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Issue 2

August / September 2006 Now 48 Pages!!

Special Feature

Introducing a Primary Angioplasty Service

coronaryheart.com

“Especially for Cardiac Cath, EP, and Non-Invasive Departments”

Raising the Profile of Cardiac Radiography

EDUCATION, CONFERENCES + more...

Royal Brisbane, Australia Waikato Hospital, NZ

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LAB VISITS

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Nanotechnology Treating Heart Disease

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NT E M UK Australia

New Zealand


A Selection of Comments From The First Issue Release “We were all really impressed. It is always good to see what other labs are doing and having the educational component in the magazine was an excellent feature.”

“I received the magazine, it looked really good.”

– Hull Royal Infirmary, UK

- Royal Brisbane & Women’s Hospital, Australia

“Great Issue!!!”

– Cardiologist, London, UK

“1st Issue has hit the coffee table, very nice work. The staff are going to keep every issue on file because of the teaching pages. Keep up the good work.”

– Harefield Hospital Cath Lab, UK

“I am writing to thank you for the article. It has given a benchmark, and gave an opportunity to measure up and compare my practice with other hospitals. Once again thank you.” - The Queen Elizabeth Hospital, Australia. “The magazine looks good - you have done a great job.”

“First impressions of Coronary Heart are great.”

– St Mary’s Hospital, London, UK

– Reading Cardiac Cath Lab, UK

“It looks excellent. Look forward to the next issues.” – Alexandra Hospital, UK

“I have seen the first edition of your magazine and found it very good.” - Royal North Shore Hospital, Sydney, Australia

“Congratulations on an excellent publication.” – Cardiac Industry Marsha, Sarah, & Steve. Wellington Hospital Cath Lab, London, UK


CONTENTS

August / September 2006

CORONARY HEART Administrators

Managers

Nurses

THIS EDITION

04

Welcome Editorial

05

Latest News

10

Future

12

Interest Groups

14

Special Feature ‘Introducing a Primary Angioplasty Service’

20

Reader Submit

22

Site Visit (AUS)

‘Radiation Dose Study’

‘Royal Brisbane Hospital’

28

Site Visit (NZ)

33

EP Education

36

Medical Imaging Education

38

Conferences

‘Waikato Hospital’

‘AVNRT explained’

Radiographers

Contents

Cardiac Physiologists

Echocardiographers

King’s Special Feature Page: 14

40

Conference Wrap-up

‘CRAG Study Day’

41

44

Employment

46

Final Word

Cardiology Languages ‘Learn French’

42

Healthy Heart ‘Our chef shows you how to cook healthily’

‘Time for a career change. You have come to the right place’.

‘Congratulations to Staff and Review of next issue’

Waikato Hospital, NZ Page: 28

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EDITORIAL

Welcome Editorial W Coronary Heart Publishing Ltd 145 - 157 St John Street London, EC1V 4PY United Kingdom Phone: +44 (0) 207 788 7967 Fax: +44 (0) 207 160 9334 Visit us online at

www.coronaryheart.com Director/Chief Editor/Designer Tim Larner Clinical Editor Dr Rodney Foale (UK) Consulting Editors Dr Richard Edwards (UK) Ian Wright (UK) ADVERTISING Media kits are available online CIRCULATION 580 Cardiac Departments, Staff, & Industry Professionals in the UK, Australia, and New Zealand Copyright 2006 by Coronary Heart Publishing Ltd. All rights reserved. Material may only be reproduced by prior arrangement and with due acknowledgment of Coronary Heart Publishing. The publication of an advertisement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

Disclaimer:

elcome to the second issue of Coronary Heart™. First of all I would like to express my thanks to all of those who wrote in congratulating the company on producing a cardiac magazine especially for them. We intentionally steered away from producing a peer reviewed scientific medical journal aimed squarely at Cardiologist’s, in favour of a publication designed for everybody in Cardiology. As one Cardiologist put it, “it makes for great update over coffee, without being as heavy going as the conventional journals, or as lightweight as some of the advertising stuff we get sent.” And from the feedback (some of which is on page 2) it showed that our market research was correct, with letters from departmental managers through to the rest of the cardiology team, in the UK, Australia, NZ, and Tim Larner Internationally. Director, Chief Editor,

Designer

We are also grateful for the advice some of you gave. There are some really good ideas out there, and some of them will be implemented over the coming issues. Our website designing has now been brought in-house which has enabled the construction of a more user friendly site than the one currently online. The site will contain the latest Adobe Flash Video which enables users to view video using your current Flash Player. The new site will be released in mid August. The magazine is still freely distributed as a hard copy and online allowing people from all over the world to view the magazine. We are offering a 30% reduction for all advertising in the Oct/Nov edition, so reserve your space now. Revised Media Kits have also been distributed with this issue. The team at Coronary Heart™ hope you enjoy this edition.

Tim



Subscribe Online to get your own free copy

Clinical Editor Dr Rodney Foale,

FRCP. FACC. FESC. FCSANZ. Clinical Director, Surgery, Cardiovascular Sciences and Critical Care. SMHT. COVER PHOTO (from left): Helen Muller (NUM), Leah McDonald (RN), David Stewart (CN), from Royal Brisbane & Women’s Hospital, Queensland, Australia

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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LATEST NEWS

Latest News BIOTRONIK Announces CE Mark Approval for Cruiser Guide Wire

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IOTRONIK GmbH & Co. KG announced that it received CE Mark approval for its new Nitinol Guide Wire, Cruiser. The Cruiser Guide Wire family incorporates Nitinol core material with improved torque transmission and distal control, for facilitating the placement of catheters and stents during an interventional procedure on coronary or peripheral vasculature. “Our unique Chromium enriched core material gives unsurpassed response for additional distal control.” remarked Mrs. Marlou Janssen, VP Sales and Marketing, BIOTRONIK Vascular Intervention.

Siemens DualSource CT Installed in Two Leading US Centers

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he Mayo Clinic in Rochester, Minnesota and NYU Medical Center in New York City are the first facilities in the U.S. to install the Siemens SOMATOM® Definition, the world’s first dualsource computed tomography (CT) system. The system, which was discussed in the Latest News section of the previous edition of Coronary Heart™, has the ability to capture data twice as fast

as any existing multi-slice CT technology, delivering motion-free cardiac images, independent of heart rate. “In cardiac imaging, the ability to image the heart with very short exposure times is essential,” said Cynthia McCollough, Ph.D., associate professor, radiologic physics, Mayo Clinic College of Medicine. “Our current systems, which require 0.16 seconds per exposure, perform very well at lower heart rates. However, dual-source CT requires only half of that time – 0.08 seconds – and thus allows us to successfully image patients with higher heart rates.” Visit www.siemens.com for more information

Visit www.biotronik.com for more information.

Siemens Somatom Definition DualSource CT Siemens Press Image

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LATEST NEWS

Latest News SonoSite MicroMaxx™ System wins 2006 Industrial Design Excellence Award

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he SonoSite MicroMaxx ultrasound system has received a 2006 Industrial Design Excellence Award (IDEA) and is one of 106 award winners out of 1,494 applicants. Sponsored by BusinessWeek and the Industrial Designers Society of America (IDSA), the IDEA awards are judged by a jury of 18 leading individuals in the design world, who focus on design innovation, benefit to the user, benefit to the client/business, ecological responsibility, aesthetics and appeal. Of interest to consumers is that the MicroMaxx has Continuous Wave (CW), Pulsed Wave (PW), Extended Resolution Harmonics, SonoRes and Tissue Doppler Imaging(TDI).

Visit www.sonosite.com for more information

Mayo Clinic Researchers Discover Genetic Cause for AF

“Identification of a new molecular basis for atrial fibrillation provides a critical step toward individualized diagnosis and treatment of arrhythmia,” stated Andre Terzic, M.D., Ph.D., director of Mayo Clinic’s Marriott Heart Disease Research Program.

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The Mayo Clinic discovery is published in the July 15 issue of the journal Human Molecular Genetics.

ayo Clinic investigators have discovered a gene mutation causing chaotic electrical activation of the heart muscle and atrial fibrillation (AF), a common heart-rhythm disturbance affecting millions around the world. 6

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Visit www.mayoclinic.org for more information

The MicroMaxx ultrasound system represents a revolutionary crossover between hand-carried and cart-based systems, weighing less than eight pounds but delivering high resolution image quality at a fraction of the cost of larger, heavier cart-based systems. On a side note, Sonosite recently announced the appointment of two new regional sales managers for the London area. Covering south of the River Thames is Lee Murray, whilst Jan Murphy will cover north of the River. Jan and Lee were selected from a highly qualified field of applicants including sonographers, sales managers and engineers from the ultrasound world.


LATEST NEWS

Latest News Boston Scientific’s New System for Removing Clots gets FDA Approval

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he U.S. Food and Drug Administration (FDA) recently gave clearance for Boston Scientific to market its Rio™ Aspiration Catheter, the latest addition to the Company’s line of vascular protection devices for minimally invasive procedures. The new device is indicated for use in the removal of thrombi, or clots, from vessels throughout the body. Clots can restrict or block blood flow in an artery, creating difficulty or risk to a patient when undergoing intravascular procedures. The Rio Aspiration Catheter can be used with other interventional devices, such as those used to place stents, to open blockages caused by clots in the target area within a vessel.

The Rio Aspiration Catheter is comprised of two tubular cavities, or lumens. The primary lumen is used to extract the thrombus. It is open on one end and attached via an extension tube to a 20-cc locking syringe on the other. The syringe is used to apply suction and aspirate the thrombus from the vessel. The second lumen accommodates a guide wire, which is used to move the catheter into position within the target artery.

The Rio Aspiration Catheter joins Boston Scientific’s FilterWire EZ™ Embolic Protection System -- which traps fragments that are released during a procedure -- to offer physicians another vascular protection treatment option.

The Rio Aspiration Catheter is compatible with large lumen 6F guide catheters (minimum inner diameter of 0.070 in.). The catheter shaft, which becomes more flexible toward the tip, is designed to help reduce trauma to the vessel and facilitate navigation through tortuous anatomies. A radiopaque marker on the tip further assists in successful manoeuvring and placement of the device.

Visit www.bostonscientific.com for more information

“The Rio Aspiration Catheter provides physicians with a simple, dependable and versatile means of restoring blood flow and improving visibility during intravascular interventions,” said Hank Kucheman, President of Boston Scientific’s Interventional Cardiology business. “We are pleased to offer physicians another treatment option in our portfolio of vascular protection devices.”

RADI Medical Launches Cardiac Training Site

The Rio Aspiration Catheter achieved the CE Mark in February this year, however was only released in the UK in June.

Rio™ Aspiration Catheter Image Courtesy Boston Scientific

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adi Medical have recently launched an online educational site designed to demonstrate the proper use of fractional flow reserve (FFR) measurement techniques, an index derived from coronary artery pressure measurements.

The site contains narrated presentations and a wide variety of interactive cases. Whilst primarily of value to Cardiologists, it can also be accessed by cardiac lab staff. Visit www.teachffr.com for more info CORONARY HEART ™ 7


LATEST NEWS

Latest News Eating fish rich in omega-3fatty acids may effect AF

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mega-3-fatty acids may have different effects on the heart’s electrical function, according to a study presented at HEART RHYTHM 2006, the Heart Rhythm Society’s 27th Annual Scientific Sessions in May, held in Boston, USA. Although previous studies have found that fish consumption may protect against the development of atrial fibrillation (AF), a new study found that eating fish more frequently was associated with a higher risk of developing AF among healthy male physicians. After adjustment for multiple risk factors for AF, lifestyle factors, and other dietary factors, men who ate fish more

than five times a week were at a 61 percent increased risk of developing AF as compared to men who ate fish once a month.

AF. In addition, omega-3 fatty acid supplementation reduced the risk of developing AF after cardiac surgery in a randomized clinical trial.

