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

Issue 37 • Jul/Aug 2012

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Featuring - Product News - Sports Hot Topic - Australia Site Visit

- ECG Challenge - Journal Reviews - Events Calendar

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CONTENTS

03 PRODUCT NEWS Round-Up

12 SITE VISIT Nambour Hospital

Get the latest news from companies related to their new products.

Nambour Hospital Cath Lab on the Sunshine Coast in Queensland, Australia.

05 CHARLIE BLOE’S ECG Challenge

15 INTERVIEW Prof Richard Schilling

Another challenging ECG Challenge to test your skills. Answer on page 17.

Dennis Sandeman interviews this leading consultant cardiologist from London.

06 COMPANIES CORNER Edwards TAVI Valves

16 JOURNALS Global Update

Improving health-related quality of life in high risk patients with aortic stenosis.

Our popular and entertaining journal trawl from around the world.

08 HOT TOPIC Heart Screening in Sport

18 EVENTS What’s On

We ask three cardiologists about their response to the increase in requests.

A quick overview of cardiology events happening around the world.

Above & Cover Photo: Nambour Hospital Staff. Photos by Adam Westerlink

EDITORIAL BOARD Mr Tim Larner Director & Chief Editor

Dr Magdi El-Omar Lead Consulting Editor

Dr Richard Edwards Consulting Editor

Consultant Cardiologist, Manchester Heart Centre

Consultant Cardiologist, Freeman Hospital

Prof Ahmed Magdy Consulting Editor (Middle East)

Dr John Paisey Journal Reviewer

Dr Dan McKenzie Journal Reviewer

Consultant Cardiologist, Royal Bournemouth Hospital

Consultant Cardiologist, Musgrove Park Hospital

Head Unit Cardiology, National Heart Institute, Cairo

+ more editors online

Copyright © 2006 - 2012 by Coronary Heart Publishing Ltd.

Prof Simon Redwood Consulting Editor

Dr Rodney Foale Consulting Editor

Consultant Cardiologist, Guy’s & St Thomas’ Hospital

Consultant Cardiologist, Imperial College Healthcare NHS Trust

Mr Dennis Sandeman Nursing Consulting Editor

Ms Sophie Blackman Management & CRM Consulting Editor

Chest Pain Nurse Specialist, NHS Fife

Head of Clinical Cardiac Physiology, West Hertfordshire NHS Trust

2 Jul/Aug 2012 www.cardiologyhd.com

All rights reserved. Material may only be reproduced by prior arrangement and with due acknowledgment of Coronary Heart Publishing Ltd. The publication of an advertisement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

Disclaimer: This publication should never be regarded as an authoritative peer reviewed medical journal. This publication has been designed as a guide only, to inform readers who work in the cardiology environment about latest news stories and the different techniques used by others around the world. Whilst all care is taken in reviewing articles obtained from various companies and contributors, it is not possible to confirm the accuracy of all statements. Therefore it is the reader’s responsibility that any advice provided in this publication should be carefully checked themselves, by either contacting the companies involved or speaking to those with skills in the specific area. Readers should always re-check claims made in this publication before employing them in their own work environment. Opinions expressed by contributors are their own and not necessarily those of their institution, Coronary Heart Publishing Ltd or the editorial staff.


PRODUCT NEWS [ Round-Up ]

Axxess™ Self-Expanding Bifurcation DES Shown to be Safe and Effective up to Four Years New data from the DIVERGE study, presented at EuroPCR 2012, showed that the use of the Axxess™ drug-eluting stent for the treatment of complex coronary bifurcation lesions resulted in low levels of both MACE and VLST over a four-year period. Axxess™ is a self-expanding bifurcation stent which releases Biolimus A9™ from an abluminal biodegradable polymer coating. “These long-term results from DIVERGE are important because of the frequent presentation of bifurcation lesions in our daily clinical practice,” commented Principal Investigator Dr. Stefan Verheye, Antwerp Cardiovascular Institute, ZNA Middelheim Hospital, Belgium. “These types of lesions are associated with higher complication and restenosis rates compared to conventional lesions. The four-year results confirm the earlier results already presented, and strengthen the evidence that the Axxess stent is a safe and effective alternative for patients with certain bifurcation lesions.”

TAVI Celebrates 10th Anniversary Edwards Lifesciences recently celebrated 10 years since the first Transcatheter Aortic Valve Implantation (TAVI) performed by Professor Alain Cribier (above) at the University Hospital of Rouen in France in 2002. More than 500 guests from around the world, including our very own Chief Editor Tim Larner, converged on Rouen to be part of the celebrations, featuring fascinating presentations on the development process and the vast number of challenges faced in order to get the TAVI valve to become a viable medical device. Since that first implantation ten years ago, more than 50,000 patients from around the world, in 500 centres have received a TAVI valve from Edwards.

