Dr. Rania Habib (Host): In 2017, the Children's Health Heart Center started lymphatic occlusion interventional care, and now they have well-established standards and protocols with positive outcomes and success stories for their congenital heart patients.

 This is Pediatric Insights, Advances in Innovation with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Rania Habib. This episode explores the advances in lymphatic occlusion interventional care. I am joined today by Dr. Suren Reddy, an Interventional Cardiologist at Children's Health, who is also the Director of Cardiac Catheterization Lab and Fontan Disciplinary team.

He is also a Professor of Pediatrics at UT Southwestern Medical Center. Welcome, Dr. Reddy. It is an honor to have you on the podcast today.

Suren Reddy, MD, FSCAI: Thank you Dr. Habib. It's an absolute pleasure to be here and look forward to chatting more about this program.

Host: As do I. In a previously recorded podcast, we discussed how lymphatic occlusion work was built on efforts within the hybrid catheterization and MRI lab. As the director of this program who built it from the ground up, how has this expanded since we talked over a year ago, and how do you collaborate with that team?

Suren Reddy, MD, FSCAI: Over the past six to seven years now, the program, the Lymphatic Evaluation and Intervention Program at Children's Health has grown tremendously. Leaps and bonds, I would say. Not just with the patient volume, but also with the expansion of what we can actually do and provide for the various types of lymphatic patients that come seeking help for their loved ones at Children's Medical Center. Talking about physician portfolio and physician team members expansion; we have added doctors from the Interventional Radiology, Dr. Sheena Pimpalwar, who is the Director of our Interventional Radiology Services, and I'll expand more on her expertise later. We also have Dr. Tarique Hussain from our Cardiac MRI team who provides excellent service and care for these patients for the evaluation part of the lymphatic program. And then you have our amazing team who takes care of the patients before and after from the CVICU, which is a Cardiovascular Intensive Care Unit where patients are housed before and after these very high risk complex procedures for their recovery.

So it's multidisciplinary team that has come together and we have grown leaps and bounds, not just with physicians that I just alluded to, but also with the technicians and the sonographers and the allied healthcare team members, including the physical therapists and the lymphatic massage therapists who are a critical component of the medical care after the procedures are done. We have also expanded, there are some patients who have lymphatic issues that needs to be addressed either before or after, that need high end pulmonary and critical care services. So we have garnered the support of our pulmonary team to help with interventional bronchoscopy, to take the major plastic bronchitis related casts out in their airways.

So that is one area of expertise that I'm really proud of that Children's Health and UT Southwestern has come together to bring those services to these high risk patients. In addition, there are multitude of other subspecialists who we can reach out to both on the Children's side and the UT Southwestern side, who play a critical role. And one such gap that was there when we started this program in 2017, which we have filled recently, is by including a Vascular Surgeon, a Microvascular Surgeon who can help with surgical anastomosis of lymphatic vessels. That was not available at that time. So I'm very, very pleased that it's a well-rounded program now, that we can cater to multitude of patients now that we were unable to take care of at that time.

Host: That is fantastic. Now, as the director of this program, what is your role on the team?

Suren Reddy, MD, FSCAI: My role as the Director of the Cath Lab, was to bring these services, the Lymphatic Evaluation and Intervention Program back in 2017 to Children's Health and UT Southwestern. As we started our initial set of patients, our stars, if you will, aligned perfectly with arrival of Dr. Sheena Pimpalwar, who is an Interventional Radiologist. She and I have developed lots of procedures here that are unique to the type of interventions that we do for, lymphatic interventions that we do here at Children's Health; that's different from the procedures being performed at other institutions. And my role, as the program expands to oversee the care of cardiac patients who have lymphatic problems, and I've requested Sheena Pimpalwar, who is my partner in this end of work to help me with non-cardiac patients, which is their expertise, and they're patients who are present with lymphatic abnormalities elsewhere, other than the chest compartment, in the brain or in the head and neck area, or in the abdomen or lower limbs, which is an area that I'm not specifically trained in. But I, can rely on Dr. Pimpalwar and her expertise to help these patients. So we divide this program into two, cardiac and non-cardiac and, and I lead the cardiac program, if you will. And, Dr. Pimpalwar leads the non-cardiac part of the Lymphatic Evaluation and Intervention Program.

Host: So when you're looking at the vast number of patients that you treat, both cardiac and non-cardiac, which patients benefit the most from these multidisciplinary evaluations?

Suren Reddy, MD, FSCAI: I think both the subset of patients actually benefit from this detailed lymphatic evaluation and intervention program that we have here. For example, my training and my more than 15, 16 years of experience in congenital heart disease gives me an advantage of taking care of lymphatic disease in congenital heart disease patients. Similarly, the Interventional Radiologists have a lot of expertise in abdominal compartment and lower limb interventions that I'm not specifically trained in and don't really keep up with all the novel and the latest and the greatest interventions that are happening in their field. So by combining our expertise, bringing the interventional cardiologist, and the interventional radiologist who are both the directors of their own field and our experience together and work on both cardiac and non cardiac patients, again, together, gives us that edge to take care of these complex patients.

