Coronary Heart #22

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Automated Inventory Management

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

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Yes or No?

Hats and Masks in the Cath Lab

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Issue 22 • Jan/Feb 2010

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ContentsJan / Feb 2010

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 publi-cati 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 .

Copyright © 2006 -2010 by Coronary Heart Publishing Ltd. All rights reserved. Material may only be reproduced by prior arrangement and with due acknowledgment of Coronary Heart Publishing. The publicati on of an adverti sement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.


Round UpInternati onal News

Ancient Egypti ans Had Heart Disease Too!

In an interesti ng study by researchers in the USA has begun to shed new light on heart disease, challenging the belief that vascular dis-ease is a modern affl icti on caused by current-day risk factors such

as stress and sedentary lifestyles. Michael Miyamoto, MD, a gradu-ate of the UC San Diego School of Medicine and assistant clinical pro-fessor made an expediti on to Egypt to evaluate the prevalence of cardiovascular disease in 3,500-year-old mummies. The results were published in the Journal of the American Medical Associati on.

Miyamoto and a team of cardiologists and Egyptologists, carefully examined 22 mummies from the Museum of Egypti an Anti quiti es using a six-slice CT scanner. In the mummies with identi fi able arter-ies, more than half had calcifi cati ons in the walls of their arteries. Those who died aft er the age of 45 showed the highest degree of calcifi cati on. Vascular disease was observed in both male and female mummies.

Surprised by their results, the cardiologists asked the Egypti an pres-ervati on team to share informati on about the lifestyle of ancient Egypt. In general, all who were later mummifi ed, served in the court of the Pharaoh or as priests or priestesses. Diet-wise, eati ng beef, duck and other poultry was not uncommon. Since refrigerati on was unavailable, salt was widely used for meat preservati on. Tobacco was not available and without mechanical transportati on, they were likely physically acti ve.

“Our fi ndings show that atherosclerosis is not strictly a disease of modern humans caused by unhealthy lifestyles,” said Miyamoto, a cardiologist and co-investi gator of the study. “In fact, it is possible that humans have a geneti c predispositi on to the development of atherosclerosis. Our fi ndings remind us of the value of preventi ve medicine in eliminati ng or controlling manifestati ons of heart and vascular disease.”

Heart Study to Target Harmful Immune Cells in the Arteries

The BBC recently reported that scienti sts are trying to devel-op a treatment to target harmful immune cells in the arter-

ies that are believed to trigger many heart att acks. The Bristol Heart Insti tute with the backing of the Briti sh Heart Founda-ti on is commencing a study which follows on from two decades of trial and error, since it was fi rst discovered that a pati ent’s immune system could produce the infl ammati on in the arteries that leads to an att ack.

So far any drugs developed have unfortunately killed off the helpful as well as the harmful cells. The new study is aimed at targeti ng just the harmful cells which, it is believed, are drawn to the arteries as a result of the plaques of fatt y depos-its that build up there. This can lead to the artery becoming infl amed, and the wall damaged, which in turn can lead to a heart att ack.

Is Your Boss Annoying You? Then Speak Up!

Swedish researchers recently undertook a study of 2,755 male employees in Stockholm whom had previously not

had a heart att ack. Each were asked about how they coped with confl ict at work, either with superiors or colleagues. The opti ons were:

Dealt with things head-onLet things pass without saying anythingWalked away from confl ict Developed symptoms like headache or stomach acheGot into a bad temper at home

Results showed that the men who coped by someti mes or oft en walking away or who oft en let things pass without saying anything, had double the risk of a heart att ack or dying from serious heart disease compared to men who challenged and dealt with the situati on head-on. The researchers believe that anger can produce physiological tensions if it is not released and that these lead to increases in blood pressure which even-tually damage the cardiovascular system.

Judy O’Sullivan, senior cardiac nurse for the Briti sh Heart Foun-dati on, said: “Stress itself is not a risk factor for heart and circu-latory disease, but some people’s responses to stress, such as smoking or overeati ng, can increase your risk.”

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Source: BBC


ProductsCardiac Imaging

An evaluati on report by KCARE, for the Centre for Evi-dence-based Purchasing (CEP), on the ACUSON P10™ ultrasound system from Siemens Healthcare suggests

that use of the handheld unit may reduce the number of people referred for full ultrasound examinati ons, parti cu-larly in Cardiology.

The P10 is a unique handheld ultrasound system small enough to fi t into a coat pocket and weighing just

700 grammes (see image left ).

Its role in cardiology could assist initi al referral or assessment on ward rounds, providing basic

informati on without the need to perform a full echocardiogram.

The KCARE report includes feedback from UK users of the P10 who assessed its clini-cal suitability, cost eff ecti veness and likeli-

hood of reducing referrals for a range of clinical applicati ons. Responses were positi ve

overall with 10 second start-up ti me, portability and reliability parti cularly well rated.

The London Chest Hospital, part of Barts and The London NHS Trust, has installed the fi rst Siemens SOMATOM® Defi niti on Flash CT system in the UK for fast CT speed combined with the

lowest radiati on dose. The scanner purchase was made possible by funding from The Nati onal Insti tute of Health Research (NIHR), enabling experts at Barts and The London Cardiovascular Biomedical Research Unit to undertake cardiac research.

The Defi niti on Flash CT is a new to market system that can perform a detailed scan of the enti re heart in just 250 milliseconds, which is less than half a heart beat.

“The Defi niti on Flash will be an invaluable tool for helping in the research of new treatments for cardiovascular disease as it presents a much clearer picture of the workings of the heart,” said Professor Anthony Mathur, Head of Advanced Cardiac Imaging at Barts and The London NHS Trust. “The CT will also be a frontline diagnosti c tool for pati ents presenti ng with chest pains. At the moment, blood tests are carried out to assess for myocardial infarcti on. A number of pati ents who present with chest pain may not be immediately diagnosed with a heart conditi on because they are at an early stage and their con-diti on may not be picked up unti l much later. Now atherosclerosis can be detected earlier and at a much lower dose than previous CT scanners potenti ally preventi ng the serious consequences of a heart conditi on.”

The Defi niti on Flash CT has a temporal resoluti on of just 75ms, which means that image quality is sti ll high even if a moving object is being scanned. For this reason, the heart does not need to be slowed with beta blockers before a scan to deliver high quality clinical images. This is a quicker process and less disrupti ve for the pati ent. The enti re chest region can also be imaged in just 0.6 seconds with-out breath holds from the pati ent so images are far clearer and the examinati on is less stressful.

The NIHR has designated Barts and The London NHS Trust and Queen Mary, University of London, a Biomedical Research Unit in advanced cardiac imaging.

“I am delighted that the Nati onal Insti tute for Health Research is able to fund the purchase of this cutti ng edge new technology,” said Professor Dame Sally C. Davies, Director General of Research and Devel-opment at the Department of Health. “Any new technology that allows us to detect heart prob-lems at an earlier stage while exposing pati ents to less radiati on is very good news. The sooner pati ents know there is a problem, the sooner they can begin to take acti on to prevent more serious problems later on.”

Aultrasound system from Siemens Healthcare suggests that use of the handheld unit may reduce the number of people referred for full ultrasound examinati ons, parti cu-larly in Cardiology.




informati on without the need to perform a

clinical applicati ons. Responses were positi ve overall with 10 second start-up ti me, portability and reliability parti cularly well rated.

This is a quicker process and less disrupti ve for the pati ent. The enti re chest region can also be imaged in just 0.6 seconds with-out breath holds from the pati ent so images are far clearer and

The NIHR has designated Barts and The London NHS Trust and Queen Mary, University of London, a Biomedical Research

Images courtesy Siemens Healthcare

3D Heart from Siemens SOMATOM® Defi niti on Flash CT system

� Jan/Feb 2010 www.cardiologyhd.com

ProductsCardiac Stents

Introduction

Since the widespread use of drug-eluting stents (DES), industry has provided interventional cardiologists with a variety of refinements – new drugs, new stent designs, new polymers and novel methods of delivering drug or altering release kinetics. Many (but not all) of these modifications have provided measurable, albeit small, improvements in performance and patient outcomes, with the result that currently-available DES provide single-figure rates of target vessel failure with an excellent safety profile at one-year follow-up. So why do we need a new stent material?

What’s wrong with current stent materials and construction?

The ideal metallic coronary stent should possess corrosion-resist-ance, biocompatibility, high radial strength and enough radio-opacity to facilitate visualisation under fluoroscopy as well as being non-fer-romagnetic1. Historically, the majority of stents have been manufac-tured from surgical grade (316L) stainless steel, which fulfils most of these criteria but has limited radio-opacity unless stent struts are thick or coated with other metals (both of which have been shown to increase rates of restenosis)2,3, and crucially may not be as biocom-patible as previously thought owing to elution of trace elements after implantation4. The advent of cobalt chromium (CoCr) alloys (L605 (Vision, Abbott Vascular), MP35N (Driver, Medtronic)) allowed for a thinner-strut stent construction from biocompatible compounds that have comparable strength and reasonable radio-opacity5,6. The stent platforms made from these alloys have proved to be highly deliverable due to enhanced flexibility, exhibit low restenosis rates in their bare-metal configurations, but have sacrificed radial strength and resistance to elastic recoil to some degree due to their thin-strut design.

PtCr alloy and the Element stent

Platinum-Chromium (PtCr) is the first alloy developed specifically for coronary stent manufacture; platinum has been used in a variety of

implantable medical devices over the last 20 years and has proved to be highly biocompatible due to its chemical stability. Addition of platinum to a stainless steel base enhances the strength of the com-pound allowing the potential for stronger struts of comparable thin-ness to those made from CoCr alloys, with improved radio-opacity7 (Table 1). The PtCr alloy was developed specifically by Boston Scien-tific for the novel Element stent design (Figure 1) – a dimensionally uniform pattern of serpentine segments with two offset connectors that reverse directions for alternate rows, providing a design partway between cellular and modular that is highly deliverable and conform-able, and provides compression/recoil resistance comparable to that of 316L stainless steel stents.

The Element platform has been optimised in its deployed conforma-tion to allow as uniform drug-delivery to the vessel wall as possible; the Promus Element was released in the UK in November 2009, with the Taxus version available later this year, followed by the bare-metal iteration in due course. For each of the drug-eluting versions, the drug concentration and polymer will be identical, respectively, to the extensively-trialled and established Promus/Xience V and Taxus Lib-erte stent designs.

The Element stent program

Prior to launch, the Element trial program was initiated, from which the first results will be presented at the ACC in March this year. For each of the drug-eluting versions of the Element stent, there already exists a large body of registry and randomised controlled trial (RCT) data relating to its ‘parent’ stents, which will be supplemented by new data comparing these platforms to their Element counterparts. The Platinum trial, involving 1532 patients in 160 centres, is a RCT comparing the Promus Element stent with the Promus stent; the study includes prespecified small-vessel and long lesion subgroups and completed enrolment in September 2009. The Perseus trials studying the Taxus Element stent include Perseus WH (Work Horse) and SV (Small Vessel) studies; the former was a 1264-patient RCT comparing the Taxus Element with the Taxus Express, and the lat-ter a smaller 224-patient single-arm trial comparing the small vessel (≤2.75 mm diameter) Taxus Element with historical controls in the

Precious metal:Platinum-Chromium alloy & the Element stent

Dr Nick WestAuthorConsultant Cardiologist,Papworth Hospital, Cambridge, UK


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InterviewCardiologist

What types of EP procedures do you do here?

We really do the full range of everything in terms of EP and devices, starti ng from the basic EP studies through to the usual SVT’s. Then we have a program of AF ablati on, and we do the VT ablati ons as and when they come up as well. In terms of devices the whole range of brachy and tachy device implantati on and extracti on as well.

What is your favourite technique for AF?

I am a big fan of linear ablati on for the persistent AF pati ents, so we sti ll do here mostly ti p catheter ablati ons. We do use a catheter called the PVAC catheter which is a dedicated pulmonary vein iso-lati on catheter for paroxysmals with structurally normal hearts and

short episodes, and there we do just the restricted PVI with those. But for anybody who has longer lasti ng episodes or persistent AF we tend to do a ti p catheter ablati on with NAVX. We are hoping to get CARTO in the future to have a choice of systems. And we tend to do wide area encirclement and then linear lesions as well for those pati ents.

Thoughts on the Hansen and Stereotaxis systems?

People tend to lump the two things together, because from the operators point of view both of them are giving you a degree of remoteness from the procedure in terms of back-ache and radiati on exposure. But they are doing rather diff erent things. The Stereotaxis system in the future is, I am not saying Stereotaxis itself, but some-thing along those lines is likely to play a large part in the future of complex ablati on. Personally I sti ll think it is in the stage of being developed rather than being a tool which adds much to the clini-cal end-points at the moment. Hansen as an interim has a bit more to off er at the stage it is at, at the moment in terms of being a tool which really adds something to the procedure, but perhaps in the future it might get superseded by something that looks more like what Stereotaxis looks like at the moment.

Dr John PaiseyConsultant Cardiologist & Electrophysiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundati on Trust

WATCH THE FULLINTERVIEW ONLINE

For the complete video interview with Dr John Paisey at the Royal Bournemouth Hospital, visit our website.



Journals

Hypertension

How exciting, just in time for Christmas a new class of anti hyper-tensive. Darusentan is a direct, selective endothelin antagonist which exerts its antihypertensive effect by vasodilation. In a placebo controlled, randomised trial of 3 doses of the drug in patients who had not achieved target blood pressure after three conventional antihypertensives, all three doses of the drug were found to be effective. One side effect was oedema; intriguingly it required 117 sites to recruit 379 patients.

Michael A Weber and others, The Lancet 374; 9699, 1423 - 1431

Many patients are prescribed prognostically significant drugs but often do not achieve the doses demonstrated to be beneficial in the trials. In a direct, randomised, blinded comparison of low (50mg) vs high dose (150mg) Losartan in 3846 patients with moderate heart failure and intolerance of ACE inhibitors the high dose group had significantly less heart failure admissions over 4.7 years follow up. The authors note the value demonstrated in the often difficult proc-ess of titrating up medication in heart failure patients.

