JACC: CARDIOVASCULAR IMAGING
VOL. 8, NO. 3, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-878X/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcmg.2015.01.010
EDITOR’S PAGE
The Symphony, the Ensemble, and the Interventional Imager. Partho P. Sengupta, MD,* Y. Chandrashekhar, MD,y Jagat Narula, MD, PHD*
T
he exponential
growth
of
transcatheter
valve therapies (1) has created exceptional
DO ALL STRUCTURAL INTERVENTIONS NEED IMAGING SPECIALISTS?
opportunities as well as unprecedented
challenges for the cardiovascular imaging commu-
To perform complex structural heart interventions,
nity. The new (October 2014) Centers for Medicaid
proceduralists must understand anatomy to a degree
and Medicare Services professional fee schedule
similar to that expected of cardiac surgeons. However,
and interventional transesophageal echocardiogra-
invasive tools available to them for providing real-
phy code for supporting imaging guidance of trans-
time 3D visualization are somewhat limited. In the
catheter interventions (2) now compensate imaging
absence of direct surgical exposure, the team must
experts for time spent in the catheterization labora-
rely heavily on noninvasive imaging for anatomic in-
tory. Although this marks an official recognition of
telligence. The expertise needed for intraprocedural
this kind of imaging and is likely to augment
multidimensional imaging, lack of resources, famil-
such procedures, the nature of involvement for
iarity, and direct operability may partly explain why
specialist imagers in the catheterization laboratory
some interventionists would find it more practical to
continues to be in a state of flux; it varies widely,
use minimalistic approaches. Although an experi-
often on the basis of available expertise, procedural
enced interventionist may be able to achieve a good
complexity, and perceived cost versus benefit. On
outcome even in the absence of imaging guidance, a
one side, some institutions are exploring minimalis-
wealth of evidence from transcatheter aortic valve
tic approaches with little or no added imaging
replacement trial registries as presented by Hahn et al.
besides fluoroscopy. In contrast, the development
(3,4) in this issue of iJACC suggests that even at the
of new techniques such as fusion imaging, holo-
best centers, experienced operators need additional
graphic
robotic
imaging for the early identification of catastrophic
3-dimensional
structural complications. It would be safe to presume
(3D) printing, and bioengineering techniques prom-
that echocardiography, at least by the transthoracic
ises more clarity in the interventional suite and
approach, would remain useful for quality assurance
also makes necessary more technical expertise in
during TAVR. For more complex transcatheter thera-
image
this
pies, however, there may be a heavier dependence on
Editor’s Page, we explore the existing challenges
imaging guidance using transesophageal echocardi-
and opportunities in the rapidly changing land-
ography. For example, structural valve interventions
arms,
displays, anatomical
acquisition
remote
imaging
modeling
and
with
with
interpretation.
In
scape of cardiac imaging for guiding structural
such as transcatheter mitral valve repair often benefit
interventions.
from using 3D and multiplanar transesophageal echocardiographic approaches. Interventionists are expected to be able to interpret the 2-dimensional (2D) and 3D echocardiographic images and use them to visualize the progress of the procedure. Several
From the *Mount Sinai School of Medicine, New York, New York; and the yUniversity of Minnesota/VA Medical Center, Minneapolis, Minnesota.
centers have already started creating special struc-
The authors have reported that they have no relationships relevant to
tural heart fellowships, and proposals have been
the contents of this paper to disclose.
made for Accreditation Council for Graduate Medical
Sengupta et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 3, 2015 MARCH 2015:384–7
Editor’s Page
Education–accredited courses for providing com-
This advantage facilitates eye-hand coordination
bined training in both structural imaging and in-
and the ability to manipulate devices in 3D space with
terventions. For the foreseeable future, there is little
more precise control of the catheter and guidewire
doubt that the model of having a skilled interven-
than with traditional fluoroscopy alone. Ongoing
tional imager in the catheterization laboratory will
research is actively seeking to reduce the use of, or
provide the highest imaging quality assurance and
even replace, fluoroscopy in cardiac interventional
optimal outcomes for complex structural interven-
procedures, especially in pediatrics.
tion. We can clearly get an excellent appreciation of the 3D space with imaging that will only get better with time, and it is logical that procedures can be better optimized when operators can visualize better. However, there remains one uphill task that needs a Gordian knot–like solution. As seen by the debate in this issue, there is still uncertainty about how much imaging is needed; the most pressing issue for imagers and imaging investigators should be not how nice the picture is but proving how much it adds to improving patient outcome.
