Dr. Deepa Gopal’s Program
Co-Directors of IPH-Lab: Nir Ayalon, MD & Deepa M. Gopal, MD, MS
We launched the IPH-Lab at Boston Medical Center (BMC) in September 2019. Our mission was to bring high-caliber, cutting-edge, and tailored cardiac hemodynamic evaluations to enhance diagnostics and optimize treatment at BMC. Two core programs are run in the IPH-Lab: the Invasive Cardiopulmonary Exercise Testing (iCPET) and Heart Failure Remote Monitoring Program (CardioMEMS). Each of our two programs are briefly discussed below.
Our iCPET program is a clinically-ordered test to help decipher unexplained dyspnea in patients. This test harnesses simultaneous invasive hemodynamics (using a Swan-Ganz catheter and radial arterial line), echocardiography, blood sampling, and cardiopulmonary exercise testing. We obtain resting hemodynamics and echocardiography and then exercise a patient on a supine bicycle until exhaustion or development of symptoms. During exercise, we measure changes in hemodynamics, obtain CPET data, sample arterial blood, and perform echocardiography. This testing modality enables deep phenotyping of individuals to tease out primary drivers of dyspnea: cardiac, pulmonary, and/or peripheral (skeletal muscle) contributors. This test can be used for earlier diagnosis of heart failure (HF) (particularly in preserved ejection fraction individuals), help identify key factors of dyspnea in patients with multiple and challenging co-morbidities (lung disease, obesity, amyloidosis, etc), and help us guide important therapies and interventions (such as timing for valvular cardiac surgery or cardiac transplantation). This testing modality is designed to assist the treating clinician and can be tailored to help them obtain the necessary data to aid in clinical-decision making. Both Drs. Ayalon and Gopal are involved in each of these tests and generate an integrative report with the findings. This testing is available to all providers at BMC to utilize for their patients with dyspnea.
The CardioMEMS is a recent FDA-approved device that is comprised of a dime-sized sensor that is placed (permanently) in a distal pulmonary artery (PA) branch. This device connects remotely (via a special electronic system in the shape of a pillow, that is given to the patient) and generates PA pressure waveforms that can be accessed via a web-based portal by the patient’s cardiology providers. This device is innovative as it allows instantaneous hemodynamic monitoring in our HF patients, often our most difficult patients to treat at BMC. It enables a precise hemodynamic information to detect volume overload 2-4 weeks prior to weight gain and initiation of symptoms and once placed, obviates any need for right heart catheterizations. The CardioMEMS has been shown in randomized-controlled trials to decrease HF hospitalizations. Early identification of volume overload enables the treating clinicians to escalate therapies and diuretics in the outpatient setting and prevents HF hospitalizations. It is placed as an outpatient or an inpatient procedure, with a minimal risk to our patients. Lastly, this device has a variety of clinical conditions that it can be applied: all HF patient with recent admission (both HFpEF and HFrEF), hemodialysis patients to help guide ultrafiltration goals, and individuals with mixed cardiac and pulmonary disease with narrow therapeutic windows of fluid management. This device is placed by Dr. Ayalon in the catheterization lab. The remote monitoring platform is established within the Cardiology clinic and is led by the Cardiomyopathy/HF NPs, with the support of the Cardiology clinic nurses, and the HF attendings. This program provides the Cardiomyopathy/HF NPs with an enhanced toolset to manage our most challenging patients, in a completely remote fashion, with high fidelity and accuracy in their home on a day-to-day manner. This program has already shown a significant reduction in HF hospitalization among the treated patients at BMC. All patients with recent admission for HF are eligible for referral for CardioMEMs device and consideration.
Both programs, iCPET and CardioMEMS, will have research IRBs in place to foster clinical research as our programs continue to grow, particularly as both testing modalities have not been evaluated clinically in such a diverse patient population as seen in BMC.