CardiologyHD #32

LATEST PRODUCT NEWS

BEHIND THE SCENESThe Making of Medtronic’sIntegrity Stents in Ireland

CARDIOLOGIST HOT TOPICWho should perform peripherals?

MANAGEMENT HOT TOPICChanging work patt erns with PPCI

UK SITE VISITSLancashire Cardiac Centre & Royal Berkshire Hospital

JOURNAL REVIEWS

EVENTS CALENDAR

Lancashire

- Uti lising Volcano’s FFR

HYBRID DESIGN + INNOVATION + LESS TREES : INTEGRATING WEB & PRINT

Cardiac Centre

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

Issue 32 • Sep/Oct 2011Subscribe FREE OnlineCardiologyHD.com

Powerful clinical outcomes for complex daily practice

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

(%)

TLF MACE

12.1 12.6 13.215.3

20

15

10

5

0

RESOLUTE ALL Comers 2-Year Results in Complex Patient Subgroup

p = 0.81p = 0.27

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

Resolute IntegrityResolute IntegrityResolute IntegrityZotarolimus-Eluting Coronary stEnt systEm

Make the complex simple

For distribution only in markets where resolute integrity DEs is approved. not for distribution in the usa or Japan. © 2011 medtronic, inc. all rights reserved. uC201200736EE 6/11

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

rEsolutE all Comers 24-month data. rEsolutE all Comers evaluated the resolute stent.

www.cardiologyhd.com Sep/Oct 2011 3

McKesson Back Cover Advert

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

Copyright © 2006 - 2011 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.


Latest Product News

Round UpEchocardiography

ONLINE DISCUSSION FORUM

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

Latest Topics from our members

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

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

Philips’ next generati on Allura Xper FD20 systems combine superb image quality with advanced interventi onal tools, seamlessly inte-grated into the clinical workfl ow, providing enhanced opportuniti es with Live 3D guidance to conti nue to expand the range of interven-ti onal procedures able to be undertaken by the user. The integrated workfl ow, intuiti ve user interface and personalised setti ngs enable the user to take full advantage of all the Allura’s capabiliti es and for a broad variety of procedures assist in providing excellent clinical care eff ecti vely and comfortably.

The Western Infi rmary opts for ‘Echo in a Heartbeat’ functi onality from Siemens

The Western Infi rmary, part of NHS Greater Glasgow and Clyde, is benefi ti ng from increased cardiac image quality fol-lowing the installati on of an ACUSON SC2000™ diagnosti c ultrasound system from Siemens Healthcare. The hospital is one of the fi rst in the UK to have installed the system. The purchase was funded by the Briti sh Heart Foundati on Glasgow Cardiovascular Research Centre, who will share use of the sys-tem for research projects.

The system will primarily be used for 3D echocardiography. The SC2000 is Siemens’ premier echocardiography system featuring ‘Echo in a Heartbeat’ imaging technology, which acquires real-ti me, full-volume images of the heart in one sin-gle cycle.

“The SC2000 generates fantasti c image quality and is allow-ing us to perform more sophisti cated 3D echocardiography examinati ons,” said Dr. Piotr Sonecki, Consultant Cardiologist at The Western Infi rmary. “Towards the end of the year, we hope to be able to carry out vascular examinati ons and further evaluate its suitability for future research work.”

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

6 Sep/Oct 2011 www.cardiologyhd.com

SonoSite’s M-Turbo® key to emergency echocardiographyRoyal Brompton Hospital in London, home to the UK’s largest specialist heart and lung centre, uses a SonoSite M-Turbo® point-of-care ultrasound system for emergency focused transthoracic echocardiography. Dr Susanna Price, consultant cardiologist and intensivist, explained: “The M Turbo is solely dedicated to emer-gency use on the intensive care unit (ICU). Its extremely fast boot-up ti me is a great advantage in life-threatening situati ons where speed is criti cal, and being equipped with both a cardiac package and a vascular probe means it serves a dual purpose.”

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

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

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

For more informati on about SonoSite products, please contact: [email protected] or www.sonosite.com

Edwards Lifesciences launches Physio Tricuspid repair ringEdwards Lifesciences has received CE mark approval and FDA clearance for a new repair ring for the treatment of tricuspid insuffi ciency. The Carpenti er-Edwards Physio Tricuspid Annu-loplasty ring features a three-dimensional waveform shape, and incorporates several ease-of-implant features.

“We designed the ring to off er surgeons confi dence when treati ng tricuspid valve insuffi ciency,” said preliminary researcher Alain Carpenti er, M.D., Ph.D., professor and chair-man emeritus of cardiovascular surgery at the Hôpital Europ-een Georges Pompidou.

“It is designed to conform to the anatomy of the valve annu-lus and preserve its natural movement to facilitate adherence of the ring to the surrounding ti ssue, while restoring proper valve functi on.”

Tricuspid insuffi ciency is progressive and may aff ect more than 150,000 Europeans. It oft en leads to severe tricuspid regurgitati on, where valve leafl ets do not close properly allowing backfl ow of blood. Annuloplasty ring repair is typically recommended for pati ents with signifi cant annular dilati on.

Improving the management and diagnosis of aorti c stenosis through treatment innovati on Aorti c stenosis is the most common cardiac valve dis-ease in developed coun-tries, aff ecti ng nearly 26% of people over 65. Once advanced disease and symptoms present, prog-nosis is poor with survival under three years for many. Additi onally, diagnosis is diffi cult and symptoms are oft en missed and fur-thermore, even if diagnosed, age and co-morbiditi es combine to render many pati ents inappropriate for traditi onal surgical valve replacement.

Recently discussed in the UK for the fi rst ti me in its enti rety, the Placement of AoRTic TraNscathetER Valve Trial (PARTNER) showed that Transcatheter Aorti c Valve Implantati on (TAVI) signifi cantly reduces the rates of death from any cause for previously inoper-able pati ents, gives pati ents substanti ally bett er quality of life and

provides pati ents with a survival rate equivalent to that of conventi onal surgery.

Specifi cally, the results from Cohort B off ered “the biggest treatment eff ects

ever seen in a randomised controlled trial” according to Mark de Belder,

consultant cardiologist at James Cook University Hospital.

For more informati on on Edwards Lifesciences products

please visit www.edwards.com

Heart Valves

researcher Alain Carpenti er, M.D., Ph.D., professor and chair-man emeritus of cardiovascular surgery at the Hôpital Europ-een Georges Pompidou.



diffi cult and symptoms are oft en missed and fur-thermore, even if diagnosed, age and co-morbiditi es combine to render many pati ents inappropriate for traditi onal surgical valve replacement.








Dr Price concluded: “The M-Turbo’s facility to record image clips for sub-sequent review is an essenti al require-ment. It provides a record of diagnosis, evidence for medico-legal purposes, and, being easy to use, the system


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INTERNATIONAL ONLINE CATALOGUE

Siemens Healthcare Arti s zee

The Arti s zee™ family is designed for interventi onal cardiology imaging. Available as fl oor or ceiling-mounted, biplane or with Magneti c Navigati on, it features a 20x20cm or 30x40cm fl at detector. This enables fl exible positi oning around the pati ent, ideally suited for imaging of structural heart diseases.

Show Site: See our website for case studies at the Bristol Heart Insti tute and the Nati onal Insti tute for Health Research.

Siemens Healthcare SOMATOM Defi niti on AS+

The SOMATOM® Defi niti on AS+ CT system from Siemens Healthcare is an adapti ve scanner that provides excepti onal image quality to make complex cardiology examinati ons routi ne.

Show Site: See our website for case studies at Borders General Hospital and Great Western Hospital.

Full descriptions, images & more online

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

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

Like to advertise your products? Contact us via the details on Page 4.

First European appearance of the newly formed Hitachi Aloka Medical Ltd. (Japan) Hitachi Medical Cor-porati on and Aloka Corporati on have combined their strengths in ultra-sound to form Hitachi Aloka Medical Ltd. (Japan), a subsidiary of Hitachi Medical Corporati on (Japan). The new company made their Europe-an debut in Vienna between 26 to 29 August 2011 at the 13th World Congress of Ultrasound in Medicine and Biology (WFUMB).

Hitachi and Aloka bring together a plethora of experience and knowledge - synergizing the experti se and talents of the peo-ple on both sides of the new merged company. Parti cipants and visitors were invited to experience this at the event booth where Hitachi Aloka Medical highlighted ‘the next generati on in high resoluti on imaging technology’, focusing on the Hitachi HI VISION and Aloka ProSound Ultrasound platf orms - intro-duced and explained by expert employees from Hitachi Aloka Medical Japan, Aloka Europe and Hitachi Medical Systems Europe.

Industry Partnerships

Above: The Two CEO’s

Cath lab Nurses/Physiologists/RadiographersOpportunity for Cath Lab Staff

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

Scarborough Hospital, North East Yorkshire

This is a long term 2-day/week service (Tuesdays and Wednesdays) providing Diagnostic Coronary Angiography and Permanent Pacing.

Fixed term and agency-style contracts available!!!

START DATE: 4th October 2011

To find out more please contact Bryn Webber, Cardiac Services Manager: [email protected] or call 07966 987712

Please visit our website for more details on our background and capabilities: www.rphc.co.uk

We look forward to hearing from you.


Cardiologist, Radiologist or Vascular Surgeon and why?

Who should perform peripheral vascular interventi on:

It is much easier to address this questi on in the NHS environment than in countries where the operator’s livelihood is dependent on cornering as much of the market as possible. In this country, we can put the interests of the pati ents and service fi rst.

Individuals from any clinical background can learn the relevant manual skills and tech-nical knowledge. Some individuals are naturally gift ed, most are trainable and very few need to be tactf ully pointed towards a diff erent career path. However, this apti -tude is independent of specialty.

Who can provide the best service to pati ents? It seems obvious to me that the spe-cialist should have a major interest in peripheral vascular disease. This includes the conservati ve, non-interventi onal management of vascular disease, such as medical therapy, exercise programmes and ulcer care. The holisti c care of the vascular pati ent requires more than treati ng the stenosis.

This logic leads to the conclusion that peripheral interventi on should be provided by vascular surgeons and this is almost certainly the directi on of travel in the UK. Radiolo-gists have been involved in peripheral interventi on since its incepti on and have provided a high quality service for years. However, the expansion and development of endovas-cular interventi ons have brought them from the margins to the mainstream. Thus it is important that the new generati on of vascular surgeons ensure that they are prop-erly trained in endovascular techniques and that consultant surgical posts have angio room sessions in the job plan. I anti cipate that the future of radiological involvement in peripheral interventi on will mirror what happened in coronary interventi on 20 years ago: the radiologists will progressively lose their role in this service provision.

This prognosis has a signifi cant downside. Vascular radiologists currently provide a broad range of services to many hospital departments for bleeding, tumour embolisa-ti on, vascular access, caval fi lter placement and so on. These are valuable services, but it will not be possible to sustain a comprehensive vascular radiology service without the workload that comes from vascular surgery referrals. The danger is that, if vascu-lar surgeons take on all the peripheral interventi on, vascular interventi onal radiology will atrophy.

The opti mal soluti on is therefore a harmonious collaborati on between radiologists and surgeons, with each specialty providing an overlapping and complementary range of skills. This is the reality in many UK centres at present, but I fear it is not sustainable in the long term.

