The Camtronics experience with the filmless digital catheterization laboratory

Systems based on the Archium® Digital Cardiac System architecture are providing filmless operation for cardiac catheterization departments in over 80 institutions today. Filmless operation provides direct cost savings from the elimination of cine film as well as its development and management. In addition to these savings, benefits are being realized from productivity associated with changes in the workflow in the department. Image quality and processing capability consistent with the image quality and processing available in the cath lab have proven to be key components in changing workflow and improving efficiency. Solutions are now available which can deliver this level of performance for most departments including multiple lab departments with cath labs from different manufacturers. With Archium, physician productivity can be enhanced with the immediate availability of studies outside the lab and the ability to consult online. Cath lab turnover can be improved significantly. Staff productivity is realized from improved image management as well. The Archium's modular architecture has already accommodated system evolution without obsolescence of existing systems.     

The DICOM review stations: are they truly different?

Digital acquisition systems are widely used nowadays. The digitization of the cath lab environment is now directed towards the change in the exchange media from an analog (i.e. cinefilm) to a digital (i.e. CD-R) medium. An important consequence of this development is the need for another type of review system. This article focuses on the replacement of the cineprojector by a digital equivalent: the DICOM review station. Since the technologies differ fundamentally, the DICOM review station has very little in common with its analog predecessor. This article explains the basics of DICOM review stations. Different approaches, both in hardware and in software, are possible, each showing their advantages and drawbacks. The impact of choices made by the industry will be illustrated by a number of commercially available DICOM review stations. Further, the article discusses the topics of diagnostic image quality and performance. In our opinion, these are the major topics when it comes to an objective comparison of the capabilities of DICOM review stations. The relation of these subjects with design choices in terms of hardware and software are discussed.     

Digital networking and archiving with ACOM T.O.P.

The international DICOM 3 standard for a single patient record exchange media (CD-R) provided the necessary definition for digital recording and distribution of cardiac angiographic patient data. The medical industry developed archive and review stations that allow the replacement of the 35 mm cine film. SIEMENS launched ACOM.T.O.P. in late 1995. The benefits and technical solution are presented in this paper. Today, the solution for networked real-time image data distribution within the hospital has become reality. Further integration of hemodynamic data, connectivity of hospital information systems, easy access and distribution of such high volume data from and to remote locations is well under way. ACOM.net is used as an example for the realization of commercial products to fulfill the demands of cardiologist and hospital administrators.     

The digital cardiac network: Today and the future

Cine replacement or cineless angiography is now a serious consideration for any new cardiac catheterization laboratory installation. Standards have been set by the Dicom committee, and CD's are rapidly appearing instead of angiogram film. Core labs. are geared to perform CD interpretation as well as film during this transition phase. Attempts are made to network multiple labs. and maintain the same kind of flow encountered in an analog lab. Labour and material costs seem to be cheaper for cineless labs. The future will see faster and deeper storage and commercially available means to network hospitals. This technology may be the forerunner of the digital patient record.     

Acquisition of endovascular skills for uterine artery embolization using a simulator

This study addresses endovascular training using simulators for uterine artery embolization. A review of endovascular skill training for surgeons using simulators was performed. Surgeons possess varying levels of proficiency in endovascular techniques. A simulator will improve endovascular skills in the following areas: C-arm image intensifier use, catheter selection and manipulation, understanding of the pelvic anatomy, and technique of embolization. Surgeons may gain realistic experience on the simulator prior to entry into the cath lab or procedure room. Using a simulator, surgeons can learn valuable endovascular skills necessary for successful performance of uterine artery embolization.     

Gate-keeper to coronary angiography: comparison of exercise testing,myocardial perfusion SPECT and individually tailored approach for risk stratification

We aimed to evaluate the differences between exercise testing (ET), myocardial perfusion SPECT (MPS) and a combination of ET and MPS based risk assessment as outlined by the guidelines with respect to their “gate-keeper” role to coronary angiography (cath) and the associated diagnostic procedural costs if prognostic considerations, as those proposed by the current guidelines and the recent literature, were taken into account. The Duke-score and the summed difference score (SDS; extent of ischemia) were assessed in 955 consecutive patients referred for MPS combined with ET. According to the guidelines and the available literature, three different algorithms for risk stratification were retrospectively applied: (1) ET based risk stratification and cath if intermediate or high risk Duke-score; (2) MPS based risk stratification and cath if SDS ≥ 8; (3) combined approach with ET as first step and MPS in case of intermediate risk Duke-score. A cath would have been suggested in every patient with either high risk Duke-score or SDS ≥ 8 in patients with intermediate risk Duke-score. The referral rate to cath was 27% according to the ET alone, 13% using MPS, and finally 12% applying the combined risk stratification. The cost of the diagnostic work-up including cath were: 615€, 1’299€, and 598€ per patient, respectively. The coronary angiography referral rate widely depends on the diagnostic modality used for risk stratification and according to the referral criteria provided by the guidelines. In the present study, the use of a stress imaging modality (MPS) and published prognostic data was associated with a lower referral rate to cath as compared to exercise testing alone and thus underlines the advantage of a risk based approach applying stress imaging in patients with intermediate risk Duke-score.     

