The Changing Face of Cardiac Labs

Today’s product ads targeted to the baby boomer generation are lauding the transformative process of aging, implying that older can be better. Think about how the field of invasive cardiology has matured – one can indeed see significant progress in terms of improved technologies and techniques, new ideas for the cath lab space, and approaches to care, along with growing and evolving skill sets of the cardiovascular team. As an industry, we need to leverage this progress and look ahead for further innovations that can again affect change for the cath labs of the future.

The Cath Lab Grows and Matures
Although there has been an evolution of care in the cath lab, the core technology of angiographic imaging, wires, catheters, and balloon interventions has not changed much over the years. Some of the incremental advancements that have changed not only the way cardiac care is delivered, but also patient and physician interactions throughout the service line include:

• Cath lab imaging technology has migrated from the analog-based image intensifiers (IIs) to fully digital flat-panel technology with 3-D reconstruction. Some in the industry may still remember having to process the cine film.
• The introduction of stents significantly altered the care landscape. The evolution of stent technology – from bare-metal stent to approval and adoption of drug-eluting stents (DES) – had a major impact on the cost of procedures, while also improving clinical outcomes. The recent FDA approval of Abbott Vascular’s Absorb, the first fully bioresorbable coronary stent, offers great potential for many patients who do not want permanent implantable devices.
• Access techniques have migrated over the years from a Sones technique, with direct access through the brachial artery, to a Judkins percutaneous approach through the femoral artery. More recently, the adoption of the radial artery approach, which can significantly decrease the risk of post-procedure bleeding and reduce post-procedure length of stay (LOS), is influencing the care delivery model. Corazon research reveals that nationally, nearly 35 percent of cases reported by the American College of Cardiology’s National Cardiovascular Data Registry are performed using the radial approach. A recent visit to a program in Michigan that performs >90 percent of their procedures via radial approach speaks of the potential of this technique. The decrease in recovery time along with increased patient satisfaction has fueled the adoption of the radial lounge for recovery areas.
• Peripheral interventions in the cath lab setting have migrated from the early days using equipment to image each leg individually to now using flat panels that image both legs for runoff evaluations at the same time. Today, industry has witnessed how peripheral angiography has largely been replaced by computed tomography angiography at many programs. This technology also supports complex endovascular chronic total occlusion (CTO) limb-salvage procedures, essentially using the power of multiple technologies to support advanced procedural techniques. The migration of vascular interventions from the cath/interventional labs in the acute care setting to the provision of vascular interventions as an extension of practice in the physician office setting can also be observed.
• Valvuloplasty, or using a balloon catheter to widen a stenotic aortic valve, has been introduced into the cath lab procedure armamentarium. The endovascular approach for valvular disease has developed significantly over the years, with the advent of transcatheter aortic valve replacement (TAVR) procedures. The adoption of TAVR has largely been fueled by research that broadens the indications for this endovascular approach and expands the patient eligibility pool to an evolving at-risk population. We believe this trend is changing the industry, especially with some cardiac surgeons predicting that the majority of aortic valves will be repaired/replaced with TAVR technology in the near future.
• The evolution of the cardiac cath lab only platform to an interventional platform, where the technology can be procedure-agnostic, has been fueled by tight capital budgets and recognition of the expanding and overlapping skill sets of the cardiovascular medical team. Physicians who traditionally worked within the cath lab, cardiac and vascular surgery, and radiology silos now are working side-by-side not only sharing space, but evaluating and managing a more complex patient population collaboratively. The cardiac cath lab of the future may function as a hybrid suite, supporting cardiac and vascular catheter-based interventions and associated complex staged/combined interventional and open surgical procedures – a long way from the community cath lab of the past, though a vision that is attainable in many hospitals, regardless of size.

Factors Aiding the Transformation
Technology advancements fueled through industry-sponsored research, development, and clinical trials have been embraced by academic centers and then are extended into larger community hospital settings. Expansion of technical capabilities and clinical applications for devices such as the biventricular implantable cardioverter-defibrillator (ICD) and the Impella left ventricular assist device (Abiomed) are examples of technology advancements that will continue to offer new treatment options for an increasing pool of eligible patients.

The evolving technical skills of the physician proceduralists can be attributed to a growing openness of the practitioners to cross-train and share techniques. This has truly been a major change from past traditions, where a specialist remained firmly within a clinical area. Today, as physicians learn alongside each other and work together in shared space on an overlapping patient population, all can benefit – the physicians themselves, with increasing knowledge and expertise, the hospital, with increased efficiencies and improved profitability, and, not least of all, the patient, with improved outcomes and higher satisfaction with the overall experience. This new care paradigm is no doubt supported by a willingness on behalf of hospital leadership and physicians to embrace a heart team approach – TAVR, PCI appropriateness evaluation, and patient optimization programs prior to OHS, are all examples of how cardiovascular leaders, cardiologists, and cardiac surgeons can and should work collaboratively in support of better care and better outcomes.

Way Ahead
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.