Coronary Heart #15

Inside Bart’s & The London NHS Trust

coronaryheart.com

November / December 200�Issue 15 November / December 200�Issue 15

Special FeatureGenerational Confl ict in the Cath Lab

Hot TopicSYNTAX Trial Results with opinions from 3 leading cardiologists

Hot TopicThe Differences between Drug Eluting Stents (Part 2)

Site VisitBart’s and The London NHS Trust

CRM EducationRV Pacing

Echo Case StudyIsolated Left Ventricular Non-compaction

ManagementHospital Management and MBA courses EM

PLOYMENT

SubscribeFree

Online

coronaryheart.com

One beat cardiac imagingAquilion ONE: the world’s first dynamic volume CT

ULTRASOUND CT MRI X-RAY SERVICE

Toshiba Medical System’s Aquilion ONE is a quantum leap in CT imaging that can capture

a 3D image of the heart in just one beat.

The wide coverage provided by the Aquilion ONE’s 16cm detector, which has 320 detector

rows, can scan the brain or heart in less than a second. So you can see an entire organ in

3D with perfect continuity along the z-axis. Or see it in 4D, moving as time passes. Or see

it extremely fast, with a lower contrast medium dose and exposure dose.

The Aquilion ONE will bring you dynamic views of the body you could not see before.

See it for yourself at www.toshiba-medical.co.uk.

Toshiba: Made for Patients, Made for You, Made for Life!

CONTENTS

Table of Contents

04 Editorial

05 Latest News

05 ECG Quiz

06 Hot Topic‘SYNTAX Trial Results’

0� Hot Topic‘Diff erences between the drug eluting stents’

11 Journal Trawl

12 Echo Case Study‘Isolated Left Ventricular Non-compaction’

14 Special Feature‘Multigenerational confl ict in the Cath Lab’

1� Special Feature‘Leveraging Generational Variety at work’

1� ECG Quiz Answer

20 Management‘Hospital Management and MBA courses’

24 CRM‘RV Pacing’

2� Site Visit‘Bart’s & The London NHS Trust’

33 Events Diary

33 Heartbeat International

34 Recruitment

35 Next Issue & Advertisers’ Index

THIS EDITION

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

November / December 2008

Page: 14

Conflict in the Cath Lab

Barts & The London NHS Trust Site Visit

Page: 28

CORONARY HEART ™ 3

EDITORIAL

From the EditorTh e “What Price for Staff Moti-vation” article in the last edition was a hot topic for many people, however I think it is important to note that the decision for staff progression is not always as clear cut as some would think.

I always believe there are two sides to every story, and although one situation may seem unfair, more often there is a valid reason for actions taking place. Th ree years after I graduated in 1998 I was promoted to Chief Radiographer of Australia’s largest private hospital cath lab, ahead of others much older than me and with more experience.

As many would now be aware competition in today’s work-place is even more intense, and managers often have to make the diffi cult decision of whether to employ someone with the most experience, or the person who would make the best manager. For many wanting to be a manager this line can be blurred, but for managers who need their labs to be com-petitive, the decision comes down to who will make the best leader. And that could be anybody no matter what experience they have.

- Tim

Free SubscriptionIf you haven’t done so yet, we recommend you take 2min off and visit our website www.coronaryheart.com to fi ll in our subscription form. It doesn’t cost you anything, and it is a legitimate way to surf the internet during work time.

Write for usShare your expertise with your fellow workers by contributing an article to Coronary Heart. All topics related to the cath lab are welcome.

For more information and a copy of Coronary Heart’s author guidelines email the Chief Editor Tim Larner at [email protected]

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

Coronary Heart Publishing Ltd145 - 157 St John Street

London, EC1V 4PYUnited Kingdom

Email: [email protected]: +44 (0) 207 788 7967

Fax: +44 (0) 207 160 9334

Visit us online at

www.coronaryheart.com

Director / Chief EditorTim Larner

Clinical EditorDr Simon Redwood

Senior Consulting EditorsDr Richard Edwards

Dr Rodney FoaleDr Divaka Perera

Mr Ian WrightMr Stuart AllenMs Mojgan Sani

Ms Voncile Hilson-Morrow

ADVERTISINGWendy Rose

Rose Media LtdEmail: [email protected]

CIRCULATION3642 Cardiac Professionals

Copyright 2006 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 publication of an advertisement or product

review does not imply that a product is recommended by Coronary Heart Publishing Ltd.

Mr Tim LarnerDirector / Chief Editor

Dr Simon RedwoodChief Clinical Editor

Dr Richard EdwardsAsst. Clinical Editor

Dr Rodney FoaleAsst. Clinical Editor

Mr Stuart AllenCRM Editor

Mr Ian WrightEP Editor

4 CORONARY HEART ™

NEWS & ECG QUIZ

ECG QUIZProvided by: Ian Wright, Technical Head EP, St Mary’s Hospital, London, UK

Ian Wright

During an episode of palpitations this ECG is recorded in a 55 year old male patient with normal coronary arteries and a structurally normal heart on echo. Th e arrhythmia is brought on by emotion.

What is the likely diagnosis?

See Page 1� for the answer

HRC SuccessTh e Heart Rhythm Congress held in Birmingham in late October was a very successful event and is growing rapidly each year. Interesting presentations and a well represented trade show for industry ensured attendees were able to stay at the cutting edge of their fi eld.

Tryton Stent Receives CE MarkCE Mark approval has been given to Tryton Medical for their revolutionary

designed Side Branch Stent System™. Th e stent will be launched in Th e Neth-erlands followed by other European countries. See Edition 7 on our website for more details.

CeloNova Catania Stent PromisingResults from the 12 month follow-up of the ATLANTA Trial at TCT showed zero percent thrombosis although patients discontinued dual anti-platelet therapy after only 30 days. Visit www.celonova.com for more details of this study.

Left: The CeloNova BioSciences CATANIA™ Stent


HOT TOPIC


One-year data from the SYNTAX (SYNergy between percutaneous coronary intervention [PCI] with

TAXus and cardiac surgery) trial suggest that revascularisation with the TAXUS™ Ex-press2™ paclitaxel-eluting stent system is as safe as revascularisation with CABG (coro-nary artery bypass graft) in patients with se-vere coronary artery disease. SYNTAX was the fi rst randomised clinical trial to compare PCI using the TAXUS™ Express2™1 stents with modern CABG in patients with left main2 and / or three-vessel disease3.

Th e purpose of this groundbreaking investi-gation was to expand the body of evidence for PCI use, and help inform physicians on appropriate treatment options for patients with complex disease, who might benefi t from this intervention and avoid the risks of major cardiac surgery.

Th e trial enrolled 1800 patients who were randomly assigned to receive either CABG (n=897) or PCI (n=903). Prior to randomi-sation, these patients were assessed by local physician teams, comprising a cardiac sur-

geon and interventional cardiologist, who assessed each patient to determine their eli-gibility for either PCI or CABG. Patients were randomised only if both physi-cians agreed that complete revascular-isation could be performed using either procedure. Th e remainder were followed up in a PCI or CABG registry.

SYNTAX was an intended all-comers trial for patients with de novo lesions with very limited exclusion criteria. Patients were re-quired to have three-vessel disease and / or left main disease, and were only excluded only if they presented with ongoing acute myocardial infarction or planned concomitant valve surgery. In all, 71% of the patients screened were included in the trial, which is consider-ably higher than historical clinical trials comparing PCI with CABG.

Due to the complexity and advanced nature of the disease, the patients re-cruited represented a unique study

SYNTAX trial shows similar safety between TAXUS Express2™ stents and CABG in patients with complex coronary artery disease

Cardiologist Hot TopicWritten by Colin RobbInterventional Cardiology Clinical Science SpecialistBoston Scientific UK and Ireland

geon and interventional cardiologist, who assessed each patient to determine their eli-gibility for either PCI or CABG. Patients

/ or left main disease, and were only excluded only if they presented with ongoing acute myocardial infarction or

SYNTAX SCOREThe goal of the SYNTAX score is to provide a tool to assist physicians in their revascularization strategies for

patients with high risk lesions.

Patients with Left Main Disease: 34.6%

Patients with Bifurcation Disease: 72.4%

Patients with Total Occlusions: 24.2%

Incidence Figures in Trial

Imag

es c

ourt

esy

Bos

ton

Sci

enti

fic

HOT TOPIC

CORONARY HEART ™ �

The data from SYNTAX gives us confidence that PCI is a val-id and safe alternative to surgery in patients with LMS and or

mutli-vessel coronary disease. When the combined endpoints from the SYNTAX trial are broken down we see that there is no significant difference in all cause death or AMI at 1 year between surgery and PCI. An important advantage for PCI is the reduced risk of stroke compared to surgery 0.6% vs 2.2%. But if you want to avoid re-inter-vention, surgery remains the best option 13.6% vs 5.9%.

When the anatomical subgroups are examined, the study findings suggests that patients with less complicated anatomy, LMS and single vessel disease, may benefit more from PCI than surgery; whilst pa-tients with more complicated disease, such as bifurcation LMS disease and > 2 vessel stenosis, are more likely to benefit from surgery.

However, revascularization decisions need to be tailor made. The nu-ances of the coronary anatomy and the patients’ co-morbidities need to be carefully assessed and discussed in an MDT meeting so the pa-tient is able to give informed consent. Although the findings from SYNTAX may have helped to break the taboo of stenting the LMS; it must be remembered that the data is only out to one year, and longer follow up is needed to define the true differences between the two revascularization strategies.

group. Of the patients enrolled into SYNTAX, 84 percent had bi / trifurcations, 22 percent had chronic total occlusion, and 39 percent had left main disease. The average patient randomised to receive PCI received 4.6 stents compared with 1.5 stents in normal clinical practice, and overall, 33 percent of patients had lesions longer than 100 mm.

At 1 year, patients in the PCI and CABG groups had similar rates of all-cause death, cerebrovascular accident and myocardial infarction (7.6% vs 7.7%, p=0.98). In addition, the rates of stroke were significantly higher in the CABG group than in the PCI group (0.6% vs. 2.2%, P=0.003). However, the overall 12-month MACCE (major adverse cardiovascular or cerebrovascular event, including all-cause death, stroke, myocardial infarc-tion and repeat revascularisation) rate was significantly higher in the PCI group than the CABG group (17.8% vs 12.1% respectively, P=0.0015) driven by a higher re-peat revascularisation rate (13.7% vs. 5.9% respectively, P<0.001).

SYNTAX was a landmark trial which has shown that PCI with TAXUS Express2™ paclitaxel-eluting stents is equally as safe as CABG in patients who are usually treated with surgery, even though the rates of revascu-larisation were higher. Further analysis of SYNTAX data along with validation of the SYNTAX score should help clarify optimal treatment strategies in these patients.

References:

The TAXUS™ Express2™ stent is currently con-traindicated for lesions involving bi- and trifurca-tions and for use in patients with total occlusions of target vessel for use in patients with unprotected left main coronary artery.Isolated or in conjunction with one-, two- or three-vessel diseaseRevascularisation of all three vascular lesions.

1.

2.

3.

Dr Richard Edwards Consultant Cardiologist The Newcastle upon Tyne Hospitals NHS Trust Newcastle-upon-Tyne

Patients with 3-Vessel Disease: 65.4%

The SYNTAX Trial results showed that there was no statistically significant differences between PCI and CABG in rates of death or myocardial infarction.

Will these findings influence your decision on what the best course of action is for a patient with similar anatomy and disease to those in the study?

Turn the page for additional responses to the above question.

Question:

HOT TOPIC (cont...)

