Stephen Bloom, M.D., FASNC, director of nonivasive cardiology (cardiac CT, nuclear cardiology and echocardiography) at Midwest Heart and Vascular Associates, Overland Park, Kansas. He is also a member of the American Society of Nuclear Cardiology (ASNC) Board of Directors, explains some of the issues involved and protocols used for cardiac imaging during the COVID-19 pandemic. His discussion includes computed tomography, cardiac ultrasound and nuclear imaging.

Right now, Bloom said it is difficult to test everybody and there is a shortage of masks, gowns and other personal protective equipment (PPE), and the imaging equipment needs to be sanitized each time it is used. He said it is just is not possible to image all the patients who need imaging right now. Hospitals also are trying to limit the number of healthy people people coming into hospitals for routine visits and tests to reduce their potential exposure to the novel coronavirus (COVID-19, SARS-CoV-2) and help containment efforts. 

"The tests should be done, very simply, if it changes the care of the patient. If it doesn't change the care of the patient, and it can be postponed, it should be postponed," Bloom explained. "I would say 80 percent of our cardiac imaging exams have stopped. It has been very dramatic."

Related Imaging Precautions During COVID-19 Content:

Cardiac Imaging Best Practices During the COVID-19 Pandemic

Best Practices for Nuclear Cardiology Laboratories During the Coronavirus (COVID-19) Pandemic

ASE Guidelines for the Protection of Echocardiography Providers During the COVID-19 Outbreak 

VIDEO: Best Practices for Nuclear Cardiology During the COVID-19 Pandemic — Interview with Hicham Skali, M.D.

VIDEO: Cancelling Non-essential Cardiac Procedures During the COVID-19 Outbreak — Interview with Ehtisham Mahmud, M.D. 

VIDEO: 9 Cardiologists Share COVID-19 Takeaways From Across the U.S.  

VIDEO: Telemedicine in Cardiology and Medical Imaging During COVID-19 — Interview with Regina Druz, M.D.

VIDEO: Use of Teleradiology During the COVID-19 Pandemic — an interview with radiologist John Kim, M.D.

Study Looks at CT Findings of COVID-19 Through Recovery

Experts Stress Radiology Preparedness for COVID-19

VIDEO: Imaging COVID-19 With Point-of-Care Ultrasound (POCUS) — Interview with emergency physician Mike Stone, M.D.,

VIDEO: How China Leveraged Health IT to Combat COVID-19 — Interview with Jilan Liu, M.D., CEO for the HIMSS Greater China

ACR Recommendations for the Use of Chest Radiography and CT for Suspected COVID-19 Cases

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The Cardiac Implications of Novel Coronavirus

Hicham Skali, M.D., a staff cardiologist and member of the Non-invasive Cardiovascular Imaging Program at Brigham and Women’s Hospital (BWH), and at Brigham and Women’s / Massachusetts General Health Care Center at Foxborough, explains the new recommendations from the American Society of Nuclear Cardiology (ASNC) and from imagers in China and Singapore. The ASNC created a best practices document for nuclear cardiology laboratories during the novel coronavirus (COVID-19, SARS-CoV-2) pandemic. The suggestions in the guidelines can ally to any imaging modality, including computed tomography (CT), MRI and ultrasound. 

Skali elaborates on the following points in his discussion, which are specific recommendations in the ASNC and SNMMI COVID-19 guidance document:
   • Rescheduling non-urgent visits
   • Rescheduling elective surgeries and procedures
   • Using separate spaces for patients with known or suspected COVID-19 to prevent spread
   • Ensuring supplies are available
   • Promoting use of telehealth
   • Screen staff, patients and visitors before they enter the department
   • Minimize non-essential visitors into the department
   • Record symptoms at the start of the shift
   • Use personal protective equipment (PPE)for healthcare personnel
   • If available, use PPE for patients due to concern of asymptomatic transmission of COVID-19
   • Maintain strict hand hygiene
   • Maintain 6 feet distance in all patient/staff interactions when possible
   • Work remotely whenever feasible, especially with ready studies
   • Rotating staff schedules for on-site and off-site work
   • Use of rest only studies if possible
   • Use of half-time SPECT to speed exam times
   • Use of PET if available to speed exam times

Skali served as the moderator in for the ASNC on demand webinar COVID-19 Preparedness for Nuclear Cardiology Labs: Insights from the US, China and Singapore.

