Dr. Lal wanted a cardiovascular-radiography system that would enable the group to lower door-to-balloon time by reducing the time required for patient setup and loading, as well as by improving clinician efficiency and confidence. The unique C-arm design of Toshiba’s Infinix-i systems—which offers 270-degree positioning for improved access to the patient, ancillary equipment, and fellow clinicians—met these requirements.

“The ability to move the C-arm quickly in and out of the way facilitates quick loading of the patient,” Dr. Lal notes. “Once the patient is in place, the C-arm is immediately moved back into the desired position to begin the case. This system has saved time by enabling us to start catheterization sooner and reducing overall setup and procedure time.”

Toshiba’s Infinix-i systems boast a five-axis design. Allan Berthe, senior cardiology product manager for the company, explains that this enhances clinician workflow by allowing uninterrupted access to the patient. “If the operators are focused on the patient and don’t have to worry about working around the C-arm or pivoting the table, they can get through the required imaging much faster,” he says. “The system provides excellent access and coverage, and the design of the tableside controls allows clinicians to keep their focus on the patient, capture all the required images and control all key system functions while staying right at the patient’s side.”

Dr. Lal offers an example of the C-arm flexibility in some cases when it is necessary to switch rapidly from femoral to radial access while inserting the catheter. “Within minutes, we have reconfigured the system components to accommodate the transradial approach,” he says. “This flexibility permits more comfortable ergonomic positions for physicians, while also keeping the patient comfortable.”

The time-saving benefits of the Infinix-i systems go beyond design, Berthe explains. Toshiba’s Next Generation Advanced Imaging Processing (AIP) technology, a combination of proprietary hardware and software, supports interventionalists using fluoroscopic and fluorographic imaging by enhancing image quality, sharpness, and contrast during procedures. The technology also substantially reduces image lag time, enabling clinicians to perform fluoroscopic procedures with increased efficiency.

“Next Generation AIP greatly improves coronary-artery visualization and the ability to identify disease,” Dr. Lal says. “The great image detail on all patient types has improved diagnostic confidence and treatment planning, resulting in more accurate device selection and placement.” He adds that Next Generation AIP has improved his department’s efficiency by reducing room time, promoting increased patient throughput: “The reduced exam times have improved the utilization of our staff members and increased patient safety,” he says.

With PCI becoming increasingly prevalent as a treatment for STEMI patients, diagnostic speed and confidence are more important than ever before (as the new ACC/AHA 90-minute door-to-balloon requirement underscores). “If you have a door-to-balloon program, speed is of the essence,” Berthe notes. “Little things matter. The combination of the Infinix-i system’s design and its AIP technology creates an environment where everything is working in concert to produce a more uniform, high-resolution image with increased speed and efficiency.”

Berthe says that smaller flat-panel detectors are ideal for imaging the heart, but a larger detector is required to cover a larger anatomical area. Toshiba’s dual-plane Infinix DP-i system solves this problem by incorporating two C-arms and two flat-panel detectors on the same unit: a floor-mounted eight-inch panel and a ceiling-mounted 12×16-inch panel. “The two C-arms operate independently; one is dedicated to cardiac cases and the other is dedicated to vascular cases,” Berthe says. “You can quickly exchange those back and forth in less than 60 seconds—a capability no other system in the industry offers.”

Working with a shared system saves valuable hospital space and reduces both maintenance and staff costs, but the advantages don’t end there, Berthe notes. “The smaller flat-panel detector can easily image the heart, but it’s not uncommon for a patient with coronary-artery disease also to have problems elsewhere in the body,” he says. “If you want to perform two procedures on the same patient (looking at the heart and the legs, for example), the DP-i excels. You could use the small panel to look at the heart and then quickly change over to the large panel to look at both legs in one view.”

