Coronary Heart #26

Subscribe FREE OnlineCardiologyHD.com

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

Hot TopicsHot TopicsHot Topics

MDT Meetings& Surviving the Spending Cuts

Issue 26 • Sep/Oct 2010

EP Education

ECG Challenge

New TAVI Technology

Cardiac CT

ultrasound

Ct

mri

x-ray

serviCes

To find out more, talk to our specialists today or visit our website.

www.toshiba-mediCal.Co.uk | t 01293 653700

sCienCe in diagnostiC imaging

entire organs in a blink,it’s in the sCienCeIn creating the world’s first dynamic volume CT system, the Aquilion ONE™, Toshiba Medical Systems

provide unimagined diagnostic capabilities. Our wide volume detector with the unique coneXact™ algorithm,

which accurately reconstructs higher resolution volumetric data sets without distortion artefacts, enables

entire organs to be captured at one time. Or moving, low-dose 4D images, for example perfusion and joint

movement. The results? The future of CT; it’s all part of our commitment to science in diagnostic imaging,

building integrity into everything we do.

13959 CH_Magazine_AD_297x210.indd 1 09/08/2010 14:45

www.cardiologyhd.com Sep/Oct 2010 3

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

Copyright © 200� -2010 by Coronary Heart Publishing Ltd. All rights reserved. Material may only be reproduced by prior arrangement and with due acknowledgment of Coronary Heart Publishing. The publicati on of an adverti sement or product review does not imply that a product is recommended by Coronary Heart Publishing Ltd.


Hot TopicCardiologist

In my view, acti ng as a ‘sole practi ti oner’ is a recipe for disaster. As a result, we have had a formal weekly MDT meeti ng to discuss pati ents being considered for revascularisati on (and transcatheter valve proce-dures) for well over 10 years. Ideally all pati ents should be discussed, although in practi ce in many cases the decision making is clear cut and oft en those pati ents will not be discussed. However, when ever there is doubt as to the best management strategy, pati ents are fully discussed. Ideally all pati ents should have SYNTAX scores and Euro-scores calculated prior to the meeti ng. For each pati ent, a lett er is produced documenti ng the staff present and decisions made.

Dr Simon RedwoodConsulti ng EditorReader in Interventi onal cardiologyHonorary Consultant CardiologistSt Thomas’ HospitalLONDON

CardiologyHD.comSee our other Cardiologist Hot Topics online today:

Opti cal Coherence Tomography (OCT)

UK Primary Angioplasty Service

Diagnosti c Pathways for Treati ng Chest Pain

Complex Strategies when Treati ng Bifurcati on Stenoses

FFR FAME Trial

SYNTAX Trial

Diff erences between Drug Eluti ng Stents

Clopidogrel

Left Main Stenti ng

NICE Guidelines For Use of Drug Eluti ng Stents

COURAGE Trial

•

•

•

•

•

•

•

•

•

•

•

conti nues >>

Questi on: Do you have an MDT meeti ng at your hospital, and if so which pati ents for coronary revascularisati on should be discussed?

Also should a formal SYNTAX Score be used with each?

12 Sep/Oct 2010 www.cardiologyhd.com

Journals

Heart FailurePati ents with heart failure oft en have depression and this is associ-ated with increased hospitalisati on and mortality. The SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial was a randomised, double-blind, placebo-controlled trial of sertraline versus placebo for 12 weeks in 469 pati ents. The primary endpoints were change in depression severity and compos-ite cardiovascular status at 12 weeks. Sertraline and placebo both improved depression scoring equally and neither made any signifi -cant diff erence to cardiovascular outcomes. Fairly depressing results, but good news for placebo.

O’Connor and others JACC 56:692-99.

Coronary Interventi onGuidelines are a double edged sword – we all like to quote them when they agree with us, but dismiss them when we think diff er-ently, stati ng that you assess pati ents on their ‘individual merits’. A recent guideline from the European Society of Cardiology addresses the interesti ng problem of anti thromboti c / anti platelet management in PCI pati ents with AF. Take home messages include several recent studies indicati ng that uninterrupted warfarin, instead of heparin bridging therapy, provides a favourable balance between bleeding and ischaemic complicati ons, especially when the PCI is performed radially. The authors also suggest that triple therapy with aspirin, clopidogrel and warfarin appears to be the best opti on to prevent stent thrombosis and thromboembolism. I suspect most interven-ti onists feel uncomfortable with the concept of triple therapy and the associated bleeding risk and would opt for bare metal, ti tanium covered, anti body-coated or biodegradable polymer stents with their shorter requirement for dual anti platelet therapy. The pati ents would take aspirin and clopidogrel for one month following the PCI and then change to aspirin and warfarin for life. The combinati on of warfarin and clopidogrel is less tested. Alternati ves in pati ents with high bleeding risk include balloon angioplasty alone, drug-coated ballloon angioplasty or CABG. The bott om line is that the guidelines are based on expert opinion with litt le supporti ng randomised data.

Lip and others European Heart Journal 31(11):1311-8

Intravascular ultrasound has taught us a lot about coronary artery dis-ease and PCI. It is very useful for assessing vessel size, plaque burden, plaque morphology (virtual histology) and also telling us why things go wrong. A recent small IVUS study from South Korea examined images from 30 pati ents with confi rmed very late stent thrombosis (>1 year). 23 had drug eluti ng stents (DES), whilst the remainder were

bare metal (BMS). Events tended to occur earlier with BMS (108.4+/- 26.5 months) compared to DES (33.2 +/- 12.5 months). There was less neointi ma in the DES than the BMS, as expected. Acquired malappo-siti on (also termed positi ve remodelling) was only seen in the DES group – the stents had been well deployed on initi al post PCI IVUS. Malappositi on likely develops when the vessel wall pulls away from the stent struts due to positi ve remodeling or thrombus resorpti on. Neointi mal or plaque rupture was seen equally in both groups. Very late stent thrombosis in DES may be due to delayed arterial healing with incomplete endothelializati on and persistent fi brin or to stent-vessel wall malappositi on. Atheroscleroti c lesions within BMS may progress to ti ght stenosis and/or rupture. Opti cal coherence tomog-raphy will provide further insights.

Lee and Others JACC Cardiovascular Interventi ons 55:1936-42.

Thrombus aspirati on in PPCI seems to have been universally accept-ed by interventi onists on the basis of one trial (TAPAS, N Engl J Med 2008;358:557-67) whilst others showed no benefi t (Circulati on. 2006;114:40-47, JACC 48:244-52). A major predictor of no-refl ow in PPCI is increasing ti me to treatment. An Italian group has pooled data from three prospecti ve trials comparing thrombus aspirati on with standard PCI. Thrombus aspirati on limits the adverse eff ects of ti me to treatment, suggesti ng it is benefi cial.

De Vita and others Heart 96:1287-90.

The HORIZONS-AMI (Harmonizing Outcomes with RevasculariZati ON and Stents in Acute Myocardial Infarcti on) trial conti nues to produce published sub-studies. The original trial showed that bivalirudin decreased major bleeding, 30-day and 1-year mortality in pati ents undergoing primary percutaneous interventi on (PPCI) when com-pared with unfracti onated heparin (UFH) plus glycoprotein IIb/IIIa inhibitors (GPI). The latest study divided the pati ents into risk terti les according to the CADILLAC bleeding risk score. The mortality rates in the bivalirudin and UFH plus GPI arms, respecti vely, were 0.4% and 1.2% (p = 0.09) in the low-risk group, 4.2% and 4.1% (p = 0.99) in the intermediate-risk group, and 8.4% and 15.9% (p = 0.01) in the high-risk group. Among high-risk pati ents, there was also a decreased rate of recurrent myocardial infarcti on in pati ents randomized to bivaliru-din as compared to UFH plus GPI (3.6% vs. 7.9%, p = 0.04). It would appear that the pati ents who benefi t the most from bivalirudin are those at the highest bleeding risk, though the usual caveats when dealing with subgroup analysis should be considered. In these aus-tere ti mes, the cost advantage may also be important.

Parodi and others JACC Cardiovascular Interventi ons 3:796-802.

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

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


Clinical Background A 68 year old lady with a history of cardiac ischaemia was admitt ed to A&E aft er a general feeling of unwell over a 24 hour period. She has a dual chamber ICD in situ and had experienced some palpitati ons but she was not aware of any therapy from her device.

This ECG was recorded in A&E at 10mm/mV and 25mm/sec.

Questi onsWhat is the presenti ng arrhythmia and how could this be confi rmed?

How does the arrhythmia terminate?

What treatment opti ons could be benefi cial to this pati ent?

1.

2.

3.

Answer on Page: 25

Ms Sophie BlackmanCoronary Heart Management and CRM Consulti ng Editor

Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust United Kingdom

ChallengeSophie Blackman’s ECG


Questi on: With the NHS facing major spending reducti ons in a bid to reduce nati onal debt, how has your department been aff ected?

What challenges are you facing, and do you believe these spending reducti ons will result in a more streamlined service and bett er pati ent care in the longer term?

Hot TopicManagement

The NHS will have to make real savings even to stand sti ll. With medical infl ati on, a budget that doesn’t increase eff ecti vely means we need to make effi ciencies every year. I suspect our

departments will manage to do this in the fi rst year but year on year cost improvements are going to be a challenge and may be unsus-tainable for some insti tuti ons. In many areas such as London there are many small hospitals all providing cardiac services; the real potenti al for cost saving is in focusing cardiac care in a large cen-tres with ambulance triage of high risk cardiology to these centres. To enable this we need to be routi nely running our centres seven days a week and getti ng maximum use our of our equipment as well as treati ng pati ents quickly to improve care and minimise length of stay. It will also lead to improved training and very large centres to support research. There are politi cal implicati ons to changes such as these in cardiology and other specialti es and we will see whether the new Government is able to rise to this challenge, perhaps driven by fi nancial necessity.

Dr Jamil Mayet

Chief of Service, Cardiovascular MedicineImperial College Healthcare NHS Trust

CardiologyHD.comSee our other Management Hot Topics online today:

Should Food/Gift s from companies be banned?

Hats and masks in the cath lab?

High Radiati on Dose Protocols

On-call Reimbursements

Radiographer Uti lisati on in EP

Are MBA’s a good idea?

Non-Professional Staff

Multi -Skilling in the Cath Lab

Future Changes?

•

•

•

•

•

•

•

•

•


Management: Listening to Staff


Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust

How oft en do we really listen to our staff ? It can be so hard to fi nd ti me for staff meeti ngs or to create forums where staff can air their opinions without having to cancel clinics or ask staff to att end an out of hours meeti ng. So long as the service is ti cking along all right

why would we really take ti me to stop and hear their suggesti ons for service improvement?

In May I wrote that by giving your staff boundaries you create autonomy and accountability, and part of the responsibility to your staff is that you should help them to provide soluti ons to their problems rather than encouraging them to bring you the problem to solve. But, if we don’t take ti me to appreciate the suggesti ons brought to us by our staff , then you are contradicti ng the expectati on of our staff to resolve their own issues and acti vely discourage this autonomy.

When your staff make suggesti ons about the service you are running it is oft en an untainted view. They don’t always consider how the changes they suggest

may aff ect your budget or how it might be seen politi cally, and whilst this can be infuriati ng to them when the ideas they have cannot be realised, adjustments they suggest are oft en insightf ul to make services bett er for the staff and for the pati ent. As managers our job is perhaps to fi nd the

twist that makes it a politi cally and fi nancially viable change and to make it work.

Many of the services that exist within Cardiology depart-ments tend to be long established, perhaps from far before

you joined the department as its manager. How many of the services and systems that you have in place are functi onal,

benefi cial and eff ecti ve? It is so important to not try to justi fy systems that do not work, or that do not enrich your depart-

ment just because they are already in existence. By reviewing the systems you have in place, from request forms, to clinic ti mes and staff roles it is possible to really redesign the functi on of your depart-ment and enhance your service delivery. In the absence of more staff and a bigger budget to work with, your role is to look at making what you have as effi cient as possible.

Trust your staff s opinions, but also listen to what they don’t say. Oft en our greatest skill as managers is to hear what is communicated to us silently. You may noti ce some clinics that your staff enjoy work-ing and others they dread. Reviewing how these clinics are struc-tured can make the service more producti ve by perhaps lengthening some clinics, shortening others and improving the turnover between pati ents. Additi onally there are many areas of the service that your staff may fi nd utt erly infuriati ng, and we are here to look at these issues more laterally to think how we can make modifi cati ons.

Structuring a department to achieve waiti ng ti me targets with the workforce you have can be a real challenge, but by involving your staff so that they support the changes you make means the chal-lenges you face become a shared responsibility, and this helps your staff to understand the bigger picture of workforce planning and service delivery whilst helping you to achieve your targets.


twist that makes it a politi cally and fi nancially viable change and to




AssistanceManagement

2� Sep/Oct 2010 www.cardiologyhd.com

October 3-6Heart Rhythm Congress 2010Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October29-30

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

November 2Chronic Total Occlusions 7Clinical Educati on Centre, Glenfi eld HospitalLeicester, Englandwww.millbrookconferences.co.uk

November 18-19

Bristol PCI Course 2010The Educati on Centre, Bristol Royal Infi rmaryBristol, Englandwww.millbrookconferences.co.uk

November 22-23

Europe AF 2010London Hilton Metropole Hotel London, Englandwww.europeaf.com

November 25

BLT Course 2010 : Bifurcati on lesion treatmentNati onal Motorcycle MuseumSolihull, Englandwww.millbrookconferences.co.uk

January 26 - 28, 2010

ACI 2011 : Advanced Cardiovascular Interventi on 2011London Hilton Metropole HotelLondon, Englandwww.millbrookconferences.co.uk

1

2

3

4

5

LIKE TO BEFEATURED?

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

[email protected]

For a list of conferences and events around the globe visit our website:www.cardiologyhd.com

6

7

1

2

3

4

6

5,7

Events


Questi on on Page: 14

1. The fi rst half of the ECG is the pati ents presenti ng arrhythmia. It is a broad complex tachycardia of 125bpm. The inferior leads are strongly positi ve suggesti ng conducti on from base to apex. It could be argued that the QRS is not parti cularly wide – but if you look in lead I – all the positi ve and negati ve components make up the QRS and the durati on of these components is about 180ms. Discrete P waves are not obvious, but take a close look at lead II. The QRS has an Rsr1 patt ern similar to that of a bundle branch block. Aft er the dominant ‘R’ wave there is a small ‘s’ wave and then another much smaller ‘r’ wave. From the small ‘r’ wave down to the most negati ve part of the T wave there is a subtle diff erence in the down stroke which alternates between being convex and concave. On every other complex it is possible to see a P wave – marked on the ECG strip below with an arrow. This suggests a dissociati on between A and V.

With a ventricular rate >100bpm, AV dissociati on, and QRS durati on 180ms, the diagnosis of this ECG is ventricular tachycardia (VT). In a non-compromised pati ent interrogati on of the ICD can help to confi rm the arrhythmia. The electrograms from the leads in the right atrium and right ventricle did indeed confi rm the ventricular rate was 480ms and the atrial rate 960ms.