The study, “Relationship Between Fish Consumption and the Development of Atrial Fibrillation in Men,” analysed data from almost 17,700 male physicians in the Physicians’ Health Study. The men reported on their fish consumption in 1983; 15 years later they reported if they had been diagnosed with AF. Of these participants, 1253 (7.1 percent) developed AF at the 15-year follow up. The analysis was adjusted for multiple cardiovascular disease risk factors and lifestyle habits.

Dr. Aizer, attending electrophysiologist, New York University Medical Center and one of the study authors, commented, “It is important to recognize that within the same population as this current study, fish consumption was associated with lower risk of sudden cardiac death, which is the result of a much more life-threatening cardiac arrhythmia, ventricular fibrillation.”

These findings are similar to those reported previously in a relatively young Danish population where the average age was 56, but stand in contrast to those

from a U.S. study conducted among an older population of men and women over the age of 65. In this older population, fish consumption was associated with reduced risks of developing 8

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The study authors noted that previous studies suggest that omega-3 fatty acids may accentuate vagal tone. Enhanced vagal tone has been shown to protect against ventricular fibrillation and sudden cardiac death, but may promote atrial fibrillation in select individuals. Dr. Aizer said the current study’s findings may be influenced by the relatively young, healthy population of physicians where vagal tone may have a more significant impact. “The message of this study is not to stop eating fish. AF is a complex condition that requires the interaction of a number of risk factors to develop. Fish may have different effects on different people. Lifestyle and dietary habits need to be tailored on an individual basis to promote overall health. Clearly, more investigation is needed to reach a more definitive answer about the multiple effects of omega-3 fatty acid on the heart’s electrical function,” Dr. Aizer concluded.


LATEST NEWS

Latest News Speeding Up Emergency PCI Treatment

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ccording to a new study in the June 6, 2006, issue of the Journal of the American College of Cardiology (JACC, Vol 47, No 11), speeding up the time it takes hospitals to deliver emergency angioplasty (the “door-to-balloon” time) will improve the survival of appropriate heart attack patients, even when patients have been feeling symptoms for a few hours. Data was viewed on 29,222 heart attack patients whom were treated with angioplasty (percutaneous coronary intervention (PCI)) from 1999 to 2002 at 395 hospitals within 6 hours of alerting health care providers to their symptoms. Overall, when patients underwent angioplasty within 90 minutes of arriving at a hospital, 3 percent died in the hospital. That in-hospital mortality rate rose to 7.4 percent for patients who were in the hospital for more than three hours before being treated. When the researchers analysed subgroups of patients who had arrived at a hospital within an hour of reporting symptoms, between one and two hours, or longer than two hours, they still saw the same pattern: within each subgroup, faster action in the hospital meant lower death rates. The same benefits of swift hospital response were seen regardless of whether patients had high-risk factors or not. The results of this study indicate that while getting to the hospital as quickly as possible is vital, rapid action by the hospital makes just as much of a difference for patients who come in late as it does for those who arrive right away.

Co-author Harlan M. Krumholz, M.D., S.M., said “From my perspective, the reason that time of onset to hospital presentation is not so important is because many patients may not completely occlude their arteries at the time they first recognize symptoms - and so the actual time of artery occlusion may not be easily predicted from the time it takes them to present to the hospital.”

Merit Receives CE Mark for Catheter

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erit Medical Systems Inc. a leading manufacturer and marketer of proprietary disposable accessories used primarily in cardiology and radiology procedures, announced recently that it had received the CE mark from its notified body to market the Impress™ catheter in Europe. Visit www.merit.com for more information

CE Mark for St Jude ICD and Heart Failure Devices

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t Jude has announced European CE Mark approval of its newest devices for treating patients with potentially lethal heart arrhythmias and heart failure. The Epic™ II ICD (implantable cardioverter defibrillator) and the Epic™ II HF CRT-D (cardiac resynchronization therapy defibrillator) feature faster device data transmission to speed patient follow-up exams and a “patient notifier” that gently vibrates to alert patients of critical changes in device function. Visit www.sjm.com for more information

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FUTURE

Cardiology Advances Nanotechnology Shows Early Promise to Treat Cardiovascular Disease

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n a paper published in the June 12 issue of the American Chemical Society’s journal Biomacromolecules, a new tactic in the battle against cardiovascular disease – employing nanoengineered molecules called “nanolipoblockers” as frontline infantry against harmful cholesterol – is showing promise in early laboratory studies at Rutgers, The State University of New Jersey. Rutgers researchers propose a way to combat clogged arteries by attacking how bad cholesterol triggers inflammation and causes plaque buildup at specific blood vessel sites. Their approach contrasts with today’s statin drug therapy, which aims to reduce the amount of low density lipids, or LDLs (“bad” cholesterol), throughout the body. In an ironic twist, the Rutgers approach aims to thwart a biological process that is typically beneficial and necessary. Prabhas Moghe, the principal investigator and associate professor of biomedical engineering and chemical and biochemical engineering at Rutgers, said that vascular plaque and inflammation develop when certain forms of LDL are attacked by white blood cells that scavenge cellular debris and disease agents. “While these scavengers, called macrophages, perform an essential role in keeping organisms healthy, their interaction with highly oxidized LDL molecules 10

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has quite the opposite effect,” he said.

and chemical biology.

Moghe explains that macrophages accumulate large amounts of oxidized LDL and secrete chemicals that can damage the neighbouring tissues and, ultimately, become fatty foam cells. The researchers’ approach, therefore, is to create clusters of

Moghe said that if this method proves feasible in living organisms, it could convey treatment to the site of the problem, rather than a systemic approach. “While statins are a great stride in preventing cardiovascular disease, they are not suitable for everyone,” Moghe said. “Our approach also has potential to topically address the recurrence of inflammation and blockage at stent surgery sites, something that systemically active drugs have not been shown to consistently do.” Research to test the performance of NLBs in living organisms is now under way. The study is supported by grants from the National Science Foundation and the American Heart Association.

nanoengineered molecules that target specific receptor molecules on cell membranes and block these oxidized LDLs from attaching to macrophages. “We’re employing the tools of nanotechnology – specifically tailoring the structure of the molecule, changing groups on the ends of the chains and closely analysing which forms of the particles bind to the different macrophage receptors,” stated Kathryn Uhrich, Rutgers professor of chemistry

For more information contact Michael Bernstein, ACS Communications Officer: m_bernstein@acs.org


FUTURE

Cardiology Advances Targeting Thrombosis at the Molecular Level

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he University of Nottingham has undertaken important new research into the prevention of thrombosis associated with heart disease and stroke. It was found that the plasma protein Factor XI (FXI) is a key culprit in the process as it can trigger the development of harmful blood clots, known as thrombi. Observations show that when the FXI molecule is exposed to injury it undergoes major changes activated

by platelets in the blood. Dr Jonas Emsley, Associate Professor and Reader in Crystallography at The University of Nottingham, said: “What is exciting about targeting proteins like FXI is that studies in mice, in which the related gene is ‘switched off’, show that the absence of FXI leads to otherwise healthy animals which do not form harmful thrombi.” “This strongly implies that anti-coagulant properties of drugs targeted at FXI to prevent or treat thrombosis i.e. heart attacks, strokes or pulmonary emboli, would not necessarily have the side effects, such as bleeding, associated with current treatments such as heparin or oral anticoagulants. Current treatments target multiple coagulation proteins which have a more central role in healthy blood clotting and hence are more prone to side effects.” “However, one obvious question

Promising new material could transform ultrasound imaging

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sing the same principles that help create a guitar’s complex tones, researchers at the University of California, Berkeley, have developed a new material that holds promise for revolutionizing the field of ultrasound imaging. The study was published in the June 1 issue of Nature Materials. The substance, dubbed an “ultrasonic metamaterial,” responds differently to sound waves than any substance found in nature. Within a decade, the researchers report, the technology they developed to create the material could be used to vastly enhance image resolution of ultrasound. As opposed to natural materials that compress when a force (such as a sound wave) is applied to them, the metamaterial expands. This response, called “negative modulus,” makes it appear as if the sound wave is

arising from the studies in mice is that FXI cannot simply be functioning to cause disease, it must also have a beneficial effect to health. It seems likely that FXI only swings into action when a person suffers a major injury or trauma, and where there is a requirement for large quantities of blood clotting.” The new study is published in the journal Nature Structural and Molecular Biology and was funded by the British Heart Foundation and the National Institutes of Health in the U.S. For more

propagating backward instead of moving forward. Therefore the material supports sound waves that are shorter and finer than sound waves that propagate through any other material. This ability provides the basis for the material’s usefulness in ultrasound imaging. One of the factors limiting resolution quality of sonograms is the ability of the ultrasound lens to capture sound waves. Currently, these lenses are made with elastic materials such as polymers. The elasticity of the materials is what allows them to capture and focus the waves. But there is a limit to the finest resolution that they can capture. Nicholas Fang, the lead author of the study stated, “With this new material with a negative modulus, all the limits can be overcome.” The research was supported by the Office of Naval Research, the Defense Advanced Research Projects Agency Multidisciplinary University Research Initiative, and the National Science Foundation Center for Nanoscale Science and Engineering. [USA] For more information visit www.berkeley.edu CORONARY HEART ™ 11


INTEREST GROUPS

CRAG X-Ray Vision Today for Tomorrow “Raising the Profile of Cardiac Radiography”

NHS Trust was a big success, with a report from the event located on our Conference Wrap-Up page. The Society of Radiographers have awarded CRAG the status of special interest group and The Society and College have agreed to assist with their promotion and act as a focus for their development.

Membership currently includes:

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he Cardiac Radiographers Advisory Group (CRAG) was established in 2001 by Lead Cardiac Catheter Laboratory Radiographers from a number of NHS Trusts and related groups. Over the years CRAG has developed to address a broader range of issues and aims to raise its profile further. The group attracts interesting speakers to their meetings and has the ability to co-opt interested parties where appropriate. Their last meeting held at the University Hospitals of Leicester

Senior and Superintendent Cardiac Radiographers from specialised hospitals, tertiary centres and district general hospitals.

KCARE representatives that report on image performance of radiological equipment for the Medical Device Agency

A representative from the Department of Health with specialist interest in cardiology NOF funding.

Membership aims to include all cardiac modalities as CRAG develops further.

Main Objectives: »

Raise the profile of Cardiac Radiography

»

Create awareness amongst NHS leaders of all Cardiac Catheter Laboratory related issues

Radiographers Alliance Forum This is a special interest forum designed solely for Radiographers whom have become disillusioned members of The Society of Radiographers. Visitors can browse the forums and discuss issues related to their profession and become actively involved in making a difference. 12

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»

Provide advice and make recommendations

»

Inform Cardiac Radiographers of current issues, e.g. advances in equipment/technology, government funding and skill mix.

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Set standards/competencies for Cardiac Radiography

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Share information and experiences

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Develop best practice

Open days are held annually and provide an interesting and thoughtprovoking opportunity to meet members, cardiac radiographers and all catheter laboratory personnel, as well as those who have a general interest in Cardiac Radiography. This is particularly useful for radiography students whom often have limited exposure to the cardiac profession, due to more emphasis placed on the higher profile MRI / CT / US environments. Coronary Heart™ fully supports CRAG and recommends all forward-thinking and motivated cardiac radiographers to log onto their website and find out more. Cardiac Radiography is an exciting profession that is constantly evolving. Don’t just sit at the sidelines and watch it happen. Have your say, and become part of the development. For more information visit www.craguk.org

Whilst aimed primarily at UK Radiographers, the forums are a valuable source of information for Radiographers overseas.

Check the site out at: www.radiographers-alliance.org.uk


Free Your Papers

Cath / EP & Non-Invasive Education Managers Nurses Physiologists Radiographers Echo

• You Submit • We Review • Your Paper Goes Free!!

