Our Covid-19 Response

BEATING HEART BYPASS FOR A HIGH-RISK PATIENT Case SHOCKWAVE IVL LUNG CANCER DIAGNOSTIC BREAKTHROUGH NotesRoyal Brompton & Harefield Hospitals Specialist Care OUR COVID-19 RESPONSE

News • Case Studies • Insight Summer 2020 Contents

Welcome to the 2 10 Summer 2020 edition What’s new? Boosting body confidence of Case Notes one chest at a time Every day, private patients are referred 4 to our hospitals for the exact same Our COVID-19 response 12 reason: to be seen by the world’s Shockwave IVL leading experts in heart and lung care.

From our diagnostic specialists, to our doctors and nurses, every member of our multi-disciplinary team has dedicated themselves to a lifetime of advancement in this field. They’re the innovators and thought leaders.

For example, we’re advancing minimally-invasive surgery and transcatheter procedures, where the heart and lungs can be accessed and treated through smaller access points than in traditional surgery. This leads to improved recovery and smaller, neater scars.

In this edition of Case Notes, you can read about how we responded to the COVID-19 pandemic on page 4, how Mr Shahzad Raja 6 performed a beating heart bypass for a high-risk patient on page 8, New consultants 14 and on page 14, about how we’re using a new, safer tool to diagnose Lung cancer lung cancer. diagnostic breakthrough If you have any questions about our services, or would like to refer 7 Research update a patient, please get in touch. We’d be delighted to hear from you.

David Shrimpton Managing director, RB&HH Specialist Care 8 Beating heart bypass for high-risk patient

16 Social news feed 4

T +44 (0)20 3131 0535 E [email protected] www.rbhh-specialistcare.co.uk

2 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes NEW DIRECTOR OF MEDICAL EDUCATION APPOINTED Dr Beverly Tsai-Goodman, consultant paediatric and foetal cardiologist, has been appointed director of medical education. Dr Tsai-Goodman has worked at the Trust for three years, having previously What’s worked as a consultant in Bristol for almost 13 years. Commenting on her new role, she said: “One of the things that attracted me to the Trust was its reputation as a leading teaching hospital within the UK and worldwide, and I was impressed that one of the Trust’s organisational values is based around sharing our knowledge through teaching so that we can help patients everywhere. I have always had a keen interest in medical education and am really looking forward to leading this vital programme.”

New directory of medical education, Dr Beverley Tsai-Goodman

PULMONARY REHABILITATION TEAM CONSULTANT RECEIVES OUTSTANDING CELEBRATE NATIONAL FIRST SERVICE AWARD new?The pulmonary rehabilitation team at Harefield Hospital has Professor Roxy Senior, consultant cardiologist and director of become the first service in the country to receive full accreditation echocardiography at Royal Brompton Hospital, has been presented in a scheme run by the Royal College of Physicians (RCP) in with an award for outstanding service by the Indian Academy of association with the British Lung Foundation and the British Echocardiography (IAE). Thoracic Society. He received the award at the academy’s silver jubilee celebration Patients with long-term respiratory conditions often face shortness conference, Echo India, held in Kolkata. of breath, which can make it difficult to move around and carry He said: “I originally came from India – studying at the University of out day-to-day activities without getting breathless. Pulmonary Calcutta (now Kolkata) and graduating with a master’s degree in rehabilitation helps patients manage this through a tailored programme medicine and cardiology before moving to the UK to develop my of exercise classes and education workshops designed to build their Professor Senior receives his award from Dr Nitin Burkule (left), past president of the career. For that reason, I was particularly delighted to be presented tolerance of physical activity and improve their quality of life. Academy of Echo. Professor H.K Chopra (second right), president of the Cardiological with this award. It made me feel very humbled and proud.” Society of India, and Dr Rakesh Gupta (far right), past president of the IAE. Dr Claire Nolan, senior research physiotherapist, said: “It’s a mark of quality which we can highlight to clinical referrers and commissioners, to be the first, and currently only, team to have met these standards. We can be proud that the clinical service GUYS AND ST THOMAS’ AND ROYAL BROMPTON we provide is second to none.” & HAREFIELD NHS FOUNDATION TRUST MERGER Since 2017, Guy’s and St Thomas’ and Royal Brompton & Harefield NHS Foundation Trust have been working together with colleagues across King’s Health Partners to develop plans to transform care for people with heart and lung disease. CYSTIC FIBROSIS TEAM WINS HSJ AWARD The two Trusts have a long history of being at the forefront of patient The Trust’s cystic fibrosis team were awarded a Health Service Journal care research and the boards of both Trusts are confident that by formally Partnership Award in February for their work in establishing a new bringing together the organisations and shared expertise, they can service with digital health start-up, NuvoAir. significantly improve care and outcomes for people with cardiovascular Key to the new service is the NuvoAir spirometer, a device that can be and respiratory disease. used at home to measure lung function and, via Bluetooth, allows the This ambitious venture, in partnership with King’s College Hospital NHS results to be seen on patients’ mobile phones or tablets. Foundation Trust and our academic partners, will create a centre of Royal Brompton’s consultant nurse in cystic fibrosis, national excellence for the care of adults and children, which will sit at Dr Susan Madge, said: “Patients were the driving force for this the heart of a population health system working together to significantly partnership and were at the centre of the design and build process. reduce the burden of these conditions. We wanted to put adults with CF back in the driving seat, to let them have ownership of their data and deliver virtual consultations to lead the way in changing the care delivered to adults with CF.”