2. The second half of the ECG shows the pati ents arrhythmia change axis and then terminate. The change in axis is due to the 8 beats of anti -tachy pacing (ATP) which are negati ve in lead II sug-gesti ng conducti on from apex to base which is consistent with ATP from the right ventricular apex lead. ATP can be used for the terminati on of monomorphic VTs involv-ing a re-entry circuit (commonly found in ischaemic VT pati ents). Several carefully ti med low-voltage pacing impulses are delivered to the heart at a faster rate than the tachycardia in order to infi ltrate the re-entry loop and terminate the arrhythmia. Success rates with ATP are very variable, and in some instances ATP can accelerate

a stable monomorphic VT into VF. Well programmed ATP in the haemodynamically stable VT pati ent can be excellent for preventi ng shock therapy and, when successful, ATP off ers a painless and rapid treatment for VT.The last few beats on this ECG are the pati ents’ intrinsic underlying sinus rhythm.

3. Terminati on of the VT by ATP demonstrates that ATP can be successful in this pati ent and it is due to the successful ATP that the pati ent had not had a shock for this slow VT. Preventi on of VT is helpful for minimising therapies from the device. This helps to pre-serve the batt ery life but also reduces the perceived fear of having shock therapy and the negati ve eff ect that can have on the pati ents’ experience of having an ICD.It is important to make sure the pati ents’ medicati on is opti mised. The EMIAT1 and CAMIAT2 trials suggest beta blockers reduce mor-tality and arrhythmic events whilst improving survival rates whereas amiodarone is suggested to reduce arrhythmic death but has not been seen to improve survival. This confl icti ng outcome proposes that the protecti ve eff ect of amiodarone may be off set by its pro-arrhythmic properti es. Beta blockers remain the anti -arrhythmic drug of choice.

With medicati ons opti mised a VT ablati on could be seriously con-sidered. Ablati on of the VT circuit can be complicated in the pati ent with serious underlying heart disease as patchy scarring can result in numerous possible circuits. However VT ablati on is usually more eff ecti ve in ischaemic heart disease (aft er MI) than cardiomyopathy. In experienced centres VT ablati on for pati ents with a previous MI is associated with a high procedural success rate (upwards of 75%) and VT recurrence requiring ICD shocks is signifi cantly reduced.

References:The European Myocardial Infarcti on Arrhythmia Trial.Julian D.G, Camm A.J, Frangin G, Janse M.J, Munoz A, Schwartz P.J, Simon P. Randomized trial of eff ect of amiodarone on mortality in pati ents with left ventricular dysfuncti on aft er recent myocardial infarcti on. EMIAT. Lancet 1997; 349: 667-674.

The Canadian Amiodarone Myocardial Infarcti on Arrhythmia Trial. Cairns J.A, Connolly S.J, Roberts R, Gent M. Randomized trial of outcome aft er myocardial infarcti on in pati ents with frequent or repeti ti ve ventricular premature depolarizati on. CAMIAT. Lancet 1997; 349:675-682.

1.

2.



AnswerSophie Blackman’s ECG Challenge


HO

T TO

PIC

We had already anti cipated a certain amount of reducti on in the budget but may not have foreseen the full extent of the reducti ons that the new government have now

announced. We have a Trust wide drive, as most NHS’s do at present, to reduce waste and increase effi ciency which, aft er a lengthy appraisal process, saw us introduce a new stock Management sys-tem called Omnicell© as one of a number of our initi ati ves. The plan is for this to be Trust wide and has been implemented and insitu in Theatres, Cath Labs and a selected unit to begin with. It will be at least 6 months to a year to actually see tangible results from this in an audit process. The challenge and the aim is to achieve a lean stock system that has high turnover therefore less expired stock and less stock being held unnecessarily. Appropriately costi ng pati ents through the use of this system ensures the PCT’s are billed accord-ingly. Also we will be able to compare costi ngs not only between pro-cedures but between consultants with similar procedures. With the new system we have seen a reducti on in nursing hours required to restock and therefore uti lising nursing ti me more eff ecti vely. Cer-tainly there is waste in the NHS but I do not personally see that it is at the point of pati ent care. Our greatest savings are always made in the purchasing of specialised kit and by using a competi ti ve tender process we have achieved marked savings. Of course market forces have an impact on this.

Greater scruti ny is occurring over all budgets and a process is under-way to analyse every expenditure within the organisati on. Therefore along with all other departments we have been asked to rati onal-ise and justi fy costs including establishment levels. As we run a PPCI service it is relati vely straight forward to justi fy the numbers required to ensure pati ent safety but we oft en talk about minimum numbers which in no way refl ects the opti mum numbers required to provide a fi rst class service.

The benefi t of such scruti ny on the budget has resulted in people coming together to brain storm to analyse work patt erns and proc-esses and work out if there are bett er ways/bett er systems to make it more streamlined. This can only be a positi ve move and we can already see benefi ts from meeti ng and discussing issues with people we would not normally. It brings new ideas and new soluti ons.

Teresa Darmody

Senior SisterCardiac Cath LabsLiverpool Heart and Chest HospitalLIVERPOOL

Mr Greg CruickshankSuperintendent Radiographer, Cardiac Catheter SuiteKing’s College Hospital NHS TrustLONDON

Here at King’s College Hospital we are trying to make savings of 10%. Obviously this is diffi cult, given we perceive ourselves as an already lean

organisati on. On the one hand it is hard to reduce staff (and hence staff costs) without reducing services, thus reducing income. We have been forced to look again at the department profi le in Radiology (I have staff whom rotate from Radiology). Over the last 12 months we have trained a number of band 5 staff in the cath labs (tradi-ti onally only had band 6/7 staff ). In Radiology (not yet Cardiology) we have extended the working day in some areas from 9-5 to 8-8, to allow more acti vity (and hence income generati on). Also have to make a robust case for every post that becomes vacant to be both re-fi lled, and at the same level/grade.

Will this lead to a more streamlined and bett er pati ent care in the long term? In order to save 10%, it seems improbable any Trust will be able to manage this without some cut in services. Perhaps now is the ti me for a more public debate about what services within the NHS should remain protected, and what services currently provided under the NHS umbrella can no longer be conti nued at current levels. The demands and expectati ons of users of the NHS today are not comparable to those of 60 years ago when it was fi rst born. As expensive technologies and treatments become more available, it is improbable the NHS can conti nue to provide a full range of services free at point of use as it initi ally set out to do. Every person in the country however will have a diff erent view about how the NHS budget should be divided up, and what should and shouldn’t be provided by the NHS. Making clear deci-sions about what can and cannot be provided with the current funding levels in the NHS should at least enable us to provide a bett er service within areas that are identi fi ed as “must be provided”. I am sure debate around this topic will conti nue to run for some ti me yet.


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

Telephone: +44 (0) 1789 450 787

www.heartrhythmcongress.com

[email protected]

+44 (0) 1789 451822

Promoting better understanding, diagnosis, treatment and quality

of life for individuals with cardiac arrhythmias

HeartRhythm

Congress2010

HeartRhythmCongress

3-6 October 2010 Hilton Birmingham Metropole

EducatitiontionEducationtion

Technology

Technology

Technologygy

DiversityDiversityDiversity

Cardiology

Our New Global Website in High Definition

HD VideosHot TopicsInterviewsEventsSite Visits

•••••

RecruitmentFacebook LinkPollsOnlineEditions

••••

CardiologyHD


ConfectionaryGood and bad news for chocolate lovers. A new observational study of >19,000 patients from Germany demonstrates that some choco-late is good for you, lowering BP and cardiovascular disease (39% relative risk reduction (RRR) in stroke or MI), compared to those that eat no chocolate. However, too much chocolate is bad for you dueto the fat and sugar. Dark chocolate has the highest content of fla-vanoids and procyanids, both associated with lower cardiovascular risk, as well as the highest antioxidant capacity. The exact types and amounts of chocolate are still to be elucidated. I imagine recruitment for further studies will be straightforward.

Buijsse and others European Heart Journal 31 (13): 1616-1623.

Valvular Heart DiseaseThe Ross procedure is an operation for aortic stenosis in which the patient’s own pulmonary valve is transferred to the aortic position as an autograft and a tissue prosthesis placed in the pulmonary posi-tion. Advantages are perceived to be better longevity than aortic homograft replacements and the avoidance of anticoagulation com-pared with mechanical prosthesis. The operation has many devotees worldwide, but been regarded as somewhat niche by most surgeonsin the UK.

A randomised single centre trial of autograft vs. homograft in 228 patients aged 18-69 found survival to be significantly better in the autograft group (97 vs 83% at 10 years).

Ismail El-Hamamsy and others Lancet 376: 524–31

Now that PCI is being performed in many DGH hospitals in the UK, a significant proportion of interventionists based in surgical centres are developing transcatheter aortic valve implantation (TAVI) pro-grams to fill their time. There are two mainstream devices approved in the UK - Edwards (Edwards Lifesciences, Nyon, Switzerland) and Medtronic CoreValve (Luxembourg City, Luxembourg). The Cor-eValve is delivered retrogradely and percutaneously (femoral or axil-lary artery) whilst the Edwards can be delivered percutaneously or transapically. They are available in different, but limited sizes and have certain patient and anatomical requirements. Edwards current-ly have 22- and 24-F, soon to be 18- and 19-F; CoreValve is 18-F, as well as certain aortic valve annular criteria (18 to 25 mm and 20 to 27 mm, respectively). A small, but valuable study from Leicester analysed 100 consecutive patients using transthoracic and transoesophageal echocardiography and invasive angiography to asses their suitability for TAVI. 97% of patients were suitable for one of the options. Edwards’ suitability was 28% for Edwards-Sapien transfemoral, 78% for Edwards Novaflex transfemoral, and 88% for Edwards-Sapien transapical. Medtronic CoreValve suitability was 84% for transfemoral and 89% using addi-tional transaxillary and direct aortic approaches. We now await the results of the trials to tell us which patients we will be routinely offer-ing this breakthrough therapy to.

Jilaihawi and others. JACC Cardiovascular Interventions 3:859-66.

Sudden Cardiac DeathUnderstandably it’s not always been easy to get quality data on the effect of interventions in cardiopulmonary resuscitation. In the past this doesn’t seem to have stopped some fairly strident views being expressed and great importance placed on the exact adherence to protocols. One area of uncertainty is what value respiratory support provides.

Two papers recently published provide valuable data of high quality to guide future practise.

In one study, over 1200 Swedish patients resuscitated in the commu-nity from cardiopulmonary arrest were randomly assigned compres-sion only or standard CPR survival was similar in both groups (8.7 vs. 7%).

In a similar trial bystanders were instructed to administer compres-sion only or standard CPR in 1941 North American victims of out of hospital arrest. Again there was no significant difference in outcomes (12.5 vs. 11% survival to discharge).

Neither of these studies examined the utility of rescue breathing by trained healthcare professionals.

Leif Svensson and others N Engl J Med 363:434-42

Thomas D Rea and others N Engl J Med 363:423-33.

In the search for predictors of sudden cardiac death two factors which consistently show value are ejection fraction and non sustained VT. In a study on the effect of Ranolazine (an anti anginal) on outcomes in non ST elevation the trial designers usefully conducted seven days ambulatory ECG monitoring. Analysis of this data reveals four to sev-en beats and eight or more beats of NSVT is associated with a hazard ratio for sudden cardiac death of 2.3 and 2.7%. In patients with Ejec-tion fractions under 40% this equates to a risk of sudden death of 2.8% (0-3 beats NSVT), 6.1% (4-8 beats) and 12.2% (>7 beats) after twelve months follow up.

Benjamin M. Scirica and others Circulation. 122:455-462

The potential benefits of an implantable defibrillator without the complication of transvenous leads are significant; easier extraction, lower risk of endocardial infection and even a simpler implant. The drawbacks are also well documented; less (if any) pacing, challenges with detection, higher defibrillation thresholds.

The results of a trial of a commercially available, wholly extravascular system are encouraging. The authors first established the optimum implant position (axilliary active can and left parasternal lead), then proceeded to demonstrate acceptable performance in 55 standard ICD indication recipients including 12/12 appropriately detected and successfully treated clinical ventricular arrhythmias.

Gust H. Bardy and others N Engl J Med 363:36-44

Call for PapersCoronary heart is pleased to receive original contributions, case reports and reviews to be considered for publication in print and on line. Contributions will be subject to peer review. Please send manuscripts in word or similar compat-ible formats with figures embedded. If accepted for publica-tion higher quality files will be requested.

Send all contributions by email to, [email protected]

� Sep/Oct 2010 www.cardiologyhd.com

There is a weekly cardiac MDT meeting at the Manchester Heart Centre, which is very well attended by Consultant Cardiologists, Cardiac Surgeons, Cardiac Anaesthesiologists and Cardiac Radiolo-gists. It is also attended by junior doctors who often present the cases, a member of the Cardiac Liaison team and the MDT co-ordi-nator. Typically between 10 and 15 cases are discussed and the Consultant responsible for each case ensures that the agreed plan is implemented and communicated as required. A formal Syntax Score is not used.

In addition there is a smaller weekly Cardiac Surgical MDT meeting attended by the Cardiac Surgeons and Cardiac Anaesthetists. In that meeting we discuss all patients who have been seen by a Cardiac Surgeon and have been accepted for surgery. The purpose of this is mainly to discuss high-risk patients and their co-morbidities and get a consensus whether it would be appropriate to operate on certain patients or not. However we also discuss all routine cases, which ensures that there are no outstanding investigations and that the key data, including the angiogram are reviewed.

Which patients should be discussed at a Cardiology and Cardiac Surgery MDT meeting is a very difficult subject. One could argue that ideally all patients with coronary artery disease should be discussed at an MDT. Mistakes can happen and things can go wrong even in the simplest of cases and for that reason to “rubber-stamp” a straightforward case by a group is valuable. I would also add that in my experience patients like to know that a group of doctors sat together and discussed their case, even if they have complete faith to the individual Consultant.

Discussing all cases however is not practical at present and if the NHS goes down that route this would have significant implications

in the workload and work pattern of Consultants. One therefore has to agree on certain criteria and I think we should be discussing patients with 3-vessel or left main stem disease and patients with a non-type A lesion of the proximal LAD. This covers the vast majority of patients where revascularization is of prognostic benefit and does not overwhelm the MDT with patients with one and 2-vessel disease who are suitable for angioplasty.

The difficult reality is that whilst at the Manchester Heart Centre we discuss the majority of patients who fulfil the above criteria, as Car-diac Surgeons we are also presented with workload from the district general hospitals of our region. Organising MDT meetings for those patients is obviously more difficult and there is a significant amount of practice based on traditional Cardiologist to Cardiac Surgeon referral without an MDT.

In view of these difficulties, I think that Syntax scoring every patient would add to the complexity of the situation. More importantly, while Syntax score is a useful research tool I don’t think it adds much to the decision making that experienced clinicians can make about individual patients. Ultimately Syntax scoring is often down to interpretation of an angiogram and that is only part of the some-times complex discussions that take place at an MDT.

I think that whether we like it or not the days when crucial deci-sions about the life and well-being of a patient could be left to the skills and talent of one individual Consultant are gone. In the years to come there will be increasing pressures for monitoring of our results and justification of our decisions. Part of this will include discussing an increasing number of patients at an MDT and the onus will be upon us to facilitate this.

We indeed have an MDT at King’s College Hospital. We have two types of MDTs: one for coronary revascularisation and other for structural heart valve disease.

