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Issue 9

November / December 2007

coronaryheart.com Site Visits

• Inside The Mayo Clinic - EP Department • Lancaster General Hospital, PA

Special Feature Cath Lab Design

T N E

EMP

Technological Advances in Lesion Assessment

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Education

YM“Subscribe

online for your FREE Copy!!”


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Agfa and the Agfa rhombus are trademarks of Agfa-Gevaert N.V. or its affiliates. All rights reserved.


November / December 2007

CONTENTS

CORONARY HEART

THIS EDITION 04

Editorial

0

Latest News

07

ECG Quiz

08

Future

09

Online Forums

10

Special Feature ‘Building a Heart Center’

1

Contents Mayo Clinic Site Visit

Page: 20 Lancaster General Hospital Site Visit

Reader Submitted ‘Anti-Coagulation Clinic’s’

20

Cardiac Site Visit ‘Mayo Clinic EP Department, Rochester, MN’

27

Interview ‘Douglas Beinborn - Mayo Clinic’

32

PLEASE SUPPORT OUR ADVERTISERS

Education ‘Technological Advances in Lesion Assessment’

02

AGFA Healthcare

‘Lancaster General Hospital, PA’

19

Wavemark

4

Events Calender

Bracco

47

Employment

24 - 2 32 - 39 48

Healthworks

40

Cardiac Site Visit

Page: 40

www.agfa.com/healthcare

www.wavemark.net/chm

www.bracco.com Special Thanks

www.healthworksonline.cc CORONARY HEART ™ 3


EDITORIAL

From The Editor S Coronary Heart Publishing Ltd Independance Wharf 470 Atlantic Avenue, 4th floor Boston, MA 02210 United States Email: admin@coronaryheart.com Phone: +1 (617) 273-8012 Visit us online at www.coronaryheart.com Director / Chief Editor Tim Larner Clinical Editor Dr Rodney Foale Consulting Editors Dr Richard Edwards Ms Voncile Hilson-Morrow Mr Ian Wright Mr Stuart Allen

ADVERTISING Request Media Kits online CIRCULATION USA edition 8521 Cardiac Professionals 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:

eptember was the month I headed back to the United States for a fifteen state whirlwind tour starting at the New Cardiovascular Horizons conference in New Orleans. For those of you who managed to attend I am sure one of the highlights was the Mardi Gras parade at the conclusion, put on by the conference organizers. Somehow I was allowed to hop on one of the floats and throw beads at people on the street. What a great time!! Travelling from state to state as an outsider it is interesting to see the subtle differences in various communities. In Colorado there is a desire to have the largest vehicle on the road. In Massachusetts drivers throw the rule book out the window. In Illinois, Tennessee, and Kentucky the freeway doubles as a speedway. And finally New York is home to the fastest taxi drivers in the world (we hit 100mph up the Van Wyck Expressway).

Tim Larner Director

For most of my travels I managed to avoid the big cities as I travelled through Colorado, Utah, Wisconsin, Minnesota, and multiple other states passing through smaller towns. These places are what America is all about. A strong sense of community where people acknowledge you, wave, and even strike up a conversation. When I asked them about what they thought of their local hospital everybody seemed proud, and strangely knew several people who worked there. You see outside of the main cities people often refer to their hospital like it was a landmark. This landmark status doesn’t get any bigger than the Mayo Clinic (featured in this edition), located in the small city of Rochester in Minnesota. Although the Mayo buildings dominate the city, Rochester has remained very pleasant with friendly people not hesitating to talk with you or to offer a helping hand. This is also true with the Lancaster General Hospital in Pennsylvania (also in this edition). It is a major reason we love doing site visits outside of the main cities. Departments are usually smaller, and the staff are extremely proud of what they have achieved. Several readers from larger facilities have written to us stating they appreciate seeing how smaller departments operate as they often have different challenges to solve. If you are a smaller department and would like to be featured in this magazine then please don’t hesitate to contact us. We are sure you will enjoy the current edition, and as always if you have any questions or comments you can email me directly at tim@coronaryheart.com. I would love to hear from you.

- Tim Larner COVER PHOTO: The Gonda Building at the Mayo Clinic, Rochester, MN.

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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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.

LATEST NEWS

What’s New? GORE HELEX Septal Occluder Approved for ASD’s

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n early October W. L. Gore & Associates announced they had gained FDA approval to market their the GORE HELEX Septal Occluder with modified catheter delivery system. The indications for this device are for the transcatheter closure of atrial septal defect (ASD). Interventional cardiologists can use the device in the cath lab as it is designed for deployment via standard femoral venous access. The device is composed of ePTFE patch material supported by a single nitinol wire frame that bridges and eventually occludes the septal

Cardiac Science Releases New System

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defect to stop the shunting of blood between the atria.

resulting in successful closure of the defect.

Over the course of several weeks to months, cells begin to infiltrate and grow over the ePTFE membrane,

Visit www.goremedical.com/helex for more information.

Six Month Results for Triton SideBranch Stent™

was used in conjunction with a standard drug eluting stent to treat 30 patients with coronary blockages involving large side-branches. After 6 months, none of the patients suffered from side-branch restenosis.

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couple of issues ago we mentioned the Triton Medical Side-Branch Stent and showed you a diagram of how it worked. Now though the six month results are in from the first in-man study.

ardiac Science Corporation have recently launched the Quinton Q-Tel RMS(R) 3.0. The Q-Tel 3.0 improves workflow efficiency with enhanced connectivity, allowing the rehab department to connect to the hospital’s HIS and EMR system. This was in response to customer requests.

The results were presented by Dr. Ralf Müller (Helios Heart Center, Siegburg, Germany) and Professor Patrick W.J.C. Serruys (Erasmus Medical Center, Rotterdam, the Netherlands) at the European Bifurcation Club Meeting in Valencia, Spain.

Visit www.cardiacscience.com for more information

The Tryton Side-Branch Stent™

Triton reported that the core laboratory quantitative analysis reported a late loss of 0.27 ± 0.42 mm in the side branch and 0.12 ± 0.47 mm in the main vessel. “The Core Angiographic Data demonstrates that the hybrid approach, bare metal Tryton SideBranch Stent used in conjunction with a standard drug eluting stent, provides the same type of restenosis reduction we have seen when drug eluding stents are used to treat standard lesions,” said Professor Serruys, Erasmus Medical Center, the Netherlands. “This is the first time, I have seen such promising results in the treatment of bifurcation disease,” added Serruys. CORONARY HEART ™  


LATEST NEWS

What’s New? Hansen Sensei™ Continues International Growth

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ince receiving both FDA and CE Mark clearance in May 2007, Hansen Medical have installed a total of five Sensei™ Robotic Catheter systems in the United States and four in Europe. The installation sites include large teaching sites through to community hospitals because physicians of differing skill level are able to successfully employ this remote catheter navigation system within their practices. As a bonus for Europe is the ability to provide robotic control of irrigated ablation catheter technology for atrial fibrillation. Hansen stated recently that “The combination of the Sensei system’s ability to accurately position catheters at targeted cardiac anatomy along with the more effective lesions created by irrigated catheters should have a powerful effect on procedure outcomes.

Stereotaxis Niobe 93% Success Rate

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ata given at the recent European Society of Cardiology Congress (ESC) in Vienna reported a 93% acute success rate in patients treated for atrial fibrillation (AF) with the Niobe® magnetic navigation system. Dr Xu Chen, M.D., of the Rigshospitalet at the University of Copenhagen presented the findings from 42 patients with AF from which in 93% of these cases the pulmonary veins were fully isolated from the left atrium, eliminating the main cause of the arrhythmia. Each case took on average slightly less than 2 1/2 hours as Dr Chen guided the catheters with the Niobe magnetic navigation system, controlled from his remote station adjacent to the procedure room. The average exposure time was less than ten minutes.

“We have performed more than 250 total cases with the Stereotaxis system,” said Dr. Chen. “The ESC presentation was based on our first series of complex ablations and since then we have performed an additional 68 complex cases. We have had zero complications, and fluoro time in the last 50 cases has dropped to five minutes per procedure. Procedures with the Stereotaxis system are faster and far more precise than I could perform with my hands. We are incredibly happy with the system’s performance.” Stereotaxis is though not only used for EP, but it is proving very useful for interventional procedures as well. At the recent TCT meeting in Washington DC, Stereotaxis utilized a Mobile Vascular Lab to perform demonstrations to show its simplicity. And with 2000 PCI’s already performed internationally, it is good to see that with such a high initial outlay it can be used in multiple procedures. Visit www.stereotaxis.com for more information

At present Hansen Medical has two centers of excellence - The Cleveland Clinic, in Cleveland, Ohio, and St. Mary’s Hospital in London. Visit www.hansenmedical.com for more information Image courtesy Stereotaxis

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LATEST NEWS

What’s New? Sonosite Releases New Ultrasound: The M-Turbo

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ith possibly the coolest name in the imaging industry, Sonosite has just released their latest creation: The M-Turbo. As you would expect with a name like that the processing speed has been thrown into overdrive with a 16-fold increase which the company says ‘generates dramatic improvements in image quality by simultaneously running multiple advanced algorithms.’ An example of this is SonoADAPT™ Tissue Optimization which automatically adjusts imaging parameters depending

ECG Quiz

on the exam type, making it easier for any cardiologist to not worry about too many buttons to push. The M-Turbo also offers seamless connectivity for digital image export in a rugged, hand-carried product weighing less than 8 pounds.

World’s Smallest Ultrasound

S

iemens have recently released a new ultrasound called the Acuson P10. This hand-held device is designed for complementary initial diagnostic care and triage, particularly in cardiology. It’s main advantage is portability because it weighs only 700grams and is barely larger than a Blackberry.

Image courtesy Siemens Image courtesy Sonosite

Compiled by: Mr Stuart Allen, Technical Head CRM, Southampton General Hospital, UK

CLUE:

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atient was admitted for a non cardiac surgical procedure and reported occasional palpitations. A pacemaker check was requested as a result of this ECG. Patient has a dual chamber pacemaker (implanted 18thms ago). Last pacemaker check 6 months ago was normal. For the answer please visit www.coronaryheart.com and click on Education CORONARY HEART ™ 7


FUTURE

Cardiology in the Future Stem Cell Advances

The cellular units are cultured for a month to obtain sufficient numbers of cells for transplantation.

Where there is no electrical activity, this corresponds with an area of myocardial infarction.

ardiologists from the University Hospital of Navarre and the Gregorio Marañón Hospital in Madrid have commenced clinical trials (Phase II) on fifty patients in order to test the efficacy of adult stem sell transplants within the hearts of patients whom have suffered a myocardial infarction and have ventricular dysfunction.

The cells are injected in and around the damaged areas of cardiac muscle using a special injection catheter.

The catheter that is used to inject the stem cells is made up of a very fine needle retractable at its end. The catheter is placed via the femoral artery and once in the left ventricle between 15 and 20 injections of myoblasts are placed. The procedure normally takes between three to four hours to complete.

The difference from other studies is the implantation of the cells is via a catheter rather than the traditional open heart approach. The technique is as follows: • Extraction of myoblast cells via a biopsy of muscular tissue from the leg of the patient.

So how do the Cardiologists know where to inject the stem cells?

C

Researchers isolate the adult stem cells.

XTENT Results Very Promising

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One of the major requirements of this trial has been to ensure no other invasive techniques are used on the patients to give more accurate results.

They use a navigation system known as non-fluoroscopic electroanatomical mapping (CARTO System). This technique is commonly used in EP whereby a three-dimensional reconstruction of the left ventricle provides information relating to the electrical activity anatomically.

Custom II: is a 100-patient study designed to evaluate the safety and efficacy of Custom NX for the treatment of long and multiple lesions. Going for one year.

X

TENT, Inc announced followup data from their CUSTOM I and CUSTOM II single-arm prospective studies evaluating the safety and efficacy of its Custom NX® drug-eluting stent.

The results for both trials showed no new major adverse cardiac events (MACE), and the incidence of late stent thrombosis for patients treated with the Custom NX was zero percent.

Custom I: is a 30-patient first-inman study designed to evaluate the preliminary safety and feasibility of in-situ stent customization. Going for two years.

Commercialization of the Custom NX is expected to commence in Europe in late 2008.

CORONARY HEART ™

Data from XTENT Inc, as reported at TCT 2008 in Washington, DC.

The aim of the trial is to see if this new treatment is effective and to improve on the cardiac function of patients who have suffered a heart attack.

