The Take Home: SCAI Scientific Sessions

Issue: July/August 2013

Image: SCAI

This year’s Society for Cardiovascular Angiography and Interventions 2013 Scientific Sessions, held in Orlando, Fla., turned a spotlight on posters, abstracts and late-breaking clinical trials detailing a broad range of trending topics, including renal denervation, FFR-guided PCI and therapeutic hypothermia. At the meeting were Chandan Devireddy, MD, FSCAI, of Emory University School of Medicine and Emory University Hospital Midtown, Atlanta, and John P. Breinholt III, MD, FSCAI, with Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, who shared with Cardiology Today’s Intervention their perspective on some of the highlights from the meeting.

Chandan Devireddy, MD, FSCAI

Late-Breaking Clinical Trials

The SCAI 2013 Late-Breaking Clinical Trials session garnered significant attention. Three trials were presented, each addressing an issue impacting patient safety and procedural outcomes. The VERITAS trial, presented by Ron Waksman, MD, examined whether TAVR procedures involving live broadcast or recording posed any disadvantages compared with matched control patients. No statistically significant differences were seen in prespecified endpoints, most importantly death and end-organ failure (2.2% in both groups), potentially validating live-case recording as a continued method of instruction when performed by experienced operators.

Chandan Devireddy

The POSEIDON trial, presented by Somjot Brar, MD, evaluated a sliding scale, left ventricular end diastolic pressure-guided personalized hydration strategy vs. control during cardiac catheterization and PCI. The primary endpoint of serum creatinine elevation was decreased by an absolute reduction of 10%. Interestingly, this strategy also reduced a 6-month composite endpoint of death, MI and need for dialysis.

A substudy of CREST, presented by Mahmoud Malas, MD, evaluated clinical outcomes in patients undergoing post-carotid stent deployment angioplasty (post-SDA) vs. those who did not. Although the rate of restenosis was significantly lower at 2 years in those who underwent post-SDA (3.7% vs. 10.3%; multivariate HR=0.36; P=.02), there was a disturbing trend toward higher stroke incidence in the same patients (5.5% vs. 1.5%; P=.26). This substudy raises the question of whether carotid stenting should pursue maximal luminal gain or plaque stabilization.

Quality Improvement

A new feature of the SCAI 2013 sessions was an educational track dedicated entirely to quality improvement, featuring educational sessions focused on key regulatory issues facing cath labs and operators today. A recurring theme was that of interventional cardiologists needing to take the lead, first in identifying areas for improvement and then as champions of quality for patient and procedural outcomes. The importance of active participation in registries, implementation of quality improvement measures such as SCAI’s Quality Improvement Toolkit (SCAI-QIT) and interventionalist champions at the local, regional and national levels, all were emphasized. Case presentations and open audience discussions helped ground the discussion with real-life practical relevance on topics such as ethical decision-making, applying appropriate use criteria to day-to-day cases, challenges of peer review and how to approach public reporting of outcomes. Intense question-and-answer sessions confirmed the importance of this topic for interventional cardiologists and cath lab teams.

State-of-the-Art Intervention

Throughout SCAI 2013, participants attended cutting-edge sessions from four tracks: coronary, peripheral, structural and congenital heart disease. The coronary sessions covered a range of topics, starting with a radial symposium that reviewed progress in streamlining success and ease of transradial PCI and ways to generalize the transradial approach to more complex types of procedures. Subsequent sessions reviewed approaches to chronic total occlusions, imaging-guided PCI, left main PCI and focused updates on the latest studies influencing current practice.

The peripheral track traversed a wide vascular territory, ranging from intracerebral rescue to below-the-knee treatment for critical limb ischemia. Lectures provided concise reviews of state-of-the-art approaches to vascular conditions that often have multiple options for treatment.

The structural program began with SCAI’s popular Hemodynamics Symposium, which reviews unique dilemmas in hemodynamic assessment that frequently arise in the cath lab. The interest in and wide range of structural heart disease topics for the interventionalist was on display with lectures on mitral valve intervention, atrial defect closure and left atrial appendage occlusion, and a comprehensive TAVR symposium.

Keynote Speakers

Highlights of SCAI Scientific Sessions always include an interesting lineup of keynote lecturers. This year was no different with special presentations over the 4-day meeting. For the first time, the meeting was launched with an opening session, featuring Reed Tuckson, MD, the immediate past executive director and chief of medical affairs at UnitedHealth Group. Dr. Tuckson delivered a powerful speech outlining his view of the impending storm of cost crisis in health care and the need for new outlooks in quality and cost-control by physicians to stay ahead of the curve. Dr. Tuckson praised SCAI and its focus on quality improvement on the societal level, saying the society “gets it.”