At Kings we have coronary revascularisation MDT meetings, but I also attend other hospitals such as the William Harvey Hospital in Ashford, Kent and Queen Elizabeth Queen Mother Hospital in Margate. So we have a very robust MDT system working in the south-east. I am a strong believer in the MDT. I personally feel that patients who have triple vessel disease, patients that have a high SYNTAX score, patients who are diabetics, patients who are young, patients who have had PCI before (once), even if it was single vessel disease, should be discussed. And I think all PAMI’s with incomplete revascularisation should be discussed.

So these would be my choices:

Firstly, patients with triple vessel coronary artery disease. •

In case of single vessel disease, for very proximal disease in the LAD or ostial LAD disease, which is the most important artery in the heart, I believe a LIMA graft would serve them better in the long run. There was reluctance to refer these cases for surgery due to need of a sternotomy. I perform the LIMA to LAD bypass in a minimally invasive technique using endoscopic instruments. Because of the MDT my cardiology colleagues now believe in options of proximal stenting or endoscopic CABG for ostial LAD lesions. At Kings we call this technique as Endoscopic Assisted Minimally Invasive Direct Coronary Artery Bypass (Endo- MIDCAB).

Traditionally single vessel disease have been excluded from MDT meetings, but with this new technique more of these patients are being presented at our MDT’s.

Now even for emergencies we have urgent MDT’s. My fel-low cardiologists will call me, or call another surgeon who is on-call, in the cath-lab, so we don’t have to wait for a for-mal MDT to happen. This is very beneficial to the patient as an option of surgery is considered instantly before they receive stents if the cardiologist is doubtful of the coronary anatomy.

•

•

Mr Ranjit P Deshpande MS MCh FRCS (C-Th/Eng)Consultant Cardiothoracic SurgeonKing’s College HospitalLONDON

Dr Theodore VelissarisConsultant Cardiothoracic SurgeonManchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust

www.cardiologyhd.com Sep/Oct 2010 �

We have a weekly MDT meeting at the Manchester Heart Centre which features formally on our job plans. In this meeting, which is attended by cardiologists, surgeons, anaesthetists, a nuclear medicine physician, a member of the cardiac liaison team and an MDT co-ordinator, we discuss all cases where either cardiologist or surgeon feels a consensus view is needed. We attempted to formal-ise this for revascularisation cases by agreeing a set of criteria for referral to the meeting, but the process remains rather ad hoc, with many of us bringing to the meeting cases which we would rather not do! We only occasionally calculate a SYNTAX or logistic Euro-score for cases presented, and to date, this has not been formally included on the case summary proformas that SpRs have to submit in advance to the MDT co-ordinator.

Some colleagues, mostly surgeons and anaesthetists, believe that all revascularisation cases should be discussed at the MDT meeting. On the other hand, some interventional cardiologists hold the view that, being the default gatekeepers of the entire process, they have the natural ‘right’ to select for PCI all cases where they feel a good final angiographic result is achievable, and to ‘pass on’ to the sur-geons other cases where this is not so. These are probably extreme views, and the truth lies somewhere in the middle! Disagreements between interventional cardiologists and surgeons as to the best revascularisation strategy are commonplace (remember only 2%-12% of patients screened for the SYNTAX Trial were actually ran-domised, which, to a large extent, was due to such disagreements), and this underscores the importance of utilising meaningful risk

scoring systems to guide all through the decision-making process.

The problem with the currently available scoring systems is that none offers a complete patient assessment with regard to proce-dural risk. While the SYNTAX Score is purely an anatomic score for risk assessment which does not include any clinical information, the Euroscore is a mortality score based on clinical variables (including co-morbidities) and type of surgery, without any reference to the anatomical complexity of coronary disease. Thus, the former is of more value to the interventionist while the latter is of more value to the surgeon, but a combination of the two may be of greater value to the patient as it would allow better-informed decision-making as to the most appropriate revascularisation strategy for that patient. Thus, in my opinion, and provided manpower is available, both scores should be calculated for every patient that goes through the MDT meeting. It is worth noting that a recent study by Serruys et al. has shown that combining the anatomic-based SYNTAX Score with 3 simple clinical variables (age, LVEF and creatinine clearance) creates a ‘clinical Syntax Score’ which is superior to the old Syntax Score at predicting MACE and mortality in patients undergoing complex PCI.

The MDT meeting is there to protect both patients and clinicians: it brings together experts in different disciplines with the aim of safe-guarding patients through consideration of all relevant important elements of their care prior to decision making, and also safe-guards clinicians through the process of seeking views from as wide a body of opinion as possible.

The Freeman Hospital Cardiothoracic MDT meeting takes place weekly, lasts about 2 hours and typically10 cases are discussed. A record of attendance and outcome of the MDT discussion are documented and the meeting is considered quorate when 2 car-diothoracic surgeons and 2 cardiologists are present. Inpatients and outpatients referred for revascularisation are presented and video conferencing can now be used with colleagues in the dis-trict. Ad-hoc MDT meetings are also held for emergent cases.

The number of coronary revascularisations at the Freeman Hos-pital is approaching 4000 per annum and not all patients referred for revascularisation are discussed at an MDT. STEMI patients and those patients presenting with ACS who have an obvious culprit lesion are usually treated immediately with PCI. However, a consensus is sought in those ACS patients who have more complex coronary disease and are high risk for PCI.

Elective patients with stable ischaemic heart disease who have had angiography performed at their local hospital are referred to the elective PCI or surgical pools at the discretion of the referring cardiologist. When the referring consultant is unsure of the best revascularisation strategy, patients are referred to the MDT for discussion. Surgeons and interventionists also bring their cases from their pool to the MDT meeting where the revascularisation

strategy can be ratified or altered by the multidisciplinary team. SYNTAX scoring is being increasingly used and is making a posi-tive contribution to our decision-making process particularly in equivocal cases. Audits of patients undergoing revascularisation are performed to examine the appropriateness of the treatment plans and quality of record keeping. We are currently perform-ing a retrospective analysis of Syntax scores in patients that have undergone elective bypass surgery and PCI over the last year.

Naturally there are disagreements as to the optimum form of revascularisation. To make the best decisions in equivocal cas-es an intimate knowledge of clinical trials and clinical data is required. If consensus cannot be reached or if it is believed both forms of revascularisation will give equal outcomes then this is reported back to the referring clinician so a discussion can take place with the patient.

CABG, PCI and medical treatments for IHD are complementary and the weekly MDT meeting allows for the formulation of an optimum revascularisation plan for patients. None more so in patients who might benefit from a hybrid procedure or who are at high risk for PCI or surgery, or in those who might benefit most from medical treatment alone.

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

Dr Magdi El-OmarLead Consulting EditorConsultant Cardiologist, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust

ContentsSep / Oct 2010


Looking for a new direction?

Siemens Healthcare leads the field in providing diagnostic imaging solutions for the NHS and private sector. Due to changes within our team, we are now looking for a Radiographer to train as Applications Specialist providing high quality user training to our customers within the UK.

This is an excellent opportunity for you to utilise your skills and knowledge whilst keeping up-to-date with the latest cutting edge technology.

Joining the Angio and X-ray team you will provide application support for the full range of Cardiac AngiographyEquipment, building relationships with internal and external customers, organising and delivering presentations for clinical professionals at customer sites.

Having strong experience in the ‘cardiac cath lab’ environment, you will be a qualified Radiographer with experienceof advanced cardiac procedures. You will also have effective communication and interpersonal skills, and experienceof teaching in a clinical setting. Any experience of using Siemens equipment is a plus, however full training will beprovided. Great flexibility is required due to extensive travel in the UK and on occasions in North West Europe.

To apply for this role please visit www.siemens.co.uk/careers/en, select careers and then enter reference number5700. If you have any questions about this vacancy please call Siemens on 01276 696407.

Siemens Healthcare

www.siemens.co.uk/jobs

Cardiac Applications SpecialistAttractive salary + car + bonus + benefits

INQUIRY REF 0910001

Round UpLatest News

BARD® EP Mini Case Review Sessions & EP Fellows Course30minute EP Teaching Sessions are to be held during breakti mes & lunchti mes on the BARD® EP stand at the Heart Rhythm Congress, Birmingham. A Consultant Electrophysiologist will present a real life EP case. Parti cipants will be encouraged to interact with the case, including making measurements of intervals. The sessions are aimed at Cardiology SpR’s or Cardiac Physiologists with at least a basic EP knowledge. The sessions will be limited to a small group of 5-6 peo-ple & thus aim to be interacti ve. Pre registrati on will be required & can be booked at the BARD® EP stand during the meeti ng.

In November another EP teaching opportunity will be a BARD® EP Fellows Course, which will take place on 21st November, preceding Europe AF 2010, London.

Pre registrati on for this event will also be required & will be via the website www.europeaf.com


The Melys Atrial Fibrillation Screening MonitorChronic Atrial Fibrillation is the most common arrhythmia seen in medical practice. It causes increased patient morbidity and mortal-ity and adds significantly to the burden of health care costs. Once identified, it can be treated to minimise risks such as stroke and heart disease. Detection of AF and proper patient monitoring as part of any treatment regime are key preventative measures.

Melys AFS Ltd has developed an instrument that provides a cost-effective and non-invasive method of screening for an irregular pulse. Such a determination can be made within a few seconds, at low cost, and the patient can be referred for ECG examination. The Melys Atri-al Fibrillation Screening Monitor uses a simple finger clip sensor and provides an easily accessible means of screening the population.

www.melysafsm.com

Melys AFS Ltd, Whit-land Abbey, Whitland, Carmarthenshire, UK,SA34 0LG

SonR technology awarded at Cardiostim (Nice France)Sorin Group’s exclusive SonR sensor technology improves responder rates for heart failure patients through the regular automatic opti-mization of CRT.

Sorin Group’s SonR technology consists of a sensor embedded in the tip of a pacing lead implanted with a CRT device1. The sensor meas-ures real-time cardiac contractility and the CRT device utilises this haemodynamic data to regularly optimize² the therapy delivered.

1. PARADYM SonR not yet available for distribution 2. REF 1: “Continuous monitoring of an endocardial index of myocardial contractility during head-up tilt test”. Deharo, J-C., et al. – Am Heart J 2000; 139:1022-30; REF 2: “Automatic optimization of rest-ing and exercise AV intervals using a PEA sensor” Leung, S-K., et al. – PACE 2000;23:1672-1766.

First Implants of Taxus Element StentsBoston Scientific has announced the mar-ket launch and first implants of its TAXUS® Element™ Paclitaxel-Eluting Coronary Stent System in the Euro-pean Union and other CE Mark countries. The TAXUS Element Stent System is the Company’s third-generation drug-eluting stent (DES) technology and incorporates a platinum chromi-um alloy with an innovative stent design and an advanced catheter delivery system. It received CE Mark approval last month, which included a specific indication for the treatment of diabetic patients

The first European implants were performed by Adrian Ban-ning, M.D., Directorate Chair of Cardiac Services at John Rad-cliffe Hospital, Oxford, U.K and Corrado Tamburino, M.D., Ph.D., Chair of the Cardiology Department at Ferrarotto Hospital, Catania, Italy. “I have found the TAXUS Element Stent to offer performance advantages in flexibility, visibil-ity and deliverability over prior-generation stents,” said Dr. Tamburino.

OrbusNeich’s Combo™ Bio-engineered Sirolimus Eluting Stent Featured in Live Case Demonstration at AICTOrbusNeich’s Combo Bio-engineered Sirolimus Eluting Stent (Combo Stent) was featured recently in a live case at the 6th Asian Interventional Cardiovascular Therapeutics 2010 (AICT) in Singapore.

Huay Cheem Tan, M.B.B.S., of the National University Hospi-tal in Singapore implanted the Combo Stent in a 56-year-old male patient who had a single lesion in the left circumflex artery.

“We have had a very positive experience with the Genous stent in patients with ST-elevation myocardial infarction, or STEMI, where the pro-healing approach of Genous technol-ogy has safely addressed concerns that the use of drug-elut-ing stents in this subgroup may delay stent endothelialization and increase the likelihood of stent thrombosis,” said Dr. Tan. “Now the Combo Stent, by combining the Genous technol-ogy with a low dose drug elution, can potentially make drug-eluting stents safer.”

The Combo Stent combines the Genous™ Bio-engineered R stent™ technology for rapid endothelial coverage with an abluminal sirolimus drug elution for the control of neointimal proliferation. It is currently being evaluated in the REMEDEE (Randomized Evaluation of an abluMinal sirolimus coatED bio-Engineered stEnt) study and is not yet CE Marked.

INQUIRY REF 0910002

INQUIRY REF 0910003

INQUIRY REF 0910004

INQUIRY REF 0910005

Heart Rhythm Congress Exhibitors3-6 October 2010


Robustness Of Aquilion ONE for Cardiac CT

Introducti on

The Royal Bournemouth Hos-pital’s Aquilion ONE CT scanner has 320x0.5mm detector chan-nels and can cover 16cm in the ‘Z’ directi on, allowing imaging of the enti re heart and coronary arteries in a low dose single rotati on with no couch movement. This arti cle will focus on the impact the robustness of this scan-ner technology has made on our cardiac CT service, which is currently one of the largest in the UK.

Why is it more robust?

Conventi onal 64 detector row systems ‘build up’ an image of the heart and coronaries over multi ple heartbeats in one of two ways:

Retrospecti ve Spiral which involves a low pitch acquisiti on acquiring an enti re image dataset of the heart in all phases of the cardiac cycle with doses of 15-25mSv, even with ECG modu-lati on techniques.

Prospecti ve Gati ng (‘Step and Shoot’) achieved by acquiring a full detector width (3.2-4cm) axial ‘block’ of data multi ple ti mes, over multi ple heartbeats with couch movement between each ‘block’ at doses 5-10mSv. ‘Blocks’ do need to be overlapped to allow ‘sti tching’. A low pulse rate is required (normally <60bpm). There is also sensiti vity to poor breath hold and pulse fl uctua-ti on and this technique is unsuitable for pati ents with arrhyth-mia or AF.

The Aquilion ONE has huge advantages over the above techniques by acquiring whole heart data in a single heartbeat giving lower doses and delivering robustness. Mainly, IV Beta-blocker is given to achieve resti ng heart rate of <65bpm allowing a 70-80% prospecti ve radiati on exposure to be made, this produces excellent coronary artery images at low dose (<3mSv) and allows +/-10% padding allowing moti onless, isophasic images to be produced. (Fig 2)

1.

2.

Where Beta blocking is contraindicated / ineff ecti ve and heart rates are >65 and <75bpm, the radiati on pulse is widened allowing single beat 30-80% R-R acquisiti on, this allows reconstructi on of end systo-lic and end diastolic images from a single heartbeat at 3-5mSv with excellent image quality.

Heart rates >75bpm are rarely scanned as beta blocking is normally successful however, where necessary there are two opti ons on the Aquilion ONE:-

Single heartbeat exposure over the whole R-R interval allowing reconstructi on at any phase, similar to conventi onal retrospec-ti ve techniques at a fracti on of the dose (4-6mSv with good image quality)

Acquiring over more than one heartbeat (2 or 3) summati ng prospecti vely acquired segments thus improving the tempo-ral resoluti on. This technique gives a higher dose (5-15mSv) although sti ll substanti ally lower than conventi onal retrospec-ti ve (15-25mSv)

1.

2.