OBITUARY Dr Henry Marriott 1917 - 2007 “World-renowned cardiologist” Dr Henry “Barney” Marriott has passed away at the age of 90. He will be best remembered for his work in the field of ECG interpretation in which he wrote a number of books. He will also be remembered for his entertaining lectures that always drew an interested crowd. At age 13 he moved to England from Bermuda where he later attended Oxford University. In London he had the opportunity to work under Sir Alexander Fleming in the penicillin research unit, and in 1946 moved to the USA where he worked at Johns Hopkins Hospital and the University of Maryland. In 1962 he moved to Florida. Marriott passed away August 31, 2007 in Riverview, FL.


coronaryheart.com

FORUMS

Online Forums EP Lab Forum: epicardial mapping ablation equipment veitch57 wrote: An embarrassingly simple question. What types of needles are around for epicardial work. Yes i know we can use good old cook needles for pericardial taps etc but i am interested in what is around for epicardial access in the cathlab. thanx Respond online

Management Forum: Inventory Management TheBoss wrote:

Cardiac Nursing Forum: Contrast allergy - what do you do? veitch57 wrote: I guess we usually aim for steroids and antihistamines. Some go for the night before for steroids if possible. Hmm there is debate about using Omnipaque or Visipaque. Some say either. Both have iodine in them of course so i suspect no difference, I must ask around to see what is the best. Respond online

With the high demand on cath labs today, streamlining services to maximise productivity is a priority. To achieve this many labs have installed state of the art inventory management systems. Please tell us the systems you use, or why maybe you have chosen to avoid this new technology for the time being? Respond online

Radiography (RT) Forum: Equipment ferretpants wrote: I am interested to know what Cardiac cath lab x-ray equipment people are using? Are you happy with it and why/why not? Respond online

Cath Lab Forum: D2B rnaden1 wrote: Hi Cath Lab friends, I am looking for info on door to balloon times for pts and staff. If you established d2b, what are your protocols. I have read that some hospitals have done d2b, but stopped. Thanks Roberta Respond online

Peripheral Vascular Forum: Acute stroke patients in the cath lab winky0107 wrote: Was wondering if any other cath labs are bringing in acute stroke patients? A group of our cardiologists (and one neurosurgeon) is putting together a “Code Stroke” protocol to bring in these patients. I know of angio departments in radiology doing this, but the argument here is that the staff in radiology cannot handle the acuity of these patients (!). I unfortunately don’t have many details yet, but am concerned about training all the on-call staff to perform competently in these procedures. As it stands now, we have a core group of only 12-15 people who assist with the carotid stenting. Any advice/suggestions/comments would be greatly appreciated. Respond online

For these and many more questions visit our FORUMS page on the website at www.coronaryheart.com It is free to browse, free to login, and free to post. Join our international community now!! CORONARY HEART ™ 9


SPECIAL FEATURE

Building A Hea Ce A facility dedicated to heart care and surgery, as well as outstanding patient outcomes and experiences.

- By Elizabeth Clark, Clinical Director, Cardiovascular Services, The University of Kansas Hospital

M

any people build a new home. When they do so, they decide what is important to them and what makes them comfortable. Design generally takes into account what the person or family enjoys or how time is spent. Many questions abound: How many bedrooms? How should we plan the living spaces? What about the kitchen, patio, den and so on? At The University of Kansas Hospital, we followed the same process in building the Center for Advanced Heart Care, a facility dedicated to heart care and heart surgery. The process of designing and building any structure typically involves working with consultants, architects and construction teams. What made our project different were the careful consideration of each patient area and how they work together, as well as a focus on staff satisfaction and retention, patient comforts, and convenience and caring for both groups.

Only the Beginning First, the process to determine the right size for the Center for Advanced Heart Care began. A consultant helped determine what would be best for our 10  CORONARY HEART ™

organization and our program. Our Business and Strategic Development Department worked carefully to determine capacity projections for both the inpatient and outpatient areas, including the cardiovascular (CV) labs and cardiovascular operating rooms (CVORs). The architectural firm RTKL, of Dallas, Texas, was chosen through a request for proposal process, as was the nationally recognized, local construction company J.E. Dunn. Owner’s Representative Services, Inc. joined the team to provide construction project management, and the design process was well on its way.

Thoughtful and Functional Design Right away, the hospital’s clinical and administrative teams had to ask themselves: What is most important for our heart center and our heart program? Of course, exceptional patient care and safety together are the top priorities. Following closely from an organizational point of view are family and visitor comforts and staff workflows, conveniences, efficiencies and comfort. The intention was


art enter

One of America’s Top Heart Hospitals - US News & World Report

The University of Kansas Hospital Center for Advanced Heart Care CORONARY HEART ™  11


SPECIAL FEATURE

Building A Heart Center (cont...) to provide a great environment in which all staff is supported to provide exceptional patient care. Design decisions were driven using the guidance of our organizational pillars of quality, service, people, cost and growth. Quality outcomes and care are most important, of course. Design that allowed for superior service, from curbside to bedside, and patient satisfaction were always taken into account. Satisfaction and retention of nursing staff, physicians and other support/ancillary staff were also considered in workflow designs.

We determined that the facility should allow for program expansion and growth, so design decisions needed to be based on that. And, of course, we had to consider how design, flow and equipment selection could be cost efficient and long lasting. Our internal clinical design team, composed of clinical staff, including nurses and physicians, began meeting with the RTKL architects in 2003. A general scheme had been developed; however, the clinical team provided essential information to create thoughtful and functional patient

care areas. Throughout the process, the focus continued to be on patient care and safety, along with efficiency of that care for both nursing staff and physicians. From the beginning, we determined it was very important to provide staff respite areas/lounges with generous square footage, natural light and amenities. Staff lounges for five of the seven units in our heart center are located on the corner of the building, providing wonderfully big, beautiful, light-filled areas. All of the lounges contain many staff conveniences that

The Foyer: The colourful hanging sculpture is called a PulseFlow composed of more than 300 pieces of blown glass. 12  CORONARY HEART ™


SPECIAL FEATURE

offer some relaxation and rejuvenation as staff members continue to provide great care to patients. We also chose to make the staff areas calm and quiet, providing comfort to those who provide so much comfort to others.

Patient Rooms: Every patient has a private room, and most have wireless internet access.

Staff support was and remains an important aspect of the Center for Advanced Heart Care. Early in the process, space was set aside for physician and support staff work areas, and they were designed into each patient care area. These work areas provide computers, phones and storage space in quiet, private locations.

A Focus on Patient Care and Comfort We paid considerable attention to all patient rooms. Clinical staff made significant contributions to the design, resulting in space that makes sense to staff as they provide care. Patient rooms also feature family areas or zones for family and visitor comfort. Small workspaces with computer access and in-room sleeper sofas are included. There are also six guest suites on the inpatient progressive care units. Suites include attached guest areas for greater privacy, as needed. A beautifully planned education area for families and patients, located on the second floor, was included to serve as a significant learning and support resource for all patients and families. Additionally, spaces were specifically planned for the display of art, adding to the building’s beautiful, healing atmosphere. The magnificently spacious entrance to the Center for Advanced Heart Care is filled with

light and beauty; natural light and a hanging glass sculpture create a soothing, healing space. Easy wayfinding also was incorporated into design. Specific colors identify each floor, and related art identifies space, such as waiting areas. As the design process continued, patient care areas were painstakingly reviewed unit by unit. Another important consideration that upheld the guiding principle of patient safety was the consistency of units from floor to floor. Nurse work areas are similarly stocked and organized throughout the facility. Universal placement and design allow for safer and more consistent patient care. This concept also allows for physician efficiencies, reducing rounding time spent looking for forms, charts, etc. An overall look at all areas ensured

appropriate and efficient patient care and workflows between areas. All work- and patient flows were specifically detailed and diagramed to ensure that the intended designs would work in practice. These flow diagrams were also used extensively in orientation training for the facility. Early in the planning, we decided that nursing and supportive care would be decentralized. This meant designing the nurse work areas so they are within steps of the patient beds, allowing nurses to easily see patients and stay close to keep them safe. Architects worked with the clinical team to draw sight lines from each patient’s room to various areas on the unit, ensuring visual lines of sight into each patient’s room from multiple points on the unit No patient rooms were tucked away out of a nurse’s or other care provider’s sight. CORONARY HEART ™  13


SPECIAL FEATURE

Building A Heart Center (cont...)

Cath Lab Floor Plan Another of our priorities was to eliminate unnecessary steps for staff to obtain supplies, medications and other patient care items. As a result, plans called for necessary supplies, materials

and medicals records to be located at workstations just outside of each patient room. Computers, phones, medications and supplies are only a few steps away from patients. Close-

by nutrition centers store the supplies that could not be kept at workstations, including clean supplies and additional medications.

Designing for Advanced Services

Cardiology Inpatient Floor Plan 14  CORONARY HEART ™

Other important aspects of most heart programs were taken into consideration. For example, doorto-balloon time, a performance improvement initiative, is closely monitored. To continue ensuring the ease and speed of care delivery, we carefully designed a plan for moving patients from ambulance, helicopter or the Emergency Department to the catheterization lab in reduced time. A new state-of-the-art Emergency Department was designed and built on the first level of the Center for Advanced Heart Care, allowing us to improve door-to-balloon times and quickly transport patients to our cardiac catheterization labs or to the


SPECIAL FEATURE

chest pain center, when appropriate. Also important to the design was the close proximity of patient care areas. For example, on the second level, which houses the cardiac catheterization and electrophysiology (EP) labs, the floor was laid out to include the labs, the Cardiovascular Treatment and Recovery (which is a prep and recovery area) and the Cardiac Intensive Care Unit. This permits the availability of RNs with a wide scope of competencies (ICU, recovery and procedural), immediate physician availability and ease of movement from one area to another. These efficiencies provide a serviceorientation to physicians and patients, along with continued focus on patient care and safety. Help is never far away. The same concept applies to the cardiothoracic surgery floor. The CVORs and the Cardiothoracic Surgery ICU are housed on a single floor, again providing access to critical care and surgical nurses and to surgeons and anesthesiologists. This floor also has a satellite pharmacy, which serves the CVORs and all ICUs in the heart center and prepares all stat medications for the entire facility. Cardiac catheterization and EP labs and CVORs are challenging and innovative areas for design. The CV labs, which include the cardiac catheterization and EP labs and the CVORs are big, remarkable areas with state-of-the-art equipment and nursedesigned workstations. The layout was planned with significant physician and staff input. To minimize time spent running for an item, some supply storage is inside the CV labs, as well as a larger stock area.

Decentralized Nursing Stations: Allowing nurses to be only steps away from their patients.

Names and titles from left to right: Mike Kaiser - PA, Shirley Verbenec - CV OR, Lynette Patocka - CV OR, Zann Roach - EP Lab, Chris Buckley - CTS ICU, Lynn Smith - Cath Lab, Annie Burger - CTS PCU, Kathy Carson - CTS ICU, Gail Schuman - CV Pre/ Post, Kate Jones - CTS Nurse Clinician, Andy Hawthorne - CTS ICU, Anna Werner - CTS PCU

Equipment selection, a tricky endeavor, could be described in an article of its own. Again, physician input is critical, as is having team members who are well versed or researched in the various equipment and options. It is also important to have someone who is very comfortable with negotiations and contracts. Many questions must be asked to make wise, cost-conscious decisions.

The University of Kansas Hospital’s Center for Advanced Heart Care opened in October 2006. The major project required the help of hundreds of people – design team, staff, community members, patients and families. We are very proud of our facility. It is a place where excellent, quality care continues to be delivered by a dedicated, committed and caring team. And the quality of care will remain at the heart of its existence.

Opening the Heart Center Design and construction soon were completed. The task of moving in, occupying and opening units, and making them operational soon became the focus of the clinical team. That successful accomplishment is also a story unto itself, for another day.

The University of Kansas Hospital Center for Advanced Heart Care 3901 Rainbow Blvd. Kansas City, KS 66160 United States of America CORONARY HEART ™  15


READER SUBMITTED

Anti-coagulation Clinic’s A Patients Newest Best Friend

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Dennis Holloway, MBA, CVT Director Invasive/Non-Invasive Cardiology Sarasota Memorial Hospital Sarasota, Florida

Anti-Coagulation Clinics have begun a new era in aiding patients in therapeutic maintenance and initial treatment for diseases requiring short or long term drug therapy. Consistent monitoring of INR’s, medication adjustments, patient education, and knowledge of blood lab values has been an uphill battle; until now!

ocated in the “heart” of downtown Sarasota stands “Sarasota Memorial Hospital’s” “Heart Vascular Institute (HVI)”. One of the major services located here is their “AntiCoagulation Clinic”. The clinic is staffed with 1 ARNP, 2 RN’s, 1 LPN, 2 Patient Representative III’s, 1 Ancillary Representative III, a department Manager, Department Director and Medical Director. Janet Delany, ARNP is a Board Certified Anticoagulation Provider. Janet is among an elite group of only 17 within the state of Florida to hold this title. Each nurse is required to take the anticoagulation course provided at the University of Southern Indiana on an annual basis. The Anticoagulation Clinic first opened its doors in 2003 and has demonstrated a remarkable growth each year. For fiscal year 2007 its volume prediction was estimated to be a 12% increase from FY06. The current analysis has them on track at 20%. As more and more physicians become aware of the success and/or value of this service their referrals for anticoagulation therapy in this clinic are ever-growing. Physicians that refer patients to the clinic include, but are not limited to: a. Primary Care

Sarasota Memorial Hospital, Heart Vascular Institute, Anticoagulation Clinic.

b. Internal Medicine c. Cardiologists d. Pain Management e. Pulmonary f.

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Family Practice

g. Orthopedic h. Surgical

What Category of Patient Types are Seen? The Sarasota Memorial Hospital Anticoagulation Clinic sees between 80 to 100 patients a day. These patients range from a variety of clinically diagnosed diseases, some of which include: a. Atria fibrillation b. Pulmonary Emboli (PE) c. Transient Ischemic Attack (TIA) d. Cerebral Vascular Attack (CVA) e. Thrombophilia f.

Vein Thrombosis Emboli (VTE)

g. Heart Disease h. Valve Disease i.