Worked hard on a paper/article that only your colleagues get to see? Share your knowledge with everybody. Submit it, and we may publish it. We give you £50 if Visit the website for more details

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published


SPECIAL FEATURE

King’s College Hospital, London, UK Photos: Tim Larner

Introducing a Primary Angioplasty Service in a Large Tertiary Centre Written by Greg Cruickshank (Superintendent Radiographer) King’s College Hospital Cardiac Cath Lab, London, UK BACKGROUND At King’s College Hospital London, we had been offering an ad hoc Primary Angioplasty for Myocardial Infarction (PAMI) service since early 1995 for local patients during normal office hours. In September 2003, we started offering the service twenty-four hours a day seven days a week, joined the National Infarct Angioplasty Project (NIAP) as one of six initial the pilot sights in early 2004. In April 2005, we extended the service to include patients from University Hospital Lewisham catchment. Since September 2005, the service is also provided for patients coming under the catchment area of Princess Royal University Hospital Bromley. INTRODUCTION Since the advent of Interventional Cardiology in the late 1980’s, the way we treat patients presenting acutely with coronary artery disease has changed quite dramatically. The treatment of choice since their arrival on the scene twenty odd years ago has been the use of thrombolitic drugs. Any patient presenting with symptoms suggestive of a myocardial infarction have been initially treated with thombolytic drugs, transferred to a Coronary Care Unit to be stabilised and monitored, and sent home once things had settled down with appropriate medication. Patients were then brought back at a later date (in some cases some months later) for a diagnostic angiogram, and were then referred on for surgery or interventional cardiology as required, often incurring further delays before eventually receiving such treatment. During the period of time from the initial cardiac event, and receiving final treatment, patients spend a significant amount of time either in hospital, or attending for further tests and clinic appointments. In addition to this, patients were at risk of their underlying cardiac condition deteriorating, complicating the treatment(s) required to resolve the situation. ---> 14

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SPECIAL FEATURE (cont...)

New Primary Angioplasty Service There were obvious questions raised once interventional cardiology progressed to the stage is has in the last few years of taking on complicated coronary artery disease in multiple vessels, and often doing so as day case procedures. Was is it possible to cut out the middle man so to speak and treat the patients as soon as practicable using interventional techniques instead of thrombolysis? If it were possible, would there be any benefit to patients? Of interest also, were there any another benefits not initially considered that would arise from such a treatment? Evidence emerging from other countries certainly seems to demonstrate there could be benefits from such treatment (1,2,3).

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THE KING’S EXPERIENCE King’s College Hospital is a large tertiary referral cardiac centre in southeast London. From 1995, we have offered an ad hoc primary angioplasty service for patients referred to us from our Accident and Emergency department during our normal working hours of Monday to Friday 9:00am – 5:00pm. In September 2003, we decided to offer a primary angioplasty service 24 hours a day 7 days a week to patients from our local catchment area. This we called Phase 1 of our journey. Patients with an ST elevation rise would be transferred up to the catheter laboratory from the Accident and Emergency Department, once the appropriate staff were available to do the procedure. During normal working hours this was straight forward, and patients were transferred up immediately to our recovery

area, until one of the two interventional laboratories was free. Out of hours however, three of the five core staff required covered on/call from home. These factors contributed delays in chest pain to balloon times, which has a direct effect on patient outcomes (4,5). We therefore had to consider ways of reducing any potential delays before rolling out phase II of the pilot. PHASE I OUTCOMES • Of the 127 patients included, 7 (5%) did not undergo angiography. Of these 3 had thrombolysis, 2 died pre-angiography, and 2 had a stroke pre-angiography. • Of the 120 (94%) who had an urgent angiogram, 10 (8%) did not undergo a PCI. Of these 3 had pericarditis, 2 had unobstructed coronaries, and for 5 PCI was technically not possible. • 110 patients (86%) had primary PCI. 104 (80% of initial cohort; 92.7% of those undergoing PAMI) survived. 6 patients (4%) died.


SPECIAL FEATURE (cont...)

New Primary Angioplasty Service Interestingly, we compared average (mean) hospital stays for phase one patients with the 34 patients who received thrombolysis treatment six months prior (March 2003 – Aug 2003). The primary PCI patients stayed an average of 3.51 days, whilst patients receiving thrombolysis stayed an average 10.2 days. Evidence suggests that early diagnosis and subsequent treatment for ST elevation myocardial infarction (STEMI) patients greatly improves patient outcomes (6). It is also apparent there is nothing to be gained by routing patients through an accident and emergency department, in fact associated delays using such a model decreases patient outcomes by adding time to the process (7,8). For this reason we decided to offer a pathway that allowed patients who rang for an ambulance due to chest pain to be brought straight to the Catheter Laboratory by Ambulance Crews who diagnosed ST elevation on an ECG, commencing in April 2005. The Ambulance Controller rang through to our Coronary Care Unit on a special Red Phone, which only they have access to. The person taking the call would then inform the Cardiology Registrar, and ensure the Senior House Officer went down to the resus bay where the ambulances come in, to meet and greet the patient and crew. This ensured they came straight up to the Catheter Laboratory, and were not diverted into the Resus area of the Accident and Emergency Department, resulting in unnecessary delays. The Cardiology Registrar would proceed to the lab, and call in the on-call Radiographer (also on site), Catheter

University Hospital (PRUH) (phase III). Research from other countries indicates it is safe to transfer patients from outlaying hospitals to receive PAMI treatment (9,10). In addition, research underlines the importance of doing so as quickly as possible to optimise patient outcomes (11). An important consideration when accepting patients from outlaying hospitals is what happens to the patient afterwards. In order to reduce demand on our beds, all patients we treat from other hospitals are repatriated the next day back to their local hospital. All post procedure care and rehabilitation is carried out locally.

Laboratory Nurse, Cardiac Technician and Cardiology Consultant (all from home). Due to three of the five core staff involved in PAMI procedures out of hours coming in from home, we second a Coronary Care Nurse to come and stay in the Catheter Laboratory recovery area with the patient, Registrar, and Paramedic Ambulance Crew, until the other staff have arrived. Coronary Care Nurses are trained up to know where things are in the department in the case of an emergency, should this happen prior to other staff getting in. PHASES II & III April 2005 saw us extend the service we were offering to patients coming under the University Hospital Lewisham (UHL) catchment area (phase II). In September 2005 this was extended to patients from Princess Royal

PHASE II & III OUTCOMES (1st April 2005 – 31st March 2006) • Of 237 patients entered on the database, 184 (77.6%) underwent primary PCI. • 53 patients (22%) did not undergo intervention. • 119 (49.8%) were discharged home, 105 (43.9%) were repatriated back to a District General Hospital. • 14 patients (5.8%) died. • 20 patients (8.4%) had intraaortic balloon pumps inserted and in 43 cases (18.1%) arthero-thombus devices were used. • Median door to balloon time for KCH patients 110 minutes. • Median door to balloon time for UHL patients 94 minutes. • Median door to balloon time for PRUH patients 106 minutes. • Median home to balloon time (Cath Lab direct) 90 minutes. • KCH patients had a mean length of stay of 2.04 days (median 1 day).

continued...... CORONARY HEART ™ 17


SPECIAL FEATURE (cont...)

New Primary Angioplasty Service their contribution. As was found in other studies, direct transfer times were much better than for patients routed though Accident and Emergency. The time of initial chest pain to either calling an ambulance for help, or self-presenting to an accident and emergency were still sometimes quite long. Perhaps consideration should be given to some sort of public awareness campaign, meaning patients do not delay seeking help when chest pain initially occurs. Hospital stays post treatment is significantly less for patients undergoing primary PCI than those given thrombolysis. This benefits both patients and hospital. Current figures suggest that a further two lives per hundred are saved with primary PCI, compared to thrombolysis. On-going evaluation of the National Angioplasty Infarction Pilot data will give us further information regarding outcomes.

• Patients repatriated to local hospital’s had a mean length of stay of 2.01 days (median 1 day). • Once repatriated, patients’ mean length of stay in their local hospital was 2.7 days (median 2 days) DISCUSSION Our experience at King’s shows it is certainly feasible to provide a primary angioplasty service. Involving all stakeholders at the planning stage and in the setting up of the service ensured its initial success. Regular audit and meetings have ensured any problems are quickly identified and dealt with in the best way possible. This team approach allowed us to be flexible, and change the way the service 18

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was delivered promptly when it was required we do so. At this point, I should emphasise the important role played by London Ambulance Service Staff play in service provision. They have been enthusiastic contributors right from the beginning, when we had meetings to discuss how the service would be set up. We also ran a study day for Ambulance Crews (which was very well attended) outlining how the service was working, and doing some live cases demonstrating how we dealt with problems facing us with patients coming in with acute coronary artery problems. We also encourage them to stay and watch procedures after they bring a patient in, which helps reinforce to them the importance of

In the case of patients coming in with diagnosed ST elevation (confirmed on arrival) who subsequently do not have coronary disease, these patients are at least not exposed to the risk associated with thrombolysis treatment. In our cohort, this number is nearly 10% of all patients. In almost all cases, such patients would have been given thrombolysis, and spent time on a Coronary Care Unit, and would have been brought back for angiogram at a later date, adding both risk, cost and time to the process. Finally and perhaps most importantly from the patients perspective. The feedback we get from patients is very positive. They are dealt with quickly, back home promptly, and able to get on with their lives more quickly than under previous treatment regimes. Being part of a team that provides such a service is a very rewarding experience.


SPECIAL FEATURE (cont...)

New Primary Angioplasty Service CONCLUSION There are a number of factors to consider when setting up a Primary Angioplasty service, all of which can have an important effect on the success or otherwise of the service provided. Perhaps the single most important factor to patient outcome is initial chest pain to balloon time. This can be broken down into chest pain to contacting emergency services time, time taken in transit (including any stops at satellite hospital), and door to balloon time at treatment centre. Each of these sub-groups have some important aspects that when optimised, can lead to shortening the overall time from the initial on-set of chest pain, to the patient receiving the appropriate treatment. Getting patients to seek help as soon as possible after the onset of chest pain is important, and there is still room for improvement in this area. Getting the support of your local Ambulance Service from the outset is vital. In addition to this, avoiding delays in Accident and Emergency Departments, and having appropriate staff available early are vital to the success of the service. Finally, regular audit and updates for all team members involved in providing the service help to streamline service provision and keep delay times down to a minimum. REFERENCES 1. Ellis S; A clinical trial comparing primary angioplasty with tissue plasminogen activator for acute myocardial infarction; The New England Journal of Medicine; 1997; 336; No 23; 1621-28. 2. Zijlstra F; Coronary disease: Acute myocardial infarction: primary angioplasty; Heart 2001; 85; 705 – 709 3. Keeley E, Boura J, Grines C; Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitive review of 23 randomised trials; The Lancet; 2003; 361; 13 – 20.

4. Nallanothu B, Bates E; Percutaneous Coronary Intervention versus Fibrinolytic Therapy in Acute Myocardial Infarction: Is Timing (Almost) Everything? American Journal of Cardiology; 2003; 92; 824-826. 5. Andersen H, Nielsen T, Vesterlund T, Grande P, Abildgaard U, Thayssen P, Pedersen F, Mortensen L, on behalf of the DANAMI-2 Investigators Aarhus, Aalborg, Copenhagen, Hellerup, Odense, and Hilleroed, Denmark; Danish multicentre randomized study on fibrinolytic therapy versus acute coronary angioplasty in acute myocardial infarction: Rationale and design of the DANish trial in Acute Myocardial Infarction-2 (DANAMI-2); American Heart Journal 2003; vol 146; number 2; 234-241.

We would like to hear your comments on our articles.

