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Advancing the world of health with cath labs

Cath labs stand as beacons of cutting-edge medical technology, revolutionizing the diagnosis and treatment of cardiovascular diseases. With state-of-the-art imaging equipment and interventional devices, cath labs are pivotal in advancing patient care.

In healthcare, few advancements have been as transformative and impactful as the evolution of cardiac care over the past seven decades. Since the achievement of the first open-heart surgery in 1955, followed by the advent of coronary angioplasty in 1977, and the introduction of implantable defibrillators in 1980, the trajectory of cardiovascular medicine has been marked by a relentless pursuit of innovation and progress. These milestones, each representing a quantum leap in medical technology and practice, have revolutionized treatment options and significantly enhanced patient outcomes while minimizing the invasiveness of procedures.

Central to this remarkable progress is the emergence and refinement of interventional cardiology (IC) within the specialized environment of the cath lab. In these state-of-the-art facilities, equipped with cutting-edge technology and staffed by highly skilled professionals, catheter-based procedures have become the cornerstone of modern cardiac care. By employing small, flexible catheters inserted through blood vessels, interventional cardiologists can diagnose and treat a wide range of heart and blood vessel conditions with unprecedented precision and efficacy.

The significance of this shift toward minimally invasive interventions cannot be overstated. Not only do these techniques offer patients a less traumatic alternative to traditional surgery but they also provide a viable option for individuals with more age or underlying health conditions. Furthermore, the versatility of cath lab procedures extends beyond therapeutic interventions to encompass diagnostic capabilities, allowing clinicians to swiftly and accurately assess cardiac function and pathology.

As the pace of medical research and technological innovation continues to accelerate, cath labs remain at the forefront of advancing the world of health. With each passing year, breakthroughs and refinements in catheter-based techniques promise to enhance patient care further, expand treatment options, and improve outcomes for individuals with cardiovascular disease.

Indian market dynamics
In 2023, the Indian cathlab market is estimated at ₹880 crore, and 310 units. The biplane segment has very limited demand, procured mainly by the government hospitals or the large chains located in the larger cities of India. These are not manufactured in India and constitute 8.5 percent of the market.

The balance 91.5-percent market is contributed by single-plane cath labs. The imported segment is dominated by GE, Siemens, and Philips. Shimadzu and Toshiba also have some presence. These are not restricted to the large cities only now. The discerning buyer in Tier-II cities also opts for these models. In 2023, the Indian market is estimated at 160 units, valued at ₹560 crore.

Indian cath lab market*

2023

Tier I GE,  Siemens & Philips
Others Allengers & Toshiba, Shimadzu, IITPL & Skanray

*Vendors are placed in different tiers on the basis of their sales contribution to the overall revenues of the Indian cath lab market.

ADI Media Research

The Indian single-plane cathlabs are available in two models – the entry level sold on an average unit price of ₹1.6 crore, and the premium model sold at ₹2.2 crore. 25 percent of the cath labs are the higher-end models. Wipro GE Healthcare, in late 2022, had launched Optima IGS 320, which is a Made in India, AI-powered cath lab. Manufactured at its facility in Bengaluru under the PLI scheme, the cath lab leverages the GE proprietary AutoRight technology. In March 2024, the vendor revealed its plans to invest ₹8000 crore over the next five years on medical devices to increase local manufacturing and research and development initiatives.

Diagnostic coronary angiography and elective angioplasty that had been put on the backburner in the Covid lockdown phase have seen a steady return. Issues as after-sales service being very expensive and the need to standardize safety and training practices for cardiac cath lab personnel remain.

The increasing prevalence of cardiovascular diseases, accompanied by technological advancements in medical care, are driving entrepreneurial activity in India’s healthcare delivery space. This is evidenced by the rapid growth of cath labs, with around 200–250 new labs being set up each year. Earlier, biplane cath labs were commonly used for diagnostic purposes. Now fixed cath labs and mobile cath labs are gaining attraction with C-arm technology integral for fluoroscopic imaging of the cardiovascular system.