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

The eagerly awaited SYNTAX Trial re-sults are out: Taxus drug-eluting stents

are inferior to CABG, but only because of a higher rate of repeat revascularisation. The ‘hard’ endpoint of ‘death, MI & stroke’ is not different between the two groups, and indeed CABG appears to quadruple stroke risk.

Subgroup analysis utilising the complex SYNTAX scoring system provides more interesting data. Patients in the highest ter-tile (score >33) have better outcomes with CABG, driven primarily by a lower rate of repeat revascularisation, while those in the low and intermediate tertiles (score 0-33) have comparable outcomes with both revas-cularisation strategies, even in the presence of LMS plus 3-vessel disease. Diabetics seem to do better with CABG, thanks to a lower repeat revascularisation rate.

Whilst these results may be a cause for cel-ebration by interventional cardiologists (af-terall, most patients enrolled in SYNTAX have traditionally been regarded as surgical), it is worth remembering that almost 1/3 of patients considered for randomisation in SYNTAX were deemed ineligible for PCI, and, when added to those SYNTAX sub-groups shown to fare better with CABG, account for 55% of all patients. In addition, I believe patients with LMS disease involv-

ing both ostia should be referred for CABG, unless further data indicates otherwise in future.

Thus, my take home messages from the Syntax Trial are:

Perform PCI if SYNTAX score is <33 and the chances of complete revascu-larisation are high,

Tackle LMS disease with less guilt, even if part of a 3-vessel PCI,

Opt for CABG, rather than ‘interven-tional heroics,’ in patients with super complex coronary anatomy, especially if diabetic,

Work closely with surgical colleagues, but leave the ultimate informed deci-sion to the patient.

1.

2.

3.

4.

Dr Azfar ZamanBSc, MB ChB, MD, FRCPDirector, Interventional CardiologyNewcastle Upon Tyne Hospitals NHS Foundation Trust

The strength of the SYNTAX study was its inclusive design based on clinical

judgment. However, its undoubted weak-ness was that the study was underpowered and did not provide a definitive result for the primary outcome, which was “non infe-

riority of PCI”. For someone who, with the best will in the world, fails to understand the design, if not the purpose, of a “non-infe-riority” trial and how one is powered, any comments risk the potential to invite ridi-cule. Nevertheless, here goes.

The first point to note is that this was not a study of left main stem lesions. Only 34% of enrolled patients had LMS lesions and only 11.4% underwent PCI. This was a study of revascularization strategies in pa-tients with high disease burden as assessed by the SYNTAX score. Even then the stand-ard deviation of the score was high. Finally, the PCI arm treated more patients with LM and single vessel disease whilst the surgery arm treated more patients with LM and 2/3 vessel disease.

With the above caveats, my brief interpreta-tion of the study merely confirms findings previously reported ie. PCI for complex dis-

ease results in more repeat interventions at one year but similar mortality when com-pared to surgical revascularization. This disadvantage of PCI is balanced by shorter hospital stay and fewer strokes immediately post procedure.

So, my answer to the question posed is – no. Until we have longer term follow up, my judgment will be based on:

patient characteristics (age, co-mor-bidities, choice etc)

lesion characteristics and

recognition (if not acceptance!) of my own limitations.

As for SYNTAX - thanks, but plus ça change…………

1.

2.

3.

The SYNTAX Trial results showed that there was no statistically significant differences between PCI and CABG in rates of death or myocardial infarction.

Will these findings influence your decision on what the best course of action is for a patient with similar anatomy and disease to those in the study?

Question:

� CORONARY HEART ™

HOT TOPIC

Dr Richard Carroll MB ChB MRCPConsultant Interventional CardiologistImperial College Healthcare NHS TrustLondon, UK

There has been a massive explosion in the use of drug-eluting stents over the last few years, tempered only re-

cently by concerns about safety which have re-balanced implantation rates back from the US peak of 70% of all stents used, to closer to 50% of all stents implanted hav-ing a drug-coating. The focus of most of the discussion over the last few years has been bare metal stent versus drug-eluting stents. However, this overlooks one significant de-bate, and that is – are all drug-eluting stents the same? Are some better than others and if so, why?

The ideal stent has several components. Firstly, it must be easy to use outside of the body. Crimping stents manually or pipet-ting drugs into cells adds a level of complex-ity to the implantation process that most lab staff could do without. Secondly, the stent itself must be deliverable – i.e. before stent deployment, the device is sufficiently slim as to easily negotiate its way down the ves-sel and into the target lesion. Having ‘a low profile’ is crucial to ease of use and first and second-generation drug-eluting stents differ markedly in their profiles and deliverability.

Third, the drug is incorporated into a poly-mer, which binds it to the stent. This poly-mer is required to release the drug locally in a gradual fashion into the wall of the vessel. Too rapid a release could mean highly effec-tive early inhibition of vessel wall re-growth but then a loss of efficacy several weeks later. The polymer must allow the drug to inhibit neo-intimal growth over the time of great-est risk – the first six months after an an-gioplasty. This polymer should also be oth-erwise relatively chemically inert – i.e. not induce reactions in the native vessel wall if possible

Fourth, the drug itself needs to inhibit neo-intimal hyperplasia to such a degree that clinical restenosis does not occur. Initially, drug regimens were designed to absolutely inhibit re-growth, which would effectively banish restenosis in the target lesion in the short to medium term – the principle aim of PCI for stable angina. However, it seems that some degree of neo-intimal growth may be valuable, as it allows coverage of the met-al stent struts of the stent itself. This removes a powerful stimulus for stent thrombosis in the medium to long-term.

Fifth, whatever the drug used, it is always possible that struts may be inadequately covered by intimal proliferation for techni-cal reasons e.g. those that are inadequately deployed or bifurcation stents, where strut disruption has occurred as a necessary part of the case. Any stent that can provide the necessary structural support in the short term, but which dissolves in the medium term to remove a focus for thrombosis is the long-term goal of current stent research.

Finally, the most important aspect of any review regarding the effectiveness of a stent technology is the strength of its’ clinical out-come data.

This review will focus on the differences in these ideal stent factors amongst the three principle players on the UK market. The Cypher (Cordis), Taxus (Boston Scientific) and Endeavour (Medtronic) drug-eluting stents. Reference will then be made to sec-ond generation drug-eluting stents coming onto the market and their proposed addi-tional benefits.

Goal 1. Ease of use.All three principle stents come ready-pre-pared and are highly useable outside of the patient. Some next generation stents pro-pose individual selection of drug coating at the bedside and whilst this may have advan-tages with regard to other goals of the ideal stent, this represents a step backwards in day-today usability of these devices.

Goal 2. Stent deliverabilityThe first generation of Cypher stent used the velocity bare-metal stent platform and Taxus used the express platform. Both of these are stainless-steel platforms and therefore suffer in comparison to the cobalt-chromium plat-form stent such as Endeavour, which uses the Driver platform. The Cypher Select and Taxus Liberte, marketed as next generation stent technology, both still use stainless steel platforms and therefore have a higher profile and reduced deliverability, in the author’s opinion, when compared with Endeavour stents.

Goal 3. Appropriate Polymer CharacteristicsAll three principle drug-eluting stents use a durable polymer i.e. one that persists be-yond the drug-elution phase. All three could therefore be said to be sub-optimal in de-sign when compared with next-generation bioasorbable polymers used in stents such as the Infinnium (SMT) or Nobori (Terumo)

- with Dr Andrew Sharp & Dr Richard Carroll

Are there important differences between the commercially available drug eluting stents?

Cardiologist Hot Topic

Part 2

CORONARY HEART ™ �

HOT TOPIC (cont...)


stents. However, the principle aim of the polymer – to regulate release of the drug during the fi rst few months of vessel heal-ing – appears successful in all three brands. Th ere is, though, substantial data that these polymers promote impaired vascular healing and all may be a stimulus for stent throm-bosis, leaving room for second-generation stents to enter the market.

Goal 4. Inhibition of neo-intimal proliferation and implications for stent thrombosis ratesOf the three stents, the Cypher stent con-tinues to show the strongest data on preven-tion of ‘late loss’ - angiographic data quan-tifying the amount of neo-intimal growth at medium-term follow-up. Endeavour have the weakest data of the three in this area; however, given that some degree of prolif-eration may be valuable in terms of prevent-ing longer-term exposure of stent struts and therefore thrombosis rates, this has been spun by the manufacturers as a potentially valuable trade-off between restenosis and thrombosis. Given that the Endeavour III and IV trials showed signifi cantly inferior restenosis rates between the Endeavor and both Cypher and Taxus stents respectively, the balance may not be ideal and the En-deavor stent has been associated with higher clinical restenosis rates in a large Scandina-

vian registry, if not in moderately sized ran-domised controlled trials.

Data from the limited head-to-head studies that are available on late-thrombosis rates do not show signifi cant diff erences between the Cypher and Taxus stents. Th ere are insuffi -cient head-to-head data for Endeavour and either stent to comment on late-thrombosis rates but it appears from registry data that Endeavour late thrombosis are at least as low as its’ rivals. Th e Xience second-generation drug-eluting stent may represent a step for-ward in terms of inhibition of late loss and has superior head-to-head data to Taxus.

Goal 5. Structural SupportAll three stents are similar in this respect. A large amount of research is underway into bioabsorbable stents made from novel met-als such as magnesium, but these are several years away from the market.

Goal 6. Quality of clinical outcome dataWhilst knowledge of angiographic data, such as in-segment late-loss is valuable, in the end, hard endpoint data such as death, MI and need for revascularisation remains the gold-standard assessment of any stent technology. Cypher continues to have the

best outcome data of the three, but its’ ad-vantage is narrowing with each year. As new stent technology comes to the market, it has some way to go to match the fi ve year clini-cal outcome data published with each of these three well tried and tested stents.

ConclusionIt is clear to the Authors from day-to-day clinical use that the Endeavor stent is the most deliverable of the three, and this con-fers it a procedural advantage in tortuous vessels. However, the data clearly suggests greater late-loss and this may confer greater restenosis rates in non-trial populations, though this remains to be proven. Th e Cy-pher stent continues to set the standard in clinical outcomes, but is the least deliverable of the three stents. New versions of these stents are being rolled out across the UK with considerably improved characteristics, but as with all stent technology, evidence proves to uncomfortably lag behind prac-tice, and caution is advised when consider-ing leaps of faith to new stent technologies. Th e fi rst generation of Cypher, Taxus and Endeavor stents are well understood and all have strong clinic outcome data. Th is sets them apart from novel stents, in our opin-ion, for all of their fl aws.

Differences between drug eluting stents (cont...)

NEXT ISSUE:

The SYNTAX Trial Result question continues.

We hear the views from Dr Faz Fath-Ordoubadi from the Manchester Royal Infirmary Heart Centre

We examine the Radi FAME Trial results

We will speak with leading Cardiologists on their views and interview Dr Keith Oldroyd, a PI for the study.

Electrophysiology Special Edition

Featuring latest news, intriguing interviews, and specialised education articles from Mr Ian Wright.

JOURNALS


The COURAGE trial has been much de-bated including on the pages of this journal previously (Coronary Heart passim). The investigators have presented some longer term follow up data demonstrating a small improvement in patients whose stable angi-na was treated with PCI rather than medical therpapy.

William S. Weintraub and others, New Eng J Med Volume 359:677-687

Our anaesthetic colleagues seem very keen on Milrinone as a means of supporting post operative cardiac output. As it is a phos-phodiesterase inhibitor acting on second messenger pathways akin to aminophylline it shouldn’t be to much of a surprise that its use appears to be associated with high rate of atrial fibrillation. This is of note because atrial fibrillation in turn is associated with adverse outcomes.