George W. Vetrovec, MD, delivered the annual Founders’ lecture, counting off the top 10 observations from 35 years of invasive cardiology practice — an entertaining, informative and emotional overview of the practice of interventional cardiology over the decades. He urged the physicians in the audience to “know their patients,” to remain proficient in their skills and to be innovative in advancing the field through collaboration with industry.

Jeffrey J. Popma, MD, delivered the society’s annual Hildner Lecture, detailing the impact of the US regulatory process on interventional device innovation. His talk was followed by a recent addition to the SCAI Scientific Sessions — a Town Hall Meeting, kicked off with a keynote address that advocated for improving the US CV device clinical research ecosystem, by Robert “Chip” Hance, entrepreneur in residence at the FDA Center for Devices and Radiological Health and the former president of Abbott Vascular. Together these two lectures emphasized the need for relationships among clinicians, industry and government in order to improve availability of new devices in the United States. In today’s complex world of innovations, the issues of necessity, safety and efficacy of new devices must be appropriately considered in the context of a rapidly prolonging US approval period.

Disclosure: Devireddy reports no relevant financial disclosures.

PAGE BREAK

John P. Brienholt III, MD, FSCAI

Pediatric/Congenital Heart Disease Program

The SCAI 2013 Scientific Sessions provided an excellent forum for pediatric/congenital interventional cardiologists to learn skills and evaluate fundamental procedures practiced for the past 30 years, including an illuminating lecture on balloon pulmonary valvuloplasty from Charles E. Mullins, MD, one of the first cardiologists to perform the procedure. Dr. Mullins discussed the technology that was available at the time and how the field has progressed with improvements both in techniques and equipment.

John P. Breinholt

From a focus on these long-standing procedures, the meeting progressed to discussion of newer procedures and advances in technology, including an impressive presentation by Jonathan Rome, MD, that focused on rerouting hepatic venous flow in the Fontan physiology using advanced MRI mapping and flow dynamics evaluation leading to the development of a novel stenting intervention. SCAI 2013 Congenital Heart Disease Program Chair Thomas Fagan, MD, demonstrated the utility of 3D transesophageal echocardiography to guide interventions, augmenting the arsenal of tools to help children with congenital heart disease.

The program’s debates were lively and humorous. In one instance, John Rhodes, MD, and Zahid Amin, MD, squared off on the use of the Gore Helex device vs. St. Jude Medical’s Amplatzer Septal Occluder for small atrial septal defects. Dr. Rhodes highlighted the absence of erosion complications of the Helex device, while Dr. Amin touted the large experience the Amplatzer has in the interventional community. No verdict was achieved, and proponents of each walked away reinforced in their own practices.

Participants stretched beyond their typical sphere of influence to discuss topics in adult congenital interventions, such as catheterization during pregnancy and managing paravalvular leaks, as well as structural heart disease topics, including the MitraClip (Abbott Vascular) and aortic valve implants that are largely addressed by adult cardiologists.

Popular meeting elements included the “Brain-Scratchers” and “I Blew It!” sessions, which yield opportunities to discuss complex problems and complications as well as the innovative interventions that pediatric interventional cardiologists use to solve these unexpected events and conditions when they occur. Given the rapid expansion of registries to track congenital heart disease and current interventions, one session was dedicated to update on the progress on several of these, including IMPACT and C3PO, as well as trials, such as COAST, whose outcomes will affect all of our practices.

Opportunities, Training for Early-Career Congenital Heart Specialists

The conference’s congenital heart disease abstract sessions provided a unique opportunity for early-career investigators to demonstrate their growth and innovation in the field in the collegial environment for which SCAI meetings are known. Overdilating stents to the point of intentional fracture, or “unzipping,” was described, with several types of stents evaluated for their response to this test. Onsite demonstrations were also done to unzip additional stent types with early-career cardiologists.

Pediatric/Congenital Heart Disease Keynote

This year’s Mullins Lecture was presented to a full room of congenital specialists, many of whom trained under Dr. Mullins. One of his trainees, Frank F. Ing, MD, delivered the keynote lecture, focusing on the state of congenital interventional training. Beginning with input from dozens of former Mullins trainees as well as other experts, Dr. Ing discussed new agendas and directions in the evaluation of training endeavors, including metrics such as entrustable professional activities (EPAs), which seek to modify the age-old apprenticeship training and procedure counting to reach “competency.”

Disclosure: Breinholt reports no relevant financial disclosures.