January / February 2009
“Slimmer for 2009”
Hot Topic SYNTAX Trial Results (Part 2) with detailed information from TCT.
Interview Dr Anthony Chow Consultant Cardiologist (Electrophysiologist) The Heart Hospital
EP Education Making sense of AF
CRM Education The Burden II Trial
Management Are radiographer’s underutilised in the EP Lab?
NT E M
Glenrose & Martin (nurses) from Bart’s in London
On-call Remuneration Have we got it right?
Staff Member Interviews
Cardiac X-Ray Software Packages
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THIS EDITION 04
Our Editorial Team
‘SYNTAX Trial Results - Part 2’ Mr Tim Larner Director / Chief Editor
Dr Simon Redwood Chief Clinical Editor
Dr Richard Edwards Asst. Clinical Editor
Dr Rodney Foale Asst. Clinical Editor
Dr Divaka Perera Asst. Clinical Editor
Mr Ian Wright EP Editor
‘Cardiac X-Ray Systems - Software Packages’
Management ‘On-call Remuneration’
Staff Members of the Issue
Ms Mojgan Sani Pharmacy Editor
‘The Burden II Trial’
& Ms Voncile Hilson-Morrow USA Management Editor
Management ‘Are radiographer’s underutilised in the EP Lab?’
EP Latest News
Mr Adam Lunghi Echo Editor
Slimmer editions: Improved page layout for an easier read in less pages.
‘Making Sense of AF’
EP Interview ‘Dr Anthony Chow’
Events Diary, Next Issue + Advertisers’ Index
The ECG Quiz will return in Edition 17 (Mar/Apr)
Mr Stuart Allen CRM Editor
Improvements We are also working towards a closer educational relationship with Third World hospitals.
Dedicated EP Special Editions: Interviews, Education, Latest News, and Management features in alternate issues: Jan/Feb, May/Jun, Sep/Oct. Dedicated Echo Special Editions: Latest News, Case Studies, and Education in alternate issues: Mar/Apr, Jul/Aug, Nov/Dec. Improved Site Visits, Management Topics, Interviews, as well as the introduction of Annual Cardiology Awards.
Coronary Heart should never be regarded as an authoritative peer reviewed medical journal. Coronary Heart has been designed as a guide only, to inform readers who work in the cardiology environment about latest news stories and the different techniques used by others around the world. Whilst all care is taken in reviewing articles obtained from various companies and contributors, it is not possible to confirm the accuracy of all statements. Therefore it is the reader’s responsibility that any advice provided in this publication should be carefully checked themselves, by either contacting the companies involved or speaking to those with skills in the specific area. Readers should always re check claims made in this publication before employing them in their own work environment. Opinions expressed by contributors are their own and not necessarily those of their institution, Coronary Heart Publishing Ltd or the editorial staff.
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www.coronaryheart.com Director / Chief Editor Tim Larner Clinical Editor Dr Simon Redwood Senior Consulting Editors Dr Richard Edwards Dr Rodney Foale Dr Divaka Perera Mr Ian Wright Mr Stuart Allen Ms Mojgan Sani Ms Voncile Hilson-Morrow
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ith two months of exact usage data in hand, the manager of a very busy Interventional Radiology department at Midwestern University Hospital was able to lower her on-hand inventory value by more than $150,000. spaceTRAX automatically calculates the number of weeks of supply on-hand for each item, based on actual usage patterns and on-hand quantities. By establishing a target of 3 weeks of supply on-hand she was able to lower 21% of the items stocked. The on-hand quantity for an average item was reduced by 42%, freeing up both capital and valuable shelf space. The savings were more than $150,000 in the first 90 days!! The savings didn’t stop there. Armed with black and white irrefutable purchasing and market share analysis, a key vendor had little option but to increase the discount offered to the University by an additional percentage point during their most recent negotiation. They expect this increased
purchase discount to generate savings of at least $30,000 this year. This is just one of the many success stories from across the USA. Now with the introduction of spaceTRAX into the already comprehensive Scan Modul System solutions offering, spaceTRAX is available for the first time in the UK. With the pressure on the NHS to reduce cost and improve service, spaceTRAX’ return on investment model is extremely appealing. As the system is web based, there is no capital investment or IT procedure to negotiate. Quite simply spaceTRAX offers a proven, immediate solution to inventory control. See Advert on Page 2
Online ECG Training gives NHS Heart
revolutionary new package for training clinicians in how to carry out and interpret ECG traces was launched worldwide in November after being developed by staff at Sheffield Teaching Hospitals. Ecgskills.net is an interactive online training course featuring animations and audio aimed at reinforcing the skills necessary for carrying out and interpreting ECG’s - and is the only online course offering training in how to carry out and interpret ECG’s. The package, which delivers standardised training for all clinical teams, has been developed by trust consultant cardiologist
Consultant Cardiologist Professor Kevin Channer (centre), Cardiology Department Carole Evans (right) and her deputy Fiona Coates (Left) from the Sheffield Teaching Hospitals NHS Foundation Trust
Professor Kevin Channer, cardiology department manager Carole Evans and her deputy Fiona Coates in collaboration with Medcom Ltd, a leading online medical education company based in York. Check it out at www.ecgskills.net
Cardiologist Hot Topic Part 2: The SYNTAX trial results as presented at TCT 2008
Written by Colin Robb Interventional Cardiology Clinical Science Specialist Boston Scientific UK and Ireland
Note - An analysis of the U.K. enrolling sites data will be presented at the ACI meeting in January.
The SYNTAX Score is breaking new ground by scientifically defining a new measure for anatomical complexity that seeks to provide guidance to physicians on optimal treatment options for this high-risk group of patients. The SYNTAX Score characterises coronary anatomy based on lesion frequency, complexity and location, relying on data from the SYNTAX trial, and assigns a score to each patient. The Syntax score will be retroactively weighted based on MACCE at 1 and 5 years to optimise its prognostic value. (Refer to Figure 1)
Images courtesy Boston Scientific
-month left main and three-vessel disease subset data from the landmark SYNTAX trial comparing percutaneous coronary intervention (PCI) using the TAXUS® Express2™ Paclitaxel-Eluting Coronary Stent System to contemporary coronary artery bypass graft (CABG) surgery were presented TCT 2008.
The analysis of the raw SYNTAX Score data demonstrated that PCI and CABG patients whose scores fell into the lower or intermediate terciles of complexity had similar rates of MACCE (Major Adverse Cardiovascular or Cerebrovascular Event rate, including all-cause death, stroke, MI and repeat revascularisation) at 12 months. For patients in whom the SYNTAX Score fell into the upper tercile – those with the greatest lesion complexity – there was a significant increase in MACCE for PCI patients compared with CABG patients. (Refer to Figure 2) The 12-month subset results for patients with left main disease reported comparable rates of overall MACCE for the CABG group and the PCI group (13.7 percent for CABG versus 15.8 percent for PCI, p=0.44), as well as similar overall safety outcomes (death, stroke, MI) for the two groups (9.1 percent for CABG versus 7.0 percent for PCI, p=0.29). As expected, the
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HOT TOPIC Figures 3-6
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Part 2: The SYNTAX Trial (cont...) rate of revascularisation was significantly higher in the PCI group (12.0 percent for PCI versus 6.7 percent for CABG, p=0.02), while the rate of stroke was significantly higher in the CABG group (2.7 percent for CABG versus 0.3 percent for PCI, p=0.009). Differences in MACCE are only apparent in the upper tercile of Syntax score. (Refer to Figure 3-6) The subset results for patients with threevessel disease reported comparable overall safety outcomes for the two groups (6.4 percent for CABG versus 7.9 percent for PCI, p=0.39), an expected higher rate of revascularization for PCI (14.7 percent for PCI versus 5.4 percent for CABG, p=<0.001) driving higher overall MACCE for the PCI group (19.1 percent versus 11.2 percent for CABG, p=<0.001). Similarly, Syntax score terciles align with outcome differences. (Refer to Figure 6-9) Therefore, similar safety and efficacy outcomes were demonstrated for two thirds of SYNTAX randomised patients.
SYNTAX Scoring The SYNTAX Scoring System is of great interest to Interventional Cardiologists however is far beyond the scope of this article. For further details we recommend reading the SYNTAX Score in EuroIntervention 2005 1:219-227
The SYNTAX Trial results showed that there was no statistically significant differences between PCI and CABG in rates of death or myocardial infarction. Will these findings influence your decision on what the best course of action is for a patient with similar anatomy and disease to those in the study?