Gregory A Flemming and others, Circulation. 2008;118:1619-1625

Two more contributions to the bare metal vs. drug eluting stent debate. A large obser-vational study attempted to match patients receiving DES and BMS in the context of acute MI by comparing a wide range of characteristics. The idea being that this data can then be compared almost as if the pa-tients had been randomised. The findings were a mortality reduction from 12.8% to 10.7% over two years. The data comes with a health warning-the authors recommend

confirming the findings with a properly ran-domised study.

Meanwhile a metanalysis in of trials involv-ing DES found that both paclitaxel and sirolimus eluting stents are safe in both dia-betic and non diabetic subjects. Only trials specifying at least six months dual antiplate-let therapy were included.

Laura Mauri and others, New Eng J Med Volume 359:1330-1342

Christoph Stettler and others, Brit Med J 2008;337;a1331

Left atrial ablation for AF consists of a step wise approach, first isolate the veins, then target areas of complex electrograms and finally divide the chamber with lines be-tween anatomical structures (linear lesions). The Bordeaux group published data show-ing surprisingly that patients who had to progress to step 3 actually did better than those whose AF terminated at step 1 or 2. The explanation seems to be that most ar-rhythmia recurrences after AF ablation are atrial tachycardia rather than AF and the lin-ear lesions prevent more of these events.

Sébastien Knecht and others Eur Heart J 2008 29(19):2359-2366

Ezetimibe seems to be a treatment looking for a disease at the moment. After some dis-appointing data in coronary artery disease an examination of its utility in combination with simvastatin at preventing progression

in aortic valve disease was assessed in a ran-domised placebo controlled trial. Unfortu-nately there was no reduction in end points such as need for valve surgery in the treat-ment arm despite a lowering of cholesterol and reduction in ischaemic events.

Anne B. Rossebø and others N Engl J Med 2008;359:1343-56..

Anaemia has been interesting heart failure doctors for some years now with elaborate interplay between uraemia, bone marrow is-chaemia and neurohormonal factors all pos-tulated as causal factors. An Austrian group however suggest it may all be a lot simpler than that, an increase in plasma volume and hence haemodilution is suggested by their study as the cause of apparent anaemia.

Christopher Adlbrecht and others European Heart Journal 2008 29(19):2343-2350

Implantable cardioverter defibrillator ad-ministered shocks are a powerful predictor of future poor outcomes. In a study of 269 ICD recipients over 45 months appropriate shocks were associated with a relative risk of death of over 5 and even inappropriate shocks a relative risk of almost 2 compared with those who received no shock. The risk remained elevated in those who survived over 24 hours and the most common cause of death was progressive heart failure.

Jeanne E. Poole and others N Engl J Med Volume 359:1009-1017

Journal Trawl

Dr John PaiseyClinical Fellow in ElectrophysiologyJohn Radcliffe Hospital, Oxford

- Dr John Paisey scans the world’s cardiology journals

ECHO CASE STUDY


Introduction:

Isolated non compaction of the left ventricle is a rare cardiomyopathy. It is relatively recently recognized entity categorized as “unclassified cardiomy-opathy” by the World Health Organization1. It is caused by failure of the developing myocardium to become compact thereby resulting in “spongy myocardium”.2 It may occur as a sporadic disease or be familial. This disor-der usually presents with signs and symptoms of cardiac failure3.We report a case of a young man, diagnosed at the age of 37 years of age, to have an isolated non compaction of the left ventricle.

Case Report:

The patient presented with a history of progressive shortness of breath for few months and features of congestive cardiac failure without any preced-ing history of any viral or bacterial infection. A loud systolic murmur of 4/6 intensity was audible best at the lower left sternal border. There were crepitations in chest and hepatomegaly.

Chest X ray showed cardiomegaly and plethoric lung fields. EKG showed features of left atrial enlargement and left ventricular hypertrophy. Echocar-diogram revealed dilated atrias and hypertrophied spongiform and poorly contractile left ventricle with an ejection fraction of 20%. Transmitral in-flow pattern was suggestive of restricted left ventricular filling. A moderate insufficiency of tricuspid valve was also seen. No abnormality of pulmonary valve and aortic valve was noted. The diagnosis was “restrictive cardiomy-opathy” with a systolic and diastolic dysfunction of the left ventricle. The patient was treated with antibiotics and duiuretics and was discharged.

He was reviewed at six months and continued to have signs of cardiac failure. He was placed on increased anti-congestive therapy with Digox-in, Captopril and Furosemide. An echocardiogram clearly revealed a non compaction type of left ventricular myocardial disorder. View Figure 1 and 2. Blood movement in the intramural recesses of the left ventricular cav-

Isolated Left Ventricular Non-compaction

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

Figure 1

Figure 2

ECHO CASE STUDY


ity were seen as demonstrated in Figure 3. There was systolic as well as diastolic dys-function of the left ventricle. Both atria were enlarged with moderate tricuspid and mitral regurgitation.

Discussion:

Isolated non compaction of the left ven-tricle is a rare disorder of endomyocardial morphogenesis characterized by numerous prominent ventricular trabeculations and deep intratrabecular recesses.3 It is supposed to result from failure of trabecular compac-tion of loose mesh of muscle fibers in the early stages of the myocardial development. Normally this process is more pronounced in the left rather than the right ventricle, re-sulting in a smooth and flat endocardial sur-face. The normal left ventricle has less than 3 trabeculations per imaging field, mostly confined to the lateral wall.4 In this disorder, however, there are abnormal trabeculations resulting from non compaction of myocar-dium scattered all over the myocardium, but most evident near the attachment of the

papillary muscles of the mitral valve.5

Echocardiography is the most valuable tool in the diagnosis of the disorder.6 Although MRI has been used by many clinicians.7

The combined echocardio-graphic features essential to make the diagnosis include a two layered ventricular myocardium consisting of an outer sub endocardial compact layer and a thick non compact endocar-dial layer with prominent

trabeculations and intratrabecular recesses; continuity between the left ventricular cav-ity and the recesses with blood flowing in and out from the ventricular cavity and absence of secondary causes of increased trabeculations.4

Clinical severity depends upon the extent of non compacted cardiac segments. Severe systolic heart failure and increased end di-astolic pressure with restrictive cardiomyop-athy is seen in more than 50% of patients. Bundle branch block, atrial arrhythmias and other serious ventricular arrhythmias are seen in 45% of cases and can cause sudden cardiac death.4

The genetic basis of this disease is not fully known, but both the isolated variety and the variety associated with other malformations are related with a mutation of the G 4,5 gene in Xq 28. The condition may be asso-ciated with Barth’s syndrome (neutropenia, impaired growth, increased organic acids in urine, low concentrations of carnitine and

mitochondrial anomalies), Emery-Dreifus muscular dystrophy, and myotubular car-diomyopathy. Familial occurrence is high, 44% of cases in the largest series. In the case of our patient, the cause of death of his mother was not determined and cardiologi-cal and genetic studies were not made of any other first-degree relative.

The disease is managed with conventional measures for heart failure, including antico-agulation and antiarrhythmic medications. Automatic defibrillator implantation has been reported. Finally, heart transplanta-tion is indicated, in accordance with current guidelines.

References:

Oechslin K, Jenni R. Isolated left ventricular myocardium: increasing recognition of this distinct, yet “unclassified” cardiomyopathy. Eur J Echocardiogr 2002; 3: 301-2.

Stollberger C, Finsterer J. Left ventricular hypertrabeculation/ non compaction. J Am Soc Echocardiogr 2004; 7: 91-100.

Chin TK, Perloff JK, Williams RG, Jue K, Mohrmann R. Isolated non compaction of left ventricular myocardium: a study of eight cases. Circulation 1990; 82:507-13.

Khan IA, Biddle WP, Najeed SA, Abdul Aziz S, Mehta NJ, Salana V, et al. Isolated non compac-tion cardiomyopathy presenting with paroxysmal supra ventricular tachycardia: case report and literature review. Angiology 2003; 54:243-50.

Varnava AM. Isolated left ventricular non compaction: a distinct cardiomyopathy: 2001; 86: 599-600.

Thuny F, Philip E, Caucino K, Ambrosi P, Jac-quier A, Avierinos JF, et al. Isolated non compac-tion of the left ventricle. Arch Mal Coeur Vaiss 2003; 96:339-43.

1.

2.

3.

4.

5.

6.

Meet Our New Echo Editor:

Mr Adam LunghiSenior Chief Cardiac Physiologist The Wellington Hospital, London

Adam is a graduate of the University of Western Australia with three ma-

jors in Pharmacology, Microbiology and

Molecular Biology. Post graduate studies lead him into diagnostic ultrasound with cardiology specialisation. Following the completion of a DMU from the Australa-sian Society of Ultrasound in Medicine he rapidly progressed to a senior position with strong understanding and applica-tion of advanced scanning techniques. Roles as a lecturer, examiner and co-editor

for the Ultrasound Bulletin shortly fol-lowed. He has spent time at institutions such as the Mayo Clinic, Royal Prince Al-fred and Massachusetts General Hospital. Currently Adam resides in the UK and is setting up and maintaining a noninvasive cardiac clinic.

Figure 3

SPECIAL FEATURE

Yvonne B. Singletary, RN, BS, RCIS, CCRN, CVRNSt. Luke’s Episcopal HospitalHouston, TXUSA

Recently I was enjoying lunch with three other colleagues, and the dis-cussion turned to a physician who

had misbehaved earlier that day. Four sepa-rate opinions emerged as to how the situ-ation should have been handled. The first person was over 60 years old. She said that she would have “blown his hair right back”. I am in my 50s. I said, “I would have waited to the end of the case, then have a serious discussion with the physician about the “ill behavior”. The next person was in her mid 30s. She said, “this is why I am looking for another job”. The last person was in their early 20s. That young man said, “payday is still Friday, ain’t it?” It was then that I real-ized the significance of working in a multi-generational workplace. I also realized that the differences in these generations could well affect the functioning of our organiza-tion and Cath Labs in general. This article attempts to address the challenges faced by Cath Lab professionals as they work side-by-side coming from a variety of generational cohorts. This article also hopes to address how to recognize the rich diversity of these generational perspectives, and realize when valued, nurtured, and integrated, can lead to a more creative, functional, and adaptable work environment.

I work in a large metropolitan multiroom Cath Lab. There are 55 technical and nurs-ing staff members here. The staff ranges in age from the early 20s to the mid 60s. The physicians range in age from the early 30s to the mid 70s. At St. Luke’s we have 11 Cath Labs with 10 labs up and functional on any given day. I am Room Leader of a very active coronary room.

Our staff is cross-trained and comes from varied allied health professions. Among the professions are RNs, LVNs, Radiology Tech-nicians, Respiratory Therapists, Circulatory Support Technicians, and Cardiovascular Technicians (both CCVT and RCIS). As varied as the professions are, the generations are just as varied. There are four generational cohorts. There are those from the Veteran generation, Baby Boomers, Generation X, and the Millennial Generation (or Nexers).

The first generation is the Veterans. These individuals have birthdates between 1925 and 1945. There are very few Veterans in our Lab, but they are here and vocal. These people grew up during an era of political and economic uncertainty. It has led them to be hardworking, financially conservative, and cautious. This generation has seen what has and hasn’t worked over the years and look to the past for guidance. Organizational loyalty is important to this generation, and they feel seniority is important to advance in one’s ca-reer (Carlson, 2005: Halfer, 2004: Ulrich: 2001). They tend to be respectful of author-ity, supportive of hierarchy, and disciplined in their work habits (Sherman, 2006).

Working in a Cath lab is physically challeng-ing at best. Wearing lead and standing long hours can lead to conflict between some veterans and other generations. Issues crop up with fair division of labor. The younger

generations can clash with the Vets about the amount of time spent out on the floor in lead. Vets often feel that the younger gen-erations should be more respectful of their wisdom and experience. The challenge rests with the management of the Lab to create an acceptable middle.

