Setting up a Cardiac Magnetic Resonance service in a District General Hospital: our experience and learning points

Transcription

1 Setting up a Cardiac Magnetic Resonance service in a District General Hospital: our experience and learning points Poster No.: C-1062 Congress: ECR 2015 Type: Educational Exhibit Authors: D. H. Kim, D. Felmeden, L. J. Archer ; Torquay/UK, Torbay/UK Keywords: Education and training, Audit and standards, MR, Management, Cardiac DOI: /ecr2015/C Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 30

2 Learning objectives We aim to present the first six months of providing a new cardiovascular magnetic resonance (CMR) service in a district general hospital (DGH) serving a population of over 275,000. We will describe the process of setting up this service and provide a template for establishing CMR in other hospitals. This will be covered in 4 main steps: Step 1: The business plan Step 2: Equipment Step 3: Training and accreditation Step 4: Protocols and reporting We will then summarise our experience to date in order to describe the types of cases that could be faced and to illustrate potential workload. We will also discuss the level of supervision required and the numbers of scans performed. Background The demand for CMR is growing in the UK. It is safe and has become the gold standard in a variety of cardiovascular conditions through the provision of improved prognostic and diagnostic accuracy in comparison to other imaging modalities [1]. CMR utilises ECG gating to avoid cardiac motion blur. The indications for CMR are wide and diverse [2]. For example, gradient-echo sequences can be used to acquire multiple images throughout the cardiac cycle to be displayed as cine loops to assess cardiac function (Fig. 1 on page 4). Page 2 of 30

3 Fig. 1: A 3 chamber cine view demonstrating normal cardiac function. References: Dr Daniel H Kim, Torbay Hospital, UK Gradient-echo sequences can also be used with velocity encoding in the signal phase to quantify flow, for example across a diseased heart valve [3]. Perfusion and viability investigation by CMR provides up to 60 times greater spatial resolution than singlephoton emission computed tomography [4]. The use of gadolinium chelate contrast enhancement, typically in 3 phases (perfusion phase, early and late phases) allows CMR to be used in a variety of clinical settings including in assessing infarct size, salvageable myocardium viability and in visualising microvascular obstruction (Fig. 2 on page 5) [1]. Page 3 of 30

4 Fig. 2: Two-chamber axial views. There is uniform suppression of signal on delayed contrast enhanced inversion recovery T1-weighted images. This is a normal study. References: Dr Daniel H Kim, Torbay Hospital, UK Additional indications for CMR include the assessment of congenital heart disease, cardiomyopathy, valvular heart disease, myocarditis, amyloidosis and pulmonary arterial hypertension. Torbay hospital benefits from an active cardiology unit, with 6 cardiology consultants and cardiac CT capability. Prior to setting up the CMR service, patients requiring CMR were required to travel to the Bristol Royal Infirmary nearly 100 miles away. Images for this section: Page 4 of 30

5 Fig. 1: A 3 chamber cine view demonstrating normal cardiac function. Page 5 of 30

6 Fig. 2: Two-chamber axial views. There is uniform suppression of signal on delayed contrast enhanced inversion recovery T1-weighted images. This is a normal study. Page 6 of 30

7 Findings and procedure details Setting up a CMR service Step 1: Business Plan Formulation of a robust business plan is essential. Coding of CMR currently does not reflect the complexity of the service and remains unbundled however the British Society of cardiovascular Magnetic Resonance (BSCMR) and the British Society of Cardiovascular Imaging have proposed a set of codes and tariffs that can be used as a starting point for local tariff negotiations [5]. At Torbay, the business plan was formulated by the cardiac radiology consultant in collaboration with the cardiology consultant and the relevant management team. The hospital serves an estimated population of 275,000 with a significant additional influx from holiday makers during the summer months. Help can be found at the NHS National Innovation Centre which provides template business plans [6]. Alternatively template CMR business plans are available from the Society of Cardiovascular Magnetic Resonance (SCMR) although they require a society membership for access [7]. Step 2: Equipment The prerequisite for a CMR service is an MR scanner with ECG-gating and corresponding CMR software. The specification and capabilities of each machine will vary and some software packages may not be suitable for all CMR indications. The authors advise that the decision over which hardware and software to purchase should not be taken lightly and that in depth discussion should be held with their reference centre and with other UK departments where possible. The 'NHS Supply Chain' can help with the procurement process [8]. At Torbay an Aera MRI Scanner with cardiac capability and 'Syngo via' reporting software was purchased. Initially the CMR patient workload was such that a weekly dedicated Friday morning session was started. This was increased to twice weekly sessions after 3 months. The scanner was used to alleviate pressures on other services during the remainder of the working week. Page 7 of 30

