Coronary Heart #23

Subscribe FREE Online

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

www.cardiologyhd.com

Yes or No?Yes or No?Yes or No?

Company Food & Gift s in the Lab

Issue 23 • Mar/Apr 2010

The New Aeris WirelessPressureWire

LASER Coronary Angioplasty

ECG Challenge

People & Service Management

Employment

ANNUAL CONFERENCE AND EXHIBITION 2010

Venue: Manchester Central, ManchesterDate: 7 to 9 June 2010

3 Day educational meeting in Cardiovascular Medicine, with a programme of case based presentations and plenary sessions

Exhibition showcasing the latest developments in cardiovascular medicine and new technologies

Educational content based on the new European Curriculum, including a Trainee day

Gain CPD points and review general cardiovascular knowledge required for revalidation.

Members of the British Cardiovascular Society can register for free before 31 March 2010. Visit www.bcs.com for online registration and further information.

www.cardiologyhd.com Mar/Apr 2010 3

ContentsMar / Apr 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 © 200� -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 UpLatest News

New Labyrinth Pati ent Tracking Soft ware

Brand new state of the art pati ent track-

ing soft ware, Labyrinth is now live at Guys St Thomas’ Hospital where it is improving communicati on and stream-lining the pati ent’s journey of care from admission to discharge.

Data can be organised by pati ents, procedures, admission types, and from both the lab or ward perspecti ve. All staff can view informati on which is relevant to their parti cular role and clinical staff can concen-trate on clinical work rather than chasing informati on.

Designed in conjuncti on with London’s leading Cath Labs, Labyrinth also monitors lab performance. It analyses data and generates reports for planning and audit purposes, giving an overall view of how labs are working and where the hold ups are. The informati on generated will allow you to evaluate and make changes to service provision pro-moti ng greater effi ciency.

This is an excellent value for money soluti on. Aff ordability has been a priority throughout development.

For more informati on visit www.gallerypartnership/labyrinth

New Cardioace Plus With Plant Sterols

Vitabioti cs Cardioace Plus with cholesterol maintaining plant

sterols is the newest additi on to the Vitabioti cs Cardioace range. Cardioace Plus is the only heart health supplement to combine plant sterols with 24 other heart maintaining nutrients.

Cardioace Plus is the most com-prehensive heart health multi -vitamin and its ingredients have been scienti fi cally proven to be of importance to heart health. The formulati on also uti lises advanced technology which off ers enhanced bioavailability as well as a natural orange oil odour mask to avoid any aft ertaste usually associated with omega-3 fi sh oil and garlic.

Plant sterols occur naturally in various plant-derived foods, including vegetable oils, nuts, grains and seeds and may be absorbed each day. The amounts however are oft en not great enough to have signifi cant cholesterol maintaining eff ects. Plant sterols have been found bene-fi cial in numerous studies where they can help maintain healthy cho-lesterol levels by aiding the reducti on of cholesterol absorpti on in the intesti nes. A regular intake of plant sterols along with a healthy diet and lifestyle may therefore be helpful for those who wish to look aft er their heart and circulati on. Cardioace Plus is priced at £15.95 for 60 caps.

For more informati on visit www.cardioace.com

All of us who work in cardiology encounter stress on a daily basis, but some are bett er at coping than oth-ers. So rather than dwell on a problem do something to make you feel happy or you to could end up on

the cath lab table. In an arti cle recently published in the European Heart Journal, a 10-year study with 1700 people showed those who were the most anxious and depressed had the highest risk of heart disease.

Researchers performed an interview and provided people with a happiness score depending upon their emoti ons. 1 = Least Positi ve and 5 = Most Positi ve. Aft er 10 years the results showed that for each level up the Happiness Score there was a 22% lower risk of developing heart disease.

Don’t Worry, Be Happy!!

� Mar/Apr 2010 www.cardiologyhd.com

Hot TopicCardiologist

Question:“What are the optimal diagnostic pathways in outpatients for the evaluation of chest pain, (i.e. patients who present to the Rapid Access Chest Pain Clinics and not acute chest pain patients)?”

NICE are set to publish their guidance on assessment and diagnosis of recent onset chest pain of suspected car-

diac origin - a vast 391 page document. Within this guidance the management of people presenting with stable angina to outpatient or chest pain clinics are described.

History and examination remain vitally important in establishing the likelihood of underlying coronary artery disease (CAD). A table toestimate a persons risk of having underlying CAD is detailed based on the persons typicality of symptoms, age, sex and presence of three recognized risk CAD risk factors (smoking, diabetes and dyslipidae-mia). Details of typical or atypical symptoms should not be defined differently between men or women or between ethnic groups. The diagnosis of angina will be more likely with increasing age, in males,those with CAD risk factors including hypertension and family history of premature CAD and in those with established CAD.

A resting ECG may provide further evidence but if normal the diag-nosis of angina should not be excluded. Further diagnostic testing is recommended based on the estimated likelihood of CAD, taking in account the risk of ionizing radiation exposure and also cost-effec-tiveness for the NHS.

People with a likelihood of CAD > 90% should be diagnosed with angina and managed appropriately which may include defining coronary anatomy, revascularisation with PCI or CABG or ischaemic assessment.

In people with chest pain in whom angina cannot be diagnosed or excluded by clinical assessment alone with an estimated likelihood of CAD of 61-90% invasive coronary angiography should be performed assuming coronary revascularisation is to be considered.

Where the likelihood of CAD is 30-60% non-invasive functional imag-ing for myocardial ischaemia (myocardial perfusion scintgraphy, stress echo, first-pass contrast-enhanced MR perfusion or MR imag-ing for stress-induced wall motion abnormalities) should be offered.

For those with an estimated likelihood of CAD 10-29% CT calcium scoring is suggested with zero felt to exclude CAD, 1-400 requiring 64-slice (or above) CT coronary angiography and invasive coronary angiography for scores > 400.

The guideline suggests that if the likelihood of CAD is < 10%, alterna-tive aetiology should be sought based on the clinical information and before even performing a resting ECG.

What about the traditional exercise ECG test? Well this is now only recommended for people with confirmed CAD and should not be used to exclude or diagnose stable angina for people without known CAD.

I welcome the NICE recommendation of defining coronary anatomy early on in those at high risk of CAD. However, I also consider thatfractional flow reserve and IVUS assessment of equivocal severity coronary lesions to be as important as non-invasive imaging in some cases but is not covered here by NICE. Furthermore, if you are fortu-nate enough to have access to a 320-slice coronary CT scanner linked with excellent Cardiac Radiologists, high image quality and very low radiation dose required negates any need for calcium scoring and permits use as a real alternative to invasive coronary angiography.

Dr Peter O’KaneConsultant Interventional Cardiologist, Royal Bournemouth Hospital, Bournemouth, UK


Laser PCICardiologists

History¹

LASER or Light Ampli-fi cati on by Sti mulated Emission of Radiati on has a variety of commercial uses and is fi nding a remerging niche in interventi onal cardiology. The early lasers were argon and Nd: YAG and generated thermal energy to vaporise ti ssue and plaque material. The disadvantage was excessive thermal injury and vascular damage. Newer lasers such as the FDA approved EXCIMER LASER (Spectranet-ics) generate cool 308 nm laser energy by electrically charging two gases, Xenon and Chloride (XeCl). The fi rst Excimer laser coronary angioplasty (ECLA) was performed in 1988.

Mechanism of acti on²

The Excimer Laser causes photo-ablati on of ti ssue. There are three stages in this process: photo-chemical, photo-thermal and photo-mechanical. In the photochemical stage UV light pulses collide with ti ssue for 125 billionths of a second resulti ng molecular bonds being fractured. Billions of minute sub cellular sized fragments fi lter through the blood stream, minimizing the risk of distal embolisati on. In the second stage the photochemical energy is generated by absorpti on of the ultraviolet waves. This creates molecular vibrati on in the ti ssue heati ng the intracellular matrix. This results in rapid vapourisati on of water and rupture of cells; the steam rapidly dissipates minimis-ing vessel trauma. The fi nal, photo-mechanical stage, creates kineti c energy from the expansion and collapse of vapor bubbles which breaks down ti ssue and clearing by-products away from ti p. The by-products of ablati on are water, gas, and small parti cles 90% of which are smaller than red blood cells.

There needs to be a conti nuous infusion of normal saline as the presence of blood or contrast in the lasing medium

can produce shock waves increasing the risk of dissec-ti on and sub opti mal ti ssue ablati on. The early cath-eters were concentric fl exible over the wire devices

but their limitati on was exposed in treatment of eccen-tric lesions, bifurcati ons and lesions over bends. Numerous reports of perforati on and dissecti on led to the development of directi onal laser catheters which allow greater fl exibility and improved tracking. A new catheter technology (termed ‘opti mal spacing’) was intro-duced in 2001 and provides a 30% increase in plaque ablati on and thrombus dissoluti on in comparison with the previous generati on of laser catheters.3

Indicati ons for ECLA⁴

The indicati ons for ECLA are as follows:

Long diff use lesions

Chronic total occlusions

Aorto- osti al lesions

Saphenous vein graft s

Non dilatable or non crossable lesions

Restenoti c lesions

The laser should be avoided in very tortuous vessels and if there is a history of previous dissecti on or perforati on.

1.

2.

3.

4.

5.

6.

LASER: Coronary Angioplasty

Dr Richard EdwardsAuthorConsultant Cardiologist, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust

History¹

LASER or Light Ampli-fi cati on by Sti mulated Emission of Radiati on has a variety of commercial uses and is fi nding a remerging niche in interventi onal cardiology. The early lasers were argon and Nd: YAG and generated thermal energy to

There needs to be a conti nuous infusion of normal saline as


Dr Niti n KumarAuthorST 3 Cardiology , Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust

10 Mar/Apr 2010 www.cardiologyhd.com

Cardiologist

Interview

Why did you decide to become a cardiologist?

I’ve always been mechanically minded and given that the heart’s themost dynamic organ in the body, I became naturally interested in car-diovascular pathophysiology at medical school. I was also attracted by the role of physicians as detectives or diagnosticians and so I also considered a career in neurology or radiology, but that was just deni-al. I always wanted to be a cardiologist because unlike these otherspecialties I felt that there was so much to offer not only in terms of diagnostic testing, but also treatment. In cardiology, you tended to get quick results from both drugs and interventions.

Where did you train

I did my medical degree at The University of Southampton and my formative training in cardiology was in London. I spent a memorable 4 years in clinical and academic cardiology at Northwick Park Hospi-tal, Harrow where I realised my passion for research and also becamefully trained in echocardiography. I then did my interventional train-ing at St Mary’s Hospital, which was also a very positive experience.

What do you believe will be the biggest change in cardiology within the next 5-10 years?

In the next 5-10 years, I think transcatheter aortic valve implantation is likely to become the first choice technique for all-comers in whom it’s technically feasible rather than simply for those turned down forsurgery. Also, stress imaging techniques will play a more prominent role as first line investigations in rapid access chest pain clinics. I’m sure if I was an electrophysiologist I’d also have something to sayabout AF ablation!

What new echo techniques will become the standard examination in a few years?

At the moment, during the trans-thoracic examination, 3-D imaging isn’t necessarily used as a matter of routine, but may add value in cer-tain circumstances for example when assessing mitral valve pathol-ogy and measuring LV volumes. With further advances in spatial resolution and acquisition of larger volume datasets, it will hopefully become the routine imaging modality. In addition, the indications for exercise echocardiography are widening and more patients with val-vular disease are likely to undergo the test to aid decision making,Finally, the bedside assessment of myocardial perfusion by myocar-dial contrast echocardiography in the post-MI setting might also be used more frequently to assess infarct size and for risk stratification.

Dr Rajdeep KhattarConsultant Cardiologist and Honorary Senior Clinical Lecturer at the Manchester Heart Centre, Manchester Royal Infirmary and The University of Manchester.


ChallengeSophie Blackman’s ECG

With 10 years experience working as a Clinical Cardiac Physiologist, Sophie Blackman took the positi on of Head of Clinical Cardiac Physiology for West Hertf ordshire NHS Trust in March 2009. Sophie successfully manages 22 Cardiac Physiologists and Cardiographers in 3

hospitals for her Trust. Her clinical areas of specialty are Cardiac Rhythm Management and Electrophysi-ology, and in her 1st year at West Herts Hospitals she has been able to introduce EP as well as ICD and CRT implantati on. Sophie’s specifi c area of interest working within a thriving and dynamic department is workforce development and educati on, parti cularly as she is an SCST examiner. Alongside this passion for educati on she enjoys managing both her staff and her departmental service whilst thriving on the broad array of challenges this brings.

CV:Sept. 1999 - Jan. 2001 Trainee Cardiac Physiologist at Kent and Sussex Hospital

Jan. 2001 - Mar. 2009 St Mary’s Hospital (Imperial) Basic Grade to Chief Cardiac Physiologist with specialist interest in complex devices and EP

March 2009 to present West Hertf ordshire Hospitals NHS Trust Head of Clinical Cardiac Physiology

Additi onal interests: SCST examiner. Work Based Assessor. RCCP registered.

Welcoming Sophie to our Teamith 10 years experience working as a Clinical Cardiac Physiologist, Sophie Blackman took the positi on of Head of Clinical Cardiac Physiology for West Hertf ordshire NHS Trust in March 2009. Sophie successfully manages 22 Cardiac Physiologists and Cardiographers in 3

Welcoming Sophie to our Team

Clinical Background This is a short rhythm strip from a 24 hour ambulatory ECG recording. The recording was from a 42 year old lady with a history of palpitati ons and dizzy episodes. She was referred by her GP to the Consultant Cardiologist aft er she had her 1st syncopal event. She had no other medical history of note, but her older cousin died in his sleep at the age of 27.

Questi onsWhat is the baseline rhythm?

Name the arrhythmia.

Is there anything else of note regarding this recording?

1.

2.

3.

Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng EditorUnited Kingdom

“View your pati ent’s heart rate on the Litt mann 3200 LCD display”

- ECG Challenge Sponsors

Answer on Page: 25


Journals

Antiplatelet Therapy

Cost efficacy analysis seems to be a real growth area in main stream journals driven largely by regulatory authorities need to demon-strate economic value as well as clinical benefit. The question in such studies is as important as the answer: in a cost analysis ofPrasugrel vs. Clopidogrel in acute coronary syndrome patients with planned PCI the clinical improvements in the Prasugrel group trans-lated into greater cost efficacy. The modelling however assumed a clopidogrel cost at current levels. As clopidogrel is shortly to comeoff patent the more relevant comparison is with a notional generic cost clopidogrel in which case Prasugrel costs almost $1K more per patient treated and by the usual extrapolation methods around $10K per life year gained.