And it has worked well. The teamwork. I can go on, talking about it forever. It's amazing to see both the cardiac and IR teams working together to bring their vast experience and their skillset to take care of our sickest of the sickest patients here.

Host: Obviously we've seen in different fields that multidisciplinary care really elevates care to another level. Can you share outcomes from previous procedures, specifically comparing, two or three patients that have had this procedure and the different results?

Suren Reddy, MD, FSCAI: We've done more than 30 or 40 patients so far, interventions wise and diagnostics, we have done plenty of them. Every single patient has their unique story of success. No one patient is similar, but broadly you can think about cardiac and non-cardiac patients. And with my background for this podcast, I will limit myself to the cardiac patients that are what I call the major wins, if you will. One such patient that comes to my mind is a patient, a toddler who was transferred to us from a different institution after a third stage open heart surgery for single ventricle palliation status post fontan procedure, who was suffering from severe chylous effusions, and was stuck in the hospital for more than two to three months, really malnourished and was transferred here to our institution for transplant evaluation.

This particular patient, back in the day before lymphatic evaluation and treatment program was started here, would've undergone a transplant evaluation and would've been listed as a high risk transplant, or some institutions actually do not list them because their morbidity and mortality after the transplant is high. You're right, they're too high risk and because the results are very bad, they would try their best not to transplant them right away, but to optimize them. And then while we were waiting, we used to lose a lot of these patients. And it was heartbreaking to see patients suffer right in front of our eyes while waiting for heart transplants. So when this patient was presented to us, we did a detailed lymphatic evaluation in the MRI suite, transferred him to the cath lab, did our unique way of getting into the thoracic duct, which is the lymphatic duct, the main channel.

There are two different ways that you can approach it, but I'll come back to that in a second. We used our low risk approach and we were able to get into his thoracic duct abnormalities, the abnormal channels, and successfully occlude them, and he was able to get off of all of the medications and the high end support he was on.

He had a successful lymphatic procedure. The chylous effusions resolved, and from there on he was able to be discharged within a few days after the procedure. He went on to go and do dirt biking for many years. And he used to send me these beautiful images. His parents are amazing. They take really good care of him and they really let him live his life, if you will. He wanted to do dirt bike racing and he won many awards doing that. And then after some time, because of his lung arteries and the way his heart function changed, he was relisted for transplant. But now, he is not that sick anymore. He is a very otherwise healthy patient who has ventricular dysfunction, not a lymphatic abnormality that has led to him to receiving a successful heart transplant.

And he's one of our few patients who has left the hospital discharged from the hospital post-transplant within 10 days or so, which is the record I believe at our institution. That has never happened post fontan transplant patients. So, this is one of the success stories that takes a different pathway.

You have a failing fontan patient, if you will, and this patient received a successful lymphatic procedure. His lymphatic complications resolved. He enjoyed his life for many years, and then for a different reason, needed a heart transplant. And he's went through heart transplant with no postoperative morbidity or mortality risks, that is traditionally associated with such patients. So he continues to thrive while post-transplant.

The other patient that comes to mind is a teenager, again, a cardiac patient, single ventricle post fontan after eight or nine years after fontan palliation, he was diagnosed to have myocarditis and his single ventricle, got a hit.

And his function was severely depressed, for which he needed a ventricular support. We have an excellent VAD team at Children's Health here. Our team with the ICU care that he received were able to place him on a VAD, ventricular assist device, but he quickly ended up with plastic bronchitis complications after that.

This are casts within the airways that causes significant lung compromise, if you will. And that is not really, a, a patient that you would want to send for transplant. So our transplant team and surgical teams have after long discussions, decided to take him off the list because of the significant post-transplant morbidity that he would have or even mortality, the risk is really high. So, I was asked to see if we can do anything for him for lymphatic interventions in a single ventricle patient on a VAD support who is on anticoagulation, meaning he is on blood thinners. So we were able to take him to the cath lab with no promises.

Cause he was a patient with lots of metal in his body, if you will. He was connected to machines, which means I cannot take him to the MRI suite, so I don't know where his lymphatic system is. If I don't know where his lymphatic system is, it's very hard for me to figure out in the cath lab, but by that time we had figured out this low risk, invasive way of doing lymphatic procedures from traditional catheterization routes from the vascular system, and we were able to go in there and enter his thoracic duct safely, identify the problem and occlude the lymphatic channels that were giving him severe plastic bronchitis problems. And then within three to four days, his symptoms resolved. He was relisted for transplant and he underwent a successful transplantation, and had no postoperative lung compromise that is traditionally seen with these patients with plastic bronchitis.

So it was a major win. And the reason we remember this patient as a major win for all of us, not just for the patient, but for the program, for our expertise and going through the learning curve is because we didn't know where his thoracic duct was. We were asked to shoot blind. We were asked to thread a needle that was in a haystack and we didn't know where the haystack was.

So it was a multitude of these pitfalls, if you will, that led it to be a very high risk procedure and we were able to not only cannulate the thoracic duct using the low risk approach, but also, addresse his lymphatic complications. So that's a great success story that we wanted to share.

