2 CA R D I O LO G Y Intracardiac echocardiography (ICE) has benef Refined guidance with no need for anaesthetic Intracardiac echocardiography (ICE) is an increasingly important guiding tool for structural heart disease interventions – without gen- eral anaesthesia. José Ribeiro, who works in the thorax and circula- tion unit at Gaia Hospital Centre, Portugal, who has worked with this technology for the past two years, explained its benefits and limitations in an exclusive interview with Daniela Zimmermann of European Hospital. Discussing developments in Intracardiac echocardiography (ICE), José Ribeiro, cardiologist at the thorax and circu- lation unit in Gaia Hospital Centre, Portugal, explained that recently the need for a different ultrasound tool to guide patient treatment beyond transoesophageal echocardiography (TEE) became clear. ‘Consequently,’ he added, ‘a significant number of interventional cardiologists have start- ed to use ICE. ‘We still have limitations with ICE for structural heart disease, because we don’t see all the structure in the same plan and need to navigate with a catheter inside the heart. That’s why it’s so important for 3-D imaging to guide procedures. ‘We don’t need too much imaging to guide the intervention for struc- tural heart disease. But we need to have a good pre-procedure evaluation and to plan the procedure, and after that we only need specific steps to ensure procedure quality and check the results. If we can get the cardiac structures on 3-D, we have a signifi- cant advantage for guidance. ‘We initially had a narrow angle catheter, which only enabled us to view small volumes of the heart. This is not enough to image entire structures, for instance a valve, left appendage or oval fossa. So we devel- oped a new device with a wide open- ing angle; it’s a 12.5-Fr catheter and this enables us to view significant vol- umes of the cardiac tissue, including the whole mitral valve. This develop- ment appears to be a great advantage for guidance.’ DZ: When using ICE, is the image in front of you and can you see the relation between the structures? ‘Yes. When we have a volume, we can look inside and decompound it in a different 2-D plan to navigate more easily, which enables us to be more confident when doing the procedure. ‘With a 3-D wide angle ICE cath- eter, we have the same benefits as with 2-D ICE, meaning we don’t need an anaesthetist, the interventional car- diologist can do the intervention him- or herself, by putting the catheter in the right place to see the heart. ‘But we can also obtain a signifi- cantly higher amount of information and anatomy, so that the interven- Images of intracardiac echocardiography obtained with Acunav V wide angle catheter (Siemens Healthineers); on 3D images we can see entire cardiac structures: on top right the fossa ovalis, on top left the left atrial appendage opening (LAA), on bottom right the mitral valve with anterior (AL) and posterior (PL) leaflets and on bottom left the device occluding LAA. More people need nuclear cardiology training Ischaemia: Advances in nuclear imaging Experts outlined approaches to ischaemia imaging during the recent British Cardiovascular Society confer- ence. In a ‘Detection of ischaemia by cardiac imaging in 2018’ session, comparisons were made between solid state SPECT cameras, whether spatial resolution or visual assessment was of the greater importance, if CT-FFR offered advantages over CT perfusion, and the challenges in defining a gold standard of imaging ischaemia Discussing ‘Advances in nuclear ischae- mic testing, from SPECT to PET and beyond’, Dr Kshama Wechalekar, who heads Nuclear medicine and PET at the Royal Brompton Hospital in London, and is President of the British Nuclear Cardiology Society (BNCS), told delegates that advances in nucle- ar imaging with solid state technol- ogy offered improved ability to detect ischaemia. ‘There is improved spatial resolution from multiple solid state CZT (Cadmium Zinc Telluride) detec- tors and therefore sensitivity is very high,’ she explained. ‘You can reduce the acquisition time at least by half President of British Nuclear Cardiology Society Dr Kshama Wechalekar leads nuclear medicine and PET at the Royal Brompton Hospital in London, where she specialises in heart/lung nuclear imaging. Her main interests lie in using hybrid- imaging techniques, such as SPECT-CT and PET-CT, to improve understanding of pathophysiological processes affecting the heart and lungs. She has special interest in cardiac sarcoidosis and other inflammatory conditions of the heart. with excellent quality and the equip- ment has a small footprint. The advan- tages of solid state detector cameras is that you can reduce the radiation dose by one third, have high sensitivity and resolution, an open design suitable for claustrophobic patients, and good image quality even in obese patients.’ SPECT, PET and CMR Recent studies have shown ability to do dynamic imaging offering potential in quantitative myocardial perfusion with SPECT, Wechalekar pointed out, adding that SPECT is less expensive than current PET and MRI. ‘The future of SPECT Nuclear car- diac imaging,’ she concluded, ‘is in solid-state technology. Dynamic imag- ing, although technically challenging, can add value to MPI in the detec- tion of ischaemia. Whilst PET is the most accurate imaging technique for ischaemia assessment and prognosis, it remains expensive and less acces- sible.’ She also felt that the new trac- er, Flurpiridaz, with results of phase III trials in the UK pending, might change the future of PET MPI. One area of concern was how to persuade more people to train in nuclear cardiology with falling num- bers in the field. ‘The BNCS Council is working hard to improve curricu- lum, organise level 1 and 2 training courses, and to identify centres that can offer nuclear cardiology training across the country that is easily acces- sible for trainees,’ she said. Dr Chiara Bucciarelli-Ducci, in Lecturer Consultant Senior Dr Chiara Bucciarelli-Ducci is Consultant Senior Lecturer in Cardiology/non Invasive Imaging at the Bristol Heart Institute, University of Bristol, and co-Director of the Clinical Research and Imaging Centre (CRIC Bristol). She is currently one of the vice-presidents and chair of cardiac MRI of the European Association of Cardiovascular Imaging (EACVI). Invasive Cardiology/non Imaging Bristol Heart Institute, University of Bristol, explored the issue of quan- titative versus visual assessment in CMR stress perfusion. She explained that stress CMR has been included in the ESC guidelines since 2014 (ESC revascularisation guidelines) based on evidence using visual assessment of ischaemia, rather than quantitative. Bucciarelli-Ducci discussed pros and cons of both visual and quan- titative assessment, limitations and opportunities to increase spatial reso- lution, and very recent studies show- ing that there is no difference in diag- nostic accuracy visual vs. quantitative. Quantitative perfusion is promising, but the acquisitions and analysis need Single photon vs. Positron ET simplification to meet the need of a busy clinical service. ‘CMR perfusion (visual) is a good clinical tool already,’ she concluded, ‘but can get better while quantita- tive CMR perfusion is evolving into faster and robust tools. While several methods are available, more in-vivo and clinical validation is needed with a number of studies in the pipeline.’ Function addition can improve specificity Dr Marc Dweck, BHF Reader in Cardiology and Consultant Cardiologist at the University of Edinburgh and the Edinburgh Heart Centre, posed the question ‘CT-FFR/CT perfusion - nei- ther or both?’ ‘CT Perfusion,’ he acknowledged, ‘is interesting, but I’m not sure how we are going to use it in clinical practice. With CT-FFR you get beautiful pic- tures, where you can look down the coronary arteries and see areas that are not getting enough blood. The advantage of this technique is that you can use it on a post-hoc basis, on scans where you are not sure if a lesion is obstructive or not, without any extra radiation or medication for the patient. This may be useful in low- ering the rates of patients being sent EUROPEAN HOSPITAL Vol 27 Issue 4/18 Dr Marc Dweck is Senior Lecturer and Consultant Cardiologist at the University of Edinburgh and the Edinburgh Heart Centre. A British Heart Foundation Intermediate Clinical Research Fellow, he is a keen advocate of multi-modality cardiovascular imaging and is trained in echocardigraphy, carotid ultrasound, computed tomography (CT), cardiovascular magnetic resonance (CMR), PET/CT and PET/MR imaging.

