Faculty Spotlight: Aarthi Sabanayagam, MD

At the Forefront of ACHD

Thanks to major advances in surgery and medicine, most babies born with heart defects – also known as congenital heart disease – are living into adulthood. But many of these patients require various levels of care and intervention to keep them healthy throughout their lives.

“In the past, 80 percent of these children would not survive past age 18, and now it’s the opposite – more than 80 percent survive into adulthood,” said Aarthi Sabanayagam, MD, a specialist in adult congenital heart disease (ACHD) who recently joined the UCSF faculty. “Over the years, these patients are living full, functional lives.”

Because of dramatically improved survival rates, ACHD is a rapidly growing subspecialty within cardiology. The field includes a wide array of different conditions ranging from simple to complex, each with its own anatomy and treatment strategy. Dr. Sabanayagam finds deep satisfaction in caring for ACHD patients, as well as teaching the next generation of physicians how to provide excellent care to these patients in the future.

Creating a Blueprint for Care

Dr. Sabanayagam was born in New York, then moved to India when she was six years old. She earned her medical degree from Sri Ramachandra Medical College and Research Institute (now the Sri Ramachandra Institute of Higher Education and Research) in Chennai, India, which had an inter-institutional alliance with Harvard Medical International. After completing her internship there, she was awarded externships in internal medicine and cardiology at Beth Israel Deaconess Medical Center and Brigham and Women’s Hospital in Boston.

She returned to New York for her internal medicine residency at Montefiore Medical Center, the teaching hospital for Albert Einstein College of Medicine. She continued working there as a hospitalist for three years. “I spent lot of time on the hospital’s telemetry and cardiac floors, co-managing patients with cardiologists, and found it exciting,” said Dr. Sabanayagam.

That inspired her to complete a cardiology fellowship at Montefiore. She particularly enjoyed caring for young patients with congenital heart disease with Daphne Hsu, MD, chief of the Division of Pediatric Cardiology at Montefiore. “I love congenital anatomy and pathophysiology – and the different hemodynamic issues that go along with these conditions, as well as the opportunity to take care of young people,” said Dr. Sabanayagam.

She came to UCSF for an ACHD fellowship for the chance to work with people like Ian Harris, MD, director of the UCSF ACHD Program, and Elyse Foster, MD, who led the UCSF ACHD Service for nearly two decades. “They both have so much expertise and experience,” said Dr. Sabanayagam. “This is also one of the oldest ACHD programs in California, and the Pediatric Heart Center here is world-renowned.”

During her training, Dr. Sabanayagam saw several young patients with a rare condition called transposition of the great vessels, in which the aorta and pulmonary artery are switched from their normal positions. Until the early 1990s, patients with this condition underwent a procedure during infancy called an atrial switch procedure, in which blood flow was re-directed using synthetic tubes called baffles. Patients usually did well for years, but some developed complications a few decades later. “When these patients came to the hospital, they had been leading active lives and maybe even playing doubles tennis,” she said. “But when they got sick, they declined pretty rapidly, and some did not make it. I always tell my trainees today that patients may look well on the outside, but their hearts are very different.”

Fortunately, most patients with ACHD do not have such a dramatic trajectory, but caring for patients like these has fueled Dr. Sabanayagam’s commitment to planning ahead. “For example, when patients who were palliated with the atrial switch procedure decline, we need to get them to transplant, if that’s within their goals of care,” she said. “While that is one of our options, not all patients are transplant candidates or will receive a donor heart in time. I’m proactive about getting patients screened, tested and plugged in with the Heart Transplant Program. If they do decline, we’re able to act quickly, since most of these patients have a very narrow window where transplant is a viable option.”

Dr. Sabanayagam appreciates developing longitudinal relationships with patients, and navigating sometimes emotionally charged conversations with sensitivity. “We want to provide reassurance that we are laying out a blueprint for their care, based on their anatomy and physiology,” she said. “I tell people, ‘If I see you once a year, let’s talk about things for this one day. I’ll tell you about warning signs to look out for, and if anything comes up in the next year, you tell me. But in the absence of warning signs, I don’t want you thinking about your heart for the next 364 days.’”

She also keeps in mind that some patients may have traumatic memories of undergoing multiple procedures and surgeries when they were very young, spending days or weeks in the hospital. “They remember all that and regress to it, even though they may be in their 30s, 40s or 50s now,” said Dr. Sabanayagam. “As a fellow, I used to feel like I needed to cover everything when I saw a patient. But sometimes you have to move with them at their pace and bring some things up down the road, especially if it’s not something that’s going to impact care at this moment.”

COVID-19 and ACHD

After completing her ACHD fellowship at UCSF, Dr. Sabanayagam was recruited to The Ohio State University and Nationwide Children’s Hospital in Columbus, Ohio. She enjoyed splitting her time between the two centers, caring for adult patients with congenital heart disease at each institution. “The ACHD program there is nationally and internationally known, and one of the largest in the country,” she said. “All the [ACHD] faculty went back and forth between both institutions, with large teams and ancillary support at both sites.” At The Ohio State Wexner Medical Center, Dr. Sabanayagam was an attending physician on the cardiology, ACHD and pulmonary hypertension services, and cared for expectant mothers with high-risk pregnancies through the cardio-obstetrics program.

