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CARDIAC CATH • EP • CRM • ECHO • CT/MRI

Issue 32 • Sep/Oct 2011

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LATEST PRODUCT NEWS BEHIND THE SCENES The Making of Medtronic’s Integrity Stents in Ireland

CARDIOLOGIST HOT TOPIC Who should perform peripherals?

MANAGEMENT HOT TOPIC Changing work patterns with PPCI

UK SITE VISITS Lancashire Cardiac Centre & Royal Berkshire Hospital

JOURNAL REVIEWS EVENTS CALENDAR

Lancashire Cardiac Centre - Utilising Volcano’s FFR HYBRID DESIGN + INNOVATION + LESS TREES : INTEGRATING WEB & PRINT


Powerful clinical outcomes for complex daily practice RESOLUTE ALL Comers 2-Year Results in Complex Patient Subgroup

Resolute DES (n = 752) Xience V DES (n = 738)

20 15

p = 0.81

12.6

(%)

12.1

p = 0.27

15.3 13.2

10 5 0 TLF

MACE

Designed for the needs of an increasingly complex clinical practice, Resolute Integrity DES combines powerful clinical performance with superior deliverability* vs. major competitors.

Make the complex simple

Resolute Integrity Zotarolimus-Eluting Coronary stEnt systEm

*

resolute integrity DEs now has expanded indications for diabetes mellitus, multivessel disease, long lesions and small vessels. Bench test data vs. abbott Xience Prime and Boston scientific Promus Element DEs on file at medtronic, inc. these tests are not indicative of clinical performance. Complex patient definition: Bifurcation, sVg, isr, ami <72 hr, llVEF <30%, unprotected lm, >2 vessels stented, renal insufficiency or failure (creatinine >140 µmol/l), lesion length >27 mm, >1 lesion/vessel, lesion with thrombus or to (preprocedure timi = 0). Currently, resolute DEs is not specifically approved for the subsets noted in this complex patient definition. p-Values are based on Fisher’s Exact test. t p-Values for outcome differences are unadjusted for multiple comparisons. rEsolutE all Comers 24-month data. rEsolutE all Comers evaluated the resolute stent. For distribution only in markets where resolute integrity DEs is approved. not for distribution in the usa or Japan. © 2011 medtronic, inc. all rights reserved. uC201200736EE 6/11


Sep / Oct 2011

Contents Heart Valves

Aortic stenosis is the most common cardiac valve disease in developed countries, affecting nearly 26% of people over 65. Once advanced disease and symptoms present, prognosis is poor with survival under three years for many. Additionally, diagnosis is difficult and symptoms are often missed and furthermore, even if diagnosed, age and co-morbidities combine to render many patients inappropriate for traditional surgical valve replacement.

Edwards Lifesciences has received CE mark approval and FDA clearance for a new repair ring for the treatment of tricuspid insufficiency. The Carpentier-Edwards Physio Tricuspid Annuloplasty ring features a three-dimensional waveform shape, and incorporates several ease-of-implant features.

Echocardiography

“We designed the ring to offer surgeons confidence when treating tricuspid valve insufficiency,” said preliminary researcher Alain Carpentier, M.D., Ph.D., professor and chairman emeritus of cardiovascular surgery at the Hôpital Europeen Georges Pompidou.

The Western Infirmary opts for ‘Echo in a Heartbeat’ functionality from Siemens

The new Queen Elizabeth Hospital, (UHB) Birmingham selected the Philips Allura Xper FD20 for its hybrid Interventional Operating Room Lab (Hybrid OR). The new system, one of seven Philips Allura’s recently purchased by the Hospital, is a dedicated Operating Theatre system, sited in the X-ray department, but only carrying out vascular surgery-related procedures (e.g. endovascular stents). Of the other six Allura systems, three are used for normal interventional radiology and three bi-plane Allura Xper FD/10 systems for cardiology and EP procedures.

“It is designed to conform to the anatomy of the valve annulus and preserve its natural movement to facilitate adherence of the ring to the surrounding tissue, while restoring proper valve function.”

BAlloon-expAndABle TrAnscATheTer AorTic VAlVe implAnTATion (TAVi)

For more information on Edwards Lifesciences products please visit www.edwards.com

The system will primarily be used for 3D echocardiography. The SC2000 is Siemens’ premier echocardiography system featuring ‘Echo in a Heartbeat’ imaging technology, which acquires real-time, full-volume images of the heart in one single cycle. “The SC2000 generates fantastic image quality and is allowing us to perform more sophisticated 3D echocardiography examinations,” said Dr. Piotr Sonecki, Consultant Cardiologist at The Western Infirmary. “Towards the end of the year, we hope to be able to carry out vascular examinations and further evaluate its suitability for future research work.”

Latest Topics from our members

ONLINE DISCUSSION FORUM

20%

reduction in all-cause mortality at one year1

Specifically, the results from Cohort B offered “the biggest treatment effects ever seen in a randomised controlled trial” according to Mark de Belder, consultant cardiologist at James Cook University Hospital.

The Western Infirmary, part of NHS Greater Glasgow and Clyde, is benefiting from increased cardiac image quality following the installation of an ACUSON SC2000™ diagnostic ultrasound system from Siemens Healthcare. The hospital is one of the first in the UK to have installed the system. The purchase was funded by the British Heart Foundation Glasgow Cardiovascular Research Centre, who will share use of the system for research projects.

Above: Philips personnel and the team from the new Queen Elizabeth Hospital in Birmingham

sTAndArd TreATmenT

Recently discussed in the UK for the first time in its entirety, the Placement of AoRTic TraNscathetER Valve Trial (PARTNER) showed that Transcatheter Aortic Valve Implantation (TAVI) significantly reduces the rates of death from any cause for previously inoperable patients, gives patients substantially better quality of life and provides patients with a survival rate equivalent to that of conventional surgery.

Tricuspid insufficiency is progressive and may affect more than 150,000 Europeans. It often leads to severe tricuspid regurgitation, where valve leaflets do not close properly allowing backflow of blood. Annuloplasty ring repair is typically recommended for patients with significant annular dilation.

Philips’ next generation Allura Xper FD20 systems combine superb image quality with advanced interventional tools, seamlessly integrated into the clinical workflow, providing enhanced opportunities with Live 3D guidance to continue to expand the range of interventional procedures able to be undertaken by the user. The integrated workflow, intuitive user interface and personalised settings enable the user to take full advantage of all the Allura’s capabilities and for a broad variety of procedures assist in providing excellent clinical care effectively and comfortably.

Latest Product News

Improving the management and diagnosis of aortic stenosis through treatment innovation

Edwards Lifesciences launches Physio Tricuspid repair ring

Latest Product News

Round Up A Philips Hybrid Cath Lab For New Queen Elizabeth Hospital Birmingham

Does any centre always set the isocentre prior to doing an angiogram? We have never done it but I’m considering introducing it if it will reduce the amount of panning that is done.

Have your say at www.cardiologyhd.com. Membership is free.

SonoSite’s M-Turbo® key to emergency echocardiography

availability of ultrasound equipment including echocardiography capability cannot be guaranteed, and the M-Turbo has been very useful as a robust, hand-carried system in these circumstances.”

Royal Brompton Hospital in London, home to the UK’s largest specialist heart and lung centre, uses a SonoSite M-Turbo® pointof-care ultrasound system for emergency focused transthoracic echocardiography. Dr Susanna Price, consultant cardiologist and intensivist, explained: “The MTurbo is solely dedicated to emergency use on the intensive care unit (ICU). Its extremely fast bootup time is a great advantage in life-threatening situations where speed is critical, and being equipped with both a cardiac package and a vascular probe means it serves a dual purpose.”

Dr Price concluded: “The M-Turbo’s facility to record image clips for subsequent review is an essential requirement. It provides a record of diagnosis, evidence for medico-legal purposes, and, being easy to use, the system is very good for training junior ICU doctors who are just starting to use focused echocardiography.”

“We use ultrasound guidance for all our central venous access, for performing pleural drainage and, in emergency situations we use the M-Turbo for focused transthoracic echocardiography. On occasions we have retrieved patients from other units where the

For more information about SonoSite products, please contact: ukresponse@sonosite.com or www.sonosite.com

A new option for your high-risk patients with aortic stenosis In the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.1 Additionally, the reduction in mortality and rehospitalization versus standard treatment at one year was 40%.1 For more information & to find a TAVI center near you please visit edwards.com/eu/products/transcathetervalves

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Reference: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607. For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN and PARTNER are trademarks of Edwards Lifesciences Corporation. © 2011 Edwards Lifesciences Corporation. All rights reserved. E2062/5-11/THV

Edwards Lifesciences Irvine, USA I Nyon, Switzerland edwards.com

I Tokyo, Japan I Singapore, Singapore I São Paulo, Brazil

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Publication: Coronary Heart Size: A4 Trim: 210 mm X 297mm Bleed: 3mm

Full descriptions, images & more online

INTERNATIONAL ONLINE CATALOGUE

What is the catalogue? To take full advantage of our new community website we added a catalogue featuring the latest products and services within cardiology, to assist you with purchase decisions. Each product

listed has a full description, photos, and contact details for real show sites so you can skip the marketing and go direct to real life examples.

Siemens Healthcare Artis zee

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The Artis zee™ family is designed for interventional cardiology imaging. Available as floor or ceiling-mounted, biplane or with Magnetic Navigation, it features a 20x20cm or 30x40cm flat detector. This enables flexible positioning around the patient, ideally suited for imaging of structural heart diseases. Show Site: See our website for case studies at the Bristol Heart Institute and the National Institute for Health Research.

Siemens Healthcare SOMATOM Definition AS+

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The SOMATOM® Definition AS+ CT system from Siemens Healthcare is an adaptive scanner that provides exceptional image quality to make complex cardiology examinations routine. Show Site: See our website for case studies at Borders General Hospital and Great Western Hospital. Like to advertise your products? Contact us via the details on Page 4. C

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Industry Partnerships

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CM

First European appearance of the newly formed Hitachi Aloka Medical Ltd. (Japan)

MY

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Cath lab Nurses/ Physiologists/Radiographers

Hitachi Medical Corporation and Aloka Corporation have combined their strengths in ultrasound to form Hitachi Aloka Medical Ltd. (Japan), a subsidiary of Hitachi Medical Corporation (Japan). The new company made their European debut in Vienna between 26 to 29 Above: The Two CEO’s August 2011 at the 13th World Congress of Ultrasound in Medicine and Biology (WFUMB).

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Card o ogyHD On ne Cata ogue + Job Advert

Coronary Heart_HeartStation -May-June 2011_Final.pdf 1 20/04/2011 11:31:46

CMY

K

Opportunity for Cath Lab Staff Regent’s Park Heart Clinics Ltd. are actively recruiting for cath lab staff within a new diagnostic angiography service at Scarborough Hospital. We are looking for enthusiastic staff to join the Regent’s Park team providing invasive cardiology services at:

Scarborough Hospital, North East Yorkshire This is a long term 2-day/week service (Tuesdays and Wednesdays) providing Diagnostic Coronary Angiography and Permanent Pacing. Fixed term and agency-style contracts available!!!

START DATE: 4th October 2011

Hitachi and Aloka bring together a plethora of experience and knowledge - synergizing the expertise and talents of the people on both sides of the new merged company. Participants and visitors were invited to experience this at the event booth where Hitachi Aloka Medical highlighted ‘the next generation in high resolution imaging technology’, focusing on the Hitachi HI VISION and Aloka ProSound Ultrasound platforms - introduced and explained by expert employees from Hitachi Aloka Medical Japan, Aloka Europe and Hitachi Medical Systems Europe.

To find out more please contact Bryn Webber, Cardiac Services Manager: bryn.webber@rphc.co.uk or call 07966 987712 Please visit our website for more details on our background and capabilities: www.rphc.co.uk We look forward to hearing from you.