6. Terkelsen C, Lassen J, Norgaard B, Gerdes J, Poulsen S, Bendix K, Ankersen J, Gotzsche L, Romer F, Nielsen T, Andersen H; Reduction of treatment in patients with ST-elevation myocardial infarction: impact of pre-hospital diagnosis and direct referral to primary percutaneous coronary intervention; European Heart Journal; 2005; 26; 770 –777. 7. Herrman H; Transfer for Primary Angioplasty: The Importance of Time; Circulation; 2005; 111; 718-20. 8. Nallamothu B, Bates E, Herrin J, Wang Y, Bradley E, Krumholz H; Times to Treatment in Transfer Patients Undergoing Primary Percutaneous Coronary Intervention in the United States; Circulation; 2005; 111; 761-767. 9. Widimsky P, Groch L, Zelizko M, Aschermann M, Bednar F, Duryapranata H, on behalf of the ‘PRAGUE’ study group investigators; Multicentre randomised trial comparing transport to primary angioplasty versus immediate thrombolysis verus combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterisation laboratory; European Heart Journal; 2000; 21; 823-831. 10. Widimsky P, Budesinky T, Vorac D, Groch L, Zelizko M, Aschermann M, Branny M, St’asek J, Formanek P, on behalf of the ‘PRAGUE’ Study Group Investigators; Long distance transport for angioplasty versus immediate thombolysis in acute myocardial infarction. Final results of the randomised national multicentre trial – PRAGUE-2; European Heart Journal; 2003; 24; 94-104. 11. De Luca G, Ernst N, Suryapranata H, Ottervanger J, Hoorntjie J, Gosselink A, Dambrink J, de Boer M, van’t Hof W; Relationship of Interhospital Delay and Mortality in Patients With ST Elevation Myocardial Infarction Transferred for Primary Coronary Angioplasty.

Email your thoughts, positive or negative, and we’ll try to publish them in the next issue. Write to us at: tim@coronaryheart.com CORONARY HEART ™ 19


READER SUBMITTED

Comparison of the Radiation Dosages Between Interventional and Non-Interventional Cardiologists During Routine Angiography Kim Millar, R.T., N. Kate Reed, R.T., B.App. Sci., Dr. Ernesto Oqueli, Dr. Ronald J. Dick. Victorian Heart Centre, Epworth Hospital, Richmond, Victoria, Australia

Overview:

I

n the performance of coronary arteriography there is a need to address the health and safety concerns about radiation exposure for patients and staff. Factors influencing radiation dose are body mass index (BMI), number of acquisition runs per study, and screening (fluoro) time. The aim of this study is to determine if there is any difference in radiation dose during routine angiography between the interventional cardiologists (IC) and the non-interventional cardiologists (NIC). Over an 18 month period we compared radiation dose during routine angiography excluding graft studies, aortic views and views for closure devices.

Winner of the Affiliates Award at CSANZ 2005 (Cardiac Society of Australia and New Zealand) and has been accepted to the 4th Australasian Conference on Safety and Quality in Health Care (2006).

We have evaluated 294 patients for this study, 187 for the IC and 107 for the NIC. The mean BMI was 28.19 for IC and 26.91 for NIC, which is not statistically significant. The IC mean screening time was shorter (2.48 minutes) than the NIC (4.11 minutes) (p<0.0001). With the BMI difference being non-significant, the lower screening time has resulted in the radiation dose for the IC being lower (mean 0.69Gy) than the NIC (mean 0.89Gy). (p<0.0001) In conclusion, non-interventional cardiologists use a longer screening time, took more acquisition runs and 20

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Are Non-Interventional Cardiologists more of a lead foot during procedures? therefore their patients and the staff received a larger radiation dose than the interventional cardiologists performing the same type of studies. After informing the cardiologists of these results and how they compared to their peers, we monitored again for a period of 4 months to see if any changes had been made. There was no significant statistical difference between the groups during this period. Both the interventional and non-interventional cardiologists reduced the number of runs and their screening times. This resulted in reduced exposure for both the patients and the staff.

Method:

. 5 interventional and 6 noninterventional cardiologists

were followed for this study . The contributing factors that vary the final dose results; patientâ&#x20AC;&#x2122;s height, weight, screening time and number of acquisition runs were noted. . Coronary and left ventriculograms performed at Epworth Hospital were included. . Graft studies, aortograms and acquisition runs for closure devices were excluded. . A 15fps frame rate was used for all acquisitions. . Statistical analysis was performed using SPSS version 10.0 (SPSS Inc., Chicago, Illinois). cont....


READER SUBMITTED

Radiation Doses Compared (cont...) . After Phase 1 all cardiologists were informed of their individual statistics and how those statistics compared to the others in the study.

Results:

. Statistical analysis standard deviation (SD): continuous variables are presented as mean values + SD and were compared using independent sample t test.

Non-interventional cardiologists had longer screening times, took more acquisitions and therefore had higher doses.

Phase 1 (6 months)

. Interventional cardiologists performed 187 procedures. . Non-interventional cardiologists performed 106 procedures.

Phase 2 (3 months)

. Interventional cardiologists performed 168 procedures. . Non-interventional cardiologists performed 34 procedures.

IRP vs DAP: Interventional reference point or IRP is an indicator of skin dose. This point is located approximately at the location of the skin at the beam entrance point when the heart is located at isocenter. IRP, although quantitatively not an exact measure of skin dose, the estimate provides a measure by which an assessment can be rendered regarding the risk of injury to the patient’s skin.

After our 6-month Phase 1, a significant statistical difference was noted between both groups.

During Phase 2, after the doctors were informed of their statistics, there was no significant statistical difference between the two groups.

Conclusion:

Because dose is determined both by the cardiologist’s behaviour and variables (i.e. BMI, equipment limitations) that are not under their control, it is impossible to identify a value for dose that denotes a boundary between appropriate and inappropriate practice. Non-interventional cardiologists tended to have higher doses for their routine angiography but the numbers are still well within an acceptable range.

Study Follow-up:

This is now an ongoing study. All patient progress notes are stamped and

the screening time and doses are made part of the patient’s history. Also, all cardiologists are informed when the dose for any case exceeds 3 Gy. A notation is then included in the progress notes, written by the doctor, for future reference if there are any problems associated with high radiation dose.

LIMITATIONS: . Interventionalists may not do as many acquisitions as noninterventionalists because they know they can do extra views when they perform the intervention. Noninterventionalists need to be more complete during the pre-intervention angiogram. . During Phase 2, the noninterventionalists did fewer procedures than during Phase 1 which could lead to an alpha error. . These statistics were generated by GE’s Innova 2000 cesium detector and may not transpose to other cath labs.

IRP is measured in Gy. DAP is the absorbed dose to air multiplied by the X-ray beam cross-sectional area at the point of measurement. It is expressed in Gy*cm2. For this study, we used IRP as our measurement. 1 rem (old) = 10 mGy (milligray) = 1 rad (old) = 10 mSv (millisievert) CORONARY HEART ™  21


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Royal Brisbane Hospital ADDRESS Cardiac Investigations Suite (Cardiac Cath Lab & Cardiac Investigations Unit) Butterfield Street HERSTON QLD 4029 AUSTRALIA

STAFF 9 Nurses 1 Assistant in Nursing (mainly in CIU) 1 Patient Support Officer 1.5 Radiographers 11 Cardiac Scientists (1 in CCL, remainder in CIU)

MAP

T

he current Royal Brisbane and Women’s Hospital is located in Brisbane, Queensland, Australia. It is a 942 bed general, tertiary referral teaching hospital. The Royal Brisbane and Women’s Hospital is the largest tertiary referral hospital in Queensland and provides services to patients throughout the State, Northern New South Wales, the Northern Territory and from neighbouring countries in the South West Pacific. The Cardiology Department is currently in a state of expansion. It comprises a 12 bed Coronary Care Unit, and a 14 bed Cardiology Ward. The Cardiac Cath Lab (CCL) is comprised of 2 labs. One is a bi-plane angiography suite, and the other an EP Lab. Non-invasive Investigations are 22

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performed in the Cardiac Investigations Unit (CIU), and a decentralised Cardiology out-patients department is located within the department. Procedures and investigations performed in the CIU include Transoesophageal Echo’s, Trans-thoracic Echo’s, ECGs, 24 hour Holter and blood pressure monitoring, Stress Echo, Exercise Stress testing, and Pre Admission clinic for the CCL.

1. Cath Lab size We have 2 Toshiba labs, a Bi-plane and an EP Lab. The EP Lab will be commissioned by the beginning of 2007. This lab has been funded for half EP and half angiography/intervention. We have a GE haemodynamic monitoring system. The 10 bed recovery bay is due to open with the increased activity. Currently the day cases are prepared and recovered in a 4


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Royal Brisbane Hospital

bed bay in the Cardiology Ward.

2. Staff numbers and their roles We currently have 9 nursing staff of which 1 RN and 1 AIN staffs the CIU. With the increased activity proposed for 2007, a further 9 nurses will be required. The nurses in the CCL are responsible for completing preparation continued......

Royal Brisbane & Women’s Hospital Cardiac Cath Lab Team (Back Row L-R): Jason Gibson (CS), David Stewart (CN), Leah McDonald (RN), Chris Hammett (Interventional Cardiologist), John Atherton (Director Cardiology), Emma Savill (CS), Mark Dooris (Dir CCL), Laura Russell (CS), Shaun Doneman (Radiographer) (Front Row L-R): Jane Henzell (CS), Maree Mills (RN), Helen Muller (NUM), Lauren White (CS), Cleonie Jayasekera (Advanced Cardiology Registrar), Adam Scott (CS I/C) NUM: Nurse Unit Manager, CS: Clinical Scientist, RN: Registered Nurse, CN: Clinical Nurse, I/C: In-Charge,

CORONARY HEART ™  23


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Royal Brisbane Hospital

4. Day cases All elective diagnostic angiograms and PPM insertions are performed as day cases. When the CCL Recovery is open in January 2007, all day cases will be prepared and recovered by the CCL nursing staff. Elective PCI’s will be prepared in CCL and recovered either in the Cardiology Ward or the CCU.

5. Cross training of staff

From Left: Belinda Swyny (RN) and Leah McDonald (RN) of patients for their procedure. A scrub and a scout nurse are required for each procedure, with sheath removal being performed in the recovery area either by digital pressure or the CompressAR device. This is usually conducted by the scrub nurse to ensure continuity of patient care. All nurses are required to be Advanced Cardiac Life Support (ACLS) competent. 1.5 FTE radiographers is allocated, with the senior radiographer based in the CCL and the further 0.5 FTE filled by a rotation of angiography trained radiographers from the Department of Medical Imaging. 1 FTE Cardiac Scientist is allocated to the CCL on a rostered basis, and they are responsible for the haemodynamic monitoring throughout the procedures. We have 2 FTE Staff Interventionalists, 1.6 FTE Cardiologists and 3 VMO’s.

PPM’s and the remainder a mixture of PFO and ASD Closures, Percutaneous Balloon Mitral and Aortic Valvotomies, Pericardiocentesis and IABP insertions. With the increased funding, we will be performing a further 560 diagnostic angiograms, 240 PCI’s and 200 EPS’s.

We currently don’t cross-train staff between disciplines. We do offer a nursing rotational position between CCU, Cardiology Ward and the Cath Lab which allows for the department to have a core group of multi-skilled nursing staff. There are 3 nurses at a time on the rotation, and they each spend 6 months in each area. If at the end of the rotation there is a position in the field of their preference, they may apply for a position there.

6. Surgical backup Currently we don’t have cardiothoracic surgery on site at the RBWH. If the patient requires urgent surgery, they are transferred to The Prince Charles Hospital, which is a 10 minute

3. Number and Types of procedures We perform approximately 1700 procedures per year, 350 of which are PCI’s, 1250 diagnostic angio’s, 60 24  CORONARY HEART ™

Trolleys for patients post procedure in recovery room


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AUSTRALIA

Royal Brisbane Hospital angiography and are accommodated in the CCU in 3 quarantined beds for Inter-hospital Transfers.

12. Training for new employees

Bi-Plane Room: Main Angiography Lab ambulance journey.

