Randolph Martin, MD speaks with Gilbert Tang, MD, and Rebecca Hahn, MD about the importance of imaging in structural heart and valve programs. Dr. Hahn discusses how interventional cardiologists are an important part of the heart team – especially in making the diagnosis, and guiding the decision making process.
Dr. Tang outlines multi-modality imaging – allowing the heart team to plan the procedure so it can be done safely and efficiently. They discuss the ASE advanced training statement for interventional echocardiographers – which is prescriptive about the minimum volume requirements. A statement for multi-modality imagers is also in development. Drs. Tang and Hahn envision what could be next in this quickly advancing field.
About the AATS Mitral Conclave: David H. Adams, MD, and Anelechi C. Anyanwu, MD, serve as the Program Directors of the AATS Mitral Conclave – a meeting that Dr. Adams created with the American Association for Thoracic Surgery in 2011. The biennial meeting brings the world’s leading experts together to examine all aspects of mitral valve disease, associated conditions, and treatment. The meeting featured more than 350 presentations, 40 focused breakout or lunch sessions, combined with four main plenary sessions – with over 900 attendees from 52 countries.
Rebecca Hahn, MD Professor of Medicine, Columbia University Irving Medical Center Chief Scientific Officer of the Echo Core Lab at the Cardiovascular Research Foundation Director of Interventional Echocardiography at the Columbia Structural Heart & Valve Center I'm Doctor Randy Martin. We're here at the 2023 A TS MA conclave, as I've said before, you can obviously hear it right behind us. But I'm thrilled to be joined by two colleagues, Becky Hahn, who's the world's expert in interventional echo and everything else. Gilbert Tang, cardiac surgeon, who's been, who's bidirectional, your cardiac surgery and interventional procedures. You know, obviously, imaging has been my life echo has been my life and I remember the early days of moving when t without te being in the or with a sterile sleeve and all that stuff, but the advances in imaging, it's absolutely critical now to any structural or valve program. And you both have been pioneers in that Becky, you can't have a program today without excellent proper imaging. That's 100% true. I think that, you know, when Marty Leon first uh coined the term for my position as an interventional image or an interventional echocardiographer, it really opened up a whole new field. This is a brand new field for us. But in it, it means that we are part of the heart team for structural heart disease, we see the patients and make the diagnosis without making the diagnosis as you know, Randy, right? It's just you're never gonna bring the patients forward. We've already seen slide after slide after slide of the under treatment under diagnosis of these patients. And so you really need excellence in imaging from the start. So it's the diagnostic phase and then all the decision making is in pre procedural planning. And for that, we have tried to develop guidelines for preprocedural imaging in order or the interventions and, and images and and heart failure, physicians and everyone on the heart team, the surgeons, et cetera to make a decision about it's best surgery, transcatheter, medical therapy and then move forward and, and it's really hinging a lot on the imaging. So yeah, and it's, it's, as you said, it's diagnosis and that's often, I mean, you know, I've been a big proponent of trying to get the patients where they are with early echoes and you don't need complex things. You can go up the echelon of what you need. But then when you get into the preprocedural and intra procedural, then imaging becomes critical and obviously following them. Gilbert, what are your thoughts? Because you're intimately involved with CT uh simulation, picking up all the stuff, but also with echo. Tell me your thoughts. Yeah, I think it's a common is what we call now multimodality image and that involves not just echo but correlating echo findings with CT and kind of interrelate each other so that you can actually plan procedure. And Becky will tell you 90% of structural heart procedure is planning correct execution is also important. But once it's a plan, then you make sure the procedure can be done safely and efficiently, I think that also maximize the patient's comfort and also safety. And, you know, Becky, I'm sure you found this but I did in the early days in the, or is that when the surgeon is cardiac ors and the surgeons know that you know what you're talking about then pretty soon, even if they don't know it, they'll ask you, what do you think? How does it look and all that the same thing now with more complex interventional procedures which you do in the tri customs? A great, yeah, it's absolutely true but it's not just, you know, what do we think we're actually doing the guiding? So the, exactly. So the, exactly. So because we have all these advanced tools and so many of the new tools Randy have been really developed for the interventional imager. So live multiplanar reconstruction, we can't live without it anymore or just being able to rotate the orthogonal plane, the secondary plane to any angle that we want in order to optimize the clip arms. I mean, it's just, these were all developed, I feel like they were developed for the intervention sphere. I'm going to come back because the CT stuff you and I were in a session this morning. You did some excellent stuff on the scope of CT Becky. It needs excellence though. And this isn't for somebody just to run down from the echo lab and do this. This is, there's got to be specific training and procedural guidance, doesn't there 100%? And that's why the A SC just came out with their advanced training statement for interventional echocardiographer because it does require advanced training. And it started with the AC C advanced echo training statement by Doctor Wiggers and then it's just moved on from there. And so it's fairly prescriptive about what the minimum requirements might be as far as volume, which obviously doesn't necessarily ensure competence. But at least it's an attempt to make sure that enough of the pathology is seen. And then the American College of Cardiology is also seen as Gilbert has mentioned about multimodality imaging. And so we're now developing an advanced training statement for multimodality images because that's you say multimodality, you're talking about CTCT CMR nuclear and echo. Yes, that's interesting. Yeah, because there's also diagnostic component as mentioned, right? And some of them require that those you know, expertise uh you know, obviously from a procedural planning standpoint is still mostly echo and NCT. But there are other diagnostic component that we need to look at as well. So if, if somebody is interested in this wants to get degrees or get certificates in multimodality