Author + information
- Boban Thomas, MD* ( and )
- Nuno Jalles Tavares, MD
- ↵*Caselas MR Centre, Rua Carolina Angelo, Lisbon 1400-045, Portugal
Geoffrey Moore (1) in his landmark book about the technology adoption lifecycle, “Crossing the Chasm,” divides the adopters into 5 phases—innovators, early adopters, the early majority, the late majority, and the laggards—with the curve forming a typical distribution curve with the major hump comprising the early and the late majority. Psychologically, others have classified these groups as technology enthusiasts (innovators), visionaries (early adopters), pragmatists (early majority), conservatives (late majority), and skeptics (laggards). Moore proposed that, for various reasons, there exists a chasm between the early adopters and the early majority and the success of any technological innovation depends on the capability of the technology to cross this chasm.
The results of the EuroCMR (European Cardiovascular Magnetic Resonance) Registry (2) seem to suggest that, at least in Germany, cardiac magnetic resonance imaging (MRI) has been able to cross this chasm with its value being understood and exploited for improving clinical care. Until now cardiac MRI has remained a niche exam with numerous cardiac MRI units performing studies for patients with congenital heart disease, cardiac masses, pericardial disease, aortic pathology, and angiography. The use of cardiac MRI in cardiomyopathies and ischemic heart disease has clearly changed the status of this technique in our diagnostic armamentarium. Because ischemic heart disease comprises the largest component of patients in contemporary clinical practice, the use of cardiac MRI in this arena for ischemia and viability assessment would seem to suggest that cardiac MRI has “crossed this chasm” and is now believed to be ready for primetime by cardiologists who do not perform cardiac MRI (because they would comprise the early and the late majority in Moore's description).
To be sure this has happened, which is welcome. Given the potential of this technique, we wish to clarify the following points:
1. Of the referrals made, how many were made by physicians who actively perform cardiac MRI and by those who do not perform cardiac MRI? This information would eliminate the potential for a referral bias by those who perform this technique. In 23.1% of patients, cardiac MRI was the first technique ordered—who referred these patients? We consider any referral from any member of any cardiac MRI group to be a potential self-referral—this could simply mean that those who perform the technique might be able to decide which patient might be best suited for a cardiac MRI study.
2. In the subgroup of those who underwent cardiac MRI as the first study, all imaging needs were satisfied in 80.3%. Some information in the remaining 20% who required further studies would be helpful for understanding the limitations of cardiac MRI.
3. We are also interested to know the reasons why 11% of those who underwent viability assessment by cardiac MRI still required a subsequent transthoracic echocardiography, because cardiac MRI is now considered the practical gold standard for viability assessment. We acknowledge that the reasons might be other than viability assessment.
4. A total of 5,025 patients in the centers in the registry underwent cardiac MRI for suspected coronary artery disease/ischemia assessment and determination of viability. It would be very informative to know the number of single-photon emission computed tomography and echocardiographic studies ordered in these centers for the same reasons, because this would reflect the positioning of the cardiac MRI study in the routine clinical practice in the centers that participated in the registry.
The authors have made a laudable effort in extending the use of a very valuable technique. If the clarifications we request indicate that the chasm has not been crossed by cardiac MRI, we hypothesize that the presentation of prognostic data based on cardiac MRI studies might be the eventual trigger and the authors have accurately emphasized the need for extension of their work.
- American College of Cardiology Foundation