Valve Replacements

Medications Dependant on the diagnosis, the type(s) of medications necessary for treatment vary. The following list contains the major pharmaceutical listing of medications our patients would receive: a. Coumadin (Warfarin Sodium): An anticoagulant (blood thinner) which acts by inhibition vitamin K-dependent coagulation factors which include Factors II, VII and


READER SUBMITTED

X and the anticoagulant proteins C and S. Coumadin is absorbed through oral intake with peak affect in about 4 hours. b. Lovenox: (enoxaparin): Lowmolecular-weight heparin (LMWH) indicated for prophylaxis of deep vein thrombosis (DVT) in abdominal surgery, hip replacement surgery, knee replacement, or patients with severely restricted mobility during acute illness. It is also used for prophylaxis of ischemic complication so of unstable angina and non-Q-wave myocardial infarction, treatment of acute deep vein thrombosis and treatment of acute ST-segment Elevation Myocardial Infarction (STEMI). c. Vitamin K: (Generic): Made up of 2-methyl-1 & 4naphthoquinone ring structures providing hemostatic traits. Originally found in green leafy vegetables, hemp, seeds, liver and fish meal. Vitamin K resides in certain proteins in the body. These proteins include the vitamin K-dependent coagulation factors II, VII, IX, X, protein C, protein S, protein Zv and a growth arrest-specific factor. Vitamin K is also key element in bone metabolism. Vitamin K is the collective term for a group of vitamin K compounds called menaquinones. Vitamin K is used to treat anticoagulant-induced prothrombin deficiency caused by warfarin, hypoprothrombinemia. d. Jantoven: This is a generic medication substituted for Coumadin by Publix Pharmacy’s. “Point of Care” testing includes

utilizing the “International Technidyne Corporation (ITC)” blood value for “international normalized ratio (INR)” results. According to a study published in the “New England Journal of Medicine by Elaine M. Hylek, MD, Massachusetts General Hospital, Boston Massachusetts, and colleagues showed that an INR >/=2.0 at the time of stroke reduced the incidence and severity of ischemic stroke, as well as the risk of 30-day mortality from stroke patients with nonvalvular AF, compared with an INR < 2.0, aspirin therapy, or no therapy at all (5).” Therapeutic measures used at this clinic follow the “American College of Surgical Chest Physicians, Jack Ansell’s Publications on Anticoagulation Forum, the Davis Health Center, and Berkley Health Center.

What to Expect on a Patients Initial Visit Once a referral has been faxed into the Anticoagulation Clinic, it is picked up by the Patient Representative. She then contacts the patient and schedules him/her for their initial visit with the ARNP. Once the patient arrives, he/she will check in at the front desk with one of the Patient Relations Representatives. Patients arriving for their initial visit will meet with the ARNP to compete a thorough History and Physical. All patients arriving for their initial visit will watch an instructional video, review prepared educational material, and take and exam which will assess the patient’s knowledge of outpatient anticoagulation. During this visit the patient will undergo a capillary blood test to determine their INR. Once the INR results are processed (this is a Point of Care test; therefore, whereas the results are close to

immediate) the ARNP can clinically diagnose if the patient is within therapeutic range of their particular disease guidelines. The patient will then be given a written dosage regimen, review their exam, clarify their education and have any questions answered. Patients are also provided with information on how to maintain a healthy lifestyle, when to notify the ACC and what to do should an adverse event occur. They are also provided with local and internet resources for education and services. As the initial visit process continues, the patient will be contacted by the Patient Relations Representatives to schedule concurrent visits. The immediate follow-up visit will be weekly for a period of 4 weeks. This is to ensure that the patient is monitored closely for INR levels, change of medicine (if appropriate) and new dosing adjustments if necessary. Blood tests are taken on each visit. This is probably the part most patients don’t like, but is vital in perfecting their therapy. Upon completion of these 4 weeks, the patient will be scheduled on a monthly or as-needed basis.

Guidelines/Tools As with any clinical program, regulations, guidelines, programs and/or processes are in place to aide the clinical staff in determining the appropriate ranges or steps necessary to give our patients the best care possible. As a result of her specialized experience in this field, Janet Delaney, ARNP, has developed a guideline of therapy that has been accepted by many physicians or practitioners in our area. This tool is referred to as the Lovenox Decision Making Protocol, and is seen on the following page. CORONARY HEART ™  17


LOVENOX DECISION MAKING PROTOCOL

PATIENT NAME_____________________________________ DATE___________________________ Risk of thromboembolism LOW VTE > 6 months ago AFIB with CHADS2 of 0-1 Bileaflet/ Mech AVR w/o CVA RF Cerebrovascular disease without TIA/ CVA

MODERATE VTE >3mos. <6mos. AFIB with CHADS2 of 2-3

HIGH VTE/AE within 3 months AFIB with CHADS2 of 4-6 or AFIB with RHD Bileaflet/ Mech AVR + CVA RF older Mech MVR or older Mech AVR (caged Mech AVR w/o CVA RF ball/tilt disk) Cerebrovascular disease with CVA/TIA Cerebrovascular disease with rec. CVA/ (no Afib) TIA +AFIB. Previous VTE post surgery New prosthetic valve/ or w/RF St. Jude Mech MVR Intracardiac Thrombus TE event with Thrombophilia TE event with Active CA

CHADS 2 Score for AFIB CONDITION Congestive Heart Failure (any history) Hypertension (prior history) Age (>75 years) Diabetes Prior ischemic stroke or TIA

CVA risk factors SCORE 1 1 1 1 2

Procedural Bleeding Risk HIGH Heart Valve Replacement/CABG Spinal anesthesia/Epidural analgesia Abdominal/Thoracic Aneurysm repair Neurological /urologic / head & neck/ abdominal / breast cancer surgeries Bilateral knee replacement Laminectomy TURP Kidney Biopsy Polypectomy/variceal repair/biliary sphincterectomy, pneumatic dilation PEG placement Endoscopically guided fine needle aspiration Multiple tooth extractions Vascular and General surgery Any major surgery > 45 minutes in length

18  CORONARY HEART ™

MODERATE/ LOW Cholecystectomy Adbominal hysterectomy Simple dental extractions GI endo w/wo biopsy, enteroscopy, biliary/pancreatic stent Carpel tunnel repair D&C Skin cancer excision Abdominal hernia repair Knee/ hip /shoulder/ foot/ hand surgery or arthroscopy Hip and Shoulder replacement Hemorrhoidal surgery Axillary node dissection Hydrocele repair Noncoronary angiography Cataract and noncataract eye surgery Pacer/defibrillator/EP testing


READER SUBMITTED

Anti-Coagulation Clinic’s (cont...) Evaluation of Risks THROMBOEMBOLISM Low Risk Moderate Risk

Lovenox

High Risk

YES

YES/NO YES

Dosing

Pre/Post Procedure Prophylactic Pre Post Prophylactic Pre Post or Full dose Full dose Pre Post

Anticoagulation Clinics provides a superior service which enables the highest level of “standard of care” for those patients who develop one of the many disease categories. I can not think of anyone better to treat these patients in collaboration with physicians, than the specialized clinical professionals dedicated to anticoagulation therapy. Anticoagulation Clinics are not only clinically productive, but financially beneficial as well. The best of both worlds for facilities and patients alike.

References 1. PDR Health: Vitamin K; Coumadin 2. Bristol-Myers Squibb Company: Coumadin Tablets; Coumadin for Injection 3. Lovenox.com: About Lovenox 4. International Technidyne Corporation: About ITC 5. Medscape.com: “Study suggests Optimal INR Value for Anticoagulation Therapy to Reduce Stroke Severity and Mortality in Patients with AF”

CORONARY HEART ™  19


CARDIAC SITE VISIT

UNITED STATES OF AMERICA

The Mayo Clinic

- EP Department

ADDRESS Mayo Clinic 200 First St. S.W. Rochester, MN 90 United States of America

FAST FACTS 1. Arguably the world’s most recognized medical institution 2. Six dedicated EP Labs. 3. Approximately 20 procedures per year. 4. Stereotaxis Niobe (current) & Hansen (coming soon).

MAP

“The best interest of the patient is the only interest to be considered.” - Dr Will J. Mayo

T

he Mayo Clinic is regarded internationally as one of the top medical institutions in the world, and has won countless awards for the high levels of service and care. This care is supported by advanced programs in medical education and research, utilizing the latest technology medical companies have to offer. Patients fly from all over the world to be treated here, however although you would expect to find the Mayo Clinic in the center of a state capital, the reality is vastly different. The Mayo is located in the regional city of Rochester surrounded by Amish farming communities in the southeast of Minnesota, one hour from Minneapolis. Rochester is the third largest city in the state with a population of 94,000, one third of which are employed at the Mayo Clinic. The city is also home to one of IBM’s largest facilities, and has long been a fixture on Money magazine’s “Best Places to Live” index, and was ranked number 67 on the 2006 list. During our visit in September with the sun shining each day, we almost considered moving here.

courtesy of Mayo Clinic

The following pages will provide you with a brief history of how the Mayo Clinic came about, followed by a look inside the world class Electrophysiology Department and an interview with the EP Department manager, Mr Douglas Beinborn. In 2008/09 we hope to return to the Mayo to perform a site visit on the interventional and non-invasive sides. 20

CORONARY HEART ™


CARDIAC SITE VISIT

“The injured are picked up, and at once taken to the hospital. Truly this is quite as astonishing as any of the fairy tales.”

I

n 1846, Dr William Worrall Mayo emigrated from England where he was born, to the United States, training to become a doctor in 1850. In 1864 his family moved to Rochester, after being appointed as a civil war examining surgeon for the Union enrollment board the year prior.

Here Dr Mayo trained his two sons, William J. and Charlie in medicine, first by observing, followed by assisting with autopsies. They both then went on to medical school before returning to their father’s practice. It was however a tornado that ravaged Dr William Worrall Mayo, 1907 the town in 1863, killing and injuring As the family practice became bigger many that Nuns from the Sisters of St and medical knowledge was increasing Francis (who acted as nurses), and the rapidly, others joined the group. Mayo Doctors combined to build the Eventually the team created a new first general hospital in southeastern system of health care, with the creation Minnesota - the 27-bed Saint Marys of the USA’s first medical specialities. Hospital which opened in 1889. Dr William Mayo and his sons

courtesy of Mayo Clinic

Right from the beginning the Mayo was at the forefront of patient care. In 1969 on a trip to New York, Dr W.W. Mayo saw for the first time civilian ambulances transporting patients in the city, amazed that doctors no longer did house calls. He later wrote, “When an accident occurs in any part of the city, there is a dispatch sent ... and the ambulance is on the ground a few minutes after. The injured are picked up, and at once taken to the hospital. Truly this is quite as astonishing as any of the fairy tales.”

The Mayo Brothers Dr. Charlie (left) and Dr. Will

Sure enough, once St Marys Hospital was built the Mayo Drs purchased a horse-drawn ambulance from the Studebaker Company. 1.

once said, “no one is big enough to be independent of others.” In other words, medicine has become so complex that it requires a team of physicians, specialists, medical professionals and scientists all working together to provide the absolutely best medical care. 2. Since those days more than eight million people have been treated at Mayo Clinic, and staying true to their word, the patient always comes first.

1 http://www.mayoclinic.org/news2007-rst/3897. html 2 http://www.mayoclinic.org/tradition-heritage/ model-care.html

CORONARY HEART ™  21

courtesy of Mayo Clinic

MAYO HISTORY


CARDIAC SITE VISIT

Mayo Clinic (cont...) MAYO CLINIC ELECTROPHYSIOLOGY DEPARTMENT

W

ith the Mayo Clinic in Rochester, MN due to its size and international interest we have to break away from our traditional site visit articles and separate it into two parts: EP and Cath. In this edition we will look at the EP department which we visited in mid September 2007. The following questions have been answered by Mr Douglas Beinborn, the EP Department Manager.

Inserting a Pacemaker

Size of the EP Department: We operate six procedure rooms on a daily basis.

Staff numbers • • • • • •

18 technical staff 21 physicians 35 RN’s 3 mid-level providers 4 secretaries 4 schedulers

Equipment:

Cross-Training:

• • • • • • •

We cross-train within the lab. We share a prep/recovery with the cath lab.

Carto ESI ICE Laser extraction Prucka recording Cryo-ablation Stereotaxis

Variety of inpatient and outpatient procedures

We utilize RCIS and CVT’s who perform the same role. We have CRNA’s in four of our procedure rooms who provide deep sedation to general anesthesia. RN’s are crosstrained to work in the procedure rooms, our clinic, and hospital service.

Procedures performed per year:

New procedures implemented:

• • • •

• •

Day Procedures: Procedures: • • • • • • •

Ablation, Diagnostic EP, Tilt table studies, Long QT testing, ICD implants including biventricular, PM implants including biventricular, lead extraction, Implantable loop recorders

22  CORONARY HEART ™

Staffing roles:

900 ablations, 1200 device implants, 350 tilts/long QT tests. 200 EP diagnostic studies.

Epicardial ablation, Tandem heart for complex VT ablation, Carto Sound.


CARDIAC SITE VISIT

Inventory Management: We work cooperatively with Mayo Materials Management and a number of our own internal staff to manage our inventories and charging in relation to usage

Hemostasis Management: Complex to cover here. Some cases heparin is reversed, most of the time we wait for ACT to be <180 prior to sheath removal

Measures implemented to cut costs: Extensive work has been done on materials management. Topics include consignment, utilization rates, automation with reordering, cost negotiation. Currently working on lab efficiencies.

