Kamel Shibbani, MD
The third and final day of PICS kicked off with Drs. Jones and Kenny welcoming us all to one of the biggest PICS meetings to take place so far, and reminding the audience to sign up for the PICS society, as we are looking for members to join and for volunteers to help! Please join today by emailing membership@CHDinterventions.org.
Our panelists for this session of live cases included Drs. Shabana Shahanavaz, Wail Alkashkari, Horacio Faella, Marco Papa, Massimo Caputo, Hideshi Tomita. Our moderators were Drs. Thomas Jones and Damien Kenny.
We started in Memphis for our first case where Drs. Rush Waller and Shyam Shathanandam had a very exciting 24w premature infant requiring PDA closure at 26 days of life and weighing 940gr! While Dr. Sathanandam obtained access, Dr. Waller reminded the audience about the importance of obtaining good access in these premature infants. They also showed us a video of the elaborate transportation process. The audience was exceptionally interactive and many questions came through the chat box. There was interest in the side effect on the tricuspid valve and possible tricuspid valve regurgitation, as well as in the CaCl dose used during the procedure. Another great question from the chat box was about the bailout plan for device embolization. Dr. Shathanandam informed us that for babies of this size, no surgical bailout is available, and that it is up to the interventionalists to remove the embolized devices. He recommends putting a long sheath up to the TV to protect the TV should that be needed. The case concluded with successful closure of the PDA using a 3:2 Piccolo device!
We then moved to Doha where we were met by Dr. Ziyad Hijazi, Dr. Younes Boudjemline, and Dr. Hesham Al-Saloos who prepared to perform a Sinus Venosus ASD closure with a NuMed 8cm 10 zig custom made CP covered stent using the Wahab procedure! To achieve that, they obtained access from 3 femoral sites and the right internal jugular vein. They advanced a wire through the right femoral vein and snared it from the right SVC to create a rail. They advanced a 12mmx6cm balloon from the femoral vein and exteriorized it from the right IJ! The stent was crimped on this balloon after a suture was placed in one of the struts of the CP covered stent to provide stability during balloon inflation! Dr. Hijazi talked about the importance of this step to help with precise placement of the stent. There was tremendous interest from the audience about this technique, and the team in Doha fielded many questions about the procedure as they worked hard to successfully deploy the stent!
As the team in Doha continued to work on their case, we moved to the first taped case session of the day, moderated by Drs. Matt Gillespie and Felix Berger. The first case was out of UT southwestern where Dr. Suren Ruddy presented a diagnostic pre-fontan cath using an iCMR. Dr. Reddy talked about the benefits of using CMR before introducing the taped case. He walked us through their usual procedure that starts with MRI time out, obtaining access, performing a metals checklist to ensure there is no metal in Zone 4, performing the pre-Fontan CMR (includes lymphatic imaging, Qp:Qs, and Cine), performing the catheterization itself, and after all the data is collected, making a decision about whether the patient will need to go to the cath lab for intervention! Dr. Reddy then engaged in a discussion about doing iCMR guided procedures and about the options of CMR systems available.
We then moved to Boston were Dr. Diego Porras walked us through a case that they performed on a 52-year-old with dTGA s/p Msutard procedure who required a transvenous ICD. They were able to obtain a pathway for the ICD placement after a very challenging procedure by stenting the superior baffle of the Mustard. Dr. Porras then reviewed valuable learning points from such a procedure that included setting clear goals and knowing when it’s best to stop, having alternative approaches if the cath was not possible, the importance of having recanalization equipment, and understanding that creating new shunts might compress adjacent structures! Dr. Porras and the panel then discussed the use of electrosurgery during such procedures, as well as the role that covered stents can play. Dr. Porras and the panel then fielded questions from the audience.
