Proceedings of TRICO 2022 from desk of Tejas Patel


TRICO 2022, the Sixteenth International TRanscatheter Intervention Course was held on 5th and 6th of November, this year. Unfortunately, we were not able to conduct this course in 2021 because of extra-ordinary circumstances created by COVID-19 pandemic. There was a demand for an on-line course for TRICO 2021. However, I was not convinced because I felt that the connectivity between the participants and guest faculties may not be as good. Moreover, the intense teaching and thought exchanges may not be up-to the mark. We got ready for TRICO 2022 in month of June and started our preparation including agenda, connecting to the international and national guest faculties and collecting some real challenging cases for the live demonstrations. Our focus this time was on imaging, physiology, demonstration of advanced coronary calcium management and also to start with a TAVR case live demonstration for the first time. We also kept some meaningful talks by the international guest faculties on relevant topics and angio-discussion sessions when young cardiologists can show some interesting cases and complications. Dr. Shigeru Saito of Japan confirmed his participation as the Course Director along with me and Sanjay. Samir Pancholy of U.S.A. also consented to be a Course Director. We choked out an intense course with 11 hours of live demonstrations and 6 didactics to be delivered by our international guest faculty. Takashi Akasaka from Japan – the world authority on OCT imaging, (Wakayama Medical University, Wakayama, Japan), Rajiv Gulati (Mayo Clinic, Rochester, U.S.A.), Mauricio Cohen (University of Miami Hospital, Miami, U.S.A.), Tak W. Kwan (Lenox Hill Hospital, N.Y., U.S.A.), John Coppola (NYU Langane Medical Center, NY, U.S.A.), Fazila Tun Nesa Malik (National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh), Mir Jamaluddin, Sabina Hashem, Amal Kumar Choudhury, Khondker Shaheed Hussain, Jafrin Jahan, Kajal Kumar Karmoker, Md. Shafiqur Rahman Patwary (National Institute of Cardiovascular Disease, Dhaka, Bangladesh), Saidur Rahman Khan (Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh) and Futoshi Yamanaka (Shonan Kamakura General Hospital, Kamakura, Japan) confirmed their participation as International Guest Faculties. There were a few new additions for international guest faculty including Sanjog Kalra (Torrento General Hospital, Torrento Canada), Elvin Kedhi (Erasme Academical Hospital Brussels, Belgium) and Lars Sondergaard (Center for Cardiac, Vascular, Pulmonary and Infectious Diseases, Copenhogen, Denmark). There was also a galaxy of 21 National Guest Faculties, who confirmed their participation. 20 patients were confirmed for live demonstrations. All the patients were admitted on 4th morning at Apex Heart Institute. I personally went to Nirma University Auditorium to check the image and sound quality for live transmission. In the evening of 4th November, I invited all the International Guests for dinner at my home. Dr. Saito, Lars Sondergaard and Sanjog Kalra could not join as they arrived late. We had a great time during dinner.

At 8.45 a.m. sharp, I gave welcome address from Apex Heart Institute. The Nirma University Auditorium was jam packed as 415 participants from India, Bangladesh and many other countries took their seat. From Bangladesh 52 interventional cardiologists participated. I really like them very much as they are very sincere and disciplined participants. The first case was a complex left main bifurcation stenosis as well as RCA bifurcation stenosis which was done by me and Sanjay. Dr. Akasaka and Dr. Gulati were on-site moderators. It was a very complicated case, but it went on smoothly. There was intense discussion between the panel sitting at Nirma Auditorium, the on-site moderators and us. Once again it was a treat to listen to Dr. Akasaka on OCT interpretation and also Rajiv was at his best. The end result was satisfactory. The second live case was a LMCA bifurcation with mid LAD, OM1 and OM2 stenoses. It was a very difficult case. Dr. Saito with Rajni gave excellent live demo of that case. The discussion of IVUS interpretation of post stent OM dissection was very interesting. Everybody was very happy. The third case was a PCI of a heavily calcified and long mid-LAD stenosis done by me and Sanjay. We demonstrated use of rotational atherectomy for plaque modification followed by use of Shockwave (Intravascular lithotripsy) followed by aggressive balloon dilatation and OCT imaging. We discussed a lot on the usefulness of this technologies in calcium management and achieving a good MSA. Stenting was done with excellent end result and OCT evaluation confirmed it. Everybody enjoyed the case. The fourth case was done by Tak Kwan with Aman Patel. It was the case of a young patient who showed significant (at least 60%) LMCA bifurcation stenosis and critical LCX stenosis. IVUS examination of LMCA revealed MLA of 8.5 mm2 which directed us to treat it conservatively. So, only LCX lesion was stented. This case again emphasized the importance of imaging in decision making for such situation. Everybody liked it very much. This ended the first live demonstration session.