Training for new employees: Formal orientation process has been developed. Staff are assigned a preceptor with outlines and goals set of the orientee and preceptor.

Siemens EP Lab with Stereotaxis Niobe The entire EP department will soon be comprised of all new Siemens imaging equipment.

EP training facility for cardiac fellows: We have four senior fellows each year.

Continuing education programs for staff: • •

We have core curriculum every Monday that are EP in origin. Ability of staff to attend conferences outside of Mayo.

Competency checks for staff: •

• • • • •

ACLS, Infection control, Safety, Equipment competency, Procedural competencies (recording system, stimulator, device programmers, etc)

What is the best part of working at your facility? Highly dedicated staff, teamwork, innovation, access to the latest technology, challenging but rewarding work environment.

BLS, CORONARY HEART ™  23


We’re shedding more New evidence confirms what we’ve known all along.

The CARE study found no statistically significant difference between Isovue® and Visipaque™ in the rate of CIN in high-risk patients undergoing cardiac angiography or PCI. The CARE study is the largest, prospective, randomized, double-blind comparison of iso-osmolar iodixanol-320 with low-osmolar iopamidol-370 in high-risk patients.1

Read the CARE study today. Visit CARECIN.com Call Bracco Sales Center at 1-866-282-2895 or call Bracco Professional Services at 1-800-257-5181 option #2 Nonionic iodinated contrast media inhibit blood coagulation, in vitro, less than ionic contrast media. Clotting has been reported when blood remains in contact with syringes containing nonionic contrast media. Serious, rarely fatal, thromboembolic events causing myocardial infarction and stroke have been reported during angiographic procedures with both ionic and nonionic contrast media. Therefore, meticulous intravascular administration technique is necessary, particularly during angiographic procedures, to minimize thromboembolic events. As with all injectable contrast agents, the possibility of severe reactions should be borne in mind, regardless of the patient’s pre-existing medical history. Please see brief summary of Prescribing Information on the following page. Reference: 1. Solomon RJ, Natarajan MK, Doucet S, et al, and the Investigators of the CARE study. The CARE (Cardiac Angiography in REnally Impaired Patients) study: a randomized, double-blind trial of contrast-induced nephropathy in high-risk patients. Circulation. 2007;115:3189-3196.

Visipaque is a trademark of GE Healthcare. ©BDI 2007


light on CIN.

CARE study: CIN* incidence in at-risk patients 1a.

20

15

P=0.39†

10

6.7%

5

4.4% 0

1b. P=0.43†

15

12.4% 10

9.8% 5

0

20

1c.

15

P=0.15† 10

5

0

10.0%

5.9%

Isovue®-370 Visipaque 320

Isovue®-370 Visipaque 320

(iopamidol injection)

(iodixanol injection)

(iopamidol injection)

(iodixanol injection)

(iopamidol injection)

(iodixanol injection)

n=204

n=210

n=204

n=210

n=204

n=210

TM

TM

• There was no statistical difference in the incidence of CIN (SCr r0.5 mg/dL) following iopamidol-370 and iodixanol-320 (see Figure 1a)1 • The rates of SCr increases r25% were not significantly different (see Figure 1b)1 • The rates of eGFR decreases r25% were not significantly different (see Figure 1c)1 * CIN defined as a) an absolute increase r0.5 mg/dL, b) a relative increase r25% in serum creatinine or c) a r25% decrease in eGFR from baseline to 45-120 hours postcontrast. †

% Patients With Decrease in eGFR ≥25%

20

% Patients With Increase in SCr ≥25%

% Patients With Increase in SCr ≥0.5 mg/dL

1

P value is not statistically significant.

Isovue®-370 Visipaque 320 TM


BRACCO DIAGNOSTICS Rx only Rx only

0LEASESEEFULLPRESCRIBINGINFORMATION !BRIEFSUMMARYFOLLOWS 0LEASESEEFULLPRESCRIBINGINFORMATION !BRIEFSUMMARYFOLLOWS

ISOVUE®-200

Iopamidol Injection 41%

ISOVUE®-300

Iopamidol Injection 61%

ISOVUE -250 Injection ISOVUE -370 Iopamidol 76% Iopamidol Injection 51% Iopamidol Injection 76% ®

®

ISOVUE®-300

NOT FOR INTRATHECAL USE

)3/65%  ANDARE./4&/2).42!4(%#!,53%3EE)NDICATIONS AND$OSAGEAND !DMINISTRATIONSECTIONSFORFURTHERDETAILSONPROPERUSE $)!'./34)#./.)/.)#2!$)/0!15%#/.42!34-%$)! &OR!NGIOGRAPHY4HROUGHOUTTHE#ARDIOVASCULAR3YSTEM )NCLUDING#EREBRALAND0ERIPHERAL !RTERIOGRAPHY #ORONARY!RTERIOGRAPHYAND6ENTRICULOGRAPHY 0EDIATRIC!NGIOCARDIOGRAPHY 3ELECTIVE6ISCERAL!RTERIOGRAPHYAND!ORTOGRAPHY 0ERIPHERAL6ENOGRAPHY0HLEBOGRAPHY AND !DULTAND0EDIATRIC)NTRAVENOUS%XCRETORY5ROGRAPHYAND)NTRAVENOUS!DULTAND0EDIATRIC#ONTRAST %NHANCEMENTOF#OMPUTED4OMOGRAPHIC#%#4 (EADAND"ODY)MAGING #/.42!).$)#!4)/.3 .ONE 7!2.).'3 3EVERE!DVERSE%VENTS LNADVERTENT)NTRATHECAL!DMINISTRATION 3ERIOUSADVERSEREACTIONSHAVEBEENREPORTEDDUETOTHEINADVERTENTINTRATHECALADMINISTRATIONOF IODINATEDCONTRASTMEDIATHATARENOTINDICATEDFORINTRATHECALUSE 4HESESERIOUSADVERSEREACTIONSINCLUDEDEATH CONVULSIONS CEREBRALHEMORRHAGE COMA PARALYSIS ARACHNOIDITIS ACUTE RENAL FAILURE CARDIAC ARREST SEIZURES RHABDOMYOLYSIS HYPERTHERMIA AND BRAIN EDEMA 3PECIAL ATTENTION MUST BE GIVEN TO INSURE THAT THIS DRUG PRODUCT IS NOT INADVERTENTLY ADMINISTEREDINTRATHECALLY 'ENERAL .ONIONICIODINATEDCONTRASTMEDIAINHIBITBLOODCOAGULATION INVITRO LESSTHANIONICCONTRASTMEDIA#LOTTING HASBEENREPORTEDWHENBLOODREMAINSINCONTACTWITHSYRINGESCONTAININGNONIONICCONTRASTMEDIA 3ERIOUS RARELYFATAL THROMBOEMBOLICEVENTSCAUSINGMYOCARDIALINFARCTIONANDSTROKEHAVEBEENREPORTED DURING ANGIOGRAPHIC PROCEDURES WITH BOTH IONIC AND NONIONIC CONTRAST MEDIA 4HEREFORE METICULOUS INTRAVASCULARADMINISTRATIONTECHNIQUEISNECESSARY PARTICULARLYDURINGANGIOGRAPHICPROCEDURES TOMINIMIZE THROMBOEMBOLIC EVENTS .UMEROUS FACTORS INCLUDING LENGTH OF PROCEDURE CATHETER AND SYRINGE MATERIAL UNDERLYINGDISEASESTATE ANDCONCOMITANTMEDICATIONSMAYCONTRIBUTETOTHEDEVELOPMENTOFTHROMBOEMBOLIC EVENTS&ORTHESEREASONS METICULOUSANGIOGRAPHICTECHNIQUESARERECOMMENDEDINCLUDINGCLOSEATTENTIONTO GUIDEWIREANDCATHETERMANIPULATION USEOFMANIFOLDSYSTEMSANDORTHREEWAYSTOPCOCKS FREQUENTCATHETER mUSHING WITH HEPARINIZED SALINE SOLUTIONS AND MINIMIZING THE LENGTH OF THE PROCEDURE4HE USE OF PLASTIC SYRINGESINPLACEOFGLASSSYRINGESHASBEENREPORTEDTODECREASEBUTNOTELIMINATETHELIKELIHOODOFINVITRO CLOTTING #AUTIONMUSTBEEXERCISEDINPATIENTSWITHSEVERELYIMPAIREDRENALFUNCTION THOSEWITHCOMBINEDRENALAND HEPATICDISEASE ORANURIA PARTICULARLYWHENLARGERORREPEATDOSESAREADMINISTERED 2ADIOPAQUEDIAGNOSTICCONTRASTAGENTSAREPOTENTIALLYHAZARDOUSINPATIENTSWITHMULTIPLEMYELOMAOROTHER PARAPROTEINEMIA PARTICULARLYINTHOSEWITHTHERAPEUTICALLYRESISTANTANURIA-YELOMAOCCURSMOSTCOMMONLY IN PERSONS OVER AGE !LTHOUGH NEITHER THE CONTRAST AGENT NOR DEHYDRATION HAS BEEN PROVED SEPARATELY TO BE THE CAUSE OF ANURIA IN MYELOMATOUS PATIENTS IT HAS BEEN SPECULATED THAT THE COMBINATION OF BOTH MAYBECAUSATIVE4HERISKINMYELOMATOUSPATIENTSISNOTACONTRAINDICATIONHOWEVER SPECIALPRECAUTIONS AREREQUIRED #ONTRAST MEDIA MAY PROMOTE SICKLING IN INDIVIDUALS WHO ARE HOMOZYGOUS FOR SICKLE CELL DISEASE WHEN INJECTEDINTRAVENOUSLYORINTRAARTERIALLY !DMINISTRATION OF RADIOPAQUE MATERIALS TO PATIENTS KNOWN OR SUSPECTED OF HAVING PHEOCHROMOCYTOMA SHOULDBEPERFORMEDWITHEXTREMECAUTION)F INTHEOPINIONOFTHEPHYSICIAN THEPOSSIBLEBENElTSOFSUCH PROCEDURES OUTWEIGH THE CONSIDERED RISKS THE PROCEDURES MAY BE PERFORMED HOWEVER THE AMOUNT OF RADIOPAQUEMEDIUMINJECTEDSHOULDBEKEPTTOANABSOLUTEMINIMUM4HEBLOODPRESSURESHOULDBEASSESSED THROUGHOUT THE PROCEDURE AND MEASURES FOR TREATMENT OF A HYPERTENSIVE CRISIS SHOULD BE AVAILABLE4HESE PATIENTSSHOULDBEMONITOREDVERYCLOSELYDURINGCONTRASTENHANCEDPROCEDURES 2EPORTS OF THYROID STORM FOLLOWING THE USE OF IODINATED RADIOPAQUE DIAGNOSTIC AGENTS IN PATIENTS WITH HYPERTHYROIDISM OR WITH AN AUTONOMOUSLY FUNCTIONING THYROID NODULE SUGGEST THAT THIS ADDITIONAL RISK BE EVALUATEDINSUCHPATIENTSBEFOREUSEOFANYCONTRASTMEDIUM

3ELECTIVE CORONARY ARTERIOGRAPHY SHOULD BE PERFORMED ONLY IN SELECTED PATIENTS AND THOSE IN WHOM THE EXPECTED BENElTS OUTWEIGH THE PROCEDURAL RISK 4HE INHERENT RISKS OF ANGIOCARDIOGRAPHY IN PATIENTS WITH PULMONARYHYPERTENSIONMUSTBEWEIGHEDAGAINSTTHENECESSITYFORPERFORMINGTHISPROCEDURE!NGIOGRAPHY SHOULD BE AVOIDED WHENEVER POSSIBLE IN PATIENTS WITH HOMOCYSTINURIA BECAUSE OF THE RISK OF INDUCING THROMBOSISANDEMBOLISM 3EEALSO0EDIATRIC5SE )NADDITIONTOTHEGENERALPRECAUTIONSPREVIOUSLYDESCRIBED SPECIALCAREISREQUIREDWHENVENOGRAPHYIS PERFORMED IN PATIENTS WITH SUSPECTED THROMBOSIS PHLEBITIS SEVERE ISCHEMIC DISEASE LOCAL INFECTION OR A TOTALLYOBSTRUCTEDVENOUSSYSTEM%XTREMECAUTIONDURINGINJECTIONOFCONTRASTMEDIAISNECESSARYTOAVOID EXTRAVASATIONANDmUOROSCOPYISRECOMMENDED4HISISESPECIALLYIMPORTANTINPATIENTSWITHSEVEREARTERIAL ORVENOUSDISEASE )NFORMATIONFOR0ATIENTS 0ATIENTSRECEIVINGINJECTABLERADIOPAQUEDIAGNOSTICAGENTSSHOULDBEINSTRUCTEDTO  )NFORMYOURPHYSICIANIFYOUAREPREGNANT  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GENETICTOXICITYWASOBTAINEDININVITROTESTS 0REGNANCY4ERATOGENIC%FFECTS 0REGNANCY#ATEGORY"2EPRODUCTIONSTUDIESHAVEBEENPERFORMEDINRATSANDRABBITSATDOSESUPTO ANDTIMESTHEMAXIMUMRECOMMENDEDHUMANDOSEGLKGINAKGINDIVIDUAL RESPECTIVELY AND HAVEREVEALEDNOEVIDENCEOFIMPAIREDFERTILITYORHARMTOTHEFETUSDUETOIOPAMIDOL4HEREARE HOWEVER NOADEQUATEANDWELL CONTROLLEDSTUDIESINPREGNANTWOMEN"ECAUSEANIMALREPRODUCTIONSTUDIESARENOT ALWAYSPREDICTIVEOFHUMANRESPONSE THISDRUGSHOULDBEUSEDDURINGPREGNANCYONLYIFCLEARLYNEEDED .URSING-OTHERS )TISNOTKNOWNWHETHERTHISDRUGISEXCRETEDINHUMANMILK"ECAUSEMANYDRUGSAREEXCRETEDINHUMANMILK CAUTIONSHOULDBEEXERCISEDWHENIOPAMIDOLISADMINISTEREDTOANURSINGWOMAN 0EDIATRIC5SE 3AFETY AND EFFECTIVENESS IN CHILDREN HAS BEEN ESTABLISHED IN PEDIATRIC ANGIOCARDIOGRAPHY COMPUTED TOMOGRAPHYHEADANDBODY ANDEXCRETORYUROGRAPHY0EDIATRICPATIENTSATHIGHERRISKOFEXPERIENCINGADVERSE EVENTSDURINGCONTRASTMEDIUMADMINISTRATIONMAYINCLUDETHOSEHAVINGASTHMA ASENSITIVITYTOMEDICATION ANDORALLERGENS CYANOTICHEARTDISEASE 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INTERVIEW

Douglas Beinborn - speaking about the Mayo EP Lab redesign and challenges to be faced in the future.

to different labs, so what we came up with was having three labs connected by one room containing all of our supplies, and that design has worked well. Now though as we are changing out the floor systems, we get to redesign again, and some of the driving factors are that the cold storage for the old equipment required a bigger space than the new equipment, so we are able to obtain space back from there.

