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Issue 4

December 2006 / January 2007

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Special Feature

Cardiac CT Overview

coronaryheart.com

“Especially for Cardiac Cath, EP, and Non-Invasive Departments” LATEST NEWS, CONFERENCES + more...

Introduction to Electrograms

• The Florida Hospital, USA • St Thomas’ Hospital, UK

EMP

LAB VISITS

LO

Left Main Aneurysm Case Study

Y

NT E M

NOW IN USA 2000+ CATH LABS


CONTENTS

December / January 2007

CORONARY HEART Managers

Nurses

Radiologic Technologists

Contents

Cardiovascular Technologists

Echocardiographers

THIS EDITION

04

Welcome Editorial

05

Readers Letters

06

Latest News

12

Cardiology Advances

14

Product Focus

16

Product Focus

18 20

‘St Jude Rhythm’

Cardiac CT - Overview 38

Medical Imaging

40

Conferences

‘Left Main Aneurysm’

Special Feature ‘Cardiac CT - Part 2’

42

Conference Review

‘BSECHO - UK’

24

44

Interview

46

Employment

50

Classifieds & Preview

Special Feature ‘CT - Calcium Scoring’

26

Site Visit (USA)

29

Site Visit (UK)

34

EP Education

Cardiac Languages

‘Learn Spanish’

‘RCA’

‘GE Vivid i’

Case Study

43

Page: 20

Florida Hospital, USA

‘Dr Rodney Foale’

Page: 26

‘Florida Hospital’

‘Guy’s & St Thomas’’ ‘Electrograms’

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EDITORIAL

Welcome Editorial

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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 Tim Larner Clinical Editor Dr Rodney Foale Consulting Editors Dr Richard Edwards Mr Ian Wright Mr Stuart Allen ADVERTISING Media kits are available online CIRCULATION 2820 Cardiac Departments, Staff, & Industry Professionals in the USA, UK, Ireland, Australia, Canada, 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 fourth edition of Coronary Heart, whereby we have just opened our doors into the US market. With over 2000 cath labs in all 50 states reached, from Alaska to Florida, and everywhere in between, we would like to welcome you to the new revolution in cardiac publications. With the cardiac industry changing so rapidly, our company decided that it was time to produce a magazine that reflected these modern times. I have worked in the cardiac arena for several years, and through years of research determined what was needed. You asked for a colourful Tim Larner magazine, that was easy to read. You asked Director for plenty of images, instead of reams of text. You asked for a magazine designed for you. A magazine that you could read during a coffee break, or on the train home from work. So this is it. The world’s first free international cardiac publication. This magazine is now distributed to virtually all cardiac departments in the USA, UK, Ireland, Australia, New Zealand, and several sites in Canada. You can also subscribe online to receive your own copy, from which several hundred staff have already done so. Our website allows you to download a copy of this and previous editions, as well as find other interesting pages, including educational Powerpoint presentations, a buyers guide, conference lists, and of course employment. We hope you enjoy it.

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): Nikki Whitfield (radiographer) and Sandy Nkomo (nurse). Guy’s and St Thomas’ NHS Foundation Trust (UK).

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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LETTERS

Readers Letters Edition 3 Readers Letters in relation to the Generic Worker Course (UK)

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have just read your featured article about the generic cath lab worker. I am the director of a large cath lab that has had crossed trained staff for the past 10 years. I employ nurses, radiographers and cardiovascular technologists (equivalent to your Cardiac Physiologists). Regardless of discipline, everyone is able to function in all lab roles. One person is responsible for recording the hemodynamics of the procedure, one person scrubs with the physician as the first assist, one person circulate, handing off sterile supplies to the field and advocating for the patient and the fourth person manages the image file and runs the room schedule. It has been great for my staff. It has improved job satisfaction as well as the quality of

the patient care. It also makes scheduling staff in the lab much easier for me. All the training was done here at the hospital. It took us over a year. I would pair one RT with one CVT and that RT would learn hemodynamics. Then I would reverse the teaching role and the RT would instruct the CVT on imaging. We also have an educational meeting once a week so much of that time is devoted to education. We have a large pharmacology competency which staff have to renew each year. All our staff are ACLS and those that deal with pediatric patients are also PALS. Ann M. Hall, RTRCV Director, Cardiac Cath Lab Maine Medical Center, MA, USA

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t is great to see that in answering some of our challenges we have been able to come up with a course that suits most people within the lab situation. I had worked over in the

GLOSSARY The American Registry of Diagnostic Medical Sonographers (ARDMS) administers exams and awards credentials in many areas including: •

UK, AUS, NZ, IRE Registered Nurse (RN) Radiographers

RDCS: Registered Diagnostic Cardiac Sonographer®

The ARDMS requires that to maintain eligible status, registrants must accrue 30 continuing medical education (CME) credits per three year period. The Cardiovascular Credentialing International (CCI) administers examinations and awards credentials in many areas including: • • • •

RCIS: Registered Cardiovascular Invasive Specialist (similar to Generic Worker course in UK) RCS: Registered Cardiac Sonographer RVS: Registered Vascular Specialist CCT: Certified Cardiographic Technician (similar to Cardiac Physiologists)

The CCI requires that to maintain eligible status, registrants must accrue 36 continuing education units (CEU), 30 of which must be cardiovascular related.

Cardiac Physiologists Echocardiographer Cardiac Registrars

Middle East for 10 years and worked in the cross trained cath labs. The one thing that came from that experience was it was possible for ALL staff to do a good job in getting the work done and supporting each other, whilst providing competent patient care. Roles were not a structured regime whereby you could not overstep boundaries. Since coming back to Australia I have endeavoured to enable the staff where I work to be able to have the same freedoms in scope that I had whilst overseas. Most managers recognize that by enabling staff a broader scope of work practice, decrease down time, improve throughput and promotes autonomy within teams. I hope that we can support such a program here in Australia. Grant Hill Angiography Suite Manager Lake Macquarie Private Hospital, NSW, Australia

USA same Radiologic or X-ray Technologists, which can include Radiation Therapists, but also others (Mammographers, CT Technologists, etc). Most Radiologic Technologists are Registered Technologists (RTs). To be a Registered Technologist, one must pass an exam and to maintain this credential, registrants must accrue 24 continuing education (CE) credits per two-year period. Canada: Medical Radiation Technologists Cardiovascular Technologists, also known as CVTs Echo Technologists Cardiology Residents CORONARY HEART ™ 5


LATEST NEWS

Latest News

UNITED STATES OF AMERICA

CAUTION: Some products within this magazine may be restricted to specific regional usage, and may not be available in your region. Always check with the manufacturer to determine availability.

Cardioscan® Reduces Unnecessary & Costly Cardiac Referrals

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n early October, Zargis Medical Corp., announced a summary of results from the clinical study it conducted in 2005 in collaboration with The Johns Hopkins University School of Medicine. The study assessed the impact of the Cardioscan® system on referral decisions made by primary care physicians regarding heart murmurs—which are potential signs of heart disease. As mentioned in the previous edition of Coronary Heart™, the Cardioscan is the only computer-assisted medical device designed to support physicians in analyzing heart sounds. The study was presented at the American Academy of Pediatrics National Conference & Exhibition in Atlanta. The study measured the accuracy of a group of primary care physicians

in evaluating a set of 100 recorded heart sounds. The heart sounds were independently evaluated by each physician both with and without access to Cardioscan’s reported findings. With Cardioscan’s findings, the physicians were able to reduce their rates of unnecessary referrals by an average of 41%. The study also revealed a reduction in the physicians’ false negative rates by an average of 46%, suggesting that Cardioscan could increase a physician’s ability to differentiate between

innocent and pathological heart murmurs that are difficult to detect with a standard stethoscope. This technology may hold genuine promise in reducing the money wasted in healthcare today. Whilst the Cardioscan is only available in the USA, there are plans to expand internationally in the near future. Visit www.zargis.com for more information

ECG Pacing Problem Solving

Answer: Page 50 6

CORONARY HEART ™

From Stuart Allen, Consulting Editor


UNITED STATES OF AMERICA

LATEST NEWS

Latest News

World’s First Installation Of Innova Ivus

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E Healthcare and Volcano Corporation recently announced the completion of the first commercial installation of Innova IVUS at PinnacleHealth Heart and Vascular Institute at Harrisburg Hospital in Harrisburg, PA. The Innova IVUS is a custom integration of the already popular digital Innova X-ray imaging equipment with the Volcano s5i IVUS imaging system. Although the s5i IVUS is available as a stand-alone unit as the s5™, the partnership with the Innova improves usability, which in turn increases productivity. This optimization is firstly due to the IVUS controls placed on the Innova Central bedside touchscreen. Secondly, the data exchange between the IVUS system and Innova allows for automatic patient data transfer from Innova for IVUS cases and advanced archiving that links IVUS cases to cath cases. Volcano’s s5i product uses a new PC-based platform that reduces the size, weight and noise of the older

The GE Innova IVUS system Image Courtesy Volcano Corporation

generation IVUS consoles. This allows the unit to be located in the control room or in other areas outside of the daily traffic pattern of the cath lab. Clinicians have the ability to control the IVUS system through a variety of control devices located at the patient bedside, at the point of care, or both. Clinicians also have the flexibility to view IVUS images on the existing monitor bank, a separate dedicated IVUS monitor, and/or on a monitor in the control room.

FDA Clearance of Near Infrared Spectroscopic System

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nfraReDx recently announced that the U. S. Food and Drug Administration (FDA) had issued a clearance to market its near infrared (NIR) spectroscopic system for examining coronary arteries. The technology, commonly used in chemical and pharmaceutical production, utilises photonic technology

Additionally, GE and Volcano announced GE’s plans to include the cabling required to operate Volcano’s IVUS technology on all future U.S. installations of GE Healthcare’s Innova imaging systems. The inclusion of IVUS cabling as part of the standard installation creates the infrastructure required to operate Innova IVUS. Visit the GE Healthcare website at www.gehealthcare.com or the Volcano website at www.volcanotherapeutics. com for more information

to identify lipid rich plaques. It is suspected these plaques are “vulnerable” to rupture, which can lead to thrombosis and potential acute coronary syndrome. The InfraReDx system consists of a laser light source, an automated pullback and rotation device and a small fiberoptic catheter. The light penetrates the vessel wall, not being affected by surrounding blood cells, and provides a map of the chemical composition of the artery wall. Visit their website www.infraredx.com for an interesting video animation as well as links to medical research articles. CORONARY HEART ™ 7


LATEST NEWS

INTERNATIONAL

Latest News Is Bypass Better than Angioplasty for Severe CAD?

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nly a few short years ago if a patient was found to have triple vessel disease they would immediately be referred to bypass surgery. Today though in many hospitals, triple vessel angioplasty is becoming commonplace. But is it in the best interest for the patient? Today it is estimated that up to 40% of patients with severe coronary disease are treated first with angioplasty or medications without the option of bypass surgery. New research though has shown that the latter may be the safer option, according to a Duke University Medical Center analysis. Used for over 40 years, bypass surgery is more expensive and more invasive, but has the benefit of increasing patient

life span significantly more than the other options, the scientists said. “It may sound very appealing to patients with severe coronary artery disease to get a treatment that is less expensive or less invasive, but they may not be getting the same survival benefit as those patients receiving bypass surgery,” said Peter Smith, M.D., chief of cardiothoracic surgery and lead investigator for the study.

1996 was when physicians first began inserting stents during angioplasty procedures. The study ended before drug-eluting stents came into use.

The researchers retrospectively analyzed the outcomes of 18,481 patients who had at least one coronary artery that was more than 75 percent blocked and who had received bypass surgery, angioplasty or heart medications at Duke from 1986 to 2000. Patients were considered to have severe coronary artery disease if three of their coronary arteries were more than 75 percent blocked.

“We believe that our findings have a particular relevance to practice today, since recent studies are suggesting that there may be problems with the longterm durability of drug-eluting stents,” Smith said. “Because of these new questions, many physicians are going back to the traditional stents.”

Patients were divided into three groups, depending on when they were treated: 1986-1990, 1991-1995 and 1996-2000. The final period is most important, the researchers said, because

GE Release the Vivid e.

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E has recently released the new ultra-portable cardiovascular ultrasound system called Vivid e. Weighing in at only 4.6kg, the unit is perfect for physicians offices around the world. The system includes: •

Comprehensive, diagnostic exams with the confidence building image quality expected from the GE Ultrasound Vivid product line .

Easy-to-use, automatic image optimization - in 2D, color and Doppler imaging - instantly

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CORONARY HEART ™

CAUTION: Some products within this magazine may be restricted to specific regional usage, and may not be available in your region. Always check with the manufacturer to determine availability.

updates thousands of parameters with one keystroke for optimal scanning. •

Anatomical M-Mode assists with off-axis orientation to make scanning easier.

The researchers found that patients in the 1996-2000 period with severe disease who received bypass surgery lived an average of 5.3 months longer than those treated by angioplasty, a statistically significant difference.

The findings appear in the October 2006 issue of the journal Annals of Thoracic Surgery. The study was supported by the Duke Clinical Research Institute and Duke’s Division of Cardiothoracic Surgery.

Sudden Cardiac Death Screening in Athletes

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ccording to a report in the October 4 issue of JAMA, the annual incidence of sudden cardiovascular deaths among young athletes in northern Italy has shown an 89% reduction. This has been due to a pre-participation cardiovascular screening program for competitive athletes which was introduced in 1982 by the Italian Government. Most of the reduced death rate was due to fewer cases of sudden death from cardiomyopathies.


LATEST NEWS

INTERNATIONAL

Latest News Kensey Nash Receives CE Are Single Mark Approval for ThromCat™ Stents Best Thrombectomy Catheter System for Bifurcation ensey Nash Corporation The ThromCat(TM) device is a Lesions? announced on October fully disposable catheter system that

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23 that it has received CE Mark Approval for its ThromCat™ Thrombectomy Catheter System, which allows the sale of the product throughout the European Union. The ThromCat™ System is a mechanical thrombectomy catheter designed to remove thrombus or blood clots from a patient, indicated for use in both the coronary and peripheral vasculature in Europe. The official US launch was held at the Transcatheter Therapeutics (TCT) Conference in Washington, D.C.

ccording to a recent study reported in the journal Circulation: Journal of the American Heart Association, it was found that using a single stent with bifurcating lesions can be just as effective as multiple ones.

For a better understanding of the system visit www.kenseynash.com where you can download a great animation video of the ThromCat™ System.

In the small study of 413 patients, doctors treated one group of patients with stents in the major artery only (with optional stenting for the side branch), and treated a matched group with stenting of the main artery and the side branch. After six months, researchers found no significant differences between the two groups in deaths or major adverse cardiac events. Moreover, the simpler procedure took less time to perform and required less imaging time and a smaller volume of imaging agents. It also had lower rates of biomarkers which indicate heart muscle damage.

ThromCat Tip Image Courtesy Kensey Nash

Cordis Launches New Cypher

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ordis recently announced the launch of their third generation of drug-eluting stents, the Cypher Select™ Plus. The new stent is now available within many countries outside the US including the regions of Western and

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incorporates HeliFlex™ technology to flush, macerate, and extract thrombus (see image). An internal rotating helix creates a powerful vacuum to draw thrombus into the catheter and then macerate it, while simultaneously flushing the vessel to aid in the thrombus removal.

Eastern Europe, Asia Pacific and the Middle East. So what has changed from the old Cypher Select? Well in addition to its flexible stent design and short tip, the CYPHER SELECT™ Plus Stent Delivery System features the CYPH2ONIC™ Hydrophilic Coating Technology. This coating is significantly more lubricious than previous sirolimus-eluting stent delivery systems, for improved deliverability in tortuous vessels.

“The technique of stenting a main vessel and optionally stenting a side branch can be recommended as the routine bifurcation stenting technique,” said Andrejs Erglis, M.D., Ph.D., co-author of the study and head of Latvian Centre of Cardiology of Paul Stradins Clinical University Hospital in Riga, Latvia. “But our study does not contraindicate the use of a complex bifurcation stenting strategy in special cases.” The researchers acknowledge several limitations including not measuring the blood flow to the heart muscle after, and the small patient numbers involved in the study. CORONARY HEART ™ 9


LATEST NEWS

INTERNATIONAL

Latest News First Commercial Implant of Endeavor DES in Melbourne

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n early October 2006, Medtronic announced that it had received regulatory approval from Australia’s Therapeutic Goods Administration to begin selling the Endeavor® drug-eluting coronary stent (DES) system. The Monash Medical Centre located in Melbourne was where the first commercial implants occurred, undertaken by Dr Ian T. Meredith, Professor of Medicine. Dr Meredith stated, “I have followed the data for Endeavor very closely over the past three years and it has provided impressive clinical outcomes. The stent is effective at reducing restenosis and it has been proven to be among the safest stents on the market.” Following on, in late October at the TCT meeting in Washington DC, Dr Meredith presented preliminary results

Early Data On Bioabsorbable Drug-Eluting Stent

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arly clinical results from Abbott’s ongoing ABSORB clinical trial were presented during the 18th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium in Washington, D.C. in late October. This is the world’s first study to evaluate the safety and performance of a fully bioabsorbable 10

CORONARY HEART ™

from the RESOLUTE clinical trial, a first-in-man study evaluating the new Endeavor RESOLUTE zotarolimuseluting stent system. The RESOLUTE trial enrolled 130 patients at 12 clinical centers in Australia and New Zealand, with a primary endpoint of late lumen loss (in-stent) at nine months and customary angiographic, intravascular ultrasound (IVUS) and clinical secondary endpoints. Thirty-day clinical results for 130 patients showed a Major Adverse Cardiac Event (MACE) rate of 3.8 percent, with zero Target Lesion Revascularization (TLR) and no stent thrombosis. In 30 patients with fourmonth angiographic follow-up, in-stent late loss was 0.12 mm and in-segment late loss was 0.05 mm. Both in-stent and in-segment binary restenosis were zero, and intravascular ultrasound (IVUS) results showed neointimal volume obstruction of 2.2 percent at four months. Stent device and lesion success was 100 percent, which means that physicians were successful in placing the assigned stents in the proper location with few complications.

drug-eluting stent platform for the treatment of coronary artery disease in humans. The stent is made from polylactic acid, derived from lactic acid, which is designed to be fully absorbed and slowly metabolized by the coronary artery. The everolimus-coated stent will release the drug into the artery and then slowly absorb over time. The goal is to leave a healed natural vessel behind. Polylactic acid is already commonly used in suture materials to close wounds after surgery. Initial results for the first 30 patients

Apart from the USA where the Endeavor is currently undergoing clinical evaluation, with FDA approval anticipated in 2007, the release in Australia brings the total to 100 countries where the stent is commercially available. And with approximately 38,000 stents implanted in Australia every year, Medtronic should be able to win some of the market back from the other DES companies which currently dominate the market. For more information visit www.medtronic.com

Philips’ New 4D Ultrasound Transducer

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he new Philips X7-2 x-MATRIX array uses breakthrough array technology with elements smaller than a human hair, giving paediatric patients the same imaging advantages as adults with live real-time 3D echocardiography. Visit www.medical.philips.com for more information in the trial demonstrated no MACE (Major Adverse Cardiac Events, such as heart attack) and no stent thrombosis at 30 days for patients who received a bioabsorbable everolimus-eluting stent. “We are highly encouraged by these initial results from the ABSORB trial,” stated John Ormiston, M.D., Auckland City Hospital, New Zealand, and co-principal investigator of the study. The ABSORB trial is a prospective, non-randomized (open label) study and has been designed to enroll up to 60 patients in six countries.


LATEST NEWS

INTERNATIONAL

Latest News Remote Control Catheterization Trial to begin soon

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orindus, developer and marketer of proprietary remote control catheterization systems, announced at the Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium in Washington, D.C., that it filed its Investigational Device Exemption (IDE) application for the CORRECT (Coronary Remote Control Catheterization Trial) clinical trial of their CorPath™ system. One hundred patients from six sites in the US and Europe will be involved in the trial which the team believe is a “step forward in angioplasty”. So why is it a step forward? According to Corindus, there are three main benefits.

Elimination of Radiation Exposure: As shown in the image above, the physician is able to stand behind a lead screen, or even in the control room during the procedure.

Eliminates Chronic Orthopaedic Ailments: A recent study published by the Interventional Committee of the Society of Cardiovascular Interventions reported that 42% of physicians had chronic orthopedic problems. Because the CorPath remote control system allows the physician to work out of the radiation zone, there is no need to wear a lead gown.

CorPathTM Remote Control Catheterization System Image courtesy Corindus

Enables physicians to deliver intracoronary devices safely and with precision: Motion modes of advance, retract, and torque in continuous or step, give the operator precise movements of the guide wires and stent systems. As you can see, we have a great image of the CorPath™. Here are the components:

Workstation: The operators workstation is comprised of a console with touch-screen and joystick control.

are unable to interpret tactile response from the wire / delivery system. However Corindus have stated initial users in clinical trials reported that the combination of fluoroscopic imaging and the element of advanced control supplant this aspect and allow for results equal to or better than usual practice. There is also an inherent safety mechanism to limit the applied forces in the procedure and by that avoid the risk of perforation Visit www.corindus.com for more information

Bedside Unit: The bedside unit is located at the femoral access site and transports the guide wire and stent system as specified by the physician at the workstation. The only disadvantage to this system that some may find is that operators CORONARY HEART ™ 11


FUTURE

Cardiology Advances New Material That Stops Bleeding in 15 Seconds

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n amazing new liquid, composed of protein fragments called peptides, has been designed to revolutionize haemostasis, stopping bleeding within fifteen seconds. Researchers at the Massachusetts Institute of Technology, and the Hong Kong University have shown that when the liquid, is applied to open wounds, the peptides selfassemble into a nanoscale protective barrier gel that seals the wound and halts bleeding. Once the injury heals, the nontoxic gel is broken down into molecules that cells can use as building blocks for tissue repair. Currently the experiments have only been carried out on rodents, whereby the clear liquid was applied to open wounds in several different types of tissue -- brain, liver, skin, spinal cord and intestine. “In almost every one of the cases, we were able to immediately stop the bleeding,” said Ellis-Behnke, the lead author of the study. This study, which appeared in the online edition of the journal Nanomedicine on Oct. 10, marked the first time that nanotechnology has been used to achieve complete hemostasis, the process of halting bleeding from a damaged blood vessel. Doctors currently have few effective methods to stop bleeding without causing other damage. More than 57 million Americans undergo nonelective surgery each year, and as much as 50 percent of surgical time is spent working to control bleeding. 12

CORONARY HEART ™

Current tools used to stop bleeding include clamps, pressure, cauterization, vasoconstriction and sponges. The exact mechanism of the solutions’ action is still unknown, but the researchers believe the peptides interact with the extracellular matrix surrounding the cells. “It is a completely new way to stop bleeding; whether it produces a physical barrier is unclear at this time,” Ellis-Behnke said. The researchers are confident, however, that the material does not work by inducing blood clotting. Clotting generally takes at least 90 seconds to start, and the researchers found no platelet aggregation, a telltale sign of clotting. This technology has the potential of greatly enhancing the time management of cath labs, by possibly eliminating the need for nurses applying pressure on the femoral artery to achieve haemostasis. New devices would need to be developed to deliver the liquid into a femoral / radial access points, and of course a few more years of clinical trials before going public to determine it is truly safe. We will keep you informed if any companies pick up this new technology.

Hypothermia may reduce Infarct Size

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ardium Therapeutics and its subsidiary InnerCool Therapies reported recently at the annual TCT meeting in Washington D.C., that rapid and short duration hypothermia before reperfusion reduces myocardial infarct size by 40%, compared with hypothermia induced at the time or after reperfusion. The system uses a combination of cold saline and endovascular cooling. The successful findings from the porcine-only trial are leading the company towards plans for a new clinical study. Visit www.innercool.com for more information.


FUTURE

Cardiology Advances Multi-Source CT May Soon Be On The Way

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n a recent article published in the journal of Applied Physics Letters, scientists at the Carolina Center for Cancer Nanotechnology Excellence, in the USA, have developed a new method to create computed tomography (CT) images using carbon nanotube x-rays. The team’s newest innovation combines a multiple-x-raysource innovation with a principle called

12-month results from Stem Cell Research

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ncouraging 12-month results have been presented at the TCT conference in Washington D.C., from a Phase 1 trial at Caritas St. Elizabeth’s Medical Center in Boston, Massachusetts. The Phase I trial involves injecting patients with severe coronary artery disease with a protein that helps to release stem cells from the patient’s own bone marrow into the blood stream. These autologous stem cells are gathered, selected and then injected into areas of the heart that have been

multiplexing, in which all the x-ray sources are turned on simultaneously to capture images from multiple views at the same time. Unlike conventional CT systems that rotate around the patient mechanically, the new machine requires no mechanical motion but is switched rapidly among many x-ray sources, each taking an image of the object from a different angle in fast succession. Whilst currently still only developed as a prototype, the potential for cardiac imaging is amazing. One of the current limiting factors with CT is heart motion reducing the diagnostic quality of the images.

damaged due to an insufficient supply of oxygen-rich blood. Data from this randomized, multicenter, placebo-controlled, doubleblind trial indicate that the therapy appears to be well-tolerated as no serious adverse events directly related to the stem cell therapy were observed. Twenty-four participants were enrolled in the study, 19 male and five female. There were no deaths or heart attacks and 15 of the 18 total Phase I study subjects who received the cells reported feeling better with reductions in chest pain and/or improved exercise capacity. Another larger 150 patient study is underway, being a randomized, multicenter, placebo-controlled, doubleblind Phase II trial.

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Like to Advertise? Download Our 2007 Media Kits Online Today

coronaryheart.com

MEDIA KIT 2007 Especially designed for the specialist medical teams working in cardiac cath/EP labs, and non-invasive departments. Distributed to virtually all departments in the USA, UK, Australia, Ireland, NZ, and several sites in Canada.

coronaryheart.com

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Recruitment MEDIA KIT 2007 Especially designed for the specialist medical teams working in cardiac cath/EP labs, and non-invasive departments. Distributed to virtually all departments in the USA, UK, Australia, Ireland, NZ, and multiple sites in Canada.

CORONARY HEART ™ 13


PRODUCT FOCUS

St Jude’s Rhythm Merlin Programmer

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ith U.S. Food and Drug Administration (FDA) approval achieved in April 2006, the Merlin has proved very popular as a universal programmer for implantable cardioverter defibrillators (ICDs) and pacemakers. So what are some of the features this system can allow you to do? Read on..... St Jude Medical markets the system to assist physicians to more efficiently conduct tests, analyze therapeutic and diagnostic data, and program implanted devices for optimal patient care. The Merlin speeds up followup testing with a new intuitive touch screen designed to give physicians and clinical workers the ability to retrieve and analyze patient information during routine follow-up visits. This in turn increases productivity.

The Merlin Patient Care System includes several advantages for physicians and patients: A new user interface that makes the entire system faster to learn and use. This interface, mimics the natural workflow of a clinic to

The Merlin Patient Care System supports the following St. Jude Medical devices: •

make it easier for clinicians to operate. •

Enhanced presentation of diagnostics, which consolidate and display patient information so clinicians can make faster decisions.

State-of-the-art hardware, including a powerful Intel Pentium M processor, an expanded disk and flexible options for future upgrades. The hardware increases speed and consumes less energy, allowing the system to weigh less, thereby making it easier for physicians, cardiovascular technologists, and nurses to carry and store.

Victory Pacemakers

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aunched in the US in early 2006, the new range of Victory Pacemakers provides users with optimized settings designed to save time at implant, VIP™ (Ventricular Intrinsic Preference) technology designed to minimize ventricular pacing, and FastPath™ summary screen to speed follow-up exams. It can also be used in conjunction with the Merlin Programmer to improve productivity during cases and at follow-up.

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The session summary screen, which shows a summary of tests performed during a pacemaker patient’s follow-up exam, and shows a comparison between presenting settings and currently programmed settings.

ICDs: Atlas(R), Atlas(R) +, Atlas(R) + HF, Epic™, Epic™+, Epic™HF, Photon(R) and Photon(R) Micro. • Pacemakers: AddVent(R), Affinity(R), Entity(R), Frontier(R), Frontier(R) II, Identity(R), Identity(R) ADx, Integrity(R), Integrity(R) ADx, Microny(R), Paragon(TM), Phoenix(R), Regency(R), Solus(R), Synchrony(R), Trilogy(R), Verity(R) ADx and Victory(R). The new user interface is currently compatible with the Identity(R), Identity(R) ADx, Integrity(R) ADx, Verity(R) ADx and Victory(R) pacemakers.

The Victory also comes with a selection of algorithms designed to make it easier for physicians to manage patients with atrial fibrillation (AF). VIP is designed to promote more natural heart function and minimize ventricular pacing. This is an important clinical consideration, since studies such as St. Jude Medical’s DAVID (Dual-Chamber And VVI Implantable Defibrillator) trial have shown that excessive ventricular pacing may contribute to heart failure in some patients. For more information visit www.stjudemedical.com


PRODUCT FOCUS

St Jude’s Rhythm

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Quick Opt

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n August 2006, St Jude Medical launched the QuickOpt™ Timing Cycle Optimization. This programmer feature is designed to improve patient outcomes for people with cardiac resynchronization therapy defibrillator (CRT-D) devices and traditional implantable cardioverter defibrillators (ICDs) by providing a programmer-based optimization method that provides comparable results to echocardiography (echo). In just over a minute, the QuickOpt feature electrically characterizes the conduction properties of the heart and uses an exclusive algorithm to calculate the optimal timing values. This allows for efficient and frequent optimization during routine device follow-up visits. In comparison, a typical echo optimization procedure takes between 30 and 120 minutes and requires manual interpretation by a technician.

Optimization: •

Optimizes AV, PV, and VV intervals at the push of a button.

Allows optimization of both nonresponders and responders.

Allows frequent optimization in response to changing timing cycles.

Is compatible with all St. Jude Medical™ multi-chamber ICDs (DR & HF).

The QuickOpt feature is available worldwide on the Merlin™ Patient Care System and 3510 programmer. Clinicians can accept or modify the recommended results and program the device accordingly. Visit www.stjudemedical.com to view online videos of the feature in action. CORONARY HEART ™ 15


PRODUCT FOCUS

GE Vivid i

“The New Generation of Cardiovascular Ultrasound”

H

ere at Coronary Heart, we just love new toys, and one of the ultimate toys for any busy cardiac department is the GE Vivid i Breakthrough 2006. Granted that it has been around for almost two years, but like all good things, it has had a recent upgrade with a lot more goodies crammed inside. So here is a brief overview of what the engineers at GE have put together. Sometimes smaller can be better!!

The i2 Performance Package includes:

Vital Statistics:

Speckle Reduce Imaging (SRI) uses an adaptive, real-time software algorithm to improve image quality.

Depth: 313 mm (12.4 in) Width: 358 mm (14.2 in) Height: 59 mm (2.3 in) Weight: without battery 4.3kg (9.4lbs) Weight: with battery 4.9kg (10.8lbs)

This is not a GE paid advert

Five new probes – including a 5S cardiac transducer and a 9T TEE transducer for pediatric exams.

Coded Phase Inversion (CPI) enhances contrast imaging with excellent sensitivity, resolution and tissue suppression.

IMT analysis package enables clinicians to quickly measure the carotid artery’s intima-media thickness.

Compound imaging processes cross-beam images to enhance border definition, reduce acoustic artifact and improve contrast resolution.

Wireless capabilities, enabling physicians to transfer files instantly from the system to other physicians for consultation.

Automatic Spectrum Optimization (ASO) provides optimization of PW or CW spectrum scale and baseline display for increased productivity and ease of use.

Harmonics on all high-frequency probes further enhance image quality.

New Features: •

SmartStress, a stress echo protocol, provides image acquisition, review, wall-segment scoring and reporting.

Tissue Velocity Imaging (TVI) and Tissue Tracking (TT) visualize and quantify left ventricle function.

An optional i2 Performance Package that enhances image quality with several innovations migrated from the Vivid 7 Dimension.

16

CORONARY HEART ™

Other Features:

With all of these extra features providing the functionality and performance that you would expect only from a much larger system, the Vivid i Breakthrough 2006 provides a real alternative to patient treatment. Be it at their bedside, or within the cath lab itself, this portable system will be popular with both large and small departments.


CASE STUDY

Submitted by: Mr Eric Simillion & Dr Shakeeb Razak Royal Perth Hospital, WA, Australia

Left Main Aneurysm Introduction:

L

eft main coronary artery (LMCA) aneurysms are of extremely low incidence (0.1% in adults) and is often an incidental finding at coronary angiograms (ref 1). Coronary artery aneurysm (CAA) exist when the dilatation of the vessel exceeds the diameter of the lumen by a factor of at least 1.5 (ref 2). The aetiology is still not well understood nevertheless in 50% to 90% of cases atherosclerotic disease of the coronary arteries via repeated destruction and remodelling of the media layer of the vessel wall is the culprit (ref 3). This case report presents a patient who was referred for coronary angiography prior to mitral valve replacement. CT angiogram was also performed to further delineate the surrounding anatomy. The patient successfully underwent surgery for coronary artery bypass grafts (CABG), mitral valve replacement and Maze procedure.

Case History: The patient was a 50 year old Aboriginal lady whose significant past medical history included: • •

• • •

Biventricular failure Worsening rest and exertional dyspnoea, associated with paroxysmal nocturnal dyspnoea, orthopnoea and peripheral oedema, associated with marked reduction in exercise tolerance Ex-heavy smoker Ex-heavy alcohol intake Past episodes of community acquired pneumonia.

Clinical examination showed: • • •

The patient was extremely dyspnoeic Oxgen saturation on room air was 90% Elevated jugular venous pulse

18  CORONARY HEART ™

Pre-operative Coronary Angiography demonstrating LMCA aneurysm & proximal LAD stenosis •

• •

She was tachycardic with a heart rate of 140 bpm and her ECG showed evidence of atrial flutter with variable block Her blood pressure was approximately 110/80 mmHg She had evidence of severe mitral regurgitation on auscultation and had pitting peripheral oedema to her mid thigh bilaterally Abdominal examination showed that she had hepatomegaly and possible underlying ascites.

Diagnostic tests: Patient was admitted to the Coronary Care Unit (CCU) and underwent aggressive diuresis with an intravenous Frusemide infusion. Over the next week, the patient lost approximately 8.5 kilograms in fluid. Continuous cardiac monitoring showed that she was in atrial flutter with variable block.

Transthoracic echocardiography: Showed evidence of severe mitral regurgitation secondary to anterior leaflet perforation with windsock and severe prolapse suggestive of past infective endocarditis. The left ventricle was mildly dilated and had overall normal preserved systolic function. There was moderate dilatation of the right ventricle with severe systolic dysfunction. There was severe biatrial enlargement with mild tricuspid regurgitation and the pulmonary artery systolic pressure was 50 mmHg. Following aggressive diuresis, the left ventricular function improved from an ejection fraction of 40% to 53%, however, the mitral regurgitation remained severe. Pre-operative coronary angiography: Revealed a very large aneurysm of the left main coronary artery which obscured the origin of the LAD and


CASE STUDY (cont...)

Left Main Aneurysm circumflex coronary arteries. There was probable mild to moderate proximal left main stenosis. The LAD had a moderate narrowing, approximately 50-60% of the origin with otherwise mild irregularities elsewhere. The intermediate coronary artery was a small calibre vessel. The circumflex coronary artery was a large and dominant vessel with moderate to severe proximal disease. The right coronary artery was a non-dominant vessel with no significant obstructive disease. The left ventriculogram showed evidence of moderate dilatation of the LV with mild to moderate global impairment of systolic function. There was severe mitral regurgitation into a hugely dilated left atrium. CT coronary angiography: Showed a very large aneurysm in the distal left main coronary artery. This measured 20 x 14 x 13 mm. This extended into the origins of the circumflex, first acute marginal and the LAD. The major vessels beyond the aneurysm were of moderate calibre with no haemodynamically significant stenoses. There was mild left and moderate right ventricular global systolic dysfunction with features of pulmonary arterial hypertension. There was thrombus present in the right atrial appendage. There was also pulmonary mosaic density which was thought to be due to inflammatory airways disease and supported by the presence of mild basal bronchiectasis. The other differential included pulmonary hypertension and thromboembolic disease.

Treatment: Underwent coronary artery bypass grafting x 1, mitral valve replacement and a Maze procedure of the left atrium. Vessels grafted included LIMA

(cont...)

Discussion: Percutaneous obliteration of LMCA aneurysm has been previously described (ref 4,5) using a PTFE covered stent and can be an option instead of surgical treatment. The current case report was not suitable for percutaneous intervention as the patient had extensive coronary artery disease and mitral valve replacement had to be performed. The American College of Cardiology (ACC) recommended CABG (ref 3) “…due to the size and location of the aneurysm, and the extent of concomitant CAD”. MRI scanner to rule out any extracardiac aneurysm was not performed but would have been of interest. To this day coronary angiography is still the gold standard to diagnose this type of pathology.

