Advancements in Structural Heart Disease and AI Are Revolutionizing Echocardiography
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Rebecca Kapur, Managing Editor for Cath Lab Digest, talks with Atul Gupta, MD, Chief Medical Officer of Philips Diagnosis and Treatment businesses, and a practicing Interventional Radiologist in Philadelphia, Pennsylvania.
Dr. Gupta has a unique perspective on advancement in the growth of structural heart disease treatment, the miniaturization and automation of echocardiography, and how AI is set to revolutionize the field.
This transcript has been edited:
Welcome to Cath Lab Conversations! I’m Rebecca Kapur, Managing Editor for Cath Lab Digest. Today we are talking with Dr. Atul Gupta, Chief Medical Officer of Philips Diagnosis and Treatment businesses, and a practicing Interventional Radiologist in Philadelphia, Pennsylvania.
Dr. Gupta has a unique perspective on advancement in the growth of structural heart disease treatment, the miniaturization and automation of echocardiography, and how AI is set to revolutionize the field.
Dr. Gupta, welcome. Can you share some of your background and how your interests drive your work around imaging in cardiology?
Well, it's a pleasure to meet you, Rebecca. And yeah, it's an interesting question. I'm a practicing interventionalist. I'm an interventional and diagnostic radiologist. I've been practicing for over 20 years. I live outside of Philadelphia, but for almost all of those 20 years, I was working with Philips, trying to get them to see some of the unmet needs that we had in our field when we're doing interventional procedures, the things that we needed an ultrasound, 3D guidance, and navigation. So I was doing a lot of research with Philips because Philips actually works with customers. They co-create, trying to figure out what are the unmet needs and then creating the technology to solve that. And then when Phillips created the image-guided therapy business about eight years ago, I ended up joining full time to be the chief medical officer for image-guided therapy. And it's my responsibility to kind of give medical leadership on our innovation roadmap, our alliances, mergers, acquisitions. Basically, I say that I have the same job as all 70,000 employees. It's my job to dream about the future of healthcare, and I think that's a pretty exciting space to be in.
What are some of the biggest healthcare challenges you see in cardiology today?
I travel all over the world, and no matter where I go, I hear the same exact things from hospitals, from physicians, from staff, from payers, from governments. There are three buckets of challenges that the world is seeing. I think the first is patients are getting older, patients are getting sicker. And what that means is that workloads are intensifying, not just for physicians, but also for staff or echocardiographers, for technologists in the cath lab, for nurses. So I think that's the first problem. We have an older, sicker population everywhere you go, put on top of that. The second challenge, you can open up your newspapers anywhere on earth, and you see the same headlines. Staff shortages are rampant and it's only growing burnout. Burnout amongst physicians. It's at an all-time high. Nurses all-time high. One recent study showed 50% of physicians are now reporting burnout.1
It's not just the great resignation as we talk about it. It's also the great retirement. One thing that gets under-reported is a large number of healthcare providers are over the age of 55, and it depends on the country you're in, but some of them even over the age of 60. And what that means is we're also headed for the great retirement and National Health Service in the United Kingdom, if you want to look at just one stat, and they have over 100,000 unfilled healthcare positions in the NHS in the UK. So we are not going to recruit our way out of this mess. I think we increasingly need to rely on digital health tools to help us. So that's the second challenge. Staff shortages. And last challenge, I don't need to tell you, I don't need to tell anybody in the audience, no matter where you live, funds are shrinking.
We're all being asked to do more with less. We desperately to increase our efficiency. So these three challenges, we validated it. In fact, we have something called, at Philips, the Future Health Index.2 It's now in its ninth year. It's the largest survey of health leaders in the world. And we ask health leaders, around the world, various questions around these challenges. This year, 75% of cardiology leaders said that staff shortages are impacting patient care at their organization. In fact, it's also an access to care problem. 53% of cardiology leaders said that they now have decreased capacity to meet the needs of their underserved communities. So they're validating this problem that we see. And nearly all of these leaders, over 90%, they believe that automation, AI, automation of these repetitive tasks, that's going to be critical to address staff shortages. It's going to be critical to save the healthcare providers, meaning not just the physicians, but also the techs. Save our time ultimately to give us more time with the patients. So that brings us back to the topic at hand, which is artificial intelligence, AI, automation. Can AI, can automation come to the rescue? And I say, yes. I think cardiology leaders recognize the potential of AI, and that's why 40% of them say that they're going to invest in AI in the next year. And that's exactly why we launched our new AI-powered echocardiography platform. It's to accelerate diagnosis, it is to handle all of these challenges that I just described.