The second group is Baby Boomers. These individuals were born between 1946 and 1964. Baby Boomers grew up in a healthy post-war economy. For the most part, they grew up in two-parent households where the father earned the family income and the mother was the home caretaker. The at-tention and prosperity afforded the Boom-ers, along with changing world and societal values, created an emphasis on freedom to be yourself and the “me” generation. Lack of conformity to the old rules became an established pattern. Longstanding soci-etal rules and expectations were examined and altered, creating the assumption in the minds of Boomers that they should question authority and that the status quo could be transformed by working together (Lancas-ter& Stillman, 2002). Boomers are known for their strong work ethic, and work has been a defining part of their self worth and their evaluation of others (Greene, 2005; Sherman, 2005). This strong work ethic can make the Boomer appear hypercritical of others, setting the stage for conflict. In nurs-ing, this group is the largest cohort in the workforce (Buerhaus, Staiger, &Auerbach, 2000; Thrall, 2005). This is not true for the Cath Lab staff of mixed professionals. The majority of cath lab professionals fall into the Generation X group (Cath Lab Digest 2008). Significant numbers of Baby Boom-ing Cath Lab professionals will be eligible to retire beginning 2010, increasing the num-bers of Xers even more.

Multigenerational Conflict in the Cath Lab



‘Cath Lab management would do well to study and recognise generational strengths and shortcomings...’

SPECIAL FEATURE

The third group is Generation X. These individuals were born between 1963 and 1980. This was the first generation where both parents were likely to work outside the home and many were raised as latchkey kids. Rising divorce rates resulted in 40% of Gen-eration X children being raised in a single parent household (Strauss &Howe, 1991). As a result many Xers learned to manage at a young age, becoming adept, clever, and re-sourceful. Their friends became increasingly important, as well.

Their formative experiences, including ex-posure to massive corporate layoffs, have led them to value self-reliance and work- life balance. They are described as less loyal to the corporate culture (Karp et al.). Technol-ogy is a major part of their lives. Generation X tends not to understand why the older generations cannot readily embrace chang-ing technology. This technogap can be a source of conflict in the Lab, with Labs be-coming more reliant on sophisticated com-puter technology. The last group is the Millennial generation or the Nexers. They were born between 1980 and 2000.

Strengths the Nex generation brings to the workplace comprise their techno com-petence, openness to expectation of vir-tual teams, ands collective action (Howe& Strauss, 2000; Kupperschmidt, 20001). They were raised in a time where violence, terrorism, and drugs were realities of life. This is a global generation and accepts multiculturalism as a way of life. Technol-ogy and instant communication by cellular phones have always been part of their lives. This generation has been compared to Vets in their work ethics.

Gerke (2001), and Duchsher and Cowan (2004), have stressed the importance of all staff learning about colleagues’ differences and dialoging about how generationally de-termined values and expectations are being played out in their organizations.Traditional colleagues value hard work and respect authority whereas Boomers value teamwork. Generation Xers value self-reli-ance and Net Generation values achieve-ment.

It is important to stress Cath Lab profes-sionals do not have to adopt colleagues’ generational values; but they do have to recognize, allow and respect these different values.

Generational conflict is nothing new. Gen-erational gaps have always been a part of our world, bringing with them the poten-tial for flash points or areas of disagreement (Greene, 2005) In 1 Kings, Chapter 12, of the Holy Bible, Rehoboam, the young king of Israel, rejected the advice of his elders (men of his father’s generation) and took the advice of younger men (his generation). This generational conflict split the nation of Israel. More recently, the presidential cam-paign of 2008 is setting historical precedents on many levels, with generational differences not being the least of these. One of the reasons working in a Cath Lab is challenging is because of the many varied professions that must work as a close team on a daily basis. Cross training of individuals in the Lab has helped make the workplace a more collegial and functional atmosphere. However, there has been no cross training for a multigenerational workplace. The best teams must be able to pull the strengths and contributions from individuals and their generational cohort’s skills and strengths.

Cath Lab management would do well to study and recognize generational strengths and shortcomings and use the information to properly place personnel and develop the best teams. Too ignore generational differ-ences and place teams together solely on the basis of professional training can be a recipe for conflict the Lab as a whole may find dif-ficult to digest. It is important that every employee is held to the same work expec-tations, organizational policies and proce-dures. However, leaders should also consider individual employee needs and generational differences.

ReferencesBuerhaus, P.I., Staiger, D.O., & Auerbach,D.I. (2003). Is the current shortage of hospital nurses ending? Health Affairs, 22(2), 191-198.

Carlson, S. (2005). The Net generation in the classroom . The Chronicle of Higher Education, pp.A34-A37.

Cath Lab Digest 2008

Gerke, M. (2001). Understanding and leading the quad matrix: Four generations in the workplace. Seminars for Nurse Managers, 9, 173-181.

Greene, J. (2005, March 14). What nurses want: Different generations, different expectations. Hospitals and Health Networks. Retrieved from www.hhnmag/hospitalconnect/search/article.jsp?

Halfer, D. (2004). Developing a multigenerational workforce. Paper presented at the annual meeting of the American Organization of Nurse Executives. Phoenix , Arizona.

Holy Bible, 1 Kings, Chapter 12

Karp, H. Fuller, C., & Sirias, D. (2002). Bridging the Boomer Xer Gap.Palo Alto: Davies-Black.

Lancaster, L. & Stillman, D. (2002). When genera-tions collide. New York: HarperCollins.

Sherman, R. O. (2005). Growing our future nurse leaders. Nursing Administration Quarterly, 25(2), 125-132.

Strauss, W., & Howe, N. (1991). Generations. New York: Quill William Morrow.

Thrall, T. H. (2005). Retirement boom? Hospitals and Health Networks, 79(11), 30-38.

Ulrich, B. T. (2001). Sucessfully managing a multi-generational workforce. Seminars for Nurse Managers, 9(3), 147-153.

Multigenerational conflict in the Cath Lab (cont...)

About the Author

Yvonne B. Singletary is an RN with 34 years of nursing experience. The last 18 years have been spent in the Cardiac Cath Lab at St. Luke’s Episcopal Hospital in Houston, Texas. St. Luke’s is in affiliation with Texas Heart Institute. She is Room Leader in a room that specializes in cardiac diagnostic and interventional cases.She can be reached at [email protected]


SPECIAL FEATURE

The world of Generational theory is vast and often unsatisfactory in pro-viding answers. In this short arti-

cle Christopher Lomas and Heledd Straker (both from Naked Generations, a London based consultancy and think-tank) provide some practical observations around why dif-ferences occur and how they can prove to be complimentary! They address three areas, and show how ‘Environment’, ‘Education’ and ‘Online’ have all affected the expecta-tions Generation Y have about workplace environments.

Maslow and Generations

Why do we work? Security? A sense of identity? Self-fulfilment? Each generation is motivated by a set of needs and thus creates an environment which satisfies them. From this new world the next generation arises with a different set of needs. The causal re-lationship between generations’ motivations can be mapped onto Maslow’s Hierarchy of Needs. Maslow explains that different needs grow out of each other, beginning with physiological, then safety, belonging, esteem and finally self-actualisation.

Baby Boomers (1946-1964), cultured by Builders (1925-1945), grew up in the af-termath of the Second World War, so when they embarked on their career, they sought security in a job (with the provision of in-come for their families – hence why we have seen 25-30 year loyalties to one firm). The world was more stable by the time Genera-tion X (1965- 1978) entered the workforce, satisfying the lower two needs, meaning they were motivated by a need for belonging (also further enforced by the divorcing of large numbers of their parents). Generation Y (1979- 1995) growing up in a ‘love’ cul-

Leveraging Generational Variety at Work

CORONARY HEART ™ 1�

SPECIAL FEATURE

1� CORONARY HEART ™

ture, and with all three of the lower needs cared for by their Baby Boomer parents, are seeking a world in which their esteem is built up. Negative feedback is very difficult for them to take.

These levels are non-exclusive and build on each other, and each generation is pushing for the next layer. For example, Generation X seeks a sense of esteem too, Generation Y wants self-actualisation, and Baby Boomers searches for both as well. This suggests that each generation’s desire is driven by envi-ronmental privilege. From a business per-spective, therefore, those that will be suc-cessful in retention strategies, will be those that satisfy the next layer for their employ-ees. To extrapolate further, an economic depression or a World War, could re-start a group of generations at the lowest level of the pyramid.

Ask me, don’t tell me

A key concept linking cross-generational tension and harmony is Education styles. Boomers and Builders have been taught us-ing a didactic (instructive) style of educa-tion (“what I tell you is the truth”). Gen-eration X and Y, products of ‘The Plowden Report’ (1967) which encouraged ‘critical analysis’ and thought processes in schools, rarely accept the ‘truth’ as is (e.g. “what I tell you is probably not the only or best truth, so find other sources to prove or disprove it”). With Generation Y’s questioning na-ture, Baby Boomers may feel their norms are challenged. By understanding that Gen-eration Y is constantly evaluating processes and behaviours, and seeks to improve its environment by testing these with a wide audience to gain feedback, they can jointly build upon what is already in existence. The intent here is positive. Tensions may occur, as Generation Y is seen to ‘know it all’ and Boomers are seen as bossy, backward and slow. By teaching employees how the differ-ent generations think and learn, mutual un-derstanding and harmony can be achieved.

Can I lead too?

Finally, Leadership in one generation means ‘Command and Control’ and at the other

end of the demographic ‘Mash-up’ leader-ship has been the style that is adopted. How has this happened and can mash-up styles work effectively?

In traditional (Builder/ Veteran) environ-ments leadership is based on ‘authority’ structures that are generally linked to years of service or where individuals sit in the or-ganisational structure. This became less in the team-focussed environments ushered in under the Boomers, but has completely shifted in recent years towards what we have come to call ‘Mash-Up’ leadership, by Gen-erations X and Y.

Mash-up leadership goes against the grain of traditional ‘fixed’ hierarchies; it is based on the ability to be a leader in the delivery of value in a particular task, and doesn’t as-sume long periods of leadership by any one person. This theory is particularly modelled in online gaming environments (MMOR-PGs), in which leadership rarely belongs to one person for any extended period.

In conclusion, Maslow’s theory highlights how technological, socio-economic and po-

litical environments affect the different rea-sons for generations to be in business. The ‘stacking’ nature of Maslow’s pyramid sug-gests that the provision of an environment in which the lower layers are assumed will produce higher expectations for subsequent generations, and also how a shift in envi-ronment can re-start the expectations for a generation. Secondly, a shift in learned be-haviours, even at the most junior levels of education, has created subliminal expecta-tions around how these same ‘pupils’ should challenge data when they enter the work-place. Finally, online environments have provided arenas for experimentation for a generation of digital natives, which has af-fected the way in which they like to be led, and like to lead.

For more information go to: www.nakedgenerations.com/blog; or email Christopher ([email protected]) or Heledd ([email protected])

Leveraging Generational Variety at Work (cont...)

ECG QUIZ


The ECG shows a broad complex tachy-cardia. In an acute setting broad com-

plex tachycardia is assumed to be VT unless proved otherwise and the patient treated on the basis of symptoms.

Th e diff erential diagnosis of broad complex tachycardia includes:

VTSVT (including atrial fl utter) with aberrant conduction – either bundle branch block or accessory pathwayAntidromic AVRT

Detailed algorithms to aid the diff erential diagnosis of broad complex tachycardias ex-ist1 but clues to the diagnosis come from:

Identifi cation of dissociated atrial (p wave) activity and capture/fusion beats.Whether the QRS morphology is consistent with or diff erent from activation by elements of the normal conduction systemSimilarity of the QRS morphology to known VT types.

