Viewing Cardiac Images: A Peek into the Future

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A 60-year-old male presented with severe chest pain. The gated chest pain protocol on the Siemens Somatom Definition Dual Source CT enabled the immediate visualization of the entire thorax as well the coronary arteries without motion artifacts. As shown, a Stanford type B aortic dissection was identified. The image was processed on the Siemens syngo MultiModality Workplace.Cardiac image viewing presents a conundrum for physicians and IT professionals. That is, cardiac and cardiovascular imaging consists of multiple types of images and datasets from a diverse array of systems including cardiac cath, echocardiography, nuclear medicine, CT and MRI. To further complicate the picture, a wide group of users need access to the cardiac datasets. Think cardiologists, radiologists, surgeons, referring physicians and more.

This month, Health Imaging & IT visits with two facilities to learn about the challenges of integrating cardiac image datasets and how cardiac image viewing platforms can be deployed to improve cardiovascular patient care.


Communication, consultation and excellence



Caritas Good Samaritan Medical Center in Brockton, Mass., is a cardiovascular center of excellence. Its objectives include state-of-the-art clinical care, standardized reporting and measurable outcomes. The hospital envisions developing a cardiovascular electronic patient record that facilitates the seamless transfer of images and clinical data across the enterprise to nurture online consultations among physicians, ease the referral process and increase workflow and efficiency.

The medical center plans to tap into Agfa HealthCare Heartlab Cardiovascular Solution as the cornerstone of its cardiovascular electronic patient record. “The primary challenge comes from the high number of cardiology sub-specialty areas. We need to deal with each area to create a complete patient record,” explains Richard Regnante, MD, FACC, cardiology consultant for cardiovascular program planning.

Heartlab Cardiovascular integrates an array of images and data, says Regnante. The center plans to use the system to address the complete cardiac care cycle. The patient care process begins with a history, physical and electrocardiogram. Standard next steps include an echocardiogram which helps the cardiologist look at the anatomy and function of the heart. “Traditional echo can help determine the presence of valvular stenosis and calculate the ejection fraction, but image quality is not always optimal. Physicians can use contrast echo or order 3D or transesophageal echo to potentially improve results.” Physicians often turn to a stress test or stress echo to detect ischemia or restricted blood flow. All of these basic assessments are critical to diagnosis, says Regnante, and should be available in the cardiac electronic patient record.

Other key diagnostic tests include nuclear stress testing to evaluate any ischemic changes. SPECT can detect perfusion abnormalities, and PET can help cardiologists determine the tissue viability and whether or not bypass surgery can improve the patient’s condition. MRI also may come into play if the physician requires an assessment of coronary and ventricular anatomy.  One of the most promising developments, says Regnante, is coronary CT angiography, which can provide a very pristine anatomical assessment of the coronary arteries. Other imaging data include cardiac cath x-rays and intravascular ultrasound (IVUS).

“Cardiologists need to pull together all of this imaging data to make a prognosis and determine treatment options,” explains Regnante. “Our vision centers on putting all of the imaging data into a single cardiology information system for analysis, storage, retrieval and multimodality comparisons. We’d like the electronic record to be available throughout the health system and at referring physician offices and home computers.” Caritas currently uses Heartlab Cardiovascular to handle cath and echo studies and just added ECG data to the system with non-invasive vascular, MRI, CT and nuclear medicine capabilities in development.

The project is expected to deliver improvements in both patient care and workflow. Physicians will have comprehensive access to patient data not only at the Caritas cardiovascular center of excellence but also at other sites across the six hospital system and at home. The ability to view and compare the complete patient dataset provides physicians with critical decision-making information and could accelerate care.

During the development process, however, Caritas needs to address multiple challenges. Proprietary data are an issue; the hospital needs to develop processes for converting and manipulating raw data. “The DICOM standard is helpful, but it doesn’t apply to non-imaging data like waveforms,” notes Regnante. Consequently, the center needs to address the issue with all of its cardiac vendors for consistency in data processing. Processing power, transmission speed and storage present additional hurdles as physicians require rapid access to the array of large datasets. Currently, Caritas relies on T3 connections among its six hospitals, a Boston data center and secondary back-up site.