or are we talking basically intensive echo interventional echo and CT or are they gonna because you mentioned five modalities for people to say I want to be through in five years. Yeah, it's pretty clear that you're not going to be an expert in all of the modalities. And that typically people will choose two depending on, typically, depending on where their focus is. If your focus is is the guiding of the procedures, then CT and echo are going to be absolutely key. But then there are those that want to do CTC CMR or have an interest in more diagnosis, which might be nuclear pet scanning. So it depends on your focus. But the nowadays, it's really gonna be more than one modality. So you and I are gonna be dinosaurs. We we, we trained in one modality. But even now with the heart team, you know, we're able to uh see the CTS on every vowel case and we're, we'll review and, and make sure that it correlates with the echo. Gilbert. Your talk this morning was excellent. I'm obviously more familiar with Echo. Obviously, I'm familiar with CT, but where is CT and diagnosis and procedural planning? I think CT has come a long way in terms of, you know, in terms of being reproducible, I think that's one of the most important thing and then the measurements are actually reliable. I think the biggest question mark is the modeling aspect of it, of this newer devices. You know, can you predict the rotation element or the or the the deformation of this. This is right now still the biggest question mark in terms of predicting the five final outcome, you know, obviously we want it to be better than expected. But unfortunately, sometimes there are still, you know, adverse events that happen because we couldn't predict it. So I think that is the biggest question and I'm now hoping that, you know, through and others to look at echo as a correlate. Can we using both? So when you do it during the procedure and we talk about, you know, even some advanced fusion fusion possibility that we can actually predict this with a higher degree of certainty that a first event and particularly for my, you have to replace one like lbot obstruction or our leak with some kind of migration that might not have been expected can be minimized as much as it's a role for CT. And obviously, I'm thinking of simulation and all those things that you mentioned. But for coronary anatomy and relationships and all of those sort of things too, I mean, it plays it. So, you know, you don't want to get too close, that's doing that. But I actually because Echo is so prevalent and so easy to do because everyone started to transfer echo, right? I mean, to diagnose and then go to tee my dream would be actually use Echo to model some of the elements that you can perhaps sup I almost like fusion to be able to model something because it's dynamic whenever ac T even multi face is still somewhat static. And you know, it's still not really truly physiologic because Echo really depends on the loading condition and, and some of the elements that would be I think a holy grail and I think some of the things that you've done such as artificial intelligence, getting all the data will get a better predictability. Yeah, it's pretty easy to do that. I mean, you can see obviously with echo the relationship of the circumplex and the right coronary to, to val your structures and all that, Becky has the American Society echo. It's come out with guidelines. OK. Are we at the stage where you really have to have certification or credentials to be an interventional Echo person? That's such a such a great question. I mean, I think that without the guidelines, first for recommendations of training, it's hard to then go to the next step of certification and board certification. And so we had to start with the guidelines and to really get the buy in of all of the stakeholders that this is actually a new field that this is a, this requires your training and now uh likely should require uh certification in order to ensure a competence. And so I think we're doing it step by step and that's uh the first step is is to develop these advanced training statements. And hope to then certify. The surgeons are familiar with that. Obviously, you'd like them to be more familiar. But remember back in the early days, Bob gotten at Emory had his cardiac surgical resin spend six weeks with me auto echo. Translucent NTE is not G is important but do the, the surgical interventionalist or the interventionist. Now, a lot of the interventionists are cardiologist. So they have some training in echo. But are they much more knowledgeable now about what the technology can do and how to interact with you all? Why? Why was it learning echo is different from knowing echo and working with the intervention echo imager? Because number one, there's new cab is to learn the new anatomy and atomic. So you kind of emerging what we learned as a surgeon into some of the anatomy to now correlate with echo. And I think it's important for any structural interventionist and operators to work with echo imager to kind of learn that. And so they are all on the same page. So so for example, I believe in the copilot model, you know, you know, procedures are echo driven, right, echo guided. But the the international operate need to know what's going on on the imaging side. And also the imager also need to know what device as well so that they can actually talk in synchrony. I think that is something that is lacking right now in the field. And and I've been trying to work on training people in that regard. Yeah, I mean, I think the communication aspect is absolutely critical in, in the procedural rules, right? And so it is really developing that special language between you and your interventionist or the interventionist and the imager so that your communication is seamless and is clear and then you can accurately position valves. And so, you know, I think it becomes part of the hard team mentality and just really accepting the fact and the word that I think they need to be humble and, and and be able to willing to communicate in the same at the same language because you know, you don't want an adverse event and you don't want and you have to be patient. I think one, the patient has not been surgeons virtual as we know. Uh but sometimes you just have to be patient and let the imager guide you and show you what you need to go. It's like, you know, driving a car, right? If you can't see the windshield, you, you grew up gonna be driving forward. Both of you have been pioneers in this. I think it's really, really important because this is a specialized field and it, and it does take a specialized language and colleagues that, that trust each other. And no, so you both have been pioneers. So thank you and uh we look forward for continued advances. So thank you for joining me. Thank you. Thank you. That's very important. So, learn about imaging, it's critical in your program. Thanks.