Dr Farzin Fath-Ordoubadi Consultant Cardiologist Manchester Heart Centre Central Manchester and Manchester Childrenâ€™s University Hospitals NHS Trust, MANCHESTER
lthough death and myocardial infarction were not significantly different between PCI and CABG arms in the Syntax trial there is a higher rate of need for revascularization in the PCI arm. Moreover I am sure our surgical
colleagues will be very keen to point out the effect needs to be seen over a longer follow up period of at least 3 to 5 years. Nevertheless speaking as an interventionalist I think the Syntax result is very reassuring and consistent with previous data. What SYNTAX tells us is that when treating patients with SYNTAX like anatomy there is a choice now and we need to get our patients more involved with this decision making process and pay more attention to their preference. They can be told that at least in the first year there is no difference in term of mortality and MI rate between two procedures but they are more likely to need a second procedure with PCI but slightly less likely to suffer from a stroke and leave the choice to them. Regarding the left main group I think ostial and mid body left main disease sparing distal bifurcation should no longer be seen as surgical disease this group should be given the same options as above.
Image courtesy Radi Medical Systems
The patients enrolled in SYNTAX are a unique study group in the PCI field, given their exceptionally complex anatomy and advanced disease. The average SYNTAX PCI patient received 4.6 stents, with one patient having 14. By contrast, the average number of stents implanted in a PCI patient in everyday practice is 1.5. In addition, the PCI patient profile includes 33 percent of patients with >100 mm stented length, 73 percent with bifurcations, 11 percent with trifurcations, 22 percent with chronic total occlusions, and 39 percent with left main disease.
Edition 17 Hot Topic
n Edition 17 (Mar/Apr) we will be looking at the Radi FAME Trial and speaking with various cardiologists for their opinion on this interesting study. We will also speak with one of the Principal Investigator, Dr Keith Oldroyd on the study and what the findings actually mean for your treatment of patients. Dr Keith Oldroyd
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Journal Trawl - Dr John Paisey scans the world’s cardiology journals
Dr John Paisey Clinical Fellow in Electrophysiology John Radcliffe Hospital, Oxford
Having worked through people with vascular disease and people likely to get vascular disease statin researchers are now attempting to pluck the higher hanging fruit of people who really ought not to get vascular disease. Among over 17000 patients with no vascular disease, normal LDLs (<3.4 mmol) and an hrCRP of over 2 the event rate at an average 1.9 years was 0.77 per 100 patient years for those treated with rosuvastaton vs. 1.36 in the placebo group. P Ridker and others, N Engl J Med 2008;359:2195-207. When it comes to diabetics and cardiovascular interventions the stakes are higher; both benefits and adverse events are amplified. Analysis of the Massachusetts registry includes over 5000 patients about two thirds of which received drug eluting stents. The outcomes were better in those receiving DES than bare metal stents once propensity scoring was performed. P Garg and others Circulation. 2008;118:2277-2285 The observation that such a high proportion of out of hospital cardiac arrests are ultimately caused by myocardial infarction or pulmonary embolism, coupled with the suggestion that the prothrombotic state of temporary death might not be the best for avoiding end organ damage has led to interest in empirical thrombolysis of individuals during resuscitation. Unfortunately the outcomes were poor with a 15-17% survival to discharge, no benefit from thrombolysis and an increase in cerebral haemorrhage with
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tenectoplase. The trial was stopped early after recruiting 1050 patients. B Bottiger and others, N Engl J Med 2008; 359:2651-62 Given the upfront costs and long term consequences of committing patients to implantable defibrillators there is an understandable drive to try and improve the specificity of primary prevention selection methods. One method tried with variable results has been T wave alternans. Applying this technique to the SCD-HeFT population there was no particular difference in terms of arrhythmias or mortality between the T wave alternans positive and negative groups. M Gold and others Circulation. 2008;118:2022-2028 Beta blockers for non cardiac surgery in anyone with a significant risk factor profile were a serious vogue and are still recommended by guidelines. A systematic review of trials looking at this treatment modality demonstrated no overall benefit with any small reduction in ischaemic events offset by an increase in strokes. The authors question the firm nature of current guidelines. S Bangalore and others The Lancet 2008; 372:1962-1976 Two recent studies have examined the utility of CT for coronary studies. In one several models and centres results were examined giving a ‘real world’ flavour. As with previous studies the sensitivity results (99%)
were more impressive than specificity. In a separate study the sensitivity for detecting lesions of 50% or greater was just 85%, the accuracy to predict which patients require revascularistion was similar at 84%. Both papers conclude that CT cannot yet replace direct angiography. W Meijboom and others J. Am. Coll. Cardiol. 2008;52; 2135-2144 J Miller and others, New Eng J Med, 2008; 359;2324-2336 Irbesartan doesn’t help in patients with heart failure but preserved (>45% systolic function). In a trial of over 4000 patients with symptomatic heart failure, age over 60 and preserved ventricular function against the usual sort of composite primary endpoint there was not even a trend to benefit in the treatment group after over 4 years follow up. B Massie and others, N Engl J Med 2008;359:2456-2467 The much vaunted surgical evidence base has never extended to the elderly so even an imperfect comparison between PCI and CABG in ocatagenerians with left main stem disease is of significant interest. A group from Quebec compared patients treated by each modality, the PCI group apparently started worse off with a higher average age and Euroscore but did just as well over two years follow up. The authors suggest a randomised study. Rodés-Cabau and others, Circulation. 2008;118:2374-2381
Software Packages Buyers Guide
Sequential Navigation? The Sequential Navigation is a standard feature for the Infinix-i Series Cathlab “Infinix CSi, CCi, CFi/SP and CFi/BP” product range. It includes up to 10.000 different protocols and helps any physician to work automatically by going from one projection to another just by pulling a trigger on the “HyperHandle”, located at the table side. The Sequential Navigation automatically sets the angles, isocenter, SID, and table height, and also synchronises the proper fluoro and acquisition protocols ‘Xray parameters and image algorithms’ for dose reduction without compromising the image quality. This gives major benefits in terms of examination time (reduced by 40%) and dose reduction (reduced by 30%).
3D detection and reconstruction software? The optional CV-3D package, allows the physician to perform 3D QCA, assisting in faster decision making and more precise stent positioning specifically for bifurcation lesions and narrowing vessels. After selecting images from two different projections, the 3D image is displayed real time in the lab. The physicians can then use the 3D to determine the best angle projection to access the lesion easier, faster and safer.
Toshiba Cardiology X-ray Systems
high power grid, liquid metal bearing Xray tube, thick beam hardening, and selectable filtration in the collimation which is available depending of patient size (paediatric, young adult, normal patient, and obese patient). For each Field of View (FOV) the system applies 4 different dose mode selections (Low, Medium, Normal and High). At anytime the physician can record unlimited numbers of fluoro loops, prospectively and retrospectively. This gives the physician the opportunity to perform QCA on fluoro images instead of having to acquire a run. A unique feature to TOSHIBA is the “Live Zoom” which gives the physician the views of different field size, but still and always working on the largest one, which gives additionally up to 75% dose reduction comparing FOV 15cm during complex PCI to a live zoomed image of the FOV 20cm. Physicians can also decide to lower the frame rates. LV can be acquire down to 10fps and coronaries down to 7.5fps without compromise to the image quality.
Cardiologists are always looking at ways to improve the outcome following interventional procedures. New stents, wires, and balloons have made the procedures easier, however to ensure this equipment is used optimally with low radiation dose, software packages can be added onto x-ray systems to radically improve the chance of success.
the need to increase frame rate. The device is enhanced in order to see proper position and deployment.
Name the x-ray systems these are available on in Cardiology? The above packages are available for the entire Infinix-i Series Cathlab.
Rotational Cardiac Acquisition? This package is used in order to get a simulated 3D view of the coronary trees, which can be achieved as a single or double axis rotation of the C-arm. The clinical feedback shows important reduction in X-ray dose (up to 75%) in combination with the standard dose reduction package, and a reduction in the use of contrast medium (up to 50%). It is very useful for diagnostic procedures and for surgery planning, saving time and dose.
