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courses across all key Radiology. So Specialties

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learn more at MRI online.com today. We're

0:43

honored to welcome Dr. Gianni Lorenz for

0:46

the lecture on chest pain evaluation during contrast shortages.

0:50

He completed his Diagnostic Radiology residency

0:53

at the San Antonio military health system and

0:56

advanced cardiac and theoretic Imaging Fellowship of

0:59

the Cleveland Clinic, Ohio. He is the section head for

1:02

thoracic Imaging.

1:04

And Lead cardiac imaging advisor for the Department of the Air Force

1:07

at the end of the lecture, please join Dr. Lorenz in

1:10

the Q&A session where he will address any questions you may have on today's

1:13

topic, please use the Q&A feature to submit your

1:16

questions and we will get to as many as we can before our time is up

1:19

with that being said we are ready to begin today's lecture Dr.

1:22

Lorenz. Please take it from here.

1:25

I want to thank you for that wonderful introduction. Thank

1:28

you so much to the MRI online team and to all of

1:31

you out there who are spending your lunch and learn

1:34

time with me. This is obviously a

1:37

very important topic to me. But to many of

1:40

you who are colleagues and friends you might be

1:43

finding yourself in a similar situation here. So

1:46

hopefully some of the material that I'm presenting to you

1:49

will be useful to you as we Deep dive

1:52

into something specific and you're in dear

1:55

to my heart which is chest pain chest pain evaluation. And

1:58

how do we evaluate this during contract

2:01

shortages?

2:11

So there are a couple things I wanted to

2:14

get across and so I decided to divide this up

2:17

into three components one of which is contrast and why

2:20

it's so important right now and why it seems

2:23

to be within the news and seems to be a big player within your

2:26

departments as well as with your patients. Then we're

2:30

going to dive into chest pain and chest pain evaluation by Imaging and

2:33

then spend the bulk of the the time

2:36

remaining on Solutions. And this will

2:39

be a distillation of some of those solutions that have come out recently as

2:42

well as my own institutions guidelines and

2:45

solutions that we've come up with.

2:47

But not everything is all doom and gloom out there. Just

2:50

remember this is still summer. It's a wonderful time to be

2:53

in the US and there are some really great things that

2:56

we can do as well as enjoying the pool, but

2:59

also within our department so always keep

3:02

that in mind that the positivity and optimism that you bring to your departments

3:05

is extremely valuable and that is worthwhile in

3:09

finding those Solutions.

3:12

So timely for me

3:15

and my department, I can't tell you how we did

3:18

probably did not pay attention

3:21

to some of the key Assets in

3:24

the service pipelines that we should have

3:27

and so had we know we might

3:30

have done things differently.

3:33

So as I mentioned we're going to Deep dive

3:36

into contrast. What is it? Why is it important now and

3:39

then see a little

3:42

bit more about how this has had such a huge impact into the

3:45

delivery of healthcare.

3:47

But first a quick case.

3:51

This is a 65 year old female with prior known

3:54

anomalous left pulmonary vein to

3:57

coronary sinus with a suspected steel phenomenon

4:00

having chest pain on this

4:03

slide. You can see on your left and axial

4:06

coronary CTA a coronal CTA

4:09

reformat and then a fractional flow

4:12

Reserve heart flow functional evaluation

4:15

of the iodine as it courses

4:18

through those coronary vessels. This exam

4:21

was done obviously with contrast about a

4:24

year and a half ago and it was

4:27

read out as being a potential intermediate

4:30

which means that the amount or

4:33

percentage of stenosis within there was less than the

4:36

degree required for further intervention the

4:39

fractional flow Reserve particularly in

4:42

that right coronary arteries, you can see starts out

4:45

proximately at 0.9 which is a very healthy blue green

4:48

and then it gets to its worse.

4:50

0.85 she comes

4:53

back to the clinic approximately two weeks ago

4:56

with persistent chest pain.

5:01

But we'll come back to that case.

5:04

Let's Deep dive into manufacturing of an eye denied

5:07

a contrast media.

5:09

And if you like me work with this substance, you

5:12

probably weren't aware of the complexity of

5:15

the manufacturer and the different components that are

5:18

necessary here.

5:21

First of all, the process begins here in beautiful Linda's Norway

5:24

linda'sness is known for

5:27

many things one. It's beautiful landscape as

5:30

well as its world famous underwater restaurants.

5:33

It also is the world's largest mining

5:36

of iodine and complexing of iodine to

5:39

create what we call iohexol which is

5:42

iodine plus sodium that's been pH stabilized.

5:45

I've never visited this restaurant, but

5:48

I'm sure that the food is fantastic.

5:53

And of course, this is a lunch and

5:56

learn. I apologize. We were unable to

5:59

provide food, but we are sending pics

6:02

and you might see a few reminders of this during my lecture.

6:07

So getting back to the contrast as you can see here, it's actually

6:10

quite simple from an organic perspective. Essentially.

6:13

It starts with a primary manufacturer of

6:16

iotexal from iodine and sodium and then

6:19

this then is stabilized or

6:22

a long journey to Shanghai approximately

6:25

by both. This is about 53 days

6:28

and there while Wilson Shanghai

6:31

it begins a purification of pH balance

6:34

and final Packaging.

6:38

Within Shanghai, there are several different Districts The

6:41

District that's important to us is the what

6:44

we call the high tech Park in Shanghai

6:47

pudong this there. There

6:50

is a facility that's approximately 15 years

6:53

old and owned by

6:56

GE and it has undergoing

6:59

several improvements in science and

7:02

Manufacturing capabilities do now it's a 350 million

7:05

dollar Behemoth of a facility that handles a

7:08

significant supply of the contrast within the

7:11

world at this facility the purification and

7:14

the pH balancing is hers and there's spinal

7:17

packaging where a purity test

7:20

of these material is approximately 99%

7:25

It's a fantastic process and one of which that that

7:28

G and other vendors should

7:31

be very proud of their capability of being able to provide.