Marvin A Konstam and others, Lancet 2009; 374: 1840–48

Antiplatelets/Anticoagulants

The new kid on the block in anti platelet therapy is Cangrelor, an intravenous, reversible ADP inhibitor with some theoretical advantages in terms of speed of action and safety compared to oral clopidogrel. A group of investigators managed the quite remarkable feat of having two simultaneous attempts at demonstrating a ben-efit over clopidogrel/placebo, failing to meet their primary endpoint and still getting both trials published in the NEJM.

Deepak L. Bhatt and others, New Eng J Med 361:2330-2341

Robert A. Harrington and others New Eng J Med 361:2318-2329

Bleeding risk on combinations of antithrombotic and antiplatelet agents are a real concern in the post infarct/PCI population. In an observational study of over 40 000 Danish patients experiencing

their first infarct, bleeding risk over a mean of 476 days was found to be 2.6, 4.6 and 4.3% aspirin, clopidogrel and warfarin mono-therapies respectively. This risk was not clinically significantly elevat-ed by either dual antiplatelets or aspirin/warfarin combination. Combination of clopidogrel and warfarin (with or without aspirin) however increased major bleeding risk to 12%. This presents a real therapeutic challenge for patients with drug eluting stents, atrial fibrillation and stroke risk factors.

Rikke Sørensen and others, The Lancet 374; 9706, 1967-1974

Cardiac Resynchronisation

Some of the most marked responses to cardiac resynchronisation therapy are seen in right ventricular paced patients. This is not sur-prising given that right ventricular pacing induces gross dysynchrony and heart failure patients respond so badly to it.

How far can this effect be demonstrated in individuals with structur-ally normal hearts? In a trial of 177 patients with normal ejection fraction randomised to either biventricular or right ventricular apical pacing there was a significant decrease in ejection fraction and increase in left ventricular dimension in the right ventricular pacing group. This did not translate into any clinical endpoints and a number of criticisms of the pacing implant and programming were raised. The proof of concept remains and we are set to see a creep of CRT into a wider range of pacing patients.

Cheuk-Man Yu and others N Eng J Med 361:2123-2134

The magnitude of the physiological benefits of cardiac resynchronis-tion therapy, should be independent on the degree of heart failure. The move to apply CRT to less symptomatic individuals is therefore no surprise. In the REVERSE study six hundred and ten NYHA class 1-2 patients were implanted and then randomised to on or off and followed for 12 months. There was significant reverse remodelling in the CRT on group compared with baseline and the CRT off group.On its own this is probably insufficient evidence to recommend CRT in NYHA 1-2 patients who are not otherwise indicated for device therapy but taken with the MADIT CRT trial a good evidence base

Dr John PaiseyJournal ReviewerConsultant Cardiologist, RoyalBournemouth and ChristchurchHospitals NHS Foundation Trust

Dr Dan McKenzieJournal ReviewerConsultant Cardiologist,Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust


FeatureInventory Management

If your department has recently installed a new inventory manage-ment system costi ng your hospital a few million pounds, it may be best to look away now. RFID has arrived!! Whilst sti ll in its early

stages here in the UK, it is now the system of choice for forward-thinking hospitals in the USA, moving beyond the traditi onal push butt on cabinets and bar-coding. But what is it, how does it work, and more importantly how can it be successfully implemented into your department today?

It is obvious to see that hospitals are struggling to reign in expenses. Companies sprout up with new ways to improve pati ent care, reduce infecti on rates, and/or increase revenue. Pop the word “medical” in front of it and quadruple the price. For this reason hospital man-agement has become very wary about new products, and it is com-monly known they now invest less in new technologies than other industries.

If you are a regular reader of our publicati on you would have noti ced in our Site Visits we always ask the questi on on Inventory Manage-ment in their department. Almost always the answer comes back as pen and paper (manual method). So what is the advantage of automated inventory management systems?

The process has moved beyond just the ordering, receiving, and tracking of supplies. Today it can do so much more. At the click of a mouse you can instantly see your available inventory, including serial numbers, used by dates, and any recalled products.

So what are your choices today?

Manual:

This is the most common technique for NHS hospitals in the UK, and involves manually counti ng each individual product used and either using a spreadsheet or pen and paper to keep track. This is very ti me consuming and is subject to human error.

Bar-Coding:

This is the next step-up from the man-ual method and involves a bar code reader which captures the product code and stores the informati on in a program for further manipulati on like is menti oned above. This is possibly the best technology available on the market today to manage stock auto-mati cally in the cath lab environment, and newer systems can be integrated easily with RFID.

Butt on Pushing:

This technology has been imple-mented into a few cath labs recently with mixed feedback. The idea is that each product on a shelf is assigned a parti cular butt on. If you remove the product you press the butt on corre-sponding to it. This technology has been around for a while and works well in theatre environments, but in stressful cath lab situati ons where you have to grab multi ple products quickly, butt on pushing is oft en for-gott en and mistakes are made.

RFID:

RFID uti lizes an inexpensive tag that is placed on the product either by the manufacturer or when stock arrives in the department. The tag links to informati on including that box’s product descripti on, expirati on date, lot number, serial number, its price upon receipt, its status as consigned or owned, and so on. From here the boxes are placed into “Smart Cabinets” which automati cally that the detect the products have been added and add them to the department inven-

RFID is the Future for Automated Inventory ManagementMr Tim Larner

Director / FounderPrevious Chief Cardiac Radiographer & Manager in Australia, now P/T Senior Radiographer at the Manchester Heart Centre.

Images courtesy Scan Modul System Ltd


Hot TopicManagement

We only wear hats and masks during device implants/TAVI’s etc where there is an open wound (and when most procedures are carried out in a room with full positi ve pressure theatre venti lati on). None of the staff wear hats and masks for inter-venti onal procedures but these are usually performed in Cath Labs with ‘treatment’ room venti lati on.

We do not allow scrub staff to wear their scrubs (which are blue) outside the immediate Lab/department but running staff may move freely around whilst inside the hospital buildings wearing theirs (pink). No problem with infecti on rates.

We are very consistent in wearing caps and masks with devices, but for very litt le else. For some congenital cases the opera-tors do, but no one else in the room. The only regular excep-ti on is that anaestheti sts appear not to adhere to this. I too wonder why.

At the Golden Jubilee Hospital in Glasgow they too do not wear hats or masks in the cath lab or EP labs unless a “device” is being implanted. Hats and masks as usual in theatre for PFO/ASD closure etc.

Should cath lab staff be wearing hats and masks when scrubbed?

What an interesti ng topic and one we have discussed numer-ous ti mes in our Cath Lab here in Truro in Cornwall. When I started my job as CCL manager seven years ago all staff

were wearing hats for all procedures and hats and masks for all pac-ing type procedures. Everyone had two pairs of shoes, blue shoes to wear outside the department and white shoes for inside the Cath Lab.

As I came from a Cath Lab that did not wear hats all day I wanted to make a change. I looked at a number of studies on the effi ciency of hats and masks on the internet to ensure ‘evidence based practi ce’ and invited the views of our consultant cardiologists.

I found no evidence that the wearing of hats and masks reduced infecti on rates. However, every hospital has it’s own policies and our hospital policy clearly states that theatre staff should must wear the full kit.

All our consultants, except one, were in favour of not wearing hats routi nely. They agreed to conti nue to wear hats and masks only for pacing procedures like ICD’s, PPM’s and Reveals.

We recently stopped the wearing of masks during pacing proce-dures for the ‘running’ staff . Only the operator and scrub nurse wear hat and mask.

We felt a CCL is not a ‘proper’ operati ng theatre and therefore we could make our own policy up.

Long hair has to be ti ed back and there have been no issues with staff not complying with this common sense rule. All staff are encouraged to wear a visor during angio and PCI procedures as protecti on from blood droplets.

We got rid of all the blue shoes. Aft er all, pati ents arriving on beds that had been pushed on public hospital corridors went straight into the labs. Why fuss with in and out shoes? They did not make sense and our changing room is less clutt ered.

Our infecti on rate is well below the nati onal average, in fact I can’t remember an infected device in the past year.

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This questi on was asked on our Cardiology HD Facebook Wall by Helen Day.Now with over 300 fans globally!!

Ms Tina PrestwoodCardiac Cath Lab Manager, Royal Cornwall Hospital, TruroUnited Kingdom

Ms Annie WilliamsonSuperintendent Radiographer, Guy’s & St Thomas’ NHS Foundati on Trust, London, United Kingdom

Mr Bryan WalkerSuperintendent Radiographer, Manchester Heart Centre, Manchester, United Kingdom

Mr Dennis SandemanNursing Consulti ng EditorChest Pain Nurse SpecialistNHS Fife, Trustee of the Scotti sh Heart and Arterial Risk Preventi on (SHARP) charity.


Site VisitUnited Kingdom

What are the sizes of your Cardiology Department and Hospital?

The Hospital has 632 beds and there are 4 cardiac wards (CCU, 2 in patient wards and an Electives ward)

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

We serve Bournemouth and the surrounding towns of East Dorset and West Hampshire for secondary referral (300,000). Angioplasty and ICD/CRT services to the Poole and Salisbury area (750,000), and Ablations to all of these areas as well as Dorchester and West Dorset (1.2 Million).

How many staff? Roles?

The Cardiac department as a whole employs 263 staff, mostly ward nurses. The Labs have a complement of 24 physiologists (who also cover other aspects of the service), 17 nurses and 6 radiographers.There are 9 consultants, 4 PCI, 3 EP, 1 imaging, 1 pacing. We also have visiting cardiologists from Poole and Salisbury, and work closely with colleagues in radiology.

Types of procedures?

We perform a full range of Interventional coronary, device implanta-tion/extraction and electrophysiology procedures.

Types of equipment used?

We have 4 new Siemens labs and a pacing theatre as well as a full range of non invasive investigations, cardiac CT and MRI.

Royal Bournemouth HospitalThe Royal Bournemouth and Christchurch HospitalsNHS Foundation Trust, Castle Lane EastBournemouth, BH7 7DW, United Kingdom

Dr John PaiseyIntervieweeConsultant Cardiologist & Electrophysiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Overhead View

Royal Bournemouth Hospital


EducationElectrophysiology

More than other disciplines electrophysiology (EP) requires the synthesis of different types of information to develop understanding. Despite years working in the environment

some individuals fail to develop an interest in EP because they fail to appreciate and combine essential elements.

These elements include:

The surface ECG

Detailed cardiac anatomy

Anatomical description and fluoroscopic views

Intra-cardiac electrograms

Cellular electrophysiology and mechanisms of arrhythmia

I have previously introduced some of these areas – intra-cardiac elec-trograms and mechanisms of arrhythmias (re-entry and focal) for example. An understanding of the surface ECG is often assumed but is lacking in some staff groups. Another neglected area is the three dimensional structure of the heart and its relation to two dimen-sional fluoroscopy. In this article I hope to give a flavour of this 3D element.

Many staff approach EP having had some experience of angiography and percutaneous coronary intervention (PCI) where the use of fluor-oscopy is quite different. This difference is not usually explored.

Fluoroscopy in coronary work and EP

In coronary work fluoroscopy is used to produce diagnostic images and to facilitate movement of wires and equipment along the coro-nary arteries. In diagnostic work the image intensifier is moved in the cranio-cordal plane in addition to the right anterior oblique (RAO) – left anterior oblique (LAO) plane to produce a great variety of views - ensuring lesions are not missed. In PCI the movement of

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the wire, balloon or stent is constrained by the vessel lumen (hope-fully!) – movements being restricted to distal and proximal within the confines of a vessel’s course. A working view is chosen that gives the operator the best information for performing the intervention.

In EP the fluoroscopy is used for “diagnosing” the position of the cath-eters within the cardiac chambers as the signals can only be under-stood when the anatomical positions of the catheters are known. Two views - RAO and LAO are usually adequate. In addition an opera-tor is often guided in moving the catheters by instructions from a senior colleague – this requires a mutually intelligible language for describing three dimensional space (see anatomical description).

Anatomical description

For the purposes of anatomical description the body is viewed inthe upright position and has three orthog-onal (90 degree) axes: superior–inferior, pos-terior–anterior, andright–left (Fig 1).

Anatomical landmarkscan be described interms of these co-ordinates and thesame axes are used to describe the ECG and also in fluoro-scopic projections. The fluoroscopic screen presents the

Learning Electrophysiology:Anatomical description and fluoroscopic views

Mr Ian WrightEP Consulting EditorTechnical Head EP, St Mary’s Hospital, Imperial College Healthcare NHS Trust

Fig 1. Orthogonal axes


CalendarCardiology Events

United Kingdom

January 27-29

Advanced Cardiovascular Interventi on 2010London Hilton Metropole HotelLondon, Englandwww.bcis-aci.co.uk

February 9-11

The Cardiff Freeman Echocardiography CourseHilton Cardiff HotelCardiff , Waleswww.millbrookconferences.co.uk

June 7-9

BCS Annual Conference and Exhibiti on 2010Manchester CentralManchester, Englandwww.bcs.com

October 3-6

Heart Rhythm Congress 2010Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October29-30

Briti sh Society of Echocardiography Annual Meeti ng & Exhibiti onBournemouth, Englandwww.bsecho.org

Internati onal

February 21-23

CRT 2010Omni Shorham HotelWashington, DC, USAwww.crtmeeti ng.org

June 2-5

New Cardiovascular Horizons ConferenceThe Roosevelt Waldorf - AstoriaNew Orleans, LA, USAwww.ncvhonline.com

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LIKE TO BEFEATURED?

For further details on how your event can be featured here contact us at:

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Upcoming Issues*

March / April 2010

Cardiologist Hot Topic: Opti mal diagnosti c pathways for the evaluati on of chest pain.

