Scott Webb (Host): Today we're going to learn about advanced cardiac imaging and how these technologies benefit patients and providers in terms of diagnosis and treatment. I'm joined today by Dr. Peter Shaw and Dr. Vikas Veeranna. They're both board-certified non-invasive cardiologists with specialty in advanced imaging, and they're both Elliot Heart and Vascular Center providers at Elliot Hospital.  

This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth, I'm Scott Webb. Doctors, thanks for joining me.

Vikas Veeranna, MD: Thanks, Scott. Great to be here.

Peter Shaw, MD: Thanks, Scott. Good to be here as well.

Host: Yeah, pleasure to have you here. Dr. Shaw, I appreciate that you're wearing your scrubs. It always adds to the authenticity of podcasts. If one of you had a stethoscope on, we'd really have something, but it's great to have you both here. And we're going to talk about advanced cardiac imaging, Dr. Veeranna, and what that is.

So, let's start there. What is it and how does it help patients?

Vikas Veeranna, MD: So, advanced cardiac imaging is the newer branch of cardiovascular medicine, probably has grown in prominence over the past, I would say, 15 or 20 years. And what it involves is use of advanced technologies like MRI, CT, and PET scans to acquire images of the heart. And this is also part of the non-invasive imaging, but offers an in-depth assessment of the heart beyond what the traditional imaging that we know of, like echocardiograms, or nuclear scans can provide.

So, this is the added dimension to cardiovascular diagnostics, which has really exploded in the past 15, 20 years. 

Peter Shaw, MD: Yeah, I just want to add, like most technology, it has gotten a lot better. With MRI and CT previously, these technologies, you couldn't get detailed pictures of the heart because it was moving. But now, because technology has gotten much more advanced, scanner speeds are much faster, we can take really nice detailed pictures of the heart and heart function, that previously wasn't able to be done.

Host: Yeah, Dr. Shaw, even for us lay people like me, the concept of the heart's moving, which is a good thing, right? We want that. We want the heart to be moving, but hard to capture those images until now, apparently. And I want to have you talk about these technologies, MRI, CT scans, nuclear imaging. How does it really help with diagnosis and treatment?

And how is it helping patients to live healthier?  

Peter Shaw, MD: We'll start with MRI. So, the MRI scanner, people always think about the long tube. The nice thing about, as technology has improved, that the small tube that people normally think of has gotten much bigger. So, in terms of access and patient being able to tolerate the scan, that's improved quite a bit.

And then also, the technology behind the scanning for MRI, has also improved. MRI works by having a patient go into a magnetic field, basically aligning all their atoms in the same direction, and then hitting them with an extra radio frequency, which then allows, not to get too technical, but as you hit the atoms with the radio frequency, as they go back to the magnetic field, they release a signal.  

And as technology's improved, you're able to see now a lot more detail than what MRI could do 10 or 20 years ago. And with that, we use a cardiac gating, which is matching the timing of the image acquisition to the cycle of the heart. We're able to basically freeze the heart in every section and then combine all the images together to create a moving picture of the heart.  

And then on top of that is, you know, people have to breathe. For MRI of the heart, we have people hold their breath to help reduce that motion, but we're able to get really good detailed images of the heart muscle, heart function, as well as the advantage of cardiac MRI now, is that we can actually look at the tissue characteristics because of the molecules in the heart, fluid, blood, muscle, all have different characteristics in that magnetic field that we're able to really distinguish. People who have scar tissue of the heart, who have this kind of what it's called infiltration or, kind of diffuse scar tissue of the heart muscle from different disease processes. We're able to see that in a cardiac MRI without actually having to go into the heart muscle and, you know, take a biopsy or take a sample, which is kind of the biggest thing that cardiac MRI has brought. 

In terms of cardiac CT, very similarly, we do cardiac gaiting, so we're following the imaging along the cardiac cycle. But technology for a CAT scanner has gotten so advanced and so fast that really with lower radiation doses, we're able to take kind of a really rapid picture of the heart at these different cycles that get really very detailed, basically what we call spatial resolution and temporal resolution images of the heart and the heart function where we are able to see the heart valves, very clearly.

Vikas Veeranna, MD: Just to add to what Dr. Shaw said, remember we are using these advanced technologies to get a precise assessment of somebody's heart. MRI, as he said, the biggest advantage is that there's no radiation involved, and we can get to the nitty gritty details of what's happening with somebody's heart. At the same time, CT, we are basically using a little bit of X-ray radiation to get pictures of the heart, but with the technology that we have today, it just takes a single heartbeat to acquire images of the heart.