Dr Russell Bull

Consultant Radiologist, Royal Bournemouth HospitalBOURNEMOUTH

Cardiac CTFollowing NICE Guidelines

the enti re heart and coronary arteries in a low dose single rotati on with no couch movement. This arti cle will focus on the impact the robustness of this scan-ner technology has made on our cardiac CT service, which is currently one of the largest in the UK.

conti nues >>


CA

RDIA

C C

T

What about Arrythmias?

Conventional scanning technique limitations mean that variations in the pulse rate when using prospective or retrospective gating cause ‘step’ artefacts as different ‘blocks’ of data are acquired at differing heart rates. Step artefacts can increase reporting time and reduce diagnostic confidence. Where the patient is in AF or has multiple ectopic beats conventional systems are unable to cope. Even with multiple tubes and fast rotation times the best scenario will be data blocks from multiple phases and multiple cardiac cycles causing severe step artefacts. Most centres will use this as a patient exclusion criterion for cardiac CT.

Aquilion ONE – any rhythm, no problem!

The Aquilion ONE has the ability to detect arrhythmia, in real time, and wait for a sufficiently long R-R interval to deliver its radiation pulse.(Fig 3). We no longer use multiple ectopic beats as an exclusion criteria, allowing many more patients to benefit from the technique (Fig 4)

Figure 2 ±10% padding allows robust image reconstruction

Images on Left:RCA image reconstructed at 70% of R-R interval – some movement

Images on Right:RCA image reconstructed at 75% R-R interval –perfect

Figure 1:


CA

RDIA

C C

T

What about Obese Pati ents?

The Aquilion ONE has a medium-pow-ered tube coupled, extremely effi cient detectors and advanced reconstructi on techniques which, when combined, produce superior low contrast resolu-ti on with high quality images for obese pati ents without the need to increase tube current (and subsequent radia-ti on dose). Larger pati ents are thus not excluded.

What Eff ect has this had on the CT Service?

The robustness of the Aquilion ONE has transformed Cardiac CT from being dif-fi cult and slow to being easy and fast. Recent analysis has shown that 99% of all our cardiac scans are diagnosti c. Because we can scan any pati ent (size, rhythm or rate) the only remaining exclusion criteria is the pati ent’s inability to lay fl at (due to poorly controlled LVF). The Aquilion ONE is High Technology made easy as all of our CT radiographers now undertake cardiac scans routi nely instead of only a specialist few. The ‘fear factor’ has now disappeared.

Throughput has increased allowing 12 cardiac pati ents to be scanned in a 4 hour session which, in turn, allow us to meet the increased demand for cardiac CT whilst meeti ng existi ng general CT demands (90% of our workload)

The economic benefi t is also clear to us as with increased throughput we can scan more pati ents (1000 cardiac and >15000 non-cardiac pa) with the Aquil-ion ONE and an Aquilion 16. Had we not chosen the Aquilion ONE the cardiac and general throughput would have been unachievable, meaning we would have needed a third CT scanner with all of the associated running costs. Car-diac CT is now used as a ‘fi rst-line’ test for many pati ents with low-intermedi-ate risk of coronary artery disease, as currently recommended in recent NICE guidelines.

Figure 4: Excellent views of right coronary artery in patient with atrial fibrillation (ventricular rate 50-70bpm)


TAVI Advancements Expand Treatment Potenti al for Severe Aorti c Stenosis

TAVI’s

Aorti c stenosis (AS) is the most common sympto-mati c valvular disorder in the Western world, predominantly seen in elderly pati ents

and largely degenerati ve in eti ology. Surgical aorti c valve replacement (AVR) has long been the gold standard treatment for severe AS, pro-viding symptomati c relief and prolonging life. However, some AS pati ents are denied surgi-cal AVR because of signifi cant risk factors such as advanced age, co-morbiditi es or frailty. The quality of life and survival with medical man-agement in symptomati c AS is poor, with mor-tality rates at 1, 5, and 10 years of 38%, 68%, and 82%, respecti vely.1

Transcatheter aorti c valve implantati on (TAVI) has emerged as a viable alternati ve for symp-tomati c AS pati ents who are denied surgical AVR. The fi rst TAVI technology to receive CE Mark in March 2007, the CoreValve system, has now been implanted in more than 10,000 pati ents worldwide. The CoreValve system, typically delivered through the femoral artery, has demonstrated high procedural success rates and positi ve two-year performance durability and outcomes. CoreValve is not available for sale or use in the United States, Canada or Japan.

With Medtronic’s acquisiti ons of CoreValve Inc. and Ventor Technologies Ltd. in 2009, the company chartered a unique course to devel-op multi ple TAVI technologies to be delivered by cardiac surgeons and interventi onal cardi-ologists, depending on pati ent needs.

Ulrich Gerckens, M.D., HELIOS Heart Center Siegburg, Siegburg, Germany, commented that recent two-year results from the CoreValve CE-Mark pivotal trial provide important evidence that CoreValve is an eff ecti ve long-term treat-ment alternati ve for many AS pati ents considered high-risk or inoperable. “Without valve treatment this pati ent populati on faces a 50 percent chance

Adverti sement

New Technology with


orti c stenosis (AS) is the most common sympto-mati c valvular disorder in the Western world, predominantly seen in elderly pati ents

and largely degenerati ve in eti ology. Surgical aorti c valve replacement (AVR) has long been the gold standard treatment for severe AS, pro-viding symptomati c relief and prolonging life. However, some AS pati ents are denied surgi-cal AVR because of signifi cant risk factors such as advanced age, co-morbiditi es or frailty. The quality of life and survival with medical man-agement in symptomati c AS is poor, with mor-



AD

VAN

CES

of death from cardiovascular events at two years. In contrast, pati ents who received CoreValve have a greater chance of

survival and overall bett er heart functi on,” he said.

TAVI outcomes are likely to conti nue to improve with new product innovati ons. Medtronic is uniquely positi oned to leverage technology from its cardio-vascular, endovascular, and structural heart busi-nesses. For example, the company is preparing to launch the CoreValve® delivery system with Accu-Trak™ Stability Layer for transcatheter aorti c valve implantati on. AccuTrak’s proprietary technology

allows physicians to achieve control and accuracy in the deployment of the CoreValve. The system makes

it easier to precisely positi on the CoreValve device, which can be important to achieving positi ve procedure

outcomes. The one-year survival rates with the CoreValve system are comparable with octogenarians who have had surgi-

cal aorti c valve replacement or surgical plus coronary artery bypass graft (CABG).² Medtronic also is developing a new valve specifi cally designed for transapical delivery with start of a CE Mark pivotal study anti cipated in the next few months.

Medtronic is also investi ng in a strong pipeline of clinical evidence including the CoreValve U.S. Pivotal Trial, a randomized controlled comparison of CoreValve to standard treatment opti ons in high risk and inoperable pati ents; ADVANCE II, designed to characterize Cor-eValve implant best practi ces; and SURTAVI, a randomized, control-led trial of TAVI versus surgical AVR in an intermediate risk pati ent populati on.

Ongoing product enhancements and clinical studies can increase the promise of TAVI and benefi t integrated teams of cardiac specialists and the pati ents they serve.

ReferencesVaradarajan P, Kapoor N, Bansal RC, Pai RG. Clinical profi le and natural history of 453 nonsurgically managed pati ents with severe aorti c stenosis. Ann Thorac Surg. 2006;2(6):2111-2115

Moat, Neal. UK TAVI Registry, TAVI Mid and Long-term Clinical Outcomes. EuroPCR 2010.

1.

2.

Images courtesy Medtronic










1.

2.


Above: CoreValve Side View

CoreValve Accutrak

Round-Up- Latest News

5

Cardiologist Hot Topic 7

12Journals

14

Cardiac CT 15

Management Hot Topic- Surviving Government Spending Cuts

1�

20

21EP Educati on- Introducti on to Entrainment

ECG Challenge Answer 25

Management Assistance- Listening to Staff

Events Calendar& New Website

2�

- MDT Meeti ngs

Coronary Revascularisati on Decisions in MDT Meeti ngs

Cardiac CT

15

07

Cover images courtesy of Toshiba and Medtronic.

- Sponsored by Toshiba

New Technology with TAVI’s 10


Introducti on to Entrainment

Entrainment is a powerful tool in the armoury of the electro-physiologist. It can be used to probe the mechanism of arrhyth-mias, as a method for diff erenti al diagnosis and to locate targets

for ablati on. Entrainment mapping is employed in determining sites that are part of a re-entry circuit and those that are not. Moreover it allows localisati on of the criti cal isthmus that is the target of ablati ve therapy for re-entrant rhythms.

The principles of reset and entrainment are not obvious and are oft en not explained. This arti cle introduces some of these principles.

Resetti ng and Entrainment

Resetti ng involves the use of a single extrasti mulus. Timed prema-ture sti muli delivered during a sustained rhythm may interact with it, causing a pause that is not fully compensatory before resumpti on of the original rhythm; this phenomenon is referred to as resetti ng.To reset a tachycardia, the impulse must be able to reach the tachy-cardia site of origin and fi nd it excitable. The phenomenon of reset-

ti ng was originally described for the sinus node and automati c focal rhythms.

Conti nuous resetti ng with multi ple sti muli is called entrainment and is a specifi c response to overdrive pacing: Following the fi rst beat of a train of sti muli that penetrates and resets the tachycardia, subse-quent sti muli interact with the reset circuit. Although resetti ng was itself fi rst described in focal rhythms, entrainment has been exhaus-ti vely studied in re-entrant rhythms and the term in usually applied in the context of a re-entrant tachycardia. Conti nual resetti ng is seen in focal rhythms but has diff erent characteristi cs to the classical descripti on of entrainment. The term overdrive suppression is some-ti mes used for conti nual resetti ng of a focal tachycardia. Analysis of responses to resetti ng and entrainment by extrasti muli can confi rm the diagnosis of a re-entrant mechanism.

Resetti ng responses can be explained on the basis of the excitable gap and recovery properti es of the ti ssue encountered by the pacing sti muli.

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

Fig 1. Probable resetti ng of ventricular tachycardia (VT) by a conducted sinus beat (fusion beat) marked with an asterisk. The QRS is interme-diate between a normal QRS and the VT morphology. The tachycardia beat following the fused beat is advanced - coming slightly earlier than expected as indicated by the verti cal dott ed lines which mark twice the tachycardia cycle (i.e. the pause is less than fully compensatory). The degree of resetti ng is subtle but demonstrable. The ability to reset a tachycardia aft er it has begun acti vati ng myocardium makes any tachy-cardia mechanism involving a single focus (whether automati c or triggered) untenable as the wavefront spreading out from the focus would block the incoming sti mulus from reaching it.

EducationElectrophysiology


EDU

CAT

ION

Excitable Gap

In the case of a re-entrant arrhythmia, an excitable gap must exist between the leading edge of the tachycardia impulse and the wave of refractoriness following the impulse - otherwise the tachycar-dia would terminate as the leading edge would be extinguished by encountering refractory tissue. The excitable gap is the interval of excitability between the head of activation of one impulse and the tail of refractoriness of the prior impulse.

The size of the excitable gap can vary greatly from one arrhythmia to another determined by the conduction velocity and refractory properties of the circuit. The coupling intervals over which resetting occurs gives a measure of the duration of the excitable gap.

For a stimulated impulse to interact with a tachycardia – to reset, entrain or terminate it the impulse must be introduced at a time when it can penetrate the excitable gap. This may be possible with a single stimulus, or multiple stimuli may be required in order to align the refractory periods of tissue between the pacing site and the cir-cuit (“peeling back refractoriness”). This may be thought of as the first impulses clearing a path for later ones and is one reason that ATP delivered by ICDs usually consist of several consecutive stimuli.

A stimulated impulse can interact with a re-entrant circuit if it enters the excitable gap. The stimulated impulse may then propagate in both directions around the circuit. The wave travelling in the oppo-site direction to the spontaneous tachycardia (antidromically) willinevitably collide with the already circulating tachycardia wavefront and both are extinguished. The stimulated impulse also conducts orthodromically (in the same direction as the tachycardia wavefront) if the tissue is not refractory. The stimulated impulse then continues to traverse the reentrant circuit to reset the tachycardia - arriving at the exit at an earlier than expected time advancing the timing of activation in the circuit and the tissue activated by it.

Termination occurs when the stimulated impulse collides retrograde-ly with the preceding tachycardia impulse (as it must) but also blocks antegradely owing to encroachment on the refractory period of the preceding wavefront.

Fig 2. Representation of a re-entrant circuit. A wave of excitation cir-culates in a clockwise direction. Green represents refractory tissue, with the intensity revealing varying stages of recovery. In classical re-entry there must be a gap of excitable tissue between the head of the wavefront and the refractory tail and this circulates around the circuit ahead of the tachycardia wavefront.

Fig 3. A pacing stimulus can interact with a circuit if it enters the excitable gap. The resulting antidromic wavefront (red arrow) is bound to extinguish the exist-ing circulating wave. During resetting the orthodromic impulse (blue) does not encounter refractory tissue and so conducts around the circuit becoming a new tachycardia wavefront. This impulse arrives at points around the circuit earlier than expected – the circuit is reset. The impulse eventu-ally reaches the exit from the circuit resulting in activation of the myocardium outside the circuit.


EDU

CAT

ION

Return cycle and post pacing interval and entrainment mapping

During entrainment each impulse following the first to reset the tachycardia propagates in both an antidromic and orthodromic direc-tion around the circuit. The antidromic impulse of the last introduced stimulus collides with the orthodromic impulse of the preceding stimulus. The orthodromic impulse of the last introduced stimulus propagates around the circuit to become the first complex of the resumed tachycardia.

Entrainment mapping involves pacing at cycle lengths shorter than that of the tachycardia cycle length from a variety of sites withinthe chamber of interest and analyzing the return cycles. The returncycle is subtracted from the tachycardia cycle length to give the post pacing interval (PPI). Sites that are within the circuit demonstrate a return cycle equal to the tachycardia cycle length (PPI approaches zero). When stimulation is carried out at sites distant from the circuit, the return cycle exceeds the tachycardia cycle length because the pacing impulse must first travel to the site of the circuit travel around the circuit and then return to the pacing site (long PPI). The return cycle is typically and ideally measured at the pacing site and is the time from the last introduced stimulus to the the electrogram result-ing from the resumed tachycardia (see fig 4).

PPI and suggesting the pacing site is far from the re-entrant circuit

and therefore not attractive for ablation. The sequence of intracar-diac signals is different during entrainment than during the resumed tachycardia (see CS signals). This is known as manifest electrogram fusion (see subsequent article).

Entrainment mapping can be used to determine the distance of a pacing site to a re-entrant circuit, sites that are within the circuit and the location of the critical isthmus. It is often employed during the mapping of atrial and ventricular tachycardias because the location of the culprit circuit is highly variable and must be established to identify targets for successful ablation.

For entrainment mapping pacing is carried out at a rate just fast enough to observe that the tachycardia has been accelerated to thepacing rate and no faster. Entraining at too fast a rate can result in slowing of conduction secondary to interval-dependent conduction delay through tissue that has only partially recovered excitability when the stimulus reached the circuit. Conduction slowing will inter-fere with assessment of the PPI. Entrainment is typically performed by pacing at 10-40ms faster than the tachycardia rate.