Hot TopicCardiologist

Questions designed by Dr Magdi El-Omar and Tim Larner

Dr Nicholas ChalmersConsultant Vascular RadiologistDepartment of RadiologyCentral Manchester University Hospitals NHS Foundati on TrustManchester Royal Infi rmaryManchester

All of the above, provided they are inter-ested and are prepared to work collabo-rati vely and share their relevant clinical

skills and experience!

I think we need to learn from the lessons gained from transcatheter aorti c valve implan-tati on (TAVI), where we have found that the multi -disciplinary “TAVI team” has been instru-mental in the successful introducti on of TAVI into mainstream treatment of aorti c valve dis-ease. Equally we need to avoid the “turf war” scenario that we have previously seen with interventi onal and surgical treatment for coro-nary disease.

In my opinion, no individual clinician has the complete range of clinical skills and experi-ence to provide a comprehensive peripheral vascular interventi onal programme. I would advocate the development of multi -discipli-nary “endovascular teams” to provide the current and likely future range of minimally invasive/ endovascular treatments for car-diovascular disease. This would be in keep-ing with the “heart team” approach recently advocated by our European colleagues for the revascularisati on of coronary artery disease. Such teams would need to take advantage of local skills, interests and resources with clinicians working collaborati vely.

Dr David SmithConsultant Cardiologist, Morriston HospitalMorristonSwansea


The sensible answer in the medical world of 2011 is a medical practi ti oner who has a suitable clinical background and knowl-edge level, but is also demonstrably competent in the interven-

ti onal technical skill sets. Of course a cardiologist, vascular surgeon or interventi onal radiologist can acquire this technical experti se in a broad array of interventi onal procedures, the same way as a limited procedural skill set can be acquired by neurologist (caroti d stenti ng) or nephrologist (fi stuloplasty). If their skills are competent and their knowledge base is sound, or if they work in a team setti ng with suit-ably trained clinicians (as we have seen for years with many inter-venti onal radiologists and vascular surgeons) then they should be recognised as such and accredited by the appropriate insti tuti on.

We have resolved this issue in Australia and NZ by establishing a com-mitt ee to recognise such peripheral endovascular training regardless of the specialty. This committ ee has been sancti oned by the 3 Colleg-es involved namely: RACS , RACP and RANZCR . It has drawn criteria for recogniti on of training in 3 areas:

1. General peripheral endovascular interventi on2. Caroti d stenti ng3. Fenestrated and branched endograft ing

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

This approach has been based on the model used by gastroenterol-ogy groups to deal with similar issues relati ng to diverse specialti es performing endoscopy.

We have completed the grandfathering component successfully, and have already discovered the uti lity of this model in resolving diffi culti es with the hospital accreditati on of specialists in ‘scope of practi ce’, and also in resolving turf wars, which were a perennial problem.

AVAILABLEONLINE

SEE OUR PREVIOUS HOT TOPICS

We have 16 Hot Topics available on our website with responses from leading cardiologists from across the UK and around the world.

A Year in CardiologyDate: 14 December 2011

Venue: Royal College of Physicians, London

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

For more details and the full programme, visit the BCS website.

Online registration is now open on www.bcs.com/education

Mr Michael DentonChief of Vascular Surgery Epworth Medical CentreMelbourne, VictoriaAustralia


IndustryBehind the Scenes

The Manufacturing of Medtronic’s Integrity StentsBehind the Scenes:

OverviewFounded in 1949 as a medical repair shop, Medtronic Inc. has stead-ily grown to become a global leader in medical technologies, initi al-ly producing pacemakers before expanding to cover the variety of products available today. 40,000 employees in 120 countries, with 44 manufacturing faciliti es, and 25 research and development cen-tres worldwide ensure they are always at the cutti ng edge in regards to R&D, producing products that comply with their mission of alleviati ng pain, restoring health, and extending life.

Cardiovascular and Cardiac Rhythm Disease Management make up over half the total revenue for the company with the evoluti on of new technologies such as conti nuous sinusoid technology (CST) for coronary stents, ensuring Medtronic remains as a leader in medi-cal product development. We visited Medtronic’s manufacturing and technology development faciliti es in Galway, Ireland for a tour of how the R&D, operati onal processes, and quality assurance is combined to create the new Integrity Bare Metal Stent (BMS) and Resolute Integrity Drug Eluti ng Stent (DES), both uti lising CST.

Conti nuous Sinusoid Technology (CST)Coronary stents used by cardiologists in the treatment of coronary artery disease were originally limited to tubular mesh or slott ed tube stent designs. Medtronic has historically been known for its

modular stent technology, as is featured in their Driver stent. However, Medtronic have advanced this technol-ogy to the next level with the introducti on of CST, which results in superior fl exibility and deliverability compared with the Driver and also other commercially available stent platf orms (Fig 1).1

The easiest way to imagine CST is with a slinky design (Fig 2), whereby a conti nu-ous piece of wire can fl ex easily in all planes. The wire involved in the constructi on is already round so therefore doesn’t require extensive pol-ishing to remove any sharp edges which can lead to metal fati gue. The stents are also

made with cobalt chromium alloy which when compared with stain-less steel allows for a reducti on in stent strut thickness (enhanced delivery and lower rates of stenosis), bett er radiopacity, and greater strength.

The conti nuous range of moti on due to the wire-forming pro-cess and fusion patt ern provide greater fl exibility and conform-ability while maintaining radial strength. This is parti cularly apparent on ti ght bends or tortuous anatomy where the CST stent tracks very easily, whereas with traditi onal stents signifi cant gaps can occur or edges can raise damaging the sensiti ve inti mal lining of the artery being passed through.

Fig 1. Separate stiff and flexible segments limit range of motion on other platforms

Fig 2. Continuous sinusoid technology flexes continually

Medtronic employees checking the quality of the stents after electropolishing


Journals

Bedside Echo

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

Acute Coronary Syndromes

Yet another drug for reducing ischaemic outcomes in ACS pati ents? Sadly, or maybe even gladly, not, according to the APPRAISE 2 tri-al. Apixaban, a direct factor Xa inhibitor used in thromboembolism prophylaxis and atrial fi brillati on (AF) (others include dabigatran and rivaroxaban) only managed to increase bleeding in high risk ACS pati ents when added to standard dual anti platelet therapy, with no signifi cant reducti on in ischaemic events. This seems to conti nue the trend that oral anti coagulants have litt le overall benefi t in ACS (warfarin, hirudin), whilst oral anti platelet agents (aspirin, clopidog-rel, prasugrel, ti cagrelor), subcutaneous anti coagulants (enoxapa-rin, fondaparinux) and intravenous anti platelet (glycoprotein IIB IIIA inhibitors) and anti coagulants (bivalirudin) do.J Alexander and others. NEJM. 2011;10.1056/NEJMoa1105819.

Good to know that cardiovascular drugs are also benefi cial in pati ents with chronic kidney disease (CKD). The SHARP trial randomised 9270 pati ents with CKD and no previous history of MI or coronary revas-cularisati on to simvastati n 20mg plus ezeti mibe 10mg daily versus matching control. The primary outcome of fi rst major atheroscle-roti c event (a combinati on of non-fatal MI or coronary death, non-haemorrhagic stroke, or any arterial revascularisati on procedure) was signifi cantly reduced with the acti ve drugs (11.3% vs. 13.%) that reduced the average LDL cholesterol by 0.85mmol/L. Another high risk group that needs targeti ng and treatment.C Baigent and others. Lancet. 2011;377:2181-92.

Angiography

A fairly disturbing registry in America showed that the likelihood of fi nding obstructi ve coronary artery disease on electi ve diagnosti c angiography varies from 23% to 100% (median 45%). The data was collected through the huge Nati onal Cardiovascular Data Registry (NCDR) from 565,504 pati ents with known coronary artery disease, undergoing angiography at 691 centres, between 2005 and 2008. The data raises more questi ons than it answers, but suggests that

some clinicians and centres signifi cantly overesti mate angiographic stenosis, or do not have a suffi ciently low enough threshold to per-form angiography in pati ents with symptoms of coronary disease, whilst other individuals and centres are doing the exact opposite. It is important to note that the health service in the US is privately funded (land of the free?) and a number of interventi onists have recently had their licences revoked or have received jail sentences for inappropriate PCI and/or billing. We sti ll do not know the cor-rect ‘hit rate’, but the current guidelines for appropriate indicati ons for revascularisati on, good history taking, assessment of risk factors, non-invasive and pressure wire FFR assessment for ischaemia seem like a good place to start.PS Douglas and others. J Am Coll Cardiol. 2011;58:801-809.

Atrial Fibrillati on

Another factor Xa inhibitor, rivaroxaban has shown more positi ve results in pati ents with atrial fi brillati on (AF). In the ROCKET AF trial pati ents with AF were randomised to rivaroxaban or warfarin, with non-inferiority demonstrated for the preventi on of stroke or sys-temic embolism. There was a signifi cant reducti on in intracranial haemorrhages and fatal bleeding in the rivaroxaban group, though these results were (part of) a secondary endpoint and should be interpreted with cauti on. Good news and less hassle for pati ents who do not need INR monitoring with rivaroxaban. The fi nancial cost and subsequent European approval for AF is now awaited. It will also be competi ng with dabigatran.MR Patel and others. NEJM. 2011. 10.1056/NEJMoa1009638.

AF ablati on

Att empti ng to ablate AF in pati ents with unresolved valvular heart disease is well known to be challenging, but how do pati ents do with AF ablati on post valve replacement? Two series of a total of 130 pati ents with prostheti c Aorti c and Mitral valves, compared with matched non valvular pati ents produced similar results. Acceptable overall success rates (fi rst procedure about 50%, 80% aft er mean 1.3 procedures), a high rate of atrial fl utt er both pre and post ablati on and effi cacy of linear ablati on in preventi ng arrhythmia recurrence. Trends were observed toward higher complicati on rates and longer procedure and fl uoroscopy ti mes in the valvular group.D Lakkireddy and others. Heart Rhythm. 2011;8:975–980.

A Hussein and others. J Am Coll Cardiol. 2011; 58:596-602.

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

Follow me @johnpaisey for the latest reviews

Follow me @danmckenzie73 for the latest reviews


With the rise in PPCI, what changes in working patt erns will benecessary so as to avoid physiologists working on average 14 to 22 hrs in one shift , when they start at 9am and conti nue on to do on-call that night?

According to the Department of Health primary PCI is available to 90% of the English populati on so this topic

has relevance to many departments and I’m sure there’s a multi tude of diff erent approaches being taken to deal with the parti cular issues it raises on a local basis. That’s exactly how it should be, there’s no single prescripti ve soluti on and individual services must work within the legislati ve frame-work, using the tools available to them in terms of local policy regarding fl exible working to achieve the best possible out-come for their pati ents.

For many the noti on that work as a cardiac physiologist is a Monday to Friday, nine ‘ti l fi ve lifestyle is long gone. On call work will, of course, be second nature to cardiac physiologists working in numerous centres and over recent years extended working weeks incorporati ng weekends and longer working days have become the norm in response to achieving diag-nosti c waiti ng ti me targets. Consequently, further tweaking of working patt erns aft er appropriate consultati on should not prove too troublesome to implement.

A move to shift -work is one potenti al approach to meet the demands of a primary PCI service although there is the ques-ti on of what roles a cardiac physiologist might undertake between primary PCI cases. Perhaps a forthcoming publi-cati on from the Briti sh Cardiovascular Society regarding the future of Cardiac Care may off er some guidance? The recom-mendati ons are likely to suggest that a full range of cardiac diagnosti c procedures are accessible on a 24 / 7 basis. Some Trusts may choose to interpret their meeti ng of this pro-posal by having on-call junior medical staff available but who would you prefer to perform your investi gati ons? A trainee doctor or a qualifi ed, competent and experienced cardiac physiologist?

