Remembering a Cardiac Cath Lab History

Let's take a nostalgic trip down memory lane. If you are old enough to remember the equipment discussed here, you are probably a baby boomer; if not, consider this both a history lesson and a peek ahead into the future. As the old saying goes, you need to know where you came from to appreciate where you are going. In the infancy of cardiac catheterization, x-ray images were high-dose, low-quality image intensifier images that were recorded on 16-mm or 35-mm film with Aero techno film magazines and video reel-to-reel tapes for playback. Processing of the images was the Achilles heel for all cases. The Jamison or Combulator processor in the darkroom could eat up a whole day™s work. Many was the night I would be in the darkroom, with not even a Wraten B Kodak filter light, hand-fishing the film out of the Jamison and smelling rancid fixer. The dryer would blow it into my nose and mouth so that for the next eight hours it was all I could taste. We also loaded film magazines with 35-mm cine film in the dark, knowing how to make the perfect loop so that the film would not jam in the camera and to make sure the film gate was closed. I remember balancing transducers for 30 minutes and testing them to make sure they were linear for that valve case, when the cardiologist would switch the gauges to make sure your gradient was accurate. I would anxiously wait for Dr. Fifer to tell me if my tracings were technically perfect. Some of you may also remember green dye studies and Beckman bags. What about developing the thermal paper? How many of you remember burning your hands in the rubber roller that spread the developer on the paper or worse yet, running out of developer in the middle of a long case? Gone also is the challenge of turning patients up on an angle, on Spectrum cradle tables. (At that time, the table™s patient weight limit was a mere 275 pounds compared to today™s 350-plus pounds.) No longer are patients being propped up on sponges for complex angle views. These once-essential sponges have long been placed back in a strategic corner of the radiology hallway or hospital basement. When the digital age arrived, the need for file rooms that reeked of ammonia from the reticulation of the film was no more. We no longer had boxes of film to go through only to find out that the patient film we sought was missing. Our leap into the future started with cine loops from companies named Eigen, Angiotech, Camtronics and Heartlab, added onto our Siemens, GE and Philips radiographic equipment. Early on, even before this period, we had cut film in a Schonander or Fisher rolled film device. We moved onto Parallelograms, LUAs and C-arms, and then Aerotechnic cameras, mounted overhead as image intensifiers. Today, only the C-arm survives. In a typical day, a large portion of the morning was spent on film and processor quality analysis before anyone in good conscience would start a case. We checked and logged the sensitometer and densitometry readings, and of course, the Line Pairs grid. Today, what used to be the biggest equipment risk factor, the film, is now a memory. At our facility, we now have echo to assist in the cath lab as well as intra-chamber echo from Siemens (Acunav). We have gone from electron-beam CT to 64-slice CT scanners, and soon we will be using a 256-slice CT scanner. Is this the new diagnostic tool that will turn the cath lab into the procedural OR arena? Or will this replace or join all the stress testing we do prior to a diagnostic cath? Will CT scanners become the new diagnostic tool in cardiology? Will diagnostic caths fade away? We have moved from image intensifiers, plumiconms, saticons, etc., to flat-panel technology, pulsed fluoroscopy, digital enhancing of images, subtracted images and bolus-chasing 3D imaging. It was farewell to the film file rooms and the order of reticulating film. We have moved on to cardiac PACS archival and transmitting images via the web. Viewing patient films has gone from a noisy Vanguard or Targano film-snagging projector to a digital computer-based PACS system that has also constantly needed our diligent attention and upgrading. Gone is the darkroom and file room person. Say hello to the high-tech, very well-compensated PACS administrator. Today, we can automatically, without radiation exposure, collimate our images (and I am positive every cardiologist and technologist is utilizing this feature) by using the previous images to collimate on and thus saving dose to our patients. We have lowered our frame rates from 60/second to 30-to-15/second and some say we may be able to go down to 7.5 (I am not so sure about that). We calculate and record our patient doses. We have patients sign consents that they understand they are receiving a radiation dose and may experience skin erythema or other radiation complications due to the accumulative doses they receive during cath and electrophysiology (EP) studies. Now our patients may also receive a high-dose CT study. How many patients undergo all three CT, catheterization and EP studies? We see and accumulate more information, and we do more intervention. Some of our volumes are declining due to the introduction of statins and the general smoking cessation of the population, but I do believe our volumes will come back in time. The 20- and 30-somethings are still smoking, so don™t put your cath labs in mothballs yet. We will return to our old volumes in a few years, if we are not all retired at that point. What else will we see if we look ahead? Procedure rooms are becoming the operating rooms of the future. I have opened two rooms in the OR and am working on my third. I have seen the cardiologist and the surgeon partnering into one cardiovascular institute, working with thoracic, neuro and peripheral vascular surgeons to form a seamless model of care for our patients. We are able to decrease open procedures, putting down the scalpel to embrace the maneuvering of catheters and insertion of drug-eluting stents, percutaneous valves, left ventricular assist devices (LVADs), and the many more procedures to come under the guide of fluoroscopy, endovascular imaging and simulation 3D technology. Now we need the equipment vendors to build radiographic tables to meet the needs of the surgeons, who today must also tilt and cradle. We need tables that must, of course, be radiolucent and have a brake in the middle like other conventional OR tables. Another thing I have discovered as we build these rooms of the future is that ceiling geography has become precious. How many lights and booms can you fit in a ceiling and still be able to move the C-arm? Today, life is definitely more challenging and our tasks more technical. I am happy to have outlived analog in the cath lab. I am proud have helped usher in the digital age and witness diagnostic cases advance to interventions. After taking my trip down memory lane, I can truly say I do not miss the old days. I never want to be in a dark room at 2 am rethreading the Jamison again. I can still smell the fixer and feel the hot air of the dryer on my face as I bend over the Jamison, standing on a stool in the dark and wondering who put that weak splice on the leader. The good old days are over! Georgann Bruski has recently been promoted to the Director of Contracting and Facilities for the entire Cardiovascular Institute of Beth Israel Deaconess Medical Center. She notes, This is what happens to old war horses. Georgann can be contacted at: gbruski@bidmc.harvard.edu

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