During entrainment different degrees of ECG fusion can be seen resulting from the interaction between paced activation and ortho-dromic and antidromic activation of the circuit. The terms entrain-ment with manifest and concealed fusion will be dealt with in thenext article and the concept is important in establishing the tachycar-dia mechanism and for identifying the critical isthmus of re-entrant circuits.

TM


EDU

CAT

ION

Advertise With UsSee Page 4 for Contact Details

References

Almendral JM, Stamato NJ, Rosenthal ME, Marchlinski FE, Miller JM, Josephson ME. Resetti ng response patt erns during sustained ventricular tachycardia: relati onship to the excitable gap. Circu-lati on 1986;74;722-730

Josephson ME. Clinical Cardiac Electrophysiology: Techniques and Interpretati ons 3rd editi on. Lippincott Williams & Wilkins Publishers 2001

CardiologyHD.comSee our other Electrophysiology Education Topics online today:

Learning Electrophysiology: Anatomical descripti on and fl uoroscopic views

Bundle Branch Re-entry VT

Atrial Tachycardia

Making Sense of AF

Atrial Flutt er

Persistent Juncti onal Reciprocati ng Tachycardia (PJRT)

Adenosine in Electrophysiology

An Introducti on to Electrograms

Monomorphic Ventricular Tachycardia

AVNRT: The most common regular tachycardia

Wolff Parkinson White Syndrome

•

•

•

•

•

•

•

•

•

•

•

ECG Challenge- with Sophie Blackman

- sponsored by Medtronic


How to get in touch@ Email

Phone

Post

Circulati on

ExpertsOur Cardiology

Editorial, Subscripti on, & General [email protected]

Adverti sing enquiriesadverti [email protected]

Coronary Heart Publishing Ltd, Peter House, Oxford Street, Manchester, M1 5AN, UK

Editorial, Subscripti on, & General enquires+44 (0) 845 299 6220

Adverti sing enquiries+44 (0) 845 299 6220

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

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

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

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

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




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

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

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

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

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

Want More Product Informati on?

INQUIRY REF 00000000

Contact us via the details below quoti ng the reference alongside each advert, and we will organise a company representati ve to send you more details.


Looking for a new direction?

Siemens Healthcare leads the field in providing diagnostic imaging solutions for the NHS and private sector. Due to changes within our team, we are now looking for a Radiographer to train as Applications Specialist providing high quality user training to our customers within the UK.

This is an excellent opportunity for you to utilise your skills and knowledge whilst keeping up-to-date with the latest cutting edge technology.

Joining the Angio and X-ray team you will provide application support for the full range of Cardiac AngiographyEquipment, building relationships with internal and external customers, organising and delivering presentations for clinical professionals at customer sites.

Having strong experience in the ‘cardiac cath lab’ environment, you will be a qualified Radiographer with experienceof advanced cardiac procedures. You will also have effective communication and interpersonal skills, and experienceof teaching in a clinical setting. Any experience of using Siemens equipment is a plus, however full training will beprovided. Great flexibility is required due to extensive travel in the UK and on occasions in North West Europe.

To apply for this role please visit www.siemens.co.uk/careers/en, select careers and then enter reference number5700. If you have any questions about this vacancy please call Siemens on 01276 696407.

Siemens Healthcare

www.siemens.co.uk/jobs

Cardiac Applications SpecialistAttractive salary + car + bonus + benefits

INQUIRY REF 0910001

Round UpHeart Rhythm Congress Latest News

BARD® EP Mini Case Review Sessions & EP Fellows Course30minute EP Teaching Sessions are to be held during breakti mes & lunchti mes on the BARD® EP stand at the Heart Rhythm Congress, Birmingham. A Consultant Electrophysiologist will present a real life EP case. Parti cipants will be encouraged to interact with the case, including making measurements of intervals. The sessions are aimed at Cardiology SpR’s or Cardiac Physiologists with at least a basic EP knowledge. The sessions will be limited to a small group of 5-6 peo-ple & thus aim to be interacti ve. Pre registrati on will be required & can be booked at the BARD® EP stand during the meeti ng.

In November another EP teaching opportunity will be a BARD® EP Fellows Course, which will take place on 21st November, preceding Europe AF 2010, London.

Pre registrati on for this event will also be required & will be via the website www.europeaf.com


The Melys Atrial Fibrillation Screening MonitorChronic Atrial Fibrillation is the most common arrhythmia seen in medical practice. It causes increased patient morbidity and mortal-ity and adds significantly to the burden of health care costs. Once identified, it can be treated to minimise risks such as stroke and heart disease. Detection of AF and proper patient monitoring as part of any treatment regime are key preventative measures.

Melys AFS Ltd has developed an instrument that provides a cost-effective and non-invasive method of screening for an irregular pulse. Such a determination can be made within a few seconds, at low cost, and the patient can be referred for ECG examination. The Melys Atri-al Fibrillation Screening Monitor uses a simple finger clip sensor and provides an easily accessible means of screening the population.

www.melysafsm.com

Melys AFS Ltd, Whit-land Abbey, Whitland, Carmarthenshire, UK, SA34 0LG

SonR technology awarded at Cardiostim (Nice France)Sorin Group’s exclusive SonR sensor technology improves responder rates for heart failure patients through the regular automatic opti-mization of CRT.

Sorin Group’s SonR technology consists of a sensor embedded in the tip of a pacing lead implanted with a CRT device1. The sensor meas-ures real-time cardiac contractility and the CRT device utilises this haemodynamic data to regularly optimize² the therapy delivered.

1. PARADYM SonR not yet available for distribution 2. REF 1: “Continuous monitoring of an endocardial index of myocardial contractility during head-up tilt test”. Deharo, J-C., et al. – Am Heart J 2000; 139:1022-30; REF 2: “Automatic optimization of rest-ing and exercise AV intervals using a PEA sensor” Leung, S-K., et al. – PACE 2000;23:1672-1766.

First Implants of Taxus Element StentsBoston Scientific has announced the mar-ket launch and first implants of its TAXUS® Element™ Paclitaxel-Eluting Coronary Stent System in the Euro-pean Union and other CE Mark countries. The TAXUS Element Stent System is the Company’s third-generation drug-eluting stent (DES) technology and incorporates a platinum chromi-um alloy with an innovative stent design and an advanced catheter delivery system. It received CE Mark approval last month, which included a specific indication for the treatment of diabetic patients

The first European implants were performed by Adrian Ban-ning, M.D., Directorate Chair of Cardiac Services at John Rad-cliffe Hospital, Oxford, U.K and Corrado Tamburino, M.D., Ph.D., Chair of the Cardiology Department at Ferrarotto Hospital, Catania, Italy. “I have found the TAXUS Element Stent to offer performance advantages in flexibility, visibil-ity and deliverability over prior-generation stents,” said Dr. Tamburino.

OrbusNeich’s Combo™ Bio-engineered Sirolimus Eluting Stent Featured in Live Case Demonstration at AICTOrbusNeich’s Combo Bio-engineered Sirolimus Eluting Stent (Combo Stent) was featured recently in a live case at the 6th Asian Interventional Cardiovascular Therapeutics 2010 (AICT) in Singapore.

Huay Cheem Tan, M.B.B.S., of the National University Hospi-tal in Singapore implanted the Combo Stent in a 56-year-old male patient who had a single lesion in the left circumflex artery.

“We have had a very positive experience with the Genous stent in patients with ST-elevation myocardial infarction, or STEMI, where the pro-healing approach of Genous technol-ogy has safely addressed concerns that the use of drug-elut-ing stents in this subgroup may delay stent endothelialization and increase the likelihood of stent thrombosis,” said Dr. Tan. “Now the Combo Stent, by combining the Genous technol-ogy with a low dose drug elution, can potentially make drug-eluting stents safer.”

The Combo Stent combines the Genous™ Bio-engineered R stent™ technology for rapid endothelial coverage with an abluminal sirolimus drug elution for the control of neointimal proliferation. It is currently being evaluated in the REMEDEE (Randomized Evaluation of an abluMinal sirolimus coatED bio-Engineered stEnt) study and is not yet CE Marked.

INQUIRY REF 0910002

INQUIRY REF 0910003

INQUIRY REF 0910004

INQUIRY REF 0910005

More Heart Rhythm Congress Exhibitors3-6 October 2010


Hot TopicCardiologist

In my view, acti ng as a ‘sole practi ti oner’ is a recipe for disaster. As a result, we have had a formal weekly MDT meeti ng to discuss pati ents being considered for revascularisati on (and transcatheter valve proce-dures) for well over 10 years. Ideally all pati ents should be discussed, although in practi ce in many cases the decision making is clear cut and oft en those pati ents will not be discussed. However, when ever there is doubt as to the best management strategy, pati ents are fully discussed. Ideally all pati ents should have SYNTAX scores and Euro-scores calculated prior to the meeti ng. For each pati ent, a lett er is produced documenti ng the staff present and decisions made.

Dr Simon RedwoodConsulti ng EditorReader in Interventi onal cardiologyHonorary Consultant CardiologistSt Thomas’ HospitalLONDON

CardiologyHD.comSee our other Cardiologist Hot Topics online today:

Opti cal Coherence Tomography (OCT)

UK Primary Angioplasty Service

Diagnosti c Pathways for Treati ng Chest Pain

Complex Strategies when Treati ng Bifurcati on Stenoses

FFR FAME Trial

SYNTAX Trial

Diff erences between Drug Eluti ng Stents

Clopidogrel

Left Main Stenti ng

NICE Guidelines For Use of Drug Eluti ng Stents

COURAGE Trial

•

•

•

•

•

•

•

•

•

•

•

conti nues >>

Questi on: Do you have an MDT meeti ng at your hospital, and if so which pati ents for coronary revascularisati on should be discussed?

Also should a formal SYNTAX Score be used with each?


There is a weekly cardiac MDT meeting at the Manchester Heart Centre, which is very well attended by Consultant Cardiologists, Cardiac Surgeons, Cardiac Anaesthesiologists and Cardiac Radiolo-gists. It is also attended by junior doctors who often present the cases, a member of the Cardiac Liaison team and the MDT co-ordi-nator. Typically between 10 and 15 cases are discussed and the Consultant responsible for each case ensures that the agreed plan is implemented and communicated as required. A formal Syntax Score is not used.

In addition there is a smaller weekly Cardiac Surgical MDT meeting attended by the Cardiac Surgeons and Cardiac Anaesthetists. In that meeting we discuss all patients who have been seen by a Cardiac Surgeon and have been accepted for surgery. The purpose of this is mainly to discuss high-risk patients and their co-morbidities and get a consensus whether it would be appropriate to operate on certain patients or not. However we also discuss all routine cases, which ensures that there are no outstanding investigations and that the key data, including the angiogram are reviewed.

Which patients should be discussed at a Cardiology and Cardiac Surgery MDT meeting is a very difficult subject. One could argue that ideally all patients with coronary artery disease should be discussed at an MDT. Mistakes can happen and things can go wrong even in the simplest of cases and for that reason to “rubber-stamp” a straightforward case by a group is valuable. I would also add that in my experience patients like to know that a group of doctors sat together and discussed their case, even if they have complete faith to the individual Consultant.

Discussing all cases however is not practical at present and if the NHS goes down that route this would have significant implications

in the workload and work pattern of Consultants. One therefore has to agree on certain criteria and I think we should be discussing patients with 3-vessel or left main stem disease and patients with a non-type A lesion of the proximal LAD. This covers the vast majority of patients where revascularization is of prognostic benefit and does not overwhelm the MDT with patients with one and 2-vessel disease who are suitable for angioplasty.

The difficult reality is that whilst at the Manchester Heart Centre we discuss the majority of patients who fulfil the above criteria, as Car-diac Surgeons we are also presented with workload from the district general hospitals of our region. Organising MDT meetings for those patients is obviously more difficult and there is a significant amount of practice based on traditional Cardiologist to Cardiac Surgeon referral without an MDT.

In view of these difficulties, I think that Syntax scoring every patient would add to the complexity of the situation. More importantly, while Syntax score is a useful research tool I don’t think it adds much to the decision making that experienced clinicians can make about individual patients. Ultimately Syntax scoring is often down to interpretation of an angiogram and that is only part of the some-times complex discussions that take place at an MDT.

I think that whether we like it or not the days when crucial deci-sions about the life and well-being of a patient could be left to the skills and talent of one individual Consultant are gone. In the years to come there will be increasing pressures for monitoring of our results and justification of our decisions. Part of this will include discussing an increasing number of patients at an MDT and the onus will be upon us to facilitate this.

We indeed have an MDT at King’s College Hospital. We have two types of MDTs: one for coronary revascularisation and other for structural heart valve disease.

At Kings we have coronary revascularisation MDT meetings, but I also attend other hospitals such as the William Harvey Hospital in Ashford, Kent and Queen Elizabeth Queen Mother Hospital in Margate. So we have a very robust MDT system working in the south-east. I am a strong believer in the MDT. I personally feel that patients who have triple vessel disease, patients that have a high SYNTAX score, patients who are diabetics, patients who are young, patients who have had PCI before (once), even if it was single vessel disease, should be discussed. And I think all PAMI’s with incomplete revascularisation should be discussed.

So these would be my choices:

Firstly, patients with triple vessel coronary artery disease. •

In case of single vessel disease, for very proximal disease in the LAD or ostial LAD disease, which is the most important artery in the heart, I believe a LIMA graft would serve them better in the long run. There was reluctance to refer these cases for surgery due to need of a sternotomy. I perform the LIMA to LAD bypass in a minimally invasive technique using endoscopic instruments. Because of the MDT my cardiology colleagues now believe in options of proximal stenting or endoscopic CABG for ostial LAD lesions. At Kings we call this technique as Endoscopic Assisted Minimally Invasive Direct Coronary Artery Bypass (Endo- MIDCAB).

Traditionally single vessel disease have been excluded from MDT meetings, but with this new technique more of these patients are being presented at our MDT’s.

Now even for emergencies we have urgent MDT’s. My fel-low cardiologists will call me, or call another surgeon who is on-call, in the cath-lab, so we don’t have to wait for a for-mal MDT to happen. This is very beneficial to the patient as an option of surgery is considered instantly before they receive stents if the cardiologist is doubtful of the coronary anatomy.

•

•

Mr Ranjit P Deshpande MS MCh FRCS (C-Th/Eng)Consultant Cardiothoracic SurgeonKing’s College HospitalLONDON

Dr Theodore VelissarisConsultant Cardiothoracic SurgeonManchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust


We have a weekly MDT meeting at the Manchester Heart Centre which features formally on our job plans. In this meeting, which is attended by cardiologists, surgeons, anaesthetists, a nuclear medicine physician, a member of the cardiac liaison team and an MDT co-ordinator, we discuss all cases where either cardiologist or surgeon feels a consensus view is needed. We attempted to formal-ise this for revascularisation cases by agreeing a set of criteria for referral to the meeting, but the process remains rather ad hoc, with many of us bringing to the meeting cases which we would rather not do! We only occasionally calculate a SYNTAX or logistic Euro-score for cases presented, and to date, this has not been formally included on the case summary proformas that SpRs have to submit in advance to the MDT co-ordinator.

