Granada said these two areas––advanced cardiac imaging AI and image analysis and robotic tele-interventions for stroke––will likely see large amounts of investment in the next few years because both have serious potential to change the standard of care and greatly improve outcomes.

Cardiac imaging AI image analysis

"One of the things I am amazed about is the rapid progression of non-invasive imaging and using artificial intelligence to try and standardize analysis," Granada explained.

This cardiac imaging technology is making reading faster by automating quantification and making measurements more consistent, eliminating the usual variability between radiologists or cardiologists. The biggest AI advances have been in echo and cardiac computed tomography (CT). Granada said one of the biggest trends having impact downstream in the cath lab is virtual assessments of fractional flow reserve (FFR) blood flow in the coronary arteries using CT-FFR. 

"Those are actually the biggest changes I predict will happen soon," Granada said. 

Cardiac CT and FFR-CT were both included in the 2021 AHA/ACC chest pain evaluation guidelines, which has led to increased interest in creating or expanding cardiac CT programs over the past year. Granada said he believes cardiac CT angiography and using virtual FFR assessments will become the predominant way to evaluate most chest pain patients and eliminate the need for the majority of diagnostic angiograms in the next decade. 

At AHA 2022, the late-breaking PRECISE trial found FFR-CT combined with CT had better outcomes than the current standard of care. Read more.

Another key area seen in cardiac CT AI is its use to automatically analyze soft plaques in the coronaries to better assess risk and to track preventive treatments before atherosclerosis progresses to cause heart attacks. Two vendors now have FDA clearance for this technology. Read more.

Use of robotic tele-interventional procedures to improve stroke care

Another important trend he sees in cardiovascular technology is the use of tele-proctoring and remote tele-interventions. This allows cardiologists to get procedural training remotely without the need to travel to distant hospitals. Tele-interventions using robotic systems in a cath lab will allow a stroke patient to be treated remotely using a robotic catheter navigation system by an experienced interventionist located at a high volume stroke center some place else in the country. This technology is on the cusp of FDA review for commercial use. Granada said these technologies will help create much greater access to new types of interventions like acute stroke care.  

Ischemic stokes and heart attacks have the same etiology. While coronary interventions are now very advanced with rapid percutaneous coronary interventions (PCI) using angioplasty and a stent to reopen the artery as a standard of care in most places in the U.S., stroke care has not evolved much. Stroke care has been frozen at about the same care level since the mid-1980s, with the drug tPA (tissue plasminogen activator) administered to dissolve the clot. This was also the standard of care for heart attacks until better outcomes were achieved using cath lab angioplasty, starting in the late 1980s.

Granada said some hospitals have created stroke centers that are now treating stroke the same way as heart attacks, with the rapid activation of cath labs to remove the clot and reopen the vessels in the brain. But, access to that level of stroke care is very sparse.

"The percentage of the population that has access to a stroke intervention, even in the big cities, is really alarming," Granada said. "For acute myocardial infarction interventions, about 75% of people have access to care like rapid PCI, but for stroke the numbers are very, very low. Remote coronary angioplasty might be beneficial in some areas, but stroke interventions are really an unmet need."

This sentiment reflects comments from several other prominent interventional cardiologists the past couple years, where they see stroke revascularization, including use of remote robotic interventions, as a major opportunity in the next few years. These experts have said this could greatly improve stroke outcomes and offer new opportunities for cath labs looking to increase procedure volumes, even in saturated hospital markets.

Other key trends in cardiovascular technology

Granada said there has been a a large number of technology advances in cardiovascular medicine over the past 20 years. This has moved from the basics of building a better coronary stent into all the vascular beds in the body. Today, he said the subspecialties of interventional cardiology, interventional radiology, vascular surgery and interventional neurology can perform minimally invasive procedures that were science fiction just 25 years ago. 

He mentioned the rapid development of structural heart interventions, especially for valvular diseases. The first transcatheter aortic valve replacement (TAVR) valve was cleared by the FDA in 2012, and within 10 years it now dominates aortic valve replacement therapy, with more than 80% of the procedure volume. This success has also led to new transcatheter repairs and valves for the mitral, pulmonary and tricuspid valves.

"If you actually look across every vascular disease on the spectrum ... we can pretty much treat—not cure—every single cardiovascular condition," Granada said. "That really shows the power of innovation."

He said these technology advances are also coming at a time when there is a great need to reduce costs and improve outcomes. FDA Director Robert Califf, MD, spoke at AHA and said the U.S. healthcare system spends more money per patient than any other country on the planet, but our outcomes are worse than other countries that spend much less per capita. He said efficiency and improved outcomes at a lower cost are imperative as the U.S. slips further into a shortage of physicians and reimbursements continue to drop for Medicare patients. 

"Technologies are evolving right now, trying to adapt to social and political changes we are living, with changes to reimbursements and the approval processes," Grenada explained. "But, everyone has to get aligned. When you have competitive reimbursement policies, or have hospitals that are incentivized to do other things, sometimes the things that make sense, are not the things that become the mainstream."

He pointed to cardiac CT as one of these areas where other medical imaging societies have contested the inclusion of CT and FFR-CT in the new chest pain guidelines. From his prospective, he said cardiology as a profession needs to do what is best for the patients and offers the most value for clinicians and hospitals. "But, I think people now are starting to understand the importance CT angiography as the predominant tool for diagnostic angiograms," Granada said, explaining CT angiography is more efficient, faster, takes less infrastructure and reduces risks to the patient.

Another technology designed to improve efficiency in cath labs and operating rooms is just starting to roll out that uses cameras to track all the staff in a room during procedures. AI algorithms can then analyze the workflow patterns to help determine how to restructure the room or locations of equipment or staff to improve efficiency, Granada said. He explained all centers are looking for ways to improve workflow efficiency in the current economic and political climate, and anything that can improve workflow and reduce costs is being considered by hospitals.