7. Inventory Management All of our interventional catheters, balloons and stents are on consignment. We pay as we use on the same day, and the replacements are delivered via urgent courier directly to the Cath Lab the next working day. This system works very well, but requires meticulous management from all nursing staff. The consumable costings are also entered on a database called ‘Cath Lab Manager’, and this is downloaded at the end of every month and fed back to the Cardiology Management Advisory Group. Case time, recovery time, set-up times and complications are also recorded in this database.

8. Haemostasis Digital pressure is the preferred mode of sheath removal as it is the ‘gold standard’. We do however have the CompressAR device, and utilise this when we are short staffed as it doesn’t require 2 nurses. The Femostop is

not routinely used for primary sheath removal, but is utilised for haematoma management. Angioseals and Starclose are used in selected patients who are anticoagulated or are unable to lie flat for an extended length of time.

9. Private Cases As the RBWH is a public hospital, few private cases are performed.

10. Measures implemented to cut costs We recently introduced a 9 day fortnight for full-time nursing staff. This has a two-fold benefit. The longer shifts have reduced the over-time claimed as the shifts finish later in the evening, and staff morale has increased as a day off is rostered every fortnight. To achieve this, staff work 8 x 8 ½ hour and 1 x 8 hour shift every fortnight.

New employees have a comprehensive orientation program. In short, they are completely ‘off-line’ for the first 2 weeks, and work with their preceptor during this time. By the end of the off-line time they are expected to be able to scrub for an angiogram alone. Once comfortable with angiography, they then learn to scrub for angioplasty. Staff must be supervised to scout by an ACLS competent nurse, until they have achieved their ACLS competency. This can take up to 6 months if the nurse has no prior Cardiology experience. IABP, Temporary Pacing Wire and Sheath removal competencies are also included in the program.

13. Continuing education programs The Cardiology Nursing Group has a weekly in-service program provided by staff who work in Cardiology. It is delivered on a rotational basis. All staff are expected to participate in the in-service program. The RBWH has a decentralised in-service program which staff are given the opportunity to attend. Every Friday morning there is a multi-disciplinary education forum where different members of the multi-disciplinary team present on Cardiology topics.

14. Competency checks for staff once employed Annual competencies are assessed once per year and they include • ACLS • Manual Handling • Fire • Performance Management

11. Alliances with other hospitals We have an alliance with hospitals in Queensland that don’t have a Cath Lab. Patients with ACS are referred for

continued...... CORONARY HEART ™  25


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Royal Brisbane Hospital 16. Training facility for Cardiac Registrars The RBWH is a major teaching hospital. We currently have 3 Advanced Cardiology Registrars, and from next year we will have 4. The Registrars are supervised by the Cardiologist whilst performing Coronary Angiography. They also perform Transthoracic and Trans-oesophageal Echo’s and attend outpatient Clinics as well as attending to the in-patients in CCU and Cardiology Ward.

17. Best part of working at RBWH Cath Lab The best part of working at the RBWH Cath Lab is being an integral part of the multi-disciplinary team.

18. Employment opportunities As the Cath Lab is opening up its second room and recovery in the coming months, nursing staff are required not only for the Cath Lab, but also for the CCU and the Cardiology Ward. If you are thinking of a change in employment, keep the RBWH Cath Lab and Cardiology Department in mind.

WHY BRISBANE? Brisbane is the capital city of Queensland located in the south east corner of the state, and is renowned around the world for its warm, friendly, and relaxed environment. It is a modern and diverse subtropical metropolis having more sunny days than Florida and warmer winter days than the Bahamas. It is the third largest city in Australia with a population of 1.8 million, and is very mulitcultural with 26% of the population born overseas.

Things to See and Do: Roma Street Parkland

Located right in the heart of Brisbane city, it is the southern hemisphere’s largest urban subtropical rainforest.

Australia Zoo

Famous for the Crocodile Hunter, this zoo occupies 20+ hectares with over 750 animals including 100 fresh and saltwater crocodiles.

XXXX Brewery

Take a tour of Australia’s famous beer brewery.

Brisbane Forest Park Special thanks to Helen Muller, Nurse Unit Manager, Cardiac Investigations Suite, for assistance with this article.

Less than an hours drive from the CBD this park offers remote gorges, sheltered pockets of subtropical rainforest, expanses of eucalypt woodland and spectacular views to Moreton Bay.

Photograph left by Tourism Queensland

26

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NEW ZEALAND

Waikato Hospital ADDRESS Cardio/ Respiratory Investigation Unit Waikato Hospital Pembroke St Hamilton New Zealand

STAFF 10 Cardiologists 11 Registered nurses 9 qualified Cardio/ RespTechnologists 4 trainee Cardio/ Resp Technologists 3 Booking Clerk / Receptionists 2 Hospital Aides 1 Service Co-ordinator

MAP

Waikato Hospital Cardiac Staff From left: nurses: (standing) Miriam Friis, Irene Gray, Kerrie Manion, Dorothy Wright. Seated: Jenny White (technologist)

Two Labs and outpatient clinics of respiratory, pacemaker and ambulatory monitoring, are run by Technologists. The ETT clinic is either Tech/Dr or Tech/ Nurse run. Tilt table testing is undertaken by nurses. The organisation is currently in the planning stage of re-development and the department will undergo significant change. By 2011 there will be three labs (one dedicated for EP) with a shell for a fourth lab.

T

he Waikato Hospital as part of the Waikato District Health Board is a tertiary centre for the Midland region servicing a population of 980,000. The area covers the central North Island of New Zealand. It currently has 597 beds, 15 operating theatres, and employs more than 5800 staff. In 1999 the existing lab was refurbished and a new lab was opened. The Cardio / Resp Investigation Unit (CRIU) has two areas within the department. 28

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Cath Lab The labs are almost 8 years old and are equipped with Toshiba KX100, supported with Marquette Maclabs haemodynamic monitoring system, Radiwire and Volcano IVUS. We are also currently moving towards PACS (Picture Archive system). The labs carry out around 2150 procedures per year that include angiograms, angioplasties, pacemaker insertions, EP / ablation and ICD

and bi-ventricular implants. Other procedures ( eg pericardial taps, temporary pacemakers) are also performed occasionally. Around 720 interventions are performed annually. Based on UK Cardiac Society recommendations of procedures per million of population (1750 per million) the dept should be performing for the number of population 2150 per million which would mean a large increase of the volumes that the dept manages to achieve currently. The cause of this is multi-factorial. Funding, staff resource, capital costs for equipment maintenance and the availability of staff to employ are just some. Despite these figures the department works an 8 hour day frequently running into overtime, manages an after hours on call service for Primary Angioplasty for Myocardial Infarction (PAMI), and Pacemaker and ETT for the Chest pain unit.


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Waikato Hospital EP

1) How many staff? Roles?

7) Are any of your staff cross-trained?

Whilst the department does not have a dedicated EP lab, two cardiologists specialise in this area in a lab which is equipped with EP Medsystems. The lab carries out around 75 EP / Ablations per year and 31 ICD implants. These numbers are somewhat limited due to the acute demand of inpatients and pressure from outlying feeder hospitals, that the EP lab is not a dedicated lab and the EP Cardiologists having other responsibilities in the department.

The department has a staff of 28 FTEs comprised of Nurses, Technologists, Radiographers and Clerical staff. The Cardiologists have dedicated sessions in the Cath Lab each week.

Historically there has been no cross training of staff in our department. Each professional group has its own responsibility in both outpatient and Cath Lab procedures. It is understood that teamwork in the Cath Lab is imperative for an efficient service and there is teamwork however no official cross-skilling of the professional groups.

PAMI service The department has been performing angioplasty in acute myocardial infarction since 1994 and to date has performed 768. (+/- 64 per year). It was the first lab in NZ and was so for several years to offer an 24 hour on-call service for the region. All staff who are on call are expected to be at the department within 20mins of been advised by pager.

Clinical Trials

3) Types of procedures? Angiography / Angioplasty / EP / Ablation / ICD implants / pacemaker implants. PAMI ( Primary Angioplasty in Myocardial Infarction) 24hrs per day 7 days per week. 5) Are patients performed as day cases? 20% procedures through the Cath Lab are elective procedures. 80% are acute from the 48 bed Cardiology ward supporting 9 outlying hospitals from both within and outside the region. Elective Angiogram / angioplasty / pacemaker implants / EP are all done as day stay patients. If the patient lives further than 20mins from the hospital they are required to stay in the hospital hotel accommodation. This has been the practice for a number of years without any adverse events.

It is anticipated that in the future there will be some form of cross training within the Cath Lab. One MRT has been training and is utilised in the scrubbing role. This has proved very successful and is hoped this will be a pathway for future professional development of all Cath Lab staff. 9) Is their any surgical back-up in the cath lab? Waikato Hospital has a Cardiac Surgery backup. PAMI procedure does not have backup. 12) How does the lab handle haemostasis? Digital / manual pressure by scrub nurse. Occasional closure device.

The department is well recognised for its long history of active participation in international clinical trials. There are frequently several trials running at any one time.

Education and Training Cardiologists working in the lab have their licence in Radiation Safety. Ongoing in-service lectures for the professional groups and attendance at national and international conferences is an important part of the yearly calendar, however this can be difficult due to organisational policies and requirements.

Cardiologist Dr Chris Nunn and nurse Kirsty Golding performing an angiogram on a patient

>>>

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Waikato Hospital adequate elective patient throughput for a variety of reasons (eg bed crises) we have recently had a successful collaborative contract with the private hospital when 120 patients had Cardiac Catheterisation performed. 14) What measures has the lab implemented to cut costs?

Waikato Hospital overlooking the Waikato River 10) What new procedures have you implemented into the department recently? We recently trialled a 3D imaging system for EP / ablation. It would be on the wish list if the funding was available. 8) What are the main roles for the radiographer, nurses, tech? The different professional groups tend to work as a team during the patient journey through the lab although they each have distinct responsibilities. Nurses: • All aspects of patient care. • Pre-admission clinic for patients on waiting list to prepare for procedure. • Preparation of elective list for Cath Lab week. • Scrub nurse who assists cardiologist with procedures. • Runner nurse who manages the care of the patient. And scouts for the scrub team. • Immediate post procedure care. MRT: • Imaging 30  CORONARY HEART ™

Technologists: • Haemodynamic monitoring. • Stimulating and analysis during EP. • Device selection and technical aspects of pacemaker / ICD insertions and temporary pacing. • The techs have speciality portfolios of responsibilities that ensure maintenance and effective service provision for each area within the department. 11) How is your inventory managed? Regular and close collaboration with sponsoring companies. Equipment is managed both consignment and purchased outright. Interventional equipment is 100% consignment. Annual tendering for purchasing of pacemakers and ICD. 13) Do you perform Private cases? No, athough we do have a close relationship with the private lab in the same city and have a “borrow and return” system for equipment (eg catheters) when stock levels have been depleted. Most of the Cardiologists and some nurses and technologists also work there in their own time. Due to difficulties in maintaining

Given the type of service delivered this is very difficult. Employing to budgeted FTEs, tender processes, seeking deals with the sponsoring companies for better pricing of equipment, legislative guidelines for use of Drug-eluting stents. Careful selection of appropriate pacemaker matching patient requirements. 15) Has the hospital formed an alliance with other hospitals for treating patients? As we are the tertiary referral centre for the region, we maintain close relationships with the feeder hospitals and a yearly forum is held to discuss clinical practice, new trends and to ensure the ongoing establishment and re establishment of guidelines to ensure equity of treatment for patients throughout the region. 16) What kind of training can new employees expect to receive? Depends on the professional group. Nurses: All are registered nurses and they receive an extensive orientation of six weeks and an ongoing training programme until practice is to the required standard that will enable participation on the on-call roster. Techs: New employees with an appropriate undergraduate degree enter a training programme which includes a 2 year post graduate diploma by distance with block courses. This group have


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NEW ZEALAND

Waikato Hospital the opportunity to specialise in various aspects of the work and as such participate in self-directed learning and on the job training to complete courses. MRT: Extensive orientation in the modality of Cardiology imaging. This continues until practice is at a level when the MRT is able to participate on the on call roster. 17) Kinds of continuing education programs are available to staff? All groups as part of their annual registration have an expectation of proof of professional development which is written into Collective agreements. Attendance at appropriate conferences with collegial feedback mechanisms. An organisational policy that only two per department attend conferences makes this form of ongoing education difficult to achieve. The organisation offers many different day courses for many aspects of professional development. Eg. Powerful Presentation / Managing Difficult Situations. Nurses: The educational opportunities for nurses are varied. Undergraduate and post-graduate papers via tertiary institutions, collaborative organisational / universities clinical papers available. MRT: Post grad papers are available via the universities. Techs: Post grad papers diploma is the basic trainee technologist expectation of employment. Masters are available via universities for individual professional development and career progression. Individuals are encouraged to attain the NASPE qualifications.