7:36

So we know now a little bit about how contrast is

7:39

made and where where

7:42

we're going to go with this is why

7:45

is this important to us particularly now?

7:49

This material as you can see packaged up ready to

7:52

go from one of our inventories so

7:55

centers they're

7:58

obviously is a medical need for

8:01

contrast and many of my colleagues who probably aren't

8:04

right now don't need to be reminded of the utility in

8:07

the usefulness of contrast agent particularly for CT, but

8:10

there's also other reasons and one of the which

8:13

is that this material has an amazing opportunity

8:16

to provide further care in areas

8:19

that we currently are not doing very well

8:22

and one of which is the research realm and another one

8:25

which is an Automation and quantification.

8:28

Much of this world supply of contrast is

8:31

airlifted around the world. So it's not necessarily a shipping

8:34

component as it

8:37

is necessarily than a other component

8:40

that I'll get into a little bit suffice to

8:43

say that this is a large Market. This is approximately five billion dollars

8:46

of a market 1980 contrast

8:49

the US market, of course makes up the

8:52

larger component of it approximately 2.4 billion

8:55

markets around 66% of

8:58

that entire world market.

9:00

As a side note contrast is

9:03

an extremely industrious area and

9:06

the compounded adjusted growth rate

9:09

of this Market continues to grow at approximately 4%

9:12

per year.

9:18

So what happens?

9:21

And why are we talking about this now?

9:24

This is what happens.

9:26

Well, actually not this this is a parascribe but

9:29

actually this just in time

9:32

medical Logistics and if you're unfamiliar with

9:35

this term or this philosophy, this is an

9:38

inventory system that acknowledges

9:41

the ratio of consuming something

9:44

and the cost to save it

9:47

storage and those two things are

9:50

always intention, right? We want

9:53

to have a certain amount to be able to do the job. We want to

9:56

be able to grow but also the same time we just don't want

9:59

to have it sit around for other reasons this

10:02

practice which is used in other Industries is

10:05

extremely extremely cost-effective and

10:08

so many institutions larger organizations

10:11

and additionally smaller

10:14

organizations that are working with a smaller footprint have utilized

10:17

just in time buying to control

10:20

those supply chain costs.

10:22

In contrast, we have another methodology

10:25

as far as how we deliver care

10:28

which is called the just in case methodology

10:31

and here's a side-by-side comparison of those

10:34

two different methods and basically

10:37

just in case is you just have a lot

10:40

more hanging around for your surge capabilities.

10:46

So let's get back to this question what happens?

10:49

Well, the pandemic taught us that no one system can

10:52

tolerate all the various stressors both

10:55

economic and in shortage

10:58

wise at the same time.

11:01

And so post pandemic we had

11:04

then a a significant restriction when

11:07

and when a pandemic

11:10

covid variant wave went through

11:13

the manufacturing center of China. And as

11:16

you can see by this craft here it from 17

11:19

march to 16 May. So approximately two months. There

11:22

is a huge shutdown of

11:25

one of the largest centers. This

11:28

was a Citywide lockdown which closed

11:31

workplaces schools and factories to give

11:34

you an idea about behind this the population

11:37

of Shanghai is 26 million

11:40

New York City population the downtown core

11:43

Manhattan Island in the Burrows is approximately

11:46

eight million. So we're talking about more than three

11:49

New York City of personnel of

11:52

workers of equipment of manufacturing that

11:55

was completely shut down for two months.

11:59

And so what we had noticed then is

12:02

around that early April timeframe as you can see from that crap

12:05

there. We started to get large callbacks

12:08

or that is delays in our inventory

12:11

requests. And unfortunately this

12:14

persisted as

12:17

by that graph and the what

12:20

we had noticed then is that by around

12:23

mid April approximately 19

12:26

April to be specific. GE

12:29

did come out and did say that the full

12:32

lockdown had unfortunately vested their

12:36

entire inventory and they were unable to make Supply

12:39

at the current needs of the world.

12:43

This is a significant blow again. The compounded

12:46

annual adjustments the amount

12:49

of market share GE is a huge player in

12:52

the world's identity contrast. And so when this

12:55

particular facility one of

12:58

their two facilities had gone down contrast across

13:02

the world Health Care in general had a

13:05

corresponding Slowdown.

13:09

So let's package that up and just do a quick review here again.

13:12

I donated salt starting in Norway are

13:15

sent to China for purification and

13:18

packaging this consumption of this

13:21

material leads led to further consolidation

13:24

of some of the vendors and so we had essentially

13:27

two to three large vendors across the world.

13:31

The philosophy of Justin time that is

13:34

ordering from your current local vendor to just in

13:37

case was a significant tenuous philosophy

13:40

and but

13:43

as you had seen before the just

13:46

in time was a prevalent Philosophy for many

13:49

different institutions.

13:53

So now let's go into a little bit about chest pain

13:56

and imaging or chest pain now that we know that contrast was

13:59

such a big deal. Let's find out where it plays

14:02

a role within chest pain.

14:06

So I'm going to pose this question to you.

14:09

And data, as you can see here provided by

14:12

the CDC indicates that the percentage of

14:15

both chest pain abdominal pain as a symptom

14:18

continues to persist that is despite all

14:21

the things we've done. We still see a huge significant

14:24

bite of the evaluation related

14:27

to the symptoms of chest

14:30

pain or abdominal pain and it would as a cardiothoracic individual

14:33

I do see that there is overlap. That

14:36

is the Epic gastric and then the lower chest pain

14:39

sort of as amalgamum much of that stuff, too.

