Coronary Heart #17

BMI London Independent+ FFR FAME Results

coronaryheart.com

March / April 200�Issue 17 March / April 200�Issue 17

Hot TopicFFR FAME trial results with opinions from 2 leading cardiologists.

InterviewDr Keith Oldroyd, PI for FAME answers your questions.

Echo Special FeatureThree interesting case studies.

Site VisitThe BMI London Independent Hospital

Cath EducationRadial Access

CRM EducationReducing in-hospital ICDfollow-ups safely

ManagementOncall Reimbursement: Your responses EM

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CONTENTS

Plumbers’ Revenge

Page 10Revenge

Page 10

Cover Photo: Kevin Chako-Konickal, Radiographer, BMI London Independent

Contents Page Photo: Annie Ollivierre-Smith, Lavern Reid and Connalyn Torres.

Disclaimer:Coronary Heart should never be regarded as an authoritati ve peer reviewed medical journal. Coronary Heart has been designed as a guide only, to inform readers who work in the cardiology environment about latest news stories and the diff erent techniques used by others around the world. Whilst all care is taken in reviewing arti cles obtained from various companies and contributors, it is not possible to confi rm the accuracy of all statements. Therefore it is the reader’s responsibility that any advice provided in this publicati on should be carefully checked themselves, by either contacti ng the companies involved or speaking to those with skills in the specifi c area. Readers should always re check claims made in this publicati on before employing them in their own work environment. Opinions expressed by contributors are their own and not necessarily those of their insti tuti on, Coronary Heart Publishing Ltd or the editorial staff .

05 FFR FAME TRIAL Update- Interview with Dr Keith Oldroyd

- Hot Topic Question

17 Site Visit- � e BMI London Independent Hospital

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CIRCULATION3642 Cardiac Professionals

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04 Latest News

09 Journal Trawl

10 Management - Finger on the Pulse

12 Echo Special Feature- Cardiac Metastases

- LASEC

- Right Atrial Myxoma

20 Radial Approach to Cardiac Caths

23 Buyers Guide- Software Packages for Cardiac X-ray

24 CRM Education- Reducing in-hospital ICD follow-ups safely

28 Events Diary

29 Next Issue + Recruitment

BMI London Independent Site Visit

FEATURES:

COVER STORIES:

Page 17

CORONARY HEART ™ 3

LATEST NEWS

- The Team -Mr Tim LarnerDirector/Chief EditorCentral Manchester University Hospitals NHS Foundation Trust

Dr Simon RedwoodChief Clinical EditorGuy’s & St Thomas’ NHS Foundation Trust

Dr Rodney FoaleSenior Clinical EditorImperial College Healthcare NHS Trust

Dr Richard EdwardsConsulting EditorNewcastle upon Tyne Hospitals NHS Trust

Dr Divaka PereraConsulting EditorGuy’s & St Thomas’ NHS Foundation Trust

Dr John PaiseyJournal EditorRoyal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Mr Ian WrightChief EP Consulting EditorImperial College Healthcare NHS Trust

Mr Adam LunghiEcho EditorCVS - CardioVascular Services, Australia

Mr Stuart AllenCRM EditorMonash Medical Centre, Australia

Ms Mojgan SaniPharmaceutical EditorSouthampton University Hospitals NHS Trust

Barnet Hospital Opens New Cath Lab

In January, Barnet Hospital, part of Barnet and Chase Farm Hospitals

NHS Trust announced the opening of their new catheter lab which includes from Siemens, the Arti s™ zee Floor digital C-arm angiography system. It is located in a purpose built extension at the hospital.

A variati on to an existi ng 33-year old contract allowed them to install the new equipment, providing the Trust with the latest technologies.

“Time, effi ciency and ergonomics is an important equati on in a cath lab. The Arti s zee encompasses all of these factors, enabling us to pro-vide opti mal soluti ons for pati ent treatment,” stated Ameet Bakhai, Consultant Cardiologist at Barnet and Chase Farm Hospital NHS Trust.

Image courtesy Siem

ens Healthcare

Barnet Hospital welcomes the Siemens Arti s zee

From left to right: Cassandra Bombata, Cardiology Manager; Ethna Doyle, Cardiology Matron; Louise Harney, Junior Sister; Kerry Boston, General Manager for Cardiology; Kathryn Laysico, Staff Nurse; Vas Shah, Senior

Superintendent Radiographer; Sara Fershi, Cath Lab Radiographer.

UK SYNTAX Results

The UK data for SYNTAX was pre-sented by Dr Keith Oldroyd at ACI

2009 in January. The key points were:

In the UK subset of the ran-domised SYNTAX cohort, 12 month MACCE (composite of Death, MI, CVA and revascularizati on) were similar in CABG and TAXUS pati ents.

The overall safety outcomes (Death, MI and CVA) were similar in CABG and TAXUS pati ents.

There were no CVAs in UK CABG pati ents, despite a stati sti cally sig-nifi cantly higher rate in the overall

SYNTAX randomised pati ent cohort (2.2% vs 0.6%, p= 0.003)

The rate of any revascularizati on in UK pati ents was numerically increased in the TAXUS arm 9.0% compared to 3.9% in the CABG arm, but the diff erence was not stati sti cally signifi cant.

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4 CORONARY HEART ™

INTERVIEW

What is FAME?FAME (Fracti onal Flow Reserve Versus Angiography for Multi vessel Evaluati on) was a large (1,005 pati ent)—in-ternati onal, multi center, prospecti ve, randomized trial, conducted in twenty centres in the UK and USA. It looked at pati ents with multi vessel coronary artery disease 12 months aft er receiving a stent, and compared outcomes for pati ents whose treatment was guided by FFR to those

whose treatment was guided only by angiography.

The investi gators used a pressure sensor mounted on a guidewire, PressureWire® Certus, developed

and marketed by Radi Medical Systems, which was ac-quired in December 2008 by St. Jude Medical.

The study showed the risk of a pati ent dying or having a heart att ack was reduced by approximately 35 percent when FFR measurement was performed (11.1 percent for the angiography-guided group compared to 7.3 per-cent for the FFR-guided group, P=0.04). The 12-month overall MACE rate was 18.4 percent, compared to 13.2 percent for the FFR-guided group (p=0.02). Therefore the study showed that the likelihood of a pati ent having to return for further treatment (repeat stent placement or coronary artery bypass graft surgery) was signifi cantly lower for the FFR-guided group.

Benefi ts:

Decreased MACE

Increased quality of life for pati ents

30% fewer stents used

Cost savings: The average procedural costs were $5,332 for the FFR-guided group compared to $6,007 for the angiography-guided group (P<0.001).

No additi onal length of procedural ti me: It took an average of 71 minutes to complete PCI in the FFR-guided group compared to 70 minutes in the angiography-guided group.

Chief Editors Note:

There is occasionally some resistance from staff work-ing in a lab when the FFR equipment is wheeled in. However aft er working at The Wellington Hos-pital in London where the system is used regularly, the equipment could be set-up extremely quickly and added virtually no ti me to the length of the proce-dure. Also with the release of the new wireless Pres-sureWire® Aeris System, it is set to become even easier to use.

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The following questi ons for Dr Oldroyd were compiled by our consulti ng editor, Dr S. Divaka Perera, Senior Lecturer and

Consultant Cardiologist, King’s College London / Guys & St Tho-mas’ Hospital, London.

Q1. FAME suggests that FFR guided PCI is superior to just using angiography – should we be measuring FFR in all vessels where there are lesions greater than about 50% on angiography?

What FAME tells us is that if, in the treatment of pati ents with multi -vessel disease, you were in the habit of implanti ng DES in all lesions with an esti mated diameter stenosis of 50% or more, you will get bett er clinical outcomes with fewer stents if you switch to using FRR guidance and only treat lesions with an FFR < 0.80.

In practi ce, and certainly in the UK, I doubt there were many interventi onists treati ng all lesions with a DS of 50% or more. Clearly if there is good evidence of the extent and locati on of re-versible ischaemia by non-invasive testi ng prior to the PCI proce-dure then FFR assessment may not be required. However this is oft en absent, even in UK practi ce and parti cularly in the context of NSTEACS which makes up so much of our work now. In that setti ng FFR can be criti cally important.

FFR FAME Trial Update

Image courtesy Radi Medical

What is FAME?FAME (Fracti onal Flow Reserve Versus Angiography for Multi vessel Evaluati on) was a large (1,005 pati ent)—in-ternati onal, multi center, prospecti ve, randomized trial, conducted in twenty centres in the UK and USA. It looked at pati ents with multi vessel coronary artery disease 12 months aft er receiving a stent, and compared outcomes for pati ents whose treatment was guided by FFR to those

whose treatment was guided only by angiography.

and marketed by Radi Medical Systems, which was ac-quired in December 2008 by St. Jude Medical.

Keith G Oldroyd MD (Hons); FSCAI; FRCP(Glasg)Consultant Interventional CardiologistDepartment of Cardiology Western Infirmary Glasgow


HOT TOPIC

FFR FAME Trial Follow-up (cont...)

Q2. There was a difference in the composite end-point, which ap-peared to be driven primarily by an increased MI rate in the angio-guided arm. Was this all down to peri-procedural MI relating to a higher amount of stenting in the an-gio group? If so, is this really relevant to long-term outcome?

All components of the combined primary EP were reduced in the FFR group includ-ing a 1.2% non-significant reduction in mortality at 12 months. We don’t know whether the reduction in MI was in the periprocedural phase because of fewer stents causing less side branch occlusion or embolisation or alternatively during fol-low-up with less stent thrombosis. Further analysis may clarify this but ultimately it’s a benefit worth having.

