Axiom 08-2008 Cardiology And Angiography

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www.siemens.com/healthcare-magazine Order No. A91AX-50801-13C1-7600 | Printed in Germany | CC AX 50801 ZS 090825. | © 09.2008, Siemens AG On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and are subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States. The information in this document contains general technical descriptions of specifications and options as well as standard and optional features that do not always have to be present in individual cases. Siemens reserves the right to modify the design, packaging, specifications and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information. Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

AXIOM Innovations

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Issue Number 8/October 2008

Global Siemens Headquarters

AXIOM Innovations The Magazine for Interventional Angiography and Cardiology, Radiography and Fluoroscopy

Issue Number 8/October 2008

New Trends in Surgery Cardiovascular Surgery opens up for New Treatment Methods Page 14

Efficiency in the EP syngo DynaCT Cardiac enhances Ablation Therapy Page 26

AXIOM Luminos TF Pediatric Imaging in Fluoroscopy Page 36

Virus protection At the University Hospital Basel, Switzerland Page 40

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Large Volume Imaging with Artis zeego More anatomical coverage with Large Volume syngo DynaCT

Imprint

Editorial

AXIOM Innovations Imprint

“Keeping our customers at the cutting edge of technology and enabling them to do more with their systems and applications is one of our most important goals.” Dr. Norbert Gaus, CEO of the Angiographic, Radiographic and Fluoroscopic Division (AX) at Siemens Healthcare

© 2008 by Siemens AG, Berlin and Munich, All Rights Reserved

Publisher Siemens AG Medical Solutions Angiography, Fluoroscopic and Radiographic Systems Siemensstr. 1, 91301 Forchheim, Germany Responsible for contents Norbert Gaus, PhD Chief editor Sabine Wich [email protected] Editorial board Monika Böhmer Klaudia Dorsch Vera Jünnemann Oliver Meissner, MD, PhD Nadine Meru, PhD Andrea Müller Prof. Georg Nollert, MD Roland Papenfuß Siegfried Prell Susanne Seah Dirk Sunderbrink Contributors to this issue Alfonso Aguilera, Erik Busch, Knut Imhof, Michaela Kandolf, Andra Kirchner, Barbara Reber, Antonio Ribeiro, Markus Rossmeier, Gerald Sandridge

Lee Benson, MD Cardiac Diagnostic and Interventional Unit, Hospital for Sick Children, Toronto, Canada

Harald Sandmayr, MD Radiography Department Landeskrankenhaus Steyr Steyr, Austria

Joris Ector, MD, Stijn De Buck, MSc ,PhD Hein Heidbuchel, MD, PhD Department of Cardiology, University Hospital Gasthuisberg Leuven, Leuven, Belgium

Prof. Martin Skalej, MD, Oliver Beuing, MD, Anja Lenz, MD University of Magdeburg, Magdeburg Germany

Erik Fosse, MD The Interventional Centre, Rikshospitalet, University of Oslo, Oslo, Norway

Prof. Wolfgang Steinbrich, MD Christian Kluth University Hospital Basel Basel, Switzerland

John P. Harris, MD Charles E. Winn, MD North Colorado Medical Center, Greeley, CO, USA

Warren Swee, MD, MPH Department of Radiology University of Virginia Health System Charlottesville, VA, USA

David Lacey, MD Iowa Methodist Medical Center Des Moines, IA, USA

Prof. Wolfram Voelker, MD University Clinic Wuerzburg Wuerzburg, Germany

Jaime Lavados, MD Eduardo Bravo, MD Neurosurgery Institute Santiago, Santiago, Chile

Production Michael Brumme Siemens Healthcare

Luis Ramos, MD, X-ray Department University Hospital Puerta de Hierro Majadahonda, Madrid, Spain.

All at Siemens AG Healthcare Sector

Layout and editorial staff Satzwerker – Jäger & Tuppi Nuremberg/Karlsruhe, Germany Printer Farbendruck Hofmann Gewerbestraße 5 90579 Langenzenn, Germany AXIOM Innovations on the net: www.siemens.com/healthcare-magazine

Note in accordance with § 33 Para.1 of the Federal Data Protection Law: Dispatch is made using an address file which is maintained with the aid of an automated data processing system. We remind our readers that, when printed, X-ray films never disclose all the information content of the original. Artifacts in X-ray, CT, MR and ultrasound images are recognizable by their typical features and are generally distinguishable

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from existing pathology. As referenced above, healthcare practitioners are expected to utilize their own learning, training and expertise in evaluating images.

pages of “AXIOM Innovations” are cited. The editors request that two copies be sent to their attention. The consent of the authors and editors is required for the complete reprint of an article.

Partial reproduction in printed form of individual contributions is permitted, provided the customary bibliographical data such as author’s name and title of the contribution as well as date and

Manuscripts submitted without prior agreement as well as suggestions, proposals and information are always welcome; they will be carefully assessed and submitted to the editorial board for review.

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Editorial

Dear Reader, Dr.-Ing. Norbert Gaus President AX Division

To be ahead of the game, you have to spot upcoming trends early enough to act on them. This goes without saying both for you, our customers, and for us at Siemens Healthcare. At Siemens, we like to keep you on the forefront of technology so you can zee more and therefore do more. One fast growing trend is minimally invasive surgery performed in so-called hybrid rooms, where high-end imaging and surgery come together. Surgeons have already recognized this and are active in bringing minimally invasive procedures with interventional imaging to their operating rooms. This combination enables procedures that give hope to a lot of very sick patients who could not undergo surgery before because of

the high risks involved. Also, after a minimally invasive procedure patients do not need to stay in intensive care as long as they do after normal surgery. So the Artis zee family for interventional imaging is finding its way into the OR. But that is not all you can read about in this edition of AXIOM Innovations. Recently, Siemens acquired a new company and further extended our product portfolio. Together with the technology and the products of CAS Innovations, we are now able to offer electro-magnetic needle guidance. Now it is possible to precisely place electrodes or biopsy devices and guide them to the region of interest very accurately and without radiation. These and many more topics, e.g clini-

cal experiences in interventional imaging and X-ray await you in this edition of AXIOM Innovations. I hope you enjoy reading this issue. I can tell you I did.

Dr. Norbert Gaus

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Content

Content

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New Treatment Possibilities for Cardiac Surgery

Electromagnetic Needle Guidance

Cover Story 8 Artis zeego in the OR Physicians at Oslo’s Rikshospitalet are achieving new levels of flexibility, efficiency and 3D imaging quality in a wide range of clinical environments, from cardiology, body and neurointerventional radiology suites to highend imaging in the OR.

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Editorial

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News

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Cover Story Artis zeego in the OR

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Special Surgery Opens up for New Treatment Methods

Cover Percutaneos Nephrostomy for an Obstructed Ectopic Pelvic Kidney Courtesy of Warren Swee, MD, MPH

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Imprint

Content

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38

Improved Efficiency in the EP Lab

Pediatric Imaging with AXIOM Luminos TF

Surgery 8 Robotic Technology with Human Benefits Artis zeego in the OR

14 Surgery Opens up to New Treatment Methods New trends in cardiac sugery

Angiography 20 Percutaneos Nephrostomy for an Obstructed Ectopic Pelvic Kidney Clinical case

Cardiology 26 Improved Efficiency in the EP Lab University Hospital Gasthuisberg, in Leuven, Belgium experiences workflow benefits with syngo DynaCT Cardiac

32 Taking Care of Children Combined imaging in pediatric cardiology

34 Hypoplastic Left Heart Syndrome Clinical case

Fluoroscopy 22 Radiofrequency Ablation of a Large Vertebral Metastasis Clinical case

24 State-of-the-Art Imaging Technology in South AmericaNeurosurgery Institute of Santiago in Chile installs first biplane system with high-end 3D imaging

Customer Care.Life 40 Virus Protection How the University Hospital in Basel protects its systems

44 Learning With and From the Experts Hands-on training for interventional cardiology

46 Light and Sound Concept Artificial light enviroments create more patient comfort

47 Upcoming Congresses & Workshops

36 AXIOM Luminos TF Digital radiography in pediatric fluoroscopy expedites clinical outcomes

38 Therapeutic Relief of Sigmoidal Volvulus under Fluoroscopy Clinical case

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News

First Ysio installation at Landeskrankenhaus Steyr, Austria

Clinical results with syngo iGuide – Endoleak Repair on an Abdominal Aortic Aneurysm

The first Ysio, a fully automated digital radiography solution, was installed on May 20th, 2008 in Landeskrankenhaus Steyr, Austria. This hospital, along with another center in Enns, has 800 beds and a staff of 1,890. The radiology Landeskrankenhaus Steyr, Austria department provides imaging services for the two medical centers and performs approximately 39,000 imaging procedures for inpatients and another 70,000 for outpatients annually. The radiological department has a fully automated Ysio equipped with an integrated 43 x 43 cm detector in the wall stand and a 35 x 43 cm wireless mobile detector (wi-D) in the table that can be used for table Bucky imaging or for free exposures. With this combination of automated tube movements, wireless detector technology and color touchscreen control on the tube, Ysio provides handling flexibility for the department to address their radiographic workload quickly and conveniently. On the first day, they performed their first study, a supine chest examination with the wi-D. Both the image quality and the easy handling of the wi-D were highly appreciated by the department and its users. At print time, the department has acquired over 5,000 images with Ysio and they are highly satisfied with their new digital radiography solution.

The new syngo iGuide application is available with the new Artis zee systems for interventional radiology and provides live and integrated needle guidance.

Ysio room – Prim. Dr. Harald Sandmayr (extreme right) and his staff

Needle path planning

Progression view

Bulls eye view

Planned needle path on live fluoro

Dr. Lacey at Iowa Methodist Medical Center, USA, is one of our first customers to work with syngo iGuide on his new Artis zeego multi-axis system. He is convinced that the application leads to effective needle results, in three easy steps . The intuitive workflow of syngo iGuide makes planning of needle procedures easy and comfortable for the user. The case above shows a type 2 endoleak repair using syngo iGuide. The needle path was planned in the syngo DynaCT images and was overlaid on the live fluoro image to provide guidance during needle progression.