Laser PCI

Interview: Dr Raj Khatt ar, Manchester Heart Centre

ECG Basics (Part 1)

Case Study: Echocardiography

Management Hot Topic: Should food and gift s from companies be banned in the cardiac lab environment?

May / June 2010

Primary Angioplasty Service: Positi ves & Negati ves

New Technologies in EP

Preview of the BCS Conference in Manchester

ECG Basics (Part 2)

Case Study: Where’s the RCA?

Management Hot Topic: Recruitment challenges

* Editorial topics subject to change

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Medical Recruitment

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Taxus V study. Both trials finished recruiting in October 2008, and although data will not be presented until later in the year, no safety concerns have arisen thus far from independent safety monitoring.

Summary & Conclusions

Novel stent designs and modifications have often promised to deliver tangible clinical improvements, but strut thickness aside, none of these have translated into measurable differences in clinical perform-ance or patient outcomes. The new PtCr alloy has facilitated devel-opment of a thin-strut stent design with preserved radial strength that will carry established drug/polymer combinations, and will likely deliver performance that is at least as good as the current Promus/Taxus Liberte designs in forthcoming trial data. Whether this novel alloy/design platform delivers performance improvements over cur-rently-available DES will remain to be seen in clinical trials in due course; only then will we be able to judge whether this alloy deserves the prestige and exclusivity that are connotations of its constituent precious metals.

References

Lau K-W, Mak K-H, Hung J-S et al. Clinical impact of stent construction and design in percutaneous coronary intervention. Am Heart J 2004; 147: 764-73.

Kastrati A, Mehilli J, Dirschinger J et al. Intracoronary stenting and angiographic results: strut thickness effect on restenosis outcome (ISAR-STEREO) trial. Circula-tion 2001; 103: 3816-21.

Kastrati A, Schomig A, Dirschinger J et al. Increased risk of restenosis after place-ment of gold-plated stents. Circulation 2000; 101: 2478-83.

Koster R, Vieluf D, Kiehn M et al. Nickel and molybdenum contact allergies in patients with coronary instent restenosis. Lancet 2000; 356: 1895-7.

Kereiakes DJ, DJ, Cox DA, Hermiller JB et al. Usefulness of a cobalt chromium coronary stent alloy. Am J Cardiol 2003; 92: 463-66.

Sketch MH Jr, Ball M, Rutherford B et al. Evaluation of the Medtronic (Driver) cobalt-chromium alloy coronary stent sytem. Am J Cardiol 2005; 95: 8-12.

Craig CH, Friend CM, Edward M et al. Mechanical properties and microstructure of platinum enhanced radiopaque stainless steel (PERSS) alloys. J Alloy Comp

2003; 361: 187-99.

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New coronary stents- Back to the future?

Nobody can dispute the impact that drug eluting stent technology has had upon coronary intervention. Effec-tive modulation of the healing process within the stent

has allowed interventionalists to treat long areas of atheroma with multiple stents and achieve results which can be com-pared with the effectiveness of a surgical bypass graft During this revolution we have all become familiar with the complex performance measures of the polymer(which modulates the release) and the drug combination – in particular the concept of late loss which is a measure of the amount of neointimal tissue one might expect to find within a stent at the end of the healing process. Much emphasis has been placed on these figures and considerable debate has surrounded what a “desir-able” late loss might be and in particular how this might relate to rates of very late stent thrombosis.

During 2010 both of the first generation drug eluting stents are scheduled for replacement. Boston Scientific will replace Taxus Liberte with the Taxus Element and Cordis Johnson and Johnson will replace the Cypher Select with the Nevo. Boston will also launch the Promus Element. The principal rationale for these changes is not to change the drug, but to improve the mechanical performance of the stent. Using thinner struts should reduce the biological signal to the vessel to produce neointima which may be clinically beneficial. But considerable emphasis is now being placed on issues which we have almost forgotten about with our concentration on different drugs and polymers. These include the need for the stent to scaffold the vessel to prevent tissue prolapse between the struts and opti-mising stent visibility to allow accurate positioning of a second stent and post dilation. However, perhaps the most important is the key issue of improved deliverability. It is hoped that these new stents will track better and fewer will end up being wasted. When a stent cannot be implanted in the patient due to vessel tortuosity and a different more flexible bare metal stent has to be used as an alternative, the cost of the wasted drug eluting stent is borne by the hospital as it is not refunded by the purchasers. Improved flexibility may also mean that interventionalists may be more confident to use one long stent rather than two short ones in difficult cases. These practical issues are rarely discussed in international meetings but they are real world issues when we are calculating the cost per case within our increasingly cash restricted Catheter labs.

With the availability of these new stents imminent, I suspect we will be going back to some of the debates we heard last heard in the late 1990s about stent flexibility and deliverabil-ity rather than the rather sterile discussion about the decimalpoints of late loss and rates of late stent thrombosis.

Dr Adrian BanningAuthorConsultant Cardiologist,John Radcliffe Hospital, Oxford, UK

Image courtesy Boston Scientific Corporation


for CRT in patients receiving a device for other reasons is emerging.

Martin St. John Sutton Circulation 2009;120;1858-1865

Clinical results in CRT have been mixed in the QRS<120 msec population. There remains a suspicion that certain subgroups of these patients would benefit. Perhaps efforts at selection have been misdirected, as the problem (and hence mechanism of benefit) is as much to with diastolic filling as systolic dysychronous contraction.In an acute study of 30 patients with heart failure and QRS<120 msec 15 were noted to have evidence of external constraint and CRT abolished this in all. This resulted in an overall increase in stroke volume and ejection fraction as well as improved filling.

Lynne K Williams and others Circ 2009;120:1687-1694

Hypertrophic Cardiomyopathy

A small study of families with identified hypertrophic cardiomyopa-thy mutations sought to investigate, amongst other things, the pen-etrance of the disease in carriers. Only 41% of carriers expressed the phenotype in this snapshot with age and male gender increas-ing risk of expression. Risk factors for sudden cardiac death were noted to be present even in (as yet) unaffected carriers.

Michelle Michels and others, European Heart Journal 2009 30(21):2593-2598

Exercise testing is often used to risk stratify hypertrophic cardiomy-opathy patients but its value is not well established. Analysis of the Heart Hospital’s referrals finds exercise induced arrhythmias to be rare (27 out 1380) but a significant predictor of malignant arrhyth-mias (a 3.73 fold increase in risk of sudden death/ICD discharge). Although the effect ceased to be significant if only NSVT patients were considered in a multivariate analysis it is the raw data that has more relevance to clinical practise as exercise induced arrhythmias are associated with a number of softer risk factors which might not score in their own right.

Perry Elliot and others Eur Heart J 2009 30(21):2599-2605

Implantable Cardioverter Defibrillators

SCD-HeFT (published 2005) continues to be mined for data. To recap this was a study of single lead ICDs in NYHA II-III individu-als with ejection fractions under 0.35. Detailed analysis of the 666 deaths in the trial has revealed that ICDs exerted their effect by cutting all cause, cardiac and tachyarrhythmic death but not non cardiac or heart failure death. Interestingly, the mortality reduc-tion was significant only in NYHA II individuals and he benefit was independent of aetiology.

Douglas L Packer and others Circulation. 2009;120:2170-2176In ICD therapy, inappropriate shocks are well recognised but the

concept of unnecessary shocks is gaining currency. The commend-ably low detection and charge times of modern devices have the potential to deliver shock therapy in patients with non sustained but fast arrhythmias, a profile known to be seen in the primary prevention CRT D population.

The RELEVANT study examined a simple programming change extending the detection interval in these patients which reduced inappropriate shocks and heart failure events compared to normal programming.

Maurizio Gasparini and others Eur Heart J 2009 30, 2758–2767

Electrophysiology

Does every patient undergoing left atrial ablation for atrial fibrilla-tion need a pre procedure transoesophageal echo? In a report of 1058 patients there was not a single incidence of left atrial append-age clot in the 47% of these patients with CHADS2 profile of 0. The authors conclude that TOE should continue to be performed in patients with a CHADS2 profile of 1 or more or in CHADS2 0 patients only if AF is persistent and anticoagulation has not been maintained for 4 weeks.

Sarinya Puwanant and others J Am Coll Cardiol. 2009 Nov 24;54(22):2032-9

Revascularisation

Not so long ago it looked as though off pump surgery was going to be the best thing since free radial grafts..... fortunately it doesn’t look as though it will be as poor as that turned out - merely time consuming, pointless and slightly worse than standard care. In the latest instalment of this story a randomised trial of 2203 patients the off pump group had worse cardiac outcomes than standard on pump operations with no difference in neurological sequelae.

Laurie Shroyer New Eng J Med 361:1827-1837

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Hypotheti cal CaseRFID vs Butt on Pushing

Situati on:

A Cardiologist dissects the Left Main, causing a spiral dissec-ti on down the LAD. The pati ent’s ECG goes haywire, and the normally calm lab becomes a scene of high stress. The cardiol-ogist screams for several stents of diff erent sizes immediately. Here every second counts.

Retrieving items:

Butt on Pushing: The nurse runs to the cabinet, has to punch in her access code on ti ny butt ons trying to stay calm, locate the pati ent’s name from the full days list and select it before the cabinet will open. They then grab sev-eral stents, having to push the butt on aft er getti ng each one, otherwise they will never be tracked, and run back to the cardiologist who is yelling at you for taking so long.

RFID: The nurse runs to the cabinet, puts their fi nger on the biometric reader and the door unlocks. The nurse grabs what they need and runs back. Sensors in the cabi-net detect automati cally what has been taken and apply them to the case.

Returning items:

Butt on Pushing: It has appeared the cardiologist took contrast streaming as a dissecti on and tells you to leave two stents and return the remaining three. The nurse has to enter their code, fi nd the pati ent again before the door unlocks, fi nd the shelf and select another butt on to return each item.

RFID: The nurse puts their fi nger on the biometric reader and door unlocks. They put the unused stents back in the cabinet without having to press another butt on. The Smart Cabinet automati cally detects the items have been returned and updates the case product usage. Simple!

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Product Choice Assistance

@ Web & Email

Phone

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tory list. Remove an item and the Smart Cabinet detects this and automati cally updates the system. Dan Sharbach, Regional Director of Invasive Cardiovascular Services at the Providence Health System in Portland, Oregon, USA recently reported for us on the use of RFID in their hospital stati ng, “By following current processes, nurses and techs are more likely to embrace this technology because, unlike many inventory systems, this approach is largely invisible to the front line clinical user.” Put simply, RFID technology closely matches the workfl ow for cath labs compared to other systems, virtually cancel-ling out human error.

Purchase Planning:

RFID is a relati vely new technology here in the UK and as such is very expensive. For large departments with a high stock turn-over the cost-benefi t can be justi fi ed. However we recommend you start with a system which can eventually be upgraded to this technology, reducing your overall expenses in the medium to long-term.

Investi gati on:

See what systems are on the market. See their installati ons, not just in theatres, but cath labs. Speak to managers who use the system across the enti re supply chain and see where their strengths and weaknesses are.

Future Proof:

Automati ng inventory management is not cheap, but the last thing you want to do is buy a system that is obsolete in fi ve years. Look at what upgrades are available. Can their cabinets be made to be RFID compliant easily? Does their soft ware easily integrate with RFID technology?

Beware:

Some companies you talk to may down play RFID technology, but that is because they don’t have it. Sure, the tags aren’t on any of the boxes here in the UK and you have to do it manually, but as with the USA this is rapidly changing, and it won’t be long before every item you order has a litt le RFID tag att ached to it.

Further Reading:

Visit our website www.cardiologyhd.com and read interesti ng arti cles from the USA on how their inventory is managed including more detailed usage of RFID.

HOME >> Features >> Management & Staff >> Inventory Management

Scan Modul System Ltd based in the UK use the automated inventory management system called SpaceTRAX. This internati onally recognised system is bar-code based, however most importantly can be easily be upgraded to RFID. They also use fi ngerprint recogniti on on their cabinets making security and instant access easy. No more codes and butt on pushing in stressful situati ons.


We use Laser systems for lead extraction and PCI, Rotablation PCI, Pressure wires, IVUS and Electro-anatomical mapping systems. Image archiving is through Medcon.

How many procedures are performed a year?

PCI: 2000

Pressure Wire: 650

IVUS: 650

Pacemakers: 650

Ablations: 500

ICD/CRTD: 150

CRT P: 50

What is the approximate percentage of cath lab cases performed radially compared with femorally?

70% of cases are performed radially.

What protocols has your department implemented to reduce door-to-balloon time?

We have a direct link from the ambulance service to the Lab, giving an average door to balloon time of 40 minutes.

Are any of your staff cross-trained (generic workers)?

Some of our staff are dual trained in nursing/ODP. We plan to intro-duce more generic working in the future.

What new procedures have you implemented into the department recently?

With the increasing financial pressures we are working hard to get maximal value with out compromising on quality. Staff are now aware of the cost of each consumable to focus efficient working.

How is your inventory managed?

Barcodes

How does the lab handle haemostasis?

Most femoral cases receive angioseals.

What measures has the department implemented to cut costs?

Consultants have introduced a flexible working regime to cover inpa-tient work. We are working hard to reduce our length of stay.

What kind of training can new employees expect to receive?

New employees receive extensive on the job and off site training opportunities.

What kinds of continuing education programs are available to staff?

There is a funded study budget and staff our encouraged to enrol on industry sponsored events.

What kinds of competency checks do staff have to undergo once employed?

Staff are expected to keep up to date with their training and prac-tice. This is monitored through HR.

Please outline the Department Management structure.

Cardiology falls within the general medicine directorate which has a general manager answerable to the board. Cardiology has its owndepartmental manager and she supervises leads from each of the disciplines. Radiology is a separate directorate.

How do you deal with late finishing of cases? For example stag-gered working hours or just staff overtime?

