Cath Lab Digest - March 2008 - (Page 18)

18 CARDIAC IMAGING MARCH 2008 Dr. Schweiger: With the smaller flat detector, it’s much easier to get very steep cranial and caudal views. That is really a function related to the size of the flat detector and is always a tradeoff. In the large detector labs, you can do peripheral work and see a larger area, but when you are working in the coronaries, you have some limitations in your view angles. With the smaller detector, it is reasonably easy to get fairly steep LAO caudal and very steep LAO cranials, which are more difficult to do in large detector rooms. Dr. Giugliano: Another workflow aspect I would add is that every time we store an image or take a digital run in our Artis zee lab, it’s automatically transmitted to our database archiving system. I’m not sure we are even capable of doing that in our other rooms. In the other rooms, a full transfer occurs at the end of the case. It’s nice to have the images transferred in real time, and it becomes important from a workflow standpoint if you are asking someone to take a look at the films and give an opinion. That leads into the reporting aspect of the Artis zee. Are there any other things that make reporting easier? Dr. Giugliano: Admittedly, we do not have the full line of Siemens integrated syngo-dynamics report generation or their hemodynamic monitoring system. We have a PhysioLog monitoring system (Oakleigh, Victoria, Australia) and a Camtronics database reporting structure (Emageon, Birmingham, AL). Dr. Schweiger: The Artis zee integrates reasonably well with what we do have. Dr. Giugliano: Yes, I think the software integration, as I outlined with the way the films come over in real-time, has been easier to work with than in our other labs. Can you share more about Baystate Medical Center’s door-to-balloon time initiative? Dr. Giugliano: We pride ourselves in treating our acute myocardial infarction population and achieving goals in how rapidly we reperfuse their obstructed vessel. It is a national effort and something that we have been able to significantly improve upon, from the time the patient hits the door of our emergency room to the time a balloon is inflated in their artery to restore flow. That is the most important clinical outcome that has changed, in no small part due to the improved workflow. Dr. Schweiger: We’re in the top 10% of the hospitals in the country for door-to-balloon time, and we have a very busy program. To be fair, we don’t only use the new Siemens lab for our STEMI patients. The fact is that we have a number of labs, but the Artis zee lab is a pleasure to use; it’s easy to get people in, get them on the table and get them started. That’s certainly contributed toward that initiative. Dr. Schweiger: We’ve been at this for a good couple of years. We’ve broken it down: first of all, what’s most important is good communication with the emergency room (ER). We have various time checkpoints, the door-to-EKG, EKG to calling the interventionalist, and taking the patient to the lab. We work to improve our times at every one of these checkpoints. The ER calls in the whole team. We obviously have people on 24 hours a day. The ER puts out the page — acute STEMI — and the people involved know to get right to the lab at night. We have also begun having EMS do EKGs in the field, which saves a tremendous amount of time. To be honest, there is no one thing that has led to our improved door-to-balloon times. It’s a collection of efforts across an entire collaborative system. We look at our results every quarter, and surprisingly, we continue to get better. I think it becomes a mindset and a little bit of a game; if you are the interventional cardiologist on call, you want to get that artery open as quickly as you can because: a) we know it’s good for the patient, but b) because we’re all competitive. Dr. Giugliano: There are people out there who have been doing it longer and/or better, and we have not been shy about trying to learn from others to take away points that can improve our own program. You don’t have to copy everything from other programs; I think every program probably tweaks things a little differently, but there is always something you can learn. We’ve visited Minnesota, Boston and elsewhere, and all of these things add up to getting us into that top percentile. In addition, communication cannot be emphasized enough. We have regular meetings with our ER physicians, nurses and critical care unit nurses, to talk about every single acute myocardial infarction we do. If there is an outlier leading to any delay at all, there is an effort to try and identify the cause. ■ Dr. Schweiger and Dr. Giugliano can be contacted at marc.schweiger@ bhs.org and gregory.giugliano@bhs. org, respectively. Cardiac Computed Tomography: What does it mean for the cath lab? Cath Lab Digest talks to Stephan Achenbach, MD, FESC, FACC, of the Department of Cardiology, University of Erlangen–Nürnberg, Erlangen, Germany. Dr. Achenbach is the founding and immediate past president of the Society of Cardiovascular Computed Tomography (SCCT). immediately rule out coronary disease, saving both time and money. The other situation where CT is useful is in patients with stable symptoms that are equivocal, or who have symptoms and a stress test that is equivocal. CT is helpful in a situation where there is remaining doubt after the stress test and it is possible, but not likely, that coronary artery stenosis is present. Instead of referring these patients to an invasive angiogram, which will probably be normal, it is a very good alternative to do a CT scan. Then, if it is normal, you have avoided the invasive angiogram. Ultimately, CT should be used to rule out coronary stenosis in situations where it is possible that coronary stenoses are present but not very likely, in patients with acute chest pain, or in patients with stable symptoms, in order to avoid the invasive angiogram. There is a group of professional societies that have issued “appropriateness criteria” for cardiac CT and cardiac magnetic resonance imaging (MRI). The criteria also list these two situations as appropriate for using CT, exactly as I outlined them: the acute chest pain patient with intermediate likelihood of disease, normal EKG and normal myocardial enzymes, and the patient with more stable symptoms, who has an equivocal stress test. How has the Siemens Definition Dual Source CT impacted your workflow and patient mix? The Definition Dual Source has one big advantage, which is the fact that the temporal resolution is higher than that of conventional 64-slice CT scanners. In conventional 64-slice CT, without the dual source design, it is very important to lower the patient’s heart rate to You have seen cardiac CT evolve over time. With the advent of CTs offering faster rotation speeds and better coverage, where do you feel CT fits into a cardiologist’s arsenal of medical equipment today? I think CT has become sufficiently robust to use it clinically, provided that the scanner is a 64-slice, and that the person operating the scanner and reading the data has sufficient experience. Both are absolute prerequisites. If both are fulfilled, then CT can be used quite accurately to rule out the presence of coronary stenosis. One clinical situation where this can be useful is in patients coming to the emergency room with acute chest pain, but with a lack of EKG findings or lab tests to indicate that there is a very high likelihood for an acute coronary syndrome. If a patient comes in with chest pain, but they have a normal EKG and no elevated myocardial enzymes, this is a situation where CT can be very helpful, because many of these patients do not have coronary artery disease. If the CT scan is normal, you can then