Members of the CF Team with representatives from NuvoAir Guy’s and St Thomas’ and Royal Brompton & Harefield NHS Foundation Trusts formally agree to merger.

2 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes 3 I will encourage our local teams to do it like the Brompton. Despite the pressure the [ECMO] teams are under, they displayed excellent patient care, helping with the transfer Our COVID-19 and maintained a friendly demeanour under the PPE. The reception we received from everyone was frankly outstanding. Given the pressure the staff must be under I was amazed at how friendly, caring and happy the entire team were. This was a shining example of care and efficiency. Acute care medical director for South Western Ambulance Service.

We helped increase We discovered We increased We maintained And we responsecapacity and saved lives and advised ECMO support private services will continue WE INCREASED ECMO SUPPORT

We helped increase We discovered We increased We maintained And we capacity and saved lives and advised ECMO support private services will continue As one of only five WE MAINTAINED PRIVATE SERVICES s a specialist heart and WE HELPED INCREASE ECMO (extracorporeal We helped increase We discovered We increased membraneWe maintained oxygenation) And we lung hospital, we made capacityCAPACITY and saved lives AND SAVEDand advised LIVES ECMO support private services will continue We have developed centres in the UK, innovative ways to a number of changes patients with the most We helped increase We discovered We increased We maintained continueAnd weproviding capacity and saved lives andWE advised DISCOVERED ANDECMO suppor ADVISEDt private services will continue Aacross our private and NHS As well as our Trust’s severe respiratory failure were sent to much needed private NHS services, we us from other NHS Trusts. patient care. services to ensure we could re-purposed some In a video produced by Channel 4 The Trust’s involvement support the NHS response to of our private patients New video consultation service News, viewers were taken behind We helped increase in theWe discovered RECOVERY We increased We maintained And we facilities and re-deployed capacity and saved lives and advised ECMO support private services willAND continue WE WILL CONTINUE the COVID-19 pandemic and the scenes to see how the sickest (Randomised Evaluation Our remote video consultation service select members of our team to swiftly patients are treated with this of COVID-19 Therapy) mirrors face-to-face clinics with our keep all our patients safe. create the necessary capacity for the game-changing life support study continues to consultants, to keep your patients safe. The pandemic is not Trust in March 2020. technology. It takes over the function support the global research efforts to We have also contacted all major over yet and won't This helped provide treatment to some of their heart and lungs to help them find effective treatments. private medical insurers to ensure likely be for some of the sickest patients affected by the recover from the virus. these consultations can be covered time. As a private Our experts recently discovered virus at our specialist centre, whilst during this time. patients service, we In response to the pandemic, we have a strong association between the maintaining an operational service for will continue to support the NHS to tripled our ECMO capacity to the highest infection and the development of our private patients. Diagnostics and outpatients treat all COVID-19 patients who need in the country – and intend to increase it blood clots in the lungs, leading to new always available specialist care, whilst ensuring our Our specialist physiotherapy team ready With our combined capacity and the further still. NHS England treatment guidelines. private patients can continue their to enter COVID-19 areas at our hospital. skills of our specialist teams, we helped 77 Wimpole Street, our dedicated They all attached a photo of themselves to Our consultants also provided and heart and lung treatment with us. many COVID-19 patients recover and outpatients and state-of-the-art diagnostics help our patients visualise who is helping them. continue to provide regular COVID-19 return home to their loved ones, and facility, has always been and continues to As the infection can leave patients with advice throughout the pandemic to continue to do so. be a ‘green zone’ during the pandemic. This ongoing respiratory and cardiac issues, help protect public health. means that we have put in place a range of our consultants and physiotherapists stringent measures to keep your patients have already helped many private safe so they can continue being assessed patients with their rehabilitation. and treated in-person, including for cancer and neurology diagnostics. For further details about what services are currently available or to refer a Harefield Hospital is a dedicated private patient, please contact the cardiac centre customer services team on +44 (0)20 3131 0535 or email As of writing, Harefield Hospital remains [email protected] one of only two dedicated cardiology hospitals in London. In addition to our resident experts at the hospital, our consultants from Royal Brompton Hospital continue to attend clinics and perform urgent procedures here (whilst Royal Brompton remains a COVID-19 centre).