We have an on call team with responsibility for mopping up late cases. They are paid an availability allowance and for the in-hospi-tal work they do out of hours. Other overtime is attempted to be reduced to the minimum manageable.

What is your policy for company reps within the labs? Are reps allowed to bring food for sharing amongst doctors and staff into the department when they visit?

We welcome reps bearing gifts of food. No value line please.

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Above: Sharon Chamberlain (nurse)


Latest Site Visit videos available online now.

Royal Bournemouth HospitalRoyal Cornwall Hospital

Featuring interviews with cardiologists, managers and staff , and an indepth look at how each department works

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Reducing radiati on dose is a high priority in the cath labs. What techniques are employed by your radiographers to ensure dosage during cases is kept to a minimum?

Where possible we reduce frame rates on fl uoroscopy, and we use Radpads for CRT cases to reduce scatt er. Everyone always hangs their leads up.

What are the advantages for SpR’s training at your facility?

We have 5 SpRs, 3 PCI fellows, 2 EP fellows and an Imaging fellow. SpRs receive training in pacing, Echo, TOE, angiography and where appropriate PCI/EP. PCI fellows perform 500 procedures per year, EP fellows learn all aspects of device implantati on and ablati on includ-ing AF ablati on. The imaging fellow has opportuniti es in echo, TOE, CT and MRI.

What is the best part of working at your facility?

We are a ti ght knit friendly group who all get on well and are focused on providing an excellent service. The knowledge of the quality of service we provide and appreciati on our pati ents express is very rewarding.

We are also a forward looking centre, and are the only UK centre performing terti ary services such as complex EP and extracti on from a DGH setti ng. On the PCI front we are prominent in running 4 laser workshops a year as well as having hosted BCIS last year.

From Left : Claire Hardman (Cardiac Physiologist), Becky Morton (Radiographer), Percy Jokhi (Cardiologist),

Alex Hobson (Cardiology Fellow)

From Left : Zhan Sun (nurse), Mel Merridew (nurse), Sue England (Radiographer), Camelia Stacy (nurse)

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For further details on how your lab can be featured here contact us at:

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Above: Neil Barbour (Medtronic Clinical Rep) and Abigail Butler (Cardiac Physiologist)

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thorax in an upright image even though the patient is lying down. Superior structures (such as the SVC) are shown in the upper part of the screen and inferior ones in the lower part (such as the IVC). The posterior–anterior direction can be identified because the spine and the sternum are clearly recognisable as reference markers. In RAO the spine which is posterior appears on the left side of the image, in LAO the spine appears at the right. In these oblique views right and left on the screen represents a combination of the posterior–anterior and right–left axes.

However in respect to the human heart this is complicated by the fact that the heart does not sit squarely within these orthogonal axes. The axis of the ventricles tilts laterally to the left from base to apex, extending anteriorly and slightly inferiorly - with tricuspid and mitral

valves following the orientation of the ventricles (fig 2). The so-called right atrium is in fact more accurately described as anterior to the left atrium and the right ventricle is anterior to the left ventricle.

In EP it is often essential to know whether the catheter is ventricular or atrial and if it is in the right or the left side of the heart (or if it is septal). The anterior oblique views can provide this information. These tilted views line up with the rotated heart so that right and left on the screen become meaningful with respect to the cardiac anatomy. In RAO the beam aligns with the AV valves such that left on the screen is atrial and right is ventricular. In LAO the beam isaligned with the apex to base axis of the heart such that left on the screen is the right heart while right on the screen is the left heart. Each view is lacking in information about one cardiac plane – in RAO

Fig 2. This image is taken as if looking up from the patient’s feet. The axis of the AV valves is marked by the line and is mainly in an anterior-posterior orientation. The line also represents the plane of the X-ray beam in an RAO view. In this view it is impossible to

resolve the position of structures in line with the beam – left heart and right heart positions cannot be distinguished from each other.

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the right and left atrio-ventricular juncti ons are superimposed and it is diffi cult to determine if a catheter (for example the coronary sinus electrode) is on the right or left side of the heart. Using the LAO view allows recogniti on of the right and left free walls and the disti nc-ti on of these zones from the septal area but lacks informati on about whether a catheter is atrial or ventricular. RAO for example is useful when positi oning the high right atrial (HRA), HIS and right ventricular

apex (RVA) catheters. LAO is useful when positi oning the coronary sinus (CS) catheter as this structure extends left wards (with respect to the heart) around the left AV groove. Swapping between the two oblique views allows the positi on of a catheter to be assessed within the geometry of the heart.

Fig 3. RAO and LAO views in the same patient. Contrast has been introduced into the coronary sinus. (The HRA and HIS catheters are somewhat displaced).

Fig 4. Anatomy and catheters in RAO (catheter diagram adapted from an image courtesy of St Jude Medical)

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The RAO View

RAO LAO


The locations of accessory pathways

The locations of accessory pathways are made as seen in the LAO projection and the terminology commonly used to describe their positions cause some confusion. The descriptive terms used are anatomically inaccurate having been derivedfrom a surgically distorted view (surgeons tended to move the heart from its natural position). The superior aspect of the heart is described as being anterior, while the anterior andposterior aspects are described as right and left lateral (see fig 6). An attempt was made ten years ago to replace the descrip-tions with a more anatomically correct system but with little success. 1

ReferencesCosio FG et al. Living anatomy of the atrioventricular junctions: A guide to electrophysiological mapping. A Consensus Statement from the Car-diac Nomenclature Study Group, Working Group of Arrhythmias, Euro-pean Society of Cardiology, and the Task Force on Cardiac Nomenclature from NASPE. European Heart Journal 1999; 20: 1068–1075

1.

Fig 5. Anatomy and catheters in LAO. In LAO the viewer looks through the heart from the ventricular apex with the tricuspid

valve (TV) and mitral valve (MV) appearing en face as “spectacles”. (Catheter image courtesy of St Jude Medical)

Fig 6. The commonly used but anatomically incorrect descrip-tion of the positions of accessory pathways (in the LAO view).

(Image courtesy of St. Jude Medical)

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The LAO View


Meetings

The Scotti sh Heart and Arterial Risk Preventi on (SHARP) char-ity held its annual scienti fi c meeti ng in Dunkeld at the end of November. The theme of the meeti ng was “Partners in Cardio-

vascular Disease Preventi on” and as usual att racted many high pro-fi le speakers for the event.

SHARP was initi ally set up in 1988 and heralded the commitment of many health care professionals across Scotland to the preventi on of cardiovascular disease (CVD), which sti ll remains a major cause of premature mortality and morbidity in Scotland. SHARP has many members throughout the UK who work in various specialti es across primary and secondary care with a specifi c interest in the preventi on and management of CVD. The work of SHARP falls into three main categories; the implementati on of evidence, educati on and research. Many of its members play an important role in the development and implementati on of nati onal guidelines such as Scotti sh Intercol-legiate Guideline Network (SIGN) guidelines for CVD and the NHS Quality Improvement in Scotland (QIS) standards on Coronary Heart Disease (CHD) and CVD. They have annual scienti fi c meeti ngs as well as regional educati onal meeti ngs. SHARP also produces educati onal material for pati ents and staff including a Cardiovascular Risk Pack to assist in the identi fi cati on and modifi cati on of risk factors for cardio-vascular disease. SHARP also facilitates research into the causes and preventi on of heart disease in Scotland.

Now in its 22nd year, SHARP held its annual scienti fi c meeti ng on the banks of Loch Tay in Dunkeld at the end of November this year. Dr Robert Finnie (GP from Livingston) opened up the meeti ng with a formal thanks to Dr Shirley McEwan, a founding member and the driving force behind SHARP, who reti red last year as this was the fi rst year she had not att ended the meeti ng.

The fi rst plenary session brought an impressive list of guest speak-ers. Dr Jonathan Morrell, GP from Hasti ngs and founding member of HEART UK and the Primary Care Cardiovascular Society (PCCS) spoke about primary care and cardiovascular disease. He told the meet-ing that a combinati on of smoking and raised lipids accounted for almost two thirds of all CVD risk. Risk tools, he told the audience, have their place but are not suitable for all pati ents and clinical judgement should be used for individual pati ents. He stressed the

most important issue in dealing with risk in primary care is commu-nicati ng cardiovascular risk in a way the pati ent will understand and modify lifestyle. He felt the work being done using a “heart age” may improve the way pati ents understand risk in the future.

Professor Keith Fox, current President of the Briti sh Cardiovascular Society (BCS) and consultant cardiologist at the Edinburgh Heart Centre told the audience that the specialty of Cardiology has made a signifi cant contributi on to the management of pati ents with CVD and CHD. As well as the initi ati on of secondary preventi on medica-ti on he highlighted the Rita-3 study which showed a 20% reducti on in mortality in the group of pati ents with Non-ST Elevati on Myocardial Infarcti on who had usual secondary preventi on medicati on with PCI compared with those who did not have interventi on. He also told the audience that the UK had bett er numbers than the USA in achieving 90 minute diagnosti c ECG to balloon ti mes. Dr Alan Rees, Chairman of HEART UK, fi nished of the fi rst session with a presentati on on lipid management for Primary Preventi on; he warned the audience that a “blanket” Simvastati n 40mg daily for all would not work. Lipid man-agement has to be tailored to each pati ent and may require more aggressive treatment depending on individual risk.

The SHARP message as strong as ever in its 22nd year!Mr Dennis Sandeman

Nursing Consulti ng EditorChest Pain Nurse SpecialistNHS Fife, Trustee of the Scotti sh Heart and Arterial Risk Preventi on (SHARP) charity.

Dr Jonathan Morrell and Professor Keith Fox


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Following the first session, there were well attended workshops cov-ering topics as varied as atrial fibrillation and stenting to the man-agement of familial hypercholesterolaemia and interpreting lipid values.

The afternoon plenary session was chaired by Dr Alan Begg, GP from Montrose and chair of the SIGN development group on the manage-ment of stable angina. This session focused on the specific problems around women and CVD then diabetes and CVD. Dr Robert Finnieinformed the audience that despite presenting more frequently with angina, presenting later to hospital and having more silent MIs than men, women continue to be under researched, diagnosed and treat-ed for CVD. Diabetes remains a major problem and risk factor for CVD. Professor John Betteridge from University College London told the group that diabetologists and cardiologists need to work more closely in the management of those patients with diabetes and CVD. He used data from the EMMACE study which showed that despite new advances in treatments such as drugs and cardiological inter-ventions, those patients with diabetes still had similar mortality rates post-myocardial infarction in 2003 than the same group of patients in 1995. Patients with diabetes should be considered for more aggres-sive lipid management. LDL cholesterol remains a high risk marker for diabetic patients and Professor Betteridge suggested a target LDL of 1.8 for diabetic patients should be considered. Blood glucose control can aid in the reduction of CVD events such as MI and CVA and premature death. He used the PROactive study as an example of how this can be achieved, which used Pioglitazone on top of normal standard care, to control blood sugar. It demonstrated an increase inHDL cholesterol by 19% and a decrease in Triglycerides by 11% and a decrease in systolic blood pressure median 3mmHg over 3 years.

The final session of the day was a light-hearted discussion looking at who the major player is in CVD Prevention. “The Great Balloon Debate” pitted the wits of G.P. Professor Lewis Ritchie, Lipidologist Dr Robert Cramb, Hypertentionologist Professor John Webster and a Geneticist, Dr Alex Doney against each other. Each had 7 minutes to persuade the audience they had a more vital role to play in CVD prevention than their colleagues. After each had presented for their 7 minutes the audience voted and the group were reduced to the GP and lipidologist. After a question and answer session the Profes-

sor Lewis our GP in the group admitted that his contribution was as part of a team which included the practice nurses. After much banter the audience voted and the GP team won the contest as the mostimportant player in the prevention of CVD. Dr Alan Begg closed the meeting by summarizing the event and thanking everyone who con-tributed and attended the successful meeting.

SHARP continues to be a major player in CVD risk preven-tion in Scotland and is always looking at news ways to spread its message. Anyone interested in joining SHARP can do so by contacting Doreen Howley Tel: 01382 660111 Ext 33124 or e-mail: [email protected].

Dr Alan Rees presents at the SHARP meeting

Round-Up- Internati onal News

5

Products 6

Products �

Interview 11

Journals 12

Feature- RFID is the Future for Automated Inventory Management

14

Hot Topic- Should cath lab staff be wearing hats and masks when scrubbed?

16

17Site Visit- The Royal Bournemouth Hospital

Educati on- Learning Electrophysiology

20

Meeti ngs- SHARP

Calendar- Cardiology Events

24

26

Employment, Adverti sers, & Next Issue

27

- Precious metal: Plati num-Chromium alloy & the Element stent

- Cardiac Imaging

- Dr John Paisey from the Royal Bournemouth Hospital

Want Fingerprint Recogniti on Access?RFID is here

The New PtCr Element Stent

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Cover and Contents Images courtesy Boston Scienti fi c Corporati on and Scan Modul.


ExpertsOur Cardiology

How to get in touch@ Email

Phone

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Circulati on

Editorial, Subscripti on, & General [email protected]

Adverti sing [email protected]

Coronary Heart Publishing Ltd, 2nd Floor, 145-157 St John Street, London, UK

Editorial, Subscripti on, & General enquires+44 (0) 20 7788 7967

Adverti sing enquiries+44 (0) 1427 668 662

Free Distributi on of 2800 copies to named individuals within cardiology in UK/Ireland.Distributed to all cardiology departments (invasive and non-invasive) and cardiologists.

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

Mr Tim LarnerDirector / FounderPrevious Cardiac Radiographer Manager in Australia, now Senior Radiographer at the Manchester Heart Centre.

