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Prof. A. Fraser is Consultant Cardiologist, University Hospital of Wales, Cardiff, UK; Visiting Prof. in Cardiac Imaging at the University of Leuven; and Emeritus Prof. of Cardiology at Cardiff University. He has received numerous awards and is a former president of the European Association of Echocardiography. He will give the Edler lecture: “A 21st century manifesto for functional imaging” during the Inaugural session, Monday 16:00–18:00, Room Beethoven.
he was invited by George Sutherland to take up the British Heart Foundation Fellowship at the Thoraxcenter in Rotterdam. That was his first real exposure to European cardiology, in a centre that made major developments in cardiac ultrasound, and where physicists and engineers worked closely with clinical academics to develop new technologies and evaluate their clinical role. The head of the Thoraxcenter at the time was Jos Roelandt, who had developed cross-sectional imaging with his engineering colleague Nicolaas Bom. Those were also the early days of transesophageal echocardiography, and Prof. Fraser contributed to how the technique is used today, particularly for valve disease and in the operating room.
As a result of his experiences, he believes that active collaboration between engineers and clinicians is crucial for the development of cardiovascular imaging. He strongly encourages younger colleagues to train in several centres and to work closely with engineers to learn the physics of imaging technologies, and so that engineers can understand which developments are needed for clinical practice.
Another key point was his clinical training in Cardiff. From Prof. Andrew Henderson, he learned to question everything and take nothing for granted, while trying to understand the basic principles behind any clinical problem in terms of its pathophysiology, so that treatment could be rational. He still likes to be challenged to a good debate and to have his mind changed, and his research has focused on using cardiac imaging to understand mechanisms of myocardial dysfunction, ventriculararterial coupling and heart failure.
Prof. Fraser is convinced that sharing experiences with colleagues and learning from each other is essential. He considers it a huge privilege that the academic subspecialty of cardiac imaging has led him across the globe to lecture and to teach, including taking part in the first echocardiography courses in places such as Rajasthan in north-west India and Sudan.
Cardiac ultrasound imaging is increasingly relevant to all clinicians, now that it is disseminating from specialist hospitals into routine clinical practice for emergency and primary care physicians. There will always be a need for education in how to use the technology properly, and for systems to ensure that technology is evaluated appropriately before being released onto the market, an objective that Prof. Fraser pursues through his chairmanship of the Committee on Regulatory Affairs at the ESC.
Alan Fraser was fortunate to meet Inge Edler in 1995, when he was in his mid-80s. One of the questions he asked was whether or not he and Carl Hertz had ever anticipated how echocardiography might develop. Prof. Edler replied that he never answered that question as it was impossible to predict technological development. Prof. Fraser feels that to some extent that remains true; technological advances will take care of themselves.
What he will concentrate on instead in his Edler lecture is the human challenge of how we think about and use all the modalities of diagnostic imaging. In other words, assuming that we have the tools we need, what should we do with them? One of the main challenges for the future, in his view, lies in harnessing information and computing technology to help clinicians to make better clinical decisions, and to reduce diagnostic error and over-diagnosis.
An important aspect is to look at how diagnostic tests are reported. They all have some imprecision, but when results are given to clinical colleagues, the conclusions are usually a discrete ‘yes’ or ‘no’. Instead, Prof. Fraser believes that the probability of a disease should be reported rather than whether or not it’s present. Experienced clinicians weigh probabilities and make judgements all the time, and so we should learn how to interpret diagnostic tests in a similar way.
Imaging is becoming more objective and more quantitative, making it increasingly difficult to interpret as subclinical abnormalities become apparent. Prof. Fraser will therefore call for decision-support tools to be developed and deployed that allow the probability of disease to be estimated while adjusting for individual patient risk factors and circumstances. Another key goal should be more research to evaluate which diagnostic tests are clinically effective in reducing disease and prolonging survival, as well as those that are cost-effective. Finally, he will suggest that manufacturers should share responsibility for supporting research to establish the utility of their systems, rather than just provide them ‘as is’.
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