4 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes 5

MORE RESEARCH FUNDING INTO KEYHOLE SURGERY FOR ATRIAL FIBRILLATION

A research project comparing two types OUR NEW of surgical techniques for patients with long-standing persistent atrial fibrillation (LSPAF) has been awarded further funding to determine the long-term effects in patients. The project, led by Dr Tom Wong, a CONSULTANTS cardiologist at Royal Brompton & Harefield NHS Foundation Trust, has been funded by the National Institute for Health Research and will compare catheter ablation to thoracoscopic s the UK's largest heart and lung centre, we attract some surgical ablation for the treatment of LSPAF. A of the most talented consultants from all over the world. The longer a person has atrial fibrillation, the more Below are some of the newest members of our team. difficult it is to go back to a normal heart rhythm. Research Those who have continuous atrial fibrillation for longer than a year are described as having LSPAF. With the additional funding, Dr Wong’s team will Dr Emmanuel Ako Dr Carles Bautista update monitor patients from the original research study Consultant cardiologist Congenital interventional cardiologist who already have a small device implanted under A STEP CLOSER TO For those patients for whom current the skin to measure their heartbeat. treatments do not work, the researchers Royal Brompton Hospital Royal Brompton Hospital, Harefield Hospital, 77 Wimpole Street PERSONALISED MEDICINE This additional data will allow the research team hope new, more effective treatments will FOR SEVERE ASTHMA to determine conclusively if thoracoscopic be developed from a better understanding An international study looking at personalised surgical ablation is better for patients with LSPAF Dr Emmanuel Ako has Dr Carles Bautista works as part of a team to provide of what is making their asthma severe. medicine for patients with severe asthma has compared with catheter ablation in the long term. special expertise in general care for children and adults with congenital or acquired been awarded £2.3 million from the Medical Professor Fan Chung, a respiratory medicine and cardiology, heart disease. His main research interests and area Research Council. consultant at Royal Brompton & Harefield with subspecialty expertise in of expertise lie in minimally invasive interventional NHS Foundation Trust and professor of The PRISM study (Precision Intervention in coronary intervention. He is a procedures, neonatal cardiology – including premature respiratory medicine at Imperial College INTERNATIONAL RECOGNITION Severe asthma) aims to introduce personalised specialist in assessing patients with chest pain, breathlessness, and neonatal intervention, and heart monitoring using London, is leading the study. FOR HAREFIELD RESEARCH TEAM medicine to ensure the right medications are palpitations, hypertension, valvular heart disease, dizziness, internet-connected devices. prescribed to the right patients. He said: “The PRISM project will bring faints and ankle swelling. hope for patients suffering from severe The PRISM study aims to better characterise It has been a period of successes for the asthma by improving the doctor’s In addition, he is an expert in the management of coronary the type of asthma in each individual by using respiratory research group at Harefield diagnosis of the type of severe asthma artery disease and cardiovascular complications in their unique makeup of genes and proteins, to Hospital, who have been recognised both they are suffering from. This will ultimately haemoglobinopathies such as Thalassaemia