Case Notes OUR COVID-19 RESPONSE - Royal Brompton & Harefield ...
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Case BEATING HEART BYPASS
FOR A HIGH-RISK PATIENT
Notes
SHOCKWAVE IVL
LUNG CANCER
DIAGNOSTIC
BREAKTHROUGH
Royal Brompton & Harefield Hospitals Specialist Care
OUR COVID-19 RESPONSE
News • Case Studies • Insight Summer 2020
Contents
Welcome to the
Summer 2020 edition
2
What’s new?
10
Boosting body confidence
one chest at a time
of Case Notes
Every day, private patients are referred
to our hospitals for the exact same
4
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
New consultants 14
performed a beating heart bypass for a high-risk patient on page 8,
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 privatepatients@rbht.nhs.uk www.rbhh-specialistcare.co.uk
2 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes
new?
What’s
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
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
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 Academy of Echo. Professor H.K Chopra (second right), president of the Cardiological
tolerance of physical activity and improve their quality of life.
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
response
Our COVID-19
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
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
capacity and saved lives
We discovered
and advised WE INCREASED ECMO SUPPORT
We increased
ECMO support
We maintained
private services
And we
will continue
WE MAINTAINED PRIVATE SERVICES
We helped increase We discovered We increased We maintained And we
A
capacity and saved lives and advised ECMO support private services will continue
As one of only five
s a specialist heart and WE HELPED INCREASE ECMO (extracorporeal
CAPACITY AND SAVED LIVES
We helped increase We discovered We increased membrane oxygenation)
We maintained And we
We have developed
lung hospital, we made capacity and saved lives and advised ECMO support private services
centres in the UK,
will continue
innovative ways to
a number of changes patients with the most continue providing
As well as our Trust’s severe respiratory failure were sent to
We helped increase
WE DISCOVERED AND ADVISED
We discovered We increased We maintained And we
across our private and NHS
capacity and saved lives and advised ECMO support private services will continue
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 the RECOVERY
We discovered We increased We maintained
AND WE WILL CONTINUE
And we
the COVID-19 pandemic and facilities and re-deployed capacity and saved lives and advised ECMO support private services will continue
the scenes to see how the sickest (Randomised Evaluation Our remote video consultation service
select members of our team to swiftly
keep all our patients safe. create the necessary capacity for the
patients are treated with this of COVID-19 Therapy) mirrors face-to-face clinics with our
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 Diagnostics and outpatients
our private patients. 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.
to enter COVID-19 areas at our hospital. 77 Wimpole Street, our dedicated private patients can continue their
skills of our specialist teams, we helped
They all attached a photo of themselves to Our consultants also provided and outpatients and state-of-the-art diagnostics heart and lung treatment with us.
help our patients visualise who is helping them. many COVID-19 patients recover and
continue to provide regular COVID-19 facility, has always been and continues to
return home to their loved ones, and As the infection can leave patients with
advice throughout the pandemic to be a ‘green zone’ during the pandemic. This
continue to do so. 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
privatepatients@rbht.nhs.uk
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
OUR NEW A research project comparing two types
CONSULTANTS
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
cardiologist at Royal Brompton & Harefield
NHS Foundation Trust, has been funded by the
National Institute for Health Research and will
A
compare catheter ablation to thoracoscopic
s the UK's largest heart and lung centre, we attract some
Research
surgical ablation for the treatment of LSPAF.
of the most talented consultants from all over the world. The longer a person has atrial fibrillation, the more
update
Below are some of the newest members of our team. difficult it is to go back to a normal heart rhythm.
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 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.
PERSONALISED MEDICINE treatments do not work, the researchers
Royal Brompton Hospital Royal Brompton Hospital, Harefield Hospital, 77 Wimpole Street This additional data will allow the research team
FOR SEVERE ASTHMA hope new, more effective treatments will
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 It has been a period of successes for the
The PRISM study aims to better characterise
In addition, he is an expert in the management of coronary asthma by improving the doctor’s respiratory research group at Harefield
the type of asthma in each individual by using
artery disease and cardiovascular complications in diagnosis of the type of severe asthma Hospital, who have been recognised both
their unique makeup of genes and proteins, to
haemoglobinopathies such as Thalassaemia and Sickle they are suffering from. This will ultimately nationally and internationally, for their work
develop biomarkers that are more accurate
Cell Disease. He performs coronary angiography, coronary lead to better treatments at a personalised on pulmonary rehabilitation and chronic
than the blood eosinophil count, in predicting
physiology measurements and coronary angioplasty. level for every patient suffering from this obstructive pulmonary disease.
good response to biologic treatments.
often very disabling condition.”
One project, led by Jessica Walsh, working
with Dr William Man, was awarded ‘Best
Abstract’ under the category of rehabilitation
Dr Jonathan Hill Dr Mumin Noor TRUST CO-FUNDS population of patients and many
and chronic care at the European Respiratory
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 Harefield Hospital for BRC status for 2022-2027 and the respiratory medicine research.
Pulmonary Disease (COPD), asthma and
Trust will collaborate with them to Dr Man’s extensive work on pulmonary
idiopathic pulmonary fibrosis (IPF) are just
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
funding via a joint funding call from Royal 10 projects were selected to receive up to his appointment as co-chair for the British
cardiologist with a clinical consultant cardiologist
Brompton & Harefield NHS Foundation Trust, £25,000 in funding, all of which demonstrated Thoracic Society Pulmonary Rehabilitation
expertise in interventional with an expertise in general
Imperial College London and Imperial College clear objectives that aligned with the key Guidelines Development group, which will
cardiology, cardiovascular risk cardiology, including angina,
Healthcare NHS Trust (ICHT). 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
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 and Idiopathic pulmonary fibrosis,’ led by “The British Thoracic Society guidelines
resynchronisation therapy. first-time trials of new discoveries, treatments and
progenitor cells in cardiovascular disease and he is the Dr Deborah Morris-Rosendahl; ‘How are very well respected and widely read
technologies in patients, to improve healthcare.
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
King’s College London. device therapy in heart failure patients. The Trust is well-positioned as a world-leading
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
Beating TACKLING CLOGGED CORONARY ARTERIES
Coronary heart disease is a leading cause of
death worldwide and occurs when the blood
CABG surgery utilising a cardiopulmonary
bypass machine which takes over the
Removal of
atheromatous
heart
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.
can be explored. be completed with greater ease. However,
bypass for
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
a high-risk
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. reconstruction
procedure may be needed for revascularisation.
of left anterior
descending
patient
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
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,
C
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
Raja is internationally renowned artery to steady the heart, temporarily occlude
demonstrated that off-pump CABG was
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
mortality, fewer postoperative complications
artery bypass surgery whilst a patient’s 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
requires great precision and skill to get experienced surgeon with exclusive off-pump
CABG. This was the longest study of its kind.
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 Mr Raja specialises in cardiac surgery, including
but repeat ECG tests came “When I woke up from the him to go ahead.
surgery, I saw Mr Raja, who coronary artery bypass, revascularisation, and
back negative, despite
came to check up on me. Mr Raja says: “Kiran’s valve replacements.
the pain continuing. After
I couldn’t talk to him at case was quite complex,
struggles booking in an
that point, but I just put as he had diabetes and
appointment with pain
two hands up to thank him multi-vessel coronary artery
management and further
for giving me a new life. disease. We recommended To find out more about our off-pump
heart exams, he decided
And after about 6 weeks I an off-pump bypass CABG surgical procedures, or
to seek private care with
was back to normal really procedure to ensure the
Royal Brompton & Harefield to refer a patient, please contact
– I was driving again and best results as he was a
Hospitals Specialist Care. 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 privatepatients@rbht.nhs.uk
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
BOOSTING
CORRECTING DEFORMITIES WITH MINIMALLY INVASIVE TECHNIQUES
Past procedures to correct chest deformities Small incisions are made either side of
were very invasive and involved surgically the chest and one to three curved metal
BODY
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
removing – after which time the ribs stay in
can be performed at any
less invasive techniques are now available.
CONFIDENCE
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
the breastbone back to where it should be. leave hospital within two to three days. 16 years of age, whilst the
ONE CHEST
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
AT A TIME
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
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.
C hest deformities are a relatively rare problem
for young teens but can greatly affect their
self-esteem and might lead to difficulties in the
KNOCKING BODY CONFIDENCE
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.
Breastbone
Breastbone Breastbone
Breastbone Breastbone
Breastbone breathing, chest pain and an irregular He explains: “It wasn’t so much the cosmetic
Heart
Heart Heart
Heart Heart
Heart 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
Lung
Lung Lung
Lung Lung
Lung
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
might do some serious damage. Also, with nature. However, we know these conditions
or to refer a patient, please contact
can cause significant embarrassment for
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 privatepatients@rbht.nhs.uk
Ribs
Ribs Spine
Spine Ribs
Ribs Spine
Spine Ribs
Ribs Spine
Spine 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
SHOCKWAVE
AN INNOVATIVE SOLUTION USING
AN OLD TECHNOLOGY SHOCKWAVE IVL
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
Revolutionary
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.
engineer (who worked on early pacemakers), were working at
technology to
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
in tackling problematic calcium in the cardiovascular system. with other methods. This allows us to fully expand a stent, to
treat calcification
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
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
CALCIFICATION PREVENTS EXISTING CORONARY at the speed of sound, breaking up denser kidney stones. Europe to conduct coronary IVL in 2015 and Professor Di Mario
A
treated most patients during both studies. Dr Jonathan Hill, also
INTERVENTIONS FROM WORKING Teaming up with Stanford University cardiologist and bioengineer,
ground-breaking Professor Todd Brinton, they experimented with a new lithotripsy
a consultant cardiologist, is now following his steps, becoming
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 interventions (PCI) available to widen narrowed atherectomy – are available to specifically
device they developed to tackle CAC. They discovered their device
European lithotripsy study which has already completed recruitment
could crack calcium-rich egg shells whilst leaving their membranes
is now available at Royal arteries and enable the placement of stents to remove CAC. They scrape away hard,
intact – which is much like the endothelium of a blood vessel. They
of its patients.
improve blood flow. However, calcification superficial calcified tissues in coronary arteries
Brompton & Harefield can limit the success of existing procedures. whilst sparing softer elastic tissues, to increase
therefore had a proof-of-concept for cardiovascular applications. “The results of these studies demonstrated that the procedure is
safe and effective for patients with moderate-to-severe calcification.
Hospitals Specialist For example, the force applied by balloon
blood vessel compliance for a stent to be fully Fast-forwarding to today and after several successful international
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
fragments which can induce slow blood flow, available as a PCI to safely and successfully treat patients with
the following day. It really is a game-changer in the treatment of
to fracture calcium and enable a stent to narrowed coronary arteries,” says Professor Di Mario.
problematic calcium in the be fully expanded – reducing its success in
cause an embolism further downstream and moderate-to-severe CAC.
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 and acute vessel closure. HOW SHOCKWAVE Shockwave IVL.”
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
increase the risk of calcification.
Professor of cardiology
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 privatepatients@rbht.nhs.uk
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
DIAGNOSTIC A SAFER APPROACH
The current gold standard for investigating pulmonary nodules EXCITING NEW POSSIBILITIES
BREAKTHROUGH
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
FOR HIGH-RISK
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
innovative Archimedes® Virtual Navigation System integrates hopefully improve outcomes for these patients.
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
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.
A
n innovative, safe and minimally
invasive lung cancer diagnostic tool BRONCHOSCOPIC TRANS-PARENCHYMAL
NODULE ACCESS (BTPNA) WITH ARCHIMEDES
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
respiratory conditions, including lung cancer,
POSES A DIFFICULT CHALLENGE 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. privatepatients@rbht.nhs.uk
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.
14 Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes Royal Brompton & Harefield Hospitals Specialist Care Summer 2020 Case Notes 15
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Patricia Anglin Krishni Kunasingham Sukhi Sohal
Heart surgery through groin offers
hope to patients in the UAE
Education at its best at
Harefield Hospital
Royal Brompton & Harefield
Hospitals partnership with Ain
private patients. 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
therapy to a live audience. The Hillingdon Integrated Respiratory team E: K.Kunasingham@rbht.nhs.uk E: S.Sohal@rbht.nhs.uk
Hospital, in Egypt, to build upon their
less-invasive procedure offers greater and Harefield Hospital Pulmonary specialised cardiac services for Egyptian E: P.Anglin@rbht.nhs.uk 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.
M: +44 (0)79 7130 1236
need for open-heart surgery.
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have an increased risk of suffering from transplant operation in Britain took to keep the sickest COVID-19 patients
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