Coronary Heart #3

“Especially for Cardiac Cath, EP, and Non-Invasive

Departments”

Cardiology in Space

coronaryheart.com

Cardiology in SpaceSpace

October / November 2006Issue 3

Introducing the Generic Worker Course

Mitral Regurgitation(MR) Overview

LATEST NEWS,CONFERENCES

+ more...

EMP

LO

YMENTMitral Regurgitation

LAB VISITSThe Wellington Hospital, UKRoyal Cornwall Hospital, UK

Special Feature

ADVERTISEVACANCIES

WITH US

• Improved endocardial

tissue contact provides

high fidelity mapping and

precise RF delivery

• Bidirectional distal

tip – enables optimal

tip orientation

• Independent proximal

and distal curves –

expand positioning

options and curve radii

EndlessPossibilities

ELECTROPHYSIOLOGY

Bard Electrophysiology announces a new addition to their line of ablation catheters with the April 3rd commercialization of the Scorpion TM ablation catheter in Europe and the US.

The Scorpion ablation catheter's dual curve design, featuring a unique bi-directional distal tip, delivers unrivalled endocardial tissue contact for improved diagnostic and therapeutic results to today's Electrophysiologists.

58,300 catheter ablation procedures were performed in Europe in 2004 and at a growth rate of 11.5% approximately 72,500 procedures are estimated to be completed in 2006.

P0706/1375ORH

C

M

Y

CM

MY

CY

CMY

K

1375 EP Scorpion Ad v2.pdf 24/7/06 09:34:33

CONTENTS

• Improved endocardial

tissue contact provides

high fidelity mapping and

precise RF delivery

• Bidirectional distal

tip – enables optimal

tip orientation

• Independent proximal

and distal curves –

expand positioning

options and curve radii

EndlessPossibilities

ELECTROPHYSIOLOGY

Bard Electrophysiology announces a new addition to their line of ablation catheters with the April 3rd commercialization of the Scorpion TM ablation catheter in Europe and the US.

The Scorpion ablation catheter's dual curve design, featuring a unique bi-directional distal tip, delivers unrivalled endocardial tissue contact for improved diagnostic and therapeutic results to today's Electrophysiologists.

58,300 catheter ablation procedures were performed in Europe in 2004 and at a growth rate of 11.5% approximately 72,500 procedures are estimated to be completed in 2006.

P0706/1375ORH

C

M

Y

CM

MY

CY

CMY

K

1375 EP Scorpion Ad v2.pdf 24/7/06 09:34:33

October / November 2006

ContentsCORONARYHEART

CORONARY HEART ™ 3

04 Welcome Editorial

05 Latest News

10 Future

12 Special Feature‘Cardiology in Space’

16 Education‘Mitral Regurgitation Explained’

20 Product Information‘Evalve’s Mitra Clip for MR’

22 Special Feature‘� e Generic Worker Course (UK)’

27 Site Visit (UK)‘Wellington Hospital’

32 Site Visit (UK)‘Royal Cornwall Hospital’

36 EP Education‘Monomorphic VT - Explained’

40 CT Overview‘Part 1 - Cardiac CT Basics’

42 Medical Imaging Education‘LAO/CRA & � e Spider’

44 Conferences

04 Welcome

THIS EDITION

The

Page: 27


Contents

Special Feature‘Cardiology in Space’

‘Mitral Regurgitation 40 CT Overview


Contents

Special Feature‘Cardiology in Space’

Page: 27Page: 27Page: 27

Hospital

TheTheThe

HospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalHospitalWellington

47 Cardiac Languages‘Learn Arabic’

48 Employment

50 Next Issue Highlights‘Including a great image from Royal Perth Hospital’

Administrators Managers Nurses Radiographers Cardiac Physiologists Echocardiographers

Mitral RegurgitationRegurgitationRegurgitation

Page: 16

Welcome EditorialEDITORIAL

Welcome to the third edition of Coronary Heart™. You may have noticed we have grown again, now packing in some 52 pages

of interesting articles to keep you up-to-date with what is happening around the world. Our subscription base from readers is also expanding since our mid August release of the new website, with a growing number of managers and staff opting to receive their own copy. Th is issue has now expanded into several hospitals in Ireland, as they operate in a similar work environment to the rest of you in the UK, Australia, and New Zealand. We are looking forward over the coming issues to visit one of these hospitals for a review.

Th e British Society of Echocardiography’s Annual Meeting in Bournemouth (UK), 26-28 October, will symbolise our fi rst mass distribution at a conference, with all delegates receiving a copy. To those attending the conference, we hope you enjoy this edition and look forward to working with you in the future as we develop the publication further.

Th is edition contains some interesting special features, with an overview of Mitral Regurgitation as well as giving readers a closer look at the new Evalve MitraClip™. Two staff from Harefi eld Hospital (UK) discuss their experiences in the new Generic Worker Course, and for a bit of fun we look at how NASA has contributed to cardiology; past, present, and future.

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

Coronary Heart Publishing Ltd145 - 157 St John Street

London, EC1V 4PYUnited Kingdom

Phone: +44 (0) 207 788 7967Fax: +44 (0) 207 160 9334

Visit us online at www.coronaryheart.com

DirectorTim Larner

Clinical EditorDr Rodney Foale (UK)

Consulting EditorsDr Richard Edwards (UK)

Mr Ian Wright (UK)Mr Stuart Allen (UK)

ADVERTISING

Media kits are available online

CIRCULATION

680 Cardiac Departments, Staff , & Industry Professionals in the UK,

Ireland, Australia, and New Zealand

Copyright 2006 by Coronary Heart Publishing Ltd. All rights reserved.

Material may only be reproduced by prior arrangement and with due acknowledgment of

Coronary Heart Publishing.Th e publication of an advertisement or product

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

Subscribe Online to get your own

free copy

Tim LarnerDirector

elcome to the third edition of Coronary Heart™. You may have noticed we have grown again, now packing in some 52 pages

of interesting articles to keep you up-to-date with what is happening around the world. Our subscription base from readers is also expanding since our mid August release of the new website, with a growing number of managers and staff

elcome to the third edition of Coronary Heart™. You may have noticed we have grown again, now packing in some 52 pages

of interesting articles to keep you up-to-date with what is happening around the world. Our subscription base from readers is also expanding since our mid August release of the new website, with a growing number of managers and staff

Tim�

Clinical Editor

Dr Rodney Foale, FRCP. FACC. FESC. FCSANZ.Clinical Director, Surgery, Cardiovascular Sciences and Critical Care. SMHT.

COVER PHOTO (from left): Tiff any Worthington (Nurse), Tina Prestwood (Unit Manager), and Jo Hope (Nurse), from the Royal Cornwall Hospital, UK.

4 CORONARY HEART ™

Latest NewsLATEST NEWS

TAXUS II Trial Four Year Results Are Released

At the World Congress of Cardiology 2006, Boston Scientifi c Corporation

announced the four-year follow-up data from its TAXUS II paclitaxel-eluting stent system clinical trial.

Th e TAXUS II trial is a 536-patient, 15-country, randomised, double-blind, controlled study of the safety and effi cacy of a TAXUS paclitaxel-eluting coronary stent, in which two sequential groups of patients with standard risk and de novo coronary artery lesions were treated with diff erent dose formulations. Lesion sizes included were ≤12 mm length, and 3.0-3.5 mm vessel diameter.

Th e long-term TAXUS II results suggest that the TAXUS stent system stably inhibits restenosis as

demonstrated by signifi cant reductions in target lesion revascularisation (TLR). TAXUS II results reported a low overall TLR rate of 7.2 percent in the slow-release formulation and 3.7 percent in the moderate-release formulation, as compared to 15.7 percent in the control group (bare-metal), resulting in an absolute reduction of 54 percent versus control for the slow-release formulation and a 76 percent absolute reduction versus control for the moderate-release formulation.

Th e Company has commercialised the slow-release formulation; the moderate-release formulation is not available for commercial distribution.

Visit www.bostonscientifi c.com for more information.

Blood Clot Fibre’s More Elastic Than Spider Web

According to fi ndings published in the journal Science recently,

it was found that the tiny fi bres that comprise blood clots show extraordinary elasticity, on average stretching to almost three times their length while still retaining their ability to go back to their normal shape and expanding to more than four times their length before breaking.

Th is discovery, which makes these fi brin fi bres the most stretchable known fi bres existing in nature, will help medical researchers create more accurate blood clot models, to off er a deeper understanding of heart attacks and strokes.

Roy Hantgan, associate professor of Biochemistry at Wake Forest University School of Medicine (USA) and a member of the research team stated, “knowing that the fi brin strands that make up a human blood clot are more stretchable than a spider’s web helps us to understand how clots can seal wounds tightly and withstand the pressure in our blood vessels. Th is new information also

helps us to understand

how tough it is to remove a clot that is preventing blood fl ow

to a person’s heart or brain, causing a heart attack or stroke.”

Th e research team have already been contacted by a company that uses an ultrasonic device to break up blood clots. Th e company told them that they have an interest in knowing the properties of the fi bres comprising a blood clot to determine how much force should be applied to break up clots.

Visit www.wfu.edu for more information

TAXUS® Express2™ Paclitaxel-Eluting

Coronary Stent SystemImage Courtesy Boston Scientific

Th is discovery, which makes these fi brin fi bres the most stretchable known fi bres existing in nature, will

more accurate blood clot models,



to a person’s heart or brain, causing a

Th is discovery, which makes these fi brin fi bres the most stretchable known fi bres existing in nature, will





Medtronic Release Three New Pacemakers

Medtronic recently announced the market introduction of its portfolio of fully

automatic pacemakers, the Medtronic Adapta™, Versa™, and Sensia™ pacemakers. Th ese pacing systems provide physiologic pacing adapted to the needs of individual patients, helping set new standards of care that reduce unnecessary pacing when the heart’s natural conduction is present.

Th e Adapta pacemaker off ers the Medtronic-exclusive pacing mode called MVP™ or Managed Ventricular Pacing, which enables the device to be programmed to deliver pacing pulses to the heart’s right ventricle only when necessary. MVP has been shown to reduce unnecessary right ventricular pacing by 99 percent (median value). Recent clinical studies have suggested that reducing this pacing stimulation may reduce the patient’s risk of developing heart failure and atrial fi brillation.

Th e Adapta, Versa and Sensia pacemakers are completely automatic, and include a special feature called Atrial Capture Management (ACM).

ACM diff ers from normal atrial capture, which usually only occurs at six-twelve monthly follow-up visits, by performing an atrial capture threshold check each night and automatically adjusting its output settings. Th is ensures the patient always has a pacemaker set for individual and changing needs. Th e automated threshold checking and adjustment for both ventricle and atrium results in the pacemaker being “fully automatic”.

Th e pacemakers recently received approval by the United States Food & Drug Administration (FDA), and have been approved for use throughout Europe and Australia.

Visit www.medtronic.com for more information

BMS vs DES

It is known that Drug-eluting stents (DES) are more eff ective than bare-metal stents (BMS) in reducing

restenosis and in repeat interventions after percutaneous coronary interventions (PCI). However a recent study presented at the World Congress of Cardiology has shown that not all patients require a DES.

Patients in the prospective and randomised BASKET trial received Cypher®, Taxus® or Vision® stents. Th e 18-month update showed that patients with small vessels/stents <3mm or bypass grafts gave a signifi cant benefi t from DES use regarding reduction of death, myocardial infarction and TVR. Patients with stenting of larger native vessels have no signifi cant benefi t and possibly even a small late harm.

Th e results concluded that DES use may be restricted to small vessels/stents <3mm and to bypass grafts for optimal cost-eff ectiveness and long-term benefi t.

Intelligent Stethoscope Runner-Up at Technology Awards

Zargis Medical Corp., a spin-off from Siemens Corporate

Research recently took home the runners-up award at the Wall Street Journals Technology Innovation Awards for their Cardioscan®.

It is the world’s fi rst computer-aided stethoscope that aids physicians in identifying and evaluating murmurs and other heart sounds that may be indicative of cardiovascular disease.

Th rough the stethoscope, the user is guided with voice prompts, with the results printed out as needed. An electronic record of the acoustic heart sounds and corresponding fi ndings are permanently stored for future reference.

Visit www.zargis.com for info

information

BMS vs DES

Irestenosis and in repeat interventions after percutaneous coronary interventions (PCI). However a recent study presented at the World Congress of Cardiology has shown that not all

Courtesy Medtronic, Inc



St Jude Releases New Products

St Jude Medical has long been established as a quality manufacturer of medical devices,

however recently they have added a few new devices to their range. Over the coming issues of Coronary Heart™ we will provide you even greater details of these products and their uses, however for now here is a quick overview of what’s on off er.

Merlin patient care system (PCS):Merlin is a new programmer for St Jude and contains a faster Pentium 4M processor, 5-lead ECG with the ability to view the ECG pre-interrogation. With the addition of a colour 15 inch screen, Merlin should make patient follow-ups quicker & easier.

Cardiac Positioning System (CPS):Th is is a new delivery system for implanting the LV lead in Bivent cases. It’s a slittable catheter system of 7 outer catheters, 3 cannulator catheters to access the coronary sinus, and 5 sub-selectors if the physician wants to subselect the target vessel.

QuickSite Lead Family:An addition to the current QuickSite LV leads is the new QuickSite XL (1058T) which has a larger amplitude curve aimed at larger target vessels. Th e leads are made up of polyurethane apart from the distal portion which is made up of silicone, for extra manoeuvrability.

Riata ST (Defi b. Lead):Th e worlds thinnest ICD lead (6.3F) which is small enough to fi t down a

7F introducer. Th e shocking coils of this lead are fl at-coils and then back-fi lled with silicone to make this lead isodiametric & less prone to tissue ingrowth (especially around the SVC).

ATLAS II ICD:In addition to the Epic II (see Coronary Heart™ Aug/Sep edition) is the new ATLAS II ICD range.It also contains a non-audible vibratory Patient Notifi er, allowing even patients with hearing problems to be alerted to a low battery, lead-related issues and more.

Squeezed in is also a 64K telemetry chip for faster interrogation/retrieval, along with QuickOpt for biventricular devices (see next edition for details).

One of the really great features of this ICD is that the device can be programmed off at the touch of a button. Called TED (therapy enable/disable), it is particularly useful in hospitals where staff are not familiar with the St Jude programmer (or those on-call).

Victory Pacemakers:Used with the new Merlin PCS, this new pacemaker range saves time at follow-up with new software & automatic tests including brand new weekly trends providing evidence to the physician or physiologist that the patient status or lead measurements are stable.

Visit www.stjudemedical.com for more information.

The new Merlin Patient Care SystemImage Courtesy St Jude Medical

In the next edition of Coronary Heart™ we will provide you with more detailed product information related to St Jude Medical products including:

The new QuickOpt feature for biventricular devices.

The new Victory Pacemakers used with the Merlin PCS.

•

•

Next Edition




New Technology for Siemens Angiographic Systems

The team at Siemens Medical Solutions seem to be constantly coming up with

new improvements to their range, and have recently introduced a new technology which further improves the image quality of the C-arm family Axiom Artis. Th e so-called Clear Technology is a new platform that focuses on two areas to optimize image quality: for one there is the so-called “intelligent optimization of the radiation parameters” prior to fl uoroscopy and for the other there is image processing during fl uoroscopy.