Elizabeth M. Mahoney and others. Circulation. 2010; 121:71-79

Ticagrelor is a new reversible platelet inhibitor thought to be morepotent than clopidogrel. In a study of 13 408 patients presenting with ACS and planning to go on to an invasive strategy randomisa-tion to Ticagrelor vs. Clopidogrel resulted in fewer instances of the primary endpoint of cardiovascular death, MI or stroke (9.0 vs.10.7%) with no difference in major bleeding (11.5 vs. 11.6 %) or severe bleeding (2.9 vs. 3.2%). All patients were also treated with aspirin.

Christopher P Cannon and others The Lancet. 2010; 375, 283 - 293

Probably the most boring pharma saga since MMR rumbles on with further inconclusive data about risk of cardiovascular eventsin those on clopidogrel and a PPI. The latest instalment is of 18 565 over 65 year olds on clopidogrel. It appears those also administereda PPI have a 22% (95% CI 0-51%) increase in the risk of MI or death. Causality is not established and the risk of major bleeding is high in older people on dual antiplatelet therapy.

Jeremy Rassen and others. Circulation. 2009;120:2322-2329

Cangrelor is a novel intravenous antiplatelet agent we may not be hearing much from in the future. In comparison with oral clopidog-rel loading it made no difference to coronary endpoints, but tended to increase major bleeding.

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

Imaging

Much debate around non invasive imaging methods relates to radia-tion dose. CT has previously come out badly in many of these argu-ments, but developments in the technology now allow imaging inselected subjects at much lower doses. In a study of 50 non obese patients in sinus rhythm undergoing CT angiography all were able to be imaged with an effective dose of <1mSv with acceptable image quality (94% good and 99.5% of segments interpretable resolution).

Stephan Achenbach and others Eur Heart J 2010 31(3):340-346

Heart Failure

The link between heart failure and anaemia is well established andusually regarded as a vicious circle. Iron deficiency is often present in heart failure patients with low normal haemoglobins or mild anaemia. In a study of 459 patients with NYHA II-III symptoms, LVEF<0.4 and biochemical markers of iron deficiency those ran-domised to intravenous iron supplementation were more twice as likely to improve as those randomised to placebo.The authors postulate that improved aerobic capacity logically fol-lows from being iron replete.

Stefan D Anker and others New Engl J Med 361:2436-2448

Left ventricular assist devices are effective in improving quality of life in severe heart failure but are cumbersome and prone tomechanical dysfunction. A new generation of continuous flow devices promise greater reliability as well as being more conven-iently proportioned than the current pulsatile flow models.In a randomised comparison of different types of device both appeared equally effective, but the newer continuous flow devices are four times more reliable.Mark S Slaughter and others. New Engl J Med 361:2241-2251

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

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


ProductsInterventi onal

BREAKING NEWS:Irish Cardiac Cath Lab Purchases New Wireless FFR PressureWire

Here at Coronary Heart we have been watching closely the development and roll-out of the new St Jude Medical Wireless PressureWire system called Aeris. Aft er the recent success of the FAME trial which showed

measuring FFR provided signifi cant improvements in pati ent treatment, there has been an increase in the usage of FFR devices, parti cularly the SJM PressureWire (formerly Radi).

As with any angiography procedure, ti me saving is criti cal. That is why the clever boffi ns at Radi came up with an even more effi cient FFR system called Aeris. Cath Lab workfl ow is simplifi ed by instant, wireless integrati on with the GE Mac-Lab® hemodynamic recording system, and with a simple soft ware upgrade the FFR results can be stored in the existi ng hemodynamic recording archive along with the procedural informati on.

The Waterford Regional Hospital in Ireland was the fi rst hospital in Europe to install this integrated system. We spoke with the Regional Development Manager for Cardiology, Ms Catherine Dwyer, and Consultant Cardiologist, Dr Patrick Owens about their new Aeris system, and also a few other depart-mental questi ons we know you would be interested in.

What are the sizes of your Cardiology Department and Hospital?

Waterford Regional Hospital is a 474 bed hospital, serving a populati on of 460,000 on a regional basis. Three outlying hospitals provide additi onal beds. The cardiology department consists of a six bedded coronary care unit, a six bedded day ward, a cardiac cath lab, and the cardiac department for non-invasive tests.

Waterford Regional Hospital

Regional Cardiology Interventi onal SuiteWaterford Regional HospitalWaterford, Co. WaterfordIreland

Above (from left ): Dr P Owens, Ms C. Dwyer, Ms C. Lambert, Ms L. Fennelly, Mr V. Sowbhagya, Ms B Lye, Ms D Shanahan,

and Ms L Furlong


Echocardiography has historically had a signifi cant role in the detecti on and monitoring of left ventricular mural thrombi. Left ventricular dilatati on and an ischaemic basis for a cardiomyopathy are both independent predictors of LV thrombi given that LV systolic

functi on is oft en impaired 2. The development of intravenous contrast agents has improved the diagnosti c yield for the detecti on of mural thrombi 3. This is most advantageous for apical mural thrombi in transthoracic imaging as transoesophageal echo oft en does not adequately interrogate the apex and thus is a poor alternati ve approach to imaging.

The use of contrast echo versus non-contrast echo and Delayed-enhancement cardiovas-cular magneti c resonance (DE-CMR), which relies on ti ssue characterizati on rather than anatomic appearance showed signifi cantly improved sensiti vity for the detecti on of mural thrombi by contrast echo compared with non-contrast echo. Contrast echo has been shown to have a lower sensiti vity for the detecti on of mural thrombi compared with the DE-CMR with the thrombi that were missed being small in volume or mural in shape 5.

The incidence of mural thrombi in acute MI has been reported to be lower than histori-cally suggested with the use of primary percutaneous coronary interventi on1. However, delayed-enhancement cardiovascular magneti c resonance (DE-CMR) showed LV mural thrombi prevalence of 7% in a high risk populati on 4.

The pati ent in this case is a 53 year old male. He was fi rst seen for an echocardiogram for an abnormal resti ng ECG although he was asymptomati c. The investi gati on revealed a dilated (ischaemic) cardiomyopathy with a large old anteroapical scar and an ejecti on fracti on of 31% (Simpson’s biplane method). Clip 1 demonstrates impaired LV systolic functi on and as common with most parasternal long axis views, the apex it not well visualised. Again in Clip 2 the apical mural thrombus is diffi cult to discern. A subsequent Dobutamine stress echocardiography was performed to evaluate for viable myocardium and inducible revers-ible ischaemia. He was seen by a cardiologist and diagnosed with having had a moderately large silent anterior myocardial infarcti on and commenced on Aspirin and Ramipril. The images from the following case were performed in our clinic 12 months aft er the initi al presentati on as part of routi ne follow up. An initi al non-contrast study was performed with a subsequent follow up contrast study. Clip 3 demonstrates the fi lling defi cit in the apex, readily identi fying the apical mural thrombus. The low fl ow velocity in the apex displayed in Clip 4 indicates the high propensity for thrombus formati on. Once the LV mural throm-bus was identi fi ed by the echocardiogram, the pati ent was advised to commence Warfarin therapy. Note: Video clips from this case study are are available on our website.

References Rehan A, Kanwar M, Rosman H, Ahmed S, Ali A, Gardin J, Cohen G: Incidence of post myocardial infarcti on left ventricular thrombus formati on in the era of primary percutaneous interventi on and glycoprotein IIb/IIIa inhibitors. A prospecti ve observa-ti onal study. Cardiovascular Ultrasound 2006, 4:20 htt p://www.cardiovascularultrasound.com/content/4/1/20 Sharma ND, McCullogh PA, Philbin EF and Weaver WD: Left Ventricular Thrombus and Subsequent Thromboembolism in Pati ents With Severe Systolic Dysfuncti on. CHEST February 2000 vol. 17 no. 2:314-320. htt p://chestjournal.chestpubs.org/content/117/2/314 Thangaraj S, Schechtman KB and Perez JE: Improved Echocardiographic Delineati on of Left Ventricular Thrombus with the Use of Intravenous Second-Generati on Contrast Image Enhancement. J Am Soc Echocardiography 1999;12:1022-6.Weinsaft JW, Kim HW, Shah DJ, Klem I, Crowley AL, Brosnan R, James OG, Patel MR, Heitner JH, Parker M, Velazquez EJ, Steenbergen C, Judd RM, Kim RJ: Detecti on of Left Ventricular Thrombus by Delayed-Enhancement Cardiovascular Magneti c Resonance. Prevalence and Markers in Pati ents With Systolic Dysfuncti on. J Am Coll Cardiol, 2008; 52:148-157 htt p://content.onlinejacc.org/cgi/content/full/52/2/148 Weinsaft JW, Kim RJ, Ross M, Krauser D, Manoushagian S, LaBounty TM, Cham MD, Min JK, Healy K, Wang Y, Parker M, Roman MJ and Devereux RB: Contrast-Enhanced Anatomic Imaging as Compared to Contrast-Enhanced Tissue Charac-terizati on for Detecti on of Left Ventricular Thrombus. J Am Coll Cardiol Img, 2009; 2:969-979 htt p://imaging.onlinejacc.org/cgi/content/abstract/2/8/969

1.

2.

3.

4.

5.

Case StudyEchocardiography

Contrast echocardiography and mural thrombus in a dilated (ischaemic) cardiomyopathy

Mr Marcus BryantCardio Vascular ServicesMelbourne, Australia

Clip 1

Clip 2

Clip 3

Clip 4


WatchVideosOnline


Hot TopicManagement

Should food and/or gift s bought into the cardiology department from companies be banned?

Ibelieve that gift s and favours should be banned to prevent favouriti sm of reps with staff . Gift s/ favours are usually more personal and individually dealt with by a rep, thus can be seen as a bribe, or infl uence parti cular staff in purchasing

equipment, or even make other staff feel uncomfortable and alienated. However, I believe that food for the department as a whole should not be banned, since this is usually not used by the rep as a bribe, but more of a thank you for using their com-pany’s products. Plus, reps can keep staff up to date with new technologies, and any problems staff may have with current equipment by talking it over a nice biscuit. I do understand that I have dissected the questi on and given two diff erent views, and that one cannot pick and choose when something is right or wrong. Nonetheless I feel that it can depend upon the circumstances, in other words if all of the staff in the department are to benefi t from an uncompromised treat then yes, but if it is only individuals who benefi t then perhaps no.

Our Trust takes what I think is a sensible approach to this matt er. We have a guidance paper that outlines what is acceptable. Provided gift s are of minor value (up to £25), and are given with no expectati on of return, and are not

for private use, then it is considered ok. Anything worth more than that must be recorded on the gift register, and generally refused. Expensive gift s, or off ers of sup-ply of goods or services to either individual employees or members of their family should be declared and refused.

With regards should it be banned altogether? I would say no. I do not believe that smaller companies that cannot or do not provide refreshments are disadvantaged. The success or otherwise of companies in a catheter lab environment depends on the quality of their products, not the quality (or quanti ty) of their cakes. There is absolutely no expectati on that when Reps come they need to bring food with them. This does not mean when they do however, it is not welcomed.

It is oft en said “every person has their price”. I would like to think that as NHS work-ers it is considerably higher than the odd jaff a cake or jam doughnut. For those whom may think otherwise, perhaps a career in politi cs awaits.

The responses from our Facebook Fan Site.Now with over 480 fans globally!!

Ms Sarah PalmerDeputy Procurement Offi cerCardiac Cath Lab - Manchester Heart Centre ManchesterUnited Kingdom

Marti n Drew: Most of our companies bring food during a booked appointment, however as long as they are not using it as an excuse to try and introduce another product (this should always be by appointment only) then I don’t see it as a problem. In fact them touching base like that can produce a good opportunity to discuss any problems or ask any off the cuff questi ons that have suddenly arisen.

Susan Evans: It’s oft en very hard to get away for lunch in our Cath lab and by bringing some food -lunch- gives us all a good opportunity to stop and have a round table discussion without leaving the dept.

Todd Ginapp: Our system put a stop of any giveaways of any kind. No food, no pens, no pads, no shirts, nothing. They strictly enforce the “corporate compliance” regulati ons. I thought it was overkill unti l the vendors, them-selves, stated that they were not allowed to do it either. I know some places allow it, and I just don’t get how it is OK some places and not OK at others.All it takes is one greedy and unethical vendor to screw it up for everyone.

Kerryn Fitzgerald: more food the bett er....

See all the responses to this questi on by searching for Cardiology HD on Facebook.

Mr Greg CruickshankSuperintendent Radiographer Cardiac Catheter Suite - King’s College Hospital NHS Trust. LondonUnited Kingdom


CalendarCardiology Events

United Kingdom

April 27 2010

7th Oxford Live CourseJohn Radcliff e HospitalOxford, Englandwww.millbrookconferences.co.uk

June 7-9

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

June 7-11

Hammersmith EchocardiologyHammersmith Conference CentreLondon, Englandwww.imperial.nhs.uk/hcc

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

June 2-5

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

September 21-25

TCT 2010Washington Conventi on CenterWashington, DC, USAwww.tctconference.com

1

2

3

4

5

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:

1

2

3

4

5


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.

HAMMERSMITH ECHOCARDIOLOGY7-11 June 2010

Course Director:Professor P Nihoyannopoulos MD, FRCP, FACC, FESC

A week-long course of contemporary echocardiography designed for cardiologists, cardiac technicians and general physicians with some previous knowledge of echocardiography.

This course is geared to those who want to improve their knowledge and keep up-to-date with the ever-expanding ultrasound modalities. This intensive course will consist of lectures from worldwide experts and discussions on controversial subjects.

The following topics will be covered:Physics of modern ultrasound technology * Comprehensive trans-oesophageal echocardiography and colour flow mapping * Congenital heart disease * Stress echocardiography * Echo in coronary heart disease * Valvular heart disease * Endocarditis * Ventricular function and quantitative echocardiography * Video tape demonstrations.

Full programme and registration details available from:Hammersmith Conference CentreWeb: www.imperial.nhs.uk/hccEmail: [email protected]: 020 8383 1601/1608

Supported by the British Society of Echocardiography and European Association of Echocardiography

Upcoming Issues*

May / June 2010

Primary Angioplasty Service: Positives and Negatives

Site Visit: West Hertfordshire Hospital NHS Trust

Preview of the BCS conference in Manchester

Advantages of Echo in a Variety of Clinical Applications

Echo Case Study

EP Education Series

ECG Challenge 15

July / August 2010

Future of Cardiac Cath Labs Special Edition

Transcatheter Aortic Valve Implantations (TAVI)

Drug Eluting Balloons and Innovative Devices

What cardiologists and staff want designed next?

ECG Challenge 16

* Editorial topics subject to change

›

›

›

›

›

›

›

›

›

›

›

›


LASE

R PC

I

A multi centre surveillance trial published in 1999⁸ evaluated safety and effi cacy of Excimer laser angioplasty for treatment of rest-enosed or occluded coronary stents. A total of 440 pati ents with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjuncti ve balloon angioplasty. The investi gators concluded that Excimer laser angi-oplasty with adjuncti ve balloon angioplasty was a safe and effi cient technology to treat in-stent restenoses.