1.2.

3.

1.

2.

3.

In this example atrial activity is diffi cult to identify but I have pointed out in the fi gure what may be dissociated p waves (there is not one p wave for every QRS). Dissociated p wave activity is indicative of VT.

Outfl ow tract tachycardiasTh e complexes are markedly positive in the inferior leads (inferior axis) suggesting a superior origin with a left bundle branch block (LBBB) morphology. Th is is typi-cal of outfl ow tract tachycardias. Both the right ventricular outfl ow tract (RVOT) and left ventricular outfl ow tract (LVOT) are su-perior cardiac structures, the RVOT being slightly more superior (and anterior) than the LVOT. Both are sites for idiopathic VTs. RVOT tachycardia is more common than LVOT but both may present in patients without structural heart disease and appear to share a common mechanism (focal trig-gered activity)2.

Th e similarity of the VT morphology to left or right bundle morphology is often used to place the origin of ventricular activation in the left or right ventricle: LBBB indicating right ventricular origin, RBBB indicating left

ventricular origin. However VTs originating from struc-tures near the septum) are more variable. In fact both RVOT and LVOT present with LBBB.

Th e precordial R wave tran-sition (the most biphasic chest lead) can provide clues to distinguish LVOT from RVOT VT. Precordial R wave transition in V1 or V2 suggests LVOT VT . RVOT VT produces a transition in V3 or V4. In this example the most biphasic lead is V1 suggesting LVOT which was confi rmed at electrophysi-ology study. Where the R wave transition is in V3 the arrythmia can be RVOT or LVOT and additional fea-tures of the ECG must be examined.

For more information see (3,4,5,6)

References

Brugada P, Brugada J, Mont L, et al: A New Approach to the Diff erential Diagno-sis of a Regular Tachycardia With a Wide QRS Complex. Circulation 1991;83:1649-59Iwai S, Cantillon DJ, Kim RJ et al: Right and Left Ventricular Outfl ow Tract Tachy-cardias: Evidence for a Common Elec-trophysiologic Mechanism. J Cardiovasc Electrophysiol. 2006;17(10):1052-58Hachiya H, Aonuma K, Yamauchi Y, et al: Electrocardiographic characteristics of left ventricular outfl ow tract tachycardia. PACE 2000; 23:1930-34Josephson ME, Callans DJ: Using the twelve-lead electrocardiogram to localize the site of origin of ventricular tachycardia Heart Rhythm 2005 Apr;2(4):443-6.Natale A.: Ventricular Tachycardia from the Aortic Sinus of Valsalva. JAAC 2001:37:1408-1414 Hachiya H, Aonuma K, Yamauchi Y et al: How to diagnose, locate, and ablate coro-nary cusp ventricular tachycardia. J Cardio-vasc Electrophysiol. 2002 Jun;13(6):551-6.

1.

2.

3.

4.

5.

6.

See original question on page 9

ECG Quiz AnswerIan Wright

MANAGEMENT


Finger on the Pulse

Courses in Hospital Management and MBA’s are common prerequisites in the USA for those wanting to become a cardiac department manager or administrator. Is this a good idea?

Stephen WeymouthCardiology and Radiology ManagerHarley Street ClinicLONDON

Do you believe courses like this would assist you in your current position?

I believe that a lot of excellent clinicians are placed in management positions due to their clinical abilities and not their manage-ment skills. Th is can become a burden on the department as their clinical skills are no longer utilised and their ability to manage people compromised due to unfavourable personality traits. In order to develop and grow as a manager you need to acquire the essential skills and knowledge provided by a management program which exposes you to diff erent management styles and tech-niques. Th ese skills enable you to recognise and eliminate potential issues that arise by adopting a leadership styles that best suits a situation and/or personnel in order to achieve maximum benefi ts. All too often the manager has been promoted within the organisation after a substantial tenure but lacks the knowledge and education to recog-

nise the importance of implementing change when needed which can lead to a stagnated department. I am studying an MBA because I believe the only way i can develop and en-hance my department is by developing my-self fi rst. I believe that the MBA is and will continue to give me a holistic view of the es-sential techniques required to run a depart-ment eff ectively by equipping me with an understanding in the areas of fi nance, lead-ership, operations, organisation behaviour, and change management. Th is combined with my existing clinical expertise can only benefi t myself, the employees, department as well as the organisation. Th is is not to say there are is no such thing as a born leader because there certainly is, however by gain-ing an insight into other areas of business you put yourself in a more favourable po-sition to understanding and communicate information to others. “You can never become too qualifi ed for your job“ - Jim Collins

Does your hospital have training programs in place for clinical staff stepping into the role of a manager?

Harley Street Clinic encourages and pro-vides management opportunities for its employees , the level of which depends on your current role and level of management experience.

Mrs Sue BrownCardiac Specialist NurseRoyal Bolton Hospital NHS Foundation Trust BOLTON


I am currently undertaking an MSc in coronary care nursing having almost fi nished (just on dissertation). Th is course has been valuable having kept me up to date with all current research and health care issues. One of the rea-sons i have subscribed to your journal is to widen my knowledge within car-diac care. Th e course has also helped me develop my clinical skills. my hos-pital have been very supportive of me by providing me with both the fund-ing and the study time to undertake the course. As a senior nurse, my job description states that i must be edu-cated to Masters level which i think is only right for the amount of re-sponsibility i have. Th e hospital likes senior nurses and managment to have a sound knowledge base which ulti-mately benefi ts patient care.

Th e current political climate and drive towards the provision of evidence based practice requires practitioners working within the NHS use research to underpin their practice. Education-al courses help reduce the research-practice gap which contributes to the modernisation and improvement agendas.

MANAGEMENT


Karen WaferCath Lab Matron / ManagerCardiac Catheter LabsLiverpool Heart and Chest HospitalLIVERPOOL

Liverpool Heart and Chest Hospital – NHS Trust (formerly The Cardiothoracic Centre Liverpool NHS Trust) provides a level 3 Leadership and Management course worth 15 credits. It is a work based learning pro-gramme and is accredited by John Moores University. The training is delivered in house by the Trusts team of Clinical Practice Fa-cilitators with the assistance of Senior mem-bers of staff from the various specialist areas; ECG, ITU etc.

It is a 13 week course and staff are identified for it by their Ward Managers as part of the PDR / CPD process. It is focused on Man-agers who are currently in post without such additional qualifications and made that step from a more clinical role and also those more junior staff who wish to develop their skills and are identified as having the potential to progress in to such roles in the future.

I completed a Leadership and Management course (whilst with a previous employer) that was run externally by the Institute of Leadership and Management (ILM).

In my current role there are many challenges which I find enormously motivating. The course I did has undoubtedly assisted me to step up to the challenges I face everyday in such a rapidly changing environment.

I now recognise the need to have an overall understanding of the Trusts business objec-tives which enables me to ensure the Depts objectives and those of the staff fit in with the bigger plan.

A key part of my role is to ensure that the Dept is effective, efficient and resourceful with quality being a key priority.

Courses that provide you with the theoreti-cal knowledge and practical guidance on im-proving your ability to communicate, nego-tiate and motivate staff are essential. To be given the skills that allow you as a Manager to invest and develop the skills of your staff is extremely rewarding. I am lucky to have a great nursing team whose focus is provid-ing the highest quality service we can to the patients in our area. Without the necessary development and investment in the team, patient care cannot improve.

These qualifications for Managers; along with clinical experience and the right atti-tude consolidate your skills and enable you and your team to progress both personally and professionally and this undoubtedly im-proves the service we are able to provide to our patients.

Greg Cruickshank Superintendent Radiographer Cardiac Catheter Suite King’s College Hospital NHS Trust. LONDON


I do believe that post graduate manage-ment qualifications such as DMS, or MBA are useful qualifications than can help equip any manager with the right tools to do the job. However just as pos-

session of a driving license doesn’t guaran-tee you will be a good driver, having man-agement qualifications will not guarantee one becomes a good manager. Not having qualifications will not automatically make you a bad manager either. Historically here in the UK staff filling middle management roles in the health service often come from a clinical rather than administrative backgrounds. Whilst it does not always follow that by rising to the top of your clinical field you will have a flair for management, a good clinical grounding can also help prepare you for future management roles.

I personally do not have any post-gradu-ate management qualifications, although I do have a strong industrial relations back-ground. I feel that if I wanted to move on managerially (I don’t), I would almost cer-tainly have to rectify that gap in my CV. I guess the debate is, would that then make me a better manager (I don’t know)?


Here at King’s we have a Management Training Unit that offers various courses for staff taking management roles for the first time. In addition to this, there is sup-port (both financial and time off) for staff doing higher degrees (both management and clinically based). A strong perform-ance management culture also helps en-sure that managers in post are properly performing the tasks asked of them.

The current and two previous Radiology Service Managers at King’s have MBA’s. The two I spoke to mention both the fi-nancial and strategy elements of their re-spective courses have proved helpful, and both feel the time and effort that went into getting the qualification is worth-while. I look forward to hearing the views of others.

MANAGEMENT

Lynne Jones Director, Cardiac Cath LabMemorial Hermann Heart & Vascular InstituteHOUSTON, TX USA


Management or administrator posi-tions should require an education plan for management positions. Busi-ness courses are important to any de-partment manager or administrator. As we all know, hospitals promote the best clinicians to manage departments. Clinical education programs focus on clinical expertise There is very little operational (business) focus. I believe that business education is very impor-tant because leadership includes fiscal management, business development, and human resource management.


Memorial Hermann Hospital System has a comprehensive management orientation. Classes cover all aspects of management including spiritual leadership. New managers and di-rectors are required to complete the curriculum within 2 years. Memorial Hermann’s commitment to leadership development contributes to the suc-cess and quality of care the System is known for.

Courses in Hospital Management and MBA’s. Are they a good idea? (cont...)

Margaret Deyo Allers RN BSN MSN ANPDirector of Cardiac Services and Clinical PracticeSt. Luke’s Cornwall HospitalNEWBURGH, NYUSA

I definitely have a strong opinion regarding management courses for cardiac manag-ers or administrators. I have my Masters in Nursing as an adult nurse practitioner, with a Minor in Nursing Administration, and I believe the financial, business, and leader-ship courses that were required were respon-sible for my successes in management. I feel you need to be financially savvy and have a strong business sense if you are going to make appropriate decisions when manag-ing a hospital unit or service line; I believe it broadened my perspective on business op-portunities and challenges.

Twenty years ago a nurse manager of a unit had a primary focus to ensure patients were taken care of in accordance with hospital pol-icies and regulatory agency standards, make sure staffing was appropriate, develop staff-ing schedules, and discipline when needed; and now, in addition to all the staffing and patient care issues we are also involved in the cost benefit decision of the organization, es-pecially that which surrounds patient care.

We need to understand the overall budget, the FTE factor, the non salary items, con-tracts, negotiate with vendors, and in addi-tion oversee the quality of care within the department. Business decisions regarding our clinical areas are formulated through myself for my areas as well as my colleagues for their areas of responsibility. The expecta-tion from our executive team is that we have a complete understanding of the costs and revenue that we bring to the organization and are accountable. We are accountable to the financial stability of our department and you just can’t do that without the business sense which you can, I believe, only obtain by attending courses, seminars, conferences etc.

I am part of the strategic planning of the organization and I would not be effective, I don’t believe, if I didn’t have a minimum

of 20 college credits in management on my CV. My nursing education alone did not provide me with the resources I needed in order to run several departments within the organization, while meeting the organiza-tions expectation. Through the ongoing training, seminars, conferences and the twenty or so credits of college courses, I was able to achieve a level of comfort as a player in formulating business decisions involving my clinical areas. This hospital believes in growth and development of their manag-ers, and all managers are expected to have a fiduciary responsibility to their unit. In order to assure this occurs we offer on-going management training throughout the year to all managers, including a new manager’s orientation program.

