Today’s product ads targeted to the baby boomer generation are lauding the transformative process of aging, implying that older can be better. If we think about how the field of invasive cardiology has matured, we 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 dramatically 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 analogue-based image intensifiers (IIs) to fully digital flat-panel technology with 3D reconstruction. Some in the industry may still remember having to process cine film.
- The introduction of stents significantly altered the care landscape. The evolution of stent technology — from the 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 (July 5, 2016) of Abbott Vascular’s Absorb, the first fully-bioresorbable coronary stent, offers great potential for many patients who do not want permanent implantable devices.
- The provision of percutaneous coronary interventions (PCI) initially was within the purview of programs that also provided open-heart surgery (OHS). The continued adoption and approval of primary and elective PCI without OHS on-site in states across the county continues, with a focus on outcomes rather than on volume thresholds. Corazon, as an approved accrediting body in states such as Michigan and Pennsylvania, has seen the evolution of practice, and has an ongoing view of process improvement and outcomes at these programs. Our team likewise witnesses a commitment to quality (often through a heart team approach), a consistent adherence to patient inclusion/exclusion criteria, and vigilance in assuring that appropriate use criteria are well documented.
- 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% 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% of their procedures via radial approach speaks to 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.
- The migration of peripheral interventions into the cath lab was fueled by cardiologists with an interest in expanding their cardiac catheter skills to other vascular beds. Turf wars emerged with interventional radiology, and then more recently with vascular surgeons, as their interest in acquiring catheter-based skills has grown considerably. 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, we have 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. In some states, we also see 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.
- Valvuloplasty, or using a balloon catheter to widen a stenotic aortic valve, was 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.
- Much like TAVR, endovascular aneurysm repair (EVAR) is now positioned to save lives for the abdominal aortic aneurysm population. Both this technique and the accompanying technology have quickly migrated from traditional academic quaternary centers to many community-based hospitals in a relatively short time. The TAVR program at Corazon client United Health Services (UHS) in Binghamton, New York, as featured in the June 2016 issue of Cath Lab Digest, is an example of a community program that has worked diligently to offer quality clinical programming by expanding service offerings for the local and regional community.
- 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 a 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.
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.
Information that supports data-driven decision-making as a means to evaluate technology and any associated improvements in clinical outcomes will be a cornerstone for measuring and tracking progress. The need for reliable data cannot be understated, whether in terms of patient volume potential for a new technology/technique or procedure, or for understanding the clinical, operational, and financial impact of an already-adopted advancement. Knowing the current situation in the cath lab AND having the information readily available for determining the future impact of something new can make all the difference between success or failure.
Looking back to gain perspective on how far we have come is always a worthwhile effort. Indeed, cutting-edge programs will embrace the “new and rejuvenated complexion” of the cath lab and look forward to the next clinically proven solution.
Susan Heck is a Senior Vice President at Corazon, Inc., providing strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon offers a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach the author, email firstname.lastname@example.org.