The Emory Cardiac Toolbox -- interpreting images, improving diagnosis and treatment

From invisibility to the spotlight

As a 12-year old newcomer to the United States, Ernest Garcia yearned to be a physicist, hoping physics would teach him how to become invisible, thus solving his problems of feeling like an outsider and not having enough food or money.

Ernie and his 13-year old brother were part of the exodus of middle-class Cuban children after the Castro takeover the year before. He had been allowed to take only one item of value – he chose his typewriter – and for years he woke from nightmares that the authorities had discovered the money his parents had hidden in his toiletries.

The brothers lived with a cousin until the arrival of their grandparents, then parents. In America, Garcia had two advantages: language and discipline. His mother, having been unable to pursue her own education, had insisted the boys attend a private school in Havana during the day and English, typing and shorthand classes at night. In Miami, Garcia studied and worked. At first he helped his grandfather – a successful journalist back in Havana – deliver food while his grandmother, fluent in seven languages, worked as a maid. At 14, when Ernie began earning $5 per hour as a saxophonist, he was the highest paid member of the family. (He still plays in a rock band, the Thallium Stallions, with other nuclear medicine professionals.) He later worked in a sheet metal company.

The University of Miami awarded him a full scholarship. No longer interested in invisibility, he was determined to become another Einstein.

Entering the new world of computers

In a life-changing lucky break, Garcia found a summer job at Florida Power and Light. FPL trained students in computers, still an exotic concept, then gave them programming assignments. One day, the college student saw a major university advertisement in a physics magazine. If you are Einstein material, we want you as a professor. Salary: $8,000 a year. Garcia was making twice that with his part-time job. Perhaps, he thought, he should continue with computers and keep physics as a hobby as Einstein had done. Einstein, however, did not have to contend with Viet Nam and the draft. He stayed in school.

One day, shortly before graduation, the University of Miami offered Garcia a fellowship to pursue a PhD in physics. He was confused. He had not applied for a fellowship. The dean said simply, "You were flagged." Forty years later, Garcia still becomes choked up, speaking about it.

On the way to becoming an astrophysicist, a friend recommended he check out a new field called nuclear medicine. Garcia never looked back. He would focus his physics, math and computer training on improving clinical medicine. As he was about to finish his PhD, the director of Miami's MD/PhD program at Miami urged him to continue his studies, warning that without an MD, physician colleagues would always treat him like a glorified technologist. But by now Garcia's vision of what he wanted to do was clear. He refused to spend the extra two years.

At Cedars-Sinai Medical Center affiliated with UCLA, Garcia worked with nuclear cardiologist Daniel Berman, a pioneer in understanding the need for computers in medicine; echocardiologist Elliot Corday, later president of the American Heart Association; and cardiovascular scientists like Jeremy Swan and Willie Ganz, famous for the catheter they invented. There he learned to adopt his training to medicine and to write the papers and grant proposals that would let him do it.

Building the Emory Cardiac ToolBox

(Note, for a longer, more scientific and detailed description of both the toolbox and the process through which it was and continues to be developed, visit the Research section.)

From art to standardization. In 1979, clinicians began to be dazzled by the first images of blood flowing in, then being pumped out, of the beating heart. These beautiful moving images were cumbersome, however, displayed without measurements or explanations. Physicians had to rely on experience or intuition to determine what was clinically significant. Garcia immediately understood that computer software could provide the necessary objective analysis and standardization. Although revolutionary, the concept was not so different from standard blood tests, in which a patient's values are scored against those of hundreds of thousands of individuals from healthy to diseased. But blood tests are based on numbers, not on subtle differences between highly variable, shifting images. Early computers were too slow to handle this complexity. Then they began to catch up to Garcia's vision. His first task was to develop a large database of images of normal hearts against which individual patient images could be compared. "It was a model T," Garcia recalls, "somewhat primitive by today's standards but nonetheless the first of its kind."

A "toolbox" to hold a growing series of tools. In 1985, Emory University was determined to become a major research institution and a major gift from Robert W. Woodruff was allowing it to grow accordingly. Garcia joined the radiology department under chairman Dr. William Casarella. Cardiology was strong at Emory, under Dr. Willis Hurst and clinician scientists like Andreas Gruentzig, who had developed the catheters that made angioplasty a clinical reality (see Gamechanger link X). Garcia was allowed to thrive in this environment. He developed his own program, pulling in collaborators from Emory and Georgia Tech. Nuclear cardiology was booming, and for every new advance in imaging, Garcia and his team developed a corresponding new tool for the growing Emory Cardiac Toolbox™.

From laboratory to marketplace to start-up. At first, Garcia simply gave his programs away, but he soon realized he was spending less time developing new programs and more time fielding calls from clinicians and computer companies. He realized that he and other software developers needed to charge for the software they created so they would have the resources to stand behind it, providing documentation and support for users. In the early 1980s, this was a strange idea. It was not uncommon for physicians to create software and share it with colleagues. The Food and Drug Administration had not yet begun to regulate medical software in the way it did medical devices, and few worried about standardization or that the various software tools circulating had never been tested as to accuracy and effectiveness.

Emory licensed the first of Garcia's tools in 1993 and the first version of the Emory Cardiac Toolbox™ in 1998 to companies such as General Electric, Siemens and Philips. In 1999, Garcia and his colleagues founded Syntermed, Inc., which took over selling the software directly to users. Although Emory and Georgia Tech remain shareholders in the privately held firm, licensing the Toolbox to Syntermed, Inc. relieved Emory of the obligation of meeting growing FDA requirements as a medical device maker and gave the researchers more flexibility – and resources -- to support existing programs and develop new ones. Syntermed brings in an average of $1.5 million a year in revenue, of which 20 percent goes to Garcia's lab, also supported by the NIH and the Georgia Research Alliance. (See web site on Syntermed and also OTT, links to be given.)

Today, the Emory Cardiac Toolbox™ is one of the most widely applied methods of cardiac imaging, used in nearly half of all nuclear medicine labs nationwide. Garcia's greatest satisfaction is walking into a hospital in China, Italy, or virtually any corner of the developed world and seeing his software up and running, improving patient outcomes (as numerous clinical trials have shown it does). When he had a cardiac episode of his own a few years ago, he found himself one of the more than four million patients whose cardiac images are interpreted each year using the Emory Cardiac Toolbox™. He had total confidence in what his doctors were seeing.