NOVEL IMAGING DISPLAYS Another technological breakthrough that may accelerate image display even further is the field of medical holography. There are already prototypes of industrial equipment for performing digital holography using interference patterns computed numerically by simulating light propagation toward an object’s geometry, including how light is scattered from an object (7). The interference pattern can be applied on a film, creating a static hologram, or on a “digital film” such as an addressable liquid crystal or
CHOICE OF IMAGING FOR
digital micromirror device, and the display is then
PROCEDURAL GUIDANCE
digitally updated to create dynamic holograms. With
Historically, x-ray fluoroscopy has been used as the primary imaging modality during catheter-based interventions. Apart from the obvious limitation of radiation cost, fluoroscopy does not provide 3D visualization. Imaging techniques such as multiplanar 2D and 3D echocardiography, computed tomography, and cardiac magnetic resonance imaging provide spatial resolution superior to that of fluoroscopy. Structural cardiac interventions have been performed directly under imaging guidance using any of these techniques, but the interventional approaches and hardware are designed mostly for fluoroscopic approaches and are not easily navigated using other imaging techniques. A previous Editor’s Page in 2011 highlighted the clinical value of multi-
increased use over time, we predict greater reliance on fusion images and 4-dimensional holographic echocardiographic displays for assisting catheter and guidewire navigation. A recent feasibility study confirmed the ability of holographic displays in analyzing mitral valve pathology using visual inspection of the mitral valve during surgery or transesophageal echocardiography serving as the gold standard (8). The use of holographic technology will have potential application during mini-invasive procedures such as MitraClip placement for effective visualization to improve patient safety and the speed of procedures. Ultimately, only robust, randomized comparisons of different approaches will establish the final clinical utility.
modality image fusion technology for scaling of the
IMAGE-DRIVEN SIMULATIONS AND
spatial information and circumventing limitations of
MODELING
a single imaging technique (5). The cover of the present issue of iJACC and in the iPIX by Clegg et al.
Within the past 5 years, simulators designed to train
(6) illustrates case scenarios in which the fusion of
operators in the intricacies of catheter-based in-
ultrasound and fluoroscopy can now be performed
terventions (i.e., eye-to-hand coordination, trans-
for
Ultrasound-
lating the manipulation of objects in 3D space with
fluoroscopy fusion entails imaging data streamed in
movements on a 2D screen, etc.) have been devel-
real-time from each image source to a personal
oped. In interventional cardiology, simulation-based
computer running the fusion and visualization soft-
training has been used in both the investigative
ware. The complex steps required for coregistration
phase as well as the post-approval rollout of a variety
and for delivering optimal display resolution and
of structural heart interventions. Moreover, recent
interpretation, however, still require the services of
studies using computational evaluation techniques
an expert imager for effective use of this technology.
combined with patient-specific 3D transesophageal
The potential advantage of hybrid echocardiography-
echocardiographic
fluoroscopy is the real-time intraprocedural panoramic
computational simulation with patient-specific 3D
volumetric 3D view of structural heart disease targets.
transesophageal echocardiographic data allows us to
structural
heart
interventions.
data
have
demonstrated
that
385
386
Sengupta et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 3, 2015 MARCH 2015:384–7
Editor’s Page
quantitatively determine both biomechanical and
and operate remote arms by using touch screens,
physiologic abnormalities in mitral valve function
touch pads, tablets, or wearable devices (14,15). For
and predict success after mitral valve repair (9).