Dr Magdi El-OmarLead Consulti ng EditorConsultant Cardiologist, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundati on Trust

Dr Richard EdwardsConsulti ng EditorConsultant Cardiologist, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust

Mr Ian WrightEP Consulti ng EditorTechnical Head EP, St Mary’s Hospital, Imperial College Healthcare NHS Trust

Dr John PaiseyJournal ReviewerConsultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundati on Trust

Dr Dan McKenzieJournal ReviewerConsultant Cardiologist, Musgrove Park Hospital, Taunton and Somerset NHS Foundati on Trust

Dr Simon RedwoodConsulti ng EditorConsultant Cardiologist & Director of the Cath Labs at Guy’s & St Thomas‘ NHS Foundati on Trust

Dr Rodney FoaleConsulti ng EditorConsultant Cardiologist, Imperial College Healthcare NHS Trust

Mr Adam LunghiEcho Consulti ng EditorSenior Echo ManagerCVS - CardioVascular Services, Australia


Mr Stuart AllenECG Consulti ng EditorHead of CRM, Monash Medical Centre, Melbourne, Australia

Special � anksMs Annie WilliamsonSt Thomas’ Hospital

Mr Greg CruickshankKings College Hospital

Mr Bryan WalkerManchester Heart Centre

Ms Peggy McElgunnExecuti ve Director, Alliance of Cardiovascular Professionals (ACVP), USA


Round UpInternati onal News

Ancient Egypti ans Had Heart Disease Too!

An interesti ng study by researchers in the USA has begun to shed new light on heart disease, challenging the belief that vascular disease is a modern affl icti on caused by current-day

risk factors such as stress and sedentary lifestyles. Michael Miya-moto, MD, a graduate of the UC San Diego School of Medicine and assistant clinical professor made an expediti on to Egypt to evaluate the prevalence of cardiovascular disease in 3,500-year-old mummies. The results were published in the Journal of the American Medical Associati on.

Miyamoto and a team of cardiologists and Egyptologists, carefully examined 22 mummies from the Museum of Egypti an Anti quiti es using a six-slice CT scanner. In the mummies with identi fi able arter-ies, more than half had calcifi cati ons in the walls of their arteries. Those who died aft er the age of 45 showed the highest degree of calcifi cati on. Vascular disease was observed in both male and female mummies.

Surprised by their results, the cardiologists asked the Egypti an pres-ervati on team to share informati on about the lifestyle of ancient Egypt. In general, all who were later mummifi ed, served in the court of the Pharaoh or as priests or priestesses. Diet-wise, eati ng beef, duck and other poultry was not uncommon. Since refrigerati on was unavailable, salt was widely used for meat preservati on. Tobacco was not available and without mechanical transportati on, they were likely physically acti ve.

“Our fi ndings show that atherosclerosis is not strictly a disease of modern humans caused by unhealthy lifestyles,” said Miyamoto, a cardiologist and co-investi gator of the study. “In fact, it is possible that humans have a geneti c predispositi on to the development of atherosclerosis. Our fi ndings remind us of the value of preventi ve medicine in eliminati ng or controlling manifestati ons of heart and vascular disease.”

Heart Study to Target Harmful Immune Cells in the Arteries

The BBC recently reported that scienti sts are trying to devel-op a treatment to target harmful immune cells in the arter-

ies that are believed to trigger many heart att acks. The Bristol Heart Insti tute with the backing of the Briti sh Heart Founda-ti on is commencing a study which follows on from two decades of trial and error, since it was fi rst discovered that a pati ent’s immune system could produce the infl ammati on in the arteries that leads to an att ack.

So far any drugs developed have unfortunately killed off the helpful as well as the harmful cells. The new study is aimed at targeti ng just the harmful cells which, it is believed, are drawn to the arteries as a result of the plaques of fatt y depos-its that build up there. This can lead to the artery becoming infl amed, and the wall damaged, which in turn can lead to a heart att ack.

Is Your Boss Annoying You? Then Speak Up!

Swedish researchers recently undertook a study of 2,755 male employees in Stockholm whom had previously not

had a heart att ack. Each were asked about how they coped with confl ict at work, either with superiors or colleagues. The opti ons were:

Dealt with things head-onLet things pass without saying anythingWalked away from confl ict Developed symptoms like headache or stomach acheGot into a bad temper at home

Results showed that the men who coped by someti mes or oft en walking away or who oft en let things pass without saying anything, had double the risk of a heart att ack or dying from serious heart disease compared to men who challenged and dealt with the situati on head-on. The researchers believe that anger can produce physiological tensions if it is not released and that these lead to increases in blood pressure which even-tually damage the cardiovascular system.

Judy O’Sullivan, senior cardiac nurse for the Briti sh Heart Foun-dati on, said: “Stress itself is not a risk factor for heart and circu-latory disease, but some people’s responses to stress, such as smoking or overeati ng, can increase your risk.”

•••••

Source: BBC


ProductsCardiac Imaging

An evaluati on report by KCARE, for the Centre for Evi-dence-based Purchasing (CEP), on the ACUSON P10™ ultrasound system from Siemens Healthcare suggests

that use of the handheld unit may reduce the number of people referred for full ultrasound examinati ons, parti cu-larly in Cardiology.




informati on without the need to perform a full echocardiogram.

The KCARE report includes feedback from UK users of the P10 who assessed its clini-cal suitability, cost eff ecti veness and likeli-

hood of reducing referrals for a range of clinical applicati ons. Responses were positi ve

overall with 10 second start-up ti me, portability and reliability parti cularly well rated.

The London Chest Hospital, part of Barts and The London NHS Trust, has installed the fi rst Siemens SOMATOM® Defi niti on Flash CT system in the UK for fast CT speed combined with the

lowest radiati on dose. The scanner purchase was made possible by funding from The Nati onal Insti tute of Health Research (NIHR), enabling experts at Barts and The London Cardiovascular Biomedical Research Unit to undertake cardiac research.

The Defi niti on Flash CT is a new to market system that can perform a detailed scan of the enti re heart in just 250 milliseconds, which is less than half a heart beat.

“The Defi niti on Flash will be an invaluable tool for helping in the research of new treatments for cardiovascular disease as it presents a much clearer picture of the workings of the heart,” said Professor Anthony Mathur, Head of Advanced Cardiac Imaging at Barts and The London NHS Trust. “The CT will also be a frontline diagnosti c tool for pati ents presenti ng with chest pains. At the moment, blood tests are carried out to assess for myocardial infarcti on. A number of pati ents who present with chest pain may not be immediately diagnosed with a heart conditi on because they are at an early stage and their con-diti on may not be picked up unti l much later. Now atherosclerosis can be detected earlier and at a much lower dose than previous CT scanners potenti ally preventi ng the serious consequences of a heart conditi on.”

The Defi niti on Flash CT has a temporal resoluti on of just 75ms, which means that image quality is sti ll high even if a moving object is being scanned. For this reason, the heart does not need to be slowed with beta blockers before a scan to deliver high quality clinical images. This is a quicker process and less disrupti ve for the pati ent. The enti re chest region can also be imaged in just 0.6 seconds with-out breath holds from the pati ent so images are far clearer and the examinati on is less stressful.

The NIHR has designated Barts and The London NHS Trust and Queen Mary, University of London, a Biomedical Research Unit in advanced cardiac imaging.

“I am delighted that the Nati onal Insti tute for Health Research is able to fund the purchase of this cutti ng edge new technology,” said Professor Dame Sally C. Davies, Director General of Research and Devel-opment at the Department of Health. “Any new technology that allows us to detect heart prob-lems at an earlier stage while exposing pati ents to less radiati on is very good news. The sooner pati ents know there is a problem, the sooner they can begin to take acti on to prevent more serious problems later on.”

Aultrasound system from Siemens Healthcare suggests that use of the handheld unit may reduce the number of people referred for full ultrasound examinati ons, parti cu-larly in Cardiology.




informati on without the need to perform a

clinical applicati ons. Responses were positi ve overall with 10 second start-up ti me, portability and reliability parti cularly well rated.

This is a quicker process and less disrupti ve for the pati ent. The enti re chest region can also be imaged in just 0.6 seconds with-out breath holds from the pati ent so images are far clearer and

The NIHR has designated Barts and The London NHS Trust and Queen Mary, University of London, a Biomedical Research

Images courtesy Siemens Healthcare

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ProductsCardiac Stents

Introduction

Since the widespread use of drug-eluting stents (DES), industry has provided interventional cardiologists with a variety of refinements – new drugs, new stent designs, new polymers and novel methods of delivering drug or altering release kinetics. Many (but not all) of these modifications have provided measurable, albeit small, improvements in performance and patient outcomes, with the result that currently-available DES provide single-figure rates of target vessel failure with an excellent safety profile at one-year follow-up. So why do we need a new stent material?

What’s wrong with current stent materials and construction?

The ideal metallic coronary stent should possess corrosion-resist-ance, biocompatibility, high radial strength and enough radio-opacity to facilitate visualisation under fluoroscopy as well as being non-fer-romagnetic1. Historically, the majority of stents have been manufac-tured from surgical grade (316L) stainless steel, which fulfils most of these criteria but has limited radio-opacity unless stent struts are thick or coated with other metals (both of which have been shown to increase rates of restenosis)2 3, and crucially may not be as biocom-patible as previously thought owing to elution of trace elements after implantation4. The advent of cobalt chromium (CoCr) alloys (L605 (Vision, Abbott Vascular), MP35N (Driver, Medtronic)) allowed for a thinner-strut stent construction from biocompatible compounds that have comparable strength and reasonable radio-opacity 5 6. The stent platforms made from these alloys have proved to be highly deliverable due to enhanced flexibility, exhibit low restenosis rates in their bare-metal configurations, but have sacrificed radial strength and resistance to elastic recoil to some degree due to their thin-strut design.

PtCr alloy and the Element stent

Platinum-Chromium (PtCr) is the first alloy developed specifically for coronary stent manufacture; platinum has been used in a variety of

implantable medical devices over the last 20 years and has proved to be highly biocompatible due to its chemical stability. Addition of platinum to a stainless steel base enhances the strength of the com-pound allowing the potential for stronger struts of comparable thin-ness to those made from CoCr alloys, with improved radio-opacity 7 (Table 1). The PtCr alloy was developed specifically by Boston Scien-tific for the novel Element stent design (Figure 1) – a dimensionally uniform pattern of serpentine segments with two offset connectors that reverse directions for alternate rows, providing a design partway between cellular and modular that is highly deliverable and conform-able, and provides compression/recoil resistance comparable to that of 316L stainless steel stents.

The Element platform has been optimised in its deployed conforma-tion to allow as uniform drug-delivery to the vessel wall as possible; the Promus Element was released in the UK in November 2009, with the Taxus version available later this year, followed by the bare-metal iteration in due course. For each of the drug-eluting versions, the drug concentration and polymer will be identical, respectively, to the extensively-trialled and established Promus/Xience V and Taxus Lib-erte stent designs.

The Element stent program

Prior to launch, the Element trial program was initiated, from which the first results will be presented at the ACC in March this year. For each of the drug-eluting versions of the Element stent, there already exists a large body of registry and randomised controlled trial (RCT) data relating to its ‘parent’ stents, which will be supplemented by new data comparing these platforms to their Element counterparts. The Platinum trial, involving 1532 patients in 160 centres, is a RCT comparing the Promus Element stent with the Promus stent; the study includes prespecified small-vessel and long lesion subgroups and completed enrolment in September 2009. The Perseus trials studying the Taxus Element stent include Perseus WH (Work Horse) and SV (Small Vessel) studies; the former was a 1264-patient RCT comparing the Taxus Element with the Taxus Express, and the lat-ter a smaller 224-patient single-arm trial comparing the small vessel (≤2.75 mm diameter) Taxus Element with historical controls in the

Precious metal: Platinum-Chromium alloy & the Element stent

Dr Nick WestAuthorConsultant Cardiologist, Papworth Hospital, Cambridge, UK

Powered by Platinum Chromium

PROMUS™ Element™Everolimus-Eluting Coronary Stent System

Experience the next generation in coronary stenting with the PROMUS™ Element™

Everolimus-Eluting Coronary Stent System. Powered by Platinum Chromium and the new, innovative Element™ Stent design, the PROMUS™ Element™ Stent is the strongest, most fl exible and most visible thin-strut coronary stent.1

1 To Date. Test conducted at Boston Scientifi c. Data on fi le. Platinum Chromium Technical Bulletin PDM 90353760.This material is not intended for use in the United States and Japan. Stent illustrations not indicative of clinical performance.All cited trademarks are the property of their respective owners. CAUTION: The law restricts these devices to sales by or on theorder of a physician. Indications, contraindications, warnings and instructions for use can be found in the product labeling suppliedwith each device. Information for the use only in countries with applicable health authority product registrations.PSST 5774 Printed in Germany by medicalvision. © 2009 by Boston Scientific Corporation or its affiliates. All rights reserved.

www.bostonscientifi c-international.comwww.elementstent.com

Strength. Flexibility. Visibility.

FV_BC24009_PROMUS_ELEMENT_Ad_A4.indd 1 04.11.2009 12:23:19 Uhr


Taxus V study. Both trials finished recruiting in October 2008, and although data will not be presented until later in the year, no safety concerns have arisen thus far from independent safety monitoring.

Summary & Conclusions

Novel stent designs and modifications have often promised to deliver tangible clinical improvements, but strut thickness aside, none of these have translated into measurable differences in clinical perform-ance or patient outcomes. The new PtCr alloy has facilitated devel-opment of a thin-strut stent design with preserved radial strength that will carry established drug/polymer combinations, and will likely deliver performance that is at least as good as the current Promus/Taxus Liberte designs in forthcoming trial data. Whether this novel alloy/design platform delivers performance improvements over cur-rently-available DES will remain to be seen in clinical trials in due course; only then will we be able to judge whether this alloy deserves the prestige and exclusivity that are connotations of its constituent precious metals.

References

Lau K-W, Mak K-H, Hung J-S et al. Clinical impact of stent construction and design in percutaneous coronary intervention. Am Heart J 2004; 147: 764-73.

