Cardiovascular Business - July/August 2008 - (Page 17)

“The technology has evolved to the point where real-time 3d transthoracic echo has to be integrated into our day-to-day evaluation of children with congenital heart diseases.” Henry issenberg, MD, director, Pediatric echocardiography Laboratory, Maria Fareri Children’s Hospital at Westchester Medical Center, Valhalla, N.y. malformations. One example where 3D TTE delivers superior clinical data over 2D echo is for ASD repairs, Issenberg says. With conventional 2D echo or x-ray angiography, ASDs often look circular, with equal diameters. Even in the operating room, the defect in the relaxed heart can look circular. In a normally beating heart, however, the defect is often oval in shape and real-time 3D echo accurately shows the shape. This realization gained through the use of live 3D echo explains the fairly high failure rate of percutaneous repair with closure devices. “You would put a round device into an oval hole and end up with portion of it not closed,” Issenberg says. One can extrapolate the potential benefits of real-time 3D TTE to other congenital heart diseases, such as complex malformations of the mitral or tricuspid valves involving both the annulus and the leaflets or the subvalvular apparatus. “To be able to see the relationships of those structures in multiple dimensions and in real-time has totally expanded our understanding of cardiac anatomy,” Issenberg says. 3D echo also is much more helpful than 2D when there are multiple congenital malformations that have to be corrected simultaneously in the operating room. For example, a mitral valve may straddle a ventricular septal defect (VSD). With 2D echo, it is difficult to determine how much of the valve is over the VSD. Without this knowledge, a surgical patch over the VSD could interfere with the valve function. With 3D echo, surgeons can clearly see the movement of the leaflet of the mitral valve and determine how much—if any—interference the repair will cause, according to Issenberg. “The technology has evolved to the point where 3D TTE has to be integrated into our day-to-day evaluation of children with congenital heart diseases,” he says. It is easy enough to post-process and manipulate the 3D images on the Philips’ machine or on a workstation with Philips’ proprietary software, but Issenberg does not like that he cannot download many of the post-processed images into the hospital PACS. “They end up in the resident archive on the workstation or remain within the platform of the echo machine,” he says. “It’s a matter of getting a DICOM standard and then having the archiving companies collaborate and adopt the standard.” Frontier modality John Erwin, senior staff cardiologist at Scott and White Memorial Hospital and Clinic in Temple, Texas, calls 3D echo “an exciting frontier, but still a frontier modality.” He cautions that if good images are not obtained with 2D echo, 3D imaging will not be helpful either. Erwin uses the GE Vivid 7 Dimension 3D TTE system, as well as the Philips 3D TEE system. Erwin is convinced of the clinical benefits of real-time 3D TEE, particularly to determine the complex geometry of the mitral valve. “Over the last decade, we’ve been leaning towards repairing the mitral valve rather than replacing it. The 3D technique helps us tremendously with repair, which has a lower rate of morbidity and mortality,” he says. Real-time 3D TEE allows cardiac surgeons to see how the two leaf lets of the mitral valve interface with each other and determine with more certainty which scallop is having the most difficulty, or if the problem is related to the mitral annular plane. “Sometimes you see that the supporting fibrotic structure of the valve is dilating too much, which calls for a particular repair, a Dacron ring sewn into the annulus to improve the competency of the valve,” Erwin says. Martin calls 3D TEE “revolutionary,” but also cautions to be careful with the first-generation product. “It’s not a simple plug and play,” he says. “One has to learn how to display and crop the complex anatomy.” Whereas 3D TTE has data points to help orient oneself in space, 3D TEE does not and getting oriented requires skill. For the 3D modalities to take hold among rank-and-file cardiologists, there needs to be improvements in image quality and throughput, Martin says. Additionally, reimbursement will have an impact as well. “You want the most accurate diagnostic and prognostic information from an echo test, but you also have to realize the economics of throughput and reimbursement,” he says. “If there is a technique that is more labor intensive but reimburses inadequately, the only reason to adopt it is because it aids in your diagnosis and in your competitive stance.” cardiovascularBusiness.com cardiovascular Business 17 http://CardiovascularBusiness.com

Table of Contents Feed for the Digital Edition of Cardiovascular Business - July/August 2008

Cardiovascular Business - July/August 2008 Table of Contents First Word Cover Story: Planning for the Ideal Cath Lab Requires the Multidisciplinary Approach Clinical Study Digest: Cell Phone Technology Speeds Ecgs As Real-Time 3d Echo Matures, It Finds a Clinical Niche Ecg Image Management Brings Increased Productivity and Confidence Overcoming Barriers to Cath Lab Inventory Control Maximizing Reimbursement, Minimizing Penalties News & Views Calendar Reader Resources The Back Page

Cardiovascular Business - July/August 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.