During intelligent beam optimization, the system automatically considers the tilt angle of the C-arm and the position of the patient table to then compute the angle of incidence with respect to the patient. Simultaneously the simulated size and weight of the patient is calculated. Th ese two parameters used in combination then ensure that the beam quality for fl uoroscopy and acquisition is optimized and the best image quality is obtained.

Th e second feature relates to image processing with a frame rate of up to 30 frames per second during fl uoroscopy. Siemens state that with each frame the system reduces the image noise, automatically sets the brightness and contrast, adjusts the edge enhancement of the vessels and optimizes the magnifi cation when using zoom mode,

all in under a second. Th is then allows for an increase in the visibility of organs and interventional tools, such as catheters, guide wires, and stents.

Clear Technology was introduced at the ESC 2006 in connection with an Axiom Artis dBC, a biplane C-arm system with dual fl at detectors (as seen in the photo above).

Visit www.siemens.com for more information

SonoSite UK Ultrasound Training

SonoSite has recently appointed a new Education and Training Manager to head up the 40

hands-on training courses off ered by the company. Jan Oliver has worked within Sonosite as an Application Specialist for the last two years however

Siemens Bi-Planewith Clear Technology



her training began as a radiographer before specialising in sonography. She even gained an MBA.

Th e list of one- and two-day courses Jan will be co-ordinating covers an impressive range of ultrasound specialities including cardiovascular and trans-oesophageal applications.

“Sonosite has teamed up with some of the leading specialists in the industry to design a series of courses focusing

on point-of-care ultrasound, “ Jan explained. “We strongly believe in the importance of education and training for users, especially those with little or no previous ultrasound experience”.

Visit www.seec-education.com where you can register and view the courses on off er. Alternatively email Michelle Hannon at the SonoSite International Headquarters on [email protected]

Preventing Injury During AF Ablation

A new imaging procedure may reduce the risk of oesophageal injury in patients undergoing

catheter ablation for atrial fi brillation (AF), according to a study published in the September 2006 edition of Heart Rhythm. Researchers used Intra-Cardiac Echocardiography (ICE) to provide real-time imaging of the oesophagus to monitor the development of lesions and other potential complications that may result from ablation.

Th e study, involving 152 patients who underwent left atrial ablation for AF, is the fi rst to identify the oesophagus and monitor lesions, known as atrio-oesophageal fi stulas, on the posterior wall of the heart’s left atrium with ICE.

In an accompanying editorial, Hugh Calkins, M.D., professor of medicine and director of the electrophysiology lab at Johns Hopkins Hospital in the USA, writes “Th ere is no question that those involved with catheter ablation of AF urgently need a method to protect the oesophagus and prevent further atrio-oesophageal fi stulas.”

Dr. Calkins writes that development of these lesions on the oesophagus is “Perhaps the most feared, and most lethal of the many complications that have been associated with this procedure, with mortality in excess of 75 percent.”

Th e editorial concludes that while the experimental procedure shows promise, the study does not prove that ICE will prevent oesophageal injury in the future and that more studies are needed.

Visit www.hrsonline.org for more info

Image courtesy Siemens

CardiologyFUTURE

AdvancesBiotechnology May Soon Replace Electronic Pacemakers

UC Davis researchers in the USA have successfully used a custom designed protein

and gene delivery system to restore normal heart rhythms in pigs with electronic pacemakers, reducing their dependence on implanted devices. Th e work has been published in the journal Circulation.

“Our study off ers positive and direct evidence in living models that bioengineered cells can replace the electronic pacemaker,” said Ronald Li, who leads the research team.

In the current study, the researchers delivered a gene encoding a bioengineered cell-surface protein to heart muscle cells of pigs. Th is protein mimics the combined action of several proteins called hyperpolarization-activated, cyclic nucleotide-gated (HCN) ion channels, which play a critical role in maintaining a normal, evenly paced heartbeat. Th ese channels control the fl ow of sodium and potassium ions in and out of cells that regulate the electrical impulses of the heart.

“Th ese channels are critical to normal

heart function. We were able to make one protein that codes for a single channel that does the work normally required by several,” Li explained. By getting heart muscle cells to produce bioengineered HCN channels, Li and his colleagues were able to reconstruct the SA node of the heart in pigs with implanted electronic pacemakers.

“We were even able to create new pacemaker regions on the left atrium,” Li said.

In the current study, researchers used radiofrequency ablation to remove the SA nodes in pigs’ hearts. Th is is the same minimally invasive technique cardiologists use in clinics to destroy the heart cells that cause abnormal electrical discharges and rapid heart rates in their patients. To restore the SA node function and evaluate the bioengineered cells, Li’s team then implanted electronic cardiac pacemakers like those used in humans and injected an adenovirus carrying a gene encoding for the engineered HCN protein into the heart muscle. Adenovirus has the ability to deliver its own genes into a host cell and hijack its protein-synthesizing machinery. Scientists use this ability to deliver genes of interest into cells.

In a matter of days following the gene transfer, the pigs’ hearts

had generated bioartifi cial nodes at the injection

sites. Li explained that, through

gene expression,

normal muscle cells

of the

heart were converted into pacemaker cells by a process called transdiff erentiation. Studies done two weeks after the injections showed the new nodes were able to take over pacemaking function from the electronic devices. Th e results also have implications for future stem cell research.

Li and his colleagues are now preparing to do long-term, follow-up experiments.

Li and his team previously generated the fi rst genetically engineered human heart cells from human embryonic stem cells, and demonstrated that they can be transplanted into a recipient heart and function normally. Li plans to combine stem cells and protein/cell engineering approaches to the treatment of heart arrhythmias. “Heart cells do not normally regenerate, but we now have the technologies to make new human heart cells using stem cells. And, we can also customize these cells to treat diseases,” he said.

AdvancesAdvancesheart were converted into pacemaker cells by a process called transdiff erentiation. Studies done two weeks after the injections showed the new nodes were able to take over pacemaking function from the electronic devices. Th e results also have implications for future stem cell

Li and his colleagues are now preparing to do long-term, follow-

Li and his team previously generated the fi rst genetically engineered human heart cells from human embryonic stem cells, and demonstrated that they can be transplanted

heart and function normally. Li plans

cells and protein/

approaches to the treatment of heart

AdvancesAdvancesheart were converted into pacemaker cells by a process called transdiff erentiation. Studies done two weeks after the injections showed the new nodes were able to take over pacemaking function from the electronic devices. Th e results also have implications for future stem cell

Li and his colleagues are now preparing to do long-term, follow-

Li and his team previously generated the fi rst genetically engineered human heart

embryonic stem cells, and demonstrated that they can be transplanted

heart and function normally. Li plans

treatment of heart own genes into a host cell and hijack its protein-synthesizing machinery. Scientists use this ability to deliver genes of interest into cells.


had generated bioartifi cial nodes at the injection

sites. Li explained that, through

gene expression,

normal muscle cells

of the

maintaining a normal, evenly paced heartbeat. Th ese channels control the fl ow of sodium and potassium ions in and out of cells that regulate the electrical impulses of the heart.

“Th ese channels are critical to normal

of pigs. Th is protein mimics the combined action of several proteins called

nucleotide-gated

play a critical role in maintaining a normal, evenly paced heartbeat. Th ese channels control the fl ow of sodium and potassium ions in

genes of interest into cells.


had generated bioartifi cial


FUTURE

In another study presented at the World Cardiology Conference, Dr. Antonio Paolo Beltrami presented the latest fi ndings of stem cell research for the treatment of

heart failure. Recent studies have shown that mammalian hearts possess a stem cell reservoir constituted of primitive cells that contribute to the formation of new vessels and myocytes during the entire organism lifespan. In other words the heart can heal itself.

However, several in vivo studies have suggested that the same pathological processes impairing the cardiac tissue

can also impair the resident cardiac stem cell reservoir which can lead to heart failure. � e search for the self-healing heart goes on.

Researchers at the Max-Planck-Institute for Heart and Lung Research (MPI)

in Germany have identifi ed a gene whose therapeutic use may be benefi cial

for patients suff ering from obstructive arterial diseases.

Patients typically suff er from coronary artery diseases leading to myocardial infarctions or peripheral ischemia, which

often leads to the loss of limbs. “It is known for centuries that the body tries

to compensate for blood fl ow defi cits by the growth of bridging arteries,” said Professor Wolfgang Schaper,

senior scientist at the MPI and expert in the fi eld. “Because it

is somewhat similar to bypass operations, we call them

’natural bypasses’.”

Th e breakthrough came when the scientists decided to look closer

at the mechanisms involved. In their

experiments on rats and rabbits they hunted down the genes from within collateral vessels.

Head of the project, Kerstin Troidl said the following: “One of them, called ABRA, seems to be the interface between the physical force and the induction of collateral growth.” Th erefore it was suggested that ABRA can be used to compensate for insuffi cient physical triggers, which probably limits spontaneous collateral growth in patients.

Th e investigators are currently fundraising for advanced studies, as they are convinced that ABRA has a strong potential for upcoming clinical uses. Th e research was funded by the German Society of Cardiology, with the data presented at the World Congress of Cardiology.

Gene � erapy is a widely publicised as “the new cure”, however it poses multiple challenges. In the near future Coronary Heart™ will delve deeper into this treatment.

New Gene Discovery That Stimulates The Growth Of Natural Bypasses

Stem Cell Research Healing the Heart

In another study presented at the World Cardiology Conference, Dr. Antonio Paolo Beltrami presented the latest fi ndings of stem cell research for the treatment of

heart failure. Recent studies have shown that mammalian hearts possess a stem cell reservoir constituted of primitive cells that contribute to the formation of new vessels and myocytes during the entire organism lifespan. In other words the heart can heal itself.

However, several in vivo studies have suggested that the same pathological processes impairing the cardiac tissue

can also impair the resident cardiac stem cell reservoir which can lead to heart failure. � e search for the self-healing heart goes on.

esearchers at the Max-Planck-Institute for Heart and Lung Research (MPI)

in Germany have identifi ed a gene whose therapeutic use may be benefi cial

for patients suff ering from obstructive











Iheart failure. Recent studies have shown that mammalian hearts possess a stem cell reservoir constituted of primitive cells that contribute to the formation of new vessels and

Researchers at the Max-Researchers at the Max-RPlanck-Institute for Heart RPlanck-Institute for Heart Rand Lung Research (MPI) Rand Lung Research (MPI) Rin Germany have identifi ed a gene

whose therapeutic use may be benefi cial for patients suff ering from obstructive

arterial diseases.











experiments on rats and rabbits they hunted down the genes from within collateral

Head of the project, Kerstin Troidl said the following: “One of them, called ABRA, seems to be the interface between the


International Space Station orbiting above Earth.Images courtesy NASA

Th e quest for knowledge and the desire for exploration has resulted in the development of new technologies to allow astronauts to explore outer space in safety. Th ese advancements are eventually picked up by other companies to use here on on Earth to improve our quality of life. Here are some examples of cardiac products that initially came from a NASA idea to improve space travel.

Patient Monitoring Systems:Cardiac monitoring systems are seen on virtually all intensive care and heart rehabilitation wards, however many aren’t aware that the technology originated in the 1960’s from the systems used to monitor astronauts during the fi rst space missions. As a direct result of this technology, a single nurse now has the ability to monitor the ECG’s on several patients at once.

Programmable Pacemaker:Th is technology originated from the development of communications between orbiting satellites and earth. Released in 1995, the Trilogy cardiac pacemaker was the fourth generation of a unit developed in the 1970s by NASA, Johns Hopkins Applied Physics Laboratory and St. Jude Medical’s Cardiac Rhythm Management Division.

Th e pacemaker incorporated bidirectional telemetry used for space communications, small implantable pulse generators from space microminiaturization, and longer-life batteries from technology for spacecraft electrical power systems.

CT and MRI Technology:Digital signal-processing techniques are used to recreate images in CT and MRI imaging. Th is technology was developed to computer-enhance pictures of the Moon for the Apollo Program.

NASA’s Spin-Offs for Cardiac MedicineSPECIAL FEATURE



Digital Cardiac Imaging System: Th is was a spin-off picked up from Philips Medical Systems International to signifi cantly improve real-time cardiac imaging and the ability to employ image enhancement techniques to bring out added details. Th e technology was developed for NASA Earth resources survey satellites from the Jet Propulsion Laboratory.

Temper Foam:Originally designed back in 1966 to improve shock and impact protection for NASA pilots, the foam is regularly used today on patient mattresses in the Cath Lab. It’s important feature is its ability to match the contour of the body part against it, evenly distributing weight over the entire body area, thereby reducing pressure sores. Once the pressure is removed it slowly returns to its original shape.Advice: Perfect for long cases such as EP studies.

Medical Gas Analyzer:Originally developed for spacecraft use when monitoring astronaut’s respiratory gases in NASA’s Gemini and Apollo program. Today the technology is used in operating rooms for the analysis of anaesthetic gases and measurement of oxygen, carbon dioxide and nitrogen concentrations. It assures that the patient undergoing surgery has the proper breathing environment.

Artifi cial Heart:Originally used in the Space Shuttle fuel pumps, NASA worked with renowned heart surgeon Dr. Michael DeBakey to develop a miniaturized ventricular assist pump. It is currently undergoing clinical trials in Europe.

Medical Telemetry:Originally developed for space operation telemetry, the technology is now regularly used to transmit medical data between emergency vehicles and hospitals. For example, an electrocardiogram from an ambulance to a hospital enables physicians to read and advise ambulance attendants on emergency procedures.Visit www.nasa.gov for more information

related to NASA activities

NASA’s Spin-Offs for Cardiac MedicineCompiled by Tim Larner

Source: NASA

SPECIAL FEATURE


Current Space StudiesSPECIAL FEATURE


Th e International Space Station (ISS) is located approximately 400km above the Earth, and although it is still being built, many experiments are still being carried out. Of interest to the cardiology world though is the following experiment which will commence shortly.

HUMAN CARDIOVASCULAR PERFORMANCE IN THE SPACE FLIGHT ENVIRONMENT

Description & Aim:Cardiac arrhythmias have recently been identifi ed in some crew members after long-duration exposure to microgravity aboard the Mir space station, which may be due to cardiac atrophy. Th e experiment will aim to determine the magnitude of left and right ventricular atrophy associated with long-duration spacefl ight (via pre- and postfl ight MRI). Th e time course and pattern of progression of cardiac atrophy in-fl ight will be determined using cardiac ultrasound.

Relevance:Once the magnitude, time course, and inciting factors for cardiac atrophy have been determined, eff ective countermeasures currently being developed by the investigators in parallel ground-based experiments, may be

applied, focused on normalizing cardiac work and volume during long-duration spacefl ight. Th e information obtained from these spacefl ight experiments also may be relevant for patients after prolonged confi nement to bed rest, or chronic reduction in physical activity, as well as for patients with

disease processes that alter cardiac stiff ness such as congestive heart failure, ischemic heart disease, and normal aging.

