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Proceedings of TRICO 2011 – from the desk of Tejas Patel

Friends,

TRICO 2011, the Seventh International Transradial Intervention Course was held on October 15th and 16th, 2011. We started preparing for it from beginning of February 2011 onwards. Hotel bookings were done by the end of March 2011. We decided to do the live cases from the Cardiology Department of Sheth V.S. General Hospital, affiliated to Smt. N.H.L. Municipal Medical College, Ahmedabad, and transmit them to Tagore Hall. This decision was taken because of several reasons. Firstly, apart from my private practice, I serve as Professor and Head of Department of Cardiology at this teaching institution, where we have a vibrant DM Cardiology Fellowship Training Program since last three years, and Ahmedabad Municipal Corporation has helped us to upgrade this department to one of the finest in India. We have two new flat panel cath labs, a new IVUS machine from Boston Scientific, a new FFR machine from Volcano and a rotablator machine from Boston Scientific. Logistically Tagore Hall was very near to this place, so spreading of a fibre optic cable for live transmission was more convenient.

This time we faced several challenges. Dr. Yvus Louvard was not available as these dates were clashing with one of the important meetings in Europe, where he already committed before. He asked me to invite Dr. Hakim Bonamer, a very talented interventional cardiologist of his group. I invited him and he agreed to come. We already completed the formalities for his licence of live transmission from Medical Council of India. Unfortunately, before two weeks of the course, he suffered a sports injury and he showed his inability to make it. Dr. Louvard then requested Professor Jacques Monsegu from Army Hospital of Paris. We sent him letter of invitation, however, unfortunately he was denied the Visa. Before four days, I received an email from my dear friend Oliver Bertrand from Canada stating that he was also denied the Visa. This was very disheartening and frustrating to us. Our very dear friend John Coppola from USA also could not come because of personal reason. This was for the first time in last seven years we missed him. Our old friends Samir Pancholy (USA), Tak Kwan (USA), Ian Gilchrist (USA) and Mitchell Krucoff (USA) confirmed their participation. James Tiftmann, one of the most experienced and famous radial operator from US also confirmed his participation. Sunil Rao, Tejan Patel and Kintur Sanghavi from US were our important international guest faculty. From Europe, my friend Sasko Kedev from Macedonia confirmed. My friend from Germany Josef Ludwig could not come because of genuine reason. However, two important senior radial operators from Germany Stefan Hoffmann and Thomas Comberg were also confirmed. Suryadharma from Indonesia and Amalkumar Chaudhary from Bangladesh were the guest faculty from Asia. Last but not the least, Junko Honye from Japan also confirmed. She was very important to me as she was supposed to act as an on-site IVUS commentator for the course. She is one of the world authorities for IVUS. We invited a mix of senior as well as young cardiologists on the national guest faculty.

This time TRICO 2011 was co-sponsored by SCAI (USA). We floated the first announcement in May 2011 and from July 2011 onwards we started registering the participants. By October 5th, 2011, we registered 700 cardiologists including 86 from different countries including Malaysia, Indonesia, Bangladesh, Yemen and Sri Lanka. From India, practically from every place there was representation that included from Srinagar to Thiruvananthapuram and from Shillong to Mumbai. We kept 50 spots for the cathlab nurses and technicians and were filled immediately. This time, we had to refuse 126 registrations considering the capacity of the hall and other logistics.

Everything was well set and well organized upto a week before the course.

On 14th of October, 2011, we received all our esteemed international guest faculties. The participants also started arriving from afternoon onwards. I had received whole hearted support from the industry both pharma as well as interventional product companies. We had a team of volunteers from the industry led by Mr. Dhanvant Shah, who managed the logistics very efficiently. This included receiving the guests from the airport, arrangement for their dinner, their transport and hotel accommodation. My Secretary, Shanti Sarvagnam and my personal staff Yash Soni worked tirelessly for almost two months. They were supported by my office staff. All these are the players behind the screen without whom the show would have been unmanageable. This time I took extra care to confirm the live transmission signals from cath labs of V.S.Hospital to Tagore Hall as we had some issues in last course. I expressed my gratitude and sincere thanks to Anand Peter and his team to give us the best signals by afternoon of 14th October 2011. Like every year, I invited the international guests at my home for the dinner on 14th evening. Everybody was happy and relaxed, so was I. We dispersed at 10.30 p.m. to have good night sleep and to prepare for next morning.