The Infinix-i DPi boasts multiple features aimed at bolstering its clinical flexibility, including a flexible C-arm for peripheral angiography, optional 3D angiography, a table that can accommodate patients weighing up to 484 pounds, and two liquid-metal–bearing X-ray tubes, one for cardiac work and one for full-body imaging. “The dual-plane systems allows you to do both types of imaging with a lot of freedom,” Berthe says. “The user will never have to compromise on the anatomy he or she wants to image.”

Ultrasound – Carotid Intervention
As with many other conditions, ultrasound is often the first modality physicians turn to when evaluating a patient presenting with stroke symptoms. It’s a key tool for evaluating the carotid arteries to identify the presence and type of plaque buildup the patient could have. Two key Toshiba features for ultrasound are particularly useful in stroke imaging.

Precision Imaging: This technology enhances image clarity and resolution to help physicians visualize plaque in the carotid arteries. Precision Imaging increases diagnostic confidence by providing more detailed ultrasound images so physicians can quickly determine the next steps in a patient’s treatment. As a multiresolution signal processing technology, it not only evaluates images line by line but also includes information from adjacent lines to enhance the amount of information obtained. As a Toshiba exclusive software, Precision Imaging’s ability to capture information from multiple lines improves the definition of the structure, provides more detail and minimizes noise and clutter.

Advanced Dynamic Flow™: Advanced Dynamic Flow improves very high resolution for greater diagnostic confidence for vascular structures. This sensitivity helps to better visualize the degree of stenosis in the carotid arteries. Using the same ultra-high bandwidth normally used only in B-mode for doppler signal processing, Advanced Dynamic Flow simultaneously provides both high spatial resolution and high frame rates to accurately display flow with directional information, even in tiny vessels.

CT – Faster Stroke Assessment
When a patient comes to a hospital’s emergency department (ED) exhibiting stroke symptoms, it can take hours to diagnose and treat the patient when time is of the essence. Toshiba’s Aquilion® ONE dynamic volume CT system has the ability to improve the quality of life for patients with neurological symptoms, especially related to stroke, by reducing diagnosis time to minutes with half the dose of conventional CT.

The Aquilion ONE allows physicians to reduce diagnosis time for life-threatening conditions such as stroke from hours or days to minutes. Unlike any other CT system available, the Aquilion ONE covers up to 16 cm of anatomy using 320 ultra-high-resolution 0.5 mm detector elements to image an entire organ, including the brain, in a single rotation. It can show the organ’s dynamic blood flow and real-time function. The ability to see dynamic function, such as blood flowing through the brain, is critical for stroke patients in emergency settings and enables rapid and accurate diagnosis when time is critical. Coverage can also be collimated to a smaller area to reduce the dose to the patient.

This Neuro ONE acute stroke imaging protocol on Aquilion ONE combines non-contrast CT, cerebral blood flow analysis and four-dimensional digital subtraction angiography (DSA) into a single exam. By combining these exams into a single low-dose protocol, full stroke workup can be performed in less than five minutes.

Magnetic Resonance – High-Sensitivity Stroke Imaging
MRI is particularly beneficial for diagnosing acute ischemic stroke because it is highly sensitive to detecting microscopic changes in blood and oxygen in the brain. Toshiba MR integrates other techniques that further enhance MR’s role in stroke diagnosis.

Non-contrast techniques: Not only are there safety concerns when imaging with gadolinium, but also having to add contrast injections to a stroke evaluation can take time that is not a luxury in these emergency situations. Toshiba offers the most robust suite of non-contrast techniques that are beneficial for stroke analysis. For example, the V-TRACE sequence can shorten brain imaging time.

V-TRACE Sequence: This non-contrast MRA sequence available on all Vantage Titan™ and Vantage Atlas® systems, streamlines MRA brain imaging. The sequence acquires four image contrasts in one sequence, providing an imaging application for visualizing slow- and fast-flow vessels separately and together, as well as the brain tissue surrounding the vessels.