Mr Douglas Beinborn, MA, RN Department Manager of Heart Rhythm Services, Mayo Clinic, Rochester

Douglas Beinborn is currently overseeing the redesign of the EP department at the Mayo Clinic in Rochester and explains the process, decisions, and challenges facing one of the world’s leading departments. He spoke with Coronary Heart’s Director and Chief Editor, Tim Larner.

Tell me about the process for upgrading your department? When we built this lab originally 12 years ago there was a group of nurses, techs, and physicians who helped with the design. Back then we did site visits

Some other guiding forces are how can we reduce the radiation exposure to our staff? How can we reduce wear and tear? How can we decrease wearing lead as much as what we have in the past, and get the best images possible? So currently in one of the procedure labs we are doing all of the work inside the room, however we have one procedure room that we are designing for the Hansen Robotics where we are moving all of the equipment outside of the lab. Therefore we will be doing the 3D mapping outside of the room, we will be able to do the intra-cardiac echo outside of the room, as well as the stimulator, recording system and ablation system. Those closest to the exposure will be the anesthesia person and one technician, but they will be far enough away from the fluoro system that the radiation dose drops significantly. In relation to wear and tear, we looked at how we were wearing lead everyday of the week, and

can we get our staff to wear it only part of the week. With the other procedure room that we are replacing we will still be leaving the equipment in the room there. Number one idea was to have 2 EP rooms and have everything in the control room but there was too much of a space crunch, and it would have been too loud to have two alongside each other. So we are redesigning that room so that the people who are doing the recording system and the ablation box will have it positioned in the room protected by lead. So that once they are behind the lead, they will be able to take off their lead gowns and be better protected. The other room that we are going to be ramping up significantly is going to be the Stereotaxis room, and that is obviously run from outside of the room, which again is less standing, less wear and tear, and less radiation exposure. So I think the main thing I see coming up is that we are fortunate to have a number of people who have been working at the Mayo for 20-30 years, and physicians who have been here for 15 years, and I don’t want to say that we are all getting older but obviously how can we better take care of our staff. CORONARY HEART ™  27


Interviewed by Tim Larner Director/Chief Editor of Coronary Heart Previous Cardiology Manager, Radiation Safety Officer, and Occupational Health & Safety Manager

INTERVIEW

Douglas Beinborn (cont...) That is obviously very important. As a radiographer I have spent many hours in lead during EP cases and it can be difficult for everybody in the lab. It is a real Occupational Health and Safety concern. Absolutely! With new technology, radiation exposure is lower, but if we can get them away from there, we will save more wear and tear on the back.

What kind of frame rates do you use during procedures? Two of the three GE rooms have a variable rate of flow and a special mag for us and 15fps and low dose, and that will be what we will be using on the new Siemens equipment with 15fps and low.

What kind of input do you have from cardiologists in the design? We have 2 physicians that work in our department, 2 technicians, and

Eighteen Bed Recovery Room: The display on the ceiling is used to communicate with staff and physicians, acting similar to a paging system. These are located throughout the department. 28

CORONARY HEART â&#x201E;˘

two nurses who sit down with us and go over all of the designs. Then we take them into the room and show them where the layout will be and see where the fluoro sits how we are going to build that section, and see where people are going to be protected during procedures, so we definitely get good input from everybody. We sit down with architects, electricians, construction managers, and even our staff get to go over the plan. The staff are involved every step of the way.


INTERVIEW

Do you use Consulting Companies? There isn’t a specific consulting company we use. There are typically local ones who contact us and we use them.

Holistic design for the patients? Obviously the needs of the patient comes first so we do whatever is needed. I think we have a very comprehensive educational program here for the patients, so before the procedure they are well informed. They are seen by one of our doctors before they have an EP procedure (can be a general cardiologist or one of our doctors who works them up before the procedure). We have nurse educators at both the EP and device side before and after the procedure.

For our complex ablations we put those patients under a general anaesthesia. Now for the other rooms we offer music for them, so they can bring their own in on personal players and listen. We honestly haven’t looked at any else other than that. So many of our patients have general anesthesia which is unique. For our VT Right Ventricular Outflow tract ones that you need them awake fully so you don’t knock down

their Catecholamine’s. But with AF it is so anatomic based that when you find a firing coming from the Right Superior Pulmonary Vein, then we not only isolate that one but we isolate all the veins. We do a thorough ablation line as well. Because although they have firings coming from one

We bring patients in the day before the procedure, so when they arrive in the morning they have been completely worked up so essentially in the morning it is to ensure there has been no change in condition and to answer any last questions. Acts more as a public relations visit by us. Plus if I see them the day before and the day of the procedure we already have an established relationship, which improves their comfort level.

Philips have released their Ambient Suite to improve comfort for the patient, and in our last issue we featured a lab in the UK which had a television above the patient during a procedure. Are you considering employing any unique patient aids?

Gonda Building. Opened in 2001 it is linked with two other buildings forming the largest interconnected medical facility of its kind in the world, more than 3.5 million square feet. CORONARY HEART ™ 29


INTERVIEW

Douglas Beinborn (cont...) pulmonary vein that doesn’t necessarily mean that is the way their normal situation is, so our goal is to do just one procedure and get everything taken care of in one procedure. So for AF they receive a general anesthetic.

Purchasing decisions in the labs? It happens every year. So for the 2008 budget we met in August to say what our capital equipment needs would be, and what we have to do is anything over $30,000 we have to put it through a committee, part of the capital

The Landow Atrium: Located in the Gonda Building. Staff regularly stop by and give an impromptu performance to patients.

equipment budget, so if it is anything under $30,000 I can sign off. So what I do is sit down with the physician leaders and both the device, EP and the whole practice and say ‘what do we need?’ So next year we have one of our main pacing room will be getting a new fluoro system, and then we are upgrading some of our 3D mapping systems, and we have put in Hansen Robotics just in case we don’t get it approved this year it is in for next year, and anything for space remodelling. Also an additional procedure room for EP was also put in there. After that it all gets sent into hospital management and reviewed by leadership there, where they ask, ‘what is your certainty of needing this equipment?’ Then they might challenge by saying ‘boy this is only 3 years old, why are you asking for a replacement for that?’ We have never had anything like that but that is the sort of questions. In Echo they may ask what is your breakdown rate, is it new technology, is it superior to what you have, or is it the same platform for what you have. So you have to expect questions. And then the institution will say this is how many millions of dollars they have budgeted for equipment this year. So they may have a budget for $100 million but there may be $170 million that people are asking for. So then you have to ask does it actually need to be replaced. What will happen if it isn’t? Is it a patient care or safety issue? We are replacing our Prucka systems this year as our communication systems are NT platform which will no longer be supported, and our fluoro systems are 12 years old so they are in need of replacement. So it is all about

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checks and balances, about how much you really need this equipment. If it is new technology you have to look at how it conforms to your business plan. Does it require more space? More staff to run it? Does it require physicians? Can you bill for it? Does it speed up cases? Does it improve outcomes? So there are a number of questions you have to answer. Good checks and balances right there.

How is the rapport between physicians and staff in the Lab? We have a very unique situation here in that the physicians really value the allied staff. I think EP procedures are a little different from Cath Lab procedures. Cath Lab procedures are quick, but with here, particularly the ablations, they are longer and technically challenging, and the physicians are very dependant on the rest of the staff. Our staff have a very good working relationship with the physicians, and are a close knit group. This has been really the success of our total group

In the UK I have worked in both public (government funded) and private (insurance funded) hospitals for EP cases. In public hospitals if the patient list hasn’t ended you do the remainder the following day, but in private the staff must stay to complete the list which takes a toll on moral. I think this is the biggest problem we have coming up is to deal with the demands on our services. If we look at AF it is only going to become a bigger problem, because if you look

at statistics now and world wide projections for 2020, they are going to go up drastically, and as people age, more people will need pacemakers. I think everywhere you turn with EP there is significant growth opportunity there. Another thing we are looking at is how can we improve efficiency and use our expensive rooms to their maximum potential, like can you do an extra case per day with the new equipment. Efficiency is key. You want to do what is best by the patient, but on the other hand if you can do different processes more smoothly and get them in and out of the procedure room more quickly then that is really important.

How is your patient turnover? Can you think of any ways you can improve? I know we have just hired mid level providers who work on the floors. Sometimes we have patients that come from the ward that aren’t properly prepared that can really slow down the day, so we look at how we can best manage. We use processes whereby we assume 80% of the patients will be straight forward, but when something happens outside the normal we are prepared to handle it. We work backwards to try and work out where was the holdup and how to improve it for next time. In the morning our nurse sees them down on the floor and gives them the final education, then a staff nurse from that floor evaluates them, then they come up to our 18 bed recovery area and are seen by a CRNA (Certified Registered Nurse Anesthetist) and have their sites prepped, and if it is

an ablation have their groins prepped there. There are many different touches, so we must look at how can we reduce this without reducing quality. Like how many times do you need to ask about medication allergies? So there are always things we can do to improve efficiency.

The best departments have good communications with all areas of the hospital, so any problems that arise can be solved almost immediately, rather than pointing the finger at each other. Prepare for the worst. Hope for the best!! We even do site visits to other hospitals and here we also bring in a multidisciplinary groups whom directly affect our workflow and try and say, ‘our goal is to try and have a patient on the table by 0745. How long do you need to bring them in? How long is your process?’ But then there are waits like with transportation, escorting patients to a different area. We look at the time they are called till the time they get there. What is that time? We are always finding ways to improve.

The Mayo is always regarded as one of the top hospitals in the USA but as you will be even visiting the Cleveland Clinic soon to see how they operate. In the back of my mind I think that wherever I go in any other institution be it a small or big lab there is always a couple of things you can take away, and say ‘boy they really do a good job with this and it would be nice if we can incorporate this in our lab.’ You can gain something from any place you go and watch.

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Technological Advances in Lesion Assessment

F

or over thirty years, cardiologists and technologists have been looking up at the cardiac cath lab angiography screen and asking each other, “What do you think?” “What should we do about that lesion?”

courtesy RADI Medical Systems, Inc.

By Charlene Shellenberger, RN, Clinical Education Specialist, Healthworks, Inc.

“Is this stenosis severe enough for the patient to benefit from intervention?” These questions were followed with multiple views and contrast injections. Unfortunately, the additional radiation exposure and contrast would rarely yield a definitive answer to these questions. However, thanks to advances in interventional cardiology, physicians who practice evidence-based medicine have at their disposal two technologies. These technologies can provide definitive answers to questions of lesion significance and direct appropriate medical and interventional therapies. The technologies that offer this supporting evidence are Fractional Flow Reserve (FFR) and Intravascular Ultrasound (IVUS). FFR can determine if a suspect lesion is limiting the flow of blood to the heart muscle, causing ischemia; while IVUS can differentiate the disease pathology, plaque burden and true cross-sectional area of the culprit lesion. These tools serve as guides in interventional therapy, determining stent expansion and apposition in an effort to achieve optimal patient results.