Table of Contents Feed for the Digital Edition of Cath Lab Digest - March 2008

Cath Lab Digest - March 2008 Are You Being Paid Fair Market Value in 2008? A Cardiac Cath Lab Professionals Survey by Cath Lab Digest and the Society of Invasive Cardiovascular Professionals Saint Joseph’s Hospital Invasive Imaging Tools for Optimizing Coronary Stent Deployment Contents Clinical Editor’s Corner A Workflow Revolution in Cath Lab Reporting Advantages of a New Digital Lab at Baystate Medical Center Cardiac Computed Tomography: What Does it Mean for the Cath Lab? The Latest in Cardiac Magnetic Resonance Imaging (MRI) Cellular Cardiomyoplasty and Cardiac Regeneration Intravascular Ultrasound in the Cath Lab: A Powerful — and Underutilized — Tool to Improve Patient Outcomes The Stentplus™ Patient Success Program Cardiac Cath Lab Clutter — or, Spring into Action! Groin Bleeds and Other Hemorrhagic Complications of Cardiac Catheterization: A List of Relevant Issues Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab What Do You Think? Experience with a New Guidewire: The Terumo Runthrough NS The Ostial Pro™ Stent Positioning System: Perfecting Aorto-Ostial Stent Placement Precious Minutes The Ten-Minute Interview with…Mark Bowles, BSN, CCRN Vascular Care in the Cath Lab: Planning a Smooth Transition Cath Laughs CMS 2008 OPPS Final Rule Review An Extensive Set of Review Courses for the CCI Basic Science, Non-Invasive Echocardiography and Vascular, and ARDMS Ultrasound Exams Meetings Calendar CEU Education Center Clinical & Industry News STEMI Interventions Classifieds Advertisers Index

Cath Lab Digest - March 2008

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