Virtual stenting (Stent Planner)? This package is available to help the physician determining the best stent selection according the lesion. 3D QCA
Device optimization as (Stent Optimiser)? Dose reduction package? It includes a true 100kw HF generator, a
This package is used to optimise any device during a procedure such as a stent without
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Siemens Cardiology X-ray Systems
Software Packages Buyers Guide
Magnetic Assisted Intervention?
CARE Dose reduction?
Artis zee® Magnetic Navigation has been specifically designed for compatibility with the Stereotaxis NIOBE® magnetic navigation system. Available as a floor-mounted or biplane system, it offers excellent precision in guide wire and catheter steering. With the help of two magnets external to the patient’s body, the clinician can accurately navigate catheters and guidewires through the complex vessels and chambers of the heart. This method has the potential to considerably accelerate workflow.
Siemens’ Combined Applications to Reduce Exposure provide innovative measures to reduce radiation dose to both patient and staff. They include:
This is an integrated scientific measuring program for clinically validated, objective, accurate and reproducible 2D evaluation of coronary arteries. QCA allows precise quantification under sterile conditions directly at table side with the touchscreen console. It is based on the gold standard in coronary analysis: CAAS II (Cardiovascular Angiography Analysis System Mark II) and is validated for vessels from 1.5mm to 7mm. •
This application enables remodelling of the segments of coronary arteries in 3D from two standard projections separated by 30°. For optimal workflow all operational steps can be performed at the tableside under sterile conditions. The 3D model that is generated can then be rotated freely in space and viewed from various angles in order to obtain the best working projection. It eliminates inherent foreshortening effects and allows greater precision during PCI.
IC Stent software is designed to enhance the visibility of the deployed stent. Following a short acquisition, IC stent is selected from the tableside control and images are integrated in less than 30 seconds to display the processed IC stent image on the reference monitor, without interruption to the normal workflow.
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CAREWATCH Dose monitoring and documentation CAREVISION Lower pulsing frequencies from 7.5 p/s down to 0.5 p/s CAREFILTER Additional Cu-filters reduce the skin dose. The variable filter (0.2 mm – 0.9 mm) is automatically set CAREPROFILE Adjustment of collimators and wedge filters without fluoroscopy
The two computer-controlled magnets of the Stereotaxis NIOBE system provide a navigational magnetic field of a maximum of 0.1 Tesla in any direction allowing the 360° rotation of the catheter device. The specifically designed catheters and guidewires contain small magnetic tips and are controlled by the simultaneous movement of the NIOBE magnets.
CAREMATIC Fully automatic exposure settings
Thanks to the Artis zee’s separate control console and the Stereotaxis Cardiodrive® Catheter Advancer System, navigational functions can be performed with a joystick directly from the comfort of the control room, keeping radiation exposure of the clinician to a minimum. Its flexible system architecture can be optimally configured for both electrophysiology and interventional cardiology procedures.
CAREPOSITION Using LIH the patient can be repositioned without fluoroscopy whilst moving the table or moving the C-arm
Name the x-ray systems these are available on in Cardiology QCA, IC3D, ICstent and Care packages are available on all Artis Zee systems including: Zee Floor / Zee Ceiling / Zee Biplane and Zeego Magnetic Navigation is available only with Zee Floor Card and Zee Biplane Card systems.
How can I improve ablation therapy?
With syngo DynaCT Cardiac, 3D images of the left atrium can be created directly in the EP lab to help guide the ablation catheter. The Artis zee imaging system, with syngo速 DynaCT Cardiac, is able to create CT-like 3D images of the beating heart, within seconds, during the procedure - directly in the EP lab. With a single click of the mouse, the left atrium is segmented. The result can be merged with electroanatomical maps and overlaid on the live fluoroscopic image, providing anatomical information to support treatment decisions. Visit our website and zee the future. www.siemens.com/artis-zee. For further information please contact: 01276 696439 or firstname.lastname@example.org
Answers for life.
On-Call Remuneration: Have We Got It Right?
Greg Cruickshank Superintendent Radiographer Cardiac Catheter Suite King’s College Hospital NHS Trust. LONDON
ith the number of Cardiac Units offering a primary angioplasty service increasing, the thorny question of on-call payments has been raised a number of times by colleagues. Where there was no previous on-call service offered, or no local agreement for on-call payment arrangements in place prior to switching to Agenda for Change (AFC) terms and conditions four years ago, any on-call activity is to be paid as per AFC provisions. The problem with this is that AFC on-call payments are several steps backwards from what most UK Radiographers are used to receiving for on-call activity. Also, if there was no Cardiac on-call service in operation prior to a primary angioplasty service being introduced, it is unlikely that staff have an obligation to provide such a service written into their job contracts. What then would be an ideal on-call remuneration package to ensure staff are prepared to undertake these duties? Also, how is it possible to allow such payments under the current AFC umbrella? Several years ago a number of Radiology Departments shifted on-call payments for Radiographers from the old Whitley terms and conditions, which paid staff on a per call-out basis, to a fixed rate payment. This largely happened when the right of employers to insist Radiographic staff worked out of hours duties expired from the old Whitley terms and conditions
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around 10 years ago. This shift in payment structure was particularly true in places with a busy Accident and Emergency workload. This meant staff knew what they were going to get paid to undertake the out of hours duties regardless of how busy they were, and Manager’s could accurately budget for such payments. It also meant that staff could negotiate a fixed payment that made it attractive enough to make it worth doing the duty. When considering what payment out of hour’s duties should attract, it is worth considering three things. •
Firstly what financial reward do staff currently receive to undertake other additional duties, for example private work, bank work, and waiting list initiative work?
Secondly, what do work groups in other industries receive to undertake work outside normal working hours?
Finally is whatever finally decided upon as financial reward for additional out of hours duties going to be attractive enough for staff to make it worth while doing it, given the disruption it can cause to life outside work?
Currently Allied Health Professional (AHP) staff working in the NHS receive £45 per hour for any private work they do outside their normal contracted hours. In addition to this, waiting list initiative work done by Allied Health Professionals at the Trust where I work is paid at £50 per hour, as it is in many other Trusts. In both cases, this work tends to be done either after 5:00pm, or on weekends, but not normally in the middle of the night, unlike a measurable portion of Catheter Lab on-call activity which is. Bank rates vary significantly from Trust to Trust depending on the nature of the duty being covered. However, a Sunday bank in A&E covered by a band 7 Radiographer (9:00am – 5:00pm) costs the Trust where I work
£38:25 per hour, of which the Radiographer gets £27:28 per hour. This is through Reed, the preferred NHS provider for bank and agency staff. For those who have ever had to call a tradesman in London out for a domestic emergency, the next set of figures will come as no surprise. Looking on the React Fast website (www.reactfast.co.uk), if you need to call out a locksmith as an emergency (1-2 hour response) to replace a front door lock having lost house keys, they quote a discounted rate of £99.90 per hour, or for any part of any hour (based on a SE London postcode). They do say that in 80% of jobs are completed within one hour. A plumber will cost a mere £71 per hour during normal working hours through the same website. Pimlico Plumbers (www.pimlicoplumbers. com) offer a range of tradesmen for domestic emergencies. A general tradesman will cost £130 per hour between 6:00pm – 12:00am Monday to Friday, and from 7:00am – 12:00am Saturday. On Sunday 7:00am – 12:00am it will cost you £140 per hour. Between midnight and 7:00am Monday through Sunday the charge is £170 per hour. A Corgi registered Engineer costs an additional £10 per hour across all the charges already mentioned, and drain jetting costs £200, £230, and £250 respectively. All charges exclude value added tax (currently 15%), and there is a minimum charge of one hour for any work done. A little cheaper for tradesman were One Central (www.onecentral.net). An Electrician or Plumber will cost you £95 per hour Saturday between 8:00am and 6:00pm, or £110 per hour on Sunday 8:00am – 6:00pm. A Gas Engineer will be £105 on Saturday and £120 on Sunday 8:00am – 6:00pm. Once again, this excludes value added tax, and there is a minimum charge of one hour for any work done. I could go on, but if you google “emergency tradesman London”, you can look for yourself (in some cases you will need to ring for a quote,
“An Electrician or Plumber will cost you £95 per hour Saturday .... or £110 per hour on Sunday....”