Q3. A cut-off of 0.80 was used in FAME, while a 0.75 threshold is used by most operators. How should results in the grey-zone (0.75 – 0.80) be interpreted?

In the grey zone of 0.75-0.80 interven-tionists have to use their clinical judge-ment. When deciding whether or not to stent a lesion with an FFR in this range I would usually quickly review the patient’s symptoms and also confirm that they are on optimal therapy. If their symptoms are convincingly ischaemic and significantly limiting despite two anti-anginal drugs I would proceed.

Q4. Has this changed your practice?

FAME hasn’t changed my own practice much as I was already using FFR regularly. However I was very surprised by the com-ments on FAME published on theheart.org by Dr Roxana Mehran (Columbia Uni-versity, New York, NY). She apparently “...offered some restraint to the enthusiastic conclusions of the FAME investigators, pointing out that the technology is ad-vanced and not every cath lab is equipped with FFR capabilities.” She also said, “It’s a new technology to be added, and having said that, I don’t want to imply it shouldn’t be [used], but to make a strong statement and say you shouldn’t be performing angi-oplasty without FFR is a far stretch for just a single study,” said Mehran. I would have the exact opposite view. The technology is actually very simple, the latest version of the pressure wire handles very well in-deed and I would say that all labs doing PCI should have FFR capability.

The following Hot Topic question was edited for distribution by our Consulting Editor Dr Richard Edwards, Consultant Cardiologist, The Newcastle upon Tyne Hospitals NHS Trust.

Cardiologist Hot Topic

“The FAME study showed that routine FFR significantly improved outcomes after (DES) stenting in Multi-Vessel Disease. Do you currently routinely use FFR when stenting equivocal lesions and will results from the FAME trial have an effect on your work practices?”

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

Professor Adam TimmisConsultant Interventional Cardiologist, The London Independent Hospital, London

The FAME study was quite convincing as a way of providing a functional assessment of coronary lesions, and in fact we rou-

tinely use FFR when assessing critical lesions for coronary stenting. Whether or not the re-sults of FAME will affect work practices I am not sure, because as I say we use FFR a lot now. The logical conclusion from FAME was that you should do FFR on every lesion, but that would really add quite a lot of time to the procedures, and I think for myself I will continue to use it for those lesions which I consider to be equivocal.

In the May/June edition we will feature Part 2 of the FAME Hot Topic question with other cardiologist’s input.

� CORONARY HEART ™

Radi was the first company to develop a pressure guidewire which facilitated the development of Fractional Flow Reserve (FFR). We are Radi Medical Systems AB, founded in Uppsala, Sweden in 1988.

Radi Medical Systems is proud to present PressureWire® Aeris – the first ever wireless interventional device. With the functionality of PressureWire® and the performance of a high end interventional guidewire, PressureWire® Aeris liberates you and your staff from the constraints of cabling and time consuming setup.

PressureWire® Aeris connects straight into your existing hemodynamic recording system, enabling what we call True FFR Integration – FFR measurement utilizing existing instrumentation, screens and archives with a setup procedure reduced to a flick of a switch, literally.

The future of FFR is coming soon.

for true ffr integration

it’s time

HOT TOPIC

� CORONARY HEART ™

Dr Magdi El-Omar BSc, MBBS, MRCP, MDConsultant Interventional CardiologistManchester Heart CentreManchester Royal Infirmary

I routinely use FFR when stenting equiv-ocal lesions. In multi-vessel PCI, I may have to do this multiple times! Overall,

I do not feel that results from FAME will alter my practices.

The recently published FAME study showed that in patients undergoing multi-vessel stenting with DES, a strategy of routine measurement of FFR for all ‘significant’ lesions yielded superior out-comes versus the standard strategy of PCI guided by angiography alone. Despite its clear message, I feel that this study does not reflect ‘real-world’ interventional practice. The design of the trial, by dedi-cated pressure wire ‘super-enthusiasts’, was such that the FFR group was bound to emerge ‘triumphant’. Here are a few observations to illustrate this:

How were FAME patients referred for coronary angiography in the first

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place? Why is there no mention of any non-invasive tests prior to PCI that could have been helpful in deci-sion making regarding which lesions to stent?

The benefit of the FFR-guided strat-egy appears to have 2 components: an early reduction in the rate of MI and a later reduction in revasculari-sation rate. In multi-vessel stenting, one would expect a higher cumula-tive enzyme leak, which may account for the slightly increased rate of peri-procedural infarctions in the an-giography group. Were IIbIIIa inhibi-tors used in this study? Real world intervention would dictate that these agents be used more commonly in multi-vessel PCI (i.e. the angiography group), and this could potentially have altered results in favour of the angiography group.

In the FFR group, 63% of lesions had an FFR ≤0.80, but how many of these fell within the grey zone (0.75-0.8)? Analysis of our own data suggests that this occurs in ~12% of cases. Thus, had the more traditional FFR value of 0.75 been chosen as a cut-off for ischaemia (as in DEFER), a significant proportion of lesions would not have been stented, which may have altered results. In fact even a cut-off value of 0.75 has mostly been validated in a select population of patients with single-vessel CAD, no prior revascularisation, normal ejection fraction and no LVH. Clearly,

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the FAME study patient population was more diverse, and the applica-bility of this cut-off value to them is unproven.

In the angiography group ~41% of all lesions were angiographically moder-ate (50-70%), yet all were ‘automati-cally’ stented. Conversely, ~14% of all lesions in the FFR group were angi-ographically very severe (91-99%), yet all were pressure-wired. Does this truly reflect normal, day-to-day interventional practice? It is worth noting that studies that have shown prognostic benefit from complete as opposed to incomplete revascu-larisation with PCI have relied on angiographic, rather than functional assessment of lesions.

Finally, why did the study protocol not mandate a repeat FFR post stent-ing, aiming for a value ≥0.90? Could this have increased procedural time, contrast usage and costs in the FFR group?

Despite these caveats, findings from the FAME study should help steer interven-tionists away from the oculo-stenotic reflex and more towards a strategy of revascularisation of ischaemic lesions and medical treatment of non-ischaemic le-sions. It behoves us all to remember that except in ACS patients and perhaps those with extensive ischaemia, revascularisa-tion with PCI does not reduce the risk of MI or death.

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Cardiologist Hot Topic (cont...)

Southampton University Hospital Trust invite you to:

Fundamentals of ICD Implantation and Introduction to CRT-DThursday 9th to Friday 10th of July 2009 - Wessex Heartbeat Suite Southampton University Hospital, UK

Attend this 2-day course with interactive sessions, and share experience with an international audience!Lectures, live implantations and hands-on programming sessions performed by Prof. J.M. Morgan,Dr P.R. Roberts and their team.To book your place on these study days please either ask your representative or contact Elspeth Hopson at Sorin Group office on 01452 638500 or at [email protected] study days are supported by an educational grant from Sorin Group.

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The "Fundamentals of ICD implantation and Introduction to CRT-D" meeting is accredited by the European Board for Accreditation in Cardiology (EBAC) for 10 hours of External CME credits. Each participant should claim only those hours of

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JOURNALS

CORONARY HEART ™ �

The Ross procedure is the Marmite of cardiac surgery. For the uninitiated it involve taking a patient needing

an aortic valve replacement, using there own pulmonary valve in the aortic posi-tion and then replacing the pulmonary valve. Either you think this is a brilliant idea allowing the preservation of a native (sort of) valve in the aorta and avoidance or anticoagulation or you cannot see the point of messing up two valves when only one was kaput. In a meta analysis of 39 case series the early mortality was 3-4.2% depending on the age of patient, the rate of failure of one or other of the valves was in the order of 1.5% per patient year per valve (or thereabouts, younger patients doing worse).

JJM Takkenberg and others, Circulation. 2009;119:222-228

Having cast aside leg warmers and big hair Leroy, Bruno Mr Shorofsky and company (John, one more gag this weak and your fired-Tim) have now turned their attention to improving outcomes by targeting stents at important lesions only. The FAME inves-tigators pose the question Does pressure wire assessment of suitability of lesions for PCI result in a measurable reduction in adverse events? The answer seems to be yes, examining a range of patients with ACS and stable angina pressure wire vs. angiographic assessment reduced the number of lesions treated from 2.7 to 1.9 per patient with no increase difference in angina over follow up and a reduction in the usual composite endpoint from 18.3 to 13.2%.

PAL Tonino and others N Engl J Med 2009; 213-224

Long QT syndrome has to be one of the hardest conditions to treat, walking a tight rope between unnecessary de-vice implantation with all its associated

complications and losing a young patient to sudden cardiac death. Over 10 year fol-low up of 216 patients with genotyped LQT1 including survivors of sudden death beta blockers were highly effective at pre-venting cardiac arrest and rendered 75% asymptomatic, of the 12 patients who did suffer cardiac arrest ‘on beta blocker’ all but one were either non compliant or tak-ing QT prolonging drugs. The authors sug-gest that even in cardiac arrest survivors if beta blocker compliance can be guaran-teed (?) ICD implantation may be unnec-essary-very ballsy.

GM Vincent and others Circulation. 2009;119:215-221

On a related note the sudden death risk associated administration of antipsychotic drugs has been examined in a large regis-try with matched controls. The take home messages are that antipsychotics more or less double sudden death risk, that the ef-fect is dose dependant and that there is no difference between typical and atypi-cal (newer) agents.

W Ray and others N Engl J Med Volume 360:225-235

Being obese almost trebles risk of devel-oping heart failure whilst regular vigorous physical activity protects against the same according to data from the physicians health study.

S Kenchaiah and others Circulation. 2009;119:44-52

Sometimes it seems like if you had to-gether all the mortality benefits sug-gested by various trials of pharmacologi-cal interventions in cardiac conditions patients should be better of than before the event. It is reassuring to learn there-fore that between 94 and 04 mortality fell and median survival increased in pa-tients presenting with heart failure. From

97 onward this coincided with an increase in beta blocker, Ace inhibitor and spironol-actone administration. An important rider however is the ongoing poor prognosis of heart failure (median survival 2.3 years in men and 1.8 years in women).

PS Jhund and others Circulation 2009;119;515-523

Thrombolysis during resuscitation from cardiac arrest is a recurring theme. The twin logics are that many arrests are due to myocardial infarction or pulmonary embolus and clotting in the microcircula-tion during the arrest impairs outcomes. The TROICA trial randomly assigned wit-nessed cardiac arrest patients undergoing resuscitation to receive tenecteplase or placebo (without heparinoids). No differ-ence was detected in outcomes such as survival to discharge or neurological im-pairment between the groups.

BW Böttiger and others N Engl J Med Volume 359:2651-2662

The ATHENA trial provides, on the face of it, encouraging results for the novel class 3 antiarrhythmic drug dronedarone (amio-darone without the liver, lung and thyroid mischief). A composite endpoint of hospi-talisation or death along with specifically hospitalisation per se, arrhythmic death and cardiovascular death (but not stroke) were all reduced compared to placebo in a randomised trial of patients with per-sistent or paroxysmal AF. Unfortunately as the authors acknowledge we have al-ready had a trial of heart failure patients stopped early due to an excess mortality in the treatment group (ANROMEDA)-a finding sure to limit the drugs indication in future.

Hohnloser and others, N Engl J Med 360;7

Dr John PaiseyConsultant Cardiologist and ElectrophysiologistRoyal Bournemouth Hospital

Journal Trawl- Dr John Paisey scans the world’s

cardiology journals

MANAGEMENT

Finger on the Pulse

In the last editi on of Coronary Heart we featured an interesti ng arti cle relat-ing to On-call Reimbursement by Greg

Cruickshank of Kings College NHS Trust. In it Greg raised concerns about the current pay and conditi ons cardiac staff work un-der and compared it with the amount you would expect to pay for other occupati ons such as plumbers and electricians.

Greg suggested an hourly rate of £50, with at least one hour’s payment guaran-teed per day on-call in-lieu of carrying the bleep. We put this and other questi ons relati ng to the arti cle to our readers.

Questi ons:

What are your thoughts on the cur-rent remunerati on for being on-call?

In your department what is the amount you receive on-call and conditi ons?

Do you support Greg’s suggesti on of an hourly rate of £50, with at least one hour’s payment guaranteed per day on-call in-lieu of carrying the bleep?

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3.

Jenn SandsRadiographerChristchurch HospitalChristchurchNew Zealand

We receive an hourly On-Call payment for each hour we are on-call for.

This consists of $4.00/hour on weekends and Public holidays and $2.50 / hour for call during the week. If we get called we are then paid for a minimum of 2 or 3 hours at T1.5 or T2 depending on which centre around NZ we work.I would like to comment on the arti cle writt en by Greg Cruikshank as I believe

a few ideas from an industry perspecti ve would add to the sense of the whole area.

In parti cular I would like to draw att enti on to his comparison with plumbers. These tradesmen are small businesses and so it is inappropriate to compare on-call rates of NHS staff with them. As a minimum they will need to fund vehicles, insurance and tools. They may also have to pay any offi ce staff , rental of build-ings, uti lity bills, etc, which would create a fi xed overhead regardless of whether they get business or not. Another key diff erence is that the plumber and his company do not know if they are going to get any business the next week. There is very litt le security in the private sector, which contrasts markedly from the situati on in the NHS.

Lastly, there is the matt er of performance. Unlike the NHS, if a privately em-ployed person doesn’t perform (especially in a sales role) or makes mistakes as with our plumber), it will not be too long before he or she is shown the door.

Many of the companies that are involved in supporti ng the acti viti es of Radiology and Cardiology would fi t the above scenario, with the excepti on that they have to budget for the cost of goods. The price they then charge the customer has to cover this cost and also must support not only his salary and expenses (car, lap-top, phone, hotel, general expenses) but also the rest of the company.

So now you know why things cost so much!

- Anonymous

The Plumbers’ Revenge


MANAGEMENT

Suzanne BrooksSnr Chief Cardiac Physiologist - CRMAshford & St.Peter’s Hospitals NHS Trust

Currently I think the fee is outrageous.

I work in a Trust that pays £15 per day to carry the bleep and pays ti me when we get called. We currently only have two members of staff that are on the rota so we do one week on one week off . We are a DGH so don’t get called all that oft en and the weekends are not covered aft er 9am on a Saturday – I suppose we have to start somewhere. They are talking about 8-8 working 7 days a week to try and move things on but that won’t happen with only two trained personnel.

Greg’s suggesti on is good but I can’t see it happening myself.

Greg Whittle,Superintendent III Radiographer (Cardiology), Cardiac LabPrincess of Wales HospitalBridgend

What are your thoughts on the current remunerati on for being on-call?

Inadequate. Usual NHS reliance on goodwill on the part of the non-medi-cal staff

In your department what is the amount you receive on-call and conditi ons?

Currently I work in a diagnosti cs-only lab that does not do on-call. At the previ-ous terti ary centre on-call was paid at an hourly rate from the moment of being alerted unti l leaving the lab.

Time and a third out-of-hours on Mon-Sat, double ti me Sunday, plus mileage allow-ance for travelling.

Do you support Greg’s suggesti on of an hourly rate of £50, with at least one hour’s payment guaranteed per day on-call in-lieu of carrying the bleep?

Yes; seems very reasonable; conservati ve if anything when considering his compari-sons with other skilled trades in the pri-vate sector.

Andrea RamsayActing Supt RadiographerCardiac Cath LabWellington HospitalLONDON

Here at the Wellington we usually do a week on call (Mon-Sun). We don’t get called in very oft en, but

oft en have to stay late to fi nish off the days lists. We get paid standby £200 for the week (£20 per night Mon-Fri and £50 per day Sat and Sun). For bank holidays we get £60 per day. On-call payment is for anything aft er 8pm and before 7.30am. We someti mes have to start a list at 7am so get paid an hours on call which makes up for having to get up at silly o’clock…! At the moment that is £40.32 per hour. This is for all of the staff in the lab (techs, rads and nurses).

I realise, compared to our NHS colleagues, that we have it relati vely easy in private practi ce, with most of the acute work go-ing to the NHS, and that our payments are prett y good, again compared to some NHS centres. I do think it is good for mo-rale that all the staff in the lab are paid the same rate, reducing any ill feeling this may cause between disciplines.

I agree with Greg that it is outrageous the small amount of money we are being paid to “save lives”, compared to emergency tradesmen etc. £50 per hour and knowing you will defi nitely be getti ng that amount for holding the bleep is acceptable.

Unfortunately, because most of us came into this profession to care for pati ents and obviously not for the money, we are clearly penalised for this.

Question 1:Radiographers: What is your experience with hybrid c-arms with large detectors for PCI’s?

Question 2:Cardiac Physiologists: In the future Cardiac MRI will become more common in departments. Like Echo do you believe Cardiac MRI should become a physiologists’ domain? Why?

Next Issue:

Due: Up to 200 words by Friday April 3Email to: [email protected]


ECHO

Cardiac Metastases- An unusual cause of left atrial mass

A 33 year old gentleman was referred with increasing neck swell-ing in the cervical region. Biopsy of the swelling confirmed met-astatic malignant melanoma. A staging CT of the chest revealed a 4 X 4cm filling defect within the left atrium. Echocardiogram

performed showed abnormal left ventricular function. A large homog-enous irregular sessile mass measuring 5.6 X 3 cm was seen attached to the basal free wall of the left atrium. It was not attached to the interatrial septum. It appeared to originate from the right pulmonary vein. The left atrium was mildly dilated. There is no stalk attached to the mass. The tip of the mass prolapses through the mitral valve during diastole. No spon-taneous echo contrast could be seen in the left atrium or appendage.

We discuss the aetiology, diagnosis and management of cardiac metastases.

Discussion

The differential diagnosis of left atrial masses includes primary cardiac tumours, cardiac metastases, atrial myxoma and thrombus within the left atrium. Cardiac metastasis is uncommon and it is discovered in autop-sies in 11.8% of all patients with malignancies1. It usually occurs late in the course of a malignant disease and generally has a poor prognosis. Sites of origin2 include lung, non-solid primary malignancies including melanoma, sarcoma and lymphoma, breast and oesophagus. It has been reported that up to 64% of patients with melanoma have cardiac metas-tases2. There have been case reports of cardiac metastasis from cancer of the cervix, kidney and thyroid.

Patients with cardiac metastases may be asymptomatic as in our case. Some patients may present with cardiac arrhythmias, impaired cardiac function or pericardial effusion. Death attributed to cardiac invasion in-cludes cardiac tamponade, congestive cardiac failure, coronary artery in-vasion and sino-atrial node invasion leading to fatal arrythmias.

Routes of invasion3 includes retrograde lymphatic extension, haematog-enous spread, direct contiguous spread and transvenous extension.

Diagnosis of cardiac metastases can be made by echocardiogram (tran-sthoracic and transoesophageal). CT and MRI scans can delineate the mass within the heart. The new technique of PET CT imaging enables us to identify the lesion as well as measures its metabolic activity using radio labelled glucose analogue 18-fluorodeoxyglucose (FDG).

Dr Sook Fong Koo, Dr Prashanth Raju, Dr Som Chuah, Dr Gershan DavisCardiology Research Group, University Hospital Aintree, United Kingdom

Corresponding Author: Dr Prashanth Raju MBBS, MRCP University Hospital Aintree, Longmoor Lane, Liverpool L31 1GA Email: [email protected]

Transesophageal Echocardiogram

Transthoracic Echocardiogram

Dr Prashanth Raju Dr Gershan Davis

....continued on page 14


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ECHO

Left Atrial Spontaneous Echo Contrast

Dr. Sadanand MyagerimathResearch/Teaching Fellow in CardiologyThe James Cook University HospitalMiddlesbrough

A 68 year old gentleman was referred by his GP with history of tran-sient ischemic att ack. His general

and systemic examinati on was normal. Echocardiography showed no evidence of structural valve disease. He had an ECG which confi rmed atrial fi brillati on (AF). In view of his history and AF he underwent transoesophageal echo (TOE) which dem-onstrated left atrial spontaneous echo contrast (LASEC), hence was anti -coagu-lated and DC cardioverted accordingly.

The left atrial (LA) appendage is a multi -lobed muscular extension of the LA.Normal blood fl ow in the LA appendage during sinus rhythm represses thrombus formati on. Pati ents with atrial fi brilla-ti on have lower fl ow velociti es, and fl ow < 20cm/sec is independently associated with increased risk of thromboembolic event1. Spontaneous echo contrast is commonly seen with TOE in pati ents with atrial fi brillati on1, 2. The smoke-like echo refl ecti ons are likely produced by back-scatt er from red cells aggregates at low fl ow rates and are markers of stasis, indi-cati ng a prothromboti c environment2. In retrospecti ve studies, dense spontaneous echo contrast has been associated with

increased risk of thromboembolic risk. Ideally all such pati ents should be anti co-agulated, to reduce the risk of thrombo-embolic events.

Reference:

Seidl K,Rameken M,Drogemuller A et al:Embolic events in pati ents with atrial fi brillati on and eff ecti ve anti coagulati on:value of transesophageal echocrdiogrphy to guide direct-current cardioversion.J Am Coll cardiol 39: 1436,2002.

Braunwald`s textbook of cardiovascular

medicine.8th editi on.

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In this case, our suspicion of cardiac metastasis was con-fi rmed by PET CT imaging.

Though myxoma can not be completely excluded with out a histological diagnosis, it is very unlikely in our case, given the appearance and atypical loca-ti on. We excluded the possibil-ity of a thrombus as there were no spontaneous echo contrast and the mass was not arising from the pulmonary vein or atrial appendages.

Although less used, defi niti ve diagnosis can be made by ob-taining histo-cytology samples from the mass itself or the peri-cardial fl uid in the presence of a pericardial eff usion.

Management of cardiac metas-tases is usually palliati ve due to the advanced course of the malignant disease. There have been reports of surgical exci-sion of the metastasis to im-prove quality of life and symp-toms4 but this is mainly limited to pati ents with good karnofsky performance status, minimal extracardiac involvement, indo-lent course of disease and main symptoms stemming from car-diac involvement.

References

Abraham KP, Reddy V, Gatt uso P. Neoplasms metastati c to the heart: review of 3314 consecuti ve autopsies. Am J Cardiovasc Pathol 1990; 3: 195-8.

Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990; 65:1456-9.

Schoen FJ, Berger BM, Guerina NG. Cardiac eff ects of noncardiac neoplasms. Cardiol Clin 1984; 2:657-70.

Messner et al. Surgical Management of metastati c melanoma to ventricle. Tex Heart

Inst J. 2003; 30(3):218-20.

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conti nued from page 12

Visit www.coronaryheart.com and click Education to see the LASEC video for this Case Study.


ECHO

Right Atrial Myxoma

Dr Mohammad Nasir Rahman and Dr Sajid DhakamCardiology DepartmentThe Aga Khan University HospitalPakistan

Introduction:

Atrial myxomas are the most common primary heart tumours. Because of nonspecific symptoms, early diagnosis may be a chal-lenge. Left atrial myxoma may or may not produce characteristic findings on auscultation. Two-dimensional echocardiography is the diagnostic procedure of choice. Most atrial myxomas are benign and can be removed by surgical resection. They affect the left side of the heart most often and are suggested when a patient devel-ops fatigue, syncope, or arrhythmia. Approximately 18% of myxo-mas involve the right side of the heart. These tumours often go undiagnosed for long periods and are most often considered when searching for a cause of recurrent pulmonary thromboembolism. . We report on a patient who presented with nonspecific abdominal complaints, shortness of breath and a clotting disorder secondary to a large right atrial myxoma.

Case Report:

This 17 year old boy presented to us with 2 months history of ab-dominal pain, shortness of breath and intermittent fever. His clini-cal examination revealed that he did have tachycardia, signs of right sided heart failure with bilateral pleural effusions. An EKG displayed low voltage with right atrial enlargement, and an echocardiogram showed a large echogenic mass extending from right atrium to right ventricle. View Figure 1. Pulmonary artery pressures and the pulmonary valve were normal but the tricuspid valve was obscured due to a large mass. There was also thrombus in the inferior vena cava. View Figure 2. Left sided chambers and valves were normal. The patient went under open heart excision of tumour, with repair of the tricuspid valve and atrial septum. A biopsy revealed diagno-sis of atrial myxoma.

The patient’s haemoglobin level was 11.0 g/dL, total WBC count 15,600/mm, and platelet count 49,000/mm. His prothrombin time was prolonged to 15.4 s, and partial thromboplastin time increased to 24 s (international normalized ratio, 1.6). His fibrinogen level was decreased to 186 mg/dL. D-dimer assay was positive at 3.2 µg/mL,

Figure 1 – an apical 4 chamber view with thrombus extending from RA to RV

Figure 2 – a subcostal long axis view of the IVC entering the RA


ECHO

1� CORONARY HEART ™

and the ratio of fibrin split products was found to be > 40. The analysis of blood gas levels with the patient breathing room air revealed the following: PaO2, 63 mm Hg; PaCO2, 23.2 mm Hg; and calculated bicar-bonate level, 18.8 mEq/L.

A dynamic CT scan of the chest also dem-onstrated bilateral effusions as well as a small pericardial effusion. The major ar-teries were free of thrombi, and the scan was interpreted as negative for pulmonary emboli. On close inspection of the helical CT scan, a mass was discerned in the right atrium and right ventricle.

On non-invasive vascular imaging of the right upper extremity, a fairly extensive deep venous thrombosis was visible. It involved the internal jugular, subclavian, and axillary veins. These vessels were distended and were filled with echo-genic material, which was consistent with thrombi.

Discussion:

Myxoma formation is three times more commonly seen in the left atrium com-pared to the right. A ventricular location is very unusual. Most commonly, it occurs in the left atrium. Patients have ranged in age from 11 to 79 years (mean, 48 years) with the majority of patients being be-tween 30 and 60 years old at the time of diagnosis. The surgical incidence was 0.5 atrial myxomas per 1 million population per year in the Republic of Ireland. Only 20% of these will involve the right atrium. Most cases are sporadic. Approximately 10% are familial and are transmitted in an autosomal dominant mode. Multiple tumours occur in approximately 50% of familial cases and are more frequently lo-cated in the ventricle (13% vs. 2% in spo-radic cases).

Myxomas take a polypoid, round, or oval shape and are gelatinous with a smooth or lobulated surface. The most common site of attachment is at the border of the fossa ovalis in the left atrium, although myxomas can also originate from the pos-terior atrial wall, the anterior atrial wall, or the atrial appendage. The mobility of the tumour depends upon the extent of

attachment to the interatrial septum and the length of the stalk.

Although atrial myxomas are typically be-nign, local recurrence due to inadequate resection or malignant change has been reported. Occasionally, atrial myxomas recur at a distant site because of intravas-cular tumour embolisation. The risk of re-currence is higher in the familial myxoma syndrome.

Symptoms are produced by mechani-cal interference with cardiac function or embolisation. Being intravascular and fri-able, myxomas account for most cases of tumour embolism. Embolism occurs in about 30-40% of patients. The site of embolism is dependent upon the location (left or right atrium) and the presence of an intracardiac shunt.

Jong-Won Ha and associates reported a more frequent occurrence of systemic em-bolism in polypoid tumours as compared to round (58% vs. 0%). Also, polypoid tu-mours more frequently prolapse into the ventricle. Prolapse of a tumour through the mitral or tricuspid valve may result in the destruction of the annulus or valve leaflets. In one study, 19% of the patients had atrial fibrillation associated with large atrial myxoma. Left atrial myxomas pro-duce symptoms when they reach about 70 g. Right atrial myxomas grow to approxi-mately twice this size before becoming symptomatic. Tumours vary widely in size, ranging from 1-15 cm in diameter. Rate of growth is not exactly known. In one case report, right atrial myxoma had a growth rate of 1.36 x 0.03 cm/month.

Removal of a right atrial myxoma is im-portant not only for preventing possible obstruction of the tricuspid orifice, elimi-nating pulmonary emboli, and maintain-ing systolic function, but also for restoring biventricular diastolic function.1 Surgical excision gives excellent short-term and long-term results that lead to an eventual cure of nonfamilial myxomas. The crucial aspects of surgery are measures taken for the prevention of intraoperative embo-lisms, en bloc excision of the tumour with a wide cuff of normal tissue, and the in-

spection of all four chambers in order to avoid missing tumour emboli or the occa-sional multicentric lesion. Clinical follow-up for at least 10 years may be needed to rule out recurrence or metastasis.

The clinical manifestations of atrial myxoma vary from no symptoms and no clinical signs to various manifestations of chronic or acute congestive heart failure, syncope, and arrhythmia, as well as vascu-lar evidence of tumour embolisation.

Sudden death may occur in 15% patients with atrial myxoma. Death is typically caused by coronary or systemic emboli-sation or by obstruction of blood flow at the mitral or tricuspid valve. Morbidity is related to symptoms produced by tumour embolism, heart failure, mechanical val-vular obstruction, and various constitu-tional symptoms.

References:

Jardine, DL, Lamont, DL (1997) Right atrial myxoma mistaken for recurrent pulmonary thromboembolism. Heart 78,512-514.

Bitner, M, Jaszewski, R, Wojtasik, L, et al (1998) Unusual course of right atrial myxoma, masked by acute abdominal pain and complicated by pulmonary embolus. Scand Cardiovasc J 32,371-373

Lijoi, A, Scoti, P, Faveto, C, et al (1993) Surgical management of intracardiac myxomas: a 16 year experience. Tex Heart Inst J 20,231-234.

Lee VH, Connolly HM, Brown RD Jr. Cen-tral nervous system manifestations of cardiac myxoma. Arch Neurol. Aug 2007; 64(8):1115-20.

Acebo E, Val-Bernal JF, Gomez-Roman JJ, Revuelta JM. Clinicopathologic study and DNA analysis of 37 cardiac myxomas: a 28-year experience. Chest. May 2003; 123(5):1379-85.

Silaruks, SS, Kiatchoosakul, S, Tatsanavivat, P, et al (1999) Atrial myxoma: a review of clinical experience at Srinagarind Hospital. J Med As-soc Thai 82,107-114

Bhan, A, Mehrotra, P, Choudhary, SK, et al (1998) Surgical experience with intracardiac myxomas: long-term follow-up. Ann Thorac

Surg 66,810-813

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Right Atrial Myxoma (cont...)

SITE VISIT


BMI London Independent Hospital

The London Independent Hospital1 Beaumont SquareStepney GreenLondon, E1 4NL

Private hospital owned by BMI Healthcare

One GE Innova Lab

Performs cardiac, endovascular, and neurology cases.

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The following site visit was undertaken by Coronary Heart Director, Tim Larner.

On the 23rd January 2009, we visited the BMI London Independent

Hospital, which is located in central London. The hospital is found close to public transport, providing easy access for staff and pati ents alike.

Unlike many of the hospitals we have visited with multi ple labs, The London Independent has just one however is for not only cardiac cases, but also endovascular and neurology procedures. This provides staff with a very unique and exciti ng work environment as they are constantly challenged with new techniques covering the enti re vascular system, a rare fi nd in the traditi onally cardiac-only orientated UK lab system.

Being one of London’s leading private hospitals the department has all the trimmings expected for the discerning pati ent, including carpeted corridors, cream walls with painti ngs, and soft lighti ng. This makes it feel more like a hotel, and gives staff a more calming work environment.

We never really knew much about this department before the site visit however we now believe it is one of those special work environments; a place you come to and are never likely to leave.

Departmental questi ons have been answered by Annie Ollivierre-Smith.

Staff numbers

We have 25 cardiologists, 4 Electro- physiologists, & 4 Radiologists.

Nurse: There are 3 nurses, which consist of a manager, 1 senior staff nurse & 1 staff nurse. We take a very traditi onal approach in our cath lab at the London Independent Hospital. Nurses are responsible for all aspects of pati ent care as well as the overall running of the cath-lab. Also nurses act as scrub or circulati ng nurses for procedures.

Fast Facts

The Cath Lab Team

From left: Sonia Pearce (Cardiac Technician), Connalyn Torres (Staff Nurse), Lavern Reid (Senior Staff Nurse), Devyani Parekh (Deputy Cardiology Manager),

Annie Ollivierre-Smith (Cath Lab Manager), Vina Kavia (Cardiology Manager)

SITE VISIT

Radiographers: There are 5 radiographers rotating from the imaging department & they are responsible for operating the X-Ray machine & all aspects of image storage.

Cardiac Technician: there are two Technicians who rotate from the cardiology department & they are responsible for the Haemo-dynamic monitoring & recordings during procedures.

Types of procedures:

Digital subtraction angiography, R&L heart catheters, PCI & stent implantation, E.P Studies & ablation, Pressure wire measurements, Temporary & permanent pacemakers implants, I.C.D’s closure of P.F.O. Aortic & Illiac stenting, Insertion of hickman, PICC lines & porta caths, embolisation of cerebral aneurysms.

Equipment:G.E. Innova 2100. Monoplane X-Ray machine

Biosense Webster carto system

Bard E.P. Monitoring System

Procedures performed per year?

There were 877 performed in 2008

Cross-training of staff:

We are a long-standing team of some 20 years plus, we all help each other.There are no plans for cross training in the future.

New procedures implemented:

We have implemented an electro physiology service, which is capable of all types of catheter ablations of ventricular Arrhythmias & percutaneous insertion of aortic stents.

Inventory Management:

We use the pen & paper method. Some of our drugs eluting stents are on consignment & the remainder of our stock is all bought. During procedures we collect all the equipment barcodes, these

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are assigned to the patient & also used to reorder stock. All our stock is ordered through the materials department once a week by the nursing staff.

Haemostasis Management:

About one third of our patients are treated by the radial route, the T.R. Band is used to manage haemostasis. The other two thirds are treated by the femoral route; half of these are managed by using an angioseal & the other half by manual compression.

Measures implemented to cut costs:

We try to standardise most of our products across the company, thereby reducing prices as a group rather than an individual hospital.

Training and continuing education procedures for staff:

New staff benefit from a comprehensive departmental & hospital orientation programme as well as multi disciplinary formal & informal teaching. All staff are encouraged to attend the in-house

training programme of manual handling, health & safety/fire awareness. All cath-lab staff attend the major cardiac meetings including the Advanced Cardiovascular intervention conference & cardiac cath lab professionals course.

Kinds of competency checks staff have to undergo once employed:

Staff are expected to have achieved competencies or certification in advanced life support/defibrillation, I.V. cannulation, groin management, removal of arterial & venous sheaths, administration of moderate sedation under verbal prescription. Nurses have to attain skill & competency levels in assisting & circulating for all procedures.

Dealing with late finishing of cases:

We are very flexible in our working hours; we stagger our times to suit our patients.

Policy for company reps within the lab:

By appointment & invitation with our consultants & cath-lab manager.

BMI London Independent Hospital (cont...)

Annie Ollivierre-Smith reviewing a case


SITE VISIT

What is the best part of working at your facility?

BMI Healthcare has a large group of hospitals & the London Independent cath- lab is well designed to suit the patient journey. There is a wide variety of work to keep all staff interested & motivated. We are very fortunate to have a well-established team with a high level of expertise in their roles & who are friendly & supportive of each other. The department works very smoothly as each team member is aware of the roles of others & is able to contribute, making the workload much easier. The procedures performed in the cath-lab are highly specialised & the contribution of all team members is greatly appreciated.

Devyani Parekh having a laugh with the rest of the team

• A long history of providing cardiac services • Some of the best consultant cardiologists and cardiac surgeons in the country• Continual investment in new equipment including a new cardiac investigations unit built in 2006• Fully supported by Level III ICU and Level II HUD 24/7• Top of the range imaging including a 128-slice CT scanner

Why is The London Independent Hospital

one of the leading providers of cardiac services in the UK?

Cardiac Services

We offer the following wide variety of complex procedures including:

• Electrophysiology Studies• Catheter ablation• Invasive cardiothoracic surgery• Coronary bypass surgery• Rapid Access Heart Centre• Renal angiogram• Renal stent implantation

• Insertion of Hickman & Picc lines • Percutaneous Aortic stent implant• Implantation of ICD’s• Implantation of pacemakers• Coronary Angioplasty & stent insertion

For further information call 0207 780 2608 or email [email protected]

CORONARY HEART ™ 1�

CATH LAB


Radial Approach To Cardiac Catheterisation

Coronary artery catheterisati on is performed through two main routes: the femoral and radial

arteries. Femoral artery access forms the traditi onal route while a third route namely, the brachial artery, involves a surgical cut down method is now largely defunct. This arti cle looks at the basic radial artery anatomy, considerati ons for radial artery access – including pati ent care, advantages and disadvantages when compared with the more popular femoral approach.

Anatomy and procedure considerati onsAnatomically, the radial artery (see fi gure A) can be traced from the brachial artery at the cubital fossa in the anterior aspect of the elbow. From here, the artery follows a lateral course of the arm, lying deep in the dorsal interosseous muscles and terminati ng at deep and superfi cial palmar arches where it joins with the ulna artery.

The fi rst step in pati ent preparati on, as is the case for all cath lab procedures, is to ensure that the pati ent understands the procedure and consents to have their angiogram via the radial artery. Pati ents undergoing the radial artery approach must have their pulse felt so that adequate blood fl ow to the

hand can be established. In most departments, it is standard practi ce to perform an Allen’s Test. This test is done to assess the adequacy of ulna collateral blood supply which reduces the risk of ischaemia to the hand if the radial artery is compromised during a case.

Another important considerati on is the radial board used. This is a very

useful aid, even if a simple and rather inauspicious accessory, because it supports both the pati ent’s arm and the accessory equipment. It is important to positi on the board reasonably well at the start of the case - the operator/cardiologist will have a preference and would normally make recommendati on here. A bag of saline or rolled up towel will help to support the pati ent’s elbow and wrist on the board making them relaxed and comfortable.

Radial boards come in diff erent shapes and sizes. The decision to use one or the other is operator dependent. At least fi ve types are available in my department. One of them (see fi g B) will not be out of place among a professional surfer’s paraphernalia. However, this board has all the advantages described above and is the preferred choice in most cases.

The pointed end of the board is positi oned under the shoulder of the pati ent while the wide end acts as support for the arm and wrist. It also acts a useful work top.

Vessel spasm and medicati on

Vessel spasm is a feature of radial artery catheterisati on. Generally, there is a mismatch in diameter between the inner lumen of the artery and that of the sheath or catheter which causes fricti on. This fricti on (and related pain felt by the pati ent) is caused by manipulati on of sheath of guide wire/catheter in the radial artery, Kiemeneij (2006). Other

Mohamed SankohSenior RadiographerThe Heart Hospital University College London NHS TrustLONDON

Fig A: Radial artery and associated blood vessels

From (http://en.wikipedia.org/wiki/Image:Gray528.png)

Figure B: White radial board

CATH LAB


causes of spasm include tortuous artery, diseased vessels and small radial artery diameter.

Artery spasm can lead to a diffi cult and someti mes impossible radial procedure. There seems to be no standard range of drugs that accompany a radial approach. However, a cocktail of drugs are used to manage artery spasm during radial catheterisati on as follows:

GTN (glyceryl trinitrate): contains nitric oxide which relaxes blood vessels thereby enhancing blood fl ow through the vessels. Some cath labs use ISDN (isosorbide dinitt rate - marketed as Isoket) or other forms of the drug. They all perform the same functi on of dilati ng the radial artery and relieving pain.

Verapamil: (2.5mg strength) Verapamil is a calcium channel blocker. It blocks the entry of calcium ions in cells of the heart muscle, coronary and systemic arteries. Verapamil relaxes smooth muscles of the heart and blood vessels and is used to treat hypertension, angina and arrhythmia. The vasodilatory property of verapamil helps to reduce the incidence of arterial spasm that may occur during radial approach. Vasodilati on will facilitate the passage of catheters and other accessories down the radial artery, resulti ng in the successful completi on of a procedure.

As both Verapamil and GTN help to dilate blood vessels, pati ents should be monitored for associated drop in blood pressure. At high doses, verapamil can cause bradycardia, arrhythmia and heart block. Other side eff ects may include nausea and headache.

Heparin may also be given as part of the radial approach cocktail. It is an anti coagulant given to stop the formati on clot within the blood vessels. Other medicines such as aspirin if given with heparin, can increase bleeding or increase the ti me it takes to stop bleeding. Cauti on must be taken where heparin is used in combinati on with other drugs.

Sedati ves are also given to help relieve pain and to relax the pati ent. Other prophylacti c and spasmolyti c drugs (and someti mes anxiolyti cs) other than those menti oned above are also used.

Aft ercare and haemostasis

Aft er the radial procedure, the access site is cleaned, the sheath removed and compression applied over the puncture wound. Compression is done either manually or by using a closure device. Two main radial artery compression devices are in use.

These are

RADISTOP

This radial compression system (fi g c) includes a Styrofoam support plate, Velcro strap and sterile compression pad. The support plate on the back of the hand/wrist helps to keep the hand straight such that the need to bend the hand and disrupt compression is prevented.

TR BAND

Two sizes are available: the regular 24cm and a 29cm long version for pati ents with bigger wrist circumference.

The device (fi g D) is made up of an injecti on port, infl ati on syringe, Velcro strap and transparent dual compression balloons which ensure exact compression of the radial artery.

For both devices, haemostasis is easily achieved in the absence of any issues such as eff ect from analgesia on the pati ent, they can mobilise immediately and even walk from the lab and back to the ward.

Advantages of radial approach

Lucien Campeau was the fi rst person to describe radial artery catheterisati on in 1989. Nearly twenty years on, technology has evolved to refi ne equipment and practi ti oner skills have advanced to off er many advantages to pati ents undergoing radial catheterisati on. These advantages are:

The artery is easily accessible and is easy to palpate. Its superfi cial locati on also makes the artery easy to compress. This is parti cularly important in anti coagulated pati ents when the radial approach off ers the best means of maintaining haemostasis.

Normal Allen test ensure collateral blood supply to the hand. Hence, any procedural occlusion in the radial artery is unlikely to compromise blood supply to the hand.

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Fig C: RADISTOP deviceImage Courtesy: Radi Medical Systems

Fig D: TR BandImage Courtesy: Terumo Interventional Systems

CATH LAB


Radial approach provides comfort for patients because the procedure assures them the ability to mobilise. In fact, it is possible for patients who have undergone this procedure to walk from the lab table and back to the ward.

It is easier to notice and control bleeding from the radial artery. The femoral artery on the other hand lies deeper in the leg and compressing the artery can be difficult. In addition bleeding would be considerably significant by the time a haematoma is noted.

The limitations and risks involved via femoral approach in the presence of vascular disease and for obese patients are overcome in the radial method.

The importance of radial artery in coronary angiography is seen in relation to the femoral approach. Several studies have compared the two approaches.

For instance, Mann et al (1998) had earlier shown that there are less complications of bleeding from the radial artery which necessitates early mobilising and a shorter length of stay in hospital. Similarly, Archbold et al (2004) showed less access site complication in the radial artery. The authors also noted a preference of radial access over femoral by patients who have had angiograms through both routes previously and by managers because of the related reduced cost of radial cases. Cost effectiveness of radial versus femoral approach has also been looked at recently by Roussanov et al (2007). This team reported that there is a significant financial benefit made (cost of vessel closure devices) for the radial artery approach.

Disadvantages of radial approach

Many of the disadvantages are related to the technical difficulties of performing the procedure.

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These difficulties are the steep learning curve involved in perfecting the technique, problem associated with placement of the catheter, all of which may explain the general reluctance of operators to try and embrace a new approach.

Other disadvantages include the small size of the radial artery and the incidence of vessel spasm.

Radial artery access is not indicated for certain patients who have a negative Allen Test.

Patients who may require placement of an IABP (intra aortic balloon pump) may not be ideal for radial angiography.

Radial approach is also contra-indicated in patients for rotablation and other procedures that may require a larger sheath size;Patients who have known vascular disease of the upper extremities.

Given the many benefits of radial catheterisation, one wonders why there are very few centres and cardiologists practising this technique. As stated by other observers, Williams (2008) also stated that the radial approach has a steep learning curve and the technique required is much greater than the femoral route. However, he observed that this problem can be overcome with experience and improvement in technology. Williams noted that ‘’although femoral arterial access is unlikely to become obsolete overnight, it may well be ultimately viewed as brachial access is today: a second line approach with an increased complication rate which is rarely required in routine practice’’

Williams is perhaps a bit overly optimistic, however, Campeau (1989) had modest expectations - when he first described radial angiography - in suggesting that radial approach could be safe and effective enough to rival and only replace the brachial route.

REFERENCES

Archbold, R.A., Robinson, N.M., Schilling, R.J. Radial artery access for coronary angiography and percutaneous coronary intervention. BMJ. 2004 21; 329(7463): 443–446.

Campeau, L. Percutaeneous Radial Artery Approach for Coronary Angiography. Catheterisation and Cardiovascular Diagnosis 1989; 16 (1): pp3-72

Kern, M.J., King 111, S.B., Douglas, J.S., Franch, R.H., Cardiac Catheterisation, Cardiac Angiography, and Coronary Blood Flow and pressure measurement. Chp17 in HURST’S THE HEART MANUAL OF CARDIOLOGY O’Rourke, R.A., Fuster, V., Alexander, R.W., King, S.B., Nash, I., Prystowsky, E.N. (Editors) (2005) 11th ed. McGraw Hill

Kiemeneij, F. Prevention and Management of Radial Artery Spasm. The journal of Invasive Cardiology 2006; 18 (4): pp159-160

Mann, T., Cubeddu, G., Bowen, J., Schneider, J.E., Michael Arrowood, M., Newman, W.N., Zellinger, M.J., Rose, G.C. Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. Journal of the American College of Cardiology, 1998; 32: pp572-576

Neal, M.J. (1992) Medical Pharmacology at a Glance. London: Blackwell Science

Rang, H.P., Dale, M.M., Ritter, J.M., Moore, P. (2003) Pharmacology. London: Churchill Livingstone

Roussonov, O., Wilson, J., Henley, K., Estacio, G., Hill, J., Dogan, B., Henley, W.F., Jarmukli, N. Cost Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterisation. Journal of Invasive Cardiology 2007; 19 (8): pp349-353

Swanton, R.H., Banerjee, S. (2008) Swanton’s Cardiology: A Concise Guide to Clinical Practice. Oxford: Blackwell Publishing

http://www.accumedsystemsinc.com/resources/radial_artery_access_manual.pdf Almany, S.L., O’Neill, W.W. Radial Artery Access for Diagnostic and Interventional Procedures. 1999 [Accessed 10/12/08]

http://www.bcs.com/pages/news_full.asp?NewsID=18866986, Williams, P. Femoral arterial access for coronary procedures - obsolete or here to stay? British Cardiovascular Society 11 November 2008 [Accessed 10/12/08].

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Radial Approaches to Cardiac Catheterisations (cont...)

BUYERS GUIDE


StentBoost?

StentBoost is controlled from table-side by the Xper module. A run of 100 images of the stent in the vessel

is taken, of which 60 are contrast filled. The system then automatically summates the images and presents an augmented image of the stent alternating subtracted and unsubtracted views. Images are dis-played immediately on the colour monitor

in the lab, without user interaction.

Allura 3D-CA?

Allura 3D-CA is an interventional tool that allows modeling of the coronary archi-tecture and visualization of the optimal projections for multiple lesions. Models are based on a simple rotational cardiac run, all controlled from the Xper mod-ule at tableside, in real time. Multiple branches can be modeled to create a full coronary tree.

As with CT TrueView, the following functionality is available:

TrueView: defines the optimal working projections, of the lesion or bifurcation, based on the Philips exclusive intuitive view map. Map colouring shows the level of foreshortening of the lesion in question.

3D Automatic Position Control (3D-APC): when the optimal projection has been chosen using TrueView, the C-arc will automatically move to this position.

3D Follow C-arc: when the position of the C-arc is changed, the 3D CA model will automatically follow the position of the C-arc, without need for radiation.

DoseWise?

DoseWise is Philips dose management programme, the main aspects in cardiac are:

Spectrabeam – High levels of beam filtration automatically available on all patients, due to the high capacity of the X-ray tubes on these cardio-vascular systems. Tube technology is liquid metal bearings with unique di-rect anode cooling for maximum heat management.

Xper beam shaping – Virtual collima-tion and movement of filters.

Xper fluoro storage - Due to the high quality of fluoro imaging available, events can be recorded without re-course to acquisition runs.

Xper dose display – Provides simple graphical display of the dose rate and acquired dose for 10 different ana-tomical areas of the cardiac patient.

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As the interventionalist moves from projection to projection, the system shows the summated skin dose for that particular region.

CT TrueView?

CT TrueView is a unique interventional tool that uses a 3D CT segmented dataset from the Philips CT Extended Brilliance Work-station to select and visualise the optimal projection to view a lesion or bifurcation. It is a fully integrated imaging application that allows fast and easy set-up of the op-timal C-arm working projection for PCI, with the same workflow as 3D CA.

Which x-ray systems are the above packages available on?

All of the above packages are available on all Philips cardiovascular systems, and all are suitable for display on our FlexVision XL (56”, 8M monitor).

Please note, we also have specialist interventional tools available for EP cardiac:

EP Navigator integrates real time fluor-oscopy with segmented cardiac anatomy from CT or spin acquisitions in the lab, and also integrates with imaging on the Bard Labsystem Pro.

StentBoost for real-time visualisation of subtracted/

unstracted stent in coronary artery

3D-CA for real-time modelling of the full cardiac anatomy

EP Navigator with segmented cardiac anatomy embedded in

real-time fluoroscopy

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Philips Healthcare Cardiology X-ray Systems

Software Packages Buyers Guide

CRM


This education article is proudly provided by

As the ICD population continues to grow at an exponential rate, the follow-up burden has also increased dramatically. In-hos-

pital follow up visits are costly and time-consuming to the Physician, Cardiac Phys-iologist and patient. Currently, patients are usually seen at follow-up clinics every 3-6 months, depending on local protocols. The logistics of monitoring these devices have already placed a substantial and in-creasing burden on the follow up centre. In fact, it is estimated that in 2006 approx-imately 2,565,000 ICD follow-up1 visits were performed worldwide.

The number of patients with ICD’s will con-tinue to increase due to an aging popula-tion, cardiovascular disease prevalence, broadening CRM indications and market penetration. Traditionally, patients are seen at device clinics every 3-6 months. The bulk of these routine visits involve data collection only, and in fact, 55% of these visits do not result in any changes to the medical therapy for the patients.1

The availability of remote monitoring of implantable cardiac devices requires a change in the follow-up model and care pathway protocols. Remote monitoring technology reduces the need for face-

to-face clinic visits and may facilitate, if needed, visits triggered by a clinical event.

The TRUST trial (Lumax-T/Lumos-T safely RedUceS rouTine office device follow-up) is a controlled multi-center, prospective, randomized trial which is the first and larg-est study in the CRM industry to provide clinical evidence of the safety and efficacy of remote monitoring. It’s a randomized trial with 1443 ICD patients enrolled to-date in 105 centers in the US and Canada. The goal of this trial is to demonstrate that the BIOTRONIK Home Monitoring® system can safely reduce in-office follow-ups, and detect silent clinical events early.

Study design:

Multi-center, prospective, controlled, randomized trial

1,443 patients enrolled to-date, 1,312 patients with at least one follow-up

105 sites in US & Canada

Patients will be implanted with Lumax or Lumos VR-T/DR-T

Any legally marketed leads may be used

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Any legally marketed leads may be used

Two group randomization (2:1 ratio):

- BIOTRONIK Home Monitoring = ON

- BIOTRONIK Home Monitoring = OFF

Patient participation and follow up period: Up to 15 months

Key Inclusion Criteria:

Implanted within the last 45 days or being considered for implantation of a BIOTRONIK Lumax/Lumos ICD with Home Monitoring technology

Ability to use Hone Monitoring system

Ability to give informed consent

Ability to return to clinic for protocol required follow-ups for

15 months

At least 18 years old

Key Exclusion Criteria:

Patients who are pacemaker dependent

Patients who are currently enrolled in any other cardiac clinical investigation

Patients who do not fulfill all inclusion criteria

Primary Objective:

Demonstrate that BIOTRONIK Home Monitoring system can safely reduce in-office follow-ups

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Reducing in-hospital ICD follow up’s safely

- The TRUST Trial

ICD global implants: Eucomed data, Morgan Stanley Research from December 10, 2007

CRM


Primary Endpoint – Effectiveness

To compare the number of in-office follow-ups for patients in BIOTRONIK Home Monitoring group vs. Control group

Primary Endpoint – Safety

To compare the composite safety event rate (SER) between the two groups:

Death

Incidence of stroke

Events requiring surgical interventions (e.g., device explants, lead revisions and ablations).

BIOTRONIK Home Monitoring group

Requires Home Monitoring follow-ups at 3, 6, 9, 12 and 15 months post-implant.

Requires an office device follow-up after 3 and 15 months.

Control group

Requires office device follow-ups at 3, 6, 9, 12 and 15 months post-implant

Home Monitoring turned off

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ControlBIOTRONIK

Home Monitoringp value

Number of patients

414 898

Age 64.0 ± 12.0 63.3 ± 12.8 n.s.

Gender (male) 73.2% 72.0% n.s.

LVEF 28.5 ± 9.7% 29.0% ± 10.7% n.s.

CAD 71.7% 64.8% 0.01

β-blocker 75.6% 79.8% n.s.

ACE-inhibitor 45.9% 42.8% n.s.

ARBs 9.4% 7.8% n.s.

Primary prevention

73.7% 72.4% n.s.

Dual chamber implants

58.1% 56.8% n.s.

Study Timeline

Results: Patient demographics

Percentage of patients with morbidity.

8.7%9.1%

Control(n=414)

Home Monitoring

(n = 898)

TRUST demonstrated comparable rate of death, stroke and events requiring surgical intervention in both groups.

3.5

Control(n=414)

Home Monitoring

(n = 898)

p<0.001

2.0

BIOTRONIK Home Monitoring delivers a reduction of 43% in-office follow-up visits.

Mean number in-office visits per patient year

CRM


Reducing in-hospital ICD follow up’s safely (cont...)

Results and Conclusions:

In comparison with the control group of patients enrolled in conventional in-hospital follow up, clinical trial data from TRUST show that remote monitoring:

Reduces the number of in-office follow-up visits, while maintaining patient safety. The remote monitoring group had approximately half the total number of office visits as compared to the conventional follow-up group while achieving the same patient outcomes.

Leads to earlier detection of ar-rhythmic events.

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In the remote monitoring group, the time from onset of the arrhythmic event to evaluation was reduced by 21-35 days compared to the control group, depending on the type of ar-rhythmia detected.

Drives efficient use of clinic time. Eighty-nine percent of remote moni-toring alerts were managed remotely and required no follow-up office visit. About 30 percent of unsched-uled office visits among patients in both the control and study groups required physician interaction and were considered actionable. * However, unscheduled office visits that were triggered by the remote monitoring system nearly doubled

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the rate of treatment; more than 51 percent led to some action by the clinician, making better use of clinic time.

Quotes about TRUST:

”The data demonstrates that the BIO-TRONIK Home Monitoring system safely reduces the need for conventional in-office visits, while improving follow-up adherence, and enables earlier evalua-tion of clinically relevant cardiovascular events,” said Dr. Niraj Varma, TRUST prin-cipal investigator, Cleveland Clinic. “Based on the results from this large-scale clinical trial, I believe remote monitoring may improve the way physicians care for patients with implanted cardiac devices.”

continues on page 28

The time to evaluation of clinically relevant tachyarrhythmia events

Days gained using BIOTRONIK Home Monitoring® to identify arrhythmia events in comparison with conventional in-office follow-up visits

About �0% of the Home Monitoring alert notifications can be managed remotely78.6%

87.6%p<0.001

BIOTRONIK Home Monitoring improves adherence to follow-ups

Adherence to scheduled follow-up visits

Control(n=414)

Home Monitoring

(n = 898)

BIOTRONIK Home Monitoring®

Advanced Patient Follow-up Management

Using the BIOTRONIK Home Monitoring® Service,

physicians get up-to-the-minute information on

their patient and the implanted device. This novel

technology automatically transmits data, enabling

them to optimize therapy and follow-up treatment.