Transcatheter aortic valve replacement (TAVR) has emerged as a game-changer in India, offering a minimally invasive solution for patients with aortic stenosis. Conducted in the cath lab, this non-surgical procedure replaces the damaged valve without chest opening, reducing complications, and promoting faster recovery. TAVR significantly improves patient life expectancy, particularly for the elderly, and minimizes hospital stays.

Catheterization system

Vinay N
Senior Architect,
Skanray Technologies

Catheterization systems, or cath labs, traditionally used for minimally invasive procedures, are now being utilized for hybrid procedures as well. They serve for diagnosing and treating vascular, cardiac, and neurological abnormalities.

A cath system includes an x-ray imaging patient positioner and a C-arm gantry with an x-ray source and detector. Monoplane systems have a single-image chain, while biplane systems have dual-image chains, typically used for neuro or pediatric imaging. Tube capacities and detector sizes vary, with smaller detectors for cardio applications and larger ones for vascular applications.
A typical cath procedure uses an x-ray fluoroscopic imaging system. A keyhole puncture is made in the femoral, radial, or subclavian regions, followed by the insertion of a sheath, catheter, and guide wire to navigate to the region of interest under x-ray guidance. Once there, a contrast agent like iodine or carbon dioxide is used to study or correct vascular abnormalities visible under x-ray.

Nowadays, hardware differences among market players are minimal, with workflow, dose management, multi-modality applications, and AI/ML decision support being the key differentiators.

Recent trends in cath labs focus on:

  • Hybrid OR. Cath systems are used for open surgeries as a backup, for pure open surgeries, or for hybrid procedures requiring intermediate imaging, such as CABG and EVAR.
  • Multi-modality imaging. Combining cath systems with other imaging modalities, like Angio-CT, is beneficial in trauma cases.
  • AR/AI/ML. Enhancing planning, visualization, and dose optimization.
  • Simplified workflow. Features assisting with planning, execution, and verification for procedures like valve replacement, liver embolization, and quantitative applications.
  • Dose optimization and improved IQ. Enhancing image quality with lower doses, using patient and anatomy-specific APR, procedure cards, and high-speed collimation.
  • Quicker and faster imaging. Reducing patient dose while improving image quality through faster imaging.

Advancements in image chain and hardware, such as cold cathode tubes, CMOS detectors, high-speed collimators and filters, AI-based dose management, and CFRP C-arms, can make cath systems less bulky, while enhancing image quality and reducing dose.

Cath labs remain the gold standard for reliable and accurate diagnosis and treatment of vascular abnormalities. With the aforementioned advancements in the pipeline, they are likely to main-tain this status for the next few years.

Global market dynamics
Cath labs are equipped with advanced medical imaging devices, such as fluoroscopy and angiography machines, along with other necessary equipment to carry out procedures like angioplasty, stenting, and cardiac catheterization. The global cath lab market size is projected to reach USD 74.8 billion by 2032 from USD 49.3 billion in 2023 at a CAGR of 4.73 percent.

With the increasing prevalence of spinal and brain disorders, the demand for diagnostic and therapeutic treatments in cath labs will rise, thereby significantly contributing to the expansion of the market.

The rise of telemedicine is shaping the functionality of modern cath labs. By integrating remote consultation and real-time data-sharing technologies, cath labs are becoming more accessible to specialists who may not be physically present. These advancements enable a collaborative approach to patient care, including immediate consultations for urgent cases.

Additionally, the market is experiencing notable investments in research and development activities aimed at introducing more efficient and innovative cath lab procedures and refining telemedicine capabilities. For example, the development of robotic-assisted catheterization technologies hold the potential to revolutionize the field by improving the precision and safety of procedures, thereby further boosting market growth.

The major restraint of the market is the high initial and ongoing costs of advanced imaging equipment, substantial financial investment, reimbursement considerations, and limited access in rural or underserved areas collectively contribute to the impediment of growth in the cath lab market.

Innovations flourish the market. The emergence of cardiovascular ambulatory surgery centers (ASCs) represents a significant evolution in the field. While cath labs traditionally served as the primary setting for cardiac interventions, the rise of ASCs offers a complementary avenue for delivering certain procedures, particularly low-risk cardiac interventions like percutaneous coronary interventions (PCI) and diagnostic catheterizations.

The integration of ASCs into the cardiovascular care landscape signifies a shift toward more cost-effective and accessible care delivery models. By leveraging ASCs for specific procedures, healthcare systems can optimize resource utilization and improve patient access, particularly in underserved rural areas where traditional hospital facilities may be limited or closed.

Navigating the future with innovations in cath labs

Ashu Goyal
Managing Director – Sales,
Allengers Medical Systems Ltd.

As pioneers in cardiovascular care, cath labs have evolved from diagnostic spaces to multifunctional hubs for interventional procedures, shaping the landscape of healthcare in India. The escalating prevalence of coronary artery disease (CAD) underscores the critical role of cath labs in addressing the healthcare needs of a burgeoning population.

Advanced applications such as transcatheter aortic valve implantation (TAVI/TAVR), fractional flow reserve (FFR), and virtual fractional flow reserve (VFFR) have revolutionized cardiovascular interventions, offering minimally invasive alternatives to traditional surgical methods. Integration of image fusion technologies from intravascular ultrasound (IVUS) and optical coherence tomography (OCT) has enhanced procedural precision, particularly in challenging cases.

Cath labs are not only instrumental in coronary interventions but are also being increasingly utilized for vascular applications, addressing the growing burden of peripheral artery disease, especially among the diabetic population. The transition toward hybrid operating theaters (OTs), where open surgeries are minimized through cath lab interventions, heralds a new era of patient-centric care.

Looking ahead, advancements in 3D imaging for neurovascular interventions and other vascular applications promise enhanced procedural outcomes. Dose reduction techniques, including variable frame rates and rotational angiography, coupled with high-speed flat panel detectors (FPDs), are poised to redefine imaging capabilities within cath labs.

Furthermore, the convergence of cath labs with imaging modalities, such as CT, MRI, OCT, and IVUS holds promise for precision medicine. By enabling precise measurements and treatment planning options within the cath lab environment, these innovations aim to optimize patient outcomes and streamline healthcare delivery.

In conclusion, as we navigate the future of cardiovascular care, cath labs stand at the forefront of innovation. With a commitment to excellence and patient-centered care, we embrace the evolving landscape of cath labs, where technological advancements pave the way for enhanced procedural efficacy and improved patient outcomes. The journey ahead promises to redefine the boundaries of cardiovascular intervention, ensuring a healthier future for all.

Emerging trends
Meta-CathLab is an innovative concept merging interventional cardiology with metaverse, offering transformative possibilities in the field. By leveraging virtual-reality (VR) technology, it provides unique training experiences for interventionists , improves procedural efficiency, and enables real-time collaboration among experts globally. Challenges include upgrading catheterization laboratories, securing patient data, and addressing ethical considerations.

Integrating IoT with hemodynamic monitoring system, plays a crucial role in assessing a patient’s cardiovascular health by providing real-time data on blood flow, pressure, and other vital parameters. Integrating IoT with hemodynamic monitoring systems has ushered in a new era of patient care, marked by improved accuracy, remote monitoring capabilities, and enhanced decision making for healthcare professionals.

It signifies a transformative shift in healthcare delivery. It empowers healthcare professionals with a wealth of data-driven insights, enables timely interventions, and enhances patient outcomes. As the market continues to evolve, collaboration between technology providers, healthcare institutions, and regulatory bodies will be pivotal in ensuring the efficacy, security, and ethical use of IoT-enabled solutions.

CT angiography-derived fractional flow reserve (CT-FFR) imaging represents a significant advancement in cardiovascular diagnostics, particularly for assessing the risk of adverse outcomes in stable angina patients. By integrating coronary CT angiography (CCTA) images with AI algorithms and computational fluid dynamics, CT-FFR provides clinicians with a non-invasive method to estimate blood flow through coronary arteries. This approach addresses a key limitation of traditional CCTA, which does not directly assess blood flow impact on arteries.

MMIF. More recently, multimodality image fusion (MMIF) has become available. With this technology, a 3D roadmap can be obtained from preprocedural imaging like CT or MRI. After segmentation, the 3D roadmap is registered with live fluoroscopy, using either two fluoroscopy or cinegraphy acquisitions in different projections, i.e., 2D–3D registration (MMIF2D−3D), or using a 3DRA acquisition, i.e., 3D–3D registration (MMIF3D−3D).