MANAGEMENT On-call Remuneration (cont...) the three I mention you can check on-line without phoning).
hours, skill level of staff involved, and the disruption caused to life outside work.
staff fairly quickly if the situation gets any worse.
If Agenda for Change terms and conditions did not exist, I would suggest that staff doing on-call activity from home should be on an hourly rate of £50, with at least one hour’s payment guaranteed per day on call in-lieu of carrying the bleep. Under the old Whitley terms and conditions, staff receive a rather derisory sum of money for actually being on-call (less than £10), which does not reflect the inconvenience of doing so. The one hour minimum payment would offset this. For any work then done over and above the one hour, staff would receive £50 per hour. This is still far less that getting a tradesman of any sort to come out after normal working hours (or indeed during normal working hours). It is the same hourly rate that some staff are currently paid to undertake waiting list initiative work, but the on-call involves far more unsociable and unpredictable hours, which has a much bigger impact on life outside work. Incidentally these payments would apply to all Catheter Lab support staff that cover on-call (i.e. Nurses and Cardiac Technicians and Radiographers). This is in-line with recommendations made in the evaluation of the National Infarct Angioplasty Project recently published by the National Institute for Health Research.
A lot of work has been done around the problems of staffing Catheter Lab’s with Nurses, Cardiac Technicians, and Radiographers. Generic working, devolving down tasks to less skilled staff, and reducing overall staff numbers considered essential to run lab’s are just some of the things that have been looked at. In my experience, it is often the out of hours commitment, and lack of suitable remuneration for that commitment, that drives staff away from Catheter Lab working. More money for out of hours activity may well seem like a blunt instrument, but it is one that has proved very effective in both recruiting and retaining Radiographic staff previously.
Two things that could happen which would prove costly to the NHS if I am right. We could go back to the days where the NHS became more reliant on agency staff to cover key staff in specialist areas (at an inflated cost), which in turn creates problems recruiting fulltime staff. Furthermore, it is possible that the very staff who are disenfranchised by the current terms and conditions, could form their own limited liability companies (either individually or collectively) and contract their services back to the NHS setting out their own terms and conditions for providing an out of hours service. I fear neither of these scenarios will benefit the NHS.
Where I work we had big recruitment and retention problems (as did most other London Trusts) eight years ago. This led to the on-call service in Radiology being severely stretched with a bare minimum of staff covering out of hours duties. A new fixed payment on-call system was introduced which was financially very attractive, which saw both recruitment and retention of fulltime staff improve dramatically, taking a lot of the pressure off cover of out of hours duties. Due to the Catheter Lab out of hours here being covered by Radiographers from Radiology, I have managed to step back from on-call duties about a year ago, meaning I have no personal conflict of interest in the rates of remuneration I am suggesting for out of hours activity. I must say as someone who had done irregular hours and shift patterns for 23 years prior to that, the improvement in the work life balance was far greater for me than I could have ever imagined.
For those staff already involved offering a primary angioplasty service, all will recognise the advantage such a service offers both the patient (by way of outcome), and us all as tax payers, by way of cost savings realised by treating patients in this fashion. It is a truly rewarding experience providing a service that is so beneficial to patients. Ultimately, it would seem a shame if the ability to sustain a 24/7 primary angioplasty service was ever compromised by failing to reward staff in an appropriate fashion for providing such an important service.
There is scope under AFC conditions to pay retention premiums, and this is where I feel employers could link retention payments to on-call activity. It is possible to be awarded up to 30% of your basic salary with such payments, which would give employers enough leeway to pay enough by way of a retention bonus to reward on-call activity at the rate suggested. The counter argument to this is that it sets a precedent. I accept it would, however there are very few staff groups left who still cover out of hour’s activity by way of on-call, rather than some sort of shift system. For those that do, especially where recruitment and retention of staff to who are being asked to do so is problematic, one could also make a similar case. The argument of “setting a precedent” only becomes relevant if the payments I am suggesting are unreasonable, and clearly I do not believe they are given the irregular
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If payments for out of hours duties are not dramatically improved from the Agenda for Change conditions (or indeed old Whitley for those still on them) I can see staff either declining the option of doing such duties if not contractually obliged to do so, or requesting a change in their work contracts to remove and compulsion to cover on call duties. Any employer threatening to terminate contracts for those making such a request could find themselves with no
What are your thoughts on this article? Go to page 22 for information on our next Management Questions relating to this article. Your responses will be included in the next edition.
Authors of the Edition 15 Site Visit
Staff Members of the Issue solely in the cardiac theatres, because it is a position I have been after for a long time.
What do you like best about your current role?
Mrs Glenrose Dubazane Senior Staff Nurse Cardiac Theatres Bart’s and The London NHS Trust LONDON
Where did you train? I trained in South Africa and started doing an enrolled nursing course. I then went on to complete my diploma, then I registered to become a registered nurse. I came over to the UK in 2003, studied outside London, and got the position here at Bart’s in 2004. I really liked working in the cardiac cath lab and theatres through a rotation. In the past few days though I have taken a position
I really enjoyed every bit of working in the labs, and for me it was more about getting advanced training. I was used to angiograms, angioplasties and pacing, but not in its broader sense as here. I didn’t know much about EP, so getting here and getting my hands on it, getting so many opportunities of being taught, I really feel I am working in a really specialised area.
Greatest career achievment? One of them really is the publication of the Site Visit article in the last edition of Coronary Heart. It is a real achievement. I would never really think that I would be able to write something and see it published, especially in England. Look where I am from, South Africa. But it goes back to the kind of people you have found in the profession, the opportunities which are there. So I really And although I was based at Whitechapel I did all my training here. I did my 3 year diploma, then 9 months on did Cardiothoracics at The London Chest. My first placement was here in Angio, then went to work on a cardiology ward, and left that after 6 weeks and came back here and have never left since.
Mr Martin Moon Clinical Teaching Charge Nurse Cardiac Cath Lab Bart’s and The London NHS Trust LONDON
Where did you train? I actually qualified as an electrician in NZ and worked until about 1986, working on and off there, then came over to the UK at the end of 1989. Worked for a little while, and then went into nurse training in 1993. It wasn’t called Bart’s then, it was called Princess Alexandra Hospital.
What do you like best about your current role? People that succeed, in that when you have somebody new start and see them flourish and take off and everything falls into place. They understand the whole greater picture everyone talks about. Nothing is worse than working with someone who is focussed on this little box. And when you see everyone when they first start they see everything in black and white and after a while things start dropping into place. It is like they are assimilating previous experiences and they are getting a good grasp, and you can almost see the penny
see myself as growing in the profession, and I strongly believe in my heart I will retire being something up there.
What did you want to be when you grew up? To be honest I saw myself in parliament. I always thought of making laws, directing people here and there, and really getting involved with what is going on in the country. But there are lots of challenges when you grow up depending on the family background and so on. So looking at my age now I am getting a bit old for that.
Look at Ghandi. He was in his 50’s when he started a revolution. (laughing) Well if I get a chance to be honest, especially if I go back to South Africa then I would like to get involved in something bigger than what I am currently doing.
drop, like a little light bulb goes on behind them. That’s what I like the most.
Greatest career achievement? Getting our Intravenous Moderate Sedation Protocol through the Trust, where nurses administer IV moderate sedation under local prescription. And this resulted in publication. It was also my dissertation, my degree. That went through and when it got published we got loads of Trusts ringing up asking if they could have a copy of it.
What did you want to be when you grew up? I wanted to be an electrician, but as soon as I got it I hated it. For the present though I am quite happy where I am. I am looking at further education by going further into nursing, so I am kind of at a cross roads.
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This education article is proudly provided by
The Burden II Trial - what have we learnt?
n August 2003, Puglisi A et al first published the results of the Burden I trial in the European Heart Journal. This randomised study, presented some interesting findings with regards to atrial tachyarrhythmia burden in Brady-Tachy Syndrome. To accomplish this, the study compared overdrive pacing, the DDDR pacing mode and Closed Loop Stimulation (CLS). Conclusions from the patient population of the study included: • •
The CLS pacing mode was associated with a lower AT burden. CLS and DDD+ algorithms could provide an eﬀective atrial overdrive with an Atrial Paced Percentage (APP) significantly higher than in DDDR.