VIDEO: Telemedicine in Cardiology and Medical Imaging During COVID-19 — Interview with Regina Druz, M.D., an ASNC Board member and also a speaker during the ASNC webinar.

Find more news and video on relating to COVID-19 and its impact on cardiology

An interview with Ehtisham Mahmud, M.D., FSCAI, chief, Division of Cardiovascular Medicine, executive director of medicine, Cardiovascular Institute, director of  interventional cardiology and cardiac cath lab at UC San Diego Medical Center, and president of the Society for Cardiovascular Angiography and Interventions (SCAI). He explains the how cardiology departments in the U.S. are now postponing cardiovascular procedures due to novel coronavirus (COVID-19, SARS-CoV-2) containment efforts and new guidelines from Medicare calling for delay of all elective procedures in the country. 

Mahmud explains how patients are being prioritized, with acute myocardial infarction patients or others with acute, life-threatening conditions, or at high risk for a near term hospital admission, will still receive cardiac catheterizations, cardiovascular surgery or structural heart procedures for MitraClip and transcatheter aortic replacement (TAVR) under certain circumstances. All other procedures are being postponed until further notice based in the spread and infection rates of COVID-19. He said most hospitals, including his own, are moving to telehealth visits via phone or online to continue clinic work with patients, including those with chronic conditions such as heart failure.

The Centers for Medicare and Medicaid Services (CMS) announced March 18, 2020, that all elective surgeries, and non-essential medical, surgical and dental procedures should be delayed during the coronavirus outbreak. This move is three-fold. 
   1. It is to help with containment efforts by reducing patient and family travel to hospitals, which are at the center of the COVID-19 outbreak. 
   2. Delaying procedures will help preserve and inventory of personal protective equipment (PPE), hospital beds and ventilators and other medical supplies. 
   3. With the start of social distancing and the shut down of all large gatherings, this has severely impacted blood drives and other blood donations, so the nation's blood banks have severely limited supplies.

“The reality is clear and the stakes are high — we need to preserve personal protective equipment for those on the front lines of this fight,” said CMS Administrator Seema Verma.

This will not only preserve equipment but also free up the healthcare workforce to care for the patients who are most in need. Additionally, as states and the nation as a whole work toward limiting the spread of COVID-19, healthcare providers should encourage patients to remain home, unless there is an emergency, to protect others while also limiting their exposure to the virus. 

Read Mahmud's SCAI President's letter The Evolving Pandemic of COVID-19 and Interventional Cardiology

Related Cardiology Related COVID-19 Content:

ACC COVID-19 recommendations for the cardiovascular care team

VIDEO: What Cardiologists Need to Know about COVID-19 — Interview with Thomas Maddox, M.D.

The Cardiac Implications of Novel Coronavirus

ESC Council on Hypertension Says ACE-I and ARBs Do Not Increase COVID-19 Mortality

VIDEO: Imaging COVID-19 With Point-of-Care Ultrasound (POCUS)

CT Provides Best Diagnosis for Novel Coronavirus (COVID-19)

Radiology Lessons for Coronavirus From the SARS and MERS Epidemics

Deployment of Health IT in China’s Fight Against the COVID-19 Epidemic

Emerging Technologies Proving Value in Chinese Coronavirus Fight

Radiologists Describe Coronavirus CT Imaging Features

Coronavirus Update from the FDA

CT Imaging of the 2019 Novel Coronavirus (2019-nCoV) Pneumonia

CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)

Chest CT Findings of Patients Infected With Novel Coronavirus 2019-nCoV Pneumonia 

Additional COVID-19 Resources for Clinicians:

   ACC COVID-19 Hub page   

   Johns Hopkins Coronavirus Resource Center with inteavtive map of cases in U.S. and worldwide 

   World Health Organization (WHO) COVID-19 situation reports

   World Health Organization (WHO) coronavirus information page

   U.S. Food and Drug Administration (FDA) COVID-19 information page

   Centers for Disease Control (CDC) COVID-19 information page

   Centers for Medicare and Medicaid Services (CMS) frequently asked questions and answers (FAQs) for healthcare providers regarding COVID-19 related payments
 

DAIC/ITN Editor Dave Fornell takes a tour of some of the most innovative new medical imaging technologies displayed on the expo floor at the Radiological Society of North America (RSNA) 2019 meeting. 

Technology examples include a robotic arm to perform remote ultrasound exams, integration of artificial intelligence (AI) to speed or automate radiology workflow, holographic medical imaging display screens, a new glassless digital radiography (DR) X-ray detector, augmented reality for transesophageal echo (TEE) training, moving DR X-ray images, 3-D printed surgical implants created from a patient's CT imaging, DR X-ray tomosynthesis datasets, radiation dose management and analytics software, and new computed tomography (CT) technologies.

Find more videos and news from RSNA 2019

James Carr, M.D., chair of the Department of Radiology, Northwestern University, and incoming 2020 President of the Society of Cardiac Magnetic Resonance (SCMR), explains why MRI is an ideal cardiac imaging modality, at the 2019 Radiological Society of North America (RSNA) meeting.

Heart MRI offers advantages over computed tomography (CT) and echocardiography because of its excellent soft tissue delineation and its ability to offer information beyond anatomical imaging, such as perfusion, morphology and metabolism. MRI can be technically challenging and the exams requiring a long time, but recent advances have helped cur cardiac imaging times down significantly. Automation and artificial intelligence (AI) also is making post-processing and quantification mush faster, brining it closer to the time it takes to scan and post-process CT imaging.

Northwestern is was one of the early adopters of cardiovascular MRI. Carr said heart MRI was not common in regular clinical use until the past decade at some luminary centers. In 2005, Carr was given the opportunity to develop a clinical cardiac MRI program at Northwestern.
 
He said MRI scanners have improved, and now much faster than a decade ago. They are also more optimized for cardiac imaging. While heart MRI is well known in large hospital centers, Carr said it still needs to develop and expand to community hospitals and rural hospitals outside major population centers. 

Artificial intelligence is playing a significant role in cardiac MRI automation of speeding workflow and quantification. Carr said these technologies will become mainstream in the next few years. AI also will play an increasing role in risk prediction based on new image analysis algorithms in development.

For more information on cardiac MRI, visit SCMR's website www.heartmri.org.

Related Cardiac MRI Content:

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VIDEO: Dedicated Cardiac MRI Use at the Baylor Scott White Heart Hospital

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VIDEO: Use of Cardiac MRI in Congenital and Women's Heart Disease — Karen Ordovas, M.D., 
 

Mahadevappa Mahesh, Ph.D., chief of medical physicist and professor of radiology and medical physics, Johns Hopkins University, Baltimore, treasurer of the American Association of Physicists in Medicine (AAPM),a board member of the American College of Radiology (ACR), presented a late-breaking study on how medical imaging radiation dose has started to drop over the past decade. He is the co-chair of the National Council on Radiation Protection and Measures Report (NCRP), and presented the most recent NCRP data analysis at the 2019 Radiological Society of North America (RSNA) meeting.

The new NCRP 184 report covers the period between 2006 and 2016, the period of the most current CMS data. It shows a decrease of about 20 percent in the radiation dose the U.S. population receives from medical imaging, compared to the NCRP 160 that covered the period of up to 2006.

Key findings of the study include:

   • CT dose dropped about 6 percent, despite a 20 percent increase CT scans since 2006;

   • Drop of more than 50 percent for nuclear imaging scans, mainly due to fewer procedures begin performed;

   • A 15-20 percent decrease across X-ray imaging modalities.

Mahesh says this shows the impact of using "as low as reasonably achievable" (ALARA) principals, new dose guidelines outlined jointly by numerous medical societies, and dose reduction initiatives like Image Wisely, Image Gently, and the American College of radiology (ACR) Dose Index Registry.

