Organization and metrics of the Division of Advanced Cardiac Imaging, King Abdulaziz Cardiac Center

Transcription

1 European Heart Journal Supplements (2014) 16 (Supplement B), B7 B11 The Heart of the Matter doi: /eurheartj/suu016 Organization and metrics of the Division of Advanced Cardiac Imaging, King Abdulaziz Cardiac Center Mouaz H. Al-Mallah 1,2 *, Ahmed Aljizeeri 1, Ihab Suliman 1, Mohsen Alharthi 1,2, Fahad Alhabshan 1,2, and Ahmed Alsaileek 1,2 1 Division of Advanced Cardiac Imaging, King Abdulaziz Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, PO BOX 22490, Riyadh 11426, Kingdom of Saudi Arabia 2 King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia KEYWORDS Advanced cardiac imaging; Coronary CTangiography; Cardiac MRI; Nuclear cardiology Introduction Non-invasive cardiac imaging refers to a combination of methods that can be used to obtain images related to the structure and function of the heart. Non-invasive cardiac imaging has developed rapidly over the years and is set to play an important role in the future. 1 Several different technologies are involved such as nuclear cardiology, cardiac computed tomography (CT), and cardiac magnetic resonance imaging (MRI) in addition to echocardiography. Nuclear cardiology techniques, both single-photon emission computed tomography (SPECT) and positron emission * Corresponding author. Tel: , Ext , Fax: , Ext , mouaz74@gmail.com Non-invasive cardiac imaging (including nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance imaging) developed rapidly over the past few years. The leadership of King Abdulaziz Cardiac Center (KACC) adopted the concept of multimodality imaging cardiologist and developed in the year 2000 a strategic plan to invest in this new branch of cardiology. A new cardiac imaging center is currently under construction with the aim to be the hub for large enterprise of clinical, research, and educational activities. Awaiting the completion of the new imaging center, the division has been active in supporting a busy clinical service in temporary locations that allow access to all imaging modalities. Of note, the first 82-Rubidium cardiac PET MPI in the Middle East was performed at KACC in In addition, the imaging division plays an important role in the teaching and training of medical and paramedical students as well as community cardiologists and radiologist instructing them on the best practices in advanced cardiac imaging. Moreover, research is going to be an integral part of the division mission with.10 research protocols currently being active in the division. Thus, the advanced cardiac imaging division at KACC performs high-quality clinical work, educates and teaches local and regional physicians, and performs research. In short, it is a Saudi cardiac imaging service that operates on high-quality academic standards. tomography (PET) myocardial perfusion imaging (MPI), are frequently the tests of choice for the assessment of myocardial ischaemia and viability 2 (Figure 1). With the availability of the 64-slice CTsystems, coronary CTangiography (CTA) is increasingly used in ruling out coronary artery disease (CAD) in patients with chest pain 3 (Figure 2). In addition, cardiac MRI with its enhanced tissue characterization and unlimited field of view allows for a comprehensive assessment of myocardium and is an invaluable tool in the assessment of cardiomyopathies 4 (Figure 3). It is therefore important that the optimal, safer, and most costeffective test for each individual clinical situation is chosen. This requires a rather new expertise, that of the imaging cardiologist, a physician able to support the different cardiac services (cardiac surgery, pediatric Published on behalf of the European Society of Cardiology. All rights reserved. & The Author For permissions please journals.permissions@oup.com

2 B8 M.H. Al-Mallah et al. Figure 1 Cardiac single-photon emission computed tomography imaging in a 59-year-old man with advanced liver disease prior to transplantation. There is evidence of an inferolateral perfusion defect, which was felt to be artifactual due to ascites. Cardiac catheterization could not be done due to coagulopathy and low platelet count. The patient underwent low-dose coronary computed tomography angiography, which confirmed the absence of obstructive coronary artery disease. Figure 2 Coronary computed tomography angiography in a middle age woman with chest pain. The patient has anomalous left main artery arising from the right coronary cusp and coursing anterior to the pulmonary artery. cardiology, and also adult cardiology) and to indicate the ideal modality to use for each different pathology. 5,6 Given the importance and the role of advanced cardiac imaging, the leadership of King Abdulaziz Cardiac Center (KACC) developed in the year 2000 a strategic plan to invest in this new branch of cardiology. Development of advanced cardiac imaging at King Abdulaziz Cardiac Center The plan consisted of two steps: first, the temporary creation, within the center, of available space for a cardiac CT service. This was followed by the creation of a temporary facility to perform MRI. Concurrent, the recruitment of expert and dedicated physicians started, allowing the actual activity to be achieved. At the same time, in late 2011, the construction of a four story cardiac imaging center began and is expected to be completed in early The upcoming imaging center will be equipped with the latest cardiac imaging systems including two cardiac PET/CT, SPECT/CT, two dedicated cardiac MRIs (1.5 and 3 T magnets), and two dedicated cardiac CT systems. This will be the largest dedicated cardiac imaging center in the region and is expected to be staffed by several cardiac imaging consultants as well as multiple junior staff, physicists, and technicians. The new center is aimed to be the hub for large enterprise of clinical, research, and educational activities serving the needs of the city of Riyadh, as well as those of the kingdom and other gulf countries. Metrics as of today Awaiting the completion of the new imaging center, the division has been active in the multiple temporary locations. Cardiac CT is used extensively for the evaluation of low- to intermediate-risk patients with chest pain. In addition, with the expansion of structural and valvular heart