Messages straight from the heart

· Wireless, fully automatic, daily monitoring

· Patient-specific review of implanted device and therapies

· High-level alerts communicated to physician

· High degree of patient acceptance

www.biotronik.com

CRM

Next Issue:

“The study results show that remote monitoring facilitates follow-up care and, very importantly, enhances pati ent safety, which can provide pati ents with additi onal security,” said Dr. Andrew Epstein, TRUST principal investi gator and professor of medicine in the division of cardiovascular disease at the Univer-sity of Alabama at Birmingham.

“Decreasing the number of non-acti onable, scheduled and un-scheduled offi ce visits through remote monitoring will ease the pressure of overloaded follow-up cardiac clinics. This will permit physicians to focus on pati ents who actually require interven-ti on,” said Dr. Charles Love, TRUST principal investi gator and director of arrhythmia device services and associate investi gator, Dorothy M. Davis Heart & Lung Research Insti tute at The Ohio State University Medical Center.

Trail Executi ve committ ee:

Niraj Varma, M.D. Principal Investi gator, Cleveland Clinic, Cleveland, OH

Venkateshwar Gotti paty M.D. South Carolina Heart, Colum-bia, SC

Shumel Inbar, M.D. Odessa, TX

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John Ip, M.D. Ingham Hospital, Lansing, MI

Charles Love, M.D. Ohio State University, Columbus, OH

Suresh Neelagaru, M.D. Lone Star Arrhythmia & HF, Am-arillo, TX

Farrell Pierson, M.D. Knoxville, TN

Robert Schweikert, M.D. Cleveland Clinic, Cleveland, OH

References:

Wilkoff Europace 2008, 10, 707

Joseph et al. Remote Interrogati on and Monitoring of Im-plantable Cardioverter Defi brillator., JICE 2004; 11: 161-166

* An acti onable follow-up visit is defi ned when there is:- An ICD lead system revision- An initi ati on or up-ti trati on of anti -arrhythmic medicati ons- A clinically signifi cant ICD re-programming, for example:• Increases in pacing output of > 1.0 V• Changes in VT/SVT algorithm/setti ngs for the purpose of preventi ng inappropri-ate shocks and delivering appropriate shocks• Changes in the programming of the lowest tachy rate boundary for the purpose of preventi ng inappropriate shocks

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Reducing in-hospital ICD follow up’s safely (cont...)

Events Diary:April 22The 4th Oxford Live CourseJohn Radcliffe Hospital, OxfordVisit: www.millbrookconferences.co.uk

April 28BSCI Spring MeetingHeartbeat Education Centre, Southampton General HospitalVisit: www.bsci.org.uk/meetings

May 19-22EuroPCR 2009Barcelona, SpainVisit: www.europcr.com

June 1-3BCS Annual Conference and Exhibition 2009London, ExCeLVisit: www.bcs.com

October 18-21Heart Rhythm Congress 2009Hilton Birmingham Metropole, BirminghamVisit: www.heartrhythmcongress.com

Edition 18 (May/June)

Electrophysiology + CRM

Latest News and ECG Quiz returns

Education Article with Ian Wright

Electrophysiologist Interview

Invasive CardiologyHot Topic:

- FAME (Part 2) & Complex strategies for treating bifurcations.

Management

Should echocardiographers run cardiac MRI units?

How to successfully implement cardiac MRI into your lab environment.

Developing partnerships with local EMS providers to decrease door to balloon times.

Your experience with hybrid labs for PCI.

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Like to advertise or submit articles? See page 3


Technical Support SpecialistBIOTRONIK® is a global player with European roots, having

established a global network with a presence in more than 100 countries around the world. Over 3,400 employees research, develop, produce and sell BIOTRONIK® products and support our customers

on every continent.

BIOTRONIK® continues to expand in the UK and we are now recruiting for a Technical Support Specialist to join the Southern CRM

and EP Team.

You must have pacemaker, ICD and CRT implantation and follow-up experience within the NHS as well as an understanding of EP

procedures. A proven ability to educate and train others is essential as is a commitment to providing industry leading service for both internal and external customers. You must be self motivated, dedicated and

work effectively as both an individual and within a team.

This position offers an excellent package and is based around the London area however a flexible approach to supporting the southern

region is desirable.

We look forward to you joining us in living the Biotronik brand and helping us to continue to achieve excellence for life.

Please apply in writing together with a CV to:Nicola Booth, Southern Regional Manager, Biotronik UK Ltd, Biotronik

House, Avonbury Business Park, Bicester, Oxfordshire, OX26 2UA or call 07802 202331.

Closing date for applicants is 27/03/2009

Advertisers’ Index:

02 Scan Modulwww.scanmodul.com/spacetrax

07 RADI Medicalwww.radi.se

08 Fundamentals of ICD Implantationemail: [email protected]

13 Siemens Healthcarewww.siemens.com/echoinaheartbeat

19 The London Independent Hospitalemail: [email protected]

27/29 Biotronikwww.biotronik.com

29 Mediplacementswww.mediplacements.com

30 Your World Medical Recruitmentwww.yourworldmedical.com

30 Kirkham Youngwww.kirkhamyoung.co.uk

31 Royal Berkshire NHS Foundation Trustwww.royalberkshire.nhs.uk/jobs

32 British Cardiac Societywww.bcs.com

CORONARY HEART ™ 2�CORONARY HEART ™ 2�

RECRUITMENT

30 CORONARY HEART ™30 CORONARY HEART ™

Medical Recruitment

Locum and permanent positions, domesticallyand internationally for Cardiac Physiologists,Cath Lab staff and Sonographers. Trainee rolesare also available.

Specialists in Cardiology and RadiographyCall now to register your interest if you

are seeking work or staff

Australia freephone 1300 36 23 37 tel +612 9994 8074

[email protected]

New Zealand Freephone 0800 508 [email protected]

Call the our specialist team direct

020 7426 [email protected]

For clients and candidates in Australiaand New Zealand please contact

RECRUITMENT

refreshinglyKirkham Young

rejuvenate... relax... revitalise...

Kirkham Young® is the registered trade mark of Kirkham Young Limited.

Clinical Trainer Roles

Clinical Education - Cardiology

Clinical Education Specialist roles offer the chance to use your hard won clinical skills and passion for teaching in a rewarding,

varied and stimulating setting. Working for global healthcare companies you will be valued and enjoy real career development.

Responsible for demonstrations and pre and post sales training and support to a wide range of customers, you will work

with cutting edge products to provide the best possible customer service and thus patient care.

Product Specialists - EP/ Pacing - UK Wide - c£35,000 basic + Bonus + Car + Benefits

Preferably educated to degree level of qualified in clinical physiology you will have strong clinical cardiology experience

from the cardiac catheter lab environment, preferably with either AF or EP experience. Urgent requirements in the

Thames Valley, Midlands and Yorkshire regions with other opportunities across the UK.

Application Specialists - Echocardiology £35-40,000 + car + bonus + package

With extensive skills in cardiac ultrasound you will have BSE accreditation or equiv and a passion for teaching

and training. Cutting edge technology and Blue Chip companies offering great long term career opportunities.

Clinical Specialist - Interventional Radiology/ Cardiology £neg + package

Great opportunity in training and support for a qualified nurse with substantial clinical experience you will

have an in depth knowledge of interventional radiology, cath lab, vascular surgery, stenting / grafting or EVAR

procedures. South East home base, potential for some international travel.

To find out more about these superb opportunities and also our current requirements for

experienced sales and marketing professionals across the UK please call 0870 787 3134 or

e-mail your CV in confidence to [email protected]

reactive... reassuring... recruitment...

0870 787 3134 www.kirkhamyoung.co.uk

190_130_110209 12/2/09 8:41 am Page 1

Staff Nurse

The Royal Berkshire NHS Foundation Trustcontinues to grow and increase our reputationfor clinical excellence. We are committed todelivering high quality care to our patients. Our cardiology service is at the forefront of innovation and as part of ourongoing development into a 24/7 Primary PCI centre, we are implementinga unique direct access chest pain assessment unit. This will consolidateour existing 16 bedded CCU, Cardiology Ward, 2 Catheterisation Labs andOut Patients department into a dynamic integrated Cardiac Centre.

As a Staff Nurse in our modern purpose built facility, you will be instrumentalin ensuring this revolutionary model of practice optimises patient care,treatment and experience to ensure better outcomes for our patients.

Our excellent on-going training includes a comprehensive induction andorientation programme. Our Department Managers provide strongleadership and clinical excellence, which combined with our PracticeDevelopment Team, will enable you to enhance your clinical skills andknowledge, and ensure that the support you get is of the highest standard.

Informal enquiries to Arran Rogers, Cardiology Projects orMark Brunton Ward Manager on 0118 322 5288

To apply go to www.royalberkshire.nhs.uk/jobs

283243 coronary heart 26/1/09 13:45 Page 1

CORONARY HEART ™ 31CORONARY HEART ™ 31

RECRUITMENT

From Basic Science to Bedside

BCS Annual Conference and Exhibition 2009Venue: London, ExCeL Date: 1 to 3 June 2009

Members of the British Cardiovascular Society

can register for free before 31 March 2009.

For registration or details on how you can

become a member of the Society please

go to www.bcs.com.

3 Day meeting of educational and scientifi c interest in Cardiovascular Medicine

International Keynote Lectures including Dr Valentin Fuster

Educational content based on the new European Curriculum

1510 Conf_A4_ad.indd 1 16/2/09 16:24:46

Coronary Heart #17

Documents

cover photo

cardiology environment

readers responsibility

work environment

interesti ng arti cles

interviewdr keith oldroyd

reviewing arti cles

leading cardiologists