Laser and AMI

The CARMEL investi gators performed Excimer Laser in 151 pati ents with AMI and found it to be is feasible and safe and provided effi cient debulking of thrombus and underlying plaque. The excepti onally low rates of distal embolizati on and ‘no refl ow’ phenomenon encoun-tered in this study has raised the intriguing possibility that, when excimer laser energy is applied, there is, no need for distal emboliza-ti on protecti on devices.⁹ Recently a single centre trial in Italy “Exci-mer laser in acute myocardial infarcti on: Single centre experience on 66 pati ents” concluded that Laser angioplasty is feasible, safe and eff ecti ve for the challenging treatment of pati ents with AMI and thrombus-laden lesions. The acute eff ects on coronary epicardial and myocardial reperfusion are excellent. In August 2003 the US FDA removed the restricti ons on the use of LASER in cases of acute myo-

Clinical Trials

There has been limited number of clinical trials with the Excimer laser.

Year Name of Trial Study Design Result

1993

AMRO ( Amsterdam – Rott erdam) Study5

No of pati ents: 308Pati ents with stable angina and lesions > 10mm assigned to ECLA or Balloon angioplasty

Primary end point : MACESimilar in two treatment groups

1996

ERBAC ( Excimer Laser-Rotati onal Atherectomy –Balloon Angioplasty Comparison)⁶

No of pati ents : 685Conventi onal balloon angioplasty: n = 222Rotati onal Atherectomy: n=231Excimer laser angioplasty: n=232

Primary end point of procedural success was 80% for balloon angioplasty , 89% for rotati onal Atherectomy and 78% for Excimer angioplastyIncidence of MACE and restenosis was slightly higher for ECLA than PTCA

1997

LAVA ( Laser Angioplasty Versus Angioplasty Trial)⁷

Pati ents with stable or unstable angina randomised to holonium:YAG laser angioplasty or PTCA

Study was planned for 500 pati ents but stopped aft er 208 pati ents with YAG laser group showing more inhospital complicati ons than PTCA group but primary end point of MACE at 6 months only slightly higher in laser group

TABLE 1


Implantable Cardiac Devices

Honestly reported studies of rates of device infection always show an alarmingly high incidence. No exception this report of 303 CRT devices where the annual rate of infection was 1.7% (4.3% over 2.6 years). Risk factors identified as independent were procedure time, dialysis, re intervention and CRT D implantation.

Cécile Romeyer-Bouchard and others. Eur Heart J, 2010 31(2):203-210

Combined atrial and ventricular tachycardia pacing to both termi-nate SVTs and discriminate them from ventricular arrhythmias is anintriguing concept. In a pilot study of such technology it appears tobe safe and to reliably identify and terminate true SVTs. Crucially the vast majority of equivocal rhythms tackled by the devices were sinus tachycardias (confusingly these are classified by ICDs as SVTs). Although true SVTs were terminated effectively by the algorithm the reliability in discriminating sinus tachycardia from ventricular tachycardia is where the real value of algorithms lies and this willrequire a larger population for testing.

Samir Saba and others Circulation. 2010;121:487-497

Electrophysiology

Antiarrhythmic drugs do not work very well in atrial fibrillation and for most patients it is the severity of symptoms that decides whether they have an ablation or not and the ritual trying of multiple pharmacological agents is a delaying strategy. That at least is the logical conclusion of a study of 167 patients with highly symptomatic paroxysmal atrial fibrillation refractory to at least one pharmacological agent randomised to further anti arrhythmic drugs or catheter ablation. Comparing the groups the treatment arm were four times less likely to experience further AF as well as being less likely to have a major treatment related adverse event and having a better quality of life.

David J Wilber and others. JAMA. 2010;303(4):333-340

There is now an emerging evidence base for performing VT ablation in those scheduled for secondary prevention ICD implantation. The latest contribution in this field comes from a St Jude Medical sponsored study at centres in Germany, Denmark and the CzechRepublic. Just over 100 patients with IHD, impaired LV function and stable VT were randomised to either ICD alone or ablation and ICD.

Both time to first arrhythmic recurrence (18.6 vs. 5.9 months) and 2 year arrhythmia freedom (47 vs. 29%) favoured the ablation group at a cost of 2 instances of significant complications.

Karl Heinz Kuck and others The Lancet, 375, 9708, 31 – 40

Revascularisation

Volume of procedures performed is a touchy subject in primary PCI with interpretation of evidence seemingly heavily influenced by other agenda on both sides of the argument. Previous data had suggested a significantly better outcome from primary PCI in higher volume centres but this was largely acquired some years ago so the time was judged to be ripe for a re examining of the issue. In a registry of almost 30 000 primary PCIs stratified by low, medium and high volume centres the high volume centres had better door to balloon times (98, 90 and 88 min respectively) and adherence to guidelines but this did not translate into any mortality reduction in hospital. It should be noted that the authors are all employed byhigh volume centres.

Dharam J. Kumbhani and others JAMA. 2009;302(20):2207-2213

Everyone seems to agree diabetics should be treated as a special case when it comes to revascularisation but unfortunately because stent thrombosis, restenosis, surgical complications and results of medical therapy are all worse in those with the sugar lurgy thenature of this special treatment is less universally agreed. A Swed-ish registry of nearly 10000 diabetic patients undergoing PCI has revealed those receiving at least one drug eluting stent in their treatment were 50% less likely to suffer an event identified as sec-ondary to restenosis than those with BMS alone with no significant difference in MI or death between the groups.

Ulf Stanestrand and others Eur Heart J 2010 31(2):177-186

A proper head to head randomised study of different stents is a rare event and worthy of comment. Among 1800 patients randomised to paclitaxel or everolimus eluting stents in the COMPARE study both the composite endpoint (death, MI and TVR) and varioussecondaryendpoints including MI, stent thrombosis and TVR were significantly reduced in the everolimus group. In the case of the compositeendpoint this was an absolute reduction from 9 to 6%. The authors conclude paclitaxel based products should no longer be routinely used.

Elvin Khedi and others The Lancet, 375, 9710, 201 - 209

JOU

RNA

LS


AssistanceManagement

Cardiology: People and Service Management

In August last year it was stated in the interim report of Dr Steven Boorman – a leading occu-pati onal health expert, that more than 45,000 NHS workers report sick each working day. As a manager it is crucial to establish any patt erns of sickness within your team and to learn

how to treat the causes of absenteeism. Sickness from the workplace is in many circumstances enti rely genuine, and these episodes are oft en easy to determine from the gradual development of symptoms or confi rmati on from a medical certi fi cate of sickness. Posing a greater diffi culty are those illnesses that are a symptom of a deeper issue, when your role is then to expose these episodes and to reaffi rm the boundaries to your staff whilst sensiti vely addressing the underly-ing problem.

It is important that as a manager you are an exemplar to your staff and encourage them to act as role models to each other also. Ensure you scruti nise your own sickness and support your staff

to maintain healthy lifestyles in order to help prevent minor ailments. With 300,000 NHS employees classifi ed as overweight, and a colossal 22% smoking more than 20-a-day,

the correlati on between absenteeism and lifestyle is evident.

Firm boundaries are crucial to minimise absence and it helps if you uphold a department where sickness does not go unquesti oned. All staff should

have a return to work interview aft er sickness, no matt er how short a period, they must provide a doctors certi fi cate or self-certi fy, and multi ple episodes or key patt erns should be addressed with the staff member directly. Your staff must understand the implicati on

of their sickness and by discussing each episode the frequency of a staff member’s absence cannot go unnoti ced. It also off ers an opportunity for them to refl ect on how their absence aff ects the remainder of the team and the service pati ents receive, whilst positi vely re-enforcing how they contribute to the team and service as a whole.

Investi gati ng multi ple sickness episodes and trends takes ti me, but the rewards are great. Someti mes absence is a symptom of work or home related issues which manifest as illness. These are highly signifi cant episodes of nonatt endance that will be repeated unti l the cause is addressed, but once man-

aged there can be a reducti on of sickness and improvement of a staff member’s morale and relati on with their work. A man-ager’s responsibility is to help the staff member to address the

problem exacerbati ng their poor att endance. You do not always need to give emoti onal advice, but try to establish if there are any practi cal ways that you can aid a return to work, such as some short term fl exibility in working hours, or assistance with any work related confl ict or stressors that are contributi ng factors.

Understanding the intricacy of sickness is so important because hos-pitals with worse staff health are proven to be less producti ve, with

higher MRSA and mortality rates. As managers and NHS staff alike we must understand our positi on in the larger NHS structure, and

how pati ents and other staff members can be negati vely aff ected by our acti ons and in parti cular our absence.

Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor

Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust United Kingdom

employees classifi ed as overweight, and a colossal 22% smoking more than 20-a-day, the correlati on between absenteeism and lifestyle is evident.







PRO

DU

CTS

How many staff?

Regional Cardiac Cath Lab Administrator, two on site Interventional cardiologists, and two visiting cardiologists once a week, Chief I Cardiac Catheterisation Technician (daily rotation of one cardiac technician from the Cardiac Dept) Clinical Specialist Radiographer,(rotation of Radiographers from Radiology Dept). One Clinical Nurse Manager, and 4 nursing staff working within this area. The imple-mentation responsibility and working of FFR as part of the MAC lab is within the Technicians remit and training has been completed.

Types of procedures?

We perform diagnostic coronary angiography, angioplasty and stent-ing, IVUS, PressureWire and rotablation, basic and advanced cardiac pacing, including defibrillator implantations, and advanced structur-al interventional cardiology, specifically ASD/PFO closures. We also provide extensive non-invasive imaging, in the form of transthoracic,transoesophageal and dobutamine stress echocardiography.

Types of equipment used?

GE Innova 2100, Mac-Lab, CA 1000 workstation, Centricity Image Archive Total integrated cardiology management (Tomcat), DICOMwork lists / work flow with immediate access to cardiology results across all sites within the region. Pressure wire is Aeris.

How many procedures are performed a year?

Our unit has just begun operating for five days a week, we estimate between 1500 - 2,000 angiograms per year, 400 to 500 PCIs per year, and between 200 and 300 device implantations.

Do you have cardiac surgical back-up onsite? If not, where is the patient transferred to?

No. On table emergencies would be transferred to Dublin or Cork.

What new procedures have you implemented into the department recently?

Given that the lab is newly opened, we are currently implementing extensive protocols for all aspects of cath lab and acute coronarymanagement.

How does the lab handle haemostasis?

For radial work, vascular closure is obtained using the TR band, theangioseal is utilised for closure of femoral puncture sites.

You recently upgraded the new GE MacLab with integrated wireless FFR measurement with Aeris from SJM. What are the advantages?

The new wireless system is much more user-friendly, is much lesscumbersome to calibrate, and because the wire is not “tethered”, the wire is much more easy to manipulate.

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

I routinely use FFR estimation for equivocal lesions, and as a way of guiding appropriate therapy. The results from the FAME trial wouldcorroborate that clinical approach FAME study, international, multi-centre using FFR guided angio vs angio alone showed that costs sav-ings were made in the FFR group by an overall statistical score of 14%. This was mainly down to reduction in stenting by 30% in the FFR group.

Other advantages include:

Reduction in the length of hospital stay in the FFR group.

Reduction in the procedural costs of the procedure (guidewires and other products) in the FFR group.

Reduction in the use of pharmaceuticals such as contrast agents – this was statistically significant in the FFR group.

Reduction in the number of readmissions in the FFR group post procedure.

Significant reduction in the number of patients requiring revascularization (either rePCI or CABG).

Clinical Argument

Significant reduction in MI and death in the FFR group by 35%

Significant reduction in overall MACE in the FFR group by 30%

These are very important clinical statistics and are creating a sea-change within cardiology globally in the strategic treatment ofpatients with expected increased rates of FFR usage by 50% in 2010.

•

•

•

•

•

•

•

Above: GE Innova 2100


PRO

DU

CTS

How many staff?

Regional Cardiac Cath Lab Administrator, two on site Interventional cardiologists, and two visiting cardiologists once a week, Chief I Cardiac Catheterisation Technician (daily rotation of one cardiac technician from the Cardiac Dept) Clinical Specialist Radiographer,(rotation of Radiographers from Radiology Dept). One Clinical Nurse Manager, and 4 nursing staff working within this area. The imple-mentation responsibility and working of FFR as part of the MAC lab is within the Technicians remit and training has been completed.


We perform diagnostic coronary angiography, angioplasty and stent-ing, IVUS, PressureWire and rotablation, basic and advanced cardiac pacing, including defibrillator implantations, and advanced structur-al interventional cardiology, specifically ASD/PFO closures. We also provide extensive non-invasive imaging, in the form of transthoracic,transoesophageal and dobutamine stress echocardiography.


GE Innova 2100, Mac-Lab, CA 1000 workstation, Centricity Image Archive Total integrated cardiology management (Tomcat), DICOMwork lists / work flow with immediate access to cardiology results across all sites within the region. Pressure wire is Aeris.






Given that the lab is newly opened, we are currently implementing extensive protocols for all aspects of cath lab and acute coronarymanagement.


For radial work, vascular closure is obtained using the TR band, theangioseal is utilised for closure of femoral puncture sites.


The new wireless system is much more user-friendly, is much lesscumbersome to calibrate, and because the wire is not “tethered”, the wire is much more easy to manipulate.


I routinely use FFR estimation for equivocal lesions, and as a way of guiding appropriate therapy. The results from the FAME trial wouldcorroborate that clinical approach FAME study, international, multi-centre using FFR guided angio vs angio alone showed that costs sav-ings were made in the FFR group by an overall statistical score of 14%. This was mainly down to reduction in stenting by 30% in the FFR group.







Clinical Argument


Significant reduction in overall MACE in the FFR group by 30%

These are very important clinical statistics and are creating a sea-change within cardiology globally in the strategic treatment ofpatients with expected increased rates of FFR usage by 50% in 2010.

•

•

•

•

•

•

•



• The Harley Street Clinic • The Lister Hospital • London Bridge Hospital• The Portland Hospital • The Princess Grace Hospital • The Wellington Hospital

World Class Hospitals.World Class Future.

THe WeLLinGTon HoSPiTaLat the leading edge of modern healthcare, HCa are responsible for six private hospitals plus HCaLaboratories in the heart of London. We’re committed to providing world-class patient care - notjust meeting the highest standards, but setting them.

