ABC | Volume 113, Nº5, November 2019

Guidelines Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(5):1006-1056 such as arterial age and the patient’s overall cardiovascular risk variation based on the ECG can also be described. Evaluation of TCA – After the appropriate acquisition phase, aiming at the best temporal and spatial resolution of the coronary arteries, and editing of the ECG, which is usually done directly in the CT equipment, other applications are helpful in establishing a diagnosis. Until the requesting physician is able to obtain a clear view, the interpretation of the findings may be helped by software programs that extend the coronary arteries in a single plane (curved planar reconstruction – CPR), visualization of three- dimensional rendered images (using a 3D-volume-rendering technique), visualization of bidimensional images with multiple oblique planes (multiplanar reconstruction – MPR), and the characterization of coronary plaques, as well as the objective measurement of stenoses. 189 Evaluation with MRI – As one of the most versatile imaging methods available, MRI is able to produce images of almost any anatomical plane and provide a wide range of pulse sequences to generate images with specific characteristics, allowing assessments that range from the evaluation of ventricular function to myocardial tissue characterization. 190 Several software applications are available for this purpose, including applications for: • assessment of volume, ventricular mass, and right and left cardiac function; • analysis of intracardiac flow to measure QP-QS, shunts, and valvular dysfunction; • magnetic resonance angiography postprocessing with measurement of vascular diameters; • tissue characterization to quantify perfusion, necrotic/ fibrotic mass, iron deposition by T2* evaluation, and parametric maps of T1, T2, and T2* values. The strategy of using software programs in MRI and CT imaging is strongly recommended and can improve the time required to read the images, the accuracy of the reading, and the clarity of the report of the findings. 2.8.6. Database, Communication, and Image Archiving The integration between radiological information system (RIS) and PACS enables the assignment of a unique registration for each patient. This optimizes the information by combining images with clinical data and making the process faster and more secure. This format has been increasingly used in health care centers and often enables remote access, facilitating the use of tele-CT/tele-MRI and improving administrative procedures and communication. Several solutions are available in this regard, including cloud-based web solutions. Remote access to images and the ability to distribute reports via a standard universal system are helpful for the workflow. A report is nothing more than a type of communication with the main objective of transmitting the assessment of images analyzed by an expert to another physician who needs such information to make decisions. The more complete and clear the transmitted information is, the more important the requested test becomes. The development of structured reports linking written information to tables, figures, and photos to make the information as clear and accurate as possible is an ongoing trend. As described earlier, reports may be made available through advanced systems like RIS, but other forms of transmission, including instant messaging applications like WhatsApp, may be used. According to the CFM, 191 WhatsApp and similar platforms can be used for communication between physicians and patients, as well as privately between physicians for transmission of data or questions, or in closed group chats between specialists or clinical staff of an institution or chair, provided that all information transmitted is absolutely confidential, remain within the group, and is not circulated to recreational groups, even if these are composed only of physicians. 2.8.7. Clinical Indications for MRI and CT Interestingly, no studies in the literature have assessed the clinical impact of the application of tele-MRI or tele-CT. Thus, clinical recommendations in this guideline are based on level C evidence, including expert consensuses, and in the absence of studies evaluating cost-effective outcomes. Aware of this limitation, we cite at the end of this document the main indications for the application of tele-CT/tele-MRI in this subarea of cardiovascular imaging. 192 The use of MRI and CT imaging has been increasing, and characteristics of these imaging methods make their use very interesting in telemedicine, particularly in countries with continental proportions like Brazil and in those with a limited number of available MRI/CT specialists. The possibility of having a specialist potentially accessible at any moment can be helpful in patient management and in lowering health care costs by optimizing the time of available specialists and expediting reports of hospitalized patients, which can shorten their hospital stay, and in other applications related to this medical progress. 3. Telerobotics Applied to Cardiology 3.1. Robotic Telesurgery The concept of telesurgery was introduced in the early 1970s by NASA. 193 The objective of the original project was to provide medical care to astronauts during remote missions. Robotic telesurgery devices are applications in which the surgeon controls remotely a robot that executes the surgical procedure. The da Vinci® system (da Vinci® surgical system; Intuitive Surgical, Sunnyvale, CA, USA), the most widely used robotics platform today, follows this approach. The surgeon works on a console separated from the surgical field, and the movement of his or her hands is perceived and transmitted to the instruments close to the patient. This technique yields great ergonomic benefit to the surgeon, incorporates functions like hand tremor cancellation, and broadens (in three dimensions) the view of the field that the surgeon is interested in. However, these platforms lack much automation and require continuous involvement of a human operator (surgeon) for regulatory reasons. 1032