That's all that's needed. So it's a quick in and out test and we are getting a whole detailed assessment of beat your heart, heart muscle, the coronary arteries, which are basically the blood supply of the heart, the heart valves, or especially in people who have had devices put in or if they're getting set up for surgeries related to the heart; this gives their, you know, a great roadmap for the surgeons and the interventional team, how to approach this. And at the same time, we also have another form of advanced imaging, which are basically using PET scans. When we talk about PET scans, people always think about, using it in cancer diagnosis or managing cancers.

But over the past, again, 15, 20 years, there has been a big push to use it in cardiac imaging as well. And now we look at stress tests through PET scans. The added advantage is we are so precise in calculating how much blood flow to each area of the heart happens before and after the stress test, which is extremely helpful.

We are getting to such minute details with this kind of precision imaging. And we also look for characteristics to say, hey, is there any ongoing inflammation of the heart muscle? Is there any scar tissue along with these kinds of testing? So, all these testing sort of helps complement each other to get to that point of giving a more specific diagnosis for the patient. 

Host: I have to be honest, Dr. Veeranna, it almost sounds like science fiction. And I find that a lot when I speak with providers and experts, I'm like, I'm, I feel like I should just be shaking my head. Well, that's out of a movie. That's not real, but apparently it is and it's happening. But I, I'm wondering from the perspective of patients who might be a little nervous, Dr. Veeranna, like, what do they need to know about the process and the safety?  

Vikas Veeranna, MD: We are entering an era of what we call precision medicine, I mean, it's not like one thing fits all. And here, the way we have been trained, it's not just we are cardiologists, we have training in advanced cardiac imaging, so we sort of provide a consultation to our colleagues, be it other cardiologists or cardiothoracic surgeons or even primary care providers, is that what is the right test for your patient?  

We're not just looking at images that are done, we are being involved before they even get some kind of an imaging. We are involved during the time of imaging and we also provide that kind of final, “Hey, what do we need to do further when we do this?” So definitely there is going to be a lot of apprehension when people hear about MRI scans or CT scans or PET scans, you know, there is always that apprehension that sort of creeps in.

But remember, there are well established guidelines and protocols to establish safety. I mean, remember, any procedure, anything, we are always talking about some risks involved with these things, but there are certain established protocols that are provided by these scientific committees or guideline committees, be it the American College of Cardiology or the American Heart Association or some of the other imaging societies that we have sort of incorporated in our advanced imaging program here at Elliot Heart and Vascular Center that we have multiple layers of checks and balances here, in the sense that there is a whole team which is going to start working with the patient to ensure their safety, that they can even get this procedure done.

So, this is going to happen in the background, even before they come in for the procedure or imaging. Even when they come in for the imaging, there is a second line where they are asked questions, have you had any procedures? Do you have any contraindications for these things? You know, if there are any questions, they always reach out to us because we are the final stop in saying, hey, whether we can do this or not.

So, there are multiple checks. And even during these procedures, we are actively involved as physicians who are monitoring, you have that extra layer of safety where we are looking at this every minute to ensure patient safety, at the same time, get the highest quality scan to get the best answer for these patients.

So, we are involved throughout the entire spectrum, be it from the time that somebody puts in an order for this test to what goes out in a report to say what's happening with the patient. 

Peter Shaw, MD: And just to add further, in terms of from the safety perspective, MRI and CAT scan technology are proven safety records. On top of that, I think the benefit of advanced imaging that it's a non-invasive modality. You're not having to go into the body to do a procedure in order to get the information.

I think for one thing I love about cardiac MRI, is where it's very good at diagnosing condition called myocarditis, which is inflammation of the heart muscle. Previously folks would have to actually go in and do what they call an endomyocardial biopsy, which is a procedure where you go into the right side of the heart and you actually take a sample of the tissue.

So, with that, you know, any kind of procedure like that, there's risk of damage to the heart, bleeding risks associated with it. But now with MRI, we're able to really make that diagnosis without even, you know, with just an IV line and contrast. On top of that also, similarly, with the CAT scan, looking at the coronary arteries.