The Cardiology Department consists of three Cardiac Cath Labs and four non invasive rooms, and has been steadily expanding over recent years achieving a high profile within the organisation due to our provision of excellent standards of patient care and delivery of a first class service to consultant cardiologists. We provide a wide range of invasive and non-invasive procedures including adult cardiac catheterisation, PTCA and Stent procedures, Rotablator and IVUS, Electrophysiology studies including 3D Mapping systems, RF and Cryo ablations, Pacemaker/Bivent/Defibrillator/Reveal implants, Transoesophageal and Stress Echos.

Cardiac Physiologists/Specialised andHighly Specialised Cardiac PhysiologistRef: 001/5410/SCTAs an experienced Cardiac Physiologist with experience in invasive and/or non invasive cardiac procedures, you will be self-motivated and well organised, with excellent interpersonal skills and the ability to prioritise and use your own initiative. Experience in a wide range of both non-invasive procedures including echo and invasive procedures, ideally including EP and rhythm management, is desirable. A willingness to participate on the on-call rota is important.Equipped with RCCP registration, you must have proven post-registration experience with a BSc (Hons) Degree qualification in Cardiac Physiology or equivalent plus proven experience as a Cardiac Physiologist. We are fully supportive of personal and professional development and you will be encouraged to attend courses, conferences and seminars relevant to you.

Multi-skilled Cardiac Cath LabPractitioner (training)Ref: 001/5410/CLPIf you are interested in becoming a specialised Cath Lab Practitioner, we’d like to hear from you. You should be a qualified Nurse, Radiographer or Cardiac Physiologist with proven experience in a Cardiac Cath Lab environment. Training will be provided in-house in addition to a post-graduate course at London South Bank University. On successful completion of the LSBU course, you will qualify for the position of Multi-skilled Cardiac Cath Lab Practitioner.

Staff nursesRef: 001/5410/SnUScrubbing and circulating in all Labs, you will provide a high standard of patient care as a skilled member of the CCL team, assisting with teaching and non nursing staff and to encourage their professional development. We provide a 24 hour emergency service, so participation in the on-call rota is required.You must be an RGN Level 1, NMC registration and previous Cath Lab experience is essential.

Healthcare assistantRef: 001/5410/HCaAssisting clinical staff in providing nursing care of the highest quality to patient, you will perform administrative duties as required, facilitating the smooth running of the department and providing support and guidance to junior Healthcare Assistants.Ideally, you will have previous Hospital experience and an NVQ Level 3. In all of these posts, you will also have the opportunity to develop additional skills and extend your clinical role within the team. Benefits include excellent salary and “Lifestyle” package, which comprises private medical insurance, critical illness cover and other optional benefits.To apply please visit www.HCARecruitment.com or call the Human Resources Department on 020 7483 5305 quoting the appropriate reference number. For further information and an informal visit, please contact Ruth Altmiks, Cardiology Manager on 020 7483 5361 or email: [email protected] date for all posts: 29 March 2010.

These posts are exempt from the Rehabilitation of Offenders Act 1974 and the successful candidate will therefore be required to apply for a standard or enhanced disclosure.

HCA is committed to equal opportunities in employment.

HRC PO Box 3697 Stratford upon Avon Warwickshire CV37 8YL UK

Telephone: +44 (0) 1789 450 787

www.heartrhythmcongress.com

[email protected]

+44 (0) 1789 451822

Promoting better understanding, diagnosis, treatment and quality

of life for individuals with cardiac arrhythmias

HeartRhythm

Congress2010

HeartRhythmCongress

3-6 October 2010 Hilton Birmingham Metropole

EducatitiontionEducationtion

Technology

Technology

Technologygy

DiversityDiversityDiversity


AnswerSophie Blackman’s ECG Challenge

The baseline of the ECG is sinus rhythm with 1st degree AV block. It is possible to see notch shaped P waves on the ECG which can be associated with left atrial enlargement.

There is a 6 beat salvo of a broad complex tachycardia of about 330ms with a sudden onset and terminati on and an axis change. Although there is a discrete P wave visible at the onset of the tachy-cardia this is the next atrial beat in the sinus sequence, notably the atrial cycle length is variable. This atrial contracti on is not the driver of the salvo as although it is followed by a ventricular complex, the PR interval is only about 200ms whereas for the rest of the recording the PR is long. The atrial contracti on is not the driver of the ventricular beat and therefore the broad complex tachycardia is ventricular in origin.

Most interesti ngly however is the down stroke of the QRS complex. As the QRS returns to the isoelectric baseline there is a small notch. This is known as a J wave or an Osborn wave. Commonly this is seen in pati ents with hypothermia but is also reported in hypocal-caemia, brain injury and subarachnoid haemorrhage¹.

Signifi cantly the Osborn wave is an ECG characteristi c associated with early repolarisati on syndrome and those with idiopathic VT ².This syndrome is understood to form the basis for triggered acti vity. Whilst Osborn waves are considered to be a benign ECG fi nding ³, a higher incidence of VT and VF has long been observed in the hypo-

thermic pati ent with dominant Osborne waves. ⁴ The signifi cance of arrhythmogenesis associated with a predomi-nant Osborn wave was only recognised recently when Brugada syndrome was identi fi ed. ⁵

For this pati ent the ‘benign’ fi nding of Osborn waves throughout her 24 hour ambulatory recording, with several salvos of VT, is certainly an interesti ng correlati on, and suggesti ve of an early repo-larisati on syndrome that is worthy of further investi gati on.

Referenes: Maruyama et al. Osborn Waves: History and Signifi cance. Indian Pacing and Electrophysiology Journal. 2004; 4(1): 33-39.

Kalla H, Yan GX, Marinchak R. Ventricular fi brillati on in a pati ent with prominent J (Osborn) waves and ST-segment elevati on in the inferior electrocardiographic leads: a Brugada syndrome variant? J Cardiovasc Electrophysiol. 2000; 11: 95–98

Gussak I, Antzelevitch C. Early Repolarizati on Syndrome: Clinical char-acteristi cs and possible cellular and ionic mechanisms. J Electrocardiol. 2000; 33: 299–309

Gussak I, Bjerregaard P, Egan TM, Chaitman BR. ECG phenomenon called the J-wave: history, pathophysiology, and clinical signifi cance. J Electrocardiol. 1995; 28: 49–58

Yan GX et al. Ventricular repolarizati on components on the electrocardiogram.; cel-lular basis and clinical signifi cane. J Am Coll Cardiol, 2003; 42:401-409

1.

2.

3.

4.

5.

CURRENTADVERTISERS

BCSPage 2

3MPage �

SJMPage 9

BARD EPPage 11

Your WorldPage 27

World Heart Federati onPage 28

Adv

erti

se W

ith

Us

See

Page

4 fo

r Con

tact

Det

ails


Questi on on Page: 10


LASE

R PC

I

Images courtesy Spectranetics

cardial infarcti on (AMI), acute thrombosis and depressed LV ejecti on fracti on.¹⁰

Summary

In summary the Excimer laser has an important role in debulking lesions which are diffi cult to cross with conventi onal equipment, however, its effi cacy is reduced in heavily calcifi ed lesions. Its role in acute myocardial infarcti on is potenti ally exciti ng but requires ran-domised trials.

References:Practi cal Interventi onal Cardiology : ED Grec & DR Ramsdale

www.spectraneti cs.com

Excimer Laser Atherectomy in Acute Myocardial Infarcti on – Evidence-based Treatment Approach ; A report by On Topaz

Practi cal Interventi onal Cardiology : ED Grec & DR Ramsdale

Textbook of Interventi onal Cardiology : 5th Editi on : EJ Topol



Laser angioplasty of restenosed coronary stents: results of a multi center surveillance trial: JACC 1999; 34:25-32

Excimer Laser Atherectomy in Acute Myocardial Infarc-ti on – Evidence-based Treatment Approach ; A report by On Topaz


1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


cardial infarcti on (AMI), acute thrombosis and depressed LV ejecti on

In summary the Excimer laser has an important role in debulking lesions which are diffi cult to cross with conventi onal equipment, however, its effi cacy is reduced in heavily calcifi ed lesions. Its role in acute myocardial infarcti on is potenti ally exciti ng but requires ran-

– Evidence-based Treatment Approach ; A report by On Topaz


ONLINE: Extreme WiringImplantati on of a coronary sinus (CS) lead for cardiac resynchronisati on.

In this case the operator decided to advance the wire into the collateral system and re-enter the CS. This sort of “buddy wire technique” helped the positi oning of the CS lead. This technique has been described in the literature but is rarely used.

Eric SimillionSupervising MIT- Systems Administrator, CardiologyRoyal Perth Hospital, Australia

See this case with video only on our website:www.CardiologyHD.com


Radial access in the cath lab is becoming more commonplace. What do you prefer, radial or femoral?

My own personal default is set on the femoral route but I’ve donea reasonable number of radial procedures and I’m perfectly happyto use the radial route when indicated or when a patient expresses a choice.

Cardiac MR, perfusion scans (MPIs) and stress echoes – are these complementary or competing techniques?

They can be both – it depends on how they’re used, there’s a lotof overlap but they also have their own uniqueness. For example, like stress echo, cardiac MR can assess regional wall motion and like radionuclide myocardial perfusion imaging, cardiac MR can assessmyocardial perfusion. On the other hand, cardiac MR, as we knowin our own region, is not readily accessible, not a bedside test andnot as truly flexible as echocardiography. A lot also depends on local expertise. I’ve always veered towards stress echo and I run a high volume service in our centre. It’s a truly flexible bedside test and the equipment (though not the expertise yet) is readily available in every hospital up and down the country. It can also detect most causes ofcardiac chest pain, not just coronary artery disease during a single examination. Therefore, I use stress echo as the foundation of func-tional imaging and refer those with contra-indications or inadequate echo windows for myocardial perfusion imaging. Because of its lim-ited availability, I reserve cardiac MR for information not available from other techniques, mainly related to myocardial morphology.

New trainees have to choose one modality now to specialise – GUCH, Echo and PCI compared to doing them all in the past. What are your thoughts on these changes?

Given the ever widening scope of our specialty with increasinglydiverse therapeutic interventions and imaging technologies, I think these changes are inevitable. Developing a wealth of experience ina given area leads to better outcomes and it’s simply not possible to spread yourself too thinly. My only concern is that this may leadto a degree of insularity such that interventionists might only feel comfortable managing chest pain and acute coronary syndromesand electrophysiologists exclusively arrhythmias. I think cardiologistsneed to be mindful of retaining core competencies in the medicalmanagement of all cardiological conditions with triage to the appro-priate subspecialty thereafter. The problem with the current training scheme per se is the erosion of training time and continuity of patient

care – whilst I fully appreciate the need for the reduced number ofworking hours per week, the problem is compounded by the reducednumber of training years. We’re looking at different models of train-ing and patient care to compensate for these changes.

INTE

RVIE

W

Above (Right):Dr Raj Khattar during a case as seen on our Site Visit in 2008

Round-Up- Latest News

5

Cardiologist Hot Topic �

Interview

7

ECG Challenge

10

Journals

12

Products- Irish Cath Lab Purchases New Wireless FFR PressureWire

14

Feature- LASER PCI

17

21

Management Hot Topic- Company Food and Gift s in the Lab

Management- People and Service Management

22

Case Study- Echocardiography

Calendar, ECG Answer& Adverti sers

23

24

Employment, Next Issue, & Conferences

2�

- Dr Rajdeep Khatt ar from the Manchester Heart Centre

- Opti mal diagnosti c pathways inoutpati ents for the evaluati on of chest pain

- with Sophie Blackman

Waterford Regional Hospital Cath Lab Purchase Aeris PressureWire

LASER Coronary Angioplasty

17

07

Cover image of Laser courtesy Spectraneti cs.


ExpertsOur Cardiology

How to get in touch@ Email

Phone

Post

Circulati on

Editorial, Subscripti on, & General [email protected]

Adverti sing [email protected]

Coronary Heart Publishing Ltd, Peter House, Oxford Street, Manchester, M1 5AN, 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 Dennis SandemanNursing Consulti ng EditorChest Pain Nurse SpecialistNHS Fife, Trustee of the Scotti sh Heart and Arterial Risk Preventi on (SHARP) charity.

Ms Sophie BlackmanManagement & CRM Consulti ng EditorHead of Clinical Cardiac Physiology, West Hertf ordshire NHS Trust


Round UpLatest News














All of us who work in cardiology encounter stress on a daily basis, but some are bett er at coping than others. So rather than dwell on a problem, do something to make you feel happier or you to could end

up on the cath lab table. In an arti cle recently published in the European Heart Journal, a 10-year study with 1700 people showed those who were the most anxious and depressed had the highest risk of heart disease.



� Mar/Apr 2010 www.cardiologyhd.com

Hot TopicCardiologist

Question: What are the optimal diagnostic pathways in outpatients for the evaluation of chest pain, (i.e. patients who present to the Rapid Access Chest Pain Clinics and not acute chest pain patients)?

NICE are set to publish their guidance on assessment and diagnosis of recent onset chest pain of suspected car-

diac origin - a vast 391 page document. Within this guidance the management of people presenting with stable angina to outpatient or chest pain clinics are described.

History and examination remain vitally important in establishing the likelihood of underlying coronary artery disease (CAD). A table to estimate a persons risk of having underlying CAD is detailed based on the persons typicality of symptoms, age, sex and presence of three recognized risk CAD risk factors (smoking, diabetes and dyslipidae-mia). Details of typical or atypical symptoms should not be defined differently between men or women or between ethnic groups. The diagnosis of angina will be more likely with increasing age, in males, those with CAD risk factors including hypertension and family history of premature CAD and in those with established CAD.

A resting ECG may provide further evidence but if normal the diag-nosis of angina should not be excluded. Further diagnostic testing is recommended based on the estimated likelihood of CAD, taking in account the risk of ionizing radiation exposure and also cost-effec-tiveness for the NHS.

People with a likelihood of CAD > 90% should be diagnosed with angina and managed appropriately which may include defining coronary anatomy, revascularisation with PCI or CABG or ischaemic assessment.

In people with chest pain in whom angina cannot be diagnosed or excluded by clinical assessment alone with an estimated likelihood of

CAD of 61-90% invasive coronary angiography should be performed assuming coronary revascularisation is to be considered. Where the likelihood of CAD is 30-60% non-invasive functional imag-ing for myocardial ischaemia (myocardial perfusion scintgraphy, stress echo, first-pass contrast-enhanced MR perfusion or MR imag-ing for stress-induced wall motion abnormalities) should be offered.

For those with an estimated likelihood of CAD 10-29% CT calcium scoring is suggested with zero felt to exclude CAD, 1-400 requiring 64-slice (or above) CT coronary angiography and invasive coronary angiography for scores > 400.

The guideline suggests that if the likelihood of CAD is < 10%, alterna-tive aetiology should be sought based on the clinical information and before even performing a resting ECG.

What about the traditional exercise ECG test? Well this is now only recommended for people with confirmed CAD and should not be used to exclude or diagnose stable angina for people without known CAD.