MMIF2D−3D enables significant radiation exposure reduction in a single-center matched CHD population. It moves the focus of the operator toward the frontal plane, obviating the need for most of the lateral fluoroscopy exposure, hence reducing FT and ultimately AK.

AI in multi-modal imaging for cardiovascular disease (CVD) holds significant promise for improving clinical outcomes and reducing healthcare costs. By combining various imaging modalities, such as X-ray, CT, MRI, and echocardiography, AI enables comprehensive assessment of CVD conditions. Applications include registration, fusion, segmentation, prediction, and diagnostic aid.’

The M2AI-CVD (multi-modal artificial intelligence for cardiovascular disease) framework employs a four-fold methodology – first, it rigorously evaluates image quality and processes lower-quality images for further analysis; subsequently, it uses the Entropy-based Fuzzy C Means (EnFCM) algorithm for precise image segmentation; the Multi-Modal Boltzmann Machine (MMBM) is then employed to extract relevant features from various data modalities, while the genetic algorithm (GA) selects the most informative features; finally, a ZFNet Convolutional Neural Network (ZFNetCNN) classifies images, effectively distinguishing between CVD and non-CVD cases.

Neurovascular intervention is revolutionizing cath lab procedures, expanding their scope beyond cardiac care. The development of versatile stent designs and innovative flow diverters initially aimed at cardiac interventions now finds application in neurovascular conditions like carotid stenosis and aneurysms.

Major enhancements are being made in neuro biplane systems. New interventional systems feature enhanced 2D and 3D imaging and X-ray detector positioning flexibility. New features include enhanced C-arm rotation, angulation (imaging angles), and parking facilities that allow rapid transitioning between 2D and 3D imaging, comprehensive table-side control that eliminates the need to leave the sterile field, automatic beam rotation to obtain correctly oriented images for every angulation and rotation, and a new head immobilizer to support enhanced stroke care.

Additionally, the exploration of biodegradable materials holds promise for reducing long-term complications. These advancements, coupled with expanded mechanical thrombectomy for stroke and advanced imaging integration, signal a transformative era in cath lab practice.

Challenges remain, including the need for enhanced simulators and the nascent integration of robotics. However, by embracing these advancements, cath labs are redefining interventional medicine, fostering interdisciplinary collaboration, and ultimately improving patient outcomes.

Robotic cath labs in India signify a significant stride in advanced healthcare, poised to revolutionize certain medical procedures. By integrating robotic technology, interventions can achieve heightened accuracy, superior visualization, and enhanced control.

The first-ever case of robotically assisted bioresorbable stent implantation in the world was done by the Department of Cardiology, Advanced Cardiac Center, PGI, Chandigarh, as an interventional procedure in September 2022. That said, the first remote robot-assisted percutaneous coronary intervention procedure (R-PCIs) was performed in India way back in 2019.

The first-in-human robotic coronary angioplasty from 1700 miles (2800 km) away was performed in China in December 2023. This world-first, performed entirely using a 5G connection, paves the way for more long-distance endovascular procedures in the future. Technical and verbal communication between the two operators was maintained throughout the procedure thanks to the stability and reliability of the 5G network, eliminating possible latency effects in the imaging and sound system.

Robotic-assisted interventions significantly reduce direct radiation exposure. Moreover, novel radiation protection methods, such as floor or ceiling-suspended body shields and patient-centered shielding systems, signify a paradigm shift toward comprehensive radiation safety.

Outlook
The promise of cath labs shines brighter than ever. With each technological breakthrough, humanity inches closer to a reality where cardiovascular diseases are not just treated but prevented, where patient outcomes are optimized, and where healthcare is truly personalized and accessible to all.

Despite the challenges that lie ahead, from financial barriers to technological complexities, the pursuit of excellence in cardiovascular care remains undeterred. Through collaboration, innovation, and a relentless commitment to patient-centered care, the boundaries of what is possible will continue to be pushed, ushering in a new era of health and well-being.

Second Opinion:-

Advancements in cath labs – Revolutionizing cardiovascular care.

How cath labs are enhancing diagnosis and treatment.

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