From single –plane to digital flat panel labs, catheterisation laboratory (cath lab) has gone a long way in serving Indian healthcare better
By Sharmila Das, ENN
Rising incidence of cardiac diseases is driving the cath lab market in India. The Indian market for cath lab is growing steadily as a result of advancements in technology and the resultant increase in demand from hospitals, nursing homes, and other medical centers. There are two types of cath labs available in the market; fixed cath labs and mobile cath labs. Fixed cath labs are installed in a specific area in a medical center and mobile cath labs can be moved from one place to another. Due to the growing healthcare centers, the cath lab market has huge potential for growth and players can benefit tremendously.
Advancements that has happened
Today, cath labs provide high resolution, low radiation, and multiple-view systems with facilities for rapid imaging from 6 to 40 frames per second. Cath labs are being used for both diagnostic and therapeutic practices. The arena of cath labs has also broadened with interventional cardiologists and interventional radiologists sharing the same space. And with the volume of minimally invasive procedures expanding, the use of hybrid cath labs/operating room (OR) has picked up, and thus, even cardiac surgeons, electrophysiologists, vascular surgeons, and neuro surgeons are using them.
Dr Balbir Singh, MBBS, MD, DM (Cardiology), Chairman – Division of Electrophysiology, Medanta Heart Institute says, “Because of big size population. the occurrence of heart diseases is increasing. Second point is that the average life- span has increased, people are living longer. Third is westernisation of the society. We are tending more towards smoking; we are eating more junks and exercising less”.
Ashok Kumar, President, Cardiology Society of India shares, “There are lots of factors fueling the need of cath labs like lack of physical activity, diabetes, hypertension etc”.
Dr Sanjay Mehrotra, Senior Consultant Cardiologist, Narayana Hrudayalaya Hospital says, “There is need of more patients with heart disease who require treatment and investigations where cath/ angiography are required and therefore there is more cath labs required”.
Dr SK Gupta, Senior Consultant- Cardiology, Indraprastha Apollo Hospitals says, “The cath lab is an examination room with diagnostic imaging equipment use to support the catheterisation procedure. It offers complete cardiac diagnostic services with critical cardiac intervention when needed”.
With sales of 135 units, the market for cath labs is estimated at `240 crore in 2010. The premium segment which is fixed cath labs continued to dominate the market in 2010, with sales contribution of `191.4 crore and unit-wise sales
of 87 numbers. The market for value segment (mobile and fixed) cath labs, with an average selling price at `1 crore remained almost stagnant at 48 units. Philips and Siemens continued to dominate the cath labs market with a combined market share of 74 percent.
The market for interventional cardiology products in India is growing in line with a dramatic rise in cardiovascular disease among increasingly affluent and urbanised Indians with a resulting surge in demand for high quality cardiac care. Established interventional cardiology procedures – diagnostic angiography, PTCA, and coronary stenting – are performed widely in India, across medium-sized and larger hospitals equipped with catheterisation laboratories. More advanced procedures and devices are concentrated at large corporate and private hospitals in key metropolitan cities. Innovative products such as drug-eluting coronary stents, rapid exchange balloon catheters, and novel vascular closure devices are providing new market opportunities.
The market is growing with the proliferation of cath labs and physicians using interventional cardiology products. New drug eluting stent designs are expected to assist physicians in treating vulnerable plaque, thus accelerating market acceptance of the products. Key demand drivers include a surge in disease incidence due to affluence and lifestyle changes, resulting increase in demand for diagnosis and treatment, and infrastructure expansion driven partly by a fast-growing cluster of corporate hospitals, among other factors. However, the main constraints to growth remain high device and procedure costs, uneven infrastructure and skill levels across hospitals, and a persistent tendency to re-use disposable devices.
Advancements in medical technology accompanied by improved patient outcomes have led to an increase in the number of catheter-based therapies performed by clinicians, a trend that is expected to continue with the discovery of novel techniques and superior medical technology. As science continues to guide medical advancement, the design and functionality of the cath lab and interventional vascular suite will likely continue to evolve.
However, the potential patient population for coronary stenting has historically been under-penetrated due to the high cost of the devices. Despite a rising incidence of coronary artery disease in the country and lowering prices of the interventional devices, many patients choose to forego a coronary intervention due to a lack of insurance coverage and an inability to privately finance these procedures.
