Insight

Coronary Heart Disease (CHD) is the single highest cause of death in the UK; as a result, Cardiology services face immense challenges and many opportunities to modernise and develop services.

Cardiac imaging has been undergoing considerable technological advance, and the rate of advancement has been accelerating in the last 5 years. Whilst established imaging techniques continue to offer front line services in cardiology (cardiac catheterisation, echocardiography and nuclear cardiology), substantial contributions are now emerging from the advanced technologies of x-ray computed tomography (CT). The most modern CT scanners have multiple detectors which rotate at great speed around the patient, to generate the highest resolution non-invasive images of the coronary arteries. This technique is complementary to PET/CT and CMR and their combined utilisation in clinical practice is expected to rise rapidly, in part replacing some activity in the more established imaging disciplines.

The Multi Slice Computerised Tomography (MSCT) Suite will provide clinical services and research opportunities to both adults and children. The aim is to develop a state-of-the-art MSCT service alongside other imaging facilities in Sydney Street and as a critical adjacency to the Adult Intensive Care Unit (AICU), and also close to Paediatric Intensive Care Unit (PICU), the paediatric ward and the cardiac catheter laboratories.

The most important driver for this MSCT development is the need to sustain best diagnostic and clinical practice for the following patient groups: adult and paediatric intensive care; paediatric cardiology and adult congenital heart disease; adult heart disease; congenital heart surgery and electrophysiology.

Until the installation of the 64-slice CT scanner in Fulham Wing in April 2005 the large majority of CT scans performed at Royal Brompton were for pulmonary cases. Since that time the number of cardiac scans has increased dramatically and there are currently about 70 cases per month, mostly for coronary artery disease, but also for patients with congenital abnormalities. At the same time, there has been an approximately 20% increase in the number of pulmonary scans. Installation of a new scanner with cardiac imaging capabilities will allow separation (in large part) of the pulmonary and cardiac CT services, and enable further expansion of these two mutually supportive activities.

The fast scanner has the following advantages:

• Ability to perform CT coronary angiography with greater accuracy and thus replace existing catheter angiography which is an invasive procedure with a small but definite risk of morbidity and mortality.
• CT coronary angiography can be performed as an out-patient procedure taking 15-30 minutes of patient´s time. It is thus greatly convenient to the patient. This will allow optimal use of cardiac catheter labs for interventional work and reduce the number of days patients have to stay in the hospital.
• Patients with pacemakers and internal cardiac defibrillators can undergo CT examination as there are no magnetic fields unlike in MRI scanners. These devices are increasingly being used in patients with cardiac disease.

A 64-slice or dual-headed scanner allows significantly faster scanning times and better resolution than a 4-slice scanner. These are significant advantages to the paediatric population where issues of breath-holding, patient movement, rapid heart rate and the need to assess small structures are particular problems. In many instances it is possible to avoid the necessity to anaesthetise patients for investigations. Another potential benefit of the dual-headed scanner is possible reduction of the x-ray dose to the patient, which is of particular importance to young patients.

The absence of advanced CT facilities disadvantages the Trust´s youngest patients and prevents the Trust from establishing therapeutic and research initiatives in this area.

Research remains central to the mission of our Trust, examining new ways of improving the diagnosis and treatment of patients with heart and lung disease, be they children or adults. The newest versions of multi-slice scanners are supplied with cardiac software providing huge potential for clinical and research purposes.

Royal Brompton Hospital has a large population of adult patients with congenital heart disease. The management of these patients is heavily dependent on Cardiac Magnetic Resonance Imaging (CMR). However, a significant proportion of these patients have required cardiac pacemaker insertion to correct arrhythmias inherent to or subsequent upon the underlying cardiac anomaly. These patients are then rendered unsuitable for CMR. A further proportion of these patients are claustrophobic and unable to tolerate CMR. As a result we are gaining experience in the application of CT angiography for comprehensive cardiac assessment of these patients.

CTCA has become established as a routine clinical test in the assessment of the coronary arterial tree. It is particularly suited to patients with a low or intermediate probability of coronary artery disease and atypical chest pain. The negative predictive value is already well proven in this patient group. There are a number of on-going studies refining the role of CTCA in the adult population, conducted as part of a series of controlled trials at the Royal Brompton Hospital. These include recruitment of patients from the Rapid Access Chest Pain Clinic.

The non-invasive nature of the new CT technology provides a unique opportunity to improve patient care, reduce invasive diagnostic procedures, reduce bed day stays for diagnostic coronary angiography patients and encourage state of the art research and education in this expanding field. A new MSCT suite is part of the Trust´s mission to create a world-class centre for translational research and clinical care in cardiac imaging.

• Heart disease is the largest single cause of death in the UK and the West.
• Heart disease causes more death in women than breast cancer.
• Heart failure is a major problem affecting over 750,000 people in the UK with 65,000 new cases being diagnosed every year.
• 1 in 7 people in the UK are affected by lung disease.
• We help over 8,000 adults who have breathing problems caused by diseases such as COPD (chronic obstructive pulmonary disease) emphysema and severe asthma.
• We are a major centre for lung, chest and oesophageal cancers and non-malignant thoracic surgery.
• We treat difficult cases which have been referred from other hospitals.
• We serve more than 90,000 outpatients and 26,000 inpatients each year.
• We are Europe´s top-ranked respiratory research centre and our cardiac, cardiovascular and critical care teams are rated in the top three most highly cited health research teams in Europe.
• Over the years our experts have been responsible for major breakthroughs such as: transplanting the first heart in Britain; implanting the first coronary stent; founding the largest centre for Cystic Fibrosis in Europe; pioneering intricate heart surgery for newly born infants;pioneering the use of artificial hearts to save the lives of patients with end stage heart failure who are deteriorating and unable to wait for a heart transplant.
• Our surgeons are pioneering techniques in minimally invasive surgery, where only a small incision is made and the operation carried out through the tiny incision with the help of catheters, cameras and robotic equipment.
• Our services for children were given the highest possible 'excellent' rating in the most recent Healthcare Commission survey.
• Our on-site foetal cardiology service enables clinicians to begin caring for babies while still in the womb; many are scanned at just 12 weeks, when the heart measures just over a millimetre.
• Our Heart Attack Centre at Harefield has pioneered the use of primary angioplasty for the treatment of heart attacks and has the fastest arrival-to-treatment time in the UK, a crucial factor in patients' survival.
• We are the country's largest centre for the treatment of adult congenital heart disease, staffed by a specialist team including four full-time specialist consultants.
• We run the world´s largest centre for Cardiac Magnetic Resonance Imaging and the UK´s largest cardiac nuclear medicine service.
• Our heart and lung transplant unit is the UK´s largest and most experienced centre. Over 2,500 operations have been carried out since the start of the programme in 1980.