He said there was growing concern a decade ago when the last council report was published, which show a steep increase in radiation dose. This was mainly due to a rapid increase in the use of computed tomography (CT) and other types of X-ray based and nuclear radiotracer medical imaging. This prompted the ACR top create the Image Wisely program and push for the use of more thoughtful imaging doses based on patient size, using the "as low as reasonably achievable” (ALARA) principle. While CT dose was lowered, he said the biggest decline was in nuclear imaging.

DAIC Editor Dave Fornell and Imaging Technology News (ITN) Consulting Editor Greg Freiherr offer a post-game report on the trends and technologies they saw on the expo floor of 2019 Radiological Society of North America (RSNA) annual meeting. This includes artificial intelligence (AI), augmented reality, holographic imaging, cybersecurity, and advances in digital radiography (DR) with a glassless detector plate, X-ray tomosynthesis, dual-energy X-ray and dynamic DR imaging. 

Find RSNA news and other videos

Piotr J. Slomka, Ph.D., FACC, research scientist in the Artificial Intelligence in Medicine Program, Department of Medicine at Cedars-Sinai, and professor of medicine in-residence of the David Geffen School of Medicine, UCLA. He explains how his team at Cedars-Sinai is working on intelligent patient risk prediction algorithms that will automatically extract information from medical imaging. He spoke on artificial intelligence (AI) development for medical imaging in sessions at the 2019 American Society of Nuclear Cardiology (ASNC) annual meeting. 

Find more articles and video on AI

Rupa Sanghani, M.D., FASNC, associate professor, Rush Medical College, director of nuclear cardiology and stress laboratory, Rush University Medical Center, and associate director, Rush Heart Center for Women, explains how to create a high-volume cardiac positron emission tomography (PET) imaging program. She spoke on this topic at the 2019 meeting of the American Society Nuclear Cardiology (ASNC) and led a tour for attendees of the PET-CT system at Rush, which was located close to the conference. 

Sanghani said the advantages of PET myocardial perfusion imaging include faster exam times and allowing additional information from coronary reserve flow assessments to better understand if revascularization will help a patient's heart recover. The 16-slice CT scanner is used not only to attenuate the PET images, but to perform a CT calcium scoring exam to assess the patient's risk for future cardiovascular events. The Rubidium-82 radiotracer used for PET exams only has a 75 second half life, so it can help increase the number of exams a center is able to perform each day. At higher volume centers, PET is optimized to handle all the patients who require pharmacological stress exams. 

In the video, Sanghani  outlines what Rush did to design its room, covers basics on training, what to look for in a scanner and other considerations when creating a PET program.

Read the article How to Start a Cardiac PET-CT Imaging Program, which includes more information from the Rush PET program.
 

Find more coverage of the ASNC

Find more news on nuclear imaging

Vivian Ng, M.D., assistant professor of medicine and an interventional cardiologist at the NewYork-Presbyterian/Columbia University Medical Center Structural Heart and Valve Center, helped organize the first Women in Structural Heart (WISH) event at the 2019 Transcatheter Cardiovascular Therapeutics (TCT) meeting. The evening session was standing room only and highlighted structural heart case presentations and discussion panels made up of all women. The session panelists and presenters were a whose-who of well known women in cardiology. The event was organized as a way to break the glass ceiling in the subspecialty of interventional cardiology, where women make up less than 5 percent of the operators.

Previous Video Interviews With Speakers and Panelists Involved in the WISH Session:

VIDEO: The Importance of the Neo-LVOT in Transcatheter Mitral Valve Replacement — Interview with Dee Dee Wang, M.D.

VIDEO: The Value of the Cardiovascular Service Line — Interview with Linda Gillam, M.D.,

VIDEO: Can We Live in 3-D Echo? — Interview with Lissa Sugeng, M.D.

VIDEO: Tricuspid Valve Imaging and Interventions Developing Hand-in-hand — Interview with Rebecca Hahn, M.D.