example, the DaVinci Canvas consists of the inte-
Another imaging-driven technology that will likely
gration of a rigid laparoscopic ultrasound probe
have a substantial impact for simulations in cathe-
with the DaVinci robot, video tracking of ultrasound
terization laboratories is the field of 3D bioprinting
probe motions, endoscope and ultrasound calibra-
(10–12). In 3D bioprinting, layer-by-layer precise
tion and registration, autonomous robot motions,
positioning of biological materials, with spatial con-
and the display of registered 2D and 3D ultrasound
trol of the placement of functional components, can
images (16).
be used to fabricate 3D structures. The creation of a
In summary, the field of interventional imaging is
real physical model of the underlying cardiac lesion
evolving rapidly, with a level of complexity that
will have a significant impact on understanding,
demands
planning, and practical preparation for catheter-
expertise. Just as the development of complex in-
based structural heart procedures. Besides actual
dustries throughout the 20th century led to the
understanding of defects, 3D bioprinting can also be
“division of labor” as a cost-effective economic
used to create device designs or even creating
model, there is little doubt that the field of struc-
a design that would best fit a given structural de-
tural heart interventions will continue to invest in
fect for more personalized therapeutic approaches
specialist imagers to conduct the steps of a well-
(13). Such device designs could also include living
orchestrated
tissue material. For example, imaging-driven bio-
there is also the danger of our enthusiasm galloping
printing of tissue-engineered living aortic valve
ahead of actual needs; we need to think about how
conduits has already been undertaken to create
we train future imagers, how we overcome modality
anatomically accurate, living valve scaffolds (11). The
parochialism, and to what degree any single imager
future will reveal the potential ways in which such
can attain proficiency (e.g., how many modalities, to
a scaffold could be delivered using transcatheter
what depth). Similarly, it is important to ponder
increasing
technical
structural
knowledge
intervention.
and
However,
where we will find suitable candidates for what is
techniques.
turning out to be an unending duration of training
ONSITE VERSUS REMOTE IMAGING
that
is
regularly
burdened
by
additional
re-
quirements, in the face of the looming physician Finally, the combination of digital imaging and tele-
shortage. Finally, and most important, the imaging
robotics is expected to expand the use of ultrasound
community should restrain its well-known enthu-
in catheterization laboratories, allowing an expert to
siasm to “see better and show better” and should
perform an examination from a distance, virtualizing
rapidly focus on marrying technological marvels
both ultrasound image acquisition and interpretation.
with robust outcome data for patient care. Other-
The emergence of such an efficient system would be
wise, interventional imaging will only come full
valuable in lieu of the shrinking pool of cardiovas-
circle.
cular specialists in the face of an aging population and the growing burden of structural heart diseases.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
It is likely that evolution of robotic systems would
Jagat Narula, Icahn School of Medicine at Mount
be matched by equal advances in remote controlling
Sinai, One Gustave L. Levy Place, New York, New
interfaces that could allow experts to be mobile
York 10029. E-mail: [email protected].
REFERENCES 1. Bax JJ, Delgado V, Bapat V, et al. Open issues in transcatheter aortic valve implantation. Part 1: patient selection and treatment strategy for transcatheter aortic valve implantation. Eur Heart J 2014;35:2627–38. 2. Centers for Medicare and Medicaid Services. Physician Fee Schedule. Available at: http:// www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeeSched/PFS-FederalRegulation-Notices-Items/CMS-1612-P.html.
during balloon-expandable transcatheter aortic valve replacement. J Am Coll Cardiol Img 2015;8: 288–318. 4. Hahn RT, Gillam LD, Little SH. Echocardiographic imaging of procedural complications during selfexpandable transcatheter aortic valve replace-
guidance for structural heart intervention. J Am Coll Cardiol Img 2015;8:371–4. 7. RealView Imaging. Home page. Available at: http://www.realviewimaging.com. Accessed January 29, 2014.
Accessed January 29, 2015.
5. Sengupta PP, Marwick TH, Narula J. Adding dimensions to unimodal cardiac images. J Am Coll Cardiol Img 2011;4:816–8.
8. Beitnes JO, Klæboe LG, Karlsen JS, Urheim S. Mitral valve analysis using a novel 3D holographic display: a feasibility study of 3D ultrasound data converted to a holographic screen. Int J Cardiovasc Imaging 2014 Nov 13 [E-pub ahead of print].