14:43

the

14:45

In our current institution, we have

14:48

provided a report to the house armed services committee. And with

14:51

that symptom chest pain they

14:54

asked us how do we evaluate it? And so when we

14:57

looked at the numbers between 16 and

15:00

20, this is sort of a spread and I don't

15:03

know if you need to get your classes on but that very very

15:06

tiny red thread of a pie

15:09

segment there or 1%

15:12

is the CT component that was

15:15

utilized for chest pain evaluation much of

15:18

this was not CT or anatomic evaluation

15:21

much of it was functional evaluation by

15:24

way of treadmill or expect

15:27

nuclear medicine.

15:31

So before we jump in I want to show you another quick

15:34

case and why then CT somehow became such

15:37

a huge player.

15:39

This is a amalgamental approximately three different cases here

15:42

of the utility of an anatomic or

15:45

CT approach to evaluation of chest pain here

15:48

on the upper left here with the big red arrow. This

15:51

was a 54 year old female who came in with chest pain her troponians

15:54

were negative. She was pending a

15:57

functional evaluation again that either the walk

16:00

treadmill test or this nuclear medicine

16:03

stress test. And so I asked her let's just go ahead and

16:06

just do a coronary CT evaluation and during that

16:09

coronary CT evaluation. I actually had her point to where the

16:12

chest pain was and she quickly pointed to the anterolateral

16:15

aspect of left aspect of

16:18

her chest. So I put a little marker there and I looked and

16:21

surprise as you can see there. The big red arrow is pointing

16:24

to an undiagnosed large left breast

16:27

cancer.

16:28

in the upper right here a 60 year

16:31

old male was who had complained to his

16:34

ER provider audismian chest pain much of

16:37

which was stridorous and with activity had a

16:41

CT chest evaluation done and was found to

16:44

have massive thyroid goiter compressing its trachea

16:47

again the chest pain evaluation up

16:50

to this point in my institution was not anatomic based

16:53

so much of these at least to these two conditions

16:56

probably would have gone a bit further without

16:59

the evaluation and finally in the lower right

17:02

this 74 year old

17:05

male with chest pain was known to have coronary artery disease who

17:08

came to the ER was further evaluated and

17:11

as you can see in this quantification and advanced

17:14

visualization breakdown here,

17:17

there's a lot of coronary artery disease in there

17:20

the calcifications than there are significant, but what

17:24

we were able to do from the CT was to add

17:27

the functional evaluation

17:28

By way of fractional flow Reserve technology and

17:31

be able to get him not into a further

17:34

or additional test, but actually to optimize medical

17:37

therapy.

17:39

So these three cases do indicate then that

17:42

there is a significant role for CT or an

17:45

anatomic based evaluation for chest

17:48

pain.

17:50

And this was also seen in much

17:53

of the data that has come out from 1999

17:56

to 2000 and reiterated that

17:59

Advanced Medical Imaging has increased in

18:02

usage within an acute

18:05

setting as well as in a routine setting here both for

18:08

abdominal pain and for chest pain as you can see there approximately 360

18:11

percent increase in

18:14

the chest pain evaluation by way

18:17

of Advanced Imaging

18:21

So we know now that CT is

18:24

a huge opportunity for us for evaluation

18:27

of chest pain.

18:29

Now I keep coming back to the incentivize portion

18:32

of it because this is essentially what creates an

18:35

opportunity for us to use what we have and so the market

18:38

for iodine contrast

18:41

and then Advanced Imaging by

18:44

way of CT continue to grow and

18:47

so when you put those two factors together usage growth

18:51

you then have a combination that

18:54

allows us then to do other things which is

18:57

to evaluate if this then has any

19:00

kind of guideline relationship.

19:02

And surprise, it does both societies

19:05

guideline care

19:08

and appropriate use criteria started to investigate

19:11

the usage of Advanced Imaging and found that

19:14

there was a significant Advantage probably the

19:17

largest or most impactful change to

19:20

chest pain just came out recently in November of 2021

19:23

that indicated with a one

19:26

am recommendation that anatomic

19:29

testing that is Advanced Imaging utilizing

19:32

a CT approach actually had a

19:35

significant backing of of evidence

19:38

to Showcase that that you can certainly do

19:41

chest pain evaluation by way of CT. So we're going

19:44

to do a quick Deep dive into this.

19:46

This guideline is a significant

19:49

policy shift and with any significant

19:52

policy policy shift is a whole

19:55

lot of pages to kind of digest so graphs and

19:58

algorithms such as this can sometimes be

20:01

very painful to review because there are

20:04

many different cases in situations to evaluate. So

20:07

we're going to hone in on this section here and

20:10

basically talk about the intermediate in

20:13

high risk chest pain individual and as

20:16

you can see coronary CTA on

20:19

the left and stress testing on the right the coronary CTA has

20:22

a 1A and stress testing has a 1B recommendation, but

20:26

both are useful for evaluation of

20:29

chest pain.

20:33

A quick breakdown between the two as far

20:36

as differences and these are just my own

20:39

interpretation and highlights for it. Coronary CTA

20:42

among others different types of CT examinations

20:45

for chest pain are highly reproducible. They oftentimes

20:48

a very quick acquisition time. They can

20:51

be done both in Retreat routine and er settings

20:54

and then there is typically a simple evaluation

20:57

or management impression that

21:00

involves grading the amounts of plaque

21:03

or the best components stress. Testing is very

21:06

much dependent on Tech and facility capabilities. Sometimes

21:09

those exams can be longer and the

21:12

reimbursements Although our higher currently

21:15

right now because the amount of time and Tech

21:18

components we do see that CMS is

21:21

eyeing these for potential shifts.