When the COVID-19 pandemic arose, Dr. Sabanayagam and her colleagues rapidly developed algorithms for treating patients with different congenital lesions. “We were afraid that our patients with congenital heart disease and pulmonary hypertension would be at higher risk, and we worked with our colleagues so we could disseminate that information to those who would be at the forefront caring for them,” she said. “For the ACHD population, we were able to put them in different groups based on how we would recommend coordinating their care specific to their anatomy, should they get COVID-19.” They published their findings in the International Journal of Cardiology.

They also found that patients with pulmonary hypertension who developed COVID-19 did better than expected, leading them to hypothesize that some pulmonary hypertension medications might have some protective effects against COVID-19.

Supporting Healthy Pregnancies

In 2020, Dr. Sabanayagam decided to return to UCSF as a faculty member in the Division of Cardiology. “We were thrilled to be able to recruit Dr. Sabanayagam back to UCSF as a member of our ACHD faculty,” said Dr. Harris. “She is a master clinician and creative teacher, and she has already enhanced the quality of our ACHD program.” She sees patients in the ACHD Clinic at Mission Bay, interprets echocardiograms and performs transesophageal echocardiograms at UCSF Helen Diller Medical Center at Parnassus Heights, and teaches residents. To help bring care closer to where patients live, she also sees ACHD patients at the Berkeley Outpatient Center and at an outreach clinic in Santa Rosa.

Dr. Sabanayagam also cares for pregnant patients with ACHD and serves as co-director of the UCSF Pregnancy and Cardiac Treatment (PACT) Program, working with a multidisciplinary team that includes specialists in maternal-fetal medicine, cardiology, obstetric anesthesia, critical care, nursing and social work. “Pregnancy is a stress test for the heart of any woman, and for patients with ACHD or other conditions, we may worry about them developing cardiac symptoms,” she said. “We do preconception counseling to help ensure that they will be able to safely undergo pregnancy. If they do become pregnant, we keep an eye on any adverse pregnancy outcomes, such as pre-eclampsia, gestational diabetes or placental issues, which may predict higher incidence of cardiovascular disease in the future.”

She and her PACT colleagues also work together to develop plans to support a healthy pregnancy. “We discuss any concerns and how to address them,” said Dr. Sabanayagam. “We also come up with a delivery plan that’s outlined and in the system, so even if they come in at 2 a.m., anybody who sees them in OB triage knows what the considerations are and how to manage them. We also come up with contingency plans. That’s where the value of a program like this comes into play, because being prepared for the unexpected is important. I think that’s why this clinic is so appreciated by patients, and also has excellent outcomes.”

The PACT program continues to care for new mothers after they give birth. “Every time I walk into the room of someone who delivered, most eyes are on the baby, but my eyes are on mom,” said Dr. Sabanayagam. “We also talk about the ‘fourth trimester.’ A lot of new mothers brush off [cardiac] symptoms, thinking it may just be sleep deprivation or adjustment to having a newborn, but if they ignore them they may end up in the emergency department. We counsel them that they need to take care of themselves first so they can take care of their baby.”

“Dr. Sabanayagam is passionate about ACHD, and her clinical acumen is exceptional,” said Anushree Agarwal, MD, who is also an ACHD subspecialist at UCSF. “She is a staunch advocate for her patients and does not hesitate to go the extra mile for them.”

A Passion for Medical Education

In addition to caring for patients, Dr. Sabanayagam has a deep love for educating the next generation of physicians, and received the Excellence in Teaching Award from The Ohio State University Department of Medicine in 2020. At UCSF, she was appointed associate director of the Cardiology Fellowship Program.

“Since joining the UCSF faculty, I’ve been very involved with teaching on the inpatient service, as well as trying to improve the curriculum in innovative ways,” said Dr. Sabanayagam. “For example, I’ve been able to go through lesion-specific details [for various types of ACHD] and help prepare our cardiology fellows for the congenital questions on their general cardiology board exams. I also like to talk about the evidence – or lack thereof – behind published guidelines for different types of ACHD, and am involved with the monthly ACHD conference. When I’m teaching, seeing a light bulb go off in the heads of medical students and residents is very satisfying. We’re training the new generation, the next cohort of physicians who will be coming on the scene.”

“Dr. Sabanayagam has been a great addition to our faculty and the fellowship program leadership,” said Atif Qasim, MD, director of the Cardiology Fellowship Program. “She has a passion for medical education, and a knack for simplifying complex concepts in congenital heart disease so they are much more digestible for our trainees.”

Dr. Sabanayagam relishes the holistic nature of caring for her patients. “What’s fascinating with ACHD is that it involves every aspect of cardiology,” she said. “You see young patients, get to care for them through pregnancy, review their imaging, and send them for surgery or interventions if they need hemodynamic optimization. We get to work with a large, multidisciplinary team and collaborate with surgeons, interventionalists and other subspecialists. Because my patients are young, I get to do a lot of counseling around lifestyle modifications and primary prevention. I get their cholesterol checked, go through a full, detailed family history, help make sure they get 150 minutes a week of moderate intensity activity, and talk to them about a healthy diet.”

In addition to medicine, Dr. Sabanayagam enjoys Peloton workouts, hiking, traveling, and trying out different cuisines with family and friends.

She is delighted to be back in the Bay Area. “UCSF is an amazing place,” said Dr. Sabanayagam. “It’s highly academic, with motivated and inspiring individuals in literally every specialty and subspecialty you can think of. It’s a very collegial group. We have a large Division of Cardiology with many women – something that absolutely attracted me to this program. The diversity of our division and the values of the University are in exact alignment with my beliefs, and make me proud to work at a place like this.”

- Elizabeth Chur