So you now have heard about two patients who, one, a successful lymphatic intervention for chylous effusions, we treated his chylous effusions, lymphatic complications were addressed, but eventually the patient ended up needing a transplant for some other reason.

The second patient that we talked about who has severe plastic bronchitis needing a transplant, came off the transplant list because we thought he was going to be too high risk. Underwent a successful heart transplant after the plastic bronchitis intervention was done, and he has no lung complications at all. The third patient that I want to talk about are many other patients like this are patients who have Fontan surgery at various stages of their life, be it a toddler, adolescent, young adult, or in their twenties or thirties when these patients present with either chylous effusions or plastic bronchitis or chylous ascitis; we have taken multitude of these patients to the cath lab for successful lymphatic interventions, and they have done well for many years. The longest patient has five, six years out now who has done really, really well and not needed any interventions, and is not on the transplant list. Many of these patients would've had to be listed for transplant and would've undergone transplant, and we would've lost some of them because the post transplant morbidity and mortality is very high in patients who have lymphatic complications after.

One recent patient that was sent to us was deemed not to be a transplant candidate because his BMI, body mass index was very high, and it was a catch-22. He was not listed for transplant because he was not in the good weight range that we wanted him to be. But because of his lymphatic complications, he was unable to exercise and do the usual activities of daily living. So he was unable to lose weight, but at the same time, we can't progress with his care. We took him on, did a successful lymphatic intervention. He was able to get rid of his plastic bronchitis concerns. He is now in a great physical activity and exercise regimen. He has lost weight and he's now in a good range. If he needs a transplant, he will be reevaluated for transplant and listed because that risk factor is taken out of the picture.

Thankfully he has not needed a re-transplant evaluation cause he's doing phenomenal. He has lost a ton of weight and he is eating well. And, his side effect profile from all the medications that he was on, is all gone. So we are very happy that he's doing great and he has kept his own organ and hopefully he and many of the patients will continue to do that for as long as we can help them.

Host: Hearing these success stories really gives us hope about the outcomes for these patients. As the director of Lymphatic Occlusion Interventional Care, and leading this multidisciplinary team, what are your future goals?

Suren Reddy, MD, FSCAI: As the program grows, I foresee further collaboration with the multidisciplinary team with Dr. Sheena Pimpalwar who will be leading the IR non-cardiac, part of the lymphatic program. Working closely closely with Dr. Tarique Hussain, who is the leader of our cardiac MRI program and our entire heart center leadership here; because we need to work on increasing our expertise and also the collaboration across multitude of disciplines to care for these complex patients. Our goal would be to tackle very high risk patients, not just from the Dallas Metroplex or adjacent states, if you will, but also the southern part of the country.

We have had many referrals for lymphatic interventions from across the pond, from UK, from European countries and South American countries, and Mexico, et cetera. So how do we come up with pathways for patients from adjacent states and also across the United States and from other parts of the world to travel here and get their care. Those are pathways that are being looked into at this time.

As far as lymphatic interventions goes, we have not done what we call as PLE interventions at our institution, protein losing enteropathies, an abdominal lymphatic compartment problem. And there are many pathways, that you can go down, for these patients. Management pathways. Right now we are in the process of setting up treatment pathways for PLE interventions. There is the newer technique that CHOP has perfected. The Children's Hospital of Philadelphia team has worked on what is called, it's a lymphatic turndown approach for complex congenital heart disease patients.

And we are working on that as well. So while the, the future is bright for this program, I'm very happy to say that we are all committed to expanding this program and advance the care for these complex patients.

Host: It sounds fantastic. I mean, I definitely think you guys are going to end up being this center that are drawing patients from all over the country, and I love that, that's one of your goals. Is there anything else that you would like to share with us today?

Suren Reddy, MD, FSCAI: Yes. Well, I want to thank, both Children's Health and UT Southwestern for helping us build this excellent multidisciplinary care. I'm very thankful for our interventional radiology colleagues, the cardiac MRI colleagues, the CVICU teams, and the entire heart center, that has come together to make this program a destination program, if you will, for the complex of our complex patients that we take care of.

So, lymphatic evaluation and intervention program is not just for cardiac patients, it's for the entire subset of patients neonates to adults with congenital heart disease or without congenital heart disease who have lymphatic problems. We are here to help Texas. We want to be the destination program, helping such complex patients who need care locally.

Host: Well, we definitely thank you so much for your time. And how can the audience, if they want to send patients to you at UT Southwestern or Children's Health, how would they do that?

Suren Reddy, MD, FSCAI: There is a multidisciplinary fontan program, and there is an lymphatic evaluation and intervention program. There are phone numbers and emails associated with it. It's on Children's Health website. I would refer you to those websites.

Host: Well, thank you so much for your time with us today, Dr. Reddy, and to our audience for listening to Pediatric Insights, Advances and Innovation with Children's Health, where we explore the latest in pediatric care and research. You can find more information at childrens.com/heart. If you found this podcast helpful, please rate, review and share this episode.

Please follow Children's Health on all of your social channels. I'm Dr. Rania Habib wishing you well.