and Sickle develop biomarkers that are more accurate nationally and internationally, for their work lead to better treatments at a personalised Cell Disease. He performs coronary angiography, coronary than the blood eosinophil count, in predicting on pulmonary rehabilitation and chronic level for every patient suffering from this physiology measurements and coronary angioplasty. good response to biologic treatments. obstructive pulmonary disease. often very disabling condition.” One project, led by Jessica Walsh, working with Dr William Man, was awarded ‘Best Abstract’ under the category of rehabilitation and chronic care at the European Respiratory Dr Jonathan Hill Dr Mumin Noor TRUST CO-FUNDS population of patients and many Society conference. Consultant cardiologist Consultant cardiologist 10 RESPIRATORY PROJECTS internationally recognised clinicians. Imperial College and ICHT will be applying The conference showcases the best of Research looking into Chronic Obstructive Royal Brompton Hospital for BRC status for 2022-2027 and the respiratory medicine research. Harefield Hospital Pulmonary Disease (COPD), asthma and Trust will collaborate with them to idiopathic pulmonary fibrosis (IPF) are just Dr Man’s extensive work on pulmonary develop a strong respiratory theme. rehabilitation has also been recognised with Dr Jonathan Hill is a consultant Dr Mumin Noor is a some of the projects that have been awarded 10 projects were selected to receive up to his appointment as co-chair for the British cardiologist with a clinical consultant cardiologist funding via a joint funding call from Royal £25,000 in funding, all of which demonstrated Thoracic Society Pulmonary Rehabilitation expertise in interventional with an expertise in general Brompton & Harefield NHS Foundation Trust, clear objectives that aligned with the key Guidelines Development group, which will cardiology, cardiovascular risk cardiology, including angina, Imperial College London and Imperial College priority areas for respiratory disease. review the latest scientific evidence over the assessment and cardiac CT. He has a special interest in acute syncope, palpitations and hypertension. He has specialist Healthcare NHS Trust (ICHT). next 18 months in order to produce clinical myocardial infarction and new biological therapy. expertise in the diagnosis and treatment of heart failure, Funding for the Biomedical Research Centre is Some examples of the projects which will practice recommendations. pacemakers and defibrillator inplantation and cardiac for 5 years (2017-2022) and aims to support be funded by this are: ‘Telomere length Dr Hill’s research programme is related to stem and resynchronisation therapy. first-time trials of new discoveries, treatments and and Idiopathic pulmonary fibrosis,’ led by “The British Thoracic Society guidelines progenitor cells in cardiovascular disease and he is the technologies in patients, to improve healthcare. Dr Deborah Morris-Rosendahl; ‘How are very well respected and widely read Clinical Senior Lecturer and Consultant Cardiologist at Dr Noor is currently involved in clinical research for cardiac exposure in infants affects respiratory health across the world. I am delighted to be able to The Trust is well-positioned as a world-leading King’s College London. device therapy in heart failure patients. in adulthood,’ led by Dr James Allinson; and contribute to these guidelines which should hospital for respiratory diseases, with a unique ‘Wheeze in Children,’ led by Dr James Harker. be a valuable resource for those providing pulmonary rehabilitation in the UK and beyond,” Dr Man said.

