Faculty Spotlight: Ayesha Salahuddin, MD

Helping Adult Congenital Heart Disease Patients Thrive

Just 60 years ago, many babies born with serious defects in the anatomy of their heart – also known as congenital heart disease (CHD) – passed away in childhood, and very few survived until adulthood. With the advent of lifesaving surgeries and other therapies starting in the 1950s, many of these babies are now living well into middle age and beyond. But while many have full, active lives, they still need treatment and care for life.

“Most of these patients will be palliated, but they are never going to be fully cured,” said cardiologist Ayesha Salahuddin, MD, who specializes in adult congenital heart disease (ACHD). “Many times, patients are just cured enough until the next procedure or complication. It’s a lifetime disease. Getting to care for patients and build relationships with them throughout their lives is a very profound experience.”

Because ACHD patients are living longer than ever before, cardiologists are still learning how their conditions unfold over time, and how to best care for them. In addition to forging long-lasting care relationships with her patients, Dr. Salahuddin appreciates the intellectual challenge.

“My clinical interests included imaging as well as cardiovascular hemodynamics, which relates to blood flow and how the pumping mechanism of the heart works, and what goes wrong in disease,” she said. “ACHD combines both these interests.”

The Importance of Clear Communication

Dr. Salahuddin’s journey to becoming an ACHD cardiologist had a long arc. She was born in Lahore, Pakistan, into a family of many doctors. “There were many dinner table discussions about medicine which got me interested, and sometimes my father, a dermatologist, would pick me up from school and bring me to the clinic, where I observed him seeing patients,” she said.

Her brother was born with congenital hearing loss at a time when there were fewer treatment options. Dr. Salahuddin witnessed her father writing letters to physicians in Germany and the United Kingdom, asking for treatment guidance and advice about speech therapy and equipment. “Because he was a physician, he was able to communicate with other physicians and advocate for my brother,” she said. Her mother also learned as much as she could about speech therapy and other aspects of treatment, and her brother went on to become a computer scientist with a family of his own.

Inspired by her early experiences, Dr. Salahuddin decided to become a doctor, earning her medical degree from King Edward Medical University in Lahore. To access the most cutting-edge advanced training, she chose to come to the U.S., completing her internal medicine residency and chief residency at Saint Francis Hospital in Evanston, Ill.

One memorable learning was the importance of clear communication, especially in difficult circumstances. She cared for a young man suffering from substance use disorder who was dying of advanced liver failure. Dr. Salahuddin saw that specialists told the patient’s mother about various test results, but nobody explained the big picture. In a quiet moment, Dr. Salahuddin sat down with the patient’s mother. “I told her that unfortunately, I didn’t think he would be a candidate for life-saving therapies,” she said. “I think deep inside she knew, but she just wanted someone to tell her. He went into hospice and passed a few days later.”

Several months later, the hospital CEO shared a letter that the patient’s mother had written. “She said I was the voice of clarity in all the noise, and that it brought her a lot of peace and helped her cope with the situation,” said Dr. Salahuddin. “Sometimes patient advocacy in difficult times is a sense of clarity.”

Cultivating Long-Term Care Relationships with Patients

After completing her residency and chief residency, Dr. Salahuddin joined the faculty of the University of Miami in Florida, working as an internist and hospitalist. She was interested in pursuing cardiology, caring for patients in the hospital’s cardiovascular and post-operative cardiothoracic surgery units, and gained clinical research experience.

She then moved to New York, becoming a research fellow at Montefiore Medical Center in the lab of cardiologist Daniel Spevack, MD, who also served on the faculty of Albert Einstein College of Medicine. “He taught me echocardiography, and I started reading echocardiograms for research,” said Dr. Salahuddin. She supported another multi-center study focused on heart failure and left ventricular assist devices (LVADs), and contributed to articles describing a new way to use echocardiography to help assess mitral valve regurgitation severity, as well as the relationship between heart rate and exercise capacity.

During her second year of fellowship, she met Ali N. Zaidi, MD, a specialist in ACHD. “He was an excellent teacher and mentor, and I got to learn about ACHD, which I hadn’t even known existed,” said Dr. Salahuddin. She planned to pursue an advanced fellowship in the burgeoning field of ACHD, which the American College of Graduate Medical Education (ACGME) had only designated as an accredited subspecialty fellowship a few years earlier. Albert Einstein College of Medicine’s ACHD program was delayed in launching, so she joined the cardiology faculty at Rutgers Robert Wood Johnson Medical School in 2018 as a general cardiologist and echocardiographer.

In addition to reading echocardiograms and performing transesophageal echocardiograms (TEEs) during procedures, she cared for hospitalized cardiology patients and saw them in clinic. In particular, she saw patients with ACHD, high-risk pregnant patients with heart disease, and performed cardiac screenings for athletes through the sports medicine program.

Responding to the COVID Pandemic

Dr. Salahuddin enjoyed her work, but still dreamed of becoming an ACHD cardiologist. “I read somewhere that the saddest words of pen and tongue are, ‘It might have been!’” she recalled. “Then COVID hit.”

Many people in New Jersey got sick in the early months of the pandemic, and Dr. Salahuddin volunteered to help cover the COVID service. “I was healthy, and didn’t want my 60- and 70-year-old cardiology colleagues with medical conditions facing the risk of COVID exposure,” she said. “It was a difficult time. Gowns were in short supply and masks were rationed.”

