Reinventing the Cardiac Cath Lab

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Hybrid catheterization suite at Columbus Children's HospitalThe cardiac catheterization lab is evolving. Just a few years ago, diagnostic cardiac catheterization was the procedure of choice for patients with equivocal or abnormal stress tests, and the other mainstay of the cath lab — interventional procedures could require a week-long hospital stay. But today’s state-of-the-art cath labs differ from their predecessors.

The hallmarks of the cath lab of the future are flexibility and efficiency. Procedures are changing. The advent of 64-slice CT and CT angiography (CTA) makes it possible to bypass diagnostic catheterization in many cases. But electrophysiology (EP) procedures are on the rise. Take for example Houston’s Methodist-DeBakey Cardiac Cath Lab at The Methodist Hospital. Three years ago, EP accounted for 15 percent of cath lab business. Today, 40 percent of cath lab volume stems from EP procedures. At the same time, increases in peripheral vascular work, and the advent of hybrid catheterization/cardiac surgical suites are re-inventing the cardiac cath lab.

As sites across the country retrofit or construct new cath labs, it’s important to design for current and future procedure load and volume. Consequently, many facilities opt for a mix of digital flat-panel imaging equipment to better meet the needs of a wider assortment of procedures. Take for example North Shore University Hospital in Manhasset, N.Y. The cardiac cath labs are equipped with an assortment of GE Healthcare Innova x-ray systems. Innova 2100, a 20 x 20 cm flat-panel system and Innova 3100, a 31 cm square system, serve as the primary cardiac x-ray systems and can be used for carotid and renal imaging as well, says Stephen Green, MD, associate director of cardiac catheterization lab. The hospital’s largest system, Innova 4100 is excellent for peripheral vascular work. If peripheral vascular volume is high, one or more of the hospital’s three Innova 3100 systems can accommodate peripheral vascular cases.
 
While digital flat panel x-ray systems are the core of the cath lab, other components like hemodynamic monitoring systems, reporting and archiving solutions also contribute to streamlined operations. 

This month, Inside Cardiac Imaging visits with several sites on the leading edge of cardiac cath lab imaging to learn about the benefits and challenges associated with outfitting a new lab.


Inside the hybrid cardiac catheterization suite

The Heart Center at Columbus Children’s Hospital in Columbus, Ohio, is a comprehensive cardiac center designed to meet the needs of pediatric and adult patients with congenital heart disease. The center is committed to state-of-the-art patient care and a minimally invasive approach to diagnosis and treatment of congenital heart disease.

Several years ago, John P. Cheatham, MD, director of cardiac catheterization and interventional therapy, and his colleagues realized that optimal treatment for many patients required a multidisciplinary approach that combines surgical and cardiac cath skills. An all-too-common conundrum in treating complex congenital heart disease is that surgeons can’t fix what they can’t see; at the same time cardiologists can not access every defect via a conventionally-placed catheter. The interdisciplinary “hybrid” approach blends cardiac catheterization and cardiac surgery to provide patients with the best of both specialties.

“Take [for example] the child with narrowing of the arteries that feed into the lungs. The arteries could be behind the aorta or inside the lung. It’s difficult for the surgeon to visualize the defect from the outside. At the same time, in selected patients it’s also difficult to access the defect via a conventional catheter,” explains Cheatham. Image-guided surgery, however, can provide access to the defect.

The hybrid approach; however, requires a different type of configuration. A typical cardiac OR suite is not x-ray or cath friendly as it lacks specialized imaging equipment. Metal OR tables compound the problem. On the other hand, a traditional cath lab is often too small for surgery and lacks operative lights, proper sterile environment and other surgical essentials.

The Heart Center solved the conundrum by building the world’s first two hybrid cardiac catheterization suites dedicated to treating complex congenital heart disease. The cornerstone of the new suites is Toshiba America Medical Systems Infinix CF-i/BP system. The Infinix system offers five-axis bi-plane x-ray imaging technology with flat-panel detectors. “The five-axis positioner allows us to rotate the bi-plane configuration around the patient in any position we need. The cameras are flexible and can be moved out of the way if we need to work from the head or either side,” says Cheatham. The system also accommodates a wide range of patient sizes from one to 200 kilograms as not only tiny babies and children are treated at Columbus Children’s Hospital, but nearly 30 percent of the patients are adults with congenital heart disease.

Another primary issue in the hybrid approach is the need to facilitate both transcatheter therapy and surgical treatment. The dual arrangement multiplies the number of personnel in the suite. A typical procedure might require a cardiac anesthesiologist, an echocardiography team, catheterization team and surgical team. During the design phase, The Heart Center realized that the number of people in the room and the accompanying equipment could present problems and carefully considered the size and layout of the room, equipment placement and balanced these considerations with a high degree of flexibility. 

At 800 square feet, the workspace of the hybrid suites nearly doubles the average cardiac cath lab workspace of 500 square feet. A control room, supply room, computer cold room and induction room provide additional space.