6 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes 7 TACKLING CLOGGED CORONARY ARTERIES

Coronary heart disease is a leading cause of CABG surgery utilising a cardiopulmonary Removal of death worldwide and occurs when the blood bypass machine which takes over the atheromatous Beating material from left flow through coronary arteries becomes functions of the heart and lungs (termed anterior descending interrupted or blocked due to atherosclerosis. ‘on-pump CABG’) is widely regarded as the artery after Depending on the extent of the blockage, gold standard surgical approach. It enables extensive coronary endarterectomy on different interventional and surgical options the heart to be stopped for the surgery to the beating heart. heart can be explored. be completed with greater ease. However, cardiopulmonary bypass machines can If the plaque is limited in size, non-surgical result in a systemic inflammatory response, coronary angioplasty with a balloon and/or leading to multiple organ dysfunction and stents may be used to widen the narrowed morbidity. The risk of complications may be sections of the artery. However, if the plaque is bypass for heightened in some patient communities more extensive and/or affects multiple vessels, such as those that are older, have renal a coronary artery bypass grafting (CABG) Final result after dysfunction or diabetes. procedure may be needed for revascularisation. reconstruction of left anterior descending a high-risk artery with left A SAFER APPROACH TO BYPASS SURGERY internal mammary artery on the ‘Off-pump CABG’ is an alternative approach practice in a high volume off-pump coronary beating heart. which enables the heart to continue surgery centre for the best results. A recent patient beating whilst the surgery is performed. 20-year investigation of over 10,000 patients The technique was revived over two decades at Harefield Hospital, which is one such centre, ago and involves the use of a tissue stabiliser compared the outcomes of on-pump and onsultant cardiac surgeon Mr Shahzad to press down around the affected coronary off-pump CABG surgery. The study artery to steady the heart, temporarily occlude Raja is internationally renowned demonstrated that off-pump CABG was C blood flow and stitch a graft beyond the for his expertise in performing coronary narrowing – ideally an internal mammary artery. associated with a lower risk of operative artery bypass surgery whilst a patient’s mortality, fewer postoperative complications Although the heart remains perfused by its and similar 20-year survival and freedom from heart is still beating. This complex technique collateral circulation, the procedure must be reintervention when compared to on-pump performed quickly and requires the skill of an CABG. This was the longest study of its kind. requires great precision and skill to get experienced surgeon with exclusive off-pump right but can significantly improve outcomes for high-risk patients. SUCCESSFUL TRIPLE BYPASS FOR HIGH-RISK PATIENT At 57, Kiran had already achieved a great deal in blocked and couldn’t be stented – that I’d need his life. He successfully started and expanded a triple heart bypass,” explains Kiran. “I was a group of elderly nursing and care homes to absolutely shocked as I was at my daughter’s 13 sites across the UK, had his first grandchild, wedding a few weeks before and was jumping and most recently attended the wedding of up and down all night. I had no idea there was his youngest daughter. He led a very active something wrong with me like this. lifestyle, regularly travelling for work, as well “I was scared of surgery initially, but when as swimming 2-3 times a week and going for I met Mr Raja who was recommended to long countryside walks. operate on me, my heart just said this was However, he noticed a persistent pain in his the right man for the job – he was just such a Mr Shahzad Raja shoulder whilst on his walks, particularly when positive man to speak to. He encouraged me Consultant cardiac surgeon going uphill. He decided to do research on him, but to see a doctor about it, I didn’t have to, I just asked “When I woke up from the Mr Raja specialises in cardiac surgery, including but repeat ECG tests came him to go ahead. coronary artery bypass, revascularisation, and back negative, despite surgery, I saw Mr Raja, who Mr Raja says: “Kiran’s valve replacements. the pain continuing. After came to check up on me. case was quite complex, struggles booking in an I couldn’t talk to him at as he had diabetes and appointment with pain that point, but I just put multi-vessel coronary artery management and further two hands up to thank him disease. We recommended To find out more about our off-pump heart exams, he decided for giving me a new life. an off-pump bypass to seek private care with And after about 6 weeks I CABG surgical procedures, or procedure to ensure the Royal Brompton & Harefield was back to normal really to refer a patient, please contact best results as he was a Hospitals Specialist Care. – I was driving again and the customer services team on going on my long walks very high-risk patient. We “All the tests were done which I love.” were very pleased with +44 (0)20 3131 0535 or email really quickly at Harefield the outcome and would [email protected] Kiran on holiday with his wife, and I met several great recommend the off-pump Shilpa, after his surgery. cardiologists. They told me that my angiogram procedure to all high-risk patients in centres showed that three of my coronary arteries were that have the expertise to perform it”.

8 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes 9 CORRECTING DEFORMITIES WITH MINIMALLY INVASIVE TECHNIQUES Past procedures to correct chest deformities Small incisions are made either side of BOOSTING were very invasive and involved surgically the chest and one to three curved metal removing the deformed cartilage around the bars are placed behind the breastbone to breast bone and fixing it into a normal position push it into a normal position. The bars are Although these procedures