The beginning of second session was by a talk “OCT Image Interpretation: An Expert Perspective” by Dr. Takashi Akasaka. It was an excellent talk on OCT image interpretation and was extremely well received by the audience. The second talk was by Elvin Kedhi on “FFR, Resting Indices and Combined Intravascular Imaging. The Present and The Future” which was a wonderful delivery and gave a lot of insight on the intricacies. The fifth live case was a type C LCX lesion and another type C RCA lesion in an RCA with anomalous origin. It was done by Mauricio Cohen with Aman Patel. A good discussion on cannulation of anomalous coronary origin and image interpretation took place. Mauricio did it very nicely with a clean end-result. The sixth case was a very complex CTO of RCA done by Dr. Shigeru Saito with Rajni. He is considered as one of the “World Gurus” for CTO. He did everything to address the lesion. There was an intense discussion between the panel and Dr. Saito. Although the case was not successful the audience loved watching Dr. Saito doing this case. The seventh live demonstration case was a heavily calcified proximal LAD lesion which was done by Samir Pancholy with Sanjay. Once again calcium management was done using rotational atherectomy followed by Shock-Wave therapy and aggressive balloon dilatation. OCT evaluation followed by stent implantation was done with excellent end result. Samir and the panel had a lot of discussion on calcium management, the mechanism of different technologies and plaque debulking versus plaque modification. Everybody enjoyed the case. The eighth live case was done by me with Rajni. It was a diffusely diseases RCA and we did endoluminal reconstruction with multiple stenting. We did both IVUS as well as OCT imaging and ran both the image loops side-by-side on big screen to discuss the intricacies of interpretation. End result was clean. We adjourned the day 1 of this course.

At night, we had a Gala Dinner which was attended by the most attendees. They could meet and discuss with the national and international guest faculties in person. The food also was great. We dispersed to have some rest to prepare ourselves for the second day.

6th November was the second day of this course. Everybody came to the auditorium at 9.00 a.m. sharp as Lars Sondergaard along with Anmol Sonawane and Sanjay were supposed to perform a live demonstration for a TAVR case. This is for the first time in TRICO the TAVR case was to be performed. The case started with a lot of discussion between Lars Sondergaard and the panel. Lars Sondergaard is one of the world authorities for TAVR and it was apparent from his demonstration and discussion during the case. The case ended in 45 minutes with a satisfactory end result. Everybody loved watching this case. The second case was done by Dr. Saito with Rajni. It was a complex LMCA bifurcation and LAD lesion. Dr. Saito in his typical Japanese style demonstrated it very elegantly with IVUS guidance. End result was excellent. The third case was done by me along with Sanjay. It was again a case of heavily calcified critical type C LAD lesion. There was 360-degree loop in the right subclavian artery. We demonstrated the technique of going through the loop and cannulating the LMCA. We used 1.5 mm burr to do rotational atherectomy. After giving at least 4 passes at the speed of 1,50,000 rpm. The lesion was not crossed. There was a lot of discussion regarding various strategies. Then we went up to 1,80,000 rpm to cross the lesion. After that, we gave all the 80 pulses of Shockwave followed by balloon dilatation and stenting to achieve an excellent MSA. It was confirmed by OCT evaluation. It was a long live demonstration, but everybody enjoyed it. The last live demonstration case was an LMCA ostial lesion and a LCX lesion to be done using zero contrast technique under IVUS guidance. It was done by me along with Aman and Sanjog navigated us through the case. We could do it and only 2 cc contrast was used. Sanjog Kalra taught us this technique, which I really liked. We dispersed for the lunch break.

After the lunch break, we had several talks back-to-back including “Establishing A New TAVR Program: A Holistic Approach” by Rajiv Gulati, “Dealing with Complications of TAVR: A Case Based Approach” by Lars Sondergaard, “Using IVUS Imaging in Daily Practice: A Simple Step-by-Step Approach” by Sanjog Kalra and “HFrEF Optimizing Outcomes with Pharmacology and Procedures” by Samir Pancholy. Even after 11 hours of live demonstrations, the audience in the auditorium was full to listen to these eloquent speakers. Everybody including me enjoyed the delivery as well as the content of the talks. Then we had an angio-discussion session. The young cardiologists of India presented their cases and there was a good amount of meaningful discussion between them and the guest faculties. We successfully ended TRICO 2022 which was a power packed, hectic and meaningful journey for two days.

I express my sincere thanks and gratitude to Dr. Saito, all the international guest faculties, as well as national guest faculties for helping me to create one more success story. Looking forward to having you all for TRICO 2024 to be held on 3rd and 4th of February 2024.

Tejas Patel,
Course Director,
TRICO 2022.