21:25

Another way of looking at CT is by other

21:28

management related outcomes. And

21:31

so on the left here, we have an long-term

21:34

outcome evaluation of coronary

21:37

CTA versus standard care. And

21:40

as you can see between the difference there standard care

21:43

alone versus coronary CTA. There was a significant

21:46

long-term change to the

21:49

outcome of the patient and I will refer you

21:52

back to that patient who complain to chest pain but had

21:55

not Corner disease but actually had breast cancer.

21:58

And so I think when we take a

22:01

anatomic approach, we sort of then have an opportunity

22:04

to see the other Myriad reasons for chest

22:07

pain as opposed to just a functional evaluation.

22:11

Radiation doses obviously dear to many of

22:14

my colleagues and so I'm highlighting here the differences

22:17

in radiation between a typical coronary CTA

22:20

from 2015 versus a

22:23

nuclear medicine examination.

22:27

Utilization of new techniques like fractional

22:30

flow Reserve can often times be obtained

22:33

from the CT. What's

22:36

interesting about this is that this is a methodology that allows

22:39

us to to functionally evaluate. So let

22:42

me say that again. We have CT information of

22:45

the anatomy and then we have the functional information that

22:48

can be obtained from the CT at any

22:51

time either immediately with the CT or at

22:54

any choosing. So this is a huge game

22:57

changer here. And so we're able then to compare the

23:00

anatomy and the function on one single

23:03

test as opposed to then a multi-test multi-interventional

23:06

sort of approach.

23:10

I'm going to go over one quick case just to highlight

23:13

this we have an individual here the 56

23:16

year old male with chest pain. He had very significant

23:19

plaque as you can see there that is very

23:22

difficult to discern as far as the amount of

23:25

stenosis. We call that a blooming calcified artifact

23:28

there. So the cataracts or the amount

23:31

of stenosis was equivocal what we're able to do was

23:34

to run the functional evaluation by

23:37

way of a fractional flow reserve and

23:40

be able to obtain then what is the amount of physically

23:43

physiologically significant stenosis of

23:46

that plaque from the CT and

23:49

avoid any further interventions or testing this

23:52

then allowed our patient then to

23:55

go straight from the CT scanner to optimize medical therapy

23:58

without any further testing.

24:03

So the last thing about why we should care then is that

24:06

there is huge opportunity

24:09

available to us. And if you

24:12

subscribe to anything to include Twitter artificial

24:15

intelligence within the cardiovascular

24:18

and cardiothoracic world is a

24:21

huge right now and it continues to be a large

24:24

player in the Advanced Imaging world

24:27

of machine learning deep deep learning capabilities.

24:30

So this is a significant opportunity

24:33

and I bring this up because much of

24:36

the Advanced Imaging ctmr and so

24:39

far are utilizing quantification for

24:43

that and make no mistake. There is a

24:46

significant incentive to evaluate this as

24:49

that market continues to increase

24:53

So let's package that off and do a quick review chest

24:56

pain represents a very top important symptom

24:59

across the world and within the US population. There

25:02

is a has been a

25:05

seismic shift from a pure functional evaluation

25:08

to inclusion or a primarily anatomic

25:11

evaluation and this

25:14

is reinforced by reimbursement as

25:18

well as guidelines and pre-authorization smart routing

25:21

and these Gold Card methodologies.

25:24

Advanced visualization Ai quantification and

25:27

registry population Health can take advantage of the

25:30

CTN Mr. Capabilities that

25:33

are built in.

25:37

So now let's do a deep dive into Solutions. I think

25:40

Solutions are probably one of the more important things so I'm going to spend a bit

25:43

of time here on this.

25:45

First I'll Trudeau's to all the administrators to

25:48

all my colleagues leaders within Radiology who very

25:51

quickly and I think probably the most.

25:55

Timely within two weeks had created

25:58

reviewed and delivered high quality articles

26:01

and opportunities for for sharing

26:04

the information across a large

26:07

swamp of the population both on social media

26:10

as well as in large articles. So this is just a

26:13

snippet of it. I currently have taken

26:16

a large opportunity an opportunity to review this

26:19

and to distal distill this down to

26:22

what I think are probably the three large

26:25

and most fruitful strategies and

26:28

so we'll go through these one by one.

26:32

So under reduced and reserve your identity contrast

26:35

media, I broke it up into probably three subgroup

26:38

categories and similar to

26:41

other Quant Mary centers those with level one missions

26:44

trauma missions and so forth. We actually

26:47

deferred our coronary CT evaluation and

26:50

the anatomic coronary evaluation to conserve

26:53

our our contrast for other chest

26:56

pain differentials and why we did

26:59

that is because we had created with many stakeholders

27:02

what we call a critical exam list. This

27:05

is a snippet of a critical exam list

27:08

from another institution and yours may be the

27:11

same or different but what's important is to identify that

27:14

line of the sand what exams if any that your

27:17

institution or Imaging Center are willing to do with contrast

27:20

and those without and for

27:23

alternative methods and I'll

27:26

highlight that this is not something done just with the Department

27:29

of radiology. This is in

27:32

Collaboration with your Administration your Departments

27:35

of Cardiology GI and Interventional Radiology

27:39

and Urology and so forth.

27:43

So the secondary thing that I think it's important

27:46

under the rubric of reducing Reserve identity contrast

27:49

is the direct evaluation and

27:52

reduction of iodenated contrast

27:55

by way of protocol updates and taking

27:58

those single use quote unquote

28:01

single use files and and basically having

28:04

that

28:06

So from the literature we had seen and many of

28:09

us know that we probably leave a

28:12

significant amount of contrast in the

28:15

non-interpreting region of

28:18

Interest.