Lecture – Interventional Cardiac MRI
The lectures this morning revolved around interventional cardiac MRI. Our panelists Drs. Kenny and Ratnayaka welcomed the first speaker Dr. Jeremy Anses, who gave us a fantastic talk about radiation exposure. Next Dr. Armstrong gave a very informative talk from Nationwide that talked about establishing an iCMR program. She then talked about the pros and cons of a 1.5Tesla and a 3Tesla MRI machine for iCMR. Dr. Toby Rogers from the NIH then discussed the workflow they have established for iCMR and how to maximize their time to get the most out of the procedure. He showed a video of a case that was started in the catheterization lab, moved to the CMR, then back to the catheterization lab, all of which are connected to each other to allow for sterile transfer. Dr. Rogers also played a video of an iCMR exercise stress test where patients exercise within the MRI machine!
We stayed in Bethesda with Dr. Robert Lederman who took us back to the basics about the physics of different imaging modalities, and talked about the advances in iCMR and the future of the field! Some of the exciting developments he talked about was the segmented nitinol guidewire that is useful in iCMR, a myocardial Bioptome, and a transmural active needle! Dr. Nugent from Lurie Children was up next and gave a talk about why iCMR will replace fluoroscopy in the near future, and it was difficult not to get excited about the future of the field! The session ended by bringing in all the speakers together for a quick Q&A.
Our global panel for the second round of live cases included: Drs. Shelby Kutty, Oscar Mendiz, Pedro del Nido, Brian Morray, Reda Ibrahim, and Joaquim Miro. Our moderators were Drs. John Carroll and Dan Levi.
We kicked off in Memphis with Drs. Shathanandam and Waller introducing their second case for today, a 28 and 5 day premature infant who will undergo PDA closure at DOL 37 for a hemodynamically significant PDA with dilated LV and LA, in the setting of a double aortic arch! Dr. Shathanandam used a 21 guage needle to obtain access, and in a nod to a question by the audience from the previous session, he informed us that he does indeed use heparinized flushes but is very careful about how much flush they give due the size of the patient. On initial angiograms the complicated anatomy of the patient was the center of discussion between Memphis and the global audience, with Dr. Shathanandam inviting panelists and the audience to weigh in before deciding on a device. After much thoughtful discussion, the decision was made to proceed with a 4:2 Piccolo device, which was deployed successfully!
We then went to Doha where Drs. Hijazi, Boudjemline, and Al-Saloos presented their second case; a 39-year-old female with SOB found to have R heart enlargement. An echo showed a large sinus venosus ASD with L to R shunt and a RUPV draining to the SVC. The intended intervention for today was another transcatheter repair of the SVASD using a CP stent (Wahab procedure). The audience was again very interactive and there were multiple questions sent to Doha throughout the procedure. As the team in Doha continued through their case, the panel and the audience engaged in a great discussion about the collective experience with sinus venosus ASD closure, and the age at which they can and have been done. Dr. Del Nido weighed in to provide an insightful surgical perspective. After placing the first stent, the team and the audience noted a residual shunt, which prompted a discussion between the audience and Dr. Hijazi about the benefit of using a second covered stent more proximal than the first to control the shunt! This was indeed the course that the team Doha decided to pursue.
Next we moved to an industry symposium sponsored by Siemens where Dr. Gregor Krings walked us through Post Processing of 3D rotational Angiograms with Siemens Artis Q.Zen System! As we watched a video of 3DRA performed by Dr. Kenny, we learned about acquisition and processing from Dr. Krings’ narration. Dr. Krings talked about the importance of being strict to follow protocol during this dynamic process, and about the importance on looking at the angiography before focusing on the 3D rendering. He then recommended that when scissoring happens, starting with highlighting the areas of interest and deleting the rest is the preferred approach.