Structural heart procedures are huge, continuing to rise. We're seeing more complex cases. And of course, as you just noted, there's this incredible innovation in technology. What are some of the new advances you're seeing around that specifically?
Well, you're exactly right, Rebecca. I think that we're seeing a massive increase in the amount of patients that are being diagnosed and therefore being able to be treated with structural heart disease. Let's just take one of them: tricuspid procedures. We kind of call it a forgotten valve. Less than 1% of patients are actually being treated, historically, but now technology exists so that we can treat these patients with minimally invasive procedures. So tricuspid procedures are just one structural heart disease procedure, and it's a new frontier, but it's going to grow tenfold in volume by 2027.3 And I think these new innovations, these innovations on the diagnosis side and also on the therapy side, are going to help us tackle this rise in these more complex procedures.
For instance, as we talk about tricuspid valve in this new echocardiography AI-powered next generation platform that we have at Philips, we have a whole bunch of artificial intelligence and automation built in for valvular assessment. So we have three-dimensional auto tricuspid valve quantification. This means basically that it will automatically detect, automatically segment, and then very consistently and reliably quantify the tricuspid valve annulus, whether you're looking at it from a transesophageal echo or whether you're doing it trans thoracically. Why is that important? Because we need this reliable measurement. There's no secret, especially to this audience, that ultrasound is very operator dependent. If I scan a patient, I may get a valvular diameter of X. If you scan the exact same patient, you may get a valvular diameter of Y. We need to get this thing much more reliable, much more consistent. And so that's where AI can come to the rescue, because you need the right measurement if you're going to implant the right valve.
So now the 3D auto tricuspid valve is FDA cleared. It was created in collaboration with one of the device manufacturers to help us. And it's been validated. It shows that there's excellent agreement with the traditional way of measuring valves. And actually it's much more reproducible. Again, because it's AI, it doesn't have the human variance that we see when two people scan a valve. So that's tricuspid valve. But if you look at the mitral valve, we have AI built into our new platform for that as well. So 3D auto color flow quantification. Basically that's automating the analysis of the mitral valve regurgitation. This mitral regurgitant volume that's historically been measured using a technique we call PISA [proximal isovelocity surface area measurement]. And that's been recommended in the ASE [American Society of Echocardiography] guidelines. But the truth is that this technique makes a lot of geometrical assumptions, it's also not very well adopted because it takes a lot of time when people have to use this technique to scan and measure the mitral. It's not reproducible for all the reasons I just said before, and it's also a 2D method, but it's making all these geometrical assumptions. So now we have this FDA-cleared 3D auto color flow quantification. Again, an AI-powered solution that's using 3D color to measure the mitral regurgitation volume. It automatically segments and studies have shown that it's equivalent to what has historically been considered the gold standard, which is cardiac MR. So I think that the bottom line is these AI solutions are about making the measurements faster, it's about making them easier, and it's about making them much more reproducible.
Is there any other way that you see AI revolutionizing echo?
Yes. I mean, we have embedded AI from beginning to end in our workflow. But let's just take another area. Let's talk about heart failure. The number of people diagnosed with heart failure is also going to rise significantly. Estimated it's going to rise by 40-50% by 2030.4 And one big cause is this growing field of cardio-oncology. I was recently at the European Society of Cardiology, and in just one year, we've seen an exponential increase in the number of presentations on this topic of cardio-oncology. Almost all of us know somebody that's been treated for breast cancer or lymphoma. And the truth is, is that chemotherapy radiation is getting much better at increasing these patients' chances of recovery. But did you also know that a lot of these therapies, these chemotherapy agents, they can increase our risk of cardiac disease? In fact, studies show that adult survivors of cancer will have about a 35-40% higher risk of developing cardiovascular disease.5
So one in 10 cancer patients, that's 1 million patients a year are surviving their cancer and ultimately actually die of cardiovascular disease.6 And this sometimes happens years, decades, after their cancer therapy has ended. And why is that? That's because these agents that we treat patients with are cardiotoxic. They damage the heart, they damage the ventricles. And so what we want to do, is we want to diagnose what we call strain in the ventricles before they manifest as symptoms, which is heart failure before the patient has a low ejection fraction. Because we can actually intervene with medication. We can put them on a cardioprotective agent. And so we've embedded AI into our next-generation echocardiography platform to automate this entire process. Again, it's reproducible. It eliminates the eyeballing that technologists sometimes have to do as they select the images, as they try to calculate the global longitudinal strain, the auto segmental wall motion.