Although the primary finding of the trial showed a reduction in Atrial Tachyarrhythmia burden associated with CLS there were some limitations however. Firstly, the study used different pacemaker models which meant the use of two different pacemaker models prevented further data reporting and comparisons concerning both the effect of pacing algorithms on the incidence of premature atrial contractions, and AT episode validation. Secondly, there was no crossover between the pacing algorithms and thirdly, one device algorithm leant towards permanent Ventricular pacing which could have possibly affected and limited the AT prevention efficacy of CLS. 1 Now, five years later, Puglisi A et al have released the findings of the Burden II trial which has tended to these limitations. This was accomplished by recruiting a greater patient population (Burden I = 149, Burden II = 451), incorporating a crossover at 4 and 7 months and also using the same pacemaker model for all patients which includes a CLS algorithm that does not require permanent Ventricular pacing (Protos DR CLS).
Study Population The population characteristics for the study were as follows: 451 Patients with Brady-Tachy-Syndrome • • • • • • • • • • •
Female gender Age (yrs) NYHA II/III LVEF (%) Left atrial size (mm) Coronary artery disease Documented AF Documented AFlut Sinus Bradycardia AV block II/III AA drug therapy
49% 75 ± 7 54/5% 55 ± 8 42 ± 6 16% 92% 13% 93% 15/3% 50%
Study design Full crossover was performed between the three pacing algorithms at 4 and 7 months: Key:
R - Randomisation M - months FU – Follow up
The following summarized information and results were the main findings from the Burden II trial. ²
* 39 patients were excluded because of death (2%), permanent AF (5%) and changed AA drug therapy due to persistent AF (2%)
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The three pacing algorithms used in the Burden II trial were: Atrial overdrive (DDDR+) An algorithm designed to almost completely suppress spontaneous atrial beats by pacing slightly above sinus rhythm Accelerometer-based rate modulation (DDDR) A conventional rate modulation algorithm using an accelerometer for the detection of exercise-induced movements Closed Loop Stimulation-based rate modulation (CLS) Rate modulation based on information about the actual metabolic demand by measuring a contractility-related impedance signal coming from a normal right ventricle lead. * Lower rate = 70 ppm, Upper rate = 130 ppm
Results - AT
* adjusted numbers; false-positive episodes are excluded
For episodes lasting longer than 1 minute and shorter than 1 hour, CLS has shown the lowest percentage of patients. During episodes lasting longer than 1 hour and shorter than 24 hours, CLS only showed significance in comparison to DDDR+. Episodes longer than 24 hours did not show significant differences.
Results – APP
* adjusted numbers; false-positive episodes are excluded
CLS was able to reduce the AT burden to only 0.04% of all atrial beats in the whole patient population. CLS reduced the AT burden significantly by 66.7% vs. DDDR+ and by 50% vs. DDDR.
Closed Loop Stimulation shows a higher atrial pacing percentage than the conventional accelerometer but lower than overdrive, which is due to the more physiological pacing behavior of CLS. There was only a very poor correlation between the APP and the AT burden during all algorithms.
Results – VPP
* adjusted numbers; false-positive episodes are excluded
177 (43%) patients had the lowest AT burden when CLS was activated in their device. Therefore the chance for patients to experience the lowest AT burden is the highest in the CLS mode.
In patients with an AV Conduction Time <270 ms, CLS combined with an AV hysteresis of 300 ms reduced the VPP to 15%. In a subgroup of patients with an AV Conduction Time <200 ms, the VPP was reduced to only 6% in the CLS group.
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The Burden II Trial - what have we learnt? (cont...)
In patients with Vp <40%, CLS demonstrates the lowest AT burden. However, the interaction of pacing mode, Vp and AT burden in patients with Vp >40% needs further investigation as each pacing therapy was active for only 3 months.
Results – PAC’s
The majority of patients (43%) experienced the lowest AT burden during CLS mode.
CLS showed the lowest number of patients, who had AT episodes
lasting longer than 1 minute (27%) and shorter than 1 hour (14%)
Therefore, from the results of the Burden II trial we can also state the following: 1.
The two rate response (Accelerometer & CLS) algorithms performed significantly better than the simple atrial overdrive algorithm.
By reducing premature atrial contractions, whilst delivering physiologic pacing therapy, CLS has a very positive effect on the AT burden.
The more physiologic behavior of CLS as compared to DDDR has the biggest impact on reducing AT episodes and AT burden in patients with Brady-Tachy-Syndrome.
References: The CLS & DDDR groups demonstrated the lowest ShortCoupling PAC occurrence per day; Short-Coupling PAC’s are considered the most important trigger for AT episodes, whereas Long-Coupling PAC’s have already proven to be substantially uncorrelated with AT burden 3
A. Puglisi, et al.; Impact of Closed-Loop Stimulation, overdrive pacing and DDDR pacing mode on atrial tachyarrhythmia burden in Brady-Tachy Syndrome. European Heart Journal (2003) 24, 1952–1961
Puglisi A, et al.; Overdrive Versus Conventional or Closed-Loop Rate Modulation in the Prevention of Atrial Tachyarrhythmias in Brady-Tachy-Syndrome. PACE 2008; 31:1443-1455
Azzolini et al.; AT burden modeling by some EP parameters in IPG patients with BTS. Europace 2006; 8:474-481
So, to answer the question, what have we learnt from Burden II?
PAC’s could be reduced significantly during the CLS & DDDR mode.
With an AV hysteresis of 300 ms, CLS was able to reduce the VPP to 15% in general and to only 6% in patients with an AVCT <200 ms.
CLS has demonstrated the lowest AT burden and a significant reduction of the mean AT burden in the complete patient population.
In a sub-group of patients (Vp<40%) CLS was able to reduce the mean AT burden even more, however, a “real” correlation between VPP and AT burden could not be established.
18 CORONARY HEART ™
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Finger on the Pulse Are radiographers underutilised in EP cases? And if so what do you think the best approach is? a. Have the radiographer isocentre the table and leave the gantry movements to the other staff so they can be utilised elsewhere? b. Better staff rotation schedules so that staff are not stuck doing EP day after day? c. Provide radiographers with other jobs such as ACT’s, and Cool Flow? d. Teach the radiographers how to scrub in on cases without the pressure of learning in a high pressure cath lab procedure? e. Employ Assistant Practitioners such as those at Kings College Hospital to do the x-ray component? Does your department employ any of the above approaches?
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Greg Cruickshank Superintendent Radiographer Cardiac Catheter Suite King’s College Hospital NHS Trust. LONDON In the current economic climate both staff shortages and cost improvement pressures have brought into focus the question of skill mix of staff in the Catheter Labs. The level of Radiography presence required in an EP lab setting is certainly a topic within the broader debate of catheter lab skill mix that most staff (and staff groups) have a view about. At King’s College Hospital about 5 years ago we were experiencing Radiographic staff shortages like most other London Trusts at that time. As we have one lab dedicated fulltime to EP and Pacing work, I decided that we could train an Assistant Practitioner up to provide Radiographic cover for the Pacing and EP service. Doing so has released a member of the Radiographic team to work elsewhere, as well as providing continuity in the service provided in the EP and Pacing lab by having the same member of staff performing the role. Our two fulltime EP and Pacing Consultants are very happy both with this arrangement and the service provided.
There are certainly other possibilities with regards to Radiographic service provision in an EP and Pacing lab setting. Cardiologists can be trained to do their own table and tube movements (in a number of cases they will already have experience doing so). This would leave the Nurse or Cardiac Tech to zero the 5 minute timer. The Nurse or Cardiac Tech could be trained to do table and tube movements (the Nurses do not scrub for these cases here at King’s), as they have to be in the lab during these cases in any case. Of the two, the Nurses probably have more time during EP and Pacing cases to do so. I know both these suggestions are contentious, but ultimately as long as the Clinician doing the case is happy to work with reduced staff number’s, a robust risk assessment is undertaken, staff have appropriate training and auditing of their new tasks, both suggestions are workable. I realise that what is right (and workable) for one department will not always be so for another. However the question of staff numbers and skill mix will not be disappearing anytime soon.
“Stand out from the crowd and be the best cardiac manager you can be”
Here is a list of the jobs we undertake during EP/Ablation cases:
Diane Evans Radiology Education Specialist Liverpool Heart & Chest Hospital LIVERPOOL
rimarily options b and c.