4 CA R D I O LO G Y Coronary angiography will lose diagnostic value The changing face of imaging in cardiology While the question is still debated as to whether MRI is the better CT, along comes a potential game changer – a new data based 3-D reconstruction method of heart anatomy and function that aims to replace diagnostic coronary angiography. In the near future not only adult patients with coronary heart disease could benefit from this new technique but also children with complex congenital heart defects. Meanwhile imaging is conquering the cardiac operating room (OR). Report: Emilie Hofstetter Long before coronary heart disease (CHD) manifests its presence on an ECG, CT and MRI can detect it due to low perfusion caused by a stenosis of the coronary vessels. Dr Bettina Baessler, radiologist and researcher at the University Hospital Cologne, Germany, looks into mul- tiparametric imaging strategies. She considers both techniques comple- ment one another although MRI definitely produces images that are ‘more beautiful, almost works of art’. Professor Ulf Teichgräber, Head of Radiology at University Hospital Jena, Germany, agrees and thus predicts the demise of cardiac angi- ography. His opinion is corrobo- rated by the recently completed SYNTAX III study, whose results will be presented at the Transcatheter Cardiovascular Therapeutics From Vision to Impact. That’s Excellence for Life. From First German Pacemaker to Connected Cardiac Care. biotronik.com flow and can thus show whether a haemodynamically relevant block- age is present, i.e. whether the patient needs a stent or a bypass. In 2015, Professor Pamela S Douglas, cardiologist and Head of Multimodal Imaging at the Duke Clinical Research Institute in Durham, North Carolina, USA, showed the potential benefit of this method using 584 patient cases from 11 hospitals. Ten patients with suspected CHD underwent diagnos- tic cardiac catheterisation, but the suspicion was confirmed only in three patients – seven underwent unnecessary catheterization. Six out of ten patients with suspected CHD, whose FFRCT was determined first, did not need angiography. In three out of the four patients who did receive angio, the suspicion was confirmed – i.e. only one patient underwent an unnecessary angiog- raphy. ‘This feasible and safe meth- od shows a significantly lower rate of unnecessary invasive angiogra- phies,’ Douglas confirmed. Investors seem to buy in: HeartFlow, which today is already cooperating with the Big Three – GE, Siemens, Philips – recently raised USD 240 million to further develop the technology, launch new studies and drive com- mercialisation of its product. To establish 3-D imaging in con- genital heart disease treatment, paediatric cardiologists Animesh Tandoon and Tarique Hussein founded VARYFII Imaging, LLC, in Dallas, USA. They construct complex anatomical models of the individual patient’s pathologies using MRI or CT data. Cardiologists as well as sur- geons can enter the virtual and aug- mented realities of the anatomical models with the help of data head- sets to lift certain structures, analyse and reposition and thus devise the best strategy them 3-D reconstruction of a coronary system, detached from the heart muscle. Fractional flow reserve in the individual vessel sections is colour-coded. Courtesy: HeartFlow, Inc. Y-conduit of right and left internal thoracic artery in epicardial ultrasound. A: 2-D Long axis view, B: 2-D short axis view, C: Colour Flow Mapping long axis, D: Colour flow short axis. Courtesy: Di Giammarco to correct the heart defect prior to surgical intervention. ‘Our heart beats in 3-D, so why not examine it in 3-D?’ asks Dr Sandy Engelhardt, researcher at the Computer-Assisted Surgery Group at the Department of Simulation and Graphics in Otto von Guericke University, Germany. In addition to treatment planning and education she envisages a further application of this new technology: informing the parents of the young patients. The flow must continue Imaging has arrived in cardiac surgery – during the intervention itself and combined with flow measurements. Professor Gabriele Di Giammarco, cardiac surgeon at Gabriele D’Annunzio University Hospital in Chieti, Italy, considers the combination of high-frequency epicardial ultrasound (ECUS) and transit flow measurement (TTFM) in a single device ‘deci- sion making’ and explains: ‘Hard calcifications in the aorta, I can feel. I do not feel the dangerous soft plaques. With MiraQ, I see them in intraoperative ultrasound, can adapt my strategy and perform surgery in no-touch technique and off-pump.’ time Dr Daniel Wendt, Managing Senior Physician at the Cardiac Surgery Department of University Hospital Essen, Germany, uses intraoperative flow measurement of newly cre- ated bypasses not only for quality assurance purposes – he records a follow-up intervention rate of slightly below three percent – but also for training purposes: ‘It’s a tool to improve your skills, helps flat- tening the learning curve.’ The combination of risk minimisation and qual- ity assurance has proved suc- In cessful. 2017, the Oslo-based m a n u - f a c t u r e r M e d i s t i m sold prod- ucts and procedures worth NOK 229.8 million, up 14.6 percent over the previ- ous year – another chapter in the success story of surgical interven- tion in CHD patients. EUROPEAN HOSPITAL Vol 27 Issue 4/18 The physician, using smart glasses, in the virtual space has just removed the aorta at its root from the heart to examine it separately. Observers can follow on conventional screens. Courtesy: S. Engelhardt Symposium 2018 in San Diego in September. A team comprised of a radiologist, cardiologist and sur- geon (Heart Team A) evaluated the angiogram of a patient, calculated the SYNTAX II score and decided on the type of therapy, either invasive or non-invasive. The team members then saw the multislice CT (MSCT) scan with 3-D reconstructed coronary vessels and the relevant fractional flow reserve (FFRCT) and could either confirm or revise their decision. A second team (Heart Team B) of those pro- fessionals received CT and FFRCT of the same patient first. The team members calculated the Syntax III score, decided on the type of ther- apy and then saw the angiogram in order to either confirm or revise their decision. ‘The Syntax score was designed to inform the decision “invasive or non-invasive”, based exclusively on anatomical features,’ Teichgräber explained. ‘Syntax II took comorbidities into account and now Syntax III includes a functional component – FFRCT. Thus coronary angiography will lose importance in diagnostics and therapy planning.’ Non-invasive first To date, only the California-based HeartFlow Inc. can calculate FFRCT. Based on data obtained in a conven- tional CT, the company’s software, using flow mechanics, can recon- struct heart, aorta and coronary ves- sels in terms of geometrics as well as pathophysiology and function in 3-D. Moreover it visualises the

6 CA R D I O LO G Y Arrhythmia news from CMR 18 Multidisciplinary cardiology Eminent Spanish cardiologist highlights the evolving role of imaging in ventricle arrhythmias treatment Report: Melisande Rouger Intervention in ventricular arrhyth- mia has improved dramatical- ly over the past three decades thanks to advances in imaging and co operation between cardiology and radiology, according to Professor Josep Brugada MD, director of the paediatric arrhythmia unit at Sant Joan de Déu Hospital in Barcelona. information from imaging. In the late 1990s, CT enabled the visualisation of more complex arrhythmia substrates, such as ven- tricular tachycardia. ‘It was not enough to use echocardiography anymore. At that time we needed to have information on the position and size of different structures, for instance the pulmonary veins. We used the CT scan to help us to do anatomy of pathways in the muscle is crucial at the time of eliminating arrhythmia, Brugada explained. ‘Using MRI, to extract anatomic information, and our mapping sys- tem, which enables us to identify where the electricity goes through, we can determine the exact point that may be responsible for arrhyth- mia. We can then target this point with radiofrequency and burn it, l e d o p x E / m o c . k c o t s r e t t u h S © ‘Echocardiography, CT and MRI, combined with cardiology,’ he said, ‘have revolutionised the field into what it is now a truly multidiscipli- nary field.’ Cardiologists have learned to use echocardiography. Collaboration with radiologists has enabled them to understand ventricular tachycar- dia and ventricular fibrillation, two life-threatening diseases that are most commonly associated with heart attacks or scarring of the heart muscle from previous heart attack. As a result, knowledge of physio- pathology and arrhythmia mecha- nisms has grown over the past thirty years, first with understanding the location of arrhythmia, a parameter that remains crucial for treatment. Decades of developments ‘Thirty years ago, we were perform- ing diagnostic electro-physiological studies, and at that time our rela- tionship with imaging was very sim- ple – we just used X-ray. But in the late 1980s, we understood that we could start treating these patients and that we could start targeting the points that we identified as the points of arrhythmia, and with more and more accuracy to under- stand where these points were,’ he explained. Using X-ray and echocardiog- raphy combined with the electric signal first enabled very simple arrhythmic substrates to be located. Cardiologists soon understood that they needed, and could get, more just that. That was a very important step,’ Brugada pointed out. Inside cardiac tissue Ten years later, around 2010, the medical team realised that they had to go even further in their under- standing of arrhythmia, beyond ana- tomic knowledge; they also needed to know what was inside the heart tissue. ‘We wanted to see how the tissue is built in the heart, to assess tissue structures and understand how dif- ferent elements of cardiac tissue can be identified as normal or abnormal areas. This can only be done with nuclear magnetic resonance imag- ing. Only then did we begin to understand what the true nature of the tissue is,’ Brugada said. MRI enables us to depict details in both ventricles. Checking the left ventricle, especially, remains crucial because of the various potential origins of arrhythmia. ‘If you have a myocardial infarction, we know the abnormal tissue can be located in the endocardium site and even the mid-myocardium site. So you need to see the structure of this tissue. That’s why all the efforts are now focused on understanding how the tissue is structured and built in the ventricles.’ MRI provides information on the nature of tissue, and, used in combi- nation with electrical mapping sys- tem, helps identify electrical path- ways or channels that may cause arrhythmia. Unveiling the electrical and thus prevent the electricity going through the pathways that cause arrhythmia.’ Major contribution MRI is also used to guide interven- tion and correct potential error; this is a new and major contribution of imaging to arrhythmia treatment. ‘You need to integrate this imag- Editor-in-Chief: Brenda Marsh Art Director: Olaf Skrober Editorial team: Wolfgang Behrends, Sascha Keutel, Brigitte Dinkloh, Marcel Rasch Senior Writer: John Brosky Executive Director: Daniela Zimmermann Founded by Heinz-Jürgen Witzke ISSN 0942-9085 Correspondents Austria: Michael Kraßnitzer, Christian Pruszinsky.China: Nat Whitney France: Jane MacDougall. Germany: Anja Behringer, Eva Britsch, Annette Bus, Walter Depner, Emelie Hofstetter, Cornelia Wels-Maug. Great Britain: Session highlights cardiac arrest in w MRI has a central role in picking up myocardial infarc nary disease, a condition that particularly af with potentially fatal outcome. Heart attack in women presents dif- ferently than in men and requires a different approach when it comes to detection and prevention, accord- ing to Allison Hays, a cardiolo- gist and assistant professor at the Johns Hopkins University School of Medicine, speaking at CMR 2018 meeting in Barcelona. ‘Women don’t present typically with chest pain, but rather with tiredness or shortness of breath. When they eventually come in for diagnosis, women have much less rates of having abnormal cardiac catheterisation test, which shows degree of stenosis in coronary arter- ies. So, much more commonly, they Allison Hays MD is a general cardiologist and interim Director of Echocardiography Programs at the Johns Hopkins Heart and Vascular Institute. She is also an assistant professor at the Johns Hopkins University School of Medicine. Having graduated from Stanford University she received medical training at the Columbia University College of Physicians and Surgeons. Following her residency at the New York Presbyterian Hospital at Columbia Hays pursued cardiology fellowships at New York University Medical Center and at the Johns Hopkins University School of Medicine. Today she studies ways to use non-invasive imaging to detect cardiovascular disease. In terms of research, Hays uses cardiac MRI as a tool to study coronary and systemic endothelial function. Professor Josep Brugada studied medicine at the University of Barcelona, Spain, before moving to the University of Montpellier, France, to specialise in cardiology. He continued training in Maastricht, Netherlands, to specialise further in the clinical and basic aspects of cardiac arrhythmias, and he worked simultaneously in the basic and clinical electrophysiology laboratory. Brugada then became Assistant Professor at the University of Limburg and was the first foreign established investigator of the Dutch Royal Academy of Arts and Sciences. In 1991 he returned to the hospital at the University of Barcelona, where he became professor of medicine, head of the arrhythmia unit, and of cardiology, director of the thorax institute and finally medical director. He is now professor of medicine, director of the paediatric arrhythmia unit at Sant Joan de Déu Hospital in Barcelona. ing and perform 3-D imaging of the heart because you want to see exactly what is happening,’ Brugada explained. ‘That’s a technique we use every day, and increasingly to treat atrial arrhythmia in atrial fibril- lation,’ The main interventional treatment of AF consists in blocking the pul- monary veins using radiofrequency, i.e. by burning around the veins to create a line of electrical block. During the procedure, gaps may occur in these lines of block; these breaches can only be spotted on MRI. Being able to pick these gaps will lead to redoing the procedure and improving treatment success and patient outcome. In the future, MRI will continue to improve treat- ment efficiency in AF, a disease that affects millions of patients world- wide, and ventricular tachycardia patients, whose only chance of sur- vival is to receive ad equate treat- ment. ‘There are fewer cases of ventricular tachycardia than AF, but these are very severe patients who need a cure. It is fundamental for their survival and the only thing we can do right now is to target the right electrical pathways.’ Brenda Marsh, Mark Nicholls. Malta: Moira Mizzi. Spain: Mélisande Rouger, Eduardo de la Sota. The Netherlands: Madeleine van de Wouw. USA: Cynthia E. Keen, i.t. Communications, Lisa Chamoff. Subscriptions Liane Kaiser, Theodor-Althoff-Str. 45, 45133 Essen, Germany Subscription rate 6 issues: 42 Euro, Single copy: 7 Euro. Send order and cheque to: European Hospital Subscription Dept Printed by: WVD, Möhrfelden, Germany Publication frequency: bi-monthly Representatives China & Hongkong: Gavin Hua, Sun China Media Co, Ltd. Phone: +86-0755-81 324 036 E-Mail: gavin_hua@163.com Germany, Austria, Switzerland: Ralf Mateblowski Phone: +49 6735 912 993, E-Mail: rm@european-hospital.com France, Italy, Spain: Eric Jund Phone: +33 493 58 77 43, E-Mail: ej@european-hospital.com GB, Scandinavia, BeNeLux: Simon Kramer Phone/Fax: +31 180 6200 20 E-Mail: sk@european-hospital.com Israel: Hannah Wizer, International Media Dep. of El-Ron Adv. & PR Co., Ltd., Phone: +972-3-6 955 367 E-Mail: hw@european-hospital.com South Korea: CH Park, MCI Phone: +82 2 730 1234, E-Mail: mci@unitel.co.kr Taiwan: Charles Yang, Phone: +886 4 232 236 33, E-Mail: medianet@ms13.hinet.net USA & Canada: Hanna Politis, Media International Phone: +1 301 869 66 10, E-Mail: hanna@media-intl.com All company, brand and product names in this publication are the property of their respective holders. Users must obtain permis- sion from those holders before copying or using the owner’s trademarks, product and company names or logos. EUROPEAN HOSPITAL Vol 27 Issue 4/18

8 CA R D I O LO G Y HemoDynamic Analytics in Ultrasound A new tool box enhances heart failure diagnosis One of the challenges for every echo- cardiography lab is the technically difficult patient. Conventionally, labs use contrast agents to enhance endocardial border visualization. The application of contrast agents increases the exam time, resources and costs. Additionally, the use of contrast turns a previously non- invasive exam into an invasive pro- cedure. Hitachi Healthcare has now devel- oped a collection of cardiovascular analytic tools called HemoDynamic Analytics (HDAnalytics). These tools can be used for evaluation of the left ventricle (LV) when visualization is limited. One of the main applica- tions of the collection, LV eFlow was designed to demonstrate the discrimination between the blood flow and the cardiac tissue and offer an alternative to contrast agent use in some cases. LV eFlow is a high-definition left ventricular cavity blood flow imaging mode which substantially improves spatial and temporal reso- lution for a better visualization of the endocardial border in the left ventricle. The new tool operates with higher sensitivity and resolu- tion than conventional methods. LV eFlow may change a technically dif- ficult study into a diagnostic exam without using contrast agent. Head-to-head with echo contrast Dr. Zuyue Wang and technolo- gist Marvin Tyson of MedStar Washington Hospital Center had an opportunity to use this tech- nology in their practice over a period of 3 months. Their protocol included identifying patients that were candidates for contrast agents due to the difficulty in visualizing the endocardial border of the left ventricle. LV eFlow was added to the exam protocol for this patient set. Following the exam, the quality of the endocardial border delineation was evaluated by comparing the LV eFlow images with the images using contrast agents. Dr. Wang and Marvin Tyson com- pared LV eFlow and echo contrast agents in patients with suboptimal image quality and were impressed with the results. They found that “LV eFlow was comparable to echo contrast in improving visualization of difficult-to-image segments in selected patients”. Additionally, they found “a markedly more precise endocardial border delineation” and stated that “contrast agents should only be utilized when LV eFlow fails to enhance the endocardial borders”. Left: LV eFLOW – technically difficult patient; right: VFM – relative pressure with a dilated cardiomyopathy. Source: Hitachi Medical Systems Europe Vector Flow Mapping & Dual Gate Doppler Another tool in the HDAnalytics collection is Vector Flow Mapping (VFM), a novel and validated appli- cation that allows users to assess cardiovascular blood flow distribu- tion in an observation plane. This non-invasive technique is derived from the Color Doppler velocity data and generates the velocity fields on the 2D image. This allows to visual- ize, measure and analyze different parameters from the blood flow dis- tribution. For example, energy loss which is the rate of energy dissipa- tion due to blood viscosity, increas- es where turbulence flow occurs. In addition, wall shear stress, relative pressure and vortex characteristics can be evaluated. The Dual Gate Doppler (iDGD) generates a full Fast Fourier Transform (FFT) analysis and dis- play from two separate sample gates allowing measurements from two different locations during the same cardiac cycle. Hitachi Artificial Intelligence technology enables automatic sample gate placement and measurement at appropriate heart beats, resulting in 5 seconds to get E/e’ (83% shorten time com- pared with conventional measure- ment). Furthermore, iDGD works well for PW/PW and TDI/TDI com- binations. 