Highlight on Technology: Video-Audio Integration for the EP Lab

Laurence M. Epstein, MD Brigham and Women's Hospital Boston, Massachusetts
Laurence M. Epstein, MD Brigham and Women's Hospital Boston, Massachusetts
Historically, electrophysiology laboratories were designed on the model of catheterization laboratories. In this model, the x-ray images were the focal point of the procedure. This model worked for early electrophysiology laboratories, which included single-plane fluoroscopy and thermal or ink recorders for a limited number of electrogram channels. However, many labs today are equipped with biplane fluoroscopy (4 monitors), multichannel recording systems (2-3 monitors), one or more three-dimensional mapping systems (1-2 monitors), intracardiac echocardiography (1 monitor), three-dimensional reconstruction workstations (1-2 monitors) and robotic catheter manipulation systems (2-3 monitors). The role of anatomy in arrhythmia treatment has become increasingly recognized, and the integration of multiple imaging modalities guide therapeutic procedures. Catheter ablation to treat atrial fibrillation is a clear example of how image-guided therapy enables the treatment approach. Unfortunately, advances are often accompanied by challenges. The modern electrophysiology laboratory has become the very embodiment of clutter (Figure 1). With technology advances such as cryoablation and saline cooling, equipment occupies more and more space in the modern electrophysiology laboratory. This has created two major issues: • The clinician must search for appropriate information amidst the clutter on the myriad monitors around the room. • There is a lack of space. Choices must often be made limiting which technology can be viewed, simply because there is not enough space in the room. There is now a need to integrate and display information rationally within a dramatically reduced footprint. Ideally, the clinician would be able to customize the organization and display of the information. A team of trained personnel now performs most complex procedures. In order to maximize procedural safety and efficacy, clear communication among the team performing the procedure is crucial. When the recording/mapping workstations are in a separate room, communication depends on overhead speakers and microphones. This can create a loud and noisy situation, and can be unsettling to the patient. Ideally, the communication system should allow private communication among all care providers. EP Lab Solutions One solution to the problems of information display, operating room clutter and private communications is CurlView IGT (Figure 2). The primary benefit of the CurlView system is that it allows the clinician and staff to maintain maximum focus and collaboration during a case. This is achieved as follows: 1. The system integrates all video displays currently carried on 6-12 separate monitors onto one large, very high-resolution video panel. 2. The operator can control multiple computers with one mouse and keyboard. 3. The entire clinical team can have private, whisper-sensitive wireless communication. 4. Concentration and focus are enhanced by background music. Video Processing and Display. The system employs a single 56-inch ultra high resolution video display panel. The display controller allows the clinician to have any combination of images, placed anywhere and in any size on the display. There is full control to manipulate the images for different segments of the case or for different procedure types. Each image can be “right sized” or even removed if not required. The front end of the system takes up to 22 input sources and selectively routes them to the Video Processing Engine. The processing engine takes up to 12 sources of virtually any video resolution or format, and displays them simultaneously on a single 56” 8 Megapixel display panel. The user can select preset configurations to manipulate the images and optimize their viewing accuracy, priority, and comfort, or may customize the display in real time to suit a particular situational need. Typically, the large display is used in the procedure room, but it can also be used at the control console to provide a duplicate view. Consolidated Keyboard and Mouse Control. The system has the option of controlling multiple computers via a single keyboard and mouse on a single display. The control of the remote machine is performed either through a USB interface or through a LAN applet. The native keyboard and mouse for each machine can also be operated independently in the event there are multiple operators during the case. Wireless and Wired Intercom. The system provides intercom options that deliver clear and accurate voice communication. The wireless option provides whisper sensitivity and privacy, regardless of commotion and distractions. The physician’s instructions and team replies are delivered to all participants. Individual users can select between “Push-to-Talk” or “Full-Duplex” modes. The wireless option also provides the added benefit of allowing participants to leave the room while still maintaining full communication with the rest of the team. Background Music. The laboratory can be configured with audiophile quality speakers and a headphone jack for the patient and staff. The source can be an MP3 player, CD player or Internet-based music. This has been shown to reduce stress and facilitate sedation. Integrated Recording Currently a case can be reviewed only in parts: electrograms can be reviewed based on a “time stamp,” the 3-D map can be viewed, as well as intracardiac echo images, and fluoroscopic images can also be reviewed if saved. However, these all occur independently, without the ability to accurately view all images simultaneously. The CurlView system can record the case as it is viewed. All images displayed are captured simultaneously. All the images and recordings from the case can be reviewed as a single image, with all of the separate systems synchronized on the screen as they occurred during the live case. This is particularly helpful for fluoroscopy. The CurlView system continuously records the displayed image, which includes all modalities being viewed. The clinician can review at any point in time the exact display of all imaging and recording modalities simultaneously. Other Benefits The CurlView system requires little space, while other systems can require banks of monitors, cables, and support structures. This system simplifies the infrastructure with a single 56” flat panel. The OEM Fluoro monitors can remain on a separate suspension and serve as a redundant “backup” display. Twenty-two source images can be selected, with up to a total of 12 displayed simultaneously. Image size is also not limited to the typical 20” monitor. When a large view is required during a case, any image can be expanded to fill one-half or even the entire 56” panel. Integration of the System at Brigham and Women's Hospital The Shapiro Cardiovascular Center at Brigham and Women’s Hospital opens this month (May 2008). This $380 million center was designed to provide state-of-the-art, patient-centered care. Including inpatient (all private rooms) and outpatient services, patients will have one location for all cardiovascular needs. In addition to a dedicated Arrhythmia Clinic, co-located with the heart failure service, The Center includes a four-laboratory electrophysiology suite. The goal of the design was to create the next generation of electrophysiology laboratories. In collaboration with General Electric, we sought to find an integrated solution for the audio-visual requirements of the modern electrophysiologist. The CurlView system provided this solution, and is being installed in the biplane rooms. Summary The integration of this system at Brigham and Women’s Hospital has helped modernize our EP lab design tremendously. In addition, the integration of multiple video sources and seamless communication in the new lab environment will allow for the efficient and safe completion of even the most complex EP procedures.