ACC 2019 Showcases Yin and Yang of Medical Imaging

The fingerprints of value-added medicine were all over products and works-in-progress on the exhibit floor of the annual meeting of theAmerican College of Cardiology(ACC). Fromcomputed tomography(CT) to沙特vs阿联酋比分预测(IT),positron emission tomography(PET) todeep learningalgorithms, vendors sought to demonstrate how cardiology could be more efficient, more effective, and convenient or comfortable for the patient.

Imaging With A Cardiac Twist

From the exhibit floor, Siemens launched a version of thego.Top CTscanner dedicated for cardiology, its compact footprint and pricing (south of $800,000) designed to fit the physical spaces of outpatient centers and their budgets. The underlying Go platform suits patients as well with a gantry-hung PC tablet that can take the place of a control room and, thereby, allows the technologist to spend more time directly with patients. (A radiological version of the 128-slice Siemens go.Top was released at theRadiological Society of North America’s (RSNA) 2017 conference.) In line with its patient centricity is the CARE kV feature, which optimizes radiation dose and image contrast, and its Check&GO algorithm, which helps identify problems with anatomical coverage and the distribution of media contrast.

Although optimized for outpatient cardiology offices, the CV version of the CT might also be installed in hospitals, according toMatthew Dedman，西门子CT产品营销总监。西门子开发了一种技术解决方案，可以优化从扫描仪到HeartFlow公司的数据传输，从而可以进行基于ct的分数流量储备(FFR)分析。然后，这个解决方案可以用于将结果反馈给医生。

Similarly, GE Healthcare directed booth goers to itsCardiographe美国早在大约两年前就推出了一台CT扫描仪。GE全球销售和营销总监菲利普•卡拉姆(Philippe Karam)指出，CardioGraphe专注于心脏病学和成本效益，并表示该系统是专门为心脏病学市场打造的。通用电气美国和加拿大高级CT主任Kira Behrens表示，该技术可用于计划经导管主动脉瓣置换术(TAVR)等手术。剂量效率是通过心血管版本的GE的ASiR(自适应统计迭代重建)软件实现的。

Priced under $800,000, the CardioGraphe — which installs in as little as 15 square meters — can typically fit in outpatient clinics, emergency departments, clinics (such as “a large interventional lab,” Behrens said, “where nuclear tests are frequently done”) or even physician offices, according to the company. In a single heartbeat, the dedicated CV scanner can create a 3-D image of the coronaries, valves, chambers and myocardium, as well as an angiogram of the aorta. Rotation speed is 0.24 seconds; single-beat heart coverage 140 mm, resolution 0.28 mm, according to the company.

这种阴阳二元的方法——管理者和医护人员要阴，病人要阳——可以在ACC展厅的其他地方看到。PET已经发展成为一种肿瘤成像方式，在心脏病学中具有潜力。At ACC 2019,Jubilant DraxImagewas working to realize at least some of that potential, promoting its RUBY-FILL (Rubidium Rb82 Generator) product for cardiac PET.

“We believe that a product that is safe and efficient and has dosing flexibility is going to probably make (PET) more convenient to use (in cardiology),” said Lisa Shearin, cardiovascular marketing director for Jubilant Draximage. “We see people who have been using PET typically in oncology trying to carve out spaces — maybe a day or half-day — to image cardiac patients.”

RUBY FILL具有60天的货架期，其灵活的剂量可以克服时间限制，使PET保持在心脏副线上。她说:“例如，你可以有信心在第57天得到与第1天或第2天相同类型的图像。”

据谢林说，RUBY FILL在北美大约有20个安装点，她说到今年年底，这个数字可能会翻一番。Shearin说，她希望美国核心脏病学会(ASNC) 2016年的一份立场声明将心肌灌注PET描述为某些患者的“一线首选检测”，这将加速心脏移植的采用。

Also on the ACC show floor, Circle Cardiovascular Imaging was talking up smart algorithms to extend the use of cardiac MRI and CT. The goal, according to Circle’s Tom Gardner, is to make life easier for cardiologists and radiologists, mostly in the cardiac MRI space but also in cardiac CT. “We have offered and introduced deep learning into our application so that we can speed up and actually improve the processing for some of the studies that you want to look at,” said Gardner, sales director for North America.