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News

Get Your Free DVD of this Year’s ECR Hands-on Workshop Sessions

At this year’s European Congress of Radiology (ECR) in Vienna, more than three hundred customers participated in the hands-on workshops organized by the Siemens Healthcare Divisions Angiography, Fluoroscopy and Radiography (AX),

Computed Tomography (CT) and Magnetic Resonance Imaging (MR). Clinical presentations by leading experts were followed by demonstrations of clinical cases during which participants were guided through the processing tools available for the syngo MultiModality Workplace platform. Sitting at one of the sixteen workstations, radiologists and technologists from over fifty countries had the opportunity to discover the capabilities of syngo software. The angiography sessions focused on the usage of syngo DynaCT. Dr. Waggershauser from the University Hospital Munich explained the benefits of syngo DynaCT for abdominal procedures while Prof. Dr. Dörfler and Dr. Engelhorn from the University Hospital in Erlangen gave an

intensive overview of the main fields of interest for syngo DynaCT for neuroradiology. The ECR hands-on workshops have now been compiled into a DVD that contains both the clinical presentations and the step-by-step hands-on demonstrations. These recordings offer over twelve hours of learning material and provide an easy way to get started or improve your skills on the state-of-the-art evaluations techniques that greatly enhance the diagnostic capabilities of AX, MR and CT. Please feel free to order your free copy of the ECR HOW DVD via: www.siemens.com/ecr-how-dvd DVD not available in the U.S.

A True Icon in Fluoroscopy – 3,000th AXIOM Iconos Delivered to Spain The AXIOM Iconos systems are one of the most successful fluoroscopy platforms worldwide. There are installations in almost every country. And hospitals use it every day in their clinical routine. In recent years the system proved to be a real workhorse. Due to its flexibility and the individual customization options, the remote-controlled system meets virtually all the requirements of its users without compromise. This spring the 3,000 th system worldwide was installed. The 3,000 th system went to the newly built University Hospital Puerta de Hierro Majadahonda in Madrid, Spain. With over 800 beds, the new hospital covers the northwest area of Madrid and offers clinical services to the public in many different clinical fields includ-

NEU Luis Ramos, MD, Head of X-ray department, in front of AXIOM Iconos R200

ing cardiology, pediatrics, obstetrics, vascular surgery, geriatrics. This site is a reference hospital in Spain in various clinical fields: it is widely recognized for its broad program of organ and tissue transplants as well as for the complexity of its clinical assistance cases. The facility purchased two AXIOM Iconos R200 systems to offer its patients improved comfort during examinations and provide the physicians greater ease of use, excellent image quality and diagnostic confidence. The digital AXIOM Iconos models can be easily integrated into the hospital’s RIS and PACS systems to store patient data and the clinical studies done on the systems. This is enabled by the FLUOROSPOT Compact digital imaging system.

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Cover Story Titel

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Artis zeego in the OR Cover Story

Artis zeego Robotic Technology with Human Benefits With the introduction of the Artis zeego, the first multi-axis C-arm system based on robotic technology from Siemens Healthcare, physicians at Oslo’s Rikshospitalet are achieving new levels of flexibility, efficiency and 3D imaging quality in a wide range of clinical environments, from cardiology, body and neurointerventional radiology suites to high-end imaging in the OR. By Nils Lindstrand

The Interventional Center Rikshospitalet in Oslo, Norway is a cutting-edge imaging department that is widely known for being at the forefront of medical technology and methodology. As part of a partnership with Siemens, the Center recently installed the Artis zeego, the newest generation of flexible interventional imaging systems. The robotic technology built into the Artis zeego makes it possible to position the C-arm exactly according for the view required,

anywhere in a sphere around the patient. The movement of Artis zeego can also be coordinated with the operating table. The coordination between the table and the C-arm means that the physician is allowed to operate at an optimal position. The advanced imaging capabilities of Artis zeego give the physician visual support beyond earlier technologies, and its software also helps physicians choose the optimal approach, says Erik Fosse, M.D., head of

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Cover Story Artis zeego in the OR

the Interventional Center at Rikshospitalet in Oslo, Norway. The Center has been working with Artis zeego since December 2007, and doctors here are very satisfied with the new features it provides. Per Kristian Hol, M.D., manager of radiology research at the Interventional Center, agrees that this new generation of the Siemens C-arm systems, the Artis zee family for interventional imaging, provides enhanced support for critical decisions. “High quality 3D imaging, such as cross-sectional imaging with syngo DynaCT and others, has been significantly improved and is executed in real time, moreso than ever before,” says Hol. We used to have to wait for the 3D images that provide us with vital information, but Artis zeego has the capacity to create them in seconds. Needless to say this means a lot for a

Highlights of Artis zeego Unique positioning flexibility Frame rates from 0.5f/s to 7.5 f/s native, optional up to 30 f/s Large Volume syngo DynaCT for visualization of the whole abdomen and thorax. Portrait syngo DynaCT increases coverage in the z-plane to image the complete thoracic aorta. Flexible isocenter adepts table height to the surgeon’s needs Table tracking automatically aligns the C-arm movements to the table position Multiple park positions away from OR table

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Artis zeego in the OR Cover Story

team making critical decisions with very narrow margins.” Hol also points to the benefits of the new C-arm in planning surgical procedures. “When we plan an operation in the limited space of an OR, the increased flexibility with Artis zeego means that we don’t have to restrict ourselves to avoid problems with the C-arm,” he says. “Instead, we can make the plan with a full focus on the patient and the best procedure for the operation at hand.”

“When we plan an operation in the limited space of an OR, the increased flexibility with Artis zeego means that we don’t have to restrict ourselves to avoid problems with the C-arm.” Per Kristian Hol, MD, Manager of Radiology Research at the Interventional Center, Rikshospitalet, Oslo, Norway

Rikshospitalet: A Leader in Medical R&D Siemens Healthcare has been working with the doctors and engineers at Rikshospitalet Intervention Center for many years, taking OR technology to new levels of flexibility and imaging quality. And the new techniques and knowledge that the facility has gained through this partnership also has a ripple effect. The Intervention Center welcomes visiting colleges virtually every week, and has invested in very advanced systems for broadcasting operations to other hospitals and medical universities all over the world. “The Intervention Center at Rikshospitalet is set up to be a department for the development of new procedures and the introduction of new technologies,” says Fosse. “The traditional way of doing this has been to just carefully implement them when treating patients. But with healthcare putting increasingly advanced technology into service, becoming more industrial if you like, we saw the benefits of setting up a department dedicated to development and working in pretty much the same way as a similar department would do in industry.” What the department is doing with the Artis zeego is therefore a natural process, including hosting a staff of equal numbers of doctors and engineers. “One of the things we are working on is improving the benefits of Artis zeego even further by designing and building a new lighting system,” says Fosse. “We

The unique park postions of Artis zeego are extremely helpful to keep the system out of the way when not needed and create sufficient space round the operating table.

With the C-arm stored away, there is always enough space for the anesthesia equipment and free access to the head of the patient.

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Cover Story Artis zeego in the OR

have bought an LED system designed for follow-spots in the theater. This allows us to place the operating lamps at a greater distance, thus giving ourselves and the C-arm a better chance to move without blocking the light, and avoiding

hitting the lamps.” The lighting system is not yet completely finished; the software still has to be further developed. But when the project is finished, the surgeons will finally be able to get both good lighting and the

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full support of the C-arm wherever they need to move around the patient. “Surgeons have been striving for many years to get better access to the patient when operating,” says Fosse. “With Artis zeego and the new lighting system, we

Artis zeego in the OR Cover Story

will really have come a long way towards the optimal solution.”

Artis zeego: A Versatile Tool Artis zeego could be considered the ultimate technological answer to the development of new procedures and new working environments like the hybrid room. When hospitals bring radiology and cardiology together with the surgeons, the flexibility and imaging capacities of the Artis zeego provides the optimal support for the team at work. “The new technologies help us to create better hybrid rooms,” says Fosse. “Wellfunctioning hybrid rooms mean we can save lives, and allow us to always choose the least invasive procedures. This means less risk for the patient and shorter hospitalization as well as huge cost savings for society.” Radiologists and cardiologists have been performing more and more advanced interventions, and even though they perform them well, this means greater risks if the planned procedure needs to be changed for any reason. Hol is equally positive about working in the hybrid room, and agrees that the new technologies such as Artis zeego mean new ways to improve procedures. “By combining knowledge and technologies from radiology, cardiology and surgery, we may even develop new tailormade procedures and techniques,” he says. “It is also a major improvement that the advanced imaging systems can give you immediate confirmation that the procedure was performed correctly and gave the expected results. When

expertise and technology are scattered, you always are at risk of losing precious time if something needs to be adjusted. The Artis zeego decreases that risk.” The Artis zeego C-arm offers better support for physicians across any clinical environment, from body and neurointerventional radiology suites to ORs and hybrid rooms. The adjustable isocenter enables off-center rotational angiography for all parts of the body. 3D imaging techniques include Siemens technologies like syngo DynaCT, syngo iPilot and syngo iGuide. syngo iPilot enables faster and more precise catheter navigation through 3D roadmapping that superimposes 3D reconstructions onto live 2D fluoroscopy images, 2D roadmaps or digital subtraction angiography (DSA). The application provides real-time updates of C-arm and table movements, as well as changes in zoom and source-to-image distance. syngo iGuide is designed to bring needle procedures back into the interventional suite, allowing them to be executed faster and with greater confidence. All in all, the Artis zeego C-arm has removed numerous obstacles for the doctors at Rikshospitalet in their pursuit of the ideal environment for invasive procedures. It’s a happy combination of advanced technology that benefits physicians and patients alike.

“Surgeons have been striving for many years to get better access to the patient when operating. With Artis zeego and the new lighting system, we will really have come a long way towards the optimal solution.” Erik Fosse, MD, Head of the Interventional Center, Rikshospitalet, Oslo, Norway

Nils Lindstrand is a freelance business, medical and technology writer based in Stockholm, Sweden.