Next it was time to turn our attention to structural interventions and adult CHD updates, a session moderated by Drs. Kavinsky and Cabalka. The first talk was about the use of the Mitraclip and was given by Dr. Scott Lim from University of Virgina, who came to us live from his car! He talked about using this clip to deal with TR and MR, as well as introducing a multitude of other options such as the cardioband, triclip, and Pascal device, among others. Next we heard from Dr. Sievert about the ability to close PFO using a “no footprint” technique, in hopes to avoid some of the complications that come with placing metal within the heart. One such technique is the HeartStitch, a suture with minimal footprint, of which there are many options! We moved back to Doha were Dr. Boudjemline for the next talk about reverse POTTS and its utility in the pediatric population! He touched on the importance of pre-planning and talked about technical considerations for such cases.
Next Dr. Horlick from Toronto General Hospital talked about transcatheter tricuspid valve replacement and repair. He talked about the frequency of TR and put the scope of the issue into view. He then fielded questions from the panel about imaging of the TV and what the future holds in that regard. We then moved to the debate portion of the session, where we heard from Dr. Shakeel Qureshi who made an argument for the need to perform a transcatheter Sinus Venosus ASD closure in all anatomically suitable candidates! On the flip side of that coin, Dr. Oliver Ghez made the argument against such closure of the Sinus Venosus ASD and argued for surgical intervention early on! A poll at the end of the debate favored, not surprisingly, a delayed approach with transcatheter closure as opposed to early surgical intervention! Most importantly however, the conclusion was that the best approach is one that incorporates a discussion between the surgical and interventional sides to come to a shared conclusion!
The afternoon session was moderated by Drs. Kenny and Morgan and revolved around lymphatic interventions. Dr. Liuba from Lund in Sweden talked about the requirements to start a lymphatic intervention program. We then moved to Ohio where Dr. Lillis talked about MR lymphangiography and the elements needed for its success! She presented several cases at the end of her talk to really drive home the utility of MR lymphangiography in our population. Next, Dr. Yoav Dori from CHOP talked about lymphatic dysfunction within CHD. He spoke about IM-DCMRL and IH-DCMRL, and how we now better understand the mesenteric, hepatic, and pulmonary lymph systems He also talked about the importance of classifying the lymphatic system in all patients with single ventricle patients.
Dr. Smith from CHOP continued the wonderful theme and focused on the use of lymphatics beyond PLE and plastic bronchitis. He also presented cases that really highlighted the tremendous clinical impact that lymphatic interventions can have on patients with CHD. Dr. Jonathone Rome from CHOP then presented amazing data about lymphatic duct rerouting in multicompartment lymphatic failure after a failed Fontan. Finally, Dr. Marc Gewillig from Leuven gave a very informative talk about lymph-occlusion by direct puncture of lymph vessels and nodes. The group then reconvened at the end to answer questions.
At the end of the meeting, Dr. Damien Kenny thanked everyone for the tremendous effort that was put into transforming the virtual PICS 2020 into a smashing success. He thanked all the directors and co-directors and in particular, Norm Linsky. He then thanked all the attendees for the input and chat, and especially thanked Kimberly Ray for her tireless efforts. He also thanked our industry partners and Mike Fitzgerald and the whole team at AVSS, as well as Lory and Troy at TLC.
In closing, Dr. Kenny announced the oral abstract winners as follows:
From room 1: Drs. Evan Zahn, Eason Abbott, Neil Tailor, Shyam Sathanandan, and Dustin Armer for their presentation titled “Development and Testing of the Renata Minima Stent and Delivery System: A New Neonatal Stent Capable of Achieving Adult Dimensions”
From room 2: Drs. Krishna Kishore Umapathi, Aravind Thavamani, and Joshua Murphy for their presentation titled “Transcatheter closure of ostium secundum atrial septal defects: Trends and comparison of outcomes from 2003-2016 in children in the United States.”
And finally, to a backdrop of virtual fireworks, he announced the upcoming planned meetings, the first at the end of March in Istanbul in partnership with Mario Carminati and IPC, and second in Las Vegas at the end of August! We look forward to seeing you all again, hopefully in person!