Harefield Hospital Research Articles

Focusing on breath

When I recorded the breath of patients with chronic obstructive pulmonary disease at the Royal Brompton and Harefield Hospitals, several of them talked about how difficult they found it to exhale. In looking for tools that were capable of registering even the most subtle of expirations, Peter Hobson (Department of Electronic and Computer Engineering, Brunel University, London, UK) and I decided to explore the potential of Schlieren imaging which can visually depict the flow of fluids or gases of varying density. Prof Hobson provided an appropriate optical setup at Brunel University (London, UK) where we explored the possibilities of this process to record the exhaled breath. The optical Schlieren system is capable of recording subtle differences in refractive indices, such as those created by warm breath in cold air. Light diverging from a laser source is focused by a spherical, concave mirror onto a knife edge (which provides a sharp line to precisely allow specific elements of the laser beam to be selected). Breathing warm air close to the surface of the mirror disturbs the light rays so that, when focussed, some bypass the knife edge and can be recorded by a camera positioned behind the system. Prof Hobson provided the breath, which I photographed to record the patterns produced by the warm breath turbulently mixing with the cool laboratory air. The image was recorded digitally directly into the camera and is therefore circular.

James Thomas Scott

James Thomas Scott (“Tom “) enjoyed a fine reputation as a consultant physician at Charing Cross Hospital. He was a gifted teacher, clinical scientific researcher, and mentor. He left a...

Does addition of a pericardial drain in patients undergoing isolated aortic valve replacement reduce post-operative complication: A comparative study of single versus two drains in the early post-operative period?

Does addition of a pericardial drain in patients undergoing isolated aortic valve replacement reduce post-operative complication: A comparative study of single versus two drains in the early post-operative period?

Extracorporeal membrane oxygenator (ECMO) and ventricular assist device (VAD) activity of a tertiary cardiothoracic centre: survival rates and length of ITU stay

Harefield Hospital accepts patients as a tertiary centre for end-stage heart and respiratory failure for the south of England. Interventions include VA-ECMO, VV-ECMO as a bridge to lung transplantation, left ventricular assist devices (LVAD) as a bridge for heart transplantation, right ventricular assist devices (RVAD) and BIVADs. The aim of this review was to identify the total number of such patients, analyse the individual length of ITU stay and calculate survival and mortality rates for each intervention.

Prognosis of primary percutaneous coronary intervention in elderly patients with ST-elevation myocardial infarction

ObjectiveTo evaluate the prognosis of primary percutaneous coronary intervention (PPCI) and medical therapy (MT) in elderly patients presenting with ST-elevation myocardial infarction (STEMI). MethodsA total of 238 STEMI patients aged above 80 and treated with PPCI (n=186) and MT (n=52) at Harefield Hospital, London were included in this study. Patients who did not have true STEMI based on non-diagnostic electrocardiogram (ECG) for STEMI and negative troponin, who presented with left bundle branch block (LBBB) and had normal coronaries were excluded from this study. Primary PCI was defined as any use of a guidewire for more than diagnostic purposes in patients with STEMI, whereas conventional MT was defined as treatment of patients with anti-platelets and anti-thrombotic medications without thrombolysis. ResultsThe survival rate of PPCI patients was 86% (n=160) at month 1 followed by 83.9% (n=156) at month 6, and 81.2% (n=151) at month 12. The survival rate of MT patients was 44.2% (n=23) at month 1 followed by 36.5% (n=19) at month 6, and 34.6% (n=18) at month 12. Compared to MT, significantly fewer comorbidities were found in the PPCI group. Ventricular fibrillation (VF) (4.8%) and consequent admission to intensive care unit (7%) were the major complications of the PPCI group. ConclusionPPCI has a higher survival rate and, compared to MT, fewer comorbidities were observed in the PPCI group of elderly patients presenting with STEMI.

Abstract 14806: Predictors of Survival and Favourable Functional Outcomes Following an Out of Hospital Cardiac Arrest in Patients Systematically Brought to a Dedicated Heart Attack Centre

BACKGROUND: Despite advances in cardiopulmonary resuscitation, survival remains low after out of hospital cardiac arrest (OOHCA), with less than 20% of patients surviving to hospital discharge. Acute coronary ischaemia is the predominating cause and prompt delivery of patients to dedicated facilities may improve outcomes. Since 2011, all patients in London with OOHCA, in whom a cardiac aetiology is suspected, are brought to dedicated Heart Attack Centres (HACs). OBJECTIVES: We sought to determine the predictors for survival and favourable functional outcomes following OOHCA in this setting. METHODS: We analysed 182 consecutive OOHCA patients brought by the emergency services to Harefield Hospital - a designated HAC in London. Of these, 174 patients achieved return of spontaneous circulation. We analysed (a) all-cause mortality at 1 year; and (b) functional status at discharge using a modified Rankins score (mRS:0-6, where mRS0-3=favourable functional status). We used multivariate models to determine predictors of survival and favourable functional status. RESULTS: The overall survival rates were 66.7% at 30 days and 62.1% at 1 year. Of the 174 patients, 95 patients (54.5%) had favourable functional status at discharge. Patients with favourable functional status had significantly reduced mortality rates compared to those with poor functional status: 30 days (1.2% vs. 72.2%, p<0.001) and 1 year (5.3% vs. 77.2%, p<0.001). Multivariate analyses identified a shorter duration of resuscitation and absence of cardiogenic shock as consistent independent predictors of both favourable functional status and long-term survival (figure). CONCLUSIONS: The strategic delivery of OOHCA patients to HACs is associated with improved functional status and survival. Those with favourable functional status at discharge have significantly improved survival. Our study supports the standardisation of care for such patients with the widespread adoption of dedicated facilities.

Genetic cascade screening for familial hypercholesterolaemia, development of a telephone appointment outreach service

In May 2008 a familial hyeprcholesterolaemia genetic cascade screening clinic (FHGSC) was established at Harefield Hospital. Following the introduction of a paediatric FHGSC and more recently an outreach clinic the service has become more comprehensive.

Detecting familial hypercholesterolaemia (FH) in general practice: An audit within the Medway Clinical Commissioning Group

Detecting familial hypercholesterolaemia (FH) in general practice: An audit within the Medway Clinical Commissioning Group

BASELINE AUDIT OF SUPPORTIVE CARE PROVISION FOR PATIENTS WHO DIED IN 2010 AND HAD LUNG TRANSPLANTS OR WERE ON THE WAITING LIST AT HAREFIELD HOSPITAL

BackgroundThere is a lack of significant literature on provision of Supportive and Palliative care (SPC) for Lung transplant patients pre and post surgery.AimsA baseline audit of patients was undertaken to...

Minimally invasive lung transplantation at Harefield Hospital: A novel strategy in the UK

Objectives: Minimally invasive lung transplantation (MILT) via bilateral anterior thoracotomies has emerged as a novel surgical strategy with potential patient benefits when compared to transverse thoracosternotomy (clamshell incision, CS). The aim of this report is to compare MILT to CS by focusing on operative characteristics, postoperative organ function and support and midterm clinical outcomes at Harefield Hospital.

Heart Failure Therapy: drugs, Genes Or Stem cells?

Professor Sian Harding talks to Caroline Telfer, Assistant Commissioning Editor. Professor Sian Harding obtained her PhD in Pharmacology from King's College, London (UK) in 1981. She became Professor of Cardiac Pharmacology at the National Heart and Lung Institute, a division of the Imperial College Faculty of Medicine, in 2002. Her work has been funded by the British Heart Foundation, the Wellcome Trust, the Medical Research Council, the Biochemical and Biophysical Research Council, the The National Centre for the Replacement, Refinement and Reduction of Animals in Research, Pfizer, GlaxoSmithKline and SmithKline Beecham. Harding is former president of the European Section of the International Society for Heart Research and has organized international cardiovascular science meetings for this society, as well as for the European Society of Cardiology. She is the principal investigator for the first UK gene therapy trial aimed at improving cardiac contractility, organized jointly at Harefield and Papworth Hospitals. Harding is a member of the Nuffield Council on Bioethics and the Medical Research Coucil Regenerative Medicine Research Committee, and Director of a recently awarded British Heart Foundation Cardiovascular Regenerative Medicine Centre. She has been elected Fellow of the American Heart Association, European Society of Cardiology, International Society for Heart Research, Society of Biology and British Society of Pharmacology.

Harry Ralph Claude Riches

Harry Ralph Claude Riches retired from the NHS in 1988 after 40 years’ service. He had been on the staff of Harefield Hospital for 34 years and, at the time...

35. Evolution from NHS Heart Valve Bank to University Hospital Ovarian Tissue bank to Oxford Biomedical Research Centre Biorepository Biobank

The Heart Valve Bank (HVB) based in the Heart Centre, Oxford University Hospital NHS Trust (OUH) procures and processes at least 150 cardiovascular tissues each year for transplantation. This HVB service has evolved now to process other tissue for transplantation and for research. The impetus for development was atypical. The HVB team reviews an average of 720 deceased patient notes per annum and interviews families of potential donors to obtain consent for transplantation. Of these, 80% families also consent to research in NHS or university setting (60% in commercial setting). The OUH is one of the largest acute teaching hospitals in the UK. Research is one of the OUH’s three key strategic activities, alongside clinical services and teaching. HVB was encouraged to fulfil the wishes of the donors and to facilitate research within OUH. HVB service has evolved from April 2011 as follows: • 181 corneas retrieved and supplied to eye bank (per annum). • Hearts unsuitable for transplantation used within OUH or Oxford University (OU) for research e.g. study to improve mitral isthmus ablation surgery (hearts placed in head coil inside MRI to enhance image clarity). • 101 aortic valves (calcified) supplied to Sir Magdi Yacoub’s researchers at Harefield Hospital developing a tissue engineered valve and at Imperial College exploring the calcification of the aortic valve using state of the art materials analyses. • More than 30 ‘control’ & diseased brains and spinal cords supplied to OUH/OU brain bank. Brain tissue used to study effects of new therapies e.g. AD vaccine trial, PD cell transplantation, development of transgenic mouse models. • Ovarian tissue cryopreservation set-up for 2013 with OU/OUH to preserve fertility in children and young females who survive cancer treatment (first UK clinical program). HVB already had an embedded system within the OUH and the community for tissue donation for transplantation and a detailed consenting procedure (recorded), working within strict EU and UK legislation e.g. regarding ‘DNA-theft’ and ‘privacy’. Prior to further development however, HVB required support and guidance from the Oxford Biomedical Research Centre (OxBRC), funded by the National Institute for Health Research (NIHR), and aims to align excellence across the Strategic Partnership of the hospital Trust and the University. In practice this means bringing together the research expertise and skills of OU and OUH staff, with the aim of supporting translational research and innovation for maximum patient benefit. The biobank activities of the HVB are standardised and comply with Human Tissue Authority (HTA) licensing and ethical requirements. Access to samples and data is facilitated via a single point of access, open to all researchers via an online website enquiry form. Accessibility, quality control, documentation and distribution are efficiently managed. Public involvement and engagement and independent review are facilitated by OxBRC. HVB now considers specific or generic requests for any tissue required for research along with biofluids and associated medical, behavioural and social data and can create prospective sample collections. HVB requires feedback from researchers to encourage consent. The HVB is thus now acting as a hospital integrated BioResource.

Let's go round again! Quality improvement through intentional rounding

Harefield Hospital is a 150-bed cardiothoracic tertiary referral centre with transplantation, artificial heart, ECMO and primary angioplasty services. Our 35-bed critical care department consists of 18 intensive therapy unit, seven recovery and 10 high-dependency beds. Intentional rounds or proactive patient rounds were recognised by the Royal College of Physicians and the Royal College of Nursing [1] as structured, evidence-based processes for nurses to carry out regular checks with individual patients at set intervals. The senior nursing team decided to adapt this initiative to the intensive care setting in order to address clinical challenges and provide guidance for shift leaders to focus on key elements of care.

David Martin Graham-Service

David Martin Graham-Service was educated at Glasgow Academy and Fettes College, Edinburgh, before studying medicine at St Andrews and Dundee. After house posts at the Victoria Infirmary, Glasgow, and Harefield...

Clinical Experience With HeartWare Left Ventricular Assist Device in Patients With End-Stage Heart Failure

The gold standard treatment for end-stage heart failure is cardiac transplantation. Because of the increasing number of heart failure patients and the limited supply of donor hearts, a ventricular assist device (VAD) is used as a bridge to transplantation, recovery, or decision. Newer generation VADs have lower risk of fatal adverse events and are also smaller in size. We present our experience with the intrapericardial HeartWare VAD (HeartWare, Framingham, MA) and its clinical outcome. The clinical outcome of HeartWare VAD implantations for end-stage heart failure patients performed at Harefield Hospital from March 2007 to June 2011 was studied. The study design was a retrospective review of the prospectively collected data. Thirty-four patients with a mean age of 51±10 years were included in this study. Twenty-nine patients were male (85%). The mean duration of mechanical support was 261±64 days. Five patients (15%) were successfully bridged to heart transplantation. The overall mortality was 24% (8 patients). There were 1 case of mechanical device failure (2%) and 3 cases of device failure due to thrombus formation (8%). Postoperative complications included 5 reoperations for bleeding (15%), 12 acute renal failures (36%), 7 respiratory failures (21%), 2 hepatic dysfunctions (6%), 3 neurologic dysfunctions (9%), 7 right-side heart failures (21%), and 5 driveline infections (15%). Although cardiac transplantation remains the gold standard for treatment of end-stage heart failure patients, the HeartWare VAD can be used as a safe alternative with a satisfactory clinical outcome.

Hounds Help Hearts

Lynda Evans discusses the rationale behind the new joint initiative from Harefield Hospital's cardiac rehabilitation service and the charity, Dogs Trust

Role of Noninvasive Imaging in the Diagnosis of Cardiac Allograft Vasculopathy

Cardiac allograft vasculopathy (CAV) is common, with a prevalence of 52% at 10 years after transplantation, and represents a leading cause of death beyond the first year, responsible for approximately 15% of deaths annually.1 It is characterized by diffuse and concentric intimal proliferation, typically involving the intramural as well as epicardial coronary arteries. Its diagnosis is difficult to establish clinically because of denervation of the transplanted heart. Consequently, it presents late with silent myocardial infarction, progressive heart failure, or arrhythmic sudden death.2 Screening is therefore required for its early detection. Although coronary intravascular ultrasound (IVUS) is considered the gold-standard technique for detecting the anatomic features of CAV (Table 1), its broad clinical use in this context is limited by cost and lack of widespread expertise, and its evaluation is limited to epicardial vessels.3 Coronary angiography, performed annually or biannually, remains the most common clinical screening method.4 However, because of the diffuse nature of CAV with a lack of normal reference segments and the relatively late occurring luminal narrowing, the sensitivity of angiography is as low as 30% when compared with IVUS (Figure 1).5 As a result, complications frequently occur before disease is evident angiographically.6 Furthermore, angiography is associated with significant albeit uncommon complications (overall complication rate, 7.4/1000 procedures, including rates of 0.65/1000, 1.6/1000, and 0.72/1000 for cerebrovascular accidents, vascular complications, and death, respectively), is disliked by transplant recipients, is costly, and repeated studies are associated with an important cumulative radiation dose.7 View this table: Table 1. Stanford Classification of CAV Severity on IVUS Figure 1. Invasive assessment of cardiac allograft vasculopathy (CAV) in a patient with severe disease, highlighting the limited sensitivity of conventional coronary angiography. Although no left anterior descending (LAD) flow-limiting stenoses are seen on angiography ( A ), intravascular ultrasound ( B ) shows significant intimal thickening, measuring up to …

635 Use of Long-Term Ventricular Assist Devices in Bridging to Heart Transplantation – A UK National Survey

Use of Long-Term Ventricular Assist Devices in Bridging to Heart Transplantation – A UK National Survey A. Emin, C.A. Rogers, H.L. Thomas, S. Tsui, G. MacGowan, J. Parameshwar, N.R. Banner. on behalf of the UK VAD Forum and UK Cardiothoracic Transplant Steering Group, Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Cardiopulmonary Transplantation, Harefield Hospital, Middlesex, United Kingdom; Statistics and Clinical Audit, NHS Blood and Transplant, Bristol, United Kingdom; Cardiopulmonary Transplantation, Papworth Hospital, Papworth Everard, Cambridgeshire, United Kingdom; Cardiopulmonary Transplantation, Freeman Hospital, Newcastle, United Kingdom.

Assessing the quality of ward pharmacists' interventions

Abstract The quality of 1,315 interventions made by pharmacists over a 12-month period at Harefield hospital, a 180-bed cardiothoracic hospital, was measured using a six-point scoring system. The system was validated by comparing a pharmacist's scores with doctors' scores on a sample of the interventions. Using the scoring system, 53 per cent of the interventions could be said to lead to an improvement in patient care, but only 2 per cent prevented major adverse reactions. No potentially life-saving interventions or any which were detrimental to patients' care were recorded. It is concluded that pharmacists do have a role in improving the quality of patient care.