using metal and mesh supports.Fortunately, kept in place for one to three years before can be performed at any less invasive techniques are now available. removing – after which time the ribs stay in BODY their new shape. age, the best results are Pectus carinatum can be treated with a chest brace which applies pressure to the “The Nuss procedure is very quick, taking achieved in patients at front and back of the ribs to gradually move around 45 minutes, and the patient can the start of puberty up to CONFIDENCE the breastbone back to where it should be. leave hospital within two to three days. 16 years of age, whilst the The patient wears the brace for anything Due to the positioning of the bars, the between a couple of months up to a few patient will need to reduce their physical bones are not yet fully set. years depending on a few variables and activities until they are removed and there Mr Nizar Asadi the severity of the deformity. Ideally, the is pain experienced to start. However, we ONE CHEST brace should be worn as many hours a day have an excellent pain management team as possible, but it could be removed for to support them and the visual results are showering or sporting activities. pretty instant.”, explains Mr Nizar Asadi, consultant thoracic surgeon at Pectus excavatum can be treated with the AT A TIME The pectus carinatum brace applies pressure to the RB&HH Specialist Care. minimally invasive Nuss surgical procedure. breastbone to move it back to a normal position. hest deformities are a relatively rare problem for young teens but can greatly affect their C KNOCKING BODY CONFIDENCE self-esteem and might lead to difficulties in the The two most common chest deformities are functioning of their heart and lungs. Fortunately, pectus excavatum (‘funnel chest’) and pectus minimally invasive techniques are available at carinatum (‘pigeon chest’). They occur when the breastbone sinks in (pectus excavatum) or Royal Brompton & Harefield Hospitals Specialist protrudes out (pectus carinatum) of the chest. Care that can safely return chests to a normal shape. It is not known exactly how these conditions occur, but it is thought to be due to the cartilage in the ribcage overgrowing. The Nuss procedure for pectus excavatum. Metal bars are inserted through incisions These conditions may not be obvious in on either side of the chest and flipped up to lift the breastbone to a normal position. childhood and present themselves mostly during the growth spurts of adolescence. They occur more often in boys than girls and HELPING A YOUNG MAN BE MORE ACTIVE Mr Nizar Asadi are relatively rare disorders affecting about 1 in every 1,000 children for pectus excavatum At the age of 22, Andrew had been living Mr Asadi says: “We performed the surgery Consultant thoracic surgeon and 1 in 1,500 for pectus carinatum. As these with pectus excavatum for years. He led a on Andrew over a year ago and were very conditions appear to run in families, there may very active lifestyle growing up, earning a pleased with his results. However, as he Mr Asadi specialises in minimally invasive be a genetic link. black belt in martial arts, as well as regularly hasn’t been able to take part in the sporting thoracic surgery. Normal Pectus excavatum Pectus carinatum cycling and rowing. However, he always felt activities he loves, he is understandably very As the ribcage is more rigid than normal for his chest was limiting his sporting abilities. keen to have the bars removed – which we both conditions, they can result in difficulty intend to do very soon. BreastboneBreastbone BreastboneBreastbone BreastboneBreastbone breathing, chest pain and an irregular He explains: “It wasn’t so much the cosmetic HearHearttt HearHearttt HearHearttt heartbeat – particularly on physical exertion. side that bothered me, but I feared that if “Andrew received the surgery through To find out more about our minimally LLungung LLungung LLungung However, the main impact is psychological. someone hit me particularly hard in the the NHS, but unfortunately it is no longer invasive chest deformity treatments, Due to the chest’s appearance, the conditions chest with my ribs that close to my heart, it funded due to being considered cosmetic in or to refer a patient, please contact can cause significant embarrassment for might do some serious damage. Also, with nature. However, we know these conditions children, resulting in low self-esteem and the shape of my chest, my lungs didn’t have can cause considerable distress to those the customer services team on clinical depression. They often exclude anywhere to go – it felt quite uncomfortable affected and encourage GPs to refer +44 (0)20 3131 0535 or email themselves from social and sporting activities, every time I exerted myself. So, I felt I had to patients who would like to explore these [email protected] RibsRibs SpineSpine RibsRibs SpineSpine RibsRibs SpineSpine particularly those that require them to expose do something about it.” treatments privately to help improve their their chests, such as swimming. body confidence.”

