Philips Azurion with IntraSight. Improved workflows. Better outcomes.

Cardiology has always been a challenging discipline. However, now the age of heart patients is increasing and they are developing comorbidities over the years. Treating their symptoms and conditions is considerably more complex than it was ten or twenty years ago. "In our hospital, more and more often we are seeing older and multimorbid patients, some of whom have very complex lesions, including ones that are high risk. As a result we are performing more complex procedures or those of a multimodality nature," says Professor Dr. med. Raffi Bekeredjian, senior physician and head of cardiology at the Robert Bosch Hospital (RBK), a 1000-bed hospital in Stuttgart. In the interdisciplinary, scientifically-oriented heart center established here, cardiologists and heart surgeons treat patients from far and wide.

Prof. Dr. Bekeredjian and his team of 36 doctors perform around 3600 operations in their cardiac cath lab per year, including over 900 coronary interventions, 400 aortic valve procedures and 150 atrioventricular valve procedures. "Trending upward," adds Prof. Dr. Bekeredjian. For him, the high patient volume means exploring new pathways. "We needed an innovative heart catheterization platform that enabled very high-quality, complex multimodality imaging, not least due to the growing number of procedures being performed," he says. With this in mind, his cardiology department opted for the new generation of Azurion from Philips.

For senior physician, Dr. Alexander Becker, head of the cardiac cath lab, and his colleague, senior physician, Dr. med. Peter Ong, the key advantage of this system lies in the integration of the different applications covered by the IntraSight module. "IntraSight is like the system's cockpit: this is where all applications meet, where they can be controlled and where we read the results," says Dr. Becker. Previously, external devices would often have to be fetched from a nearby room, plugged in and turned on – all while the patient was already on the examination table. Becker: "That wasn't just more work for us, it also meant an additional strain on the patient." The duration of the procedure is often critical: "Many people, often older people, come to us who cannot or should not be on the table for too long due to poor pumping of the heart."

The Azurion unites multiple applications in one system, meaning the functions can be selected easily and intuitively using a touch screen, and individual work steps no longer have to be supervised. This saves medical staff a lot of time, particularly in more complex diagnostic tasks. Dr. Ong gives an example: "Before we had the new system, when we examined a patient with main stem stenosis or triple vessel disease we would need a good hour to perform the diagnostic surgery. Today, with the Azurion and IntraSight, we can usually do it in 45 minutes."

This also means less of a burden on the medical assistants. The system is very easy to use, as Julia Frank, healthcare nurse and deputy head of the cardiac cath lab, reports that the dose, frame rate, changing the individual programs – can all be set directly on the system, simply and highly intuitively. "This makes our jobs considerably easier and more efficient." She says she now spends comparatively less time operating the system and no longer has to keep leaving the examination table, meaning she can fully focus on assisting. "And on what matters most, the patient."

No one has to leave the room to get results now either. The system makes them available right there via the integrated intravascular ultrasound (IVUS). "The IVUS module even delivers a pre-evaluation to me as the examiner,” says Dr. Becker. An automated process that makes the system considerably easier to use – right through to the diagnosis decision.

The system helps optimize patient care, because the stenoses can be examined with regard to their effect on the patient. As such, doctors can make evidence-based decisions on which stenoses need to be treated with a stent and which ones do not. "Thanks to the different information I am shown by the evaluations of the various integrated modalities, I am able to make decisions relatively quickly, and above all safely, without leaving the table," says Julia Frank. "And this is exactly what counts in our big facility: creating an optimal treatment concept for patients focused on achieving the best for them and their illness while minimizing risk, and working cost-effectively. This is precisely where the new capabilities of the Azurion are critical.”

This also includes recognizing when patients do not require a complex surgical procedure such as a bypass. This assessment is made possible by the field of coronary physiology, for which a specific work and research group was set up at the RBK under Dr. Ong. The cardiologist explains the background: "The regulation of the coronary flow takes place in the resistance vessels of the microcirculation. Here, in an interaction between the coronary stenosis and downstream microcirculation, we can see the functional relevance of the stenosis." A state that the field of coronary physiology takes advantage of: "We use validated coronary physiological measurements to better understand the causes of the symptoms and to see whether the microcirculation of the heart is reacting incorrectly because it is clenched up or not opening properly."

These functions are integrated in the Azurion: according to Dr. Ong, coronary physiological analyses of the iFR (instantaneous wave-free ratio) or the FFR (fractional flow reserve) are a highly precise way of establishing whether a stenosis is hemodynamically relevant. For this, he and his colleagues insert a wire into the vessel and measure the pressure before and after the constriction. This allows them to establish whether the stenosis has to be treated, for instance by inserting a stent. "Conversely, we can also see which patients do not require this, and thus protect them from the risks associated

The measurement functions in the Azurion are complemented by solutions such as the co-registration.* "It helps us to say where circulatory disruptions are present in the coronary vessel," says Dr. Ong. For Dr. Becker, it is this function in particular that makes "such a big difference, because we can also use it to identify patients who don't have a focal lesion, but whose vessel disease is more diffuse." From there, Dr. Ong says it is "just a small step" to a treatment recommendation. He sees another advantage of the iFR measurement in that administration of adenosine is not required. The doctor is in no doubt: "In terms of patient safety, coronary physiological measurements like those made possible by our new heart catheter system in the form of integrated solutions represent a big step forward."

The staff at the RBK are also impressed by the system's modern design and its large monitor. Dr. Becker openly says that they "really enjoy" working with the system. Out of all the tools that the Azurion offers, medical professionals are already starting to choose their favorites. For Julia Frank, her favorite is StentBoost, which enables correct stent positioning in the vessel. Dr. Becker enjoys working with this application, because it lets him recognize when the stent has expanded without accompanying imaging. In this way he can spot problems before they occur. Overall he values the image quality of the entire system: He says it is so great that he can also work with radiation at "very low levels." He adds, "This is a big advantage, particularly for our many elderly patients."

"The Azurion offers us exactly what we need to handle the increasing number of complex coronary procedures in our facility," Dr. Becker sums up his experience adding, "It's a modern heart catheterization platform that enables excellent and complex multimodality imaging, works with low radiation levels and lets us perform both intracoronary imaging and physiological examinations without any time delay." With the Azurion, he and his colleagues feel their hospital is well equipped for the future and the growing number of complex cases.