In the algorithms, the company leverages deep learning — a type of artificial intelligence — to calculate ejection fraction and stroke volumes, for example, from cardiac MRI. These algorithms take over such tedious manual processes as drawing contours, a process that is not only tedious but time-consuming, “so you can spend your time really understanding patients’ needs,” he said.

Enterprise Imaging Stands Out

某些其他产品可以分为不同的类别。其中之一就是企业形象。Change Healthcare介绍了开发支持云计算的供应商神经存档(VNA)的努力，该公司计划在今年夏天将其应用于初始客户。

心脏病产品管理总监Ori Garini说，目标是使VNA成为一个信息学主干，与公司自己的产品和第三方供应商的产品兼容，主要使用基于标准的接口，“在标准存在的地方”。“在他们不需要的地方，我们有一个非常好的机制来创建合适的界面。”

Aaron Green, general manager of theChange Healthcarecardiology division, expects to initially take about a half dozen sites to the cloud. This will spread, eventually, to most or all Change customers. The company has a substantial installed base, about 20 percent of the total market in North America; the whole country of Ireland; 90 percent of the cardiology trusts in the United Kingdom; and “large cardiology footprints” in Australia and Germany.Green said: “I would say you are going to see a massive shift within the market over the next five years to cloud-based solutions.”

At ACC 2019, Philips showcased the latest version of itsIntellispace Cardiovascular, an image and information management system designed specifically for cardiology. Key features include the integration of images and data from multiple modalities amid streamlined workflow to help improve operational performance from the cath lab to nuclear medicine, electrophysiology to stress echo.

A standout is the system’s timeline, which serves up a graphical and chronological overview of patients — and provides “launch points” from which patient records can be obtained. Images and data about patients, as well as a worklist of cases, can be viewed in the Intellispace Cardiovascular Workspace.

Standards-based interconnectivity is the lever of choice as Philips works with customers and third-party vendors to create a seamless informatics environment, according to Jon Kamerman, Philips senior market manager.

Precision Medicine Shines on ACC Exhibit Floor

Philips framed need — and value — of a product in its portfolio with results from an international study presented during the ACC meeting. The study concluded blood flow restrictions remained in coronary vessels in as many as 25 percent of patients who underwent coronary interventions. Importantly, the lesions that caused these restrictions could be localized using a technology called iFR (instantaneous wave-free ratio, also referred to as instant wave-free ratio or instant
flow reserve).

When localized, the lesions might be resolved, according toJustin Davies, Ph.D.他是伦敦帝国理工学院NHS信托医疗保健中心心胸外科和胸外科的顾问心脏病学家，发明了这项技术。Davies解释说，位于iFR导线不同位置的压力传感器可能会显示出不同的压力。当iFR钢丝从初始治疗部位拉回时，这些差异可能会很明显。

“With IFR, you know not only that you need to treat this patient but also where to treat,” saidBert van Meurs, Philips’ chief business leader for image-guided therapy.

If the pressure drops, the interventionalist knows that residual stenosis occurs somewhere between the two pressure sensors. Philips SyncVision iFR Co-registration product maps the pressure readings onto angiograms, allowing interventionalists to see where in the artery the lesion is likely located.

The iFR technology is already used in cath labs around the world to determine the severity of these coronary restrictions. Philips, which sponsored the study that demonstrated the extended value of iFR, has licensed this technology from the Imperial College. Philips looks at “the total procedure and how can we help to develop more integral solutions to address that specific patient in a more effective way,” said van Meurs, who noted that the company focuses on the combination of imaging and intervention.

The study, which was conducted at major U.S. and European medical centers, showed that the positive effects of coronary interventions in patients suffering from coronary artery disease may be limited by residual lesions. The study suggests that patient outcomes might be improved if the locations of these residual stenoses could be determined.