Edwards Receives CE Mark for Ascendra+ System for Transapical and Transaortic Delivery of Sapien XT Valve Edwards Lifesciences Corporation recently announced that it had received the CE Mark in Europe for the Ascendra+ System for the delivery of the Edwards SAPIEN XT Transcatheter Heart Valve. It is the first delivery system optimized for both transapical and transaortic implantation of a transcatheter heart valve. The CE Mark includes a new transaortic indication for delivery of the valve through a small incision in the upper part of the chest (mini-sternotomy) or via a small incision between the ribs (mini-thoracotomy), after which the valve is then implanted through a small incision in the aorta. “Edwards’ enhanced delivery system, with new features that aid in optimizing valve positioning during transapical and now transaortic implantation, provides Heart Teams in Europe with an even broader array of options to ensure patients are treated with the technique best suited to their anatomical needs,” said Vinayak (Vinnie) Bapat, MBBS, MS, FRCS(CTh), consultant cardiothoracic surgeon at Guys and St. Thomas’ Hospital in London, UK. “This is a meaningful development for clinicians and the patients in their care who suffer with severe, symptomatic aortic stenosis.”

Above: Edwards 29mm Valve

www.cardiologyhd.com

Jul/Aug 2012 3


Philips’ new AlluraClarity family offers outstanding image quality at a fraction of the dose Philips Healthcare’s new AlluraClarity family of next generation interventional X-ray systems comes with Philips’ unique ClarityIQ technology that dramatically reduces X-ray dose (typically by 73 percent in neuro, 50 percent in cardiac and 83 percent in vascular interventional procedures), while delivering equivalent or better image quality. ClarityIQ pushes the boundaries of the ALARA (As Low as Reasonably Achievable) principle, so that patient and staff risks from radiation exposure are radically reduced, and longer and more complex procedures can now be performed more safely. It incorporates powerful state-of-the-art image processing technology, developed by Philips Research, all working in real-time, enabled by the latest computing technology.

Above: Philips AlluraClarity

Philips Healthcare in the UK has already secured a commitment for the new equipment, with The Royal Victoria Hospital, Belfast being the first institution in the UK to place an order for the AlluraClarity. For more information visit www.philips-events.co.uk/alluraclarity

Papworth invests in SonoSite’s M-Turbo® for cardiac anaesthesia and intensive care Papworth Hospital, Cambridgeshire, the UK’s largest specialist cardiothoracic hospital and main heart and lung transplant centre, has invested in SonoSite’s M-Turbo® point-of-care ultrasound system for its cardiac intensive care unit (ICU). Dr Kamen Valchanov, consultant anaesthetist, explained: “We mainly use the M-Turbo in ICU for diagnosis of cardiac and thoracic pathology, and for performing ultrasound­guided procedures. The system is mostly used for venous access procedures, but we are increasingly using it for nerve blocks in the operating theatres and the pain clinic.” “The portability of the M­Turbo is good, and the image quality is much better than our previous instrument, which was only good enough to allow us to perform vascular access procedures. The M­Turbo has much better resolution, allowing us to do much more, and is very intuitive, requiring minimal training. We also have an excellent relationship with the team at SonoSite, who provide us with good support.” For more information about SonoSite products, please contact: SonoSite UK, T +44 (0)1462 444 800, ukresponse@sonosite.com, www.sonosite.com

Above: Kamen Valchanov and Hannah Pettigrew with the SonoSite M-Turbo

Ambu has acquired Unomedical’s electrode and diathermy business resting, stress and neonatal ranges for both monitoring and diagnostic electrodes. 40 years of experience with electrodes Ambu has 40 years of experience in the electrode business, which began with the development of Blue Sensor electrodes in 1972. Today, Ambu is one of the world leaders within electrodes and Blue Sensor ECG electrodes are well recognised as the electrode of choice for diagnostic purposes. In addition, Ambu is well-known for EEG and EMG electrodes.

From 1st June 2012, Unilect, Neutralect, and Biotab electrodes will be available alongside Ambu Blue Sensor and Ambu Neuroline ranges. Ambu are pleased to announce that they now offer the widest range of electrodes available from one supplier. Ambu are now able to offer ECG electrodes for short-term and long-term monitoring along with

4 Jul/Aug 2012 www.cardiologyhd.com

Unomedical has produced electrodes for over 20 years. Unilect and Biotab ECG electrodes are well-known within the high volume market in general monitoring and 12 lead/resting ECG. Merging both ECG assortments Ambu is now able to fulfil all of their customers’ electrode requirements. Please contact Ambu Tel: +44 1480 498403 or email uksales@ambu.com for further information.


CHARLIE BLOE’S [ ECG Challenge ]

History This 42 year old man presented to his GP complaining of intermittent chest pain. He has been experiencing similar chest pain on and off for 2 years. The pain is localised in the centre, lower third of his chest. It comes on typically at rest and most commonly an hour or so after eating. He becomes aware of it building up in intensity over several minutes. It peaks at about 7 out of 10. The pain resolves spontaneously after 10 minutes and he’d experience a number of episodes over several hours before it resolves. These episodes occur on average every 4-6 weeks.

He has a past medical history of anxiety and hypertension. He smokes 40 cigarettes a day.

His BP was 164/92 mmHg when seen by the GP. Other vitals were normal.

This ECG was recorded while he was pain free. The interpretative ECG suggested ‘abnormal ECG’.

[ More Information ] ECG Challenges We have multiple ECG Challenges on our website for you to challenge yourself, along with a variety of educational topics related to cardiology. If you have an interesting ECG that you think would work well as a challenge, send it through to us. Visit our website: www.cardiologyhd.com Our main contact details can be found on page 18.