10 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes 11 AN INNOVATIVE SOLUTION USING AN OLD TECHNOLOGY SHOCKWAVE IVL With existing PCI techniques limited in their ability to safely and The device is composed of a fine 0.014-inch guide wire with an successfully dilate calcified coronary arteries, an entrepreneurial array of lithotripsy emitters enclosed in an integrated balloon. This team of three came together to develop an innovative device to enables clinicians to use the same minimally-invasive technique as SHOCKWAVE tackle calcification with a technology that has long existed. balloon angioplasty to get directly to the site of calcified lesions and transmit the sonic pressure waves to the blood vessel wall, In 2007, Daniel Hawkins, a businessman, and John Adams, an electrical to fracture calcium. Revolutionary engineer (who worked on early pacemakers), were working at a medical incubator to service unmet medical needs with new “The technology enables the coronary artery to become much technology. It is here they discovered the application of lithotripsy more compliant before dilation – much more than is possible technology to in tackling problematic calcium in the cardiovascular system. with other methods. This allows us to fully expand a stent, to successfully increase blood flow to the heart,” explains Professor Lithotripsy has been used for over 30 years in medicine to safely Carlo Di Mario, consultant cardiologist and professor of cardiology. fragment kidney and gallbladder stones, facilitating their excretion treat calcification without harming soft tissues. An electrical current is used to Professor Di Mario was the Co-Principle Investigator of the Disrupt generate a spark which vapourises fluid to produce powerful CAD I and II study trialling the new Shockwave IVL technology pressure waves that travel safely through the body’s soft tissues on 160 patients. As such, Royal Brompton Hospital was the first in IVLCALCIFICATION PREVENTS EXISTING CORONARY at the speed of sound, breaking up denser kidney stones. Europe to conduct coronary IVL in 2015 and Professor Di Mario treated most patients during both studies. Dr Jonathan Hill, also INTERVENTIONS FROM WORKING Teaming up with Stanford University cardiologist and bioengineer, a consultant cardiologist, is now following his steps, becoming ground-breaking Professor Todd Brinton, they experimented with a new lithotripsy There is a range of percutaneous coronary Other PCI techniques – orbital and rotational Co-Principle Investigator of the Disrupt CAD III trial, a larger US and new technology device they developed to tackle CAC. They discovered their device A interventions (PCI) available to widen narrowed atherectomy – are available to specifically European lithotripsy study which has already completed recruitment could crack calcium-rich egg shells whilst leaving their membranes arteries and enable the placement of stents to remove CAC. They scrape away hard, of its patients. is now available at Royal intact – which is much like the endothelium of a blood vessel. They improve blood flow. However, calcification superficial calcified tissues in coronary arteries therefore had a proof-of-concept for cardiovascular applications. “The results of these studies demonstrated that the procedure is Brompton & Harefield can limit the success of existing procedures. whilst sparing softer elastic tissues, to increase safe and effective for patients with moderate-to-severe calcification. Hospitals Specialist blood vessel compliance for a stent to be fully Fast-forwarding to today and after several successful international For example, the force applied by balloon Also, it has quick recovery times, with the patient able to go home expanded. However, the techniques create clinical trials, Shockwave Intravascular Lithotripsy (IVL) is now Care, which can fracture angioplasty to vessel walls may not be sufficient the following day. It really is a game-changer in the treatment of fragments which can induce slow blood flow, available as a PCI to safely and successfully treat patients with to fracture calcium and enable a stent to narrowed coronary arteries,” says Professor Di Mario. cause an embolism further downstream and moderate-to-severe CAC. problematic calcium in the be fully expanded – reducing its success in result in peri-procedural myocardial infarction. “I recommend any patient with angina or silent ischaemia, walls of coronary arteries, preventing restenosis. The calcification may and moderate-to-severe CAC, be referred for treatment with also increase the risk of vessel dissection enabling optimal stent Shockwave IVL.” and acute vessel closure. HOW SHOCKWAVE expansion and improved INTRAVASCULAR LITHOTRIPSY WORKS blood flow to the heart. 1. 2. 3. 4.

Coronary artery calcification (CAC) can result in increased stiffness, preventing arteries from dilating to their full capacity and so reducing oxygen supply to the heart. Left untreated, this can greatly increase the risk of future adverse cardiovascular events. The IVL catheter is delivered An electrical discharge from The waves create a localised After calcium modification, across a calcified lesion over an the emitters vaporises the fluid field effect that travels through the integrated balloon may CAC is age and gender-dependent, 0.014” wire and the integrated within the balloon, creating soft vascular tissue, selectively subsequently be used to dilate with 10-15% of patients with significant balloon is expanded to 4 a rapidly expanding and cracking intimal and medical the lesion at low pressure in coronary stenosis having enough atm to facilitate efficient collapsing bubble that generates calcium within the vessel wall. order to maximise luminal gain. calcium to prevent optimal plaque energy transfer. sonic pressure waves. dilatation and stent expansion. Dr Jonathan Hill Professor Carlo Di Mario Adapted with permission from Shockwave Medical Inc. Diabetes mellitus, chronic kidney Consultant cardiologist Consultant cardiologist, disease and a high BMI may also Professor of cardiology increase the risk of calcification. Dr Hill specialises in interventional cardiology, To find out more, or to refer a patient to assess their suitability for Shockwave IVL, please contact cardiovascular risk assessment and cardiac CT. Professor Di Mario specialises in coronary and the customer services team on +44 (0)20 3131 0535 or email [email protected] structural (valvular) interventional cardiology.