3D reconstruction of aneurysm from CT coronary angiography

Authors: Eric Simillion: BSc. (Medical Imaging Technology) PG Dip MIS, Curtin University, Australia. Dr. Shakeeb Razak MBBS; FRACP (Cardiology), at Royal Perth Hospital.

Reference(s) to LAD and saphenous vein graft to OM1. The mitral valve was replaced with a 29mm Mosaic mitral valve prosthesis. The findings during the operation were a dilated right atrium and right ventricle with organised clot in the right atrium. Examination of the anterior mitral leaflet of the mitral valve showed it to be thin and flail with marked perforations. A Maze procedure was also performed interoperatively. Post-operative transthoracic echocardiography demonstrated a normal left ventricular size and systolic function with mild right ventricular dilatation and mild to moderate systolic dysfunction. The Mosaic mitral valve prosthesis was functioning normally.

1.

2.

3.

4.

5.

Elahi MM, Dhannapuneni RV, Keal R. Giant left main coronary artery aneurysm with mitral regurgitation. Heart 2004:90: 1430. Lima B, Varma SK, Lowe JE. Monsurgical management of left main coronary aneurysm. Tex Heart Inst J. 2006; 33(3): 376-379. Gassis SA, Helmy T.‘Left main coronary aneurysm’ from American College of Cardiology website :http://www. cardiosource.com/casestudies/Casestudy. asp?StudyID=397&tabID=2845&reset= 397# Young JJ, Schreiner AD, Shimshak TM et al. Successful exclusion of a left main coronary artery aneurysm with a PTFE-covered coronary stent. J Invasive Cardiology 2004;16:433-434. Strozzi M, Ernst A, Banfic L. Obliteration of a left main coronary artery aneurysm with a PTFE-covered stent. J Invas Cardiol 2002;14:280–281.

CORONARY HEART ™ 19


CARDIAC CT - (Part 2)

By Trupti Patel, CT Radiographer

Cardiac CT: Uses, Advantages, and Future Direction

H

ere is Part 2 of our Special Feature related to Cardiac CT. Part 1 in the previous edition gave you a basic understanding of what CT actually is, where as now we delve in a bit deeper, looking at the advantages and future direction of this exciting field. CT cardiac imaging is expanding rapidly, and it won’t be long before you, if you haven’t already, have one at your hospital. The following article is written by Trupti Patel, the Superintendent Radiographer for CT at Harefield Hospital in London, UK. Multislice CT scanning (MSCT) has and will continue to open new opportunities to see the heart and its surrounding tissue in greater depth and detail. Recent advances in 16 and 64 slice CT technology mean you can acquire several thin slices with a single rotation of the gantry. The introduction of ECG synchronised CT scanning of the heart means that the whole procedure can be done in a single breath hold (total scanning times of 1012secs). Most importantly this means that rapid scanning ‘freezes’ the heart. Prior to fast scanning techniques in CT, the heart was very difficult to visualise other than with conventional angiography. Electron beam computed scanners (EBCT) were first used to image the heart in 1979.Until recently; EBCT was commonly used to detect plaque in the coronary arteries and therefore was the gold standard for Coronary artery calcification (CAC)(16) 20

CORONARY HEART ™

3D Reconstruction of the heart demonstrating the LAD and Circumflex arteries All images provided courtesy Toshiba Medical Systems.

However cardiac optimised CT scanners now have higher temporal and spatial resolution, which allows us to see small structures without motion artefact. Ultimately it gives us better actualisation and visualisation of the vessels of the heart, surrounding vessels

and coronary anatomy. With further advancement of new technologies, post-processing packages have become available. This has meant the visualisaton of anatomy can be done in several planes. The manipulation of the acquired data allows us to show


CARDIAC CT - (Part 2)

Cardiac CT detail in several formats. E.g. curved reformats, multiplanar reconstruction, volume rendered images etc. The use of specially adapted cardiac CT techniques allows you to visualising the heart and surrounding vessels from adjacent structures, which can be difficult to differentiate as they all lie very close to each other. CT cardiac imaging can be performed with or without the use of non-ionic contrast (x-ray dye) depending on the clinical indications and diagnosis required. Simply put, non-ionic contrast is used within the body to highlight/opacify relevant structures. The use of contrast to delineate structures in and around the heart is already used in the catheter labs whilst performing coronary angiography. When utilised properly, MSCT can aid in the reliable diagnosis and exclusion of coronary artery disease (CAD). With one cardiac CT scan it is possible to determine causes of unexplained chest pain and shortness of breath. (E.g. Heart attack, pulmonary emboli, and aortic dissection –‘triple rule out’). The most common non-invasive cardiac imaging procedure carried out in CT scanning departments is a

calcium scoring CT scan. The images produced are used to assess the calcium in coronary arteries. This technique can identify non-calcified (soft) and calcified plaques. The calcium that is detected in all the coronary arteries is reported as a “calcium score”. The higher the calcium score, the higher your chance of having a heart attack or needing coronary bypass surgery, unless you are treated appropriately with medications.

To date CT cardiac imaging and CT angiography (CTA) of the heart is clinically being used for the following examinations: • • • • • • • •

Coronary artery imaging, using CTA, looking at the vessels surrounding the heart Functional assessment of the heart, assessing the state of the chambers Coronary artery stenosis as explained above Post stent visualization Graft patency post coronary artery by-bass surgery (CABG) Detection of coronary artery anomalies: - cardiac mass and congenital heart disease (CHD) Aneurysms Pulmonary vein mapping

Axial Reconstruction demonstrating calcified LAD and Diagonal branches

(cont...)

Using CT as a diagnostic tool to aid diagnosis in cardiac cases has the advantage that: • • • • • • • •

It is a cheaper diagnostic tool It is quick and non-invasive compared to standard coronary angiography Has a lower risk than conventional angiography Can help in earlier detection of disease Can be used to visualise anatomy in 3D and 4D Requires less or no time in hospital therefore frees up vital bed spaces Frees up and makes available other diagnostic services Can be cost effective compared to 2/3 investigations required to make a diagnosis.

However as with all great advances in technology there are disadvantages, and the use of cardiac CT as a diagnostic tool has quite a few! We still need to be aware of the importance that there is a radiation dose involved. Cardiac MRI does not use radiation to acquire images. Cardiac MRI of the heart still produces superior images. But cardiac MRI imaging in itself is very long procedure

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Axial Reconstruction demonstrating a stent in the proximal LAD CORONARY HEART ™ 21


CARDIAC CT - (Part 2)

Cardiac CT

(cont...) Disadvantages of Cardiac CT: • • • • • • • •

Above: 3D Reconstruction demonstrating LIMA and SVG grafts

A non compliant patient, leads to movement artefact Lack of IV access makes the CT procedure difficult to interpret CTA is unsuitable when there is a large amount of existing coronary artery calcification Arrhythmias and unusually high heart rates (>85 beta blocker may be administered) Artefact due to pulsation from blood flow in vessels and the chambers of the heart. Respiratory artefact Contrast induced artefacts Implant/metal artefacts

Currently at Harefield Hospital cardiac CT is not routinely performed. However, we have a one-stop GP referral clinic in operation for patients with non-urgent chest pain. Patients are routinely referred for CT calcium scoring if clinically indicated e.g. strong family, history diabetics, all men over 40 and all women over 50 years of age. Occasionally we are asked by the Cardiologist to perform CTA on difficult Cath lab patients when the Cardiologist is unable to locate the origin of an artery and more often for graft studies and to clarify anomalies.

and is still a very expensive diagnostic scanning tool. The confined space and constant ‘noise’ in an MRI scanner can make the whole procedure uncomfortable for the patient. As mentioned before, multislice CT on the other hand can be a very fast cost effective imaging tool. The time taken to perform a cardiac CT can take up to 20 minutes compared to an MRI scan that can take up to 1.5 hrs.

3D Reconstruction demonstrating a blocked RCA 22

CORONARY HEART ™


CARDIAC CT - (Part 2)

Cardiac CT However as we are due to have a 64-slice Toshiba scanner (Aquilion) installed in early January 2007, we hope to offer specialised Cardiac CT scans as a part of the service for patients referred to Harefield.

Future of Multislice CT Scanning in Cardiac imaging. As the use of Multislice CT in cardiac becomes more frequent, it is apparent that we need to be more aware of coincidental findings that may be malignant and non-malignant In some cases we may also find pulmonary nodules, aortic aneurysms, acute dissections, pneumonia. PE, nonurgent findings can include benign liver/adrenals lesions emphysema. Therefore we all need to look beyond the area of our interest. With faster scanning times and the imminent release of 256-technology and dual source technology Cardiac CT is evolving into it own. The advantages of using Coronary artery CT are growing with advances in multislice scanning.

Right: 3D Reconstruction demonstrating LIMA and SVG grafts

Special thanks to Toshiba Medical Systems for providing the images for this article.

Useful websites: www.auntminnie.com www.practicalCT.com 1.

2.

3.

4.

5.

Mautner, G.C., et al., Coronary artery calcification: assessment with electron beam CT and 8histomorphometric correlation. Radiology, 1994. 192(3): p. 619-23. Fallavollita, J.A., et al., Fast computed tomography detection of coronary calcification in the diagnosis of coronary artery disease. Comparison with angiography in patients < 50 years old. Circulation, 1994. 89(1): p. 285-90. Wexler, L., et al., Coronary artery calcification: pathophysiology, epidemiology, imaging methods, and clinical implications. A statement for health professionals from the American Heart Association. Writing Group. Circulation, 1996. 94(5): p. 1175-92. Kaufmann, R.B., et al., Detection of heart calcification with electron beam CT: interobserver and intraobserver reliability for scoring quantification. Radiology, 1994. 190(2): p. 347-52. Becker, C.R., et al., Helical and single-slice conventional CT versus electron beam CT for the quantification of coronary artery

(cont...)

We would like to hear your comments on our articles.

calcification. AJR Am J Roentgenol, 2000. 6.

174(2): p. 543-7.

Broderick, L.S., et al., Measurement of coronary artery calcium with dual-slice helical CT compared with coronary angiography: evaluation of CT scoring methods, interobserver variations, and reproducibility. AJR Am J Roentgenol, 1996. 167(2): p. 439-44.

Email your thoughts, positive or negative, and weâ&#x20AC;&#x2122;ll try to publish them in the next issue. Write to Tim at: tim@coronaryheart.com CORONARY HEART â&#x201E;˘ 23


SPECIAL FEATURE - CT

Why I like calcium scoring for coronary disease

Written By: Dr Rodney Foale, FRCP. FACC. FESC. FCSANZ.

Clinical Director, Surgery, Cardiovascular Sciences and Critical Care. SMHT. Clinical Editor for Coronary Heart™ Magazine

T

o begin, it is undeniable that in virtually any countries adult population, coronary artery disease is often grossly under diagnosed and treated. This particularly applies to certain ethnic groups particularly of South Asian (Indian) origin who have over recent years been shown as having a high incidence of coronary disease yet often undeclared by typical symptoms. The medical culture has historically led us through a stepwise progression of focused diagnosis using a clinical algorithm beginning with symptoms and ending with angiographic study. However, it is sad but true that all too often the first presentation is with death and the first positive diagnosis is by autopsy. Therefore, any tests that apply to the community to increase health professionals’ awareness of coronary disease, and which fast tracks past culturally historic thinking about diagnostic pathways to achieve more rapid diagnosis, must be to my mind, be welcomed.

Above and Below: Calcium Scoring during CT Calcium scoring for coronary artery disease is one such test. It relies on CT imaging of the heart which detects focal Calcium deposits somewhere in the walls of the coronary arteries providing a numeric “score” ranked as a percentile against various known patient and normal populations. The score is then used to extrapolate to luminal coronary narrowings. The procedure has been enthusiastically embraced, mostly in the independent sectors, but this is not to say that the test is 24

CORONARY HEART ™

without its detractors and indeed some of the detractions are arguably fair. These concerns relate for example to the fair equitable access for populations dependent upon cost sensitive organisations who purchase their care be it in the UK primary care trusts, purchasing organisations elsewhere, or third party private insurers; the radiation dosage which might limit the applicability of longitudinal follow up to assess treatment strategies and, the validity of correlations between mural calcium and obstructive endoluminal arthosclerotic lipid disease.


SPECIAL FEATURE - CT

Calcium Scoring

(cont...)