“After the discovery of flat panel cath lab where the resolution has improved drastically, there are other improvement in combining various features like inclusion of hybrid systems, intravascular ultrasound, CT angiography and more recently combined cath lab and CT machines”
Dr Sanjay Mehrotra, Senior Consultant Cardiologist, Narayana Hrudayalaya Hospital
Mobile versus fixed cath lab
Most catheterisation laboratories are “single plane” facilities, those that have a single X-ray generator source and an image intensifier. Older cath labs used cine film to record the information obtained, but since 2000, most new facilities are digital. The latest digital cath labs are biplane (have two X-ray sources) and digital, flat panel labs. Biplane laboratories achieve two separate planes of view with the same injection and thus save time and limit contrast dye, limiting kidney damage in susceptible patients.
Dr Gupta says, “About 70 to 90 per cent of labs in India are fixed labs and the rest are mobile. Contribution in terms of quality of fixed cath labs in the total markets is much larger as compared to that of mobile cath labs. Mobile cath labs can easily be wheeled into the sterile environment of the operation theatre that enables the cardiologist to carry procedures peacefully. The biggest advantage of the mobile cath labs is that it avoids the inconvenience of patients travelling to big cities to avail the facilities. That said, fixed cath labs are the preferred choice of bigger hospitals with heavy load of cardiac-related procedure, whereas mobile cath labs need a rest after attending a patient and therefore cannot be used continuously”. Dr Amar Singhal, HOD, Interventional Cardiology, Sri Balaji Action Medical Institute says, “Benefit of fixed cath lab is better for bigger hospital because they can take excess load of diagnosing and treating patients while a mobile cath lab has limited usage which can be more beneficial to smaller cities and town”.
Dr Singh says, “The mobile cath labs have their own advantages and disadvantages. Advantages are that they are cheaper and they require less peripheral like generator to run them. Mobile cath lab doesn’t mean that you can take them from one state to another state. They have to be stationed somewhere to get the maximum benefits. But the picture quality is not good in mobile cath lab. People who use mobile cath lab should understand these boundaries cannot be crossed using mobile cath. We use mobile cath labs in small centers of outside Delhi”.
Dr Mehrotra says, “Mobile cath lab may be of use but have not taken up in our country in a big way but there is need of more cath lab systems. Mobile cath labs can be helpful for travel minimisation but they do not provide proper pictures. There is also lack of back-up facility in mobile cath labs. Fixed cath labs on the other hand are equipped with better equipments and services. It is easier for the doctor and the team to operate at the hospital where the cath lab is situated”.
Technology advancement in the space
With coming of newer devices/technology the market for cath lab is set for a giant leap.
Dr Singh says, “Everyday we see something new is coming up. Quality of images we use in cath labs got improved. Now there is use of intravascular ultrasound, we can see the heart through ultrasound and then there is optical tomography, which is again another lift. With this you can go into the artery or perform CT scan of the arteries and see what is happening inside and how the development of cholesterol has happened etc. In the field of electrophysiology, there have been a lot of achievements. For example, we could see into arterial fibrillation
through doing Dyna CT Scan in the cath lab. So you could do the scan of the heart in the cath lab itself to look where the impulses originating, how to carried it etc. Then new technology also has come in the pacemaker, defibrillator and device that save human life. So there has been huge development in each area then we have stem cells transplant in the cath lab too”.
“Mobile cath labs can easily be wheeled into the sterile environment of the operation theatre that enables the cardiologist to carry procedures peacefully. Mobile cath avoids the inconvenience of patients travelling to big cities to avail the facilities”
Dr SK Gupta, Senior Consultant- Cardiology, Indraprastha Apollo Hospitals
Dr Gupta says, “This technology has graduated from high resolution to multiple-view rapid-imaging systems. The effect of radiation is much lesser for both the patient as well as the operator. Today, cath labs are more sophisticated, flat panel and digital”.
Dr Mehrotra says, “Over a period of time, resolution of pictures used at the cath labs have improved. The advancement of digitisation has helped in the improvement. Another upgradation is in terms of the compactness of the labs. After the discovery of flat panel cath lab where the resolution has improved drastically there are other improvement in combining various features like inclusion of hybrid systems, intravascular ultrasound, CT angiography and more recently combined cath lab and CT machines”. Looking at the demand side, it is imperative to conclude that that in the years to come majority of Indian hospitals will think of having cath labs in their infrastructure.