A work week consisti ng of four working days from 8am-6pm, with the day off preceded by an on call night is the best working pat-

tern for physiologists on call as:

• The on call person is guaranteed to have rest the next day.• Clinical work and lab over run can be covered between 8-9am

and 5-6pm by the staff working the long shift that week.• If a member of the team isn’t on call, then they can work a nor-

mal (9am-5pm) shift patt ern that week. Hence, only an extra member of staff is required to cover the unavailability of the on call person the next day.

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

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

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

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

AVAILABLEONLINE

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

Management

Hot Topic

Dr Chris Eggett Cardiac Physiologist Deputy Service ManagerFreeman HospitalNewcastle upon Tyne

Nishat JahagirdarLead Cardiac Physiologist (Invasive)Kings College HospitalLondonUnited Kingdom

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

Edwards Lifesciences Irvine, USA I Nyon, Switzerland I Tokyo, Japan I Singapore, Singapore I São Paulo, Braziledwards.com

A new option for your high-risk patients with aortic stenosisIn the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve

implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.1

Additionally, the reduction in mortality and rehospitalization versus standard treatment at one year was 40%.1

For more information & to find a TAVI center near you please visit edwards.com/eu/products/transcathetervalves

Reference: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607.

For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events.

Edwards, Edwards Lifesciences, the stylized E logo, Edwards SAPIEN and PARTNER are trademarks of Edwards Lifesciences Corporation.

© 2011 Edwards Lifesciences Corporation. All rights reserved. E2062/5-11/THV

20%BAlloon-expAndABle

TrAnscATheTer AorTic VAlVe implAnTATion (TAVi)

reduction in all-cause mortality at one year1

sTAndArd TreATmenT

In the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve

implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.1In the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve

implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.

Additionally, the reduction in mortality and rehospitalization versus standard treatment at one year was 40%.


1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis

For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings,


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

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MY

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CMY

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

SUPERIOR DELIVERABILITY

Integrity BMS–#1 for a reason

*Superiority against major bare metal stents: Bench test data vs. Abbott Multi-link Vision and Boston Scientific VeriFlex (Liberté) coronary stents on file at Medtronic, Inc.

†In Europe. Data on file at Medtronic, Inc.Not for distribution in the USA or Japan. © 2011 Medtronic, Inc. All rights reserved. Printed in the EU. UC201200800EE 7/11

IntegrityCORONARY STENT SYSTEM

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

Find out more at medtronicstents.com

Integrity BMS–#1 for a reasonIntegrity BMS–#1 for a reasonIntegrity BMS–#1 for a reason


The Manufacturing Process

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

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

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

The electropolish provides a polished surface area of round struts.

The wrap-crimp provide for low profi le and good retenti on to ensure the catheter can deliver the stent to the target lesion.

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

Open Cell DesignOne of the major advantages of the Integrity stent is its open cell design. Basically this relates to the perimeter of a cell between fusion points that can be expanded in the case of allowing for sidebranch access. This is parti cularly important for complex interventi ons, allowing accurate positi oning and adequate wall coverage. The Resolute Integrity stent has a cell perimeter of 28.9mm (small vessel design), compared to other popular stents such as the Xience Prime with only 14.42mm.2

This increased cell perimeter is achieved through the specifi c fusion patt ern deter-mined by Medtronic’s engineers. Every 4th stent crown (medium vessel) and every 5th crown (small vessel) are fused.

Factory TourVisiti ng the Medtronic manufacturing plant in Ireland is an amazing experience. The large amount of labour required working harmoniously alongside sophisti cated auto-mati ons makes you understand the value in the fi nal product. The enti re process is rig-orously checked for quality, and the employees show pride in the products they make. For more informati on visit www.medtronic.com

References:1: Coronary Heart Publishing Ltd confi rmed this on external models only.2: Test data provided by Medtronic, Inc.

Cobalt alloy wireThin, round struts

Continuous sinusoid formed and wrapped around a mandrel

Laser-fused at key points

Electropolished for smooth surface

Wrap-crimped for low profile

The Future of Stents

4 5321

CST gives rise to broad applicati ons for the development of next

generati on BMS and DES. These include the development of drug-fi lled stents, which forgo the need for a polymer coati ng, and core wire stents for thinner struts, amongst other design benefi ts.

Above: Drug-Filled Stent

Above: Core Wire Stent


A big concern in AF ablati on is stroke risk. Measures are taken to avoid performing the procedure in the context of pre existi ng throm-bus, but generati on of embolic material during the procedure can-not be enti rely prevented. A comparison of three ablati on modaliti es (irrigated radiofrequency, Cryo and non irrigated phased RF) with MRI brain follow up revealed a much higher incidence of sub clinical cerebral infarcts in the non irrigated group (7.4 vs. 4.3 vs. 37.5%).

Two cauti ons with these data. Firstly, these are not strokes, they are an asymptomati c radiological fi nding (there were no clinical strokes). Secondly, a proporti on of the energy delivered in the non irrigated phased RF group was done so in a fashion not recommended by the manufacturer and known to be associated with increased char and micro bubble formati on.C Siklody and others. J Am Coll Cardiol. 2011;58;681-688.

Sudden Death Syndromes

We sti ll don’t really know what to do about early repolarisati on syn-drome yet, so two new contributi ons are welcome. Japanese atom bomb survivors get regular medicals including 12 lead ECGs. Head-line fi ndings are that early repolarisati on is common (23% lifeti me incidence with a peak fi rst manifestati on in the late second and early third decade), has a signifi cant cross over with Brugada syndrome and is associated with a modest overall increase in sudden death rate (HR 1.8 vs. controls, in comparison to Brugada ECGs HR 27.5). Widespread abnormaliti es (slurring and/or notching) were associ-ated with higher rates of sudden cardiac death.

It does seem clear that early repolarisati on is at best a spectrum and possibly no more than a hotchpotch of vaguely connected conditi ons. In an att empt to split out higher and lower risk phenotypes a Finn-ish group examined various cohorts (Finnish athletes, US athletes and a middle aged group). They conclude that in early repolarisati on (notching or slurring of the terminal QRS) where the ST segments are upsloping there is no increased risk of SCD and this represents a normal fi nding parti cularly prevalent in athletes. Where early repo-larisati on is associated with a down sloping ST segment there was some increased risk of SCD (albeit modest, RR 1.43).D Haruta and others. Circulati on. 2011;123:2931-2937.

J Taikkanen and others. Circulati on. 2011;123:2666-2673.

Short QT syndrome is the other end of the spectrum; very rare, high-ly malignant. The European registry includes just 53 pati ents, follow up on this highly selected group, 89% of whom have personal or fam-ily histories of SCD reveals two fi ndings. Firstly, they have a lot of arrhythmias (4.9% per year if untreated). Secondly, Hydroquinidine is eff ecti ve in reducing the event rate (no events in the 12 pati ents treated).C Giustett o and others. J Am Coll Cardiol, 2011; 58:587-595

Lead Extracti onLead extracti on is oft en considered a special case among percutane-ous procedures with percepti ons of high mortality and high rates of surgical interventi on. Indeed some have advocated all such proce-dures being performed in cardiothoracic theatre to facilitate earliest possible surgical interventi on.

In this series of 1364 leads in 864 consecuti ve pati ents the authors studied the diff erences in outcome between procedures performed in theatre and in the cathlab. The fi ndings were of an overall mor-tality of 0.2%, with surgical interventi ons required at some stage in 0.9%. The only two massive haemorrhages due to SVC lacerati on died despite surgical interventi on. Older leads were independently associated with increased complicati ons, 92% of leads were extract-ed in their enti rety. There were no diff erences in outcomes between

pati ents extracted in theatre vs. those extracted in the EP lab. One pati ent underwent unproducti ve surgical explorati on for a transient blood pressure drop, but did fi ne despite this.F Freceschi and others. Heart Rhythm 2011;8:1001–1005.

Communicati on

Is it good to talk? When we quote fi gures on risks and benefi ts to pati ents, what are we trying to achieve? Do we just want to write something in the notes to cover ourselves or do we really want to help the pati ent understand?

A survey of what pati ents took in from writt en and diagrammati c explanati ons challenges perceived wisdom and existi ng guidelines. Pati ents do understand (sort of) low risk expressed as very small per-centages (e.g. less than 1%, 0.02%) which we are supposed to avoid but do not understand numerator/denominator comparisons espe-cially where the denominator changes (e.g. risk of stroke 1 in 100, risk of death 2 in 1000). Furthermore, pati ents understand absolute risk and changes therein much bett er than relati ve risk.S Woloshin and others. Ann Intern Med. 2011;155:87-96.

How about communicati on between district hospital interventi onal cardiologists and surgeons at a remote surgical centre? Apparently a video link system in Sussex signifi cantly increased the number of pati ents with complex coronary disease having surgical revasculari-sati on rather than PCI. We have mixed views on this. Cardiothoracic surgeons, in the main, will perform coronary artery bypass graft ing (CABG) on electi ve pati ents, even when high risk, if they have appro-priate coronary disease. The problems come with acutely unwell pati ents, when shock, renal dysfuncti on or troponin elevati on seem to put them off ! The SYNTAX study (CABG vs. PCI in high risk coronary artery disease) and ongoing trans-aorti c valve implantati on (TAVI) programmes have certainly improved relati ons between cardiotho-racic surgeons and interventi onists, and this must be a good thing.R.A Veasey and others. Int J Clin Pract. 2011;65:658-663.

TAVI

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

Coronary Artery Bypass Graft ing

And whilst we are talking about cardiothoracic surgeons, we should briefl y menti on this study looking at saphenous venous graft s in pati ents undergoing CABG (PREVENT IV trial). Essenti ally, vein graft failure is signifi cantly worse at one year if there are multi ple rather than single distal targets (something to do with fl ow presumably?). This results in a signifi cantly poor clinical outcome at fi ve years (worse composite of death, MI or revascularisati on), so is best avoided.R Mehta and others. Circulati on. 2011;124:280-288.

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Email: [email protected]

Promoting better understanding, diagnosis, treatment and quality of life for individuals with cardiac arrhythmias

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2nd - 5th October 2011

HRC 2011 A4 NO DATES.indd 1 18/05/2011 15:32:09

ContentsSep / Oct 2011


Lancashire Cardiac Centre

Blackpool Teaching Hospitals NHS Trust:

The Lancashire Cardiac Centre provides a variety of cardiovascular treatment opti ons for the people of Lancashire, Cumbria and sur-rounding counti es. The centre comprises the latest faciliti es, including four state-of-the-art cardiac catheter labs, which perform a variety of investi gati ons and treatments. These include angiograms, angioplas-ti es (stents), internal cardioversions, pacemakers, biventricular pace-makers, ICD’s and electrophysiology studies.