8 Sep/Oct 2011 www.cardiologyhd.com

Questions designed by Dr Magdi El-Omar and Tim Larner

Mr Michael Denton Chief of Vascular Surgery Epworth Medical Centre Melbourne, Victoria Australia

Cardiologist

Hot Topic

T

he sensible answer in the medical world of 2011 is a medical practitioner who has a suitable clinical background and knowledge level, but is also demonstrably competent in the interventional technical skill sets. Of course a cardiologist, vascular surgeon or interventional radiologist can acquire this technical expertise in a broad array of interventional procedures, the same way as a limited procedural skill set can be acquired by neurologist (carotid stenting) or nephrologist (fistuloplasty). If their skills are competent and their knowledge base is sound, or if they work in a team setting with suitably trained clinicians (as we have seen for years with many interventional radiologists and vascular surgeons) then they should be recognised as such and accredited by the appropriate institution.

Who should perform peripheral vascular intervention: Cardiologist, Radiologist or Vascular Surgeon and why? Consultant Vascular Radiologist Department of Radiology Central Manchester University Hospitals NHS Foundation Trust Manchester Royal Infirmary Manchester

1. 2. 3.

I

t is much easier to address this question in the NHS environment than in countries where the operator’s livelihood is dependent on cornering as much of the market as possible. In this country, we can put the interests of the patients and service first.

Individuals from any clinical background can learn the relevant manual skills and technical knowledge. Some individuals are naturally gifted, most are trainable and very few need to be tactfully pointed towards a different career path. However, this aptitude is independent of specialty. Who can provide the best service to patients? It seems obvious to me that the specialist should have a major interest in peripheral vascular disease. This includes the conservative, non-interventional management of vascular disease, such as medical therapy, exercise programmes and ulcer care. The holistic care of the vascular patient requires more than treating the stenosis. This logic leads to the conclusion that peripheral intervention should be provided by vascular surgeons and this is almost certainly the direction of travel in the UK. Radiologists have been involved in peripheral intervention since its inception and have provided a high quality service for years. However, the expansion and development of endovascular interventions have brought them from the margins to the mainstream. Thus it is important that the new generation of vascular surgeons ensure that they are properly trained in endovascular techniques and that consultant surgical posts have angio room sessions in the job plan. I anticipate that the future of radiological involvement in peripheral intervention will mirror what happened in coronary intervention 20 years ago: the radiologists will progressively lose their role in this service provision. This prognosis has a significant downside. Vascular radiologists currently provide a broad range of services to many hospital departments for bleeding, tumour embolisation, vascular access, caval filter placement and so on. These are valuable services, but it will not be possible to sustain a comprehensive vascular radiology service without the workload that comes from vascular surgery referrals. The danger is that, if vascular surgeons take on all the peripheral intervention, vascular interventional radiology will atrophy. The optimal solution is therefore a harmonious collaboration between radiologists and surgeons, with each specialty providing an overlapping and complementary range of skills. This is the reality in many UK centres at present, but I fear it is not sustainable in the long term.

Integrity BMS–#1 for a reason

We have completed the grandfathering component successfully, and have already discovered the utility of this model in resolving difficulties with the hospital accreditation of specialists in ‘scope of practice’, and also in resolving turf wars, which were a perennial problem.

AVAILABLE ONLINE SEE OUR PREVIOUS HOT TOPICS We have 16 Hot Topics available on our website with responses from leading cardiologists from across the UK and around the world.

SUPERIOR DELIVERABILITY

A

ll of the above, provided they are interested and are prepared to work collaboratively and share their relevant clinical skills and experience! I think we need to learn from the lessons gained from transcatheter aortic valve implantation (TAVI), where we have found that the multi-disciplinary “TAVI team” has been instrumental in the successful introduction of TAVI into mainstream treatment of aortic valve disease. Equally we need to avoid the “turf war” scenario that we have previously seen with interventional and surgical treatment for coronary disease.

A Year in Cardiology Date: 14 December 2011 Venue: Royal College of Physicians, London

In my opinion, no individual clinician has the complete range of clinical skills and experience to provide a comprehensive peripheral vascular interventional programme. I would advocate the development of multi-disciplinary “endovascular teams” to provide the current and likely future range of minimally invasive/ endovascular treatments for cardiovascular disease. This would be in keeping with the “heart team” approach recently advocated by our European colleagues for the revascularisation of coronary artery disease. Such teams would need to take advantage of local skills, interests and resources with clinicians working collaboratively.

Providing a succinct review of the years’ hot topics with particular emphasis on clinical practice and a round-up of key developments in the sub-specialties. This symposium is a must for consultants and trainees wishing to keep abreast of major advances in Cardiology. For more details and the full programme, visit the BCS website.

Integrity CORONARY STENT SYSTEM

Superior deliverability* depends on the crossability, flexibility and responsiveness of the stent and delivery system. The unique Integrity design allows for a continuous range of motion and articulation, providing a clear advantage vs. the competition.* The result? Integrity BMS is now the #1 bare metal stent.†

Find out more at medtronicstents.com

Online registration is now open on www.bcs.com/education *Superiority against major bare metal stents: Bench test data vs. Abbott Multi-link Vision and Boston Scientific VeriFlex (Liberté) coronary stents on file at Medtronic, Inc. † In Europe. Data on file at Medtronic, Inc. Not for distribution in the USA or Japan. © 2011 Medtronic, Inc. All rights reserved. Printed in the EU. UC201200800EE 7/11

Card o og st Hot Top c

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Who shou d pe o m pe phe a n e ventions?

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The Manufacturing Process

Behind the Scenes

Industry Behind the Scenes: The Manufacturing of Medtronic’s Integrity Stents Continuous sinusoid formed and wrapped around a mandrel

Cobalt alloy wire Thin, round struts

Overview Founded in 1949 as a medical repair shop, Medtronic Inc. has steadily grown to become a global leader in medical technologies, initially producing pacemakers before expanding to cover the variety of products available today. 40,000 employees in 120 countries, with 44 manufacturing facilities, and 25 research and development centres worldwide ensure they are always at the cutting edge in regards to R&D, producing products that comply with their mission of alleviating pain, restoring health, and extending life.

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Electropolished for smooth surface

Laser-fused at key points

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High precision cobalt alloy wire same as Driver made to Medtronic spec’s for thin round struts.

Cardiovascular and Cardiac Rhythm Disease Management make up over half the total revenue for the company with the evolution of new technologies such as continuous sinusoid technology (CST) for coronary stents, ensuring Medtronic remains as a leader in medical product development. We visited Medtronic’s manufacturing and technology development facilities in Galway, Ireland for a tour of how the R&D, operational processes, and quality assurance is combined to create the new Integrity Bare Metal Stent (BMS) and Resolute Integrity Drug Eluting Stent (DES), both utilising CST.

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Wire is formed into sinusoids before it is wrapped onto a mandrel with crown to crown alignment. This squares up the end of the stent.

The electropolish provides a polished surface area of round struts.

Open Cell Design

Medtronic employees checking the quality of the stents after electropolishing

other platforms

made with cobalt chromium alloy which when compared with stainless steel allows for a reduction in stent strut thickness (enhanced delivery and lower rates of stenosis), better radiopacity, and greater strength.

The easiest way to imagine CST is with a slinky design (Fig 2), whereby a continuous piece of wire can flex easily in all planes. The wire involved in the construction is already round so therefore doesn’t require extensive polishing to remove any sharp edges which can lead to metal fatigue. The stents are also

The continuous range of motion due to the wire-forming process and fusion pattern provide greater flexibility and conformability while maintaining radial strength. This is particularly apparent on tight bends or tortuous anatomy where the CST stent tracks very easily, whereas with traditional stents significant gaps can occur or edges can raise damaging the sensitive intimal lining of the artery being passed through.

The wrap-crimp provide for low profile and good retention to ensure the catheter can deliver the stent to the target lesion.

The Future of Stents

Whilst there are a wide range of stents diameters available (2.25 to 4.0mm) in reality only two stent designs are manufactured for the Integrity platform. Each of the two stents manufactured are crimped onto the appropriate sized balloons, with the nominal diameter of the balloon determining the diameter of the stent once placed. This provides a much greater opportunity to post inflate the stent if it is determined the original placement was undersized.

Continuous Sinusoid Technology (CST)

Wrap-crimped for low profile

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The strategically located fusion points are laser fused to keep the same or better performance features of Driver.

Stent Diameters

Coronary stents used by cardiologists in the treatment of coronary artery disease were originally limited to tubular mesh or slotted tube stent designs. Medtronic has historically been known for its modular stent technology, as is featured in their Driver stent. However, Medtronic have advanced this technology to the next level with the introduction of CST, which results in superior flexibility and deliverability compared with the Driver and also other Fig 1. Separate stiff and flexible commercially available stent segments limit range of motion on platforms (Fig 1).1

CST

gives rise to broad applications for the development of next generation BMS and DES. These include the development of drug-filled stents, which forgo the need for a polymer coating, and core wire stents for thinner struts, amongst other design benefits.

Beh nd the Scenes

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Journa s

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Management Hot Top c

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The manu ac u ng o Med on c s n eg y S en s

One of the major advantages of the Integrity stent is its open cell design. Basically this relates to the perimeter of a cell between fusion points that can be expanded in the case of allowing for sidebranch access. This is particularly important for complex interventions, allowing accurate positioning and adequate wall coverage. The Resolute Integrity stent has a cell perimeter of 28.9mm (small vessel design), compared to other popular stents such as the Xience Prime with only 14.42mm.2 This increased cell perimeter is achieved through the specific fusion pattern determined by Medtronic’s engineers. Every 4th stent crown (medium vessel) and every 5th crown (small vessel) are fused.

Above: Drug-Filled Stent

Factory Tour Visiting the Medtronic manufacturing plant in Ireland is an amazing experience. The large amount of labour required working harmoniously alongside sophisticated automations makes you understand the value in the final product. The entire process is rigorously checked for quality, and the employees show pride in the products they make. For more information visit www.medtronic.com References: 1: Coronary Heart Publishing Ltd confirmed this on external models only. 2: Test data provided by Medtronic, Inc.

Above: Core Wire Stent

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A big concern in AF ablation is stroke risk. Measures are taken to avoid performing the procedure in the context of pre existing thrombus, but generation of embolic material during the procedure cannot be entirely prevented. A comparison of three ablation modalities (irrigated radiofrequency, Cryo and non irrigated phased RF) with MRI brain follow up revealed a much higher incidence of sub clinical cerebral infarcts in the non irrigated group (7.4 vs. 4.3 vs. 37.5%).

Journals Dr John Paisey Journal Reviewer

Two cautions with these data. Firstly, these are not strokes, they are an asymptomatic radiological finding (there were no clinical strokes). Secondly, a proportion of the energy delivered in the non irrigated phased RF group was done so in a fashion not recommended by the manufacturer and known to be associated with increased char and micro bubble formation.

Dr Dan McKenzie Journal Reviewer

Consultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust Follow me @johnpaisey for the latest reviews

General peripheral endovascular intervention Carotid stenting Fenestrated and branched endografting

Supervisor’s reports +/_ references are also required to confirm competence.

Dr David Smith Consultant Cardiologist, Morriston Hospital Morriston Swansea

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Fig 2. Continuous sinusoid technology flexes continually

This approach has been based on the model used by gastroenterology groups to deal with similar issues relating to diverse specialties performing endoscopy.

We have resolved this issue in Australia and NZ by establishing a committee to recognise such peripheral endovascular training regardless of the specialty. This committee has been sanctioned by the 3 Colleges involved namely: RACS , RACP and RANZCR . It has drawn criteria for recognition of training in 3 areas:

Dr Nicholas Chalmers

C Siklody and others. J Am Coll Cardiol. 2011;58;681-688.

