Amid changing regulations, intense scrutiny of proper reimbursement, pressure to reduce costs, and the need to both measure and achieve high-quality outcomes, the way hospitals provide care has been transformed. It is no wonder that cardiovascular (CV) services are at the forefront of administrators' minds, as CV diseases (CVDs) have now become the leading cause of mortality in India.

There is a growing understanding of the importance of strategies that foster early detection and treatment of CVDs. The government aims to develop India as a global healthcare hub and increase healthcare awareness and investments. Funding for cardiac imaging modalities is crucial, as these services are very important in the diagnosis of CVDs, but can be costly. There have been great advances in the field of global cardiac imaging. However, the need for further research, continued innovation, and advocacy is tremendous.

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Advancement in technology has given interventional cardiologists a helping hand, first through angiographic guidance – the gold standard for decades – and, more recently, through tools like fractional flow reserve (FFR), intravascular ultrasound (IVUS), and optical coherence tomography (OCT). Though the benefits of these devices have been shown, their usage for percutaneous coronary intervention (PCI) remains spotty. Hospitals have an intrinsic conflict of interest because these tools may end up reducing the number of PCIs and bypass surgeries, which are huge revenue boosters for them. What then is the incentive to use them? Only that they would be providing state-of-the-art medicine to patients and that use of these tools would be a compelling draw relative to their competitors, who are practicing old medicine.

Indian Market

In 2016, the Indian cath labs market is estimated at 632 crore, with the imported segment at 295.75 crore and the indigenous and unorganized segment constituting 70 crore. The contribution of this segment is for the performance and value systems, which are more popular in Tier-II and now in Tier-III cities. The government continues to account for the top-of-the line models. The mobile systems are finding preference over the fixed ones in the value segment.

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The differentiating factors between various brands are diminishing, with most systems on similar price points offering similar capabilities and features. Gradually, brand loyalty and other factors such as prompt servicing, attitude of sales and marketing team, proximity with customers, etc., will be the determining factors for gaining market share. Undoubtedly, digital detector size (the smaller ones optimal for cardiac procedures and the larger ones used to perform run-offs), ablation techniques, or tumor/vein embolizations are major causes of price variation. On a similar note, swing labs, digital cath lab equipment that is suitable for both cardiac work and a variety of vascular and neurological applications, are gaining popularity.

Philips continues to lead the segment, with GE and Siemens offering stiff competition. Toshiba is more successful with the government, whereas Allengers is dominating the indigenous segment in Tier-II (and now Tier-III) cities. Shimadzu and Schiller are also aggressive in this segment.

Technological Advancements

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Healthcare providers are exposed to scattered radiation from patients during the procedures, and need to protect themselves appropriately. The introduction of robotic technology in the cath lab to protect against radiation exposure and associated risks is expected to have a huge future impact on both patient and physician care. It makes a huge difference by allowing physicians to sit behind a radiation-shielded cockpit without needing to wear heavy lead protective gear, thus offering protection to the medical staff against occupational health hazards associated with radiation exposure.

Angiographic imaging system vendors have developed new technologies to address emerging cath lab trends, including the need to reduce radiation dose, improve image quality, and enable advanced procedural image guidance. All these points have become increasingly important as more complex procedures like TAVR, left atrial appendage (LAA) occlusion, and atrial and ventricular septal defect closure are attempted in interventional cath labs and hybrid ORs.

Newer angiography imaging systems enable advanced 3-D imaging with rotational angiography, which uses a quick spin around the patient to create a computed tomography (CT)-like, 3-D image of the anatomy. This can all be done tableside in the cath lab. Some systems allow these images, or CT or magnetic resonance imaging (MRI) 3-D images, to be overlaid or fused with the live 2-D fluoroscopic images.

This fusion technology is used with TAVR planning and navigation software to better guide device placement. Software also allows 3-D images to be integrated with EP electromapping systems to guide catheter ablation procedures without the need for live fluoro, helping reduce dose.

All these new angiography systems in the market offer dose-lowering technologies. These advances include improved X-ray tubes, more sensitive detectors, and software to help improve image quality at lower doses, in addition to noise reduction.

The Philips Allura Clarity is an example of the next-generation system that can help lower standard procedural dose by 50–75 percent. Toshiba's Spot Fluoroscopy software for its Infinix-i systems allows clinicians to observe a target region of anatomy using Spot Fluoro's live fluoroscopy, while viewing the last image hold (LIH) in the surrounding area that has been collimated out of the field of view to cut dose. GE, Toshiba, and Philips offer software to visualize the dose accumulation (peak skin dose) on a patient in real time to serve as a reminder to move the C-arm to avoid burns.

Way Forward

There is increasing interest from healthcare institutions to provide value-based healthcare in order to ensure that the right people, institutions, and resources deliver healthcare services that ultimately meet the health needs of the target population.

This opens several opportunities for healthcare companies to support hospitals and other healthcare providers in the transition towards value-based healthcare through systems that optimize the way they operate in order for them to compare outcomes.

Knowing the current situation in the cath lab and having the information readily available for determining the future impact of something new can make all the difference between success and failure. Looking back to gain perspective on how far we have come is always a worthwhile effort. Indeed, cutting-edge programs will embrace the new and rejuvenated complexion of the cath lab and look forward to the next clinically proven solution.


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