Roundtable | PCI Imaging: Before, During and After
Physicians are under constant pressure to provide quality care using the latest evidence-based medicine, reduce overhead costs amidst declining reimbursements and remain competitive with the latest technologies. Cardiovascular Business invited a group of interventional and diagnostic cardiologists to discuss the latest practice and imaging trends that support a busy cath lab.
| Participants of the discussion are: |
 Gary Ansel, MD, an interventional cardiologist with MidOhio Cardiology and Vascular Consultants, and director of the Center for Critical Limb Care at Riverside Methodist Hospital in Columbus, Ohio. |
 Joe Galloway, MD, an interventional cardiologist from Inland Cardiovascular Associates in Spokane, Wash. |
 Stephen Green, MD, chief of cardiology, associate director of the cath lab, associate chairman of the department of cardiology and director of performance improvement for cardiac services at North Shore University Hospital in Manhasset, N.Y. |
 Russel Hirsch, MD, director of the cardiac cath laboratory at the Heart Institute at Cincinnati Children's Hospital, Ohio. |
 Louise E. J. Thomson, MBChB, a physician in cardiac imaging, and director of cardiac MRI, at the S. Mark Taper Foundation Imaging Center, Heart Institute, Cedars Sinai Medical Center in Los Angeles, Calif. |
| Moderator |
| C.P. Kaiser, Cardiovascular Business |
What can practices and hospitals do to stay solvent as the new Medicare reimbursement cuts take effect this month?
Green: From my standpoint, as chief of the department, and particularly concerning my imaging staff, I have to ensure that they practice as efficiently as possible. For example, during the workday, the digital echo images are dropped into the reading network. The sonography techs electronically enter patient data directly to the electronic reporting system based on their scans. The active readers can then review the images as well as the tech-generated preliminary reports and finish the reports online, without transcription. The reports are then placed into the result section of the patient’s EMR.
During off hours, our fellows or attendings drop the digital emergency studies into the network. Our on-call echocardiographer can then download them to a laptop, where the images can be reviewed and a report generated remotely to the patient’s EMR. In this way, the overall process of image analysis and report generation is streamlined to optimize efficiency. Echocardiographers are therefore more able to focus on quality of interpretation and educational activities for the ultrasonographers and cardiology fellows.
Thomson: The challenge for noninvasive cardiologists is to ensure that the tests we are performing are appropriate. The challenge for all of us is to use these resources wisely. What we don’t want to see happen is imaging practices trying to increase volume to maintain their revenues, because that will just make the situation worse.
Galloway: We have several outpatient imaging centers around Spokane that may need to consolidate if they can’t pay for the square footage. I also am concerned that the nuclear, vascular and echo diagnostic services in rural areas may not be utilized to the fullest potential, creating a scenario for some to be discontinued.
In our physician-owned outpatient cath lab, our technical reimbursement is about $1,250 for a left heart cath, which is quite a bit less than what hospitals receive. With the new cuts, that reimbursement will decrease to about $1,000, which barely allows us to break even.
Ansel: It will be interesting to see what happens in smaller communities. In Ohio, the CON [certificate of need] just went down a few years ago, so even smaller hospitals have a cath lab. With these reimbursement cuts, that business plan doesn’t appear to make sense anymore.
Hirsch: The cuts won’t affect pediatric intervention as much as they will impact noninvasive imaging, particularly transthoracic echo with respect to color flow Doppler.
What techniques or protocols do you use to reduce radiation dose exposure?
Ansel: I’m concerned not only for patients, but also for our staff. We employed several tactics. We had our radiation physicist check our shielding and found some incorrect assumptions. Some of us also use extra shielding, which dramatically decreases the radiation dosage to the operators. And we’ve educated our operators to change the angles to reduce the risk of radiation dermatitis.