Consultant Cardiologist, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust

Sudden Death Syndromes

Follow me @danmckenzie73 for the latest reviews

Bedside Echo Stop the press: pocket echo machines are OK-ish, in a vague sort of way, with lots of qualifications (how does this stuff get published?). M Llebo and others. Ann Intern Med. 2011;155:33-38.

Acute Coronary Syndromes Yet another drug for reducing ischaemic outcomes in ACS patients? Sadly, or maybe even gladly, not, according to the APPRAISE 2 trial. Apixaban, a direct factor Xa inhibitor used in thromboembolism prophylaxis and atrial fibrillation (AF) (others include dabigatran and rivaroxaban) only managed to increase bleeding in high risk ACS patients when added to standard dual antiplatelet therapy, with no significant reduction in ischaemic events. This seems to continue the trend that oral anticoagulants have little overall benefit in ACS (warfarin, hirudin), whilst oral antiplatelet agents (aspirin, clopidogrel, prasugrel, ticagrelor), subcutaneous anticoagulants (enoxaparin, fondaparinux) and intravenous antiplatelet (glycoprotein IIB IIIA inhibitors) and anticoagulants (bivalirudin) do. J Alexander and others. NEJM. 2011;10.1056/NEJMoa1105819. Good to know that cardiovascular drugs are also beneficial in patients with chronic kidney disease (CKD). The SHARP trial randomised 9270 patients with CKD and no previous history of MI or coronary revascularisation to simvastatin 20mg plus ezetimibe 10mg daily versus matching control. The primary outcome of first major atherosclerotic event (a combination of non-fatal MI or coronary death, nonhaemorrhagic stroke, or any arterial revascularisation procedure) was significantly reduced with the active drugs (11.3% vs. 13.%) that reduced the average LDL cholesterol by 0.85mmol/L. Another high risk group that needs targeting and treatment. C Baigent and others. Lancet. 2011;377:2181-92.

Angiography A fairly disturbing registry in America showed that the likelihood of finding obstructive coronary artery disease on elective diagnostic angiography varies from 23% to 100% (median 45%). The data was collected through the huge National Cardiovascular Data Registry (NCDR) from 565,504 patients with known coronary artery disease, undergoing angiography at 691 centres, between 2005 and 2008. The data raises more questions than it answers, but suggests that

some clinicians and centres significantly overestimate angiographic stenosis, or do not have a sufficiently low enough threshold to perform angiography in patients with symptoms of coronary disease, whilst other individuals and centres are doing the exact opposite. It is important to note that the health service in the US is privately funded (land of the free?) and a number of interventionists have recently had their licences revoked or have received jail sentences for inappropriate PCI and/or billing. We still do not know the correct ‘hit rate’, but the current guidelines for appropriate indications for revascularisation, good history taking, assessment of risk factors, non-invasive and pressure wire FFR assessment for ischaemia seem like a good place to start. PS Douglas and others. J Am Coll Cardiol. 2011;58:801-809.

Atrial Fibrillation Another factor Xa inhibitor, rivaroxaban has shown more positive results in patients with atrial fibrillation (AF). In the ROCKET AF trial patients with AF were randomised to rivaroxaban or warfarin, with non-inferiority demonstrated for the prevention of stroke or systemic embolism. There was a significant reduction in intracranial haemorrhages and fatal bleeding in the rivaroxaban group, though these results were (part of) a secondary endpoint and should be interpreted with caution. Good news and less hassle for patients who do not need INR monitoring with rivaroxaban. The financial cost and subsequent European approval for AF is now awaited. It will also be competing with dabigatran.

We still don’t really know what to do about early repolarisation syndrome yet, so two new contributions are welcome. Japanese atom bomb survivors get regular medicals including 12 lead ECGs. Headline findings are that early repolarisation is common (23% lifetime incidence with a peak first manifestation in the late second and early third decade), has a significant cross over with Brugada syndrome and is associated with a modest overall increase in sudden death rate (HR 1.8 vs. controls, in comparison to Brugada ECGs HR 27.5). Widespread abnormalities (slurring and/or notching) were associated with higher rates of sudden cardiac death. It does seem clear that early repolarisation is at best a spectrum and possibly no more than a hotchpotch of vaguely connected conditions. In an attempt to split out higher and lower risk phenotypes a Finnish group examined various cohorts (Finnish athletes, US athletes and a middle aged group). They conclude that in early repolarisation (notching or slurring of the terminal QRS) where the ST segments are upsloping there is no increased risk of SCD and this represents a normal finding particularly prevalent in athletes. Where early repolarisation is associated with a down sloping ST segment there was some increased risk of SCD (albeit modest, RR 1.43). D Haruta and others. Circulation. 2011;123:2931-2937. J Taikkanen and others. Circulation. 2011;123:2666-2673. Short QT syndrome is the other end of the spectrum; very rare, highly malignant. The European registry includes just 53 patients, follow up on this highly selected group, 89% of whom have personal or family histories of SCD reveals two findings. Firstly, they have a lot of arrhythmias (4.9% per year if untreated). Secondly, Hydroquinidine is effective in reducing the event rate (no events in the 12 patients treated). C Giustetto and others. J Am Coll Cardiol, 2011; 58:587-595

MR Patel and others. NEJM. 2011. 10.1056/NEJMoa1009638.

Lead Extraction

AF ablation Attempting to ablate AF in patients with unresolved valvular heart disease is well known to be challenging, but how do patients do with AF ablation post valve replacement? Two series of a total of 130 patients with prosthetic Aortic and Mitral valves, compared with matched non valvular patients produced similar results. Acceptable overall success rates (first procedure about 50%, 80% after mean 1.3 procedures), a high rate of atrial flutter both pre and post ablation and efficacy of linear ablation in preventing arrhythmia recurrence. Trends were observed toward higher complication rates and longer procedure and fluoroscopy times in the valvular group. D Lakkireddy and others. Heart Rhythm. 2011;8:975–980. A Hussein and others. J Am Coll Cardiol. 2011; 58:596-602.

Lead extraction is often considered a special case among percutaneous procedures with perceptions of high mortality and high rates of surgical intervention. Indeed some have advocated all such procedures being performed in cardiothoracic theatre to facilitate earliest possible surgical intervention. In this series of 1364 leads in 864 consecutive patients the authors studied the differences in outcome between procedures performed in theatre and in the cathlab. The findings were of an overall mortality of 0.2%, with surgical interventions required at some stage in 0.9%. The only two massive haemorrhages due to SVC laceration died despite surgical intervention. Older leads were independently associated with increased complications, 92% of leads were extracted in their entirety. There were no differences in outcomes between

patients extracted in theatre vs. those extracted in the EP lab. One patient underwent unproductive surgical exploration for a transient blood pressure drop, but did fine despite this. F Freceschi and others. Heart Rhythm 2011;8:1001–1005.

Communication Is it good to talk? When we quote figures on risks and benefits to patients, what are we trying to achieve? Do we just want to write something in the notes to cover ourselves or do we really want to help the patient understand? A survey of what patients took in from written and diagrammatic explanations challenges perceived wisdom and existing guidelines. Patients do understand (sort of) low risk expressed as very small percentages (e.g. less than 1%, 0.02%) which we are supposed to avoid but do not understand numerator/denominator comparisons especially where the denominator changes (e.g. risk of stroke 1 in 100, risk of death 2 in 1000). Furthermore, patients understand absolute risk and changes therein much better than relative risk.

Question asked by Mr Stuart Allen, Principal Cardiac Physiologist, Manchester Heart Centre

Management

With the rise in PPCI, what changes in working patterns will be necessary so as to avoid physiologists working on average 14 to 22 hrs in one shift, when they start at 9am and continue on to do on-call that night?

M Thomas and others. Circulation. 2011 124:425-433.

Coronary Artery Bypass Grafting And whilst we are talking about cardiothoracic surgeons, we should briefly mention this study looking at saphenous venous grafts in patients undergoing CABG (PREVENT IV trial). Essentially, vein graft failure is significantly worse at one year if there are multiple rather than single distal targets (something to do with flow presumably?). This results in a significantly poor clinical outcome at five years (worse composite of death, MI or revascularisation), so is best avoided. R Mehta and others. Circulation. 2011;124:280-288.

AVAILABLE ONLINE

Heart Rhythm Congress

Heart Rhythm Congress

2nd - 5th October 2011

Chang ng wo k patte ns w h PPC

Nishat Jahagirdar

For many the notion that work as a cardiac physiologist is a Monday to Friday, nine ‘til five lifestyle is long gone. On call work will, of course, be second nature to cardiac physiologists working in numerous centres and over recent years extended working weeks incorporating weekends and longer working days have become the norm in response to achieving diagnostic waiting time targets. Consequently, further tweaking of working patterns after appropriate consultation should not prove too troublesome to implement. A move to shift-work is one potential approach to meet the demands of a primary PCI service although there is the question of what roles a cardiac physiologist might undertake between primary PCI cases. Perhaps a forthcoming publication from the British Cardiovascular Society regarding the future of Cardiac Care may offer some guidance? The recommendations are likely to suggest that a full range of cardiac diagnostic procedures are accessible on a 24 / 7 basis. Some Trusts may choose to interpret their meeting of this proposal by having on-call junior medical staff available but who would you prefer to perform your investigations? A trainee doctor or a qualified, competent and experienced cardiac physiologist?

Beh nd the Scenes at Medtron c

R.A Veasey and others. Int J Clin Pract. 2011;65:658-663.

TAVI Having mentioned TAVI, it would be remiss of us not to comment on the one year results of the SOURCE registry, which has reported the outcomes of 1038 patients enrolled at 32 centres undergoing implantation of the Edwards SAPIEN aortic valve, either transapically (575 patients) or transfemorally (463 patients). Transapical TAVI is performed in those patients with peripheral vascular disease, whom represent a higher risk group at baseline (logistic EuroSCORE 29% for transapical vs. 25.8% for transfemoral). Total one year survival was 76.1% overall, with 72.1% for transapical and 81.1% for transfemoral. Impressive results, that are only going to improve as the experience and the kit gets better.

Lead Cardiac Physiologist (Invasive) Kings College Hospital London United Kingdom

Dr Chris Eggett

ccording to the Department of Health primary PCI is available to 90% of the English population so this topic has relevance to many departments and I’m sure there’s a multitude of different approaches being taken to deal with the particular issues it raises on a local basis. That’s exactly how it should be, there’s no single prescriptive solution and individual services must work within the legislative framework, using the tools available to them in terms of local policy regarding flexible working to achieve the best possible outcome for their patients.

14

S Woloshin and others. Ann Intern Med. 2011;155:87-96.

www.cardiologyhd.com Sep/Oct 2011 17

Hot Topic

A

Roya Berksh re NHS Foundation Trust

How about communication between district hospital interventional cardiologists and surgeons at a remote surgical centre? Apparently a video link system in Sussex significantly increased the number of patients with complex coronary disease having surgical revascularisation rather than PCI. We have mixed views on this. Cardiothoracic surgeons, in the main, will perform coronary artery bypass grafting (CABG) on elective patients, even when high risk, if they have appropriate coronary disease. The problems come with acutely unwell patients, when shock, renal dysfunction or troponin elevation seem to put them off! The SYNTAX study (CABG vs. PCI in high risk coronary artery disease) and ongoing trans-aortic valve implantation (TAVI) programmes have certainly improved relations between cardiothoracic surgeons and interventionists, and this must be a good thing.

16 Sep/Oct 2011 www.cardiologyhd.com

Cardiac Physiologist Deputy Service Manager Freeman Hospital Newcastle upon Tyne

24

A

work week consisting of four working days from 8am-6pm, with the day off preceded by an on call night is the best working pattern for physiologists on call as: •

The on call person is guaranteed to have rest the next day.