Previously with appropriate patients, instead of doing a catheterization, which is going up to the heart, injecting dye with wires and catheters, where you have that infection, that bleeding risk, we have a patient on the CT scanner, we give them IV contrast, and, you know, within probably 30 seconds, we can get an answer of do you have a blockage, or not? Is it something you have to worry about heart disease? Maybe if you have a big family history or something like that. So, I think the saving of that procedural risk also further increases the relevancy of non-invasive advanced cardiac imaging.

Host: Yeah, I host a lot of these, and I get the, I have the pleasure of speaking with a lot of experts, doctors, and when I hear non-invasive, it always just brings a smile to my face. The smiles on your faces, right? It just, for those patients, as we were saying, Dr. Veeranna, patients who might be a little nervous, the non-invasive approach of MRI, CT scan, it does, brings a smile to my face because you know, I don't know that I want one of these procedures, but if I have to have it, I'm all in on non-invasive. And Dr. Shaw, I just want to give you first last word today. If you could dispel one misconception about cardiac imaging, what would it be?

Peter Shaw, MD: It's not a misconception, but it's more understanding the types of modality that the imaging can tell you. And that's the thing as Dr. Veeranna had mentioned about the benefit of getting imaging with us.

We provide kind of that cardiac consultation where we read the images, but we also get the advantage of, we know all the modalities. We know what the best test is. Previously, we used to order an echocardiogram, which is an ultrasound of the heart.

People always ask, can you tell if I have blockages? Well, no, that's, not the right test for it. Even, you know, primary care providers, want to have a question about what technology would be the best. I think, not so much a misconception, but I think having advanced cardiac imaging it's the Swiss Army.

You have so many tools in this toolbox now that we can look at various things with different types of technologies to answer the questions without, having to go in and do the procedure and, subjecting patients to that procedural risk. 

Vikas Veeranna, MD: As I said in, the mid part of this conversation, we have entered into what we call a precision medicine era. We are tailoring these therapies to an individual patient. We have various tools in this toolbox, but remember, with choosing this, it's always hard, and there are these apprehensions that the patients have. So, coming back to the misconceptions, what are the things that I can think of in terms of misconception is that from the patient standpoint, remember, there are lots of patients who have had surgeries, who have had devices put in or implants and things like that, and somewhere they would have gotten, somebody would have said, oh, you can never get an MRI scan in your life.

Alright, that's one of the most common misconceptions that we come across from the patient standpoint. Oh, somebody told me that I can't get an MRI because I have this. Guess what? Most of the devices, even the device companies or the implant companies that are producing, they have an understanding that a patient may need an MRI somewhere down the line in their life, and most of them are compatible with MRIs.

So, before making that decision, before the patient makes that decision saying, I can never get an MRI, let us know. We have a whole team which works on that, getting that information, and going back to these companies and saying, okay, is this compatible to put them under MRI? So, we do that background work.

So, that's a misconception that I would probably want to emphasize that there are very minimal restrictions now in terms of who cannot MRI and the same thing with CT, people talk about going through a CT scan is basically exposing myself to a cancer risk. Yes. But remember, radiation is there all around us.

You don't have to be going under a CT scan or an x-ray to get that. If you have a cross country flight, that's probably what you're going to get by getting a CAT scan. That's the amount of radiation that you're going to be exposed to. And with the technology being where we can get images with one heartbeat, we are working hard, in terms of reducing these risks. So that's another misconception that I would want to let the patients know, yes, there is a theoretical risk.

But we are working towards, our entire advanced imaging program here, is based off of what we call patient first and patient safety first. That's paramount for us. And, clearing these misconceptions is an important part of how we deal with. And another misconception that we typically encounter is, oh, I had this test, why do I need the other test? That's where I said, one complements the other. There's no one thing that fits all here.  

This is where advanced imaging sort of helps us get to the bottom of things, which can not only impact their diagnosis, but also is going to shape how they're going to be managed, and how they are going to be monitored for the future. So, we are giving a roadmap here of how we are going to manage patients in future. And that's true to that precision medicine, as we are talking about, and it's an invaluable toolbox here. 

Host: Yeah, well, I always know when it comes to the Elliot that we're talking cutting edge technologies, patient centered care, multidisciplinary teams, as we talked today, non-invasive technologies. It's all good stuff. Thank you both for being here.

Vikas Veeranna, MD: Thank you so much.

Peter Shaw, MD: Thanks for having us.

Host: And if you enjoyed this podcast, please be sure to tell a friend, share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.