8 Step 3: Training and Accreditation CMR Accreditation is provided by the SCMR and the European Association of Cardiovascular imaging (EACVI/EuroCMR), and is based on internationally agreed standards [9,10]. In addition, the BSCMR have published an expansion to this guidance [11]. Assessment is via examination, case based discussions and direct observation of procedural skills. In brief, there are currently 3 training levels, as described in Table 1 on page 18. Table 1: CMR training levels and training requirements as specified by the EACVI and the SCMR. References: Dr Daniel H Kim, Torbay Hospital, UK At Torbay Hospital, training to level 2 was undertaken by 2 doctors; 1 practising in Clinical Radiology and the other in Cardiology. Both attended a one week intensive course at Southampton General Hospital. Training of the radiologist was carried out at the Bristol Heart Institute, a level 3 accredited centre. Training was arranged to take place over a one year period. The radiologist then sat the European exam in Cardiac MRI at EuroCMR (held yearly) and is currently applying for Level 3 competency. Page 8 of 30

9 In terms of radiographer training, several observational visits to the Bristol Heart Institute were made prior to the start of the service. The manufacturer of the scanner also provided 2 days of supervised training. This was followed by several visits from the superintendant from the level 3 supervising centre designed to improve radiographer technique. Lastly the radiographer team was sent on the "Cardiac MRI for Radiographers" 1 week intensive training course at the Southampton General Hospital. As training is likely to take several months it is advised that this take place in conjunction with the business plan development and procurement process. Step 4: Protocols and Reporting Standardised CMR protocols have been published by the SCMR [12] and the EACVI [13]. It is recommended that these are adhered to with protocol alterations only being made in conjunction with the level 3 supervising centre. The SCMR have also published a set of standardised reporting guidelines for CMR [14]. At Torbay, the existing reporting structure at the level 3 supervising centre was adopted. The multidisciplinary approach of dual reporting with a radiologist and a cardiologist was particularly effective, and this was the aim wherever possible. The Friday morning reporting sessions were arranged to coincide with the availability of a level 3 CMR trained practitioner at the supervising site so that cases could be reviewed immediately when necessary. The Torbay Hospital CMR service: progress to date th The patient and reporting statistics taken from our CMR service between 9 June 2014 th and 9 December 2014 are displayed in Table 2 on page 19. Page 9 of 30

10 Table 2: Torbay CMR service: patient and reporting statistics. References: Dr Daniel H Kim, Torbay Hospital, UK Studies that were 'Dual Reported' benefitted from collaborative input from both the Radiology and Cardiology consultants. Scan indications were varied and are illustrated in Fig. 3 on page 19. Page 10 of 30

11 Fig. 3: Indications for CMR studies performed. Arrhythmogenic right ventricular cardiomyopathy. References: Dr Daniel H Kim, Torbay Hospital, UK Other indications included investigation for Becker's muscular dystrophy, for Fabry's disease, family screening for bicuspid aortic valves and for quantification of ejection fraction following inadequate ultrasound. The types of diagnosis encountered and their relative frequencies of observation are illustrated in Fig. 4 on page 20. Page 11 of 30

12 Fig. 4: Bar chart illustrating diagnoses made and their relative freqencies. Arrhythmogenic right ventricular cardiomyopathy Left ventricular outflow obstruction. References: Dr Daniel H Kim, Torbay Hospital, UK Cases In this section we present a selection of some of the more common and interesting cases observed in our CMR centre so far. Page 12 of 30

13 Fig. 5: Two-chamber axial views. There is a diffuse subendocardial heterogeneous pattern of increased signal on delayed contrast enhanced inversion recovery T1weighted images consistent with amyloidosis. References: Dr Daniel H Kim, Torbay Hospital, UK Page 13 of 30

14 Fig. 6: Four-chamber cine clip demonstrating apical hypertrophic cardiomyopathy. References: Dr Daniel H Kim, Torbay Hospital, UK Page 14 of 30

15 Fig. 7: Apical hypertrophic cardiomyopathy in a) diastole and b) systole. References: Dr Daniel H Kim, Torbay Hospital, UK Page 15 of 30

16 Fig. 8: Four-chamber cine view demonstrating a dilated right ventricle. The wall is dyskinetic and is hypertrabeculated with microaneurysms. This patient has arrhythmogenic right ventricular wall cardiomyopathy. The left ventricle also has a thin inferior lateral wall which is hypokinetic. References: Dr Daniel H Kim, Torbay Hospital, UK Page 16 of 30

17 Fig. 9: Two-chamber cine view demonstrating a severely dilated and impaired left ventricle consistent with dilated cardiomyopathy. References: Dr Daniel H Kim, Torbay Hospital, UK Page 17 of 30

18 Fig. 10: Three-chamber cine views in a) diastole and b) systole. This patient has septal hypertrophic cardiomyopathy. References: Dr Daniel H Kim, Torbay Hospital, UK Images for this section: Page 18 of 30

19 Table 1: CMR training levels and training requirements as specified by the EACVI and the SCMR. Table 2: Torbay CMR service: patient and reporting statistics. Page 19 of 30

20 Fig. 3: Indications for CMR studies performed. Arrhythmogenic right ventricular cardiomyopathy. Page 20 of 30

21 Fig. 4: Bar chart illustrating diagnoses made and their relative freqencies. Arrhythmogenic right ventricular cardiomyopathy Left ventricular outflow obstruction. Page 21 of 30