Clinical work and lab over run can be covered between 8-9am and 5-6pm by the staff working the long shift that week.

If a member of the team isn’t on call, then they can work a normal (9am-5pm) shift pattern that week. Hence, only an extra member of staff is required to cover the unavailability of the on call person the next day.

The on call person works from (10am-8pm/11am-9pm), with two 30 minutes breaks for lunch and pre on call at 5:30pm, reducing the number of hours worked continuously. With the normal (9am-5pm) shift pattern, if the number of on call hour’s increases, the physiologists are less likely to work the next day, as per European Working Time Directive. The suggested working pattern reduces the need to change the work rota for the day at the last minute, due to unavailability of the on call staff. It eliminates the system of giving back time/not getting paid, for any hours accumulated due to staff taking rest the next day (11 hours post on call).

As of now, the physiologists cannot work the day/night 12 hours shift, as there is no other work that can be done during a night shift other than PPCI’s!

www.heartrhythmcongress.com Tel: +44 (0) 1789 451822 Email: info@heartrhythmcongress.org.uk Promoting better understanding, diagnosis, treatment and quality of life for individuals with cardiac arrhythmias HRC PO Box 3697 Stratford upon Avon Warwickshire CV37 8YL UK Telephone: +44 (0) 1789 450 787

AVAILABLE ONLINE

Supported by

Have your say to this Hot Topic on our website today along with other topics from previous editions.

HR-UK

Arrhythmia Alliance

Heart Rhythm UK

The Heart Rhythm Charity

18 Sep/Oct 2011 www.cardiologyhd.com

HRC 2011 A4 NO DATES.indd 1

18/05/2011 15:32:09

UK S te V s t

United Kingdom

Site Visit Blackpool Teaching Hospitals NHS Trust:

Lancash e Ca d ac Cen e

Lancashire Cardiac Centre Whinney Heys Road, Blackpool Lancashire United Kingdom

What are the sizes of your Cardiology Department and Hospital? The £52million Lancashire Cardiac Centre forms part of the Blackpool Teaching Hospitals NHS Foundation Trust, which comprises around 830 beds across several hospitals, the largest of which being Blackpool Victoria Hospital where the cardiac centre is located. The Trust serves a population of approximately 330,000 residents of Blackpool, Fylde and Wyre and the 12 million holidaymakers who visit the area every year. We are also one of four tertiary cardiac centres in the North West, providing specialist cardiac services to heart patients from Lancashire and South Cumbria. The centre was opened in 2006. How many staff? Roles? • • • •

10 cardiology consultants. 14 Cardiac Physiologists 9 Radiographers 10 Nurses

Types of procedures? • • • • • •

Diagnostic and interventional (PCI’s) + regionwide PPCI service Electrophysiology Full range of cardiac physiology services including Echo Internal Cardioversions Pacemakers & ICD’s TAVI

20

Types of equipment use?

The Lancashire Cardiac Centre provides a variety of cardiovascular treatment options for the people of Lancashire, Cumbria and surrounding counties. The centre comprises the latest facilities, including four state-of-the-art cardiac catheter labs, which perform a variety of investigations and treatments. These include angiograms, angioplasties (stents), internal cardioversions, pacemakers, biventricular pacemakers, ICD’s and electrophysiology studies. Recently the centre opted to embrace McKesson’s fully integrated haemodynamic system, featuring built-in fractional flow reserve (FFR) software, to address the growing frequency of its use within the cath lab environment. The team have also commenced using the Volcano PrimeWire Prestige, which integrates seamlessly with the McKesson system. The PrimeWire Prestige was chosen due to specially designed features including a heavier core and improved tip, which aid the operator to cross challenging lesions

• • • • • • • •

IVUS Boston and Volcano Integrated FFR Volcano SJM FFR St Jude’s LightLab OCT Rotoblation. Philips and Siemens Cath Labs. McKesson Cardiovascular Information solution GE Vivid 7 Echo

How many procedures are performed a year? • • • •

PCI = 1600 (target of >2000 PCI’s for 2011-2012) Diagnostic procedures 2000 Tavi 36 240 EP proceedures

What is the approximate percentage of cath lab cases performed radialy compared with femoraly? 65-70%

20 Sep/Oct 2011 www.cardiologyhd.com

United Kingdom

Site Visit The Royal Berkshire NHS Foundation Trust

UK S te V s t

24

Events Ca endar

26

Roya Be ksh e NHS Foundation T us

Jim Shahi Unit (Cardiac Catheterisation Laboratory) pm. In 2009 we introduced the Primary PCI service 24/7. This has been implemented very successfully with a median call to balloon time (CTB) of 77 minutes and door to balloon time (DTB) of 28 minutes in the first 12 months. South Central ambulance service provides an excellent response to emergency calls for patients with chest pain. The PPCI team members all live locally and are able to be at the Cath Lab within 20 minutes. This enables patients to receive early reperfusion and optimal treatment and outcomes. The ward base consists of an 18 bedded CCU Department with 1 Chest Pain assessment bed and a 28 bedded Cardiology Ward including 6 Telemetry beds. The Cardiology Department provides a full range of Cardiac Investigations along with outpatient’s clinics, Rapid Access Chest Pain Clinic and Heart Failure Clinics. A full range of Cardiac Rehabilitation is offered as an inpatient and outpatient service. What are the sizes of your Cardiology Department and Hospital? • • •

Jim Shahi Unit – 16 beds CCU 18 beds + 1 Chest pain assessment bed Whitley Ward – 28 beds

What is the geographical intake area and population served by your hospital? • •

Half a million catchment PPCI catchment is up to 750,000

How many staff? Roles?

The Royal Berkshire NHS Foundation Trust is situated in the centre of Reading covering western and central portions of Berkshire. It is one of the largest general hospital trusts in the country, which has recently undergone £132 Million redevelopment. The hospital provides 813 inpatient beds together with 204 day beds, in doing so it employs 4000 staff.

• • • • • • • • • • •

5 Consultant Interventionalist Cardiologists 1 Consultant Electrophysiologist (visiting) 1 Consultant Cardiac Surgeon (visiting) 1 Consultant Cardiac Imaging (CT/MRI) 2 Associate Specialist 3 SpRs 3 ST grades 2 FY grade juniors JSU = 8.2 Nurses WTE 3.6 Radiographers WTE 24 Cardiac Physiologists (

The specialty of Cardiology provides a combination of inpatient work, a large outpatient service and a full range of Cardiac Investigations. The Cardiac Catheterisation Laboratory is named after the late Dr. Jim Shahi, a Consultant Cardiologist who helped set up the unit in 1994. We have 2 Catheterisation Laboratories which offers an extensive range of elective and emergency procedures. Alongside the labs we have a 16 bedded day bed unit which opens from 8:00 am to 6:00

24 Sep/Oct 2011 www.cardiologyhd.com

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28

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www.cardiologyhd.com Sep/Oct 2011 3


Our Cardiology

Experts Mr Tim Larner Director / Founder

Dr Magdi El-Omar Lead Consulting Editor

Dr Richard Edwards Consulting Editor

Mr Ian Wright EP Consulting Editor

Previous Cardiac Radiographer Manager in Australia, & Senior Radiographer at multiple sites in the UK.

Consultant Cardiologist, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust

Consultant Cardiologist, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust

Technical Head EP, St Mary’s Hospital, Imperial College Healthcare NHS Trust

Dr John Paisey Journal Reviewer

Dr Dan McKenzie Journal Reviewer

Prof Simon Redwood Consulting Editor

Dr Rodney Foale Consulting Editor

Consultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Consultant Cardiologist, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust

Consultant Cardiologist & Director of the Cath Labs at Guy’s & St Thomas‘ NHS Foundation Trust

Consultant Cardiologist, Imperial College Healthcare NHS Trust

Mr Adam Lunghi Echo Consulting Editor

Mr Dennis Sandeman Nursing Consulting Editor

Senior Echo Manager CVS - CardioVascular Services, Australia

Chest Pain Nurse Specialist NHS Fife, Trustee of the Scottish Heart and Arterial Risk Prevention (SHARP) charity.

Ms Sophie Blackman Management & CRM Consulting Editor

Dr Mojgan Sani Pharmaceutical Editor

Head of Clinical Cardiac Physiology, West Hertfordshire NHS Trust

Head of Clinical Pharmacy, Royal Berkshire Foundation Trust & National Non-medical Prescribing Facilitator, National Prescribing Centre.

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For your free copy subscribe on our website at www.cardiologyhd.com.

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4 Sep/Oct 2011 www.cardiologyhd.com


Latest Product News

Round Up Echocardiography

A Philips Hybrid Cath Lab For New Queen Elizabeth Hospital Birmingham The new Queen Elizabeth Hospital, (UHB) Birmingham selected the Philips Allura Xper FD20 for its hybrid Interventional Operating Room Lab (Hybrid OR). The new system, one of seven Philips Allura’s recently purchased by the Hospital, is a dedicated Operating Theatre system, sited in the X-ray department, but only carrying out vascular surgery-related procedures (e.g. endovascular stents). Of the other six Allura systems, three are used for normal interventional radiology and three bi-plane Allura Xper FD/10 systems for cardiology and EP procedures. Philips’ next generation Allura Xper FD20 systems combine superb image quality with advanced interventional tools, seamlessly integrated into the clinical workflow, providing enhanced opportunities with Live 3D guidance to continue to expand the range of interventional procedures able to be undertaken by the user. The integrated workflow, intuitive user interface and personalised settings enable the user to take full advantage of all the Allura’s capabilities and for a broad variety of procedures assist in providing excellent clinical care effectively and comfortably.

The Western Infirmary opts for ‘Echo in a Heartbeat’ functionality from Siemens

The Western Infirmary, part of NHS Greater Glasgow and Clyde, is benefiting from increased cardiac image quality following the installation of an ACUSON SC2000™ diagnostic ultrasound system from Siemens Healthcare. The hospital is one of the first in the UK to have installed the system. The purchase was funded by the British Heart Foundation Glasgow Cardiovascular Research Centre, who will share use of the system for research projects. The system will primarily be used for 3D echocardiography. The SC2000 is Siemens’ premier echocardiography system featuring ‘Echo in a Heartbeat’ imaging technology, which acquires real-time, full-volume images of the heart in one single cycle.

Above: Philips personnel and the team from the new Queen Elizabeth Hospital in Birmingham

“The SC2000 generates fantastic image quality and is allowing us to perform more sophisticated 3D echocardiography examinations,” said Dr. Piotr Sonecki, Consultant Cardiologist at The Western Infirmary. “Towards the end of the year, we hope to be able to carry out vascular examinations and further evaluate its suitability for future research work.”

Latest Topics from our members

ONLINE DISCUSSION FORUM Does any centre always set the isocentre prior to doing an angiogram? We have never done it but I’m considering introducing it if it will reduce the amount of panning that is done.

Have your say at www.cardiologyhd.com. Membership is free.

www.cardiologyhd.com Sep/Oct 2011 5


Heart Valves

Edwards Lifesciences launches Physio Tricuspid repair ring Edwards Lifesciences has received CE mark approval and FDA clearance for a new repair ring for the treatment of tricuspid insufficiency. The Carpentier-Edwards Physio Tricuspid Annuloplasty ring features a three-dimensional waveform shape, and incorporates several ease-of-implant features. “We designed the ring to offer surgeons confidence when treating tricuspid valve insufficiency,” said preliminary researcher Alain Carpentier, M.D., Ph.D., professor and chairman emeritus of cardiovascular surgery at the Hôpital Europeen Georges Pompidou. “It is designed to conform to the anatomy of the valve annulus and preserve its natural movement to facilitate adherence of the ring to the surrounding tissue, while restoring proper valve function.” Tricuspid insufficiency is progressive and may affect more than 150,000 Europeans. It often leads to severe tricuspid regurgitation, where valve leaflets do not close properly allowing backflow of blood. Annuloplasty ring repair is typically recommended for patients with significant annular dilation.

