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FIT Insights

Cutting-edge technologies:

How they may change our knowledge and practice

In 2019, most of our practice in cardiovascular medicine is lead by a technology-based approach. If we examined every aspect of cardiology nowadays, we would find that the effectiveness, diagnostic accuracy, and treatments are based on technological advancements. This involves general non-invasive cardiology, interventional cardiology, advanced imaging, electrophysiology and even advanced heart failure and the transplant arena.

Cutting-edge technology development through the implementation of artificial intelligence (AI) to the readily available and affordable test - electrocardiogram (ECG) - has recently been shown to be an effective screening tool for early development of asymptomatic left ventricular dysfunction and heart failure (1). The application of the AI-based algorithms to the ECG has revealed promising favorable results when compared to other screening tests, such as mammography for breast cancer, in terms of accuracy (1). So far, no other clinical or laboratory marker has shown such promising results in the early detection of heart failure, which already affects more than 5 million people in the U.S., with an estimated associated health care cost of $30 billion in recent reports (2). This new development might significantly impact our practice and patient care in the near future.

The new (2) development of Coronary Computed Tomography Angiography-based (CTA) Fractional Flow Reserve (FFR) using computational fluid dynamics (CFD) has recently emerged and been implemented in some practices as a non-invasive tool to assess hemodynamic severity of coronary artery disease . It has shown great results compared to the invasive assessment through coronary angiography (3). This will have a positive impact on our patients by reducing the complications rate from many unnecessary invasive tests. Over the next decade and after more generalized adoption of this tool, we will need a larger study to assess the true effect of this approach on our practice and patent care.

In the interventional arena, cutting-edge technology is leading the field on a daily basis. For example, robotic-assisted percutaneous coronary intervention (PCI) is being used more frequently since its FDA clearance in 2012 (4). It presented itself as a very effective tool in reducing the interventionalist and staff radiation exposure while delivering accurate results compared to manual interventions in many observational studies. In addition, intra-coronary laser therapy (Excimer Laser Atherectomy) which was initially approved for femoropopliteal artery disease interventions is now being used for coronary in-stent restenosis with great results (5,6). Furthermore, Extracorporeal Shockwave lithotripsy/lithoplasty is being used more often off-label for severely calcified iliac and femoral arteries to provide adequate access for mechanical circulatory support in high-risk interventions or structural heart disease interventions such as transcatheter aortic valve implantation (TAVI).

More devices are now coming to practice with the advancements that we see in structural heart disease interventions. For example, transcatheter mitral-valve repair in symptomatic heart failure patients with moderate to severe mitral regurgitation on optimal medical therapy has recently been shown to provide morbidity and mortality benefit with early detection and intervention (7). More recently, the SUMMIT trial was launched to evaluate the next-generation transcatheter mitral valve implantation through the Tendyne system, which, if approved, will be the first and only mitral valve replacement that can be repositioned and fully retrieved. The initial presented data of the first 100 patients implanted showed great promise with symptom improvement (NYHA class) and low mortality at 30 days.

These are only a few examples among others on how technological advancements are leading and shaping our clinical practice and patient care in 2019; there are more to come. I am a strong believer that, by 2030, the cardiovascular medicine practice will be significantly different given the current pace of new devices and programs leveraging AI.

Author

Abdalla Hassan, MD

Abdalla Hassan is a physician specializing in cardiovascular diseases at the University of Massachusetts Medical School (UMass) and UMass Memorial Medical Center in Worcester, MA. He has a special interest in interventional cardiology and structural heart disease interventions. Within the AHA, he is a FIT and active member of the Council on Clinical Cardiology.

Reference

  1. Attia ZI, et al. Screening for cardiac contractile dysfunction using an artificial intelligence-enabled electrocardiogram. Nat Med. 2019 Jan;25(1):70-74.
  2. https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-research-uses-artificial-intelligence-to-develop-inexpensive-widely-available-early-detector-of-silent-heart-disease 
  3. Coenen A, et al. Diagnostic Accuracy of a Machine-Learning Approach to Coronary Computed Tomographic Angiography-Based Fractional Flow Reserve: Result From the MACHINE Consortium. Circ Cardiovasc Imaging. 2018 Jun;11(6):e007217.
  4. https://www.dicardiology.com/article/fda-clears-first-robotic-system-coronary-stent-procedures
  5. Nishino M, et al. Indications and outcomes of excimer laser coronary atherectomy: Efficacy and safety for thrombotic lesions—The ULTRAMAN registry. Journal of Cardiology. 2017 Jan;69 (1):314-319.
  6. Ashikaga T, et al.  “The effectiveness of excimer laser coronary atherectomy with contrast medium for underexpanded stent: The findings of optical frequency domain imaging,” Catheterization and Cardiovascular Interventions, 2015; 86(5): 946–949.
  7. Stone GW, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018; Dec 13;379(24):2307-2318.