Part 4 of 6 in Circle CVI's Structural Heart series. Every Scan. One Plan. One Platform.

Structural heart programs get measured on procedure volume. Case counts, room utilization, length of stay, the board slide with the line going up.



None of that is where the queue forms. Every structural referral begins with a CT and a heart-team decision, and both of those happen in imaging. When referral volume rises, the cath lab feels it second.

The volume is not a forecast anymore

US TAVR volume passed surgical aortic valve replacement in 2019, at 72,991 transcatheter procedures against 57,626 surgical in the STS/ACC TVT Registry. In the 39 months from January 2019 through March 2022 the registry captured 210,495 TAVR procedures across 786 US hospitals. That was before the two things that just happened.

The first is evidentiary. EARLY TAVR randomized 901 patients with asymptomatic severe aortic stenosis to intervention or surveillance and found a primary composite of 26.8 percent against 45.3 percent. The composite was driven by unplanned cardiovascular hospitalization rather than mortality, and the most operationally significant number in the trial is a different one: 87 percent of the surveillance arm underwent valve replacement anyway. Watchful waiting largely defers the procedure rather than avoiding it, and deferred patients still need imaging while they wait.

The second is regulatory. The 2025 ESC/EACTS valvular heart disease guidelines lowered the age for a Class I, Level A TAVI recommendation to 70 and now state that intervention should be considered in asymptomatic patients with preserved ejection fraction. In the United States, CMS finalized a revised TAVR national coverage determination on 10 September 2026, extending coverage to asymptomatic severe aortic stenosis under coverage with evidence development, removing the CED requirement for symptomatic patients, and replacing facility procedural minimums with infrastructure and quality expectations.

A wider eligible population and fewer facility-level barriers produce more referrals. Referrals arrive as CT studies.

Departments were already at capacity

This lands on a service line that has been absorbing growth for two decades without a proportional increase in staff.

A systematic appraisal of 440 published imaging studies found that 48.3 percent would increase radiologist workload in an academic setting, against 4.5 percent that would reduce it. The authors identify the mechanism directly: increased interpretation time for existing applications, often combined with increased post-processing time. At a single large hospital, on-call relative value units rose 297 percent between 2006 and 2020, roughly a fourfold increase, with CT procedure types growing by more than 500 percent while radiographs declined.

Advanced post-processing is not a side effect of doing more sophisticated work. It is the work, and it is the part that does not scale by reading faster.

What fragmentation costs, itemized

The usual response to a new structural program is to buy the tool that does the new thing. Do that three times and the department is running aortic planning in one application, mitral in another, appendage work in a third, with cardiac CT and CMR somewhere else again.

The costs are not hidden, they are just distributed so that no single line looks large.

Each application carries its own license and renewal cycle. Each carries a training curve, paid for in the time of the people least able to spare it, and paid again with every staff change. Each produces its own output format, which the heart team reconciles manually. Each is a separate vendor relationship, a separate support path, a separate security review. And each holds its own measurement standard: two established planning packages measuring the same 100 patients produced significantly different mean annulus areas, 482 mm² against 464 mm². A department running two tools is not running one standard.

The most expensive line is the least visible. Lab time on a structural procedure is among the highest-cost blocks in the institution, and planning quality moves it. In PREDICT-LAA, CT simulation-based planning cut procedure time from 55.2 to 45.1 minutes and fluoroscopy time from 17.6 to 12.5 minutes, with cases requiring more than three device repositionings falling from 22.7 percent to 10.0 percent. The trial's primary endpoint was not met, and the efficiency findings are secondary endpoints, which is how they should be presented. A 2026 meta-analysis across 978 patients found procedure time shorter by 13.29 minutes with CCTA planning and device resizing reduced at a relative risk of 0.42.

Ten minutes a case, across a growing LAAC program, in the most expensive room in the building.

One platform, across the whole caseload

This is the argument that consolidation actually rests on, and it is not about having fewer logos on the desktop.

A cardiac imaging department reading CMR and cardiac CT already owns most of what structural planning requires. The scanner is the same. The readers are the same. The priors are in the same archive. What a separate structural application adds is not capability the department lacks, it is a boundary the department has to staff around.

cvi42 reads cardiac MR, cardiac CT, vascular CT and structural planning for aortic, mitral and LAAC in one environment. One license, one training curve, one vendor relationship, one upgrade cycle, one measurement standard applied to every case. Assisted annulus and landmark detection across the Interventional Planning Suite removes 80 to 100 clicks from a typical case, and every contour remains physician-editable. LAAC planning for WATCHMAN TruPlan was developed by Circle working directly with Boston Scientific. Analysis runs on-premises, so patient data stays inside the institution.

For a director, the practical consequence is that taking on structural volume becomes a scheduling question rather than a procurement question.

The workload nobody put in the business case

There is one more line, and it is the one that gets missed because it does not appear until eighteen months after go-live.

Structural patients do not leave the imaging service after the procedure. Some of them come back, and CT is what answers the question when they do. The 2025 multi-society consensus on CT for prosthetic heart valve assessment is explicit that cardiac CT is not used for routine screening of valve degeneration, which is worth stating clearly because it is often claimed otherwise. Follow-up imaging is indication-driven. But the indications accumulate as the implanted population grows: suspected leaflet thrombosis, suspected valve failure, coronary access assessment, and planning for a redo procedure.

Hypoattenuated leaflet thickening alone was found in 10 percent of patients at 30 days and 24 percent at one year in the PARTNER 3 CT substudy. A program implanting several hundred valves a year is building a surveillance population, and those studies land on the same readers who planned the index case.

A department that plans structural cases in the same environment where it reads everything else absorbs that into a streamlined workflow.

Capacity is the constraint worth managing

Procedure capacity is visible, funded and discussed. Evaluation capacity is none of those things, and it is where the growth actually lands first.

The department that consolidates before the volume arrives is the one that treats the next fifty referrals as a scheduling problem.

Talk to us about structural planning throughput in your department →

Stay tuned for more on Structural Heart from the perspective of IT and PACS, and procurement and administration.