Improving the management and diagnosis of aortic stenosis through treatment innovation Aortic stenosis is the most common cardiac valve disease in developed countries, affecting nearly 26% of people over 65. Once advanced disease and symptoms present, prognosis is poor with survival under three years for many. Additionally, diagnosis is difficult and symptoms are often missed and furthermore, even if diagnosed, age and co-morbidities combine to render many patients inappropriate for traditional surgical valve replacement. Recently discussed in the UK for the first time in its entirety, the Placement of AoRTic TraNscathetER Valve Trial (PARTNER) showed that Transcatheter Aortic Valve Implantation (TAVI) significantly reduces the rates of death from any cause for previously inoperable patients, gives patients substantially better quality of life and provides patients with a survival rate equivalent to that of conventional surgery. Specifically, the results from Cohort B offered “the biggest treatment effects ever seen in a randomised controlled trial” according to Mark de Belder, consultant cardiologist at James Cook University Hospital.

For more information on Edwards Lifesciences products please visit www.edwards.com

SonoSite’s M-Turbo® key to emergency echocardiography

availability of ultrasound equipment including echocardiography capability cannot be guaranteed, and the M-Turbo has been very useful as a robust, hand-carried system in these circumstances.”

Royal Brompton Hospital in London, home to the UK’s largest specialist heart and lung centre, uses a SonoSite M-Turbo® pointof-care ultrasound system for emergency focused transthoracic echocardiography. Dr Susanna Price, consultant cardiologist and intensivist, explained: “The MTurbo is solely dedicated to emergency use on the intensive care unit (ICU). Its extremely fast bootup time is a great advantage in life-threatening situations where speed is critical, and being equipped with both a cardiac package and a vascular probe means it serves a dual purpose.”

Dr Price concluded: “The M-Turbo’s facility to record image clips for subsequent review is an essential requirement. It provides a record of diagnosis, evidence for medico-legal purposes, and, being easy to use, the system is very good for training junior ICU doctors who are just starting to use focused echocardiography.”

“We use ultrasound guidance for all our central venous access, for performing pleural drainage and, in emergency situations we use the M-Turbo for focused transthoracic echocardiography. On occasions we have retrieved patients from other units where the

For more information about SonoSite products, please contact: ukresponse@sonosite.com or www.sonosite.com

6 Sep/Oct 2011 www.cardiologyhd.com


sTAndArd TreATmenT

20%

reduction in all-cause mortality at one year1 BAlloon-expAndABle TrAnscATheTer AorTic VAlVe implAnTATion (TAVi)

A new option for your high-risk patients with aortic stenosis In the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.1 Additionally, the reduction in mortality and rehospitalization versus standard treatment at one year was 40%.1 For more information & to find a TAVI center near you please visit edwards.com/eu/products/transcathetervalves Reference: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607. For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN and PARTNER are trademarks of Edwards Lifesciences Corporation. © 2011 Edwards Lifesciences Corporation. All rights reserved. E2062/5-11/THV

Edwards Lifesciences Irvine, USA I Nyon, Switzerland edwards.com

I Tokyo, Japan I Singapore, Singapore I São Paulo, Brazil


INTERNATIONAL ONLINE CATALOGUE

Full descriptions, images & more online

What is the catalogue? To take full advantage of our new community website we added a catalogue featuring the latest products and services within cardiology, to assist you with purchase decisions. Each product

listed has a full description, photos, and contact details for real show sites so you can skip the marketing and go direct to real life examples.

Siemens Healthcare Artis zee

1 2

The Artis zee™ family is designed for interventional cardiology imaging. Available as floor or ceiling-mounted, biplane or with Magnetic Navigation, it features a 20x20cm or 30x40cm flat detector. This enables flexible positioning around the patient, ideally suited for imaging of structural heart diseases. Show Site: See our website for case studies at the Bristol Heart Institute and the National Institute for Health Research.

Siemens Healthcare SOMATOM Definition AS+ The SOMATOM® Definition AS+ CT system from Siemens Healthcare is an adaptive scanner that provides exceptional image quality to make complex cardiology examinations routine. Show Site: See our website for case studies at Borders General Hospital and Great Western Hospital. Like to advertise your products? Contact us via the details on Page 4.

Industry Partnerships

First European appearance of the newly formed Hitachi Aloka Medical Ltd. (Japan) Hitachi Medical Corporation and Aloka Corporation have combined their strengths in ultrasound to form Hitachi Aloka Medical Ltd. (Japan), a subsidiary of Hitachi Medical Corporation (Japan). The new company made their European debut in Vienna between 26 to 29 Above: The Two CEO’s August 2011 at the 13th World Congress of Ultrasound in Medicine and Biology (WFUMB). Hitachi and Aloka bring together a plethora of experience and knowledge - synergizing the expertise and talents of the people on both sides of the new merged company. Participants and visitors were invited to experience this at the event booth where Hitachi Aloka Medical highlighted ‘the next generation in high resolution imaging technology’, focusing on the Hitachi HI VISION and Aloka ProSound Ultrasound platforms - introduced and explained by expert employees from Hitachi Aloka Medical Japan, Aloka Europe and Hitachi Medical Systems Europe.

8 Sep/Oct 2011 www.cardiologyhd.com

Cath lab Nurses/ Physiologists/Radiographers Opportunity for Cath Lab Staff Regent’s Park Heart Clinics Ltd. are actively recruiting for cath lab staff within a new diagnostic angiography service at Scarborough Hospital. We are looking for enthusiastic staff to join the Regent’s Park team providing invasive cardiology services at:

Scarborough Hospital, North East Yorkshire This is a long term 2-day/week service (Tuesdays and Wednesdays) providing Diagnostic Coronary Angiography and Permanent Pacing. Fixed term and agency-style contracts available!!!

START DATE: 4th October 2011 To find out more please contact Bryn Webber, Cardiac Services Manager: bryn.webber@rphc.co.uk or call 07966 987712 Please visit our website for more details on our background and capabilities: www.rphc.co.uk We look forward to hearing from you.


Questions designed by Dr Magdi El-Omar and Tim Larner

Cardiologist

Hot Topic Who should perform peripheral vascular intervention: Cardiologist, Radiologist or Vascular Surgeon and why? Dr Nicholas Chalmers Consultant Vascular Radiologist Department of Radiology Central Manchester University Hospitals NHS Foundation Trust Manchester Royal Infirmary Manchester

I

t is much easier to address this question in the NHS environment than in countries where the operator’s livelihood is dependent on cornering as much of the market as possible. In this country, we can put the interests of the patients and service first.

Individuals from any clinical background can learn the relevant manual skills and technical knowledge. Some individuals are naturally gifted, most are trainable and very few need to be tactfully pointed towards a different career path. However, this aptitude is independent of specialty. Who can provide the best service to patients? It seems obvious to me that the specialist should have a major interest in peripheral vascular disease. This includes the conservative, non-interventional management of vascular disease, such as medical therapy, exercise programmes and ulcer care. The holistic care of the vascular patient requires more than treating the stenosis. This logic leads to the conclusion that peripheral intervention should be provided by vascular surgeons and this is almost certainly the direction of travel in the UK. Radiologists have been involved in peripheral intervention since its inception and have provided a high quality service for years. However, the expansion and development of endovascular interventions have brought them from the margins to the mainstream. Thus it is important that the new generation of vascular surgeons ensure that they are properly trained in endovascular techniques and that consultant surgical posts have angio room sessions in the job plan. I anticipate that the future of radiological involvement in peripheral intervention will mirror what happened in coronary intervention 20 years ago: the radiologists will progressively lose their role in this service provision. This prognosis has a significant downside. Vascular radiologists currently provide a broad range of services to many hospital departments for bleeding, tumour embolisation, vascular access, caval filter placement and so on. These are valuable services, but it will not be possible to sustain a comprehensive vascular radiology service without the workload that comes from vascular surgery referrals. The danger is that, if vascular surgeons take on all the peripheral intervention, vascular interventional radiology will atrophy. The optimal solution is therefore a harmonious collaboration between radiologists and surgeons, with each specialty providing an overlapping and complementary range of skills. This is the reality in many UK centres at present, but I fear it is not sustainable in the long term.

10 Sep/Oct 2011 www.cardiologyhd.com

Dr David Smith Consultant Cardiologist, Morriston Hospital Morriston Swansea

A

ll of the above, provided they are interested and are prepared to work collaboratively and share their relevant clinical skills and experience! I think we need to learn from the lessons gained from transcatheter aortic valve implantation (TAVI), where we have found that the multi-disciplinary “TAVI team” has been instrumental in the successful introduction of TAVI into mainstream treatment of aortic valve disease. Equally we need to avoid the “turf war” scenario that we have previously seen with interventional and surgical treatment for coronary disease. In my opinion, no individual clinician has the complete range of clinical skills and experience to provide a comprehensive peripheral vascular interventional programme. I would advocate the development of multi-disciplinary “endovascular teams” to provide the current and likely future range of minimally invasive/ endovascular treatments for cardiovascular disease. This would be in keeping with the “heart team” approach recently advocated by our European colleagues for the revascularisation of coronary artery disease. Such teams would need to take advantage of local skills, interests and resources with clinicians working collaboratively.


A/Prof Michael Denton Director of Vascular Surgery St Vincents Hospital University of Melbourne Melbourne, Victoria Australia

T

he sensible answer in the medical world of 2011 is a medical practitioner who has a suitable clinical background and knowledge level, but is also demonstrably competent in the interventional technical skill sets. Of course a cardiologist, vascular surgeon or interventional radiologist can acquire this technical expertise in a broad array of interventional procedures, the same way as a limited procedural skill set can be acquired by neurologist (carotid stenting) or nephrologist (fistuloplasty). If their skills are competent and their knowledge base is sound, or if they work in a team setting with suitably trained clinicians (as we have seen for years with many interventional radiologists and vascular surgeons) then they should be recognised as such and accredited by the appropriate institution.

This approach has been based on the model used by gastroenterology groups to deal with similar issues relating to diverse specialties performing endoscopy. We have completed the grandfathering component successfully, and have already discovered the utility of this model in resolving difficulties with the hospital accreditation of specialists in ‘scope of practice’, and also in resolving turf wars, which were a perennial problem.

We have resolved this issue in Australia and NZ by establishing a committee to recognise such peripheral endovascular training regardless of the specialty. This committee has been sanctioned by the three Colleges involved namely: RACS , RACP and RANZCR . It has drawn criteria for recognition of training in 3 areas: 1. 2. 3.

General peripheral endovascular intervention Carotid stenting Fenestrated and branched endografting

Supervisor’s reports +/- references are also required to confirm competence.

AVAILABLE ONLINE SEE OUR PREVIOUS HOT TOPICS We have 16 Hot Topics available on our website with responses from leading cardiologists from across the UK and around the world.

A Year in Cardiology Date: 14 December 2011 Venue: Royal College of Physicians, London Providing a succinct review of the years’ hot topics with particular emphasis on clinical practice and a round-up of key developments in the sub-specialties. This symposium is a must for consultants and trainees wishing to keep abreast of major advances in Cardiology. For more details and the full programme, visit the BCS website. Online registration is now open on www.bcs.com/education

12 Sep/Oct 2011 www.cardiologyhd.com


Integrity BMS–#1 for a reason

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Superior deliverability* depends on the crossability, flexibility and responsiveness of the stent and delivery system. The unique Integrity design allows for a continuous range of motion and articulation, providing a clear advantage vs. the competition.* The result? Integrity BMS is now the #1 bare metal stent.†

Find out more at medtronicstents.com

*Superiority against major bare metal stents: Bench test data vs. Abbott Multi-link Vision and Boston Scientific VeriFlex (Liberté) coronary stents on file at Medtronic, Inc. † In Europe. Data on file at Medtronic, Inc. Not for distribution in the USA or Japan. © 2011 Medtronic, Inc. All rights reserved. Printed in the EU. UC201200800EE 7/11


Behind the Scenes

Industry Behind the Scenes: The Manufacturing of Medtronic’s Integrity Stents Overview Founded in 1949 as a medical repair shop, Medtronic Inc. has steadily grown to become a global leader in medical technologies, initially producing pacemakers before expanding to cover the variety of products available today. 40,000 employees in 120 countries, with 44 manufacturing facilities, and 25 research and development centres worldwide ensure they are always at the cutting edge in regards to R&D, producing products that comply with their mission of alleviating pain, restoring health, and extending life. Cardiovascular and Cardiac Rhythm Disease Management make up over half the total revenue for the company with the evolution of new technologies such as continuous sinusoid technology (CST) for coronary stents, ensuring Medtronic remains as a leader in medical product development. We visited Medtronic’s manufacturing and technology development facilities in Galway, Ireland for a tour of how the R&D, operational processes, and quality assurance is combined to create the new Integrity Bare Metal Stent (BMS) and Resolute Integrity Drug Eluting Stent (DES), both utilising CST.

Continuous Sinusoid Technology (CST) Coronary stents used by cardiologists in the treatment of coronary artery disease were originally limited to tubular mesh or slotted tube stent designs. Medtronic has historically been known for its modular stent technology, as is featured in their Driver stent. However, Medtronic have advanced this technology to the next level with the introduction of CST, which results in superior flexibility and deliverability compared with the Driver and also other Fig 1. Separate stiff and flexible commercially available stent segments limit range of motion on platforms (Fig 1).1 other platforms

Fig 2. Continuous sinusoid technology flexes continually

The easiest way to imagine CST is with a slinky design (Fig 2), whereby a continuous piece of wire can flex easily in all planes. The wire involved in the construction is already round so therefore doesn’t require extensive polishing to remove any sharp edges which can lead to metal fatigue. The stents are also

14 Sep/Oct 2011 www.cardiologyhd.com

Medtronic employees checking the quality of the stents after electropolishing made with cobalt chromium alloy which when compared with stainless steel allows for a reduction in stent strut thickness (enhanced delivery and lower rates of stenosis), better radiopacity, and greater strength. The continuous range of motion due to the wire-forming process and fusion pattern provide greater flexibility and conformability while maintaining radial strength. This is particularly apparent on tight bends or tortuous anatomy where the CST stent tracks very easily, whereas with traditional stents significant gaps can occur or edges can raise damaging the sensitive intimal lining of the artery being passed through.


The Manufacturing Process

Cobalt alloy wire Thin, round struts

1 High precision cobalt alloy wire same as Driver made to Medtronic spec’s for thin round struts.

Continuous sinusoid formed and wrapped around a mandrel

2 Wire is formed into sinusoids before it is wrapped onto a mandrel with crown to crown alignment. This squares up the end of the stent.

Laser-fused at key points

3 The strategically located fusion points are laser fused to keep the same or better performance features of Driver.

Electropolished for smooth surface

5

4 The electropolish provides a polished surface area of round struts.

Open Cell Design

The wrap-crimp provide for low profile and good retention to ensure the catheter can deliver the stent to the target lesion.

The Future of Stents

Stent Diameters Whilst there are a wide range of stents diameters available (2.25 to 4.0mm) in reality only two stent designs are manufactured for the Integrity platform. Each of the two stents manufactured are crimped onto the appropriate sized balloons, with the nominal diameter of the balloon determining the diameter of the stent once placed. This provides a much greater opportunity to post inflate the stent if it is determined the original placement was undersized.

Wrap-crimped for low profile

CST

gives rise to broad applications for the development of next generation BMS and DES. These include the development of drug-filled stents, which forgo the need for a polymer coating, and core wire stents for thinner struts, amongst other design benefits.

One of the major advantages of the Integrity stent is its open cell design. Basically this relates to the perimeter of a cell between fusion points that can be expanded in the case of allowing for sidebranch access. This is particularly important for complex interventions, allowing accurate positioning and adequate wall coverage. The Resolute Integrity stent has a cell perimeter of 28.9mm (small vessel design), compared to other popular stents such as the Xience Prime with only 14.42mm.2 This increased cell perimeter is achieved through the specific fusion pattern determined by Medtronic’s engineers. Every 4th stent crown (medium vessel) and every 5th crown (small vessel) are fused.

Above: Drug-Filled Stent

Factory Tour Visiting the Medtronic manufacturing plant in Ireland is an amazing experience. The large amount of labour required working harmoniously alongside sophisticated automations makes you understand the value in the final product. The entire process is rigorously checked for quality, and the employees show pride in the products they make. For more information visit www.medtronic.com References: 1: Coronary Heart Publishing Ltd confirmed this on external models only. 2: Test data provided by Medtronic, Inc.

Above: Core Wire Stent

www.cardiologyhd.com Sep/Oct 2011 15


Journals Dr John Paisey Journal Reviewer

Dr Dan McKenzie Journal Reviewer

Consultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Consultant Cardiologist, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust

Follow me @johnpaisey for the latest reviews

Follow me @danmckenzie73 for the latest reviews

Bedside Echo Stop the press: pocket echo machines are OK-ish, in a vague sort of way, with lots of qualifications (how does this stuff get published?). M Llebo and others. Ann Intern Med. 2011;155:33-38.

Acute Coronary Syndromes Yet another drug for reducing ischaemic outcomes in ACS patients? Sadly, or maybe even gladly, not, according to the APPRAISE 2 trial. Apixaban, a direct factor Xa inhibitor used in thromboembolism prophylaxis and atrial fibrillation (AF) (others include dabigatran and rivaroxaban) only managed to increase bleeding in high risk ACS patients when added to standard dual antiplatelet therapy, with no significant reduction in ischaemic events. This seems to continue the trend that oral anticoagulants have little overall benefit in ACS (warfarin, hirudin), whilst oral antiplatelet agents (aspirin, clopidogrel, prasugrel, ticagrelor), subcutaneous anticoagulants (enoxaparin, fondaparinux) and intravenous antiplatelet (glycoprotein IIB IIIA inhibitors) and anticoagulants (bivalirudin) do. J Alexander and others. NEJM. 2011;10.1056/NEJMoa1105819. Good to know that cardiovascular drugs are also beneficial in patients with chronic kidney disease (CKD). The SHARP trial randomised 9270 patients with CKD and no previous history of MI or coronary revascularisation to simvastatin 20mg plus ezetimibe 10mg daily versus matching control. The primary outcome of first major atherosclerotic event (a combination of non-fatal MI or coronary death, nonhaemorrhagic stroke, or any arterial revascularisation procedure) was significantly reduced with the active drugs (11.3% vs. 13.%) that reduced the average LDL cholesterol by 0.85mmol/L. Another high risk group that needs targeting and treatment. C Baigent and others. Lancet. 2011;377:2181-92.

Angiography A fairly disturbing registry in America showed that the likelihood of finding obstructive coronary artery disease on elective diagnostic angiography varies from 23% to 100% (median 45%). The data was collected through the huge National Cardiovascular Data Registry (NCDR) from 565,504 patients with known coronary artery disease, undergoing angiography at 691 centres, between 2005 and 2008. The data raises more questions than it answers, but suggests that

16 Sep/Oct 2011 www.cardiologyhd.com

some clinicians and centres significantly overestimate angiographic stenosis, or do not have a sufficiently low enough threshold to perform angiography in patients with symptoms of coronary disease, whilst other individuals and centres are doing the exact opposite. It is important to note that the health service in the US is privately funded (land of the free?) and a number of interventionists have recently had their licences revoked or have received jail sentences for inappropriate PCI and/or billing. We still do not know the correct ‘hit rate’, but the current guidelines for appropriate indications for revascularisation, good history taking, assessment of risk factors, non-invasive and pressure wire FFR assessment for ischaemia seem like a good place to start. PS Douglas and others. J Am Coll Cardiol. 2011;58:801-809.

Atrial Fibrillation Another factor Xa inhibitor, rivaroxaban has shown more positive results in patients with atrial fibrillation (AF). In the ROCKET AF trial patients with AF were randomised to rivaroxaban or warfarin, with non-inferiority demonstrated for the prevention of stroke or systemic embolism. There was a significant reduction in intracranial haemorrhages and fatal bleeding in the rivaroxaban group, though these results were (part of) a secondary endpoint and should be interpreted with caution. Good news and less hassle for patients who do not need INR monitoring with rivaroxaban. The financial cost and subsequent European approval for AF is now awaited. It will also be competing with dabigatran. MR Patel and others. NEJM. 2011. 10.1056/NEJMoa1009638.

AF ablation Attempting to ablate AF in patients with unresolved valvular heart disease is well known to be challenging, but how do patients do with AF ablation post valve replacement? Two series of a total of 130 patients with prosthetic Aortic and Mitral valves, compared with matched non valvular patients produced similar results. Acceptable overall success rates (first procedure about 50%, 80% after mean 1.3 procedures), a high rate of atrial flutter both pre and post ablation and efficacy of linear ablation in preventing arrhythmia recurrence. Trends were observed toward higher complication rates and longer procedure and fluoroscopy times in the valvular group. D Lakkireddy and others. Heart Rhythm. 2011;8:975–980. A Hussein and others. J Am Coll Cardiol. 2011; 58:596-602.


A big concern in AF ablation is stroke risk. Measures are taken to avoid performing the procedure in the context of pre existing thrombus, but generation of embolic material during the procedure cannot be entirely prevented. A comparison of three ablation modalities (irrigated radiofrequency, Cryo and non irrigated phased RF) with MRI brain follow up revealed a much higher incidence of sub clinical cerebral infarcts in the non irrigated group (7.4 vs. 4.3 vs. 37.5%). Two cautions with these data. Firstly, these are not strokes, they are an asymptomatic radiological finding (there were no clinical strokes). Secondly, a proportion of the energy delivered in the non irrigated phased RF group was done so in a fashion not recommended by the manufacturer and known to be associated with increased char and micro bubble formation. C Siklody and others. J Am Coll Cardiol. 2011;58;681-688.

Sudden Death Syndromes We still don’t really know what to do about early repolarisation syndrome yet, so two new contributions are welcome. Japanese atom bomb survivors get regular medicals including 12 lead ECGs. Headline findings are that early repolarisation is common (23% lifetime incidence with a peak first manifestation in the late second and early third decade), has a significant cross over with Brugada syndrome and is associated with a modest overall increase in sudden death rate (HR 1.8 vs. controls, in comparison to Brugada ECGs HR 27.5). Widespread abnormalities (slurring and/or notching) were associated with higher rates of sudden cardiac death. It does seem clear that early repolarisation is at best a spectrum and possibly no more than a hotchpotch of vaguely connected conditions. In an attempt to split out higher and lower risk phenotypes a Finnish group examined various cohorts (Finnish athletes, US athletes and a middle aged group). They conclude that in early repolarisation (notching or slurring of the terminal QRS) where the ST segments are upsloping there is no increased risk of SCD and this represents a normal finding particularly prevalent in athletes. Where early repolarisation is associated with a down sloping ST segment there was some increased risk of SCD (albeit modest, RR 1.43). D Haruta and others. Circulation. 2011;123:2931-2937. J Taikkanen and others. Circulation. 2011;123:2666-2673. Short QT syndrome is the other end of the spectrum; very rare, highly malignant. The European registry includes just 53 patients, follow up on this highly selected group, 89% of whom have personal or family histories of SCD reveals two findings. Firstly, they have a lot of arrhythmias (4.9% per year if untreated). Secondly, Hydroquinidine is effective in reducing the event rate (no events in the 12 patients treated). C Giustetto and others. J Am Coll Cardiol, 2011; 58:587-595

Lead Extraction Lead extraction is often considered a special case among percutaneous procedures with perceptions of high mortality and high rates of surgical intervention. Indeed some have advocated all such procedures being performed in cardiothoracic theatre to facilitate earliest possible surgical intervention. In this series of 1364 leads in 864 consecutive patients the authors studied the differences in outcome between procedures performed in theatre and in the cath lab. The findings were of an overall mortality of 0.2%, with surgical interventions required at some stage in 0.9%. The only two massive haemorrhages due to SVC laceration died despite surgical intervention. Older leads were independently associated with increased complications, 92% of leads were extracted in their entirety. There were no differences in outcomes between

patients extracted in theatre vs. those extracted in the EP lab. One patient underwent unproductive surgical exploration for a transient blood pressure drop, but did fine despite this. F Freceschi and others. Heart Rhythm 2011;8:1001–1005.