Kastrati A, Mehilli J, Dirschinger J et al. Intracoronary stenting and angiographic results: strut thickness effect on restenosis outcome (ISAR-STEREO) trial. Circula-tion 2001; 103: 3816-21.

Kastrati A, Schomig A, Dirschinger J et al. Increased risk of restenosis after place-ment of gold-plated stents. Circulation 2000; 101: 2478-83.

Koster R, Vieluf D, Kiehn M et al. Nickel and molybdenum contact allergies in patients with coronary instent restenosis. Lancet 2000; 356: 1895-7.

Kereiakes DJ, DJ, Cox DA, Hermiller JB et al. Usefulness of a cobalt chromium coronary stent alloy. Am J Cardiol 2003; 92: 463-66.

Sketch MH Jr, Ball M, Rutherford B et al. Evaluation of the Medtronic (Driver) cobalt-chromium alloy coronary stent sytem. Am J Cardiol 2005; 95: 8-12.

Craig CH, Friend CM, Edward M et al. Mechanical properties and microstructure of platinum enhanced radiopaque stainless steel (PERSS) alloys. J Alloy Comp

2003; 361: 187-99.

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New coronary stents- Back to the future?

Nobody can dispute the impact that drug eluting stent technology has had upon coronary intervention. Effec-tive modulation of the healing process within the stent

has allowed interventionalists to treat long areas of atheroma with multiple stents and achieve results which can be com-pared with the effectiveness of a surgical bypass graft During this revolution we have all become familiar with the complex performance measures of the polymer(which modulates the release) and the drug combination – in particular the concept of late loss which is a measure of the amount of neointimal tissue one might expect to find within a stent at the end of the healing process. Much emphasis has been placed on these figures and considerable debate has surrounded what a “desir-able” late loss might be and in particular how this might relate to rates of very late stent thrombosis.

During 2010 both of the first generation drug eluting stents are scheduled for replacement. Boston Scientific will replace Taxus Liberte with the Taxus Element and Cordis Johnson and Johnson will replace the Cypher Select with the Nevo. Boston will also launch the Promus Element. The principal rationale for these changes is not to change the drug, but to improve the mechanical performance of the stent. Using thinner struts should reduce the biological signal to the vessel to produce neointima which may be clinically beneficial. But considerable emphasis is now being placed on issues which we have almost forgotten about with our concentration on different drugs and polymers. These include the need for the stent to scaffold the vessel to prevent tissue prolapse between the struts and opti-mising stent visibility to allow accurate positioning of a second stent and post dilation. However, perhaps the most important is the key issue of improved deliverability. It is hoped that these new stents will track better and fewer will end up being wasted. When a stent cannot be implanted in the patient due to vessel tortuosity and a different more flexible bare metal stent has to be used as an alternative, the cost of the wasted drug eluting stent is borne by the hospital as it is not refunded by the purchasers. Improved flexibility may also mean that interventionalists may be more confident to use one long stent rather than two short ones in difficult cases. These practical issues are rarely discussed in international meetings but they are real world issues when we are calculating the cost per case within our increasingly cash restricted Catheter labs.

With the availability of these new stents imminent, I suspect we will be going back to some of the debates we heard last heard in the late 1990s about stent flexibility and deliverabil-ity rather than the rather sterile discussion about the decimal points of late loss and rates of late stent thrombosis.

Dr Adrian BanningAuthorConsultant Cardiologist, John Radcliffe Hospital, Oxford, UK

Image courtesy Boston Scientific Corporation


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InterviewCardiologist

What types of EP procedures do you do here?

We really do the full range of everything in terms of EP and devices, starti ng from the basic EP studies through to the usual SVT’s. Then we have a program of AF ablati on, and we do the VT ablati ons as and when they come up as well. In terms of devices the whole range of brachy and tachy device implantati on and extracti on as well.

What is your favourite technique for AF?

I am a big fan of linear ablati on for the persistent AF pati ents, so we sti ll do here mostly ti p catheter ablati ons. We do use a catheter called the PVAC catheter which is a dedicated pulmonary vein iso-lati on catheter for paroxysmals with structurally normal hearts and

short episodes, and there we do just the restricted PVI with those. But for anybody who has longer lasti ng episodes or persistent AF we tend to do a ti p catheter ablati on with NAVX. We are hoping to get CARTO in the future to have a choice of systems. And we tend to do wide area encirclement and then linear lesions as well for those pati ents.

Thoughts on the Hansen and Stereotaxis systems?

People tend to lump the two things together, because from the operators point of view both of them are giving you a degree of remoteness from the procedure in terms of back-ache and radiati on exposure. But they are doing rather diff erent things. The Stereotaxis system in the future is, I am not saying Stereotaxis itself, but some-thing along those lines is likely to play a large part in the future of complex ablati on. Personally I sti ll think it is in the stage of being developed rather than being a tool which adds much to the clini-cal end-points at the moment. Hansen as an interim has a bit more to off er at the stage it is at, at the moment in terms of being a tool which really adds something to the procedure, but perhaps in the future it might get superseded by something that looks more like what Stereotaxis looks like at the moment.

Dr John PaiseyConsultant Cardiologist & Electrophysiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundati on Trust

WATCH THE FULLINTERVIEW ONLINE

For the complete video interview with Dr John Paisey at the Royal Bournemouth Hospital, visit our website.



Journals

Hypertension

How exciting, just in time for Christmas a new class of anti hyper-tensive. Darusentan is a direct, selective endothelin antagonist which exerts its antihypertensive effect by vasodilation. In a placebo controlled, randomised trial of 3 doses of the drug in patients who had not achieved target blood pressure after three conventional antihypertensives, all three doses of the drug were found to be effective. One side effect was oedema; intriguingly it required 117 sites to recruit 379 patients.

Michael A Weber and others, The Lancet 374; 9699, 1423 - 1431

Many patients are prescribed prognostically significant drugs but often do not achieve the doses demonstrated to be beneficial in the trials. In a direct, randomised, blinded comparison of low (50mg) vs high dose (150mg) Losartan in 3846 patients with moderate heart failure and intolerance of ACE inhibitors the high dose group had significantly less heart failure admissions over 4.7 years follow up. The authors note the value demonstrated in the often difficult proc-ess of titrating up medication in heart failure patients.

Marvin A Konstam and others, Lancet 2009; 374: 1840–48

Antiplatelets/Anticoagulants

The new kid on the block in anti platelet therapy is Cangrelor, an intravenous, reversible ADP inhibitor with some theoretical advantages in terms of speed of action and safety compared to oral clopidogrel. A group of investigators managed the quite remarkable feat of having two simultaneous attempts at demonstrating a ben-efit over clopidogrel/placebo, failing to meet their primary endpoint and still getting both trials published in the NEJM.

Deepak L. Bhatt and others, New Eng J Med 361:2330-2341

Robert A. Harrington and others New Eng J Med 361:2318-2329

Bleeding risk on combinations of antithrombotic and antiplatelet agents are a real concern in the post infarct/PCI population. In an observational study of over 40 000 Danish patients experiencing

their first infarct, bleeding risk over a mean of 476 days was found to be 2.6, 4.6 and 4.3% aspirin, clopidogrel and warfarin mono-therapies respectively. This risk was not clinically significantly elevat-ed by either dual antiplatelets or aspirin/warfarin combination. Combination of clopidogrel and warfarin (with or without aspirin) however increased major bleeding risk to 12%. This presents a real therapeutic challenge for patients with drug eluting stents, atrial fibrillation and stroke risk factors.

Rikke Sørensen and others, The Lancet 374; 9706, 1967-1974

Cardiac Resynchronisation

Some of the most marked responses to cardiac resynchronisation therapy are seen in right ventricular paced patients. This is not sur-prising given that right ventricular pacing induces gross dysynchrony and heart failure patients respond so badly to it.

How far can this effect be demonstrated in individuals with structur-ally normal hearts? In a trial of 177 patients with normal ejection fraction randomised to either biventricular or right ventricular apical pacing there was a significant decrease in ejection fraction and increase in left ventricular dimension in the right ventricular pacing group. This did not translate into any clinical endpoints and a number of criticisms of the pacing implant and programming were raised. The proof of concept remains and we are set to see a creep of CRT into a wider range of pacing patients.

Cheuk-Man Yu and others N Eng J Med 361:2123-2134

The magnitude of the physiological benefits of cardiac resynchronis-tion therapy, should be independent on the degree of heart failure. The move to apply CRT to less symptomatic individuals is therefore no surprise. In the REVERSE study six hundred and ten NYHA class 1-2 patients were implanted and then randomised to on or off and followed for 12 months. There was significant reverse remodelling in the CRT on group compared with baseline and the CRT off group.On its own this is probably insufficient evidence to recommend CRT in NYHA 1-2 patients who are not otherwise indicated for device therapy but taken with the MADIT CRT trial a good evidence base

Dr John PaiseyJournal ReviewerConsultant Cardiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Dr Dan McKenzieJournal ReviewerConsultant Cardiologist, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust


for CRT in patients receiving a device for other reasons is emerging.

Martin St. John Sutton Circulation 2009;120;1858-1865

Clinical results in CRT have been mixed in the QRS<120 msec population. There remains a suspicion that certain subgroups of these patients would benefit. Perhaps efforts at selection have been misdirected, as the problem (and hence mechanism of benefit) is as much to with diastolic filling as systolic dysychronous contraction.In an acute study of 30 patients with heart failure and QRS<120 msec 15 were noted to have evidence of external constraint and CRT abolished this in all. This resulted in an overall increase in stroke volume and ejection fraction as well as improved filling.

Lynne K Williams and others Circ 2009;120:1687-1694

Hypertrophic Cardiomyopathy

A small study of families with identified hypertrophic cardiomyopa-thy mutations sought to investigate, amongst other things, the pen-etrance of the disease in carriers. Only 41% of carriers expressed the phenotype in this snapshot with age and male gender increas-ing risk of expression. Risk factors for sudden cardiac death were noted to be present even in (as yet) unaffected carriers.

Michelle Michels and others, European Heart Journal 2009 30(21):2593-2598

Exercise testing is often used to risk stratify hypertrophic cardiomy-opathy patients but its value is not well established. Analysis of the Heart Hospital’s referrals finds exercise induced arrhythmias to be rare (27 out 1380) but a significant predictor of malignant arrhyth-mias (a 3.73 fold increase in risk of sudden death/ICD discharge). Although the effect ceased to be significant if only NSVT patients were considered in a multivariate analysis it is the raw data that has more relevance to clinical practise as exercise induced arrhythmias are associated with a number of softer risk factors which might not score in their own right.

Perry Elliot and others Eur Heart J 2009 30(21):2599-2605

Implantable Cardioverter Defibrillators

SCD-HeFT (published 2005) continues to be mined for data. To recap this was a study of single lead ICDs in NYHA II-III individu-als with ejection fractions under 0.35. Detailed analysis of the 666 deaths in the trial has revealed that ICDs exerted their effect by cutting all cause, cardiac and tachyarrhythmic death but not non cardiac or heart failure death. Interestingly, the mortality reduc-tion was significant only in NYHA II individuals and he benefit was independent of aetiology.

Douglas L Packer and others Circulation. 2009;120:2170-2176

In ICD therapy, inappropriate shocks are well recognised but the concept of unnecessary shocks is gaining currency. The commend-ably low detection and charge times of modern devices have the potential to deliver shock therapy in patients with non sustained but fast arrhythmias, a profile known to be seen in the primary prevention CRT D population.

The RELEVANT study examined a simple programming change extending the detection interval in these patients which reduced inappropriate shocks and heart failure events compared to normal programming.

Maurizio Gasparini and others Eur Heart J 2009 30, 2758–2767

Electrophysiology

Does every patient undergoing left atrial ablation for atrial fibrilla-tion need a pre procedure transoesophageal echo? In a report of 1058 patients there was not a single incidence of left atrial append-age clot in the 47% of these patients with CHADS2 profile of 0. The authors conclude that TOE should continue to be performed in patients with a CHADS2 profile of 1 or more or in CHADS2 0 patients only if AF is persistent and anticoagulation has not been maintained for 4 weeks.

Sarinya Puwanant and others J Am Coll Cardiol. 2009 Nov 24;54(22):2032-9

Revascularisation

Not so long ago it looked as though off pump surgery was going to be the best thing since free radial grafts..... fortunately it doesn’t look as though it will be as poor as that turned out - merely time consuming, pointless and slightly worse than standard care. In the latest instalment of this story a randomised trial of 2203 patients the off pump group had worse cardiac outcomes than standard on pump operations with no difference in neurological sequelae.

Laurie Shroyer New Eng J Med 361:1827-1837

JOU

RNA

LS


FeatureInventory Management

If your department has recently installed a new inventory manage-ment system costi ng your hospital a few million pounds, it may be best to look away now. RFID has arrived!! Whilst sti ll in its early

stages here in the UK, it is now the system of choice for forward-thinking hospitals in the USA, moving beyond the traditi onal push butt on cabinets and bar-coding. But what is it, how does it work, and more importantly how can it be successfully implemented into your department today?

It is obvious to see that hospitals are struggling to reign in expenses. Companies sprout up with new ways to improve pati ent care, reduce infecti on rates, and/or increase revenue. Pop the word “medical” in front of it and quadruple the price. For this reason hospital man-agement has become very wary about new products, and it is com-monly known they now invest less in new technologies than other industries.

If you are a regular reader of our publicati on you would have noti ced in our Site Visits we always ask the questi on on Inventory Manage-ment in their department. Almost always the answer comes back as pen and paper (manual method). So what is the advantage of automated inventory management systems?

The process has moved beyond just the ordering, receiving, and tracking of supplies. Today it can do so much more. At the click of a mouse you can instantly see your available inventory, including serial numbers, used by dates, and any recalled products.

So what are your choices today?

Manual:

This is the most common technique for NHS hospitals in the UK, and involves manually counti ng each individual product used and either using a spreadsheet or pen and paper to keep track. This is very ti me consuming and is subject to human error.