Historical Perspective. In 1977, when Andreas Gruntzig, one of the pioneers of modern interventional cardiology, performed the first balloon angioplasty, coronary angiography was the only modality available for lesion assessment. Thus, the angiogram has been integral to cardiological diagnosis. However, the limitations of angiography are well documented. The injection of contrast medium into an epicardial vessel provides a lumen gram only. Furthermore, the appearance of that lumen is dependent on the angle at which the lumen is viewed. For

The following article was made possible in part by an unrestricted educational grant from Bracco Diagnostics Inc. For more information, please visit them at www.bracco.com

32

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instance, an eccentric (elliptical shaped) lesion may appear to have a 75% stenosis in one view, but the orthogonal view of the same area can give an appearance of only a 25% stenosis (see figure 1). In addition, is the worst single view representative of the clinical importance of the narrowing? So, is seeing really believing? Do we send this patient for bypass surgery based solely on the one view in which the left main coronary artery appeared narrowed? For a lesion which cannot be seen well enough to gauge its clinical importance, additional information is needed. 1. Overcoming the limitations of angiography is the reason ischemic stress testing with pressure wire FFR, which measures physiologic impact of lesion severity, and IVUS, which provides an anatomic assessment of lesion severity, were developed. If the angiogram did the job in every case we wouldn’t need these tools. Development of FFR Technology. FFR technology was actually developed by Radi Medical Corporation in conjunction with two European cardiologists, Dr. Nico Pijls and Dr. Bernard De Bruyne. The first version was an optical wire released in 1992. Radi’s current pressure wire technology for assessment of FFR celebrates its tenth anniversary this year. FFR-What is it? By definition, FFR is: Maximum achievable blood flow to the myocardium supplied by a stenotic artery as a fraction of normal maximum flow-pressure distal to the lesion divided by the pressure at the tip of the guide catheter, expressed as pD/ pA=FFR. Thus, in the absence of any coronary disease a normal value would

be 1.0, as these two pressures would be equal. However, a FFR value of <0.75 identifies a stenosis associated with inducible ischemia, in other words, the lesion is reducing the flow of blood to the myocardium by 25% and is responsible for patient symptoms of chest pain-ischemia. This lesion is considered functionally significant and requires interventional therapy. Furthermore, FFR is a lesion specific, physiological index determining the hemodynamic severity of intracoronary lesions. FFR can accurately identify lesions responsible for ischemia, which in many cases would have been undetected or not correctly assessed by angiography. Using FFR, the operator can guide intervention to the lesions responsible for the patient’s problem, saving time, cost and optimizing clinical outcome. 2. How is the Functional Assessment of Coronary Artery Disease with FFR performed? By inserting a specialized 0.014-inch guidewire into the coronary artery, the pressure within the vessel can be accurately measured across a lesion. Two systems are currently available for

clinical use: the RADI® Pressure Wire®/RADI Analyzer®, and the Volcano Corporation Smartwire/ ComboMap systems. Vital to this is understanding the physiologic basis of these

measurements, a term referred to as hyperemia. When a vessel is in a state of maximum dilation it is said to be in a state of hyperemia. Hyperemia can be induced in the cath lab with vasodilatory drugs, providing an invasive stress test. ³. Two drugs have been used to induce hyperemic states in the cath lab, adenosine and paperverine. Adenosine, diluted to 10mcg/cc may be administered intracoronary (IC) starting with 30 mcg in the right coronary or 40 mcg in the left coronary. When given IC, adenosine has a very short half life –about 15 seconds. Adenosine may also be given IV at 140mcg/kg/min. Maximum hyperemia is achieved in one to two minutes. Patients may experience chest pain and/or shortness of breath during the infusion, these symptoms will dissipate quickly after the infusion is discontinued. IV adenosine administration is contraindicated in patients with COPD. IV adenosine administration is preferred by most high-volume RADI institutions (due to the high degree of reproducibility). It is required when performing a pullback of the RADI Pressurewire through multiple lesions within the same vessel, or left main evaluation. Papaverine has been used in the past but suffers from many complications which include incompatibility with heparin and iodinated contrast agents, prolonged Q-T interval, and occasionally torsades de pointes.

courtesy RADI Medical Systems, Inc.

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Advances in Lesion Assessment (cont...) The RADI® Pressure Wire. The latest generation RADI® wire, Certus, is a sterile 0.014-inch guide wire with a 3-cm shapeable, radiopaque tip. The wire is hydophyllic to aid placement in tortuous anatomy and hydrophopbic to help maintain wire position during intervention. Three microsensors are located 3cm proximal to the distal tip of the wire. The first sensor is a silicon plezoresistive microsensor coupled with a Wheatstone bridge. It has a range of 30-300 mmHg and measures FFR. The second sensor measures thermodilution derived CFR (Coronary Flow Reserve) which is a measurement of microvasculature flow. The third microsensor is a temperature sensor. The Certus® wire is available in 175-cm and 300-cm lengths. A six foot adapter cable connects the Pressurewire® to the RADI Analyzer® during pressure measurements. The cable can be disconnected during wire placement, manipulation and intervention. ⁴. The Pressurewire may be placed in a diagnostic catheter or an interventional guide with no sideholes. Patients must be heparinized prior to wire insertion per hospital protocol. The RADI Analyzer®. The RADI Analyzer® is a polemounted computer system. It may be portable or integrated into the cath lab. The Analyzer interfaces with the cardiac cath lab’s hemodynamic monitoring system. It collects and interprets signals from the guide wire (micromanometer) and arterial waveform from the guide catheter to 34

CORONARY HEART ™

Limitations of Coronary Angiography Coronary Cross-section

Angiogram Silhouette

7%

X-rays

2%

Figure 1 be simultaneously displayed on both the RADI Analyzer® and the cath lab hemodynamic screen. Instructions for setup are displayed on the screen. The entire process of FFR evaluation (including equipment setup, hyperemia induction and recording) can be accomplished in five minutes or less. Capitol equipment cost for a RADI analyzer is about $20,000. Each RADI® Pressure Wire® costs between $600-$700. DEFER Study. A landmark study that investigated the appropriateness of stenting a functionally nonsignificant lesion. 325 patients were referred for PCI of an intermediate stenosis. FFR was measured just prior to the planned intervention. If the FFR was ≥0.75 patients were randomly assigned to deferral (Defer group n=91)(medical therapy with aspirin and statins) or performance (Perform group n=90) of PCI. If FFR <0.75, PCI was performed as planned. There was a five-year follow-up. The conclusion of

this study was that five year outcomes after deferral of PCI of an intermediate lesion based on FFR >0.75 is excellent. The risk of cardiac death or MI related to this stenosis is 1% per year and is NOT decreased by stenting. ⁵. “If it ain’t broke-don’t fix it!” Conclusions and Take Home Points about FFR evaluation with RADI Pressurewire system. Functional assessment of ischemia prior to stenting intermediate lesions is mandatory because it determines if a patient will benefit from PCI or not. FFR evaluation is easy to perform, accurate, lesion-specific, quick and the cheapest diagnostic adjunct to nonconclusive angiographic data. The immediate and accurate identification of culprit lesions enables easy, complete and effective diagnosis and treatment. ⁶⁷. If the stenosis is functionally significant, use IVUS to examine the morphology and composition of the plaque, vessel and lumen size, and lesion length to provide the appropriate interventional therapy for


EDUCATION

IVUS Benefits vs. Angiography. Intravascular Ultrasound is the only way to evaluate vessel morphology. IVUS can determine the composition of a lesion: soft plaque, fibrous, calcified or fibro-fatty. IVUS allows insight into the pathophysiology of the plaque formation. Utilization of IVUS gives quantitative measurements of vessel and lumen areas at the stenosis, diameters and lesion length. IVUS provides an evaluation of stent deployment, apposition to the vessel wall, and edge-dissection assessment. Finally, angiography is a 2-D “lumen gram”, while IVUS gives a 3-D, realtime picture of the vessel from the inside out. IVUS Technology. The first human coronary IVUS in the United States was performed in 1987 by Dr. John Hodgson. 8. The components of IVUS technology are an ultrasound machine, IVUS catheter, an interface and optional pullback

courtesy Boston Scientific Corporation

Normal Vessel

Which is more diagnostic? courtesy Volcano Corporation

the patient. Currently, only 10% of all cath cases employ FFR as a diagnostic tool to guide PCI decision making. 2

Normal angiographic image of RCA

device. Ultrasound machines can either be portable or integrated into the cath lab as a permanent structure. Portability has made great strides in the last few years, as units used to average about 400-500 pounds and required a strong back and arms to maneuver. Now, the new generation units for both Volcano, (s5), and Boston Scientific Corporation, (iLab) weigh about 100 pounds and can be moved with the pressure of one finger.

Dissection

IVUS image of RCA with eccentric plaque

There are two types of IVUS catheters: Mechanical and Phased Array. A mechanical catheter has a central driveshaft and a single transducer mounted at the catheter tip which quickly rotates (1800 rpm) to visualize the entire vessel in crossection. Mechanical transducers provide excellent image quality. However, the disadvantages of the central driveshaft is diminished flexibility and image distortion termed NURD (Non Uniform Rotational Distortion). Boston Scientific utilizes mechanical catheter technology. Phased array catheters consist of multiple transducer elements permanently mounted along the circumference of the catheter tip. Because this catheter has no moving parts or central driveshaft there is greater flexibility, no NURD, and may be used in the carotids. 9. Volcano utilizes phased array technology for their Eagle Eye Gold catheter. Anatomy of the Coronary Artery from the Inside of the Vessel to the Outside. Coronary arteries are composed of three layers. The INTIMA-innermost CORONARY HEART ™  35


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Advances in Lesion Assessment (cont...) layer, only one to two cell layers thick but can greatly enlarge with the deposition of atherosclerotic plaque. The intima is defined by the internal elastic lamina (IEL) and the external elastic lamina (EEL). The MEDIA- middle surrounds the intima with a homogenous layer of smooth muscle cells (40 layers), providing vascular tone to the artery. The ADVENTITIA- outer layer surrounds the media and is composed of fibrous connective tissue which adds external support to the vessel.

courtesy Volcano Corporation

Formation of Ultrasound Image. Ultrasound waves transmitted from the transducer will “bounce” back whenever it encounters an interface of different acoustic impedance. Therefore, ultrasound waves will traverse the blood in a vessel with minimal reflection, but will be highly reflected when it meets with the intima, which will be displayed as a single concentric echo. Based on the echo density of the structures of the artery, normal coronary anatomy produces alternating bright and dark echos: A bright echo from the intima, a dark zone from the media

and multiple bright echos from the adventitia. In addition, this explains why calcium, which is very dense and does not allow any penetration of the sounds waves beyond its borders appears bright white (echo dense) with a black shadow behind it (acoustic shadowing). Atherosclerosis is a wall disease, not a lumen disease as plaque is laid down between the intima and the media. Atherosclerotic vessels may undergo either positive or negative remodeling. Positive remodeling of the coronary artery is when the vessel grows to accommodate plaque formation in attempt to retain the integrity of the lumen size. Positive remodeling occurs about 80% of the time. Positively-remodeled vessels are composed more of softer plaque and respond more favorably to PCI than does a negatively-remodeled vessel. In negative remodeling, the vessel shrinks as plaque formation encroaches on the vessel lumen. Negative remodeling occurs 20% of the time and can be associated with more difficult PCI revascularization therapies. Remember, with angiography we do not see the plaque, we see only the EFFECTS of the plaque. Visualization of plaque is only possible with IVUS.

Volcano IVUS (Virtual Histology) 36  CORONARY HEART ™

IVUS-Guided PCI and Determination of Lesion Significance. The key concept of using IVUS

to guide interventional therapy is determining the MLA (Minimal Luminal Area) of the most diseased segment of the vessel. Thus, if the MLA is <4mm² in the proximal third of an epicardial vessel the lesion is considered significant and is justified for intervention. If the left main is being interrogated, an area of <67mm² is significant and that patient may be referred for bypass surgery. These MLA parameters correlate with FFR values of <0.75 in determination of hemodynamically and structurally significant lesions. Heavily calcified lesions. Calcium poses special consideration in guiding therapeutic treatment. Large amounts may require debulking with rotational atherectomy prior to stent placement. The plaque may be modified with a cutting balloon or pre-dilating with a compliant balloon. Nearly all calcified lesions will require post-dilatation with a high-pressure balloon to achieve full stent expansion. It is interesting to note that stable lesions may have a high calcium component. This is due to the deposition of calcium by red blood cells at a time of previous plaque rupture in attempts to repair and give stability to the arterial wall. 10. Stent Sizing Guided by IVUS. It is important to determine the proximal and distal reference lumen of the target vessel. Reference lumens are the most near “normal” segment adjacent to the stenosis. Aggressive operators may choose to size their stent to the proximal reference which would be larger than the distal reference, as vessels taper in size from proximal to distal. More conservative physicians size the stent to the distal reference,


EDUCATION

while others take an average of the two sizes. The MLA of the diseased segment compared to the vessel size of the same segment provides the amount of plaque burden, expressed as a percentage. Plaque burden is not the same as percent stenosis. Percent stenosis is derived by a ratio of the MLA of the diseased segment to the MLA of the proximal reference lumen. The number that appears on the IVUS screen after the determination of the vessel and lumen size with either manual or automatic edge detection is percent plaque burden. Key to successful stenting and optimal patient outcomes with IVUSguided stenting is to adhere to the principle of stenting from normal to normal, with good coverage over the diseased portion of the vessel. 11. Therefore, routine use of a pullback device provides lesion length and is instrumental in choosing stent length and preventing geographic miss and inappropriate stenting. A mechanical pullback device may be set to move at either 0.5mm/sec or 1mm/sec, thus providing quantitative data for lesion length. Detection of edge-dissection post stenting is enhanced when the automatic mechanical pullback is utilized. IVUS post-stent placement can determine if there is adequate stent strut expansion as well as apposition to the vessel wall. This is of paramount importance in the world of drug eluting stents (DES). Multiple studies have shown optimal deployment of DES is critical to positive patient outcomes. The CRUISE study (Can Routine Ultrasound Influence Stent

Expansion) found a 44% reduction in TLR (Target Lesion Revascularization) with IVUS guided post dilatation. This coordinates with a 2006 study by Dr. Ron Waxman at Washington Hospital Center who found that up to 80% of DES may be inadequately deployed. IVUS use can reduce the number of sub-optimally deployed stents, which should positively affect or reduce the risk of restenosis. 12. Financially, it is better for the patient and the cath lab to place one appropriately sized stent with IVUS guidance than multiple stents due to geographic miss. The STLLR trial showed up to 75% of the time there is some geographic miss. In addition, studies show each episode of restenosis costs an additional $15,000. Finally, these are monetary costs of restenosis. The emotional cost to the patients and their families cannot be reflected in a monetary value. Getting the Most From Your Coronary Stent. Utilizing IVUS to assess the lesion pre-stenting and for verification of apposition and expansion poststenting. Pre-treat the vessel with compliant balloon or debulk if calcium is present as lesion preparation is necessary to optimize stent deployment. Post-dilatation with a non-compliant balloon catheter will ensure good stent expansion and complete apposition. These measures will help reduce the risk of complications associated with coronary stenting such as SAT ( Sub Acute Thrombosis-blood clot), TLR (Target Lesion Revascularization) and restenosis.