Recently the centre opted to embrace McKesson’s fully integrated haemodynamic system, featuring built-in fracti onal fl ow reserve (FFR) soft ware, to address the growing frequency of its use within the cath lab environment. The team have also commenced using the Volcano PrimeWire Presti ge, which integrates seamlessly with the McKesson system. The PrimeWire Presti ge was chosen due to spe-cially designed features including a heavier core and improved ti p, which aid the operator to cross challenging lesions

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

How many staff ? Roles? • 10 cardiology consultants.• 14 Cardiac Physiologists• 9 Radiographers• 10 Nurses

Types of procedures? • Diagnosti c and interventi onal (PCI’s) + regionwide PPCI service• Electrophysiology• Full range of cardiac physiology services including Echo• Internal Cardioversions• Pacemakers & ICD’s• TAVI

Types of equipment use?• IVUS Boston and Volcano• Integrated FFR Volcano • SJM FFR• St Jude’s LightLab OCT • Rotoblati on. • Philips and Siemens Cath Labs. • McKesson Cardiovascular Informati on soluti on• GE Vivid 7 Echo

How many procedures are performed a year?• PCI = 1600 (target of >2000 PCI’s for 2011-2012)• Diagnosti c procedures 2000• Tavi 36• 240 EP proceedures

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

Site VisitUnited Kingdom

Whinney Heys Road, BlackpoolLancashire United Kingdom


Jim Shahi Unit (Cardiac Catheterisati on Laboratory)

The Royal Berkshire NHS Foundati on Trust


The Royal Berkshire NHS Foundati on Trust is situated in the centre of Reading covering western and central porti ons of Berkshire. It is one of the largest general hospital trusts in the country, which has recently undergone £132 Million redevelopment. The hospital pro-vides 813 inpati ent beds together with 204 day beds, in doing so it employs 4000 staff .

The specialty of Cardiology provides a combinati on of inpati ent work, a large outpati ent service and a full range of Cardiac Investi gati ons. The Cardiac Catheterisati on Laboratory is named aft er the late Dr. Jim Shahi, a Consultant Cardiologist who helped set up the unit in 1994. We have 2 Catheterisati on Laboratories which off ers an exten-sive range of electi ve and emergency procedures. Alongside the labs we have a 16 bedded day bed unit which opens from 8:00 am to 6:00

pm. In 2009 we introduced the Primary PCI service 24/7. This has been implemented very successfully with a median call to balloon ti me (CTB) of 77 minutes and door to balloon ti me (DTB) of 28 min-utes in the fi rst 12 months. South Central ambulance service provides an excellent response to emergency calls for pati ents with chest pain. The PPCI team members all live locally and are able to be at the Cath Lab within 20 minutes. This enables pati ents to receive early reperfu-sion and opti mal treatment and outcomes.

The ward base consists of an 18 bedded CCU Department with 1 Chest Pain assessment bed and a 28 bedded Cardiology Ward includ-ing 6 Telemetry beds. The Cardiology Department provides a full range of Cardiac Investi gati ons along with outpati ent’s clinics, Rapid Access Chest Pain Clinic and Heart Failure Clinics. A full range of Car-diac Rehabilitati on is off ered as an inpati ent and outpati ent service.

What are the sizes of your Cardiology Department and Hospital?• Jim Shahi Unit – 16 beds• CCU 18 beds + 1 Chest pain assessment bed• Whitley Ward – 28 beds

What is the geographical intake area and populati on served by your hospital?• Half a million catchment • PPCI catchment is up to 750,000

How many staff ? Roles?• 5 Consultant Interventi onalist Cardiologists• 1 Consultant Electrophysiologist (visiti ng)• 1 Consultant Cardiac Surgeon (visiti ng)• 1 Consultant Cardiac Imaging (CT/MRI)• 2 Associate Specialist• 3 SpRs• 3 ST grades• 2 FY grade juniors• JSU = 8.2 Nurses WTE• 3.6 Radiographers WTE• 24 Cardiac Physiologists (10 Rotates in the Lab)• 2 Waiti ng List Offi cers• 5 Secretaries• 5 Admin Staff • 3 Volunteers• CCU = 33.5 Nurses WTE• Whitley Ward = 34.74 Nurses WTE• Heart Failure Nurses- 2.66 • Cardiac Rehab Nurses - 3

The Royal Berkshire NHS Foundati on TrustLondon Road, ReadingBerkshire, United Kingdom


October 2-5HRC 2011Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October 7-8Briti sh Society of Echocardiography Annual Meeti ngEdinburgh Internati onal Conference CentreEdinburgh, Scotlandwww.bsecho.org

October 14-15Cardiac Risk in the Young (CRY) Internati onal Conference The Cavendish Conference CentreLondon, Englandwww.c-r-y.org.uk

October 16-18PCR London Valves 2011London Englandwww.pcrlondonvalves.com

November 24SHARP Annual Scienti fi c Meeti ng “Cardiovascular Disease, Every Day Management”Dunkeld, ScotlandContact: Miss Victoria Kirkwood, Email: [email protected] or Tel 01382 60111 ext 33124

December 2CCO Nati onal ConferenceCardiovascular Update 2011 - Strategies for diagnosis & TreatmentLondon, EnglandEmail: [email protected] or [email protected]

December 14BCS - A Year in CardiologyRoyal College of Physicians London, Englandwww.bcs.com/educati on

MOREONLINE

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

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

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

From Management and Cardiologist point of view, what are your thoughts on FFR technology, and why did you choose a completely integrated solution?• FFR is a fantastic tool for the Cardiac Interventionalist and now

we have integration to improve safety and efficiency in the lab. Only today we had an example of a possible surgical case being changed into a single stent procedure as a result of the technol-ogy. (Dr Gavin Galasko, Consultant Cardiologist)

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

What new procedures / techniques have you implemented into the department recently?Recent = OCT, EP expansion (more comprehensive). Future = CT coronary angio, hybrid lab, radial lounge

How does the lab handle haemostasis? Radial = TR and Helix. Femoral = Angioseal, and Exoseal

The Volcano SmartMap for FFR

The Cath Lab Team

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VIS

IT

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www.volcanocorp.com

Multiple Solutions

One Company

IMAGING PHYSIOLOGY THERAPY

One Platform

Grayscale IVUS

ChromaFlo® Imaging

VH® IVUSImaging

FFR Case Manager™VIBE® RX Vascular Imaging Balloon

CatheterRotationalIVUS Imaging


Types of procedures?Jim Shahi Unit :• Angiograms (Inpati ents and

Outpati ents)• PCI • Permanent Pacemakers• PPM Box Changes• Reveals• Cardioversions• ICD’s and CRT’s• EP’s• Pressure Wire Study• IVUS• Rotablati on

Cardiac Outpati ents:• Echo• Stress Echo• TOE• Stress Test• Holter Monitoring• Tilt Testi ng• 12 Lead ECG’s• Pacemaker Checks• Cardiac MRI• Cardiac CT

Types of equipment used?• Siemens Axiom Arti s Dfc & Dtc• Boston Scienti fi c Rotablati on Machine• Boston Scienti fi c iLab IVUS Machine• St. Jude Pressure Wire• Phillips Echo Machines

How many procedures are performed a year? April 2010- April 2011:Angio’s: 1400PCI: 618Electi ve PCI: 232Primary PCI: 202Permanent Pacemakers: 300EP: 60Cardioversions: 166ICD: 20Bi vents: 10CRT: 10

Does your department off er a Primary Angioplasty Service? If yes, what have been some of the challenges setti ng it up?YES 24/7 since April 2009Challenges:

1. Having suffi cient staff to cover the service e.g. extra Radiogra-phers recruited and trained up to on call standard.

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

What are the benefi ts to pati ents att ending your facility?• The best Door to Balloon Time in the Country. See link below: htt p://www.bbc.co.uk/news/uk-england-berkshire-11441743• We off er a complete cardiac service and have very low waiti ng

ti mes

How is your inventory managed?Pen and paper

What measures has the department implemented to cut costs?• We use fewer Angioseals these days to cut cost• Regular Tendering especially high cost consumables

What kinds of conti nuing educati on programs are available to staff ?• Criti cal Care Course• Mentorship Course• IVUS and Rotablati on Study Days• Leadership/management courses

Reducing radiati on dose is a high priority in the cath labs. What techniques are employed by your radiographers to ensure dosage during cases is kept to a minimum? Also what is the maximum dose limit a pati ent can receive in your labs before it is recorded in their notes, and what is the follow-up process?• Reduced Pulse Rate ( 4pps or 6 pps) dependant on Consultants • Appropriate collimati on• If dose is 10,000 mcGy m2 or above the radiographer informs

the operator who will advise the pati ent of possible erythema.

What is the best part of working at your facility?• friendly atmosphere• good working team• positi ve feedback from pati ents, pati ent relati ve, student

nurses and other members of staff • Good and sustained publicity• staff retenti on• effi cient service

AVAILABLEONLINE

Royal Berkshire Hospital: More photos and questi ons online

From Left: Erick Omana, Bonita Chizambire, Jan Marshall, Javon Lorde, Melanie Bailey, Charlie McKenna, Rowena Soar, Alisa Greener, Amande Searle, Debbie Daniel-Best,

Chris Mwenda, Paul Gentle, Chris Hayes, Bhavesh Sachdev

experiencethe future of CVIS

© 2011 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Horizon Cardiology is a trademark of McKesson Corporation and/or one of its subsidiaries.

Learn what more than 75 institutions in the UK already know. McKesson sets the industry standard in helping clinicians make quicker, better and

safer decisions. By seamlessly connecting hospitals through automated workflow,

our cutting-edge cardiovascular information solution, Horizon Cardiology, enables you

to increase efficiency and place the patient at the centre of care. Horizon Cardiology

provides a single database for haemodynamic monitoring, cardiac and peripheral

catheterisation, echocardiography, vascular ultrasound, CT, MRI, NM and ECG

management, streamlining the report process and allowing you to focus on what

you do best – deliver better health.

To learn more, visit AllAboutCVIS.com/CardioHD.

Scan here with your code reader on your smartphone.

McKesson Provider TechnologiesBlock 3The ExchangeBrent Cross GardensLondon NW4 3RJUnited KingdomPhone: 01926 478728


Course Directors

Martyn ThomasSimon RedwoodPatrick W. SerruysOlaf WendlerAlec VahanianMark MonaghanJean FajadetCarlos RuizPhilipp BonhoefferJohn WebbOlaf FranzenA. Pieter KappeteinCarlo Di MarioStephan Windecker

Programme Committee Members

Vinayak BapatJonathan ByrneRanjit DeshpandeJane HancockPhilip MacCarthyChristopher Young

Chairman of PCR

Jean Marco

SEE YOU IN LONDON16th-18th October 2011

VALVES FOR THE HEART TEAM

Visit www.pcrlondonvalves.com

Come as a Heart team.

Whether you're an interventional cardiologist, an anaesthetist, a radio-logist or a nurse, you'll go back tothe cathlab with with the tools youneed to advance your daily practice.

Connect to www.pcrlondonvalves.com to register today

Registration is open!

g St Thomas' Hospital, London, UKg Bern University Hospital, Bern,

Switzerlandg Clinique Pasteur, Toulouse,

France

Live demonstrationsSessions

Adjuvant therapies in TAVITo understand the indication andtechnique for aortic balloon valvu-loplasty, coronary revascularisationand LV support before and duringTAVI.

Improving the results of TAVITo understand how we can improvepatient selection and the results ofTAVI.

Is the percutaneous mitral valve ready for prime time?To understand the current clinical indications for transcatheter mitralvalve intervention.

What remains difficult about TAVITo understand what remains diffi-cult clinical situations in TAVI andhow to deal with them.

The dataTo understand the current clinicaloutcomes of TAVI.

LTTCome and see these interactive ses-sions:g On 17th October, you will enjoy

an interactive and practical LTT on"How to perform a TAVI" includingimaging, access (femoral, sub-clavian, transapical, transaortic), deployment and valve in valve.gOn 18th October, expect to see

the same format on "Percutaneousmitral valve regurgitation repair".