Communication Is it good to talk? When we quote figures on risks and benefits to patients, what are we trying to achieve? Do we just want to write something in the notes to cover ourselves or do we really want to help the patient understand? A survey of what patients took in from written and diagrammatic explanations challenges perceived wisdom and existing guidelines. Patients do understand (sort of) low risk expressed as very small percentages (e.g. less than 1%, 0.02%) which we are supposed to avoid but do not understand numerator/denominator comparisons especially where the denominator changes (e.g. risk of stroke 1 in 100, risk of death 2 in 1000). Furthermore, patients understand absolute risk and changes therein much better than relative risk. S Woloshin and others. Ann Intern Med. 2011;155:87-96. How about communication between district hospital interventional cardiologists and surgeons at a remote surgical centre? Apparently a video link system in Sussex significantly increased the number of patients with complex coronary disease having surgical revascularisation rather than PCI. We have mixed views on this. Cardiothoracic surgeons, in the main, will perform coronary artery bypass grafting (CABG) on elective patients, even when high risk, if they have appropriate coronary disease. The problems come with acutely unwell patients, when shock, renal dysfunction or troponin elevation seem to put them off! The SYNTAX study (CABG vs. PCI in high risk coronary artery disease) and ongoing trans-aortic valve implantation (TAVI) programmes have certainly improved relations between cardiothoracic surgeons and interventionists, and this must be a good thing. R.A Veasey and others. Int J Clin Pract. 2011;65:658-663.

TAVI Having mentioned TAVI, it would be remiss of us not to comment on the one year results of the SOURCE registry, which has reported the outcomes of 1038 patients enrolled at 32 centres undergoing implantation of the Edwards SAPIEN aortic valve, either transapically (575 patients) or transfemorally (463 patients). Transapical TAVI is performed in those patients with peripheral vascular disease, whom represent a higher risk group at baseline (logistic EuroSCORE 29% for transapical vs. 25.8% for transfemoral). Total one year survival was 76.1% overall, with 72.1% for transapical and 81.1% for transfemoral. Impressive results, that are only going to improve as the experience and the kit gets better. M Thomas and others. Circulation. 2011 124:425-433.

Coronary Artery Bypass Grafting And whilst we are talking about cardiothoracic surgeons, we should briefly mention this study looking at saphenous venous grafts in patients undergoing CABG (PREVENT IV trial). Essentially, vein graft failure is significantly worse at one year if there are multiple rather than single distal targets (something to do with flow presumably?). This results in a significantly poor clinical outcome at five years (worse composite of death, MI or revascularisation), so is best avoided. R Mehta and others. Circulation. 2011;124:280-288.

AVAILABLE ONLINE

www.cardiologyhd.com Sep/Oct 2011 17


Question asked by Mr Stuart Allen, Principal Cardiac Physiologist, Manchester Heart Centre

Management

Hot Topic With the rise in PPCI, what changes in working patterns will be necessary so as to avoid physiologists working on average 14 to 22 hours in one shift, when they start at 9am and continue on to do on-call that night? Nishat Jahagirdar

Lead Cardiac Physiologist (Invasive) Kings College Hospital London United Kingdom

Dr Chris Eggett

Cardiac Physiologist Deputy Service Manager Freeman Hospital Newcastle upon Tyne

A

ccording to the Department of Health primary PCI is available to 90% of the English population so this topic has relevance to many departments and I’m sure there’s a multitude of different approaches being taken to deal with the particular issues it raises on a local basis. That’s exactly how it should be, there’s no single prescriptive solution and individual services must work within the legislative framework, using the tools available to them in terms of local policy regarding flexible working to achieve the best possible outcome for their patients. For many the notion that work as a cardiac physiologist is a Monday to Friday, nine ‘til five lifestyle is long gone. On call work will, of course, be second nature to cardiac physiologists working in numerous centres and over recent years extended working weeks incorporating weekends and longer working days have become the norm in response to achieving diagnostic waiting time targets. Consequently, further tweaking of working patterns after appropriate consultation should not prove too troublesome to implement. A move to shift-work is one potential approach to meet the demands of a primary PCI service although there is the question of what roles a cardiac physiologist might undertake between primary PCI cases. Perhaps a forthcoming publication from the British Cardiovascular Society regarding the future of Cardiac Care may offer some guidance? The recommendations are likely to suggest that a full range of cardiac diagnostic procedures are accessible on a 24 / 7 basis. Some Trusts may choose to interpret their meeting of this proposal by having on-call junior medical staff available but who would you prefer to perform your investigations? A trainee doctor or a qualified, competent and experienced cardiac physiologist?

18 Sep/Oct 2011 www.cardiologyhd.com

A

work week consisting of four working days from 8am-6pm, with the day off preceded by an on call night is the best working pattern for physiologists on call as: •

The on call person is guaranteed to have rest the next day.

Clinical work and lab over run can be covered between 8-9am and 5-6pm by the staff working the long shift that week.

If a member of the team isn’t on call, then they can work a normal (9am-5pm) shift pattern that week. Hence, only an extra member of staff is required to cover the unavailability of the on call person the next day.

The on call person works from (10am-8pm/11am-9pm), with two 30 minutes breaks for lunch and pre on call at 5:30pm, reducing the number of hours worked continuously.

With the normal (9am-5pm) shift pattern, if the number of on call hour’s increases, the physiologists are less likely to work the next day, as per European Working Time Directive. The suggested working pattern reduces the need to change the work rota for the day at the last minute, due to unavailability of the on call staff.

It eliminates the system of giving back time/not getting paid, for any hours accumulated due to staff taking rest the next day (11 hours post on call).

As of now, the physiologists cannot work the day/night 12 hours shift, as there is no other work that can be done during a night shift other than PPCI’s!

AVAILABLE ONLINE Have your say to this Hot Topic on our website today along with other topics from previous editions.


Heart Rhythm Congress

Heart Rhythm Congress

2nd - 5th October 2011

www.heartrhythmcongress.com Tel: +44 (0) 1789 451822 Email: info@heartrhythmcongress.org.uk Promoting better understanding, diagnosis, treatment and quality of life for individuals with cardiac arrhythmias HRC PO Box 3697 Stratford upon Avon Warwickshire CV37 8YL UK Telephone: +44 (0) 1789 450 787

Supported by HR-UK

Arrhythmia Alliance

The Heart Rhythm Charity

Heart Rhythm UK


United Kingdom

Site Visit Blackpool Teaching Hospitals NHS Trust: Lancashire Cardiac Centre Whinney Heys Road, Blackpool Lancashire United Kingdom

What are the sizes of your Cardiology Department and Hospital? The £52million Lancashire Cardiac Centre forms part of the Blackpool Teaching Hospitals NHS Foundation Trust, which comprises around 830 beds across several hospitals, the largest of which being Blackpool Victoria Hospital where the cardiac centre is located. The Trust serves a population of approximately 330,000 residents of Blackpool, Fylde and Wyre and the 12 million holidaymakers who visit the area every year. We are also one of four tertiary cardiac centres in the North West, providing specialist cardiac services to heart patients from Lancashire and South Cumbria. The centre was opened in 2006. How many staff? Roles? • • • •

10 cardiology consultants. 14 Cardiac Physiologists 9 Radiographers 10 Nurses

Types of procedures? • • • • • •

Diagnostic and interventional (PCI’s) + regionwide PPCI service Electrophysiology Full range of cardiac physiology services including Echo Internal Cardioversions Pacemakers & ICD’s TAVI

Types of equipment used?

The Lancashire Cardiac Centre provides a variety of cardiovascular treatment options for the people of Lancashire, Cumbria and surrounding counties. The centre comprises the latest facilities, including four state-of-the-art cardiac catheter labs, which perform a variety of investigations and treatments. These include angiograms, angioplasties (stents), internal cardioversions, pacemakers, biventricular pacemakers, ICD’s and electrophysiology studies. Recently the centre opted to embrace McKesson’s fully integrated haemodynamic system, featuring built-in fractional flow reserve (FFR) software, to address the growing frequency of its use within the cath lab environment. The team have also commenced using the Volcano PrimeWire Prestige, which integrates seamlessly with the McKesson system. The PrimeWire Prestige was chosen due to specially designed features including a heavier core and improved tip, which aid the operator to cross challenging lesions.

20 Sep/Oct 2011 www.cardiologyhd.com

• • • • • • • •

IVUS Boston and Volcano Integrated FFR Volcano SJM FFR St Jude’s LightLab OCT Rotablation. Philips and Siemens Cath Labs. McKesson Cardiovascular Information solution GE Vivid 7 Echo

How many procedures are performed per year? • • • •

PCI = 1600 (target of >2000 PCI’s for 2011-2012) Diagnostic procedures = 2000 Tavi = 36 EP procedures = 240

What is the approximate percentage of cath lab cases performed radially compared with femorally? 65-70%


One Platform

s5i

Multiple Solutions IMAGING

PHYSIOLOGY

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FFR Case Manager™

VIBE® RX Vascular Imaging Balloon Catheter

Grayscale IVUS VH® IVUS Imaging

ChromaFlo® Imaging

Rotational IVUS Imaging

One Company www.volcanocorp.com


SITE VISIT

From Management and Cardiologist point of view, what are your thoughts on FFR technology, and why did you choose a completely integrated solution?

The Volcano SmartMap for FFR Does your department offer a Primary Angioplasty Service? If yes, what have been some of the challenges setting it up? Yes, we started our PPCI service in 2007. 24/7 PPCI has been running for 2yrs. As with virtually all Trusts that implement this service there are several teething problems to overcome, primarily those related to staffing. Whilst this has not affected our ability to provide a complete service, difficulties occasionally arise when the on-call team are called in overnight and are required to have the following day off. It is a fine balance of not being over staffed during the day and being able to provide a complete PPCI service. This is an issue not just for the professionals who work in our department but also the cardiologists.