Green: In general, American cardiologists seem to believe radiation doesn’t exist. We have witnessed more of a commitment to lower radiation from international and Canadian visiting physicians than from their American counterparts. It’s important that we keep pushing the educational component of radiation dose reduction.
Practically, we try to minimize the frame rates on all of our cases. We have about 50 physicians in the lab and some of them are better at that than others. We try to go from 30 to 15 frames per second for interventional cardiology and electrophysiology. We also try to get as many shots at 7.5 frames per second. Beyond that, we decrease the dose with technical adjustments.
Galloway: All the scrub and radiation techs are trained to help the physician with the frame rates, as well as coning and utilizing shielding. During the interventions, we use a function called fluorosave, which takes a low-dose fluoroscopic image—and they are frequently quite adequate—making that part of the permanent digital record without having to do a cine or digital run.
Hirsch: As a teaching hospital, we have new fellows coming through the cath labs all the time. I cannot underscore enough the importance of ongoing education for some of the very mundane things that either add radiation exposure, such as keeping your foot on the pedal longer than it needs, or decrease it, such as proper shielding. We also use the fluorosave function, which is phenomenal. I’m particularly interested in the issue of cumulative dose, because so many of our patients come back as part of their ongoing palliation for presurgical catheterizations with single ventricle palliation. We are very cognizant of repeated exposures in same body areas, even if the exposures are months or years apart. In addition, we have almost completely gone away from using CT angiography [CTA] in these patients, preferring instead to use MRI.
Thomson: Radiology in general has not embraced the routine reporting of radiation dose on imaging reports. In nuclear medicine, this is done routinely. In radioiodine therapies, we keep a check on the cumulative exposure of patients to radiation, which goes into the patient’s record. At our institution, we report the dose for cardiac CT by including it with the patient’s EMR. In diagnostic radiology, it is not the standard of care to report radiation dose for a routine CT, but that’s where standards may go in the future. That record then needs to stay with the patient and physicians can make decisions based on their cumulative exposure.
How is IVUS [intravascular ultrasound] used in the cath lab?
Hirsch: The main indication for IVUS in pediatric cardiology is to rule out transplant coronary arteriopathy in the follow-up of transplants, but more and more we have gone towards using fractional flow reserve [FFR].
Galloway: We are using IVUS quite a bit for our coronary interventions, but not much for peripheral interventions. I want an objective measurement, either by FFR or IVUS, that a lesion is definitely obstructive. We’ll also use IVUS to ensure the cross-sectional area is a good fit for the stent and later to ensure the stent is well opposed throughout its length.
Ansel: Joe, in your practice, are you using more IVUS for the indeterminate lesion or are you using more FFR?
Galloway: I am using FFR, and once we decide to go forward, then I will size it with IVUS.
Ansel: Yes, that’s what we do as well.
If you have a hybrid lab at your facility, how is it being used?
Hirsch: As much as the primary focus of the rooms are for cardiac catheterization, they are completely perfusion—cardio-pulmonary bypass—ready. So, we are able to support our patients with congenital heart disease if there is a need to perform simultaneous cath interventions with the heart stopped, or through beating hearts with direct periventricular approaches. The set-up also allows us to approach the main pulmonary artery or the aorta directly in infants where standard approaches are impossible, or the size of the patient dictates.
We are doing approximately two to three hybrid type interventions a month, most commonly for distal pulmonary arteries where access into those very small stenotic branches can sometimes be very difficult. An example of that would be tetralogy of Fallot with multiple AP collaterals after unifocalization. We also use the hybrid lab to close muscular ventricular septal defects, and for sequential atrial septal defects when we are concerned that we may not be able to achieve closure percutaneously. We attempt to close the atrial septal defect in those children with larger sized defects percutaneously; however, if we are unsuccessful, the surgeons take over and they close the defect there and then without having to move the patient or reschedule the procedure.
Green: We do not currently have a hybrid lab, but we are going though the CON in New York State to build one.
Why do you want one?
