Five Questions with Dr. Megha Prasad, Interventional Cardiologist and Head of the Cardiorenal Care Program
How did you find your way to Columbia?
I started at Columbia as an interventional fellow in 2018. I’m originally from California and did my undergraduate and medical school at the University of Southern California. As I worked my way through my education, I became interested in trying to develop better ways to deliver clinical care. And that's how I ended up at the Mayo Clinic in Rochester, Minnesota. It just sounded like a cool place to be—how do you have a hospital in the middle of nowhere that people come to from everywhere? I just thought the very concept was interesting.
So I went on a rotation there and fell in love with the place. I was recruited for residency and stayed on for a cardiology fellowship. I decided to leave for an interventional fellowship because I saw Columbia as a place that was really pushing the envelope in a way I hadn't seen anywhere else. It was one of the only places that offered training for both high-risk coronary interventions and low-contrast interventions. They were doing all these new and exciting things and I wanted to be part of that.
I was offered a spot at Columbia in July 2018 as a fellow and stayed on for a CHiP (complex higher-risk [and indicated] patients) fellowship for 2019. I came on staff in July 2020 and have had a very fulfilling experience here. In the last three years, we have grown the cardiorenal medicine and interventions programs considerably, increasing academic initiatives in this space while continuing to pursue other clinical and academic interests, including management of cardiogenic shock and diagnosis and treatment of small-vessel disease in adults with chest pain. We are working on better understanding the role of small-vessel cardiovascular disease in kidney disease.
What is the connection with renal disease and cardiology?
The kidney and heart are closely connected, and some patients with kidney disease may also have heart disease. For angiograms and many interventions, we need to use contrast dye, which can damage the kidneys. Even for a patient with normal, healthy kidneys, it’s not a good idea to give them more dye than they need. But for people with renal disease, it’s a huge problem.
We are now able to perform angiograms and stent placement using almost no dye, preventing patients from incurring kidney damage as a result of their heart procedure. While many angiograms are done using more than 40 cc of dye, we do them with closer to six to eight. Studies have shown that this small amount does not affect kidney function. We can also place stents with less than 2 cc of dye as opposed to many of these procedures that are performed with more than 100 cc.
I was fortunate to train in a program that had several individuals who specialized in this low-contrast approach and taught me in treating patients with chronic kidney disease (CKD). I'm trying to go to national meetings and raise awareness that we do this here at Columbia and that these techniques should be applied to more patients. On the academic front, I am studying this patient population and our techniques to understand how to optimize this and what factors accelerate CKD in patients with heart disease.
Low-contrast angiography and interventions are not performed as frequently as may be necessary. There's a large population of patients who are underserved because programs often turn down those with CKD to avoid kidney damage. Patients also may not want to do further testing on their heart because they don’t want to compromise their kidneys. It should not be a choice, as there are ways both organs can be protected.
We have developed a multidisciplinary program, partnering with specialists in valvular heart disease, electrophysiology, and heart failure, as well as peripheral arterial disease, who all share a common goal—improving the overall cardiovascular health of patients with CKD and facilitating next steps in their care.
We are continuing to develop our center of excellence, which specializes in managing the spectrum of cardiovascular disease seen in CKD patients. This has been possible due to the world-class experts here at Columbia who work collaboratively to improve the overall health of these patients.
Why is this low-contrast technique so important for patients seeking a kidney transplant?
It is pretty common for patients with renal disease to also have a high risk of cardiovascular burden, and many patients need a coronary angiogram to get cardiovascular clearance for a kidney transplant.
CKD patients who have abnormalities on their echocardiograms and stress tests often need an angiogram to diagnose and treat any underlying coronary artery disease. Minimizing the amount of contrast dye allows these patients to undergo testing without progression to dialysis.
The goal of our program is to improve a patient’s cardiovascular health so they can safely undergo renal transplant and thrive postsurgery. We work with them to treat any significant underlying coronary artery disease, rhythm abnormality, valvular heart disease, or peripheral arterial disease. And once they get the transplant, we can help manage their cardiovascular risk factors long-term in conjunction with their transplant team.
How do you approach working with these patients?
We take a personalized multidisciplinary approach, offering patients the care they need to improve their health. This often means improving their cardiovascular health to gain clearance for renal transplant surgery, but we also treat many patients who have been refused a kidney transplant from other programs because they are considered too high risk. The most common reason for this is concern for their cardiovascular prognosis.
We can treat complex coronary, peripheral, or valvular heart disease other programs may not due to concern for progressive renal dysfunction, overall risk, or limited technical expertise. We incorporate the CHiP philosophy into our patient care: If somebody needs something, we will provide that care as long as we're safely able to do so, so patients can get the therapies they need regardless of their kidney function. And we work closely with the renal transplant team and our cardiovascular specialists to tailor a treatment plan that aligns with the goals of the patient.
There's a huge population of patients getting turned down elsewhere who we are able to treat and clear for transplant. These are the most rewarding experiences for us as a program.
Do you see low-contrast approaches becoming more prominent?
That is my hope! There are many patients who would benefit from these techniques, and I hope we can continue to train providers to be proficient in minimizing dye when doing these procedures.
It takes some expertise to diagnose and treat blockages with less dye, but we use technology like intravascular imaging to precisely treat these patients. All our fellows graduate being able to do these procedures, and my hope is that with time, as other centers also perform these procedures and train the next generation, we will be able to keep improving our approach to patients with CKD.
Another goal of mine is to start seeing patients with renal disease better represented in clinical trials, as they are typically excluded from cardiovascular studies. They make up more of the population than we realize and it’s important to understand them better.