that have transformed treatment options. 

The team at Columbia was the first to perform a unidirectional valved shunt in a young adult with idiopathic pulmonary hypertension, a potential alternative to lung transplantation. It’s one of only a few programs to offer pulmonary thromboendarterectomy, where clots are removed from the lungs of patients with chronic thromboembolic pulmonary hypertension, which is potentially a cure for some patients. Columbia was also one of the first to apply extracorporeal membrane oxygenation (ECMO) to stabilize adult patients with pulmonary hypertension. “Nobody would previously put a patient with pulmonary hypertension on ECMO because they never thought they’d survive. We changed the whole paradigm,” says Dr. Berman Rosenzweig.

“I’ve seen incredible advances over the years, from saying, ‘We don’t have anything to offer you,’ to being able to tell people, ‘We’ve got this. We’re going to work on this together,’” Dr. Berman Rosenzweig says. She’s cared for some patients for 25 years. “It’s a miracle. No one ever imagined that we could manage patients for so long with this previously universally fatal disease.”

A More Robust Clinical Picture

The multidisciplinary model isn’t just a cornerstone of clinical care at Columbia. It’s an essential element of programs in lymphatic imaging and intervention and advanced cardiac imaging. These programs help guide patient care in important ways, thanks to advances in technologies and imaging techniques over the past several years. Advances have led to imaging studies that give physicians a deeper understanding of a patient’s clinical picture.

The genesis of the lymphatics imaging and intervention program can be attributed to a little bit of kismet, fate, and location. The interventional radiology, MRI, and interventional cardiology suites are located next door to each other. “In our close proximity, we realized that we were all caring for similar patients with similar problems,” including patients with congenital heart disease who have lymphatic disorders, says Sheryl Tulin-Silver, MD, director of pediatric interventional radiology. 

Lymphatic disorders are complex and present in many different ways. Dr. Tulin-Silver, along with Michael DiLorenzo, MD, a pediatric cardiologist who specializes in noninvasive imaging, and Matthew Crystal, MD, a pediatric interventional cardiologist, saw an opportunity to improve patient care and treatment. “It was an ‘aha!’ moment. We have the imaging opportunity, the interventional opportunity, and the clinical expertise. We can make this work,” Dr. DiLorenzo says. 

The team adapted imaging techniques used for other organ systems and applied them to the lymphatic system. The process takes a team of 15 to 20 people to coordinate all the details. The patient is placed on a special MRI- and fluoroscopy-compatible board. In the fluoroscopy suite, Dr. Tulin-Silver uses ultrasound to place small needles into the patient’s inguinal lymph nodes and glues them in place.

The patient is then transferred to the MRI suite. “I’m in the scanner with the patient injecting contrast into the lymph nodes,” says Dr. Tulin-Silver, while Dr. DiLorenzo performs the imaging. The contrast tracks the flow through the lymphatic system in real time and with fine detail to identify leakages, blockages, anatomical variations, or other concerns. If an intervention is appropriate, the patient is transferred to the interventional suite.

The imaging studies have assisted the care team in making important decisions. “It’s helped us down that fork in the road,” Dr. Tulin-Silver says, “either medical, surgical, or just answered the question of what a patient’s anatomy looks like.” They have identified important blood vessel problems. Other patients have gone on medical therapy, which improved their condition based on what was found in the studies.

Similarly, the advanced cardiac imaging group is an important part of care for patients with advanced cardiac disease. “We are consultants to our cardiology and cardiac surgery colleagues,” says Jay Leb, MD, director of cardiac imaging in radiology. “It is our role to utilize advanced cardiac imaging techniques to help explore complex clinical questions and guide patient management.” The imaging modalities include echocardiography, CT, MRI, and nuclear medicine. 

The group is composed of both cardiologists and radiologists who work collaboratively—each bringing their respective clinical perspective and imaging expertise—to interpret the images and arrive at the correct diagnoses. Imaging is also critical in planning complex surgical and percutaneous procedures, such as transcatheter valve replacement, and in evaluating the results of these procedures. 

Additionally, improved technology has made it possible to better assess patients’ risk for heart disease. CT scanners are now so fast they can image the heart in one heartbeat with exceptional clarity. As the demand for cardiac imaging has exponentially increased, Columbia and NewYork-Presbyterian continue to invest in new and advanced scanners and technology. “This allows for greater patient access to cutting-edge cardiac imaging technologies and enables the physicians to explore complex clinical questions with greater accuracy,” says Dr. Leb.

Who's Who

• Kelly Axsom, MD, assistant professor of medicine 
• Erika Berman Rosenzweig, MD, professor of pediatrics (in medicine)
• Paolo Colombo, MD, the Sudhir Choudhrie Professor of Cardiology (in Medicine)
• Matthew Crystal, MD, associate professor of pediatrics
• Michael DiLorenzo, MD, assistant professor of pediatrics
• Jay Leb, MD, assistant professor of radiology
• Sheryl Tulin-Silver, MD, assistant professor of radiology