However, Dr. Salahuddin also had some unexpected down time. “All elective procedures were cancelled,” she said. “When I wasn’t working in the hospital, I was reading echocardiograms from home or isolated in my office. It gave me a lot of time to think about the game plan [for my life]. That’s when I called my ACHD mentor, Dr. Zaidi. He said, ‘I know it’s a tough decision, but I’d love you to come back into the field, because not many people are providing ACHD care.’” She also contacted Aarthi Sabanayagam, MD, an ACHD cardiologist at UCSF, who urged her to apply for UCSF’s ACHD fellowship program.

Helping Patients Meet Their Life Goals

Dr. Salahuddin was accepted into UCSF’s program, and she moved to San Francisco along with her husband and two children.

“During my ACHD fellowship at UCSF, I met some excellent teachers,” said Dr. Salahuddin. “I learned a lot from Ian Harris, our program director, not just about patient care, but also the overall approach towards patients as individuals. Aarthi Sabanayagam and Anu Agarwal have been phenomenal – they are very supportive and great teachers….  ACHD is a challenging field, and the training is long. The people who come into it are genuinely interested in the disease process and in getting to know patients and their families. By the process of selection, you are among people who enjoy peeling the layers of the onion further and want to take a deep dive.”

After completing her fellowship she was recruited to the UCSF Cardiology faculty. Her main focus is clinical care of patients with ACHD, and she has clinics at both the Parnassus and Mission Bay campuses. She also holds an outreach clinic in Modesto, providing more access to patients who might have difficulty traveling from the Central Valley to San Francisco for appointments. Dr. Salahuddin also spends one to two days each week in the Echocardiography Laboratory, reading echocardiograms and performing TEEs, and cares for hospitalized patients on the cardiology service.

One of the things she enjoys most about her work is the opportunity to take care of patients throughout their life course. “With ACHD we often care for patients during their formative years,” said Dr. Salahuddin. “These are people who are planning to go to college, get married, run a marathon. We manage them through all of these milestones, including when there are interruptions in their plans.”

For example, one of her patients is in graduate school and needed heart surgery, and was debating whether to delay her licensing exam or to take a semester off. “I get to be an advocate for her to the surgeon and say, ‘Plan the surgery around her licensing exam,’ said Dr. Salahuddin. “Getting to have an impact on patients’ lives in their formative years is very profound, and helps build a certain kind of trust.”

Dr. Salahuddin also specializes in caring for pregnant people with heart disease, and is part of the UCSF Pregnancy and Cardiac Treatment (PACT) Program. “We have a very strong collaboration with our excellent OB/GYN colleagues, and UCSF is fortunate to have a very good maternal-fetal medicine program,” she said. “These patients have pregnancies that are often very much desired, but which can be detrimental to their health. It is very gratifying to support these patients through these pregnancies.”

Dr. Salahuddin collaborates with Dr. Agarwal on clinical research, including investigations focused on patients who have undergone Fontan surgery, which is the third of a series of three palliative surgeries to help patients with single ventricle physiology. “Because this is a palliative procedure, we know many of these patients will develop heart failure, liver failure, possible cognitive decline, and other issues,” she said. “My interest is finding any predictors from their clinical or imaging history that could help us identify these complications in a timely fashion, as well as the best way to counsel them. For example, do these patients do poorly if they develop hypertension? Do they develop diabetes? Is their trajectory the same as any other population? I have a huge interest in identifying potential risk factors that we could potentially modify.” For example, she and her colleagues recently found that elevated body mass index (BMI) in adults who had undergone Fontan surgery was associated with poorer outcomes.

“Dr. Salahuddin is an amazing colleague and friend,” said Dr. Agarwal. “She is mature, cares deeply about her patients, and is passionate about working collaboratively with a team to provide the best care to adults with congenital heart disease. She brings experience, dedication and compassion to caring for patients who may have complex health care needs.” 

“Ayesha has been an amazing addition to our ACHD group,” said Dr. Harris. “She came to us as an ACHD fellow with a great deal of clinical experience in both internal medicine and general adult cardiology, as well as an enthusiasm and passion for learning about congenital heart disease. We were very pleased to be able to convince her to stay on as a faculty member here at UCSF, and look forward to seeing her develop her ideas for an innovative, comprehensive single ventricle clinic. I believe this will be a great asset for UCSF as we develop a model of continuous care for patients throughout the lifecycle.”

Staying Curious

In addition to her research and clinical work, Dr. Salahuddin is active in service work. She is a member of the Institutional Review Board committee, which ensures that research projects are conducted in an ethical way, and focuses on reviewing cardiology proposals.

She also serves as diversity, equity and inclusion champion for the Division of Cardiology. She is working with her counterparts throughout the Department of Medicine to assess the sense of belonging among medical students, residents, fellows, faculty and staff. “We may think we’re creating a very safe environment, but not everyone may feel that way,” said Dr. Salahuddin. “I am a Brown woman who is an immigrant and a Muslim. I have two young daughters. Particularly with the polarization that is happening in our country and world, representation at the right time, in front of the right audience, is very important. I want to do whatever I can do to improve a sense of inclusion and belonging.”

She appreciates the opportunity for lifelong learning. “I’ve been very persistent and motivated to get here, and it was all worthwhile, even if it’s been a long journey,” said Dr. Salahuddin. “I want to stay curious and inquisitive my entire life. That curiosity is well suited to being an ACHD physician, because each patient is new, and each patient’s upcoming year is a new year, which we may never have seen before.”

Outside of medicine, Dr. Salahuddin enjoys reading, listening to audiobooks, traveling, and hiking with her family. She is married to Taimoor Hassan, a software engineer. Together they have two daughters.

 

- Elizabeth Chur