I alongwith my team, reached Sheth V.S. General Hospital at 7.30 a.m. because we were supposed to start sharp at 8.45 a.m. We lined up 24 complicated coronary as well as peripheral cases to be shown live during these two days. As always my colleague and course director Sanjay Shah stood by me like a rock. I received unparallel support from my course co-ordinators including Bhupesh Shah, Chirayu Vyas, Surendra Deora, Leena Shah, Rajni Radadia, Keith Fonseca, Biren Gandhi and Anand Jethwa during tense situations. My secretary, Geeta alongwith cathlab nurses, technicians and attendants also worked very hard for the arrangements inside and outside the cathlab. My DM Cardiology residents Kiran Prajapati, Pankaj Joshi and Dhiraj More also worked hard for the patient management. The Dean, Smt. N.H.L. Municipal Medical College, Prof. Pankaj Patel, Superintendent, Sheth V. S. General Hospital, Prof. M. H. Makwana, Deputy Commissioner, AMC, Capt. Dilip Mahajan and Deputy Director, AMC MET, Ashish Raja alongwith their staff extended whole-hearted support for preparation of this event. Honâ??ble Mayor Shri Asit Vora and Municipal Commissioner Dr. Guruprasad Mahapatra alongwith Prof. Pankaj Patel and Prof. M. H. Makwana consented to be the Patrons of this event.

Sharp at 8.40 a.m., I gave welcome address to the audience. This was followed by a brief inauguration ceremony done by Honâ??ble Mayor Shri Asit Vora. I started with my first case of a complex bifurcation LMCA. We demonstrated T-stenting in LMCA successfully. We also evaluated the result by IVUS. The case was moderated by Samir Pancholy, Mitchell Krukoff and Sunil Rao very nicely. There was a lot of fruitful discussion regarding different strategies between us, panel and participants. Sanjay helped me very efficiently for successful completion of this difficult case.

Second case was a CTO of LAD. It was done very elegantly by Tak Kwan. He was assisted by Bhupesh Shah. Tak demonstrated sheathless guide catheter insertion so nicely. He completed the case in a very elegant manner.

Sunil Rao delivered an elegant talk on â??TRI : Lessons learnt from important trialsâ??, which was very well received. Sunil is an eloquent speaker.

The third live case was a mid-RCA CTO (heavily calcified). I alongwith Sanjay started the case. We encountered so many difficulties. We could cross the CTO with a pilot 150 wire, but we tried several balloons including 1.25 x 6 mm balloon, but we could not cross. We used stride micro catheter and changed the pilot wire to a rota wire. We rotablated the lesion with 1.25 rota burr and balloon dilated the lesion. The flow was established. We could then deploy a long stent with excellent end result. There was continuous discussion between us and the panel consisting of Ian Gilchrist, James Tiftmann, Tak Kwan and Tejan Patel. The national guest faculties also participated alongwith the audience. It was a great learning throughout for everybody. I am sure, everybody enjoyed the case.

The fourth live case was done by Sasko Kedev and was assisted by Bhupesh Shah. It was a bifurcation of proximal LAD and D-1. As usual, Sasko did excellent demonstration of his technique and successfully performed the case.

Following that I delivered my talk â??TRA â?? Just do it!â??, which was well received. Just before lunch, Sanjay did a case of RCA osteal and mid-segment stenosis alongwith Chirayu Vyas. Patient had a small diameter radial artery arising from axillary artery. Sanjay did an elegant demonstration of balloon assisted tracking of a guide catheter through small radial artery which received a lot of applause. We had a lunch break after this case.

In post-lunch session, I alongwith Sanjay demonstrated a case of a complex LAD lesion and RCA CTO. While we were addressing RCA CTO, after balloon dilatation, when we were deploying the stent, the stent got dislodged at the RCA ostium. We shared tense moments alongwith our moderators and the audience. We retrieved the stent and did another radial puncture just above the previous puncture and completed the case. We showed the management of this complication live. The moderators Stefan Hoffmann, Thomas Goldberg, Tak Kwan and Tejan Patel had some nice discussion with us as well as the audience. I think the case was well received by the audience. Next case was done by Samir Pancholy with Bhupesh Shah. It was a nice OM bifurcation case and was done in a flawless manner by Samir. It was moderated very nicely by Ian Gilchrist, Kintur Sanghavi, Amalkumar Chaudhary and Sunil Rao. Kintur Sanghavi who was trained by us and John Coppola for TRA and who represented international guest faculty volunteered a great job of interviewing all the international guest faculties one-by-one. These interviews will be delivered on the website soon.