VIDEO: Strategies to Avoid Acute Kidney Injury Caused by Cath Lab Contrast — Interview with Roxana Mehran, M.D.,

Find more news and videos from TCT 2019

A discussion with Nicolas Bevins, Ph.D., vice chair, physics and research, and Jessica Harrington, RCIS. They explain the use of shields, technique and use of newer angiography technologies to reduce X-ray radiation dose in the cardiac cath labs at Henry Ford Hospital, Detroit.

Watch the VIDEO: Technologies and Techniques to Reduce Radiation Dose in the Cardiac Cath Lab — Interview with Akshay Khandelwal, M.D., director of medical operations at the Henry Ford Heart and Vascular Institute

Additional articles and videos on Henry Ford Hospital 

For more on how to reduce dose in the cath lan, read these related articles:

Cardiology Societies Call for Better Radiation Dose Tracking

Defining the Cath Lab Workplace Radiation Safety Hazard

Dose-Lowering Practices for Cath Lab Angiography

5 Technologies to Reduce Cath Lab Radiation Exposure

VIDEO: Heart Surgeon Shares Effects of Fluoroscopic Radiation Exposure

Helping Interventional Cardiologists Reduce Exposure to Ionizing Radiation

14 Ways to Reduce Radiation Exposure in the Cath Lab

(Editor's note - this video was originally published in September 2018 and was revised September 2019)

Scott Schwartz, M.D., interventional radiologist and program director for IR residencies and the vascular and interventional radiology fellowship at Henry Ford Hospital, explains how the department uses Yttrium-90 (Y90) embolization therapy to treat liver cancer.

Additional articles and videos on Henry Ford Hospital 

Related Articles on Y-90 Radiotherapy:

Current Advances in Targeted Radionuclide Therapy

A Look Ahead in Targeted Radionuclide Therapy

Radioactive Bead Therapy Now Used for Head, Neck Tumors

NCCN Guidelines Recommend Y-90 Microspheres for Metastatic Colorectal Cancer Treatment

(Editor's note - this video was originally published in November 2018 and was revised September 2019)

This is a quick video example of a cardiac computed tomography (CT) exam showing a Medtronic CoreValve transcatheter aortic valve replacement (TAVR) device implanted. The image was reconstructed using Canon Medical’s Global Illumination photo-realistic rendering advanced visualization post-processing software. Vendors who offer this realistic type of CT image rendering say it is not used for diagnostics. However, the technology can be helpful when explaining things to the patient and their family, educating physicians and staff, and for surgeons, since it offers a realistic view of the anatomy that is easier for most people to understand who are not familiar with cardiac anatomy as it appears in traditional CT multiplanar reconstruction (MPR) images. 

This example of software was demonstrated on the expo floor at the 2019 Society of Cardiovascular Computed Tomography (SCCT) meeting. 

This is an example of in-stent restenosis shown using spectral CT imaging. This example was demonstrated by Philips Healthcare at the 2019 meeting of the Society Of Cardiovascular Computed Tomography (SCCT). It can sometimes be difficult to determine if showing inside a stent of CT is artifact or real. Spectral CT can definitely help make a diagnosis. This example shows Philips’ Effective Z visualization, where the image is created based on the atomic number of the elements present in the image. After removal of iodine from the image, it shows the shadow in the stent has the same atomic composition as the vessel intima.  

This example is from a Philips IQon dual-energy CT scanner. This system has spectral imaging always on without any need to change protocols. This allows the spectral to be used when needed for additional information without need to rescan a patient.

Read more on this CT system.

VIDEO: Applications of Spectral CT — Interview with Suhny Abbara, M.D.

Mark Ibrahim, M.D., FACC, assistant professor of medicine and radiology, associate program director, advanced cardiac imaging fellowship, University of Utah, explains what radiologists and cardiologists need to know what is needed from CT imaging prior to ablation procedures for atrial fibrillation (AF) and ventricular fibrillation (VF). He spoke at a joint session of the Heart Rhythm Society (HRS) and the Society of Cardiovascular Computed Tomography (SCCT) at the 2019 SCCT meeting. 

