Will the Cath Lab of the Future be Radiation-Free?

Radiation safety has been a hot topic for continuing education in recent years, but will the cath lab of the future feature fluoroscopy at all? This blog takes a look at future technology developments that may drastically reduce radiation exposure for professionals in the cath lab, or eliminate ionizing radiation altogether.

Growing Recognition of Need for Radiation Safety

Widespread recognition of the need for radiation safety has ballooned due to a confluence of factors. On one hand, advancements in what can be done via percutaenous coronary intervention in the cath lab have introduced longer and more involved procedures which increase the risks of radiation exposure for both patients and clinicians.

On the other hand, experts like Dave Fornell of the publication Diagnostic and Interventional Cardiology rightly point out that the impact of long-term radiation exposure in interventional cardiology is only just now coming to light, 30 years after the subspecialty's inception. In 2015, for example, we published a blog series about non-physician professionals in the cath lab reporting more work-related pain due to wearing radiation protective gear.

A proliferation of best practice resources now exist to help clinicians reduce radiation exposure, like the 2018 Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging, or the Society for Cardiovascular Angiography & Inteventions (SCAI)'s Quality Improvement Toolkit resource on radiation safety.

Of course, these resources are reflective of the status quo, and not predictive of the cath lab of the future—or even the near future—an environment where new technology may drastically reduce radiation used or eliminate the need for ionizing radiation entirely.

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Should CT Coronary Angiography be a First-Order Test?

New guidelines could impact cardiovascular practice.

Results presented at the European Society of Cardiology Congress in August sparked debate ahead of new guidelines for the diagnosis and management of patients with stable ischemic heart disease. Should the U.S. follow the UK in making CT coronary angiography a first-order test for the diagnosis of stable angina?

Headline grabbing results from the five-year SCOT-HEART update showed conducting CT coronary angiography (CTA) in patients with chest pain to be superior to standard care, even reducing rates of heart attack over a five-year period by 41 percent.

With these eye-catching results derived from a well-organized and randomized study, many experts responded with excitement for CTA. "This is one of the most impactful trials, not just in imaging but in cardiovascular medicine," said Todd C. Villines, MD of the Uniformed Services University School of Medicine during the session. David Newby, MD, PhD, of the University of Edinburgh capped the presentation by asking, "Should CT angiography be viewed as the test of choice in patients with stable chest pain?"

This question could have a massive impact on practice, and U.S. physicians eagerly await new consensus guidelines for patients with stable ischemic heart disease, due out this Fall. Following these impressive results, new guidelines could follow suit with the National Institutes for Health and Care Excellence in the United Kingdom, which recommended in 2016 that CT angiography be a first-order investigation for patients with stable chest pain.

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Transradial Access: where we are

A popular hashtag among cardiologists on Twitter, #RadialFirst hopes to promote the adoption of transradial access for cardiac catheterization and percutaneous coronary intervention (PCI) in cath labs across the world thanks to a deepening evidence base of positive outcomes.

The evidence shows that transradial access is associated with reductions in bleeding, vascular complications, and time to ambulation compared with a femoral approach. However, while the adoption of the transradial approach is increasing in the United States, the approach is not as widely used as it is in Europe, Canada and Asia—perhaps due to the challenges in the approach's learning curve.

So, what is the current state of the transradial approach in the United States? That is the question a new comprehensive literature review from the Duke Clinical Research Institute, published in Cardiovascular Innovations and Applications, set out to answer.

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TAVR Volume Requirements Spark Continued Debate

CMS considers changing TAVR volume requirements

CMS Considers Changing TAVR Volume Requirements

Debate over transcatheter aortic valve replacement (TAVR) procedures continues as the Centers for Medicare and Medicaid Services (CMS) considers changing the status quo. Are TAVR volume requirements limiting rural and minority access to this life-saving procedure, or are they still necessary for patient safety?

In June 2018, cardiology news sources widely reported that CMS opened public comment on established volume requirements for hospitals and heart teams to perform TAVR. The Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) then met on July 25 to discuss the issue. A report in Cardiovascular Business suggested that the committee appeared split on the subject—especially in weighing the potential harms of limiting TAVR to only high volume hospitals.

Cases for and against TAVR volume requirements

The Case for TAVR Volume Requirements

For those on the side of maintaining TAVR volume requirements, the benefits are obvious—volume is associated with positive outcomes and lower rates of complications. In fact, a 2018 expert consensus document from four major cardiology societies actually supported increasing volume requirements to maintain a TAVR program, to ensure adequate data collection for statistically reliable quality metrics and quality assurance.

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