ComplicationsJoin the popular Complication ses-sions, based on a call for submission.

Interactive Case CornerA new place of communication, freefrom time constraints and definedprogramme, where participants willbe invited to share their experience& point of view on the case theysubmitted, in a welcoming and re-assuring environment.

11TXXXX_PCRLONDON_PUB_CORONARY_HEART_AUGUST 18/07/11 18:02 Page1


Claire Overstall (Cardiac Physiologist) reviewing an FFR case

What measures has the department implemented to cut costs? • One of the major ways to reduce costs and improve effi ciency is

to decrease the length of stay for pati ents. We are in the process of implementi ng a dedicated radial lounge where pati ents can relax in comfort whilst waiti ng for their procedure instead of taking up beds.

• We are also working on ways to streamline product usage to reduce wastage.

How do you deal with late fi nishing of cases? For example staggered working hours or just staff overti me?One lab late aft er 7pm everyday. Cases fi nish ACS treatment within 72 hours. 1 dedicated PPCI lab.

What is your policy for company reps within the labs? Are reps allowed to bring food for sharing amongst doctors and staff into the department when they visit? Yes, company reps are welcome in our department for educati onal as well as for new product awareness and on-going support. They are allowed to bring food into the department, however they must make prior arrangements with the senior nurse on duty to ensure there is no overlap with other companies.

What is the best part of working at your facility?It is a modern, well-equipped facility located in one of the UK’s favourite holiday regions. We have a wonderful team working on cut-ti ng edge procedures, which all combined produces a fresh environ-ment, and great staff atmosphere.

SITE

VIS

IT

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ECG Challenge

We ran out of space in this editi on to include the next ECG Challenge, but it is available on our website. Challenge yourself today!!

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Events Calendar

- Who should perform peripheral interventi ons?

- The manufacturing of Medtronic’s Integrity Stents

- Lancashire Cardiac Centre

- Royal Berkshire NHS Foundati on Trust

Behind the Scenes

UK Site Visit

UK Site Visit

10

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Royal Berkshire NHS Foundati on Trust

Behind the Scenes at Medtronic

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Pharmaceuti cal EditorHead of Clinical Pharmacy, Royal Berkshire Foundati on Trust & Nati onal Non-medical Prescribing Facilitator, Nati onal Prescribing Centre.

Mr Tim LarnerDirector / FounderPrevious Cardiac Radiographer Manager in Australia, & Senior Radiographer at multi ple sites in the UK.

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



Prof 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


Latest Product News

Round UpEchocardiography

ONLINE DISCUSSION FORUM

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

Latest Topics from our members

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

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

Philips’ next generati on Allura Xper FD20 systems combine superb image quality with advanced interventi onal tools, seamlessly inte-grated into the clinical workfl ow, providing enhanced opportuniti es with Live 3D guidance to conti nue to expand the range of interven-ti onal procedures able to be undertaken by the user. The integrated workfl ow, intuiti ve user interface and personalised setti ngs enable the user to take full advantage of all the Allura’s capabiliti es and for a broad variety of procedures assist in providing excellent clinical care eff ecti vely and comfortably.

The Western Infi rmary opts for ‘Echo in a Heartbeat’ functi onality from Siemens

The Western Infi rmary, part of NHS Greater Glasgow and Clyde, is benefi ti ng from increased cardiac image quality fol-lowing the installati on of an ACUSON SC2000™ diagnosti c ultrasound system from Siemens Healthcare. The hospital is one of the fi rst in the UK to have installed the system. The purchase was funded by the Briti sh Heart Foundati on Glasgow Cardiovascular Research Centre, who will share use of the sys-tem for research projects.

The system will primarily be used for 3D echocardiography. The SC2000 is Siemens’ premier echocardiography system featuring ‘Echo in a Heartbeat’ imaging technology, which acquires real-ti me, full-volume images of the heart in one sin-gle cycle.

“The SC2000 generates fantasti c image quality and is allow-ing us to perform more sophisti cated 3D echocardiography examinati ons,” said Dr. Piotr Sonecki, Consultant Cardiologist at The Western Infi rmary. “Towards the end of the year, we hope to be able to carry out vascular examinati ons and further evaluate its suitability for future research work.”

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


SonoSite’s M-Turbo® key to emergency echocardiographyRoyal Brompton Hospital in London, home to the UK’s largest specialist heart and lung centre, uses a SonoSite M-Turbo® point-of-care ultrasound system for emergency focused transthoracic echocardiography. Dr Susanna Price, consultant cardiologist and intensivist, explained: “The M Turbo is solely dedicated to emer-gency use on the intensive care unit (ICU). Its extremely fast boot-up ti me is a great advantage in life-threatening situati ons where speed is criti cal, and being equipped with both a cardiac package and a vascular probe means it serves a dual purpose.”

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

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

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

For more informati on about SonoSite products, please contact: [email protected] or www.sonosite.com

Edwards Lifesciences launches Physio Tricuspid repair ringEdwards Lifesciences has received CE mark approval and FDA clearance for a new repair ring for the treatment of tricuspid insuffi ciency. The Carpenti er-Edwards Physio Tricuspid Annu-loplasty ring features a three-dimensional waveform shape, and incorporates several ease-of-implant features.

“We designed the ring to off er surgeons confi dence when treati ng tricuspid valve insuffi ciency,” said preliminary researcher Alain Carpenti er, M.D., Ph.D., professor and chair-man emeritus of cardiovascular surgery at the Hôpital Europ-een Georges Pompidou.



Improving the management and diagnosis of aorti c stenosis through treatment innovati on Aorti c stenosis is the most common cardiac valve dis-ease in developed coun-tries, aff ecti ng nearly 26% of people over 65. Once advanced disease and symptoms present, prog-nosis is poor with survival under three years for many. Additi onally, diagnosis is diffi cult and symptoms are oft en missed and fur-thermore, even if diagnosed, age and co-morbiditi es combine to render many pati ents inappropriate for traditi onal surgical valve replacement.








Heart Valves

researcher Alain Carpenti er, M.D., Ph.D., professor and chair-man emeritus of cardiovascular surgery at the Hôpital Europ-een Georges Pompidou.



diffi cult and symptoms are oft en missed and fur-thermore, even if diagnosed, age and co-morbiditi es combine to render many pati ents inappropriate for traditi onal surgical valve replacement.








Dr Price concluded: “The M-Turbo’s facility to record image clips for sub-sequent review is an essenti al require-ment. It provides a record of diagnosis, evidence for medico-legal purposes, and, being easy to use, the system

Edwards Lifesciences Irvine, USA I Nyon, Switzerland I Tokyo, Japan I Singapore, Singapore I São Paulo, Braziledwards.com

A new option for your high-risk patients with aortic stenosisIn the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve

implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.1

Additionally, the reduction in mortality and rehospitalization versus standard treatment at one year was 40%.1


Reference: 1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-1607.

For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions, and adverse events.


© 2011 Edwards Lifesciences Corporation. All rights reserved. E2062/5-11/THV

20%BAlloon-expAndABle

TrAnscATheTer AorTic VAlVe implAnTATion (TAVi)

reduction in all-cause mortality at one year1

sTAndArd TreATmenT

In the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve

implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.1In the landmark clinical study—The PARTNER Trial—Edwards SAPIEN balloon-expandable transcatheter aortic valve

implantation demonstrated a 20% absolute reduction in all-cause mortality versus standard treatment at one year.

Additionally, the reduction in mortality and rehospitalization versus standard treatment at one year was 40%.


1. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis

For professional use. See instructions for use for full prescribing information, including indications, contraindications, warnings,


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


1

2

INTERNATIONAL ONLINE CATALOGUE

Siemens Healthcare Arti s zee

The Arti s zee™ family is designed for interventi onal cardiology imaging. Available as fl oor or ceiling-mounted, biplane or with Magneti c Navigati on, it features a 20x20cm or 30x40cm fl at detector. This enables fl exible positi oning around the pati ent, ideally suited for imaging of structural heart diseases.

Show Site: See our website for case studies at the Bristol Heart Insti tute and the Nati onal Insti tute for Health Research.

Siemens Healthcare SOMATOM Defi niti on AS+

The SOMATOM® Defi niti on AS+ CT system from Siemens Healthcare is an adapti ve scanner that provides excepti onal image quality to make complex cardiology examinati ons routi ne.

Show Site: See our website for case studies at Borders General Hospital and Great Western Hospital.

Full descriptions, images & more online

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

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

Like to advertise your products? Contact us via the details on Page 4.

First European appearance of the newly formed Hitachi Aloka Medical Ltd. (Japan) Hitachi Medical Cor-porati on and Aloka Corporati on have combined their strengths in ultra-sound to form Hitachi Aloka Medical Ltd. (Japan), a subsidiary of Hitachi Medical Corporati on (Japan). The new company made their Europe-an debut in Vienna between 26 to 29 August 2011 at the 13th World Congress of Ultrasound in Medicine and Biology (WFUMB).

Hitachi and Aloka bring together a plethora of experience and knowledge - synergizing the experti se and talents of the peo-ple on both sides of the new merged company. Parti cipants and visitors were invited to experience this at the event booth where Hitachi Aloka Medical highlighted ‘the next generati on in high resoluti on imaging technology’, focusing on the Hitachi HI VISION and Aloka ProSound Ultrasound platf orms - intro-duced and explained by expert employees from Hitachi Aloka Medical Japan, Aloka Europe and Hitachi Medical Systems Europe.

Industry Partnerships

Above: The Two CEO’s

Cath lab Nurses/Physiologists/RadiographersOpportunity for Cath Lab Staff

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

Scarborough Hospital, North East Yorkshire

This is a long term 2-day/week service (Tuesdays and Wednesdays) providing Diagnostic Coronary Angiography and Permanent Pacing.

Fixed term and agency-style contracts available!!!

START DATE: 4th October 2011

To find out more please contact Bryn Webber, Cardiac Services Manager: [email protected] or call 07966 987712

Please visit our website for more details on our background and capabilities: www.rphc.co.uk

We look forward to hearing from you.

C

M

Y

CM

MY

CY

CMY

K

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


Cardiologist, Radiologist or Vascular Surgeon and why?

Who should perform peripheral vascular interventi on:

It is much easier to address this questi on in the NHS environment than in countries where the operator’s livelihood is dependent on cornering as much of the market as possible. In this country, we can put the interests of the pati ents and service fi rst.

Individuals from any clinical background can learn the relevant manual skills and tech-nical knowledge. Some individuals are naturally gift ed, most are trainable and very few need to be tactf ully pointed towards a diff erent career path. However, this apti -tude is independent of specialty.

Who can provide the best service to pati ents? It seems obvious to me that the spe-cialist should have a major interest in peripheral vascular disease. This includes the conservati ve, non-interventi onal management of vascular disease, such as medical therapy, exercise programmes and ulcer care. The holisti c care of the vascular pati ent requires more than treati ng the stenosis.

This logic leads to the conclusion that peripheral interventi on should be provided by vascular surgeons and this is almost certainly the directi on of travel in the UK. Radiolo-gists have been involved in peripheral interventi on since its incepti on and have provided a high quality service for years. However, the expansion and development of endovas-cular interventi ons have brought them from the margins to the mainstream. Thus it is important that the new generati on of vascular surgeons ensure that they are prop-erly trained in endovascular techniques and that consultant surgical posts have angio room sessions in the job plan. I anti cipate that the future of radiological involvement in peripheral interventi on will mirror what happened in coronary interventi on 20 years ago: the radiologists will progressively lose their role in this service provision.

