Improving Treatment for the Smallest Heart Patients

August 17, 2022

More and more, babies with congenital heart diseases are diagnosed before they are born thanks to advances in ultrasound technology. Dr. Sheetal Patel, Director of Lurie Children’s Fetal Cardiology Program with the hospital’s nationally ranked Heart Center, discusses advances in this type of medicine, including a newly developed process at Lurie Children’s that streamlines the transferal of newborns with heart conditions to Lurie Children’s from their hospital of birth, reducing transfer time and risks to the baby.

Featuring

Sheetal Patel, MD, MSCI, FAAP is Medical Director, Fetal/Neonatal Cardiology; Fetal Cardiac Co-Director, The Chicago Institute for Fetal Health; Attending Physician, Cardiology; Assistant Professor of Pediatrics, Northwestern University Feinberg School of Medicine. 

Learn more about Sheetal Patel, MD, MSCI, FAAP

Topics Covered

Dr. Sheetal Patel is the Medical Director of Fetal Cardiology at Lurie Children’s, helping diagnose and make treatment plans for pregnant patients when their unborn baby has a heart condition.
Once a heart abnormality is detected in an unborn child, Dr. Patel and team make a plan for delivery and cardiac care for the baby. The team ensures all the specialists and equipment or surgical care the baby will need once born is in place.
The goal of the fetal care team is ensuring every baby with a diagnosis has an individuated plan to ensure the best outcome for the child.
Most babies even with complex cardiac conditions do well in utero because the pregnant patient does most of the physiological work for the fetus. The fetal cardiology team’s focus tends to be on making plans after the baby is born.
Certain fetal cardiac conditions, though, will require close monitoring during pregnancy and possibility of early delivery.
Lurie Children’s is connected to Prentice Women’s Hospital via a bridge so if a baby is born there with a complex heart condition, transfer of the baby is streamlined and efficient.
Dr. Patel and team developed “Code Rainbow,” a protocol to reduce transfer time from a baby’s hospital of birth to the hospital where they will receive cardiac care. The fetal cardiology team prepares everything the baby will need following birth so the child just has to be stabilized and brought to the location where the team is ready for them. This approach helps reduce the time the baby spends in transport and prevents the baby from having low oxygen or blood pressure.
Survival rates for babies with congenital heart defects have vastly improved the past 40 years, and Dr. Patel anticipates even better survival rates 10 years from now.

Additional Resources

Transcription

Maggie McKay (Host): More and more babies with congenital heart diseases are diagnosed before they are born thanks to advances in ultrasound technology. Our guest today is Dr. Sheetal Patel, Director of the Fetal Cardiology Program at the Ann & Robert H. Lurie Children’s Hospital of Chicago with the hospital's nationally ranked heart center, who will discuss advances in this type of medicine, including a newly developed process at Lurie Children’s that streamlines the transferal of newborns with heart conditions to Lurie Children’s from their hospital of birth, reducing transfer time and risks to the baby.

This is Precision: Perspectives on Children’s Surgery, the podcast from Lurie Children’s Hospital. I'm Maggie McKay. What a pleasure to have you here today, Dr. Patel. Thank you so much for being here and making the time.

Dr. Sheetal Patel: Hi. Thanks, Maggie. Thank you for having me on the podcast.

Maggie McKay (Host): Absolutely. I am so interested to talk to you and find out more about how you're improving treatment for the smallest heart patients and the advances in fetal cardiology. So will you please introduce yourself and tell us your title?

Dr. Sheetal Patel: Of course, Maggie. I'm Sheetal Patel, I'm one of the pediatric cardiologists and fetal cardiologists. I'm also Director for the Fetal Cardiac Program here at Lurie Children’s Hospital and Chicago Institute for Fetal Health.

Maggie McKay (Host): And as the director of the Fetal Cardiology Program at Lurie Children’s, what is your role treating heart conditions in fetuses and newborns?

Dr. Sheetal Patel: So I overlook the program that provides a study called fetal echocardiogram, which is ultrasound for the baby before they're born. So we are scanning the pregnant mothers to see if they're unborn babies have a heart condition or not. Once we detect the abnormality, we go into detail of exactly how this heart is. And then, we make a plan for the delivery and cardiac intervention for the baby based on the cardiac diagnosis. So we go into whole lot of detail and very precise cardiac diagnosis, which helps us then plan what the baby will need after birth so that we can have all the specialists, all the surgical equipment, everything ready for this baby.

Our goal is for precise diagnosis and then, once we make diagnosis, to make appropriate and individualized delivery plan for each mother-baby dyads. So that way, every single baby has individualized delivery and intervention plans before they are even born. And that way, all the teams are ready for this baby.

Maggie McKay (Host): Wow. How did you get into this specialty?

Dr. Sheetal Patel: While doing the pediatric cardiology training, I always loved imaging, because I'm a very visual learner, I learn by seeing things. I am a lot into photography as well in my non-professional life. So, the imaging was very much of interest of mine. And then, after I started doing cardiac imaging as a specialty, I really connected well with the parents who were expecting babies with heart conditions, because that's a very stressful time. And I felt that I was able to talk with them and counsel them and help them. So, that experience was so good. I just continued working in that field. So that's how I ended up here, doing mainly cardiac imaging and spending a lot of time in prenatal detection and planning for the congenital heart disease.

Maggie McKay (Host): And tell me about the range of fetal heart conditions that you see.

Dr. Sheetal Patel: We see like all the way from screening fetal echocardiogram, which means that if a baby is at a higher risk for congenital heart defect, we are just screening the heart to make sure everything is okay. And most of the time, these are the normal hearts and parents come in worried and then go home happy. So that would be the normal heart.

And, on the other end, we see very complex cardiac conditions where there are missing chambers, missing valves in the fetal heart. Also, other complex groups when there's complex cardiac condition along with other organ problems, such as missing kidneys or underdeveloped lungs, which makes the postnatal management far more challenging. So we take care of fetuses with structural heart conditions. We also see fetuses with cardiac rhythm abnormalities, so too fast of a heartbeat, too slow of a heartbeat. And then also, cardiac function abnormalities where heart is not working well and, therefore, the fetuses are going in heart failure.

Maggie McKay (Host): That is a lot of possibility. I mean, who knew that there were all those things that could be missing? I mean, can a fetus survive a missing chamber in their heart until they're born?

Dr. Sheetal Patel: Yeah. So the interesting thing is that because mother is doing most of the work for the baby while baby is in utero, surprisingly, even if a chamber is missing, they do well in utero. They go full term. They are able to be born by normal vaginal delivery. They don't need C-section. So most of the babies do well in utero and our focus is just making plans after baby's born, so that we can support the babies appropriately.

Now, there are certain instances where the baby is not doing so well with the cardiac condition and we need to have a close monitoring and possibility of early delivery, because baby's not doing so well inside. So yes, there are some conditions like that. But most of these babies do really well while they are inside.

Maggie McKay (Host): Dr. Patel, what makes Lurie Children’s and the Chicago Institute for Fetal Health within the hospital a uniquely qualified place to diagnose and to care for the unborn and newborns with congenital heart conditions?

Dr. Sheetal Patel: I would say our strength lies in our team. We are 11 fetal cardiologists. But not only that, we have tremendous amount of support structure, whether it is having social work, genetics, nurse coordinators, navigators supporting the family as a whole. So we don't only look at the baby's heart, but we look at how the mom is doing, how dad is doing, how the family support structure is, what else the baby and the family will need. We also are fortunate to work with many other subspecialties that all come to the table. And we are able to do combined counseling. For example, if there is a cardiac condition and kidney condition, then cardiologists and nephrologists are doing joint counseling, so that we can kind of base our counseling based on what other conditions are there.