V-TRACE MRA is a dual-echo 3D FE sequence in which the first echo is acquired using Time-Of-Flight (TOF) and the second echo is acquired using Flow Sensitive Black Blood (FSBB). The sequence combines the advantages of both techniques to produce MRA images that depict blood vessels with both high and low velocity. The sequence design reduces the Specific Absorption Rate (SAR), which is a measurement of heat generated to the body during a MRI. Additionally, the TOF data can be used to evaluate the brain parenchyma. The images produced by the V-TRACE sequence improve the speed and accuracy of diagnosis.

Patient-friendly features: Toshiba’s patient friendly MR features make imaging easier for the patient. Several features reduce the feeling of claustrophobia that often accompanies MR exams. For example, the Titan’s large bore allows patients more room during the exam. Also, Toshiba’s head coil – important in the imaging of stroke – has 10 elements and very high signal to noise, which means it is not always necessary to utilize the top of the coil to image, reducing claustrophobia during an exam.

Infinix™-i Biplane Vascular X-ray System – Efficient Stroke Treatment
Toshiba’s Infinix-i biplane system has been developed with a number of tools to provide methods for neuro-interventionalists to develop treatment plans for patients more quickly. There are four key components of the system that make it ideal for stroke analysis.

Two 12×12-inch detectors: The midsize flat-panel detectors are ideal for brain imaging because they allow physicians to get two complete views of the cerebral vascular anatomy with each contrast injection, which not only helps to minimize the contrast load to the patient, but also provides better visualization due to the increased anatomical coverage when compared to two small detectors. Additionally, these midsized detectors allow physicians to obtain steeper compound angle views than can be obtained on systems with two large detectors.

3D angio visualization: This technology provides a three-dimensional image volume that can be rotated and manipulated in real time to ideally sort out superimposed vascular anatomy. Additionally, the two-dimensional multiplanar reformations enable physicians to dissect the image data from a variety of angles.

Variable isocenter: This key feature can dramatically improve patient safety during imaging. For example, some patients who are experiencing an aneurysm or subarachnoid hemorrhage may need a ventriculostomy to monitor and control intracranial pressure. Changing the table height in order to get the best imaging angles can present a dangerous challenge for physicians, because changing the table height can negatively impact the intracranial pressure and potentially injure the patient. Toshiba’s lateral plane variable iso-center feature allows optimal positioning for imaging the brain, eliminating the need for table height adjustment, as is done on all competitive biplane angiographic systems. Physicians do not have to raise or lower the table to get the best angle, eliminating simple positioning as a concern for causing change in intracranial pressure.

Five-axis positioner: Toshiba’s Infinix-i C-arm offers unprecedented patient access with a C-arm five-axis positioner that allows head-to-toe and fingertip-to-fingertip coverage. The freely moving components, ergonomically friendly design and five-axis positioner enable physicians to obtain optimal angles for neurological diagnosis and interventional procedures without repositioning the patient. Neuro-interventions typically are done with the patient under general anesthesia or heavy sedation, requiring anesthesia support during the procedure. The five-axis c-arm provides multiple setup configurations to provide unrestricted access to the headend of the table for patient care while preserving biplane projection capabilities.

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Toshiba’s Aquilion® ONE dynamic volume CT system has changed the scope of brain perfusion analysis by enabling dynamic imaging of the entire brain and dramatically improving the ways physicians diagnose and treat stroke. One feature, available only on the Aquilion ONE, due to its ability to image the entire brain in one rotation, is the Singular Value Decomposition Plus (SVD+) perfusion algorithm. The SVD+ algorithm produces advanced CT perfusion imaging that is unmatched in the industry.

“The Aquilion ONE dynamic volume CT system with the SVD+ perfusion algorithm is emerging as a new standard of care for brain perfusion analysis,” said Erin Angel, PhD, manager, CT Clinical Science, Toshiba. “The fast exam time, high image quality and lower radiation doses of the Aquilion ONE, combined with the more accurate perfusion analysis produced by SVD+, are changing the ways physicians identify and treat stroke quickly.”

