Cath Lab Digest - March 2008 - (Page 22)

CARDIAC IMAGING MARCH Normal angiograms can never be eliminated, but at least they can be reduced. There are also patients where both current-generation and future CT scanners will not be able to provide sufficient image quality. For example, take patients who have small implanted coronary artery stents, which are very difficult to analyze by CT. Also difficult are patients who have renal disease. They often have tremendous amounts of coronary calcification, and then CT has problems. Injection of contrast agent may also be a problem in these patients. So there are some patient groups that cannot be studied very well by CT, and in these patients, the invasive angiogram will always remain the clinical test that will help us decide whether or not they have coronary disease. What about reimbursement? Currently, we are in a phase of turmoil in every country. Nobody knows exactly how and under which circumstances this test should be reimbursed, but I am certain this is all going to level out in the years to come. As we have larger studies — and many of them are coming out right now — insurers will recognize that if this test is used reasonably and according to the guidelines, it can actually save them money. Of course, the concern is for an initial phase where the test is perhaps not being done in a qualified fashion (and that is sometimes the danger), meaning that the results are not very helpful. Then I can understand that insurance might be initially reluctant to reimburse for the test. If people look very closely at the data we have now and limit the use of CT to patients where it is truly appropriate, they will clearly see that it can save money, and work for the benefit of the patient and society. That is why I believe the payers will eventually decide to pay for this test; I hope it will be very soon. This holds true for every country. In Germany, we do not have reimbursement at the moment, but we see it coming, slowly. In the United States, I know that a great deal hinges on the decision of CMS as to whether there should be a positive or negative national coverage determination for the reimbursement of CTA in Medicare patients, which is completely open at the moment that we are having this interview — but it might be finalized when it is published. It is going to be interesting to see what happens. Even if the decision were negative, I think it will be only a temporary problem. Eventually, in the long run, if this technique is used reasonably and cost-effectively, it will be recognized and reimbursed. You are involved with the Society of Cardiovascular CT (SCCT). Can you describe the purpose and work of the society? The Society is an amazing phenomenon. I was fortunate enough to be the founding president of this group, which started early in the year 2005, when there were two separate groups involved in cardiac CT. Each group felt a professional organization was necessary to get behind all of the problems we mentioned: reimbursement, advocacy, education, training, verification and credentialing. As cardiac CT grows, all of that is important. There definitely needed to be a society devoted exclusively to cardiac CT in order to manage these issues, without inherent competing interests. Out of this desire arose two different groups very early in 2005. One group first met in Atlanta, and the other in Chicago, on the same date (by total coincidence), independently from one another, seeking to start a professional society. Very soon it was recognized that it would not make any sense to have two societies competing. With the massive help of the American College of Cardiology (ACC), a process ensued that, within a few weeks, led to the fusion of these two initial organizations. In March 2005 in Orlando, Florida, the Society of Cardiovascular CT was founded. The two original groups merged and leadership was elected, consisting of representatives from both initiatives. In the first two years, SCCT grew to more than 4000 members, which, we were told, was the fastest-growing society that has ever been seen in this field. SCCT continues strongly, with 4,473 active members as we speak. It is very active in issues of education; for example, doing courses with the ACC, providing input to international meetings of the radiology and cardiology societies, and in the SCCT Annual Meetings, which are attended by close to 1000 people each year. There is a verification program of training experience as well as a credentialing program that we helped create. A journal has been created, the Journal of Cardiovascular CT, which is free of charge to all of our members. It has turned out to be a very nice resource of up-to-date information about the clinical applications and science of cardiac CT. We have also started our first international chapter, in Japan. I The Latest in Cardiac Magnetic Resonance Imaging (MRI) Cath Lab Digest talks with Robert O. Bonow, MD, Goldberg Distinguished Professor at Northwestern University Feinberg School of Medicine; Chief, Division of Cardiology, Northwestern Memorial Hospital; Co-director, Bluhm Cardiovascular Institute, Chicago, Illinois What are “cardiac perfusion MRI” and “delayed enhancement imaging”? Perfusion imaging with MRI is very similar to perfusion imaging with nuclear tracers (single photon emission computed tomography [SPECT] imaging or positron emission tomography [PET] imaging). Each test has an imaging (contrast) agent which can be tracked as it goes through the myocardium, so MRI is the same principle as a study using SPECT imaging or PET imaging. In cardiac perfusion MRI, you look at blood flow at rest and with a stressor, like adenosine. We use the contrast agent gadolinium, a standard MR contrast agent which washes in and out of the myocardium fairly quickly, and first-pass imaging, which means we are looking at the first pass of the contrast agent as it enters into the chambers and then into the myocardium itself. In the myocardium, we are looking at the perfusion. As with nuclear cardiology perfusion imaging, we evaluate blood flow changes from rest to stress. The difference between MRI and SPECT imaging is that the spatial resolution of MRI is much better and there are no attenuation artifacts. MRI cannot be done in patients with implanted devices, like pacemakers and ICDs. With that exception, very good images are available in virtually all patients, without some of the attenuation issues one has with overweight patients or women who have breast artifacts, where you may see attenuation artifacts with SPECT imaging. It is possible to get around the attenuation artifacts with PET imaging, but PET is less available in most centers. Most large hospitals do Continued on the next page am happy to see that SCCT has grown to be very strong within a very short period of time. Any advice for those physicians referring patients for cardiac CT? I am deeply convinced that cardiac CT is a tremendously useful test, if it is used in the right patient and if it is done appropriately. If you use inadequate technology, or if the person who uses the technology, who does the scan and interprets the scan, is not sufficiently experienced, that can be a problem. Then the quality will not be good. It is not a terribly difficult test to perform, but the equipment has to be good and a few things have to be taken care of and done right. Then the scans are usually of very high quality. Low-quality scans are impossible to interpret, and if interpreted, the result is likely to be wrong. Getting trained and having a high level of quality at the site that performs the scan is very important. Anyone who thinks about referring a patient to a cardiac CT scan should only refer the patient to a center that has sufficient experience. In some places, they do one cardiac CT per week, and it is likely to be bad. The quality has to be good and the volume has to be high. Then it is a very, very useful test. ■ Dr. Stephan Achenbach can be contacted at stephan.achenbach@ uk-erlangen.de

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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