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PICS 2020 Daily Briefing – Day 2

Kamel Shibbani, MD


Introduction

Good morning from online PICS! Today, Drs. Kenny and Hijazi kicked us off with a recap of Friday and another reminder about the initiation of the PICS Society under the guidance of Norm Linksy, the executive director of the society. Norm has massive experience running organizations and his knowledge and expertise will enable the PICS Society to safely start its long journey. The society is actively looking for members to join and for volunteers to help! Please join today by emailing membership@CHDinterventions.org.


Live Cases

We moved to London for the first live case with Dr. Iqbal Malik and his team at Hammersmith Hospital, where we attended a possible redo PFO closure in a 51-year-old woman with cryptogenic stroke, now known as a PFO associated stroke! After a wonderful interrogation by 3D ultrasound followed by a negative bubble study and a global discussion, the decision was made to not proceed with any further intervention. It was another example of the worldwide discussion that PICS’s platform allows for.

Next we moved to Ohio where Drs. Berman, Armstrong and Boe introduced the case of a 15 year old with a history of TOF and absent PV. The intended procedure in Ohio today is 3D rotational angiography and a conduit rehabilitation after her conduit was found to have narrowing with a significant pressure gradient across it. Dr. Berman showed the audience convincingly that there was coronary compression with balloon inflation at 20mm. The team from Ohio fielded many interesting questions from the audience and there was an informative discussion about the steps moving forward. A poll was created during the discussion that asked audience whether they would put a valve in at this point, with 80% or responders indicating that they would not. Ultimately, the team in Ohio decided that it would be safest to stop the procedure and follow the patient with serial imaging.

Taped Cases

A wonderful set of taped cases was started with Dr. Howaida El-Said from UCSD, who walked us through her team’s case of creating a connection between the azygous and Fontan circulation in a patient with easy fatigability. Dr. El-Said played a very informative video explaining the crossing system and showing the creation of the connection with subsequent closure of the Fontan fenestration with resultant increase in flow to the left lung and resolution of clinical symptoms. Dr. El-Said then fielded questions from the audience.

We stayed in California for our next case and moved to sunny LA where Dr. Levi at UCLA talked about a Harmony valve implantation in a patient with native PV stenosis. He started by emphasizing the importance of prescreening using CT angio. Dr. Levi showed us the valve within a 3D model and how it would sit once deployed – then showed us a fantastic video of the preparation of the valve and deployment within the heart. Dr. Levi talked about the importance of the DrySeal sheath in these procedures, which serves as a great safety net. He also fielded questions from the audience in a very interactive taped case session!

Newer Stuff

After a brief break, Drs. Mark Osten and Julie Vincent started us off with a series of lectures about innovation within the world of interventional congenital heart disease. Dr. Ratnayaka from San Diego started this very exciting session with a presentation about Transcatheter Glenn procedures, where he showed the steps of performing such a procedure and talked about the challenges faced and the importance of having a purpose built device to help mitigate these challenges.

In a seamless transition, Dr. Lederman from the NIH then presented a talk about the concept of Transcatheter electro-intervention, which allows for innovative procedures such as the one that Dr. Ratnayaka showed.

Moving all the way to Germany, Dr. Schranz talked about trancatheter PA banding with a Microvascular plug. This was followed by a discussion about the marriage of MVP with bioresorbable materials to help mitigate the difficulty of plug removal later on.

Dr. Justino from Texas Children’s then talked about VSD enlargement/creation in the setting of Sub AS and presented 4 cases where this technique was used. We then switched gears slightly to address CHD from an engineering perspective, where Dr. Lally from Trinity college in Dublin gave an amazing presentation about her work on 3D printing and its use in designing patient specific stents, particularly in the setting of aortic coarctation!


Live Cases

Moving back to London, we rejoined Dr. Malik for a 52 year old male with a PFO associated stroke requiring device based closure. We watched a live TEE with 3D rendering that showed a fossa ovalis with shunting across it. After a discussion with the audience about the suggested device sizes, the case proceeded with successful deployment of an Occlotech 23/25mm device across the PFO.

Back in Ohio, Dr. Armstrong presented another TOF with absent pulmonary valve and severe PS across her bioprosthetic valve who is presenting for Perimount valve fracture and a PV replacement with a valve in valve procedure using a Melody or Sapien 3. There was a dynamic discussion between the panel, the audience, and the folks at Ohio about the utility of checking the coronary arteries before fracturing the Perimount valve. Some educational banter took place in the comments while the audience discussed the ideal valve in this situation. Ultimately, the decision was made to use the 23mm Sapien S3 for this patient.

