Clinical confidence and efficiency in SHD: a physician’s perspective

With more patients of younger age and lower risk getting referred for structural heart procedures, minimally invasive procedures offer important benefits, such as faster recovery time and less use of anesthesia. Dr. Safi also notes a greater variety of procedures are being performed, including more mitral and tricuspid valve interventions, driven by the fact that clinicians are able to perform more interventions percutaneously.

The Structural and Congenital Heart Center at Hackensack is involved in several key clinical trials that will shape the future of SHD. There is a tremendous amount of innovation in the field around new technologies and devices, and one of the keys to successfully bringing this innovation to patients lies in equipping operators with the support they need to handle new devices and techniques safely and confidently.

Structural heart procedures deal with complex anatomical structures that must be clearly visualized to help clinicians confidently diagnose and treat each patient.

From the moment a patient is assessed for structural heart disease, the care team must work together to ensure the patient receives the right diagnosis and the appropriate treatment. Accurate diagnostic images, clear image guidance, seamless communication and efficient workflows are essential—and the Philips suite of cardiology solutions is purposefully designed to deliver this confidence and efficiency at each point on the patient journey.

As a large referral center, many of Hackensack’s challenges lie in the evaluation of pre-procedural imaging—making sure that each patient receives the appropriate exams and that the images are of diagnostic quality so that the patient can be moved quickly and confidently into treatment.

Dr. Safi states, “As an imager, my job is to evaluate all the images and pre-procedural tests that a patient has. Having the right workup and good quality images is necessary, so the patient gets an overall accurate diagnosis.”

Dr. Safi also notes that Hackensack has observed an increase in the number of mitral valve procedures, which bring challenges in assessment and modification due to the complexity of the valve’s saddle-shaped anatomy and its tendency to calcify.

Properly sizing and evaluating the function of the valve is a time-consuming process, but Dr. Safi has found the Philips EPIQ ultrasound system to provide excellent 3D imaging, with built-in automation that provides fast, easily reproducible results that are less dependent on the operator’s level of experience. Tools such as 3D AutoMV quantify the function, key structures, and size of the mitral valve anatomy to help Dr. Safi and her team quickly and accurately assess each patient and identify the right path to treatment.

Other tools such as Cardiac TrueVue provide new ways to further visualize the mitral valve’s function and anatomy.

Once a patient is diagnosed and moved into treatment, a new set of challenges arise related to ensuring the room is set up correctly and the clinical team has access to the tools and information they need for a successful procedure.

During the procedure, the interventionalist and imager must work together seamlessly to navigate and deploy the device at the right location. This process relies on the imager using ultrasound to move back and forth between multiple imaging modes—and between 2D and 3D images—to accurately determine device placement.

Both Dr. Pasala and Dr. Safi have seen the value of EPIQ’s multiplanar reconstruction in driving both confidence and efficiency during the procedure.

“If we are able to see the device well on the image, it gives the operators a feeling of confidence and safety,” says Dr. Pasala.

And Dr. Safi observes, “As a proceduralist, when you have literally seconds to get the image and give an answer, you want the best technology there to help you. Multiview multiplanar reconstruction helps you get the right image quickly.”

Both Dr. Pasala and Dr. Safi have found fusion imaging to be a critically important diagnostic and therapeutic tool in structural heart procedures. Dr. Pasala states, “Where we’re seeing the most advantage is to actually marry everything together into one image – where catheters are well seen on fluoroscopy, where there is a three-dimensional understanding of anatomy, so you’re putting everything together for operators…Now they have all the information they need in procedures.”

Both echocardiography and fluoroscopy are essential to interventional imaging—echocardiography visualizes soft tissue, while fluoroscopy visualizes devices. But the two modalities are acquired and displayed in different orientations, which can make understanding and communication difficult during the procedure.

With Philips EchoNavigator, echocardiography and fluoroscopy images display in the same orientation, helping to improve understanding and communication between the imager and interventionalist. EchoNavigator allows visualization of both live echocardiograpy and live fluoroscopy images, to provide accurate views of both soft tissue and devices—and markers placed on echo can appear in fluoro to allow precise guidance.

After a device is placed, clinical teams require high-quality imaging and efficient workflows to assess the completeness of treatment and document results. Tools like TrueVue and GlassVue help the echocardiographer visualize any residual leakage and confirm that functional results are as expected.

Dr. Safi states, “TrueVue is very helpful in patients with prosthetic valve replacements. When we use TrueVue, we’re able to move the light source and really take a full look at the prosthesis. If the patient has a perivalvular leak, we can really see where that leak is by moving the light source.“

Cardiac TrueVue Glass is really helpful for multiple things. When we’re doing MitraClip procedures or assessing a mitral valve, we’re able to change the density of the tissue to see exactly where the regurgitation is coming from. It saves so much time. When doing LAAO devices, we can make tissue translucent to see the ostium of the left atrial appendage very clearly.”

For interventionalists like Dr. Pasala, an efficient workflow is essential to help assess hemodynamic function and document the results in the clinical documentation system. Azurion’s touchscreen module allows Dr. Pasala to confirm hemodynamic function using the Philips HemoSystem while automatically documenting results on XperIM reporting software—directly from the tableside.

As Dr. Pasala and Dr. Safi consider the future of structural heart disease treatment, they are excited by the tremendous pace of innovation that is happening in the space. Hackensack is on the leading edge of this innovation. It’s currently one of three sites enrolled in a clinical trial for a new tricuspid annuloplasty device.

Hackensack is also a leader in transcatheter mitral valve replacement, and the center is involved in two heart failure/structural heart collaborative studies. All of these studies are very imaging-intensive, and one of the advantages of Hackensack as a trial site is that the center offers advanced imaging capabilities, including fusion imaging from Philips.

As Dr. Pasala considers the future of structural heart disease treatment and how these new innovations can change patient care, he notes, “I think there is value being able to partner and standardize some of the procedural steps from an imaging perspective. Echo fusion and CT fusion are game changers in terms of operator confidence and safety for these new procedures.”

As Hackensack continues to grow its structural heart center of excellence, its clinicians have recognized the value of partnership with Philips in helping them deliver optimal outcomes with efficiency.