Contact [email protected]

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Kategorie Titel

Surgery Opens up to New Treatment Methods Recent developments in cardiac surgery have led to new therapies integrating surgical procedures with skin incisions and interventions, e.g. transcatheter techniques with the puncture of a vessel. For these procedures, integrated operating rooms are needed. In addition to surgical equipment, these hybrid operating rooms need high-end imaging equipment equivalent to the angiography devices used in interventional radiography and cardiology. By Prof. Dr. Georg Nollert

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Titel Kategorie

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Special New Trends in Surgery

Imaging devices have been used in operating theaters for a long time. Mobile C-arms, ultrasound, and endoscopy are standard of care for many operations. However, complex transcatheter techniques demand high powered equipment to visualize thin guidewires, quantify small vessel diameters, and evaluate delicate anastomoses. Because of their size and complexity, these integrated endovascular suites or hybrid ORs require special consideration, planning, and design as well as new skills to be learned by the surgical team.

Basics of the hybrid room There is no doubt that an interdisciplinary team of surgeons, interventionalists, anesthesiologists, and other associated specialists should plan and run such a facility. Centers in close proximity to intervention rooms and ORs probably have better prerequisites than hospitals with the classic separation that placed interventional rooms in the internal medicine building and operating theaters in the surgery building. In this situation, it is recommended to install the hybrid room in the surgical wing, where all OR equipment and personnel (e.g. heart-lung machine and perfusionists), anesthesia and surgical intensive care are readily available. Reasonable proximity of the hybrid room to other imaging systems like computed tomography scanning or magnetic resonance imaging should also be taken into consideration. A hybrid OR should be larger than a standard OR and the basic principle for planning is “the larger the better”, because not only the imaging equipment needs sufficient space. Staff calculations have shown that in hybrid procedures up to 18 people need to be in the hybrid room. Experts recommend 70 m2 for new ORs being built. Additional space for a control room is mandatory.

If a fixed C-arm system is being considered, 45 m2 space is the lower limit. Lead shielding (2-3 mm) will need to be built into existing rooms. In some countries, special training for the use of X-ray devices may be required. In general, all members of the team need access to all important information. Therefore, multiple moveable and flexible booms need to be installed in the operating room. If there are two booms to be installed, a boom on every side of the OR table serves the operative team. Collision of the ceilingmounted displays with operating lights or other ceiling-mounted equipment should be avoided. A dedicated ceiling plan with all ceiling-mounted components including air conditioning should be drawn to ensure the function and usability of all devices.

New therapies have emerged Pediatric hybrid operations, hybrid coronary revascularization, transcatheter valve replacement and repair, or stentgraft placement in the thoracic aorta are new developments that are ideally performed in a hybrid operating room. Although hybrid therapies were first developed in a close collaboration be-

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tween pediatric cardiology and pediatric cardiac surgery, currently the strongest driver for hybrid therapies is transcatheter replacement of the stenotic aortic valve.

Trends in pediatric cardiac surgery Surgery remains the treatment of choice for most congenital cardiac malformations. But interventional cardiology approaches are increasingly being used in simple and even complex lesions. The percutaneous approach can be challenging due to low patient weight or poor vascular access. The passage of large catheters through the heart in small infants may result in rhythm disturbances and hemodynamic compromise. Difficult and complex anatomy such as in double-outlet right ventricle or transposition of the great arteries, or acute turns or kinks in the pulmonary arteries in tetralogy of Fallot patients can make percutaneous procedures challenging if not impossible. Surgery also has its limitations, when it comes to operative closure of multiple apical muscular ventricular septal defects, adequate and lasting relief of peripheral pulmonic stenosis, or management of a previously implanted

New Trends in Surgery Special

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CoreValve

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Edwards Sapien protheses

stenotic stent. Furthermore, in some complex malformations, the presence of multiple ventricular septal defects increases the mortality risk, because they are difficult to access by surgery. Combining interventions and surgery into a single therapeutic procedure reduces complexity, cardiopulmonary bypass time, risk, and improved outcomes.

New possibilities for heart patients Surgical and percutaneous coronary artery interventional revascularization are traditionally considered isolated options. A simultaneous hybrid approach may allow an opportunity to match the best strategy for a particular anatomic lesion. Revascularization of the left anterior descending artery with the left internal mammary artery is by far the best treatment option in terms of long-term results. Integrating this therapy with percutaneous coronary angioplasty offers multi-vessel revascularization through a mini-thoracotomy. Particularly in high risk patients, morbidity and mortality decreases compared to conventional surgery. Reasons are the avoidance of cardiopulmonary and its bypass-related morbidity, no manipula-

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Transapical technique

tion of the aorta, which reduces the chance of potentially fatal emboli, and the low surgical trauma by using minimally invasive techniques. Hybrid revascularization is currently performed only in a few centers worldwide. One reason is the real challenge regarding logistics, because an interventional and surgical team have to work together, and the environment in which to perform this therapy – a hybrid room – is scarce. But in the end, a higher number of repeat interventions compared with off-pump coronary artery bypass grafting was seen, because the stented vessels had a higher occurrence of restenoses. However, with the advent of drug-eluting stents, the reintervention rate decreased. A recent feasibility study from the University of Maryland evaluated 13 patients with multi-vessel coronary artery disease who underwent left internal mammary artery-to-LAD minimally invasive direct coronary bypass performed through a lateral thoracotomy, followed by stenting of non-LAD lesions, in a fluoroscopy-equipped operating room. These patients had a more than 40% decreased length of stay and a more than 90% decrease in intubation times. Despite aggressive anticoagulation and confirmed platelet inhibition, the patients had less blood loss and de-

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Transfermoral technique

creased transfusions. Six-month angiographic vessel patency and major adverse cardiac events were similar in the hybrid and off-pump coronary artery bypass groups. These clinical advantages will probably lead to a spread of hybrid revascularization techniques when hybrid rooms become more commonly available.

Trends in transcatheter valve therapy Transcatheter valve therapies are currently developed for the most common valve diseases: mitral valve regurgitation, aortic stenosis, and – in children – pulmonary valve disease. For repair of mitral regurgitation, more than 30 devices are currently under investigation and await market approval. Experimentally, prostheses for mitral und tricuspid valve replacement are under development and certainly will be available within the next several years. Aortic stenosis is the most frequent acquired heart valve lesion in developed countries. Conventional aortic valve replacement for aortic stenosis is based upon standardized guidelines with excellent outcomes particularly in younger patients at relatively low risk. Advanced

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Special New Trends in Surgery

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5 AXIOM Artis U, the room-mobile system for small ORs.

age and severe co-morbidities lead to an increased surgical risk. Cardiologists are reluctant to refer these patients to surgery, because they are considered to be ‘too sick’, although conservative treatment of aortic stenosis carries a fatal prognosis. Low-risk, minimally invasive techniques are needed to treat these very high-risk patients.

Transcatheter aortic valve replacement (TAVR) In 2002, Cribier reported the first human transcatheter aortic valve replacement (TAVR) using a transfemoral, antegrade, transseptal approach. Subsequently two valves were introduced to the market, i.e., the CoreValve and the Edwards Sapien prostheses (Fig. 1 and 2)1 . Both valves have some similar fundamental design features, including xenogenic pericardial valve cusps and a compressible stent suspending these cusps allowing for transcatheter delivery. There are, however, significant differences. The CoreValve prosthesis has an approximately 50 mm long selfexpanding nitinol stent, with a tubular ‘hour glass’ shape that can deploy in the aortic root, above the level of the coro-

6 Artis zee floor-mounted system brings high-end imaging to the OR.

nary artery ostia, and a wide mesh allowing for unobstructed coronary flow. The Edwards Sapien prosthesis has a 14 – 16 mm balloon-expandable straight-tube steel stent, mimicking a standard stented bioprosthetic valve. It is strictly deployed within the aortic annulus and sits in a subcoronary position in vivo. With regard to the leaflet cusps, the CoreValve device is constructed of porcine pericardium, whereas the Edwards Sapien device utilizes bovine pericardium. Three generations of the CoreValve device have been implanted, the 24F, 21F, and now the 18F prostheses. Two inflow diameters, 26 and 29 mm, are available, allowing for sufficient oversizing. With the Edwards Sapien valve, diameters of 23 and 26 mm are offered. A 29 mm prosthesis is under development. Current sheath diameters for transfemoral implantation are 22F and 24F, with smaller versions on the horizon. Implantations have been performed using both the transfemoral and the transapical route with each device. Up to now, more than 1,000 patients have received a CoreValve or an Edwards Sapien prosthesis. In parallel with the development of the transfemoral technique (Fig. 3), the direct, antegrade, transapical technique was explored (Fig. 4). The first successful

18 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

transapical valve implantations using an oversizing technique were published in summer 2006. When both techniques are compared, stroke risk was demonstrated to be lower with the transapical approach, which could be related to less aortic manipulation. A second important complication of TAVR is the high incidence of AV block, which is obviously valve-dependent and reported to be higher with the CoreValve. ATS, JenaValve, Sorin, and Ventor, among other companies, are currently conducting experimental evaluations and are on the verge of clinical implantations. Further systems for TAVR including the Lotus, AorTx, the Direct Flow Medical valve and the PercValve are under development and further systems will follow. For TAVR, valve positioning remains the most critical part of implantation with the risk of coronary artery obstruction and the risk of paravalvular leak. Exact positioning, optimal imaging during implantation and an experienced team performing the procedure are critical. TAVR requires some specific equipment. A hybrid operative theater is the ideal setting for TAVR and is recommended by the European Association for CardioThoracic Surgery. The hybrid OR offers the sterile environment with emergency

New Trends in Surgery Special

7

8

7 Flexibility and whole body coverage is provided by the Artis zee ceiling-mounted solution.

back-up measures and the angiographic imaging technology needed in the catheterization laboratory. Excellent imaging capabilities are the most important criterion for exact valve positioning and thus optimal patient outcome. The overall setting of a hybrid operative theater is of specific value most importantly when emergency cardiopulmonary bypass or conversions to conventional surgery are required. This life-saving effect has certainly been demonstrated in some of the current studies. In addition to the environment, a dedicated team of cardiologists, cardiac surgeons, anesthetists, scrub nurses, and technicians are necessary for successful TAVR. In some centers the same integrated team performs both transfemoral and transapical approaches. TAVR is not a mature method yet; experience with it is limited and long-term results lacking. The clinical value has to be proven in a randomized, controlled trial. Without the results of such a comparison, the excellent long-term results of conventional aortic valve replacement make this therapy the gold standard. Patients with an acceptable risk profile should therefore continue to undergo the standard therapy. However, in the long run, valve therapy – for all valves - will certainly change from con-

8 Flexible park positions, variable iso-center and new 3D imaging capabilities are possible only with Artis zeego.

ventional surgery with cardiopulmonary to the less invasive catheter techniques.