2D tissue tracking (i2DTT) With 2D Tissue Tracking (i2DTT), the HDAnalytics set also provides an advanced tool which allows users to track the displacement of the cardiac tissue by using a novel and accurate algorithm of “Speckle Tracking”. Doppler based methods such as TDI are limited in evaluat- ing the displacement velocity of the tissue due to angle dependency. i2DTT allows the detection of veloc- ity components perpendicular to the beam which is impossible with conventional Doppler techniques. Tracking image by image, the natu- ral patterns of the cardiac tissue in B-Mode permits the user to quanti- tatively evaluate the movement and the thickening of the myocardium. i2DTT provides precise quantitative information such as longitudinal and radial strain, torsion rotation angle, displacement, wall thicken- ing and various other parameters to visualize, quantify and analyze myocardial mechanics. Applications include cardiac function analysis, resynchronization therapy, cardio- myopathy, stress echo and other global and regional studies. New analysis suggests workflow is key in remote monitoring It’s time to look again at IN-TIME As the world’s largest cardiology con- gress gets underway in Munich, it’s worth looking back to previous ESC sessions to see how scientific debates have evolved. At ESC 2016, held in Rome, REM-HF investigators presented data suggesting remote monitoring in implantable cardiac devices offered no added clinical benefit. Two years on, there are new reasons to re-examine that conclu- sion, with a recent analysis of the IN-TIME trial suggesting the key to remote monitoring benefits might be found in workflow processes. Published in The Lancet in 2014, the IN-TIME study is the only trial, to date, to have demonstrated a clear benefit of implant-based remote monitoring in heart failure (HF) patients – showing a more than 50% reduction in all-cause mortality – while eight other studies included in a 2015 meta-analysis, and three other recent trials, found no signifi- cant clinical benefit. However, IN-TIME was also the only implant-based remote monitor- ing trial using a transmission tech- nology that sent daily updates to a central monitoring unit. By contrast, REM-HF used technology that trans- mitted implant data on a weekly basis. So why does IN-TIME show positive results when other remote monitoring studies don’t? What is so fundamentally different in its methodology that might account for its results? Multiparametric data in This the recently published Remote is a central question Monitoring and Clinical Outcomes: Details on Information Flow and Workflow in the IN-TIME Study by Husser et al. The authors note that IN-TIME featured multiparamet- ric data that was transmitted daily. Crucially, a workflow process was set up such that study investigators could typically contact patients less than a day after receiving an event alert and arrange any necessary follow-ups for less than a week later. The study authors point out that, in the recent TRUECOIN meta- analy sis, the IN-TIME approach was shown to be beneficial for patients with heart failure, since it provides early enough warning to potentially prevent deterioration in the patient’s condition due to new onset atrial fibrillation, asymptomatic ventricu- lar tachycardia, or other adverse events. It is this early appraisal – facilitated by efficient workflow processes, including multiparamet- ric daily transmissions — that make the difference in the IN-TIME study, authors argue. As the European cardiology com- munity gathers for ESC 2018, it’s an excellent time to re-examine exist- ing evidence for clues we may have missed, alongside the latest break- ing research. That’s why it’s time to look again at IN-TIME. EUROPEAN HOSPITAL Vol 27 Issue 4/18 Home Monitoring Service Center Central Monitoring Unit Clinic Patient BIOTRONIK ICD/CRT-D Prompt in-office FU if interview is ‘positive’ (asap) Daily automatic transmission (Mo-Su) Prompt patient contact if IN-TIME event is clinically relevant (asap) Daily HM alert evaluation and classification as IN-TIME events (Mo-Fr) Device diagnostics (last 24h) HM alerts IN-TIME Events Structured Interview Immediate automatic data evaluation (Mo-Su) IN-TIME 365 messages 83% - 94% received after 1 - 3 day(s) n.a. 100% of HM alerts notified on the same day 4.0 In-Time events n.a. Until next working day 2.1 contacts n.a. Median 1 day [IQR 0 – 5] ACTIVITY WORKFLOW PERFORMANCE Events per patient year Success Delay IN-TIME Workflow Performance Less than one week