Some colleagues, mostly surgeons and anaesthetists, believe that all revascularisation cases should be discussed at the MDT meeting. On the other hand, some interventional cardiologists hold the view that, being the default gatekeepers of the entire process, they have the natural ‘right’ to select for PCI all cases where they feel a good final angiographic result is achievable, and to ‘pass on’ to the sur-geons other cases where this is not so. These are probably extreme views, and the truth lies somewhere in the middle! Disagreements between interventional cardiologists and surgeons as to the best revascularisation strategy are commonplace (remember only 2%-12% of patients screened for the SYNTAX Trial were actually ran-domised, which, to a large extent, was due to such disagreements), and this underscores the importance of utilising meaningful risk

scoring systems to guide all through the decision-making process.

The problem with the currently available scoring systems is that none offers a complete patient assessment with regard to proce-dural risk. While the SYNTAX Score is purely an anatomic score for risk assessment which does not include any clinical information, the Euroscore is a mortality score based on clinical variables (including co-morbidities) and type of surgery, without any reference to the anatomical complexity of coronary disease. Thus, the former is of more value to the interventionist while the latter is of more value to the surgeon, but a combination of the two may be of greater value to the patient as it would allow better-informed decision-making as to the most appropriate revascularisation strategy for that patient. Thus, in my opinion, and provided manpower is available, both scores should be calculated for every patient that goes through the MDT meeting. It is worth noting that a recent study by Serruys et al. has shown that combining the anatomic-based SYNTAX Score with 3 simple clinical variables (age, LVEF and creatinine clearance) creates a ‘clinical Syntax Score’ which is superior to the old Syntax Score at predicting MACE and mortality in patients undergoing complex PCI.

The MDT meeting is there to protect both patients and clinicians: it brings together experts in different disciplines with the aim of safe-guarding patients through consideration of all relevant important elements of their care prior to decision making, and also safe-guards clinicians through the process of seeking views from as wide a body of opinion as possible.

The Freeman Hospital Cardiothoracic MDT meeting takes place weekly, lasts about 2 hours and typically10 cases are discussed. A record of attendance and outcome of the MDT discussion are documented and the meeting is considered quorate when 2 car-diothoracic surgeons and 2 cardiologists are present. Inpatients and outpatients referred for revascularisation are presented and video conferencing can now be used with colleagues in the dis-trict. Ad-hoc MDT meetings are also held for emergent cases.

The number of coronary revascularisations at the Freeman Hos-pital is approaching 4000 per annum and not all patients referred for revascularisation are discussed at an MDT. STEMI patients and those patients presenting with ACS who have an obvious culprit lesion are usually treated immediately with PCI. However, a consensus is sought in those ACS patients who have more complex coronary disease and are high risk for PCI.

Elective patients with stable ischaemic heart disease who have had angiography performed at their local hospital are referred to the elective PCI or surgical pools at the discretion of the referring cardiologist. When the referring consultant is unsure of the best revascularisation strategy, patients are referred to the MDT for discussion. Surgeons and interventionists also bring their cases from their pool to the MDT meeting where the revascularisation

strategy can be ratified or altered by the multidisciplinary team. SYNTAX scoring is being increasingly used and is making a posi-tive contribution to our decision-making process particularly in equivocal cases. Audits of patients undergoing revascularisation are performed to examine the appropriateness of the treatment plans and quality of record keeping. We are currently perform-ing a retrospective analysis of Syntax scores in patients that have undergone elective bypass surgery and PCI over the last year.

Naturally there are disagreements as to the optimum form of revascularisation. To make the best decisions in equivocal cas-es an intimate knowledge of clinical trials and clinical data is required. If consensus cannot be reached or if it is believed both forms of revascularisation will give equal outcomes then this is reported back to the referring clinician so a discussion can take place with the patient.

CABG, PCI and medical treatments for IHD are complementary and the weekly MDT meeting allows for the formulation of an optimum revascularisation plan for patients. None more so in patients who might benefit from a hybrid procedure or who are at high risk for PCI or surgery, or in those who might benefit most from medical treatment alone.

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

Dr Magdi El-OmarLead Consulting EditorConsultant Cardiologist, Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust



TAVI’s

Aorti c stenosis (AS) is the most common sympto-mati c valvular disorder in the Western world, predominantly seen in elderly pati ents

and largely degenerati ve in eti ology. Surgical aorti c valve replacement (AVR) has long been the gold standard treatment for severe AS, pro-viding symptomati c relief and prolonging life. However, some AS pati ents are denied surgi-cal AVR because of signifi cant risk factors such as advanced age, co-morbiditi es or frailty. The quality of life and survival with medical man-agement in symptomati c AS is poor, with mor-tality rates at 1, 5, and 10 years of 38%, 68%, and 82%, respecti vely.1

Transcatheter aorti c valve implantati on (TAVI) has emerged as a viable alternati ve for symp-tomati c AS pati ents who are denied surgical AVR. The fi rst TAVI technology to receive CE Mark in March 2007, the CoreValve system, has now been implanted in more than 10,000 pati ents worldwide. The CoreValve system, typically delivered through the femoral artery, has demonstrated high procedural success rates and positi ve two-year performance durability and outcomes. CoreValve is not available for sale or use in the United States, Canada or Japan.

With Medtronic’s acquisiti ons of CoreValve Inc. and Ventor Technologies Ltd. in 2009, the company chartered a unique course to devel-op multi ple TAVI technologies to be delivered by cardiac surgeons and interventi onal cardi-ologists, depending on pati ent needs.


Adverti sement

New Technology with


orti c stenosis (AS) is the most common sympto-mati c valvular disorder in the Western world, predominantly seen in elderly pati ents

and largely degenerati ve in eti ology. Surgical aorti c valve replacement (AVR) has long been the gold standard treatment for severe AS, pro-viding symptomati c relief and prolonging life. However, some AS pati ents are denied surgi-cal AVR because of signifi cant risk factors such as advanced age, co-morbiditi es or frailty. The quality of life and survival with medical man-agement in symptomati c AS is poor, with mor-



AD

VAN

CES



TAVI outcomes are likely to conti nue to improve with new product innovati ons. Medtronic is uniquely positi oned to leverage technology from its cardio-vascular, endovascular, and structural heart busi-nesses. For example, the company is preparing to launch the CoreValve® delivery system with Accu-Trak™ Stability Layer for transcatheter aorti c valve implantati on. AccuTrak’s proprietary technology

allows physicians to achieve control and accuracy in the deployment of the CoreValve. The system makes








1.

2.











1.

2.


Above: CoreValve Side View

CoreValve AccuTrak


Journals

Heart FailurePati ents with heart failure oft en have depression and this is associ-ated with increased hospitalisati on and mortality. The SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial was a randomised, double-blind, placebo-controlled trial of sertraline versus placebo for 12 weeks in 469 pati ents. The primary endpoints were change in depression severity and compos-ite cardiovascular status at 12 weeks. Sertraline and placebo both improved depression scoring equally and neither made any signifi -cant diff erence to cardiovascular outcomes. Fairly depressing results, but good news for placebo.

O’Connor and others JACC 56:692-99.

Coronary Interventi onGuidelines are a double edged sword – we all like to quote them when they agree with us, but dismiss them when we think diff er-ently, stati ng that you assess pati ents on their ‘individual merits’. A recent guideline from the European Society of Cardiology addresses the interesti ng problem of anti thromboti c / anti platelet management in PCI pati ents with AF. Take home messages include several recent studies indicati ng that uninterrupted warfarin, instead of heparin bridging therapy, provides a favourable balance between bleeding and ischaemic complicati ons, especially when the PCI is performed radially. The authors also suggest that triple therapy with aspirin, clopidogrel and warfarin appears to be the best opti on to prevent stent thrombosis and thromboembolism. I suspect most interven-ti onists feel uncomfortable with the concept of triple therapy and the associated bleeding risk and would opt for bare metal, ti tanium covered, anti body-coated or biodegradable polymer stents with their shorter requirement for dual anti platelet therapy. The pati ents would take aspirin and clopidogrel for one month following the PCI and then change to aspirin and warfarin for life. The combinati on of warfarin and clopidogrel is less tested. Alternati ves in pati ents with high bleeding risk include balloon angioplasty alone, drug-coated ballloon angioplasty or CABG. The bott om line is that the guidelines are based on expert opinion with litt le supporti ng randomised data.

Lip and others European Heart Journal 31(11):1311-8

Intravascular ultrasound has taught us a lot about coronary artery dis-ease and PCI. It is very useful for assessing vessel size, plaque burden, plaque morphology (virtual histology) and also telling us why things go wrong. A recent small IVUS study from South Korea examined images from 30 pati ents with confi rmed very late stent thrombosis (>1 year). 23 had drug eluti ng stents (DES), whilst the remainder were

bare metal (BMS). Events tended to occur earlier with BMS (108.4+/- 26.5 months) compared to DES (33.2 +/- 12.5 months). There was less neointi ma in the DES than the BMS, as expected. Acquired malappo-siti on (also termed positi ve remodelling) was only seen in the DES group – the stents had been well deployed on initi al post PCI IVUS. Malappositi on likely develops when the vessel wall pulls away from the stent struts due to positi ve remodeling or thrombus resorpti on. Neointi mal or plaque rupture was seen equally in both groups. Very late stent thrombosis in DES may be due to delayed arterial healing with incomplete endothelializati on and persistent fi brin or to stent-vessel wall malappositi on. Atheroscleroti c lesions within BMS may progress to ti ght stenosis and/or rupture. Opti cal coherence tomog-raphy will provide further insights.

Lee and Others JACC Cardiovascular Interventi ons 55:1936-42.

Thrombus aspirati on in PPCI seems to have been universally accept-ed by interventi onists on the basis of one trial (TAPAS, N Engl J Med 2008;358:557-67) whilst others showed no benefi t (Circulati on. 2006;114:40-47, JACC 48:244-52). A major predictor of no-refl ow in PPCI is increasing ti me to treatment. An Italian group has pooled data from three prospecti ve trials comparing thrombus aspirati on with standard PCI. Thrombus aspirati on limits the adverse eff ects of ti me to treatment, suggesti ng it is benefi cial.

De Vita and others Heart 96:1287-90.

The HORIZONS-AMI (Harmonizing Outcomes with RevasculariZati ON and Stents in Acute Myocardial Infarcti on) trial conti nues to produce published sub-studies. The original trial showed that bivalirudin decreased major bleeding, 30-day and 1-year mortality in pati ents undergoing primary percutaneous interventi on (PPCI) when com-pared with unfracti onated heparin (UFH) plus glycoprotein IIb/IIIa inhibitors (GPI). The latest study divided the pati ents into risk terti les according to the CADILLAC bleeding risk score. The mortality rates in the bivalirudin and UFH plus GPI arms, respecti vely, were 0.4% and 1.2% (p = 0.09) in the low-risk group, 4.2% and 4.1% (p = 0.99) in the intermediate-risk group, and 8.4% and 15.9% (p = 0.01) in the high-risk group. Among high-risk pati ents, there was also a decreased rate of recurrent myocardial infarcti on in pati ents randomized to bivaliru-din as compared to UFH plus GPI (3.6% vs. 7.9%, p = 0.04). It would appear that the pati ents who benefi t the most from bivalirudin are those at the highest bleeding risk, though the usual caveats when dealing with subgroup analysis should be considered. In these aus-tere ti mes, the cost advantage may also be important.

Parodi and others JACC Cardiovascular Interventi ons 3:796-802.




ConfectionaryGood and bad news for chocolate lovers. A new observational study of >19,000 patients from Germany demonstrates that some choco-late is good for you, lowering BP and cardiovascular disease (39% relative risk reduction (RRR) in stroke or MI), compared to those that eat no chocolate. However, too much chocolate is bad for you due to the fat and sugar. Dark chocolate has the highest content of fla-vanoids and procyanids, both associated with lower cardiovascular risk, as well as the highest antioxidant capacity. The exact types and amounts of chocolate are still to be elucidated. I imagine recruitment for further studies will be straightforward.

Buijsse and others European Heart Journal 31 (13): 1616-1623.

Valvular Heart DiseaseThe Ross procedure is an operation for aortic stenosis in which the patient’s own pulmonary valve is transferred to the aortic position as an autograft and a tissue prosthesis placed in the pulmonary posi-tion. Advantages are perceived to be better longevity than aortic homograft replacements and the avoidance of anticoagulation com-pared with mechanical prosthesis. The operation has many devotees worldwide, but been regarded as somewhat niche by most surgeons in the UK.

A randomised single centre trial of autograft vs. homograft in 228 patients aged 18-69 found survival to be significantly better in the autograft group (97 vs 83% at 10 years).

Ismail El-Hamamsy and others Lancet 376: 524–31

Now that PCI is being performed in many DGH hospitals in the UK, a significant proportion of interventionists based in surgical centres are developing transcatheter aortic valve implantation (TAVI) pro-grams to fill their time. There are two mainstream devices approved in the UK - Edwards (Edwards Lifesciences, Nyon, Switzerland) and Medtronic CoreValve (Luxembourg City, Luxembourg). The Cor-eValve is delivered retrogradely and percutaneously (femoral or axil-lary artery) whilst the Edwards can be delivered percutaneously or transapically. They are available in different, but limited sizes and have certain patient and anatomical requirements. Edwards current-ly have 22- and 24-F, soon to be 18- and 19-F; CoreValve is 18-F, as well as certain aortic valve annular criteria (18 to 25 mm and 20 to 27 mm, respectively).

A small, but valuable study from Leicester analysed 100 consecutive patients using transthoracic and transoesophageal echocardiography and invasive angiography to asses their suitability for TAVI. 97% of patients were suitable for one of the options. Edwards’ suitability was 28% for Edwards-Sapien transfemoral, 78% for Edwards Novaflex transfemoral, and 88% for Edwards-Sapien transapical. Medtronic CoreValve suitability was 84% for transfemoral and 89% using addi-tional transaxillary and direct aortic approaches. We now await the results of the trials to tell us which patients we will be routinely offer-ing this breakthrough therapy to.

Jilaihawi and others. JACC Cardiovascular Interventions 3:859-66.

Sudden Cardiac DeathUnderstandably it’s not always been easy to get quality data on the effect of interventions in cardiopulmonary resuscitation. In the past this doesn’t seem to have stopped some fairly strident views being expressed and great importance placed on the exact adherence to protocols. One area of uncertainty is what value respiratory support provides.

Two papers recently published provide valuable data of high quality to guide future practise.

In one study, over 1200 Swedish patients resuscitated in the commu-nity from cardiopulmonary arrest were randomly assigned compres-sion only or standard CPR survival was similar in both groups (8.7 vs. 7%).

In a similar trial bystanders were instructed to administer compres-sion only or standard CPR in 1941 North American victims of out of hospital arrest. Again there was no significant difference in outcomes (12.5 vs. 11% survival to discharge).

Neither of these studies examined the utility of rescue breathing by trained healthcare professionals.

Leif Svensson and others N Engl J Med 363:434-42

Thomas D Rea and others N Engl J Med 363:423-33.

In the search for predictors of sudden cardiac death two factors which consistently show value are ejection fraction and non sustained VT. In a study on the effect of Ranolazine (an anti anginal) on outcomes in non ST elevation the trial designers usefully conducted seven days ambulatory ECG monitoring. Analysis of this data reveals four to sev-en beats and eight or more beats of NSVT is associated with a hazard ratio for sudden cardiac death of 2.3 and 2.7%. In patients with Ejec-tion fractions under 40% this equates to a risk of sudden death of 2.8% (0-3 beats NSVT), 6.1% (4-8 beats) and 12.2% (>7 beats) after twelve months follow up.