A whole new spectrum of therapies

its flexible patient access, outstanding 3D imaging capabilities and its variable iso-center make Artis zeego an ideal system for imaging in the OR. References

The hybrid operating room facilitates a whole new spectrum of cardiac surgical therapies and will therefore become an essential resource of every cardiac center. The trend towards hybrid techniques is more a revolution than an evolution. Stanford University is already including catheter techniques into training of cardiovascular surgeons. Within only two years the majority of all German heart centers started planning a hybrid OR. Cardiac surgeons around the world emphasize that cardiac surgery is moving rapidly towards the hybrid procedure and that the change is now, not in 5 years. Siemens Healthcare has recognized these trends in surgery and offers a complete portfolio of high-end angiography systems for imaging in an OR environment. From a semi-mobile system for smaller ORs to the flagship of innovation Artis zeego, the new angiography system based on robotic technology, Siemens delivers floor- and ceilingmounted systems dedicated to surgery procedures. Especially Artis zeego with

1. Walther T, Chu MW, Mohr FW. Transcatheter aortic valve implantation: time to expand?Curr Opin Cardiol. 2008 Mar;23(2):111-6. 2. Vahanian A, Alfieri OR, Al-Attar N, Antunes MJ, Bax J, Cormier B, Cribier A, De Jaegere P, Fournial G, Kappetein AP, Kovac J, Ludgate S, Maisano F, Moat N, Mohr FW, Nataf P, Pierard L, Pomar JL, Schofer J, Tornos P, Tuzcu M, van Hout B, von Segesser LK, Walther T. Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2008 Jul;34(1):1-8. 3. Reicher B, Poston RS, Mehra MR, Joshi A, Odonkor P, Kon Z, Reyes PA, Zimrin DA. Simultaneous “hybrid” percutaneous coronary intervention and minimally invasive surgical bypass grafting: feasibility, safety, and clinical outcomes. Am Heart J. 2008 Apr;155(4):661-7 4. Bacha EA, Marshall AC, McElhinney DB, del Nido PJ. Expanding the hybrid concept in congenital heart surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2007:146-50. Review.

Contact [email protected]

AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

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Angiography Large Volume syngo DynaCT

Percutaneos Nephrostomy for an Obstructed Ectopic Pelvic Kidney in an Obese Patient Supported by Artis zeego and Large Volume syngo DynaCT Warren Swee, MD, MPH Division of Angiography and Interventional Radiology, Department of Radiology University of Virginia Health System, Charlottesville, VA, USA

Patient history 46-year-old morbidly obese female presented with high fevers, chills and lower abdominal pain. Her condition rapidly worsened to include lethargy and hypotension. Diagnosis Pyelonephritis and urosepsis. The etiology was found to be ureteral obstruction of an ectopic right pelvic kidney on a multidetector CT scan of the abdomen and pelvis. An attempt to treat the obstruction using cystoscopy resulted in inadvertent ureteral perforation with placement of a double J ureteral stent outside of the collecting system. The patient’s condition continued to deteriorate requiring urgent placement of a percutaneous nephrostomy tube under general anesthesia. Treatment Multiple Large volume syngo DynaCT acquisitions with Artis zeego were performed to guide a 22-gauge Chiba needle into the posterior calyx of the ectopic pelvic kidney. The ectopic position πof the kidney left only a narrow window for percutaneous access requiring passage through the psoas muscle to a depth of 20 cm. After access was obtained, fluoroscopy was used to position a 10 French nephrostomy tube within the renal pelvis.

Dr. Warren Swee and the new Artis zeego multi-axis system at UVA

Comments Following nephrostomy tube placement and medical management, there was complete resolution of the patient’s urosepsis.

20 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

Acknowledgements I would like to thank Zachary Ryan, R.T. (R) for his assistance in image acquisition. Contact [email protected]

Large Volume syngo DynaCT Angiography

1 A+B Axial Large Volume syngo DynaCT images demonstrate a narrow window to access the ectopic pelvic kidney (Kid) between the spine and liver (Lv). Fig 1 shows the first needle pass to be directed laterally toward the liver capsule. Fig 2 shows successful redirection of the needle along the intended course through the psoas muscle (PM). Due to massive percutaneous fat issue, a Large Volume syngo DynaCT acquisition is extremely helpful.

1A

1B

2 A+B Axial and sagittal MIP (maximum intensity projection) reconstructions of a Large Volume syngo DynaCT acquisition to demonstrate successful access to the renal collecting system. A previously placed malpositioned double J ureteral stent is also seen. (*) 3 A+B Axial and sagittal MIP reconstructions of a Large Volume syngo DynaCT acquisition demonstrate successful placement of a percutaneous nephrostomy tube within the renal pelvis.

2A

2B

3A

3B

AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

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Angiography Electromagnetic Needle Guidance

Radiofrequency Ablation of a Large Vertebral Metastasis Using iGuide CAPPA Electromagnetic Needle Guidance Prof. Martin Skalej, MD, Oliver Beuing, MD, Anja Lenz, MD Department of Neuroradiology, University of Magdeburg, Germany

1

2a

1 T1-weighted image without gadolinium enhancement demonstrates large metastasis with intraspinal growth and extension to the lungs, the aortic arch, the trachea and the esophagus.

2 a+b The electromagnetic tracking shows progression of the needle into the soft tissue mass.

Patient history 68-year-old female with known renal cell carcinoma first diagnosed in 1996 with worsening pain in the upper thoracic spine. Patient showed discrete paresis of the left arm, but no other neurologic deficit.

nal and paravertebral infiltration and slight compression of the myelon (Fig 1). The lesion extends to the trachea and the aortic arch ventrally and the lungs laterally. No other spinal metastases were detected.

Pre-treatment Imaging MRI of the spine revealed a large metastasis with destruction of the second thoracic vertebra and extensive intraspi-

Treatment The patient was considered inoperable concerning tumor resection and vertebral body replacement. Thus radiofre-

22 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

quency ablation and subsequent radiation therapy was planned. For radiofrequency ablation, first imaging with syngo DynaCT was performed. The electromagnetic tracking system iGuide CAPPA, which superimposes the puncture needle on the syngo DynaCT data set, was used for precise placement (Fig. 2 a + b). Then the electrodes were introduced through the puncture needle. The final position achieved

Electromagnetic Needle Guidance Angiography

2b

3

3 Documentation of the final position of the electrodes with syngo DynaCT. The image was reconstructed at a syngo X Workplace.

according to the electromagnetic tracking system was confirmed by another syngo DynaCT run (Fig. 3) and the ablation was conducted with a total energy of 40 kJ. The patient tolerated the intervention without any complication, pain improved immediately after the procedure.

Comments The electromagnetic tracking system in combination with syngo DynaCT allows precise placement of electrodes or biopsy devices even in regions that are difficult to evaluate with fluoroscopy or where critical anatomic structures not visible with fluoroscopy alone must be avoided. The tracking system provides excellent depiction of the progression of the needles and anatomic detail is provided by syngo DynaCT. Also no fur-

ther imaging is necessary during the intervention. X-ray exposure to the examiners is reduced when compared to interventions performed under CTfluoroscopy guidance. If wanted, a control scan can be performed to document the final position. Contact [email protected]

AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

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Angiography Imaging Technology in South America

State-of-the-Art Imaging Technology Raises Healthcare in South America to a New Level High-end 3D imaging with reduced dose and other

innovative medical imaging is important and a matter of fact in highly developed countries like the U.S, Canada, Japan, or the European Union. For South America this is still not the standard equipment for hospitals. With the biplane AXIOM Artis dBA the Neurosurgery Institute of Santiago, Chile, became the first public hospital in South America with new high-end medical imaging equipment.

In December 2007, the President of Chile, Michelle Bachelet, inaugurated the first AXIOM Artis dBA with syngo DynaCT in South America. The system was installed at Neurosurgery Institute in Santiago. The renowned institute is the most prestigious in Chile and the first in South America with an installed biplane FD Artis angiography system from Siemens.

A great imaging tool President Bachelet and the Minister of Health, Soledad Barría, had the opportunity to see the system in action. Dr. Jaime Lavados, Director of the institute and Dr. Eduardo Bravo, Head of the Neuroradiology Department, presented the various benefits and features of the new AXIOM Artis biplane system. The system is equipped with the syngo DynaCT application to create cross-sectional images during an angiography procedure, which had helped us reach a fast and reliable treatment decision in 121 procedures performed between June 2007 and January 2008. The insti-

President of Chile, Michelle Bachelet, and the team of the Neuroradiology Department at the Neurosurgery Institute in Santiago, Chile Source: Presidency of the Republic of Chile

tute confirms that the application is a great imaging tool and has fast acquisition and processing times.

24 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

“For us AXIOM Artis dBA is special in two ways”, says Dr. Bravo. “The two C-arms allow us to acquire two views

Imaging Technology in South America Angiography

“Working with the biplane system reduces the expenses for contrast agent and speeds up procedures because it is not necessary to change C-arm positioning during the procedures.” Dr. Eduardo Bravo, MD, Head of Neuroradiology Department, Neurosurgery Institute in Santiago, Chile

during a neuroradiological intervention, so we can see the same pathology in two different planes, which provides us with a 3D view of millimetrical structures for greater safety in our work and minor risk for the patient.” The other great benefit is that it enables the physician to see complications in the treatment of patients in the same room without moving the patient to another imaging modality. “Without moving the patient, it is possible to see any kind of complication during treatment in a very user-friendly way”, affirmed Bravo.

1

2

Improved patient care Among advanced imaging capabilities, AXIOM Artis dBA brings other advantages to the facility. Dr. Bravo is very satisfied with the new system, mainly because it is the first in a public hospital in South America and because of the financial benefits. “Working with the biplane system reduces the expenses for contrast agent and speeds up the procedure because it is not necessary to change C-arm positioning during the procedures,” he explains. At the end of February 2008, the same

3

institute hosted a workshop with 37 Latin American neuro-interventionalists focusing on syngo DynaCT and how its soft tissue imaging capabilities can display details that no other angiography system on the market can offer. These details range from hemorrhages in the brain to stent visualization. Many live cases were discussed with the participating radiologists who also confirmed the high clinical value of syngo DynaCT.

Contact [email protected]

1 Vertebral aneurysm treated with stent and coils. The 6 months control angiography and syngo DynaCT showed stent herniation into the embolized aneurysm. 2 Cavernous segment aneurysm treated with a cardiological stent visualized with syngo DynaCT MIP images. 3 Ruptured basilar tip aneurysm treated with stend and coils. The stent was positioned from the basilar artery to the right P1 segment.

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Cardiology Efficiency in EP

Improved Efficiency in the EP Lab with syngo DynaCT Cardiac By Joris Ector, M.D., Stijn De Buck, M.Sc., Ph.D., Hein Heidbuchel, M.D., Ph.D Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium

At the University Hospital Gasthuisberg in Leuven, Belgium syngo DynaCT Cardiac has become a useful application during ablation therapy. The team in the cardiology department describes their experiences with the system and how it contributes to an efficient workflow and excellent results.

Image integration for ablation of atrial fibrillation Pre-procedural imaging and three-dimensional (3D) reconstruction of the left atrium and pulmonary veins is performed in the majority of centers before atrial fibrillation (AF) ablation procedures.1 Detailed anatomical information can help achieve a more effective and successful ablation and may prevent procedure-related complications. Patient-specific 3D models can be integrat-

26 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

ed with 3D mapping systems. The University Hospital Gasthuisberg pioneered integration of 3D models with real-time biplane fluoroscopic imaging to guide catheter navigation and ablation.2 Image integration is usually based on cardiac CT or MRI images that are acquired prior to the procedure, and reconstructed into a 3D model for treatment planning. One drawback of this approach is the possibility of changes in the left atrial geometry between imaging and the ablation procedure due to differences in

Efficiency in EP Cardiology

cardiac loading conditions, resulting in inaccurate image integration during the procedure. Moreover, an additional ambulatory hospital visit or earlier hospitalization is often required for the patient to acquire the images necessary for 3D reconstruction. This leads to extra logistical overhead. syngo DynaCT Cardiac now offers the possibility of CT-like imaging of the left atrium and pulmonary veins during the ablation procedure. At the beginning of 2008, we evaluated a new workflow in which syngo DynaCT Cardiac images were acquired during AF ablation procedures and reconstructed into a 3D model for integration with biplane fluoroscopic imaging. Catheter navigation and ablation were guided solely by syngo DynaCT Cardiac-based 3D-fluoroscopy integration, without the use of a 3D mapping system. Our goal was to develop a workflow resulting in high quality 3D reconstructions of the left atrial anatomy with the lowest possible patient radiation exposure, eliminating the need for additional pre-procedural imaging and improving image integration accuracy.

per second during a single 5-second rotation and were automatically transferred to the Siemens Workplace for 3D reconstruction to axial images and further 3D processing (Fig. 1 A-C). Whereas contrast administration for left atrial syngo DynaCT Cardiac examinations is conventionally performed in the pulmonary artery, we developed a new approach in which diluted contrast agent is directly injected into the left atrium. To obtain optimal contrast filling and to reduce cardiac motion artifacts, contrast injection and syngo DynaCT Cardiac acquisition were performed after administration of adenosine-triphosphate (ATP) to induce transient ventricular asystole (Fig. 2 A) or during rapid right ventricular pacing to reduce cardiac output and cardiac motion (Fig. 3 A-B). This approach resulted in high quality 3D reconstructions of the left atrium and pulmonary veins, using only a limited dose of ionizing radiation and contrast agent. Given the excellent quality of syngo DynaCT Cardiac, pre-procedural imaging with Cardiac CT or MRI is no longer considered necessary for clinical use in our center.

Imaging the left atrium with a single C-arm rotation

syngo DynaCT Cardiac for 3D image integration

syngo DynaCT Cardiac offers the possibility for both ungated image acquisition with a single 5-second C-arm rotation over 200°, and an ECG-gated image acquisition using 4 sequential 5-second rotations with retrospective ECG gating. To reduce patient radiation dose, we opted for the ungated acquisition protocol. Images are acquired at 60 frames

In our opinion, one of the most important advantages of syngo DynaCT Cardiac lies in the new possibilities for 3D image integration. AF ablation procedures are performed in our center under general anesthesia. As a result, no patient movements occur and patient position is identical during syngo DynaCT Cardiac acquisition and fluoroscopic im-

1A Ungated syngo DynaCT Cardiac acquisition (after ATP) 1B 2D Slice Reconstruction 1c 3D Volume Rendering syngo DynaCT Cardiac: (LA: left atrium, LV: left ventricle, RIPV: right inferior pulmonary vein, LSPV: left superior pulmonary vein, RSPV: right superior pulmonary vein, ap: anterior papillary muscle, pp: posterior papillary muscle, LAA: left atrial appendage)

1A

1B

1C

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Cardiology Efficiency in EP

2A

2B

3A

2A syngo DynaCT Cardiac, ungated acquisition after ATP

Coronary Sinus Catheter

2B Cardiac CT image

Comparison of 3D surface models of the left atrium in the same patient, based on ungated syngo DynaCT Cardiac acquisition after administration of ATP and ECG-gated 64-slice cardiac CT. The quality and accuracy of the ungated syngo DynaCT Cardiac-based 3D model is remarkable. (RSPV: right superior pulmonary vein, RIPV: right inferior pulmonary vein, LSPV: left superior pulmonary vein, LAA: left atrial appendage, TS: transseptal sheath)

4A

3B

4B

Coronary Sinus Catheter

4 A+B Integration of syngo DynaCT Cardiac-based 3D model of the left atrium with fluoroscopy using Siemens syngo iPilot. Left: fluoroscopic image in the right anterior oblique view showing the ablation catheter (Abl) and circumferential mapping catheter (Lasso). Right: after syngo iPilot image integration of the syngo DynaCT Cardiac-based 3D model, the position of the ablation and mapping catheters at the ostium of the left superior pulmonary vein can be accurately determined. (Abl: ablation catheter, Lasso: circumferential mapping catheter, LA: left atrium, RSPV: right superior pulmonary vein, RIPV: right inferior pulmonary vein, LSPV: left superior pulmonary vein, LAA: left atrial appendage)

28 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

Efficiency in EP Cardiology

5A

5C

5B

5D

5 A+B RAO view visualized with LARCA (Leuven Augmented Reality for Catheter Ablation) software 5 C+D LAO view visualized with LARCA software Biplane integration of a syngo DynaCT Cardiac 3D dataset of the left atrium in the right-anterior oblique (RAO) and left-anterior oblique (LAO) imaging planes. A shaded and semi-transparent visualization of the 3D model are shown in the upper and lower panes respectively. Ablation target lines are indicated as yellow dotted circles . The position of the ablation catheter (Abl) and the circumferential mapping catheter (Lasso) can be accurately depicted relative to the ostium of the left inferior pulmonary vein (LIPV), as shown in the semi-transparent LAO view. (TS: transseptal sheaths, Abl: ablation catheter, Lasso: circumferential mapping catheter)

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Cardiology Efficiency in EP

aging. The location of the reconstructed 3D model relative to the fluoroscopic imaging geometry is therefore precise and exact. Using the Siemens syngo iPilot function, syngo DynaCT Cardiac-based 3D volumes can be accurately projected as a 3D overlay on fluoroscopic images in the primary imaging plane (Fig. 4). Automatic syngo DynaCT Cardiac integration in a biplane fluoroscopy environment is already performed in our research setting using in-house developed software (Leuven Augmented Reality for Catheter Ablation, LARCA, Fig.5). It may be available in later versions of systems using syngo DynaCT Cardiac, further increasing the value of 3D-fluoroscopy integration. Moreover, 3D overlay provides direct image integration with electroanatomical mapping systems, obviating the need for registration with 3D geometries acquired with a roving catheter and thereby reducing the duration of the procedure. References 1. Calkins H, Brugada J, Packer DL et al. HRS/ EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007; 4(6):816-861. 2. Ector J, De Buck S, Huybrechts W et al. Biplane three-dimensional augmented fluoroscopy as single navigation tool for ablation of atrial fibrillation : accuracy and clinical value. Heart Rhythm 2008;In Press.

University Hospitals Leuven, Campus Gasthuisberg With 1,894 patient beds and 8,447 employees, the University Hospital Leuven is Belgium’s largest medical institution. Recently, the Medical Imaging Center was identified as a new interdisciplinary research center, with a central position in the University Hospital Gasthuisberg. The center is a joint initiative of the University of Leuven (faculties of medicine and engineering) and the University Hospitals Leuven. Over 80 engineers, physicians and physicists from ESAT/PSI, Radiology, Nuclear Medicine, Cardiology and Radiotherapy are working closely together on innovative imaging applications.

Contact [email protected]

30 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

Efficiency in EP Cardiology

“Given the excellent image quality with syngo DynaCT Cardiac, pre-procedural imaging with cardiac CT or MRI is no longer considered necessary for clinical use in our center.” Joris Ector, M.D., Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium

Left to right: Prof. H. Heidbüchel, MD, J. Ector, MD, PhD, S. de Buck, PhD

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Cardiology Pediatric Cardiac Surgery

With the unique transfer shell system, patient transfer from the MRI system to the Artis cardiovascular imaging system is fast, smooth and easy. Specially floor-embedded motorized rails allow the table of the angiography system to be moved conveniently between modalities.

MR table integration with angiographic tabletop

32 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

Pediatric Cardiac Surgery Cardiology

“With the MIYABI concept we were able to get more imaging information during complex procedures under the same anesthetic. This improves workflow and avoids two procedures” Lee N. Benson, MD, The Hospital for Sick Children, Toronto, Canada

Taking Care of Children Pediatric cardiology has always been a special field with special requirements. Reduced radiation exposure and state-of-the-art imaging are required to treat complex cases such a hypoplastic left heart syndrome. The MIYABI concept combines MRI and angiography systems from Siemens Healthcare to optimize these procedures.

Unlike other medical disciplines there has been a long and productive relationship between the pediatric cardiologist and cardiovascular surgeon, together focusing on improving the lives of children with congenital heart lesions. This cooperative spirit found its origins, when in November 1944, Dr. Alfred Blalock, encouraged by Dr. Helen Taussig, performed the first arterial shunt, setting the stage for a revolution in cardiac care. That spirit continues today in very specialized centers dealing with congenital heart disorders like The Hospital for Sick Children in Toronto, Canada. With the development of percutaneous techniques for cardiovascular interven-

tion, treatment plans have evolved that utilize the unique attributes of what at first may seem like competitive specialties, but have come together, as Taussig did with Blalock, to develop new techniques and management strategies. The case presented on the following pages is one such contemporary example, that of management of the newborn with hypoplastic left heart syndrome. The treatment algorithm was bilateral pulmonary artery banding and placement of a ductal stent in a hybrid surgical angiography suite, with prior cardiac MR imaging, and transfer on Siemens Miyabi system from the MRI scanner to the hybrid room for angiography.

With this system combination, workflow is streamlined, all anatomical data is available prior to the surgery and the complete treatment can be done under the same anesthetic. The MIYABI concept offers flexibility for system usage, as both systems can be operated separately as well. But when used together, they become a very powerful high-performance interventional system. The availability of two imaging technologies during interventional procedures and the convenient way to move the patient from one system to the other quickly and easily supports an optimized treatment and gives seriously ill children new hope.

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Cardiology Pediatric Cardiac Surgery

Hypoplastic Left Heart Syndrome Combined Imaging – Angiography and MRI Lee N. Benson, M.D. The Hospital for Sick Children, Toronto, Canada

Patient history 3-day-old baby boy, weight 2.5 kg. Diagnosis Hypoplastic left heart syndrome. Therapy planning At three days of life, after consultation with the family, the management decision was to follow single ventricle palliation towards an eventual Fontan procedure. The first stage of palliation was either a standard Norwood operation or

a hybrid procedure. Because of the child’s size it was determined that the hybrid procedure would be a better option.

stent into the arterial duct through the main pulmonary artery was successfully performed.

Treatment The child was anesthetized and underwent a pre-procedural MRI to define the anatomy. (Fig. 3) Following the MRI, the child was moved into the angiography suite while under the same anesthetic. A bilateral pulmonary artery banding procedure and insertion of a

Comments The child recovered well, was extubated on day three following the procedure and returned home on day seven.

Contact [email protected]

Treatment at the biplane AXIOM Artis dBC angiography system with the C-arm in park position for best patient access.

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Pediatric Cardiac Surgery Cardiology

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1 Placement of sheath into main pulmonary artery for insertion of the stent into the arterial duct. 2 Band (white) around right pulmonary artery. 3 MR image of hypoplastic left heart syndrome before hybrid treatment.

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4 Banded pulmonary arteries, Patent Ductus Arterious injection. 5 Opened stent in PDA. 6 Angiogram of ductal stent in position.

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The Hospital for Sick Children (SickKids), affiliated with the University of Toronto, is Canada's most research-intensive hospital and the largest center dedicated to improving children's health in the country. Its mission is to provide the best in family-centered, compassionate care, to lead in scientific and clinical advancement, and to prepare the next generation of leaders in child health.

www.sickkids.ca

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Fluoroscopy Pediatric Imaging

Pediatric Fluoroscopy with Digital Radiography Expedites Clinical Outcomes AXIOM Luminos TF, the proven system for fluoroscopy, has many features to ease workflow and facilitate system handling. Together with the mobile digital flat detector it becomes even more versatile, producing excellent results in pediatric care. same patient folder and displayed in the order of acquisition.

Tailored for optimal patient care

Fast diagnosis by the patient’s side

The open design of AXIOM Luminos TF facilitates easy and comfortable access to the patient. The large distance between the tabletop and digital imaging tower as well as a wide tabletop make user perform patient repositioning more conveniently. All operator controls are within easy reach during the procedure, allowing the operator to select organ programs and control radiographic parameters directly in the examination room.

Digital radiographic exposures in addition to fluoroscopy can be acquired directly in the fluoroscopic suite with the integrated mobile Flat Detector (mFD). The light -weight, mobile and easy-tohandle mFD is quickly positioned in the Bucky tray or used for free exposures. The acquired images are available in seconds and eliminate time-consuming examination steps such as cassette handling, allowing the operator to remain in the examination room. Diagnosis from the entire procedure can be accomplished faster. All acquired images, whether fluoroscopy scenes or radiographic images are located in the

Brilliant image quality and lowest dose levels With convenient and efficient system handling and the outstanding image quality at low dose levels, pediatric examinations can be performed with radiation exposure levels that are as low as reasonably achievable while maintaining diagnostic image quality. Equipped with the comprehensive radiation reduction program CARE, AXIOM Luminos TF with mFD can reduce the skin entrance dose by a factor of eleven in pediatric fluoroscopy*. *Data on file. Results may vary.

1

With mFD Patient positioning

Exposure

Repositioning

Images available within seconds

Exposure

Images available within seconds

With CR cassettes Patient positioning

Insert cassette

Exposure

Exchange cassette

Reposition Patient

Exposure

Remove cassette

Scan cassette

Read out cassette

Images available for review

1 Compared to CR cassettes, working with the mFD is faster and requires fewer steps. Furthermore there is no need to leave the examination room for cassette processing, thereby increasing quality of patient care.

36 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

Pediatric Imaging Fluoroscopy

“Overhead radiographs acquired with the mobile flat detector are not only of outstanding image quality but also significantly enhance the procedure workflow. Our technologists were able to remain with the patient during the entire examination, greatly improving patient care.” John P Harris, MD, North Colorado Medical Center, Greeley, CO, USA

2 Fully digital imaging with the mobile Flat Detector enhances flexibility and efficiency.

3 Convenient and efficient system handling for a smooth procedure.

2

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Fluoroscopy Pediatric Imaging

Therapeutic Relief of Sigmoidal Volvulus Under Fluoroscopy Supported by AXIOM Luminos TF with mobile Flat Detector (mFD) John P. Harris, M.D., Charles E. Winn, M.D. North Colorado Medical Center, Greeley, CO, USA

Dr. John Harris and his team at the AXIOM Luminos TF.

Patient history A 13-year-old female presented to the emergency department with sudden nausea, vomiting and abdominal pain. No history of surgery or injury given.

North Colorado Medical Center, Greeley, CO, USA.

1

Diagnosis The initial X-ray radiograph of the abdomen showed a large bowel ileus with some mild dilatation. The repeat radiograph and a subsequent CT scan two hours later confirmed a persistent, progressive air-filled distention to the sigmoid colon and the large bowel. As these findings are very suspicious for a volvulus of the sigmoid colon a gastrografin enema was considered for further validation with the possibility of immediate therapeutic relief to ensure the blood flow to the intestine.

38 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

1 Delayed radiograph taken 10 min. after the therapeutic relief started.

Pediatric Imaging Fluoroscopy

2

2 Gastrografin enema validating the volvulus at the rectosigmoid junction.

3 Delayed radiograph approx. 20 min. after procedure started showing contrast passing into the descending and transverse colon.

3

Treatment The treatment initially began in the SIMMs position where the patient is laying on the left side with the right knee brought up to the chest. The introduction of the contrast agent was conducted under fluoroscopy control. At the junction of the rectosigmoid, a volvulus could be verified. Very slight hydrostatic pressure was utilized before draining the contrast back. This procedure was repeated several times under fluoroscopy. Within about 20 minutes of starting this process, contrast was seen to enter the more proximal portion of the sigmoid colon and the patient began feeling relieved of symptoms. An additional delayed radiograph showed contrast agent passing into the left and the transverse colon. The colon was of more normal caliber. The following delayed images indicated further evacuation. There was still some dilatation to the sigmoid colon but the patient showed considerable improvement in symptoms. The patient was observed in the emergency department for an additional two hours and could be released with no residual pain or symptoms. A follow-up with abdominal imaging in three months time was recommended. Comments With the Siemens AXIOM Luminos TF fluoroscopy system and its mobile Flat Detector for digital radiographic imaging, the therapeutic relief of the volvulus and overhead delayed images could be completed within 23 minutes due to less processing time and well organized workflow. The radiographs acquired with the mobile flat detector were available within seconds and allowed the technologist to remain with the patient at all times. Patient care was perceived to be of higher quality.

Contact [email protected] [email protected]

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Customer Care.Life Virus Protection

Virus Protection at the University Hospital Basel, Switzerland The University Hospital in Basel provides a good example of broad-based virus protection for medical technology systems. With Siemens Virus Protection, the hospital proactively protects most Siemens modalities against potential attacks.

“Today our capacity is configured in such a way that the devices always have to be functioning. That’s why in addition to system quality, operational security is our most important goal.” Professor Wolfgang Steinbrich, Director of the Institute for Diagnostic Radiology, University Hospital Basel, Switzerland

In the University Hospital Basel, on a daily basis, about ten thousand patient images – corresponding to a volume of 18 gigabytes – are processed and registered in the network of the radiological image storage system. Currently, the entire quantity of stored image data amounts to about 32 terabytes, which is equivalent to the contents of over 5,000 kilometers of file shelves.