22 Fig. 5: Two-chamber axial views. There is a diffuse subendocardial heterogeneous pattern of increased signal on delayed contrast enhanced inversion recovery T1-weighted images consistent with amyloidosis. Page 22 of 30

23 Fig. 6: Four-chamber cine clip demonstrating apical hypertrophic cardiomyopathy. Page 23 of 30

24 Fig. 7: Apical hypertrophic cardiomyopathy in a) diastole and b) systole. Page 24 of 30

25 Fig. 8: Four-chamber cine view demonstrating a dilated right ventricle. The wall is dyskinetic and is hypertrabeculated with microaneurysms. This patient has arrhythmogenic right ventricular wall cardiomyopathy. The left ventricle also has a thin inferior lateral wall which is hypokinetic. Page 25 of 30

26 Fig. 9: Two-chamber cine view demonstrating a severely dilated and impaired left ventricle consistent with dilated cardiomyopathy. Page 26 of 30

27 Fig. 10: Three-chamber cine views in a) diastole and b) systole. This patient has septal hypertrophic cardiomyopathy. Page 27 of 30

28 Conclusion Setting up a CMR service at a regional district general hospital is feasible, realistic and can greatly improve the patient experience by providing improved diagnostic and prognostic services closer to home. A template has been proposed which may be used by any department looking to replicate this process. This will be necessary to keep up with the growing demand for CMR in the UK and to continue to improve the level of care provided in this country. Personal information Dr Daniel H Kim joined Torbay Hospital, South Devon in 2014 as a Radiology Registrar. Dr Dirk Felmeden joined the Consultant Cardiology team at Torbay Hospital, South Devon in Dr Lesley J Archer joined the Consultant Radiology team at Torbay Hosptial, South Devon in References 1. Flett AS, Westwood MA, Davies LC, Mathur A, Moon JC. The Prognostic Implications of Cardiovascular Magnetic Resonance. Circ Cardiovasc Imaging. 2009; 2: Pennell DJ, Sechtem UP, Higgins CB, Manning WJ, Pohost GM, Rademakers FE, van Rossum AC, Shaw LJ, Yucel EK. Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report. European Heart Journal. 2004; 25: Kilner PJ, Gatehouse PD, Firmin DN. Flow measurement by magnetic resonance: a unique asset worth optimising. J Cardiovasc Magn Reson. 2007; 9: Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, Parker M, Klocke FJ, Bonow RO, Kim RJ, Judd RM. Contrast-enhanced MRI and routine single photon emission Page 28 of 30

29 computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet. 2003;1: BSCMR/BSCI. (2009) CMR Commissioning in England BSCMR/ BSCI Suggested new CMR codes and tariffs. Available from: & circumstances/2163.html#.vkgeztksxjn [Accessed 03 Jan 2015] 6. NHS NATIONAL INNOVATION CENTRE. (2012) Stage - ID2: Design the Solution > Write a Business Plan. Available from: rd stage=id2&taskid=29 [Accessed 03 Jan 2015] 7. SOCIETY FOR CARDIOVASCULAR MAGNETIC RESONANCE. Resources - Clinical Practice, Service Delivery and set-up. Available from: rd CMR-in-specific-circumstances/2163.html#.VKgeZtKsXJn [Accessed 03 Jan 2015] rd 8. NHS SUPPLY CHAIN. Available from: [Accessed 03 Jan 2015] 9. Kim RJ, de Roos A, Fleck E, Higgins CB, Pohost GM, Prince M, & Manning WJ. Guidelines for Training in Cardiovascular Magnetic Resonance (CMR). Journal of Cardiovascular Magnetic Resonance. 2007: 9, European Association of Cardiovascular Imaging (EACVI) Cardiovascular Magnetic Resonance Certification. Available from: accreditation/cmr/pages/certification-processes.aspx [Accessed: 07/01/15] 11. BRITISH SOCIETY FOR CARDIOVASCULAR MAGNETIC RESONANCE (2008). BSCMR Guidance for CMR training (cardiology). Available from: rd training/accreditation/ [Accessed 03 Jan 2015] 12. Kramer CM, Barkhausen J, Flamm SD, Kim RJ & Nagel E. Standardized cardiovascular magnetic resonance imaging (CMR) protocols, society for cardiovascular magnetic resonance: board of trustees task force on standardized protocols. Journal of Cardiovascular Magnetic Resonance. 2008; 10:35 Page 29 of 30

30 13. Herzog BA, Greenwood J & Plein S. Cardiovascular Magnetic Resonance: Pocket Guide European Association of Cardiovascular Imaging (EACVI). Available from: [Accessed: 07/01/15] 14. Hundley WG, Bluemke D, Bogaert JG, Friedrich MG, Higgins CB, Lawson MA, McConnell MV, Raman SV, van Rossum AC, Flamm S, Kramer CM, Nagel E and Neubauer S. Society for Cardiovascular Magnetic Resonance guidelines for reporting cardiovascular magnetic resonance examinations. Journal of Cardiovascular Magnetic Resonance. 2009; 11:5 Page 30 of 30