3. Hahn RT, Kodali S, Tuzcu EM, et al. Echocar-
6. Clegg SD, Chen SJ, Nijhof N, et al. Inte-
9. Rim Y, Chandran KB, Laing ST, Kee P,
diographic imaging of procedural complications
grated
McPherson
ment. J Am Coll Cardiol Img 2015;8:319–36.
3D
echo-x
ray
to
optimize
image
DD,
Kim
H.
Can
computational
Sengupta et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 3, 2015 MARCH 2015:384–7
Editor’s Page
simulation quantitatively determine mitral valve abnormalities? J Am Coll Cardiol Img 2014 Nov 26 [E-pub ahead of print].
preoperative planning and simulation of transcatheter valve replacement. Ann Thorac Surg 2012;93:e31–3.
10. Witschey WR, Pouch AM, McGarvey JR, et al. Three-dimensional ultrasound-derived physical mitral valve modeling. Ann Thorac Surg 2014;98:691–4.
13. Ryan JR, Moe TG, Richardson R, Frakes DH, Nigro JJ, Pophal S. A novel approach to neonatal management of tetralogy of fallot,
11. Hockaday LA, Kang KH, Colangelo NW, et al. Rapid 3D printing of anatomically accurate and mechanically heterogeneous aortic valve hydrogel scaffolds. Biofabrication 2012;4:035005.
with pulmonary atresia, and multiple aortopulmonary collaterals. J Am Coll Cardiol Img 2015;8:103–4.
12. Schmauss D, Schmitz C, Bigdeli AK, et al. Three-dimensional printing of models for
14. Sengupta PP, Narula N, Modesto K, et al. Feasibility of intercity and trans-Atlantic telerobotic remote ultrasound: assessment facilitated
by a nondedicated bandwidth connection. J Am Coll Cardiol Img 2014;7:804–9. 15. Boman K, Olofsson M, Berggren P, Sengupta PP, Narula J. Robot-assisted remote echocardiographic examination and teleconsultation: a randomized comparison of time to diagnosis with standard of care referral approach. J Am Coll Cardiol Img 2014;7:799–803. 16. Schneider C, Baghani A, Rohling R, Salcudean S. Remote ultrasound palpation for robotic interventions using absolute elastography. Med Image Comput Comput Assist Interv 2012;15:42–9.
387
VOL. 8, NO. 3, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-878X/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcmg.2015.01.010
EDITOR’S PAGE
The Symphony, the Ensemble, and the Interventional Imager. Partho P. Sengupta, MD,* Y. Chandrashekhar, MD,y Jagat Narula, MD, PHD*
T
he exponential
growth
of
transcatheter
valve therapies (1) has created exceptional
DO ALL STRUCTURAL INTERVENTIONS NEED IMAGING SPECIALISTS?
opportunities as well as unprecedented
challenges for the cardiovascular imaging commu-
To perform complex structural heart interventions,
nity. The new (October 2014) Centers for Medicaid
proceduralists must understand anatomy to a degree
and Medicare Services professional fee schedule
similar to that expected of cardiac surgeons. However,
and interventional transesophageal echocardiogra-
invasive tools available to them for providing real-
phy code for supporting imaging guidance of trans-
time 3D visualization are somewhat limited. In the
catheter interventions (2) now compensate imaging
absence of direct surgical exposure, the team must
experts for time spent in the catheterization labora-
rely heavily on noninvasive imaging for anatomic in-
tory. Although this marks an official recognition of
telligence. The expertise needed for intraprocedural
this kind of imaging and is likely to augment
multidimensional imaging, lack of resources, famil-
such procedures, the nature of involvement for
iarity, and direct operability may partly explain why
specialist imagers in the catheterization laboratory
some interventionists would find it more practical to
continues to be in a state of flux; it varies widely,
use minimalistic approaches. Although an experi-
often on the basis of available expertise, procedural
enced interventionist may be able to achieve a good
complexity, and perceived cost versus benefit. On
outcome even in the absence of imaging guidance, a
one side, some institutions are exploring minimalis-
wealth of evidence from transcatheter aortic valve
tic approaches with little or no added imaging
replacement trial registries as presented by Hahn et al.