Most vascular interventions begin with access through the femoral artery. At ACC 2019,Terumo Interventional Systems通过手腕桡骨入路是一种安全且经济的选择。然而，由于与桡动脉相兼容的介入性设备相对较少，因此桡动脉的进入受到限制。

3D Systems laid about a dozen different simulators on tables at its ACC booth. Simulations, said company rep Michelle Halsne, are critically important to achieving good outcomes. “The first time you see an aortic dissection, you hope it is not on your patient,” said Halsne, regional sales manager for medical simulation at 3D Systems, which she estimated has sold about 3,000 simulators worldwide, many of them to educational facilities. “You build confidence and competence and skills for patient one to patient 10,000.”

The simulators used wires and catheters to provide the tactile feeling of a real intervention. Although virtual reality (VR) simulations were not apparent at the company’s ACC booth, VR is integrated in some simulators to provide a visual sense, she said. “(Interventionalists) are seeing it as though they are working on a patient,” said Halsne, who noted that tactile feedback is an important part of VR. The VR simulation, she said, “feels just like they are pushing the wire through. If they are doing a chronic total occlusion case, (the occlusion) is going to fight back, just like it would in a real case.”

Linking Multiple Modalities By Integrating Data

Philips’ angiographic platform, called Azurion, is more focused on the interventional procedure than the imaging modality, according to van Meurs. Azurion combines angiography with other technologies, such as iFR, in ways that optimize workflow. “The focus is on innovating the procedure and not just innovating one imaging modality,”
范·穆尔说。

结合来自多种模式的数据可以包括联合登记最近获得的CT和实时回波图像。GE医疗展示了其Vivid E95如何融合回波和CT数据。

CT data has proven useful when planning interventional procedures, “but we had lost that data when we were in the (interventional) lab,” said Jake Dewees, clinical commercial marketing manager for GE ultrasound. GE’s fusion feature on the E95, a feature that was commercially released in January 2019, fixes that.

And the CT data does not have to come from a GE scanner. “You can take anybody’s 3-D CT data set and download that into the (E95) and have that available to you during the case,” said
Al Lojewski, vice president and general manager of GE cardiovasular ultrasound.

Similarly, Philips showcased the integration of CT on its Epiq-CVx ultrasound system, which allows the user to navigate through the fused CT echo image. Data from a third modality, digital angiography, can also be co-registered onboard this newly updated version of Philips’ high-end echo system, which the company showed at the ACC along with a new 3-D transesophageal echo probe.

Particularly intriguing on the Epiq-CVx is the “dynamic heart model” feature, which automatically calculates 3-D ejection fraction and chamber volumes. “You want to let the machine do everything,” said Steven Blankenship, a Philips applications specialist. Blankenship noted that the automatic calculations add consistency and reproducibility. “The artificial intelligence of the machine is doing all the work,” he said.

AI-based algorithms can pick the most relevant echo views to assess on GE’s Vivid E95, according to Lojewski. Using the algorithms, which were developed using GE’s Edison platform, he said, “reduces the amount of time that (physicians and sonographers) are spending and it improves the consistency (from scan to scan). You want to make it as simple as you can. That is what we are doing. (The machine) picks the views for you and you can spend more time with the patient reviewing their chart.”

通过人工智能实现的自动化不是为了人工智能而实现的，而是为了达到更高的目标。这并不是什么新鲜事。长期以来，该行业一直在寻求通过自动化提高效率和效益。

这种努力不仅体现在最近开发的智能算法上，而且体现在促进模式更充分使用的技术发展上，从在心脏应用中使用PET成像，到使用其他优质扫描仪的部分构建专用的心脏ct。

Greg Freiherris a contributing editor to Imaging Technology News (ITN). Over the past three decades, Freiherr has served as business and technology editor for publications in medical imaging, as well as consulted for vendors, professional organizations, academia and financial institutions.

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