My own personal algorithm for assessing patients who come to my consulting rooms or Hospital with a CT test result, (and at the present time the investigation is not particularly high on my radar), is to hope for a zero score. Zero scores are very predictive of very normal arterial anatomy. Of course if such a patient has, usually quite unlikely, a bunch of risk factors such as smoking, cholesterol and family history etc depending on age and gender a negative score does not necessarily demand that no statin agent is applied. If I am presented with a patient at the other end of the spectrum with an extremely high score of above the 90 percentile of the published normal population for example, then notwithstanding the often completely irrelevant little diagrams that accompanies some reports (which seems to indicate that everyone seems to have entirely the same coronary anatomy i.e. shared dominant right circumflex and LAD with the calcium deposits illustrated as black lines imprinted on such an improbable likelihood) then I will first think of major risk factor modifications and I confess to whatever the cholesterol levels I will attack risk factors with gusto including statin agents. For those patients with scores in the middle range, around the 50th percentile, again I would not accept the standard report of “almost certain obstructive coronary disease” that appears with the report, I would return to the principles of history and examination and would look towards aggressive control of the risk factors. Should the exercise test prove positive then this would probably lead to invasive diagnostic angiography. In any patient or perhaps I should say person with elevated calcium scores we should turn to a properly conducted

Calcium Scoring sheet sample of same patient Images provided by Toshiba Medical

exercise test as a check. Exercise testing if properly conducted to maximum protocols with careful attention to blood pressure, heart rate responses and a sensible analysis of decent base lined ECG, remains the tool of choice and my view is a first stop assessment rather than a CT examination. I don’t in this brief editorial mean to denigrate any of the scientific data whatsoever. I mean only to express as a rather old fashioned clinical cardiologist a simple personal view. However, I would have to say that in some examples of patients presenting with a high score, I have had patients despite a complete absence of symptoms and

actually a negative exercise test, who have had critical coronary stenosis (it must be said that usually in relatively “ECG silent” areas of the heart. So in summary, I welcome the procedure as a valid screen and if it were a test associated with less radiation and perhaps more diagnostic accuracy in the middle score ranges and if it were more generally available to populations often in the poorer social economical groups that could afford it, I would perhaps show a little more enthusiasm for its first line use. No doubt as more correlative data becomes available, these views might change. CORONARY HEART ™ 25


CARDIAC SITE VISIT

UNITED STATES OF AMERICA

Florida Hospital ADDRESS Cardiovascular Institute Florida Hospital - Orlando 601 East Rollins Street Orlando, 32803 Florida United States of America

FAST FACTS 1. Ranked one of USA’s Best Hospitals by US News. 2. 94 staff over 5 campuses. 3. 13 Cath labs 4. 4 EP labs 5. 1 Endovascular lab 6. All staff cross-trained

MAP

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he Florida Hospital is owned and operated by the Adventist Health System, located in the city of Orlando, and is spread over seven campuses. The main campus is an 881-bed acute-care community hospital, that serves as a major tertiary facility for much of Southeastern Florida, the Caribbean and South America. The Cardiovascular Institute at Florida Hospital has earned a national reputation for its leadership in advanced cardiac care, and with a team of 130 board-certified cardiologists, and over 1000 cardiac nurses and technicians across all campuses, it isn’t 26

CORONARY HEART ™

hard to see why. The Florida Hospital also offers 24hour emergency services and helicopter transport for cardiac patients, as well as a 24-hour chest pain center. The following questions have been completed by Donna Ortkiese, the Marketing and Planning Manager at the Florida Hospital Cardiovascular Institute.

1) Size of the Cath Lab facility: We are a seven campus facility with 13 cath labs and four EP labs at five of the campuses. The main campus has seven cath labs, four EP labs and one endovascular lab. Three of the campuses have a single lab with one campus having two.

2) Staff Numbers & Roles: If we look at the cath labs only, there are 94. All roles are cross trained to


CARDIAC SITE VISIT

UNITED STATES OF AMERICA

Florida Hospital A small selection of the Cath Lab staff located at Main Campus at Florida Hospital

year and performed 43,800 procedures

6) Cross-Training: Every team member who works in the lab is cross trained into every position. This allows for an extremely flexible and strong team with little concern for call team or room assignments.

7) Surgical Back-up: Interventions are only performed at the main campus which has a large operating suite giving full surgical back up.

8) New Procedures Implemented: Many of our physicians are involved in research so we get to see all the latest and greatest procedures.

9) Inventory Management:

perform every duty. This includes circulating and administering medications. We have one job description for all team members no matter what your qualifications (Registered Nurse, Respiratory Therapist, Radiology Tech or RCIS).

3) Procedures: We are a full service facility. With some of the campuses used by cardiology and radiology and the endovascular lab we perform all types of procedures including cardiac

interventions. rotoblator, athrectomy, PFO Closures, Peripherals and Carotid Stenting to name only a few.

4) Day Cases: Our current process is that all interventional procedures are performed as inpatients. Diagnostic procedures are normally performed as an outpatient.

5) Procedures per Year: We had 13,500 patient contacts last

We are using Apollo, a comprehensive system of computer documentation that tracks utilization and is balanced by a strong team of dedicated inventory personnel.

10) Haemostasis Management: We use a variety of devices which include Vasoseal, Perclose, Syvek and when needed Femstop.

11) Measures Implemented to Reduce Costs: We use the Apollo System for documentation, inventory and patient

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CORONARY HEART â&#x201E;˘â&#x20AC;&#x192; 27


CARDIAC SITE VISIT

UNITED STATES OF AMERICA

Florida Hospital database. From this database we can track a number of variables to assist in productivity improvements, price negotiations and physician feedback. We have also partnered with our physicians to help reduce the size of our inventory and reduce supply costs.

15) Regular Staff Competency Checks: After completing the initial training and orientation there are annual competency requirements.

12) Alliances with Other Hospitals:

16) How long has the cardiovascular program been going for?

We have affiliations with some outlying facilities to offer tertiary care and surgical back up.

The program has been in place for 39 years.

13) Training for New Employees:

17) Training facility for students:

We have a comprehensive education program that includes didactic and hands on training. Due to the intensity of the training and exposure to the large variety of cases we have placed a value on the training that requires a commitment to the facility to repay if the employee leaves in less than 2 years.

Our facility is affiliated with two cardiovascular technologist programs, a radiology technologist program and a Nursing School.

14) Continuing Education:

Aside from working with a world class team of highly skilled staff and physicians it is exciting to be on the leading edge of technology and treatment.

There are frequent in-services, LunchN-Learn, conferences, research and formal educational opportunities.

18) What is the best part of working at your facility?

WHY ORLANDO? Orlando is located in central Florida with a population of approximately 180,000. Apart from the fantastic weather which bathes this region, Orlando is famous for its nearby attractions which attract millions of people to the area each year.

Things to see and do: Walt Disney World

The world’s most famous resort spread over four theme parks and two water parks. Meet Mickey Mouse and at the Magic Kingdom, and visit multiple countries faster than buying a Eurail at Epcot Center. Fun for the whole family and a must see once in your life.

Kennedy Space Center

Visit the home of NASA. There are interesting museums, and great tours of the working facilities. Be an astronaut for the day with the ATX program where you can fly a simulator, meet and astronaut, and stand below the shuttle launch pad.

Sea World Adventure Park

Meet Shamu, the world’s most famous Killer Whale or have an up close and personal encounter with a dolphin. The theme park has it all for those interested in the deep blue.

Seaworld, Orlando 28

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Courtesy: NASA


CARDIAC SITE VISIT

UNITED KINGDOM

Photos by: Tim Larner

Guy’s & St Thomas’ NHS Foundation Trust

ADDRESS The Cardiothoracic Centre St Thomas’ Hospital Lambeth Palace Road London SE1 7EH United Kingdom

FAST FACTS •

Home to the Coronary Disease Research Centre www.angioplasty.org.uk

One of the highest volume Cardiac departments in the UK with over 6000 diagnostic procedures & 2000 PCI case per year.

Cardiac Radiology Manager – Annie Williamson Email: annie.williamson@gstt.nhs.uk

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ocated in the best site in London for a hospital, Coronary Heart’s Director, Tim Larner wandered past Big Ben, the Houses of Parliament, & across the River Thames, and into the department for this issues site visit:

A selection of Cath Lab staff From Left: Dr Peter O’Kane, Ola Banjoh, Nikki Whitfield, Dwayne Evans, Juliet Jaikumar, Matt Allen, & Sandy Nkomo Guy’s and St Thomas’ NHS Foundation Trust is made up of two of London’s oldest and most well known teaching hospitals. The hospitals have a long history dating back almost 900 years and have been at the forefront of medical innovation and progress since they were founded. The trust became an NHS Foundation Trust in July 2004. As well as providing a full range of hospital services for the local communities in Lambeth, Southwark and Lewisham, the Trust provides specialist cardiothoracic services for patients from further afield. The Coronary Disease Research Centre is an integral part of the department, and due to the large volume of patients,

provides the perfect opportunity for specialist registrars to continue research. During my site visit, I don’t think I have ever laughed so much. Everybody is friendly including the cardiologists and managers. Also the teaching is great!! I come from a radiography background and had the pleasure of watching Nikki Whitfield, one of the UK’s most well known cardiac radiographers, instruct a new radiographer. She has a wonderful teaching style and is extremely knowledgable. New staff would love to train here. The following questions have been answered by the cardiac department’s managers and senior staff:

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CORONARY HEART ™ 29


CARDIAC SITE VISIT

UNITED KINGDOM

Guy’s & St Thomas’ Lab 1 – Innova 2000 + Sensis haemodynamic monitoring system Lab 2 – Innova 2100 + Sensis haemodynamic monitoring system Lab 3 – Siemens Hicor/coroscop (for replacement 2006) + BARD/PRUKKA EP system Lab 4 - Siemens Hicor/coroscop (for replacement 2007) + BARD/PRUKKA EP system Lab 5 – Siemens Artis + Sensis haemodynamic monitoring system

Lab 3: Dr Jaswinder Gill (Consultant Cardiologist) performing a research EP Ablation Study with NAVEX & CARTO.

1) Size of the hospital and cath lab facilities? Guy’s and St Thomas’ NHS Foundation Trust (GSTT) is situated on two main sites:

contains 1 bi-plane lab (Siemens Artis) where all paediatric and the majority of Adult Congenital cases are performed. The adult cardiology department contains 5 single plane cath labs:

Four of the cath labs are situated together on the same floor. These are configured in pairs (side by side) with a joint control room providing quick and easy access between them. Work within the paired labs is scheduled to take advantage of this design eg the EP and Pacing labs are adjacent and two interventional labs are adjacent.

2) Staff Numbers? Physiology The Cardiothoracic Centre employs 31

1. Guy’s Hospital – next to London Bridge station and Borough Market. 2. St Thomas’ Hospital – looking across the Thames at the House of Commons, by Westminster Bridge. We have 1200 beds and employ approximately 8,000 staff The Cardiothoracic Centre has 154 beds. Cardiac inpatient services are based on the St Thomas’ site alongside A&E and acute facilities. The trust as a whole has 6 cath labs. The Evelina Children’s Hospital 30  CORONARY HEART ™

Lab 1: Dr Simon Redwood (Cath Lab Director), left, performing a Rotablator case with Dr Rainer Zbinden (Registrar). Nikki Whitfield can be seen on right teaching.


CARDIAC SITE VISIT

UNITED KINGDOM

Guy’s & St Thomas’ cardiac physiologists of whom 12 are in specialist posts working in one area or service eg Pacing and electrophysiology. We have at least 6 physiologists present in the labs at one time. Each technical area (Pacing, EP, Cardiac Catheterisation and Intervention, Echocardiography and Non invasive cardiology) has a lead physiologist whose role encompasses developing and maintaining professional standards, training, quality control and audit as well as providing a technically excellent level of service. In addition we have 6 BSE accredited echocardiographers, 3 NASPE qualified Pacing specialists, 2 NASPE qualified Electrophysiology specialists. These staff work predominantly in one area of service at a highly specialised level. The remaining staff rotate through all areas of technical cardiology providing a mix of service provision and training and development opportunities for the individual. Radiography There is one radiographer that works full time in the adult cardiac cath labs. Unusually, the cath lab radiography team is employed directly by the Cardiothoracic Centre and is managed independently from radiology. Nursing There are 17 WTE nurses employed within the cath lab area rotating through the 5 labs and a 4 bay recovery area. All nurses scrub for invasive procedures.