besides fluoroscopy. In contrast, the development
(3,4) in this issue of iJACC suggests that even at the
of new techniques such as fusion imaging, holo-
best centers, experienced operators need additional
graphic
robotic
imaging for the early identification of catastrophic
3-dimensional
structural complications. It would be safe to presume
(3D) printing, and bioengineering techniques prom-
that echocardiography, at least by the transthoracic
ises more clarity in the interventional suite and
approach, would remain useful for quality assurance
also makes necessary more technical expertise in
during TAVR. For more complex transcatheter thera-
image
this
pies, however, there may be a heavier dependence on
Editor’s Page, we explore the existing challenges
imaging guidance using transesophageal echocardi-
and opportunities in the rapidly changing land-
ography. For example, structural valve interventions
arms,
displays, anatomical
acquisition
remote
imaging
modeling
and
with
with
interpretation.
In
scape of cardiac imaging for guiding structural
such as transcatheter mitral valve repair often benefit
interventions.
from using 3D and multiplanar transesophageal echocardiographic approaches. Interventionists are expected to be able to interpret the 2-dimensional (2D) and 3D echocardiographic images and use them to visualize the progress of the procedure. Several
From the *Mount Sinai School of Medicine, New York, New York; and the yUniversity of Minnesota/VA Medical Center, Minneapolis, Minnesota.
centers have already started creating special struc-
The authors have reported that they have no relationships relevant to
tural heart fellowships, and proposals have been
the contents of this paper to disclose.
made for Accreditation Council for Graduate Medical
Sengupta et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 3, 2015 MARCH 2015:384–7
Editor’s Page
Education–accredited courses for providing com-
This advantage facilitates eye-hand coordination
bined training in both structural imaging and in-
and the ability to manipulate devices in 3D space with
terventions. For the foreseeable future, there is little
more precise control of the catheter and guidewire
doubt that the model of having a skilled interven-
than with traditional fluoroscopy alone. Ongoing
tional imager in the catheterization laboratory will
research is actively seeking to reduce the use of, or
provide the highest imaging quality assurance and
even replace, fluoroscopy in cardiac interventional
optimal outcomes for complex structural interven-
procedures, especially in pediatrics.
tion. We can clearly get an excellent appreciation of the 3D space with imaging that will only get better with time, and it is logical that procedures can be better optimized when operators can visualize better. However, there remains one uphill task that needs a Gordian knot–like solution. As seen by the debate in this issue, there is still uncertainty about how much imaging is needed; the most pressing issue for imagers and imaging investigators should be not how nice the picture is but proving how much it adds to improving patient outcome.
NOVEL IMAGING DISPLAYS Another technological breakthrough that may accelerate image display even further is the field of medical holography. There are already prototypes of industrial equipment for performing digital holography using interference patterns computed numerically by simulating light propagation toward an object’s geometry, including how light is scattered from an object (7). The interference pattern can be applied on a film, creating a static hologram, or on a “digital film” such as an addressable liquid crystal or
CHOICE OF IMAGING FOR
digital micromirror device, and the display is then
PROCEDURAL GUIDANCE
digitally updated to create dynamic holograms. With
Historically, x-ray fluoroscopy has been used as the primary imaging modality during catheter-based interventions. Apart from the obvious limitation of radiation cost, fluoroscopy does not provide 3D visualization. Imaging techniques such as multiplanar 2D and 3D echocardiography, computed tomography, and cardiac magnetic resonance imaging provide spatial resolution superior to that of fluoroscopy. Structural cardiac interventions have been performed directly under imaging guidance using any of these techniques, but the interventional approaches and hardware are designed mostly for fluoroscopic approaches and are not easily navigated using other imaging techniques. A previous Editor’s Page in 2011 highlighted the clinical value of multi-
increased use over time, we predict greater reliance on fusion images and 4-dimensional holographic echocardiographic displays for assisting catheter and guidewire navigation. A recent feasibility study confirmed the ability of holographic displays in analyzing mitral valve pathology using visual inspection of the mitral valve during surgery or transesophageal echocardiography serving as the gold standard (8). The use of holographic technology will have potential application during mini-invasive procedures such as MitraClip placement for effective visualization to improve patient safety and the speed of procedures. Ultimately, only robust, randomized comparisons of different approaches will establish the final clinical utility.
modality image fusion technology for scaling of the
IMAGE-DRIVEN SIMULATIONS AND
spatial information and circumventing limitations of
MODELING
a single imaging technique (5). The cover of the present issue of iJACC and in the iPIX by Clegg et al.