I welcome the NICE recommendation of defining coronary anatomy early on in those at high risk of CAD. However, I also consider that fractional flow reserve and IVUS assessment of equivocal severity coronary lesions to be as important as non-invasive imaging in some cases but is not covered here by NICE. Furthermore, if you are fortu-nate enough to have access to a 320-slice coronary CT scanner linked with excellent Cardiac Radiologists, high image quality and very low radiation dose required negates any need for calcium scoring and permits use as a real alternative to invasive coronary angiography.

Dr Peter O’KaneConsultant Interventional Cardiologist, Royal Bournemouth Hospital, Bournemouth, UK

Dr Azfar ZamanDirector, Interventional CardiologyNewcastle Upon Tyne Hospitals NHS Foundation Trust

If the history is convincing – coronary angiography

If the history is equivocal – coronary angiography

Access to coronary angiography has improved in the UK to the extent where (in our institu-tion) it is easier and quicker to perform CA than DSE or CT angio or MPI. Those with normal or only minor disease can then be dis-charged from cardiology care. Only those with documented CAD will receive specialist input.

•

•


Laser PCICardiologists

History¹

LASER or Light Ampli-fi cati on by Sti mulated Emission of Radiati on has a variety of commercial uses and is fi nding a remerging niche in interventi onal cardiology. The early lasers were argon and Nd: YAG and generated thermal energy to vaporise ti ssue and plaque material. The disadvantage was excessive thermal injury and vascular damage. Newer lasers such as the FDA approved EXCIMER LASER (Spectranet-ics) generate cool 308 nm laser energy by electrically charging two gases, Xenon and Chloride (XeCl). The fi rst Excimer laser coronary angioplasty (ECLA) was performed in 1988.

Mechanism of acti on²

The Excimer Laser causes photo-ablati on of ti ssue. There are three stages in this process: photo-chemical, photo-thermal and photo-mechanical. In the photochemical stage UV light pulses collide with ti ssue for 125 billionths of a second resulti ng molecular bonds being fractured. Billions of minute sub cellular sized fragments fi lter through the blood stream, minimizing the risk of distal embolisati on. In the second stage the photochemical energy is generated by absorpti on of the ultraviolet waves. This creates molecular vibrati on in the ti ssue heati ng the intracellular matrix. This results in rapid vapourisati on of water and rupture of cells; the steam rapidly dissipates minimis-ing vessel trauma. The fi nal, photo-mechanical stage, creates kineti c energy from the expansion and collapse of vapor bubbles which breaks down ti ssue and clearing by-products away from ti p. The by-products of ablati on are water, gas, and small parti cles 90% of which are smaller than red blood cells.

There needs to be a conti nuous infusion of normal saline as the presence of blood or contrast in the lasing medium

can produce shock waves increasing the risk of dissec-ti on and sub opti mal ti ssue ablati on. The early cath-eters were concentric fl exible over the wire devices

but their limitati on was exposed in treatment of eccen-tric lesions, bifurcati ons and lesions over bends. Numerous reports of perforati on and dissecti on led to the development of directi onal laser catheters which allow greater fl exibility and improved tracking. A new catheter technology (termed ‘opti mal spacing’) was intro-duced in 2001 and provides a 30% increase in plaque ablati on and thrombus dissoluti on in comparison with the previous generati on of laser catheters.3

Indicati ons for ECLA⁴

The indicati ons for ECLA are as follows:

Long diff use lesions

Chronic total occlusions

Aorto- osti al lesions

Saphenous vein graft s

Non dilatable or non crossable lesions

Restenoti c lesions

The laser should be avoided in very tortuous vessels and if there is a history of previous dissecti on or perforati on.

1.

2.

3.

4.

5.

6.


Dr Richard EdwardsAuthorConsultant Cardiologist, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust

History¹

LASER or Light Ampli-fi cati on by Sti mulated Emission of Radiati on has a variety of commercial uses and is fi nding a remerging niche in interventi onal cardiology. The early lasers were argon and Nd: YAG and generated thermal energy to

There needs to be a conti nuous infusion of normal saline as


Dr Niti n KumarAuthorST 3 Cardiology , Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust


LASE

R PC

I

A multi centre surveillance trial published in 1999⁸ evaluated safety and effi cacy of Excimer laser angioplasty for treatment of rest-enosed or occluded coronary stents. A total of 440 pati ents with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjuncti ve balloon angioplasty. The investi gators concluded that Excimer laser angi-oplasty with adjuncti ve balloon angioplasty was a safe and effi cient technology to treat in-stent restenoses.

Laser and AMI

The CARMEL investi gators performed Excimer Laser in 151 pati ents with AMI and found it to be is feasible and safe and provided effi cient debulking of thrombus and underlying plaque. The excepti onally low rates of distal embolizati on and ‘no refl ow’ phenomenon encoun-tered in this study has raised the intriguing possibility that, when excimer laser energy is applied, there is, no need for distal emboliza-ti on protecti on devices.⁹ Recently a single centre trial in Italy “Exci-mer laser in acute myocardial infarcti on: Single centre experience on 66 pati ents” concluded that Laser angioplasty is feasible, safe and eff ecti ve for the challenging treatment of pati ents with AMI and thrombus-laden lesions. The acute eff ects on coronary epicardial

Clinical Trials

There has been limited number of clinical trials with the Excimer laser.

Year Name of Trial Study Design Result

1993

AMRO ( Amsterdam – Rott erdam) Study5

No of pati ents: 308Pati ents with stable angina and lesions > 10mm assigned to ECLA or Balloon angioplasty

Primary end point : MACESimilar in two treatment groups

1996

ERBAC ( Excimer Laser-Rotati onal Atherectomy –Balloon Angioplasty Comparison)⁶

No of pati ents : 685Conventi onal balloon angioplasty: n = 222Rotati onal Atherectomy: n=231Excimer laser angioplasty: n=232

Primary end point of procedural success was 80% for balloon angioplasty , 89% for rotati onal Atherectomy and 78% for Excimer angioplastyIncidence of MACE and restenosis was slightly higher for ECLA than PTCA

1997

LAVA ( Laser Angioplasty Versus Angioplasty Trial)⁷

Pati ents with stable or unstable angina randomised to holonium:YAG laser angioplasty or PTCA

Study was planned for 500 pati ents but stopped aft er 208 pati ents with YAG laser group showing more inhospital complicati ons than PTCA group but primary end point of MACE at 6 months only slightly higher in laser group

TABLE 1


LASE

R PC

I


and myocardial reperfusion are excellent. In August 2003 the US FDA removed the restricti ons on the use of LASER in cases of acute myo-cardial infarcti on (AMI), acute thrombosis and depressed LV ejecti on fracti on.¹⁰

Summary

In summary the Excimer laser has an important role in debulking lesions which are diffi cult to cross with conventi onal equipment, however, its effi cacy is reduced in heavily calcifi ed lesions. Its role in acute myocardial infarcti on is potenti ally exciti ng but requires ran-domised trials.

References:Practi cal Interventi onal Cardiology : ED Grec & DR Ramsdale

www.spectraneti cs.com


Practi cal Interventi onal Cardiology : ED Grec & DR Ramsdale




Laser angioplasty of restenosed coronary stents: results of a multi center surveillance trial: JACC 1999; 34:25-32



1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


and myocardial reperfusion are excellent. In August 2003 the US FDA removed the restricti ons on the use of LASER in cases of acute myo-cardial infarcti on (AMI), acute thrombosis and depressed LV ejecti on

In summary the Excimer laser has an important role in debulking lesions which are diffi cult to cross with conventi onal equipment, however, its effi cacy is reduced in heavily calcifi ed lesions. Its role in acute myocardial infarcti on is potenti ally exciti ng but requires ran-

– Evidence-based Treatment Approach ; A report by On Topaz


ONLINE: Extreme WiringImplantati on of a coronary sinus (CS) lead for cardiac resynchronisati on.

In this case the operator decided to advance the wire into the collateral system and re-enter the CS. This sort of “buddy wire technique” helped the positi oning of the CS lead. This technique has been described in the literature but is rarely used.

Eric SimillionSupervising MIT- Systems Administrator, CardiologyRoyal Perth Hospital, Australia

See this case with video only on our website:www.CardiologyHD.com


Cardiologist

Interview

Why did you decide to become a cardiologist?

I’ve always been mechanically minded and given that the heart’s the most dynamic organ in the body, I became naturally interested in car-diovascular pathophysiology at medical school. I was also attracted by the role of physicians as detectives or diagnosticians and so I also considered a career in neurology or radiology, but that was just deni-al. I always wanted to be a cardiologist because unlike these other specialties I felt that there was so much to offer not only in terms of diagnostic testing, but also treatment. In cardiology, you tended to get quick results from both drugs and interventions.

Where did you train

I did my medical degree at The University of Southampton and my formative training in cardiology was in London. I spent a memorable 4 years in clinical and academic cardiology at Northwick Park Hospi-tal, Harrow where I realised my passion for research and also became fully trained in echocardiography. I then did my interventional train-ing at St Mary’s Hospital, which was also a very positive experience.

What do you believe will be the biggest change in cardiology within the next 5-10 years?

In the next 5-10 years, I think transcatheter aortic valve implantation is likely to become the first choice technique for all-comers in whom it’s technically feasible rather than simply for those turned down for surgery. Also, stress imaging techniques will play a more prominent role as first line investigations in rapid access chest pain clinics. I’m sure if I was an electrophysiologist I’d also have something to say about AF ablation!

What new echo techniques will become the standard examination in a few years?

At the moment, during the trans-thoracic examination, 3-D imaging isn’t necessarily used as a matter of routine, but may add value in cer-tain circumstances for example when assessing mitral valve pathol-ogy and measuring LV volumes. With further advances in spatial resolution and acquisition of larger volume datasets, it will hopefully become the routine imaging modality. In addition, the indications for exercise echocardiography are widening and more patients with val-vular disease are likely to undergo the test to aid decision making, Finally, the bedside assessment of myocardial perfusion by myocar-dial contrast echocardiography in the post-MI setting might also be used more frequently to assess infarct size and for risk stratification.

Dr Rajdeep KhattarConsultant Cardiologist and Honorary Senior Clinical Lecturer at the Manchester Heart Centre, Manchester Royal Infirmary and The University of Manchester.


Radial access in the cath lab is becoming more commonplace. What do you prefer, radial or femoral?

My own personal default is set on the femoral route but I’ve done a reasonable number of radial procedures and I’m perfectly happy to use the radial route when indicated or when a patient expresses a choice.

Cardiac MR, perfusion scans (MPIs) and stress echoes – are these complementary or competing techniques?

They can be both – it depends on how they’re used, there’s a lot of overlap but they also have their own uniqueness. For example, like stress echo, cardiac MR can assess regional wall motion and like radionuclide myocardial perfusion imaging, cardiac MR can assess myocardial perfusion. On the other hand, cardiac MR, as we know in our own region, is not readily accessible, not a bedside test and not as truly flexible as echocardiography. A lot also depends on local expertise. I’ve always veered towards stress echo and I run a high volume service in our centre. It’s a truly flexible bedside test and the equipment (though not the expertise yet) is readily available in every hospital up and down the country. It can also detect most causes of cardiac chest pain, not just coronary artery disease during a single examination. Therefore, I use stress echo as the foundation of func-tional imaging and refer those with contra-indications or inadequate echo windows for myocardial perfusion imaging. Because of its lim-ited availability, I reserve cardiac MR for information not available from other techniques, mainly related to myocardial morphology.

New trainees have to choose one modality now to specialise – GUCH, Echo and PCI compared to doing them all in the past. What are your thoughts on these changes?

Given the ever widening scope of our specialty with increasingly diverse therapeutic interventions and imaging technologies, I think these changes are inevitable. Developing a wealth of experience in a given area leads to better outcomes and it’s simply not possible to spread yourself too thinly. My only concern is that this may lead to a degree of insularity such that interventionists might only feel comfortable managing chest pain and acute coronary syndromes and electrophysiologists exclusively arrhythmias. I think cardiologists need to be mindful of retaining core competencies in the medical management of all cardiological conditions with triage to the appro-priate subspecialty thereafter. The problem with the current training scheme per se is the erosion of training time and continuity of patient

care – whilst I fully appreciate the need for the reduced number of working hours per week, the problem is compounded by the reduced number of training years. We’re looking at different models of train-ing and patient care to compensate for these changes.

INTE

RVIE

W

Above (Right): Dr Raj Khattar during a case as seen on our Site Visit in 2008


ChallengeSophie Blackman’s ECG

With 10 years experience working as a Clinical Cardiac Physiologist, Sophie Blackman took the positi on of Head of Clinical Cardiac Physiology for West Hertf ordshire NHS Trust in March 2009. Sophie successfully manages 22 Cardiac Physiologists and Cardiographers in 3

hospitals for her Trust. Her clinical areas of specialty are Cardiac Rhythm Management and Electrophysi-ology, and in her 1st year at West Herts Hospitals she has been able to introduce EP as well as ICD and CRT implantati on. Sophie’s specifi c area of interest working within a thriving and dynamic department is workforce development and educati on, parti cularly as she is an SCST examiner. Alongside this passion for educati on she enjoys managing both her staff and her departmental service whilst thriving on the broad array of challenges this brings.

CV:Sept. 1999 - Jan. 2001 Trainee Cardiac Physiologist at Kent and Sussex Hospital

Jan. 2001 - Mar. 2009 St Mary’s Hospital (Imperial) Basic Grade to Chief Cardiac Physiologist with specialist interest in complex devices and EP

March 2009 to present West Hertf ordshire Hospitals NHS Trust Head of Clinical Cardiac Physiology

Additi onal interests: SCST examiner. Work Based Assessor. RCCP registered.

Welcoming Sophie to our Teamith 10 years experience working as a Clinical Cardiac Physiologist, Sophie Blackman took the positi on of Head of Clinical Cardiac Physiology for West Hertf ordshire NHS Trust in March 2009. Sophie successfully manages 22 Cardiac Physiologists and Cardiographers in 3

Welcoming Sophie to our Team

Clinical Background This is a short rhythm strip from a 24 hour ambulatory ECG recording. The recording was from a 42 year old lady with a history of palpitati ons and dizzy episodes. She was referred by her GP to the Consultant Cardiologist aft er she had her 1st syncopal event. She had no other medical history of note, but her older cousin died in his sleep at the age of 27.

Questi onsWhat is the baseline rhythm?

Name the arrhythmia.

Is there anything else of note regarding this recording?

1.

2.

3.


“View your pati ent’s heart rate on the Litt mann 3200 LCD display”

- ECG Challenge Sponsors

Answer on Page: 25

3M, manufacturer of world-renowned Littmann stethoscopes, has

introduced the 3M™ Littmann® Electronic Stethoscope Models 3200 ® Electronic Stethoscope Models 3200 ®

& 3100 into the range. Both build on the established benefits of Littmann

electronic stethoscopes: 24x sound amplification to assist in hearing faint heart,

lung or body sounds; and patented Ambient Noise Reduction technology, which

acoustically cancels out an average of 85% of distracting background noise.