So our large team and multiple specialties would be definitely a plus point, because it's never just heart. You have to look at the baby as a whole child. And then, not only that, we need support from our coordinators and other support staff because, at the end of the day, we are not only treating the fetus, but we have mom and we have dad and we have family that we are supporting.

Another good thing that I love, working at Lurie Children’s, is that we have all the specialties that we could think of in taking care of any complex lesion. For example, we have the only heart transplant center in the state of Illinois, so that if baby has cardiomyopathy and heart is not working well and needs transplant after birth, then we would be the center taking care of that baby. We have cardiac catheterization, electrophysiology, really highly ranked cardiac surgical program with great outcomes. So, I think the combination of that makes it very satisfying to work in a center like Lurie Children’s.

Maggie McKay (Host): You recently helped develop a streamlined process of transporting newborns from their place of birth, usually Prentice Women's Hospital within Northwestern Memorial Hospital to Lurie Children’s for care. Tell us about this process and why it's so beneficial for the baby.

Dr. Sheetal Patel: Lurie Children’s is not the only unique Children’s hospital in a sense when I say that we don't have delivery services within the Lurie Children’s Hospital, because we are a Children’s hospital. We are connected with our maternal hospital and both hospitals are connected with a bridge. So, the scenario is that a baby with very complex cardiac condition is being born at Prentice Women's Hospital, and they need to be transported to Lurie Children’s, either operating room, cardiac cath lab, or our cardiac ICU for further monitoring and management.

Sometimes, depending on the heart condition, every minute counts. Every minute between the birth to the intervention is putting the baby at risk of problem maintaining the oxygen saturation and blood pressure. So we are trying to reduce the time from the birth to the intervention. So this new process that we developed three years ago is called Code Rainbow. We prepare everything this baby's going to need after the birth and everything is ready at Children’s Hospital, wherever the baby's going to go after their transfer. All that preparation happens even before the baby's born, so that after baby is born, all we have to do is stabilize the baby and bring to the location where the teams are ready for intervention. And this helps us reduce the time that we spend in transport and reduce the time that we are spending in preparation, because all the preparations are done. Not every single baby's going to need that, but there are certainly one or two babies every month that utilizes this workflow, whether that baby needs immediate cardiac catheterization or immediate surgical intervention. We have all the teams ready for the baby.

And that, over three years, we had 36 babies undergo this Code Rainbow workflow and our data shows that we have significantly reduced the transport time, we have reduced the time from birth through the intervention, and also this prevents baby spending time in low oxygen or low blood pressure state, which is great.

Maggie McKay (Host): That's impressive. Your research interests include congenital heart defects and cardiac imaging, including pediatric and fetal echocardiography. How does your research work translate to better patient care?

Dr. Sheetal Patel: We have been involved in many multicenter collaborative studies related to fetal cardiology, along with our collaborators through fetal heart society. Through those multicenter studies, we are trying to understand if we could predict the patient outcomes or baby outcomes based on their fetal echocardiogram, because that helps us counsel the parents and families about, "This is what we see on the fetal echocardiogram. And based on my findings, this is what I could predict," and lay out the anticipated surgeries, outcomes, et cetera.

In the prenatal life, once we make the diagnosis, it's a stressful time for parents and as much information we can provide or accurate information we can provide, it helps them understand the situation and get prepared. And that's what we are trying to do through our multicenter research, trying to pull data from about 20 other North American fetal centers and gathering the information, trying to be more precise in our prediction of what to expect after a baby is born with a congenital heart.

Maggie McKay (Host): Can you please tell us some details about the current research you're involved in at Lurie Children’s and the Stanley Manne Children’s Research Institute? How might it impact diagnosis and outcomes and treatment for fetuses and newborns who have heart conditions?

Dr. Sheetal Patel: So I'm currently a senior investigator on two multi-center studies in the fetal cardiology world. One is looking at the outcomes after prenatal detection of a condition called truncus arteriosus. We have 22 centers, we have completed the data and we are analyzing it, trying to predict the factors that affected the survival of those babies. The second research study that I am senior investigator is looking at the outcomes in condition called transposition of great arteries. So those are the two large studies going on, also looking at our Code Rainbow transport process data and then few other single-center or three or four-center data, all predicting the outcomes after the prenatal detection of the congenital heart defect.

