If a patient had a heart attack in Mankato, MN, last year, the only treatment available was thrombolytic therapy-even though primary angioplasty has proved to be more effective in clinical trials, and Immanuel St. Joseph's Hospital has a catheterization laboratory. That's because the hospital was not prepared to do coronary artery bypass surgery on site if the patient developed serious problems while undergoing angioplasty to open the blocked coronary artery.
Now, a telemedicine link to the Mayo Clinic in Rochester, some 90 miles away, is enabling interventional cardiologists in Mankato to treat heart attack patients with angioplasty while maintaining contact with colleagues in the cath lab at St. Mary's Hospital, one of two Mayo medical centers in Rochester. It also gives cardiac surgeons in Rochester immediate access to angiographic images and other clinical data needed to prepare for bypass surgery, so they can be ready to operate as soon as the patient arrives from Mankato by air or ambulance.
The program, which will be the subject of a report at the annual scientific sessions of the American Heart Association this month, means that patients can stay near home while receiving world-class treatment for a potentially life-threatening condition. It also means that Mankato's interventional cardiologists, all of whom also pull duty in Rochester's cath lab on a regular basis, no longer have to stand idly by when a heart attack victim arrives at the Mankato emergency room.
"They wanted to be able to provide optimal care of the patients wherever they were, not just here in Rochester," said Dr. David R. Holmes Jr., who directs the cath lab at the Mayo Clinic and was one of the telemedicine project's founders.
During angioplasty procedures, a T3 line connects the cath labs in Rochester and Mankato, a town of some 31,000 residents that serves a population 10 times larger than that from the surrounding 12 south-central Minnesota counties. The telemedicine link carries angiographic images, compressed 6:1, in real-time, as well as a delayed set of uncompressed angiograms from Mankato to Rochester. In addition, the standby cardiologist in Rochester can see hemodynamic pressure readings and waveforms, intravascular ultrasound images, and the hands and face of the Mankato cardiologist.
The videoconferencing consultations have included discussions on such matters as the best angioplasty balloon to select for a specific coronary artery and type of lesion, balloon positioning, stent size and positioning, and whether to use intravascular ultrasound to guide some of these decisions.
It's not that the three interventionalists in Mankato are inexperienced, but rather that at the Mayo Clinic, collaboration is the norm in the cath lab, said Dr. Henry Ting, an interventional cardiologist who leads the Mankato team.
"We wanted to recreate the cath lab environment that exists at St. Mary's Hospital Mayo Clinic, where there are five adult labs that are operational at all times with five different consultants. So if there is an issue, we can always ask someone else in another room for an opinion or put our heads together. That's what we instituted with the telemedicine system, so that if there were issues or questions, we could immediately get continuous real-time consultation from Rochester," Ting said.
It's as if the Mankato cath lab was another room in the same institution; it just happens that the institution is 90 miles away, Holmes said.
The program has gone so well that a similar project was launched last November in another Mayo Clinic-affiliated hospital, in La Crosse, WI. Equally important, the Mankato program will likely take another step closer to replicating the atmosphere at the Mayo Clinic cath lab by replacing routine, hour-long telemedical consultations between Rochester and Mankato with on-demand consultations, only when a specific question arises.
The teledilatation project, as it is called, is an acknowledgement that cardiac surgical backup during angioplasty, despite being officially recommended by the American College of Cardiology, does not really exist. Even at tertiary-care centers with a full staff of cardiac surgeons, it is unheard of to routinely hold open a surgical suite just in case a problem develops in the cath lab, so getting a patient who "crashes" during angioplasty to emergency surgery involves lengthy delays under the best of circumstances.
Though the teledilatation project represents a bold use of technology, it laid a careful foundation when it began in March 1999, defining eligibility criteria and emergency transport procedures in detail. The first 50 or so cases involved very low risk patients in need of elective-not infarct-angioplasty. All procedures were completed with 100% success.
Only in March did the Mankato team begin treating heart attack victims with angioplasty. By late July, it had completed 26 cases in this much higher risk group, all successfully. All told, more than 120 patients have had elective or infarct angioplasty at Mankato; none has required transport to Rochester for cardiac surgery.
In addition to seeking institutional approval to change to on-demand consultation with Rochester, the Mankato interventionalists expect to begin doing more complex elective procedures soon, such as rotational atherectomy for calcified lesions.
"I think we have demonstrated that elective as well as acute myocardial infarction angioplasty can be done safely and effectively in a community hospital that does not have on-site cardiac surgical capabilities," Ting said. "It all comes back to providing the best quality care locally-but making sure it's appropriate care at the appropriate place."