Who Benefits the Most from IVUS? The more complex the case, the more IVUS is needed. Any lesion with a known high restenosis rate such as bifurcations, ostial, left main, relatively small vessels in diabetics, and long lesions should be IVUSed. Another group of patients who would also benefit from IVUS are older patients with chronic stable angina. These patients, in most cases, have a lot of calcium build-up. Finally, any case where an unclear angiogram warrants further diagnostic evaluation with IVUS. IVUS would provide the least benefit for a young patient with a short lesion in a large vessel, or, patients with very small vessels 2.0-2.25mm diameter. Challenges with IVUS- Three Reasons Cited by Physicians NOT to use IVUS. 1. Too much time and or money. a. Actual set up time is 5 minutes b. Actual cost savings as restenosis and acute problems of thrombosis are reduced. 2. Lack of Clinical Data a. Nine angiographic vs. IVUS-guided studies performed. b. Eight studies in favor of IVUSguided stenting and one neutral. c. Studies show IVUS-guided expandable stent implantation have better outcomes both acutely and chronically, CRUISE study. 3. Physicians unable to interpret the image or work the machine, too technically challenging for them. a. Most important to be able to obtain lumen diameter and lumen area. b. Know epicardial vessel MLA <4mm² and left main <6-7mm² CORONARY HEART ™  37


EDUCATION

Advances in Lesion Assessment (cont...)

courtesy Volcano Corporation

converted to 3-D as well.

IVUS - VH Plaque progression is Associated with Thrombus require interventional therapy. Differentiate between % plaque burden and % stenosis. c. Well-trained techs and nurses to run the machine making setup faster and interpretation of images more routine will facilitate greater implementation of IVUS technology. Just announced at TCT 2007, nationwide, 15% of all cath cases use IVUS, up from a previous figure of 10%. However, large research and teaching hospitals, such as Washington Hospital Center, may use IVUS on up to 95% of their cases. It is interesting to note, in Japan IVUS usage is in the range of 65-75%, and SAT rates are lower in Japan than the US. 8. New and Upcoming Technology with Volcano IVUS. Virtual HistologyVH VH technology provides a virtual 38  CORONARY HEART ™

biopsy in the cath lab with real time plaque characterization that correlates with actual histology specimens. VH allows the identification of a vulnerable plaque, or a plaque that is unstable. Intermediate lesions are the unstable lesions. Faulk, in Circulation ’99, stated that 68% of MI’s are caused by intermediate lesions of 50-70% stenosis. VH technology uses eight spectral parameters to gather information and an algorithm is used to correlate plaque composition with what the ultrasound picks up according to pixels of color: light green = fibro-fatty, dark green = fibrotic, red = necrotic core, white = dense calcium. A plaque is considered vulnerable if there is >10% necrotic core next to the lumen. 12. AIM- Angio IVUS Mapping. This technology is still in development. However, this will allow the angiogram and the IVUS image to appear together on one screen. The IVUS image is 3-D and the angio will be

Integrated IVUS. Integrated, or built in, systems for IVUS are available from both Volcano and Boston Scientific companies. Both systems are DICOM compatible and easy to set up with minimal training. The capital cost for an IVUS machine is in the $100,000 range. Each catheter costs between $600-800. The SIPS trial showed the acute costs associated with IVUS are greater than angiography alone, but the chronic costs are less because patients have better outcomes, less TVR,TLR, SAT and most importantly less MACE (Major Adverse Cardiac Events-death, MI, stroke). Conclusion-Tying it all Together. This is an exciting time in interventional cardiology. It is a time when adherence to true, evidencebased medicine as physicians guide medical and mechanical treatment of coronary artery disease will make a positive impact on the lives of patients in our cath labs every day. As baby boomers with cardiac risk factors face their inevitable visits to the cardiac cath lab, it will be critical that cardiologists and their teams use evidence-based protocols to thoroughly investigate these patients’ coronary anatomies, using the complete array of tools that are available to them prior to any interventional therapy and treatments. These patients will then leave the interventional suite knowing, with confidence that physicians have taken the appropriate measures to ensure the best possible outcome. Synergistic use of FFR to determine functional significance of a lesion and IVUS-guided stenting of that lesion will provide patients with


EDUCATION

Modality of Investigation Assessment of:

Critical Values

Fractional Flow Reserve (FFR) Functional severity of a lesion, examines physiology-inducible ischemia. Lesion specific.

FFR <0.75 functionally significant lesion

IVUS Examine lesion morphology, can determine vessel and lumen diameter, area, and lesion length. Minimal Luminal Area MLA for epicardial vessels <4mm² Left Main <6-7mm²

Manufactures of Technology

RADI® Medical-Pressure Wire®/RADI Analyzer®

Volcano Theraputics- s5Phased Array Cathether

Volcano Corporation Smartwire/ComboMap

Boston Scientific CorporationiLab- Mechanical Catheter

Medication Requirements

Heparin prior to Heparin prior to insertion 30-40units/cc 8. insertion 30-40 units/kg

angiographically-moderate lesions definitive evidence to support the decision to the question, “To stent, or not to stent?” Bibliography 1.

Kern M , MD. Letter from the Editor: Is Seeing Believing? Cath Lab Digest 2006;14(8):4.

2.

www.radi.se/education

3.

Pijls, N. Non-invasive Testing is Not Specific Enough: Why and How to Obtain Objective Signs of Ischemia in the Cath Lab. Cath Lab Digest 2004; 12(10): 12-20. (Weissman, 2007)

4.

Kenneth A. Gorski, RN, RCIS,FSICP. Book Chapter: Functional Assessment of Coronary Artery Disease. Cath Lab Digest 2005;19(9): 8-16.

5.

Pijls, N., Schaardenburgh, P. v., Manoharan, G., & al., e. (2007;49:21). Percutaneous Coronary Intervention of Functionally Nonsignificant Stenosis 5-year Follow-Up of the DEFER study. Jorunal of the American College of Cardiology, 2105-2111.

6.

Fearon W F; Yeung A C; Lee DP et al. Costeffectiveness of measuring coronary flow reserve to guide coronary interventions. American Heart Journal 2003; 145(5): 882-887.

7.

Pijls NH, De Bruyne B,Peels K, et al. (1996;334). Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. New England Journal of Medicine 1996; 334:11703-1708.

8.

Cath Lab Digest talks with John Hodgson, MD, FSCAL, Professor of Medicine; Chief, Academic Cardiology, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, about ways stent implantation can be optimized to avoid this complication. Stent Thrombosis: A WakeUp Call? Cath Lab Digest 2007; 14: 1-10.

9.

Weissman NJ, MD. Techniques and interpretation of Intravascular (Intracoronary) ultrasonography. UpToDate® 2007.

10.

Mintz GS, Leon MB, Popma JJ, et al. Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography. Circulation 1995; 9: 1959-1965.

11.

Henry K Lui, MD, Bruce R. Brodie, MD. The Perfect Fit: Getting the Most Out of Your Coronary Stent. Cath Lab Digest 2005; 13(10): 20-26.

12.

El-Shafel A, Kern M. New Techniques for the Evaluation of the Vulnerable Plaque. The Journal of Invasive Cardiology 2002; 14 (3):129-137.

Adenosine IV-140mcg/ kg/min Adenosine 30mcg in RCA/40 LCA

Capital Costs/ Catheter cost Additional Applications

$20,000 / $600-700

$100,000 / $600-800

Carotid, renal, peripheral Volcano & BSC for and CFR (Coronary Flow coronary and peripheral Reserve) use Volcano approved for Carotids

Want to learn More?

www. teachFFR.com Access code: RA47W www.radi.se/education

www.teachivus.com

CORONARY HEART ™  39


CARDIAC SITE VISIT

UNITED STATES OF AMERICA

Lancaster General Hospital ADDRESS

Lancaster General Hospital  North Duke Street Lancaster PA 1704 United States of America

FAST FACTS 1. Named by Solucient in Top 100 US Hospitals 8 out of last 10 years. 2. 4 procedure rooms. 3. All staff cross-trained via an innovative Apprenticeship Program. 4. One of busiest hospitals in Pennsylvania.

MAP

T

he Lancaster General Hospital in Pennsylvania was the winner of our global photo competition whereby we asked you to provide an interesting photo of your staff holding a copy of our magazine. So it was we travelled across the rolling hills dotted with the famous Amish farms to the city of Lancaster to meet the 40

CORONARY HEART â&#x201E;˘

Lancaster General Hospital Cath Lab Staff Kneeling Left to Right: Tim Martin, RCIS, Bill Crosby RCIS, Lavonne Morris RCIS Next Row (Left to Right): Dawn Shelley CIS, Ronda Moore RCIS, Educational Coordinator Next Row (Left to Right): Fara Tahmasbi, RCIS Megan Mann, RTR, RCIS Patti Miraglia, RCIS Rose Iandolo, RCIS Christine Vlassis, RCIS Clinical Supervisor Nina Bostanjan, RCIS Richard Hinkle RN,RCIS, Manager of Invasive Services Next Row (Left to Right): Joe Iacono, RCIS Mike Bell, RCIS Joe Haas, RCIS Tim Lapp, RT, RCIS John Metzger, CIS


CARDIAC SITE VISIT

cardiac team. Upon arrival though the red shirts were gone (acquired only for the winning photo) and replaced with traditional hospital blue. The following questions have been answered by Cath lab Management. Lancaster General Hospital is a 590-bed acute-care facility that is the keystone of Lancaster General, a non-profit health system. Also included in the system are Lancaster General Women & Babies Hospital, an outpatient Health Campus and several health centers throughout the county. Lancaster General Hospital registered nearly 39,800 inpatient cases and 93,500 emergency department cases in fiscal year 2006-07, making it one of the busiest hospitals in Pennsylvania. The Heart Center offers an uncommon combination of leading edge diagnostics, state-of-the-art procedures, comprehensive rehabilitation, and the compassionate care of experienced staff and physicians, which help our patients live fuller, healthier lives. Lancaster General Hospital has a reputation for excellence in cardiac care and has been recognized with multiple distinctions and awards. Solucient, an independent evaluator of hospital performance for business and industry, named LGH among the 100 Top Hospitals in America 8 out of the last 10 years.

Size of the Department: Currently the Cath Lab facilities of Lancaster General Hospital are comprised of 4 multipurpose procedure rooms (cath & intervention) and two pre-post procedure areas (one having 13 beds and one having

The Winning Photo 11 beds). We have treated more than 100,000 patients.

Staff numbers:

1 Manager Cardiology Decision Support

1 Cardiology IT Administrator

1 Cardiology Data Coordinator 2 Abstractors

21 Registered Cardiovascular Specialists

3 Non Registered Cardiovascular Specialists

Pre-Post Procedure Area:

2 Patient Care Facilitators

1 Senior Vice President

1 Senior Director, Cardiovascular & Pulmonary Services

• • • • •

1 Manager

1 Clinical Coordinator

1 Educational Coordinator

1 Image Librarian

1 Cardiology Data Assistant

2 Billing Coordinators

1 Housekeeper

1 Quality Control / Materials Manager

1 Clinical Nurse Manager 1 Secretary 8 Patient Care Assistant 1 Transporter 8 Registered Nurses

There are three technologists assigned to each cath lab, circulator, scrub & recorder. Specialty roles include intervention, hemodynamics, charge, research, moderate sedation. Additional responsibilities include: materials management, quality control, medication inventory and sterile supplies. CORONARY HEART ™  41


CARDIAC SITE VISIT

Lancaster General Hospital (cont...) insertion and chronic total occlusion interventions with radiofrequency ablation. We support many of our interventions with distal protection devices and are we actively participating in numerous research studies.

Procedures performed per year: We perform approximately 4500 diagnostic procedures and 1400 interventional procedures annually, however, we do not perform peripheral interventions at this time.