Providing operating security for the systems Given the high level of system utilization, equipment reliability is crucial. And security considerations play an increasingly important role in providing this reliability. On the one hand, networked communications and the exchange of data worldwide brings the risk of contamination by malicious software, such as viruses, worms, and Trojan horses. On the other hand, the systems need to be protected from risks resulting from

40 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

the hospital’s internal operating network. The systems are increasingly threatened by viruses stemming from data exchange, for example through USB devices and network-connected laptops or from files downloaded from the Internet. For the University Hospital Basel, the safety and protection of medical technical systems with their enormous volumes of data have top priority. Professor Wolfgang Steinbrich, MD, Director of the Institute for Diagnostic Radiology, explains: “Today our capacity is configured in such a way that the de-

Virus Protection Customer Care.Life

“If I open a network connection to the outside world for the protection of our own network, then it’s important for me to work together with an expert provider. With Siemens we can implement this innovative protection.” Franz Buffon, Director of IT, University Hospital Basel, Switzerland

vices always have to be functioning. That’s why in addition to system quality, operational security is our most important goal.” To achieve this, the University Hospital Basel installed full-scale protection against malicious attacks – the first hospital in Switzerland to take this step. To protect against viruses, worms, and Trojan horses, most imaging systems from Siemens are equipped with Siemens Virus Protection. The University Hospital currently has 27 Siemens modalities that are secured

through Siemens Virus Protection. The service consists of virus detection and elimination as well as prevention. Through the installation of a virus scanner and connection of the systems to Siemens Remote Service (SRS), remote updates with relevant hotfixes are imported proactively to protect the systems against attacks from every type of known virus. Should a virus infection nevertheless occur, the Siemens experts can frequently detect this very early – thanks to remote monitoring via SRS – and take suitable action before the cus-

tomer is even aware of the virus on-site and before the virus can cause any damage. Professor Steinbrich values this aspect in particular: “It’s our responsibility to safeguard and protect our image data. Due to new technologies, new dangers have arisen that we must eliminate. I was very positively impressed by Siemens’ proactive approach with Virus Protection. That’s why I strongly supported this solution.” The director of Medical and Operational Technology, Christian Kluth, attaches special importance to ensuring that all

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Customer Care.Life Virus Protection

Siemens Virus Protection continuously monitors the large-scale equipment operated at the University Hospital Basel. This includes systems used in various areas, such as angiography, computed tomography, magnetic resonance tomography, and medical imaging stations. The solution includes proactive virus protection as well as virus detection and virus elimination. Virus Protection is one of the innovative service offerings made possible by Siemens Remote Service (SRS), the infrastructure for long-distance data transmission.

“Just one insecure site would be one too many. Only the installation of Virus Protection in all equipment offers the protection we prefer to help ensure the operating reliability of our machines and systems.” Christian Kluth, Director of Medical and Operational Technology, University Hospital Basel, Switzerland

The benefits at a glance Reliable protection against software attacks Expert problem resolution Reduced technical and IT costs Smoothly running clinical routines Higher system availability Improved efficiency Increased planning security

large-scale equipment in the University Hospital Basel is equipped with virus protection. As he says, a complete solution of this kind is a highly feasible approach for providing comprehensive protection against virus attacks: “Just one insecure site would be one too many. Only the installation of Virus Protection in all equipment offers the protection that we prefer to help ensure the operating reliability of our machines and systems.” Professor Steinbrich attributes the dangers to two principal causes: “First, clini-

cal diagnostic equipment has become highly developed – from the original precision mechanical systems with analog electronics to computer-controlled instruments with complex software for digital imaging. Second, the stand-alone workstation systems of former times are today interconnected and networked with the image viewing units of image storage networks. In addition, a highperformance link to the radiological information system and to the hospitalwide network of the clinical information system is planned.” Steinbrich con-

42 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

cludes: “Although the different networks are physically decoupled, they are connected through the exchange of information. In order to prevent the misuse of personal data at the interfaces and to avert threats, for example, from Trojan horses or viruses, comprehensive innovative protection systems are required – such as Siemens Virus Protection.”

Contact [email protected] www.siemens.com/virus-protection

How can I improve ablation therapy?

With syngo DynaCT Cardiac 3D images of the left atrium can be created directly in the EP lab to help guide the ablation catheter. The Artis zee imaging system with syngo® DynaCT Cardiac is able to create CT-like 3D images of the beating heart within seconds during the procedure – directly in the EP lab. With a single click of the mouse, the left atrium is segmented. The result can be merged with electroanatomical maps and overlain on the live fluoroscopic image, providing anatomical information to support treatment decisions. Visit our website and zee the future. www.siemens.com/artis-zee +49 69 797 6420

Answers for life. AX-Z1089-2-7600

Customer Care.Life Learning with and from the Experts

Learning With and From the Experts Siemens offers intensive hands-on training for interventional cardiology using state-of-the-art simulation technologies

The 3-level CME accredited diagnostic and interventional cardiology course led by Prof. Wolfram Voelker and his team, offers attendees a unique opportunity to get extensive hands-on experience using cutting edge simulation technologies. The practical training course, initiated and organized by Siemens Healthcare is widely recognized as one of the most successful methods to learn and master new techniques for catheterbased procedures. Over the last three years, our simulation-based training has offered cardiologists the chance to enhance their skills in interventional cardi-

ac procedures from basic diagnostics to complex interventional procedures. In a simulated cath lab environment, participants can broaden knowledge in the techniques of coronary angiography and interventional techniques, including three-dimensional imaging to quantify and visualize coronary artery lesions with more accuracy. Besides the use of the imaging system and catheter advancing techniques, the learning objectives vary from the right selection and handling of catheter materials to complication management in the cath lab during an intervention. In small groups,

44 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

under the expert tuition of Prof. Voelker and his team, the trainees can directly feel and see, in real-time, the consequences of their handiwork with catheters, stents and balloons. The simulator also provides feedback on radiation dose during the simulated catheterization. Participants come from all over the world and have the opportunity to exchange experience on an international level in a relaxed and mistake-tolerant atmosphere. “In the clinical routine, there is often not enough time for precise teaching in the cath lab. At the center in Forchheim, on the other hand, workshop participants can take their time working through all functions of the radiographic device and simulation models”, says Dr. Wolfram Voelker from the University Clinic in Wuerzburg, Germany. His opinion is also reflected by the participants. For Dr. Hannes Lafenthaler from Austria the course was a great inspiration. He had also attended other Siemens handson workshops before and liked the balance between theory and hands-on training. “The intensive practical training on the simulators and the individual mentoring by experienced cardiologists in a real cath lab environment enabled me to greatly improve my skill set. After this instruction, I now pay special attention on how to keep the radiation exposure in the cath lab at a minimum,” he

Learning with and from the Experts Customer Care.Life

“At the training center in Forchheim, workshop participants can take their time working through all functions of the radiographic device and simulation models.” Prof. Wolfram Voelker, MD, Wuerzburg, Germany, Course instructor

“My expectations of this course were more than fulfilled. We had a lot of opportunities to train on the various simulation systems, and being supported by an experienced cardiologist extraordinarily increased the learning curve.” Sabine Bleiziffer, MD, Munich, Germany

explained. Also Dr. Sabine Bleiziffer’s expectations of the course were more than fulfilled and she appreciated the use of various simulation systems. “Especially the lesson about measurements for coronary arteries greatly increased my knowledge and will be productive in my daily routine. I also appreciated the limited group size and being supported by an experienced cardiologist which extraordinarily increased the learning curve.” Dr. Ibrahima Bara Diop from CHU Fann in Senegal confirmed: “I significantly improved my skill set in coronary angioplasty. The hands-on sessions

taught me effectively about catheters and guidewire selection and the necessary maneuvering of catheter through coronary vessels. To me it was very important to learn about radiation reduction in the cath lab. Less dose is not only beneficial for the patient, but also crucial for me as a physician.”

Further information and registration: [email protected]

Available hands-on courses (English and in German)

Level 1 Introduction in Diagnostic Coronary Angiography Level 2 Introduction in Interventional Cardiology Level 3 Complex cases in Interventional Cardiology

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New Light and Sound Concept

Siemens Presents New Light and SoundConcept*

Many patients are anxious or even scared prior to a catheterization procedure and need to be calmed down with sedatives. Various studies revealed that sound and light effects in the room can help take away that fear and anxiety,

Components of the light and sound concept Skylight LED Wall lightening French Window – artificial door/window TRAXON Nano Liner for patient table lighting BOSE Sound System with iPod Touch connection

especially in children. Interventional treatment becomes faster and more effective when the patient is calmer and more at ease. For these reasons, Siemens created a new light and sound concept which can be individually designed for the customers’ needs. It creates a soothing light environment consisting of various elements the customer can choose from. LED tubes on the wall can create a warm light with different soft and fluid colors that can also be coordinated with music. A skylight with a customized image can be tailored to any room size, even with a ceiling-mounted system, to create the impression of a large and airy room. Another highlight is the artificial French door which is ideal to simulate daylight or to cover up objects that

46 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

should remain out of view. To work effectively in this light environment, Siemens offers the TRAXON ™ Nano Liner, a white light for clinical use to provide adequate table lighting during the procedure. And with the BOSE ™ sound system connected to an iPod® Touch, the whole sound and light environment can be operated with a syngo-like user interface. For the light and sound installation different themes like landscapes or special images for children are also available. * Siemens light and sound concept is currently only available in Europe.

Contact [email protected]

Congresses & Workshops

Upcoming Congresses & Workshops 2008 / 2009 We always would like to give you the opportunity to get in “touch” with the real system and learn more about system handling to keep you in step with

the latest technological advances. You will have the chance to experience our technology at international congresses, trade fairs, and workshops. In the list

below you will find information on various events where we offer you the opportunity to meet AX.