Industry Symposium

Abbot Industry Symposium: Dr. Patrick McNamara from the University of Iowa was asked to give his talk again due to the technical difficulty encountered yesterday, only this time it was live! He talked about the pioneering work taking place in Iowa regarding the closure of PDA in neonates, and the effects it has had on lung disease, ROP, survival rates, IVH, NEC, and much more. Dr. McNamara then tied this interesting topic to interventional cardiology and fielded questions from the audience.

Edwards Lifescience Industry Symposium: There was also a simultaneous video presentation about the use of Edwards SAPIEN 3 for transcatheter heart valve implantation with the Edwards commander delivery system.


Another industry session sponsored by Medtronic took place on Friday that focused on Imaging of the Native/Patch repaired RVOT anatomy as presented by Dr. Hor from Nationwide Children’s. He talked about the importance of understanding that RVOTs are not created equal and provided a very colorful slide showing as much! This necessitates obtaining detailed imaging of the RVOT in setting of TPVR.

Afternoon Main Session – Interventions on Low Birth Weight Infants

Back to Iowa with Dr. McNamara who started the afternoon main session by sharing his experience regarding gaps in current understanding regarding low birth weight neonates and the need for more evidence-based medicine in this population. In particular, he showed the effect of CHD on the mortality of these infants, and the role that cardiologists and hemodynamic neonatologists can play moving forward. Next, Dr. Glantowicz from Nationwide talked about a surgeon’s prospective regarding interventions on low birth weight infants. He emphasized the importance of collaboration, short- and long-term planning, and the importance of working to grow a collaborative hybrid approach. Dr. Glantowicz ended on a much more somber note by sharing with the audience a video of Darren, Amiee, and Brian’s thoughts about surgery.

Dr. Zampi from Michigan was up next, who talked about the ideal time to intervene in low weight infants with severe PS. He weighed the pros and cons of intervening and promoted a very thoughtful approach to individualizing this decision on a case by case bases.

Dr. Chris Petit from Emory then talked about his experience with percutaneous carotid artery access. He emphasized the advantages of its use over the femoral artery and dispelled some of the concerns traditionally associated with such an access!

Dr. Gordon from Loma Linda then walked us through the Hybrid approach for LBW infants, the extensive planning needed for such cases, and the challenges these procedures pose. Finally, Dr. Balzer from Washington University and Dr. Del Nido from Boston Children’s engaged in a fantastic debate, each making a case for percutaneous approach and surgical approach, respectively.

Advances in Imaging for Interventions

The last session of the day began with Dr. Armstrong informative talk of advances in imaging to guide complex interventions. She talked about Echo-Flouro fusion techniques, MRI 4D flow, computational fluid dynamics, and more! Next Dr. Goreczny from Poland talked about the requirements of setting up CT/MRI overlay in the cath lab by discussing proper hardware and software requirements, 3D datasets, obtaining the needed skills, and understanding the limitation of such technology. Dr. Fagan was up next and talked about the CTA fusion and 3D Rotational Angiography in complex PPVI as well, as well the use of 3DRA to assess coronary compression via Dynamic Projection Coronary Artery Compression Testing. Dr. Berman next talked about the application of 3DRA in single ventricle patients. He went through the perceived barriers or risks of using 3DRA and proceeded to debunk some of them while affirming that there are associated risks such as the risk that comes with pacing. Next Dr. Bruckheimer from Israel walked us through the very exciting innovation of holography, and its use within the cath lab! He informed us that they are getting ready to submit their novel holoscope to the FDA soon! Last, Dr. Gregor Krings talked about airway compression after biventricular repair, or indeed any a surgery that involves the aortic arch, or LPA and RPA. The panel then opened the floor to questions before signing out!

On Tomorrow’s schedule, we will continue with our live cases, this time from Doha and Memphis, as well as taped cases from Dallas! We will also hear from various speakers about lymphatic interventions, structural interventions in adult CHD, new approaches to venous occlusion and stenosis, and more information about the ever popular 3D rotational angiography! And let’s not forget about the much-anticipated yearly “best and worst interventions”!


Before we sign out today, we would like to congratulate the recipient of the Young Leadership Award: Dr. Gurumurthy Hiremath from the University of Minnesota, and the recipient of the Charles S. Kleinman Scientific Scholarship Award: Dr. Catherine Tomasulo from CHOP! Congratulations to them both for the much-deserved recognition of their hard work in advancing the field of Pediatric Interventional Cardiology!

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