CARDIO-ONCOLOGY Building a Subspecialty Clinic

Rey Vivo, MD, FACC

Medical Director, Cardiology

Director, Cardio-Oncology Program

Community Health Network

No disclosures

European Society of Medical Oncology:

decline in LVEF of at least 5% to less than 55% with HF signs or symptoms, or

decline in LVEF of at least 10% to below 55% without HF

American Society of Echocardiography:

decrease in LVEF of >10 percentage points, to a value <53%

CTRCD: Cancer therapeutics-related cardiac dysfunction

Strain:

- regional deformation

- describes lengthening,

shortening, or thickening

4 types:

- longitudinal, radial,

circumferential, and rotational

Myocardial Strain

Gorcsan and Tanaka. JACC 2011;58:1401-13.

Myocardial Strain

LVEF 55% LVEF 60% LVEF 54%

GLS 19% GLS 17% GLS 16%

Mar 2015 July 2015 Aug 2015

Cardio-oncology consult: 60F

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Plana, et al. J Am Soc Echocardiogr 2014;27:911-39.

Echo [Oncology] protocol: Strain

Plana, et al. J Am Soc Echocardiogr 2014;27:911-39.

Echo [Oncology] protocol: Strain

Echo [Oncology] protocol: Report

Objectives Accurate interpretation of myocardial strain by echo is considered the backbone of cardio-oncology (CO) imaging. We aim to describe our CO program experience in training staff, and improving throughput and quality in our echo lab to optimize strain imaging.

Methods and Results Sonographer training In March 2015, operations began at our largest site with 3 sonographers (staff ). They received initial instruction in strain imaging from the technical director. With continual training and technique refinement, a total of 23 staff across two other sites met technical standard. Strain adds 3 – 5 minutes to echo workflow. All sites utilize GE equipment and the EchoPAC work station.

Physician interpretation From initially one reader, there are currently 3 cardiologists (MD) interpreting strain. Results are reported within 24 hours of acquisition. Abnormal findings are conveyed directly to the cancer center.

Volume of echoes and strain In 2015, we performed 370 CO echoes (mean: 37/month); 65% of studies had reportable strain. In 2016, the numbers rose to 687 (mean: 57/mo); 75% had reportable strain. As of April 2017, our mean volume is 74/mo with 88% reportable strain.

Quality improvement The technical director and MDs provide regular feedback to staff. We keep a log of strain that needed MD re-processing to build case studies for continuing staff training.

Conclusions In 3 years, our CO program has seen a progressive increase in throughput and quality of strain imaging using an algorithm that may be replicated in other echo labs.

Proposed Algorithm to Optimize Myocardial Strain Imaging: Improving Echo Lab Throughput and Quality in a Cardio-Oncology Program

Robert Monroe, RCS1 | Nadine Henning, NP1 | Jothiharan Mahenthiran, MD1 | Kiran Kareti, MD1 | Sumeet Bhatia, MD2 | Rey P. Vivo, MD1

1Community Heart and Vascular Hospital, 8075 Shadeland Ave. Ste. 310, Indianapolis, IN, USA | 2Community Cancer Centers

Official Scientific Abstract for 2017 Global Cardio-Oncology Summit, London, UK

Methods and Results

This presentation is the intellectual property of the author. Contact rvivo@ecommunity.com.

1. Get “buy-in” from Cancer Center (“Win Win”)

2. Plan ahead with Cardiology (equipment, staffing, clinic)

3. Invest time/training and ensure quality in echo lab

4. Commit fully (Physician lead)

5. Build a database; spread the word

Building a Cardio-Oncology Program