Benjamin M. Scirica and others Circulation. 122:455-462

The potential benefits of an implantable defibrillator without the complication of transvenous leads are significant; easier extraction, lower risk of endocardial infection and even a simpler implant. The drawbacks are also well documented; less (if any) pacing, challenges with detection, higher defibrillation thresholds.

The results of a trial of a commercially available, wholly extravascular system are encouraging. The authors first established the optimum implant position (axilliary active can and left parasternal lead), then proceeded to demonstrate acceptable performance in 55 standard ICD indication recipients including 12/12 appropriately detected and successfully treated clinical ventricular arrhythmias.

Gust H. Bardy and others N Engl J Med 363:36-44

Call for PapersCoronary heart is pleased to receive original contributions, case reports and reviews to be considered for publication in print and on line. Contributions will be subject to peer review. Please send manuscripts in word or similar compat-ible formats with figures embedded. If accepted for publica-tion higher quality files will be requested.

Send all contributions by email to, [email protected]


Clinical Background A 68 year old lady with a history of cardiac ischaemia was admitt ed to A&E aft er a general feeling of unwell over a 24 hour period. She has a dual chamber ICD in situ and had experienced some palpitati ons but she was not aware of any therapy from her device.

This ECG was recorded in A&E at 10mm/mV and 25mm/sec.

Questi onsWhat is the presenti ng arrhythmia and how could this be confi rmed?

How does the arrhythmia terminate?

What treatment opti ons could be benefi cial to this pati ent?

1.

2.

3.

Answer on Page: 25



ChallengeSophie Blackman’s ECG


Robustness Of Aquilion ONE for Cardiac CT

Introducti on

The Royal Bournemouth Hos-pital’s Aquilion ONE CT scanner has 320x0.5mm detector chan-nels and can cover 16cm in the ‘Z’ directi on, allowing imaging of the enti re heart and coronary arteries in a low dose single rotati on with no couch movement. This arti cle will focus on the impact the robustness of this scan-ner technology has made on our cardiac CT service, which is currently one of the largest in the UK.

Why is it more robust?

Conventi onal 64 detector row systems ‘build up’ an image of the heart and coronaries over multi ple heartbeats in one of two ways:

Retrospecti ve Spiral which involves a low pitch acquisiti on acquiring an enti re image dataset of the heart in all phases of the cardiac cycle with doses of 15-25mSv, even with ECG modu-lati on techniques.

Prospecti ve Gati ng (‘Step and Shoot’) achieved by acquiring a full detector width (3.2-4cm) axial ‘block’ of data multi ple ti mes, over multi ple heartbeats with couch movement between each ‘block’ at doses 5-10mSv. ‘Blocks’ do need to be overlapped to allow ‘sti tching’. A low pulse rate is required (normally <60bpm). There is also sensiti vity to poor breath hold and pulse fl uctua-ti on and this technique is unsuitable for pati ents with arrhyth-mia or AF.

The Aquilion ONE has huge advantages over the above techniques by acquiring whole heart data in a single heartbeat giving lower doses and delivering robustness. Mainly, IV Beta-blocker is given to achieve resti ng heart rate of <65bpm allowing a 70-80% prospecti ve radiati on exposure to be made, this produces excellent coronary artery images at low dose (<3mSv) and allows +/-10% padding allowing moti onless, isophasic images to be produced. (Fig 2)

1.

2.

Where Beta blocking is contraindicated / ineff ecti ve and heart rates are >65 and <75bpm, the radiati on pulse is widened allowing single beat 30-80% R-R acquisiti on, this allows reconstructi on of end systo-lic and end diastolic images from a single heartbeat at 3-5mSv with excellent image quality.

Heart rates >75bpm are rarely scanned as beta blocking is normally successful however, where necessary there are two opti ons on the Aquilion ONE:-

Single heartbeat exposure over the whole R-R interval allowing reconstructi on at any phase, similar to conventi onal retrospec-ti ve techniques at a fracti on of the dose (4-6mSv with good image quality)

Acquiring over more than one heartbeat (2 or 3) summati ng prospecti vely acquired segments thus improving the tempo-ral resoluti on. This technique gives a higher dose (5-15mSv) although sti ll substanti ally lower than conventi onal retrospec-ti ve (15-25mSv)

1.

2.

Dr Russell Bull

Consultant Radiologist, Royal Bournemouth HospitalBOURNEMOUTH

Cardiac CTFollowing NICE Guidelines

the enti re heart and coronary arteries in a low dose single rotati on with no couch movement. This arti cle will focus on the impact the robustness of this scan-ner technology has made on our cardiac CT service, which is currently one of the largest in the UK.

conti nues >>


CA

RDIA

C C

T

What about Arrythmias?

Conventional scanning technique limitations mean that variations in the pulse rate when using prospective or retrospective gating cause ‘step’ artefacts as different ‘blocks’ of data are acquired at differing heart rates. Step artefacts can increase reporting time and reduce diagnostic confidence. Where the patient is in AF or has multiple ectopic beats conventional systems are unable to cope. Even with multiple tubes and fast rotation times the best scenario will be data blocks from multiple phases and multiple cardiac cycles causing severe step artefacts. Most centres will use this as a patient exclusion criterion for cardiac CT.

Aquilion ONE – any rhythm, no problem! The Aquilion ONE has the ability to detect arrhythmia, in real time, and wait for a sufficiently long R-R interval to deliver its radiation pulse.(Fig 3). We no longer use multiple ectopic beats as an exclusion criteria, allowing many more patients to benefit from the technique (Fig 4)

Figure 2 ±10% padding allows robust image reconstruction

Images on Left:RCA image reconstructed at 70% of R-R interval – some movement

Images on Right:RCA image reconstructed at 75% R-R interval –perfect

Figure 1:


CA

RDIA

C C

T

What about Obese Pati ents?

The Aquilion ONE has a medium-pow-ered tube coupled, extremely effi cient detectors and advanced reconstructi on techniques which, when combined, produce superior low contrast resolu-ti on with high quality images for obese pati ents without the need to increase tube current (and subsequent radia-ti on dose). Larger pati ents are thus not excluded.

What Eff ect has this had on the CT Service?

The robustness of the Aquilion ONE has transformed Cardiac CT from being dif-fi cult and slow to being easy and fast. Recent analysis has shown that 99% of all our cardiac scans are diagnosti c. Because we can scan any pati ent (size, rhythm or rate) the only remaining exclusion criteria is the pati ent’s inability to lay fl at (due to poorly controlled LVF). The Aquilion ONE is High Technology made easy as all of our CT radiographers now undertake cardiac scans routi nely instead of only a specialist few. The ‘fear factor’ has now disappeared. Throughput has increased allowing 12 cardiac pati ents to be scanned in a 4 hour session which, in turn, allow us to meet the increased demand for cardiac CT whilst meeti ng existi ng general CT demands (90% of our workload) The economic benefi t is also clear to us as with increased throughput we can scan more pati ents (1000 cardiac and >15000 non-cardiac pa) with the Aquil-ion ONE and an Aquilion 16. Had we not chosen the Aquilion ONE the cardiac and general throughput would have been unachievable, meaning we would have needed a third CT scanner with all of the associated running costs. Car-diac CT is now used as a ‘fi rst-line’ test for many pati ents with low-intermedi-ate risk of coronary artery disease, as currently recommended in recent NICE guidelines.

Images courtesy Toshiba

Figure 4: Excellent views of right coronary artery in patient with atrial fibrillation (ventricular rate 50-70bpm)


Questi on: With the NHS facing major spending reducti ons in a bid to reduce nati onal debt, how has your department been aff ected?

What challenges are you facing, and do you believe these spending reducti ons will result in a more streamlined service and bett er pati ent care in the longer term?

Hot TopicManagement

The NHS will have to make real savings even to stand sti ll. With medical infl ati on, a budget that doesn’t increase eff ecti vely means we need to make effi ciencies every year. I suspect our

departments will manage to do this in the fi rst year but year on year cost improvements are going to be a challenge and may be unsus-tainable for some insti tuti ons. In many areas such as London there are many small hospitals all providing cardiac services; the real potenti al for cost saving is in focusing cardiac care in a large cen-tres with ambulance triage of high risk cardiology to these centres. To enable this we need to be routi nely running our centres seven days a week and getti ng maximum use our of our equipment as well as treati ng pati ents quickly to improve care and minimise length of stay. It will also lead to improved training and very large centres to support research. There are politi cal implicati ons to changes such as these in cardiology and other specialti es and we will see whether the new Government is able to rise to this challenge, perhaps driven by fi nancial necessity.

Dr Jamil Mayet

Chief of Service, Cardiovascular MedicineImperial College Healthcare NHS Trust

CardiologyHD.comSee our other Management Hot Topics online today:

Should Food/Gift s from companies be banned?

Hats and masks in the cath lab?

High Radiati on Dose Protocols

On-call Reimbursements

Radiographer Uti lisati on in EP

Are MBA’s a good idea?

Non-Professional Staff

Multi -Skilling in the Cath Lab

Future Changes?

•

•

•

•

•

•

•

•

•


HO

T TO

PIC

We had already anti cipated a certain amount of reducti on in the budget but may not have foreseen the full extent of the reducti ons that the new government have now

announced. We have a Trust wide drive, as most NHS’s do at present, to reduce waste and increase effi ciency which, aft er a lengthy appraisal process, saw us introduce a new stock Management sys-tem called Omnicell© as one of a number of our initi ati ves. The plan is for this to be Trust wide and has been implemented and insitu in Theatres, Cath Labs and a selected unit to begin with. It will be at least 6 months to a year to actually see tangible results from this in an audit process. The challenge and the aim is to achieve a lean stock system that has high turnover therefore less expired stock and less stock being held unnecessarily. Appropriately costi ng pati ents through the use of this system ensures the PCT’s are billed accord-ingly. Also we will be able to compare costi ngs not only between pro-cedures but between consultants with similar procedures. With the new system we have seen a reducti on in nursing hours required to restock and therefore uti lising nursing ti me more eff ecti vely. Cer-tainly there is waste in the NHS but I do not personally see that it is at the point of pati ent care. Our greatest savings are always made in the purchasing of specialised kit and by using a competi ti ve tender process we have achieved marked savings. Of course market forces have an impact on this.

Greater scruti ny is occurring over all budgets and a process is under-way to analyse every expenditure within the organisati on. Therefore along with all other departments we have been asked to rati onal-ise and justi fy costs including establishment levels. As we run a PPCI service it is relati vely straight forward to justi fy the numbers required to ensure pati ent safety but we oft en talk about minimum numbers which in no way refl ects the opti mum numbers required to provide a fi rst class service.

The benefi t of such scruti ny on the budget has resulted in people coming together to brain storm to analyse work patt erns and proc-esses and work out if there are bett er ways/bett er systems to make it more streamlined. This can only be a positi ve move and we can already see benefi ts from meeti ng and discussing issues with people we would not normally. It brings new ideas and new soluti ons.

Teresa Darmody

Senior SisterCardiac Cath LabsLiverpool Heart and Chest HospitalLIVERPOOL

Mr Greg CruickshankSuperintendent Radiographer, Cardiac Catheter SuiteKing’s College Hospital NHS TrustLONDON

Here at King’s College Hospital we are trying to make savings of 10%. Obviously this is diffi cult, given we perceive ourselves as an already lean

organisati on. On the one hand it is hard to reduce staff (and hence staff costs) without reducing services, thus reducing income. We have been forced to look again at the department profi le in Radiology (I have staff whom rotate from Radiology). Over the last 12 months we have trained a number of band 5 staff in the cath labs (tradi-ti onally only had band 6/7 staff ). In Radiology (not yet Cardiology) we have extended the working day in some areas from 9-5 to 8-8, to allow more acti vity (and hence income generati on). Also have to make a robust case for every post that becomes vacant to be both re-fi lled, and at the same level/grade.

Will this lead to a more streamlined and bett er pati ent care in the long term? In order to save 10%, it seems improbable any Trust will be able to manage this without some cut in services. Perhaps now is the ti me for a more public debate about what services within the NHS should remain protected, and what services currently provided under the NHS umbrella can no longer be conti nued at current levels. The demands and expectati ons of users of the NHS today are not comparable to those of 60 years ago when it was fi rst born. As expensive technologies and treatments become more available, it is improbable the NHS can conti nue to provide a full range of services free at point of use as it initi ally set out to do. Every person in the country however will have a diff erent view about how the NHS budget should be divided up, and what should and shouldn’t be provided by the NHS. Making clear deci-sions about what can and cannot be provided with the current funding levels in the NHS should at least enable us to provide a bett er service within areas that are identi fi ed as “must be provided”. I am sure debate around this topic will conti nue to run for some ti me yet.


Management: Listening to Staff


Head of Clinical Cardiac PhysiologyWest Hertf ordshire NHS Trust

How oft en do we really listen to our staff ? It can be so hard to fi nd ti me for staff meeti ngs or to create forums where staff can air their opinions without having to cancel clinics or ask staff to att end an out of hours meeti ng. So long as the service is ti cking along all right

why would we really take ti me to stop and hear their suggesti ons for service improvement?

In May I wrote that by giving your staff boundaries you create autonomy and accountability, and part of the responsibility to your staff is that you should help them to provide soluti ons to their problems rather than encouraging them to bring you the problem to solve. But, if we don’t take ti me to appreciate the suggesti ons brought to us by our staff , then you are contradicti ng the expectati on of our staff to resolve their own issues and acti vely discourage this autonomy.

When your staff make suggesti ons about the service you are running it is oft en an untainted view. They don’t always consider how the changes they suggest


twist that makes it a politi cally and fi nancially viable change and to make it work.

Many of the services that exist within Cardiology depart-ments tend to be long established, perhaps from far before

you joined the department as its manager. How many of the services and systems that you have in place are functi onal,

benefi cial and eff ecti ve? It is so important to not try to justi fy systems that do not work, or that do not enrich your depart-


Trust your staff s opinions, but also listen to what they don’t say. Oft en our greatest skill as managers is to hear what is communicated to us silently. You may noti ce some clinics that your staff enjoy work-ing and others they dread. Reviewing how these clinics are struc-tured can make the service more producti ve by perhaps lengthening some clinics, shortening others and improving the turnover between pati ents. Additi onally there are many areas of the service that your staff may fi nd utt erly infuriati ng, and we are here to look at these issues more laterally to think how we can make modifi cati ons. Structuring a department to achieve waiti ng ti me targets with the workforce you have can be a real challenge, but by involving your staff so that they support the changes you make means the chal-lenges you face become a shared responsibility, and this helps your staff to understand the bigger picture of workforce planning and service delivery whilst helping you to achieve your targets.


twist that makes it a politi cally and fi nancially viable change and to




AssistanceManagement


Introducti on to Entrainment

Entrainment is a powerful tool in the armoury of the electro-physiologist. It can be used to probe the mechanism of arrhyth-mias, as a method for diff erenti al diagnosis and to locate targets

for ablati on. Entrainment mapping is employed in determining sites that are part of a re-entry circuit and those that are not. Moreover it allows localisati on of the criti cal isthmus that is the target of ablati ve therapy for re-entrant rhythms.

The principles of reset and entrainment are not obvious and are oft en not explained. This arti cle introduces some of these principles.

Resetti ng and Entrainment

Resetti ng involves the use of a single extrasti mulus. Timed prema-ture sti muli delivered during a sustained rhythm may interact with it, causing a pause that is not fully compensatory before resumpti on of the original rhythm; this phenomenon is referred to as resetti ng. To reset a tachycardia, the impulse must be able to reach the tachy-cardia site of origin and fi nd it excitable. The phenomenon of reset-

ti ng was originally described for the sinus node and automati c focal rhythms.

Conti nuous resetti ng with multi ple sti muli is called entrainment and is a specifi c response to overdrive pacing: Following the fi rst beat of a train of sti muli that penetrates and resets the tachycardia, subse-quent sti muli interact with the reset circuit. Although resetti ng was itself fi rst described in focal rhythms, entrainment has been exhaus-ti vely studied in re-entrant rhythms and the term in usually applied in the context of a re-entrant tachycardia. Conti nual resetti ng is seen in focal rhythms but has diff erent characteristi cs to the classical descripti on of entrainment. The term overdrive suppression is some-ti mes used for conti nual resetti ng of a focal tachycardia. Analysis of responses to resetti ng and entrainment by extrasti muli can confi rm the diagnosis of a re-entrant mechanism.

Resetti ng responses can be explained on the basis of the excitable gap and recovery properti es of the ti ssue encountered by the pacing sti muli.


Fig 1. Probable resetti ng of ventricular tachycardia (VT) by a conducted sinus beat (fusion beat) marked with an asterisk. The QRS is interme-diate between a normal QRS and the VT morphology. The tachycardia beat following the fused beat is advanced - coming slightly earlier than expected as indicated by the verti cal dott ed lines which mark twice the tachycardia cycle (i.e. the pause is less than fully compensatory). The degree of resetti ng is subtle but demonstrable. The ability to reset a tachycardia aft er it has begun acti vati ng myocardium makes any tachy-cardia mechanism involving a single focus (whether automati c or triggered) untenable as the wavefront spreading out from the focus would block the incoming sti mulus from reaching it.

EducationElectrophysiology


EDU

CAT

ION

Excitable Gap

In the case of a re-entrant arrhythmia, an excitable gap must exist between the leading edge of the tachycardia impulse and the wave of refractoriness following the impulse - otherwise the tachycar-dia would terminate as the leading edge would be extinguished by encountering refractory tissue. The excitable gap is the interval of excitability between the head of activation of one impulse and the tail of refractoriness of the prior impulse.

The size of the excitable gap can vary greatly from one arrhythmia to another determined by the conduction velocity and refractory properties of the circuit. The coupling intervals over which resetting occurs gives a measure of the duration of the excitable gap.

For a stimulated impulse to interact with a tachycardia – to reset, entrain or terminate it the impulse must be introduced at a time when it can penetrate the excitable gap. This may be possible with a single stimulus, or multiple stimuli may be required in order to align the refractory periods of tissue between the pacing site and the cir-cuit (“peeling back refractoriness”). This may be thought of as the first impulses clearing a path for later ones and is one reason that ATP delivered by ICDs usually consist of several consecutive stimuli.

A stimulated impulse can interact with a re-entrant circuit if it enters the excitable gap. The stimulated impulse may then propagate in both directions around the circuit. The wave travelling in the oppo-site direction to the spontaneous tachycardia (antidromically) will inevitably collide with the already circulating tachycardia wavefront and both are extinguished. The stimulated impulse also conducts orthodromically (in the same direction as the tachycardia wavefront) if the tissue is not refractory. The stimulated impulse then continues to traverse the reentrant circuit to reset the tachycardia - arriving at the exit at an earlier than expected time advancing the timing of activation in the circuit and the tissue activated by it.

Termination occurs when the stimulated impulse collides retrograde-ly with the preceding tachycardia impulse (as it must) but also blocks antegradely owing to encroachment on the refractory period of the preceding wavefront.

Fig 2. Representation of a re-entrant circuit. A wave of excitation cir-culates in a clockwise direction. Green represents refractory tissue, with the intensity revealing varying stages of recovery. In classical re-entry there must be a gap of excitable tissue between the head of the wavefront and the refractory tail and this circulates around the circuit ahead of the tachycardia wavefront.

Fig 3. A pacing stimulus can interact with a circuit if it enters the excitable gap. The resulting antidromic wavefront (red arrow) is bound to extinguish the exist-ing circulating wave. During resetting the orthodromic impulse (blue) does not encounter refractory tissue and so conducts around the circuit becoming a new tachycardia wavefront. This impulse arrives at points around the circuit earlier than expected – the circuit is reset. The impulse eventu-ally reaches the exit from the circuit resulting in activation of the myocardium outside the circuit.


EDU

CAT

ION

Return cycle and post pacing interval and entrainment mapping

During entrainment each impulse following the first to reset the tachycardia propagates in both an antidromic and orthodromic direc-tion around the circuit. The antidromic impulse of the last introduced stimulus collides with the orthodromic impulse of the preceding stimulus. The orthodromic impulse of the last introduced stimulus propagates around the circuit to become the first complex of the resumed tachycardia.

Entrainment mapping involves pacing at cycle lengths shorter than that of the tachycardia cycle length from a variety of sites within the chamber of interest and analyzing the return cycles. The return cycle is subtracted from the tachycardia cycle length to give the post pacing interval (PPI). Sites that are within the circuit demonstrate a return cycle equal to the tachycardia cycle length (PPI approaches zero). When stimulation is carried out at sites distant from the circuit, the return cycle exceeds the tachycardia cycle length because the pacing impulse must first travel to the site of the circuit travel around the circuit and then return to the pacing site (long PPI). The return cycle is typically and ideally measured at the pacing site and is the time from the last introduced stimulus to the the electrogram result-ing from the resumed tachycardia (see fig 4).

Entrainment mapping can be used to determine the distance of a pacing site to a re-entrant circuit, sites that are within the circuit and the location of the critical isthmus. It is often employed during the mapping of atrial and ventricular tachycardias because the location of the culprit circuit is highly variable and must be established to identify targets for successful ablation.

For entrainment mapping pacing is carried out at a rate just fast enough to observe that the tachycardia has been accelerated to the pacing rate and no faster. Entraining at too fast a rate can result in slowing of conduction secondary to interval-dependent conduction delay through tissue that has only partially recovered excitability when the stimulus reached the circuit. Conduction slowing will inter-fere with assessment of the PPI. Entrainment is typically performed by pacing at 10-40ms faster than the tachycardia rate.

During entrainment different degrees of ECG fusion can be seen resulting from the interaction between paced activation and ortho-dromic and antidromic activation of the circuit. The terms entrain-ment with manifest and concealed fusion will be dealt with in the next article and the concept is important in establishing the tachycar-dia mechanism and for identifying the critical isthmus of re-entrant circuits.

TM

Radia_UK_190x119mm.eps 1 8/23/2010 12:04:05 PM


EDU

CAT

ION

References

Almendral JM, Stamato NJ, Rosenthal ME, Marchlinski FE, Miller JM, Josephson ME. Resetti ng response patt erns during sustained ventricular tachycardia: relati onship to the excitable gap. Circu-lati on 1986;74;722-730

Josephson ME. Clinical Cardiac Electrophysiology: Techniques and Interpretati ons 3rd editi on. Lippincott Williams & Wilkins Publishers 2001

CardiologyHD.comSee our other Electrophysiology Education Topics online today:

Learning Electrophysiology: Anatomical descripti on and fl uoroscopic views

Bundle Branch Re-entry VT

Atrial Tachycardia

Making Sense of AF

Atrial Flutt er

Persistent Juncti onal Reciprocati ng Tachycardia (PJRT)

Adenosine in Electrophysiology

An Introducti on to Electrograms

Monomorphic Ventricular Tachycardia

AVNRT: The most common regular tachycardia

Wolff Parkinson White Syndrome

•

•

•

•

•

•

•

•

•

•

•

AboveFig 4. Entrainment of a macro re-entrant atrial tachycardia. Overdrive pacing has accelerated the arrhythmia to the pacing rate (200ms). Tachycardia resumes at the original rate (216ms) when pacing is stopped. The return cycle measured at the pacing site (MapD) clearly exceeds the tachycardia cycle length giving a long PPI and suggesti ng the pacing site is far from the re-entrant circuit and therefore not att racti ve for ablati on. The sequence of intracardiac signals is diff erent during entrainment than during the resumed tachycardia (see CS signals). This is known as manifest electrogram fusion (see subsequent arti cle).


Questi on on Page: 14

1. The fi rst half of the ECG is the pati ents presenti ng arrhythmia. It is a broad complex tachycardia of 125bpm. The inferior leads are strongly positi ve suggesti ng conducti on from base to apex. It could be argued that the QRS is not parti cularly wide – but if you look in lead I – all the positi ve and negati ve components make up the QRS and the durati on of these components is about 180ms. Discrete P waves are not obvious, but take a close look at lead II. The QRS has an Rsr1 patt ern similar to that of a bundle branch block. Aft er the dominant ‘R’ wave there is a small ‘s’ wave and then another much smaller ‘r’ wave. From the small ‘r’ wave down to the most negati ve part of the T wave there is a subtle diff erence in the down stroke which alternates between being convex and concave. On every other complex it is possible to see a P wave – marked on the ECG strip below with an arrow. This suggests a dissociati on between A and V.

With a ventricular rate >100bpm, AV dissociati on, and QRS durati on 180ms, the diagnosis of this ECG is ventricular tachycardia (VT). In a non-compromised pati ent interrogati on of the ICD can help to confi rm the arrhythmia. The electrograms from the leads in the right atrium and right ventricle did indeed confi rm the ventricular rate was 480ms and the atrial rate 960ms.

2. The second half of the ECG shows the pati ents arrhythmia change axis and then terminate. The change in axis is due to the 8 beats of anti -tachy pacing (ATP) which are negati ve in lead II sug-gesti ng conducti on from apex to base which is consistent with ATP from the right ventricular apex lead. ATP can be used for the terminati on of monomorphic VTs involv-ing a re-entry circuit (commonly found in ischaemic VT pati ents). Several carefully ti med low-voltage pacing impulses are delivered to the heart at a faster rate than the tachycardia in order to infi ltrate the re-entry loop and terminate the arrhythmia. Success rates with ATP are very variable, and in some instances ATP can accelerate

a stable monomorphic VT into VF. Well programmed ATP in the haemodynamically stable VT pati ent can be excellent for preventi ng shock therapy and, when successful, ATP off ers a painless and rapid treatment for VT.The last few beats on this ECG are the pati ents’ intrinsic underlying sinus rhythm.

3. Terminati on of the VT by ATP demonstrates that ATP can be successful in this pati ent and it is due to the successful ATP that the pati ent had not had a shock for this slow VT. Preventi on of VT is helpful for minimising therapies from the device. This helps to pre-serve the batt ery life but also reduces the perceived fear of having shock therapy and the negati ve eff ect that can have on the pati ents’ experience of having an ICD.

It is important to make sure the pati ents’ medicati on is opti mised. The EMIAT1 and CAMIAT2 trials suggest beta blockers reduce mor-tality and arrhythmic events whilst improving survival rates whereas amiodarone is suggested to reduce arrhythmic death but has not been seen to improve survival. This confl icti ng outcome proposes that the protecti ve eff ect of amiodarone may be off set by its pro-arrhythmic properti es. Beta blockers remain the anti -arrhythmic drug of choice.

With medicati ons opti mised a VT ablati on could be seriously con-sidered. Ablati on of the VT circuit can be complicated in the pati ent with serious underlying heart disease as patchy scarring can result in numerous possible circuits. However VT ablati on is usually more eff ecti ve in ischaemic heart disease (aft er MI) than cardiomyopathy. In experienced centres VT ablati on for pati ents with a previous MI is associated with a high procedural success rate (upwards of 75%) and VT recurrence requiring ICD shocks is signifi cantly reduced.

References:The European Myocardial Infarcti on Arrhythmia Trial.Julian D.G, Camm A.J, Frangin G, Janse M.J, Munoz A, Schwartz P.J, Simon P. Randomized trial of eff ect of amiodarone on mortality in pati ents with left ventricular dysfuncti on aft er recent myocardial infarcti on. EMIAT. Lancet 1997; 349: 667-674.

The Canadian Amiodarone Myocardial Infarcti on Arrhythmia Trial. Cairns J.A, Connolly S.J, Roberts R, Gent M. Randomized trial of outcome aft er myocardial infarcti on in pati ents with frequent or repeti ti ve ventricular premature depolarizati on. CAMIAT. Lancet 1997; 349:675-682.

1.

2.



AnswerSophie Blackman’s ECG Challenge


October 3-6Heart Rhythm Congress 2010Hilton Birmingham MetropoleBirmingham, Englandwww.heartrhythmcongress.com

October29-30

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

November 2Chronic Total Occlusions 7Clinical Educati on Centre, Glenfi eld HospitalLeicester, Englandwww.millbrookconferences.co.uk

November 18-19

Bristol PCI Course 2010The Educati on Centre, Bristol Royal Infi rmaryBristol, Englandwww.millbrookconferences.co.uk

November 22-23

Europe AF 2010London Hilton Metropole Hotel London, Englandwww.europeaf.com

November 25

BLT Course 2010 : Bifurcati on lesion treatmentNati onal Motorcycle MuseumSolihull, Englandwww.millbrookconferences.co.uk

January 26 - 28, 2010

ACI 2011 : Advanced Cardiovascular Interventi on 2011London Hilton Metropole HotelLondon, Englandwww.millbrookconferences.co.uk

1

2

3

4

5

LIKE TO BEFEATURED?

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

[email protected]

For a list of conferences and events around the globe visit our website:www.cardiologyhd.com

6

7

1

2

3

4

6

5,7

Events


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

Telephone: +44 (0) 1789 450 787

www.heartrhythmcongress.com

[email protected]

+44 (0) 1789 451822

Promoting better understanding, diagnosis, treatment and quality

of life for individuals with cardiac arrhythmias

HeartRhythm

Congress2010

HeartRhythmCongress

3-6 October 2010 Hilton Birmingham Metropole

EducatitiontionEducationtion

Technology

Technology

Technologygy

DiversityDiversityDiversity

Cardiology

Our New Global Website in High Definition

HD VideosHot TopicsInterviewsEventsSite Visits

•••••

RecruitmentEducationECG ChallengesOnline EditionsFacebook Link

•••••

CardiologyHD

Horizon Cardiology

FFR support with Horizon Cardiology further improves cath lab workflow and ensures critical data is instantaneously available to cardiologists.

Support for all major FFR vendors’ pressure wires

Reduce capital expense by eliminating the need to purchase separate FFR analyzers

Easily incorporate the FFR result to a lesion via an intuitive user interface

Automatically store FFR pressure waveforms and numeric results in patient’s central cardiac file

Eliminate time and errors associated with manual data entry

Horizon Cardiology Delivers Fully Integrated Fractional Flow Reserve (FFR) Support

Please contact our sales team for an onsite demonstration

McKesson (Medcon), UKPremier House 112 Station RoadEdgware, MiddlesexHA8 7BJ United KingdomPhone: 0208 [email protected]/cardiology

Copyright © 2010 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Horizon Cardiology is a trademark of McKesson Corporation and/or one of its subsidiaries.

™

™

AllAboutCVIS.com/ffr

Coronary Heart #26

Documents

Transcript of Coronary Heart #26