Screening angiography of supraaortic vessels performed by invasive cardiologists at the time of cardiac catheterization: indications and results

An aging population makes multiple vascular distributions more likely in patients arriving at the cath lab for coronary artery angiography or complete cardiac catheterization. Whether or not screening angiography of supraaortic vessels can be performed at the time of cardiac catheterization by the invasive cardiologist is still debatable. We sought to determine safety and utility of performing angiography of supraaortic vessels during cardiac catheterization. Medical records of all patients undergoing combined coronary and noncoronary angiography between May 1998 and December 2002 was retrospectively reviewed. One hundred and forty patients (80 males, mean age 67.8 ± 5.4 years) underwent combined cardiac catheterization and angiography of supraaortic vessels. Carotid artery angiography was performed at the same time of cardiac catheterization in 62 patients and subclavian artery angiography in the other 78 patients. Significant findings were reported in 32 (22.8%) patients. Complications included 1 transient ischemic attack and 2 carotid spasm resolved with nitrates infusion. In most cases the same standard catheters used during coronary angiography were used also for noncoronary angiography (119 patients, 85%). The incidence of significant angiographic findings and the relatively frequent association of CAD with supraaortic vessel atherosclerosis supports combined cardiac catheterization and angiography of supraaortic arteries but only in patients with multivessel coronary artery disease.     

A Method for Improving Arrival-to-electrocardiogram Time in Emergency Department Chest Pain Patients and the Effect on Door-to-balloon Time for ST-segment Elevation Myocardial Infarction

Objectives: The objectives were to determine if an emergency department (ED) could improve the adherence to a door‐to‐electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door‐to‐balloon (DTB) time for ST‐segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients. Methods: This was a planned 1‐month before‐and‐after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders. Results: A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (±standard deviation [SD]) age was 50 (±16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty‐nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. Conclusions: The overall percentage of patients with a door‐to‐ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.     

Transition to an All-Digital Echocardiography Laboratory: A Large, Multi-site Private Cardiology Practice Experience

Acquisition, interpretation, and storage of digital echocardiographic images has many advantages over the standard videotape-based method. Archival, transmission, and comparative interpretation are all optimized with digital echocardiography. A study performed at one site can be immediately available for viewing and analysis at another site by means of standard data transfer technology. Echocardiograms can be interpreted in the context of prior studies, which are readily available for side-by-side comparison. The transition to an all-digital laboratory involves the commitment of persons at multiple levels in the cardiology practice, including administrators, information technology specialists, sonographers, and physicians. Quality of patient care, use of physicians' and sonographers' time, and long-term financial benefit are all areas where improvement may be realized with the use of digital echocardiography. We present our experience in the development of an all-digital echocardiography laboratory, and we conclude that digital echo-cardiography is practical and can be implemented readily in a clinical setting. We performed several correlative analyses during this transition to validate the consistency and accuracy of digital interpretation compared with those of analog methods. The transition process from analog (videotape) to digital, including full wide area network exchange, took approximately 8 months. As technology advances, issues surrounding storage, comparison, and acquisition formats will continue to develop. We hope that our experience will help others make the transition to the digital environment and benefit from the ease of image access, the ability to comparatively interpret echocardiograms, and the superior image quality afforded by this advancement.     

数字人体数据质量标准

本文研究了数字人体数据质量含义、数字人体数据质量标准、数字人体数据质量内容、数字人体数据集质量分析和数字人体数据误差传递,包括数据质量概念、影响数字人体数据质量的因素、数据质量的数字化误差和数据质量模型等,并进行数字人体数据质量评价,为研究数字人体标准体系提出理论依据.     

Requirements for cardiac interchange media and the role of recordable CD

Over the past two years, representatives of the American College of Cardiology (ACC) have collaborated with the x-ray equipment industry through the National Electrical Manufacturers Association (NEMA) to develop a digital standard for the exchange of x-ray angiographie images. These efforts have resulted in an extension of the Digital Imaging and Communications in Medicine (DICOM) Standard and the selection of recordable CD as the medium for interchange. This report, which is based on an INCIS '94 presentation in Mainz, Germany, is focused on the results of the medium selection. Included is a discussion of the distinction between archiving and interchange of digital image data, an outline of the medium selection criteria, a mapping of recordable CD against these criteria, and a discussion of the future of this medium. Finally, this report contains information about the ongoing ACC-NEMA activities.     

A stepwise validation of a wearable system for estimating energy expenditure in field-based research

Regular physical activity (PA) is an important contributor to a healthy lifestyle. Currently, standard sensor-based methods to assess PA in field-based research rely on a single accelerometer mounted near the body's center of mass. This paper introduces a wearable system that estimates energy expenditure (EE) based on seven recognized activity types. The system was developed with data from 32 healthy subjects and consists of a chest mounted heart rate belt and two accelerometers attached to a thigh and dominant upper arm. The system was validated with 12 other subjects under restricted lab conditions and simulated free-living conditions against indirect calorimetry, as well as in subjects' habitual environments for 2 weeks against the doubly labeled water method. Our stepwise validation methodology gradually trades reference information from the lab against realistic data from the field. The average accuracy for EE estimation was 88% for restricted lab conditions, 55% for simulated free-living conditions and 87% and 91% for the estimation of average daily EE over the period of 1 and 2 weeks.     

Information management in the cardiology department

A major cost component in cardiac angiography is the use of cinefilm for archiving. In addition, cinefilm is difficult to reproduce. There is only one unique archival copy, and if it becomes torn, or lost, it cannot be replaced. Consequently, physicians and administrators looking to save time, increase efficiency and cut costs are also looking for ways to eliminate cinefilm use. Major driving forces that must lead to a replacement of cinefilm are: Cost reduction and Efficiency improvement. The challenge in cardiology is to find a digital cardiac archiving solution that meets the three basic requirements: 1. Cost effectiveness, 2. Ability to perform the basic clinical functions: Review, Exchange and Archive, and 3. Standard format for exchange. A single medium solution, based on CD technology, can fulfill all requirements for review, exchange and archiving. This CD solution, based on CD-Recordable must conform to the DICOM standard for exchange as defined by the ACC/NEMA committee. As advanced technology becomes available, further efficiency improvement can be achieved as extensions to the digital cine replacement based on CD technology. Such networked, multi media solutions are based on a hierarchical storage management concept, incorporate short term archives for on-line availability, and long term archives based on CD for immediate retrieval and exchange.     

数字化X线机胸部描准照片摄影技术的临床应用

目的 探讨数字化X线机胸部描准照片摄影技术质量控制(Qc)的最佳方法。方法 对38例胸部瞄准照片进行了效果分析。就照片中肺尖、外带肺纹理、肋骨重叠的肺纹理、肺的血管、空洞液平面等阴影的显示几率、照片层次等作一评价。结果 由于Qc的较好实施，提高了胸部瞄准照片的质量。结论 用数字化X线机摄影技术做胸部描准照片对于早期发现肺肿瘤、转移性结节、肺结核及其他弥漫性病变有着极其重要的意义。     

Efficacy and limitations of a STEMI network: 3 years of experience within the myocardial infarction network of the region of Augsburg - HERA

Aims

The HERA Registry investigates logistics, adherence to standards, time intervals, and mortality in a regional network for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) in a mixed urban and rural area.

Methods and results

We included 826 consecutive patients (pts) within the HERA network with its dedicated PPCI strategy (female n = 243, mean age 64 years, range 25–98 years) with acute STEMI (May 2007 until January 2010). 680 pts (82 %) received PPCI and 45 (5.4 %) acute bypass surgery. Of 512 pts seen by an emergency physician (EP) as first medical contact (FMC) 87 % received on-scene 12-lead ECG. ECG transmission rate to the PPCI center was 29 %. Median FMC-to-balloon time (CBT) was 135 min and door-to-balloon time (DBT) 70 min. With EP FMC DBT was 38 min with direct transfer to cath lab (n = 70), 69 min via ICU (n = 240), and 132 min via ER (n = 91, p < 0.01). Out of 826 pts, 143(17.3 %) presented in cardiogenic shock. In-hospital mortality was 8.8 % (n = 73), 35.7 % for shock pts versus 3.2 % for non-shock pts (p < 0.01). For pts receiving PPCI, in-hospital mortality was 6.2 %, for shock pts (n = 107) 28.0 %, and for non-shock pts (n = 573) 2.1 % (p < 0.01).

Conclusion

Prehospital management, CBT and DBT compare favourably to data from studies and registries, but do not yet fulfill strict guideline requirements. Real world mortality in non-shock pts is very low. Direct transfer to cath lab reduces DBTs by 49 %. For this crucial improvement, transmission of a 12-lead ECG to the PPCI center is mandatory.     

The peak atrioventricular pressure gradient to transmitral flow relation: kinematic model prediction with in vivo validation.