28:19

And so here is a snippet of volumes of

28:22

contrast based on type of exam and I've got

28:25

a big red arrow on a cardiac coronary CT examination based

28:28

on size and we're going to use the greater than 90 kilogram

28:31

because we're here in Texas and we modified

28:34

this and similarly. We don't

28:37

use a 90 milliliter of volume. We actually

28:40

use a 60 to 50 milliliter volume

28:43

routinely and so I would suggest

28:46

taking those aliquots of volume

28:49

and actually making

28:52

them smaller going 50 75 100 and

28:55

200. So when you create a quartile

28:58

sort of situation, then that allows

29:01

the opportunity to use the less but then also helps

29:04

then to try to increase then the opportunistic

29:07

evaluation on

29:10

the area of Interest as opposed to then other

29:13

areas. So in a corner CTA, we'd

29:16

like to pacify the left side of the heart as opposed to the

29:19

right.

29:19

So we want to time all the contrast on that area by

29:22

using flow rate as well as ensuring them. There's a

29:25

good region of Interest protocol adjustments as well are

29:28

extremely important not just in contrast shortages, but

29:31

in general and so I highly recommend that you set up if you

29:34

haven't already a CT team that is set up to ensure that

29:37

evaluation.

29:39

Other methodologies and scanner

29:42

capabilities are also important and so I'm talking about

29:45

dual energy and Photon counting. So I'm gonna

29:48

go over a case here. This is a 20 year old female with

29:51

a high suspicion of PE. We use a

29:54

dual energy technique with a 50 milliliter dose

29:57

of contrast. And as you can see in that that beginning

30:00

portion of the exam there still was a long

30:03

train of contrast still available. The sequence

30:06

here that I'm showing is an iodine perfusion map. It is

30:09

set up to only show you the brightness of own but

30:12

also the iodine that is in the vessels and within

30:15

the pulmonary Prime come on the idea is here is that

30:18

there is a defect in iodine within the print come

30:21

out or within the vessel. This can be subtracted out for

30:24

their mind or the examination here.

30:26

And so I'll give you a second here to see if you can find the

30:29

area of defect.

30:31

Did you find it?

30:34

It's in that little area there there

30:37

in the bottom right of the lung and there's

30:40

a little arrow there pointing to that region of a filling defect.

30:43

This is a an envelope a

30:46

pulmonary thrombus associated with

30:49

covid-19 pneumonia. Essentially. It's

30:52

an eccentric complete non-acluding thrombus

30:55

that can hurt due to

30:58

inflammation.

31:03

So we've gone over establishing a critical

31:06

exam list a direct reduction of ionated

31:09

contrast. And finally we're going to go into the discussion

31:12

behind deferment of Imaging.

31:15

So learning from our pandemic experience

31:18

we felt as an institution that deferment

31:21

enclosure of services and service pipelines

31:24

was not in our best interest not only for our departments and

31:27

for our fellow colleagues and other departments,

31:30

but also for the patients this case backlog

31:33

this lost to follow up we're significant concerns

31:36

and we actually did a significant evaluation

31:39

of this by way of surveys and so forth and

31:42

we found that patients were also fatigued they just didn't

31:45

like their services delayed and so we decided

31:48

not to do a deferment of

31:51

Imaging as as possible here.

31:54

So I would recommend not doing that. There is

31:57

also some great literature that indicates that deferment or

32:00

of services can create in a deficit and

32:03

so it is postulated and

32:06

this particular study here that approximately 9.4

32:09

million Services were potentially

32:12

at risk and

32:15

screening deficits were were a

32:18

large component that was still sitting there

32:21

in the population. And I think that's actually underestimated. I

32:24

suspect that the covid shut downs and

32:27

restrictions have actually probably increased it even

32:30

more.

32:31

Okay, so we talked a little bit about deferment

32:34

we talked a little

32:37

bit about reducing and reducing identity contrast. Let's

32:40

jump into then alternate Pathways. And so

32:43

I broke up alternative Pathways into three of

32:46

the major chest pain components PE evaluation

32:50

aortic evaluation and coronary evaluation.

32:55

So a timely article by radiographics came out last

32:58

fall and alternative to

33:01

the low dose coronary evaluation VQ

33:04

scans are a viable alternative solution

33:07

and VQ scans ventilation profusions

33:10

evaluation has been around forever 1964.

33:13

I believe was the first use in

33:16

humans and this exam continues to provide some significant value

33:19

with the continued updates based on

33:23

new protocols. We actually have a very truncated examination

33:26

that in some instances

33:29

is pretty quick.

33:31

so

33:32

I'm going to take you through a very quick case here. This was a

33:35

30 minute acquisition of perfusion.

33:38

And this individual here had

33:41

no perfusion defects. So yeah, this is

33:44

an extremely easy way of evaluating for perfusion

33:47

defects. And so I consider bringing in

33:50

your nuclear medicine colleagues to

33:53

see what kind of additional resources might help contribute to

33:56

the evaluation pulmonary Amazon / chest pain.

34:01

When we talk about aortic pathology, we are essentially talking

34:04

about dilation of the of the

34:07

chain of the vessels. So caliber related in components

34:10

as well as intimal injury and I think

34:13

we have some really wonderful techniques available to

34:16

us outside of CT CT is an extremely useful

34:19

in Mainstay modality, but there are

34:22

some really wonderful ways and I'm gonna go over one with you

34:25

here Mr. A is a non-radiating

34:28

evaluation of vessels. And

34:31

as you can see from this non-contrasted examination that took

34:34

approximately five minutes a table time. We're able

34:37

to get Exquisite evaluation of caliber as

34:40

well as potential intimal relationships.

34:43

So this contrast to know is ratio again

34:46

without getting contrast is available due

34:49

to the spin capabilities inherent within

34:52

the protons that are floating through that blood. So

34:55

this is a wonderful opportunity to divert CT

34:58

evaluation of aortic path.