Julia Watts Superintendent Radiographer

Lab 5: Dr David Lythall with nurse Liz Ford at the start of a case.

3) Main roles for the radiographers, nurses and physiologists? The standard British system is in place here: Nurses For most procedures we have only one cardiologist operating so we provide two nurses One ‘scrubs’ to assist the operator and the other ‘runs’ ie administers any drugs and fetches consumables as necessary. Maintains procedural documentation and responds to patient needs during the procedure. In this department very few procedures are performed under GA. We have only one anaesthetic machine covering all 5 labs.

Radiographers • Image quality • Radiation protection (both patient and team) • Operation of the x-ray equipment and table • Image archive • Equipment maintenance and supervision (including Quality Assurance) • Relevant documentation • Equal/shared responsibility for patient advocacy and care We also assist the other disciplines whenever possible eg operating temporary pacing boxes, management of haemostasis/sheath removal, attaching ECG’s, opening packs etc – the usual Physiologists • Haemodynamic monitoring • Procedural documentation • Assistance with procedures • Management of IABP

>> CORONARY HEART ™ 31


CARDIAC SITE VISIT

UNITED KINGDOM

Guy’s & St Thomas’ of working and a second radiographer is participating in an ‘in house’ generic training programme and will join the next intake of CCLP students at London South Bank University. We would like to have all staff ‘crosstrained’ to improve staff flexibility and efficiency but will ensure that all three disciplines are represented in the Labs to maintain specialist expertise and quality control.

Admission Staff: Guillermo and Julie We also get to play with all the cath lab ‘toys’ so we operate radiwire, laser, rotablation machines, IVUS, Navex, Carto, Ensite and Cryocor.

4) Procedures? This department performs the full range of procedures from the routine through to the very complex. Just too many to list!

5) Day cases? Our elective angiography has of course always been performed as day cases. We are now operating a ‘Treat and Transfer’ PCI service to some Trusts and a limited number of elective PCI’s and EP studies are also performed as day cases.

6) Cross-Training? We were one of the original pilot sites for the Cardiac Catheter Laboratory Practitioner (CCLP) project and have 2 members of staff (one nurse and one radiographer) who have successfully completed the course. The radiographer has now been seconded to the cardiac physiology team. We are fully committed to this new way 32  CORONARY HEART ™

7) Surgical Back-up? There are x 4 cardiac theatres two floors below the cath labs. If necessary we can have a surgeon in any lab within a couple of minutes and all our lab images are available within theatres.

8) Inventory Management? A member of staff is employed by physiology. Inventory is currently managed manually but we are investigating wireless bar code scanners linked to a central database.

9) Haemostasis Management? We use ‘strong arm’ devices, radistops, starclose devices and angioseals as well as good old manual pressure.

perform per week about 4 are private. Private cases are treated in exactly the same way as NHS ones and are performed within normal operating sessions. Priority is given to any case on grounds of clinical need and NOT funding stream.

11) Training for new employees? For physiology there are training programmes in place for each specialist field, supervised and supported by a clinical lead physiologist. Training within the labs can range from an introduction to angiography through to training in IVUS, rotablation and other complex procedures. For radiography there are training programmes and clinical competence assessments for each area (assessments repeated annually). Each training programme starts with a comprehensive departmental induction followed by a structured training plan covering each procedure from simple diagnostic caths to complex intervention. There are further training programmes for the more demanding aspects of the role eg co-ordinating the patient list for the 5 labs. Personal development is actively encouraged and departmental training

10) Private cases? Any special considerations? We do perform private cases within the labs but the numbers are relatively low. Out of the 150 plus cases that we would expect to

Lab 1: Dr Simon Redwood (Cath Lab Director) during the Rotablator case


CARDIAC SITE VISIT

UNITED KINGDOM

Guy’s & St Thomas’ WHY LONDON? 12) Is the department used as a training The Christmas, New Year facility for cardiac registrars Period is a special time to (USA = residents)? Yes. We currently have 8 Calman registrars but additional honorary registrars from other trusts, research registrars and medical staff from abroad also come here for training.

13) What is the best part of working at your facility?

From Left: Alex Slatter & Liz Ford (both nurses) opportunities are provided in the form of tutorials, lectures and meetings. The Cath Lab training programme for nurses starts with a 2 week orientation period (including Trust Induction). Trained and experienced Mentors are appointed to all new staff and development needs are discussed and identified during the first 6 weeks in post. We aim to have new staff independently scrubbing/running for diagnostic catheters at the end of a 6 week programme. The Cath Lab training for nurses involves meeting cath lab specific competences.

‘We like to think of ourselves as more like a family than a facility (only joking)!’ This is a very high profile unit within a world famous hospital. The variety of acute and elective work is both challenging and interesting. We also participate in a lot of research and development projects. We have a large multidisciplinary team who enjoy socialising and making the most of all that London has to offer. We are 5 minutes from the Royal Festival Hall, the London Eye and all the great theatres, restaurants, art galleries and shopping opportunities are within easy reach.

be in London. Although it is dark by 4pm the city comes alive. Enjoy a hot gluvine under the Christmas tree in Covent Garden, go ice skating on several outdoor rinks, or just snuggle up in front of a roaring log fire in a traditional English pub.

Things to see and do: Christmas Eve:

Visit the world famous Royal Albert Hall for a night of Carols by Candlelight.

New Years Eve:

Arrive early opposite the London Eye for a spectacular fireworks show, or book a ferry and sail past Big Ben as it chimes at midnight.

Shopping:

Beautiful window displays, magical street lighting, & children singing carols makes an evening shopping trip in central London a truly special experience. View of Big Ben, the Houses of Parliament, and the River Thames from St Thomas’ Hospital

There are excellent training and development opportunities for nurses at GSTT. We offer diploma, degree and masters programmes via our link with Kings College London and London South Bank University. We also offer internal/local developmental programmes for nurses to meet generic /cardiac/area specific competencies. © Guy’s & St Thomas’ NHS Foundation Trust

CORONARY HEART ™ 33


EP EDUCATION An Introduction to

ELECTROGRAMS

I

Written By: Ian Wright, St. Mary’s Hospital, London

nvasive cardiac electrophysiology is based on the interpretation of intra-cardiac signals (electrograms or EGMs for short) to study arrhythmias and guide ablation.

Why are intra-cardiac signals important? The surface ECG represents the sum of electrical activity from the heart, presenting lots of information in one easily digestible form. However it does not reveal the timing or sequence of activation of specific locations within the chambers – the distal coronary sinus or the left upper pulmonary vein The His Bundle Electrogram for example. For this we need local electrograms picked up by endocardial to stretch the signals out which has the key locations within the heart allows catheters. With these it is also possible side effect of making the ECG look a electrophysiologists to follow the to record signals from structures too bit odd at first sight (see Fig 2). propagation of electrical activation by small to produce sufficient voltage to noting the order of the signals in time register on the surface ECG. One such - the more signals that can be displayed structure is the His bundle - crucial the more of the for understanding wave’s propagation the heart’s electrical through the heart Fig. 2: The surface ECG during EP studies system and many can be understood. tachycardias. So, unlike the ECG, The figure below shows a surface ECG (V1) recorded at 200mm/sec. it is the activation The complex is stretched out – an appearance not unlike old analogue The His Bundle sequence which is Holter recorders with “tape stretch” Electrogram (HBE) most important not first recorded the morphology endocardially in of the signals. The humans in 1969 electrograms are provides the key to filtered so that the unlock the mysteries timing of local of many tachycardias. activation is clear It consists of three and repolarisation is signals in one – an atrial component, What do the signals reveal largely removed. the His “spike” and a ventricular and why record so many? component. The His spike or potential The example on the opposite page cannot be seen on the surface ECG The signals in EP are a lot like floating (figure 3) demonstrates a simple use – it is only by going inside the heart objects that bob up and down as an of electrograms in the diagnosis of a that it can be recorded. The separate ocean wave passes them by. If there tachycardia. The ECG shows a regular components would appear jumbled are enough floating objects around broad complex tachycardia for which together and confusing at the paper they may give an impression of the the differential diagnosis is VT or speed of a standard ECG recording direction of motion of the wave by SVT with aberrant conduction. If (25mm/sec). As a result EP signals are the order in which they are moved (or the rhythm were SVT with aberrant usually recorded at 100 or 200mm/sec activated) by it. Placing catheters in conduction there would be an atrial 34

CORONARY HEART ™


EP EDUCATION

Electrograms

(cont...)

Figure 3 signal (HRAp) for each ventricular signal (RVAp). In the example there are clearly more ventricular signals than atrial -making this VT. Cardiac physiologists may be familiar with using the electrograms stored by pacemakers and ICDs in this way.

Distinguishing atrial from ventricular signals Atrial signals occur during the P wave on the ECG. Ventricular signals occur during the QRS complex. In sinus rhythm (right and below) the His spike can be seen on the His channel spanning the gap between the two (when all is quiet on the ECG).

Fig (above). The two vertical lines contain all the atrial signals, which line up with the P wave on the surface ECG (at the bottom)

Fig (above). The His spike (or potential) occurs in between the P wave and the QRS complex and there is no sign of it on the surface ECG.

Fig (above). The vertical lines now contain all the ventricular signals, which line up with the QRS on the ECG

>> CORONARY HEART â&#x201E;˘ 35


EP EDUCATION (cont...)

Electrograms

(cont...)

Near and far-field signals Signals from tissue close to the recording catheter usually appear large and sharp whereas signals from tissue farther away appear somewhat smaller and more rounded. An example of this is seen the in the coronary sinus signals in the sinus rhythm example above. The coronary sinus signal labelled CS 7-8 shows an initial sharp signal from the atrium followed by more rounded one from the ventricle. This is because the proximal coronary sinus is physically closer to the atrium than the ventricle. Distinguishing between near and far field signals can be an additional way to determine if they originate from atrium or ventricle. This can be useful when

Figure 7 the A and V signals become very close together or superimposed - as occurs in patients with accessory pathways or during AVNRT. The example above (figure 7) shows A and V signals almost superimposed during ventricular pacing

Bipolar and Unipolar Signals

T

here are two types of signals in EP - bipolar and unipolar. Bipolar signals are produced when the voltages on the two recording electrodes both vary with time - as is the case when each is positioned within the heart. This is equivalent to plotting the height of two floating objects relative to each other as they are moved up and down by passing waves. Unipolar signals in contrast are produced when one varying signal is compared with a constant

in a patient with a pathway. The signals are separated in sinus rhythm (right hand side). The mapping catheter is on the atrial side of the valve annulus and the atrial signal is the slightly sharper of the two.

reference (an indifferent) placed outside the heart. This is equivalent to recording the position of our floating object compared to something fixed on the beach. Most signals used in EP are bipolar because they reduce far-field signals and they are less prone to electrical noise. Unipolar signals are sometimes used - because they reveal when all activation is headed away from an electrode or to see the signals from each pole of a catheter separately. The surface ECG also contains bipolar and unipolar elements – the standard limb leads are bipolar, the chest leads unipolar.

More about the His Bundle Electrogram (HBE) The His signal is so important because it reveals information about conduction through the AV node, essential for normal conduction and critical for many arrhythmias. Although it is not possible to record signals directly from the AV node itself we can make inferences about its behaviour by observing the atrial signal as the wave “disappears” into the node and the timing of the His spike as the wave emerges from the node and whizzes down the His bundle. If the time between these two components (the AH interval) increases, conduction through the AV node is said to have slowed. The interval between the His spike and the ventricular component (the HV interval) represents conduction down the His Purkinje system. If AV block occurs it is possible to identify the site of block – whether in the AV node or the distal conduction system (the His Purkinje tissue). 36

CORONARY HEART ™

The figure above shows block in the AV node. There are atrial signals (A) on the His channel but no His spikes.

>>


EP EDUCATION (cont...)

Electrograms

(cont...)

The figure below shows block in the distal conduction system beyond the AV node. There are atrial signals (A) and His potentials but no ventricular component or QRS complexes. This type of block has a high incidence of progression to complete heart block.

Š Ian Wright. Nov 2006

Write for us

Send us your articles, studies, hot tips, interesting ECGS, and cases

coronaryheart.com CORONARY HEART â&#x201E;˘ 37


MEDICAL IMAGING

LAO 40 RCA

Right Coronary

AM

Acute Marginal

PDA

Posterior Descending

PLV

Posterior Left Ventricular

Alternatives: Less LAO (eg. LAO 20):

LAO 40

This will have the effect of foreshortening the proximal and distal sections of the RCA. The PDA and PLV branches will still be foreshortened and possibly overlapped. This view would only be need for the mid RCA which demonstrates well. Stick with the LAO 40. More LAO (eg. LAO 50):

Objectives: This angle is used as the first projection when viewing the Right Coronary Artery (RCA) as it demonstrates the origin clearly for intubation. Many doctors prefer to be in PA when passing the catheter up the aorta, so when they begin pulling the wire out once over the arch, the radiographer should immediately rotate the camera to LAO 40. You will notice that the doctor will initially have the catheter pointing towards the left before rotating it, which should, hopefully, engage the origin of the RCA. This projection is good for demonstrating the proximal, mid and distal RCA, however there is foreshortening of the PDA and PLV branches. Radiographers (RT) should be aware that the RCA can extend a long way on the inferior aspect of the heart, and be prepared to follow. This can be difficult due to doctors leaning on the table in the opposite direction to where you want to go. Also be aware that narrowings in the left system can be demonstrated by collateral filling from the right.

Catheter Positioning On-Screen: The catheter should be positioned in the middle of the screen close to the top before the start of the acquisition. 38

CORONARY HEART â&#x201E;˘

Increasing your angle to this degree, not only increases the radiation dose but it foreshortens the proximal RCA. This view only demonstrates well the Acute Marginal and RV branches, which are rarely stented.

LAO 40


MEDICAL IMAGING

LAO 20 / CRA 20 RCA

Right Coronary

AM

Acute Marginal

PDA

Posterior Descending

PLV

Posterior Left Ventricular

Alternatives: More CRA (eg. LAO 20 / CRA 40): This will have the effect of grossly foreshortening the proximal and mid sections, and moderate foreshortening of the distal RCA. The PDA and PLV branches will be better separated.

LAO 20 / CRA 20

Less LAO (eg. PA CRA 30):

Objectives: This angle is often used as the second projection after the LAO 40. It is useful for demonstrating the distal RCA, including the PDA and PLV branches. The radiographer should always be ready to pan the table to the left side of the heart to demonstrate any collateral filling of the LAD or Circumflex arteries. There will be foreshortening of the proximal and mid RCA in this view. As a result of this foreshortening, radiographers should also be able to collimate in further reducing the radiation dose even more. Be aware that 50% of doctors (including our Clinical Editor) prefer to use the PA Cranial 30 rather than this view. See right for an explanation.

This view is used by approximately 50% of cardiologists as it demonstrates the PDA and PLV branches better, as they are further separated. The disadvantage of this projection is that the distal RCA, PDA and PLV also overlap the spine which can reduce visibility and increase radiation dose.

This view is used when the coronary system is right dominant. If the RCA is non-dominant then LAO 40 will suffice.

Catheter Positioning On-Screen:

LAO 20 / CRA 20

The catheter should be positioned in the middle of the screen, close to the top before the start of the acquisition. Prepare to pan.

MODEL: Rob Edwards

CORONARY HEART â&#x201E;˘ 39


CONFERENCES

Conferences January 15-19

38th Annual Cardiovascular Conference at Snowmass Location: Snowmass, CO, USA Website: www.scai.org

January 24-26

Advanced Angioplasty 2007 Location: London, UK Website: www. advancedangioplasty.co.uk

January 26-27

2007 March 11-15

23rd Annual Cardiovascular Conference (CSS)

Location: Lake Louise, Canada Website: www.css.ca

March 24-27

American College of Cardiology 56th Annual Scientific Sessions

Location: New Orleans, USA Website: www.acc.org

The Heart of Women’s Health

April 29 - May 2

February 2-4

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

Location: Washington, DC, USA Website: www.acc.org

CardioRhythm 2007

Location: Hong Kong, China Website: www.cardiorhythm.com

February 10-11

First International Rural Cardiac Care Conference Location: Kerala, India Website: www.frontierlifeline.com

8th International Conference of Nuclear Cardiology (ICNC8)

May 4-5

Challenges in Cardiology VII Location: Brisbane, QLD, Australia Website: www. heartfoundation.com.au/qld

February 12-16

22nd Annual Cardiovascular Conference at Hawaii Location: Hawaii, USA Website: www.scai.org 40

CORONARY HEART ™

May 9-12

Heart Rhythm 2007

Location: Denver, CO, USA Website: www.heartrhythm2007.org


CONFERENCES

Conferences 2007 May 9-12

SCAI 30th Anniversary Annual Scientific Scientific Sessions

Location: Orlando, FL, USA Website: www.scai.org

May 22-25

EuroPCR Congress

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

June 24-27 EuroPace

Location: Lisbon, Portugal Website: www.escardio.org

June 28 - July 1

1st World Congress on Controversies in Cardiovascular Diseases Location: Berlin, Germany Website: www.comtecmed.com/ccare

June 4-7

British Cardiac Society Annual Scientific Conference Location: Glasgow, UK Website: www.bcs.com

June 7-10

The 2007 Port Douglas Heart Meeting & Expo

Location: Port Douglas, QLD, Australia Email: s.bain@idaustralia.com

June 9-12

August 9-12

55th ASM of the Cardiac Society of Australia and New Zealand Location: Christchurch, NZ Website: www.csanz.edu.au

October 20-24

Canadian Cardiovascular Congress 2007 Location: Quebec City, Canada Website: www.css.ca

Heart Failure 2007

Location: Hamburg, Germany Website: www.escardio.org

June 18-21

American Society of Echocardiography 18th Annual Scientific Sessions

Location: Seattle, WA, USA Website: www.asecho.org

October 22-26

TCT 2007: Transcatheter Cardiovascular Therapeutics Location: Washington DC, USA Website: www.tctmd.com

Like your meeting or conference listed free? Visit us online: coronaryheart.com CORONARY HEART ™ 41


CONFERENCES

Conference Review British Society of Echocardiography Annual Clinical & Scientific Meeting

October 26-28, 2006 Bournemouth, UK

T

he Bournemouth International Center (BIC) on the southern coast of England was the site for this years BSECHO meeting. Over 600 delegates from around the UK converged on the resort town of Bournemouth for an interesting mix of education, seeing new company products, and of course socialising. The most popular speaker over the two days was Guest Lecturer, Professor John Gorscan III from the University Hospital of Pittsburgh, USA. His presentation on “Echo Jeopardy” designed around the TV show of the same name was a hit. The conference organisers also made use of the latest interactive technologies to ensure participants were kept awake by using hand-held “guns” with Yes & No buttons to answer questions. Echo companies were also well represented showing off their latest equipment to potential buyers. All of the participants we spoke to enjoyed the conference which is growing in size each year. Of course the highlight for many was the now infamous Friday night social event being the theme Hero’s and Villains. The night had no major casualties however in true British style the evening finished with some table dancing. See you there next year!!!

Karen Hill (Business Development Manager) from Toshiba demonstrating the new Aplio CV

ROVING REPORTERS Local National WANTED Meetings Conferences All you have to do is tell us the best bits, the worst bits, some entertaining facts, and what extra knowledge attendee’s departed with. You must also have a digital camera for some event photos. What do you get for the work? 1. Your photo placed on a new “Roving Reporter” web page, 2. Your article published in this magazine. 3. International recognition and admiration!! (not guaranteed) Visit our website to find out how you can become involved:

coronaryheart.com

42

CORONARY HEART ™


LANGUAGES

SPAIN

T

o assist you in the cardiac environment with patients whom have limited knowledge of English we have given you a helping hand. With the assistance of internationally recognised translators we have converted common cardiac phrases into foreign languages, and also provided their phonetic pronunciation in English. This issue we look at the romantic language of Spanish, spoken by approximately 410 million people. Along with English it is one of the most used languages, and is very popular in Europe and the America’s due to early explorers and colonists, who sought to expand the Spanish Empire. The language is famous for the catch phrase:

Cardiac Spanish English

Spanish

Phonetic

Hola

Ola

Buenos días

bu’enos ‘dias

Yes.

Si

No.

No

No

Don’t move.

¡No se mueva!

no se mu’eva

Breathe in.

Inspire

ins’pire

No respire

No res’pire

Respire

res’pire

Bien

bi’en

Despacio, despacio

des’pathio, des’pathio

¿Puede que esté embarazada ahora? No recomendamos una corrida de toros a un corazón sano

pu’ede ke es’te embara’thada a’ora No recomen’damos ‘una co’rida de ‘toros a un cora’thon ‘sano

Hello. Good Morning.

Don’t breathe. Breathe Good Slowly, slowly. Any chance of being pregnant? We don’t recommend bull fighting for a healthy heart.

Ole!

Translated with the assistance of Ms Celia Cordero, from Spain. CORONARY HEART ™  43


INTERVIEW

Clinical Editor for Coronary Heart™

Dr Rodney Foale 1. Why did you decide to become an Invasive Cardiologist? When I started in Cardiology diagnosing Valvular Heart Disease and reading ECG’s were what most cardiologists did, coronary heart disease was barely noticed. At that time angiography of the coronary arteries was quite restricted and patients diagnosed with Coronary disease were always sent for bypass surgery. However in 1979 I assisted my boss at the time, the National Heart Hospital Cardiologist Dr Tony Rickards, when he performed the first balloon angioplasty in the UK, and I knew this was where my future lay. Although retaining a keen interest in all things within the broad title of “general Cardiology” I have never looked back from my principle interest in coronary intervention.

Hammersmith Hospital in London under Professor Attileo Maseri, is famous for his discoveries in coronary spasm and syndrome X and other aspects in the pathogenesis of Angina pectoris. Finally in 1985 I took a

FRCP. FACC. FESC. FCSANZ. Clinical Director, Surgery, Cardiovascular Sciences and Critical Care. SMHT. Consultant Cardiologist position at St Mary’s Hospital in London, where I am now the Clinical Director of Surgery, Cardiovascular Sciences, and Critical Care and where I am the oldest and most senior Interventional cardiologist!

2. Where did you train? I graduated from Melbourne University, Australia in 1971 whereby I trained at St Vincents Hospital. Leaving Australia I moved to the UK where I worked for three wonderful years as an SHO at the London Hospital under the brilliant Clinical Cardiologist, Dr Wallace Brigden, famous for coining the term and describing the condition of “cardiomyopathy”. This time was followed by becoming a registrar at the National Heart Hospital where I studied and researched for six years. I then moved to the USA to Boston at Harvard University, working at the Massachusetts General Hospital, and for three years to pursue senior training in invasive and non-invasive cardiology with some wonderful senior Cardiologists. In 1983 I headed back to the UK, working as senior registrar at the 44  CORONARY HEART ™

Dr Rodney Foale at his consulting rooms in Harley Street, London


INTERVIEW (cont...)

Dr Rodney Foale 3. What are some of your career highlights? •

Working for Dr Wallace Brigden where cardiology was nothing more than having good hearing through a stethoscope.

Working with Professor Attillio Maseri whom took invasive cardiology to the limits of possibility. There was nothing he wouldn’t try, he would never give up asking questions and his intellectual curiosity was a great lesson to me.

Assisting Dr RicKards when performing the first balloon angioplasty in the UK. Being the first Cardiologist in the UK to use a monorail balloon.

Actually, there is a funny story there with the last one. I happened to be having lunch with the Head of Schneider one day in 1985, when she said she was on her way to give Dr Rickards a try of their New “Monorail” balloon upon which they held the patent. I grabbed it from her and told her that we were going to use it in the next case straight after lunch, and it was quite a lunch!. So what was going to be another first for Dr Rickards, became a first for me!! Since that day I have never gone back to Over the Wire, because the Monorail system is just so easy to use. •

Working at St Mary’s we occasionally organise clinical conferences in fantastic places like Malta or France, whereby we take a full team (including nurses, radiographers, and techs) to perform cases. Just because the locations happen to be near a beach, a great ski resort, a brilliant night life, we can only put down to luck. We are in the process

of organising a “hemispheric” conference in Tobago, next March, 2007, which just happens to coincide with the World Cup Cricket being on in the region at the time. •

We were also the first UK hospital to consider that multi-disciplinary teamwork in carotid stenting was better than “turf wars” and I headed a team to Germany to learn the technique..

