New Leader of Pediatric Cath Lab Addresses Complex Congenital Heart Disease

In 2018, Thomas E. Fagan, MD, joined Cleveland Clinic Children’s as its new Director of the Pediatric and Congenital Cardiac Catheterization Laboratory. This appointment follows two years of leading the advanced cardiac catheterization interventional laboratory and teaching at the University of Tennessee School of Medicine and 10 years serving in a similar capacity with the University of Colorado, Children’s Hospital in Denver.

Dr. Fagan is leading an advanced team with a deep understanding of congenital heart disease and its treatment. Consult QD sat down to talk to him about his new role.

Q: What drew you to Cleveland Clinic Children’s?

A: When Cleveland Clinic approached me, I was naturally drawn to the opportunity to join a world-renowned institution, and one where I could advance programs addressing the most complex congenital cardiovascular conditions.

Q: What are some of these programs?

A: We are doing several novel procedures, including transcatheter implantation of heart valves, which is much less invasive than traditional open heart surgery. When needed, we partner with our surgical colleagues to provide minimal incisions, so we can still avoid use of the heart-lung bypass machine. We have the most well-developed program to treat pulmonary vein stenosis (PVS), especially in adults after ablation for atrial fibrillation. Other complex interventions include placement of patent ductus arteriosus (PDA) stents and right ventricular outflow tract (RVOT) stents in newborns and infants.

Q: Why would physicians refer families to Cleveland Clinic Children’s for their kids’ congenital heart problems?

The answer is easy. We provide outstanding care for all aspects of congenital heart disease, especially in the most complex and high-risk patients. Particularly in recent years, our surgical outcomes are as good as, if not better than, those of any other program in Ohio and the region. The success rate for nonsurgical treatment of patients, including catheter-based therapy for infants and children, is outstanding, and this comes with an extremely high level of safety.

Cleveland Clinic Children’s has proven successful in tackling some of the most confounding cases where the condition and the intervention are both extremely complex. PVS is a good example. It is one of the most common congenital heart defects threatening the lives of infants. Since it can be particularly challenging, it is performed at a limited number of centers. Cleveland Clinic is also one of the few centers that performs ex utero intrapartum treatment (EXIT) procedures for perineal interventions before full delivery of the child.

Q: What adult procedures do you perform and what are the challenges?

A: There is a large population of adult patients born with congenital heart disease who are followed and treated at Cleveland Clinic. These are patients who much earlier in their lives had complex surgeries, many of which are not longer performed, leading to very unique and complex situations that now need to be addressed. Most of these treatments start with catheterization procedures.

Often we are assessing narrowed cardiac baffles placed in the heart to channel blood to proper chambers. These are in patients who have had atrial switch procedures (Mustard or Senning) or Fontan operations. These baffles may also have leaks where blood can still go to the wrong chamber; these can be quite challenging to successfully close.

We often see patients who have had heart valves placed earlier in life that have become too tight or leaky. For most of these patients we have options for replacing these valves without using the heart-lung machine and, in most situations, surgery is not needed.

As I mentioned, we also treat many patients who develop PVS after ablation for afib, drawing patients from around the world. Oftentimes these patients’ pulmonary veins are completely occluded, creating technically very challenging and complex cases. We have had a track record of remarkably safe and effective procedures.

Q: What is driving advancement in catheterization procedures at Cleveland Clinic and elsewhere?

A: We have well-developed programs with access to the latest technology for cath-guided closure of a variety of “holes in the heart”— defects that include atrial septal defects (ASDs), ventricular septal defects (VSDs) and patent ductus arteriosus (PDA). We can successfully treat narrowing that occurs in all the large vessels in the chest and sometimes abdomen. In addition to pulmonary vein stenosis, we treat the most complex forms of coarctation of the aorta and pulmonary artery stenosis, as well as reopening completely occluded superior and inferior venae cavae.

Q: How do you define leadership in your new role?

A: The big picture is about providing comprehensive and inclusive services to our patients and the institution. This means working collegially with all providers at Cleveland Clinic and referring entities, being attentive to needs that can be met by our services and therapies, both new and established.

In order to succeed in providing optimal services, the cath lab team works cohesively as one unit. This involves all the staff in the cath lab regardless of their individual job functions. We have included our staff into administrative meetings and educational programs. We want everyone to understand the basics of congenital heart lesions, what the procedure is to produce, and what is needed to make the lab run. This understanding helps ensure everyone in the room has a clear idea of what it is we’re doing and why. It helps expedite procedures, ensures that they plan next steps as we go and are attuned to what to watch for that might jeopardize patient safety so we are not missing anything.

Q: What do you think makes the cardiology group at Cleveland Clinic function at the top level it does?

A: I think there is a collegiality and an approachability among the cardiology and cardiac surgery staff here that is hard to find. It tends to be a much more cohesive group and a much more mature group in attempting to use all the disciplines to do what’s best for each individual patient. This is also true of the developing partnership we have with Akron Children’s Hospital, where we are striving to advance together in a complementary way to provide optimal care for patients in Northeast Ohio and beyond. I am encouraged by this, as it is the best way to develop strong programs that will succeed now and into the future.