This prognosis has a signifi cant downside. Vascular radiologists currently provide a broad range of services to many hospital departments for bleeding, tumour embolisa-ti on, vascular access, caval fi lter placement and so on. These are valuable services, but it will not be possible to sustain a comprehensive vascular radiology service without the workload that comes from vascular surgery referrals. The danger is that, if vascu-lar surgeons take on all the peripheral interventi on, vascular interventi onal radiology will atrophy.

The opti mal soluti on is therefore a harmonious collaborati on between radiologists and surgeons, with each specialty providing an overlapping and complementary range of skills. This is the reality in many UK centres at present, but I fear it is not sustainable in the long term.

Hot TopicCardiologist

Questions designed by Dr Magdi El-Omar and Tim Larner

Dr Nicholas ChalmersConsultant Vascular RadiologistDepartment of RadiologyCentral Manchester University Hospitals NHS Foundati on TrustManchester Royal Infi rmaryManchester

All of the above, provided they are inter-ested and are prepared to work collabo-rati vely and share their relevant clinical

skills and experience!

I think we need to learn from the lessons gained from transcatheter aorti c valve implan-tati on (TAVI), where we have found that the multi -disciplinary “TAVI team” has been instru-mental in the successful introducti on of TAVI into mainstream treatment of aorti c valve dis-ease. Equally we need to avoid the “turf war” scenario that we have previously seen with interventi onal and surgical treatment for coro-nary disease.

In my opinion, no individual clinician has the complete range of clinical skills and experi-ence to provide a comprehensive peripheral vascular interventi onal programme. I would advocate the development of multi -discipli-nary “endovascular teams” to provide the current and likely future range of minimally invasive/ endovascular treatments for car-diovascular disease. This would be in keep-ing with the “heart team” approach recently advocated by our European colleagues for the revascularisati on of coronary artery disease. Such teams would need to take advantage of local skills, interests and resources with clinicians working collaborati vely.

Dr David SmithConsultant Cardiologist, Morriston HospitalMorristonSwansea


The sensible answer in the medical world of 2011 is a medical practi ti oner who has a suitable clinical background and knowl-edge level, but is also demonstrably competent in the interven-

ti onal technical skill sets. Of course a cardiologist, vascular surgeon or interventi onal radiologist can acquire this technical experti se in a broad array of interventi onal procedures, the same way as a limited procedural skill set can be acquired by neurologist (caroti d stenti ng) or nephrologist (fi stuloplasty). If their skills are competent and their knowledge base is sound, or if they work in a team setti ng with suit-ably trained clinicians (as we have seen for years with many inter-venti onal radiologists and vascular surgeons) then they should be recognised as such and accredited by the appropriate insti tuti on.

We have resolved this issue in Australia and NZ by establishing a com-mitt ee to recognise such peripheral endovascular training regardless of the specialty. This committ ee has been sancti oned by the three Colleges involved namely: RACS , RACP and RANZCR . It has drawn criteria for recogniti on of training in 3 areas:

1. General peripheral endovascular interventi on2. Caroti d stenti ng3. Fenestrated and branched endograft ing

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

This approach has been based on the model used by gastroenterol-ogy groups to deal with similar issues relati ng to diverse specialti es performing endoscopy.

We have completed the grandfathering component successfully, and have already discovered the uti lity of this model in resolving diffi culti es with the hospital accreditati on of specialists in ‘scope of practi ce’, and also in resolving turf wars, which were a perennial problem.

AVAILABLEONLINE

SEE OUR PREVIOUS HOT TOPICS

We have 16 Hot Topics available on our website with responses from leading cardiologists from across the UK and around the world.

A Year in CardiologyDate: 14 December 2011

Venue: Royal College of Physicians, London

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

For more details and the full programme, visit the BCS website.

Online registration is now open on www.bcs.com/education

A/Prof Michael DentonDirector of Vascular SurgerySt Vincents HospitalUniversity of MelbourneMelbourne, VictoriaAustralia

SUPERIOR DELIVERABILITY

Integrity BMS–#1 for a reason

*Superiority against major bare metal stents: Bench test data vs. Abbott Multi-link Vision and Boston Scientific VeriFlex (Liberté) coronary stents on file at Medtronic, Inc.

†In Europe. Data on file at Medtronic, Inc.Not for distribution in the USA or Japan. © 2011 Medtronic, Inc. All rights reserved. Printed in the EU. UC201200800EE 7/11

IntegrityCORONARY STENT SYSTEM

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

Find out more at medtronicstents.com

Integrity BMS–#1 for a reasonIntegrity BMS–#1 for a reasonIntegrity BMS–#1 for a reason


IndustryBehind the Scenes

The Manufacturing of Medtronic’s Integrity StentsBehind the Scenes:

OverviewFounded in 1949 as a medical repair shop, Medtronic Inc. has stead-ily grown to become a global leader in medical technologies, initi al-ly producing pacemakers before expanding to cover the variety of products available today. 40,000 employees in 120 countries, with 44 manufacturing faciliti es, and 25 research and development cen-tres worldwide ensure they are always at the cutti ng edge in regards to R&D, producing products that comply with their mission of alleviati ng pain, restoring health, and extending life.

Cardiovascular and Cardiac Rhythm Disease Management make up over half the total revenue for the company with the evoluti on of new technologies such as conti nuous sinusoid technology (CST) for coronary stents, ensuring Medtronic remains as a leader in medi-cal product development. We visited Medtronic’s manufacturing and technology development faciliti es in Galway, Ireland for a tour of how the R&D, operati onal processes, and quality assurance is combined to create the new Integrity Bare Metal Stent (BMS) and Resolute Integrity Drug Eluti ng Stent (DES), both uti lising CST.

Conti nuous Sinusoid Technology (CST)Coronary stents used by cardiologists in the treatment of coronary artery disease were originally limited to tubular mesh or slott ed tube stent designs. Medtronic has historically been known for its

modular stent technology, as is featured in their Driver stent. However, Medtronic have advanced this technol-ogy to the next level with the introducti on of CST, which results in superior fl exibility and deliverability compared with the Driver and also other commercially available stent platf orms (Fig 1).1

The easiest way to imagine CST is with a slinky design (Fig 2), whereby a conti nu-ous piece of wire can fl ex easily in all planes. The wire involved in the constructi on is already round so therefore doesn’t require extensive pol-ishing to remove any sharp edges which can lead to metal fati gue. The stents are also

made with cobalt chromium alloy which when compared with stain-less steel allows for a reducti on in stent strut thickness (enhanced delivery and lower rates of stenosis), bett er radiopacity, and greater strength.

The conti nuous range of moti on due to the wire-forming pro-cess and fusion patt ern provide greater fl exibility and conform-ability while maintaining radial strength. This is parti cularly apparent on ti ght bends or tortuous anatomy where the CST stent tracks very easily, whereas with traditi onal stents signifi cant gaps can occur or edges can raise damaging the sensiti ve inti mal lining of the artery being passed through.

Fig 1. Separate stiff and flexible segments limit range of motion on other platforms

Fig 2. Continuous sinusoid technology flexes continually

Medtronic employees checking the quality of the stents after electropolishing


The Manufacturing Process

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

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

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

The electropolish provides a polished surface area of round struts.

The wrap-crimp provide for low profi le and good retenti on to ensure the catheter can deliver the stent to the target lesion.

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

Open Cell DesignOne of the major advantages of the Integrity stent is its open cell design. Basically this relates to the perimeter of a cell between fusion points that can be expanded in the case of allowing for sidebranch access. This is parti cularly important for complex interventi ons, allowing accurate positi oning and adequate wall coverage. The Resolute Integrity stent has a cell perimeter of 28.9mm (small vessel design), compared to other popular stents such as the Xience Prime with only 14.42mm.2

This increased cell perimeter is achieved through the specifi c fusion patt ern deter-mined by Medtronic’s engineers. Every 4th stent crown (medium vessel) and every 5th crown (small vessel) are fused.

Factory TourVisiti ng the Medtronic manufacturing plant in Ireland is an amazing experience. The large amount of labour required working harmoniously alongside sophisti cated auto-mati ons makes you understand the value in the fi nal product. The enti re process is rig-orously checked for quality, and the employees show pride in the products they make. For more informati on visit www.medtronic.com

References:1: Coronary Heart Publishing Ltd confi rmed this on external models only.2: Test data provided by Medtronic, Inc.

Cobalt alloy wireThin, round struts

Continuous sinusoid formed and wrapped around a mandrel

Laser-fused at key points

Electropolished for smooth surface

Wrap-crimped for low profile

The Future of Stents

4 5321

CST gives rise to broad applicati ons for the development of next

generati on BMS and DES. These include the development of drug-fi lled stents, which forgo the need for a polymer coati ng, and core wire stents for thinner struts, amongst other design benefi ts.

Above: Drug-Filled Stent

Above: Core Wire Stent


Journals

Bedside Echo

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

Acute Coronary Syndromes

Yet another drug for reducing ischaemic outcomes in ACS pati ents? Sadly, or maybe even gladly, not, according to the APPRAISE 2 tri-al. Apixaban, a direct factor Xa inhibitor used in thromboembolism prophylaxis and atrial fi brillati on (AF) (others include dabigatran and rivaroxaban) only managed to increase bleeding in high risk ACS pati ents when added to standard dual anti platelet therapy, with no signifi cant reducti on in ischaemic events. This seems to conti nue the trend that oral anti coagulants have litt le overall benefi t in ACS (warfarin, hirudin), whilst oral anti platelet agents (aspirin, clopidog-rel, prasugrel, ti cagrelor), subcutaneous anti coagulants (enoxapa-rin, fondaparinux) and intravenous anti platelet (glycoprotein IIB IIIA inhibitors) and anti coagulants (bivalirudin) do.J Alexander and others. NEJM. 2011;10.1056/NEJMoa1105819.

Good to know that cardiovascular drugs are also benefi cial in pati ents with chronic kidney disease (CKD). The SHARP trial randomised 9270 pati ents with CKD and no previous history of MI or coronary revas-cularisati on to simvastati n 20mg plus ezeti mibe 10mg daily versus matching control. The primary outcome of fi rst major atheroscle-roti c event (a combinati on of non-fatal MI or coronary death, non-haemorrhagic stroke, or any arterial revascularisati on procedure) was signifi cantly reduced with the acti ve drugs (11.3% vs. 13.%) that reduced the average LDL cholesterol by 0.85mmol/L. Another high risk group that needs targeti ng and treatment.C Baigent and others. Lancet. 2011;377:2181-92.

Angiography

A fairly disturbing registry in America showed that the likelihood of fi nding obstructi ve coronary artery disease on electi ve diagnosti c angiography varies from 23% to 100% (median 45%). The data was collected through the huge Nati onal Cardiovascular Data Registry (NCDR) from 565,504 pati ents with known coronary artery disease, undergoing angiography at 691 centres, between 2005 and 2008. The data raises more questi ons than it answers, but suggests that

some clinicians and centres signifi cantly overesti mate angiographic stenosis, or do not have a suffi ciently low enough threshold to per-form angiography in pati ents with symptoms of coronary disease, whilst other individuals and centres are doing the exact opposite. It is important to note that the health service in the US is privately funded (land of the free?) and a number of interventi onists have recently had their licences revoked or have received jail sentences for inappropriate PCI and/or billing. We sti ll do not know the cor-rect ‘hit rate’, but the current guidelines for appropriate indicati ons for revascularisati on, good history taking, assessment of risk factors, non-invasive and pressure wire FFR assessment for ischaemia seem like a good place to start.PS Douglas and others. J Am Coll Cardiol. 2011;58:801-809.