Bar-Coding:

This is the next step-up from the man-ual method and involves a bar code reader which captures the product code and stores the informati on in a program for further manipulati on like is menti oned above. This is possibly the best technology available on the market today to manage stock auto-mati cally in the cath lab environment, and newer systems can be integrated easily with RFID.

Butt on Pushing:

This technology has been imple-mented into a few cath labs recently with mixed feedback. The idea is that each product on a shelf is assigned a parti cular butt on. If you remove the product you press the butt on corre-sponding to it. This technology has been around for a while and works well in theatre environments, but in stressful cath lab situati ons where you have to grab multi ple products quickly, butt on pushing is oft en for-gott en and mistakes are made.

RFID:

RFID uti lizes an inexpensive tag that is placed on the product either by the manufacturer or when stock arrives in the department. The tag links to informati on including that box’s product descripti on, expirati on date, lot number, serial number, its price upon receipt, its status as consigned or owned, and so on. From here the boxes are placed into “Smart Cabinets” which automati cally that the detect the products have been added and add them to the department inven-

RFID is the Future for Automated Inventory ManagementMr Tim Larner

Director / FounderPrevious Chief Cardiac Radiographer & Manager in Australia, now Senior Radiographer at the Manchester Heart Centre.

Images courtesy Scan Modul System Ltd


Hypotheti cal CaseRFID vs Butt on Pushing

Situati on:

A Cardiologist dissects the Left Main, causing a spiral dissec-ti on down the LAD. The pati ent’s ECG goes haywire, and the normally calm lab becomes a scene of high stress. The cardiol-ogist screams for several stents of diff erent sizes immediately. Here every second counts.

Retrieving items:

Butt on Pushing: The nurse runs to the cabinet, has to punch in her access code on ti ny butt ons trying to stay calm, locate the pati ent’s name from the full days list and select it before the cabinet will open. They then grab sev-eral stents, having to push the butt on aft er getti ng each one, otherwise they will never be tracked, and run back to the cardiologist who is yelling at you for taking so long.

RFID: The nurse runs to the cabinet, puts their fi nger on the biometric reader and the door unlocks. The nurse grabs what they need and runs back. Sensors in the cabi-net detect automati cally what has been taken and apply them to the case.

Returning items:

Butt on Pushing: It has appeared the cardiologist took contrast streaming as a dissecti on and tells you to leave two stents and return the remaining three. The nurse has to enter their code, fi nd the pati ent again before the door unlocks, fi nd the shelf and select another butt on to return each item.

RFID: The nurse puts their fi nger on the biometric reader and door unlocks. They put the unused stents back in the cabinet without having to press another butt on. The Smart Cabinet automati cally detects the items have been returned and updates the case product usage. Simple!

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Product Choice Assistance

@ Web & Email

Phone

Webwww.scanmodul.com/spacetrax

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tory list. Remove an item and the Smart Cabinet detects this and automati cally updates the system. Dan Sharbach, Regional Director of Invasive Cardiovascular Services at the Providence Health System in Portland, Oregon, USA recently reported for us on the use of RFID in their hospital stati ng, “By following current processes, nurses and techs are more likely to embrace this technology because, unlike many inventory systems, this approach is largely invisible to the front line clinical user.” Put simply, RFID technology closely matches the workfl ow for cath labs compared to other systems, virtually cancel-ling out human error.

Purchase Planning:

RFID is a relati vely new technology here in the UK and as such is very expensive. For large departments with a high stock turn-over the cost-benefi t can be justi fi ed. However we recommend you start with a system which can eventually be upgraded to this technology, reducing your overall expenses in the medium to long-term.

Investi gati on:

See what systems are on the market. See their installati ons, not just in theatres, but cath labs. Speak to managers who use the system across the enti re supply chain and see where their strengths and weaknesses are.

Future Proof:

Automati ng inventory management is not cheap, but the last thing you want to do is buy a system that is obsolete in fi ve years. Look at what upgrades are available. Can their cabinets be made to be RFID compliant easily? Does their soft ware easily integrate with RFID technology?

Beware:

Some companies you talk to may down play RFID technology, but that is because they don’t have it. Sure, the tags aren’t on any of the boxes here in the UK and you have to do it manually, but as with the USA this is rapidly changing, and it won’t be long before every item you order has a litt le RFID tag att ached to it.

Further Reading:

Visit our website www.cardiologyhd.com and read interesti ng arti cles from the USA on how their inventory is managed including more detailed usage of RFID.

HOME >> Features >> Management & Staff >> Inventory Management

Scan Modul System Ltd based in the UK use the automated inventory management system called SpaceTRAX. This internati onally recognised system is bar-code based, however most importantly can be easily be upgraded to RFID. They also use fi ngerprint recogniti on on their cabinets making security and instant access easy. No more codes and butt on pushing in stressful situati ons.


Hot TopicManagement

We only wear hats and masks during device implants/TAVI’s etc where there is an open wound (and when most procedures are carried out in a room with full positi ve pressure theatre venti lati on). None of the staff wear hats and masks for inter-venti onal procedures but these are usually performed in Cath Labs with ‘treatment’ room venti lati on.

We do not allow scrub staff to wear their scrubs (which are blue) outside the immediate Lab/department but running staff may move freely around whilst inside the hospital buildings wearing theirs (pink). No problem with infecti on rates.

We are very consistent in wearing caps and masks with devices, but for very litt le else. For some congenital cases the opera-tors do, but no one else in the room. The only regular excep-ti on is that anaestheti sts appear not to adhere to this. I too wonder why.

At the Golden Jubilee Hospital in Glasgow they too do not wear hats or masks in the cath lab or EP labs unless a “device” is being implanted. Hats and masks as usual in theatre for PFO/ASD closure etc.

Should cath lab staff be wearing hats and masks when scrubbed?

What an interesti ng topic and one we have discussed numer-ous ti mes in our Cath Lab here in Truro in Cornwall. When I started my job as CCL manager seven years ago all staff

were wearing hats for all procedures and hats and masks for all pac-ing type procedures. Everyone had two pairs of shoes, blue shoes to wear outside the department and white shoes for inside the Cath Lab.

As I came from a Cath Lab that did not wear hats all day I wanted to make a change. I looked at a number of studies on the effi ciency of hats and masks on the internet to ensure ‘evidence based practi ce’ and invited the views of our consultant cardiologists.

I found no evidence that the wearing of hats and masks reduced infecti on rates. However, every hospital has it’s own policies and our hospital policy clearly states that theatre staff should must wear the full kit.

All our consultants, except one, were in favour of not wearing hats routi nely. They agreed to conti nue to wear hats and masks only for pacing procedures like ICD’s, PPM’s and Reveals.

We recently stopped the wearing of masks during pacing proce-dures for the ‘running’ staff . Only the operator and scrub nurse wear hat and mask.

We felt a CCL is not a ‘proper’ operati ng theatre and therefore we could make our own policy up.

Long hair has to be ti ed back and there have been no issues with staff not complying with this common sense rule. All staff are encouraged to wear a visor during angio and PCI procedures as protecti on from blood droplets.

We got rid of all the blue shoes. Aft er all, pati ents arriving on beds that had been pushed on public hospital corridors went straight into the labs. Why fuss with in and out shoes? They did not make sense and our changing room is less clutt ered.

Our infecti on rate is well below the nati onal average, in fact I can’t remember an infected device in the past year.

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This questi on was asked on our Cardiology HD Facebook Wall by Helen Day.Now with over 300 fans globally!!

Ms Tina PrestwoodCardiac Cath Lab Manager, Royal Cornwall Hospital, TruroUnited Kingdom

Ms Annie WilliamsonSuperintendent Radiographer, Guy’s & St Thomas’ NHS Foundati on Trust, London, United Kingdom

Mr Bryan WalkerSuperintendent Radiographer, Manchester Heart Centre, Manchester, United Kingdom



Site VisitUnited Kingdom

What are the sizes of your Cardiology Department and Hospital?

The Hospital has 632 beds and there are 4 cardiac wards (CCU, 2 in patient wards and an Electives ward)

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

We serve Bournemouth and the surrounding towns of East Dorset and West Hampshire for secondary referral (300,000). Angioplasty and ICD/CRT services to the Poole and Salisbury area (750,000), and Ablations to all of these areas as well as Dorchester and West Dorset (1.2 Million). How many staff? Roles?

The Cardiac department as a whole employs 263 staff, mostly ward nurses. The Labs have a complement of 24 physiologists (who also cover other aspects of the service), 17 nurses and 6 radiographers.There are 9 consultants, 4 PCI, 3 EP, 1 imaging, 1 pacing. We also have visiting cardiologists from Poole and Salisbury, and work closely with colleagues in radiology.

Types of procedures?

We perform a full range of Interventional coronary, device implanta-tion/extraction and electrophysiology procedures.

Types of equipment used?

We have 4 new Siemens labs and a pacing theatre as well as a full range of non invasive investigations, cardiac CT and MRI.

Royal Bournemouth HospitalThe Royal Bournemouth and Christchurch HospitalsNHS Foundation Trust, Castle Lane EastBournemouth, BH7 7DW, United Kingdom

Dr John PaiseyIntervieweeConsultant Cardiologist & Electrophysiologist, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Overhead View

Royal Bournemouth Hospital

1� Jan/Feb 2010 www.cardiologyhd.com

We use Laser systems for lead extraction and PCI, Rotablation PCI, Pressure wires, IVUS and Electro-anatomical mapping systems. Image archiving is through Medcon.

How many procedures are performed a year?

PCI: 2000

Pressure Wire: 650

IVUS: 650

Pacemakers: 650

Ablations: 500

ICD/CRTD: 150

CRT P: 50

What is the approximate percentage of cath lab cases performed radially compared with femorally?

70% of cases are performed radially.

What protocols has your department implemented to reduce door-to-balloon time?

We have a direct link from the ambulance service to the Lab, giving an average door to balloon time of 40 minutes.

Are any of your staff cross-trained (generic workers)?

Some of our staff are dual trained in nursing/ODP. We plan to intro-duce more generic working in the future.

What new procedures have you implemented into the department recently?

With the increasing financial pressures we are working hard to get maximal value with out compromising on quality. Staff are now aware of the cost of each consumable to focus efficient working.

How is your inventory managed?

Barcodes

How does the lab handle haemostasis?

Most femoral cases receive angioseals.

What measures has the department implemented to cut costs?

Consultants have introduced a flexible working regime to cover inpa-tient work. We are working hard to reduce our length of stay.

What kind of training can new employees expect to receive?

New employees receive extensive on the job and off site training opportunities.

What kinds of continuing education programs are available to staff?

There is a funded study budget and staff our encouraged to enrol on industry sponsored events.

What kinds of competency checks do staff have to undergo once employed?

Staff are expected to keep up to date with their training and prac-tice. This is monitored through HR.

Please outline the Department Management structure.

Cardiology falls within the general medicine directorate which has a general manager answerable to the board. Cardiology has its own departmental manager and she supervises leads from each of the disciplines. Radiology is a separate directorate.

How do you deal with late finishing of cases? For example stag-gered working hours or just staff overtime?

We have an on call team with responsibility for mopping up late cases. They are paid an availability allowance and for the in-hospi-tal work they do out of hours. Other overtime is attempted to be reduced to the minimum manageable.

What is your policy for company reps within the labs? Are reps allowed to bring food for sharing amongst doctors and staff into the department when they visit?

We welcome reps bearing gifts of food. No value line please.

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Above: Sharon Chamberlain (nurse)


Latest Site Visit videos available online now.

Royal Bournemouth HospitalRoyal Cornwall Hospital

Featuring interviews with cardiologists, managers and staff , and an indepth look at how each department works

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Reducing radiati on dose is a high priority in the cath labs. What techniques are employed by your radiographers to ensure dosage during cases is kept to a minimum?

Where possible we reduce frame rates on fl uoroscopy, and we use Radpads for CRT cases to reduce scatt er. Everyone always hangs their leads up.

What are the advantages for SpR’s training at your facility?

We have 5 SpRs, 3 PCI fellows, 2 EP fellows and an Imaging fellow. SpRs receive training in pacing, Echo, TOE, angiography and where appropriate PCI/EP. PCI fellows perform 500 procedures per year, EP fellows learn all aspects of device implantati on and ablati on includ-ing AF ablati on. The imaging fellow has opportuniti es in echo, TOE, CT and MRI.

What is the best part of working at your facility?

We are a ti ght knit friendly group who all get on well and are focused on providing an excellent service. The knowledge of the quality of service we provide and appreciati on our pati ents express is very rewarding.

We are also a forward looking centre, and are the only UK centre performing terti ary services such as complex EP and extracti on from a DGH setti ng. On the PCI front we are prominent in running 4 laser workshops a year as well as having hosted BCIS last year.

From Left : Claire Hardman (Cardiac Physiologist), Becky Morton (Radiographer), Percy Jokhi (Cardiologist),

Alex Hobson (Cardiology Fellow)

From Left : Zhan Sun (nurse), Mel Merridew (nurse), Sue England (Radiographer), Camelia Stacy (nurse)

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Above: Neil Barbour (Medtronic Clinical Rep) and Abigail Butler (Cardiac Physiologist)

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EducationElectrophysiology

More than other disciplines electrophysiology (EP) requires the synthesis of different types of information to develop understanding. Despite years working in the environment

some individuals fail to develop an interest in EP because they fail to appreciate and combine essential elements.

These elements include:

The surface ECG

Detailed cardiac anatomy

Anatomical description and fluoroscopic views

Intra-cardiac electrograms

Cellular electrophysiology and mechanisms of arrhythmia

I have previously introduced some of these areas – intra-cardiac elec-trograms and mechanisms of arrhythmias (re-entry and focal) for example. An understanding of the surface ECG is often assumed but is lacking in some staff groups. Another neglected area is the three dimensional structure of the heart and its relation to two dimen-sional fluoroscopy. In this article I hope to give a flavour of this 3D element.