What is your conclusion? See the answer on page 17

www.cardiologyhd.com

Jul/Aug 2012 5


COMPANIES CORNER [ Edwards Lifesciences ]

Improving Health-Related Quality of Life in High Risk Patients with Aortic Stenosis

T

en years since the first procedure, transcatheter aortic valve implantation (TAVI) has become an important treatment option for elderly patients with aortic stenosis (AS). Now a proven technique, TAVI not only improves survival, but also provides a range of quality of life benefits for those considered unsuitable for conventional aortic valve replacement surgery. AS causes the hardening and narrowing of the aortic valve, and is already the most common form of valvular heart disease in England. An ageing population could leave more than 150,000 people affected by 2020. Symptoms can be debilitating. Patients may experience shortness of breath, chest pain, fainting or extreme fatigue. No medication slows its progression. Untreated, the prognosis is poor, with an average survival rate of just 2.3 years. While surgical valve replacement remains the “gold-standard” treatment, a large number of patients with severe AS still go untreated. Elderly patients are often deemed too high-risk; others do not want to undergo major heart surgery. This is changing thanks to TAVI, which is now performed routinely at certified heart centres across Europe and the United States. Globally, over 50,000 patients have undergone the procedure. Minimally invasive With TAVI, a catheter is used to carefully introduce a collapsible valve into the femoral artery and then up into the aortic valve, before it is secured by balloon inflation. Further options include introducing the valve via a catheter into a small incision in the chest (transapical access), or via a mini-sternotomy or mini-thoracotomy (transaortic).

One year PARTNER Cohort B results, published in The New England Journal of Medicine, found that compared with medical therapy, patients who were too ill or old for surgery had a 20 percent improvement in survival after one year with TAVI. The authors concluded that balloon expandable TAVI using the Edwards SAPIEN valve, “should be the new standard of care for patients with aortic stenosis who are not suitable candidates for surgery”. At two years, TAVI remained superior to standard therapy. TAVI patients also spent significantly less time spent in hospital, with median days alive outside hospital of 699 days, and 355 for standard therapy – a difference of nearly one year. In Cohort A, 699 patients with the same condition received either the Edwards SAPIEN valve or traditional open-heart surgery. Data demonstrated that survival of patients treated with the SAPIEN valve was equivalent to those treated with surgical aortic valve replacement. At two years, all cause mortality for TAVI patients was statistically equivalent to surgical replacement. Ten years younger Cohort B analysis in November 2010 revealed that TAVI patients experienced cardiovascular and physical-health benefits that the authors suggested were roughly comparable to a ten-year reduction in age. Further data comparing TAVI with standard care, demonstrated that TAVI patients achieved higher physical and mental health scores. In November 2011, data also demonstrated that transfemoral TAVI patients felt better at one month and had comparable results to one year to surgical aortic valve replacement. Transapical and surgical groups showed comparable results at one year. Now… and the future

The valve replaces the patient’s existing valve without the need for conventional openheart surgery. It takes place under local or general anaesthetic while the heart continues to beat. Not everyone may be suitable, and treatment options are considered by heart teams comprising cardiologists, cardiac surgeons, anaesthetists, intensive-care staff, vascular specialists and care-of-the-elderly physicians. Improvement in survival The Edwards SAPIEN valve was used in the landmark PARTNER Trial, the world’s first randomised, controlled trial of a transcatheter aortic heart valve.

Above: Edwards SAPIEN XT transcatheter heart valve, transfemoral access

The trial involved two patient groups. In the first (Cohort B), 358 patients with severe, symptomatic AS, deemed inoperable for traditional open-heart surgery were evenly randomised to receive either the Edwards SAPIEN valve or standard medical therapy.

6 Jul/Aug 2012 www.cardiologyhd.com

TAVI has developed rapidly over the last ten years. A commitment to research and development has helped create innovative new valves, delivery systems, approaches and techniques. The next-generation Edwards SAPIEN XT transcatheter valve is currently used widely across Europe, and received CE Mark approval in March 2010. It is produced in three sizes, 23mm, 26mm, and a recently approved larger 29mm valve, allowing heart teams to treat a broader population. Innovations to delivery systems and two new valve platforms – currently beginning clinical research – also indicate a promising future for patients. In the United States, the Edwards SAPIEN valve became the first transcatheter device approved for aortic heart valve replacement following FDA approval in November 2011. References: 1.

Leon M, Smith C et al. Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery. N Engl J Med (2010).

2.

Makkar R.R., Fontana G.P., Jilaihawi H., et al. Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis. N Engl J Med 2012; 366:1696-1704.

3.

Leon M, Smith C et al. Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients. N Engl J Med 2011;364:2187-98.

4.

Kodali SK et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012 May 3; 366:1686.

5.

Reynolds MR, Magnuson EA et al. Health-Related Quality of Life After Transcatheter Aortic Valve Replacement in Inoperable Patients With Severe Aortic Stenosis. Circulation. 2011;124:1964 –197.


A new option for your aortic stenosis patients who cannot undergo surgery

Edwards transcatheter heart valves: The life-changing innovation that improves quality of life Thousands of patients in Europe have received Edwards transcatheter heart valves as an effective therapy. Cohort B of the PARTNER Study demonstrated a large survival benefit1 and an improvement in physical health equivalent to reversing by 10 years2 the normal decline.2 For more information and to find a TAVI center near you, please visit edwards.com/eu/products/transcathethervalves. References: 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. 2. Reynolds MR et al; PARTNER Trial Investigators. Health-Related Quality of Life After Transcatheter Aortic Valve Replacement in Inoperable Patients With Severe Aortic Stenosis. Circulation. 2011;124(18):1964-1972. For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events. Edwards Lifesciences devices placed on the European market meeting the essential requirements referred to in Article 3 of the Medical Device Directive 93/42/ECC bear the CE marking of conformity. Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN, PARTNER, and SAPIEN are trademarks of Edwards Lifesciences Corporation. Š 2012 Edwards Lifesciences Corporation. All rights reserved. E2409/11-11/THV

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

I Tokyo, Japan I Singapore, Singapore I SĂŁo Paulo, Brazil


HOT TOPIC

[ Heart Screening in Sport ] Following Fabrice Muamba’s cardiac arrest during an FA Cup tie in March of this year, there has been “a surge” in requests for heart screenings from young people: In your opinion... Dr Duncan Dymond Consultant Cardiologist Barts and The London NHS Trust London United Kingdom

Should all professional sports people be screened for heart disease, and if so, how often? In an ideal world the answer is yes, although I suppose it depends on your definition of a professional sportsman. We are talking about screening young apparently super-fit people for the sort of rare diseases that cause sudden death during extreme levels of physical exercise. So a darts champion might not qualify, although many of them look high risk of coronary disease! There is much debate on how athletes should be screened, but most of us agree that a detailed history and full physical examination, plus a 12 lead ECG is the minimum. We ask if there is any family history of sudden unexplained death in a young family member, although we must recognise that high earning athletes might not admit to anything that could jeopardise their income. Experts disagree on whether screening should always include an echocardiogram, and cost is cited as an argument against the routine use of echo’s. It is true that a completely normal 12 lead ECG makes a diagnosis if Hypertrophic Cardiomyopathy (HCM) unlikely, but then again, I have picked up various degrees of mitral valve prolapse and bicuspid aortic valves in professional athletes. These might not be important now but could be in later life. Many of our best athletes are of Afro-Caribbean origin and the resting ECG may be difficult to interpret because of racial differences in ST segments and T waves compared to their white counterparts. Also, many athletes have physiological left ventricular hypertrophy which produces ECG changes and some conduction abnormalities. Echocardiography can reassure that all is well, and my own view is that an echo is so easy to do, quick, carries no risk, and provides such clear information that wherever possible it should be done.

8 Jul/Aug 2012 www.cardiologyhd.com

In the wake of Fabrice Muamba’s illness much has been said about the need for all athletes to undergo cardiac MRI scans, but quite honestly there is no real evidence yet that it would make a difference. Of course MRI is much less widely available, expensive and time consuming so it is not practicable. How often to screen an athlete is a moot point. The real worry is that HCM can become expressed during the twenties or even early thirties, so a normal echo at one point in time may not be enough. A test every two years is recommended by many experts, and is currently what many professional football clubs do. What do you say to those young people out there who play competitive, but non-professional sport, who might be worried about a similar fate as that of Fabrice’s? First of all let’s remember that what happened to Fabrice is incredibly rare but of course in the modern world information about catastrophes during sports is spread globally within hours. Its hard not to worry, but statistically you are more likely to come to grief crossing the road than during sport. My daughter is about to run a half marathon, and as a concerned father I am arranging for her to have an ECG and an echo beforehand!! That is the real world answer!!


Dr Simon Modi Consultant Cardiologist & Electrophysiologist Liverpool Heart and Chest Hospital Liverpool United Kingdom

Should all professional sports people be screened for heart disease, and if so, how often? High level competitive sports undoubtedly increase a person’s risk for sudden cardiac arrest (SCA). This is not to say that sport causes heart disease but that adrenaline surges unmask latent conditions such as ischaemic heart disease in the ‘older sports person’ and hypertrophic cardiomyopathy, right ventricular cardiomyopathy and long QT syndrome in the young. Although screening for SCA comes under debate regularly, I personally believe that provisions should be made to screen professional sports people, probably on a 1-2 yearly basis. The principle reasons for not rolling out screening are cost (lots of tests to find one abnormal), risk of false positives (many athletes have ‘abnormal’ ecgs and echocardiograms when compared to the normal population and distinguishing ‘abnormal’ from ‘normal for an athlete’ can be challenging), risk of ‘medicalizing’ normals (the sporting career of people with these borderline tests may be affected), a significant body of evidence suggesting that screening doesn’t save lives (principally from USA where athletes were not screened by doctors specialising in screening). The principle reasons for screening are the founded in the large Italian cohort of professionally screened (sports cardiologists) sportsmen and women in whom a 3 fold reduction in SCA was noted since screening began, the quest to further our knowledge about what constitutes a normal athletic heart (and thereby reduce the number of false positive tests), and the quest to reduce the highly emotive and publicised sudden deaths of those people perceived to be the least likely suffer ill health, i.e. athletes.

National Cardiology Programme Regent’s Park is rolling out a national programme to provide one of its clients with 12-lead ECG’s, non-invasive cardiac monitoring & vital signs measurement. Would suit cardiac physiologists or qualified nurses who have ECG recognition skills and the ability to carry out these tests. Opportunities available for occasional sessions without the need for full/part time commitment. To find out more please email Bryn Webber, Cardiac Services Director: bryn.webber@rphc.co.uk

www.rphc.co.uk

What do you say to those young people out there who play competitive, but non-professional sport, who might be worried about a similar fate as that of Fabrice’s? The risk of sudden death is very low, but is increased by competing regularly in sports. Undertaking screening is entirely voluntary and if you do opt for screening then you must be made aware that screening is not absolutely fail safe (as seen with each of the professional sports people above that were screened) and there is a small chance of having ‘borderline’ tests for which further tests may be required. In rare cases repeated annual tests may be recommended, and in certain rare situations you may be asked to ‘detrain’ for a period of 3 months to see if ‘bordeline’ tests return to normal. Nevertheless, screening is really the only way we have of reducing the incidence of tragic events seen above. If you suffer from dizzy spells or faints/ blackouts, particularly during sporting activity, have symptoms of chest pain, palpitations or excessive shortness of breath or if there is anyone in the family who has died at a young age, drowned, had an unexplained motor vehicle accident, known sudden infant death, uncontrolled epilepsy or recurrent miscarriages then you should definitely undergo screening for inherited cardiac conditions that predispose to SCA.

Dr Adam Fitzpatrick Consultant Cardiologist & Electrophysiologist Manchester Royal Infirmary Manchester United Kingdom

Should all professional sports people be screened for heart disease, and if so, how often? The answer is yes, at least once. The main reason is that minor abnormalities could have a major consequence, and the numbers to be screened are small. The virtue of repeated screening is less clear, since the major abnormalities, WPW, Long QT, Brugada Syndrome, ARVD, HCM will likely show up first time. If the ECG and echo are completely normal, I doubt that there would be an abnormality that could be detected and a disaster prevented. If there are subtle or uncertain electrocardiographic abnormalities, then repeated ECGs should be done, sooner rather than later. The ECG in Brugada Syndrome can change minute-to-minute, and the ECG in Long QT can vary. However, they usually don’t look right in the first place. What do you say to those young people out there who play competitive, but non-professional sport, who might be worried about a similar fate as that of Fabrice’s? In Italy, all schoolchildren must be screened before they can participate in sport. This practice has been questioned like all screening has been questioned. A very large number of people must be screened to find one case at risk, because these conditions are generally rare. The exception is probably WPW which is present in about 1:500 people. However, sudden death occurs in less than 1% of these, and the question to be asked is whether ablation should be offered when an asymptomatic patient is discovered. Adult cardiologists may not be familiar with the appearances of the ECG in children which can look abnormal to the adult cardiologist’s eye. In general, there is a reasonable argument that the mass-screening of asymptomatic young people could result in a lot of unnecessary worry, misdiagnoses, unnecessary procedures and a few diagnoses that could save a life.

www.cardiologyhd.com

Jul/Aug 2012 9


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SITE VISIT

[ Nambour General Hospital ] N

ambour is a town in South East Queensland, Australia, 101 kilometres north of the state capital, Brisbane. The town lies in the sub-tropical hinterland of the Sunshine Coast at the foot of the Blackall Range and has a population of 9,774. It is now the administrative centre of the Sunshine Coast Region, with the popular coastal towns of Noosa, Caloundra, and Maroochydore all a very short drive away.

Nambour

Sydney

Hospital Road NAMBOUR Queensland 4560 Australia

The name ‘Nambour’ is derived from the Aboriginal word “naamba”, referring to the red-flowering tea tree Callistemon viminalis.

It’s easy to reach Nambour from Brisbane either by road or the Tilt Train passenger railway, with only 1.5 hours travel time. Nambour is also served by Sunshine Coast Airport, with direct flights to and from Sydney, Melbourne, Lady Elliot Island, and Auckland. - Source: Wikipedia

The following site visit (including interviews and photos) has been completed by Mr Adam Westerlink, Team Leader Radiographer, Royal Brisbane & Women’s Hospital, Queensland First of all, I have to start by saying that this is a very nice part of the world here! The views from the hospital are amazing! For those that aren’t from around here, describe your hospital. Nambour General Hospital is an acute tertiary public hospital located in the heart of the Sunshine Coast, approximately 100km north of Brisbane. A 15 minute drive will get you to magnificent beaches in one direction and stunning rainforest walks in the other direction.

What are the sizes of you Cardiology department and hospital? We have 450 beds in total with 16 beds in our coronary care unit. The cardiovascular section of the procedural suite comprises of an 8 bay recovery. We have two integrated cardiovascular suites. Judging by the shiny surfaces, this is a new department. When did you commence doing cases? Above: Nambour General Hospital

12 Jul/Aug 2012 www.cardiologyhd.com

The 16th of April 2012. Our team had a two week orientation period prior to this date. We were finally able to put into practice what we had been planning for the past two years. It was a very exciting time for everyone!


Above (in Cardiology Lab): From Left: Brendan Godber, Chris Payne, Paul Wallis, Esteban Diaz, David Didlock, Jacob Fitzpatrick, Peter Larsen, Sue Bradley, Kerry Hall, Mark Gilbert, Carmel McErlean, Andrew James, Michelle Holly, Christopher Bates, Leah Godfrey, Laura Best, and Angus Gallard

What existing cardiac services were offered at Nambour prior to the cardiac labs opening? The cardiac investigations unit performed stress echos, ECGs, holters, myocardial perfusion studies, CTCA & cMRI etc

And how many staff rotate through the labs? At this point in time we have three full time cardiologists: one interventional and two staff specialists. We also have one full time staff vascular surgeon. There are nine nursing staff led by a nurse unit manager, who cover pre-op, procedural and recovery areas. There are four radiographers trained in cardiovascular procedures, led by a team leader. There are six cardiac scientists covering cardiovascular procedures as well as the cardiac investigation procedures. Above: The Vascular Lab with large windows overlooking the Australian bush

It’s important to note, at the time of print, that we are actively recruiting more specialists to support the rapid expansion of our services in the next 12-24 months ...continued www.cardiologyhd.com Jul/Aug 2012  13


Above (in Cardiology Lab): Chris Bates and Angus Gallard What procedures do you currently perform? Cardiology: Diagnostic angiograms, IABPs, TPWs. Vascular: Diagnostic and interventional procedures including EVARs and acute trauma.

And if we come back to Nambour hospital in 2 years time, what range of procedures would you anticipate to be performing by then? Cardiology: We anticipate that by the end of 2012 we will have established an interventional service including pressure wire, IVUS, OCT, rotablation as well as a primary PCI service. In addition to this, we plan to commence structural heart interventions (PFO/ASD closures). The next 12 months is going to be a busy one for us as we also intend on implementing a full EP & implantable device service as well. We also anticipate that a full range of diagnostic and interventional cases will be performed not only by the vascular surgeons, but also by interventional radiologists.

What imaging / haemodynamic equipment do you use? Two ceiling mounted Siemens Artis Zee single plane angiography suites with integrated Ultrasound capabilities. •

GE Maclab haemodynamics system

Boston Scientific IVUS

St Jude Medical “Illumien” console which combines the wireless PressureWire Aeris for FFR with OCT

Philips Ultrasound machine

ACIST automatic contrast injection system

14 Jul/Aug 2012 www.cardiologyhd.com

We also have a full EP system for use when this service is established towards the end of 2012: •

GE Cardiolab EP system

MicroPace stimulator

St Jude / IBI 1500T RF generator with remote control

What challenges have you faced in starting up a new CCL? Approximately half of our current staff had limited experience in a cardiac setting when they were initially employed months before the lab was even installed. This required coordination with other nearby facilities to assist in initial training and exposure to these sorts of procedures. This was probably the biggest hurdle we encountered. Being involved with the establishment of a new service is a unique experience and it certainly was a challenge making sure that we had thought of absolutely everything before we started. But when you think you have thought of everything, then something else always pops up!

What one bit of advice would you give others who face this same challenge of starting a CCL service from scratch? Be prepared to sit in on a lot of meetings and think ahead! (and even then there will be things you haven’t thought of).

What makes Nambour a special place to work? Who wouldn’t want to be able to go for walk along the beach before work?


INTERVIEW

[ Professor Richard Schilling ] Consultant Cardiologist St Bartholomews & The Royal London Hospital London United Kingdom

Where did you train? I trained St Thomas` Hospital in London; I did my postgrad in Hull and then St Marys Hospital in London.

Why did you choose to specialise in cardiology and then in particular electrophysiology? I chose cardiology because I’m not terribly bright! Cardiology is a very physics based subject which I was always much better at than chemistry. Electrophysiology began to interest me while I was working in Hull and the concept of being able to genuinely cure a patient rather than just delay the march of time that happens with coronary intervention, was very appealing. I eventually gave up coronary intervention because I realised that I could not be as good at both as I could sub-specialising. I much prefer doing things that I am good at rather than average or below average at.

You have been involved in live case demonstrations, what has been your most difficult case? The most difficult live case is always in a foreign lab particularly when you have no choice over patient selection or the equipment you use and the lab staff do not all speak English. Probably the toughest has been performing AF ablation in India where the standard of clinical care is excellent but they re-use their equipment many times. The advantage of greater experience was therefore nullified by these other factors and it was a challenge to teach and make myself look credible when using kit that was below par.

What do you feel have been the biggest changes in electrophysiology management in the past 5 years? AF ablation has transformed many people’s lives and we are only seeing the tip of the iceberg. We have already demonstrated in case controlled studies that AF ablation reduces risk of stroke or death. If this is corroborated by randomised multicentre trials, which I believe it will do, there will be a huge demand for this therapy.

You are a founding member of Arrhythmia Alliance and Heart Rhythm UK. How have these influenced the management of patients with arrhythmias? Politicians are not really interested in what professionals think and are much more likely to listen to patients who they see as their core voters (even though the actually number of patients being vocal is often relatively small). To collaborate with patients and their representatives has been the single most important thing that heart rhythm specialists have done to get changes to the standards of arrhythmia care in the UK. It is remarkable how often the interests of the patients and the professionals are aligned and patients are usually highly intelligent and motivated to help with improving care. The Arrhythmia Alliance, Atrial Fibrillation Association and the professional society has achieved this collaboration incredibly well.

Looking ahead what do you see as the biggest challenges ahead for cardiology in the UK over the next 5-10 years? The biggest challenge for us all will be relative reduction in spending on the health service with increasing demands. At some point we will all have to face up to what therapies patients and the public feels are a priority. There is also a big problem developing in clinical research with increasing legislation and bureaucracy involved. The committees of grant awarding bodies tend to be dominated by basic scientists who do not really understand the priorities or complexity of carrying out clinical research which make finding funding always hugely time consuming and difficult. This is going to result in the continued collapse of clinical research in the UK and fewer and fewer younger clinicians maintaining an interest in research which in turn will affect the quality of all aspects of cardiology care.

What do you do to relax when you are not working? I still enjoy playing football regularly, climbing and hiking.

This interview was performed by Mr Dennis Sandeman, Chest Pain Nurse Specialist, NHS Fife

www.cardiologyhd.com

Jul/Aug 2012 15


JOURNALS [ Global Update ] 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

Fire and Brimstone

Implantable devices

Ablation of ventricular tachycardia in ischaemic and other sick hearts is an ever expanding area of practice given the evolution of arrhythmias in ICD patients who would otherwise have shuffled off their mortal coil. All the more reason to explore more effective, faster and safer ways of performing the procedure than painstakingly mapping umpteen poorly tolerated tachycardias. Recently this has led to the pursuit of what has been euphemistically described as a substrate based approach (basically blast the bejeezus out of the dodgy areas of myocardium). Predictably, enter the French with a way of bringing some élan to this process. They describe culprit electrograms (localised abnormal ventricular activities-LAVA) and how to identify and treat them in sinus rhythm.

We have had remote monitoring of devices for some years and know how to use it for follow up of arrhythmia and device function, but not really for heart failure. This study confirms that it works for the bits we know how to use. Outpatient visits halved without any apparent adverse effects. It is always good to have randomised data, no doubt a cost-efficacy spin-off publication will follow soon.

Pierre Jais and others. Circulation. 2012; 125:2184-2196. The risks of sudden cardiac death associated with Wolf Parkinson White syndrome (i.e. symptomatic pre excitation) are the subject of a reasonable volume of publication but what about asymptomatic pre excitation? This systematic review of data on 1869 patients followed up over 11722 patient years from a range of studies and registries puts the instance of sudden cardiac death at 1.25 per 1000 patient years in patients not offered EPS +/-ablation. The authors contend that the results argue strongly against routine ablation of all such patients but acknowledge, in their discussion, the role of EPS in risk stratification in some patients and the importance of very careful history taking. An accompanying editorial welcomes the data, but challenges the conclusions. The data on risks on catheter ablation are two decades old (I would add to this that many patients would require diagnostic EPS only - much lower risk than ablation) and the authors rejected 570 publications in selecting their 20 studies and retrospectively re categorised some patients from asymptomatic to symptomatic. WPW, it is argued is, another reason for a prospective observational research database of 12 lead ECGs in ‘normal’ patients. Manoj Obeyesekwere and others. Circulation 2012; 125:2308-2315. Michael M Laks and others Circulation 2012; 125:2288-2290.

16 Jul/Aug 2012 www.cardiologyhd.com

Philip Mabo and others. European Heart Journal 2012; 33:1105–1111. Filtering out those patients too likely to die of non arrhythmic causes (especially heart failure) to be appropriate recipients of ICDs is an active area of investigation. Among 300 patients enrolled in this study, a CRP of greater than 3 mg/l was associated with heart failure death (HR 3.2), but not arrhythmia events. Luigi Biasucci and others. Eur Heart J 2012; 33(11):1344-1350. On a related note, application of a previously described composite score (one point each for NYHA>II, age>70, renal impairment, QRS>0.12, AF) appears to be useful for selecting out those patients likely to benefit from ICD out to 8 years follow up. Using the patients in the MADIT 2 study, those with 0-2 risk factors benefited significantly from ICD, whereas those with a score of 3 or greater derived no measurable benefit. It should be noted that none of the patients received CRT as part of the trial. Alon Barsheshet and others. J Am Coll Cardiol 2012; 59:2075-2079. Some have advocated that after an infected device is removed, reimplantation with an epicardial device should be considered. In this registry of 197 extracted patients matched to controls the outcomes were no worse in the extracted than control patients at a year despite the 4% in hospital mortality. An exception however was those reimplanted with RV epicardial systems who did significantly worse than endocardial reimplants or non reimplanted patients Jean-Claude Deharo and others. Heart 2012; 98:724e731.


Response to cardiac resynchronisation is variable, two factors suggested to predict response are pacing scar (negatively predictive) and pacing late contracting areas (positively predictive). The TARGET study looked at the use of speckle tracking echo to identify viable late contracting myocardium randomising patients to either blinded or guided implant. Response rates (70 vs. 55%) were significantly higher in the guided group with less heart failure event rates.

The fear of stent thrombosis (ST) continues to drive randomised studies, registries and meta-analysis. This latest ‘network meta-analysis’ (i.e. it is very big) looked at 49 trials of 50,844 patients and showed lower rates of definite ST with cobalt-chromium everolimus eluting stents (Xience V) than with bare metal stents (OR 0.23) at 30-days, 1-year and 2-year follow up. The rates were also lower than any other drug eluting stent currently approved in the USA.

Fakher Khan and others. J Am Coll Cardiol 2012; 59:1509-1518.

Tullio Palmerini and others. Lancet 2012;379:1393-1402.

Acute Coronary Syndromes How can we improve outcomes in ACS patients? By practicing good medicine. In Brazil, ‘multifaceted quality intervention’ was effective – essentially encouraging people to use evidence-based therapies (education, training, reminders, checklists etc). Whilst in America, hospital strategies e.g. monthly MDT meetings, having on-site Cardiologists and having an organisational environment in which clinicians are encouraged to solve problems creatively (nice and subjective then) were shown to improve outcomes. Otavio Berwanger and others. JAMA 2012; 307:2041-2049. Elizabeth Bradley and others. Ann Intern Med 2012;156:618-626.

Intervention Distal thrombus embolization is a bad thing during primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI). Thrombus extraction and bolus intracoronary abciximab have previously been shown (independently of one another) to reduce distal embolization and improve outcomes (in some studies, but not all). Contemporary PPCI includes bivalirudin anticoagulation in many centres, so time for another study to see whether the techniques were still beneficial. Bolus intracoronary abciximab was effective, reducing infarct size (on MRI) at 30-days in patients having a large anterior STEMI within 4 hours of symptom onset, but manual thrombus aspiration was not. The authors surmise, but do not know, whether this will impact hard endpoints like dying.

However, a European meta-analysis comparing early generation drug-eluting stents (DES) and bare metal stents (BMS) in 15 trials enrolling 7,867 patients (i.e. smaller, but biggest so far of a STEMI population) showed an early benefit of drug eluting stents in PPCI for STEMI with a reduction in target vessel revascularisation (TVR) and a numerical reduction in definite ST that is offset in subsequent years by an increased risk of very late ST (after one year). Bindu Kalesan and others. European Heart Journal 2012;33:977-987.

Heart Failure The SHIFT trial demonstrated better heart failure outcomes adding the sinus node blocking agent Ivabradine to beta blockers in those not adequately heart rate controlled on maximum tolerated beta blocker doses. Some concerns were raised that proven benefits of beta blockade might be compromised by the easy way out of Ivabradine with less good real world outcomes. This scrutiny of the data suggests the more important prognostic factor is on treatment heart rate rather than baseline beta blocker dose. Karl Swedberg and others J Am Coll Cardiol 2012; 59:1938-1945.

Imaging We use ejection fractions derived from different modalities as if they were interchangeable but are they? No. Johannes Greupner and others J Am Coll Cardiol 2012; 59:1897-1907.

Gregg Stone and others. JAMA 2012; 307:1817-1826. The ASCERT study is yet another publication from America comparing PCI and CABG. This was a retrospective analysis of data from 2004 to 2008 from two large databases. It compared 86,244 patients that underwent CABG and 103,549 that underwent PCI. The patients were all 65 years old or older, had two or three vessel coronary artery disease and no acute myocardial infarction. There was no difference in adjusted mortality at 1 year, but there was lower mortality with CABG than with PCI at 4 years (16.4% vs. 20.8%, RR 0.79). This further supports the role of CABG in selected patients. Standard caveats apply – this is American, retrospective, observational data; and other randomised studies with contemporary techniques are awaited (e.g. SYNTAX 2). William Weintraub and others. NEJM 2012;366:1467-76.

CTCA has a high negative predictive value in the investigation of stable coronary disease. In this randomised trial of CTCA to facilitate early discharge vs. traditional care in patients with TIMI scores of 0-2 the CTCA guided strategy was both effective in facilitating early discharge and safe in predicting lack of events. Harold Litt and others N Engl J Med 2012 366:1393-1403.

[ ECG Challenge Answer ] from page 5 •

The ECG shows normal sinus rhythm.

And another study from America comparing PCI at hospitals with or without on-site cardiac surgery – the Atlantic CPORT study. Guess what? There was no significant difference in outcome. Again.

Cardiac axis is normal.

This is a normal ECG.

Thomas Aversano and others. NEJM 2012;266:1792-1802.

Following investigation the diagnosis was dyspepsia and after proton pump inhibitor was commenced. He has remained free of symptoms since.

www.cardiologyhd.com Jul/Aug 2012  17


EVENTS [ What’s On ] September 23 - 26

September 30 - October 2

December 4 - 6

HRC 2012 The ICC Birmingham, UK www.heartrhythmcongress.com

PCR London Valves 2012 Queen Elizabeth II Conference Centre London, UK www.pcrlondonvalves.com

7th UK Stroke Forum Conference Harrogate International Centre Harrogate, UK www.ukstrokeforum.org

October 22 - 26

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TCT 2012 Miami, Florida, USA www.tctconference.com

CSANZ 2012 Brisbane Convention & Exhibition Centre Brisbane, QLD, Australia www.csanz2012.com

November 3 - 7

February 21 - 24, 2013

AHA Scientific Sessions 2012 Los Angeles Convention Center Los Angeles, CA, USA my.americanheart.org

Asian PaciďŹ c Society of Cardiology 2013 Congress PEACH Pattaya, Thailand www.apsc2013.org

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Heart Rhythm Congress

HRC2012 23rd – 26th September 2012 The ICC, Birmingham UK

www.heartrhythmcongress.com info@heartrhythmcongress.org.uk Providing education and training to promote diversity and improved technology for all involved in the treatment of cardiac arrhythmia patients

Supported by HR-UK

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HRC PO Box 3697 Stratford upon Avon Warwickshire CV37 8YL UK Telephone: +44 (0) 1789 450 787


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