Physiologists and cardiologists estimate peak transvalvular pressure gradients (DeltaP) by Doppler echocardiographic imaging of peak flow velocities using the simplified Bernoulli relationship: DeltaP (mm Hg) = 4V(2) (m/s). Because left ventricular filling is initiated by mechanical suction, V can be predicted by the motion of a simple harmonic oscillator by the parametrized diastolic filling formalism that characterizes E-wave contours by 3 unique simple harmonic oscillator parameters: initial displacement (x(o) cm); spring constant (k g/s(2)); and damping constant (c g/s). Parametrized diastolic filling predicts peak atrioventricular pressure gradient as kx(o), the peak simple harmonic oscillator force. For validation, simultaneous (micromanometric) left ventricular pressure and E-wave data from 19 patients were analyzed. Model-predicted peak gradient (kx(o)) was compared with actual gradient (DeltaP(cath)) and with 4V(2). Multiple linear regression results for all patients yielded highly significant relation between kx(o) and DeltaP(cath) (kx(o) = m(1)DeltaP(cath) + b(1), where m(1) = 40.7 +/- 8.0 dyne/mm Hg, b(1) = 1540 +/- 116 dyne, r(2) = 0.97, P <.001). Regression analysis showed no significant correlation between 4V(2) and DeltaP(cath) (4V(2) = m(2)DeltaP(cath) + b(2), where m(2) = 0.01 +/- 0.03, m(2)/s(2)/mm Hg and b(2) = 2.07 +/- 0.44 m(2)/s(2), P = nonsignificant). We conclude that E-wave analysis by parametrized diastolic filling predicts peak atrioventricular gradients reliably and more accurately than 4V(2).     

39例超声引导下颈内静脉置管异位的原因分析与对策

目的:总结39例超声引导下颈内静脉置管异位的部位、原因和对策。方法:回顾性分析我院导管室2010年3～12月期间采用超声引导下行颈内静脉置管2428例患者的临床资料。结果:发生导管异位39例,左侧异位发生率显著高于右侧(P<0.05),女性高于男性(P<0.05),左侧异位易发生在对侧的无名静脉,右侧异位易发生在同侧的腋静脉。结论:颈内静脉置管异位与患者性别、个体因素、血管选择部位、操作者技能水平、操作者的个人习惯有关。操作者重视自身技术水平的提高,操作中认真选择穿刺部位,穿刺成功后及时行X线检查确认,能提高颈内静脉穿刺置管成功率,减少并发症的发生。     

直接数字化成像双能量减影对肋骨骨折诊断的价值

目的： 探讨直接数字化成像(Direct digital radiography,DDR)双能量减影在肋骨骨折中的应用及诊断价值。 方法： 搜集40例肋骨骨折的病例行DDR双能量减影，并选取60名正常人为对照组。 结果： DDR双能量减影标准片图像中,实验组诊断骨折36例,诊断正确率为90%。正常对照组未发现骨折,假阳性率为0%。骨组织像中,实验组40例肋骨骨折均被发现,诊断正确率100%,但假阳性率为30%（12例）；对照组假阳性率为40%。 结论： DDR双能量减影对肋骨骨折敏感性高,对肋骨骨折诊断具有一定的辅助作用,可作为常规检查手段的一种补充方法。     

慢性肾功能衰竭患者腹腔镜引导下腹膜透析置管术11例临床分析

目的:总结腹腔镜外科技术应用在放置Tenckhoff卷曲腹透管的经验。方法:选择11例慢性肾功能衰竭患者,在腹腔镜引导下将Tenckhoff卷曲腹透管置入腹腔并经皮下隧道引出。结果:11例患者腹透管均放置成功,手术时间约45min,均成功进行了腹膜透析,患者术后一周内出院。结论:腹腔镜引导下放置Tenckhoff卷曲腹透管具有腹透管放置定位准确,无手术切口,优于常规开腹手术,值得推广应用。     

Accelerated management of patients with ST-segment elevation myocardial infarction in the ED

Purposes

The objective of this study was to evaluate improvement opportunities in the emergency department for timely ST-segment elevation myocardial infarction management and evaluated the new process flow.

Basic Procedures

In a prospective study, we compared time from door to cath laboratory before and after implementation of a new ST-segment elevation myocardial infarction (STEMI) protocol. The new protocol included a blend of strategies to reduce door to cath laboratory time.

Main Findings

We included 55 patients. After implementing a new STEMI protocol, we included 54 patients. Time to cath laboratory was 21 (interquartile range, 9-40) minutes before and 10 (interquartile range 5-25) minutes after initiation of the new protocol (P = .02). A door to cath laboratory time less than 15 minutes was reached in 36% of our patients in phase 1 and in 61% in phase 2 (odds ratio; 0.36, 95% confidence interval, 0.16-0.81; P = .01).

Principal Conclusion

Simple changes in organizational strategies resulted in a significantly faster care for patients with acute uncomplicated STEMI.