Cath Labs, Setting The Stage For Better Care

The cath lab has now metastasized and is found in radiology departments and in operating rooms. It is anticipated that this trend will continue in the future, leading to shorter hospitalizations, less morbid interventions, and shorter times for patients to recover from procedures.

Cath labs have come a long way, but what is next on the horizon? Will cath labs as they exist today become obsolete as CT and MRI technologies advance? Will robot-assisted procedures in the cath lab become commonplace in all hospital settings? No one can predict for sure, but one thing is certain, the healthcare delivery of the future will require a willingness to think creatively and investigate out-of-the-box solutions. Care that provides value — high quality at the lowest cost — will require administrative and medical staff leadership support and collaboration in order to drive sustainable change. 

Information that supports data-driven decision-making as a means to evaluate technology and any associated improvements in clinical outcomes will be a cornerstone for measuring and tracking progress.  The need for reliable data cannot be understated, whether in terms of patient volume potential for a new technology/technique or procedure, or for understanding the clinical, operational, and financial impact of an already-adopted advancement. Knowing the current situation in the cath lab and having the information readily available for determining the future impact of something new can make all the difference between success and failure. 

Looking back to gain perspective on how far industry has come is always a worthwhile effort. Indeed, cutting-edge programs will embrace the new and rejuvenated complexion of the cath lab and look forward to the next clinically proven solution.

Indian market
In 2017, the Indian cath labs market is estimated at Rs 745 crore, at 414 units, a 12 percent increase in volume terms and a 17 percent in value terms over 2016. The premium biplane segment saw an increase, with 12 units sold at an average unit price of Rs 6 crore, and 10 units in the Rs 3.2 crore unit price category. This is a distinct shift from 2016, when the premium segment, here defined as higher than unit price of Rs 3.2 crore, constituted 6 systems in comparison to 22 systems in 2017. The flat panel digital performance systems, in the unit price range of Rs 1.5 crore to Rs 3.2 crore have a combined 56 percent share in volume terms, and 68.5 percent in value terms. The value fixed systems constitute 14.5 percent of the market, and the value mobile 24 percent in quantity terms. In volume terms, the corresponding shares are 7.8 percent for value fixed and 9.7 percent for value mobile. The value fixed segment includes 35 units of the refurbished systems.

Philips, GE, and Siemens have a combined 90 percent share in this segment. Toshiba is more successful with the government, whereas Allengers is making inroads with their indigenous machines in Tier-II and Tier-III cities. Ziehm, marketed by Bet Medical, Shimadzu, and Schiller are also aggressive in this segment.

2017 saw more of government buying, while the private sector in the backdrop of price control on stents and challenges in some cases on obtaining funding somewhat held back. The MNC vendors are also being asked to quote prices in Indian rupees. Indigenous systems are being offered by leading brands such as Intius from Philips. Metros and Tier-I cities are more or less saturated, and the players are moving into smaller cities and semi urban areas, which are price sensitive. With satellite centers becoming popular, the mobile version is gaining popularity.

The premium systems are focusing on obtaining clearer images and low dose radiation. When it comes to diagnosing disease, image is everything. It is difficult to treat what you can not see. That’s especially true in the cardiac cath lab where cardiologists performing procedures ranging from simple diagnostic tests to more complex interventional manoeuvres rely on imaging technology to guide their course. To ensure patients get the best treatment possible — and to remain competitive — cardiologists more and more are demanding state-of-art equipment in the cath lab.

One method of obtaining clearer images of complex vascular and cardiac anatomy is with flat panel digital angiography systems. Angiography systems have been a diagnostic mainstay in cardiac cath labs for over 50 years, playing a pivotal role in the diagnosis and treatment of heart and vascular diseases. The introduction of flat panel detectors (FPD) — replacing image intensifiers — for angiography has broadened digital imaging’s role in the cath lab. Now cardiologists can see, immediately and with greater clarity, the intricacies of the heart, the vascular system, and how well they are functioning.

With the image intensifier there are approximately nine steps involved in creating an image, and each step brings with it about 10-15 percent noise. In contrast, flat panel systems can produce an image in two steps, which dramatically reduces the possible number of sources for error and chances for image degradation. Image intensifiers are bulkier and limit the movement of the cameras. Flat panel detector systems give a more discrete image of the anatomy. More acute angles separate out vessels that have a tendency to overlap, opening up the coronary tree for optimal visualization. Better visualization of the vessels is experienced in obese patients with the flat panel systems, and they make it easier and quicker to do peripherals on all patients.

A mobile cath lab is gradually becoming a preferred form of cardiac care in Tier-II and Tier-III cities as it decreases procedural costs, thus increasing feasibility. There has also been a significant growth in the demand for mobile flat-panel cath labs, as they operate on a single phase, thus reducing heavy electricity bills, improving image quality significantly, and lowering dosage.

Way ahead
Recent years have seen a variety of new procedures performed in the cardiac cath lab and in a variety of similar interventional suites in other areas of the hospital; valve repairs and replacement, closure of a number of congenital heart defects, peripheral vascular interventions for limb and cerebral vascular obstruction, mechanical approaches seeking to prevent arterial embolism from the heart, or dissolving thrombi already present in the peripheral and cerebral arterial circulation. Other catheter interventions include a variety of approaches for managing venous disease as well as cardiac electrophysiology procedures seeking to control atrial and ventricular arrhythmias. The volume of these procedures is increasing every year, resulting in a lessened need for so-called open operations for many individuals with cardiovascular disease. Practitioners are no longer cardiologists alone. Indeed, a considerable number of radiologists, vascular surgeons, and cardiothoracic surgeons are now performing interventional procedures in the cath lab and in specially designed interventional suites. Indeed, the cardiac cath lab has now metastasized and is found in radiology departments and in operating rooms. It is anticipated that this trend will continue in the future, leading to shorter hospitalizations, less morbid interventions, and shorter times for patients to recover from procedures.