Title

Location

Short Description

Date

Contact

Hospeq

Beijing, China

Trade Fair

Oct. 10 – 12, 2008

www.chinahospeq.com

TCT

Washington DC, USA

Transcatheter Cardiovascular Therapeutics

Oct. 12 – 17, 2008

www.tctconference.com

ISHAHD

Beijing, China

International Symposium on Hybrid Approach to Heart Diseases 2008

Oct. 18 – 20, 2008

www.hybridheartbeijing.org

JFR

Paris, France

Journées Francaise de Radiologie

Oct. 24 – 28, 2008

www.jfrexpo.com

AOCR

Seoul, South Korea

12th Asian Oceanian Congress of Radiology

Oct. 24 – 28, 2008

www.aocr2008.org

CMEF

Suzhou, China

Medical Trade Fair

Oct. 29 – Nov. 1, 2008

www.cmef.com.cn

AHA

New Orleans, LA, USA

American Heart Association

Nov. 9 – 11, 2008

www.americanheart.org

Medica

Düsseldorf, Germany

Trade Show

Nov. 19 – 22, 2008

www.medica.de

RSNA

Chicago, IL, USA

94th Annual Meeting

Nov. 30 – Dec. 5, 2008

www.rsna.org

Cardiac Pacing and Electrophysiology

Rome, Italy

13 International Symposium

Dec. 2 – 5, 2008

www.aimgroup.it/2008/pacing

APCC

Taipei, Taiwan

16th Asian Pacific Congress of Cardiology

Dec. 13 – 16, 2008

www.apcc2008.org

IROS

Salzburg, Austria

Interventional Workshop

Jan. 2009

www.irosonline.org

AF Symposium

Boston, MA, USA

13th Annual Meeting

Jan. 15 – 17, 2009

www.afsymposium.com

STS

San Francisco, CA, USA

Annual Meeting of the Society of Thoracic Surgeons

Jan. 26 – 28, 2009

www.sts.org

Arabhealth

Dubai, United Arab Emirates

Exhibition and Congress

Jan. 26 – 29, 2009

www.arabhealthonline.com

CCT

Kobe, Japan

Complex Catheter Therapeutics

Jan. 29 – 31, 2009

http://cct.gr.jp

DGHTG

Innsbruck, Austria

38th Jahrestagung der dt. Gesellschaft für Thorax-, Herz- und Gefäßchirugie

Feb. 15 – 18, 2009

www.dgthg.de

ECR

Vienna, Austria

European Congress of Radiology

Mar. 6 – 10, 2009

www.ecr.org

SIR

San Diego, CA, USA

Annual Scientific Meeting

Mar. 7 – 12, 2009

www.sirmeeting.org

CIT 2009

Beijing, China

China Interventional Therapeutics 2009

Mar. 18 – 22, 2009

www.citmd.com

JCS

Osaka, Japan

Japanese Circulation Society

Mar. 20 – 22, 2009

www.j-circ.or.jp

ACC

Orlando, FL; USA

58th Annual Meeting

Mar. 29 – 31, 2009

www.acc09.acc.org

JRS

Yokohama, Japan

Japan Radiological Society

April 17 – 19, 2009

www.radiology.jp

th

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Subscription

Siemens Healthcare – Customer Magazines Our customer magazine family offers the latest information and background for every healthcare field. From the hospital director to the radiological assistant – here, you can quickly find information relevant to your needs.

Medical Solutions News Our latest topics such as product news, reference stories, reports, and general interest topics are always available at www.siemens.com/ healthcare-news

Innovation and trends in healthcare. The magazine, published three times a year, is designed especially for members of hospital management, administration personnel, and heads of medical departments.

AXIOM Innovations The Magazine for Interventional Angiography and Cardiology, Radiography and Fluoroscopy

Issue No. 8 | October 2008

New Trends in Surgery Cardio-vascular surgery opens up for new treatment methods Page 14

Efficiency in the EP syngo DynaCT Cardiac enhances ablation therapy Page 26

AXIOM Luminos TF Pediatric imaging in fluoroscopy Page 36

Virus protection at the University Hospital Basel, Switzerland Page 40

08

Large Volume Imaging with Artis zeego More anatomical coverage with Large Volume syngo DynaCT

AXIOM Innovations Everything from the worlds of interventional radiology, cardiology, fluoroscopy, and radiography. This semi-annual magazine is primarily designed for physicians, physicists, researchers, and technical personnel.

MAGNETOM Flash Everything from the world of magnetic resonance imaging. The magazine presents case reports, technology, product news, and how-to’s. It is primarily designed for physicians, physicists, and technical personnel.

SOMATOM Sessions Everything from the world of computed tomography. With its innovations, clinical applications, and vision, this semiannual magazine is primarily designed for physicians, physicists, researchers, and technical personnel.

Perspectives Everything from the world of clinical diagnostics. This semi-annual publication pro-vides clinical labs with diagnostic trends, technical innovations, and case studies. It is primarily designed for laboratorians, clinicians and technical personnel.

For current and older issues and to order the magazines, please visit www.siemens.com/healthcare-magazine

48 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

Imprint

Editorial

AXIOM Innovations Imprint

“Keeping our customers at the cutting edge of technology and enabling them to do more with their systems and applications is one of our most important goals.” Dr. Norbert Gaus, CEO of the Angiographic, Radiographic and Fluoroscopic Division (AX) at Siemens Healthcare

© 2008 by Siemens AG, Berlin and Munich, All Rights Reserved

Publisher Siemens AG Medical Solutions Angiography, Fluoroscopic and Radiographic Systems Siemensstr. 1, 91301 Forchheim, Germany Responsible for contents Norbert Gaus, PhD Chief editor Sabine Wich [email protected] Editorial board Monika Böhmer Klaudia Dorsch Vera Jünnemann Oliver Meissner, MD, PhD Nadine Meru, PhD Andrea Müller Prof. Georg Nollert, MD Roland Papenfuß Siegfried Prell Susanne Seah Dirk Sunderbrink Contributors to this issue Alfonso Aguilera, Erik Busch, Knut Imhof, Michaela Kandolf, Andra Kirchner, Barbara Reber, Antonio Ribeiro, Markus Rossmeier, Gerald Sandridge

Lee Benson, MD Cardiac Diagnostic and Interventional Unit, Hospital for Sick Children, Toronto, Canada

Harald Sandmayr, MD Radiography Department Landeskrankenhaus Steyr Steyr, Austria

Joris Ector, MD, Stijn De Buck, MSc ,PhD Hein Heidbuchel, MD, PhD Department of Cardiology, University Hospital Gasthuisberg Leuven, Leuven, Belgium

Prof. Martin Skalej, MD, Oliver Beuing, MD, Anja Lenz, MD University of Magdeburg, Magdeburg Germany

Erik Fosse, MD The Interventional Centre, Rikshospitalet, University of Oslo, Oslo, Norway

Prof. Wolfgang Steinbrich, MD Christian Kluth University Hospital Basel Basel, Switzerland

John P. Harris, MD Charles E. Winn, MD North Colorado Medical Center, Greeley, CO, USA

Warren Swee, MD, MPH Department of Radiology University of Virginia Health System Charlottesville, VA, USA

David Lacey, MD Iowa Methodist Medical Center Des Moines, IA, USA

Prof. Wolfram Voelker, MD University Clinic Wuerzburg Wuerzburg, Germany

Jaime Lavados, MD Eduardo Bravo, MD Neurosurgery Institute Santiago, Santiago, Chile

Production Michael Brumme Siemens Healthcare

Luis Ramos, MD, X-ray Department University Hospital Puerta de Hierro Majadahonda, Madrid, Spain.

All at Siemens AG Healthcare Sector

Layout and editorial staff Satzwerker – Jäger & Tuppi Nuremberg/Karlsruhe, Germany Printer Farbendruck Hofmann Gewerbestraße 5 90579 Langenzenn, Germany AXIOM Innovations on the net: www.siemens.com/healthcare-magazine

Note in accordance with § 33 Para.1 of the Federal Data Protection Law: Dispatch is made using an address file which is maintained with the aid of an automated data processing system. We remind our readers that, when printed, X-ray films never disclose all the information content of the original. Artifacts in X-ray, CT, MR and ultrasound images are recognizable by their typical features and are generally distinguishable

2 AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

from existing pathology. As referenced above, healthcare practitioners are expected to utilize their own learning, training and expertise in evaluating images.

pages of “AXIOM Innovations” are cited. The editors request that two copies be sent to their attention. The consent of the authors and editors is required for the complete reprint of an article.

Partial reproduction in printed form of individual contributions is permitted, provided the customary bibliographical data such as author’s name and title of the contribution as well as date and

Manuscripts submitted without prior agreement as well as suggestions, proposals and information are always welcome; they will be carefully assessed and submitted to the editorial board for review.

AXIOM Innovations · October 2008 · www.siemens.com/healthcare-magazine

49

Siemens AG Wittelsbacherplatz 2 DE-80333 Muenchen Germany

Siemens AG Healthcare Sector Henkestr. 127 91052 Erlangen Germany Phone: +49 9131 84-0 www.siemens.com/healthcare

www.siemens.com/healthcare-magazine Order No. A91AX-50801-13C1-7600 | Printed in Germany | CC AX 50801 ZS 090825. | © 09.2008, Siemens AG On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and are subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States. The information in this document contains general technical descriptions of specifications and options as well as standard and optional features that do not always have to be present in individual cases. Siemens reserves the right to modify the design, packaging, specifications and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information. Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.

AXIOM Innovations

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Global Siemens Healthcare Headquarters

Global Business Unit Siemens AG Medical Solutions Angiography, Fluoroscopic and Radiographic Systems Siemensstr. 1 DE-91301 Forchheim Germany Phone: +49 9191 18-0 www.siemens.com/healthcare

Local Contact Information In Asia Siemens Medical Solutions Asia Pacific Headquarters The Siemens Center 60 MacPherson Road Singapore 348615 Phone: +65 9622-2026 www.siemens.com/healthcare In Canada Siemens Canada Limited Medical Solutions 2185 Derry Road West Mississauga ON L5N 7A6 Canada Phone: +1 905 819-5800 www.siemens.com/healthcare In Europe/Africa/Middle East Siemens AG, Medical Solutions Henkestr. 127, D- 91052 Erlangen Germany Phone: +49 9131 84-0 www.siemens.com/healthcare In Latin America Siemens S.A., Medical Solutions Avenida de Pte. Julio A. Roca No 516, Piso 7 C1067ABN Buenos Aires Argentina Phone: +54 11 4340 8400 www.siemens.com/healthcare

In USA: Siemens Medical Solutions U.S.A., Inc. 51 Valley Stream Parkway Malvern, PA 19355-1406 USA Phone: +1-888-826-9702 www.siemens.com/healthcare

Issue Number 8/October 2008

Global Siemens Headquarters

AXIOM Innovations The Magazine for Interventional Angiography and Cardiology, Radiography and Fluoroscopy

Issue Number 8/October 2008

New Trends in Surgery Cardiovascular Surgery opens up for New Treatment Methods Page 14

Efficiency in the EP syngo DynaCT Cardiac enhances Ablation Therapy Page 26

AXIOM Luminos TF Pediatric Imaging in Fluoroscopy Page 36

Virus protection At the University Hospital Basel, Switzerland Page 40

08

Large Volume Imaging with Artis zeego More anatomical coverage with Large Volume syngo DynaCT