Toshiba’s SVD+ Perfusion Algorithm
Brain perfusion imaging in CT is used to determine if the patient has had a stroke and to distinguish which areas of the brain are beyond repair and which areas of the brain may be saved through intervention. Perfusion analysis can help clinicians estimate treatment response and develop therapeutic pathways designed specifically for individual patients. The advanced SVD+ algorithm was developed for the Aquilion ONE to improve the quantitative maps produced by perfusion imaging and to give physicians more accurate data for the evaluation of stroke.

Standard SVD algorithms can sometimes produce perfusion maps that are not completely accurate, since they have difficulty calculating certain delays in blood flow. These blood flow delays, if not identified appropriately, produce perfusion maps that provide unclear results to the physician. Toshiba’s SVD+ is an advanced perfusion algorithm that eliminates these issues. SVD+ is a delay-insensitive SVD algorithm that uses an innovative technique to account for delays in blood flow and perform calculations with faster computation times. The SVD+ algorithm is unique in that it always begins prior to the contrast’s arrival to more accurately quantify the region of the brain being imaged.

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Congenital Heart Disease (CHD) is a birth defect or malformation of the heart which can impact the heart’s structure and function. According to the American Heart Association, nearly 36,000 babies are born with a heart defect each year. While CHD can affect both children and adults and can be life threatening, revolutionary advancements in diagnosis and surgery have made treatment and reparation of such defects possible. In 2008, over one million people with CHD had survived through adulthood.

Cardiac Catheterization is a non-surgical procedure that can be used for hemodynamic and angiographic evaluations of the structure and function of the heart, helpful in the diagnosis of CHD. Transcatheter interventions for treatment of CHD can also be performed using stents, coils, and other interventional devices.

Used in conjunction with the Toshiba Infinix-i cardiac systems, the Toshiba 3D-Digital Acquisition (3D-DA) software package allows physicians to view a three-dimensional perspective of a variety of vascular structures including the pulmonary arteries. 3D reconstruction is ideal for optimizing vessel-viewing angles prior to intervention, providing a better understanding of complex anatomy and helping to determine the proper size of interventional devices to be used for planning and treatment.

Case Study: 3D rotational angiography using 3D-DA software.

Technology: Toshiba Infinix CF-i Biplane cardiovascular cath lab using 3D-DA software.

Patient History: A 14 year old girl born with complex congenital heart disease (interrupted aortic arch, ventricular septal defect) required numerous surgical procedures beginning in early infancy which culminated in a Fontan procedure at age 4. Recently she began complaining of decreased exercise tolerance prompting a cardiac MRI which raised the possibility of a left pulmonary artery stenosis which had not been appreciated during previous cardiac catheterizations despite selective left pulmonary arteriography.

Diagnosis: During catheterization performed via a right femoral venous approach, selective 2D left pulmonary angiography failed to adequately demonstrate any stenosis. Due to the high degree of suspicion a 3D-DA was performed at 30f/s using a 206 degree rotation over a 5 second acquisition while holding respiration. Fifty milliliters of undiluted contrast were injected at a rate of 10 cc/sec to obtain the images shown in figure 1. Reconstruction took 35 seconds and post-processing took another 2 minutes to produce the images shown here. By rotating the reconstructed image 90% caudal (a view, not possible with standard angiography) physicians were able to clearly view the compression of the left pulmonary artery in a front to back orientation. Two overlapping Genesis XD stents were implanted across the area with 12 mm balloon and further dilated to 14 mm to obtain the image shown in figure 2.

In this particular case the use of 3D-DA greatly enhanced the ability to diagnose an important stenotic lesion which was undetected by 2D-DA despite multiple bi-plane acquisition imaging angles. Furthermore, using 3D-DA, post-intervention provided excellent imaging of the vessel stent interface and allowed for improved assessment of the result as well as any potential complication.