Within the past 5 years, simulators designed to train
(6) illustrates case scenarios in which the fusion of
operators in the intricacies of catheter-based in-
ultrasound and fluoroscopy can now be performed
terventions (i.e., eye-to-hand coordination, trans-
for
Ultrasound-
lating the manipulation of objects in 3D space with
fluoroscopy fusion entails imaging data streamed in
movements on a 2D screen, etc.) have been devel-
real-time from each image source to a personal
oped. In interventional cardiology, simulation-based
computer running the fusion and visualization soft-
training has been used in both the investigative
ware. The complex steps required for coregistration
phase as well as the post-approval rollout of a variety
and for delivering optimal display resolution and
of structural heart interventions. Moreover, recent
interpretation, however, still require the services of
studies using computational evaluation techniques
an expert imager for effective use of this technology.
combined with patient-specific 3D transesophageal
The potential advantage of hybrid echocardiography-
echocardiographic
fluoroscopy is the real-time intraprocedural panoramic
computational simulation with patient-specific 3D
volumetric 3D view of structural heart disease targets.
transesophageal echocardiographic data allows us to
structural
heart
interventions.
data
have
demonstrated
that
385
386
Sengupta et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 3, 2015 MARCH 2015:384–7
Editor’s Page
quantitatively determine both biomechanical and
and operate remote arms by using touch screens,
physiologic abnormalities in mitral valve function
touch pads, tablets, or wearable devices (14,15). For
and predict success after mitral valve repair (9).
example, the DaVinci Canvas consists of the inte-
Another imaging-driven technology that will likely
gration of a rigid laparoscopic ultrasound probe
have a substantial impact for simulations in cathe-
with the DaVinci robot, video tracking of ultrasound
terization laboratories is the field of 3D bioprinting
probe motions, endoscope and ultrasound calibra-
(10–12). In 3D bioprinting, layer-by-layer precise
tion and registration, autonomous robot motions,
positioning of biological materials, with spatial con-
and the display of registered 2D and 3D ultrasound
trol of the placement of functional components, can
images (16).
be used to fabricate 3D structures. The creation of a
In summary, the field of interventional imaging is
real physical model of the underlying cardiac lesion
evolving rapidly, with a level of complexity that
will have a significant impact on understanding,
demands
planning, and practical preparation for catheter-
expertise. Just as the development of complex in-
based structural heart procedures. Besides actual
dustries throughout the 20th century led to the
understanding of defects, 3D bioprinting can also be
“division of labor” as a cost-effective economic
used to create device designs or even creating
model, there is little doubt that the field of struc-
a design that would best fit a given structural de-
tural heart interventions will continue to invest in
fect for more personalized therapeutic approaches
specialist imagers to conduct the steps of a well-
(13). Such device designs could also include living
orchestrated
tissue material. For example, imaging-driven bio-
there is also the danger of our enthusiasm galloping
printing of tissue-engineered living aortic valve
ahead of actual needs; we need to think about how
conduits has already been undertaken to create
we train future imagers, how we overcome modality
anatomically accurate, living valve scaffolds (11). The
parochialism, and to what degree any single imager
future will reveal the potential ways in which such
can attain proficiency (e.g., how many modalities, to
a scaffold could be delivered using transcatheter
what depth). Similarly, it is important to ponder
increasing
technical
structural
knowledge
intervention.
and
However,
where we will find suitable candidates for what is
techniques.
