Report from Hannah Bellsham-Revell

March 29, 2017

Here’s an update of Hannah Bellsham-Revell’s work in Philadelphia

Children’s Hospital of Philadelphia, October 2016

Aims

To observe the congenital heart disease MRI department and learn a new technique
To observe the congenital heart disease echocardiography department
To observe an overseas department and their decision making
To participate in a research project

Congenital Cardiac MRI

I observed two congenital MRI lists a week. Each list started at 07:00 and had around 6 patients, alternating awake and sedated/anaesthetised. These lists started much earlier than the lists at Evelina and ran very smoothly thanks to a dedicated anaesthetic team. The magnet was set-up in a hybrid catheter lab, but with a door between the two rooms, so the catheter lab can be used separately. It was interesting to observe the quality of images that could be obtained with free-breathing sedated patients, avoiding anaesthetics. Although I did not see it in action in my time in the unit, I also saw the exercise bike that can be attached to the MRI table to allow exercise-MRI. Reporting was on CVI 42 which we do not routinely use at Evelina and so I was able to gain experience with this system which was very user-friendly and had many functions.

Examples of MRI cases seen:

Cardiac assessment of non-cardiac conditions: Duchenne muscular dystrophy, proprionic acidaemia, iron overload
Routine surveillance: transposition of the great arteries, tetralogy of Fallot
Vascular rings
Single ventricle patient with persistent chylothorax
Coronary imaging: stress perfusion imaging after coronary re-implantation, coronary artery abnormalities
Single ventricle Fontan patients including one with the conduit going through the atrial mass

CHOP has been developing MRI lymphangiograms to plot routes for lymphatic interventions. I have a research interest in the single ventricle patients and CHOP has had some very promising results in treating plastic bronchitis. I was very keen to learn this technique and bring it back to Evelina, as it is not used in the UK. I observed several patients undergoing MRI lymphangiography with and without contrast and the MRI and access techniques. I am now working with the Evelina MRI and interventional department and we have our first patient identified.

Congenital Echocardiography

I spent one day a week in the echo laboratory. The set-up of the echocardiography service is very different to that in the UK. Due to technical and professional billing, all echocardiograms have to be reported by a consultant, meaning a very high workload. I am very involved in intraoperative imaging and the Technical Performance Score at Evelina, and was interested to see that at CHOP they do not use epicardial echocardiography and do not feel that the Technical Performance Score is useful. 3D echocardiography is used for valve assessment, but not routinely for ventricular septal defects and surgical planning of complex routing. I was asked to give a teaching talk on this element of 3D practice, and also gave a talk about my research on the assessment of right ventricular performance in hypoplastic left heart syndrome.

Observing an Overseas Department

I attended the weekly surgical meeting and was able to observe the decision making process. I saw that there were very similar issues to problems we see at Evelina, and a large forum discussion was the preferred method also. I was able to speak to the fellows about their training to gain some ideas that could be brought to our department and even UK training. I also attended teaching sessions within the department.

Research Project

Ethical approval was gained for a research project and I completed the America equivalent of the Good Clinical Practice course. My research project was reviewing the MRI, echocardiographic and catheter data on patients where there was debate over whether a single or biventricular repair was possible. I identified the patients from 2005 to 2016 and reviewed the clinical and demographic papers, and then re-analysed the MRI scans and echocardiograms. The data was then reviewed in terms of imaging and eventual repair. This is being submitted as an abstract to the World Congress.

Future Directions

Along with introducing MRI lympangiography to Evelina, we are planning on a collaborative project between CHOP and Evelina to increase numbers of patients in the study and also forming a good relationship for future research.

Conclusion

I am extremely grateful to the Madeleine Steel Foundation for enabling me to spend this 6 week period at CHOP. From an educational point of view I learnt several things that I am hoping to use to improve my clinical practice and from a personal point of view I had a very enjoyable trip to the East Coast.