It's automated. It's just a click. There's less variability in the measurements. And why is that important? Because what we do is we track these patients. The guidelines say that you need to have a scan every three months or every six months. Well, if you get a certain score in January and then you come back in March or April, and you have a different score because a different technologist scans you, that data is no good. AI is making this very reproducible. So we can very easily track whether or not your number is actually changing. And if it is, then we can change the therapy. And going back to the original problem of the staff shortages, echocardiographers, there's a tremendous shortage of echocardiographers. Any echocardiographer listening to this podcast knows every day they're getting job requests in the mail. It's hard to get. And so what that means is we have a shortage of echocardiographers. We have a lot of junior echocardiographers and an explosion in the number of people needing these types of strain scans, which are very difficult to perform. So AI is helping make these scans faster. It's making them much more accurate. It's making them much more reproducible. So that's one example of how AI is revolutionizing echocardiography for heart failure.
What about on the hardware side?
Well, it's a very good point. It's not just about the software. It's not just about the AI. It's also about the hardware. And so we have a couple of innovations on the hardware side as well with our next-generation echocardiography platform. Let's take the probe itself. Let's talk about transesophageal echo. We actually now have a mini 3D trans esophageal echo. So what does mini mean? It means it's 35% smaller. At its tip, it's only 11 millimeters in diameter. It's kind of pill shaped. It's also longer. And so what does that mean? It means that basically you can scan patients, pediatric patients, as small as five kilograms. You could scan a hundred-year-old patient and everybody in between. And by the way, that's including patients that are at risk for complications, patients with esophageal strictures, narrowings in their esophagus. Well, if it's a narrower probe, you can get through some of these strictures easily.
Also, patients that are in the ICU where maybe the traditional large transducer might be too large. So that helps significantly with many of these procedures. But it's also about the patient themselves. Because if you think about it, a smaller probe means more patient comfort. In fact, we asked, because everything we do is in collaboration with our customers, with cardiologists and echocardiographers. So we asked our experts and 87% of the experts, the cardiologists, the echocardiographers, those that are in clinical practice, they believe that mini TEE or mini 3D TEE would improve patient comfort. Why? Because of the smaller size, the better design. In fact, people like Rebecca Hahn at Columbia and others, they're telling us it's unlocking the ability to do some of these procedures potentially without general anesthesia.7 And that's a big deal. And by the way, even though we've miniaturized these probes, the feedback from these physicians has been the image quality still is outstanding despite the smaller size.
So yeah, hardware is very important. Hardware not just in terms of the size but also the design. These things have to be easy to use. And so our probes, they have four-way articulation. They're longer. So you can do these transgastric views, especially in taller adult patients, with the same handle as the traditional transesophageal echo, which means that minimizes the training time as you transition over to this smaller platform. So transesophageal echo, mini 3D TEE, that's one hardware evolution that I think you're going to hear a lot more about. But also as a complement to transesophageal echo, as we talk about structural heart disease, there's another area that's growing immensely, and that's the use of intracardiac echo. It's a huge advancement as well. And so we have an intracardiac echo called VeriSight Pro. We've recently launched it because we're seeing an increased desire for intracardiac echocardiography. It is critical for procedures like the tricuspid valve. And so our device, our endovascular device that you navigate through the blood vessels into the heart, it's nine French in diameter, really tiny. You can operate it with a single hand. Remember, design is super important when we do this, and when you do these tricuspid procedures, the best practice is to switch back and forth between the visualization that we get from the transesophageal echo probe, which shows you certain things, and the intracardiac echo probe, which shows you some other things. And that's why we built into this echocardiography platform of ours, the ability of rapid switching from one view to the other, from one probe to the other, which is so important for the tricuspid valve. So we see a huge increase in intracardiac echo as well, not just for tricuspid valve, but also for things like electrophysiology where we have to do transseptal puncture.