Many staff approach EP having had some experience of angiography and percutaneous coronary intervention (PCI) where the use of fluor-oscopy is quite different. This difference is not usually explored.

Fluoroscopy in coronary work and EP

In coronary work fluoroscopy is used to produce diagnostic images and to facilitate movement of wires and equipment along the coro-nary arteries. In diagnostic work the image intensifier is moved in the cranio-cordal plane in addition to the right anterior oblique (RAO) – left anterior oblique (LAO) plane to produce a great variety of views - ensuring lesions are not missed. In PCI the movement of

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the wire, balloon or stent is constrained by the vessel lumen (hope-fully!) – movements being restricted to distal and proximal within the confines of a vessel’s course. A working view is chosen that gives the operator the best information for performing the intervention.

In EP the fluoroscopy is used for “diagnosing” the position of the cath-eters within the cardiac chambers as the signals can only be under-stood when the anatomical positions of the catheters are known. Two views - RAO and LAO are usually adequate. In addition an opera-tor is often guided in moving the catheters by instructions from a senior colleague – this requires a mutually intelligible language for describing three dimensional space (see anatomical description).

Anatomical description

For the purposes of anatomical description the body is viewed in the upright position and has three orthog-onal (90 degree) axes: superior–inferior, pos-terior–anterior, and right–left (Fig 1). Anatomical landmarks can be described in terms of these co-ordinates and the same axes are used to describe the ECG and also in fluoro-scopic projections. The fluoroscopic screen presents the

Learning Electrophysiology:Anatomical description and fluoroscopic views

Mr Ian WrightEP Consulting EditorTechnical Head EP, St Mary’s Hospital, Imperial College Healthcare NHS Trust

Fig 1. Orthogonal axes


thorax in an upright image even though the patient is lying down. Superior structures (such as the SVC) are shown in the upper part of the screen and inferior ones in the lower part (such as the IVC). The posterior–anterior direction can be identified because the spine and the sternum are clearly recognisable as reference markers. In RAO the spine which is posterior appears on the left side of the image, in LAO the spine appears at the right. In these oblique views right and left on the screen represents a combination of the posterior–anterior and right–left axes.

However in respect to the human heart this is complicated by the fact that the heart does not sit squarely within these orthogonal axes. The axis of the ventricles tilts laterally to the left from base to apex, extending anteriorly and slightly inferiorly - with tricuspid and mitral

valves following the orientation of the ventricles (fig 2). The so-called right atrium is in fact more accurately described as anterior to the left atrium and the right ventricle is anterior to the left ventricle.

In EP it is often essential to know whether the catheter is ventricular or atrial and if it is in the right or the left side of the heart (or if it is septal). The anterior oblique views can provide this information. These tilted views line up with the rotated heart so that right and left on the screen become meaningful with respect to the cardiac anatomy. In RAO the beam aligns with the AV valves such that left on the screen is atrial and right is ventricular. In LAO the beam is aligned with the apex to base axis of the heart such that left on the screen is the right heart while right on the screen is the left heart. Each view is lacking in information about one cardiac plane – in RAO

Fig 2. This image is taken as if looking up from the patient’s feet. The axis of the AV valves is marked by the line and is mainly in an anterior-posterior orientation. The line also represents the plane of the X-ray beam in an RAO view. In this view it is impossible to

resolve the position of structures in line with the beam – left heart and right heart positions cannot be distinguished from each other.

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the right and left atrio-ventricular juncti ons are superimposed and it is diffi cult to determine if a catheter (for example the coronary sinus electrode) is on the right or left side of the heart. Using the LAO view allows recogniti on of the right and left free walls and the disti nc-ti on of these zones from the septal area but lacks informati on about whether a catheter is atrial or ventricular. RAO for example is useful when positi oning the high right atrial (HRA), HIS and right ventricular

apex (RVA) catheters. LAO is useful when positi oning the coronary sinus (CS) catheter as this structure extends left wards (with respect to the heart) around the left AV groove. Swapping between the two oblique views allows the positi on of a catheter to be assessed within the geometry of the heart.

Fig 3. RAO and LAO views in the same patient. Contrast has been introduced into the coronary sinus. (The HRA and HIS catheters are somewhat displaced).

Fig 4. Anatomy and catheters in RAO (catheter diagram adapted from an image courtesy of St Jude Medical)

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The RAO View

RAO LAO


The locations of accessory pathways

The locations of accessory pathways are made as seen in the LAO projection and the terminology commonly used to describe their positions cause some confusion. The descriptive terms used are anatomically inaccurate having been derived from a surgically distorted view (surgeons tended to move the heart from its natural position). The superior aspect of the heart is described as being anterior, while the anterior and posterior aspects are described as right and left lateral (see fig 6). An attempt was made ten years ago to replace the descrip-tions with a more anatomically correct system but with little success. 1

ReferencesCosio FG et al. Living anatomy of the atrioventricular junctions: A guide to electrophysiological mapping. A Consensus Statement from the Car-diac Nomenclature Study Group, Working Group of Arrhythmias, Euro-pean Society of Cardiology, and the Task Force on Cardiac Nomenclature from NASPE. European Heart Journal 1999; 20: 1068–1075

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Fig 5. Anatomy and catheters in LAO. In LAO the viewer looks through the heart from the ventricular apex with the tricuspid

valve (TV) and mitral valve (MV) appearing en face as “spectacles”. (Catheter image courtesy of St Jude Medical)

Fig 6. The commonly used but anatomically incorrect descrip-tion of the positions of accessory pathways (in the LAO view).

(Image courtesy of St. Jude Medical)

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The LAO View


Meetings

The Scotti sh Heart and Arterial Risk Preventi on (SHARP) char-ity held its annual scienti fi c meeti ng in Dunkeld at the end of November. The theme of the meeti ng was “Partners in Cardio-

vascular Disease Preventi on” and as usual att racted many high pro-fi le speakers for the event.

SHARP was initi ally set up in 1988 and heralded the commitment of many health care professionals across Scotland to the preventi on of cardiovascular disease (CVD), which sti ll remains a major cause of premature mortality and morbidity in Scotland. SHARP has many members throughout the UK who work in various specialti es across primary and secondary care with a specifi c interest in the preventi on and management of CVD. The work of SHARP falls into three main categories; the implementati on of evidence, educati on and research. Many of its members play an important role in the development and implementati on of nati onal guidelines such as Scotti sh Intercol-legiate Guideline Network (SIGN) guidelines for CVD and the NHS Quality Improvement in Scotland (QIS) standards on Coronary Heart Disease (CHD) and CVD. They have annual scienti fi c meeti ngs as well as regional educati onal meeti ngs. SHARP also produces educati onal material for pati ents and staff including a Cardiovascular Risk Pack to assist in the identi fi cati on and modifi cati on of risk factors for cardio-vascular disease. SHARP also facilitates research into the causes and preventi on of heart disease in Scotland.

Now in its 22nd year, SHARP held its annual scienti fi c meeti ng on the banks of Loch Tay in Dunkeld at the end of November this year. Dr Robert Finnie (GP from Livingston) opened up the meeti ng with a formal thanks to Dr Shirley McEwan, a founding member and the driving force behind SHARP, who reti red last year as this was the fi rst year she had not att ended the meeti ng.

The fi rst plenary session brought an impressive list of guest speak-ers. Dr Jonathan Morrell, GP from Hasti ngs and founding member of HEART UK and the Primary Care Cardiovascular Society (PCCS) spoke about primary care and cardiovascular disease. He told the meet-ing that a combinati on of smoking and raised lipids accounted for almost two thirds of all CVD risk. Risk tools, he told the audience, have their place but are not suitable for all pati ents and clinical judgement should be used for individual pati ents. He stressed the

most important issue in dealing with risk in primary care is commu-nicati ng cardiovascular risk in a way the pati ent will understand and modify lifestyle. He felt the work being done using a “heart age” may improve the way pati ents understand risk in the future.

Professor Keith Fox, current President of the Briti sh Cardiovascular Society (BCS) and consultant cardiologist at the Edinburgh Heart Centre told the audience that the specialty of Cardiology has made a signifi cant contributi on to the management of pati ents with CVD and CHD. As well as the initi ati on of secondary preventi on medica-ti on he highlighted the Rita-3 study which showed a 20% reducti on in mortality in the group of pati ents with Non-ST Elevati on Myocardial Infarcti on who had usual secondary preventi on medicati on with PCI compared with those who did not have interventi on. He also told the audience that the UK had bett er numbers than the USA in achieving 90 minute diagnosti c ECG to balloon ti mes. Dr Alan Rees, Chairman of HEART UK, fi nished of the fi rst session with a presentati on on lipid management for Primary Preventi on; he warned the audience that a “blanket” Simvastati n 40mg daily for all would not work. Lipid man-agement has to be tailored to each pati ent and may require more aggressive treatment depending on individual risk.

The SHARP message as strong as ever in its 22nd year!Mr Dennis Sandeman

Nursing Consulti ng EditorChest Pain Nurse SpecialistNHS Fife, Trustee of the Scotti sh Heart and Arterial Risk Preventi on (SHARP) charity.

Dr Jonathan Morrell and Professor Keith Fox


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Following the first session, there were well attended workshops cov-ering topics as varied as atrial fibrillation and stenting to the man-agement of familial hypercholesterolaemia and interpreting lipid values.

The afternoon plenary session was chaired by Dr Alan Begg, GP from Montrose and chair of the SIGN development group on the manage-ment of stable angina. This session focused on the specific problems around women and CVD then diabetes and CVD. Dr Robert Finnie informed the audience that despite presenting more frequently with angina, presenting later to hospital and having more silent MIs than men, women continue to be under researched, diagnosed and treat-ed for CVD. Diabetes remains a major problem and risk factor for CVD. Professor John Betteridge from University College London told the group that diabetologists and cardiologists need to work more closely in the management of those patients with diabetes and CVD. He used data from the EMMACE study which showed that despite new advances in treatments such as drugs and cardiological inter-ventions, those patients with diabetes still had similar mortality rates post-myocardial infarction in 2003 than the same group of patients in 1995. Patients with diabetes should be considered for more aggres-sive lipid management. LDL cholesterol remains a high risk marker for diabetic patients and Professor Betteridge suggested a target LDL of 1.8 for diabetic patients should be considered. Blood glucose control can aid in the reduction of CVD events such as MI and CVA and premature death. He used the PROactive study as an example of how this can be achieved, which used Pioglitazone on top of normal standard care, to control blood sugar. It demonstrated an increase in HDL cholesterol by 19% and a decrease in Triglycerides by 11% and a decrease in systolic blood pressure median 3mmHg over 3 years.

The final session of the day was a light-hearted discussion looking at who the major player is in CVD Prevention. “The Great Balloon Debate” pitted the wits of G.P. Professor Lewis Ritchie, Lipidologist Dr Robert Cramb, Hypertentionologist Professor John Webster and a Geneticist, Dr Alex Doney against each other. Each had 7 minutes to persuade the audience they had a more vital role to play in CVD prevention than their colleagues. After each had presented for their 7 minutes the audience voted and the group were reduced to the GP and lipidologist. After a question and answer session the Profes-

sor Lewis our GP in the group admitted that his contribution was as part of a team which included the practice nurses. After much banter the audience voted and the GP team won the contest as the most important player in the prevention of CVD. Dr Alan Begg closed the meeting by summarizing the event and thanking everyone who con-tributed and attended the successful meeting.

SHARP continues to be a major player in CVD risk preven-tion in Scotland and is always looking at news ways to spread its message. Anyone interested in joining SHARP can do so by contacting Doreen Howley Tel: 01382 660111 Ext 33124 or e-mail: [email protected].

Dr Alan Rees presents at the SHARP meeting


CalendarCardiology Events

United Kingdom

January 27-29

Advanced Cardiovascular Interventi on 2010London Hilton Metropole HotelLondon, Englandwww.bcis-aci.co.uk

February 9-11

The Cardiff Freeman Echocardiography CourseHilton Cardiff HotelCardiff , Waleswww.millbrookconferences.co.uk

June 7-9

BCS Annual Conference and Exhibiti on 2010Manchester CentralManchester, Englandwww.bcs.com

October 3-6

Heart Rhythm Congress 2010Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October29-30

Briti sh Society of Echocardiography Annual Meeti ng & Exhibiti onBournemouth, Englandwww.bsecho.org

Internati onal

February 21-23

CRT 2010Omni Shorham HotelWashington, DC, USAwww.crtmeeti ng.org

June 2-5

New Cardiovascular Horizons ConferenceThe Roosevelt Waldorf - AstoriaNew Orleans, LA, USAwww.ncvhonline.com

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LIKE TO BEFEATURED?

For further details on how your event can be featured here contact us at:

[email protected]

For a list of conferences and events around the globe visit our website:


Upcoming Issues*

March / April 2010

Cardiologist Hot Topic: Opti mal diagnosti c pathways for the evaluati on of chest pain.

Laser PCI

Interview: Dr Raj Khatt ar, Manchester Heart Centre

ECG Basics (Part 1)

Case Study: Echocardiography

Management Hot Topic: Should food and gift s from companies be banned in the cardiac lab environment?

May / June 2010

Primary Angioplasty Service: Positi ves & Negati ves

New Technologies in EP

Preview of the BCS Conference in Manchester

ECG Basics (Part 2)

Case Study: Where’s the RCA?

Management Hot Topic: Recruitment challenges

* Editorial topics subject to change

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Medical Recruitment

Short &Long termVacanciesAvailableCall the our specialist team direct

020 7426 [email protected]

GENERAL RADIOGRAPHYECHOCARDIOGRAPHYSONOGRAPHYSLEEP STUDIESMRIPACINGCATH LABEPRESPIRATORYEEG’S

Cardiac and RespiratoryRecruitment SpecialistsWe have the latest temporaryand permanent positionsavailable throughout the UKand worldwide.

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Coronary Heart #22

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