turning out to be an unending duration of training
ONSITE VERSUS REMOTE IMAGING
that
is
regularly
burdened
by
additional
re-
quirements, in the face of the looming physician Finally, the combination of digital imaging and tele-
shortage. Finally, and most important, the imaging
robotics is expected to expand the use of ultrasound
community should restrain its well-known enthu-
in catheterization laboratories, allowing an expert to
siasm to “see better and show better” and should
perform an examination from a distance, virtualizing
rapidly focus on marrying technological marvels
both ultrasound image acquisition and interpretation.
with robust outcome data for patient care. Other-
The emergence of such an efficient system would be
wise, interventional imaging will only come full
valuable in lieu of the shrinking pool of cardiovas-
circle.
cular specialists in the face of an aging population and the growing burden of structural heart diseases.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
It is likely that evolution of robotic systems would
Jagat Narula, Icahn School of Medicine at Mount
be matched by equal advances in remote controlling
Sinai, One Gustave L. Levy Place, New York, New
interfaces that could allow experts to be mobile
York 10029. E-mail: [email protected].
REFERENCES 1. Bax JJ, Delgado V, Bapat V, et al. Open issues in transcatheter aortic valve implantation. Part 1: patient selection and treatment strategy for transcatheter aortic valve implantation. Eur Heart J 2014;35:2627–38. 2. Centers for Medicare and Medicaid Services. Physician Fee Schedule. Available at: http:// www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeeSched/PFS-FederalRegulation-Notices-Items/CMS-1612-P.html.
during balloon-expandable transcatheter aortic valve replacement. J Am Coll Cardiol Img 2015;8: 288–318. 4. Hahn RT, Gillam LD, Little SH. Echocardiographic imaging of procedural complications during selfexpandable transcatheter aortic valve replace-
guidance for structural heart intervention. J Am Coll Cardiol Img 2015;8:371–4. 7. RealView Imaging. Home page. Available at: http://www.realviewimaging.com. Accessed January 29, 2014.
Accessed January 29, 2015.
5. Sengupta PP, Marwick TH, Narula J. Adding dimensions to unimodal cardiac images. J Am Coll Cardiol Img 2011;4:816–8.
8. Beitnes JO, Klæboe LG, Karlsen JS, Urheim S. Mitral valve analysis using a novel 3D holographic display: a feasibility study of 3D ultrasound data converted to a holographic screen. Int J Cardiovasc Imaging 2014 Nov 13 [E-pub ahead of print].
3. Hahn RT, Kodali S, Tuzcu EM, et al. Echocar-
6. Clegg SD, Chen SJ, Nijhof N, et al. Inte-
9. Rim Y, Chandran KB, Laing ST, Kee P,
diographic imaging of procedural complications
grated
McPherson
ment. J Am Coll Cardiol Img 2015;8:319–36.
3D
echo-x
ray
to
optimize
image
DD,
Kim
H.
Can
computational
Sengupta et al.
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 3, 2015 MARCH 2015:384–7
Editor’s Page
simulation quantitatively determine mitral valve abnormalities? J Am Coll Cardiol Img 2014 Nov 26 [E-pub ahead of print].
preoperative planning and simulation of transcatheter valve replacement. Ann Thorac Surg 2012;93:e31–3.
10. Witschey WR, Pouch AM, McGarvey JR, et al. Three-dimensional ultrasound-derived physical mitral valve modeling. Ann Thorac Surg 2014;98:691–4.
13. Ryan JR, Moe TG, Richardson R, Frakes DH, Nigro JJ, Pophal S. A novel approach to neonatal management of tetralogy of fallot,
11. Hockaday LA, Kang KH, Colangelo NW, et al. Rapid 3D printing of anatomically accurate and mechanically heterogeneous aortic valve hydrogel scaffolds. Biofabrication 2012;4:035005.
with pulmonary atresia, and multiple aortopulmonary collaterals. J Am Coll Cardiol Img 2015;8:103–4.
12. Schmauss D, Schmitz C, Bigdeli AK, et al. Three-dimensional printing of models for
14. Sengupta PP, Narula N, Modesto K, et al. Feasibility of intercity and trans-Atlantic telerobotic remote ultrasound: assessment facilitated
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