For the first time, however, the next-generation Model 3200 features on-board

seamless two-way Bluetooth® transfer of heart, lung and other body sounds to ® transfer of heart, lung and other body sounds to ®

software for storage and further analysis.

In a further development, 3M has partnered with Zargis Medical Corp., a

leader in advanced diagnostic decision support products, to develop exclusive

complementary software packages including StethAssist.™

Included with the Model 3200 at no additional charge, StethAssist allows the

visualisation, manipulation and slowing down of auscultated sounds to allow

focus on particular areas of interest. Recordings can be stored electronically for

comparison to future auscultations and sent to colleagues for a second opinion.

Both Littmann models have a sleek, streamlined design and exceptional sound

capabilities, delivered through a state-of-the-art central 15mm sound sensor.

Together with a flat diaphragm for stability, both stethoscopes are ideally sized

for neonatal, paediatric and adult auscultation.

Extensive user feedback of the stethoscopes has led to the introduction of

additional, innovative performance features. Subtle design changes in the

chestpiece reduce frictional handling noise and hence distraction, whilst the

LCD interface, with backlight for low-light conditions, now indicates current

sound level, current selected mode and remaining battery life. Once switched

on, the stethoscope stays in battery- saving ‘sleep-mode’ so there is no waiting

to start the next auscultation.

Peter Robinson, Senior Technical Specialist at 3M believes the new technology

will help enhance clinicians’ natural abilities, and enable them to confirm

diagnoses and more easily gather a second opinion from colleagues.

“Of particular importance

is the “extended range”

filter of the Model 3200

stethoscope” he commented. stethoscope” he commented. stethoscope”

“The traditional bell and

diaphragm focus respectively

on lower and higher

frequency sounds – but

during separate auscultation

events. The Model 3200

covers the complete range

of 20-2000Hz and may help

to address the concerns of

physicians who feel that low

frequency lung sounds are

often missed due to sole use

of diaphragm mode during

the auscultation.”

Both models have been reviewed by UK cardiologists with extremely positive

results. Dr Satish Adwani, Consultant Paediatric Cardiologist, John Radcliffe

Hospital, said “The telemedicine aspect of the Model 3200 probably

provides the greatest opportunities for development of the way we

provide healthcare. GPs are able to transmit murmurs to a specialist,

together with a clinical letter which could, in theory, prevent in-

hospital consultations. In the future, I am pretty sure that community

workers will do the same, allowing clinicians to decide whether a patient

needs immediate consultation or could wait for a routine outpatient

appointment.”

Dr Sajad Hayat, Cardiology Specialist Registrar, Manchester Royal Infirmary

said “Despite my initial reservations of switching from a traditional

stethoscope, I’ve been hugely impressed with the Model 3200, particularly

its crisp sound quality and degree of ambient noise reduction. It has proved

an excellent teaching tool on ward rounds for our medical students. They

have benefitted hugely from being able to repeatedly listen to sounds and

discuss and debate what they hear.”

For further information or to request a free trial of the Littmann

electronic stethoscope models 3200 & 3100, please visit:

littmann.co.uk or call 3M on 01509 613584.k or call 3M on 01509 613584.k

Littmann® Introduces First Electronic Stethoscope with Bluetooth® Technology and Sound Analysis Software

3

LCD Interface with Backlight

3M and Littmann are trademarks of the 3M Company. Bluetooth is a registered trademark of

Bluetooth SIG. StethAssist is a trademark of Zargis Medical Corp.






results.

Hospital, said



Bluetooth

Technology

and

StethAssist

Software

Advertising Feature


Journals

Antiplatelet Therapy

Cost efficacy analyses are a growth area in mainstream journals, their presence driven largely by regulatory authorities need to dem-onstrate economic value as well as clinical benefit. The question in such studies is as important as the answer: in a cost analysis of Prasugrel vs. Clopidogrel in acute coronary syndrome patients, with planned PCI, the clinical improvements in the Prasugrel group trans-lated into greater cost efficacy. The modelling however assumed a clopidogrel cost at current levels. As clopidogrel is soon to come off patent the more relevant comparison is with a notional generic cost, in which case Prasugrel costs almost $1000 more per patient and by extrapolation around $10000 per life year gained.

Elizabeth M. Mahoney and others. Circulation. 2010; 121:71-79

Ticagrelor is a new reversible platelet inhibitor thought to be more potent than clopidogrel. In a study of 13 408 patients presenting with ACS and planning to go on to an invasive strategy randomisation to Ticagrelor vs. Clopidogrel resulted in fewer instances of the primary endpoint of cardiovascular death, MI or stroke (9.0 vs. 10.7%) with no difference in major bleeding (11.5 vs. 11.6 %) or severe bleeding (2.9 vs. 3.2%). All patients were also treated with aspirin.

Christopher P Cannon and others The Lancet. 2010; 375, 283 - 293

Probably the most boring pharma saga since MMR! Further incon-clusive data about risk of cardiovascular events in those on clopidog-rel and a PPI. The latest instalment is of 18 565 over 65 year olds on clopidogrel. It appears those also administered a PPI have a 22% (95% CI 0-51%) increase in the risk of MI or death. Causality is not established and the risk of major bleeding is high in older people on dual antiplatelet therapy.

Jeremy Rassen and others. Circulation. 2009;120:2322-2329

Cangrelor is a novel intravenous antiplatelet agent we may not be hearing much from in the future. In comparison with oral clopidogrel loading it made no difference to coronary endpoints, but tended to increase major bleeding.

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

Imaging

Much of the debate around non invasive imaging methods relates to radiation dose. CT has previously come out badly in many of these arguments, but developments in the technology now allow imaging in selected subjects at much lower doses. In a study of 50 non obese patients in sinus rhythm undergoing CT angiography all were able to be imaged with an effective dose of <1mSv with acceptable image quality (94% good and 99.5% of segments interpretable resolution).

Stephan Achenbach and others Eur Heart J 2010 31(3):340-346

Heart Failure

The link between heart failure and anaemia is well established and usually regarded as a vicious circle. Iron deficiency is often present in heart failure patients with low normal haemoglobins or mild anae-mia. In a study of 459 patients with NYHA II-III symptoms, LVEF<0.4 and biochemical markers of iron deficiency, those randomised to intravenous iron supplementation were more twice as likely to improve as those randomised to placebo.

The authors postulate that improved aerobic capacity logically fol-lows from being iron replete.

Stefan D Anker and others New Engl J Med 361:2436-2448

Left ventricular assist devices are effective in improving quality of life in severe heart failure but are cumbersome and prone to mechanical dysfunction. A new generation of continuous flow devices promise greater reliability as well as being more conveniently proportioned than the current pulsatile flow models.

In a randomised comparison of different types of device both appeared equally effective, but the newer continuous flow devices are four times more reliable.

Mark S Slaughter and others. New Engl J Med 361:2241-2251

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


Implantable Cardiac Devices

The incidences of device infection, in honestly reported studies, always seem to show an alarmingly high rate. This report is no excep-tion; of 303 CRT devices the annual rate of infection was 1.7% (4.3% over 2.6 years). Risk factors identified as independent were proce-dure time, dialysis, re intervention and CRT D implantation.

Cécile Romeyer-Bouchard and others. Eur Heart J, 2010 31(2):203-210

Combined atrial and ventricular tachycardia pacing to both termi-nate SVTs and discriminate them from ventricular arrhythmias is an intriguing concept. In a pilot study of such technology it appears to safely and reliably identify and terminate true SVTs. Crucially the vast majority of equivocal rhythms tackled by the devices were sinus tachycardias (confusingly these are classified by ICDs as SVTs). Although true SVTs were terminated effectively by the algorithm the reliability in discriminating sinus tachycardia from ventricular tachy-cardia is where the real value of algorithms lies and this will require a larger population for testing.

Samir Saba and others Circulation. 2010;121:487-497

Electrophysiology

Antiarrhythmic drugs do not work very well in atrial fibrillation and for most patients it is the severity of symptoms that decides whether they have an ablation or not and the ritual trying of multiple phar-macological agents is a delaying strategy. That at least is the logical conclusion of a study of 167 patients with highly symptomatic par-oxysmal atrial fibrillation refractory to at least one pharmacological agent randomised to further anti arrhythmic drugs or catheter abla-tion. Comparing the groups; the treatment arm was four times less likely to experience further AF as well as being less likely to have a major treatment related adverse event, they also had a better qual-ity of life.

David J Wilber and others. JAMA. 2010;303(4):333-340

There is now an emerging evidence base for performing VT ablation in those scheduled for secondary prevention ICD implantation. The latest contribution in this field comes from a St Jude Medical spon-sored study at centres in Germany, Denmark and the Czech Repub-lic. Just over 100 patients with IHD, impaired LV function and stable VT were randomised to either ICD alone or ablation and ICD. Both time to first arrhythmic recurrence (18.6 vs. 5.9 months) and 2 year arrhythmia freedom (47 vs. 29%) favoured the ablation group at a cost of 2 instances of significant complications.

Karl Heinz Kuck and others The Lancet, 375, 9708, 31 – 40

Revascularisation

Volume of procedures performed is a touchy subject in primary PCI with interpretation of evidence seemingly influenced by other agen-da on both sides of the argument. Previous data had suggested a sig-nificantly better outcome from primary PCI in higher volume centres but this was largely acquired some years ago so the time was judged to be ripe for a re examining of the issue. In a registry of almost 30 000 primary PCIs stratified by low, medium and high volume centres the high volume centres had better door to balloon times (98, 90 and 88 min respectively) and adherence to guidelines but this did not translate into any mortality reduction in hospital. It should be noted that the authors are all employed by high volume centres.

Dharam J. Kumbhani and others JAMA. 2009;302(20):2207-2213

Everyone seems to agree diabetics should be treated as a special case when it comes to revascularisation but unfortunately because stent thrombosis, restenosis, surgical complications and results of medical therapy are all worse. A Swedish registry of nearly 10000 diabetic patients undergoing PCI has revealed those receiving at least one drug eluting stent in their treatment were 50% less likely to suffer an event identified as secondary to restenosis than those with BMS alone. There was however, no significant difference in MI or death between the groups.

Ulf Stanestrand and others Eur Heart J 2010 31(2):177-186

A proper head to head randomised study of different stents is a rare event and worthy of comment. Among 1800 patients randomised to paclitaxel or everolimus eluting stents in the COMPARE study both the composite endpoint (death, MI and TVR) and various secondary endpoints including MI, stent thrombosis and TVR were significantly reduced in the everolimus group. In the case of the composite end-point this was an absolute reduction from 9 to 6%. The authors con-clude paclitaxel based products should no longer be routinely used.

Elvin Khedi and others The Lancet, 375, 9710, 201 - 209

JOU

RNA

LS

Incorporating FFR Measurement into Procedures

Significantly Reduces Major Adverse Coronary Events.

1. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med.2009;360(3):213-24.

2. TCT (Transcatheter Cardiovascular Therapeutics) 2009. Late Breaking Clinical Trials.

Brief Summary: Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use.

PressureWire is designed, developed and manufactured by Radi Medical Systems AB. Patent Pending. PressureWire, Radi, ST. JUDE MEDICAL, the nine-squares symbol and MORE CONTROL. LESS RISK. are registered and unregistered trademarks and service marks of St. Jude Medical, Inc. and its related companies. ©2010 St. Jude Medical. All rights reserved.

Fractional flow reserve (FFR) as measured by the St. Jude Medical PressureWire™ System makes stent

placement more efficient and cost-effective.1 The FAME study’s one-year results show that therapy

guided by the routine measurement of FFR in patients with complex coronary artery disease reduces

the incidence of major adverse coronary events by 28%.1 Recently released two-year FAME results

show a 34% reduction in combined mortality and myocardial infarction (MI) and a 37% reduction in

MI alone.2 Compared to using only angiography, measuring FFR allows physicians to more accurately

identify and treat physiologically significant stenoses.

FAMEstudy.com

FFR ad UK A4.indd 1 1/18/10 9:45:29 AM


ProductsInterventi onal

BREAKING NEWS: Irish Cardiac Cath Lab Purchases New Wireless FFR PressureWire

Here at Coronary Heart we have been watching closely the development and roll-out of the new St Jude Medical Wireless PressureWire system called Aeris. Aft er the recent success of the FAME trial which showed

measuring FFR provided signifi cant improvements in pati ent treatment, there has been an increase in the usage of FFR devices, parti cularly the SJM PressureWire (formerly Radi).

As with any angiography procedure, ti me saving is criti cal. That is why the clever boffi ns at Radi came up with an even more effi cient FFR system called Aeris. Cath Lab workfl ow is simplifi ed by instant, wireless integrati on with the GE Mac-Lab® hemodynamic recording system, and with a simple soft ware upgrade the FFR results can be stored in the existi ng hemodynamic recording archive along with the procedural informati on.

The Waterford Regional Hospital in Ireland was the fi rst hospital in Europe to install this integrated system. We spoke with the Regional Development Manager for Cardiology, Ms Catherine Dwyer, and Consultant Cardiologist, Dr Patrick Owens about their new Aeris system, and also a few other depart-mental questi ons we know you would be interested in.

What are the sizes of your Cardiology Department and Hospital?

Waterford Regional Hospital is a 474 bed hospital, serving a populati on of 460,000 on a regional basis. Three outlying hospitals provide additi onal beds. The cardiology department consists of a six bedded coronary care unit, a six bedded day ward, a cardiac cath lab, and the cardiac department for non-invasive tests.

Waterford Regional Hospital

Regional Cardiology Interventi onal SuiteWaterford Regional HospitalWaterford, Co. WaterfordIreland

Above (from left ): Dr P Owens, Ms C. Dwyer, Ms C. Lambert, Ms L. Fennelly, Mr V. Sowbhagya, Ms B Lye, Ms D Shanahan,

and Ms L Furlong

PressureWire™ AerisWireless FFR Measurement System

PressureWire™ CertusFFR Measurement System



Mac-Lab is a registered trademark of GE Healthcare.


SJMprofessional.com

Radi Medical Systems is now a part of St. Jude Medical.

Routine use of the PressureWire System offers physicians more control when assessing complex

coronary lesions. When integrated into routine lab procedures, measuring fractional flow reserve

(FFR), as shown by the FAME study (FFR versus Angiography for Multivessel Evaluation), reduces

the incidence of major adverse coronary events by 28%.1 Using PressureWire Aeris or PressureWire

Certus to measure FFR helps ensure access to accurate information in the cath lab, increasing

the efficiency and efficacy of coronary revascularization.1 In addition, PressureWire Aeris provides

instant, wireless integration of FFR data into the Mac-Lab® hemodynamic recording system from

GE Healthcare, eliminating the need for a separate analyzer for simplified cath lab workflow and

optimum efficiency.