In addition, six flat-screen monitors are tied into the Infinix system. The boom-mounted monitors display AP and lateral x-rays, video and vital signs and can be rotated around the patient.  Finally, another rotatable, adjustable three-boom system is equipped with two video monitors. A touchscreen video router controls each monitor pair. “The arrangement allows us to direct any feed or image from inside or outside of the hospital onto a monitor to provide the necessary information to the appropriate operator, regardless of their position in the room. For example, any member of the team can access the PACS to route a CT or MRI study onto any monitor. We can call up ultrasound studies or echocardiograms, view physiologic data and even use two permanently mounted video cameras in the suite to provide live images to all of the team. We frequently participate in live case demonstrations of new hybrid procedures via satellite to educational conferences inside and outside of the U.S. using the sophisticated equipment in the suites,” sums Cheatham.        

The purpose of the state-of-the-art suites is simple. “Combined transcatheter and surgical therapy can be used to lessen the overall impact to the patient,” states Cheatham. Early data indicates The Heart Center is meeting its goal. Take for example the case of the child with a narrowing of the arteries going into the lung. The surgical half of the hybrid equation entails a sternotomy, or opening the chest. The cath team uses the opening to direct a catheter, acquire images and guide stent placement. In other cases, the surgeon opens the patient and manipulates an endoscopic camera; images acquired by the camera are fed to a monitor that the cath team uses to guide treatment.

The costs of the two hybrid suites are approximately $8 million, but The Heart Center is banking that its investment will improve care and cut costs. “In the long run, this is a more cost-effective way to administer care for patients with congenital heart diseases.” Patients spend less time in the ICU, and overall length of stay is down. Conventional treatment could entail a hospital stay of seven days, but similar patients undergoing hybrid therapy can leave the hospital in two to three days. Several years ago, a patient required open heart surgery and a three- to seven-day hospital stay to repair a hole in the heart. Today, the same patient could be treated with transcatheter therapy in the cath lab and return home in 24 hours.

“Multidisciplinary management is the future,” states Cheatham. Indeed, The Heart Center frequently hosts other sites evaluating the pros and cons of the hybrid approach. The approach is relevant not only for complex congenital heart disease but also for adult coronary surgery and interventional cardiology, says Cheatham. For example, a hybrid suite allows surgeons to use catheterization to determine if narrowing remains after coronary bypass surgery.


The new digital standard

Many hospitals find that cath lab volume is increasing, and at the same time, the types of procedure are changing. Take for example Methodist-DeBakey Cardiac Catheterization Lab at The Methodist Hospital in Houston. Nearly four years ago, the hospital embarked on an ambitious cath lab upgrade project. “Our volume was increasing,” recalls Cath Lab Director Katrina Dunn, RN. “We were seeing more carotids, peripheral vascular and EP procedures. We needed flexibility to meet the demand.”

In addition to flexibility, the hospital also wanted to standardize rooms as much as possible. Prior to the upgrade, the cath lab housed a variety of analog imaging equipment, and physicians developed preferences for certain rooms. Plus some patients needed to be treated in certain rooms, which led to backlogs. A typical daily schedule shuffled 40 to 45 patients among eight cath labs. Three of the suites were equipped with relatively new analog x-ray equipment with little degradation in image quality. The remaining labs suffered some degradation in image quality. Consequently, physicians demanded the newer rooms in many cases, which made scheduling a daily balancing act, says Dunn.  

Standardization seemed to be the best solution. The hospital decided to equip eight of its nine labs with Siemens Medical Solutions AXIOM Artis digital flat-panel x-ray system. The ninth lab is equipped with AXIOM Artis dTC; at 30 x 40 cm the larger flat-panel facilitates imaging of the carotids and peripheral vascular anatomy. “Physicians are pleased with the consistent, high-resolution images acquired by the new digital systems,” confirms Dunn. Patient distribution, and thus throughput, is simplified as most patients can be accommodated in any room.

Digital flat panel x-ray systems have become standard for cath labs everywhere. “Very few labs are buying image intensifiers. Physicians are clamoring for digital solutions because they provide better image quality, better contrast resolution with a lower x-ray dose,” states Green.

Digital systems, however, are not the only driver in the cath lab market. “All of the major vendors’ systems provide high quality images,” opines Mark Goodwin, MD, director of the cardiac cath lab at Edward Heart Hospital in Naperville, Ill.

Other essential criteria include ease of use, says Goodwin. A variety of staff and cardiologists use the cath lab and everyone should be able to use the equipment without lengthy instructions. If systems are not user friendly, says Goodwin, patient throughput and workflow may suffer. Edward Heart Hospital selected Philips Medical Systems Allura Xper flat detector family for its four cardiac cath labs based on the systems’ user-friendliness. “A physician can observe one 3D angiography case and complete the next one independently,” says Goodwin.

Another consideration in new cath lab projects is patient safety. Contrast use and radiation dose are concerns, says Goodwin. The right equipment and processes can improve patient safety in multiple ways. For example, physicians can acquire three rotational views to assess whether a case is normal or not and potentially reduce radiation dose by 30 to 50 percent, says Goodwin.


