Innovation and collaboration are at the heart of the Cardiac Catheterization Program

For more than 60 years, the Cardiac Catheterization Program at Boston Children’s Hospital has been at the cutting edge, developing and refining innovative catheterization techniques and procedures. Cardiac catheterization at Boston Children’s was pioneered by Abraham Rudolph, MD, and Donald Fyler, MD, in the 1950s. The program has a storied record of innovations, most recently led  for more than 25 years by James Lock, MD, and, until her recent departure, Audrey Marshall, MD. Now, under the leadership of Diego Porras, MD, FAAP, chief of the Division of Invasive Cardiology, the team is continuing to advance the field through its culture of collaboration, training and innovation.

Cardiac catheterization is often a less invasive solution for some cardiac interventions.

As one of the largest pediatric catheterization programs in the U.S., the team performs more than 1,500 catheterizations each year, including more than 800 interventional catheterizations, more than any other pediatric heart center in the country.

“Over the past 32 years, we’ve seen the focus of the catheterization program change dramatically, from purely diagnostic in the 1970s to primarily interventional today as non-invasive imaging has largely replaced catheterization for diagnostic purposes and we continue to increase the scope of treatment possibilities within the cath lab,” says Porras. “Within that time, as the number of interventional procedures continues to grow, we’ve doubled our volume.”

Taking a collaborative approach

Collaboration is a crucial part of the program’s approach to patient care. Porras and colleagues Jesse Esch, MD, MSc; Ryan Callahan, MD; and Nicola Maschietto, MD, PhD, routinely partner with cardiac surgeons and other clinicians to develop new approaches to care, combining surgical and catheter treatments when appropriate. Recent collaborations have yielded new approaches to midaortic syndrome and using endovascular grafts to treat intracardiac lesions.

“We take a step back and look at all the options available before deciding what we want to use for an individual case,” says Porras. “Some centers tend to do mainly surgery or mainly cath for a particular condition — we make our treatment decisions based on data and the individual patient, so sometimes it’s cath and sometimes it’s surgery. Our goal is to ensure each patient gets the treatment modality that’s best suited for their unique case.”

The team also collaborates with the medical device industry to continue to expand the number of tools available to treat patients. The team routinely participates in cutting-edge clinical trials of new medical devices, such as stents and valves. This participation gives our patients access to treatment options they wouldn’t have elsewhere and makes these new devices accessible to those who would otherwise require surgery.

Porras examines a patient.

Current trials the program is participating in include:

  • Gore Cardioform ASD Occluder device to evaluate safety and efficacy in the treatment of transcatheter closure of ostium secundum atrial septal defects (ASDs)
  • SAPIEN XT Post-Approval Study to evaluate the safety of the FDA-approved SAPIEN XT THV in the pulmonic position

Training through simulation

From training pediatric cardiology fellows on simulation models to practicing various types of vascular access to using 3-D printed heart models to help experienced catheterization doctors practice interventions on complex hearts, the team is always developing new simulation technologies.

Cardiology fellows receive crisis resource management training using a high-performance mannequin in one of the catheterization labs, based on previous adverse events. They also use an angiosimulator to learn fundamental skills, such as coronary angiography interpretation and basic catheterization techniques.

Looking to the future, the team is working with a bioengineer in the Boston Children’s Simulation Program to take training one step closer to real life by designing a heart model based on 3-D printing technology. The goal is to give fellows more realistic hands-on experience moving catheters through a heart and doing basic interventions, such as balloon angioplasty and device closures of congenital heart defects.

Innovative interventions: From the common to the complex

The Cardiac Catheterization Program has a long history of developing non-surgical ways of treating children with heart disease. The team has developed and perfected catheterization procedures for a wide range of clinical uses, from relatively common heart defects to the most rare and complex.

The program was one of the first in the U.S. to perform pulmonary valve replacements (PVRs) in the catheterization lab, starting in 2007 as part of a clinical trial for the Melody valve, and it continues to be a leader in this area. The team is continually looking for new ways to bring the benefits of transcatheter PVR to a wider range of patients. In 2015, the program performed more PVRs in the catheterization lab than by surgery for the first time.

Cardiac catheterization is often a less invasive solution for some cardiac interventions.

The team has also combined catheter and medical treatment of pulmonary vein stenosis, developed innovative catheter and surgical approaches to multiple left heart obstructions, and replaced pulmonary valves in patients who have had surgery for tetralogy of Fallot that preserved the native outflow, including a novel use of hybrid procedures for this indication.

Our forward-thinking approach has supported the development of a list of innovations that weren’t previously available at Boston Children’s, including 3-D rotational angiography, intravascular ultrasound (IVUS), intracardiac echocardiogram (ICE), use of 3-D printed models to plan complex interventions and the use endovascular grafts to treat complex intracardiac defects.

“We continue to foster innovation and constantly strive towards improving and developing new approaches to care,” says Porras.