4. What is the most bizarre case you have been involved in? We were performing a graft study on a very powerful UK business man, when upon intubating the LIMA we caused a massive dissection which I saw spiral down the vessel. Actually we didn’t see it for a while after that because a power cut out, turning the x-rays off, and turning the lights out. We lost the ECG and had to use torches to offload the patient onto a trolley with the sheath still in. With the family outside the room and a laughing patient who didn’t seem at all bothered, we wheeled him into the next room to complete the procedure. Naturally the ECG was in a shocking state, but I managed to stent the entire length of the LIMA. The reward though came a few weeks later when the grateful patient donated a large sum of money to the department as thanks, which we responsibly used to fund one of the best Christmas parties ever had at St Mary’s.

5. What advice would you give to new cardiologists just making their way in the field? The main advice I could give is to travel abroad to gain extra work experience, and experience another culture. Try somewhere different like South

America. It will give you a different perspective of how things operate, which will enhance your abilities in all areas of your life upon return. Gaining an international network of friends is also very rewarding and important. However if you do go abroad make sure you pick a fun city. Boston is great, Sydney is greater, Cleveland is average. (Chief Editor note: I think we better head to Cleveland for a site visit shortly, plus take lots of chocolates!)

6. What changes do you think will occur over the next decade in Cardiology? I believe that heart failure treatments will change over the coming years, when new technologies can solve the current rejection issues of porcine hearts. The next few years will be very exciting in the industry.

7. Do you only work in the UK? No, I also work in Australia, Europe, and the West Indies, primarily Trinidad.

8. What is it like being the Clinical Editor for this publication, and why did you get involved? The publication is fantastic, and I’m not just saying that because you are sitting in front of me. You have produced a publication that hits the target audience exactly, because it is extremely unlikely you are going to find a staff member reading a heart journal. Actually because I am so busy, it is where I actually get all my updates from now. Okay, thanks. I’m illegally parked and don’t want to get a £50 fine, so I have to go. CORONARY HEART ™ 45


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Cath Lab/EP Nurses and Technologists +HDOWKZRUNV ,QF LV D QRQSK\VLFLDQ KHDOWKFDUH SURIHVVLRQDOV JURXS SURYLGLQJ VSHFLDOW\ VWDIILQJ DQG HGXFDWLRQ VHUYLFHV WR KRVSLWDOV  SK\VLFLDQRIILFHVLQ 3KLODGHOSKLD3$ %DOWLPRUH 0' :DVKLQJWRQ'& DQGVXUURXQGLQJDUHDV 9LVLWRXUZHEVLWHDWZZZKHDOWKZRUNVRQOLQHFF IRUPRUHGHWDLOV

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UNITED KINGDOM The Royal Brompton and Harefield NHS Trust is a world leader in the diagnosis and management of heart and lung disease. The Trust works closely with the National Heart and Lung Institute, part of Imperial College. At Harefield Hospital, based in beautiful countryside, yet close to the attractions of London, weâ&#x20AC;&#x2122;re part of the countryâ&#x20AC;&#x2122;s largest specialist heart and lung centre. With an international reputation for innovation and leadership in research, treatment and education, we use every available technique to help improve patientsâ&#x20AC;&#x2122; health and quality of life. Due to further expansion of the Cardiac Physiology Services provided by this hospital we are looking for experienced and enthusiastic staff to help us provide these services in a rewarding and pleasant environment. Join us in one of the following positions and you will have the opportunity to rotate through all areas of Invasive and Non-Invasive Cardiology, Transplant Cardiology, Echocardiography and Pacemaker and ICD therapy and follow-up. Whatâ&#x20AC;&#x2122;s more, youâ&#x20AC;&#x2122;ll be part of an extremely friendly and successful team thatâ&#x20AC;&#x2122;s justifiably proud of being amongst the best in its field. In return for your hard work, we offer a relocation allowance, onsite accommodation, subsidised meals and crèche facilities.

Chief Cardiac Physiologist Harefield Hospital Band 7, ÂŁ30,209 - ÂŁ40,362 p.a. inc.

&RQWURO\RXURZQVFKHGXOH )7DQG37SRVLWLRQVDYDLODEOH&RQWDFW +HDOWKZRUNV DW  RU DGPLQ#KHDOWKZRUNVRQOLQHFF ,I\RXDUHLQWHUHVWHGLQZRUNLQJLQWKHVHDUHDVZHDOVRSURYLGHWUDLQLQJWR KHOS\RXPHHW\RXUSURIHVVLRQDOJRDOV

Employment Advertising â&#x20AC;˘ â&#x20AC;˘ â&#x20AC;˘

1/4 Page = ÂŁ180 (approx. US$342) 1/2 Page = ÂŁ280 (approx. US$532) Full Page = ÂŁ410 (approx. US$779)

Coronary Heart magazine is released bi-monthly. Next issue release: 01 Feb 2007. International Express Airmail for fast global delivery. Payment methods: We offer a variety of local and international payment options to make it easier for you. Visit coronaryheart.com for Media Kit

Ref: HH/CA/953

Senior Cardiac Physiologist Harefield Hospital Band 6, ÂŁ25,282 - ÂŁ34,950 p.a. inc.

Ref: HH/CA/952

Cardiac Physiologist Harefield Hospital Band 5, ÂŁ20,858 - ÂŁ28,523 p.a. inc.

Ref: HH/CA/951

Invasive Cardiology at Harefield Hospital is leading the country in providing a Primary Angioplasty Service to patients in the community and is involved in all other aspects of cardiac investigation and therapy including IVUS, Pressure Wire, Rotablator, Laserplasty, Electrophysiology, Laser Lead Extraction and Pacemaker and ICD implantation. The departmentâ&#x20AC;&#x2122;s Pacemaker/ICD Clinic provides a service to over 7000 patients running Physiologist-led pacemaker and heart failure device follow-up clinics and an ICD support group whilst the Electrophysiology service expands to provide the screening and ablation therapies for the tachyarrhythmia patients. The Non-Invasive and Transplant Cardiology sections provide an ECG, ambulatory monitoring, exercise, MVO2 exercise and tilt-testing analysis and reporting services whilst the Echocardiography section perform and report on patients with a wide range of diseases and anatomies using contrast, dysynchrony, stress and trans-oesophageal echo techniques as well as the standard echo modalities. Applicants should have BSc in Clinical Physiology (Cardiology), BTEC/HNC MPPM or equivalent. RCCP registration, ILS/ALS and post qualification accreditation in specialist subject(s) would be an advantage. For an informal discussion, please contact Bob Hirst on 01895 828561. For an application form and job description, please contact Sian Vincent on 01895 828 940 or alternatively Recruitment Bureau by email on s.vincent@rbht.nhs.uk quoting the above reference number Closing date: 14th December 2006. We promote diversity within our workforce. We operate a no smoking policy DEVELOPING YOUR

www.rbht.nhs.uk

CAREER THROUGH LEARNING

UK - US exchange rates correct as at 22/11/2006

CORONARY HEART â&#x201E;˘ 47


Setting new standards for Cardiac Professionals RIG Radiography Recruit has expanded it’s highly successful Radiography business to now include a team dedicated to the Cardiac sector. We have become the largest supplier of Radiography staff to the UK through our premier level of service and the proactive nature of our staff. The team operates throughout various Cardiac Service departments including Angiography and Pacing/Cardiac Units, Cardiac Physiology Clinical Units and Cardiothoracic Units amongst others. Our team has over twenty years specialist recruitment experience and we pride ourselves on the level of service we offer to both clients and candidates.

We cover the following areas– Cardiac Cath Labs ECG Echocardiography Holter Monitors Exercise Stress Tests Pacing Implants Lung Function Testing Tape Analysis BP Monitoring Tilt Testing Our comprehensive Benefits and Support Structure includes– Highly Competitive Rates Wide range of posts across the UK Limited Company Set up Dedicated Cardiac Recruitment Consultants CPD Contributions* CV Assistance and Preparation * Subject to qualification criteria.

We are always recruiting for Cardiac Cath Lab Technicians, Cardiac Physiologists, Cardiac Clinical Scientific Officers, Echocardiographers Cardiac Sonographers amongst others.

Check out our website and contact the team today to see what we can do for you!

Telephone 0845 363 1187 Facsimile 020 8249 6561 Email info@rigradiography.co.uk Internet www.rigradiography.co.uk


EMPLOYMENT ADVERTISING

INTERNATIONAL

Job Ads Online FREE*

December / January 2007

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coronaryheart.com * when you advertise in the magazine

Add Colour at No Extra Cost

Medical Recruitment Specialists in Cardiology and Radiography

Your Career is our world LONDON

SYDNEY

AUCKLAND

Locum and Permanent positions domestically and internationally for Cardiac Physiologists, Cath Lab staff, Cardiology Nurses and Echo/Sonographers. Trainee roles are also available. UNITED KINGDOM – OFFICE

Your World Recruitment 17 Blossom Street, London, E1 6PL, United Kingdom PHONE +44 (0) 20 7426 6992 FAX +44 (0) 20 7426 6990 info@yourworldmedical.com www.yourworldmedical.com

AUSTRALIA – OFFICE

Your World Recruitment Pty Ltd Level 14 Lumley House 309 Kent Street, Sydney 2000, Australia

FREEPHONE 1300 36 23 37 PHONE +612 9994 8074 FAX +612 9994 8075 info@yourworldmedical.com.au www.yourworldmedical.com.au

NEW ZEALAND – OFFICE Your World Recruitment Level 20 ASB Bank Centre 135 Albert Street, Auckland, New Zealand

FREEPHONE 0800 508 018 FREEFAX 0800 543 615 info@yourworldmedical.co.nz www.yourworldmedical.co.nz

PLEASE CALL NOW TO REGISTER YOUR INTEREST IF YOU ARE SEEKING WORK OR STAFF.

CORONARY HEART ™ 49


CLASSIFIEDS / PREVIEW

NEXT EDITION PREVIEW Take a look inside the Massachusetts General Hospital Cath Lab in Boston, USA.

NEW CATH LAB? Looking for a new haemodynamic system that will keep you within budget? We’ve just had all the equipment in our 3 Cath Labs standardised and sadly no longer have any need for our Mennen Medical Horizon SE haemodynamic Cath Lab system. Purchased less than 1 year ago and used for approx 6 months, it is still covered by the manufacturers’ warranty. SPECIFICATIONS: • <1 year old • Complete haemodynamic waveform analysis • Large, networkable Hemocis database • On line thermodilution cardiac output • 32 channel colour physiological display • 4 invasive pressure channels • 12 lead ECG • Pulse oximetry • NIBP PACKAGE INCLUDES: • ECG cables x 2 (incl spare set leads.) • Pressure transducer cables x 4 • Cardiac output cable • Finger pulse oximeter cable • NIBP cuff x 2 • 1 pack chart recorder paper • All manuals

£15,000 – Reasonable offers considered For further information phone Wellington Cardiology Dept: 020 7586 5795 or email cardiologywellington@hcahealthcare.co.uk

Have a sneak peek at a new ‘virtual cath lab’ 3D computer simulation program

Plus a lot more.......

Released: Feb 1, 2007

Main Ads Due: Jan 12, 2007

Recruitment Ads Due: Jan 19, 2007

Please confirm ads at least 3 days in advance. Media Kits available from our website.

ECG Pacing Problem Solving Answer (pg. 6) The paced ECG shows Right bundle branch block, this indicates that the pacing lead is pacing the left ventricle and not the right ventricle which would show Left bundle branch block. The pacing lead had gone across a PFO into the left ventricle. This problem could have been avoided by having an ecg lead V1 during the implant. 50

CORONARY HEART ™


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A CARDIAC PUBLICATION THAT’S A BEAT ABOVE THE REST


Let us help you solve your cardiovascular and imaging challenges. EDUCATION Boost employee retention and cut the productivity losses that often accompany new hires or service lines with Healthworks clinical education programs, available both onsite and online.

CONSULTING Resolve challenging service line issues like staffing shortages, quality assurance, inventory control and cath lab planning and construction with expert advice from Healthworks consultants.

STAFFING “When I call Healthworks, I don’t have to worry about quality.”

Meet your staffing needs with help from our experienced technologists and nurses. Or achieve financial efficiencies of up to 30% when Healthworks manages and staffs your lab. Staffing services are currently available in the Mid-Atlantic region. To find out more, just call us at 1-610-385-1227 or e-mail marketing@ healthworksonline.cc.

Charles Minehart, MD, FACC Berks Cardiologists, Ltd. Pennsylvania

Solutions for cardiovascular and imaging services 515 Old Swede Road, Suite C-1, Douglassville, PA 19518 Phone 610-385-1227 n Fax 610-385-1229 www.healthworksonline.cc

Coronary Heart #4  

Coronary Heart December 2006 / January 2007 edition

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