Cardiac radiographers are ‘highly skilled and specialised’ staff – I make no apology for the old Whitley reference – and are undervalued, and underutilised in EP. The solution is not to withdraw these staff – options a and e – but to enhance their roles. Certainly all of our radiographers are ILS, some ALS, who have a good understanding of ECG etc and can be relied on to cardiovert the patients during VT studies, and could perform the additional duties as suggested in option c. Yet as a profession, we seem very hesitant to blur the boundaries, and venture into other roles, unlike nurses, who excel at this! So come on, guys, let’s raise our sights, and hopefully in turn, our AFC bandings!!!
Andrea Ramsay Acting Supt Radiographer Cardiac Cath Lab Wellington Hospital LONDON
ith regard to the radiographers’ role in EP cases, here at the Wellington the radiographers have quite an active role. As well as performing the usual radiographic tasks i.e. moving the table and C-arm, ensuring the dose is kept as low as reasonably achievable with strict collimation, keeping detector as close to patient as possible – reducing scatter and dose to patients and staff, informing the operator of excessive fluoro times and doses, sorting out any equipment problems and making sure the pulsed fluoro frame rate is kept as low as diagnostically achievable, the radiographers also are responsible for setting up and operating the cool flow machine during the procedure. They are responsible for performing ACT blood tests and ensuring they are taken every 15-30mins after heparin is given and also operating the Cryo ablation equipment. I feel it is very important that a radiographer is present during EP cases, even though they aren’t always the most thrilling of procedures. We also try to send our radiographers on training courses on EP to make the cases more interesting for them.
Moving C-arm and table
Strict collimation and keeping the detector as near to the patient as possible to reduce scatter and dose.
Informing the operator of excessive fluoro times and doses.
Sort out any problems with equipment faults.
Making sure the pulsed fluoro frame rate is as low as is diagnostically achievable.
Ensuring an ACT is taken every 1530mins after heparin is given.
Setting up and operating the cool flow machine during the case.
Operating the Cryo.
Sue Reed Supt Radiographer Cardiac Cath Lab Glenfield Hospital LEICESTER
his is the set up at Glenfield.
We now have 2 labs doing EP. One lab is staffed by a radiographer and one is staffed by a Radiology Assistant to cover the x-ray side of things. We tend to do half day sessions for EP. I think our radiology assistants have been taught to set up the Cool Tip stuff.
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Finger on the Pulse (cont...)
Suzanne Crown Medical Imaging Clinical Services Manager Cardiac Catheter Laboratory Princess Alexandra Hospital Woolloongabba QLD AUSTRALIA
Suggestion c. If they are happy enough to take that on .... bearing in mind they should still be responsible for Radiation Safety and Hygiene.
adiographers CAN be under utilised in this area ..... if you don’t plan well enough.
Suggestion a. NEVER. We have a licensed person (Radiographer) in the room at all times when Radiation is being used. They are allowed to work on in service presentations during this time, read professional journals (for continuing professional development), write articles for Radiology or Cardiology and / or update protocols etc.
Suggestion b. Certainly ...... EP everyday would be monotonous. We have staff doing approx 4 hour sessions each. Divided into morning and afternoon. Share the load makes management sense.
If they are happy enough to take that on .... bearing in mind they should still be responsible for Radiation Safety. This can become an issue if they are actually scrubbed.
Suggestion e. No .....NO ...... we should be expanding the Radiographers roles NOT reducing them and giving less “exciting” jobs to Assistants.
reg Cruickshank’s article in this edition on On-call Remuneration will form the next edition Management question. Therefore can you please answer the following questions: •
What are your thoughts on the current remuneration for being on-call?
In your department what is the amount you receive on-call and conditions?
Do you support Greg’s suggestion of an hourly rate of £50, with at least one hour’s payment guaranteed per day on call in-lieu of carrying the bleep?
We would encourage ANY actions that expand the Radiographers roles, not delegate to others. If the staff are under utilised, then you have failing management practices.
Please email your answers to email@example.com for us to publish in the next edition. If you are based outside of the UK we would also like to hear from you on your workplace conditions.
Hope this gives you an idea of OUR Radiographers roles.
Answer is due by Friday February 6, 2009
NB. I have been in charge for 10 years now, and all the qualified staff are happy to come to the Labs on rotation, for any duties.
If you haven’t done so yet, we recommend you take 2min off and visit our website www.coronaryheart.com to fill in our subscription form. It doesn’t cost you anything, and it is a legitimate way to surf the internet during work time.
Write for us
Share your expertise with your fellow workers by contributing an article to Coronary Heart. All topics related to cardiology are welcome. For more information and a copy of Coronary Heart’s author guidelines email the Chief Editor Tim Larner at firstname.lastname@example.org
22 CORONARY HEART ™
Next Edition Management Topic
EP LATEST NEWS
What’s New? Scorpion2™ & EPLogix™ goes live
elegates attending the Heart Rhythm Congress at Birmingham in October were able to watch live cases taking place from the Cardiac Catheter Labs at the Wessex Cardiology Unit, Southampton General Hospital.
Dr Sabine Ernst, Consultant Electrophysiologist from the Royal Brompton & Harefield NHS Trust, London, performed an atrial flutter ablation. Dr Ernst used a BARD Scorpion2™ 8mm tip ablation catheter. The new BARD Scorpion2™ has the advantage of a bidirectional distal tip, which can be very useful, especially for flutter ablations, offering different tip orientations & curves. During the case Dr Ernst also demonstrated BARD EPLogix™. This electrical mapping software is incorporated into the BARD LabSystem™ Pro EP recording system, so requires no additional equipment. It allows a 3D visual representation of the intra cardiac signals. Here the EPLogix™ images demonstrate bidirectional isthmus block at the end of the successful case.
For further information on Scorpion2™ or EPLogix™ please contact your local Bard EP Sales & Clinical Specialist.
2-catheters-in-1 Diagnostic mapping of RA & CS in one catheter Easily positioned from inferior or superior approach Bard Limited, Forest House, Tilgate Forest Business Park, Brighton Road, Crawley, West Sussex RH11 9BP, UK
One less stick, one less catheter, one less cable
Tel: +44 (0) 1293 527 888 Fax: +44 (0) 1293 552 428 Bard Customer Care: +44 (0) 1293 529 555 Bard and the stylised heart design are registered trademarks of C. R. Bard, Inc., or an affiliate. Conforma is a trademark of C. R. Bard, Inc., or an affiliate. © 2008 C. R. BARD, Inc. All Rights Reserved. 1208/2185
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Making Sense of AF An Introduction to the Ablation of Atrial Fibrillation cardiac rhythm disturbance² and a quarter of the population will develop AF during their lifetime.3 In 2000 a staggering 1% of the UK National Health Service budget was spent on AF (€ 688 million).⁴ Many patients experience intolerable symptoms during AF. Ian Wright, Technical Head EP, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
“During the past decade, catheter ablation of atrial ﬁbrillation (AF) has evolved rapidly from a highly experimental unproven procedure, to its current status as a commonly performed ablation procedure in many major hospitals throughout the world”. - HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation1
AF is a supraventricular tachycardia characterized by uncoordinated atrial activation with loss of atrial mechanical function. The ECG in AF shows irregular fibrillatory waves instead of organised p waves and an irregular ventricular response. Catheter ablation of AF has been the “Holy Grail” of EP over recent decades. Why is this, why has an ablative cure been difficult to achieve and how does AF ablation work?