Hardware Description:Equipment already aboard the ISS includes a Human Research Facility (HRF) Ultrasound (ATL HDI 5000) with P4-2 Echo Probe, an exercise device, and the HRF PC and Workstation. Equipment due to arrive on additional missions include a twelve-lead and signal averaged electrocardiograph, ambulatory BP device, ambulatory Holter monitor device, ambulatory activity monitors, and kits for media and consumables.All studies are performed within the Destiny Laboratory aboard the ISS. Space Shuttle Discovery docked to the Destiny Laboratory

of the International Space Station.Image courtesy NASA

An astronaut works at the HRF Ultrasound Module in the Destiny Laboratory of the ISS.

Image courtesy NASA

Source: NASA

coronaryheart.com

Conferences 2006CONFERENCES


October 5-7Annual General Meeting of the Irish Cardiac SocietyLocation: Killarney, Co. Kerry, IrelandWebsite: www.irishcardiacsociety.com

October 15-1921st Scientific Meeting of International Society of HypertensionLocation: Fukuoka, JapanWebsite: www.congre.co.jp

October 21-24Acute Cardiac CareLocation: Prague, Czech RepublicWebsite: www.escardio.org

October 21-25Canadian Cardiovascular SocietyLocation: Vancouver, BC, CanadaWebsite: www.ccs.ca

October 22-27TCT 2006: Transcatheter CardiovascularTherapeuticsLocation: Washington DC, USAWebsite: www.tct2006.com

LIST YOUR CARDIAC

CONFERENCEHERE FREE

Email the details to:[email protected]

October 26-28Autumn Congress of the Netherlands Society of CardiologyLocation: Ermelo, NetherlandsWebsite: www.cardiologie.nl

November 1-4New Cardiovascular HorizonsLocation: New Orleans, Louisiana, USAWebsite:www.newcvhorizons.com

December 3-719th World Diabetes CongressLocation: Cape Town, South AfricaWebsite: www.idf2006.org

December 6-9EuroEcho 10Location: Prague, Czech RepublicWebsite: www.euroecho.org

Conferences 2006

CORONARY HEART ™

LIST YOUR CARDIAC

CONFERENCEHERE FREE


October 26-28Autumn Congress of the Netherlands Society of CardiologyLocation:Website: www.cardiologie.nl

November 1-4New Cardiovascular HorizonsLocation:Louisiana, USAWebsite:www.newcvhorizons.com

December 3-719th World Diabetes CongressLocation: Cape Town, South AfricaWebsite: www.idf2006.org

December 6-9EuroEcho 10Location:RepublicWebsite: www.euroecho.org

MEDICAL IMAGING

RAO 30 / CAU 20


RAO 30 / CAU 20

Objective:

This angle is used primarily to demonstrate the Left Main and the Circumflex arteries, and is the best view for demonstrating the proximal Obtuse Marginal branch. The Left Anterior Descending artery is also seen however is often overlapped by the Diagonal branches. Acquisition time should be long enough to obtain adequate contrast filling of the distal arteries, and if necessary pan to the anatomical right to visualise collateral filling of the Right Coronary artery. Visualising the right coronary artery filling distally may assist Cardiologist of the possible lesion length occurring in that artery.

Alternatives:

More CAU (eg. RAO 30 / CAU 40):

This decreases the foreshortening of the proximal circumflex improving visualisation. The distal circumflex can be foreshortened and overlapped by distal branches. Foreshortening of the LAD occurs mid /distal with overlap of the diagonal branches.

Less CAU (eg. RAO 30 / CAU 10):

Increases foreshortening of proximal circumflex, however improves visualisation distally by separating the distal branches. The obtuse marginal is often overlapped by large septals from the LAD or diagonal branches.

More RAO (eg. RAO 40 / CAU 20):

This separates the diagonal branches further from the LAD, demonstrating them inferior to the LAD. This view can also improve visualisation of the mid / distal Obtuse Marginal branch

Less RAO (eg. RAO 10 / CAU 20):

This separates the diagonal branches further from the LAD, demonstrating them superior to the LAD.


RAO 30 / CAU 20

LM Left Main

LAD Left Anterior Descending

D1 Diagonal

LCX Circumflex

OM1 ObtuseMarginal 1

RAO 30 / CAU 20

More RAO (eg. RAO 40 / CAU 20):

This separates the diagonal branches further from the LAD, demonstrating them inferior to the LAD. This view can also improve visualisation of the mid / distal Obtuse Marginal

This separates the diagonal branches further from the LAD, the LAD.

CORONARY HEART ™

Left Main

Left Anterior Descending

Diagonal

Circumflex

ObtuseMarginal 1

EP EDUCATION

An Introduction to Wolff Parkinson White Syndrome Written by Ian Wright

St Mary’s Hospital, London, UK


“WPW syndrome is present in approximately three in every 2,000 people”

In 1930 Wolff, Parkinson and White first described the syndrome that bears

their name as “bundle-branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia.” We now know that the condition is caused by one or more strands of myocardial tissue, known as accessory pathways, which bridge the atrio-ventricular (AV) ring that electrically isolates atria from ventricles. In the normal heart the AV ring is bridged only by the His bundle arising from the AV node - this forms the sole route for an impulse to pass from atria to ventricles (other connections having been severed during foetal development of the heart valves).

The presence of this extra pathway (or “bypass tract”) explains the features that define WPW syndrome and is present in approximately three in every 2,000 people.

An important role of the AV node is to slow impulses on route from atria to ventricles, allowing optimal time for ventricular filling. By comparison accessory pathways conduct very rapidly. This manifests on the ECG as a short P-R interval.

Rapid conduction of the impulse around the ventricles by the specialised conduction system results in the narrow QRS complexes seen on a normal ECG. As accessory pathways connect to non-specialised myocardial cells that conduct slowly, activation of the ventricles via such pathways results in a broad initial QRS - the delta wave seen in WPW patients.

1.

2.

AV nodal conduction eventually catches up and the QRS changes from broad to narrow. This activation of the ventricles from two different routes produces the characteristic fusion complex that characterises WPW syndrome (see Fig 2).

Patients with this ECG appearance are said to have a manifest accessory pathway. With the knowledge available at the time Wolff, Parkinson and White incorrectly described this ECG appearance as bundle branch block.

Figure 1: 12 Lead ECG in WPW

Figure 2

Wolff Parkinson Written by Ian WrightSt Mary’s Hospital, London, UK

CORONARY HEART ™

AV nodal conduction eventually catches up and the QRS changes from broad to narrow. This activation of the ventricles from two different routes produces the characteristic fusion complex that characterises WPW

Patients with this ECG appearance are said to have a manifest accessory pathway. With the knowledge available at the time Wolff, Parkinson and White incorrectly described this ECG appearance as bundle branch block.

Figure 1: 12 Lead ECG in WPW

SPECIAL FEATURE (cont...)


angiography are that the patients are elective, stable and suitable for femoral access. 95% of our elective angiograms are performed via the femoral route using 4 or 5 french systems. At the end of the session, the Cardiologists will review all the films, the management plans will be discussed and the patients medications are reviewed. The practitioner will then discuss the outcome with the patient and complete any referral documentation.

Negative aspects

There was no funding identified for this role prior to commencing training and we were informed that as this was a pilot role there may not be a post at the end of the training period.

Our posts were not backfilled which meant that we had to undertake our very demanding current roles in addition to undertaking our training.

Our posts including the extended role of coronary angiography practitioner are yet to be banded satisfactorily in line with Agenda for Change.

Benefits

We have significantly improved the utilisation of our cath labs and have reduced our waiting times from 9 months to 4 months. We have reduced patient cancellations by 10% because of the flexibility of a practitioner being available for example when there is sickness, urgent meetings, leave.

The routine medical workload is alleviated to allow Consultant Cardiologists to undertake complex coronary intervention and assist the possible introduction of primary PCI.Obviously for the organisation there is a huge cost saving due to eliminating the need to pay medical staff for carrying out extra sessions.

Evaluation

We are now almost 2 years into sustaining this new role. The coronary angiography practitioners in our organisation have performed almost 700 procedures in that time. We collect and examine our audit data 6 monthly looking specifically at success rates, screening times, complications and diagnostic quality. Initially we compared our data with that of our Cardiology Specialist Registrars as a benchmarking exercise and found the outcomes to be very similar.

Our original intention was to have a dedicated role of coronary angiography practitioner but as we have progressed we have recognised that a flexible, more balanced role is more beneficial to all parties. We continue with our original roles and backfill sessions when necessary and only when there is no SpR to fill the session. For anyone to carry out coronary angiography on a full time basis would we suggest, become rather monotonous.

From a practitioners point of view it has been a very enjoyable challenge that has enhanced job satisfaction. The new challenges for year 2 have been to progress to radial procedures and to include more complex procedures such as patients with previous CABG. From a patients point of view we have received very positive feedback.

The future

We have a new cardiothoracic centre due to open in 2007/2008 with a further increase in cath lab capacity. It has been useful to explore new ways of working and hopefully the introduction of this role will provide an attractive cath lab career ladder, improving our recruitment and retention prospects and we aim to expand our team of coronary angiography practitioners.

Coronary Angiography Practitioner

We would like to hear your

comments on this article.

Email your thoughts,positive or

negative, and we’ll try to

publish them in the next

issue.

Write to us at:

[email protected]

Coronary Angiography PractitionerCoronary Angiography Practitioner


comments on

negative, and

publish them

[email protected]

SPECIAL FEATURE

by Maria Whitehead and Jenny LavenderHull and East Yorkshire Hospitals NHS Trust, UK


Introduction

In this article we will discuss the Hull experience of why we decided to introduce the role of coronary angiography practitioner. We will include the stages we went through to gain approval within our organisation and how we set the program up including the training needs. We will evaluate the reality of the role highlighting the advantages and disadvantages and discuss our plans for future development.

Background

Hull is a tertiary centre providing interventional cardiology services for a population of 1.2 million. We perform 2000 coronary angiograms per annum. Our cardiology services are currently split between three sites, which poses us quite a challenge in terms of medical staffing. This has been further increased by the European Working Time Directives reducing the availability of cardiology SpRs in the cath lab and the new Consultant contracts, which has reduced the flexibility of the Cardiologists to backfill empty cath lab sessions.

These issues led to our cath labs being under utilised and we were struggling to meet the National Service Framework Target waiting times for coronary angiography.

Our service manager and clinical director for cardiology considered that a solution to the problem could be to train non medical practitioners to perform coronary angiography.

Setting up a program

Who

We acknowledged that any of the three professional groups within the cath lab with the relevant experience could be trained equally effectively. However within our cardiac cath labs, our nurses and radiographers are dedicated, permanent staff whereas our cardiac physiologists work on a rotational basis and already have their own specialist areas of practice.

Experience

We enrolled a senior cardiac nurse and a senior radiographer to undertake training, each with around 10 year’s cath lab experience. Obviously an extensive knowledge of the procedure, equipment selection, potential problems and the ability to manage them is essential.

Introducing the role of Coronary Angiography Practitioner

them is essential.

The traditional roles of lab professionals may be changing

by Maria Whitehead and Jenny LavenderHull and East Yorkshire Hospitals NHS Trust, UK

Experience

We enrolled a senior cardiac nurse and a senior radiographer to undertake training, each with around 10 year’s cath lab experience. Obviously an extensive knowledge of the procedure, equipment selection, potential problems and the ability to manage them is essential.

Coronary Angiography Coronary Angiography

them is essential.

The traditional roles of lab professionals may be changing

Product FocusPRODUCT INFORMATION

Medtronic Endeavor Drug Eluting Stent

The long awaited arrival of Medtronic’s drug eluting stent, the Endeavor™ is finally here. Although in some

countries it is still under investigational use we will give you a brief run down on the facts and figures.

Platform:

The popular Driver coronary stent system provides the platform for the Endeavor™. Already popular with physicians for its manoeuvrability and ease of use, the Driver is a cobalt alloy stent, meaning it is denser and stronger than traditional stainless steel stents, whilst having thinner struts.

Drug:

Licensed by Abbott Laboratories to Medtronic, the drug code named ABT-578 (zotarolimus), is believed to reduce restenosis in clogged arteries by preventing smooth cell proliferation. It achieves this by blocking the function of the cell cycle regulatory protein, mTOR, stopping the growth of new tissue.

Polymer:

The delivery matrix for the stent is coated with a Phosphorylcholine (PC) polymer, licenced from Abbott Laboratories, called PC Technology™. It is designed to slowly release the drug into the arterial wall.

Delivery System:

The Endeavor Drug Eluting Coronary Stent is intended to be released on Rapid Exchange, Over-the-Wire (USA), and Multi-Exchange technologies for International markets.

Trials:

These trials have been undertaken at various sites to determine the effectiveness of the Endeavor™ in reducing coronary artery restenosis.

Endeavor I: Safety and efficacy of Endeavor™ in de novo coronary lesions in native coronary arteries. Results: A 24-month target lesion revascularization (TLR) rate of 2.0 percent, and no additional cases of stent thrombosis in the 97 study patients who received follow-up over the second 12-month period.

Endeavor II: Compared the Endeavor™ stent to the traditional Medtronic Driver bare metal stent. Results: Demonstrated no observed cases of stent thrombosis between nine and 12 months in either study arm. A 12-month TLR rate of 6.0 percent for Endeavor™ patients, compared to 13.2 percent in the Driver control group.

Endeavor III: Compares the Endeavor™ against the Cypher™ drug-eluting stent marketed by Cordis Corporation, a Johnson & Johnson company. Results: Showed that Endeavor provides clinical and angiographic outcomes consistent with previous Endeavor trials and with no statistical differents between Endeavor and Cypher.

Endeavor IV: Compares the Endeavor™ against the TAXUS™ Paclitaxel-Eluting Coronary Stent System from Boston Scientific Corporation. Results: Still enrolling.


Medtronic Endeavor Drug-Eluting StentCourtesy Medtronic, Inc.

Medtronic Endeavor Drug-Eluting StentCourtesy Medtronic, Inc.

The delivery matrix for the stent is coated with a Phosphorylcholine (PC) polymer, licenced from Abbott Laboratories, called PC Technology™. It is designed to slowly release the drug into the arterial wall.

Delivery System:

The Endeavor Drug Eluting Coronary Stent is intended to be released on Rapid Exchange, Over-the-Wire (USA), and Multi-Exchange technologies for International markets.

These trials have been undertaken at various sites to determine the effectiveness of the Endeavor™ in reducing coronary artery restenosis.

Safety and efficacy of Endeavor™ in de novo coronary lesions in native coronary arteries. 24-month target lesion revascularization (TLR) rate of 2.0 percent, and no additional cases of stent thrombosis in the 97 study patients who received follow-up over the second 12-

Compared the Endeavor™ stent to the traditional Medtronic Driver bare metal stent. Demonstrated no observed cases of stent thrombosis between nine and 12 months in either study arm. A 12-month TLR rate of 6.0 percent for Endeavor™ patients, compared to 13.2 percent in the Driver control group.

Compares the Endeavor™ against the Cypher™ drug-eluting stent marketed by Cordis Corporation, a Johnson & Johnson company. Endeavor provides clinical and angiographic outcomes consistent with previous Endeavor trials and with no statistical differents between Endeavor and Cypher.

Compares the Endeavor™ against the TAXUS™ Paclitaxel-Eluting Coronary Stent System from Boston Scientific Corporation.



World’s FirstBioabsorbable DES Trial BeginsMarch 9, 2006:

Guidant Corporation announced enrolment of the first patient in

a first-in-man clinical trial designed to evaluate the safety of a fully bioabsorbable everolimus eluting stent platform for the treatment of coronary artery disease.

“We are excited about our bioabsorbable drug eluting stent program, which is aligned with Guidant’s strategy of leveraging bioabsorbable technologies to provide innovative site-specific therapy for the

treatment of heart disease,” stated John M. Capek, Ph.D., president, Vascular Intervention, Guidant Corporation.The first implant was performed by a team headed by Drs. John Ormiston and Mark Webster at Auckland City Hospital, New Zealand. The ABSORB trial will enrol up to 60 patients in Belgium, Denmark, France, New Zealand, Poland and The Netherlands.

Visit www.guidant.com for more info

Siemens Unveil their Most Advanced CTMarch 3, 2006:

Siemens has pushed the technical and clinical boundaries of CT with this latest innovation, the

Somatom Definition, which is faster than every beating heart and capable of imaging full cardiac detail with as much as 50 percent less radiation exposure compared to traditional CT scans.

Setting new standards in cardiac diagnosis, the Somatom Definition will image patients with high or irregular heart rates, or even arrhythmia, without beta blocker medications that have been previously needed to slow a patient’s heart. The system also enables physicians to better identify and characterize plaque, an early indicator of heart disease.

The Somatom Definition has enhanced capabilities not previously available from any type of diagnostic imaging technology, which are expected to lead to new breakthroughs in clinical research. These capabilities include scanning with two different X-ray energies simultaneously, which allow physicians to better differentiate,

characterize, isolate and distinguish bone, soft tissue and fluid. With 0.33 seconds per rotation, electrocardiogram- (ECG) synchronized imaging can be performed with 83-millisecond temporal resolution, independent of the heart rate, resulting in motion free cardiac images.

The first Somatom Definition was installed at the University of Erlangen (Germany) in October 2005. “Siemens’ newest CT system provides very valuable clinical informationfor patients presenting in our department with acute chest pain and suspicion of coronary artery disease,” said Dr. Stephan Achenbach, associate professor of Cardiology, University of Erlangen. “We expect that the Somatom Definition will have a significant role in even the most demanding environments, such as emergency departments,”

added Prof. Werner Bautz, chairman of Radiology, University of Erlangen, Germany.

Visit www.medical.siemens.com for more information

treatment of heart disease,” stated John

Siemens press picture

MEDIA KIT 06-07

Special Prices...

30% off all AdvertisingOctober / November

2006 issue.For more information contact:

[email protected]

The new magazine designed for managers and staff working in cardiac cath / EP labs, and non-invasive departments.Distributed to UK, Australia, and NZ.

Latest News

treatment of heart disease,” stated John M. Capek, Ph.D., president, Vascular Intervention, Guidant Corporation.The first implant was performed by a team headed by Drs. John Ormiston and Mark Webster at Auckland City Hospital, New Zealand. The ABSORB trial will enrol up to 60 patients in Belgium, Denmark, France, New Zealand, Poland and The Netherlands.

Visit www.guidant.com for more info

added Prof. Werner Bautz, chairman of Radiology, University of Erlangen, Germany.

Visit www.medical.siemens.com for more information

treatment of heart disease,” stated John

coronaryheart.com

Using Magnetic Fields to fix Atrial Fibrillation

“Especially for Cardiac Cath, EP, and Non-Invasive

Departments”

June / July 06 International Double IssueJune / July 06 International Double Issue

EDUCATION,CONFERENCES

+ more...

Medtronic Endeavor DES Product Focus

coronaryheart.com

Lab Staff Performing Angiograms

EMP

LO

YMENT

LAB VISITSEpworth Hospital, AustraliaEast Surrey Hospital, UK

UK

Australia

New Zealand

Special Feature

Revised Prices

06-07

coronaryheart.com

RecruitmentAdvertising Rates

Special Prices...

AdministratorsManagersCardiac NursesCardiac PhysiologistsEchocardiographersRadiographersCardiac IndustryOther Cardiac Professions

••••••••

AUSTRALIA

UNITED KINGDOM

NEW ZEALAND

AUSTRALIA

30% off all Advertising October 2006

issue.Contact:

[email protected]

Revised Pri

ces

06-0706-0706-0706-0706-0706-0706-0706-0706-07

Like to Advertise?

Download our Media Kits

Onlinecoronaryheart.com

Mitral RegurgitationEDUCATION


Alternative Names:

Mitral Insuffi ciency or Mitral Incompetence.

Defi nition:

Mitral regurgitation (MR) is a condition whereby an injury or disease has resulted in the mitral valve becoming leaky through not closing properly, causing blood to regurgitate backwards into the left atrium (LA) from the left ventricle (LV) during systole (contraction). Th is can result in blood backing up into the lungs.

Incidence:

1 in 5 over the age of fi fty-fi ve (Western world) have some form of mitral regurgitation.

Th e Normal Valve:

Th e mitral valve consists of two triangular shaped fl aps called leafl ets. Th ese are attached to the heart muscle via a ring called the annulus. Th e mitral valve is attached to the left ventricle by chordae tendineae cordis, which resemble the strings of a parachute. When working properly, the mitral valve closes fully, preventing blood from passing back into the left atrium during systole of the left ventricle.

Causes:

Mitral Valve Prolapse: A condition whereby the cordae and leafl ets become weakened causing the prolapse of the valve back into the left atrium as the left ventricle contracts.Annular Dilatation.Ruptured papillary muscle or chordae tendineae due to acute myocardial infarction or trauma.Rheumatic Fever: a complication, which can sometimes occur following streptococcal infection. It is still common in parts of the third world and its reduced incidence in the western world has correlated with improved public health and routine use of penicillin.Endocarditis: Infection involving the heart valves whereby growths or vegetation can develop on the surface. Th is can result in perforation of the mitral leafl et.

•

••

•

•

Normal Mitral ValveOpen Closed

By Tim Larner

Open Closed

Mitral Insuffi ciency or Mitral Incompetence.

Mitral regurgitation (MR) is a condition whereby an injury or disease has resulted in the mitral valve becoming leaky through

4 Chamber Cross Section of Heart

Left Atrium

Bicuspid Valve(Mitral)

Left Ventricle

Right Ventricle

Tricuspid Valve

>>>

EDUCATION (cont...)

Mitral Regurgitation


Congenital heart disease: some babies are born with leaky valves and there is a strong association between certain types of defects in the atrial septum and cleft mitral valves which can leak severely.

Symptoms: Acute vs Chronic

Acute - Breathless symptoms that occur suddenly may be result of an acute mitral regurgitation which can be secondary to either papillary muscle rupture or its function in acute myocardial infarction (MI), or rupture chordae tendineae. Th ese patients often present directly to the A&E Department.

Symptoms include:

Severe shortness of breath.Heart Palpitations - rapid or irregular.Chest pain (only in context of MI)Cough (can be productive of white sputum).

Chronic - Symptoms that have been occurring for a longer period (can be several years) is referred to as chronic mitral regurgitation.

Symptoms include:

Shortness of breath - particularly when laying fl at or exercising.Heart Palpitations - rapid or irregular.Cough.Increased fatigue – due to reduced cardiac output.Swollen ankles or feet due to increased fl uid.

Diagnosis:

Stethoscope – Can often be identifi ed by a characteristic “whooshing” sound in systole. Referred to as a heart murmur, due to the sound of turbulent blood passing from the left ventricle into the left atrium.

Echocardiogram and Transoesophageal Echo (TOE) – Cardiac ultrasound can determine the effi ciency of the left ventricle during contraction, and using colour Doppler can visualise a leaky valve. Continuous Wave (CW) jet can be used to determine the intensity.

ECG - Atrial Fibrillation due to left atrium enlargement.

•

••••

•

••••

>>>

LA

LV

MitralValve

Mitral Valve Open

Mitral Valve Closed

Colour DopplerLeft Atrium Start Systole

Colour DopplerLeft Atrium End Systole

SevereMR

SevereMR

Mitral RegurgitationEDUCATION (cont...)


Cardiac Catheterisation – Performing a left ventriculogram can demonstrate the fl ow of contrast back into the atrium during systole. During a right heart cath there is also a signifi cant increase in V wave size of the Pulmonary Capillary Wedge (PCW) pressure.

Chest X-ray – Th e left ventricle can often be enlarged. Th is can be seen on a chest x-ray by the left side of the heart being enlarged, which may indicate a leaky valve. Pulmonary Oedema is also a possible sign of the presence of MR.

Pathophysiology:

When MR is present the LV becomes enlarged due to the creation of two outlets (aorta and left atrium) as it tries to compensate for the decreased output.

Medical Treatment:

Medication won’t fi x the damaged valve but they can reduce heart size and annular dilatation reducing MR.

Diuretics – Used to reduce the fl uid build-up in the lower legs and lungs.

ACE Inhibitors – Th ese dilate the arteries reducing the workload on the heart, which in turn reduces the amount of regurgitation into the left atrium.

Surgical Treatments:

Valve repair is performed if the valve is only partially damaged. Valve Replacement occurs if the valve can’t be repaired.

Valve Repair – Th is is achieved by repairing either the leafl ets or valve tissue so it can close tightly. An example of this is an annuplasty ring which is sewn on the left atrial aspect of the valve.

Valve Replacement - In this procedure the surgeon removes the damaged mitral valve and replaces it with an artifi cial version. Th ere are two types of valves available: Mechanical and Biological.

Annuloplasty RingImage courtesy St Jude Medical

LV Gram showing severe MR with left ventricle at end of systole

LV gram in diasystole showing contrast in the left atrium with severe MR.

EDUCATION (cont...)

Mitral Regurgitation

Mechanical: Th ese valves are made of metal and as such are easily shown on x-ray. Th ese valves last a long time however may result in clot formation around the device. For this reason the patient must medicated with an anticoagulant, such as warfarin to prevent the formation of clots which may detach and cause a stroke.An example of this device is the St Jude Masters Series Mechanical Heart Valve as seen above.

Biological: Th ese are tissue valves often removed from a pig. Referred to as bioprostheses, these valves don’t last as long as mechanical valves however allow the patient not to use long-term anticoagulants.

Percutaneous Treatments:

Th is treatment is relatively new, however companies such as Evalve Inc., produce the MitraClip™ to allow cardiologists to repair the mitral valve in the cath lab. Turn over the page for a full review on this technique which is still undergoing clinical trials.

References:

1. ‘Mitral valve regurgitation’, Mayo Clinic website: http://www.mayoclinic.com/health/mitral-valve-regurgitation/DS00421/DSECTION=12. Shivkumar Jha, MD, ‘Mitral Regurgitation’, eMedicine from WebMD website: http://www.emedicine.com/med/topic1485.htm3. ‘Mitral Regurgitation,’ Cardiology Channel website: http://www.cardiologychannel.com/mitralregurgitation/index.shtml4. ‘Mitral Regurgitation – Chronic’, US National Library of Medicine & the National Institutes of Health, MedlinePlus website: http://www.nlm.nih.gov/medlineplus/ency/article/000176.htm5. ‘Mitral Regurgitation – Acute’, US National Library of Medicine & the National Institutes of Health, MedlinePlus website: http://www.nlm.nih.gov/medlineplus/ency/article/000177.htm6. ‘Mitral Valve Regurgitation,’ from WebMD website: http://www.webmd.com/hw/heart_disease/aa143445.asp7. Interview with Marcia Abbott, Cardiac Physiologist, Th e Wellington Hospital, London, UK.

Porcine Valve Mechanical ValveImages courtesy St Jude Medical


PRODUCT INFORMATION

Mitral Valve Treatment


Evalve’s MitraClip™ � e Evalve MitraClip™ is still undergoing clinical trials, however is set to revolutionise mitral valve repair, by shifting treatment from the operating

theatres to the cardiac cath lab.

Evalve Inc.’s MitraClip™ device is designed to enable interventional cardiologists to perform a percutaneous repair of the mitral valve while the heart is beating,

as an alternative to the conventional open heart surgical approach. Percutaneous repair with the MitraClip device adapts an existing surgical Edge-to-Edge technique⁽¹²⁾ for mitral regurgitation (MR), which has been reported in more than 1500 cases published in peer-reviewed literature with up to 15 years of follow-up.

Th e procedure is conducted in the cardiac catheterisation laboratory under general anaesthesia using fl uoroscopic and echo-cardiographic imaging. A catheter is introduced through the patient’s skin in the groin area, and is guided from the femoral vein to the mitral valve. Th en, a smaller delivery catheter that holds the MitraClip device is introduced through the fi rst catheter so that the Clip can be

guided into place and attached to the leafl ets of the mitral valve. Once the Clip is securely attached, it is deployed and the catheters are removed. Th e patient is recovered from general anaesthesia and discharged a few days after the procedure. After treatment, patients generally return to modifi ed activity within one week.

Several early patients have now been followed for over two years. Findings to date in the EVEREST Registry showed that of 70 patients enrolled in the non-randomized arms of the EVEREST studies:

Th e MitraClip device reduced MR at hospital discharge to ≤1+ (see grading system below) in majority of patients, Durable MR reductions were seen in initial 24-month follow-up,Both degenerative valve disease and secondary (functional) MR have been treated,Low complication rates were noted, andSurgical options appear to be preserved.

MR reduction from 3-4+ to 2+ or less was achieved in 73% of patients. Discharge MR of ≤1+ was achieved in the majority (70%) of these 51 patients. Ninety-six percent of patients were free from signifi cant adverse events at 30 days. While all 70 patients required surgery prior to the PMR procedure, to date 76 % of those who underwent the catheter-based procedure remain free from open-heart surgery.

� e MitraClip™ is currently in Phase II of clinical trials (EVEREST II) in the US and Canada and is not approved by the FDA for use outside the patient population enrolled in the study.

MR Grading: 1+ (Mild), 2+ & 3+ (Moderate), 4+ (Severe)

References:Ted Feldman, Hal S. Wasserman, Howard C. Herrmann, William Gray, Peter C. Block, Patrick Whitlow, Fred St. Goar, Leonardo Rodriguez, Frank Silvestry, Allan Schwartz, Timothy A. Sanborn, Jose A. Condado and Elyse Foster. Percutaneous Mitral Valve Repair Using the Edge-to-Edge Technique: Six-Month Results of the EVEREST Phase I Clinical TrialJ. Am. Coll. Cardiol. 2005;46;2134-2140Francesco Maisano, MD; Giorgio Vigano, MD; Andrea Blasio, MD; Antonio Colombo, MD; Chiara Calabrese, Ottavio Alfi eri, MD. Surgical isolated edge-to-edge mitral valve repair without Annuloplasty: clinical proof of the principle for an endovascular approach. EuroInterv.2006;2:181-186

For additional information about the EVEREST II clinical research study and Evalve, Inc., visit www.evalveinc.com

•

•

•

••

1.