Maggie McKay (Host): Wow. You must be very busy. Do you live at the hospital? Wow. That's a lot of time, isn't it?

Dr. Sheetal Patel: It is a lot of time, but we have great support structure at Lurie Children’s with our research team that helps with the researchers. I cannot think of doing it on my own. I have to give credit to the research team and my other colleagues or collaborators and also the Fetal Heart Society that have been awesome at pulling all the centers together so that we can do multi-center studies with fetal cardiology. These lesions are not that common to have any one center published meaningful data and, therefore, it is so helpful to get multiple centers contributing the data, so that we can reach to a sample size to make more accurate prediction. So, I am fortunate to have that team support to be able to do these research studies.

Maggie McKay (Host): Right. So looking back 10, 20 years, Dr. Patel, how has your field advanced? What does the future hold?

Dr. Sheetal Patel: Wow. I am so curious to see what I would be doing 20 years from now, honestly speaking, because the field is moving so fast. I would say that in last the 10 years we have so many added technologies for imaging. So for example, for the heart function, how well it is squeezing the blood, we used to just look at the ventricle and say, "Hmm, I think it works well" and "I don't think it works well," but that was about it about 10 years ago. But now, we have new technology of something called fetal ventricular strain imaging, which literally, it's artificial intelligence and it gives you a numerical value of how well or not well a ventricle is working.

We also are working with 3D technology to look at the heart. The heart is obviously a 3D structure and sometimes, a 2D representation doesn't help all the time. So we are working with a 3D fetal echocardiography. We are also making a lot of progress in fetal cardiac MRI, which lets you look at a cross-sectional imaging of the heart. There are few other things in the pipeline, which are related to artificial intelligence and trying to feed into the images. And then, the machine would suggest that this is a normal heart versus abnormal heart.

Now, at Lurie Children’s, we luxury of having fetal cardiology services. So we don't quite need that artificial intelligence, but we are working with industry to make the software so that when a woman gets her level 2 ultrasound, anatomy scan is what it's called in simple terms, they can have really good fetal cardiac evaluation so that if the heart does not look good, then somebody refers her to fetal echocardiography for further evaluation. And I think it's really important because, although fetal echocardiography technique has gotten really well, that technology's not accessible to the whole population. Although we have made progress, not all congenital heart defects are being detected prenatally. So we continue to get these babies who get diagnosed after birth, because it was missed before. Not because their fetal echocardiography was incorrect, but they never got fetal echocardiography

Maggie McKay (Host): And why is that?

Dr. Sheetal Patel: Well, the OB and MFM team, when they evaluate baby's anatomy, they're not trained adequately to look at the baby's heart to detect every single thing. If there's a major thing, for example, a missing chamber, that gets detected more easily and the percentage of prenatal detection is high. But when the defects are not so obvious to untrained eyes of OB ultrasound technologists, that's when things get missed. We are also doing a lot of workshops, training workshop, or fetal cardiac workshop what we call it, in order to provide more skill and more training to OB and MFM sonographer, so that they can detect these things. See, it wouldn't be logistically possible for every single pregnant woman to get a fetal echocardiography. It's a resource-intensive test, but every single pregnant woman does get level 2 ultrasound, also known as anatomy scan. So if we could train the anatomy scan technician to look at the heart in more detail, or we can provide them with an AI software, which says, "Yes, heart is good" and "No, something is wrong," then we can help all those women with possible cardiac heart defects in their babies have further the evaluation. So hopefully, we can make some differences and hopefully we can continue increasing the percentage of these babies with congenital heart defect detected prenatally.

Maggie McKay (Host): And you've said you get emotional fuel from the families of your patients. What gives you hope for pediatric patients with these conditions?