AF: The Problem AF affects a lot of people and costs a lot of money. It is the most common clinically significant cardiac arrhythmia accounting for over one third of hospitalisations for a
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It is the most frequent sustained arrhythmia and increases with each decade of life, approaching 5% in pts over 60 and some 9% in those over 80. The cardiovascular effects of AF are many and include decrease in stroke volume, increased LA pressure and volume, loss of atrial systole, shortened diastolic ventricular filling period and AV valvular regurgitation. AF is associated with approximately 10-15% of all strokes⁵ due to stasis of blood in a non-contractile left atrium and is a confounding factor in the treatment of 20-26% of all heart failure patients.3
Rationale for AF Ablation The primary justification for an AF ablation procedure is to improve quality of life -ablation is currently indicated in patients with symptomatic drug refractory AF. There are broadly two approaches to the treatment of patients with AF, ablation aiming at rhythm control. Rhythm control seeks restoration & maintenance of sinus rhythm (SR). Drugs, permanent pacing and ablation have all been utilised in an attempt to restore and preserve sinus rhythm. Rate control seeks to control symptoms from AF by restricting the fluctuations in heart rate typical of this arrhythmia. Rate slowing drugs can be used to limit the severity of tachycardia during fast AF, but in some patients theses encourage bradycardia which, if symptomatic requires pacemaker insertion. Despite optimal medical rate con-
trol many patients still experience debilitating symptoms. In the past, catheter ablation or modiﬁcation of the AV junction was a common procedure to restrict fast ventricular rates during AF in patients where rate slowing medications failed. The need for permanent pacemaker implantation and the success of catheter AF ablation now restrict AV node ablation to patients with permanent AF. There have been several randomized clinical trials that address whether rate or rhythm control is more beneficial for AF patients. These trials show that using antiarrhythmic drugs to maintain SR does not realise the potential benefits. An analysis of the AFFIRM study - one of the largest, suggests that a beneficial effect on survival of restoring sinus rhythm is being masked by the adverse effects of antiarrhythmic drugs. This analysis reveals that the presence of sinus rhythm is associated with a 47% lower risk of death but use of antiarrhythmic drugs increased mortality by 49% effectively cancelling out the benefit. The conclusion is that restoration of, and maintenance of SR is of potential benefit if it can be achieved without the use of anti-arrhythmic drugs – i.e. by ablation. The results of recent studies suggest there are benefits to sinus rhythm obtained by ablation techniques over rate control.1 The recognition that AF, once initiated, alters atrial electrophysiological properties in a manner favouring the induction and maintenance of the arrhythmia (AF begets AF)⁶ provides additional impetus for early intervention to maintain SR.
Eﬃcacy of AF Ablation There is now substantial evidence for the efficacy of catheter ablation.1 Outcomes vary considerably however, influenced by differences in technique, experience and technical proficiency. Differences
Classification of AF ACC/AHA/ESC 2006 Guidelines These definitions apply only to AF episodes which are of at least 30 seconds’ duration and do not have a reversible cause. A particular patient may have AF episodes that fall into one or more of these categories. Patients are then categorized by their most frequent pattern of AF.
Paroxysmal AF (pAF) Defined as recurrent AF (2 episodes) that terminates spontaneously within seven days.
Persistent AF Represents the vast majority of patients presenting with AF. Defined as AF which is sustained beyond seven days, or lasting less than seven days but necessitating pharmacologic or electrical cardioversion.
Included within the category of persistent AF is “longstanding persistent AF”, defined as continuous AF of greater than one year duration. The term permanent AF - AF in which cardioversion has either failed or not been attempted is not appropriate in the context of patients undergoing catheter and/or surgical ablation of AF, as it refers to patients where a decision has been made not to pursue restoration of sinus rhythm by any means..
Why bother to categorise AF? The ablation strategy, likelihood of success and the number of procedures required differ for patients with paroxysmal verses persistent AF. The distinction reveals differences in the relationship between substrate and trigger in the mechanism underlying the arrhythmia.
in follow-up, definitions of success and variation in the use of antiarrhythmic therapy also affect reported outcomes.1, A worldwide survey on the methods, efficacy, and safety of catheter ablation of AF was published in 2005.7 The success rate, defined as freedom from symptomatic AF in the absence of antiarrhythmic drug therapy, was 52%. An additional 24% of patients were free of symptomatic AF in the presence of a previously ineffective antiarrhythmic.. More than one ablation procedure was performed in 27% of patients.
introducing risk of tamponade. Other risks include PV stenosis, phrenic nerve damage and oesophageal fistula.
There is a body of evidence for additional benefits, such as decreased stroke risk, decreased heart failure risk, and improved survival - but they have not yet been systematically evaluated as part of a large randomized clinical trial.
For many years, three major schools of thought competed to explain the mechanism(s) of AF: •
Multiple, random propagating wavelets - multiple wavelet hypothesis
The incidence of major complications in the 2005 study was 6%. The left atrium (LA) harbours the majority of AF sources and so AF ablation requires transeptal puncture –
Focal electrical discharges
Localized re-entrant activity with fibrillatory conduction.
Mechanisms of Atrial Fibrillation AF is different to other tachycardias treated in the EP lab. It is more complex and appears chaotic. Despite considerable progress having been made in recent years the mechanisms of initiation and perpetuation of AF they remain incompletely understood.
All three are now thought to play a role but until the mid to late 1980s, the multiple wavelet hypothesis proposed by Moe and colleagues was widely accepted as the dominant AF mechanism and provided the intellectual foundation for attempts at surgical and catheter ablation. The hypothesis asserts that AF requires a critical number of circulating re-entrant wavelets, each of which requires a critical mass of atrial tissue. In other arrhythmias such as atrial flutter the re-entrant circuit has a fixed anatomical location and so lesions placed across a critical isthmus lead to termination and cure. If AF is a more random process with meandering and unstable re-entrant circuits and no definable critical location, lesions based on electrophysiological mapping will have no effect. However a series of continuous lesions that compartmentalize the enlarged atria, forming barriers to interrupt potential wavefronts might be effective. In the late 80s Cox and colleagues performed a series of very successful operations based on this principle – the Maze procedure. Unfortunately this required a thoracotomy and could lead to loss of atrial mechanical function and sinus node damage requiring a pacemaker. The surgical incisions were extremely difficult to replicate with catheter ablation, particularly with technical limitations of that era.
Importance of the Pulmonary Veins The development of AF requires both a trigger and a susceptible substrate. The goals of AF ablation procedures are to prevent AF by either eliminating the trigger that initiates AF or by altering the arrhythmogenic substrate (or both). Tachycardias treated by ablation are usually split into re-entrant and focal. Focal tachycardias result from localised regions of tissue behaving abnormally – firing off rapid impulses instead of being depolarised by an external impulse originating from the SA node. Re-entrant rhythms consist of “endless loops” of activation where the advancing wave can return to the starting point, similar to a Mexican wave. However, the distinction is not straightforward as re-entrant arrhythmias are often initiated by premature ectopic beats from an automatic or triggered focus.
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Image courtesy St Jude Medical
Figure 1. Initiation of atrial fibrillation by rapid PV firing. The left atrium (LA) is unable to “keep pace” with the PV and LA. Atrial conduction fragments into daughter wavelets due to differences in conduction and refractory properties of the atrial tissue.
The ectopic is focal but it triggers a sustained re-entrant tachycardia. A great advance was the observation by Haissaguerre and colleagues that in a subset of patients AF was initiated and in some cases maintained by rapid ectopic beats which were not randomly distributed but were concentrated at the four pulmonary veins (PVs). In a landmark paper in 1998 Haissaguerre concluded that the pulmonary veins are an important source of ectopic beats, initiating frequent paroxysms of AF and that these foci respond to treatment with RF ablation. 8
the time of the procedure. Many foci were ablated deep within the PVs causing PV stenosis9 sometimes resulting in pulmonary hypertension. These drawbacks lead to a new approach – pulmonary vein isolation.
Pulmonary Vein Isolation Pulmonary vein isolation (PVI) prevents potential AF initiators from exiting the vein by electrically disconnecting the PVs from the left atrium by ablation.
It is now well established that the PVs are a crucial source of triggers which initiate AF are mark the beginning of the modern era of AF ablation.
Focal ablation Early focal AF ablations sought to observe spontaneous ectopics triggering AF, identify the focal source and eliminate it by ablation. The procedure was successful in some patients but had drawbacks. Although patients with frequent ectopy were selected, the ectopy could only be mapped if it occured at
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Figure 2. Rapid focal firing from a pulmonary vein after electrical isolation, which does not affect the atrial rhythm. This is demonstrated by the slower, regular activation on the high right atrial catheter (HRAp) in response to coronary sinus (CS) pacing.
Image courtesy St Jude Medical
Figure 3. Pulmonary vein Isolation achieved by circumferential lesions. Conduction of the paced beat into the vein fails on the last complex, as evidenced by the disappearance of the sharp PV potential.