2.

www.siemens.com/medical

M-Z

91

7-1

-76

00 Proven Outcomes in Cardiology. Caring for

more patients, over a longer period of time, with

fewer resources. Impossible? On the contrary: We can

prove it. With integrated solutions that create a seamless

cardiology workflow. Where images and data are retrieved

instantaneously. Where cutting-edge technology enables

absolute precision. Where clinicians are free to provide

the best care possible. These are the Proven Outcomes

that are transforming the delivery of health care. Today.

We see a way to reduce cardiac cath lab reportturnaround times from 48 hours to 15 minutes

Proven OutcomesHelping cardiologists make 24 hours work like 48.

Siemens Medical Solutions that help

Results may vary. Data on file.

98257_M-Z917_A4_eng.qxd 17.05.2006 13:49 Uhr Seite 1

SPECIAL FEATURE


By Alison Sutcliffe and Denise Arthur

The following report details the new Pilot Course provided by London South Bank

University from the perspective of two students from Harefi eld Hospital. It was the only hospital to have each of the three modalities represented during the course.

Although the idea of generic workers is controversial, the advantages are easy to see. London South Bank University (LSBU) is leading the way with this course, and one of the main outcomes will eventually be that departments can reduce lab downtime by allowing staff to participate in alternative roles.

As the Pilot Course mentioned in this feature is new, the following article has been edited to remove any specifi c course details which are subject to copyright or that the LSBU deemed inappropriate for public release.

Background

Th e recent increase in the provision of day case cardiac angiography has highlighted the shortage of suitably trained healthcare professionals. Th e Cardiac Catheter Lab Practitioner project was set up to develop a new way of working which hopes to ease staff shortages by creating a more fl exible non-medical workforce. By multi-skilling the existing work force it is anticipated that downtime will be reduced. One of the main goals of the course was to reduce patients waiting

time, both on the waiting list and also on the day of procedure.

Th ree trusts, in partnership with London South Bank University (LSBU), developed a one year course in elective angiography. Th ese were Th e Royal Brompton and Harefi eld NHS Trust, St Mary’s NHS Trust and the Guy’s and St Th omas’ Hospital NHS Trust.

Th e aim of the course was to up skill existing cardiac staff to undertake a range of non-medical clinical

From Left: Alison Sutcliffe and Denise Arthur

Two students from Harefi eld Hospital in London share their experiences on the new Pilot

Course in Elective Angiography.

Th e GenericCath Lab Worker



Th e Generic Cath Lab Worker


activities performed during elective angiography. Dr. Nikki Ellis was appointed by the LSBU as the project leader and developed the course with the collaboration of the trusts. A group of senior staff from each discipline from each of the trusts together with staff from the university set up a Pilot Leaders Workgroup. Th is group met to discuss and agree the course content, their main objectives being to combine theory and practice to provide a coherent and comprehensive course. Approval for the course was successfully sought from appropriate professional bodies (Th e Society and College of Radiographers, Th e Nursing and Midwifery Council and Th e Society for Cardiological Science and Technology). Th e issues considered were Radiation protection, Drug administration, need for transferable skills and need for enhanced skill structure.

Selection

Students were then invited to apply for a place on the course. Initially it was just off ered to the three trusts that had been involved with its implementation and then applications were accepted from further afi eld. Th e student prerequisites were:

Qualifi ed health care professional in one of the three disciplines

Employed in CCL for at least 25 hours per week

Two years experience in a Cardiac Cath Lab

Immediate Life Support Certifi cate

Support from Trust and service manager with access to the appropriate work environment and tuition during clinical training

•

•

•

•

•

Sixteen students were hoping to enrol (nine nurses, fi ve radiographers, and two cardiac physiologists), however only eleven of these were able to commence training. Th is was due to the other students unable to get the full support of their hospitals. Any prospective student must ensure they gain full support from hospital management prior to undertaking the course, particularly for non-radiographers to allow usage of the x-ray equipment.

Course Content

Th e course ran over one year and could be taken at Level H (graduate certifi cate) or Level M (post graduate certifi cate). It was divided into four units, with academic assessment by London South Bank University staff and the clinical assessment performed locally by clinical experts within the Trusts that the students worked.

Students received 135 hours taught time at university and in addition were enabled to act in a supernumerary

Alison hard at work in the cath lab>>>


Th e Generic Cath Lab WorkerSPECIAL FEATURE (cont...)

role for 8 months in order to pass rigorous clinical competencies which were compiled by clinical experts from the 3 pilot Trusts. As well as the University based learning there was also an emphasis on mentorship and self managed learning.

Th e competencies were the same for Level H and M level but M level students were required to demonstrate a deeper knowledge of the evidence behind the clinical competencies and an ability to think critically about protocols and problem solving. Th is was evidenced by an extra assignment for each unit.

Th e aims of the course encompass day case angiography excluding paediatrics, ACHD, EPS, emergency work and PCI but including temporary pacing and knowledge of IABP. Once qualifi ed there will be scope to extend our roles to include PCI with the approval of the Trust.

Units

Th ere are four units in all, of which each student is required to do three.

Diagnostic ImagingCardiac PhysiologyPatient Management

•••

Eff ective Delivery

We were able to undertake an Assessment of Prior Experiential Learning AP(E)L in our own discipline. For example, a nurse was not required to do the Patient Management unit on the assumption they already have that knowledge. It is fair to say we have certainly had our highs and lows, but in particular we have all enjoyed the clinical aspect very much. Academically we found it fairly challenging, and from the beginning were encouraged to take charge of our own learning, something that some

•

The new GE Innova 2100 at Harefield Hospital.The Cardiac Physiologists sit behind the lead screen in the background



Th e Generic Cath Lab Workerof us had not experienced before, as some of us had not done any serious academic work for more than 20 years!

We began by formulating our own timetable in the clinical environment. Th is was done in partnership with our clinical mentors, and as there were three of us we had to devise a tight timetable to ensure we all had equal opportunity to have clinical training without overstretching our mentors. We met with our mentors formally to do a pre-course assessment; another was done at midpoint and a fi nal one towards the end of the year. Th is way we were able to see if there were areas in which we not achieving and in which we therefore needed to focus more. Obviously, we had diff erent learning curves but all passed our clinical competencies by the end of the year, some faster than others!

Th ose of us who had a management role within the department initially found it hard to combine the two roles. Th e answer to this was to actively take a back seat from our usual roles for a while, and setting aside at least one ‘management’ day a month in order to catch up.

Diagnostic Imaging

Th e nurses and cardiac physiologists undertook this unit. Th e academic bias was towards science (physics) and equipment, the science being quite detailed, but necessary to comprehend radiation regulations (E.U. Legislation).

As a nurse, I found it quite challenging but very rewarding and was very well supported by the University. Th e clinical experience was likened to learning to drive a JCB…some of us took longer than others! In our trust we had a fantastic mentor who made the whole experience enjoyable and we now feel very confi dent in our skills. Initially

some medics were quite sceptical and impatient but the majority were supportive and encouraging and have been converted now they see how much lab downtime is avoided.

Cardiac Physiology

Nurses and radiographers undertook this unit.

Th e content of this unit was quite in-depth and we found some of the topics too much so. We would have preferred more coverage of E.C.G traces, pressures and O2 saturations in the classroom.

Due to the work commitments of our mentor it was sometimes diffi cult to get any clinical continuity, the labs had several types of diff erent equipment and at the time we were training there were several other students also training which meant that we had less opportunity for clinical learning.Again the learning curve was steep but

our colleagues were very supportive which helped us to overcome our diffi culties.

Patient Management

Radiographers and technicians undertook this unit.

Th e main emphasis of this unit was re-enforcement of sterile techniques, patient observations etc. with a lean towards pharmacology. Th e pharmacology was very in-depth but it was enjoyed immensely. For us in particular an off -site mentor made achieving the clinical competencies diffi cult and some of them were diffi cult to fulfi l particularly in relation to drug administration. Th e students found that the role of the nurse is not as clearly defi ned as their normal roles, and was quite hard to adapt to.

The new ANZAC wing at Harefield Hospital

>>>



Th e Generic Cath Lab Worker


Eff ective Delivery

Th e aim of this unit was to examine and evaluate current management concepts in health and social care relevant to the CCL with particular emphasis on the KSF (Knowledge and Skills Framework). To this end, students were required to write a personal Learning Contract, which was then updated and referred to throughout duration of the course. We all found this very challenging and, it being a pilot course, we had no previous students’ work to refer to. Some of us struggled with this unit and needed a lot of help from tutors before we knew if we were on the right track. Evaluation of the Learning Contract enabled us to refl ect on our personal achievements over the year.Our Learning Contract has become a useful ongoing document, which we can keep under constant review with relevance to future appraisal and CPD record if we wish.

Conclusion

Th e philosophy underpinning the entire project is evolution not revolution; it is not intended to replace professional expertise or to reduce the numbers of staff present. Its aim is to provide fl exibility, increased knowledge and skills and improve team working.We have now completed the course

and are due to receive our certifi cates in April 2007.

At Harefi eld Hospital we were the only hospital to have three students,

from 3 diff erent disciplines to complete the course, and so have been able to maximise our experience by working a

lab ‘generically’ twice a week; we swap roles for each

case and therefore keep up our skills

with the support of our generic colleagues, should we encounter a problem. Th e added enthusiasm and interest in our daily tasks and scope for future learning has been marked. As a nurse I have been

able to step into the role of radiographer

on several occasions, covering lunch breaks

etc and have saved downtime in the lab for

over 20 hours since April.

Team working has improved. Th ere has been heightened awareness and interest from all disciplines, which has led to greater understanding of each other’s roles and problems. Th e doctors are now very supportive and encourage the multi-tasking, which we are now able to competently do. We have been

instrumental in some changes in departmental working

and are looking forward to the next group of students to follow our success and

do the next course, which will begin in September (2006).


comments on this article.

Email your thoughts, positive or

negative, and we’ll try to

publish them in the next

issue.

Write to Tim at:

[email protected]

concepts in health and social care relevant to the CCL with particular emphasis on the KSF (Knowledge and Skills Framework). To this end, students were required to write

knew if we were on the right track. Evaluation of the Learning Contract enabled us to refl ect on our personal achievements over

Our Learning Contract has become a useful ongoing document, which we can keep under constant review with relevance to future appraisal and CPD record if we wish.

Th e philosophy underpinning the entire project is evolution not revolution; it is not intended to replace professional expertise or to reduce the numbers of staff present. Its aim is to provide fl exibility, increased knowledge and

hospital to have three students, from 3 diff erent disciplines to complete the course, and so have been able to maximise our experience by working a


case and therefore keep up our skills

colleagues, should

future learning has been marked. As a nurse I have been

able to step into the role of radiographer

on several occasions, covering lunch breaks

etc and have saved downtime in the lab for

over 20 hours since April.



and are looking forward to the next group of students to follow our success and

concepts in health and social care relevant to the CCL with particular emphasis on the KSF (Knowledge and Skills Framework). To this end, students were required to write

knew if we were on the

of the Learning Contract enabled us to refl ect on our personal achievements over

Our Learning Contract has become a useful ongoing document, which we can keep under constant review with relevance to future appraisal and CPD record if we wish.

Th e philosophy underpinning the entire project is evolution not revolution; it is not intended to replace professional expertise or to reduce the numbers of staff present. Its aim is to provide

hospital to have three students, from 3 diff erent disciplines to complete the course, and so have been able to maximise our experience by working a


role of radiographer on several occasions,

covering lunch breaks etc and have saved

downtime in the lab for over 20 hours since April.



and are looking forward to the next group of students

CARDIAC SITE VISIT

Th e Wellington Hospital


The Wellington Hospital located in London is the largest independent hospital

in the UK, and is part of the Hospital Corporation of America (HCA) Group, the largest private hospital group in the capital. Th e hospital is internationally recognized for its excellence of its services especially the cardiology department which showcases the latest equipment backed up by some of the UK’s leading cardiologists, and a highly skilled team of nurses, cardiac physiologists, and radiographers. Located over three sites, the 266 bed hospital is located in the sought after

area of St John’s Wood, located in Zone 2 on the edge of central London. Th e hospital is well serviced by public transport, with the Jubilee Line of the Underground only a fi ve minute walk away. Th e world famous Lords Cricket Ground is located next to Th e Wellington Hospital, and it is not uncommon for staff to wander down to the ground after work to watch a match.

Recent changes in the department have included the employment of a new Superintendent Radiographer (Stephen Weymouth), Lead Cardiac Physiologist (Candice Henry) and Acting Senior Sister (Muriel Bartes), all of whom are well supported by the Cardiology Manager, Ruth Altmiks, with over 13 years experience at Th e Wellington.

Th e Director of Coronary Heart, Tim Larner, recently visited the department and spoke with Ruth and Stephen.

UNITED KINGDOM

ADDRESS

STAFF

MAP

10 Nurses10 Cardiac Physiologists4 Radiographers2 HCA’s1 Porter 1 Material’s Technician1 Office Co-ordinator

Cardiac DepartmentThe Wellington HospitalCircus RoadLondon, NW8 9JGUnited Kingdom

Back Row (from left): Albin Szot (Nurse) & Muriel Bartes (Nurse)Front Row (from left): Sarah Brookman (Radiographer)

& Michael King (HCA)

>>

The Wellington HospitalCARDIAC SITE VISIT


1) Size of the Department The cardiac department is located in the first floor of the North Building and is all situated on the one floor which it shares with the cardiac theatres. There are three cath labs, two of which are Siemens Axiom Artis, and one Philips Allura Xper. The Non-Invasive section of the department is split into four rooms, comprising of a stress-echo, echo, pacing, and stress room. The three echo machines are all GE, including a Vingmed System V, Vivid 7 (see photo right), and a Vivid i, all of which were acquired this year. On the second floor is the Intensive Care Unit (ICU) and the Progressive Care Unit (PCU) where all post intervention patients are sent. 2) Procedures: The cath labs perform angiograms, PTCA’s, stent procedures, ablations, cardioversions, electrophysiology studies, pacemakers, and ICD implants. The non-invasive department performs ECG’s, Echo, 24 hour blood pressure and holter monitoring, loop recorders, TOE’s, rhythm management including bi-vent devices and AV optimisation, stress tests, and stress-echo. 3) Main Roles: Cardiac Physiologists – In lab monitoring of ECG and pressures during procedures, operating the EP / Ablation equipment (including the 3D mapping of CARTO and N-Site), lead measurements during pacemaker and defibrillator implants, perform and report: echo, stress-echo, stress tests, pacing / defib clinics, 24 hour holter and BP monitoring, ECG’s, and TOE’s. They are also responsible for inventory charging and review.

Radiographer – The radiographers are responsible for controlling the movements of the imaging equipment including the table during procedures. They are also responsible for radiation protection and awareness, QCA, QA, lead apron checks, stock ordering, statistics, and procedure charging. Nurses – The nurses main responsibilities are assisting the

Cardiologist during all procedures (scrub nurse), circulating (scouting), checking patients in pre procedure, drug administrating, charging for inventory, and stock and pharmacy control.

4) Procedures per Year: The cardiac department performs approximately 3500 per year. This figure relates to 2005 when only two

UNITED KINGDOM

The Wellington HospitalCARDIAC SITE VISIT


cath labs were installed.

5) Cross-Training: At present there are no opportunities for cross-training of jobs within the department.

6) Day Cases: The cath lab does perform day cases.