Equipment:

The Main Corridor with viewing windows into each Lab Left to Right: Mark Koch, RCIS, Nora Martin, RCIS, and Rose Iandolo, RCIS

GE Digital Imaging Equipment® with one room having DSA capability for peripheral studies.

Staffing roles: All employees regardless of their background, function equally in all roles, (circulate, scrub and record). Occasionally, senior technologists are required to be present in new procedures and complex cases.

Procedures: Our cath lab performs diagnostic procedures including: LHCC’s, RLHCC’s, Swan Ganz insertion, central line insertion, FFR measurement, coronary ultrasound, and PA-gram. Interventional procedures include: angioplasty, stenting, rotational atherectomy, thrombectomy, ASD/PFO closure, IABP insertion, vena cava umbrella 42  CORONARY HEART ™

Hemodynamic Monitoring Left to Right: Bill Crosby, RCIS, Tim Martin, RCIS


CARDIAC SITE VISIT

Surgeons. Should the need for emergent surgical backup arise during a routine interventional case, our cath lab to OR time is minimal.

New procedures implemented: Boomerang® closure device

Inventory Management:

Left to Right: Fara Tahmasbi, RCIS and John Metzger CIS

Day Procedures: Approximately 35% of our diagnostic cases are performed on an outpatient basis.

Cross-Training: Our team is comprised of several credentials including, RCIS, RT, RN, RTR, RRT, EMT-P, etc. Our entire staff is cross trained in all positions within the cath lab through our clinical ladder process that utilizes formal didactic education and clinical experiences to achieve competency. All staff members who have passed the required competency exams are permitted to administer the 71 medications on the cath lab formulary in the cath lab setting. Each individual is required to obtain his/her RCIS credential within 3 years of date of hire as we believe the RCIS is the unified credential of choice for

personnel working in the Cardiac Cath Laboratory. To promote the RCIS credential, our lab has formed a local chapter of The Society of Invasive Cardiovascular Professionals. We are currently working on national and state legislation to further recognize the RCIS credential as the credential of choice to work in an invasive lab.

Surgical Back-up: Our routine interventional cases do not utilize direct OR backup, however, we do have a system in place which utilizes what we call an “A” window for high risk patients. When a case is identified as an extremely high risk procedure (determined by the Cardiologist) an OR room is set up and a surgical team is put on standby. Our charge techs coordinate this effort with the OR and Cardiothoracic

Inventory is managed and tracked via our Data Management System. Bar code scanning of supplies used during the procedure generates data for our patient record, reordering, and patient billing. Requisitioning of supplies is completed by technologists that perform interventional procedures, and also patient care assistants. Equipment procurement is the responsibility of the materials manager of the Heart Center who works directly with the purchasing department.

Hemostasis Management: All patients (other than ICU patients) return to the post procedure holding area to have their lines discontinued. Our physicians use 4 and 5 Fr diagnostic catheters and 6 Fr interventional systems. Our hospital primarily uses Syvek® and Syvek® NT patches & Boomerang® for line removal. Other products used on occasion include Angioseal® & Starclose®. If the sheath is less than 6Fr, the ACT must be less than, or equal to 200. These lines are pulled with a Syvek patch holding manual pressure for 10 minutes. If the sheath is a 6Fr or larger, the ACT must be less than, or equal to 250 CORONARY HEART ™  43


CARDIAC SITE VISIT

Lancaster General Hospital (cont...) sec. These lines are pulled with a Syvek® NT patch holding manual pressure for 20 minutes. We have trained several patient care assistants (PCA) to discontinue lines, and they are responsible for the majority of

sheath removals. When a PCA is not available, the scrub tech assigned to the case is responsible for the line management. We have also set up a line removal training system for the ICU nurses. After hours, the ICU

nursing staff is responsible for the removal of indwelling lines.

Measures implemented to cut costs: Lancaster General continually negotiates contracts with various vendors based on current market trends.

Alliances with other hospitals for the treatment of patients: Our hospital has a transfer agreement with a rural hospital for the treatment of acute MI patients, patients requiring interventional procedures as well as open heart surgery patients.

Training for new employees:

Scrubbed During Case Left to Right: Rose Iandolo, RCIS, Mike Bell, RCIS, Joe Iacono, RCIS 44  CORONARY HEART ™

Our clinical ladder has evolved over the last 15 years. Currently, a new employee (with little or no experience) will begin the clinical ladder as a CVT Trainee. During the initial 3 month period, the Trainee will complete orientation rotations through all positions in the lab including circulate, scrub, record and pre/post procedure area. Once the individual can perform the positions independently, competency checklists are completed and an entry level pharmacology examination is passed, the CVT Trainee will then enter the Apprentice Program. The Apprenticeship is a two part program through which the employee will have an opportunity to take advantage of numerous lectures that are offered. The lectures prepare the new employee for a series of pharmacology and core knowledge


CARDIAC SITE VISIT

examinations. This is, of course, in addition to clinical skills they are required to learn and fine tune. The maximum time allotted for completion of the Apprenticeship is 18 months (or 24 months from the date of hire). Following completion of our Apprenticeship Program, the employee is referred to as a CVT. At this time, a department specialty must be declared. The specialty is an area of which the employee will focus their education and clinical skills. Such specialties in our lab include intervention, hemodynamics, charge technologist, pharmacology/sedation and research. We also require that all CVT’s attain the RCIS credential within 1 year of completing the Apprentice Program (no longer than 3 years from the date of hire). At this point, all minimal requirements for employment will have been met, however, an RCIS can choose to go one step further and be declared a Senior RCIS. The Senior RCIS candidate is one that has mastered the outlined objectives and skills in their chosen specialty. The Senior RCIS must annually submit a portfolio that describes in detail how they demonstrate expertise in their cardiovascular technologist role. This is for the technologist that goes above and beyond what is expected on a daily basis in order to better themselves, the care of our patients and the cardiovascular technologist profession. New technologists that are hired with previous experience may have a shorter orientation period, but must still challenge all examinations required of the clinical ladder. This is to ensure all of our technologists have been presented with the same opportunities

and requirements.

Continuing education programs for the staff: Our educational coordinator identifies the needs of staff and organizes CEU programs with clinical specialists throughout the year. There are also numerous opportunities within the organization to attend continuing education programs. We also corporate annual reviews of various diagnostic and interventional modalities.

Competency checks for staff: In addition to hospital mandatory competencies our staff are required to maintain an active RCIS status, certification in BLS, and ACLS. Annually, we have a day designated for the completion of the following competencies: point of care testing, IV insertions, airway, cardioversion/ defibrillation, medication administration, rhythm analysis, LV analysis, groin management, t-pacers and balloon pumps.

students in Lancaster General’s School of Cardiovascular Technology.

What is the best part of working at your facility? We have the privilege of working with a great group of physicians that are highly skilled and apt to utilize the most current modalities available. We also enjoy scheduling flexibility and a family oriented atmosphere. Our cath lab is unique because we function under one unified credential, “The RCIS”. Every technologist in the lab performs all positions including medication administration. We have a very team-oriented environment which translates into superior patient care.

Inside Humor

Training facility for cardiac fellows: No, however it is utilized for training of CORONARY HEART ™  45


CALENDER

Events Calender Date

Name

Location

Website / Contact

November 18-19

Cardiovascular Management Strategies — Medical, Interventional and Surgical Therapies (CMS – MIST)

New York, NY

www.crf.org

November 25-30

RSNA

Chicago, IL,

www.rsna.org

December 1

2007 Cath Lab Basics with Dr. Morton Kern and Dr. Michael Lim

San Diego, CA

www.naccme.com

December 2-4

Fourth Charleston Symposium on Interventional Pediatric Electrophysiology

Charleston, SC

www.musckids.com/heart/ conferences

December 10-11

CTA Academy Training Course: Hands on Introduction to Coronary CT Angiography

Atlanta, GA

www.scct.org/training/cta

January 20-24

International Symposium on Endovascular Therapy (ISET)

Hollywood, FL

www.iset.org

January 23-25

Advanced Angioplasty 2008

London, UK

www.andvancedangioplasty.co.uk

February 3-6

27th Cardiovascular Conference at Snowshoe

Snowshoe, WV

www. acc.org/education/programs/ programs.htm

February 10-16

Cardiovascular Professionals Week

USA

www.acp-online.org

February 11-15

23rd Annual Cardiovascular Conference at Hawaii

Big Island, Hawaii

www.scai.org

February 18-22

30th Annual Cardiology at Big Sky

Big Sky, Montana

www.acc.org/education/programs/ brochures/bigsky_08.htm

March 29

3rd Annual Clinical Pharmacology in the Management of Cardiovascular Disease

Chicago, IL

www.acc.org/education/programs/ brochures/pharmacology.htm

March 29 - April 1

ACC 2008 + i2 Summit

Chicago, IL

www.acc08.acc.org

May 14-17

Heart Rhythm 2008 - 29th Annual Scientific Sessions

San Francisco, CA

www.hrsonline.org

May 28-31

SCAI 31st Annual Scientific Sessions

Las Vegas, NV

www.scai.org

2007

2008

46  CORONARY HEART ™


EMPLOYMENT ADVERTISING

A Career in Caring

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with Catholic Health System

MANAGER INVASIVE CARDIOLOGY BUFFALO, NY

Sunglasses, Sandals & Swimsuits! Looking for an exciting work environment, wonderful team members & the beautiful Delaware beach resort right in your own backyard? Join the Beebe family today! We are experiencing unprecedented growth and are very excited about our new Interventional and Invasive Cardiology program. RNs: Invasive Cardiology • Cardiac Rehab • CCU/ICU • CV-OR CARDIAC CATH TECHS: Excellent opportunities for registered Cardiac Cath Techs. Must obtain Delaware licensure. Be a part of our new interventional cardiac program and expand your career with this exceptional team. ECHO TECHS: Seeking RDCS or RCS Echo Techs. Two-three years exp., with exceptional technical and diagnostic skills. Immediate need due to expansion. WE OFFER A FANTASTIC SIGN-ON BONUS AND RELOCATION ASSISTANCE PROGRAM Ask HR for details. Please visit our website for more information and detailed job descriptions: www.beebemed.org We offer competitive compensation and benefits.

Due to program expansion and the explosive growth of new interventional vascular services, the Catholic Health System, a four-hospital system, mission-driven organization employing over 8,200, located in Buffalo, NY, has an outstanding management career opportunity immediately available in our cardiac service line for MANAGER INVASIVE CARDIOLOGY. Responsible for planning, coordinating, organizing, and directing all Invasive Cardiology staff including operational aspects of the Cardiac Cath Lab, Holding Room, and the Cardiac Transfer Center. Works collaboratively with the Manager of the Electrophysiology Lab to create, manage, and maintain staff, physician, and patient-friendly environment to further promote growth, innovation, and efficiency.

QUALIFICATIONS

•BS in health-related field and min. 3 yrs. relevant clinical experience required. •Previous work experience in an interventional cardiology, neurology, radiology, and/or electrophysiology laboratory is required. •BLS/ACLS validation required. Relocation assistance available. Outstanding compensation and benefits package. Values-based organization. At the Catholic Health System, WE BELIEVE in a corporate culture based on family and work-life balance. WE BELIEVE in career advancement and associate recognition. WE BELIEVE you won’t find a better place to work or a better place to live. QUALIFIED CANDIDATES ARE INVITED TO APPLY, IN CONFIDENCE, ONLINE AT WWW.CHSBUFFALO.ORG. PLEASE INCLUDE SALARY HISTORY AND RESUME.

Beebe Medical Center

424 Savannah Rd., Lewes, DE 19958 302-645-3336 • fax: 302-645-0965 Apply online at: www.beebemed.org employment@bbmc.org • EOE

EOE M/F/D/V

BE RESPECTED FOR YOUR EXPERTISE. At the Hospital of the University of Pennsylvania, our Nurses play an integral role in positive patient outcomes. Join us and practice where technology is making a remarkable impact on health care and how nursing is practiced. Here you’ll find a commitment to your professional growth, excellent compensation, 100% prepaid tuition and much more. We are expanding our services and seeking the following EPS professionals to join our team:

EPS LAB REGISTERED NURSE

Job Code # 968569 Critical Care experience, a current PA RN License and BLS and ACLS Certification are required. A BSN and EPS Lab experience is preferred.

EPS EDUCATION SPECIALIST

Job Code # 968703 A minimum of 3 years of EPS experience, and BLS, ACLS and either RCIS certification or a current PA RN license are required. NASPExAM TESTAMUR certification preferred.

EPS LAB TECHNICIAN

Job Code # 19095 BLS and ACLS Certification is required. RCIS is preferred. Previous EP Lab experience preferred. For a complete position description and to apply on-line, please visit: www.pennhealth.com/jobs and select the appropriate Job Code # as listed above.

*The Hospital of the University of Pennsylvania is a Magnet recognized hospital.

www.pennhealth.com/jobs AA/EOE, M/F/D/V

Recruitment Advertising Rates ‘2008’

Why Pay More?

Online only: $150 for 60 days + hypertext link CORONARY HEART 11/1/2007 Magazine + Free Online: 1893363-PL66711 1/4 Page = $495 UNIPEH 3.7” x 5.12” 1/2 Page = $795 Stephanie SimmonsFull v.8Page = $1495

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Prices are Net and do not include agency commission

CORONARY HEART ™ 47


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 #9 US