35:01

Allergy to Mr. Evaluation. Now, of course again, as we said

35:04

with nuclear medicine this does recall require then

35:07

a collaboration with your Mr. Colleagues

35:10

to ensure then that their space and time for it in our

35:13

institution. We have this down to approximately five minutes. So

35:16

that's five minutes of table time. And if you'd like I can go

35:19

that protocol with you, of course, it has been written up.

35:23

Finally, we're going to talk about coronary evaluation of

35:26

chest pain and this is one that's again something that I think we find

35:29

fairly frequently is being a positive concern.

35:34

The 2021 aha guidelines gave

35:37

us a lot of opportunity to play with new rather

35:40

routing modalities. So

35:43

utilizing the algorithm is indicated here.

35:46

We'll go through about three different ones. So for

35:49

our acute chest pain population with no known coronary

35:52

artery disease again. This is an individual

35:55

acute chest pain rolls into your er, no known

35:58

Corner art or disease essentially we're going to do a stress

36:01

evaluation and functional evaluation and this

36:04

is a 1B recommendation. So it's wonderful evidence, but

36:07

there are many options available to you as you

36:11

can see there highlighted in red

36:14

When we look at that acute Chase pain patient

36:17

with no Corner artery disease

36:20

again, we have some options. But again, this is a

36:23

functional evaluation. So I would highly recommend ensuring then

36:26

that you have the surge capability to handle

36:29

this with your with your nuclear medicine

36:33

as well as your Mr. Colleagues there your ER

36:36

colleagues love this examination because it can

36:39

answer a question relatively quickly. The problem

36:42

is that you've gotten so used to

36:45

CT evaluation. Then that that can sometimes

36:48

be something that they want to look at a little bit later on.

36:51

When we Deep dive into those who have known

36:54

Corner artery disease, we essentially have an opportunity

36:57

here to divert them that red arrow straight

37:00

to the stress testing. And so I'm going

37:03

to highlight this because in our next few slides

37:06

we're going to show what we did in our institution. So

37:09

again, this is a patient stable routine

37:12

chest pain known coronary artery disease

37:15

by some other methodology or met or exam.

37:20

So in our institution, we have quite a

37:23

list a two to three month scheduling and

37:27

so we had moved these individuals from from a

37:30

straight. Coronary CT angiogram to something

37:33

that was a combination of both an anatomic calcium

37:36

scoring examination and the functional evaluation

37:39

which is a stress MRI. And so

37:42

for those that had routine chest, I I think this

37:45

worked really nicely to provide that anatomic evaluation

37:48

and then the stress evaluation. So essentially if

37:51

we had a high enough pre-test probability or

37:54

risk that this individual had some disease

37:57

we can then evaluate that anatomically

38:00

by way of looking at the calcium distribution

38:03

and then see then if that then

38:06

warranted a media follow-up evaluation with

38:09

a stress test evaluation. So we

38:12

actually did have slots available immediately after

38:15

the coronary artery calcium

38:18

scoring evaluation to then

38:20

Directly to the Mr. Department for stress test

38:24

and I thought this made sense. I thought this was a really

38:27

nice way of utilizing both anatomy and functional evaluation

38:30

at one time and we have

38:33

a significant amount of patients who did go through this now many

38:36

of you might be thinking. Well, what about the time constraints behind us? Well,

38:39

according a tax score is essentially a five-minute examination.

38:42

We probably budgeted around a 10

38:45

minute 15 minute at most on the schedule.

38:48

But the stress test which some institutions can

38:51

have a significant time frame on

38:54

it. We narrow this down to less than

38:57

30 minutes. This is a 20 minute exam. This is in your same time

39:00

slots with your your neuro

39:03

or your msk. This is something that needs to

39:06

fit within there.

39:07

And so this of course has been written up and written

39:10

up recently that 30 minute stress testing

39:13

by way of Mr. Is an extremely useful examination and

39:16

I'll break down that timeline essentially what we're doing is

39:19

we're doing a functional evaluation that is

39:22

the anatomy of opening and closure of the left

39:25

ventricle. We're adding then contrast following a

39:28

stress chemical and then we're looking then for

39:31

the signal defect that we indicate a

39:34

vascular territory. We then of course add the

39:37

link down enhancement to help improve then our

39:40

specificity and sensitivity for a defect or

39:43

ischemic by way of then some potential other non-evaluated.

39:51

Myocardial infarctions so as recap CMR

39:54

is a wonderful methodology. It's

39:57

non-inferior both in determining ischemia and

40:00

the acute and the outpatient setting

40:03

and went head-to-head with invasive coronary

40:06

angiography and had wonderful results. This

40:09

is both in the spins registry and the Mr.

40:12

In form things.

40:16

registries

40:18

so let's go back to that first case. And if you remember we

40:21

had that individual 65 year old female known

40:24

anatomic anomalous left

40:27

pulmonary vein to the coronary sinus previously read

40:30

out as a cadrats 3 functionally evaluated

40:33

by way of heart flow and was found to have a

40:36

greater than 0.85 in her right corner artery.

40:39

So we actually because she had persistent chest pain.

40:42

We went through the process of a coronary calcium score

40:45

again, probably not going to change too much but just went through

40:48

the process and then put her into a stress evaluation by

40:51

the way of Mr. And we found that actually

40:54

she did have ischemic changes.

40:57

And so that's what the red arrow is showing is that area

41:00

of perfusion defect and the subbedocardium of

41:03

her mid proximal to Mid

41:06

right? Coronary territory. Now, I think what's important to

41:09

realize here is that things are always progressing. So maybe her

41:12

plaque progressed or that the test highlights

41:15

some extremely

41:18

For information that you can gain out

41:21

of the functional as well as the anatomic evaluation.