So that's also another hardware evolution. And at the end of the day, again, this is, we're talking about the cath lab, right? Cath Lab Digest. Azurion is the image-guided therapy platform, the world's leading image-guided therapy platform, the cath lab that bridges the diagnosis and the treatment. It's sort of the foundation of this whole ecosystem. And what we want to do is we want to integrate the echocardiography images, the ultrasound images, with the fusion of the x-ray images from Azurion. And that's what we could do to give you the best of both worlds: x-ray to see the device, the mitral or tricuspid implant from Azurion, and then the echo to see the soft tissue, the native valve, and in 3D, integrating them together. When you automatically fuse those images together, it assists the heart teams with this image guidance during the procedure. Think about things like anatomic intelligence, transseptal guidance, 3D photorealistic rendering of these valves with TrueVue and GlassVue, automatic planes, multiplanar reconstructions. It makes these complex structural heart disease procedures simpler, faster. And we're talking about things like TAVI, aortic valve replacements, left atrial appendage closures, electrophysiology procedures, and certainly mitral and tricuspid procedures.
Thank you. This has been amazing! Can you give us a 10,000 foot view about the evolution of innovation in echocardiography in general?
Well, I think at the end of the day, it's all about, as I said from the beginning when we first started, how I came to Philips, it's about addressing an unmet need. The last thing that we ever do at Philips is want to just create a technology, throw it out there, and hope it sticks. Every single innovation we make, whether it's artificial intelligence software, whether it's our hardware, whether it's our design, whether it's our echocardiography, whether it's our Azurion, and the workflow associated with all of this, is done in co-creation with the end user, with customers, with physicians, with technologists, with nurses, with hospital administrators. And we take that feedback from these customers and their patients, by the way. And that assists us in the design of things like our mini 3D transesophageal echo probe. It tells us how our AI software should look, how does it feel? These aren't easy things to do, but they're critical if you want to increase adoption of these tools so that we can help improve patient outcomes. It's this feedback from the co-creation that we always feed back into the design, the design of our hardware and our software. So I always say it's the collaboration that leads to the best innovation. That is what we do. Collaborating — and I think, Rebecca, the future of echocardiography, the future of artificial intelligence and structural heart disease is very bright. So stay tuned. I cannot wait for you to see where we're headed next.
Our thanks to Dr. Atul Gupta for sharing his perspective and experience.
This podcast was sponsored by Philips Healthcare. Learn more about their cardiovascular ultrasound solutions at Philips.com
References
1. United States report. Future Health Index 2024. 9th Ed. https://www.usa.philips.com/a-w/about/news/archive/standard/news/future-health-index/reports/2024/better-care-for-more-people.html. Accessed November 21, 2024.
2. Global report. Future Health Index 2024. 9th Ed. https://www.philips.com/a-w/about/news/future-health-index/reports/2024/better-care-for-more-people. Accessed November 21, 2024.
3. Structural heart devices global market - forecast to 2027. Reportlinker. July 16, 2020. https://www.prnewswire.com/news-releases/structural-heart-devices-global-market--forecast-to-2027-301094672.html. Accessed November 21, 2024.
4. Benjamin EJ, Blaha MJ, Chiuve SE, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017 Mar 7; 135(10): e146-e603. doi:10.1161/CIR.0000000000000485
5. Florido R, Daya NR, Ndumele CE, et al. Cardiovascular disease risk among cancer survivors: the Atherosclerosis Risk In Communities (ARIC) study. J Am Coll Cardiol. 2022 Jul 5; 80(1): 22-32. doi:10.1016/j.jacc.2022.04.042
6. López Fernández T, López Sendón J. Chapter 41. Cardiotoxicity: Future Research Directions. How to Improve Therapeutic Strategies to Reduce Cardiotoxicity. In: López Fernández T, López Sendón J, eds. Anti-Cancer Treatments and Cardiotoxicity. Elsevier Inc.; 2016: 409-411.
7. New Philips Mini TEE ultrasound transducer helps improve cardiac care for more patients. Philips. January 31, 2024. https://www.usa.philips.com/a-w/about/news/archive/standard/news/press/2024/new-philips-mini-tee-ultrasound-transducer-helps-improve-cardiac-care-for-more-patients.html. Accessed November 21, 2024.
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