Although I strongly believe that managers need to have full understanding of the oper-ational requirement of the clinical unit; the manager needs to remain clinically savvy; I also believe that without a business sense in this difficult health care climate, you would never be able to move on managing issues unless you take into consideration those fi-nancial constraints placed upon health care.

Matthew Gibson, FACHEAdministrationUniversity HeartUniversity of Mississippi Medical Center, JACKSON, MSUSA

Formal healthcare management train-ing is extremely valuable for leaders of cardiac programs. I possess an MBA and MSHA. This education and my internship and residency experiences provided a firm foundation for me.


MANAGEMENT

Bryan Walker HDCR MDCR FAETC SRR (R) MBASuperintendent RadiographerManchester Heart CentreMANCHESTER


Between 1990 and 2005 I have had the priv-ilege of undertaking several senior manage-ment roles within hospitals in Manchester. Having returned to radiography in 2005, I have recently gained promotion to the posi-tion of superintendent radiographer in the catheter laboratories of Manchester Royal Infi rmary.

As part of my management education, in 1998 I gained an MBA from the Business

School of Manchester Metropolitan Uni-versity (MMU). Th is course contained ex-tremely valuable insights into budgeting and stock control, fi nancial analysis, negotiating skills and marketing to mention just a few aspects. I found that the course helped me mostly by improving my self-confi dence and background knowledge, making it more un-likely that I would be ‘blinded by science’ when confronted by specialists from diff er-ent fi elds.

Another signifi cant advantage is the em-phasis on presentation of results, fi ndings, opinions and projects to one’s peers and lec-turers within the course. Th is has had an impact on my ability to remain calm when faced with a similar requirement and a short deadline.

I expect the role of the cardiac departmental manager in the USA is signifi cantly diff er-ent from the role of the catheter lab superin-tendent radiographer in the UK. Whilst all the above reasons would propose that such a course is a good idea, and I strongly be-lieve that education is never wasted, I feel an MBA is unnecessary for the role that I now undertake.

Letter to the EditorIn response to the “What Price for Staff Motivation” article written by Mohammed Sankoh in Edition 14 (Sept/Oct)

Just emailing to say that was a won-derful article in Coronary Heart. I

have been a victim of this favortism system for many years. Th ese manag-ers and god forbid its one who was of your same rank do everything possible to keep you down. Th ey give fake an-nual evaluations, spread lies, etc. Th e place I was at last the girls mother-in-law was a big wig in corporate. No experience in echo yet they wanted to make her a technical director of a lab over people with 12 years experience.

- Name withheld.


CRM


This education article is proudly provided by

It is widely accepted that long term RV apical pacing has detri-mental effects on the myocardial function and, as a result, the clinical outlook for patients. RV apical pacing facilitates an

unnatural and unfamiliar depolarisation pathway giving an electro-physiological left bundle branch block appearance on the surface ECG. It is this unusual pathway that allows for remodelling of the LV. Le Clercq et al 1 reported this remodelling as thinning of the areas of myocardium which were activated earlier than normal and a characteristic thickening of the areas which were activated later than normal. The clinical picture of such patients is one of reduced

systolic function, increased hospital admissions, worsening of CHF and increased incidence of AF. It is widely accepted that haemody-namically significant intrinsic activation is the gold standard where possible in patients requiring permanent pacing. The DAVID trial 2 was a landmark study that randomised ICD patients (no brady indication) to DDDR with a low rate limit of 70bpm or VVI pacing at 40bpm. It was predicted that the DDDR group would have improved haemodynamics due to the nature of dual chamber pacing and the AV synchrony; however, it was the

CharacteristicsDanish Study

(2�1)PASE(23)

CTOPP(2�2,2�4,2�5)

MOST(22, 31, 4�, 4�,

2�6, 2��)

UK-PACE(2�3)

Pacing Indication SND SND and AVB SND and AVB SND AVB

No. of patients randomised

225 407 2568 2010 2021

Mean follow-up (years)

5.5 1.5 6.4 2.8 3

Pacing modes AAI vs. VVI DDDR* vs. VVIR* DDD/AAI vs. VVI(R) DDDR vs. VVIR* DDD(R) vs. VVI(R)

Atrium-based pacing superior with respect to:

- Quality of life or functional status

NA SND patients: YesAVB patients: No

No Yes NA

- Heart FailureYes No No Marginal No

- Atrial FibrillationYes No Yes Yes No

- Stroke or thromboembolism

Yes No No No No

- MortalityYes No No No No

Cross-over or pacing dropout

VVI to AAI/DDD: 4%AAI to DDD: 5%AAI to VVI: 10%

VVIR* to DDDT*: 26%

VVI(R) dropout: 7%DDD/AAI dropour: 25%

VVIR* to DDDR*: 37.6%

VVI(R) to DDD(R): 3.1%DDD(R) dropout: 8.3%

RV Pacing – How Low is Low Enough?

Table 1 – Randomised trials comparing atrial based pacing with ventricular based pacing

CRM


DDDR group who had increased all cause mortality at the one year follow up. It was demonstrated that the poor performance of the DDDR group was related to the high percentage of RV pacing. Olshamsky et al 3 challenged these findings when he presented his findings of the INTRINSIC RV trial at the HRS meeting in 2006 when he claimed that the high rate of RV pacing was to blame and not the device itself. He hypothesised that by utilising algorithms to minimise RV pacing, dual chamber pacing would equal or better single chamber pacing. INTRINSIC RV looked at 1530 patients implanted with a dual chamber ICD, patients with very high pacing rates were excluded and a remain-ing 988 patients were then randomised to DDDR with an AV search hysteresis algo-rithm programmed on and the other group were programmed VVI 40bpm back up pac-ing. There was a definite trend in favour-ing the DDDR group and a trend towards superiority of this group, although the study design was not powered to detect superior-ity. From these results, we could surmise

that DDDR pacing with an AV hysteresis algorithm to minimize RV pacing is an ac-ceptable method of pacing 4 5

The MOST study 6 in 2002 was a 6 year trial which compared VVIR with DDDR with an end point of non fatal stroke or death from any cause, the outcome was a significant reduction in hospitalizations in the DDDR group. Sweeny et al 7 used a study population extracted from this study to look at the effects of DDDR and VVIR pacing on heart failure hospitalization and AF. The results showed an obvious linear re-lationship between the percentage of V pace and the increased risk of AF and heart failure hospitalization. He revealed that the extent of increased risk of AF was 1% for each 1% increase in V pace. He also demonstrated that the risk of heart failure hospitalization increased 2.5 fold when ventricular pacing reached 80% or more. However, heart fail-ure hospitalizations can be reduced to 2% by reducing pacing to less than 10%.

An interesting question then arises, should pacing therefore be as low as possible? Ad hoc analysis of the available data would sug-gest that too little pacing could also be det-rimental and the lowest rates of death and hospitalisation appear in the 10 – 19% RV pacing group 4. It is vital to consider the patient when making assumptions regarding the necessity of pacing. For example, some patients with a definite pacing indication will require some degree of pacing, this is an inevitable situation in patients with symp-tomatic bradycardia. It would be unaccept-able to assume that these patients would require the same degree of pacing minimi-zation strategies as those with a pure ICD indication. It is also unlikely that in order to reduce the possible risk of heart failure and AF you would sacrifice the primary function of the pacemaker – to pace during episodes of symptomatic bradycardia, especially since this is the likely primary indication for the device. It would seem acceptable that in these patients that it is the haemodynamic significance of the electro-mechanical event

Table 2Kaplan-Meier rates for freedom from first HFH by percent

ventricular paced during the first 30 days. a, DDDR mode; b, VVIR mode

Table 3 Kaplan-Meier rates for freedom from first documented

incidence of atrial fibrillation by percent ventricular paced during the first 30 days. a, DDDR mode; b, VVIR mode

CRM


RV Pacing - How Low is Low Enough? (cont...)

that should dictate whether or not intrinsic or paced events are preferred.

The main aim would appear to be to pro-gramme an optimal AV delay to encourage appropriate and haemodynamically sig-nificant intrinsic ventricular depolarization rather than artificial paced depolarization.

The normal AV interval is 120 – 210 ms 8 with AVI (sensed) 30 – 50 ms shorter than AVI (paced). Von Knorre et al 9 examined this concept of programmable AV delays in DDD pacemakers with 200 patients using left atrial electrography, in an attempt to de-fine a programmability standard. He found that in atrial sensed stimulation the optimal AV delay was between 40 – 205 ms and in atrial paced stimulation the optimal AV de-lay was between 85 – 245 ms

It could be proposed that programming a long AV delay will inevitably uncover some form of underlying intrinsic rhythm. This was investigated by Neilson et al10 who ex-amined sick sinus syndrome patients with normal AV conduction who were rand-omized to AAIR and DDDR with a fixed long AV delay. Although these fixed AV delays were effective in 2/3 of patients, 1/3 of patients suffered sub optimal pacemaker function and were more at risk of pacemaker arrhythmias. Long AV delays can impede ap-propriate DDDR function such as delayed AF detection, impaired mode switching and susceptibility to Endless Loop Tachycardia.

From a physiological standpoint AV delays that are too long can shorten filling time and therefore negatively impact on cardiac output. Conversely AV delays that are pro-grammed too short will not allow for intrin-sic rhythm and will inevitably give way to more pacing.

Optimization of the AV delay is a means of uncovering intrinsic rhythm which restores the hearts natural and effective depolariza-tion pathways. Considering that a properly timed AV delay can contribute to between 13% and 40% of the cardiac output, it would seem that this is a worthwhile aspect of programming11. All devices should of-fer some kind of algorithm or programming option which allows for as much program-mability of these parameters as possible in order to maximize the cardiac output and reduce the complications associated with RV pacing. It is also clear that there is no single answer to the difficulties that RV pacing imposes. Perhaps there is no magic number which pacing needs to fall below to ensure patients have a positive response to the device. Search hysteresis algorithms have the potential to adjust and respond to individual dynamic patients rhythms and continually self optimize in order to quickly react to any changes the patient may experi-ence. With intelligent device programming it should be possible to limit the dreaded negative outcomes associated with RV api-cal pacing.

References

LeClercq C, Gras D, Le Helloco A, Nocil L , Haemodynamics importance of preserving the normal sequence of ventricular activation in permanent cardiac pacing, Am Heart J 1995 129 1133 - 1141

Sharma AD, Rizo-Patron C, Hallstrom AP, et al; DAVID Investigators. Percent right ventricular pacing predicts outcomes in the DAVID trial. Heart Rhythm. 2005;2:830-834

Olshansky B, Day JD, Moore S, et al. Is dual chamber programming inferior to single cham-ber programming in an implantable cardioverter defibrillator? Results of the INTRINSIC RV study. Program and abstracts from the Heart Rhythm Society 2006 Annual Scientific Ses-sions; May 17-20, 2006; Boston, Massachusetts

Olshansky B, Day J, McGuire M, Hahn S, Brown S, Lerew DR. Reduction of right ven-tricular pacing in patients with dual-chamber ICDs. Pacing Clin Electrophysiol. 2006;29:237-243

Gardiwal A, Hong Yu, OswaldH, Luesebrink U, Ludwig A, Pichlmaier AM, Drexler H, Klien G, Right ventricular pacing is an independent predictor for ventricular tachycardia / ventricular fibrillation occurrence and heart failure events in patients with an implantable cardioverter defibrillator, Europace 2008 10 (3) 358 -363

Link MS, Hellkamp AS, Estes III NAM, et al., for the MOST Study Investigators. High incidence of pacemaker syndrome in patients with sinus node dysfunction treated with ven-tricular-based pacing in the Mode Selection Trial (MOST). J Am Coll Cardiol 2004;43:2066–71.