18) What kinds of competency checks do staff have to undergo once employed? This is done as part of the orientation for the Nurses. Following this period there is no formal department competency checks, however organisational requirements require generic competency checks for IV and ACLS. Technicians follow a trainee and advanced training manual of competencies, with a specified time-line. They must show competency in each procedure prior to working autonomously. 19) What have been some of the challenges in setting up the new department? Difficulty in attracting staff due to the chronic national shortage of appropriately trained technologists. 20) Is the department used as a training facility for cardiac registrars? We have had training registrars fellows who have supervised training in angiography and intervention. They have proved very effective in the increasing the throughput of acute patients through the labs. 21) What is the best part of working at your facility? The teamwork. The ability to make a difference. The diversity of work. The weekend! The department boasts a nationally recognised service and strives for excellence.

WHY HAMILTON? Hamilton is located one hours drive south of New Zealand’s largest city Auckland, and is the Country’s largest inland city supporting a population of 130,000. The Waikato River passes through the city and with its walkways alongside, provide a peaceful environment for tourists and locals.

Things to see and do: Waitomo Caves

Marvel at the underground labyrinth of ancient limestone caverns containing amazing formations, and when the lights go out the seemingly millions of glowworms above. One hours drive from Hamilton.

Hobbiton Movie Set

45min from Hamilton is the site of the original Hobbiton village used during filming of The Lord of the Rings Trilogy.

Balloons over Waikato

Held every April, this event attracts hot-air ballooning enthusiasts from around the world.

Waikato Stadium

Come to watch the Super 12’s, and other local and international tournaments, at this sensational stadium.

Special thanks to Diane Penney, Service Co-ordinator Cardio / Resp Investigation Unit for assistance with this article.

CORONARY HEART ™ 31


• Improved endocardial tissue contact provides high fidelity mapping and precise RF delivery • Bidirectional distal tip – enables optimal tip orientation • Independent proximal and distal curves – expand positioning options and curve radii

Bard Electrophysiology announces a new addition to their line of ablation catheters with the April 3rd commercialization of the Scorpion TM ablation catheter in Europe and the US. The Scorpion ablation catheter's dual curve design, featuring a unique bi-directional distal tip, delivers unrivalled endocardial tissue contact for improved diagnostic and therapeutic results to today's Electrophysiologists. 58,300 catheter ablation procedures were performed in Europe in 2004 and at a growth rate of 11.5% approximately 72,500 procedures are estimated to be completed in 2006.

ELECTROPHYSIOLOGY P0706/1375ORH

Endless Possibilities


EP EDUCATION

AVNRT: The most common regular tachycardia

Written by Ian Wright St Mary’s Hospital, London, UK

T

he anatomical atrio-ventricular (AV) node was first described in 1906 but even today much about it and the tachycardia with which it is associated remains only partially understood. AVNRT (AV node re-entrant tachycardia) is the most common regular supra-ventricular tachycardia treated by ablation. More common in women than men it usually occurs in the absence of structural heart disease and can occur at rates from 150 to 250 bpm. Symptoms typically start after 20 years of age. If you are reading this, are a female in your twenties or thirties, have started getting regular palpitations which start/stop suddenly –you may already know something about AVNRT.

Mechanism of AVNRT As the name suggests AVNRT is a reentrant rhythm involving the AV nodal region. Re-entry, a concept introduced in

12 lead ECG during AVNRT 1913, describes the mechanism by which a continuous wave moves around a circuit comprised of excitable heart cells, in much the same way as a Mexican wave moving around a stadium full of excitable football fans. In the heart, circuits form when two pathways with different properties connect and one path conducts slowly - conditions that often exist in the AV node region. Later two discrete modes of AV transmission were recognised -one with

Terminating AVNRT Interventions that slow/interrupt AV node conduction such as carotid sinus massage and the valsalva manoeuvre may terminate AVNRT. Similarly, drugs which cause AV block such as adenosine are effective. These manoeuvres terminate other tachycardias that involve the AV node such as AV re-entry tachycardia (AVRT) described in the last issue. Patients often develop their own techniques for stopping attacks, such as breath holding, straining or crouching.

fast conduction and a long refractory period, the other with slow conduction and short refractory period. Atrial premature stimuli conduct first via the fast mode and then with increasing prematurity via the slow mode of conduction. This phenomenon is known as dual AV nodal physiology and is associated with AVNRT. In the 1960s it became apparent that the AV node was less of a discrete structure than at first imagined, instead comprising of a complex of fibres interposed between true atrial fibres and the His bundle. Two types of fibres known as the fast pathway and the slow pathway were identified as responsible for the two modes of transmission. The switch from fast to slow is known as a “jump” and is identified by a dramatic lengthening of the AH interval (representing the time an impulse takes continued....... CORONARY HEART ™ 33


EP EDUCATION (cont...)

AVNRT The 12-lead ECG Fast Pathway

Slow Pathway

AVNRT is a type of narrow complex tachycardia. A narrow QRS is produced when the ventricles are activated rapidly by the specialised His-Purkinji system. In AVNRT each revolution of the re-entry circuit generates an impulse that exits the AV node via the His bundle to activate the ventricles. Other regular tachycardias that produce a narrow complex include:

HBE

A H V

H AV

A

Pacing Spike QRS Complex on ECG

• Atrial tachycardia • AV re-entrant tachycardia (AVRT) • Atrial flutter

Atrial Echo

ABOVE: His bundle electrogram (HBE) recorded during the delivery of atrial premature stimuli showing jump from fast to slow pathway and an echo in a patient with AVNRT. The lower two traces are ECG leads. to cross the nodal region and emerge into the His bundle). Under the right conditions an impulse may retrogradely enter the fast pathway and re-activate the atria. This represents half a circuit of AVNRT and is known as an echo.

In typical AVNRT simultaneous atrial and ventricular activation causes contraction of the atria against closed AV valves - producing retrograde pulses called “cannon waves” that patients feel as pulsing or pounding in the neck.

These fast and slow Fast fibres form the circuit Pathway for AVNRT. In it’s typical form a premature atrial beat “blocks” in the fast pathway but Activation of is conducted toward Atria the compact AV node by the slow pathway. The impulse emerges from the compact node AVNRT Circuit via the His bundle to activate the ventricles whilst simultaneously activating the atria via the fast pathway and completes the circuit by re-entering the slow Coronary pathway. Sinus 34

CORONARY HEART ™

Just to make things difficult, the QRS in AVNRT can occasionally be broad - if part of the His-Purkinji system fails to cope with the high rate (rate related bundle branch block) or when there is pre-existing conduction system disease.

Slow pathway ablation for the treatment of AVNRT

Compact Node HIS

Activation of Ventricles Slow Pathway

ABOVE: Diagrammatical representation of AVNRT

Catheter ablation of the slow pathway using radio frequency current can eliminate AVNRT while leaving normal AV nodal conduction intact. Success rates are high despite much about the underlying anatomy and physiology of AVNRT being unclear. The slow-pathway is located in the inferoposterior septum, close to the coronary sinus ostium. In addition to anatomical landmarks catheter ablation may be guided by slow pathway potentials also referred to as “bump and spike” signals. These


EP EDUCATION (cont...)

AVNRT correlate with sites of successful ablation but it is not certain exactly what the bump and spike represent.

The P wave is either buried within the QRS complex or inscribed just after it because atria and ventricles are activated simultaneously from the AV nodal region sitting between them. Simultaneous activation seen on the intra-cardiac signals during an EP study and is a key feature of AVNRT.

SPIKE

BUMP

ATRIAL

The P wave in AVNRT

VENTRICULAR

Heat generated by ablation usually provokes the AV node into firing off impulses called an accelerated junctional rhythm. This can be recognised from signals recorded on the His catheter - each junctional beat being preceded by a His potential.

The P wave is narrower than in sinus rhythm because left and right atria are activated simultaneously not sequentially and it is negative in the inferior leads and positive in V1. It may appear at the end of the QRS complex as a small negative deflection in the inferior leads and a small positive deflection in V1 – an appearance similar to incomplete RBBB. This is known as a pseudo r¹ pattern and if absent during normal rhythm it strongly suggests AVNRT. In the example below the P wave is quite easily seen -often it is quite subtle.

Slow junctional rhythm during ablation correlates with procedural success. It is probably due to warming of the AV node but more intense heating appears to increase the rate of firing, producing fast junctional activity associated with AV node damage. Success can sometimes be achieved without achieving junctional rhythm Because the slow pathway is close to the compact AV node the most significant complication of ablation is AV block requiring a permanent pacemaker – a risk usually quoted at around one percent. Consequently during ablation the operator(s) must scrutinise the signals for any sign of impaired AV node function. Ablation is stopped immediately if this occurs or if interpreting the signals becomes difficult. These procedures therefore require intense concentration during ablation.

Lead 3: Sinus rhythm

Lead 3: AVNRT

V1: Sinus rhythm

V1: AVNRT

© Ian Wright, 14 July 2006. CORONARY HEART ™ 35


MEDICAL IMAGING

RAO 40 / CRA 30 LM

Left Main

LAD

Left Anterior Descending

D1

Diagonal

LCX

Circumflex

OM1

Obtuse Marginal 1

Catheter Positioning On-Screen: The catheter should be positioned on the left side of the screen and slightly up from the middle before the acquisition is commenced.

RAO 40 / CRA 30 Objectives:

Alternatives: More RAO (eg. RAO 50 / CRA 30):

The aim of this projection is to demonstrate the LAD in a different projection, however due to overlap proximally with the Circumflex and OM1, should only be used to demonstrate the mid / distal LAD. This projection also can demonstrate the mid circumflex well.

RAO 40 / CRA 30

Separates the OM1 more from the proximal LAD, overlapping it on the Left Main, however the Diagonals are now completely overlapping the LAD, obscuring any potential narrowing’s. The mid / distal Circumflex is opened up more due to further distance from any overlapping LAD branches. Less RAO (eg. RAO 30 / CRA 30): This projection demonstrates the mid / distal LAD, however is often overlapped by the Circumflex and OM1. More CRA (eg. RAO 40 / CRA 40): Good projection for prox / mid LAD. Foreshortening of the distal LAD. This angle can sometimes be used as an alternative for showing the proximal Circumflex, forming the middle part of the shape of an “M” as it divides into the OM1. Less CRA (eg. RAO 40 / CRA 20): Good for mid / distal Circumflex. The LAD is often overlapped by Diagonal branches and the OM1.

36

CORONARY HEART ™


MEDICAL IMAGING

PA Cranial 40 LM

Left Main

LAD

Left Anterior Descending

D1

Diagonal

LCX

Circumflex

OM1

Obtuse Marginal 1

Objectives:

PA CRANIAL 40

Remember to instruct the patient to move their head to the left or right so as not to hit them with the detector. The aim of this projection is to demonstrate the mid / distal LAD, free from overlap of the OM1. The proximal LAD is often overlapped by the Circumflex.