Dr. Sheetal Patel: Yeah. The time that we are in right now are good times to be a fetal cardiologist, because for most of the cardiac defects, I could tell them that, "Hey, there is more than 95% of chance that your baby will survive this surgery," which is much better compared to what we used to quote just 30 years ago. Even for the very, very complex conditions where half of the heart is missing, even with that condition, we could say, yeah, that 80% of those be we survive up to five years of age. So I think as the congenital heart surgical outcomes are improving, I think that, although it is a really stressful situation for parents, knowing that their baby has really good chances of survival, I think that's very encouraging. I feel like it would be a really sad field to be in, if I could say, "Your baby has a heart condition and we have nothing to offer." I think that will be really sad. But I'm happy I'm not a fetal cardiologist that was born 40 years earlier. And these survivals are getting better. So I'm sure 10 years from now, we would be quoting even better survival rates.

So I think that's what gives you hope. It's a hard situation, but I think that if we detect appropriately, we plan correctly, I think we can look forward to good survival outcomes and that's what gives me hope.

Maggie McKay (Host): So of course, you take care of the littlest heart patients, but it's got to be especially nerve-wracking for the parents and the family. And at Lurie Laurie Children’s, you do even more for the families and the moms after the baby arrives. Can you tell us about that?

Dr. Sheetal Patel: So, because we are focused in taking care of the whole family, not just the baby, we have also created a lot of parent resource material to help parents get ready for having their baby with congenital heart defect. For example, we have created videos for how to get ready to breastfeed your baby with congenital heart defect. And the video was compiled with the help of lactation specialists and speech therapists and expert nurses, so that the mothers can view those videos and get ready. If they are interested in breastfeeding their baby with congenital heart defects, then we are ready to support them.

We have also made other videos, for example, what is interstage monitoring for very complex congenital heart defect babies, so that the families would understand how the care of the baby will look like for a few months after the surgery and once they take the baby home. These videos are very helpful. And again, we did all that to achieve our goal of preparing the family to have the baby with a congenital heart defect.

Maggie McKay (Host): The Chicago Institute for Fetal Health at Lurie Children’s is made up of specialists in other fields as you were talking about a little bit earlier that you work closely with for some patients, such as genetics and neonatology. How does it enhance care for patients to have all these specialists working together? I know we talked about it a little bit, but can you talk a little bit more about that?

Dr. Sheetal Patel: So, congenital heart defect is never a one-person sport. It's a team sport. From the time the baby's born, I am going to need help from my neonatology colleague for initial stabilization. Then, I'm going to need help from my cardiac ICU attendings to take care of the baby once baby arrives to cardiac ICU. And then, I'm going to need CV surgery, cardiac anesthesia, sometimes cardiac catheterization. And then, if babies have other organ abnormalities, for example, renal problems happen more often in babies with heart conditions. So if there are renal abnormalities, then I need my nephrology colleagues to chime in.

So that's why it's so nice to look at the baby and summarize all the things and then bring all the specialists on the table. And it's super valuable to do counseling together because then, for example, in a big team meeting, we would usually have six or seven providers in the meeting. And I would go over my cardiac findings, then my nephrology colleague will go over the renal findings and then, together, we'll go over what it means for the baby to have a heart condition and the renal condition. After the meeting, we all get together and make the plan for the delivery and after birth and all the things get factored in. So that's why I think for the fetal world, it is absolutely necessary to have a team aspect for the planning and counseling.

Maggie McKay (Host): Dr. Patel, thank you so much for making the time to be here today to share your expertise on this crucial and oftentimes life-saving work that you do. Thank you so much.

Dr. Sheetal Patel: You're welcome. Thank you for having me.

Maggie McKay (Host): To learn more, please visit luriechilDr.ens.org/heartcenter. For more information or to find out how to make an appointment, you can call 1-800-KIDS-DOC. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you.

This is Precision: Perspectives on Children’s Surgery, the podcast from Lurie Children’s Hospital. I'm your host, Maggie McKay. Be well.