A steady growth in the number of patients suffering from cardiovascular diseases in India is resulting in an increase in the need for cardiac care services in the country.

Indian healthcare industry is showing great progress. The number of hospitals and nursing homes is continuously increasing and this is resulting in a growing demand for various kinds of medical equipment, ranging from simple instruments to more sophisticated devices and equipment that work on complex mechanisms. Moreover, the increasing requirement of healthcare facilities on account of changing demographics and increasing lifestyle is fueling growth in the healthcare sector. While most of the simple instruments are manufactured indigenously, there is a high presence of MNCs when it comes to complex and sophisticated devices. The market for cath labs is showing a similar trend, and a significant share of the market is occupied by a few major foreign companies.

Indian Market Dynamics

The Indian cath labs market in 2014 remained stagnant primarily as the procurement by the government was very low. However, this is set to change in 2015, as many tenders have been invited in H1 2015. The market in 2014 is estimated at Rs.670 crore, with sales of 250 units. The market is dominated by the monoplane segment, with the premium and performance having a combined market share of 69 percent. The biplane equipment is gathering momentum and it is also being purchased by government hospitals now; the six new AIIMS have all procured biplane cath labs. As transcatheter procedures become more complex and require longer imaging times, radiation exposure to both patients and operators is increasing. There is an increasing awareness of this aspect with patients and doctors, resulting in a growing preference for equipment offering lower dose of radiation. New technology as robotic systems and new radiation protection systems is available to help block radiation scatter.

Another trend that is gaining strength in the Indian market is hybrid ORs. Hybrid ORs with advanced imaging capabilities have integrated traditional surgery options with complex minimally invasive surgical techniques. Out of the total procedures performed in a cath lab, 80 percent remain cardiac surgeries and 20 percent are neurosurgery procedures. Tier-II and tier-III cities are also investing in hybrid ORs.

Dr Ajay Yadav, Director, Cath Lab, Sir Gangaram Hospital, Delhi

"Peripheral artery disease (PAD) is caused by the build-up of plaque in the arteries that carry oxygenated blood from the heart to the rest of the body. The plaque can harden over time, narrowing the arteries and restricting blood flow. PAD most commonly affects arteries in the legs and has been found to have a direct correlation to increased risk of sudden heart attack or stroke. The drug-coated balloon (DCB) represents a technology that has emerged as a therapeutic alternative in the interventional field. As the name implies, the balloon is coated with the medicine called paclitaxel. During dilatation, a precise dose of this medicine is released within seconds, directly onto the vessel wall. In this way, the development of scar tissue, one of the most common causes of restenosis, is suppressed. This results in better long-term results with lower rates of re-interventions. One such DCB is the IN.PACT Admiral DCB which is a clinically-proven, primary endovascular therapy that enables physicians to confidently treat femoropopliteal disease, reduce re-intervention, and preserve future treatment options."

Dr Ajay Yadav,
Director, Cath Lab,
Sir Gangaram Hospital, Delhi

Future Outlook

Advanced imaging, guidance, planning. New imaging techniques will enter standard practice in the cath lab to enable advanced 3-D imaging to facilitate more accurate navigation inside vessels and device placement. Most modern angiography systems offer rotational 3-D angiography, which uses a quick spin around the patient to create a CT-like 3-D image of the anatomy, which can all be done tableside in the cath lab. Some systems allow these or CT or MRI (magnetic resonance imaging) 3-D images to be overlaid or fused with live 2-D fluoroscopic images. This fusion technology is used with TAVR planning and navigation software to better guide precise device placement of procedures. The next step in advanced visualization will be the use of free-floating, 3-D holographic images in the cath lab. This technology, developed by RealView, is already being used in the prototype stage in a handful of cath labs. It allows physicians to interact with the 3-D datasets, rotating them and even being able to slice through the image on any plane to see cross sections.

Cardiology IT. Information technology in the near future will go far beyond reporting and PACS (picture archiving and communication system). There is rapid proliferation of tiny and inexpensive patient-monitoring devices that will bring new patient-monitoring data into patient's electronic medical records (EMRs). These will be used to better monitor diabetes, heart failure, hypertension and arrhythmias. Current technology allows 3-D images to be printed by special printers as resin 3-D models. This technology is now being experimented with, using bio-materials to print custom-made implantable devices, such as heart valves.

Holographic navigation. Today's cath lab makes regular use of 3-D technology, including rotation angiography, TEE (transesophageal echo), CT and MRI reconstructions, EP (electrophysiology) lab navigation systems, and structural heart procedure 3-D fusion imaging systems. However, none of these is true 3-D, because they are still viewed on 2-D display screens. The problem is not the people using the system; it is the fact that the image data are trapped in the screen. This may soon change with the introduction of free-floating holographic imaging, which will allow image projections in the cath lab above the patient where the image can be rotated or sliced through on any axis.

Fractional flow reserve. In cath labs, bread-and-butter stenting procedures may need justification using FFR data to show that a lesion being treated is flow-limiting. FFR requires the use of adenosine. A new non-adenosine method called iFR was recently validated with a close 90 percent correlation with FFR. This will make FFR faster and easier to use, and limit the need for adenosine to only about 30 percent of patients.

MRI could replace angiography. Ionizing radiation could be completely eliminated from the cath lab if the angiography system is replaced by MRI image guidance. The cath lab at the National Institutes of Health (NIH) has one lab that uses MRI instead of X-ray angiography to visualize procedures inside patients. The advantage of MRI is that it can visualize the patient's entire anatomy, not just an X-ray of unblocked coronary artery lumens. Another advantage is that MRI does not use radiation to image, so it is safe for patients during longer procedures and the physician can use live imaging during the entire procedure. Additionally, cath lab staff and operators do not need to wear lead.

MRI shows all of the soft tissue anatomy in the field of view, including chambers of the heart and blood flow, which can help visualize clots or pulmonary embolisms. One of the great things about MRI is that you can see where your catheters are going.

Indian Market Dynamics is based on Market research conducted by Medical Buyer in May 2015

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