Reliable, Accurate FFR Measurementfor More Effective Coronary Lesion Assessment.

PressureWireFamily Ad UK A4.indd 1 1/18/10 9:46:10 AM


PRO

DU

CTS

How many staff?

Regional Cardiac Cath Lab Administrator, two on site Interventional cardiologists, and two visiting cardiologists once a week, Chief I Cardiac Catheterisation Technician (daily rotation of one cardiac technician from the Cardiac Dept) Clinical Specialist Radiographer, (rotation of Radiographers from Radiology Dept). One Clinical Nurse Manager, and 4 nursing staff working within this area. The imple-mentation responsibility and working of FFR as part of the MAC lab is within the Technicians remit and training has been completed.


We perform diagnostic coronary angiography, angioplasty and stent-ing, IVUS, PressureWire and rotablation, basic and advanced cardiac pacing, including defibrillator implantations, and advanced structur-al interventional cardiology, specifically ASD/PFO closures. We also provide extensive non-invasive imaging, in the form of transthoracic, transoesophageal and dobutamine stress echocardiography.


GE Innova 2100, Mac-Lab, CA 1000 workstation, Centricity Image Archive Total integrated cardiology management (Tomcat), DICOM work lists / work flow with immediate access to cardiology results across all sites within the region. Pressure wire is Aeris.






Given that the lab is newly opened, we are currently implementing extensive protocols for all aspects of cath lab and acute coronary management.


For radial work, vascular closure is obtained using the TR band, the angioseal is utilised for closure of femoral puncture sites.


The new wireless system is much more user-friendly, is much less cumbersome to calibrate, and because the wire is not “tethered”, the wire is much more easy to manipulate.


I routinely use FFR estimation for equivocal lesions, and as a way of guiding appropriate therapy. The results from the FAME trial would corroborate that clinical approach FAME study, international, multi-centre using FFR guided angio vs angio alone showed that costs sav-ings were made in the FFR group by an overall statistical score of 14%. This was mainly down to reduction in stenting by 30% in the FFR group.







Clinical Argument


Significant reduction in overall MACE in the FFR group by 30% These are very important clinical statistics and are creating a sea-change within cardiology globally in the strategic treatment of patients with expected increased rates of FFR usage by 50% in 2010.

•

•

•

•

•

•

•



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

We do not currently perform 24/7 primary angioplasty. During working hours, the casualty department is instructed to contact the cath lab immediately upon the arrival of an ST elevati on myocardial infarcti on.

Achievements

The Regional Cardiac Catheterisati on Laboratory operates with opti -mum clinical and administrati ve effi ciency by coupling the highest level of clinical experti se and state of the art pati ent record man-agement. That essenti al combinati on has directly resulted in the highest standards of pati ent care including ti mely interventi ons and superior outcomes for all pati ents presenti ng for this criti cal service in the south east area. Acknowledging this cath lab service has only operated on a 3-days per week basis (due to budget limitati ons), the accrued benefi ts from that restricted cath lab service over the past 18months is exemplary in the context of any similar service else-where; this is testi fi ed through the acti vity stati sti cs, range of proce-dures and sample anecdotal evidence above. This criti cal service now desperately needs the requisite minimum funding to allow it expand those services and thus realise its overdue acknowledged objecti ve. Since October 14 2009 we have opened the cath lab 5 days per week with a full range of services.

What is the best part of working at your facility?

Parti cipati ng in a program that delivers modern cardiology care to the populati on of the South East of Ireland.

PressureWire for FFR & FAME Explained

The PressureWire™ Certus and PressureWire™ Aeris aid in the diagnosis of coronary artery blockages by measuring Fracti onal Flow Reserve (FFR). FFR measurement indicates

the severity of blood fl ow blockages in the coronary arteries, allowing physicians to bett er identi fy which specifi c lesion or lesions are responsible for a pati ent’s ischemia, a defi ciency of blood supply to the heart caused by blood restricti on. The Pres-sureWire technology will help physicians determine the ideal treatment opti on for their pati ents during coronary interven-ti ons, such as stent procedures.

St. Jude Medical recently launched the next-generati on of the PressureWire Certus -- the only FFR measurement system used in the recent FAME (Fracti onal fl ow reserve (FFR) vs. Angiogra-phy in Multi vessel Evaluati on) study, which found both supe-rior clinical outcomes and reduced healthcare costs in pati ents whose treatment was based on FFR rather than angiography alone. The combined risk of death or myocardial infarcti on (heart att ack) was 34% lower for pati ents whose treatment was guided by PressureWire technology prior to coronary stenti ng; also, there was a diff erence of about $2,000, or 14%, in health-care costs between the two pati ent groups aft er one year. The Gen 7 PressureWire includes modifi cati ons to the design and functi onality to help provide physicians with improved handling and more versati lity

The PressureWire Aeris is a fi rst-of-its-kind wireless FFR meas-urement system which requires no additi onal equipment or cabling in the cardiac catheterizati on laboratory. The elimina-ti on of additi onal equipment and cabling has the potenti al to simplify set-up and increase procedural effi ciencies.

PRO

DU

CTS

Above: Waterford Regional Hospital


Echocardiography has historically had a signifi cant role in the detecti on and monitoring of left ventricular mural thrombi. Left ventricular dilatati on and an ischaemic basis for a cardiomyopathy are both independent predictors of LV thrombi given that LV systolic

functi on is oft en impaired 2. The development of intravenous contrast agents has improved the diagnosti c yield for the detecti on of mural thrombi 3. This is most advantageous for apical mural thrombi in transthoracic imaging as transoesophageal echo oft en does not adequately interrogate the apex and thus is a poor alternati ve approach to imaging.

The use of contrast echo versus non-contrast echo and Delayed-enhancement cardiovas-cular magneti c resonance (DE-CMR), which relies on ti ssue characterizati on rather than anatomic appearance showed signifi cantly improved sensiti vity for the detecti on of mural thrombi by contrast echo compared with non-contrast echo. Contrast echo has been shown to have a lower sensiti vity for the detecti on of mural thrombi compared with the DE-CMR with the thrombi that were missed being small in volume or mural in shape 5.

The incidence of mural thrombi in acute MI has been reported to be lower than histori-cally suggested with the use of primary percutaneous coronary interventi on1. However, delayed-enhancement cardiovascular magneti c resonance (DE-CMR) showed LV mural thrombi prevalence of 7% in a high risk populati on 4.

The pati ent in this case is a 53 year old male. He was fi rst seen for an echocardiogram for an abnormal resti ng ECG although he was asymptomati c. The investi gati on revealed a dilated (ischaemic) cardiomyopathy with a large old anteroapical scar and an ejecti on fracti on of 31% (Simpson’s biplane method). Clip 1 demonstrates impaired LV systolic functi on and as common with most parasternal long axis views, the apex it not well visualised. Again in Clip 2 the apical mural thrombus is diffi cult to discern. A subsequent Dobutamine stress echocardiography was performed to evaluate for viable myocardium and inducible revers-ible ischaemia. He was seen by a cardiologist and diagnosed with having had a moderately large silent anterior myocardial infarcti on and commenced on Aspirin and Ramipril. The images from the following case were performed in our clinic 12 months aft er the initi al presentati on as part of routi ne follow up. An initi al non-contrast study was performed with a subsequent follow up contrast study. Clip 3 demonstrates the fi lling defi cit in the apex, readily identi fying the apical mural thrombus. The low fl ow velocity in the apex displayed in Clip 4 indicates the high propensity for thrombus formati on. Once the LV mural throm-bus was identi fi ed by the echocardiogram, the pati ent was advised to commence Warfarin therapy. Note: Video clips from this case study are available on our website.

References Rehan A, Kanwar M, Rosman H, Ahmed S, Ali A, Gardin J, Cohen G: Incidence of post myocardial infarcti on left ventricular thrombus formati on in the era of primary percutaneous interventi on and glycoprotein IIb/IIIa inhibitors. A prospecti ve observa-ti onal study. Cardiovascular Ultrasound 2006, 4:20 htt p://www.cardiovascularultrasound.com/content/4/1/20 Sharma ND, McCullogh PA, Philbin EF and Weaver WD: Left Ventricular Thrombus and Subsequent Thromboembolism in Pati ents With Severe Systolic Dysfuncti on. CHEST February 2000 vol. 17 no. 2:314-320. htt p://chestjournal.chestpubs.org/content/117/2/314 Thangaraj S, Schechtman KB and Perez JE: Improved Echocardiographic Delineati on of Left Ventricular Thrombus with the Use of Intravenous Second-Generati on Contrast Image Enhancement. J Am Soc Echocardiography 1999;12:1022-6.Weinsaft JW, Kim HW, Shah DJ, Klem I, Crowley AL, Brosnan R, James OG, Patel MR, Heitner JH, Parker M, Velazquez EJ, Steenbergen C, Judd RM, Kim RJ: Detecti on of Left Ventricular Thrombus by Delayed-Enhancement Cardiovascular Magneti c Resonance. Prevalence and Markers in Pati ents With Systolic Dysfuncti on. J Am Coll Cardiol, 2008; 52:148-157 htt p://content.onlinejacc.org/cgi/content/full/52/2/148 Weinsaft JW, Kim RJ, Ross M, Krauser D, Manoushagian S, LaBounty TM, Cham MD, Min JK, Healy K, Wang Y, Parker M, Roman MJ and Devereux RB: Contrast-Enhanced Anatomic Imaging as Compared to Contrast-Enhanced Tissue Charac-terizati on for Detecti on of Left Ventricular Thrombus. J Am Coll Cardiol Img, 2009; 2:969-979 htt p://imaging.onlinejacc.org/cgi/content/abstract/2/8/969

1.

2.

3.

4.

5.

Case StudyEchocardiography

Contrast echocardiography and mural thrombus in a dilated (ischaemic) cardiomyopathy

Mr Marcus BryantCardio Vascular ServicesMelbourne, Australia

Clip 1

Clip 2

Clip 3

Clip 4


WatchVideosOnline


Hot TopicManagement

Should food and/or gift s bought into the cardiology department from companies be banned?

I believe that gift s and favours should be banned to prevent favouriti sm of reps with staff . Gift s/ favours are usually more personal and individually dealt with by a rep, thus can be seen as a bribe, or infl uence parti cular staff in purchasing

equipment, or even make other staff feel uncomfortable and alienated. However, I believe that food for the department as a whole should not be banned, since this is usually not used by the rep as a bribe, but more of a thank you for using their com-pany’s products. Plus, reps can keep staff up to date with new technologies, and any problems staff may have with current equipment by talking it over a nice biscuit. I do understand that I have dissected the questi on and given two diff erent views, and that one cannot pick and choose when something is right or wrong. Nonetheless I feel that it can depend upon the circumstances, in other words if all of the staff in the department are to benefi t from an uncompromised treat then yes, but if it is only individuals who benefi t then perhaps no.

Our Trust takes what I think is a sensible approach to this matt er. We have a guidance paper that outlines what is acceptable. Provided gift s are of minor value (up to £25), and are given with no expectati on of return, and are not

for private use, then it is considered ok. Anything worth more than that must be recorded on the gift register, and generally refused. Expensive gift s, or off ers of sup-ply of goods or services to either individual employees or members of their family should be declared and refused. With regards should it be banned altogether? I would say no. I do not believe that smaller companies that cannot or do not provide refreshments are disadvantaged. The success or otherwise of companies in a catheter lab environment depends on the quality of their products, not the quality (or quanti ty) of their cakes. There is absolutely no expectati on that when Reps come they need to bring food with them. This does not mean when they do however, it is not welcomed. It is oft en said “every person has their price”. I would like to think that as NHS work-ers it is considerably higher than the odd jaff a cake or jam doughnut. For those whom may think otherwise, perhaps a career in politi cs awaits.

The responses from our Facebook Fan Site.Now with over 480 fans globally!!

Ms Sarah PalmerDeputy Procurement Offi cerCardiac Cath Lab - Manchester Heart Centre ManchesterUnited Kingdom

Marti n Drew: Most of our companies bring food during a booked appointment, however as long as they are not using it as an excuse to try and introduce another product (this should always be by appointment only) then I don’t see it as a problem. In fact them touching base like that can produce a good opportunity to discuss any problems or ask any off the cuff questi ons that have suddenly arisen.

Susan Evans: It’s oft en very hard to get away for lunch in our Cath lab and by bringing some food -lunch- gives us all a good opportunity to stop and have a round table discussion without leaving the dept.

Todd Ginapp: Our system put a stop of any giveaways of any kind. No food, no pens, no pads, no shirts, nothing. They strictly enforce the “corporate compliance” regulati ons. I thought it was overkill unti l the vendors, them-selves, stated that they were not allowed to do it either. I know some places allow it, and I just don’t get how it is OK some places and not OK at others.All it takes is one greedy and unethical vendor to screw it up for everyone.

Kerryn Fitzgerald: more food the bett er....

See all the responses to this questi on by searching for Cardiology HD on Facebook.

Mr Greg CruickshankSuperintendent Radiographer Cardiac Catheter Suite - King’s College Hospital NHS Trust. LondonUnited Kingdom


AssistanceManagement

Cardiology: People and Service Management

In August last year it was stated in the interim report of Dr Steven Boorman – a leading occu-pati onal health expert, that more than 45,000 NHS workers report sick each working day. As a manager it is crucial to establish any patt erns of sickness within your team and to learn

how to treat the causes of absenteeism. Sickness from the workplace is in many circumstances enti rely genuine, and these episodes are oft en easy to determine from the gradual development of symptoms or confi rmati on from a medical certi fi cate of sickness. Posing a greater diffi culty are those illnesses that are a symptom of a deeper issue, when your role is then to expose these episodes and to reaffi rm the boundaries to your staff whilst sensiti vely addressing the underly-ing problem.

It is important that as a manager you are an exemplar to your staff and encourage them to act as role models to each other also. Ensure you scruti nise your own sickness and support your staff

to maintain healthy lifestyles in order to help prevent minor ailments. With 300,000 NHS employees classifi ed as overweight, and a colossal 22% smoking more than 20-a-day,

the correlati on between absenteeism and lifestyle is evident.



of their sickness and by discussing each episode the frequency of a staff member’s absence cannot go unnoti ced. It also off ers an opportunity for them to refl ect on how their absence aff ects the remainder of the team and the service pati ents receive, whilst positi vely re-enforcing how they contribute to the team and service as a whole.

