How 3 New Technical Advances are Improving Patient Care: Introperative MRI, PET, & VAD
The patient was only 21, but she had serious heart disease – and week by week her symptoms were growing worse. Sick as she was, she did not yet qualify for a heart transplant. So how could physicians ease her ragged breathing, improve her crippling fatigue and give her back some energy and quality of life?
An implantable heart pump, or ventricular assist device (VAD), dramatically improved the health of this young woman. And the VAD is just one example of the technology revolution that is sweeping medicine today. At Barnes-Jewish Hospital, Washington University physicians in every medical field are at the leading edge, using these sophisticated devices daily to save patients’ lives.
This high-tech transformation is particularly visible in three areas— neurosciences, cancer and heart care. In each case, Barnes-Jewish and Washington University physicians are bringing their patients a range of extraordinary new devices, some that are still being tested in clinical trials and others that exist at only a handful of medical centers in the nation.
1. Seeing Brain Tumors Better
Bending over an operating table, a neurosurgeon is tracing the extent of a patient’s brain tumor: an aggressive, deadly glioma with a vicious habit of infiltrating the brain’s normal tissue.This tumor begins in the right frontal lobe and snakes back toward the base of the brain. The trick is to figure out the extent of its invasion and remove as much as possible, down to the very last cell.
This spring, new technology—a high-field strength intraoperative magnetic resonance imaging (iMRI)system—was installed in two surgical suites,representing the latest advance in neurosciences at Barnes-Jewish and Washington University.Barnes-Jewish Hospital is one of only eight hospitals in the country to own this state-of-the-art device.
Physicians use the mobile, ceiling-mounted iMRI system to produce highly detailed 3-D pictures of the brain during surgery. In the case of the glioma, neurosurgeons can check the scan immediately to see whether they have removed all the tumor they safely can. No previous technology could do what this intraoperative MRI does: provide instantaneous feedback during surgery for surgeons to determine how much removal is possible against what they had previously planned.
“Recently, it has been shown that for many brain tumors, our ability to remove them is directly related to patient outcome,” says Ralph Dacey, MD,Washington University chairman of neurosurgery.“That is, the more we take out, the better the outcome for long periods of time. Instead of estimating the degree of removal that we have achieved, we will now be determining it during surgery, and if it isn’t enough, we will continue on and remove more.”
This new system has other advantages as well. Integrating data obtained from intraoperative MRI scans into their treatment plans, surgeons can target only those areas of the cortex that can be safely removed—making surgery safer and more effective for patients. These state-of-the-art operating rooms also offer video conferencing equipment, allowing surgeons to interact with other experts during surgery.
“This imaging technology is enhancing what we are able to do,” says Dacey. “We have been waiting for this development, and it is really exciting.”
2. Tracking Treatment for Cervical Cancer
“When patients have cancer of any type and get treatment for it, what do they want to know?” asks Perry Grigsby, MD,Washington University radiation oncologist. “They want to know if they are cured. And many people have the notion of five years in their head, thinking:‘If I make it to five years, I’m considered cured of this.’”
In the case of cervical cancer, that time line has shrunk dramatically, thanks to a Siteman Cancer Center study recently published in the prestigious Journal of the American Medical Association. It showed that scans performed three months after the end of therapy using positron-emission tomography(PET)—a tool developed at Washington University’s Mallinckrodt Institute of Radiology and now used worldwide—are remarkably accurate in predicting whether patients are free of disease or will need further treatment.
In the past, physicians used X-ray studies, primarily CT scans, to assess whether cervical cancer had spread. But these tools were not as accurate as PET, and sometimes recurrences went undetected until the patient developed symptoms—too late for treatment to be effective. Finding a recurrence early means that patients get new kinds of lifesaving therapy quickly.
“For patients who have completed therapy and have a negative scan, we can reassure them that they are going to do extremely well,” says Julie Schwarz, MD, PhD, a Barnes-Jewish resident physician and study co-author, with Grigsby as senior author. “This is really powerful and important for our patients.”
Schwarz and Grigsby’s study comes out of a Siteman research program focused on gynecologic cancers, including cervical, endometrial and ovarian cancers.Led by gynecologic oncologist David Mutch, MD,and geneticist Paul Goodfellow, PhD, the program is producing promising clinical advances.One of these advances that also involves PET benefits Barnes-Jewish patients with cervical cancer who receive radiation therapy. “We use the PET scanner to specifically target radiation to areas where the tumor has spread,” says Grigsby.“I am not aware that this is done anywhere else besides St. Louis.”
3. Buying Time for Heart Transplant
A decade ago VADs existed, but they were big, bulky and noisy with uncertain durability. Today, an exciting new generation of VADs is being tested, and Washington University cardiac surgeons at Barnes-Jewish are implanting two of them: the HeartMate II and the VentrAssist. They serve as a temporary measure in some patients who will ultimately need a transplant and as permanent therapy in others who are not candidates for transplantation.
“Initial results with these devices have been very positive,” says Washington University cardiothoracic surgeon Nader Moazami, MD. “They have been miniaturized, they are noiseless and we believe they are more durable. But the great accomplishment is that patients can get back to a level of activity they were never able to achieve before.They are no longer bound to the hospital. Now they can go home and assume a nearly normal life.”
These VADs help the heart in the work of circulation.The basic unit is a tiny pump with small blades that rotate on bearings. It connects to the heart’s diseased ventricle to help its pumping function.While that part of the VAD is implanted inside the body, another piece is external: a cord that emerges from the abdomen and connects to a small control and battery system.
For critically ill patients who are imminently in need of a transplant, Barnes-Jewish is one of only 11 centers nationally to offer another lifesaving option: the CardioWest temporary Total Artificial Heart. Patients who receive it must remain in the hospital but have a much improved chance to survive until a donor heart becomes available.
“Today, patients have more options, and it is a very exciting time because we are moving to newer devices that have a lot of promise,” says Moazami.What about that 21-year-old who received a VAD?“She was out of the intensive-care unit in three days and is now doing very well.”