Carl Maronich (Host): This is Healthy with VCU Health. I'm Carl Maronich. Dr. Samuel Casella knows that in pediatric cardiology, the smallest details make the biggest difference, especially when the patient weighs less than two pounds. With a new piece of equipment, he's addressing congenital heart defects in premature infants right at the bedside in the most advanced neonatal intensive care unit in the Richmond area at Children's Hospital of Richmond at VCU. He's here to talk about that procedure and the other minimally invasive approaches he uses in caring for kids' hearts. Dr. Casella is an interventional cardiologist and the Medical Director of Pediatric Catheterization at VCU Health. Doctor, welcome to the podcast.

Dr. Samuel Casella: Thanks for having me, Carl. It's a pleasure to be here.

Host: Well, so great to have you and your expertise with us. And maybe we could start by having you talk about what congenital heart defects are and how common are they in children.

Dr. Samuel Casella: So, congenital heart defects are problems with how the heart was formed before a baby was ever born. They occur in approximately one in a hundred live births. And around one in a hundred of those, so one in a thousand total, generally need be referred to a pediatric cardiologist. They can range in severity. They could be a tiny little hole that has no symptoms or clinical relevance at all, or they could be severe holes or leaky valves or tight valves that might even need surgery on the first day of life.

Host: So typically, you mentioned possibly a need for surgery in some cases. But it also sounds like based on the variety of potential types, that there could be a number of ways to treat them. Historically, how have they been addressed?

Dr. Samuel Casella: When the field first got developed, the only options that we had were surgery. And that was literally open heart surgery where you open up the patient's chest and repair the defects, using a heart lung machine. As the field has advanced and, you know, evolved and technology has caught up, we've been able to offer a variety of interventions from less invasive means.

And so, what I'm the director of is interventional catheterization. Catheterization is accessing the blood vessels of the body using things. Basically, they're glorified IVs, and we can put small tubes in the blood vessels and get them to the heart. And through those tubes, we're able to close holes. We can open holes if needed. We can open tight valves or tight blood vessels. And we can actually even replace some valves these days through transcatheter interventions, which enables us to provide these procedures without open heart surgery, which is really a game-changer because the recovery for these patients is just so much easier than when you're doing open heart surgery.

Host: And, Doctor, we're talking about newborns here, so the tiniest of vessels and arteries. I mean, it's amazing that you're able to do that kind of work and how technology has advanced to be able to allow you to do even more than historically you've been able to do.

Dr. Samuel Casella: It truly is. And the size of the babies that we're doing these procedures on is really profound. These are children that can literally fit in the palm of your hand and if you think about the size that we're dealing with, usually a baby's heart is the size of their fist. And so, we're operating in a space that's as small as a quarter or even a nickel. And we're able to go through with these very small catheters and perform these procedures.

The most recent one that we've been doing is bedside PDA device closure. PDAs are connections between the aorta and the pulmonary artery that is supposed to be there when a baby is inside their mother. But after they're born, it's supposed to close. But the earlier that you're born, if you're born prematurely, or the smaller you are, the more likelihood that that hole will not close. And so, in about half of patients born between 22 and 24 weeks, that hole does not close. And it can present a number of problems such as breathing; a lot of patients cannot get off the ventilator. It can also be related to inability to eat or even have problems with the bowel wall needing surgery. So, it can be a big deal in many of those patients.

In the past, the options were open heart surgery or medicines. The open heart surgery was very effective in that they could successfully close the hole, but it was related to a lot of complications and they had to open up the baby's chest and a lot of babies got very sick afterwards. And so, that really fell out of favor as a procedure over time, and that left the neonatologist with medicines as really their only option. But the medicines that we use are effective in only about half of the cases. And so, it's not a very effective treatment.

It was in 2019 that the FDA approved its first transcatheter device for PDA device closure in these very small infants, as small as 700 grams, which is one and a half pounds. And since then, the field has really taken off. We brought the technology here to VCU. And we started doing our first procedures in the catheterization lab, which went very well. And we were very happy with our ability to close these holes successfully. However, it was very labor-intensive and we had to bring the children from the NICU to the catheterization lab, which was, as you can imagine transporting an extremely small infant that's on a ventilator, could be very high-risk and it can just be very stressful for them. And so, we actually developed the ability to do this procedure at the bedside, and we did so following some of the technology that has been studied by some of my colleagues in the field. And we procured a C-arm, which is basically an x-ray machine that's extremely small and portable, and that is able to be brought to the bedside and put over the baby's incubator. We're able to perform the procedure right there at the bedside, which has just really been remarkable. And we were studying this over time. And it was taking about two hours door to door to transport patients to the cath lab and back. But my portion of the procedure only takes about 30 minutes. So, an hour and a half of that was wasted time. And what we've been able to do now is do it at the bedside and you basically cut out all of that wasted time. And the only time that we're touching the patient is during the procedure itself. So, it's enabled us to do this at the bedside with a lot less trauma to the patient, which is really remarkable.

Host: Really amazing innovations and quite a commitment by VCU to bring that technology to the community.

Dr. Samuel Casella: Truly. And we're really proud of it. And we want to provide this service to our community. My purpose here is to offer the best world-class heart care to the people and the community of Richmond. And that means being available to anybody in need. And we work very well with our surrounding providers, our surrounding NICUs in particular. And we've been working with our NICU. We're the only level four NICU in the region, meaning that we provide all the surgical services and ECMO, which is the heart lung machine for these patients. And that means we take the sickest children, but we want to work with the NICUs.