12 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes 13 LUNG CANCER A SAFER APPROACH The current gold standard for investigating pulmonary nodules EXCITING NEW POSSIBILITIES DIAGNOSTIC is CT-guided percutaneous transthoracic pulmonary biopsy. This “This is a really exciting new technology. We see it offering approach achieves high sample yields to assist with diagnostic a safe alternative to the traditional CT-guided transthoracic accuracy but can lead to significant complications such as approach – particularly for high-risk patients such as those pneumothorax, particularly amongst emphysema patients. with emphysema. We are therefore very pleased to be the first BREAKTHROUGH Thankfully, a new minimally invasive bronchoscopic technique is UK centre to offer this service,” says Dr Samuel Kemp, consultant now available which enables safe access to pulmonary nodules respiratory physician at RB&HH Specialist Care. “It also has the even when they are beyond the limits of the airways. The potential to reduce waiting times for lung cancer biopsies, to FOR HIGH-RISK innovative Archimedes® Virtual Navigation System integrates hopefully improve outcomes for these patients. CT, pattern recognition software and fused fluoroscopy to provide “Additionally, due to co-morbidities and older age, up to a third three-dimensional, real-time airway Guided Transbronchial of patients with potentially curable lung cancer cannot undergo Needle Aspiration (TBNA) and Bronchoscopic Trans-Parenchymal surgical resection. In future, we think this technology may go PATIENTS Nodule Access (BTPNA) to collect biopsy samples with accuracy. one step further and provide an opportunity to deliver local The advanced technology enables blood vessels to be identified treatment to early lung cancers in these patient groups to offer to ensure a safe, non-vascular path during both Guided TBNA and a better chance of a cure.” Bronchoscopic and Virtual Visualisation Fluoroscopic Visualisation BTPNA procedures. In addition, the Archimedes system assists respiratory physicians to identify multiple targets, regardless of location in the lung, to enable multiple biopsies to be performed with minimal additional risk. Results from a cohort of 25 patients demonstrated a high diagnostic yield of 85%, and there were no pneumothoraces reported despite over half the nodules sampled being within 1cm of the lung edge.

n innovative, safe and minimally invasive lung cancer diagnostic tool BRONCHOSCOPIC TRANS-PARENCHYMAL NODULE ACCESS (BTPNA) WITH ARCHIMEDES A is now available at Royal Brompton & Harefield Hospitals Specialist Care, and offers new hope to patients at high-risk of complications Dr Samuel Kemp associated with the current gold standard. Consultant respiratory physician

EARLY LUNG CANCER DIAGNOSIS Dr Kemp specialises in treating a range of POSES A DIFFICULT CHALLENGE respiratory conditions, including lung cancer, 1. 2. COPD, emphysema and pleural disease. Lung cancer is the most commonly diagnosed of all types, with over 470,000 new cases reported in Europe in 2018. However, due to the delay in symptoms appearing, it is often diagnosed at an advanced stage, resulting in a poor prognosis – the 5-year survival rate is currently To find out more about our minimally 9% and caused an estimated 1.8 million deaths worldwide in 2018. invasive lung cancer diagnostics, Chest CT screening has offered a promising improvement in lung cancer or to refer a patient, please contact prognosis, with data indicating a 20% reduction in lung cancer mortality. the customer services team on However, almost a third of patients undergoing screening have at least +44 (0)20 3131 0535 or email 3. 4. one pulmonary nodule which requires further diagnostic assessment. [email protected] The Archimedes system in action. After a non-vascular path to the pulmonary nodule has been mapped out by the advanced software, the Archimedes Sheath is advanced through the lung tissue via the airways to collect a biopsy sample.

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Contact them today to access world-leading heart and lung care for your Krishni Kunasingham Sukhi Sohal Heart surgery through groin offers Education at its best at Royal Brompton & Harefield private patients. Patricia Anglin hope to patients in the UAE Harefield Hospital Hospitals partnership with Ain Primary care manager Primary care manager Primary care manager At the 2020 Arab Health Exhibition, Dr William Man and Dr Samantha Shams University Hospital in Egypt Dr Robert Smith presented a simulated Kon delivered a lung health master Royal Brompton & Harefield Hospital are Northwest and West and Southwest London Middlesex and Herts surgical demonstration of MitraClip skills workshop supported by the partnering with Ain Shams University Central London E: [email protected] E: [email protected] therapy to a live audience. The Hillingdon Integrated Respiratory team Hospital, in Egypt, to build upon their less-invasive procedure offers greater and Harefield Hospital Pulmonary specialised cardiac services for Egyptian E: [email protected] M: +44 (0)79 7107 5727 M: +44 (0)74 8333 9569 hope to older patients without the Rehabilitation team. nationals, and carry out joint research. +44 (0)79 7130 1236 need for open-heart surgery. M: