Hosting Live Cases Requires Significant Preparation, but for NorthShore, It Was an Exercise in Teamwork and Learning

The interventional cardiology team at NorthShore University HealthSystem performed four complex cardiology cases at Evanston Hospital on Saturday and Sunday, April 2nd and 3rd, that were streamed live to the 2016 American College of Cardiology Scientific Sessions in downtown Chicago. With over 1,500 conference attendees gathered in an auditorium at McCormick Place (the convention center) to watch on oversized screens and a panel of cardiologists providing real-time commentary and asking questions (Figure 1), the NorthShore team worked on two complex cases each day. 

Led by Ted Feldman, MD, director of the cardiac catheterization laboratory, the team also included cardiology division head Jorge Saucedo, MD, cardiologists Justin Levisay, MD, Mayra Guerrero, MD, and Michael Salinger, MD, and support staff from the cath lab, echocardiography, anesthesia, and surgery. The physician operators at the hospital, located in suburban Chicago, interacted in real time with panelists at the conference who asked questions, challenged the operators, and provided suggestions.

“These were complex cases, they all went well, and it provided a great learning opportunity for those at the conference as well as our team here at NorthShore,” said Dr. Feldman. “It was also a chance to highlight both the teamwork and cardiology expertise here at NorthShore to a very knowledgeable audience.” 

Live case transmissions have been an integral part of procedure teaching and training since the very beginning of catheter intervention (Figure 2). Andreas Gruentzig, the inventor of coronary angioplasty, introduced live case transmissions in his first meeting in Zurich in 1978. Live cases have become part of many interventional educational meetings throughout the U.S. and internationally. The educational value of observing procedures in real time, unedited, with each decision and challenge, and often less-than-perfect result, has been invaluable. Taped procedures, or procedures that are shown in PowerPoint format, are edited, and often show only best case results and outcomes. While there is great value to these formats, there is no substitute for the live case format.

Critics of the live case format suggest there is the “NASCAR” factor, with the potential for complications being a large part of the attraction. There are also concerns about the distraction of the operators resulting from the back-and forth real-time discussion with the panel at the meeting site. 

Both the best of the educational value of live cases and the response to the criticisms of the format are addressed largely by what goes on at the site during patient selection and procedure planning. The process of preparation begins months ahead with a site visit from the audiovisual (AV) company. Assuring seamless transmissions is not only part of the technical success of the transmissions, but also makes the physicians and cath lab staff comfortable with the AV team.

In NorthShore’s case, since the transmissions were planned for a weekend, significant effort went into organizing all the needed support services. For example, the pre-procedure admission process had to be run through the cath lab rather than pre-op admitting. The staff for cath labs and the hybrid OR, including backup staff for anesthesia and standby cardiopulmonary bypass, had to be specifically defined, since regular weekday staffing could not be assumed.

However, that wasn’t a big issue, because there was no shortage of volunteers, said Cris Villanueva, senior manager of the Cardiac Catheterization/Electrophysiology Lab at NorthShore. “One of our concerns was the fact that the live case transmission fell on a weekend. The cath lab/OR/anesthesia teams dedicate many hours of work during the week and are also on call,” he said. “However, we had more than enough volunteers for the weekend. The enthusiastic response from the team members kept us from changing any of our staffing models. The cases were performed as usual, except being performed electively on a weekend with cameras around.”

Case selection was required to be not too far ahead of the meeting, since by its very nature, this patient population can’t wait indefinitely, and not too close to the meeting, so the procedures could be planned, including all the necessary special equipment and supplies for backup. A basic principle in NorthShore’s case selection for live transmissions has been to do procedures on camera that are part of the everyday, regular practice. The idea that only never-done-before procedures or techniques are needed to make for interesting live cases is attractive and sometimes appropriate, but in general, NorthShore has found that real-world procedures are educational for the meeting audience, and at the same time, safer.

In this instance, the team performed complex coronary cases (complex percutaneous coronary intervention [PCI] combined with balloon aortic valvuloplasty, with left ventricular [LV] support) and structural heart cases (atrial septal defect closure and valve-in-valve transcatheter aortic valve replacement [TAVR]). “They were complex procedures, but were cases the team had performed many times,” said Villanueva. “So that was helpful with setup and accommodating the camera crews. It’s almost like staging a play, and everyone knows where their marks are and where the actors and actresses are going to be.” (Figure 3)

In the week ahead of the transmissions, the cath staff, OR staff, and echo staff met to discuss staffing, patient management, and equipment needs for each case. The day prior and on the morning of the procedures, the physician team met for planning. Part of this discussion is defining the roles of the first and second operators, with the focus of the first operator on doing the procedure, and the second operator interacting more with the panel. A third operator is assigned to watch the hemodynamics, electrocardiogram (ECG), and patient.

Both Villanueva and Dr. Feldman said staff found it an exciting and enjoyable experience, and the whole team is already planning live cases for another upcoming meeting. 

The authors can be contacted via Dr. Ted Feldman at tfeldman@tfeldman.org.