Investi gati ng multi ple sickness episodes and trends takes ti me, but the rewards are great. Someti mes absence is a symptom of work or home related issues which manifest as illness. These are highly signifi cant episodes of nonatt endance that will be repeated unti l the cause is addressed, but once man-

aged there can be a reducti on of sickness and improvement of a staff member’s morale and relati on with their work. A man-ager’s responsibility is to help the staff member to address the




how pati ents and other staff members can be negati vely aff ected by our acti ons and in parti cular our absence.

Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor

Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust United Kingdom

employees classifi ed as overweight, and a colossal 22% smoking more than 20-a-day, the correlati on between absenteeism and lifestyle is evident.







CalendarCardiology Events

United Kingdom

April 27 2010

7th Oxford Live CourseJohn Radcliff e HospitalOxford, Englandwww.millbrookconferences.co.uk

June 7-9

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

June 7-11

Hammersmith EchocardiologyHammersmith Conference CentreLondon, Englandwww.imperial.nhs.uk/hcc

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

June 2-5

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

September 21-25

TCT 2010Washington Conventi on CenterWashington, DC, USAwww.tctconference.com

1

2

3

4

5

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:

1

2

3

4

5


AnswerSophie Blackman’s ECG Challenge

The baseline of the ECG is sinus rhythm with 1st degree AV block. It is possible to see notch shaped P waves on the ECG which can be associated with left atrial enlargement.

There is a 6 beat salvo of a broad complex tachycardia of about 330ms with a sudden onset and termination and an axis change. Although there is a discrete P wave visible at the onset of the tachycardia this is the next atrial beat in the sinus sequence, notably the atrial cycle length is variable. This atrial contraction is not the driver of the salvo as although it is followed by a ventricular complex, the PR interval is only about 200ms whereas for the rest of the recording the PR is long. The atrial contraction is not the driver of the ventricular beat and therefore the broad complex tachycardia is ventricular in origin.

Most interestingly however is the down stroke of the QRS complex. As the QRS returns to the isoelectric baseline there is a small notch. This is known as a J wave or an Osborn wave. Commonly this is seen in patients with hypothermia but is also reported in hypocalcaemia, brain injury and subarachnoid haemorrhage1.

Significantly the Osborn wave is an ECG characteristic associated with early repolarisation syndrome and those with idiopathic VT 2. This syndrome is understood to form the basis for triggered activity. Whilst Osborn waves are considered to be a benign ECG finding 3, a higher incidence of VT and VF has long been observed in the hypo-thermic patient with dominant Osborne waves. 4

The significance of arrhythmogenesis associated with a predominant Osborn wave was only recognised recently when Brugada syndrome was identified. 5

For this patient the ‘benign’ finding of Osborn waves throughout her 24 hour ambulatory recording, with several salvos of VT, is certainly an interesting correlation, and suggestive of an early repolarisation syndrome that is worthy of further investigation.

Referenes: Maruyama et al. Osborn Waves: History and Significance. Indian Pacing and Electrophysiology Journal. 2004; 4(1): 33-39.

Kalla H, Yan GX, Marinchak R. Ventricular fibrillation in a patient with prominent J (Osborn) waves and ST-segment elevation in the inferior electrocardiographic leads: a Brugada syndrome variant? J Cardiovasc Electrophysiol. 2000; 11: 95–98

Gussak I, Antzelevitch C. Early Repolarization Syndrome: Clinical char-acteristics and possible cellular and ionic mechanisms. J Electrocardiol. 2000; 33: 299–309

Gussak I, Bjerregaard P, Egan TM, Chaitman BR. ECG phenomenon called the J-wave: history, pathophysiology, and clinical significance. J Electrocardiol. 1995; 28: 49–58

Yan GX et al. Ventricular repolarization com-ponents on the electrocardiogram.; cellular basis and clinical significane. J Am Coll Cardiol, 2003; 42:401-409

1.

2.

3.

4.

5.

CURRENTADVERTISERS

BCSPage 2

Labyrinth & CardioacePage 5

St Jude MedicalPage 16

St Jude MedicalPage 18

HRC & Wellington HospitalPage 27

World Heart FederationPage 28

Adv

erti

se W

ith

Us

See

Page

4 fo

r Con

tact

Det

ails

Ms Sophie BlackmanCoronary Heart Management and CRM Consulting EditorUnited Kingdom

Question on Page: 12



World Class Hospitals.World Class Future.

THe WeLLinGTon HoSPiTaLat the leading edge of modern healthcare, HCa are responsible for six private hospitals plus HCaLaboratories in the heart of London. We’re committed to providing world-class patient care - notjust meeting the highest standards, but setting them.


Cardiac Physiologists/Specialised andHighly Specialised Cardiac PhysiologistRef: 001/5410/SCTAs an experienced Cardiac Physiologist with experience in invasive and/or non invasive cardiac procedures, you will be self-motivated and well organised, with excellent interpersonal skills and the ability to prioritise and use your own initiative. Experience in a wide range of both non-invasive procedures including echo and invasive procedures, ideally including EP and rhythm management, is desirable. A willingness to participate on the on-call rota is important.Equipped with RCCP registration, you must have proven post-registration experience with a BSc (Hons) Degree qualification in Cardiac Physiology or equivalent plus proven experience as a Cardiac Physiologist. We are fully supportive of personal and professional development and you will be encouraged to attend courses, conferences and seminars relevant to you.

Multi-skilled Cardiac Cath LabPractitioner (training)Ref: 001/5410/CLPIf you are interested in becoming a specialised Cath Lab Practitioner, we’d like to hear from you. You should be a qualified Nurse, Radiographer or Cardiac Physiologist with proven experience in a Cardiac Cath Lab environment. Training will be provided in-house in addition to a post-graduate course at London South Bank University. On successful completion of the LSBU course, you will qualify for the position of Multi-skilled Cardiac Cath Lab Practitioner.






Telephone: +44 (0) 1789 450 787


[email protected]

+44 (0) 1789 451822



HeartRhythm

Congress2010

HeartRhythmCongress



Technology

Technology

Technologygy



Medical Recruitment












Upcoming Issues*

May / June 2010





Echo Case Study

EP Education Series

ECG Challenge 15

July / August 2010





ECG Challenge 16


›

›

›

›

›

›

›

›

›

›

›

›

PressureWire™ AerisWireless FFR Measurement System

PressureWire™ CertusFFR Measurement System



Mac-Lab is a registered trademark of GE Healthcare.


SJMprofessional.com

Radi Medical Systems is now a part of St. Jude Medical.

Routine use of the PressureWire System offers physicians more control when assessing complex

coronary lesions. When integrated into routine lab procedures, measuring fractional flow reserve

(FFR), as shown by the FAME study (FFR versus Angiography for Multivessel Evaluation), reduces

the incidence of major adverse coronary events by 28%.1 Using PressureWire Aeris or PressureWire

Certus to measure FFR helps ensure access to accurate information in the cath lab, increasing

the efficiency and efficacy of coronary revascularization.1 In addition, PressureWire Aeris provides

instant, wireless integration of FFR data into the Mac-Lab® hemodynamic recording system from

GE Healthcare, eliminating the need for a separate analyzer for simplified cath lab workflow and

optimum efficiency.

Reliable, Accurate FFR Measurementfor More Effective Coronary Lesion Assessment.

Incorporating FFR Measurement into Procedures

Significantly Reduces Major Adverse Coronary Events.


2. TCT (Transcatheter Cardiovascular Therapeutics) 2009. Late Breaking Clinical Trials.



Fractional flow reserve (FFR) as measured by the St. Jude Medical PressureWire™ System makes stent

placement more efficient and cost-effective.1 The FAME study’s one-year results show that therapy

guided by the routine measurement of FFR in patients with complex coronary artery disease reduces

the incidence of major adverse coronary events by 28%.1 Recently released two-year FAME results

show a 34% reduction in combined mortality and myocardial infarction (MI) and a 37% reduction in

MI alone.2 Compared to using only angiography, measuring FFR allows physicians to more accurately

identify and treat physiologically significant stenoses.

FAMEstudy.com

3M, manufacturer of world-renowned Littmann stethoscopes, has

introduced the 3M™ Littmann® Electronic Stethoscope Models 3200 ® Electronic Stethoscope Models 3200 ®

& 3100 into the range. Both build on the established benefits of Littmann

electronic stethoscopes: 24x sound amplification to assist in hearing faint heart,

lung or body sounds; and patented Ambient Noise Reduction technology, which

acoustically cancels out an average of 85% of distracting background noise.

For the first time, however, the next-generation Model 3200 features on-board

seamless two-way Bluetooth® transfer of heart, lung and other body sounds to ® transfer of heart, lung and other body sounds to ®

software for storage and further analysis.

In a further development, 3M has partnered with Zargis Medical Corp., a

leader in advanced diagnostic decision support products, to develop exclusive

complementary software packages including StethAssist.™

Included with the Model 3200 at no additional charge, StethAssist allows the

visualisation, manipulation and slowing down of auscultated sounds to allow

focus on particular areas of interest. Recordings can be stored electronically for

comparison to future auscultations and sent to colleagues for a second opinion.

Both Littmann models have a sleek, streamlined design and exceptional sound

capabilities, delivered through a state-of-the-art central 15mm sound sensor.

Together with a flat diaphragm for stability, both stethoscopes are ideally sized

for neonatal, paediatric and adult auscultation.

Extensive user feedback of the stethoscopes has led to the introduction of

additional, innovative performance features. Subtle design changes in the

chestpiece reduce frictional handling noise and hence distraction, whilst the

LCD interface, with backlight for low-light conditions, now indicates current

sound level, current selected mode and remaining battery life. Once switched

on, the stethoscope stays in battery- saving ‘sleep-mode’ so there is no waiting

to start the next auscultation.

Peter Robinson, Senior Technical Specialist at 3M believes the new technology

will help enhance clinicians’ natural abilities, and enable them to confirm

diagnoses and more easily gather a second opinion from colleagues.

“Of particular importance

is the “extended range”

filter of the Model 3200

stethoscope” he commented. stethoscope” he commented. stethoscope”

“The traditional bell and

diaphragm focus respectively

on lower and higher

frequency sounds – but

during separate auscultation

events. The Model 3200

covers the complete range

of 20-2000Hz and may help

to address the concerns of

physicians who feel that low






results. Dr Satish Adwani, Consultant Paediatric Cardiologist, John Radcliffe

Hospital, said “The telemedicine aspect of the Model 3200 probably


provide healthcare. GPs are able to transmit murmurs to a specialist,

together with a clinical letter which could, in theory, prevent in-


workers will do the same, allowing clinicians to decide whether a patient

needs immediate consultation or could wait for a routine outpatient

appointment.”

Dr Sajad Hayat, Cardiology Specialist Registrar, Manchester Royal Infirmary

said “Despite my initial reservations of switching from a traditional

stethoscope, I’ve been hugely impressed with the Model 3200, particularly

its crisp sound quality and degree of ambient noise reduction. It has proved

an excellent teaching tool on ward rounds for our medical students. They

have benefitted hugely from being able to repeatedly listen to sounds and

discuss and debate what they hear.”

For further information or to request a free trial of the Littmann

electronic stethoscope models 3200 & 3100, please visit:

littmann.co.uk or call 3M on 01509 613584.k or call 3M on 01509 613584.k

Littmann® Introduces First Electronic Stethoscope with Bluetooth® Technology and Sound Analysis Software

3

LCD Interface with Backlight

3M and Littmann are trademarks of the 3M Company. Bluetooth is a registered trademark of

Bluetooth SIG. StethAssist is a trademark of Zargis Medical Corp.






results.

Hospital, said



Bluetooth

Technology

and

StethAssist

Software

Advertising Feature


Round UpLatest News














All of us who work in cardiology encounter stress on a daily basis, but some are bett er at coping than oth-ers. So rather than dwell on a problem do something to make you feel happy or you to could end up on

the cath lab table. In an arti cle recently published in the European Heart Journal, a 10-year study with 1700 people showed those who were the most anxious and depressed had the highest risk of heart disease.



ANNUAL CONFERENCE AND EXHIBITION 2010

Venue: Manchester Central, ManchesterDate: 7 to 9 June 2010

3 Day educational meeting in Cardiovascular Medicine, with a programme of case based presentations and plenary sessions

Exhibition showcasing the latest developments in cardiovascular medicine and new technologies

Educational content based on the new European Curriculum, including a Trainee day

Gain CPD points and review general cardiovascular knowledge required for revalidation.

Members of the British Cardiovascular Society can register for free before 31 March 2010. Visit www.bcs.com for online registration and further information.

3MPage 13

Hammersmith Hospital & Your WorldPage 26

2� Mar/Apr 2010 www.cardiologyhd.com

Medical Recruitment












Upcoming Issues*

May / June 2010





Echo Case Study

EP Education Series

ECG Challenge 15

July / August 2010





ECG Challenge 16


›

›

›

›

›

›

›

›

›

›

›

›



World Class Hospitals. World Class Future.

THe WeLLinGTon HoSPiTaLat the leading edge of modern healthcare, HCa are responsible for six private hospitals plus HCa Laboratories in the heart of London. We’re committed to providing world-class patient care - not just meeting the highest standards, but setting them.


Cardiac Physiologists/Specialised and Highly Specialised Cardiac Physiologist Ref: 001/5410/SCTAs an experienced Cardiac Physiologist with experience in invasive and/or non invasive cardiac procedures, you will be self-motivated and well organised, with excellent interpersonal skills and the ability to prioritise and use your own initiative. Experience in a wide range of both non-invasive procedures including echo and invasive procedures, ideally including EP and rhythm management, is desirable. A willingness to participate on the on-call rota is important.Equipped with RCCP registration, you must have proven post-registration experience with a BSc (Hons) Degree qualification in Cardiac Physiology or equivalent plus proven experience as a Cardiac Physiologist. We are fully supportive of personal and professional development and you will be encouraged to attend courses, conferences and seminars relevant to you.

Multi-skilled Cardiac Cath Lab Practitioner (training) Ref: 001/5410/CLPIf you are interested in becoming a specialised Cath Lab Practitioner, we’d like to hear from you. You should be a qualified Nurse, Radiographer or Cardiac Physiologist with proven experience in a Cardiac Cath Lab environment. Training will be provided in-house in addition to a post-graduate course at London South Bank University. On successful completion of the LSBU course, you will qualify for the position of Multi-skilled Cardiac Cath Lab Practitioner.






Telephone: +44 (0) 1789 450 787


[email protected]

+44 (0) 1789 451822



HeartRhythm

Congress2010

HeartRhythmCongress



Technology

Technology

Technologygy


World Congress of CardiologyScientific Sessions 2010Featuring the 3rd International Conference on Women, Heart Disease and Stroke

16 –19 June 2010 | Beijing, China

www.worldcardiocongress.org

WCC_advert_A4.indd 1 17.3.2009 9:50:36

Coronary Heart #23

Documents

cardiovascular medicine

clinical staff

pati ents journey of

new european curriculum

british cardiovascular

editorial staff

product review

londons leading cath