Atrial Fibrillati on

Another factor Xa inhibitor, rivaroxaban has shown more positi ve results in pati ents with atrial fi brillati on (AF). In the ROCKET AF trial pati ents with AF were randomised to rivaroxaban or warfarin, with non-inferiority demonstrated for the preventi on of stroke or sys-temic embolism. There was a signifi cant reducti on in intracranial haemorrhages and fatal bleeding in the rivaroxaban group, though these results were (part of) a secondary endpoint and should be interpreted with cauti on. Good news and less hassle for pati ents who do not need INR monitoring with rivaroxaban. The fi nancial cost and subsequent European approval for AF is now awaited. It will also be competi ng with dabigatran.MR Patel and others. NEJM. 2011. 10.1056/NEJMoa1009638.

AF ablati on

Att empti ng to ablate AF in pati ents with unresolved valvular heart disease is well known to be challenging, but how do pati ents do with AF ablati on post valve replacement? Two series of a total of 130 pati ents with prostheti c Aorti c and Mitral valves, compared with matched non valvular pati ents produced similar results. Acceptable overall success rates (fi rst procedure about 50%, 80% aft er mean 1.3 procedures), a high rate of atrial fl utt er both pre and post ablati on and effi cacy of linear ablati on in preventi ng arrhythmia recurrence. Trends were observed toward higher complicati on rates and longer procedure and fl uoroscopy ti mes in the valvular group.D Lakkireddy and others. Heart Rhythm. 2011;8:975–980.

A Hussein and others. J Am Coll Cardiol. 2011; 58:596-602.



Follow me @johnpaisey for the latest reviews

Follow me @danmckenzie73 for the latest reviews


A big concern in AF ablati on is stroke risk. Measures are taken to avoid performing the procedure in the context of pre existi ng throm-bus, but generati on of embolic material during the procedure can-not be enti rely prevented. A comparison of three ablati on modaliti es (irrigated radiofrequency, Cryo and non irrigated phased RF) with MRI brain follow up revealed a much higher incidence of sub clinical cerebral infarcts in the non irrigated group (7.4 vs. 4.3 vs. 37.5%).

Two cauti ons with these data. Firstly, these are not strokes, they are an asymptomati c radiological fi nding (there were no clinical strokes). Secondly, a proporti on of the energy delivered in the non irrigated phased RF group was done so in a fashion not recommended by the manufacturer and known to be associated with increased char and micro bubble formati on.C Siklody and others. J Am Coll Cardiol. 2011;58;681-688.

Sudden Death Syndromes

We sti ll don’t really know what to do about early repolarisati on syn-drome yet, so two new contributi ons are welcome. Japanese atom bomb survivors get regular medicals including 12 lead ECGs. Head-line fi ndings are that early repolarisati on is common (23% lifeti me incidence with a peak fi rst manifestati on in the late second and early third decade), has a signifi cant cross over with Brugada syndrome and is associated with a modest overall increase in sudden death rate (HR 1.8 vs. controls, in comparison to Brugada ECGs HR 27.5). Widespread abnormaliti es (slurring and/or notching) were associ-ated with higher rates of sudden cardiac death.

It does seem clear that early repolarisati on is at best a spectrum and possibly no more than a hotchpotch of vaguely connected conditi ons. In an att empt to split out higher and lower risk phenotypes a Finn-ish group examined various cohorts (Finnish athletes, US athletes and a middle aged group). They conclude that in early repolarisati on (notching or slurring of the terminal QRS) where the ST segments are upsloping there is no increased risk of SCD and this represents a normal fi nding parti cularly prevalent in athletes. Where early repo-larisati on is associated with a down sloping ST segment there was some increased risk of SCD (albeit modest, RR 1.43).D Haruta and others. Circulati on. 2011;123:2931-2937.

J Taikkanen and others. Circulati on. 2011;123:2666-2673.

Short QT syndrome is the other end of the spectrum; very rare, high-ly malignant. The European registry includes just 53 pati ents, follow up on this highly selected group, 89% of whom have personal or fam-ily histories of SCD reveals two fi ndings. Firstly, they have a lot of arrhythmias (4.9% per year if untreated). Secondly, Hydroquinidine is eff ecti ve in reducing the event rate (no events in the 12 pati ents treated).C Giustett o and others. J Am Coll Cardiol, 2011; 58:587-595

Lead Extracti onLead extracti on is oft en considered a special case among percutane-ous procedures with percepti ons of high mortality and high rates of surgical interventi on. Indeed some have advocated all such proce-dures being performed in cardiothoracic theatre to facilitate earliest possible surgical interventi on.

In this series of 1364 leads in 864 consecuti ve pati ents the authors studied the diff erences in outcome between procedures performed in theatre and in the cath lab. The fi ndings were of an overall mor-tality of 0.2%, with surgical interventi ons required at some stage in 0.9%. The only two massive haemorrhages due to SVC lacerati on died despite surgical interventi on. Older leads were independently associated with increased complicati ons, 92% of leads were extract-ed in their enti rety. There were no diff erences in outcomes between

pati ents extracted in theatre vs. those extracted in the EP lab. One pati ent underwent unproducti ve surgical explorati on for a transient blood pressure drop, but did fi ne despite this.F Freceschi and others. Heart Rhythm 2011;8:1001–1005.

Communicati on

Is it good to talk? When we quote fi gures on risks and benefi ts to pati ents, what are we trying to achieve? Do we just want to write something in the notes to cover ourselves or do we really want to help the pati ent understand?

A survey of what pati ents took in from writt en and diagrammati c explanati ons challenges perceived wisdom and existi ng guidelines. Pati ents do understand (sort of) low risk expressed as very small per-centages (e.g. less than 1%, 0.02%) which we are supposed to avoid but do not understand numerator/denominator comparisons espe-cially where the denominator changes (e.g. risk of stroke 1 in 100, risk of death 2 in 1000). Furthermore, pati ents understand absolute risk and changes therein much bett er than relati ve risk.S Woloshin and others. Ann Intern Med. 2011;155:87-96.

How about communicati on between district hospital interventi onal cardiologists and surgeons at a remote surgical centre? Apparently a video link system in Sussex signifi cantly increased the number of pati ents with complex coronary disease having surgical revasculari-sati on rather than PCI. We have mixed views on this. Cardiothoracic surgeons, in the main, will perform coronary artery bypass graft ing (CABG) on electi ve pati ents, even when high risk, if they have appro-priate coronary disease. The problems come with acutely unwell pati ents, when shock, renal dysfuncti on or troponin elevati on seem to put them off ! The SYNTAX study (CABG vs. PCI in high risk coronary artery disease) and ongoing trans-aorti c valve implantati on (TAVI) programmes have certainly improved relati ons between cardiotho-racic surgeons and interventi onists, and this must be a good thing.R.A Veasey and others. Int J Clin Pract. 2011;65:658-663.

TAVI

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

Coronary Artery Bypass Graft ing

And whilst we are talking about cardiothoracic surgeons, we should briefl y menti on this study looking at saphenous venous graft s in pati ents undergoing CABG (PREVENT IV trial). Essenti ally, vein graft failure is signifi cantly worse at one year if there are multi ple rather than single distal targets (something to do with fl ow presumably?). This results in a signifi cantly poor clinical outcome at fi ve years (worse composite of death, MI or revascularisati on), so is best avoided.R Mehta and others. Circulati on. 2011;124:280-288.

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With the rise in PPCI, what changes in working patt erns will benecessary so as to avoid physiologists working on average 14 to 22 hours in one shift , when they start at 9am and conti nue on to do on-call that night?

According to the Department of Health primary PCI is available to 90% of the English populati on so this topic

has relevance to many departments and I’m sure there’s a multi tude of diff erent approaches being taken to deal with the parti cular issues it raises on a local basis. That’s exactly how it should be, there’s no single prescripti ve soluti on and individual services must work within the legislati ve frame-work, using the tools available to them in terms of local policy regarding fl exible working to achieve the best possible out-come for their pati ents.

For many the noti on that work as a cardiac physiologist is a Monday to Friday, nine ‘ti l fi ve lifestyle is long gone. On call work will, of course, be second nature to cardiac physiologists working in numerous centres and over recent years extended working weeks incorporati ng weekends and longer working days have become the norm in response to achieving diag-nosti c waiti ng ti me targets. Consequently, further tweaking of working patt erns aft er appropriate consultati on should not prove too troublesome to implement.

A move to shift -work is one potenti al approach to meet the demands of a primary PCI service although there is the ques-ti on of what roles a cardiac physiologist might undertake between primary PCI cases. Perhaps a forthcoming publi-cati on from the Briti sh Cardiovascular Society regarding the future of Cardiac Care may off er some guidance? The recom-mendati ons are likely to suggest that a full range of cardiac diagnosti c procedures are accessible on a 24 / 7 basis. Some Trusts may choose to interpret their meeti ng of this pro-posal by having on-call junior medical staff available but who would you prefer to perform your investi gati ons? A trainee doctor or a qualifi ed, competent and experienced cardiac physiologist?

A work week consisti ng of four working days from 8am-6pm, with the day off preceded by an on call night is the best working pat-

tern for physiologists on call as:

• The on call person is guaranteed to have rest the next day.• Clinical work and lab over run can be covered between 8-9am

and 5-6pm by the staff working the long shift that week.• If a member of the team isn’t on call, then they can work a nor-

mal (9am-5pm) shift patt ern that week. Hence, only an extra member of staff is required to cover the unavailability of the on call person the next day.

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

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

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

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

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

Management

Hot Topic

Dr Chris Eggett Cardiac Physiologist Deputy Service ManagerFreeman HospitalNewcastle upon Tyne

Nishat JahagirdarLead Cardiac Physiologist (Invasive)Kings College HospitalLondonUnited Kingdom

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

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

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Email: [email protected]

Promoting better understanding, diagnosis, treatment and quality of life for individuals with cardiac arrhythmias

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2nd - 5th October 2011

HRC 2011 A4 NO DATES.indd 1 18/05/2011 15:32:09


Lancashire Cardiac Centre

Blackpool Teaching Hospitals NHS Trust:

The Lancashire Cardiac Centre provides a variety of cardiovascular treatment opti ons for the people of Lancashire, Cumbria and sur-rounding counti es. The centre comprises the latest faciliti es, including four state-of-the-art cardiac catheter labs, which perform a variety of investi gati ons and treatments. These include angiograms, angioplas-ti es (stents), internal cardioversions, pacemakers, biventricular pace-makers, ICD’s and electrophysiology studies.

Recently the centre opted to embrace McKesson’s fully integrated haemodynamic system, featuring built-in fracti onal fl ow reserve (FFR) soft ware, to address the growing frequency of its use within the cath lab environment. The team have also commenced using the Volcano PrimeWire Presti ge, which integrates seamlessly with the McKesson system. The PrimeWire Presti ge was chosen due to spe-cially designed features including a heavier core and improved ti p, which aid the operator to cross challenging lesions.