FFR is a fantastic tool for the Cardiac Interventionalist and now we have integration to improve safety and efficiency in the lab. Only today we had an example of a possible surgical case being changed into a single stent procedure as a result of the technology. (Dr Gavin Galasko, Consultant Cardiologist)

Cardiac Physiologists standpoint is that the new method is very quick and user friendly. The new method streamlines patient procedure and data collection, especially as in the near future Blackpool Victoria Hospital is moving towards electronic patient records. (Gill Burnett, Cardiac Physiologist Cath Lab Manager)

What new procedures / techniques have you implemented into the department recently? Recent = OCT, EP expansion (more comprehensive). Future = CT coronary angio, hybrid lab, radial lounge How does the lab handle haemostasis? Radial = TR and Helix. Femoral = Angioseal, and Exoseal

What are the benefits to patients attending your facility? We offer a modern, brand new, comprehensive tertiary service within a dedicated facility, custom built to provide patients with the highest levels of care. To respect patient’s privacy, religious and personal beliefs, patients stay in same sex bays while on the ward and sometimes single rooms depending on circumstances. The Cath Lab Team

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SITE VISIT What measures has the department implemented to cut costs? •

One of the major ways to reduce costs and improve efficiency is to decrease the length of stay for patients. We are in the process of implementing a dedicated radial lounge where patients can relax in comfort whilst waiting for their procedure instead of taking up beds. We are also working on ways to streamline product usage to reduce wastage.

How do you deal with late finishing of cases? For example staggered working hours or just staff overtime? One lab late after 7pm everyday. Cases finish ACS treatment within 72 hours. 1 dedicated PPCI lab.

What is your policy for company reps within the labs? Are reps allowed to bring food for sharing amongst doctors and staff into the department when they visit? Yes, company reps are welcome in our department for educational as well as for new product awareness and on-going support. They are allowed to bring food into the department, however they must make prior arrangements with the senior nurse on duty to ensure there is no overlap with other companies. What is the best part of working at your facility? It is a modern, well-equipped facility located in one of the UK’s favourite holiday regions. We have a wonderful team working on cutting edge procedures, which all combined produces a fresh environment, and great staff atmosphere.

AVAILABLE ONLINE

Claire Overstall (Cardiac Physiologist) reviewing an FFR case

www.cardiologyhd.com Sep/Oct 2011 23


United Kingdom

Site Visit The Royal Berkshire NHS Foundation Trust Jim Shahi Unit (Cardiac Catheterisation Laboratory) pm. In 2009 we introduced the Primary PCI service 24/7. This has been implemented very successfully with a median call to balloon time (CTB) of 77 minutes and door to balloon time (DTB) of 28 minutes in the first 12 months. South Central ambulance service provides an excellent response to emergency calls for patients with chest pain. The PPCI team members all live locally and are able to be at the Cath Lab within 20 minutes. This enables patients to receive early reperfusion and optimal treatment and outcomes. The ward base consists of an 18 bedded CCU Department with 1 Chest Pain assessment bed and a 28 bedded Cardiology Ward including 6 Telemetry beds. The Cardiology Department provides a full range of Cardiac Investigations along with outpatient’s clinics, Rapid Access Chest Pain Clinic and Heart Failure Clinics. A full range of Cardiac Rehabilitation is offered as an inpatient and outpatient service. What are the sizes of your Cardiology Department and Hospital? • • •

Jim Shahi Unit – 16 beds CCU 18 beds + 1 Chest pain assessment bed Whitley Ward – 28 beds

What is the geographical intake area and population served by your hospital? • •

Half a million catchment PPCI catchment is up to 750,000

How many staff? Roles? The Royal Berkshire NHS Foundation Trust London Road, Reading Berkshire, United Kingdom The Royal Berkshire NHS Foundation Trust is situated in the centre of Reading covering western and central portions of Berkshire. It is one of the largest general hospital trusts in the country, which has recently undergone £132 Million redevelopment. The hospital provides 813 inpatient beds together with 204 day beds, in doing so it employs 4000 staff. The specialty of Cardiology provides a combination of inpatient work, a large outpatient service and a full range of Cardiac Investigations. The Cardiac Catheterisation Laboratory is named after the late Dr. Jim Shahi, a Consultant Cardiologist who helped set up the unit in 1994. We have 2 Catheterisation Laboratories which offers an extensive range of elective and emergency procedures. Alongside the labs we have a 16 bedded day bed unit which opens from 8:00 am to 6:00

24 Sep/Oct 2011 www.cardiologyhd.com

• • • • • • • • • • • • • • • • • • •

5 Consultant Interventionalist Cardiologists 1 Consultant Electrophysiologist (visiting) 1 Consultant Cardiac Surgeon (visiting) 1 Consultant Cardiac Imaging (CT/MRI) 2 Associate Specialist 3 SpRs 3 ST grades 2 FY grade juniors JSU = 8.2 Nurses WTE 3.6 Radiographers WTE 24 Cardiac Physiologists (10 Rotates in the Lab) 2 Waiting List Officers 5 Secretaries 5 Admin Staff 3 Volunteers CCU = 33.5 Nurses WTE Whitley Ward = 34.74 Nurses WTE Heart Failure Nurses- 2.66 Cardiac Rehab Nurses - 3


Types of procedures? Jim Shahi Unit : • Angiograms (Inpatients and Outpatients) • PCI • Permanent Pacemakers • PPM Box Changes • Reveals • Cardioversions • ICD’s and CRT’s • EP’s • Pressure Wire Study • IVUS • Rotablation Cardiac Outpatients: • Echo • Stress Echo • TOE • Stress Test • Holter Monitoring • Tilt Testing • 12 Lead ECG’s • Pacemaker Checks • Cardiac MRI • Cardiac CT

From Left: Erick Omana, Bonita Chizambire, Jan Marshall, Javon Lorde, Melanie Bailey, Charlie McKenna, Rowena Soar, Alisa Greener, Amande Searle, Debbie Daniel-Best, Chris Mwenda, Paul Gentle, Chris Hayes, Bhavesh Sachdev

Types of equipment used? • • • • •

Siemens Axiom Artis Dfc & Dtc Boston Scientific Rotablation Machine Boston Scientific iLab IVUS Machine St. Jude Pressure Wire Phillips Echo Machines

How many procedures are performed a year? April 2010- April 2011: Angio’s: 1400 PCI: 618 Elective PCI: 232 Primary PCI: 202 Permanent Pacemakers: 300 EP: 60 Cardioversions: 166 ICD: 20 Bi vents: 10 CRT: 10 Does your department offer a Primary Angioplasty Service? If yes, what have been some of the challenges setting it up? YES 24/7 since April 2009 Challenges: 1.

Having sufficient staff to cover the service e.g. extra Radiographers recruited and trained up to on call standard.

2.

Providing training to CCU staff to call PPCI team members, to prepare the Cath Lab for the incoming PCI and to act as runners during the case.

What are the benefits to patients attending your facility? • The best Door to Balloon Time in the Country. See link below: http://www.bbc.co.uk/news/uk-england-berkshire-11441743 • We offer a complete cardiac service and have very low waiting times How is your inventory managed? Pen and paper

What measures has the department implemented to cut costs? • •

We use fewer Angioseals these days to cut cost Regular Tendering especially high cost consumables

What kinds of continuing education programs are available to staff? • • • •

Critical Care Course Mentorship Course IVUS and Rotablation Study Days Leadership/management courses

Reducing radiation dose is a high priority in the cath labs. What techniques are employed by your radiographers to ensure dosage during cases is kept to a minimum? Also what is the maximum dose limit a patient can receive in your labs before it is recorded in their notes, and what is the follow-up process? • • •

Reduced Pulse Rate ( 4pps or 6 pps) dependant on Consultants Appropriate collimation If dose is 10,000 mcGy m2 or above the radiographer informs the operator who will advise the patient of possible erythema.

What is the best part of working at your facility? • • • • • •

friendly atmosphere good working team positive feedback from patients, patient relative, student nurses and other members of staff Good and sustained publicity staff retention efficient service

AVAILABLE ONLINE Royal Berkshire Hospital: More photos and questions online

www.cardiologyhd.com Sep/Oct 2011 25


United Kingdom

Events 1

October 2-5 HRC 2011 Hilton Birmingham Metropole Birmingham, England www.heartrhythmcongress.com October 7-8

2 5

British Society of Echocardiography Annual Meeting Edinburgh International Conference Centre Edinburgh, Scotland www.bsecho.org October 14-15

2

3

Cardiac Risk in the Young (CRY) International Conference The Cavendish Conference Centre London, England www.c-r-y.org.uk October 16-18

4

PCR London Valves 2011 London England www.pcrlondonvalves.com November 24

5

1

4

3

SHARP Annual Scientific Meeting “Cardiovascular Disease, Every Day Management” Dunkeld, Scotland Contact: Miss Victoria Kirkwood, Email: SHARP@dundee.ac.uk or Tel 01382 60111 ext 33124 December 2

6

6

7

CCO National Conference Cardiovascular Update 2011 - Strategies for diagnosis & Treatment London, England Email: cardiac@talktalk.net or cco@onetel.com December 14

MORE ONLINE To have your event listed see page 4 for contact details.

26 Sep/Oct 2011 www.cardiologyhd.com

7

BCS - A Year in Cardiology Royal College of Physicians London, England www.bcs.com/education


VALVES FOR THE HEART TEAM Course Directors Martyn Thomas Simon Redwood Patrick W. Serruys Olaf Wendler Alec Vahanian Mark Monaghan Jean Fajadet Carlos Ruiz Philipp Bonhoeffer John Webb Olaf Franzen A. Pieter Kappetein Carlo Di Mario Stephan Windecker Programme Committee Members Vinayak Bapat Jonathan Byrne Ranjit Deshpande Jane Hancock Philip MacCarthy Christopher Young Chairman of PCR Jean Marco

SEE YOU IN LONDON th th 16 -18 October 2011 Sessions Adjuvant therapies in TAVI

To understand the indication and technique for aortic balloon valvuloplasty, coronary revascularisation and LV support before and during TAVI. Improving the results of TAVI

To understand how we can improve patient selection and the results of TAVI. Is the percutaneous mitral valve ready for prime time?

To understand the current clinical indications for transcatheter mitral valve intervention. What remains difficult about TAVI

To understand what remains difficult clinical situations in TAVI and how to deal with them.

The data

To understand the current clinical outcomes of TAVI.

Live demonstrations LTT

Come and see these interactive sessions: g On 17th October, you will enjoy an interactive and practical LTT on "How to perform a TAVI" including imaging, access (femoral, subclavian, transapical, transaortic), deployment and valve in valve.

g On 18th October, expect to see the same format on "Percutaneous mitral valve regurgitation repair". Complications

Join the popular Complication sessions, based on a call for submission. Interactive Case Corner

A new place of communication, free from time constraints and defined programme, where participants will be invited to share their experience & point of view on the case they submitted, in a welcoming and reassuring environment.

g St Thomas' Hospital, London, UK g Bern University Hospital, Bern, Switzerland g Clinique Pasteur, Toulouse, France

Registration is open! Come as a Heart team. Whether you're an interventional cardiologist, an anaesthetist, a radiologist or a nurse, you'll go back to the cathlab with with the tools you need to advance your daily practice. Connect to www.pcrlondonvalves.com to register today

Visit www.pcrlondonvalves.com

www.cardiologyhd.com Sep/Oct 2011 27


experience the future of CVIS

Learn what more than 75 institutions in the UK already know. McKesson sets the industry standard in helping clinicians make quicker, better and safer decisions. By seamlessly connecting hospitals through automated workflow, our cutting-edge cardiovascular information solution, Horizon Cardiology, enables you to increase efficiency and place the patient at the centre of care. Horizon Cardiology provides a single database for haemodynamic monitoring, cardiac and peripheral

Scan here with your code reader on your smartphone.

catheterisation, echocardiography, vascular ultrasound, CT, MRI, NM and ECG management, streamlining the report process and allowing you to focus on what you do best â&#x20AC;&#x201C; deliver better health.

To learn more, visit AllAboutCVIS.com/CardioHD. Š 2011 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Horizon Cardiology is a trademark of McKesson Corporation and/or one of its subsidiaries.

McKesson Provider Technologies Block 3 The Exchange Brent Cross Gardens London NW4 3RJ United Kingdom Phone: 01926 478728

CardiologyHD #32  

CardiologyHD - Coronary Heart magazine Edition 32

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