Sweeney MO, Hellkamp AS, Ellenbogen KA, et al. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunc-tion. Circulation. 2003;107:2932–2937

S. S. Barold Adverse effects of ventricular desynchronization induced by long-term right ventricular pacing J. Am. Coll. Cardiol., August 20, 2003; 42(4): 624 - 626.

Von Knorre GH, Ismer B, Voss W,Petzson M, Pulya K , What range of programmable AV delay is necessary in anti bradycardia DDD stimulation? Pacing Clin Electophysiol 1998 21 264 – 267

Neilson JC, Pederson AK, Morternson PT, Anderson HR, Programming a fixed AV delay is not effective in preventing ventricular pacing in patients with sick sinus syndrome, Europace 1999 1 113- 120

Ovsyscher I, Zimlichman R, Katz A, Bondy C, Furman S, Measurements of cardiac output by impendence cardiography in pacemaker patients at rest : effects of various atrioventricular delays, J Am Cardiol 1993 March1 21 (3) 761 – 767

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Table 4

Cylos 990. The perfect solution for optimized hemodynamics.

You don’t have to choose between optimizing your patients' hemodynamics or reducing the complexities of therapy.

Closed Loop Stimulation emulates the nature of the healthysinus node, assuring you proven physiologic rate regulation.

And the fully automated, streamlined follow-up suite lets youconcentrate on the essentials...your patients.

Cylos 990. The nature of advanced patient management.

www.biotronik.com

080241_AZ_Cylos_PRINT.indd 1 10.04.08 09:16:36

SITE VISIT

2� CORONARY HEART ™

Size of the hospital and department:

Bart’s and Th e London NHS Trust (BLT) is comprised of three hospitals over three sites: Th e Royal London, Whitechapel (with a major Accident and Emergency and other walk in centres and specialities on site); Th e London Chest Hospital, Bethnal Green; and Saint Bartholomew’s Hospital (Bart’s), West Smithfi eld. Th e total bed capacity for the three hospitals is 1310.

Th e London Chest Hospital has 242 beds, of which there are 49 dedicated Cardiology

beds including 10 as a part of the Angio Day Case ward. Th e London Chest Hos-pital also off ers a 24-hour acute myocardial infarction service.

Of Saint Bartholomew’s Hospitals’ 400 beds, Cardiology has 15 situated on the Cardiology ward, nine on the Coronary Care Unit, and a further ten on the Angio Day Ward.

Staff Numbers and the Departmental Hierarchy Structure:

We have six electrophysiology (EP) Con-sultants and six Specialist Registrars, all of whom work in the Catheter Labs. Nurs-ing falls under the overall jurisdiction of a

Divisional Nurse, who has a Head Nurse to oversee the Cardiology Wards at Th e London Chest and Saint Bartholomew’s Hospitals. Th e Catheter Labs are the responsibility of the Clinical Operations Manager, who again is the lead for Th e London Chest and Bart’s Cath Labs, and each site has a Cath Lab Manager (Band 7 Senior Sister or Charge Nurse). Th e Catheter Labs at Saint Bartholomew’s has established posts of four Band 6, 10 Band 5 nurses, and four Band 3 nursing assistants. We have a team of 10 radiogra-phers on rotation, with usually 4-5 in the department at one given time. Cardiac Physiologists also rotate between pacing / echo / invasive and non-invasive cardiac clinics.

Bart’s and The London NHS Trust

ADDRESS

FAST FACTS

St Bartholomew’s Hospital (Barts) West Smithfield London EC1A �BEUnited Kingdom

MAP

Internationally recognised teaching hospital.

Trust comprised of 3 hospitals.

Hansen EP Robotic System

Dedicated Arrhythmia Research department.

•

•

•

•

Front Row: (right to left) Susan Joseph (Cath lab nurse), Joanne Whitehead (Senior Radiographer), Clarice Bonifacio (Nurse Assistant), Joice Jose (Cath lab nurse), Celestine Lepcha (Cath lab nurse)Second Row: Sarah Way (Sister), Alfa Ali (Cardiac Physiologist), Victoria Muller (Cardiac Physiolo-gist), Maegan Williams (Chief Cardiac Physiologist), Mizanur Rashid (Senior Cardiac Physiologist).Back Row: Ben Tiongo (Cardiac Physiologist), Dr S Schilling (EP Consultant), Cameron Pfeff er (Cardiac Physiologist), and Dr S Sporton (EP Consultant).

Cath Lab Team at Bart’s Hospital

SITE VISIT


New Developments at Barts:

A reconfi guration of services has seen all coronary intervention work being redirect-ed to the London Chest Hospital; this was completed on September 1st 2008.

Bart’s has recently expanded from two dedicated EP labs to 2.8 in order to accom-modate the increase in EP-related work. Th is enables the EP team to have two full time labs capable of undertaking all forms of electrophysiological work, with the other 0.8 lab per week to meet pacing demands. Th e remaining 0.2 lab is used by the Radiology department for procedures such as venous samplings. Th is lab is also being considered for upgrade to permit Gamma-knife procedures, with further considera-tions for increasing radiology procedures.

New developments at Bart’s include the establishment of London’s only 24-hour, seven–day-a-week ventricular tachycardia (VT) referral service. Th e London VT Centre is primarily focused on provid-ing catheter ablation of VT, and is aimed at Implantable Cardioverter Defi brilla-tor (ICD) patients who experience a ‘VT storm’, or any patient suff ering an episode of a suspected ventricular arrhythmia. Th e VT service is available to any patient within the United Kingdom. As a result of this, we now have a rapid ICD access service to ensure patients receive an ICD implant within 48 hours.

We have established a Congenital and Inherited Arrhythmia Clinic, designed specifi cally for patients with arrhythmia associated with congenital heart disease and prior cardiac surgery, and also patients with arrhythmic syndromes such as Long Q-T and Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia and ar-rhythmic right ventricular cardiomyopathy. As the arrhythmic syndromes are inher-ited and run within families, we perform cascade screening in the family members of aff ected individuals to allow for early disease detection and treatment.

Cardiac Physiology Team

Th e Cardiac Physiology team consists of 17 clinical and two administrative staff across a range of bandings. At each staff grade there are varying depths of experience in one or all of the procedures that are performed within the Cardiology department. Th e services provided or assisted in include: all non-invasive diagnostic tests, Pacemaker/ICD and Biventricular follow-ups and implants, Echocardiography (including Dyssynchrony studies and Bivent optimisa-tions) and EP studies. Career progression, personal development and the attainment of external postgraduate qualifi cations are actively supported in this busy, diverse department.

Th e Research Team:

Th e Arrhythmia Research department is a multi-disciplinary team (MDT) who between them share the responsibility for organising and administering all aspects of ethically approved research studies. Some of the current areas of research include catheter ablation for atrial fi brillation (AF), VT and device therapies. Th e research department is fully self-suffi cient, obtain-ing grants for research from independent sources such as charities and industry.

Rapid Access Clinic:

Th e clinic is run by cardiac arrhythmia spe-cialist nurses. Patients presenting with real Brugada arrhythmia syndrome, pre-synco-pal and fainting episodes are assessed by a Specialist Nurse, with EP Cardiologist in-put if necessary. Patients seen in this clinic are often referred by General Practitioners, but may be self-referred.

Pre-Assessment Clinics for EP patients

Th ese clinics are run by two Senior Spe-cialist Nurses, who pre-assess all patients booked for EP procedures. Patients have a full history taken, bloods (where appli-cable), medication reviewed as some may need to be omitted prior to the procedure, teaching sessions undertaken (i.e. where warfarin is discontinued but there is a need for subcutaneous self-administration of low molecular heparin), general fi tness for the procedure, and any other issues worthy of medical attention Th ere is always a registrar available to write out a prescription, off er advice and/or answer questions the pre-as-sessment nurse is unable to.

Types of procedures and Cath Lab workload

Previous to the service reconfi guration, Bart’s undertook all forms of coronary in-tervention and diagnostic work, valvoplast-ies, rotoblations, IVUS and pressure wire studies, as well as EP work, which included all forms of EP studies and RFA (or other electrical pathway obliteration methods), permanent pacemaker (PPM), ICD and device implantations (including cardiac resynchronisation therapy), box changes and extractions.

Left: Hansen EP Robotic System

SITE VISIT


BART’S and THE LONDON NHS TRUST (cont...)

Types of procedures performed in 2007:

Procedures undertaken and numbers per-formed by Bart’s included:

Bart’s does not undertake private work, as the labs are working to capacity fulfilling NHS service requirements. As word of mouth and reputation spreads concern-ing the types of procedures performed,

and the development of the new services, Bart’s is increasingly taking on work from all around the United Kingdom We have had prospective AF patients ringing up to ask questions about the “new remote technique” (the Hansen robotic catheter navigation system).

The Coronary Care Unit generally attends to acutely ill or unstable patients with associated EP problems, while the Cardiol-ogy Ward may have more stable patients, such as those for ICD implants, wound revisions, PPM implants, elective RFA, and stable EP related concerns. Elective RFA would include those who require at least an overnight admission, AF patients, or those who require cardiac resynchronisation therapy.

On top of this daily workload, the EP service has the capacity to provide a 24-hour service for patients requiring emer-gency device explanation, or those who are referred to the VT Centre for potential VT ablation.

In the rare event of an emergency requir-ing surgical intervention, Bart’s has a full cardiothoracic surgery service on site.

Day case procedures and alliances with other hospitals:

The Angio Day Unit accommodates all patients suitable for day case procedures, including elective admissions for PPM / ICD implant or device change, stable su-pra-ventricular tachycardia studies and ab-lations, EP studies and cardioversions. The Day Ward also admits and receives patients’ referred from District General Hospitals affiliated with BLT. Included in these refer-rals are device procedures which require a more advanced level of EP experience (e.g. wound revisions, device extractions, lead repositions).

Lab equipment:

The labs are fitted with:

Toshiba Infinix x-ray system – mono-plane (for EP)

General Electric x-ray system – mono-plane (for EP)

Siemens x-ray system – monoplane (for pacing and device implantation and radiology procedures).

All Cardiac images are archived via a central GE Centricity system, and there is

•

•

•

Above: During an EP procedure.

Diagnostic Coronary Angiography

1403

Coronary Intervention ��2

Radiology (e.g. venous sampling etc.)

3�

PPM (new system implants) 3�6

PPM (box changes) 112

Cardiac Resynchronisation Therapy (CRT) pacemaker implants

16

Other pacing 12�

ICD (procedures) 256

CRT-D device implants �6

AF radio-frequency ablations

2�6

EP/ SVT and VT ablations 246

Fontan procedure ablations 1

SITE VISIT


work toward developing a PACS Radiology work-station to enable the reviewing of any relevant diagnostic images.

The EP and ablating systems used in the labs are:

Hansen EP robot system, integrated with Navx fusion – used for atrial fibrillation cases

Biosense Webster Carto and St Jude Medical NavX Navigation Systems, which are anatomical 3-dimensional mapping systems capable of merging computerised tomography and mag-netic resonance images

Cryocath ablation technology

Bard EP recording systems

Training for new employees, cross training of staff, and continuing education programmes for staff:

New staff who join the team at Bart’s re-ceive a Trust induction course and manda-tory training (annual manual handling, fire, health and safety etc.), as well as a depart-mental orientation programme.