41:28

So she's happy. We're happy that we both did this

41:31

Examination for her.

41:32

So now broadly speaking we've

41:35

gone over reduced and Reserve identity contrast. We've

41:38

gone over alternative chest pain Pathways by

41:41

way of coronary of ctpas as

41:45

well as an aortic evaluation and then coronary

41:48

and then now let's talk about administrative.

41:52

So I'm breaking up administrative into three subgroups.

41:55

One of them. First of all, I think is probably my most controversial

41:58

idea and I can't wait to hear your thoughts on this but

42:01

I would suggest or consider setting up a radiology operation

42:04

and control center.

42:06

And so hear me out here as leaders in

42:09

healthcare operation and and service line

42:12

management is a crucial responsibility in

42:15

the Radiology service line and I'm

42:18

a big fan of putting Radiologists who

42:21

understand systems and system approaches into these roles.

42:24

I'm convinced that if we have a centralized management

42:27

of exam maturity from the ordering

42:30

from the provider to the patient showing up

42:33

to the reporting and an appropriate turnaround time.

42:36

I think if we invest a bit of infrastructure into

42:39

evaluating this real time, I think

42:42

we will actually get some significant gains and this of course

42:45

has been written up.

42:46

This is different than an Emergency Operations Center,

42:49

which is relative to a mass casualty

42:52

or a surge component. I think this

42:55

should be actually part of the day-to-day operations.

42:59

And when we think about what we've

43:02

gone through starting at the top of this

43:05

particular graphic here with the pandemic and making our way down

43:08

to where I believe we are with strained Supply chains labor

43:11

shortages component shortages and

43:14

shortages of durable goods. We find ourselves constantly in

43:17

this stop stutter. Stop stutter sort

43:20

of approach and I think having then an operation

43:23

control center would actually be extremely useful for

43:26

that adaptation into evaluate

43:29

Corruption of product lines real time.

43:33

back to food

43:37

So the secondary thing I think that's important from an administrative standpoint

43:40

is simulating mass casualty and

43:43

corrupted service lines and a post-pandemic world.

43:46

So this actually means getting out there and obligate

43:49

you sometime to then going through this

43:52

process in my institution. We obligate

43:55

time to provide surgery

43:58

resources and mash casualty response Department defense.

44:01

So we do this day to day this

44:04

Falls within the just in case

44:07

philosophy if you remember where we should practice and

44:10

have things available to us.

44:14

Now finally this last one here is an

44:17

important one again to my institution here, but

44:20

establishing a strategic reserve and following

44:23

this just in case model of a two

44:26

valuable to lose. This also has been written up and should

44:29

be something that we should.

44:31

Pivot towards not necessarily all the way but pivot

44:34

towards so unless you're a coordinary or

44:37

large tertiary regional health plan. You may not

44:40

be getting contrast or be able

44:43

to develop a strategic reserve of identity contrast

44:46

or other components in the near or the

44:49

short term maybe in the longer term. This is a viable

44:52

goal but I would suggest considering this something as a

44:55

as a larger goal to work towards and

44:58

you got to remember other regions too are

45:01

are unfortunately without contrast. So while

45:04

we may be the first in line to

45:07

receive contrast US market, there are

45:10

other areas that may not be able to get this and so they have

45:13

to then consider what are the Alternatives and where

45:16

are the administrative capabilities that they can then consider?

45:22

so in summary

45:25

Chest pain evaluation during contract shortage again. Remember

45:28

that iodine and salts

45:31

are sent to China for purification and packaging the consumption

45:34

of this over time has led to the consolidation and

45:37

the World Market Domination by essentially two

45:40

vendors the just-in-time versus the just

45:43

in case methodology is essentially a

45:46

save on cost versus a preparation for extra need

45:49

and you as a radiologist should be aware that you

45:52

have the capability to provide that input.

45:54

Chest pain represents a top symptom in the

45:57

US and across the world and we are shifting from a functional

46:00

evaluation of chest pain to a more anatomic evaluation

46:03

by way of CT or MRI in terms of

46:06

reimbursement guidelines and pre-authorization smart routing

46:09

and so forth.

46:11

Don't forget that in the future Advanced visualization and currently

46:14

right now ai and quantification registry development

46:17

are huge markets for CT and

46:20

Mr. Particularly in chest pain, and so I currently I'd

46:23

ask you to consider those as additional reasons

46:26

to evaluate for chest pain.

46:29

We have some strategies that we talked about one of which is

46:32

the reduce and reserve your identity contrast by setting

46:35

up a critical exam list alternative chest

46:38

pain Pathways do exist in our extremely useful and

46:41

then administratively Radiology operation

46:44

control center a strategic reserve of

46:47

identity contrast and other materials are extremely

46:50

important things to consider. So with that

46:53

I'm going to stop and take any questions you may have

46:58

but first in to tie it all up, let's build out

47:01

new workflows and service lines. Let's turn it on for 2022. We

47:04

have new opportunities to do things here. So

47:07

take every opportunity to learn from these. I

47:10

know I am and so I think you for your time and your

47:13

patience with me.

47:14

And we'll open up to any questions.

47:19

Okay, Dr. Lorenz, if you want to look at that Q&A section, you

47:23

do have two questions as of current.

47:27

Great.