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

How many staff ? Roles? • 10 cardiology consultants.• 14 Cardiac Physiologists• 9 Radiographers• 10 Nurses

Types of procedures? • Diagnosti c and interventi onal (PCI’s) + regionwide PPCI service• Electrophysiology• Full range of cardiac physiology services including Echo• Internal Cardioversions• Pacemakers & ICD’s• TAVI

Types of equipment used?• IVUS Boston and Volcano• Integrated FFR Volcano • SJM FFR• St Jude’s LightLab OCT • Rotablati on. • Philips and Siemens Cath Labs. • McKesson Cardiovascular Informati on soluti on• GE Vivid 7 Echo

How many procedures are performed per year?• PCI = 1600 (target of >2000 PCI’s for 2011-2012)• Diagnosti c procedures = 2000• Tavi = 36• EP procedures = 240

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


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

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

From Management and Cardiologist point of view, what are your thoughts on FFR technology, and why did you choose a completely integrated solution?• FFR is a fantastic tool for the Cardiac Interventionalist and now

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

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

What new procedures / techniques have you implemented into the department recently?Recent = OCT, EP expansion (more comprehensive). Future = CT coronary angio, hybrid lab, radial lounge

How does the lab handle haemostasis? Radial = TR and Helix. Femoral = Angioseal, and Exoseal

The Volcano SmartMap for FFR

The Cath Lab Team

SITE

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Claire Overstall (Cardiac Physiologist) reviewing an FFR case

What measures has the department implemented to cut costs? • One of the major ways to reduce costs and improve effi ciency is

to decrease the length of stay for pati ents. We are in the process of implementi ng a dedicated radial lounge where pati ents can relax in comfort whilst waiti ng for their procedure instead of taking up beds.

• We are also working on ways to streamline product usage to reduce wastage.

How do you deal with late fi nishing of cases? For example staggered working hours or just staff overti me?One lab late aft er 7pm everyday. Cases fi nish ACS treatment within 72 hours. 1 dedicated PPCI lab.

What is your policy for company reps within the labs? Are reps allowed to bring food for sharing amongst doctors and staff into the department when they visit? Yes, company reps are welcome in our department for educati onal as well as for new product awareness and on-going support. They are allowed to bring food into the department, however they must make prior arrangements with the senior nurse on duty to ensure there is no overlap with other companies.

What is the best part of working at your facility?It is a modern, well-equipped facility located in one of the UK’s favourite holiday regions. We have a wonderful team working on cut-ti ng edge procedures, which all combined produces a fresh environ-ment, and great staff atmosphere.

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AVAILABLEONLINE


Jim Shahi Unit (Cardiac Catheterisati on Laboratory)

The Royal Berkshire NHS Foundati on Trust


The Royal Berkshire NHS Foundati on Trust is situated in the centre of Reading covering western and central porti ons of Berkshire. It is one of the largest general hospital trusts in the country, which has recently undergone £132 Million redevelopment. The hospital pro-vides 813 inpati ent beds together with 204 day beds, in doing so it employs 4000 staff .

The specialty of Cardiology provides a combinati on of inpati ent work, a large outpati ent service and a full range of Cardiac Investi gati ons. The Cardiac Catheterisati on Laboratory is named aft er the late Dr. Jim Shahi, a Consultant Cardiologist who helped set up the unit in 1994. We have 2 Catheterisati on Laboratories which off ers an exten-sive range of electi ve and emergency procedures. Alongside the labs we have a 16 bedded day bed unit which opens from 8:00 am to 6:00

pm. In 2009 we introduced the Primary PCI service 24/7. This has been implemented very successfully with a median call to balloon ti me (CTB) of 77 minutes and door to balloon ti me (DTB) of 28 min-utes in the fi rst 12 months. South Central ambulance service provides an excellent response to emergency calls for pati ents with chest pain. The PPCI team members all live locally and are able to be at the Cath Lab within 20 minutes. This enables pati ents to receive early reperfu-sion and opti mal treatment and outcomes.

The ward base consists of an 18 bedded CCU Department with 1 Chest Pain assessment bed and a 28 bedded Cardiology Ward includ-ing 6 Telemetry beds. The Cardiology Department provides a full range of Cardiac Investi gati ons along with outpati ent’s clinics, Rapid Access Chest Pain Clinic and Heart Failure Clinics. A full range of Car-diac Rehabilitati on is off ered as an inpati ent and outpati ent service.

What are the sizes of your Cardiology Department and Hospital?• Jim Shahi Unit – 16 beds• CCU 18 beds + 1 Chest pain assessment bed• Whitley Ward – 28 beds

What is the geographical intake area and populati on served by your hospital?• Half a million catchment • PPCI catchment is up to 750,000

How many staff ? Roles?• 5 Consultant Interventi onalist Cardiologists• 1 Consultant Electrophysiologist (visiti ng)• 1 Consultant Cardiac Surgeon (visiti ng)• 1 Consultant Cardiac Imaging (CT/MRI)• 2 Associate Specialist• 3 SpRs• 3 ST grades• 2 FY grade juniors• JSU = 8.2 Nurses WTE• 3.6 Radiographers WTE• 24 Cardiac Physiologists (10 Rotates in the Lab)• 2 Waiti ng List Offi cers• 5 Secretaries• 5 Admin Staff • 3 Volunteers• CCU = 33.5 Nurses WTE• Whitley Ward = 34.74 Nurses WTE• Heart Failure Nurses- 2.66 • Cardiac Rehab Nurses - 3

The Royal Berkshire NHS Foundati on TrustLondon Road, ReadingBerkshire, United Kingdom


Types of procedures?Jim Shahi Unit :• Angiograms (Inpati ents and

Outpati ents)• PCI • Permanent Pacemakers• PPM Box Changes• Reveals• Cardioversions• ICD’s and CRT’s• EP’s• Pressure Wire Study• IVUS• Rotablati on

Cardiac Outpati ents:• Echo• Stress Echo• TOE• Stress Test• Holter Monitoring• Tilt Testi ng• 12 Lead ECG’s• Pacemaker Checks• Cardiac MRI• Cardiac CT

Types of equipment used?• Siemens Axiom Arti s Dfc & Dtc• Boston Scienti fi c Rotablati on Machine• Boston Scienti fi c iLab IVUS Machine• St. Jude Pressure Wire• Phillips Echo Machines

How many procedures are performed a year? April 2010- April 2011:Angio’s: 1400PCI: 618Electi ve PCI: 232Primary PCI: 202Permanent Pacemakers: 300EP: 60Cardioversions: 166ICD: 20Bi vents: 10CRT: 10

Does your department off er a Primary Angioplasty Service? If yes, what have been some of the challenges setti ng it up?YES 24/7 since April 2009Challenges:

1. Having suffi cient staff to cover the service e.g. extra Radiogra-phers recruited and trained up to on call standard.

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

What are the benefi ts to pati ents att ending your facility?• The best Door to Balloon Time in the Country. See link below: htt p://www.bbc.co.uk/news/uk-england-berkshire-11441743• We off er a complete cardiac service and have very low waiti ng

ti mes

How is your inventory managed?Pen and paper

What measures has the department implemented to cut costs?• We use fewer Angioseals these days to cut cost• Regular Tendering especially high cost consumables

What kinds of conti nuing educati on programs are available to staff ?• Criti cal Care Course• Mentorship Course• IVUS and Rotablati on Study Days• Leadership/management courses

Reducing radiati on dose is a high priority in the cath labs. What techniques are employed by your radiographers to ensure dosage during cases is kept to a minimum? Also what is the maximum dose limit a pati ent can receive in your labs before it is recorded in their notes, and what is the follow-up process?• Reduced Pulse Rate ( 4pps or 6 pps) dependant on Consultants • Appropriate collimati on• If dose is 10,000 mcGy m2 or above the radiographer informs

the operator who will advise the pati ent of possible erythema.

What is the best part of working at your facility?• friendly atmosphere• good working team• positi ve feedback from pati ents, pati ent relati ve, student

nurses and other members of staff • Good and sustained publicity• staff retenti on• effi cient service

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Royal Berkshire Hospital: More photos and questi ons online

From Left: Erick Omana, Bonita Chizambire, Jan Marshall, Javon Lorde, Melanie Bailey, Charlie McKenna, Rowena Soar, Alisa Greener, Amande Searle, Debbie Daniel-Best,

Chris Mwenda, Paul Gentle, Chris Hayes, Bhavesh Sachdev


October 2-5HRC 2011Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October 7-8Briti sh Society of Echocardiography Annual Meeti ngEdinburgh Internati onal Conference CentreEdinburgh, Scotlandwww.bsecho.org

October 14-15Cardiac Risk in the Young (CRY) Internati onal Conference The Cavendish Conference CentreLondon, Englandwww.c-r-y.org.uk

October 16-18PCR London Valves 2011London Englandwww.pcrlondonvalves.com

November 24SHARP Annual Scienti fi c Meeti ng “Cardiovascular Disease, Every Day Management”Dunkeld, ScotlandContact: Miss Victoria Kirkwood, Email: [email protected] or Tel 01382 60111 ext 33124

December 2CCO Nati onal ConferenceCardiovascular Update 2011 - Strategies for diagnosis & TreatmentLondon, EnglandEmail: [email protected] or [email protected]

December 14BCS - A Year in CardiologyRoyal College of Physicians London, Englandwww.bcs.com/educati on

MOREONLINE

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

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EventsUnited Kingdom


Course Directors

Martyn ThomasSimon RedwoodPatrick W. SerruysOlaf WendlerAlec VahanianMark MonaghanJean FajadetCarlos RuizPhilipp BonhoefferJohn WebbOlaf FranzenA. Pieter KappeteinCarlo Di MarioStephan Windecker

Programme Committee Members

Vinayak BapatJonathan ByrneRanjit DeshpandeJane HancockPhilip MacCarthyChristopher Young

Chairman of PCR

Jean Marco

SEE YOU IN LONDON16th-18th October 2011

VALVES FOR THE HEART TEAM

Visit www.pcrlondonvalves.com

Come as a Heart team.

Whether you're an interventional cardiologist, an anaesthetist, a radio-logist or a nurse, you'll go back tothe cathlab with with the tools youneed to advance your daily practice.

Connect to www.pcrlondonvalves.com to register today

Registration is open!

g St Thomas' Hospital, London, UKg Bern University Hospital, Bern,

Switzerlandg Clinique Pasteur, Toulouse,

France

Live demonstrationsSessions

Adjuvant therapies in TAVITo understand the indication andtechnique for aortic balloon valvu-loplasty, coronary revascularisationand LV support before and duringTAVI.

Improving the results of TAVITo understand how we can improvepatient selection and the results ofTAVI.

Is the percutaneous mitral valve ready for prime time?To understand the current clinical indications for transcatheter mitralvalve intervention.

What remains difficult about TAVITo understand what remains diffi-cult clinical situations in TAVI andhow to deal with them.

The dataTo understand the current clinicaloutcomes of TAVI.

LTTCome and see these interactive ses-sions:g On 17th October, you will enjoy

an interactive and practical LTT on"How to perform a TAVI" includingimaging, access (femoral, sub-clavian, transapical, transaortic), deployment and valve in valve.gOn 18th October, expect to see

the same format on "Percutaneousmitral valve regurgitation repair".

ComplicationsJoin the popular Complication ses-sions, based on a call for submission.

Interactive Case CornerA new place of communication, freefrom time constraints and definedprogramme, where participants willbe invited to share their experience& point of view on the case theysubmitted, in a welcoming and re-assuring environment.

11TXXXX_PCRLONDON_PUB_CORONARY_HEART_AUGUST 18/07/11 18:02 Page1

experiencethe future of CVIS

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safer decisions. By seamlessly connecting hospitals through automated workflow,

our cutting-edge cardiovascular information solution, Horizon Cardiology, enables you

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