The day is not far when cath labs, like X-ray machines, will be availab

With induction of newer technologies, the cath lab market is set for a giant leap. The next generation of advances will improve operator performance, enable more complex procedures, change the reimbursement system, improve patient and operator safety, and expand the use of minimally invasive cardiovascular procedures into new areas that were previously only the domain of surgeons.

Indian Market Dynamics

In 2015-16, the Indian cath labs market after stagnant growth in 2014-15 (over 2013-14) saw an almost 40 percent growth in 2015-16 (over 2014-15), as government tenders which had been pending in 2014-15, were released in 2015-16. The increase came primarily from the premium biplane segment. The six new AIIMS hospitals procured premium biplanes; HLL bought about eight premium biplanes too. Two systems were donated by the Prime Minister's National Relief Fund for flood relief in Jammu and Kashmir and one was bought by Government Medical College and Hospital, Nagpur. The remaining major contribution came from the premium monoplane segment.

cath-labsThe value segments remained stagnant, albeit the unit prices dropped by about 10–20 percent since 2014.

New cath labs, new cardiac centers in existing hospitals, and dedicated cardiac centers are emerging in Tier II and III cities. The government continues to play a key role both as a buyer and a clinical solution provider in increasing access of cath labs to the patients. State government insurance schemes are making cath lab procedures viable for BPL patients and this will result in expanding the market size.

Over the last decade, advancements in technology have changed imaging and reporting systems. Due to the lower risk of invasive procedures, there are now cardiac cath labs without onsite surgical backup, a trend that highlights the importance of quality assurance and quality improvement initiatives. Meanwhile, the cath labs have become a multipurpose suite for diagnostic and therapeutic procedures for pediatric and adult patients. While hybrid cath labs are not a new phenomenon, more medical centers are looking into creating them as they consider starting trans-catheter aortic valve replacement programs.

Challenges

Translesional stenosis physiology determines the ischemic potential of a given coronary stenosis. While FFR-guided compared to angiographic-guided stenting is now strongly associated with superior outcomes, FFR is still infrequently used in most labs. One of the postulated reasons for such low utilization is the need for IV adenosine and it is perceived as uncertain hyperemic response. The notion that a hyperemia-free index can accurately determine the ischemic potential of the stenosis is conceptually appealing, but fundamentally challenging.

cath-labsMedical therapies, including vasopressors and inotropes/vasodilators, remain the first-line treatment for shock despite a dearth of randomized trial data showing mortality benefit and, on the contrary, association with potentially negative physiologic effects, including tachycardia, arrhythmogenicity, and an increase in left ventricular (LV) afterload. These pharmacologic therapies increase myocardial oxygen demand in the most precarious of clinical settings, resulting in both acute and long-term declines of cardiac function. Although patients have traditionally been able to get out of the immediately critical setting, with the use of such agents, long-term survival appears negatively affected due to these effects.

A chronic total occlusion (CTO) is one of the highest complexity lesion subsets witnessed in the cath lab. Barriers to starting a CTO program include appreciating the clinical benefits, costs, time, and the acquisition of the needed special skill-set. It is known that high costs are associated with CTO PCI procedures. An average CTO case requires 5–10 guide wires, adjunctive imaging, multiple stents, specialized catheters, and additional vascular access sites. The lab and operators must devote several hours to these procedures until the team's skill-sets have developed to the level of the experts performing multiple CTOs in less than an hour. The acquisition of special techniques includes increased expertise in wiring collaterals, retrograde wire tracking, and the use of microcatheters with special sub-intimal luminal re-entry systems. Contrast load and radiation exposure will need to be monitored more closely.

cath-labsComputed tomography FFR (CT-FFR) is one of the major imaging advancements impacting the cath lab. Not only cardiologists can identify culprit lesions immediately with quantifiable, significant flow restriction, but it also allows implantation of a virtual stent or stents to see how it impacts flow. This tool will enable cardiologists to plan the access route and take extremely accurate measurements so that a personalized procedural kit for each patient can be assembled for required guide catheters, wires, balloons, and stents. While the technology has shown considerable promise, it is by no means the perfect diagnostic test. Under the current model of CT-FFR analysis, where data has to be sent for FFR calculation and sent back to the hospital, turnaround times are a concern, particularly for emergency department cases. The other limitation of the technology is that the FFR calculations can only be as precise as the CT images allow, and it is also noted that false-positives are still a risk, but a conclusive result is retrieved in more than 95 percent of cases.

Future Outlook

Much new advancements in technology have taken place; the technologies which are going to be very useful for the cardiologists will be stent boost and hybrid cath labs, in the near future. With incidence of heart diseases on the rise, interventional cardiologists increasing in number, and primary angioplasty becoming standard of care for acute heart patients, the demand for cath labs is going to increase and facilities will enter into small towns. The day is not far when cath labs will be available like X-ray machines even in the smallest town of the country.

Indian Market Dynamics is based on market research conducted by Medical Buyer in May 2016.


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