7) Surgical Back-up: Located on the same floor as the cardiac department are the cardiac theatres whom are always on standby with a surgeon when angioplasties are performed. During theses procedures it is not uncommon for the surgeons to overview the cases as they are occurring with the cardiologist.

8) New Procedures Implemented: Cath Lab – New lab (Lab 3) installed in January, with an upgrade to Lab 1 in April. Both of these labs were fitted out with the new Siemens Axiom Artis, with the Haemodynamic equipment being Marquette. Carto-Merge was installed into Lab 1 in April, with N-Site for EP in the summer 2006. Non-Invasive – AV Optimisation commenced in January, whilst a new stress-echo room became operational in April.

9) Inventory Management: The inventory is managed using the Meditech system which allows stock usage to be tracked, and by generating re-order points, assists with ordering. Regular stock taking is also performed, and department has employed a fulltime staff member (Michelle) whom is responsible for ensuring the stock is ordered, expiry dates are checked, and stock levels are maintained.

10) Haemostasis Management: Starcloses and Angioseals are used whenever possible. Femostops are available if required and Radistops (TR bands) for radial pressure. All nurses are trained at manual compression to reduce the possibility of a haematoma.

UNITED KINGDOM

The Wellington HospitalCardiac Physiologists

From Left: Faizel Khan, Ruth Altmiks (Department Manager), Candice Henry, Sandra Assaye, & Marcia Abbott

>>

Th e Wellington HospitalCARDIAC SITE VISIT

11) Training for New Employees: All employees undergo a comprehensive clinical and corporate induction / orientation program. Mandatory training is also given in Occupational Health and Safety, Fire Awareness, Basic Life Support (BLS), and Manual Handling. Opportunities also exist for general staff to undertake Intermediate Life Support (ILS) and Advanced Life Support (ALS) for nurses and cardiac physiologists. Staff also receive ECG recognition training.A mentor is assigned to every new employee to provide training and support. Th ere is also a departmental induction program and regular in-house training.

Th e hospital also off ers regular training for clinical and managerial skills.

12) Methods Implemented to Reduce Costs:

PACS installation (September) rolled out throughout hospital making entire hospital fi lmless. All computers within the cardiac department are connected.

Standardisation throughout other HCA hospitals in London for stock purchases.

Installation of the Meditech Materials Management System (refer to Inventory Management question for details).

•

•

•

13) Alliances with Other Hospitals: Th e Wellington has alliances with other HCA hospitals for stock and equipment when required.

14) Continuing Education: Th e department is very supportive of staff members attending conferences and courses to further enhance their clinical skills. Every six months staff must undertake BLS training, with yearly training for the other mandatory courses. Teaching sessions also occur within the department. Company representatives regularly visit the department to discuss new products, as well as review previously installed equipment / products to ensure the staff are kept highly skilled. Th e Superintendent Radiographer, Stephen Weymouth is also a committee member of the Cardiac Radiographers Advisory Group (CRAG) to ensure that the radiographers within the Department are kept up-to-date with the latest developments within their fi eld. Th e Cardiac Physiologists are all registered to the Society for Cardiological Science and Technology (SCST). And all nurses are registered with the NMC.

UNITED KINGDOM

Advisory Group (CRAG) to ensure that the radiographers within the Department are kept up-to-date with the latest developments within their fi eld. Th e Cardiac Physiologists are

the radiographers within the Department are kept up-to-date with the latest developments within their fi eld. Th e Cardiac Physiologists are

Deputy Superintendent Radiographer Andrea Blakey (left) and Nurse Benita Felaar, with the Lab 2 Philips Allura Xper.


Th e Wellington HospitalCARDIAC SITE VISIT

15) Regular Staff Competency Checks: New Radiographers must undertake a 6 week competency check on all equipment and computer systems. Th is is reviewed annually. Cardiac Physiologists have annual competency checks on all procedures. Nurses undergo competency checks every six months in relation to groin management, performance, daily techniques, and trouble shooting. New nurses must complete a competency in scrubbing and circulating before being able to work unsupervised.

16) Th e main challenge faced in 2006? Providing a full functioning department whilst redevelopment was occurring.

17) Cardiac Registrars at the Wellington? Th e are no cardiology registrars working at the cardiac department.

18) Best Part of working at your facility? Th e cardiac department is well designed with the invasive and non-invasive departments,

along with theatres located next to each other. Th ere is also a wide variety of work to

keep things interesting. We are lucky that the entire team have a high level of expertise in their roles, and are

very friendly and supportive of one another.

Another bonus is it is quite a friendly department so social evenings are a regular occurrence Th ere are regular events organised by

the hospital which are open to all staff .

UNITED KINGDOM

WHY LONDON?

London is not only the capital of the United Kingdom, but is the cultural capital of Europe. With a population of seven million, London has it all. Castles, palaces, and stately homes are dotted all over London, easily reached by the Tube and bus network. The great eating areas of Soho and Covent Garden provide diners with a perfect meal before wandering down to watch a stage show in the West End.

London is big, bold, and brash, which can be daunting at first. But stay for a while and it soon draws you in. It’s an experience!!

Interesting facts about London:

Deepest Underground Station:Hamstead Station is the deepest Underground Tube Station at 58m.

London’s Black Cabs:Not many people know that the famous Black Cab actually comes in 12 diff erent colours.

Number of Passengers on the Tube:976 million passengers are carried on the Tube each year at a rate of 150,000 per hour.

Public Spaces:Th ere are 39 Urban Parks in London (30% of the city).

18) Best Part of working at your facility?

18) Best Part of working at your facility?

18) Best Part of working at your

Th e cardiac department is well designed with the invasive and non-invasive departments,


keep things interesting. We are lucky that the entire team have a high level of expertise in their roles, and are

very friendly and supportive of one

Another bonus is it is quite a friendly department so social evenings are a regular occurrence Th ere are regular events organised by


facility?

Th e cardiac department is well designed with the invasive and non-invasive departments,


keep things interesting. We are lucky


From left: Stephen Weymouth (Superintendent Radiographer), & Mitchell Ashton (Radiographer)


Royal Cornwall HospitalCARDIAC SITE VISIT


It is a relaxing 4.5 hour fast train service from London Paddington to Truro in Cornwall, upon which

Coronary Heart’s Director, Tim Larner travelled on for this issues site visit article:

•Th e Royal Cornwall Hospital NHS Trust, has been in the news recently due to cash fl ow problems, however although many hospitals throughout the UK suff er similar problems, the Royal Cornwall has been very proactive

in relation to getting the budget back on track.

Th e hospital has a modern open plan feel with very friendly and helpful staff , both of which are often lacking in many bigger hospitals. Th e cath lab team were also very accommodating for the afternoon I visited.

Th e following questions were completed by Tina Prestwood, Manager of the Cardiac Catheter Laboratories.

UNITED KINGDOM

ADDRESS

STAFF

MAP

Cath Lab Staff: 8 Nurses1 Health Care Assistant1 Porter

Rotational staff:RadiographersCardiac Physiologists7 Consultant Cardiologists

(4 Interventionalists, 1 Electrophysiologist, 1 special interest in Echocardiography, 1 general cardiology)

Trainee Registrars

••

•

•••

•

Cardiac Catheter LaboratoriesRoyal Cornwall Hospital TruroTR1 3LJCornwallUnited Kingdom

Royal Cornwall Hospital

CARDIAC SITE VISIT


Hospital and Cardiac Labs:

The Royal Cornwall Hospital Trust (RCHT), in the extreme south west of England, serves a population of 400.000 people in Cornwall and the Isles of Scilly. Cornwall is a popular holiday destination all year around and the population increases noticeably during the summer months. We frequently treat patients that have become unwell during their holiday.

The Cardiac Catheter Laboratories (CCL) are based at Treliske Hospital in Truro, a busy District General Hospital (DGH). Truro is the only city in Cornwall.

There are two labs comprising of the Siemens Coroscope Plus and Axiom Artis Flat Plate. The digital archiving system is Medcon, and there is also a TOMCAT database. Haemodynamic monitoring is via a Marquette Mac Lab 5000 and a Fysicon system.

The first CCL opened in May 2000 for diagnostic angiography, pacing procedures and EP studies. In 2001 a selective PCI service was introduced. Since 2005 we have a second CCL and provide 17 to 20 sessions a week. We work closely with our 18-bedded Cardiac Investigation Unit (CIU). The CIU team organise a pre-assessment clinic for all elective patients and provide nursing care pre and post all CCL procedures. Inpatients from non-cardiac wards are also admitted here, usually the day before the CCL procedure, to ensure thorough preparation of the patients. Overall, since the opening of the CIU in 2005, the CCL have been able to work more efficiently.

UNITED KINGDOM

>>

Royal Cornwall HospitalCath Lab Staff

Back Row (from left): Ian Davies (Cardiac Physiologist), Faith Westwood (Cardiac Physiologist), Jo Hope (Nurse), Tina Prestwood (Manager), and Jo Nicholls(Nurse).

Front Row (from left): Robert Brassington (Radiographer) and Tiffany Worthington (Nurse)

Additional Staff

Bev Holmes (Nurse)

Zoe Evans (Nurse)

Sue Webber (Nurse)

Royal Cornwall HospitalCARDIAC SITE VISIT


Staff Roles:

We currently work in the ‘traditional’ CCL set up. Nurses are responsible for all aspects of patient care as well the overall organisational running of the labs. Nurses act as scrub nurse or runners during the procedure. Radiographers are responsible for operating the X-ray machine and all aspects of image storage. The fairly new PACS (Picture Archiving and Communication System) system allows viewing of all clinical images on computer monitors within the trust.

Cardiac Technicians are responsible for the haemo-dynamic monitoring during procedures as well as recording of procedural details on the TOMCAT system.

CCL staff have their own roles but will help each other out and multi-task as and when required.

Generic Working:

We are working towards a generic working programme by developing a competency based, in-house ‘Cath Lab Practitioner’ training course.

Day case procedures:

All patients awaiting elective angiogram, EPS, TOE and Cardioversion are day case procedures. These patients have been pre assessed and are cared for on CIU (Cardiac Investigation Unit). Patients, without an adult carer available at home for the night following the procedure, are admitted over night.

Private Cases:

We regularily perform private procedures outside the regular NHS lists. Most of these patients are cared for on the CIU or the nearby Capio Duchy Hospital.

Types / Volume of Procedures per Year (2005/06):

Diagnostic angiography = 2600

PCI = 850 (in 70% of procedures DES used; 28% of procedures GPllb/llla blocker used)PPM = 450EP/RF = 30ICD = 40IVUS = 13PWS = 78

Surgical Back-up:

The nearest Cardio-thoracic operating theatre is Derriford Hospital in Plymouth, Devon. Failed PCI patients requiring urgent surgical intervention are transferred by Air Ambulance.

Haemostasis:

60% of all procedures are performed using radial arterial access. Radial arterial sheaths are removed in the CCL and a Terumo TR band is applied for later removal on the wards.75% of CCL nurses are trained in the deployment of Angio Seals, which are frequently used.

UNITED KINGDOM

Cardiac Investigations Unit StaffFrom left: Andrea Jacobs (HCA),

Robert Tong (Nurse), and Angie Diment (Nurse)

Interior of the new Lab at the Royal Cornwall Hospital

CARDIAC SITE VISIT

Royal Cornwall Hospital


Femoral arterial sheaths are removed by nursing staff on the cardiology wards using digital pressure or Femo stop devices.

Inventory:

All stock is purchased outright.Nurses in the CCL and our Health Care Assistant are involved in ordering and stock control by accepting responsibility for a specifi c area, e.g. guide catheters, wires, DES, pharmacy, disposable procedure packs. Th is system seems to work well and no single person is overwhelmed by this time consuming task. Due to storage restrictions, orders have to be placed weekly. Th ere is an annual stock check for the benefi t of the fi nance department.

Cost Cutting and Alliances:

Continuously rising procedure costs have to be balanced against budgetary restrictions. Th e Catheter Laboratories in Plymouth, Exeter, Torbay and Truro are part of the South West Peninsula Purchasing Alliance. Th e main aim of the alliance is to reduce purchasing costs by combining the requirements of four hospitals. Tender contracts are negotiated for the alliance and not individual hospitals. High cost items are tendered annually.For example, disposable procedure packs have been standardised between the participating Catheter Labs to reduce the purchase price.

Training / Continuing Education:

New staff benefi t from an orientation program as well as multi disciplinary formal and informal teaching. Th e RCHT has an extensive in house training program for continuous clinical and non-clinical education. Th ere are regular educational meetings

within the cardiology directorate.Staff are encouraged to attend meetings and conferences and to develop special interests. Self directed learning is expected of all members of the multi disciplinary team to continuously further their knowledge of cardiology.CCL nursing staff from Plymouth, Torbay, Exeter and Truro founded SWING – South West Interventional Nurses Group. Generous sponsorship has made this regular professional and social meeting possible and provides a lively discussion forum. Past topics include payment by results, primary PCI, and generic working.

Competencies:

Staff are expected to achieve competencies in IV cannulation, basic and immediate life support/ defi brillation. Nurses should also achieve competencies in groin management and femoral arterial sheath removal.

Challenges:

Th e usual… staffi ng shortages, high demand on service, lack of money.

Th e best bit about working at the Royal Cornwall Hospital Cath Lab:

Working with a lively team of committed and hard working individuals.

And fi nally, there is Cornwall, with hundreds of the most beautiful beaches, fantastic recreational opportunities, pasties and, if you want, a diff erent life style. As a recent survey said, ‘…people living in Cornwall are the happiest in the UK…’

WHY CORNWALL?

Cornwall is located in South West England, on a peninsula jutting out into the Atlantic Ocean. This region becomes jammed with holiday makers in the summer as the Gulf Stream pushes warm currents up from the Equator. Golden beaches and great waves makes this area popular with surfers. The region also has dramatic coastal landscapes and is dotted with stunning heritage towns, such as St Ives (see photo below). The Royal Cornwall Hospital is located in Truro in the middle of the county, making it the perfect base for touring the region.

UNITED KINGDOM

touring the region.


St Ives

Truro Cathedral

MONOMORPHIC VENTRICULAR TACHYCARDIA

An Introduction to

EP EDUCATION


Ventricular Tachycardia (VT) is an A-list celebrity in the arrhythmia world! When I

began my involvement with EP, two cases convinced me it was worth continuing with. Th e fi rst was seeing ablation of an accessory pathway but the most impressive was termination of incessant VT by ablation.

VT is a term used to describe a rapid rhythm (>100 b.p.m) originated in the ventricles (distal to the bundle of His) and lasting at least 3 beats or more. VT attracts attention because it can be life threatening and indeed it is the initiating arrhythmia in the majority of cases of sudden cardiac death (SCD). However, the risk to the patient is strongly related to the presence and degree of ventricular dysfunction (and to an extent the rate of the tachycardia) and in patients without structural heart disease VT has a much more benign prognosis.

If the rhythm lasts for >30 seconds it is described as sustained VT. Th e rhythm can be regular or irregular and the QRS shape (it’s morphology) can be stable or continually changing. A stable morphology is described as monomorphic VT and changing complexes as polymorphic VT. Th is article is about monomorphic VT.

VT is a broad complex tachycardia. Th e QRS complexes are broad because the impulse, which originates in ventricular muscle, spreads slowly through the tissue from myocyte to myocyte rather than being distributed rapidly by cells of the specialised conduction system. A broad QRS complex can sometimes

occur during supra ventricular tachycardias (SVTs) due to bundle branch block or the presence of an anterogradely conducting accessory pathway. Features such as dissociated p waves and fusion or capture beats (narrowing of the QRS complexes due to conducted p waves activating some or all of the ventricle) strongly suggest

a diagnosis of VT. Th e example below (fi g 2) shows a fusion beat (middle complex).

All VTs are not the same

You can fi nd descriptions of lots of diff erent types of VT but they tend to fall into two distinct categories, with two diff erent electrophysiological mechanisms and two diff erent approaches to ablation.

Normal heart VT

Th is VT occurs in patients with a structurally normal heart as determined by tests such as echocardiography and cardiac MRI and is also referred to as idiopathic VT. Th e patients are typically (but not exclusively) relatively young, with a higher incidence in

Fig. 1 12 lead ECG of VT

Fig.2: Fusion Beat

Written By: Ian Wright, St. Mary’s Hospital, London


Monomorphic VT

EP EDUCATION


women. Th e VT is often brought on by exercise or emotion and may be present in a spectrum from frequent ectopics through to sustained VT. Th ese are focal tachycardias where the underlying mechanism is usually triggered automaticity – where cells that should only “follow orders” start fi ring off repetitive impulses as if they were the sino atrial node, in response to certain stimuli. Examples include right ventricular outfl ow tract VT (RVOT), left ventricular outfl ow tract VT (LVOT) and idiopathic VTs from other parts of the left ventricle. Th e fl ow of calcium ions across cell membranes is important in these tachycardias and drugs aff ecting calcium channels such as verapamil may terminate this type of VT. Other drugs such as beta blockers that reduce sympathetic tone can be eff ective by preventing conditions that promote the arrhythmia. One type of normal heart VT, called fascicular VT, doesn’t quite fi t the mould – it has a higher incidence in men and the mechanism may involve re-entry.

Th is image on the right (Fig. 3) is from a patient with RVOT VT and clearly demonstrates the focal nature of the arrhythmia. Colours indicate the timing of signals recorded at various locations compared to a fi xed reference. Th e earliest signals are coded red, followed by shades of yellow, green, blue and lastly purple. Th e tachycardia starts from the red point (the originating focus) and spreads outwards evenly in all directions. Th e map looks like a target and is used as one – to guide an ablation catheter to the red focus, which can then be ablated to get rid of the VT. Th e technology used to create these maps is called CARTO (Biosense-Webster) and works on a similar principle to GPS navigation, using magnetic fi elds.

Ablation of normal heart VT

Th e outlook for patients with normal heart VT is usually very good and ablation is used to eliminate symptoms from the arrythmia – either because the patient prefers this to taking long-term medication or where medical therapy is ineff ective.

Th e ablation team study the patient’s ECG in VT for clues to the location of the focus in the right or left ventricle (there are published algorithms to help with this). During the ablation procedure an attempt is made to initiate the clinical tachycardia by pacing manoeuvres (programmed

stimulation). Normal heart VT in addition often requires the administration of isprenalin to get it started. If VT is present or can be induced the team fi nd the earliest signals (activation mapping) that occur during the tachycardia which occur just before the onset of the QRS complex on the ECG. 3D mapping systems (see above) can be used to help record and display this data more easily. Ablation at the site of earliest activation will usually eradicate the tachycardia. If inducing the rhythm becomes diffi cult pace-mapping can help pinpoint the focus – if the ECG during pacing looks the same as the ECG recorded during tachycardia the catheter is likely to be a the origin of the arrhythmia.

Fig 3: Patient with Right Ventricular Outflow Tract VT

>>CORONARY HEART ™ 37

EP EDUCATION (cont...)

Monomorphic VT

VT in structural heart disease

At least 90% of patients presenting with VT have underlying structural heart disease. Any form of heart disease that causes myocardial scarring can lead to VT because the scar tissue provides conditions necessary for re-entry. Re-entry describes the formation of circuits around or between areas of conduction block (such as scar tissue). Th ese circuits are very similar to a Mexican wave around a football stadiumWhere there is myocardial scarring the mechanism is almost always re-entry.

Conditions causing myocardial scarring and consequently VT include: MI, dilated and hypertrophic cardiomyopathy,

sarcoid and arrhythmogenic right ventricular cardiomyopathy (ARVC).

Patients with VT and structural heart disease may be at risk from sudden death resulting from degeneration of VT into VF. Th e most important indicator of risk in these patients is the degree of ventricular dysfunction – poor function = greater risk. Patients at high risk will usually receive an implantable cardioverter defi brillator (ICD).

Ablation of VT in structural heart disease

Reasons to ablate VT in patients with structural heart disease:

Treatment of symptomatic VT in patients who do not require an ICDTreatment of symptomatic VT in patients with an ICD where anti-tachycardia pacing (ATP) is ineff ective at terminating the arrhythmia.Patients with an ICD shock frequency that is not acceptable to the patient. For example one of our VT ablation patients had received 18 shocks in a 3 weeks. Ablation can reduce or eliminate shocks in these patients.

Ablation in these patients is complicated because they may have serious underlying heart disease and patchy scarring can result in numerous possible circuits. VT ablation is usually more eff ective in ischaemic heart disease (after MI) than cardiomyopathy.

•

•

•

Initiation of LVOT VT by programmed stimulation following the administration of isoprenalin

Failure to re-induce VT in the same patient following ablation at the site of earliest activation

An LV aneurysm (arrowed) following myocardial infarction

– a prime site for the formation of VT circuits


EP EDUCATION (cont...)

Monomorphic VTTh e strategy for ablation of re-entrant VT is somewhat diff erent to normal heat VT. Th e best area to ablate to achieve long-term success is a narrow region of the circuit (an isthmus) with very slow conduction where the circuit passes between areas of scar tissue. In VT this critical region is called the diastolic pathway and is located by a pacing technique known as entrainment. Th e images below come from a patient in VT caused by a previous MI and were produced using another 3D mapping system called non-contact mapping (ESI/St. Jude). Th ey show the propagation of the electrical wave during one beat of VT.

� e impulse is about to enter an area of diseased but still living tissue between areas of dead scar tissue from the old infarct.

� e impulse is seen moving through the narrow isthmus region of the diastolic pathway. � e activation of this tissue is not suffi cient to register on the surface ECG – it occurs during electrical diastole in between QRS complexes.

� e impulse leaves the infarct zone (from a point known as the exit) and moves in two directions around the two regions of scar

1.

2.

3.

producing the QRS complex on the ECG.

� e impulse has reached it’s starting point and the cycle begins again

In experienced centres VT ablation for patients 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.

© Ian Wright, September 2006.

4.

1 2 3 4

Do you have any interesting cases related to EP that would be of interest to others?

Are you working on or have finished a study that would interest our readers?

If so, send them to us.

All you need to do is send the article in Word format and attach uncompressed (high resolution) images from the case and we’ll do the rest.

Visit www.coronaryheart.com for more details

related to EP that would be of interest


Visit www.coronaryheart.com for more

related to EP that would be of interest


Visit www.coronaryheart.com for more Doris Helen(UK Nurse)


Cardiac CT - � e Basics

CARDIAC CT - (Part 1)


Cardiac CT is rapidly making a name for itself as a viable alternative to traditional

diagnostic angiograms, and with technology advancing so quickly, we believe it won’t be too long before you see a CT in your department.

Some cardiologists in the USA are retraining to become qualifi ed to perform CT’s, and speak to the majority of cardiac registrars today and they will tell you cardiac CT (and MRI) is the way of the future.

So over the next two editions Coronary Heart™ will be examining this new trend, starting fi rstly with the basics of CT to give those with no knowledge some grounding. Th e next issue (Dec/Jan) will focus on the advantages of cardiac CT, and the future direction of this exciting fi eld.

Sarah Brookman is an experienced CT Radiographer from Adelaide, South Australia, currently working in London.

Computed Tomography (CT), previously known as Computed Axial Tomography (CAT), uses x-rays to image the body in ‘slices’ or cross section. CT was invented in 1972 and was fi rst used in clinical practice in 1974. Early scanners were dedicated to brain imaging and took hours to produce one image. CT scanners have advanced signifi cantly since the 1970s and are used today to produce fast, high resolution images of just about any part of the body.

CT scanners consist of an x-ray tube and a row (array) of detectors which are fi xed opposite each other on a ring that rotates inside the gantry. Th e gantry is the main hardware component of the CT and is often described as a big donut. Th e patient table sits within the opening of the gantry and is able to move in both directions through

it. A computer is another necessary component of a CT and is used to control the scanner, store acquired data and reconstruct images.

Th e basic principle of CT is the same as that of radiographs. An x-ray beam that passes through a body will be absorbed or attenuated according to the density of structures it passes through. Th e resulting beam can be described as a profi le of the diff ering tissues within the body through which it has passed.

Unlike radiographs which use a single stationery x-ray beam, CT requires the x-ray tube to rotate around the patient. X-rays are directed through the body onto the detectors for an

entire 360° rotation. Th e detectors record hundreds of samples of the x-ray beam during this rotation. Th ese samples are back projected (reconstructed) by the computer into a 2D image or one slice.

Th e CT image is made up of a grid or

Lateral View of Multi-Slice CT.The more detectors means a greater body area covered with one rotation.

Courtesy Philips Medical Systems

By Sarah Brookman, Radiographer

Multiple RowDetectors

X-Ray TubeCollimator

X-Ray Beam

CARDIAC CT - (Part 1)

Cardiac CT - � e Basics


matrix of pixels. Each pixel is given a CT number or Hounsfi eld unit (HU) according to the attenuation of the x-ray beam at each point in the body on that slice. Th ese numbers are assigned relative to the attenuation of water which has a HU of 0. Air has a HU of -1000 and bone +1000. On the CT image Hounsfi eld units are represented on a grey scale which ranges from black (-1000 HU) up to white (+1000 HU). Th e human eye cannot diff erentiate between 2000 shades of grey so the operator can select a range and level on the grey scale (windowing) to best demonstrate certain structures.

Conventionally, CT scans were performed in a rotate-step manner. Th e x-ray tube would rotate once around the patient, then rotate once the other way to unwind the high voltage cables attached. Th e patient table moved to the position of the next slice to be scanned while the tube reversed. Th is was a very slow process, especially for imaging large areas of the body.

A major development in CT scanning occurred in the late 1980s when the slip ring was introduced, eliminating the need for cables. Th e x-ray tube was able to continuously rotate around the patient as they moved through the gantry in a manner called spiral or helical CT. Scanning became much quicker and whole areas of the body could be imaged at once. Instead of imaging the body in slices, in spiral CT a volume of data is acquired from which slices are reconstructed. Th is volume data set can also be reconstructed into slices in other planes and 3D images of bones and blood vessels.

One of the latest advances in CT technology is multi-slice CT in which there are multiple rows of detectors so

several slices can be acquired at once. A greater area of the body is covered

during one rotation of the x-ray tube so scan times are even quicker and a larger area of the body can be imaged at once. Very thin slices are able to be scanned without lengthening scan time so the reconstructed images have more detail (resolution). Th is has led to new applications for CT such as imaging of the coronary arteries and CT colongraphy. Th e fi rst multi-slice CT scanners had two detector rows, followed by four eight and sixteen rows. Th e most advanced CT scanner in clinical use today has 64 detector rows. Manufacturers are trialling detectors with even more slices, improving reconstruction methods and developing software all the time.

Who knows what CT will be able to do in the future, but it is certain there will be many more exciting developments to come.

matrix of pixels. Each pixel is given a

Axial View (cross-section). Tube and Detector rotates

simultaneously around the patient

3D CT Reconstruction of Heart and major vesselsImage courtesy Siemens

X-Ray Tube

X-Ray Beam

Patient

Detector

MEDICAL IMAGING

LAO 45 / CRA 30

LAO 45 / CRA 30

Objectives:

Th e aim of this projection is to demonstrate the mid / distal LAD and the proximal / mid circumfl ex, free from overlap. Th e diagonal branches are also demonstrated well in this view. Th is projection is prone to being overlapped by the spine, so ensure enough LAO is given to prevent overlap. Th is will reduce the radiation dose to the patient and operator as in this view the x-ray tube is closest to the operators’ legs.Ensure the patient turns their head to the right to avoid being hit by the detector.

Catheter Positioning On-Screen:

Th e catheter should be positioned at the top of the screen and slightly to the left before the start of the acquisition.

Alternatives:

Less LAO (eg. LAO 30 / CRA 30):

Th is projection causes foreshortening of the proximal / mid Circumfl ex, however demonstrates the mid / distal OM1 well. Th e LAD is often overlapped by the circumfl ex and Diagonals.

More CRA (eg. LAO 45 / CRA 40):

If you are able to actually reach this angle you will fi nd it demonstrates the distal left main, and proximal / mid LAD well without overlap. Demonstrates the proximal diagonal branches well. Also demonstrates the proximal circumfl ex, and distal OM1 without overlap or foreshortening.

Less CRA (eg. LAO 45 / CRA 20):

Demonstrates the mid / distal LAD and distal circumfl ex free from overlap. Proximal LAD and Proximal / Mid Circumfl ex is foreshortened.

well. Th e LAD is often overlapped by the circumfl ex and

well without overlap. Demonstrates the proximal diagonal

LAO 45 / CRA 30

LM Left Main


D1 Diagonal

LCX Circumflex

OM1 Obtuse Marginal 1


MEDICAL IMAGING

Objectives:

Th e aim of this projection is to demonstrate the Left Main bifurcation with the LAD and Circumfl ex. Th ere is severe foreshortening of the LAD, however the proximal circumfl ex is demonstrated well. Often known as the “Spider”.

Cardiologists often go to this projection as a second shot after the RAO 10 if there is pressure

damping of the catheter as soon as it is engaged, which usually indicates an ostial narrowing of the Left Main. Radiographers

or whoever is controlling the detector should be able to reach this projection instantly if this

occurs.


Th e catheter should be positioned in the middle of the screen and slightly to the left before the acquisition is commenced.

Alternatives:

Less LAO (eg. LAO 30 / CAU 30):

Th is projection causes overlap of the Left Main and bifurcation, however allows better visualisation

of the proximal / mid Circumfl ex and OM1.

Less CAU (eg. LAO 40 / CAU 20):

Causes overlap of the Left Main bifurcation by the Diagonal branches. Demonstrates the Proximal circumfl ex well however sometimes overlapped by Diagonal branches.

LAO 45 / CAU 30


damping of the catheter as soon as it is engaged, which usually indicates an ostial narrowing of the Left Main. Radiographers




Alternatives:



of the proximal / mid Circumfl ex and OM1.

Less CAU (eg. LAO 40 / CAU 20):

Causes overlap of the Left Main bifurcation by the Diagonal branches. Demonstrates the Proximal circumfl ex well however sometimes overlapped by Diagonal branches.


damping of the catheter as soon as it is


occurs.



