Learning
from India

Between the Himalayas and the Indian Ocean lies India, the second most popu­lous coun­try in the world. More than 1.37 bil­lion peo­ple live here, and pop­u­la­tion growth con­tinues thanks to pro­gres­sive modern­i­za­tion and improved health­care. Western stan­dards are the bench­mark for hospi­tals and prac­tices, and expen­sive high-end medi­cal tech­nol­ogy is find­ing an increas­ing num­ber of cus­tomers here. But it is not only in this respect that India cor­re­sponds with the West. The country is strug­gling with a grow­ing num­ber of cardio­vascular diseases, well-known in the United States and Europe for many years. India plans to master this chal­lenge with so-called ‘cath labs.’ Here, cath labs are more com­mon than in almost any other country. In the big cities, they are multi­ply­ing as fast as mush­rooms. The term ‘cath lab’ refers to an oper­a­ting room that requires little equip­ment and in which only mini­mally inva­sive pro­ce­dures are per­formed. Open sur­gery does not take place in cath labs; instead, the small sur­gical units are used, for example, to insert pace­makers or con­duct angio­plasties, and minimally-invasive tests.

Today, many hospitals in India are installing catheter­i­za­tion labora­tories. In Salem, a large city 200 kilo­meters south of Bangalore in the Indian province of of Tamil Nadu, there are more than ten catheter­i­za­tion labora­tories alone. One of them belongs to cardi­ol­ogist Dr. Rajaram Prasad, whose oper­ating room is located in the SIMS Chellum Hospital. Dr. Prasad founded his cath lab in 2018 to ensure better care for his patients. In a public hospital, people are referred from one depart­ment to the other and little or no relation­ship is estab­lished with them, says Dr. Prasad. His own catheter­i­zation lab, on the other hand, gives him pro­found patient contact, from diag­nosis to treat­ment. The deci­sion to go into busi­ness for him­self was not easy for Dr. Prasad. In addi­tion to find­ing the suit­able prem­ises, financ­ing the proj­ect was a major chal­lenge. Pur­chasing high-end medi­cal tech­nol­ogy is expen­sive, and the pur­chase of a high-quality fixed sys­tem, like an X‑ray unit per­ma­nently installed in the oper­at­ing room, which is con­sid­ered stan­dard imaging in the cath lab, did not seem affordable to Dr. Prasad.

“There are only a few local medi­cal tech­nology manu­fac­turers in India that meet the require­ments for cardio­vascular inter­entions. Most systems are imported and are very expen­sive by our stan­dards,” says Dr. Prasad. He there­fore began to think about a ‘mobile cath lab’ in which a mobile high-end C‑arm would replace the fixed sys­tem. Initially, he was skepti­cal as to whether the per­for­mance of the mobile system would be suf­ficient for his needs. Although Dr. Prasad had pre­vi­ously worked with mobile C‑arms from various manu­facturers, the results were not always con­vinc­ing: “Some­times the image quality was so poor that I could hardly see the arteries. I was able to achieve good results there as well, but at a certain degree of difficulty in the pro­ce­dure, it became prob­lem­atic because the images were too noisy.” Dr. Prasad was con­cerned that a new C‑arm could result in similar image quality issues.

He found the Ziehm Imaging brand during a search for suppliers on the Internet. “My brother is a cardi­ol­ogist in the USA and warmly recom­mended the Ziehm sys­tem, which is used there in vascular sur­gery and inter­ventions. He said it was ideal for my pro­ce­dures,” says Dr. Prasad. He was more than sur­prised when he visited the Ziehm Vision RFD Hybrid Edition CMOSline¹ live in Chennai: “The X‑ray images had a sharp­ness and accuracy I did not expect from a mobile C‑arm.” Dr. Prasad does not need much space for his mobile cath lab. The C‑arm, an oper­at­ing table, and a ceiling-mounted moni­tor, which dis­plays the live and refer­ence X‑ray images as well as the vital func­tions of the patient, are easily housed in his oper­at­ing room. There are three people in the oper­ating room for each pro­ce­dure: Dr. Prasad is sup­ported by a nurse and a cardio­vascular tech­nician. He selects his cases care­fully, mainly per­form­ing primary angio­plasty and stent­ing, which is the treat­ment of choice for acute myo­cardial infarc­tion (heart attack). “Since I operate without a sur­gical backup, I am more care­ful about select­ing my patients for the pro­ce­dure. I generally refer patients who have triple ves­sel disease, left main bifur­cation, or a com­plex cor­onary anat­omy to an insti­tu­tion that is better equipped for cardio­vascular sur­gical pro­ce­dures, as these patients do bet­ter with sur­gical management,” he says.

In most cases Dr. Prasad per­forms an angio­gram in the cath­e­ter labo­ra­tory, i.e., an X‑ray of the vessels with a con­trast medium, to exam­ine the con­dition of the vessels. The most com­mon pro­ce­dure is angio­plasty, in which narrowed or closed vessels are widened or opened again with balloon dila­tion, followed by stent­ing. It is pre­cisely these proce­dures that aroused Dr. Prasad’s interest in cardi­ol­ogy. “Angio­grams fasci­nated me from the begin­ning of my training. You can see exactly what you did and if you were suc­cess­ful. Good imag­ing is very impor­tant to me because it allows me to measure my results exactly,” says Dr. Prasad. For him, it makes no differ­ence whether the images are taken by a fixed sys­tem or by his mobile C‑arm: “People should not judge the image quality just because it is a mobile C‑arm. Initially, I was also skepti­cal as to whether the image quality could com­pete with that of a fixed instal­lation. If my col­leagues saw the X‑rays I acquire in my mobile cath lab, they would think differ­ently. The image quality I get with my C‑arm is as good as that of a fixed sys­tem and defi­nitely better than any image taken with a low-cost fixed system.”

The mobile cath lab has proven to be the right choice for Dr. Prasad. Not only are the acqui­si­tion costs of a mobile system lower than those of a fixed instal­lation, but also the main­te­nance costs, he says: “For fixed instal­lations you need a high-capacity power supply, which of course costs money. My elec­tric­ity costs for the mobile cath lab are signif­i­cantly lower than what I would have with a stan­dard cath lab.” In addition, install­ing a fixed sys­tem would require struc­tural changes that are not nec­es­sary with his mobile con­cept. The per­son­nel costs are also man­age­able, as he only needs an assis­tant and a cardio­vascular tech­nician. Another positive side-effect for Dr. Prasad is the dose-saving work in the oper­a­ting room, which is very impor­tant to him: “It is not pos­sible to esti­mate the amount of radia­tion my team is exposed to. That’s why it is crucial to have medi­cal tech­nol­ogy that is as dose-saving as pos­sible. Ziehm Imaging’s C‑arm with a CMOS detec­tor is the answer for me.”

When asked whether the mobile cath lab has limi­ta­tions, Dr. Prasad shakes his head: “Our mobile con­cept has only advan­tages for me, my employees, and my patients. I haven’t had a case that I could have solved bet­ter with a fixed sys­tem.” For him, the mobile cath lab is a model for the future. “Medical imag­ing is becom­ing more and more impor­tant for us, and it is getting better every day. If we can afford the latest technology, everyone wins.”