And so, we have enabled our services where we are willing to transport patients from the referral NICU to our NICU where we do the procedure, but then we send the patients back. And it involves a lot of paperwork, and it involves a lot of work with insurers. And to be perfectly honest, that involves VCU eating a lot of the costs of transport. Because a lot of insurance will not pay for the transport back, but it's a service that we feel obligated to provide to the community and that we want to bring to our patients. And so, we've been doing that frequently. I've had patients transferred from basically all the surrounding NICUs. And we transfer them back after the procedure is done to get them at their home environment and closest to their home as well.

Host: Amazing, and so reassuring to those in the community just to know it's there. You know, it's the kind of thing that you hope you don't need—but should you, thank goodness that it's right there so close. And the investment has been made to bring that to the community.

Dr. Samuel Casella: Absolutely. You know, we have the big shiny tower now that we've opened up the new inpatient tower. And it's become more obvious that we are there. But it's funny that a lot of people don't realize it. It's a new service that we're providing and sometimes I've seen patients that have been driven an hour and a half away to a surrounding institution just not knowing that the service was available right here at home. And we want to make sure people know that.

Host: Maybe you could talk a little more about the pediatric catheterization and electrophysiology lab and all that goes on in the lab. As you mentioned, a lot is able to be done now at the bedside, but the lab certainly plays an important role in all of that.

Dr. Samuel Casella: Yes. We opened in 2024, and this is the region's only combined electrophysiology and cardiac catheterization lab. We have truly state-of-the-art equipment, which enables us to do these procedures with the lowest radiation dose in the region. And we are members of multiple collaboratives where we are actually tracking things like radiation doses, case times, complication rates in order to compare ourselves to similar institutions and to learn from each other in order to ensure that we are providing the absolute best care that we can.

We offer the full gamut of services from an interventional side of things. That includes things like PDA closures or ASD closures. We do transcatheter valve replacement, pretty much everything under the sun. And we have a full electrophysiology service as well, where electrophysiology is the electrical activity of the heart, so people with funny heartbeats. A common diagnosis would be a Wolff–Parkinson–White syndrome, WPW. We are able to treat that here and we work very well together—myself and the electrophysiologist—and we do joint procedures if need be. We were one of the first places in the state of Virginia to place a leadless pacemaker in a child. And that is a little device that can make the heartbeat when a child's native electrical activity isn't working. And the old devices needed wires that went through the patient's blood vessels to a device under the patient's skin, and there are all sorts of complications from those wires and the device. But this device that we put in is contained within that patient's heart. It looks kind of like a little bit bigger than the eraser of a pencil. And we were able to put that into a small child and eliminate the need for all those wires and a big box and all that stuff, which was really exciting to provide that for a patient in the region.

Host: Amazing. Yeah. It must be great for you to see these innovations come along knowing that they're going to be able to serve patients in a much better way. And, Doctor, I understand you also see adult patients, and maybe you could talk about when a pediatric cardiologist would care for an adult.

Dr. Samuel Casella: This a really developing field is that of adult congenital heart disease and it's a reflection of the progress that we've made in our field. In the past, a lot of children had severe congenital heart disease and, unfortunately, were not surviving. But as we have improved our technology and our procedures, those children have survived into adulthood. And now, there's actually more adult survivors of congenital heart disease than there are children. And they're a very unique population because they've had procedures done that are unique to pediatric cardiology and they're not the type of procedures that adult cardiologists deal with on a regular basis.

And that leads to a lot of problems that patients can have later in life. And you really need knowledge of what happened to them as they were a kid. And that's what we're specialists in. So, we do have a wonderful program here, an adult congenital program, which my colleague, Dr. Sangeeta Shah, is the director of. And she is credentialed in adult congenital heart disease, where she's an adult doctor that has specialized in these pediatric patients. But I come in and I work with her from an interventional catheterization side of things to bring my knowledge to the table to help any kind of interventional needs for these patients. But I also work alongside of my adult colleagues very closely because they're so good at the traditional adult disease like coronary artery disease, which is not my expertise.

So, what it really requires is that you have people that collaborate and we put all of our brains together in the same room, and that's what we do here to take care of this really unique population.

Host: Yeah, that's incredible and great, again, that that's available locally. So, folks in that circumstance are able to get the care they need. Doctor, what other unique services does the heart team at Children's Hospital of Richmond at VCU offer.

Dr. Samuel Casella: Here at VCU, we offer the full gamut of services for a world-class pediatric and adult congenital heart disease program. We have all the service lines including echocardiography, MRI or CT interventional catheterization, electrophysiology. And we have fetal echocardiography. So, fetal echocardiographers are people who can diagnose congenital heart disease in infants before they are born. And that enables us to counsel families about what to expect, and it enables us to prepare before a child is ever born. If that patient needs to have emergent surgery, well, we can be ready before the patient ever comes out of the womb.

We have a fantastic congenital heart surgeon, Dr. Brian Kogon, who works here. He is one of the most well-known congenital heart surgeons in the country, and he has a vast experience operating on both infants and adults with congenital heart disease, which is really unique to VCU that we're able to offer that full range of services for the patients of Virginia.

Host: Yeah. Amazing stuff. And again, as you said, so great that all that's available to folks here in the community. Dr. Samuel Casella, sharing your expertise, we appreciate that so much. Great information. We appreciate you being with us today.

Dr. Samuel Casella: Thank you so much for having me.

Host: For more information about heart care for children, visit Children's Hospital of Richmond at VCU's website chrichmond.org, or call 804-828-CHOR. If you enjoyed this podcast, please share it on your social channels and explore our entire library of podcasts for topics of interest to you. I'm Carl Maronich and this is Healthy with VCU Health. Thanks for listening.