Green: Hybrid labs are sort of like robotic surgery in some ways because everyone wants one, but no one is 100 percent certain what we’re going to be doing in those rooms five years from now. Personally, we want to have a room where vascular surgeons can perform endografts with better imaging than they have in the OR with the C-arm. We also want to become involved with percutaneous valves, which is the golden ring for everyone to grab at this point.
Ansel: When we built our new labs several years ago, we designed four of them with laminar flow or OR capability. We have been doing AAAs [abdominal aortic aneurysms] and some thoracic aneurysm repairs since then, so we have been primarily performing these procedures in a cath lab. Interestingly, in 12 years, we’ve never had complications and now AAAs are increasingly being done percutaneously, so for routine cases we won’t need the OR in another four years or so. The reason we are maintaining those labs is primarily for the potential of performing hybrid procedures, percutaneous valve repairs and emergency procedures such as aneurysm rupture.
Galloway: We have two hybrid labs in Spokane—both of which have been built within the last 18 months—and right now, we are using them for our AAA grafts and thoracic grafts.
Please, talk about the imaging that is involved prior to percutaneous valve placement.
Thomson: I have been involved in imaging the pulmonic valve in patients having the percutaneous placement of a valve in the setting of chronic pulmonic regurgitation and unsuitability for surgical treatment. We have been using MRI to look at size and shape of the right ventricular outflow tract, the size of the pulmonary arteries and the severity of regurgitation. Imaging can be quickly done even in patients who have trouble with breath holds and lying still.
Regarding contrast media, what precautions do you take to reduce the risk of contrast-induced nephropathy?
Galloway: We have been very concerned about this. All of our patients have their most recent estimated GFR [glomerular filtration rate] on their EMR face sheet. We use the MDRD [modification of diet in renal disease] formula and not the Cockcroft-Gault formula, which can overestimate due to weight. Usually for diagnostic angiography, unless patients have a GFR approaching 30, we feel comfortable doing a single vascular bed as an outpatient with a good, inexpensive low-osmolar agent. We try not to double up on both diagnostic and intervention in someone whose GFR is less than 45, unless they are coming in as an acute patient. If somebody needs a dual vascular bed angiogram, we may use the higher-end low osmolar/iso-osmotic agents, but usually not.
Ansel: We have similar protocols. We use nonionic contrast for patients that have GFRs that are significantly reduced. Our main focus is on hydration before and after the procedure. From a peripheral vascular standpoint, since we are using digital subtraction views, we cut the contrast tremendously. We may use 25 percent contrast and 75 percent saline in an attempt to obtain adequate views.
We also will limit our study. If we know somebody has a disease process below the inguinal ligament, we may not even take a picture of the abdominal aorta or the iliacs. We will just check pressure gradients throughout the anatomy, even for the patients with critical limb ischemia. We may just be checking pressure gradients all the way down to the popliteal artery with no imaging and then save all the contrast for the tibial vessels. Then, here again, we are using diluted contrast for that. Another thing we do that doesn’t have data behind it is replace the 10 cc syringe with a 3 cc or 5 cc syringe for injection of contrast, and it tends to decrease the amount administered at any one time.
Green: We do not utilize handheld automatic injectors, as we feel it would be a step back compared to what we currently do. I hand-injected coronaries for about 10 years, but now for over 15 years, we have been power-injecting coronaries with the standard power injector that is used for ventriculography. We have different programmed rates for right coronary, left coronary and graft injections. The image quality of the injections is consistently excellent, and not reliant on the hand power of the operator. By using the standard power injector, there is no additional cost per case that the new handheld injectors add.
We routinely use 4F and 5F catheters, and do not stock any diagnostic catheters over 5F. I’m sure many of the 40 cardiologists that use our labs were as concerned about the possibility of the power injector causing dissection as I initially was, but these concerns did not materialize. If we need to stop the injection early, we simply turn the stopcock to off.