47:35

So one of the first questions is what are some patient safety

47:38

risks that the Radiology technologist need to

47:41

be to pay attention to these type of patients. That's a

47:44

very good question. I would suggest that

47:47

guideline care should always

47:50

be maintained and patient safety

47:53

as well as the medical legal risk

47:56

with not having contrasting is a

47:59

very important point. We actually did have our medical

48:02

legal team evaluate this and

48:05

provide then some short-term suggestions recommendations

48:08

as far as interpretation reporting again, that

48:12

is risk benefit. So if you and your colleagues

48:15

are providing a standard temporary standard

48:18

care secondary to constraints, I

48:21

think that you your technologists would then

48:24

also be in within line. So hopefully that

48:27

answers that question. I'm going to move on to the

48:30

second question here ethical considerations of pursuing chest

48:33

pain studies based on huge Market.

48:35

Reimbursement factors. Absolutely, there is

48:38

no question that the ethics behind

48:41

doing something always should be in the

48:44

Forefront of any radiologist or ordering provider. There

48:47

is no reason to believe that we should

48:51

order anything based on the incentive

48:54

reimbursement. This is always guideline based

48:57

and there are many different types of guidelines that are

49:00

useful for this evaluation. Thankfully though ctmr and

49:03

some of these other ways of sense chest pain

49:06

evaluation have the backing of guidelines to show

49:09

their utility.

49:12

So when diagnosing a simple and common cause of chest

49:15

pain for instance, teeth syndrome here.

49:18

Can we use sonography to reduce the contrast cost of

49:21

time? That's a wonderful question and I do believe that you

49:24

have a very cost-effective mindset

49:27

as well as an appropriate mindset into what

49:30

is the best test that I can do right here right. Now that's going to

49:33

help the individual. I would consider it. I think that's

49:36

an opportunity. I think then additionally other

49:39

modalities can have then an opportunity to

49:42

evaluate this as well. Mike caveat

49:45

is ensuring them that there is a correlation to

49:48

appropriate use criteria as well as then what

49:51

you've considered as methodology for evaluating.

49:56

standard of care in your local region

49:59

the follow-up question to this is ultrasound usage for

50:02

covid triage and follow-up could save contrast and

50:05

cost both. Do you agree? I have certainly seen and

50:08

used and interpreted lung code

50:11

lung ultrasound and I do

50:14

believe that there is a role for it. There are some very specific and wonderful

50:17

biomarkers on ultrasound that can

50:20

be useful and I think that is something that certainly should be

50:23

looked at even more. My concern is

50:26

however is that large Society guidelines have not

50:29

endorsed the use of ultrasound for this and

50:32

so I'm unaware of those

50:35

large Society guidelines that have come out completely endorsing

50:38

but I like where you're going. I think this is useful

50:41

from a triage standpoint.

50:43

And finally role of artificial intelligence in

50:46

early diagnosis of ihd and

50:49

congenital heart disease. That's a wonderful question and

50:55

suggestion and an entire webinar on

51:00

its own. I personally am a big fan of artificial intelligence

51:03

and I do work with my vendors my colleagues my research

51:06

collaborators within my institution and

51:09

do find some significant gain of

51:13

trust that we can use with artificial intelligence.

51:16

I I look forward

51:19

to seeing more of it in terms of congenital heart disease. I

51:22

think actually it was just recent recently written up that

51:25

there has been larger gains in this what I would

51:28

probably consider more than the visualization is

51:31

the clinical decision support that

51:34

is how congenital heart disease can

51:37

then play a role and AI

51:40

technique can play a role into evaluating this

51:43

In determining then is a test useful right

51:46

now as opposed to having the radiologist or the ground

51:49

truth being able to identify that.

51:53

So if you like we can talk about that a little bit more another follow-up

51:56

question. Do you feel that post-pandemic period now is the

51:59

best time to promote preventative Radiology for chest pain

52:02

about Imaging and other Imaging absolutely there

52:05

is no better time to begin to evaluate for

52:08

preventative radiology and preventative that

52:11

is population health and registry development.

52:14

Then right now we have a Exquisite opportunity

52:17

to show people that enduring times of shortage. We

52:20

can still create a huge value

52:23

in our service lines. We can also create them opportunity

52:26

to do more population registry

52:29

development extraction of biomarkers that

52:32

are sitting on a CT or Mr. Examination that can

52:35

then move the patient to a different

52:38

service line osteopenia. For

52:41

instance in the evaluation bone mineral density

52:44

on the CT or visceral fat evaluation our two

52:47

areas that I personally am working on so I completely

52:50

agree.

52:51

And when is the iodine shortage going

52:54

to be over? That is an absolutely wonderful question. I

52:57

wish I had the crystal ball for that. I will tell you

53:00

however as I'm looking through the news there has

53:03

been additional screenings covid related screenings

53:06

in Shanghai as a today that make

53:10

me worry that this is not we're not

53:13

completely out of the Woodworks yet. And I would be cautious

53:16

as to ensure suggesting

53:19

that that we're out

53:22

of this and that contrast will be available at 100% capability

53:25

to all those I would continue to

53:28

consider alternative Pathways and some of

53:31

the solutions that I mentioned there.

53:33

All right. So seeing as there are no

53:36

more additional questions. Thank you so much for that. Great talk Dr. Lorenz.

53:39

I learned a lot and thanks to all for your participation in

53:42

our new conference a reminder that you can access the recording of

53:45

today's conference and all our other previous noon conferences by creating

53:48

a free MRI online account. If you'd like to access, our

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Mastery series courses case series and much more educational content

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with a limited CME. You can sign up for a free seven-day

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trial of our MRI online premium membership. You can

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learn more at MRI online.com in the URL in the

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chat box. Be sure to join us next week on Thursday, July 14th 12:00

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p.m. Eastern time for a lecture with Dr.

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Jocelyn. Rapella on a practical guide to

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diagnosis a diagnostic breast ultrasound.

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You can register for that lecture at MRI online.com and

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follow us and social media at the MRI online

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for updates and reminders on upcoming noon conferences. Thanks

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again, and have a wonderful day. Thank you everyone. Take

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care.