Beyond imaging

Although imaging is an important component of the cath lab, other solutions are essential. The Methodist-DeBakey Cath Lab upgraded to Siemens Sensis hemodynamic monitoring and recording system when it added new x-ray systems. The new hemodynamic system helps the cath lab meet its goal of streamlined patient flow by calculating and storing hemodynamic monitoring information and data obtained during the catheterization. The system also stores reference images and enables physicians to create the lion’s share of the report during the procedure to improve workflow, patient documentation and communication with referring physicians.

North Shore University Hospital relies on GE’s Mac-Lab IT hemodynamic monitoring system and Centricity Cardiology Data Management System for a streamlined, integrated approach to monitoring and report generation. “Mac-Lab IT integrates with the HIS; demographic data is automatically downloaded into Mac-Lab. As Mac-Lab acquires waveforms, pressures and inventory data, information is downloaded into Centricity for report generation and quality assurance,” explains Green. The hospital also employs Centricity for point-and-click reporting. “We don’t use transcription at all. Our goal is to include a complete report in the chart as soon as the patient leaves the room,” says Green. With Centricity, reports can be emailed or faxed to referring physicians immediately after the procedure.

Improving patient flow and workflow are essential to the cath lab business. Another ticket to profitability is trimming costs. According to Dunn, Siemens Interventional Cardiac 3D (IC3D) technology saved the labs $60,000 in its first year of use. The IC3D/Artis combination provides 3D views of the coronary arteries to help cardiologists better determine appropriate stent size and length. As a result, Methodist-DeBakey cardiologists are less likely to use two stents during a procedure. Instead, they use one longer stent. Each stent, regardless of size, costs $2,400, which translates into a significant savings.

Edward Heart Hospital achieves a comparable cost savings with Philips Allura 3D-CA, which provides immediate 3D reconstruction. A better view translates into less time moving off and on cine, faster cases and lower fluoroscopy and contrast exposures. In addition, the tool can trim costs as enhanced visualization allows physicians to substitute one stent for two in some cases. “If we use one stent instead of two in one case weekly, the hospital can save $100,000 over the course of a year,” calculates Goodwin. 


Future directions

Cath labs everywhere are evolving. Even state-of-the-art programs are changing and upgrading. On the imaging side, North Shore plans to add a bi-plane flat-panel angiography system in the next year. The bi-plane approach handles diagnostic and interventional procedures with fewer images and less contrast. Similarly, Edward Heart Hospital expects to add two labs configured for multiplane use over the next 18 months.

On the IT front, horizontal integration could deliver critical benefits, predicts Green. North Shore University Hospital plans to take Centricity into other hospitals in the 14-hospital Long Island Jewish Health System. The enterprise approach to archiving will make images and reports from all hospitals available across the system.  

Cheatham foresees increased interest in hybrid suites; Columbus Children’s plans to add a third hybrid suite to its program. “Multidisciplinary management is the future of cardiac cath medicine.”


Advice from the cath lab trenches

Upgrading or constructing new cath labs is an investment, and there are multiple solutions on the market. A hospital can rely on common guiding principles to drive the process. “A site must be able to demonstrate [that the investment] delivers improvements in clinical outcomes, patient safety or costs,” begins Goodwin. Each of these goals can be facilitated in a variety of ways. For example, a multi-purpose, mid-sized digital flat-panel system can improve patient flow, accelerate workflow, trim costs and enhance safety.

“Complete site visits to see how equipment functions, and solicit recommendations from other sites and vendors,” says Dunn. When Methodist-DeBakey hospital began its cath lab remodel, Dunn was pleasantly surprised to find out that Siemens could provide additional solutions like IC3D for a marginal additional investment.  At the same time, Dunn recommends sites remember that the cath lab is more than the sum of its equipment. “Anything you can do to enhance patient flow is a benefit. How you manage data and employees can enhance the program,” she opines. For example, systems and processes that facilitate information flow across and beyond the enterprise can boost referring physician satisfaction.

Finally, remember that equipment has varying lifespans, and plan and budget accordingly. North Shore University Hospital schedules hardware and software upgrades every two to three years for its cath lab archive while a cath suite could last seven to 10 years or longer. The combination of 10 to 15 percent annual growth rate and a desire to archive 1024 x 1024 resolution images rather than 512 x 512 translate into the need for regular storage upgrades, says Green.


Conclusion

The cath lab building business is booming with hospitals building new labs and upgrading previous spaces to keep up with growing volumes and changing procedures. The cornerstone of the state-of-the-art cath lab is the digital flat-panel x-ray system, and most sites opt for a mixture of sizes to accommodate different needs like cardiac imaging, peripheral vascular work and EP cases.

But the modern lab transcends digital imaging and includes hemodynamic monitoring and reporting systems, a digital archive and 3D reconstruction tools to complete the program and streamline procedures and reporting, optimize patient care and trim costs.