Cardiac catheterization is one of the most widely performed cardiac procedures. As expected, in any invasive procedure, there are some patient-related and procedure-related complications. With significant advances in the equipment used for cardiac catheterization, the improved skill of the operators, and newer techniques, the rates of these complications have been reduced significantly.
Indeed, today image-guided interventions have become the treatment of choice for a broad range of diagnoses, thanks to their minimally invasive nature. But even with the success achieved with widespread dissemination of these technologies and techniques, there remains significant opportunity to improve technology and techniques, to access and treat more patients, and to do so more safely and with even greater clinical success.
Angiographic-imaging system vendors have developed several new technologies to address emerging cath lab trends, including the need to reduce radiation dose, improve image quality, and enable advanced procedural image guidance.
All three of these points have become increasingly important as more complex procedures are attempted in interventional cardiology cath labs and hybrid ORs. These procedures include transcatheter aortic valve replacement (TAVR), MitraClip repairs, left atrial appendage (LAA) occlusions, atrial and ventricular septal defect closures, and new interventions for both electrophysiology (EP) and heart failure.
All of the major vendors have introduced new systems and technologies in the past few years to reduce dosage, and enhance visualization in the cath lab. The vendors have tailored their systems into various models for specific specialties and at various price points, depending on the degree of functionality. Most vendors also offer software to enhance visualization of stents and other devices.
Advances in cath lab technology are so fast-paced that any new state-of-the-art cath lab begins to appear jaded in less than 5 years. A cath lab now means much more than a fluoroscopy unit. Vascular imaging has become an integral part of any cath lab setup.
The cath lab and hybrid suite face some challenges that innovators are hard at work to address. The ability to visualize soft tissue, and to appreciate complex three-dimensional structures with a fundamentally two-dimensional X-ray-based imaging modality, still leaves something to be desired. The exposure to ionizing radiation is now known to represent an occupational hazard to interventionalists, carrying radiation-related risks including an elevated cancer rate. And, there yet remain many types of surgical procedures that have no commonly available minimally-invasive counterpart, although conceptually an interventional approach is possible. Nascent solutions have appeared, many reflecting trends in the latest in computational and electromechanical technology. And while these first-movers have made a significant impact, the industry has now advanced to an even more rapid pace of innovation, as access to engineering and design necessities has exploded. Building blocks are increasingly available to those with the concepts, understanding, and ability to execute.
Dr Sameer Gupta
Director, Cardiac Cath Lab, Metro Group of Hospitals
Computational power and high volumes of data storage are widely available in cloud-based form at reasonable monthly rates. Google provides machine learning services online. Three-dimensional hubs allow access to 3D printing for quickly prototyping new inventions. And network infrastructure interconnectedness allows collaboration between innovators around the world.
As a result, the market is at a tipping point after which it will see cath labs and hybrid suites become more and more technologically sophisticated at an increasing rate. The independent components of predictive analytics, interventional robotics, and advanced imaging will converge and provide clinicians with immensely powerful tools.
Surgical and interventional robotic systems have already made a significant impact. Just as the da Vinci system facilitated minimally invasive therapies, which previously could only be done invasively, the Hansen Magellan and Corindus Systems have demonstrated the capability to perform interventional procedures with vastly decreased radiation exposure to the operator. They are joined by startup companies like Restore Surgical who are developing more compact, cost-effective, and workflow-compatible robotic solutions.
The industry is now at the verge of expanding these technologies and truly realizing robot-assisted procedures, in which clinicians are given mechanical and navigational tools that allow certain actions or portions of the procedure to be performed autonomously, with a level of control only possible with robotics.
A new technology that is already on the horizon to aid procedural navigation in the cath lab is augmented reality (AR). The technology enables operators to see true 3D images of anatomy in a heads-up display while they are looking at the patient or at the main screen in the lab. Manufacturers are showing a conceptual work-in-progress of this technology, and some have already commercialized AR technology to aid in advanced visualization of the patient’s 3D datasets. AR allows physicians to view, measure, and manipulate real-time holographic images of the patient’s heart during procedures, while still being able to clearly see around the room. Using real-time navigation data feeds rather than MRI or CT, the solution provides clinicians with patient-specific anatomy in a holographic display, including catheter movement. The software is aimed at reducing operating time and radiation exposure to clinicians, and potentially improving outcomes for patients.
Predictive analytics allow the mining of vast amounts of data to extract information and patterns, which can provide valuable guidance to clinicians. One reason that the highest-volume practitioners are also the highest-performing is that they are able to draw upon the greatest pools of experiential knowledge. Analytics will allow us to spread this wealth. The widespread use of electronic medical records (EMRs) has set the stage for this type of technology, the most significant remaining piece is to encode data regarding anatomy. The development of technologies capable of transforming imaging data into models suitable for computerized analysis will close this gap and allow computational systems to provide valuable clinical decision support.
In addition to augmented reality, live, 3D, and transesophageal echo (TEE) holographic imaging can be projected in the cath lab now without the need for special glasses or AR visors. Recently, EchoPixel showed how a GE TEE system can project holograms of live views of heart valves or the left atrial appendage (LAA) using a special display screen. A couple of large angiography-system vendors are looking at the system for possible integrations with their own technologies. It may soon be possible to direct LAA occlusions or MitraClip implants using holograms and eliminate the need to have three different 2D echo views, so the operators can reconstruct the 3D image in their brain. The holograms will make visualization much easier and intuitive for device deployments.
Advanced technologies coming into play
Tomorrow’s cath lab will see an integration of today’s most advanced technologies, and the result will be much more than the sum of its parts. This will facilitate continued growth of the capabilities and reach of catheter-based interventional therapies, allowing a greater patient population to be treated with greater success. It will empower clinicians to make the best possible decisions for patients and to protect themselves and their patients from undesired exposure to radiation in imaging. Especially, advances in interventional structural heart therapies, complex percutaneous coronary interventions, and endovascular aortic repair (EVAR), will create value for clinicians, patients, and the healthcare system alike.