The middleware option


Richard M. Ross Heart Hospital at Ohio State University in Columbus is a state-of-the-art hospital dedicated to providing comprehensive care to patients with cardiovascular disease. The hospital is equipped with multiple cardiac and cardiovascular imaging systems including GE Healthcare’s Innova cardiovascular cath imaging system, Siemens Medical Solutions’ Somatom Sensation 64 scanner and Philips Medical Systems’ SONOS 5500 and 7500 echocardiography systems. The challenge, says Coyt Watters, manager of Heart Center PACS, is to provide a single point of reference for physicians.

The hospital deployed Heart Imaging Technologies’ HeartIT WebPAX as the bridge from imaging modalities to end-users. “WebPAX takes data feeds from all of the different systems, so physicians can go to a single workstation to view everything including echo, CT and MR images,” explains Watters.

The system enables enterprise viewing of 3D reconstructions as well as standard cardiac image datasets. After techs complete reconstructions on a TeraRecon Aquarius workstation, they can push DICOM files to clinicians through WebPAX. “WebPAX also serves as an aggregator or bridge among different systems,” explains Watters. For example, the echo system can talk to HeartIT to pull up cath results.

The hospital has not yet integrated all modalities and historical datasets into WebPAX. Echo, for example, is a work in progress. Storage is a primary concern, says Watters, as the hospital houses multi-terabytes of historical studies that should be added to WebPAX. Communication and collaboration with multiple vendors is another challenge; the hospital must educate all of its cardiac vendors about its needs and goals to ensure a smooth implementation.


Conclusion


Cardiology is an image-intense specialty with cardiologists requiring access to multiple types of imaging and non-imaging datasets. What’s more, non-specialists also need access to the cardiac patient record. More sites are turning to digital solutions to integrate cardiac imaging data and share studies across and beyond the enterprise. Implementation is a multi-step process that requires communication and collaboration with all the vendors in the cardiac arena. Other issues include high storage demands, transmission speed and processing power. In the end, comprehensive cardiac image viewing platforms promise to deliver both improved patient care and accelerated workflow.

 

Inside Cardiac 3D Applications: Transesophageal Echo
Using Siemens syngo FourSight TEE View, a  surgical view of the mitral valve shows the mitral valve annulus and cusp delineation in a patient with mitral valve prolapse.Radiologists see things differently from their clinical peers. Radiologists typically take images, even 3D datasets, and slice them into 2D to make a diagnosis. But other clinicians, particularly cardiologists, operate from a different perspective. 3D is their native language; they are used to viewing and handling anatomical structures in three dimensions.

 The advent of transesophageal echocardiography (TEE) could initiate a shift in cardiac surgical processes. “TEE is most relevant for mitral valve surgery. It displays the anatomy better than 2D echo studies,” reports Mani Vannan, MD, associate chief of cardiology at University of California Irvine (UC Irvine) in Orange, Calif. UC Irvine uses Siemens Medical Solutions syngo FourSight TEE View to complete TEE studies in mitral valve repair cases. “TEE provides information in a way that surgeons understand; it shows structures in a surgical orientation to help surgeons better grasp what repair is needed and how much repair to undertake,” continues Vannan.

Data are not yet available, but anecdotally TEE could impact surgical procedures. That’s because 3D data could provide information that leads surgeons to change strategies.

Current TEE use is fairly limited at UC Irvine. Typically, the invasive procedure is completed 15 to 30 minutes prior to surgery. The surgeon and echocardiographer review and discuss images prior to surgery to help steer the procedure.

“TEE is valuable and could extend to other procedures,” states Vannan. Take for example heart failure surgery where surgeons remodel the left ventricle. 3D images could provide data that lead to a different way to handle the reconstruction. Similarly, the technology could prove useful in congenital heart cases. “Cardiac anatomy is very complex. In congenital heart disease where there is a hole in the heart or valve issues, spatial orientation is very important because structures could be malpositioned,” notes Vannan. TEE may provide an accurate view of the structures, which is critical in cases where anatomy veers from the norm.

Although 3D seems to be everywhere, applications are continuing to develop and evolve. 3D applications like TEE will continue to provide better, more accurate images and improve cardiac diagnosis and treatment.