Catheter Positioning On-Screen: The catheter should be positioned in the upper left corner of the screen before the start of the acquisition. PA CRANIAL 40

Alternatives: More CRA (eg. CRA 50): Separates the proximal circumflex from the proximal LAD, however the distal circumflex (if long) is now overlapping the LAD. This angle can not often be achieved due to patient and/or equipment limitations. Less CRA (eg. CRA 30): Demonstrates the mid / distal circumflex well. The LAD is often overlapped by diagonals and the OM1. Overlapping of the proximal circumflex and proximal LAD.

MODEL: Rob Edwards

CORONARY HEART â&#x201E;˘ 37


CONFERENCES

Conferences August 10-12

Australian Cardiac Rehabilitation Association 16th Annual Conference

Location: Melbourne, Australia Contact: info@conorg.com.au

2006 September 15-17 ASUM 2006 Annual Scientific Meeting

Location: Melbourne, Australia Website: www.asum.com.au

September 19-21

Heart Rhythm Congress

August 12-13

Advanced Angiography 2006 - LIVE Location: National Heart Centre, Singapore Website: www.singlivecourse.com

Location: Birmingham, UK Website: www.ukheartrhythm.org.uk

September 20-23

CCT 2006 Complex Catheter Therapeutics Location: Kobe, Japan Website: www.cct.gr.jp

September 2-6

World Congress of Cardiology 2006

October 5-7

September 9-13

Location: Killarney, Ireland Website: www.irishcardiacsociety.com

Location: Barcelona, Spain Website: www.worldcardio2006.org

Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Location: Rome, Italy Website: www.cirse.org

September 11-13 BACCN Conference 2006 Location: Newcastle upon Tyne, UK Website: www.baccnconference.org.uk

38

CORONARY HEART ™

Annual General Meeting of the Irish Cardiac Society

October 21-24

Acute Cardiac Care

Location: Prague, Czech Republic Website: www.escardio.org

October 22-27

TCT 2006: Transcatheter Cardiovascular Therapeutics Location: Washington DC, USA Website: www.tct2006.com


CONFERENCES

Conferences October 27-28

British Society of Echocardiography Annual Clinical & Scientific Meeting

Location: Bournemouth, UK Website: www.bsecho.org

Oct 29 - Nov 1

7th Annual Congress of the South African Heart Association Location: Cape Town, South Africa Website: www.saheart.org

Nov 26 - Dec 1 RSNA 2006

Location: Chicago, USA Website: www.rsna.org

2006 - 2007 May 22 -25

EuroPCR Congress

Location: Barcelona, Spain Website: www.europcr.com

June 4-7

BCS Annual Scientific Conference Location: Glasgow, UK Website: www.bcs.com

June 27 - 30

34th International Congress on Electrocardiology, and 48th International Symposium on Vectorcardiography

Location: Istanbul, Turkey Website: www.ice2007.com

December 6-9 EuroEcho 10

Location: Prague, Czech Republic Website: www.euroecho.org

January 24-26 (‘07) Advanced Angioplasty 2007 Location: London, UK Website: www. advancedangioplasty.co.uk

April 29 - May 2

8th International Conference of Nuclear Cardiology - ICNC8 Location: Prague, Czech Republic Website: www.escardio.org

LIST YOUR CARDIAC CONFERENCE HERE FREE Email the details to: tim@coronaryheart.com

CORONARY HEART ™ 39


CONFERENCE WRAP-UP

UNITED KINGDOM

CRAG Study Day CRAG Presents “Broken Heart Mountain”

A

nother excellent study day from the Cardiac Radiographers Advisory Group took place in Leicester, England on the 3rd June. It proved a very informative program, concentrating on the many exciting changes that are occurring within the field of cardiac radiography and the interesting advances being made in Cardiac CT, MRI and cardiac surgery. Greg Cruickshank described his experience of the implementation of a 24 hour primary angioplasty service for acute myocardial infarction at Kings College Hospital, the problems experienced, how the new service was rolled out sector wide and the obvious benefits to the patients was of great interest to those still in the process of setting up their own service. Nikki Whitfield talked about her role in the organisation of the Cardiac Catheter Laboratory Practitioner Course which, having just completed

Cardiac Radiographers from all over the UK enjoying the presentations its first year, aims at providing a multiskilled team environment within the laboratory. This was followed by Angela Hunter with another, very different, service development at Castle Hill hospital, whereby a radiographer and nurse are now performing their own diagnostic coronary angiograms. Dr Adrian Holden from GE reminded us all of everything we should know about contrast media and its adverse effects.

Denise Arthur from Harefield Hospital won the quiz prize 40  CORONARY HEART ™

Film critiquing from Consultant Cardiologist Dr Nik Patel and Nikki Whitfield, Superintendent Radiographer focused on the important role the radiographer plays in the lab and how to obtain high quality images every time.

And finally Mark Bowers, CRAG chairman finished the day with a fun quiz to check if we had being paying attention throughout a very enjoyable day. Nicky Moore Superintendent Cardiac Radiographer St Georges Hospital, UK For further information on CRAG activities visit www.craguk.org

Angela Hunter on stage presenting the Castle Hill Hospital Service


LANGUAGES

FRANCE

Cardiac French English

French

Phonetic

Yes

oui

we

No

non

non

Don’t move.

ne bougez pas

ne boojey pa

Breathe in.

Inspirez

ainspeerey

Hold your breath.

Tenez votre respire

theney votre respeer

You can breathe.

vous pouvez respirez

voo poovey respeerey

Turn your head left.

tournez votre tête vers la gauche

tourney votre tight vair la goch

Turn your head right.

tournez votre tête vers la droite

tourney votre tight vair la droite

Lay on your back

Couchez-vous sur le dos

coochey-voo sir le dos

This hospital doesn’t serve snails.

L’hôpital ne sert pas d’escargots.

L’opeetal ne ser pa d’escargo

E

very so often cardiology staff are faced with an interesting dilemma; an inability to speak a patient’s native tongue. Some people try to employ sign language to communicate, whilst others begin shouting, with the strange belief that the patient will suddenly begin understanding English. Although English is commonly understood in the younger generations around the world, it is the older patients that cardiac staff often have to treat. Just by attempting to speak a few words of their native language can sometimes mean the difference between a fast procedure and a frustratingly slow one. Each issue contains language assistance to help staff in the cath lab environment, with common instructions in English converted into the foreign language equivalent. For further assistance we have also included the phonetic pronunciations (how to say it).

Photo: Tim Larner

CORONARY HEART ™  41


HEALTHY EATING

Healthy Heart

2004 Finalist in Best New Restaurant in Australia

Salad of Avocado, Smoked Tasmanian Salmon, Mixed Leaves, Fetta and Roe This salad is quick, easy to prepare and very tasty. It is fantastic with a glass of Sparkling and is a great Spring/ Summer dish to either have on itâ&#x20AC;&#x2122;s own or as a starter before main course.

To Serve 4 240g Sliced Smoked Tasmanian Salmon 100g Mixed Mesclun Leaves 2 Whole Avocadoes 80g Marinated Fetta 4 teaspoons Salmon Roe 60mls Balsamic Dressing. i.e. 45mls Extra Virgin Olive Oil mixed together with 15mls Balsamic Vinegar and a pinch of sea salt and cracked black pepper

Method Wash the leaves and dress with the Balsamic dressing reserving a small amount of the dressing to garnish the plate. Arrange the leaves on a flat plate. Cut the avocado in half and remove the seed and shell. Place 1 half on each plate. Lay 4 slices of smoked salmon over the top and garnish with fresh chervil. Scatter with the fetta and roe and serve.

Photo: Wineglass Bay, Tasmania (Tourism Tasmania & Chris McLennan)

Situated in the City of Devonport, In the beautiful State of Tasmania, Australia www.thedeckcafe.com.au 42

CORONARY HEART â&#x201E;˘

Troy Baggett, Manager & Head Chef


Like to Advertise? coronaryheart.com

MEDIA KIT 06-07

CONFERENCES

Conferences October 5-7

Annual General Meeting of the Irish Cardiac Society

RAO 30 / CAU 20 Location: Killarney, Co. Kerry, Ireland Website: EP EDUCATION Left Main LM www.irishcardiacsociety.com

An Introduction to Wolff Parkinson White Syndrome Coronary Angiography Practitioner

Revised Prices

October 15-19

LAD

21st Scientific Meeting of D1 International Society of Hypertension LCX

Location: Fukuoka, Japan SPECIAL FEATURE (cont...) OM1 Website: www.congre.co.jp Written by Ian Wright

Left Anterior Descending Diagonal Circumflex Obtuse Marginal 1

St Mary’s Hospital, London, UK

October 21-24

Acute Cardiac Care More RAO (eg. RAO 40 / CAU 20): Location: Prague, Czech

angiography are that the patients are elective, stable and suitable for femoral access. 95% of our elective angiograms are performed via the femoral route using 4 or 5 french systems. At the end of the session, the Cardiologists will review all the films, the management plans will be discussed and the patients medications are reviewed. The practitioner will then discuss the outcome with the patient and complete any referral documentation.

New Cardiovascular Horizons

Location: New Orleans, Louisiana, USA Website: www.newcvhorizons.com

December 3-7

19th World Diabetes Congress

Location: Cape Town, South

October 22-27

LIST YOUR CARDIAC CONFERENCE HERE FREE

Latest News

Email the details to:

Email your thoughts, positive or negative, and we’ll try to publish them in the next issue.

S

Lab Staff Performing Angiograms

coronaryheart.com

The Somatom Definition has enhanced capabilities not previously available from any type of diagnostic imaging technology, which are expected to lead to new breakthroughs in clinical research. These capabilities include scanning with two different X-ray energies simultaneously, which allow physicians to better differentiate,

World’s First

Using Magnetic FieldsBioabsorbable to fix Atrial Fibrillation DES Trial

Begins

March 9, 2006: DES

G

Epworth Hospital, Australia East Surrey Hospital, UK

bioabsorbable everolimus eluting stent EDUCATION, platform for the treatment of coronary CONFERENCES artery disease.

+ more...

“We are excited about our bioabsorbable drug eluting stent program, which is aligned with Guidant’s strategy of leveraging bioabsorbable technologies to provide innovative site-specific therapy for the

LO

uidant Corporation announced enrolment of the first patient in

platform for the Endeavor™. Already popular with physicians a Johnson & Johnson company. Results: Showed that University for its manoeuvrability and ease of use, the Driver is service a cobaltmanager Our and clinical of Erlangen. Endeavor provides clinical and angiographic outcomes alloy stent, traditional director for cardiology considered that Endeavor trials and with no “We expect that meaning it is denser and stronger than consistent with previous stainless steel stents, whilst having thinner struts.a solution to the problem be between Endeavor and Cypher. the Somatom statisticalcould differents to train non medical practitioners to Definition will have a Drug: perform coronaryEndeavor angiography.IV: Compares the Endeavor™ against the significant role in even the most demanding TAXUS™ Paclitaxel-Eluting Coronary Stent System from Licensed by Abbott environments, such as Laboratories to Medtronic, the drug Siemens pressBoston picture Scientific Corporation. Results: Still enrolling. code named ABT-578 (zotarolimus), is believed to reduce emergency departments,” restenosis in clogged arteries by preventing smooth cell proliferation. It achieves this by blocking the function of the cell cycle regulatory mTOR, stopping growth of a first-in-man clinical trialprotein, designed treatmentthe of heart disease,” stated John new tissue. to evaluate the safety of a fully M. Capek, Ph.D., president, Vascular

EMP

Medtronic Endeavor Product Focus

November 1-4

this article.

Medtronic Endeavor LATEST NEWS Drug Eluting Stent

LAB VISITS

Location: Ermelo, Netherlands Website: www.cardiologie.nl

monthly looking specifically at success demonstrating them superior to the LAD. demonstrating the proximal Obtuse Marginal branch. The Canada Website: www.euroecho.org rates, screening times, complications Left Anterior Descending artery is also seen however is often www.ccs.ca Website: and diagnostic quality. Initially overlapped we by the Diagonal branches. Acquisition time n 1930our Wolff, compared dataParkinson with that of should our be long enough to obtain adequate contrast filling of and White first described Specialist Registrars the as adistal arteries, and if necessary pan to the anatomical right by Maria WhiteheadCardiology and Lavender theJenny syndrome that bears benchmarking exercise and found the to visualise collateral filling of the Right Coronary artery.2006: Transcatheter Negative aspects Hull and East Yorkshiretheir TCT Hospitals NHS Trust, UK nameto asbe “bundleoutcomes very similar. Visualising the right coronary artery filling distally may assist branch block with short P-R Cardiovascular There was no funding identified for Cardiologist of the possible lesion length occurring in that Figure 1: 12 Lead ECG in WPW interval in healthy young Therapeutics Our original intention was to have a thisup roleaprior to commencing training artery. Introduction Experience Setting program prone dedicated roletoofparoxysmal coronary angiography and we were informed that as this was a people Location: Washington DC,the AV nodal conduction eventually catches up and tachycardia.” Wecardiac now that the condition is caused by In this article we will discuss the We enrolled a senior nurseprogressed practitioner but as we know have pilot role there may not be a post at the USAbroad to narrow. This activation of Alternatives: QRS changes from Who one or more strands of myocardial tissue, known as accessory Hull experience ofPolymer: why we decided and a senior radiographer undertake we have recognised to that a flexible, end of the training period. Website: www.tct2006.com the ventricles from two different routes produces the pathways, which bridge the atrio-ventricular (AV) ring that to introduce the role of coronary training, eachbalanced with around year’s more role is10more beneficial We acknowledged that any of the three More CAU (eg. RAO 30 / CAU 40): characteristic fusion complex that characterises WPW electrically isolates atria from ventricles. In the normal heart angiography practitioner. We will Obviously an with toexperience. all parties. We continue our Our posts were which cath lab groups within the cath lab The delivery matrix for theprofessional stent is coated with a not backfilled syndrome (see Fig 2). the AV ring bridged onlysessions by the when His bundle arising from include the stagesPhosphorylcholine we went through to(PC) polymer, extensive knowledge of the procedure, original rolesis and backfill meant thatfrom we had to could undertake with the relevant experience be This decreases the foreshortening of the proximal licenced Abbott the AV node forms sole route impulse to The long awaited arrival of Medtronic’s drug eluting within gain approval our organisation selection, potential necessary and- this only when the there iscircumflex no for an very demanding current trainedour equally However improving visualisation. The distal Laboratories, called PC Technology™. It iseffectively. designed to slowly roles in equipment Patients with circumflex this ECG appearance are said to have a pass from to ventricles (other connections having been and how we set the program up into the arterial ability to manage SpRand to the fillatria the session. For anyone stent, the Endeavor™ is finally here. Although in some addition to undertaking training.problems withinwall. our cardiac cath labs, ourour nurses cantobe foreshortened and overlapped by distal branches. release the drug manifest accessory pathway. With the knowledge available at during foetalangiography development including the training needs. We them issevered essential. carry out coronary onof the heart valves). and radiographers are dedicated, Foreshortening of the LAD occursthe mid /distal with overlap of countries it is still under investigational use we will time Wolff, Parkinson and White incorrectly described will evaluate the reality of the System: role a full time basis would we suggest, Our staff postswhereas including extended role permanent ourthe cardiac the diagonal branches. Delivery give isolate you a and briefdistinguish run down on the factsProf. and figures.Bautz, this ECG appearance as bundle branch block. International Double Issue conferences@coronaryheart.com The presence this extra pathway (or “bypass tract”) characterize, added Werner chairman and highlighting the advantages become ratherofmonotonous. of coronary practitioner physiologists work angiography on a rotational basis explains the features that define WPW syndrome and is bone, soft tissue and fluid. With 0.33 of Radiology, Universityand of Erlangen, disadvantages discuss our plans are yethave to be satisfactorily in and already their own specialist Less CAU (eg. RAO 30 / CAU 10): The Endeavor DrugforEluting Coronary Stent isbanded intended to present approximately in every seconds per rotation, electrocardiogram- Germany.future development. The traditional rolespoint of three From a in practitioners of view it 2,000 people. line with Agenda for Change. areas of practice. be released on Rapid Exchange, Over-the-Wire (USA), and CORONARY HEART ™ 33 Figure 2 (ECG) synchronized imaging can lab hasprofessionals been a very enjoyable challenge that foreshortening of proximal circumflex, however Increases Multi-Exchange technologies for International markets. 1. An important role of the AV node is to slow impulses be performed with 83-millisecond Visit www.medical.siemens.com for may changing hasbe enhanced job satisfaction. Benefits improves visualisation distally by separating the distal on route from atria to ventricles, allowing optimal time temporal resolution, independent of more information Background Trials: The new challenges for year 2 have been The obtuse marginal is often overlapped by large branches. for ventricular By comparison accessory pathways the heart rate, resulting in motion free We have significantly improved the March 3, 2006: to progress to radialfilling. procedures and to from septals the LAD or diagonal branches. Hull is a tertiary centre providing conduct rapidly. This manifests cardiac images. utilisation of our cath labs and have include morevery complex procedures such on the ECG as a These trials have for been at various sites to interventional cardiology services a undertakenreduced short P-R interval. our waiting times from 9 iemens has pushed the technical as patients with previous CABG. theperform effectiveness of the Endeavor™ in reducing RAO 30 / CAU 20 population of 1.2determine million. We The first Somatom Definition months to 4 months. We have reduced and clinical boundaries of CT From a patients point of view we have coronary artery restenosis. 2000 coronary angiograms per annum. 2. Rapidvery conduction of the impulse around the ventricles was installed at the University patient cancellations by 10% because with this latest innovation, the received positive feedback. CORONARY HEART ™ 31 Our cardiology services are currently by the specialised conduction system results in the of Erlangen (Germany) in of the flexibility of a practitioner being Somatom Definition, which is faster Endeavor Safety and efficacyavailable of Endeavor™ in de when novo there is split between three sites, whichI:poses October 2005. “Siemens’ for example than every beating heart and capable of Thenarrow futureQRS complexes seen on a normal ECG. coronary lesions in native coronary arteries.urgent Results: A leave. us quite a challenge in terms of medical As accessory pathways connect to non-specialised sickness, meetings, imaging full cardiac detail with as much newest CT system target lesion revascularization (TLR) rate of 2.0 staffing. This has 24-month been further increased that conduct slowly, activation of the provides very We myocardial have a new cells cardiothoracic centre as 50 percent less radiation exposure percent, and no additional cases of stent thrombosis in the by the European Working Time such pathways in a broad initial valuable clinical due ventricles to open invia2007/2008 with results a The routine medical workload compared to traditional CT scans. 97 the study patients who received follow-up overtothe second 12Directives reducing availability QRSincrease - the delta wave in WPW information further in cath labseen capacity. It patients. is alleviated allow Consultant month for Cardiac of cardiology SpRs in theperiod. cath lab for“Especially patients has been useful to explore new ways of Cardiologists to undertake complex Setting new standards in cardiac and the new Consultant contracts, presenting our Non-Invasive working and hopefully the introduction coronary intervention and assist the EP,inand diagnosis, the Somatom Definition will Cath, CORONARY HEART ™ 27 II: ofCompared the Endeavor™ stent to theof primary PCI. which has reducedEndeavor the flexibility the department with of this role will provide an attractive possible introduction image patients with high or irregular Departments” traditional Medtronic metal stent. Cardiologists to backfill empty cath lab Driver bareObviously acute chest pain cath lab career ladder, improving our for Results: the organisation there is heart rates, or even arrhythmia, Demonstrated no observed cases aofhuge stentcost thrombosis between sessions. and suspicion recruitment and retention prospects saving due to eliminating without beta blocker medications nine and 12 months in either study TLR Write to us at: of coronary and we aim to expand our team of thearm. need A to12-month pay medical staff for that have been previously needed to Medtronic Endeavor Drug-Eluting Stent These issues led torate 6.0 labs percent for Endeavor™carrying patients,out compared to 13.2 ourofcath artery disease,” coronary angiography practitioners. extra sessions. slow a patient’s heart. The system also Courtesy Medtronic, Inc. percent in the being under utilised and we wereDriver control group. tim@coronaryheart.com enables physicians to better identify and said Dr. Stephan Platform: struggling to meet the National Service characterize plaque, an early indicator of Achenbach, Framework TargetEndeavor waiting times associate professor III:forCompares the Endeavor™ against the heart disease. CORONARY HEART ™ 19 The popular Driver coronary stent system provides the angiography. coronary of Cardiology, Cypher™ drug-eluting stent marketed by Cordis Corporation,

Siemens Unveil their Most Advanced CT

Special Feature

Autumn Congress of the Netherlands Society of Cardiology

Republic This separates the diagonal branches further from the LAD, Africa Evaluationsyndrome “WPW demonstrating them inferior to the LAD. This view can also Website: www.escardio.org Website: www.idf2006.org SPECIAL FEATURE We would are now almost 2 years into improve visualisation of the mid / distal Obtuse Marginal isWepresent in RAO 30 / CAU like 20 sustaining this new role. The coronary branch approximately angiography practitioners in ourObjective: to hear your October 21-25 December 6-9 Canadian Cardiovascular organisation have performed almost Less RAO (eg. RAO 10 / CAU 20): three in every EuroEcho 10 700 procedures in that time. WeThis angle is used comments primarily to demonstrateon the Left Society Location: Prague, Czech collect andpeople” examine our audit data 6 and the Circumflex arteries, and is the bestLocation: 2,000 This separatesBC, the diagonal branches further from the LAD, Main view for Vancouver, Republic

Introducing the role of Coronary Angiography I Practitioner Product Focus PRODUCT INFORMATION

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Intervention, Guidant Corporation. Endeavor TheMedtronic first implant wasDrug-Eluting performedStent by a Courtesy Medtronic, Inc. team headed by Drs. John Ormiston and Mark Webster at Auckland City Hospital, New Zealand. The ABSORB trial will enrol up to 60 patients in Belgium, Denmark, France, New Zealand, Poland and The Netherlands.

• • • • • • • •

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CORONARY HEART ™ 13

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CONGRATULATIONS Coronaryheart

CORONARY HEART ™ 45


FINAL WORD

Congratulations!!!

C

ongratulations to Alison Sutcliffe (Sister), Denise Arthur (Senior Radiographer) and Julius Mas (Chief Cardiac Physiologist) who recently passed their Cardiac Catheter Laboratory Practitioner Project exams run at London South Bank University. Harefield Hospital is currently the only hospital in the UK to have 3 generic cath lab angiography workers. The course enables all 3 workers to multi-skill as a nurse/ radiographer/cardiac physiologist during cardiac procedures. Already the trio have managed to prevent many hours of “lab downtime” due to a shortage of staff. The course has not only developed their roles in other areas but has promoted a good sense of teamwork and improved working relationships. Across the UK there is an acute shortage of appropriately qualified nonmedical staff to deliver a cardiac

Alison Sutcliffe, Denise Arthur, and Julius Mas at Harefield Hospital Cath Lab catheter lab service. There is a service pressure to reduce the downtime. It is anticipated that the downtime can be improved by multi-skilling the existing workforce and developing a new

generic workforce. Harefield Hospital is in the process of submitting two more applicants for the next course that is due to commence in September.

C

oming up in the next issue of Coronary Heart™ which will be released on October 1 will be all of our usual features: •

Coming Up in the Oct / Nov Issue

46

CORONARY HEART ™

• •

The most interesting cardiology news from around the world. The latest equipment available to keep your Department at the cutting edge. The best conferences and meetings. And of course a whole lot more.

Our Special Feature article will be on the Generic Worker Course described above, which allows for cardiac staff to multi-skill as a nurse, radiographer, and cardiac physiologist during cardiac procedures.


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