Dr. Y.S. Chandrashekhar

Looking ahead to the annual ACC meeting

April 26, 2021
by Sean Ruck, Contributing Editor
The American College of Cardiology's 70th Annual Scientific Session & Expo will take place virtually from May 15 – 17. In advance of the show, we spoke to Dr. Y.S. Chandrashekhar, editor-in-chief of the Journal of the American College of Cardiology: Cardiovascular Imaging and professor of medicine at the University of Minnesota.

Dr. Chandrashekhar offered insight into the changes and challenges wrought by COVID-19 and talked about some of the exciting advances that are happening in cardiac imaging today.

HealthCare Business News: How has the role of cardiac imaging evolved over the course of the pandemic?
Dr. Y.S. Chandrashekhar: The greatest difficulty was how to calibrate imaging volume with the ebb and flow of the pandemic. Even with curtailed imaging, we had a lot of challenges — which patients do we bring in for imaging? How do we choose the tests that are the most efficient and expose both patients and technicians to the least risk?

Our labs also had to be configured to accommodate for social distancing. There were lots of things that we normally don’t think of. Then, of course, we have to do something called focus studies instead of our full regular protocol. In some cases, answering very targeted questions. And we had to innovate sometimes. For example, our patients used to be in the ICU in a prone positon, and if you had to do an echocardiogram on them, that’s a tough thing to do. So there was a group in England that created a workaround where they positioned the probe between the bed and the patient and they could create an echo picture with reasonable utility.

Lastly, we found things in the imaging tests that we didn’t know about and are still fretting about now — something you see on an MRI for a patient who was asymptomatic, was it myocardic? Should I worry?

HCB News: One post-COVID-19 ailment that crops up is heart issues. Is that something that has required new learning for clinicians or was it something that professionals were reminded to be more aware of looking for?
YC: There are two sets of issues. Most of these problems we’ve seen with other diseases, but here what happens is that they’re concentrated in a sick patient. The second thing, while some of these changes, like the inflammation of the heart, are seen in other diseases, what to do with the COVID patient is continually evolving with no strongly established guidelines. But yes, they’re problems we’re familiar with and we’re on the lookout more for them.

HCB News: As the editor of JACC: Cardiovascular Imaging, did you feel extra responsibility to highlight the right research in the early days of the pandemic? If so, can you tell us about that experience?
YC: JACC: Cardiovascular Imaging is one of the top journals on imaging for the entire world. So we felt a special pressure, when people were finding all these changes, to bring out all the information about what was happening, what the cause is, and what should be done. It was a difficult time for my journal as well as other journals I’m sure. Everyone had to figure out the path they felt was best with the rush of papers coming in. We had a 35% increase year-over-year in the number of papers submitted to us — both COVID related and non-COVID related. So lots of people were doing research despite the difficult environment. However, most of these papers were small, they were observational studies… They needed to be confirmed with better studies before we could act on them. Even during a pandemic, though, it’s our responsibility to maintain quality. Papers have to be robust, they have to have sizable data. We, as a group, felt most of the submitted papers would not pass the traditional metrics of quality. Throughout the whole year, we only published four original papers on COVID. We may have gotten two or three hundred COVID-focused submissions and found just the four that cleared the bar. Our usual acceptance rate is about 5%.

HCB News: Aside from the pandemic, where is cardiac imaging making the biggest impact in clinical practice?
YC: Lots of areas. Some of the biggest impact immediately seen would be marrying imaging with structural intervention, like putting an aortic valve through a catheter or closing a leaky valve through a catheter. These techniques need a lot of imaging support. Similarly for electrophysiology procedures, where to burn, where the focus of the scar is, becomes very important.

Then of course, there are new things happening in CT. Especially with CT perfusion gathering good data. In one test you can get anatomy, physiology and blood flow at the same time.
PET scans are coming up in a big way as well, because they allow you to measure blood flow and that, coupled with new neurotracers, will allow us to get better answers. CMR is the other that tops the list. There are lots of new things coming there. At this time, there isn’t much uptake, but in the next few years, it will be a very powerful tool.

HCB News: Despite lots of research showing its value, cardiac CT is underutilized and perhaps under-reimbursed. Has that been your impression?
YC: Very true. CT is probably the area with the strongest emerging evidence for its use. It is data-based, clearly showing where it’s useful and where it has limitations. We are gathering more knowledge about that faster than we have for technologies like echo and nuclear. CT has provided similar kinds of information in a much shorter time. And an important thing to note is that the evidence has been gathered from contemporary patients. It’s easy to do and it acts as a great gatekeeper to more invasive procedures.

HCB News: Are there any emerging use cases for cardiac imaging that researchers are particularly excited about?
YC: There are lots of questions we can answer now that we couldn’t in the past. One area that stands out is cardiotoxicity. We give radiation to patients with cancer to help them, but there’s a risk we may end up damaging the heart, which, in some cases can be permanent. That means it can be a very heavy decision. So being able to identify the potential for damage, and if there is early evidence of damage, you can stop the chemotherapy and protect the heart, is incredibly valuable.

Then, there are questions regarding things like ventricular stiffness. That’s an epidemic itself. Of course, there’s always the question of how to measure how well the heart is pumping. The metric we have now is called ejection fraction. It’s not very good. There are better techniques coming out that measure myocardial mechanics, so that’s very exciting. Lastly, there are some advances in CMR which allow you to extract a bunch of parameters from one single scan. That’s going to be a game changer. My journal has been fortunate to showcase a lot of the outstanding papers in this area.

HCB News: What are some of the big cardiac imaging topics to look forward to at the upcoming ACC virtual meeting?
YC: The program for this year hasn’t been released yet, but I expect to see a fair amount of machine learning AI. There will be a lot of discussions about how to evaluate patients with chest pain and ischemia since the ischemia trials came out a few months ago with some very interesting results that the imaging community may or may not have been expecting. There will be all the usual topics as well – CT and CMR will feature prominently.

HCB News: We think of cardiac MR as a somewhat sophisticated exam that is not available in the routine clinical environment. Is that changing?
YC: It is, but very slowly. We are a little behind compared to Europe — especially Germany and the United Kingdom. There’s a big opportunity here to enhance utilization of CMR. It provides so much information, it can become a one-stop shop for most diagnostic conditions. It also provides something unique that most other tests don’t have — or even if they have, it’s extremely difficult to get — and that is tissue signatures.

HCB News: How much of a role is AI playing in cardiac imaging today and how much growth do you expect in the coming years?
YC: It’s already playing a fairly large role in the background in how machines analyze data and how they produce models of the heart, but we’re moving into uncharted territory. It’s extremely exciting, but also potentially unnerving, with what AI can and cannot do. The imaging leaders of the future may not necessarily only be the doctors. Of course doctors will still be there, but a lot of imaging technology may move from companies that are currently in health care to companies who are experts on handling large amounts of data: Facebook, Alphabet, Amazon, Microsoft.

There is also some mind-blowing technology coming up. There’s one called GAM (generalized additive model) which gives you the ability to take a data set generated for say, a CT, and without having to repeat the test, you can convert that into an MR image or an echo image.

HCB News: So GAM could take something in one modality and translate a difficult case into a modality where an organization has an absolute superstar available to offer expertise?
YC: Totally. But the experts for GAM aren’t sitting in universities. They’re sitting in big data mining companies. This is something that comes up in discussions with my colleagues all the time — what will be the role of doctors in the future? We will probably farm out the low-level things to machine technology and add more value to the high-end tasks. We’ll probably be concentrating on things that make a big difference to the patient rather than spending as much of our time acquiring or interpreting images.