As the medical community continues its shift toward less invasive interventions, cardiac catheterization is becoming more commonplace within care plans for pediatric and adult patients. In many cases, this less invasive approach is the standard of care.

“We're addressing more issues on a regular basis in the cardiac catheterization laboratory,” says Daniel Duarte, MD, pediatric and congenital interventional cardiologist with the Heart Institute at Nicklaus Children's Hospital. “As we advance our techniques and technology, I fully expect this trend to continue.”

Foundation of Success

At Nicklaus Children's, pediatric interventional cardiologists serve the needs of children born with congenital heart defects from birth and when appropriate, throughout their adult years. Regardless of the age or stage of the patient, two goals define success for cardiac catheterization procedures:

1. The family and patient perspective. First and foremost, the patient must return to his or her family safely.
2. The operational and technical perspective. The procedure goes smoothly and as planned, without complications and meets the objectives for which the patient was taken into the catheterization laboratory.

“We try to meet the operational and technical perspective 100 percent of the time,” Dr. Duarte says. “If we think the procedure will not achieve this, or the risks of the procedure are much higher than any other therapy, we don't take the patient to the cath lab because the family and the patient are our priority.”

Before performing a cardiac catheterization, the interventional team reviews the case thoroughly and decides to proceed only when other noninvasive medical treatments are ruled out and it is agreed upon that it is the appropriate therapy. However, when there is no clear answer of whether to perform catheterization, the case is discussed among Heart Institute specialists until a consensus is reached. These specialists may include:

• Echo laboratory technicians
• Cardiac surgeons
• Noninvasive imaging cardiologists
• Cardiac intensivists
• Cardiac anesthesiologists
• Pediatric cardiologists
• Electrophysiologists

This thorough treatment planning provides a strong foundation and leads to excellent outcomes.

Particular Pediatric Considerations

The pediatric population presents unique cardiac needs that must be taken into account when considering a cardiac catheterization. Congenital heart disease can come in very different forms, and coming to a decision about the procedure may not always be straightforward. It requires thoughtful consideration by the Heart Institute team, and in some occasions, innovative techniques that may not have been described or must be adapted for the patient's size and physiology. In addition, most studies performed in transcatheter devices come from adult populations and are untenable in younger patients. For example, transcatheter aortic valve replacement (TAVR), mitral valve replacement (TMVR) and tricuspid valve replacement (TTVR) have proven effective options for valve replacement strategy in adults. However, these are currently not options for children.

“The idea behind treating pediatric patients is for them to live a long life post-catheterization or any other intervention,” Dr. Duarte says. “We always take that into consideration. No one wants a child to undergo multiple interventions, so we have to choose the best intervention for each patient with the lowest likelihood of repeat future interventions.”

Despite these efforts, repeat cardiac catheterizations are sometimes required, particularly for patients with highly complex heart disorders, such as hypoplastic left heart syndrome.

While catheterization reduces pain, hospitalization, infection risk and the need for post-surgical medication, open heart surgery remains a viable and appropriate approach in specific situations. Notably, open surgery may be indicated in very complex heart disease such as hypoplastic left heart syndrome or tricuspid atresia. 

It's About the Family

Dr. Duarte not only discusses the plan with the team, but he also goes out of his way to educate and comfort family members.

“When a baby is born, there is a lot of expectation, and to have a child with a heart condition is distressing,” Dr. Duarte says. “I let them know I will care for their child with the same dedication as I would for my own daughters.”
At Nicklaus Children's, this personalized care extends beyond the catheterization room. Dr. Duarte and others engage with families to understand and meet their unique needs. This includes helping with social issues, including financing concerns that arise from financial insecurity or a lack of insurance.

Promoting Tomorrow's Catheterization Advances

“Over the last 15 to 20 years, the advances in technology and approaches have moved very quickly in the pediatric interventional cardiology world,” Dr. Duarte says. “We're now pushing the envelope with very small kids and all kinds of devices.”

One specific area that has seen growth is transcatheter pulmonary valve replacement. Today, Nicklaus Children's interventional cardiologists can replace pulmonary valves via cardiac catheterization with any of the available transcatheter valves.

Moving forward, Dr. Duarte anticipates increased interest in radiation-free catheterizations. Some centers in the U.S. have already started performing rudimentary, diagnostic MRI-guided catheterizations in an effort to eliminate radiation.

Looking ahead, Dr. Duarte wonders how well ultrasound technology could serve cardiac catheterization patients. That answer may come in the near future. Until then, researchers at Nicklaus Children's and beyond must move toward these and other advances with wisdom and caution.

“Our team provides excellent results that improve quality of life for our patients,” Dr. Duarte says. “We don't want to put a patient in danger just to push the envelope. Everything we do must be with the patient's well-being in mind.”