Boston Children’s brings technical precision to pediatric heart surgery
By using computational fluid dynamics software and other modeling techniques for patients with complex congenital heart disease, the pediatric cardiology team at Boston Children’s Hospital says it now better understands flow balance and characteristics in preoperative planning and can improve surgical decision-making and improves patient outcomes.
Turn to CFD for decision support
When you as a parent discover that your child’s heart is not working perfectly, you turn to the most talented surgeons you can find to repair and restore the flow pathways. Although there are many different types of heart surgery in children, most children require multiple surgeries.
The sizes and shapes of these areas and sometimes the physiological outcomes can cause children to put extra pressure on their hearts. Historically, it has been difficult to predict exactly how to operate to achieve long-term results for each growing patient.
“It’s about how do you get that patch perfect so that the child doesn’t have to come back for a revision of that patch, or get a narrowing of that patch that creates extra work for the heart over time, and that’s historically it has been that way.” left to the discretion of the surgeon in the operating room,” explains Dr. David Hoganson, director of the Computational 3D Visualization Program in the Department of Cardiac Surgery at Boston Children’s Hospital.
Engineering efforts that are now standard outside of healthcare help “take a lot of the guesswork and intraoperative decision-making off the table and dramatically increase the consistency of outcomes, both from a geometric standpoint and a physiological standpoint,” he says. told Healthcare IT news.
“I think we had one patient for whom we ran about 80 different flow simulations before we knew exactly what the best approach was,” Hoganson said. “If we had done what we expected from the beginning, we would have been 100% wrong and the patient would have been back for another operation.”
When the program first attempted to assemble a team of professional engineers seven years ago, Boston Children’s hired a computational fluid dynamics expert from the U.S. Department of Defense who was intimately familiar with the ANSYS software that the hospital had chosen to establish a pre-surgical computer modeling program for cardiac patients.
By adding more engineers from different academic and industry backgrounds, the hospital now has a team of 12 – soon to be 14 – running the 3D modeling workflows for patients, Hoganson said.
Getting solutions before surgery
Patients and parents will seek out multiple opinions and viewpoints when time allows. But of course there are times when the engineers are racing against the clock.
“It’s built into the challenge of this disease,” Hoganson said.
“Sometimes you have the luxury of time and sometimes you don’t. I think building a professional engineering team that can respond and do it as quickly as possible has been a total transformation.”
He said it was exciting as a doctor to see the CFD technical analysis delivered on time and when patients needed it most. The time constraint piece is an important part of the solution.
“It’s not just the math. It’s not just the science. It’s the service, the delivery and the on-time delivery that’s really important.”
Hoganson said his team has worked with several pediatric heart centers, adopting their model and hiring engineers. While the program doesn’t have any quality metrics to share at this time, they are working to get data published.
“We now have 75 patients in a particular valve repair workflow, and you know, the data is extraordinary,” he said.
Pediatric patients and parents embrace CFD
While the math, science and engineering behind CFD modeling are extraordinary, Hoganson said it’s the three-dimensional images of a child’s heart that resonate with clinical families.
Because there is a lot of reliance on physicians to make complex decisions in pediatric cardiac surgery, Boston Children’s families are shown the models and flow simulation data for those options to participate in the results and “see what we see,” Hoganson said .
“My little line drawings and hand movements and the things that are kind of standard in this field are really not ideal,” he said.
“We’re literally taking the best technology in the world and applying it to these patients and doing our very best to eliminate any questions about variability that might come up during surgery because we’ve thought about all that. tested, and we know this is the best option.”
“We’ve had teenage patients who say, ‘Well, you’re obviously going to do that, right?’
“They know we’re doing everything we can, but we want the families to feel like they really understand what’s on the table.”
Evolving practice, billing code proposals
CFD is also used in respiratory medicine, developing medical devices such as dialysis machines to improve their function, pharmaceutical efficacy, patient education, treatment decisions, air quality systems and more. The technology can also be used with artificial intelligence to analyze complex data sets and develop diagnostics.
Using CFD to model congenital heart defect repairs used to take two months with more than 19 software packages, Hoganson said, but now it takes about three weeks.
“We wanted to get to about four days for submission. Or, what’s taking us now is twelve hours, we should get to two hours, right?
“A big part of that is software and workflow development,” which is constantly being refined, he said.
Although some of the program’s modeling workflows were not created with CFD software, Hoganson said the team is working with other heart centers and the U.S. Food and Drug Administration to standardize the workflows and build on the use of CFD in other practices.
Case complexity may challenge modeling assumptions, or team members may experience differing opinions about the iterations produced by the modeling.
“We want to simulate a lot more things than we can right now,” Hoganson said.
Confidence from a technical point of view requires simulating heart flows “in a way that the results are reliable” and currently CFD cannot be used in all patient cases.
Where there is complexity, particularly in the area of arterial circulation, a very careful assessment is needed of: ‘Are the tools adequate to address this?’ And yet in many of these areas the answer is no,” he said.
Hoganson and his team are also working to build payer support for CFD modeling, working on a national level.
“No billing codes have been approved for this effort yet, but we are working on it now,” he said.
“We submitted billing codes to the CPT in collaboration with the Society of Thoracic Surgeons and several other cardiology, radiology and other groups to come together to try to get this approved, which was very exciting.”
Andrea Fox is editor-in-chief of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.