Following Samirâ??s case, Mitchell Krukoff alongwith Sanjay demonstrated a multi-vessel intervention. Mitch and Junko did a good discussion on the IVUS findings which was very important for our participants as the use of IVUS is still limited in India and young cardiologists are very interested in the basic learning of IVUS. James Tiftmann alongwith Bhupesh Shah did a live case of an LCX lesion. In this case, LCX was arising at a very sharp acute angle from LMCA making the case quite challenging. Tiftmann made it look quite easy and it was the result of his vast experience. Following this case, I alongwith Sanjay demonstrated OM stenting in a case of difficult arteria-lusoria. Any new radial operator must have some insight and understanding of arteria-lusoria. There was a fruitful discussion between us and the moderators.

In the last session of the first day, we had several important talks. It started with Ian Gilchristâ??s lucid presentation of â??Cruising through TR Route : My Voyage is my messageâ??. Following that there was an informative presentation from James Tiftmann â??TRA for carotid stentingâ??. We had an extra-curricular talk by Sasko Kedev â??How I conquered Mount Everestâ??. I specifically kept this talk because it is a matter of pride for the world cardiologist community that Sasko is the only Cardiologist who has been successful to conquer Mount Everest and all seven summits from different continents. It was a very absorbing talk. Mitchell Krukoff delivered a talk on â??Cannulating coronary ostiaâ??, which was very important for the young cardiologists and the beginners as he gave some very important tips. We ended our first day here.

We had a nice gala dinner arranged at the Lawn of Karnavati Club, where the participants had a good chance to interact with the international guests.

Second day, we started at 9.00 a.m. with the first case of LAD diagonal bifurcation lesion. Tejan Patel was assisted by Bhupesh Shah. Tejan did FFR of angiographically significant LAD stenosis. However, FFR was 0.9 and there was a good discussion between Tejan and moderators, Mitchell Krukoff, Thomas Comberg and Stefan Hoffmann. Ultimately, after FFR the decision was taken to treat the patient medically. I think this was a great message to the audience. It requires guts to differ the intervention which everybody should learn. Tejan did a good justice to this case. Following that I alongwith Sanjay tackled an extremely difficult in-stent CTO of LAD. Throughout the live demo, there was discussion between us and the panel. We used micro-catheter and pilot 150 wire to cross the lesion. It was dilated and stented using a long stent. Junko Honye gave an excellent IVUS commentary for this case.

Third case was done by Ian Gilchrist alongwith Bhupesh Shah. It was a tight RCA lesion. In this case, a lengthy discussion on FFR and the adenosine dosage took place between Ian and the moderators. End result was excellent and audience learnt a lot about FFR. Following this case, Samir Pancholy delivered a talk on â??Overcoming the fear of RA occlusion â?? Mission almost accomplishedâ??. He has done original work on this subject and he delivered an excellent talk. The fourth case was done by me and Sanjay. It was a case of a very complex LMCA bifurcation. Patient had a very small radial artery. Again we demonstrated balloon assisted tracking of a 7F guide catheter through small RA. During the case, we had several challenges and long discussions with the panel. We successfully did T-stenting. The case was very well received. Rajesh Rajani gave his presentation â??Radial Puncture : Well begun is half doneâ??. It was a nice presentation. We had a lunch break after that.

In post-lunch session, we had two important talks. First one was â??Real World Utility of IVUSâ?? delivered by Junko Honye and second one was â??Transulnar approach â?? Pros and Consâ?? delivered by Sasko Kedev. Both were excellent talks. Then, we had angio discussion session. Some young cardiologists from India showed their cases. International guest faculty gave their comments, which were important. From International guests, Tejan Patel and Kintur Sanghavi showed some very challenging cases, which generated good discussion. At 3.45 p.m., I gave concluding remarks and we officially ended TRICO 2011.

TRICO 2012 will be held on 3rd and 4th of November, 2012. In coming months, we will be providing further information on this website. I sincerely thank from bottom of my heart to everybody who helped us making this purely educational venture successful once again. If by chance, I have forgotten to acknowledge the important work of anybody, I apologize for the same.

Tejas Patel
Course Director

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