CD&D

The company that brought the world 3-D echocardiography (3-D echo), TomTec (Unterschleissheim, Germany), is returning to its roots to refresh the picture in cardiac magnetic resonance imaging (MRI). At last month's European Society of Cardiology (ESC; Sophia Antipolis, France) congress in Munich, Germany, TomTec was showing CardioArena, a multi-modality imaging workstation pre-announced in March, that featured the soon-to-be-famous "beutel."

Also called the "dancing bag," the green 3-D rendering on the CardioArena screen is actually the left ventricle of a patient shown in a view as intuitively friendly as the pictures in an anatomy book rather than the familiar but disorienting black-and-white 2-D images produced by MRI. "Beutel" is the German word for "bag" and in a moment of national pride, TomTec trademarked the word for cardiac imaging. "Dancing bag" is far more catchy for radiology staff, while cardiologists are quite likely to call it the left ventricle.

Already used in reconstructions of temporal 3-D echo, also called 4-D echo because the dimension of time is added, the beutel representation combined with MRI allows the cardiologist to click on slice views to zoom in on suspect areas of the ventricle.

As a result, a consultation can be conducted simultaneously with reference to echo and MRI images on the same screen with intuitive navigation.

CardioArena is the only platform capable combining 2-D, 3-D and 4-D imaging data from three modalities ultrasound, MRI and the cath lab and it is vendor-independent. CardioArena also connects with the hospital information system, the picture archiving and communication system (PACS) and is accessible over CardioArena Web for anytime/anywhere consultations by referring physicians, surgeons or satellite hospitals.

"Some cardiologists are echo-oriented while some have a preference for MRI, and those orientations affect their perceptions," said Bernard Mumm, president/chief technology officer of TomTec. "There is a difference in quantification for each modality and they can show different results with echo saying everything is all right and MRI showing things are not good," he said.

"Up to now, if you looked at the left ventricle it is always in 2-D and cardiologists need to do a mental reconstruction," Mumm said, adding that studies showed their mental reconstructions are less-than-perfect.

The other problem for clinicians is that a single patient may undergo imaging in different modalities and these images are locked in silos, such that the consulting cardiologist needs to visit multiple silos or even physical sites to view diagnostic images of the same patient. "What we have done is combine all modalities on one platform and can show it to them in temporal 3-D," said Mumm. A CT-enhanced prototype for CardioArena is now in development, "but it is not yet ready to talk about as a product," he said.

TomTec's approach to imaging for radiology, cardiology and ob/gyn is mathematical and not visual reducing modalities to common quantification methods and then specializing in the algorithms to render a single view in 3-D with the capability now to switch between modalities.

The company generates only 20% of its revenues from direct sales of branded products such as CardioArena. The remaining 80% is generated through licensing of its modules and algorithms to original equipment manufacturers (OEMs) such as Philips (Eindhoven, the Netherlands), Toshiba (Tokyo), or in ophthalmology, Carl Zeiss (Jena, Germany), which is developing images of the retina acquired by optical coherence tomography (OCT) and processed using Tomtec technology. Siemens (Erlangen, Germany) offers TomTec ultrasound workstations directly on its website.

Mumm said among TomTec's OEM customers, some can be competitors, but most are partners. "We bring them a module, show that it is both CE-marked and FDA-approved, which makes it easy for them to include the module in their applications," he said.

At ESC, TomTec unveiled the 2-D Cardiac Performance Analysis, a new product feature for the new CardioArena. A speckle tracking analysis tool that can analyze 2-D data from a range of ultrasound machines from different vendors, the 2-D cardiac performance package enables quantitative assessment of displacement, velocity and strain in individual muscle segments.

This analysis aids in the diagnosis of pathologies such as hypertrophic cardiomyopathy or dyssynchronous ventricles, which may need to be treated by cardiac resynchronization therapy.

TomTec began with a management buyout from Kontron (Plaisir, France) in 1990 by a group of executives who had developed 3-D MRI imaging. The company made waves when this team applied its know-how to ultrasound and introduced the world's first 3-D imaging capable of transforming the grainy black-and-white images into intuitive, anatomical renderings.

TomTec remains privately held, with employees holding the majority of shares, and does not report revenues.

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