Alternatives:



LAO 45 / CAU 30

LM Left Main


LCX Circumflex

OM1 Obtuse Marginal 1

MEDICAL IMAGINGMEDICAL IMAGING

Descending

MEDICAL IMAGINGMEDICAL IMAGING

LM Left Main


LAO 45 / CAU 30

LAO 45 / CAU 30

MODEL: Rob Edwards




October 5-7Annual General Meeting of the Irish Cardiac SocietyLocation: Killarney, IrelandWebsite: www.irishcardiacsociety.com

October 19-21X World Congress of Echocardiography and Cardiovascular ImagingLocation: Rome, ItalyWebsite: www.worldechocardio2006.com

October 21-24Acute Cardiac CareLocation: Prague, Czech RepublicWebsite: www.escardio.org

October 22-27TCT 2006: Transcatheter Cardiovascular TherapeuticsLocation: Washington DC, USAWebsite: www.tct2006.com

October 26-28British Society of Echocardiography Annual Clinical & Scientifi c MeetingLocation: Bournemouth, UKWebsite: www.bsecho.org

Oct 29 - Nov 17th Annual Congress of the South African Heart AssociationLocation: Cape Town, South AfricaWebsite: www.saheart.org

Nov 22 - 23British Congenital Cardiac Association Annual Scientifi c meetingLocation: Bath, UKWebsite: www.congenitalheart.co.uk

Nov 26 - Dec 1RSNA 2006Location: Chicago, USAWebsite: www.rsna.org

December 3-5Innovations in Cardiovascular Interventions (ICI)Location: Tel-Aviv, IsraelWebsite: www.congress.co.il/intercard7

December 6-9EuroEcho 10Location: Prague, Czech RepublicWebsite: www.euroecho.org



January 24-26Advanced Angioplasty 2007Location: London, UKWebsite: www.advancedangioplasty.co.uk

April 29 - May 28th International Conference of Nuclear Cardiology - ICNC8Location: Prague, Czech RepublicWebsite: www.escardio.org

May 22 -25EuroPCR CongressLocation: Barcelona, SpainWebsite: www.europcr.com

June 4-7BCS Annual Scientifi c ConferenceLocation: Glasgow, UKWebsite: www.bcs.com

June 9-12Heart Failure 2007Location: Hamburg, GermanyWebsite: www.escardio.org

June 24-27EuroPaceLocation: Lisbon, PortugalWebsite: www.escardio.org

June 27 - 3034th International Congress on Electrocardiology, and 48th International Symposium on VectorcardiographyLocation: Istanbul, TurkeyWebsite: www.ice2007.com

October 22-26TCT 2007: Transcatheter Cardiovascular TherapeuticsLocation: Washington DC, USAWebsite: www.escardio.org

October 7-10Venice Arrhythmias 2007 - Tenth International workshop on Cardiac ArrhythmiasLocation: Venice, ItalyWebsite: www.venicearrhythmias.org

LIST YOUR CARDIAC

MEETINGSHERE FREE


Help Coronary Heart™ reach the world.Submit an article/case study/interesting ECG

or become a regular contributing writer for us. Visit the website for more details

coronaryheart.com

Help Coronary Heart™ reach the world.

You Submit We Review

Your Article Goes Free!!

•

•

•

Cath / EP & Non-Invasive

Education

ManagersNurses

PhysiologistsRadiographers

Echo

Free Your Writing

coronaryheart.comcoronaryheart.com

Bring the World of

Cardiology Closer

English Arabic* Phonetic

Hello. مر حبا marhaba

Good Morning. صباح الخير sabah el-kheir

Yes. نعم na’em

No. ال la

Lay on your back. استلق على ظهرك istelk a’la zahrik

Don’t move. ال تتحرك la tatahark

Breathe in. تنفس بعمق tanafes bee’omq

Hold your breath. احبس نفسك ihbis nafasek

Continue breathing. استمر فى التنفس istamer fi altanafus

Turn your head left. أدر رأسك جهة الشمال ader raesek gehet al-shamal

Turn your head right. أدر رأسك جهة اليمين ader raesek gehet al-yamin

* written right to left

To assist you in the cardiac environment

with patients whom have limited knowledge of English we have given you a helping hand. With the assistance of internationally recognised translators we have converted common cardiac phrases into foreign languages, and also provided their phonetic pronunciation in English.

Th is issue we look at the mystic language of Arabic, the offi cial language of 26 countries, and spoken by approximately 300million people globally. We have given you the standard version to avoid any specifi c dialect.

Th e fl ag above is from the League of Arab States which was formed in 1945 and comprises of 22 Arabic countries. It is one of the oldest International Organisations, predating the United Nations.

Translated with the assistance of Mrs Amal Ibrahim, Cairo, Egypt

LEAGUE OF ARAB STATES LANGUAGES

Cardiac ArabicFree Your Writing


Telephone 0845 363 1187 Facsimile 020 8249 6561Email [email protected] Internet www.rigradiography.co.uk

Setting newstandards for Cardiac ProfessionalsRIG Radiography Recruit has expanded it’s highlysuccessful Radiography business to now include ateam dedicated to the Cardiac sector.

We have become the largest supplier of Radiographystaff to the UK through our premier level of serviceand the proactive nature of our staff.

The team operates throughout various Cardiac Servicedepartments including Angiography andPacing/Cardiac Units, Cardiac Physiology Clinical Unitsand Cardiothoracic Units amongst others.

Our team has over twenty years specialist recruitmentexperience and we pride ourselves on the level ofservice we offer to both clients and candidates.

We cover the following areas–

Cardiac Cath LabsECGEchocardiographyHolter MonitorsExercise Stress TestsPacing ImplantsLung Function TestingTape AnalysisBP MonitoringTilt Testing

Our comprehensive Benefitsand Support Structure includes–

Highly Competitive RatesWide range of posts acrossthe UKLimited Company Set upDedicated Cardiac Recruitment ConsultantsCPD Contributions*CV Assistance and Preparation

* Subject to qualification criteria.

We are always recruiting for Cardiac Cath LabTechnicians, Cardiac Physiologists, Cardiac Clinical Scientific Officers, Echocardiographers Cardiac Sonographers amongst others.

Check out our website and contact the team today to see what we can do for you!

Medical Recruitment Specialists in Cardiology and Radiography Your Career is our world

LONDON SYDNEY AUCKLAND

Locum and Permanent positions domestically and internationally for Cardiac Physiologists, Cath Lab staff, Cardiology Nurses and Echo/Sonographers. Trainee roles are also available.

AUSTRALIA – OFFICEYour World Recruitment Pty LtdLevel 14 Lumley House309 Kent Street, Sydney 2000, AustraliaFREEPHONE 1300 36 23 37PHONE +612 9994 8074FAX +612 9994 [email protected]

UNITED KINGDOM – OFFICEYour World Recruitment17 Blossom Street,London, E1 6PL, United KingdomPHONE +44 (0) 20 7426 6992FAX +44 (0) 20 7426 [email protected]

NEW ZEALAND – OFFICEYour World RecruitmentLevel 20 ASB Bank Centre135 Albert Street, Auckland, New ZealandFREEPHONE 0800 508 018FREEFAX 0800 543 [email protected]

PLEASE CALL NOW TO REGISTER YOUR INTEREST IF YOU ARE SEEKING WORK OR STAFF.Telephone 0845 363 1187 Facsimile 020 8249 6561

Email [email protected] Internet www.rigradiography.co.uk

Setting newstandards for Cardiac ProfessionalsRIG Radiography Recruit has expanded it’s highlysuccessful Radiography business to now include ateam dedicated to the Cardiac sector.

We have become the largest supplier of Radiographystaff to the UK through our premier level of serviceand the proactive nature of our staff.

The team operates throughout various Cardiac Servicedepartments including Angiography andPacing/Cardiac Units, Cardiac Physiology Clinical Unitsand Cardiothoracic Units amongst others.

Our team has over twenty years specialist recruitmentexperience and we pride ourselves on the level ofservice we offer to both clients and candidates.

We cover the following areas–

Cardiac Cath LabsECGEchocardiographyHolter MonitorsExercise Stress TestsPacing ImplantsLung Function TestingTape AnalysisBP MonitoringTilt Testing

Our comprehensive Benefitsand Support Structure includes–

Highly Competitive RatesWide range of posts acrossthe UKLimited Company Set upDedicated Cardiac Recruitment ConsultantsCPD Contributions*CV Assistance and Preparation

* Subject to qualification criteria.

We are always recruiting for Cardiac Cath LabTechnicians, Cardiac Physiologists, Cardiac Clinical Scientific Officers, Echocardiographers Cardiac Sonographers amongst others.

Check out our website and contact the team today to see what we can do for you!

EMPLOYMENT ADVERTISING INTERNATIONAL


* when you advertise in the magazine

Job Ads OnlineFREE*

coronaryheart.com

Don’t Just Advertise Jobs in

Black & White

Add Colour at No Extra

Cost


NEXT ISSUE

Coming up in Next IssueThe fourth edition (Dec/Jan) of Coronary Heart™

is well under way, and with the release covering Christmas and New Years we will begin introducing

a few extra surprises. As the Director, Tim Larner has confessed to sneakily opening presents under the tree before the big day, we have decided that it is only fair we give you a heads-up on what is coming soon in either the next or future editions.

Regional cardiology meeting list.Interesting ECG’s to test your knowledge.Head-to-Head Equipment Reviews.Interviews with leading cardiac professionals.

We are also in the development stages of creating an international online forum so people just like you from around the world can exchange ideas and learn from each other. If you would like to be involved with this project, or would just like to share some ideas, email Tim at: [email protected]

Don’t forget to keep the articles, case studies, interesting ECG’s, hot tips, new equipment purchases, etc coming in.

••••

So, what else is in the next edition?

Part 2 of our Cardiac CT special, explaining the advantages, uses, and future direction of this rapidly advancing field.

Echocardiographer submitted case study on pericardial effusion

We visit Sydney, Australia for our next Site Visit.

Product Review of St Jude’s new Victory Pacemakers with the Merlin PCS.

Plus the usual mix of interesting articles.

•

•

•

•

This image was sent in by Mr Eric Simillon, a Medical Imaging Technologist from the Royal Perth Hospital in Western Australia.

It shows a patient with a “large” aneurysm in the distal left main.

The full Case Study will be included in the next edition.

Send us your interesting images of either cath, echo, or cardiac CT to [email protected]

FINAL IMAGE

Dec/JanEdition 4Advertising Closes

General Ads:

16th November 2006

Employment Ads:

20th November 2006

Released: December 1

Visit the website or email: [email protected]


Chesterfield Royal HospitalEaling Hospital NHS TrustScunthorpe General HospitalMedway Maritime HospitalRoyal Albert Edward InfirmaryCountess of Chester HospitalConquest HospitalStaffordshire General HospitalMilton Keynes General HospitalWarrington Hospital University Hospital of Hartlepool Warwick HospitalStepping Hill HospitalSt Richard’s HospitalPeterborough District HospitalFrimley Park Hospital Westmorland General HospitalEast Surrey HospitalWorthing HospitalRotherham General HospitalDoncaster Royal InfirmaryLincoln County Hospital King’s Mill HospitalThe Great Western HospitalWatford General HospitalHemel Hempstead HospitalSt Albans City Hospital MEHT cardiac servicesBasildon HospitalBedford Hospital NHS TrustLister Hospital

Whipps Cross University HospitalKing George HospitalDarlington Memorial HospitalWansbeck General Hospital Sunderland Royal HospitalHull Royal InfirmaryYork Hospital University Hospital AintreeBlackpool Victoria HospitalWycombe General HospitalWilliam Harvey HospitalDorset County HospitalUniversity Hospital of North StaffordshireWorcestershire Royal HospitalThe Ipswich Hospital NHS TrustRoyal United HospitalManor HospitalRochdale Infirmary Aberdeen Royal InfirmaryBelfast City HospitalBirmingham City HospitalBirmingham Heartlands HospitalBMI Alexandra HospitalBMI Park HospitalBMI Priory HospitalBristol Royal InfirmaryBUPA Cambridge Lea HospitalBUPA Hospital BristolBUPA Hospital Hull BUPA Hospital LeedsBUPA Hospital LeicesterBUPA Hospital SouthamptonCapio Yorkshire ClinicCastle Hill HospitalCheltenham General HospitalCity General HospitalCromwell HospitalDerriford HospitalEastbourne Hospital

Edinburgh Royal InfirmaryFreeman HospitalGlasgow Royal InfirmaryGlasgow Western InfirmaryGlenfield Hospital

Golden Jubilee National Hosp.Hairmyres HospitalHammersmith HospitalHarefield HospitalHarley Street Clinic

Heart Hospital (UCLH)James Cook University HospitalJohn Radcliffe HospitalKings College HospitalLeeds Nuffield HospitalLiverpool Cardiothoracic CentreLondon Bridge HospitalLondon Chest HospitalLondon Independent Hospital

Manchester Royal InfirmaryManor HospitalMorriston Hospital

New Cross HospitalNorth Hampshire HospitalNorthern General Hospital

Northwick Park HospitalNottingham City HospitalPapworth HospitalQueen Elizabeth HospitalRoss Hall HospitalRoyal Berkshire and Battle HospitalRoyal Brompton HospitalRoyal Cornwall HospitalRoyal Devon & Exeter HospitalRoyal Free HospitalRoyal Sussex County HospitalRoyal Victoria HospitalSandwell District General HospitalSouthampton General HospitalSouthend HospitalSt Anthony’s HospitalSt Bartholomew’s HospitalSt George’s HospitalSt Mary’s HospitalSt Peter’s HospitalSt Thomas’ HospitalMusgrove Park HospitalTorbay HospitalUniversity Hospital of WalesVictoria HospitalWalsgrave HospitalWellington HospitalWestern General HospitalWythenshawe HospitalYorkshire Heart CentreNorth Middlesex University HospitalBarnet HospitalBristol Royal Hospital for ChildrenHull and East Riding HospitalLeeds General InfirmaryQueen Alexandra HospitalRoyal Bournemouth General HospitalRoyal Infirmary of Edinburgh

BUPA Hospital SouthamptonCapio Yorkshire ClinicCastle Hill HospitalCheltenham General HospitalCity General HospitalCromwell HospitalDerriford HospitalEastbourne Hospital



Heart Hospital (UCLH)James Cook University HospitalJohn Radcliffe HospitalKings College HospitalLeeds Nuffield HospitalLiverpool Cardiothoracic CentreLondon Bridge HospitalLondon Chest HospitalLondon Independent Hospital



BUPA Hospital SouthamptonCapio Yorkshire ClinicCastle Hill HospitalCheltenham General HospitalCity General HospitalCromwell HospitalDerriford HospitalEastbourne Hospital





Cath Labs and ECG Departments receive their own free copies bi-monthly.

+ Free Subscription to Staff

1/4 Page Colour Employment Ads

only £180.

Free Placement of Job Ads Online.

Also distributed to hundreds of Departments in Australia, Ireland, and NZ.

Just a Small List of Hospitals we

Distribute to in the UK


EMPLOYMENT

coronaryheart.com

NOT YOUR AVERAGE CARDIAC

PUBLICATION

Subscribe Online for

Your Free Copy

Distributed Free

to Departments

Distributed Free

to Your Home

Coronary Heart #3

Documents

Transcript of Coronary Heart #3