Find more SCCT news and videos

Pierre Qian, MBBS, cardiac electrophysiologist fellow, Brigham and Women's Hospital, explains how his facility is working with radiation oncology to use radio therapy to noninvasively ablate ventricular tachycardia (VT). He spoke on this topics during a joint electrophysiology session by the Heart Rhythm Society (HRS) and the Society of Cardiovascular Computed Tomography (SCCT) at the SCCT 2019 meeting.

Here is a link to another radiotherapy EP project Qian recently had published - A Novel Microwave Catheter Can Perform Noncontact Circumferential Endocardial Ablation in a Model of Pulmonary Vein Isolation. 

Find more SCCT news and videos

Related Radiotherapy for Cardiac Ablation Content:

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Arthur Agatston, M.D., clinical professor of medicine, Florida International University, Herbert Wertheim College of Medicine, is the name-sake of the Agatston score used in CT calcium scoring. He explains the history of the scoring system from the early 1990s and the evolution of CT technology for cardiac imaging. The latest American Heart Association (AHA) 2018 cholesterol guidelines now include the use of CT calcium scoring, which was a big topic at the Society of Cardiovascular Computed Tomography (SCCT) 2019 meeting.

Read the article How the Agatston Calcium Score Was Created and its Impact on Heart Attack Prevention.

See a quick example of a CT calcium scoring exam in the VIDEO: Example of an Automated CT Cardiac Calcium Scoring Exam.

Related CT Calcium Scorining Content:

VIDEO: New Cholesterol Guidelines Support CT Calcium Scoring for Risk Assessment — Interview with Matthew Budoff, M.D.

CT Calcium Scoring Becoming a Key Risk Factor Assessment

ACC and AHA Release Updated Cholesterol Guidelines for 2018

VIDEO: CT Calcium Scoring to Screen For Who Should Take Statins — Interview with Matthew Budoff, M.D.

Find more SCCT news and videos

Quynh Truong, M.D., MPH, associate professor of radiology and medicine at Weill Cornell and director of cardiac CT, NewYork Presbyterian Hospital, offers 10 tips to help improve image quality for cardiovascular computed tomography (CTA) exams. She spoke on this topic at the Society of Cardiovascular Computed Tomography (SCCT) 2019 meeting.

Her discussion includes:

1. Practice the breath hold

2. Give nitrate to vasodilate

3. Slow the heart rate

4. Acquire multiple phases with padding

5. Include systolic imaging for irregular heart beats

6. Consider cauo-cranial imaging to avoid contrast enhancement issues

7. Use a high contrast injection rate

8. Right ventricular opacification for function

9. Use a hard kernel

10. Know your post-processing software

VIDEO: Tips and Tricks to Aid Cardiac CT Technologist Workflow

VIDEO: How to Prepare a Patient for a Cardiac CT Scan

Find more SCCT news and videos

Judy Hung, M.D., director of echocardiography, Division of Cardiology, Massachusetts General Hospital, Boston, discusses how her center is partnering to develop artificial intelligence (AI) applications to help improve image quality and speed workflow in cardiac ultrasound. She spoke to DAIC at the 2019 American Society of Echocardiography (ASE).

Partho Sengupta, M.D., MBBS, chief of cardiology, West Virginia Heart and Vascular Institute, explains how wearable, smartphone-based apps and medical devices, and artificial intelligence (AI) might be used to cost-effectively triage larger numbers of patients in rural areas and in the developing world for serious diseases. He spoke at the 2019 American Society Of Echocardiography (ASE) meeting.

Sengupta is involved with a pilot program using the Butterfly app and transducer to turn a smartphone into an inexpensive ultrasound system. He said the idea is to have novice ultrasound users screen more patients with these types of devices and the exams either being sent to a remote hospital for reading. He said AI algorithms also could be used to help flag any exams that show abnormalities, which would greatly speed reads and getting these patients treatment. 

Watch the related VIDEO: How Smartphones May Revolutionize Healthcare in the Developing World — Interview with Jacques Kpodonu, M.D.,

Find more news and video from ASE 2019