Ablation strategies which target the PVs and/ or PV-LA junction are now the cornerstone for most AF ablation procedures. Today the primary aim of ablation is electrical isolation of the PVs by creation of circumferential lesions around the PV ostia, avoiding ablation within the PVs. Circumferential lesions also modify the AF substrate by a variety of means including elimination of tissue near the atrial–PV junction that provides a substrate for re-entrant circuits, reduction of the mass of atrial tissue which would otherwise be available to sustain re-entry1 and ablation of epicardial autonomic ganglia that are implicated in AF initiation.
What’s wrong with the pulmonary veins? Trigger: myocardial muscle fibres extend from the LA into all the PVs for between one and three centimetres. Spontaneous electrical activity within the PVs is commonly observed after electrical disconnection. The mechanisms of focal PV firing are incompletely understood. Substrate: the PVs and the posterior LA are also a preferred site for re-entrant arrhythmias implicated in the maintenance of AF. The refractory period inside PVs is often very short compared to myocardium in the atrial chamber. This is illustrated in the figure 4 by the extremely rapid activity inside a PV (Mapd) compared with the main body of the LA (P1-20). Such activity can represent a “driver” for AF, helping to perpetuate the arrhythmia. Figure 4
In patients with persistent AF and particularly those with longstanding persistent AF, ostial PV isolation alone may not be sufficient. Inclusion of the atrial myocardium in ablation strategies is particularly important in these patients.
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EP Cardiologist Interview References
Dr Anthony Chow
Calkins H, Brugada J, Packer DL et al. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up Heart Rhythm, 2007; Vol 4, No 6,
Consultant Cardiologist (Electrophysiologist) The Heart Hospital UCLH LONDON
Bialy D, Lehmann MH, Schumacher DN, Steinman RT, Meissner MD. Hospitalization for Arrhythmias in the United States: Importance of Atrial Fibrillation [abstr]. J Am Coll Cardiol. 1992; 19: 41A.
Why did you decide to become a Cardiologist?
Benjamin E.J., Levy D, et al. Independent risk factors for atrial fibrillation in a population-based cohort; The Framingham Heart Study JAMA 1994; 271(11):840-844. Stewart, S. et al. “Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK.” Heart 90.3 (2004): 286-92
Stafford R.S., Robson D.C., et al. Rate control and sinus rhythm maintenance in atrial fibrillation: National trends in medication use. Arch Intern Med 1998; 158: 2144-2148.
Wijffels et al:Atrial Fibrillation begets Atrial Fibrillation. Circulation 92, 1954-1968(1995)
Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation 2005;111:1100– 1105. Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le MA, Le MP, Clementy J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339:659–666. Ernst et al. Total pulmonary vein occlusion as a consequence of catheter ablation of atrial fibrillation. European Heart Journal Vol.22, Abstr.Suppl. September 2001:p244, Abstr1322
28 CORONARY HEART ™
When I was undergoing general medical training, Cardiology was probably the most interesting of all the specialities; and I think very early on you decide what you don’t want to do.
Where did you train? I had a good school in London. I had rotations in Sussex and then I went up to Sheffield. I came back to do specialist cardiology training in the North Thames rotation which merged with my EP training, research and clinical years, and finally with about 5 years at St Mary’s. Today I am based at The Heart Hospital but do occasional private work at The Wellington Hospital. I also now have an outpatient clinic outside London in Reading.
What is your single greatest career achievement? Very difficult to pin-point this. The job is very multi-faceted, so that you make your research interest grow. You take on clinical need roles and the development of clinical services, for example at The Heart. Five years ago it was a hospital doing 30 odd ablations and a dozen ICD’s. Now we do 300 devices a year, and over 700 ablations. We have exceeded 1000!! So that is how much we have grown. I joined a colleague there 4 years ago, and at the time he was the only one just starting off, and now it is 6 consultants, 5 or 6 specialist trainees, and a research fellow. It has all grown beyond recognition. I have had collaboration with other groups as well. I have written a book, and there should be another book coming out in an-
other year or two. The first book was on pacing and devices – all you want to know, with a chap called Alfred Buxton from the States. That’s been out for a couple of years now. And we are scheduled to have a second EP book out; so there is a number of things in development. I also have 2 research fellows full-time and we are collaborating with 3 other centres on projects. Last year I was also the joint clinical lead for Arrhythmia Sudden Death in the Thames Valley region.
What do you see as the future role of a cardiologist in a department? You can’t practice medicine now without some degree of cardiac management. That’s because strategic planning services catering for clinical governance, quality outcomes, dealing with waiting lists and demand, it is not going to be met without management in some way. If you are going to leave it to managers to do most of that you can’t have control, so you always have to actively participate in the process, to make it function more efficiently, leading to a benefit in pa-
tient care. I don’t think you can disassociate from that arrangement but it requires time.
EP is a rapidly growing field, and appears to be overtaking intervention in regards to development. Why? It has been a wind of change that has only really happened in the last few years. I remember speaking with one of my old mentors who believed that every major centre in the country will have an AF Lab in 10 years, and we laughed at that, because we thought it was just some sort of experimental treatment 10 years ago. Now it is a reality and unfortunately with the devolution of angioplasty and revascularisation being taken to DGH’s, they have removed a lot of the work from the major tertiary centres, like this one (The Wellington Hospital). They are almost a victim of their own success in that acute coronary syndromes, acute infarcts, etc I have dealt with them and mopped up very efficiently, and the patients get a very good quality of care. So in what to some extent has been a saviour to some tertiary centres is that the growth and the technology of dealing with previously medical managed conditions like atrial fibrillation has just exploded, and successes and complication rates have actually increased and improved upon year on year. We are only treating the very symptomatic tier of patients, which is only a very small proportion, as our patients are still not referred appropriately.
So how are you keeping up-to-date with these changes? There are endless meetings and conferences, and if you look at just the AF meetings, there is a European one, a Boston AF meeting, a Mediterranean AF meeting; there is just so many, and that is outside the core American Heart meetings, European Heart meetings, and HRS meetings. You can just keep going on meetings every month. For me there are 2-3 key meetings I try to attend for CPD and education. We take part in the HRUK meeting, being the na-
tional one here. If we are obviously presenting research we tend to go and support our fellows and oversee the process. The others being the European Society of Cardiology and the North American Heart Rhythm Society meeting. I always try and limit myself to one other AF meeting per year otherwise I would never get any work done. It’s fine if you are one of those semi retired clinical figures who just go from meeting to meeting but they don’t get any work done either.
There seems to be an array of new technologies for treating AF. What do you prefer and why? Currently every few months there is a new technology that comes out, a new robot, a new arm, a new navigation tool, and there is a danger of too much technology that front loads a lot of these procedures, which makes it more complicated, and not necessarily provides a better outcome. So therefore it is actually the results from clinical trials with these new devices that look at efficacy, complication rates, and the relapse rates that we base our current practice on. I use both the Carto and NAVX systems for the AF work. We have Stereotaxis and we are about to get the Hansen. I am still not sure if the latter two officially confers really with benefits.
What about the new technology from Ablation Frontiers? They have really simplified which is a good thing, the process of AF ablation, and potentially streamlined procedure times because it is a very simple tool. I think the jury is still out, because they have had an abstract published on about 100 patients, and I think you can’t compare paroxysmal and chronic fibrillation because they are two different diseases. And that is why with Ablation Frontiers there are two different tools for the two conditions. Anecdotally some people believe it works very well and others believe it works very badly with a lot of
recurrences. So although it is quick, that’s fine, but when it is not better than your conventional tools, I think people will be cautious and wait and see. There has been a much more wholesale uptake of Ablation Frontiers by a number of centres because it’s quick. It gets through waiting lists. I have yet to be entirely convinced until major numbers come out. Editors note: The first peer-review manuscript using the AFI system was the “featured” article in Heart Rhythm Journal in December. Refer to: Boersma, L.V.A., Wijffels, M.C.E.F., Oral, H., Wever, E.F.D.,Morady, F., Pulmonary Vein Isolation by Duty-Cycled Bipolar and Unipolar RF energy With a Multi-Electrode Ablation Catheter. Heart Rhythm 2008; 5:16351642.
Hobbies and passions outside of work? I have three great children that keep me very very busy. Most of my free time on the weekend is ferrying them around, with swimming competitions, tennis competitions, and homework. I am relearning biology and chemistry at the moment. But they are great, and they take up a lot of my time.
CORONARY HEART ™ 29
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