3 Organization and metrics of the Division of Advanced Cardiac Imaging B9 Figure 3 Severe apical hypertrophic cardiomyopathy in a 22-year-old lady with palpitations. Cardiac magnetic resonance imaging delayed-enhancement imaging revealed no evidence of left ventricular scarring. disease interventions (transcatheter aortic valve replacement, mitral clip, ventricular and atrial septal defects closure) as well as complex coronary and chronic total occlusion interventions, cardiac CT is an essential test in the evaluation of these patients to determine their eligibility for the procedures. Until the new imaging center will be opened, the advanced cardiac imaging division is utilizing the CTsystems in the medical imaging department (CT High Definition for General Electric, and FLSH from Siemens). The current clinical volume of each imaging modality is shown in Figure 4A C. More specifically, the main use of CT was: coronary calcium scores (14%), diagnosis and assessment of CAD (69%), pre-surgical evaluation (7%), assessment of patency of bypass grafts (4%), anomalous coronary artery (4%), and assessment of cardiac morphology (2%). In addition, the first 82-Rubidium cardiac PET MPI in the Middle East was performed at KACC in 1 May By May 2014,.2700 cardiac PET cases have been performed to assess myocardial ischaemia and/or viability before invasive interventions. PET MPI has also been demonstrated to have better diagnostic accuracy 7 and a predictive value of postrevascularization recovery. The study is usually completed in 30 min, in comparison with a much longer duration with SPECT imaging (4 h for a same day protocol). Finally, a dedicated cardiac MRI was installed and commissioned in 2013, and the first cardiac stress MRI was performed at our center in October The most common indications for this imaging modality are the assessment of viability and different types of cardiomyopathies allowing to differentiate the different forms such as hypertrophic cardiomyopathy, arrhythmogenic right ventricular dystrophy, and infiltrative diseases such as sarcoidosis and amyloid, pericardial and myocardial diseases, as well as evaluation and follow-up of congenital heart disease. Not only metrics, but also constant improvements Patient safety is a primary aim at KACC. It follows that several projects have been implemented and will continue to be implemented in order to improve safety of our patients in need of an imaging test. A radiation dose reduction campaign started already in The use of prospective gating and iterative reconstruction tools are attempted in every cardiac CT. This resulted in significant reduction in the median radiation dose of coronary CT from.18 msv to,2 msv for adults. 8 Many pediatric cardiac CTcases are done with,0.2 msv. In nuclear cardiology, routine use of cardiac PET is encouraged given its favourable dosimetery (nearly 3 msv for cardiac PET compared with 15 msv for cardiac SPECT). Obviously, all of the routine measures for patients safety precaution before any procedure are implemented and constantly monitored. Particular care is taken to control anxiety and claustrophobia of patients undergoing CMR, sometimes, when necessary, by using optimal low-dose sedation. Other measures are taken to improve the quality of the advanced cardiac imaging center. Audits are performed