Figure 1: Pre-intervention 3D-DA of the branch pulmonary arteries in a child with a significant left pulmonary artery stenosis (arrow) after a Fontan operation. In a standard projection (LAO 21/caudal 7) the stenosis is difficult to appreciate (left), however, after rotating the image to a virtual angle (LAO 35/Cranial 71), the stenosis is clearly visible as shown by the arrow (right).

Figure 2: The same structure seen in the comparable views as above following implantation of two endovascular stents to enlarge the area. Note the excellent clarity and detail of the newly implanted stents and their relationship to the vessel wall.

Pre- (left) and post- (right) 3D-DA spins.

Images courtesy of Dr. Evan M. Zahn, M.D., Miami Children’s Hospital, Miami Florida

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Echocardiography is a valuable tool in the diagnosis of coronary artery disease, but evaluation of myocardial function using 2D echocardiography relies primarily on visual detection of wall-motion abnormalities. In 2009, Toshiba America Medical Systems introduced a proprietary 3D Wall Motion Tracking (WMT) tool for its Aplio™ Artida ultrasound system, which helps clinicians quantify the function of the left ventricle in 3D—including left-ventricular ejection fraction, volume, and strain information.

“3D Wall Motion Tracking allows sonographers and physicians to quickly and accurately identify wall motion defects and the timing of cardiac events,” Berkeley Cameron, cardiac marketing manager for Toshiba, explains. “This greatly improves the detection of wall motion abnormalities in many cardiac disease states and Cardiac Resynchronization Therapy (CRT), and helps physicians optimize pace maker settings.”

In addition, the tool can be useful in diagnosing heart disease in women. Although stress studies have been shown to detect heart disease fairly accurately in men, women sometimes experience an increased risk of false-positive results. “Usually, for women, physicians want to do stress echocardiography instead of a treadmill study,” Cameron says. “That’s one area where Wall Motion Tracking is particularly useful for women. Having quantitative data help make the diagnosis more accurate.”

The response from clinicians using the tool has been enthusiastic, Cameron says. “We’ve gotten quite a bit of positive feedback,” she notes. “The clinicians using WMT feel it’s going to help them diagnose coronary artery disease. Anything they can do to diagnose disease earlier and to be more accurate—to make echocardiography less subjective—is a big benefit.”

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ASD is a congenital heart defect that is ideally suited for evaluation using cardiac MRI. Cardiac MRI allows accurate assessment of heart structure, function, and blood flow. In addition, cardiac MRI is an ideal method of evaluation because it does not use radiation and is non-invasive.

Cardiac Magnetic Resonance imaging can be challenging due to the constant motion of a beating heart and respiration. To successfully image the heart using MR it is essential to acquire images rapidly with optimal resolution and contrast.

Toshiba uses a 16 element Atlas SPEEDER body array coil coupled with the 32 element Atlas SPEEDER spine array coil to produce the signal required for successful evaluation of the heart. Vantage MRI systems have a complete cardiac software package available which includes specialized sequences for speed and image quality as well as the post processing software for cardiac analysis.

Case Study: MRI of the heart to evaluate cause for shortness of breath and heart murmur.

Technology: Toshiba Vantage Atlas MRI system using body array and spine array coils. The heart is imaged using SSFP cine sequences in varying planes.

2D cine sequences clearly depict the atrial septal defect allowing blood to flow between the right and left atrium. High blood-flow between the atria leads to volume overload and can lead to right heart failure. In this patient the right ventricle is enlarged consistent with a large ASD. This contributes to the patient’s shortness of breath and can progress to heart failure if not treated.

By using Toshiba’s cardiac MR system and specialized sequences no contrast or radiation was necessary in making this diagnosis.

Four-chamber (left) and short axis (right) cine views of the heart demonstrating atrial septal defect (ASD). (Cines and images courtesy of Dr. T. Albert, MD, FACC, Cardiovascular Diagnostic Center, Monterey, CA.)

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