The School of Nursing situated at Saint Bartholomew’s and The Royal London Hospital is now amalgamated with City University, and offers staff access to profes-sional development programmes, includ-ing diploma and degree level courses and pathways. Cardiac degree level courses at City (with funding largely provided to nursing staff who wish to pursue profes-sional development) are available to nurses within the Cardiac Directorate, and every opportunity is taken to encourage nursing staff to maintain and improve their knowl-edge base. There is also a Clinical Teaching Nurse post-holder who is available to act as a preceptor, assessor and to facilitate learn-ing opportunities.

Each discipline has its own departmental competencies, developed by senior mem-bers of the team and generally specific to a procedure - all multi-disciplinary junior staff members are trained by their lead cli-nicians, and are duly competency assessed. There are ‘in-house’ BLT run courses avail-able to staff, which range from Knowledge

•

•

•

•

Skills Framework awareness, managerial, and rhythm recognition courses, as well as short personal development programmes.

The nursing team has developed com-prehensive competencies and standards addressing procedures and activities that range from acting as a circulating assist-ant, femoral sheath removal, to nurse administration of intravenous moderate sedation under verbal prescription – these competencies and standards are recognised by the Trust, and staff must be assessed and deemed competent before they are permit-ted to work without senior nurse supervi-sion. To ensure objectivity, this assessment is carried out by at least two different senior members of staff, which also offers those being assessed the opportunity to pick a different perspective.

The Catheter Labs at Bart’s have devel-oped a competency for nursing assistants to develop their skills to permit them to act as the scrub assistant during PPM / ICD implantation and box reviews. This has proven to be a popular skill with both the medical team and with the nursing assistants, who have found this enhances

their job satisfaction. The competency and standard by which the nursing assistants are assessed requires that a qualified nurse must act as the circulating personnel and the nursing assistant is absolutely not permitted to administer any drugs.

Challenges at Bart’s and the EP centre:

New equipment requires staff training, which company specialists often pro-vide. The introduction of new procedures requires updating departmental compe-tencies, and is a challenge that falls under the responsibility of the Clinical Teaching Charge Nurse. These competencies act as a standard for clinical practice, and the format in which they are produced provides additional guidance for nurses about why and how procedures are performed. Addi-tionally, the competencies explain poten-tial complications and how these may be detected, prevented and/or treated.

We use a number of communication chan-nels to make GPs and District General Hospitals within our catchment area aware of the services and clinics we have devel-

Above: Terry (Cardiac Physiologist) during an EP procedure.

SITE VISIT


oped. Barts publishes information in its newsletter through its house magazine Link and its specialist publication for GPs entitled ‘GP Link’ which is available on the website at www.bartsandthelondon.nhs.uk.

The challenge of late finishing times:

AF ablation procedures are notoriously lengthy procedures, which place extra stresses upon staffing issues beyond the normal working day. Late finishes are generally covered by the on-call team, and there is an agreement with all staff that one lab must finish by 17.00, a second by 18.00 thus leaving the on-call team to complete the late finish. To address the potential of two labs running beyond 18.00, the Cath Lab manager introduced a system of working four long days to cover these late finishes, and to assist staff on the Angio Day Ward. The ‘long day shift’ starts at 08.00-18.00, although there is a 09.00-19.00 to assist on the Day ward, it also allows staff a day off per week.

On-call differs for each discipline, but nurses cover from Thursday evening to the following Thursday morning, and the European Working Time Directive is ad-hered to. On rare occasions, such as staffing issues, time owing is taken within the next two weeks.

Policy for the company reps within the labs:

There is a “Code of Conduct” all visit-

ing industry / com-pany representatives or specialists subscribe to. This is to prevent confu-sion, address Health & Safety and security, and to demonstrate a high standard of respect and dignity toward patients. This Code of Conduct also requires company representatives to ensure they are ‘booked’ or scheduled to be in the lab for specific sessions. The Catheter Lab Man-ager ensures they have a record of those present.

Managing stock levels and implemented cost-cutting measures:

Most of our stock is set on a negotiated price every 12 months following standard tender review processes to provide device consumables (e.g. EP equipment, ablation catheters, devices and electrodes etc.), which provides us with a substantial saving when purchasing large quantities of goods. We are conscious of tender processes and the binding nature of these, and also the need for stock control and cost effective-ness, therefore all cardiac consumable stock is maintained at a suitable level by the Catheter Lab Manager and Senior Chief / Chief Cardiac Physiologists.

Haemostasis management:

The vast majority of EP cases require femoral venous access – those which require ‘work’ in the left atrium are usually undertaken via the femoral venous route with trans-septal punctures. Once the trans-septal puncture has commenced, a bolus of 5,000iu heparin is administered peripherally, with a second bolus of 5,000iu heparin administered once all electrodes / catheters are across the septum – an acti-vated clotting time (ACT) is taken within 15 minutes, and then again every 30 min-utes, with an ACT required to exceed 300 seconds, hence there are inevitably subse-quent boluses administered to maintain this ACT. Femoral venous sheaths are capped, and secured using a bioclusive™ style dress-

ing. Sheaths are removed when the ACT is below 150 seconds, using manual digital pressure. Bleeding and bruising of the groin post femoral venous sheath removal is an acknowledged risk, and this is explained to patients carefully to enhance compliance with limb immobility, particularly in those patients who have received heparin during their procedures.

Patients who do not receive heparin have their femoral venous sheaths removed in the lab, with a minimum of two hours limb immobility. Femoral arterial punctures are exceptional, and usually sealed using the Angioseal™ device, or if there are circum-stances where an Angioseal is not able to be used, manual digital pressure is applied in recovery, where there is readily available assistance in the event of emergency. Hae-matomas and bleeding issues are seldom reported to the lab staff as they occur so infrequently. The use of Femostop™ is prescribed in the event of ooze without uncontrolled haematoma.

The best part of working in our facility:

Bart’s is internationally recognised and highly regarded as a teaching hospital; this means the working environment is condu-cive to learning, with all members of the MDT participating in both teaching and learning. Barts encourages staff to develop multiple skills. Equally, the department works much more smoothly when each member of the team is aware of the role of others and is able to contribute to the workload.

The work and procedures performed are highly specialised, and the input of the team as a whole is greatly appreciated by all. At Barts, the staff work in a friendly and highly professional environment. Audit days are held regularly to allow members of the team to learn and reflect upon cur-rent practice. Support between disciplines makes life easier, and much of the equip-ment in the department is state of the art. There are research projects reaching completion, others being introduced or formulated, making the overall atmosphere exciting and stimulating.

Above: Cameron (Cardiac Physiologist) during an EP procedure.

DIARY


December

“The Pharmacy White PaperBuilding on strengths – delivering the future”National Pharmacy Conference 2008. Primary & Secondary Care Senior Pharmacists1 December, 2008London, UKEmail: [email protected]

January

Advanced Cardiovascular Intervention 2009 28 -30 January, 2009London, UKWeb: www.bcis-aci.co.uk/

MarchAmerican College of Cardiology - 58th Annual Scientific Session29 - 31 March, 2009Orlando, FLUSAWeb: http://acc09.acc.org

April

31st International Symposium Charing Cross - Controversies, Challenges, Consensus 4 - 7 April, 2009London, UKWeb: www.cxsymposium.com

MayEuroPRevent 20096 - 9 May, 2009Stockholm, SwedenWeb: www.escardio.org

EuroPCR 200919 - 22 May 2009Barcelona, SpainWeb: www.europcr.com

JuneBritish Cardiac Society (BCS) Annual Scientific Conference 20091 -3 June, 2009London, UKWeb: www.bcs.com

It is three years since the pacemaker op-eration. I have lived a happy life and have not fainted since then. Now I can

still work and ride a bike. In 1995 I got married and now have a lovely healthy girl. I must say I am really blessed, for which I am especially grateful to the Donation Fund of Heartbeat International. They go across the territory boundaries to spread their self-less love to the East and to every corner on earth, the whole world. Also I must thank all the doctors and nurses in the Cardiology Department of the First Affiliated Hospital of Kunming Medical College. With their enterprising spirit they have built a friendly bridge between the loving and the loved.

I hope that more needy people like me will

receive a second chance to live with the help of Heartbeat International! I sincerely hope that I can be like them; help to others! I faithfully hope that peace and love will exist forever. I devotedly hope that God will bless them – our kindhearted angels!

Written by: Li WushengTranslated by: Zhou Xing

Submitted by the medical staff of Cardiology Department of the First Affiliated Hospital of Kunming Medical College, Kunming, Yunnan, P.R.C.

See new videos from Heartbeat International (including the one above)

at their website www.heartbeatintl.org

Coronary Heart officially endorses the non-profit organization Heartbeat International. In each issue we will bring you interesting patient stories.

Heartbeat International

Events Diary

34 CORONARY HEART ™34 CORONARY HEART ™

Medical Recruitment

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

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

are seeking work or staff

Australia freephone 1300 36 23 37 tel +612 9994 8074

[email protected]

New Zealand Freephone 0800 508 [email protected]

Call the our specialist team direct

020 7426 [email protected]

For clients and candidates in Australiaand New Zealand please contact

RECRUITMENT

Next Issue

January / February 200�

EP Special Edition with Latest News, Interviews, and Education

Hot Topics: SYNTAX + FAME Results

Radial Approaches

Echo Case Study: Right Atrial Mass

Site Visit: The Heart Hospital, London

March / April 200�

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

A Brief History of Cardiology

Echo Case Study: Giant left atrial appendage.

Management: Should echocardiographers run cardiac MRI units?

Advertising

For general and recruitment advertising please contact Wendy Rose: [email protected]

•

•

•

•

•

•

•

•

•

ADVERTISERS’ INDEX

02 Toshiba Medical Systemswww.toshiba-medical.co.uk

2� Biotronikwww.biotronik.com

34 Mediplacementswww.mediplacements.com

34 Your World Medical Recruitmentwww.yourworldmedical.com

35 Vascular Perspectiveswww.vascularperspectives.com

36 Boston Scientificwww.bostonscientifi c-international.com

Seek an Interventional Cardiology Sales Specialist for London and the

South of England

We are a distributor of niche products for the Cath Lab, a small, but rapidly growing company offering products that doctors want and need. Further information and our full product overview can be viewed

www.vascularperspectives.com

You should only apply for this position if:

• You really want to make a difference• You want to be a name, not just a number• You are an order maker and not just an order taker• You get a real buzz from opening new accounts• You don't mind spending hours alone in the car• You are articulate in both written and verbal communication• You have the confidence and knowledge to be welcomed by the Cardiologist

You must have:

Intimate knowledge of PCI proceduresA current, full UK Driving LicenseFirst class written and spoken EnglishComputer skills and competenceDrive and enthusiasm - you must be a self-starter

In return we offer:

Immense job satisfactionA good basic salary commensurate with your experienceCommission on all new accountsAll reasonable expenses Mileage/car allowance Laptop

Please send a covering letter and CV to:

Chris Brown - Managing [email protected]

CORONARY HEART ™ 35CORONARY HEART ™ 35

RECRUITMENT + NEXT ISSUE

A Landmark Study ...

Epic™

Self-Expanding Nitinol Vascular Stent with Delivery SystemPCI with DES or Cardiac Surgery?

Copyright © 2008 by Boston Scientific Corporation or its affiliates. All rights reserved.

www.bostonscientific-international.com

Landmark Syntax Trial reports comparable safety outcomes for complex patients treated with TAXUS™ Express2™ Paclitaxel-Eluting Coronary Stent System or Bypass surgery.

TAXUS™ Express2™

Paclitaxel-Eluting Coronary Stent System

L2_Syntax_Advert_A4.indd 1 15.10.2008 15:23:26 Uhr

Coronary Heart #15

Documents

Transcript of Coronary Heart #15