4 B10 M.H. Al-Mallah et al. Figure 4 The annual volume of (A) cardiac computed tomography, (B) cardiac MRI, and (C) cardiac PET at King Abdulaziz Cardiac Center, Riyadh, KSA. to ensure that the studies are reported with 48 h, and that critical findings are clearly and simply reported to the referring physicians. All these efforts have been recognized by the hospital quality assurance department, and the cardiac imaging units are constantly ranked in the top decile in the Joint Commission surveys. Future projects will focus on the appropriateness of referral to cardiac imaging and the choice of the best imaging modality to answer the clinical question, the so-called patient-centered imaging approach. 9 This is essential to decrease the need for serial testing before a definite diagnosis is made and a management plan is implemented. Teaching and training The advanced cardiac imaging of KACC plays an important teaching and training role of medical and paramedical students at the King Saud bin Abdulaziz for Health Sciences University. Equally, specific teaching courses are organized for community physicians and cardiologists to allow them to make the best possible use of the information provided by the different modalities. Multiple lectures and workshops have been, and are, organized to increase awareness about cardiac imaging and its clinical utility. Four hands-on cardiac CT courses were conducted by the division staff. These courses include didactic sessions as well as review of 50 cardiac CT cases on dedicated workstations. The attendee was instructed on ways to improve the quality of scan and to reduce radiation exposure. Importantly, the informal survey after the course reveals that the attendees were able to reduce in their practice the cardiac CT radiation dose by 80 90%, implementing the suggestions given at the course. Indeed, this is the most important value of our courses and we are proud to make this possible. Research The advanced cardiac imaging division always aims to conduct and/or participate at different research projects. Two typology of research projects is ongoing in the division: those sponsored, i.e. participation in multicentric trials and those spontaneous, i.e. those organized in order to answer a specific question relevant to the center. Regarding participation in multicentric trials, KACC is currently the only center representing Saudi Arabia that participates in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA), a trial funded by the US National Institute of Health (NIH). The trial aims to compare invasive reperfusion strategy vs. optimal medical therapy to reduce cardiovascular death or non-fatal myocardial infarction in stable ischaemic heart disease patients. King Abdulaziz Cardiac Center is also the only site outside the USA to participate in the CT-Dose trial, a prospective, multicenter, controlled study comparing radiation doses and image quality between first generation and second generation or CTscanners, 10 and in the VICTORY trial (Validation of an Intracycle CT Motion Correction Algorithm for Diagnostic Accuracy: a prospective center study) Regarding investigator initiated studies originated by King Abdulaziz Cardiac Center The advanced cardiac imaging center is instrumental for the ongoing prospective studies aiming to estimate the prevalence of coronary artery plaque characteristics in asymptomatic intermediate- or high-risk individuals. Another project, conducted in conjunction with the Department of Oncology and the University of Ferrara (Italy), utilizes advanced echocardiography with strain imaging as well as cardiac MRI in the evaluation of patients with breast cancer receiving Herceptin therapy. The above two projects are directly funded by King Abdullah International Medical Research Center (KAIMRC). In addition, multiple registry-based projects are underway utilizing data from the center CT database (.2000 patients), MRI database (.1500 patients), and PET database (.2700 patients).

5 Organization and metrics of the Division of Advanced Cardiac Imaging B11 All these projects have generated several publications in peer-reviewed journals. In summary, the advanced cardiac imaging division at KACC is a state of the art that performs high-quality clinical work, educatesand teaches local andregional physicians, and performs high impact research. In short, it is a Saudi cardiac imaging service that operates on high-quality academic standards. Conflict of interest: none declared. References 1. FraserAG, Buser PT, Bax JJ, Dassen WR, Nihoyannopoulos P, Schwitter J, Knuuti JM, Hoher M, Bengel F, Szatmari A. The future of cardiovascular imaging and non-invasive diagnosis: a joint statement from the European Association of Echocardiography, the working groups on cardiovascular magnetic resonance, computers in cardiology, and nuclear cardiology, of the European Society of Cardiology, the European Association of Nuclear Medicine, and the Association for European Paediatric Cardiology. Eur Heart J 2006;27: Di Carli MF, Hachamovitch R. New technology for noninvasive evaluation of coronary artery disease. Circulation 2007;115: Raff GL, Gallagher MJ, O Neill WW, Goldstein JA. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol 2005;46: 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. Eur Heart J 2004;25: Beller GA. A proposal for an advanced cardiovascular imaging training track. J Am Coll Cardiol 2006;48: Douglas PS, Beller GA, Auseon AJ, Ryan T. The multimodality imager: reality or fantasy? JACC Cardiovasc Imaging 2008;1: Parker MW, Iskandar A, Limone B, Perugini A, Kim H, Jones C, Calamari B, Coleman CI, Heller GV. Diagnostic accuracy of cardiac positron emission tomography versus single photon emission computed tomography for coronary artery disease: a bivariate meta-analysis. Circ Cardiovasc Imaging 2012;5: Al-Mallah MH, Aljizeeri A, Alharthi M, Alsaileek A. Routine lowradiation-dose coronary computed tomography angiography. Eur Heart J Suppl 2014;16B:B12 B DePuey EG. Patient-centered imaging: more relevant (and perhaps more elusive) than ever. J Nucl Cardiol 2014;21: Chinnaiyan KM, Bilolikar AN, Walsh E, Wood D, DePetris A, Gentry R, Boura J, Abbara S, Al-Mallah M, Bis K, Boswell G, Gallagher M, Arunakul I-O, Halliburton S, Jacobs J, Lesser J, Schoepf UJ, Valeti US, Raff GL. CT dose reduction using prospectively triggered or fast-pitch spiral technique employed in cardiothoracic imaging (the CT dose study). J Cardiovasc Comput Tomogr 2014;8: