Very early invasive strategy in higher risk non-ST-elevation acute coronary syndrome: the RAPID NSTEMI trial

OBJECTIVE

To investigate whether a very early invasive strategy (IS)±revascularisation improves clinical outcomes compared with standard care IS in higher risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS).

METHODS

Multicentre, randomised, controlled, pragmatic strategy trial of higher risk patients with NSTE-ACS, defined by Global Registry of Acute Coronary Events 2.0 score of ≥118, or ≥90 with at least one additional high-risk feature. Participants were randomly assigned to very early IS±revascularisation (<90 min from randomisation) or standard care IS±revascularisation (<72 hours). The primary outcome was a composite of all-cause mortality, new myocardial infarction or hospitalisation for heart failure at 12 months.

RESULTS

The trial was discontinued early by the funder due to slow recruitment during the COVID-19 pandemic. 425 patients were randomised, of whom 413 underwent an IS: 204 to very early IS (median time from randomisation: 1.5 hours (IQR: 0.9-2.0)) and 209 to standard care IS (median: 44.0 hours (IQR: 22.9-72.6)). At 12 months, there was no significant difference in the primary outcome between the early IS (5.9%) and standard IS (6.7%) groups (OR 0.93, 95% CI 0.42 to 2.09; p=0.86). The incidence of stroke and major bleeding was similar. The length of hospital stay was reduced with a very early IS (3.9 days (SD 6.5) vs 6.3 days (SD 7.6), p<0.01).

CONCLUSIONS

A strategy of very early IS did not improve clinical outcomes compared with a standard care IS in higher risk patients with NSTE-ACS. However, the primary outcome rate was low and the trial was underpowered to detect such a difference.

TRIAL REGISTRATION NUMBER

NCT03707314.

A RANDOMISED CONTROLLED TRIAL TO INVESTIGATE THE USE OF ACUTE CORONARY SYNDROME THERAPY IN PATIENTS HOSPITALISED WITH COVID-19: THE C19-ACS TRIAL

BACKGROUND

Patients hospitalised with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease.

OBJECTIVES

To investigate efficacy of an acute coronary syndrome regimen in patients hospitalised with COVID-19 and coronary disease risk factors.

PATIENTS/METHODS

A randomised controlled open-label trial across acute hospitals (UK and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28-days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, death).

RESULTS

320 patients from 9 centres were randomised. The trial terminated early due to low recruitment. At 30 days there was no significant difference in mortality (intervention: 11.5% vs control: 15%, unadjusted OR 0.73, 95%CI 0.38 to 1.41, p=0.355). Significant bleeds were infrequent and not significantly different between the arms (intervention: 1.9% vs control 1.9%, p>0.999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR 1.46, 95% CrI 0.88 to 2.37, Pr(Beta>0)=93%; adjusted OR 1.50, 95% CrI 0.91 to 2.45, Pr(Beta>0)=95%) and median time to discharge home was two days shorter (95% CrI -4 to 0, 2% probability that it was worse).

CONCLUSIONS

Acute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.

Improving radiology: a whole-system opportunity

In this article, we set out the current context and case for change in radiology in England and how quality-improvement approaches can support the development of sustainable Imaging services and networks to meet the challenges faced now and in the future.

Ultra-low contrast, complex left main coronary intervention case series using novel intravascular ultrasound technology

Background

Contrast-induced nephropathy (CIN) in patients with chronic kidney disease (CKD) carries a high morbidity and mortality. Ultra-low contrast percutaneous coronary intervention (ULPCI) has previously been described. Complex left main (LM) ULPCI using two-stent strategy guided by novel intravascular ultrasound (IVUS) co-registration software has not been described. We report a series of complex LM ULPCI using IVUS co-registration.

Case Summaries

Five patients with estimated glomerular filtration rate ≤20 mL/min who presented with stable angina or non-ST segment elevation acute coronary syndrome underwent percutaneous coronary intervention (PCI). The patients previously had diagnostic angiography performed as a separate procedure. Successful LM ULPCI was performed in all patients with a provisional and two-stent bifurcation strategies. These were complex procedures, some of which required haemodynamic support and rotational atherectomy.

Discussion

This report describes the first ULPCI using a dedicated two-stent LM bifurcation strategy and using rotational atherectomy and IVUS co-registration. This technology facilitated complex PCI in this high-risk patient group with minimal contrast use (≤6 mL) with optimal results and no patients developed acute kidney injury after intervention. The adaptation of ULPCI to daily practice in patients at risk of CIN will improve treatment for this underserved patient group.

Use of dalbavancin in infective endocarditis: a case series

Background

Infective endocarditis, typically caused by Gram-positive organisms such as viridans group streptococci and Staphylococcus aureus, is associated with high mortality and morbidity and requires aggressive, prolonged antimicrobial treatment and sometimes surgery. Dalbavancin, a lipoglycopeptide active against Gram-positive pathogens, has a long half-life, which allows IV treatment as one dose or two doses with a prolonged interval, offering personalized treatment for complex psychosocial situations or facilitating early discharge. In the absence of randomized controlled trials in infective endocarditis, current evidence derives from real-world case series involving off-licence use. The Austrian Society for Infectious Disease and Tropical Medicine includes dalbavancin as an option for infective endocarditis.

Objectives

This retrospective case series reports use of dalbavancin in a small cohort of patients with infective endocarditis treated at Lancashire Cardiac Centre, Blackpool Teaching Hospitals Foundation Trust, UK.

Results

The pharmacy database included 11 patients in whom dalbavancin was used to address either complex psychosocial circumstances or the need for early discharge. The endocarditis multidisciplinary team selected dalbavancin from available treatment options. Structures affected by infective endocarditis included aortic, mitral and tricuspid valves; aortic composite grafts; implantable cardioverter defibrillator leads; and prosthetic aortic valves. Eight patients underwent surgery; three were managed conservatively with antibiotics. Dalbavancin was curative in all but one patient, whose signs and symptoms of infection improved. No patients developed adverse reactions.

Conclusions

Dalbavancin is an alternative treatment option at hospital discharge when conventional antibiotics may not be suitable due to complex psychosocial issues or early discharge is required.

Mental Health Outcomes Among British Healthcare Workers-Lessons From the First Wave of the Covid-19 Pandemic

OBJECTIVE

To ascertain the level of psychological distress, using validated psychology tools, among British National healthcare workers (HCW) during the first wave of the Covid-19 crisis.

METHODS

A multi-centre, anonymized, all-comer staff survey across 3 hospitals in Lancashire, England during the Covid-19 first wave (April to June 2020), consisting of Patient Health Questionnaire (PHQ-9), Perceived Stress Scale-10 (PSS-10), Generalized Anxiety Disorder-7 (GAD-7), and Impact of Events Scale (IES-6).

RESULTS

Among 1113 HCW, median (IQR) PHQ-9, GAD-7, PSS-10, and IES-6 score was 7 (3 to 11), 6 (3 to 11), 19 (13 to 24), and 9 (5 to 14), respectively. Potential predictors of higher levels of psychological distress included living alone, disabled dependents, history of depression/anxiety, and being female.

CONCLUSIONS

The study indicates a high prevalence of psychological distress during the acute Covid-19 period among HCW, identifies groups at risk and areas of future research.

Meta-Analysis Comparing Direct Oral Anticoagulants to Vitamin K Antagonists for The Management of Left Ventricular Thrombus

Introduction: To compare vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) treatment in patients with left ventricular (LV) thrombus. The primary outcome was stroke or systemic embolism (SSE). Secondary outcomes were thrombus resolution, bleeding, and death.Areas covered: Five observational studies were included (total n = 700; VKAs n = 480; DOACs n = 220). There was a trend toward less SSE with VKAs compared to DOACs (5.2% vs. 9%; odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.29-1.01, p = 0.05). No significant difference between VKAs and DOACs in rates of thrombus resolution (61.6% vs. 56.8%; OR = 1.00, 95% CI = 0.58-1.73, p = 0.99), bleeding (8.2% vs. 4.4%; OR = 1.62, 95% CI = 0.69-3.77, p = 0.27), or death (12.7% vs. 11.8%; OR = 1.09, 95% CI = 0.59-2.0, p = 0.79) was noted. In non-primary percutaneous coronary intervention setting, VKAs were associated with less SSE in prespecified analysis (5.2% vs.10.6%; OR = 0.48, 95% CI = 0.25-0.93, p = 0.03).Expert opinion: The current meta-analysis suggests a trend toward higher SSE with the use of DOACs compared to VKAs. Our recommendation is for VKAs to retain the preferred management of LV thrombus with cautious off-label use of DOACs.

One-year outcomes of percutaneous coronary intervention in native coronary arteries versus bypass grafts in patients with prior coronary artery bypass graft surgery

Background

Patients with prior coronary artery bypass graft (CABG) surgery often require percutaneous coronary intervention (PCI). Data are still limited in regards to the outcomes of native versus graft PCI after CABG.

Methods

We performed a retrospective study in a tertiary reference cardiac centre of consecutive patients who underwent PCI after CABG. The data were collected for patients who underwent either native or graft PCI from January 2008 to December 2018. Major adverse cardiac events (MACE) included death or myocardial infarction (MI) or revascularization. All outcomes were assessed at 1-year after each index procedure.

Results

A total of 445 PCI were performed in 410 patients (209 had native PCI and 201 had graft PCI). The groups of patients with native vessel PCI and graft PCI were statistically comparable regarding their baseline characteristics. In multivariable Cox regression graft PCI relative to native PCI was an independent risk factor for MACE (hazard ratio [HR] 1.818, 95% confidence interval [CI] 1.148–2.878).

Conclusion

Compared with native coronary PCI, bypass graft PCI was significantly associated with higher incidence of MACE at 1-year and this was mainly driven by MI and revascularization.

MACE outcomes

Funding Acknowledgement

Type of funding source: None

Hospital admission with non-alcoholic fatty liver disease is associated with increased all-cause mortality independent of cardiovascular risk factors

Non-alcoholic fatty liver disease (NAFLD) is common and strongly associated with the metabolic syndrome. Though NAFLD may progress to end-stage liver disease, the top cause of mortality in NAFLD is cardiovascular disease (CVD). Most of the data on liver-related mortality in NAFLD derives from specialist liver centres. It is not clear if the higher reported mortality rates in individuals with non-cirrhotic NAFLD are entirely accounted for by complications of atherosclerosis and diabetes. Therefore, we aimed to describe the CVD burden and mortality in NAFLD when adjusting for metabolic risk factors using a ‘real world’ cohort. We performed a retrospective study of patients followed-up after an admission to non-specialist hospitals with a NAFLD-spectrum diagnosis. Non-cirrhotic NAFLD and NAFLD-cirrhosis patients were defined by ICD-10 codes. Cases were age-/sex-matched with non-NAFLD hospitalised patients. All-cause mortality over 14-years follow-up after discharge was compared between groups using Cox proportional hazard models adjusted for demographics, CVD, and metabolic syndrome components. We identified 1,802 patients with NAFLD-diagnoses: 1,091 with non-cirrhotic NAFLD and 711 with NAFLD-cirrhosis, matched to 24,737 controls. There was an increasing burden of CVD with progression of NAFLD: for congestive heart failure 3.5% control, 4.2% non-cirrhotic NAFLD, 6.6% NAFLD-cirrhosis; and for atrial fibrillation 4.7% control, 5.9% non-cirrhotic NAFLD, 12.1% NAFLD-cirrhosis. Over 14-years follow-up, crude mortality rates were 14.7% control, 13.7% non-cirrhotic NAFLD, and 40.5% NAFLD-cirrhosis. However, after adjusting for demographics, non-cirrhotic NAFLD (HR 1.3 (95% CI 1.1–1.5)) as well as NAFLD-cirrhosis (HR 3.7 (95% CI 3.0–4.5)) patients had higher mortality compared to controls. These differences remained after adjusting for CVD and metabolic syndrome components: non-cirrhotic NAFLD (HR 1.2 (95% CI 1.0–1.4)) and NAFLD-cirrhosis (HR 3.4 (95% CI 2.8–4.2)). In conclusion, from a large non-specialist registry of hospitalised patients, those with non-cirrhotic NAFLD had increased overall mortality compared to controls even after adjusting for CVD.

One-year outcomes of percutaneous coronary intervention in native coronary arteries versus saphenous vein grafts in patients with prior coronary artery bypass graft surgery

BACKGROUND

Patients with prior coronary artery bypass graft (CABG) surgery often require percutaneous coronary intervention (PCI). Data are still limited in regards to the outcomes of native saphenous vein graft (SVG) PCI after CABG.

METHODS

We performed a retrospective study in a tertiary reference cardiac center of consecutive patients who underwent PCI after CABG. The data were collected for patients who underwent either native or graft PCI from January 2008 to December 2018. Arterial graft PCIs were excluded. Multivariable Cox regression analysis with propensity matching was performed, and major adverse cardiac events (MACE) outcomes including death or myocardial infarction (MI) or revascularization were assessed at 1-year after each index procedure.

RESULTS

A total of 435 PCI were performed in 401 patients (209 had native PCI and 192 had graft PCI). Target lesions were classified as following: 235 (54%) native coronary arteries and 200 (46%) SVG. Propensity matching resulted in 167 matched pairs. In multivariable Cox regression graft PCI relative to native PCI was an independent risk factor for MACE (hazard ratio [HR] 1.725, 95% confidence interval [CI] 1.049-2.837) which was primarily driven by increased incidence in revascularization (HR 2.218, 95% CI 1.193-4.122) and MI (HR 2.248, 95% CI 1.220-4.142) and with no significant difference in mortality (HR 1.118, 95% CI 0.435-2.870).

CONCLUSIONS

Compared with native coronary PCI, bypass graft PCI was significantly associated with higher incidence of MACE at 1-year and this was mainly driven by MI and revascularization.

Meta-Analysis Comparing Percutaneous to Surgical Access in Trans-Femoral Transcatheter Aortic Valve Implantation

To compare the outcomes in trans-femoral transcatheter aortic valve implantation (TF-TAVI) performed with percutaneous approach (PC) versus surgical cut-down (SC). In 13 trials including 5,859 patients (PC = 3447, SC = 2412), the outcomes based on Valve Academic Research Consortium criteria were compared between PC and SC in TF-TAVI. Compared with SC, PC was associated with similar major vascular complications (VCs) (8.7% vs 8.5%; odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.76 to 1.15, p = 0.53), major bleeding (OR = 1.09, 95% CI = 0.66 to 1.8, p = 0.73), perioperative mortality (5.7% vs 5.2%; OR = 1.13, 95% CI = 0.85 to 1.49, p = 0.4), urgent surgical repair (OR = 1.27, 95% CI = 0.81 to 2.02, p = 0.3), stroke (3.3% vs 3.9%; OR = 0.85, 95% CI = 0.53 to 1.36, p = 0.5), myocardial infarction (1.3% vs 1.1%; OR = 1.06, 95% CI = 0.53 to 2.12, p = 0.86), and renal failure (5.2% vs 5.9%; OR = 0.68, 95% CI = 0.38 to 1.22, p = 0.2), but shorter hospital stay (9.1 ± 8.5 vs 9.6 ± 9.5 days; mean difference = -1.07 day, 95% CI = -2.0 to -0.15, p = 0.02) and less blood transfusion (18.5% vs 25.7%; OR = 0.61, 95% CI = 0.43-0.86, p = 0.005). Minor VCs occurred more frequently in PC compared to SC (11.9% vs 6.9%; OR = 1.67, 95% CI = 1.04-2.67, p = 0.03). In conclusion, in TF-TAVI, PC is a safe and feasible alternative to SC, and adopting either approach depends on operator experience after ensuring that vascular access could be safely achieved with that specific technique.

Initial experience of a self-expanding transcatheter aortic valve with an outer pericardial wrap: The United Kingdom and Ireland Implanters' registry

OBJECTIVES

The United Kingdom and Ireland Implanters' registry is a multicenter registry which reports on real-world experience with new transcatheter heart valves.

BACKGROUND

The Evolut PRO (Medtronic, Minneapolis, MN) transcatheter aortic valve is a self-expanding transcatheter aortic valve with an outer pericardial wrap, designed to minimize paravalvular regurgitation.

METHODS

Between July 2017 and December 2018, clinical, procedural, and 30-day outcome data were prospectively collected from all patients receiving the Evolut PRO valve across nine participating centers in the United Kingdom and Ireland. The primary efficacy outcome was the Valve Academic Research Consortium-2 (VARC-2)-defined endpoint of device success. The primary safety outcome was the VARC-2-defined composite endpoint of early safety at 30 days.

RESULTS

A total of 317 patients underwent implantation. Mean age was 81.8 ± 6.4 years and Society of Thoracic Surgeons Predicted Risk of Mortality Score 5.5 ± 1.8%. Iliofemoral access was used in 99.1% of patients. Device success was 91.2%. Mean gradient was 7.6 ± 4.7 mmHg and effective orifice area 1.9 ± 0.7 cm² . The incidence of moderate paravalvular regurgitation was 1.7% and there was no severe paravalvular regurgitation. A new permanent pacemaker was implanted in 17.8% of patients without a pacemaker at baseline. Early safety was demonstrated in 92.7%. At 30 days, all-cause mortality was 0.6%, stroke 3.8%, and major vascular complication 2.8%.

CONCLUSIONS

Real-world experience of the Evolut PRO transcatheter aortic valve demonstrated favorable procedural success, safety, valve function, and incidence of new permanent pacemaker implantation.

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial

BACKGROUND

Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months.

METHODS

We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed.

FINDINGS

Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed.

INTERPRETATION

Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI.

FUNDING

British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden.

P2797Clinical outcomes of an ultra-thin strut sirolimus-eluting stent with biodegradable polymer in all-comers patients undergoing coronary intervention

Background

Thin stent struts may be associated with reduced vessel injury and use of biodegradable polymers may further improve long term outcomes. However, data with earlier stents has been inconsistent; thus further studies with newer devices are needed.

Purpose

To evaluate the efficacy and safety of a new ultra-thin (65um) strut cobalt chromium sirolimus-eluting stent with a hybrid design (closed cell at ends and open cells in middle to reduce edge injury and optimise conformability) in all-comers patients undergoing percutaneous coronary intervention (PCI).

Methods

We enrolled 752 patients from 14 sites undergoing PCI into a prospective, non-randomised, multi-centre, open-label, observational registry. Inclusion of patients with complex anatomy (long stent lengths, bifurcations and chronic total occlusions) was encouraged. Clinical follow-up was scheduled at 1, 9, 12 and 24 months. The primary endpoint was incidence of major adverse cardiac events (MACE) - cardiac death, non-fatal myocardial infarction (MI), or target vessel revascularization (TVR) - at 9 months.

Results

Mean patient age was 64.7±12.2 years, 20.7% had diabetes, 58.8% had dyslipidaemia, 40.4% had multi-vessel disease, 22% had previous PCI, 4.7% had previous coronary-artery bypass graft, and 19.6% had a clinical history of previous MI. Mean lesion length was 25.7±17.3 mm. The primary endpoint of cumulative MACE up to 9 months (from 624 patients reaching 9 months follow-up) occurred in 12 patients (1.92%), including 6 (0.96%) cardiac death, 5 (0.80%) MI and 6 (0.96%) clinically indicated TVR. Definite stent thrombosis was reported in 3 patients (0.48%) and probable stent thrombosis in 2 patients (0.32%).

Conclusions

Use of an ultra-thin strut biodegradable polymer sirolimus-eluting stent in all-comers patients undergoing PCI was associated with good clinical efficacy and safety.

Acknowledgement/Funding

Meril Life

P6381Cardiac arrest patients presenting to hospitals at weekends are not subject to the weekend effect: insights from ACALM big data, United Kingdom

Introduction

Patients presenting to hospital with a cardiac arrest are associated with significant mortality in the United Kingdom. The evidence for the weekend affect involving cardiac arrests is unclear and we investigated this further with ACALM big data.

Methods

Anonymous information on patients presenting to hospital with a cardiac arrest was obtained from several hospitals in UK between 2000–2014. ICD-10 and OPCS-4 codes were used to trace patients coded for primary cardiac arrest, co-morbidities and mortality data.

Results

Details of 4803 patients presenting with cardiac arrest is shown in Table1. Cox regression model including age, gender, ethnic group, Charlson score and the top ten causes of death in the UK showed that weekend presentation did not contribute to increased mortality (OR 1.01; 95%C.I 0.94–1.11; p=0.692)

Table 1. Demographics and co-morbidities of cardiac arrest patients presenting on weekdays and weekends Weekday Weekend N (%) 3892 (81.0) 919 (19.0) Mean age ± S.D (years) 67.7±16.6 67.4±17.5 Male, % 55.4 54.1 Co-morbidities   Mean Charlson Index 1.52 1.33   Heart Failure % 21.4 20.4   IHD % 38.4 37.1   Cancer (Lung, Breast or Colon) % 5.2 3.8   Cerebrovascular Disease % 6.4 6.3   COPD % 15.0 12.0   CKD % 9.4 7.7   Dementia % 4.7 2.6   Pneumonia % 14.7 14.4 Outcomes   Crude 30 day mortality % 25.4* 32.8*   Crude 1 year mortality % 41.0* 44.3* *Cox regression analyses showed no significant differences in mortality between weekend and weekday presentation.

Conclusion

We have demonstrated that the “weekend effect” is not present in patients admitted to hospital with cardiac arrest. Our findings can perhaps be explained by the presence of 24/7 cardiac arrest teams present in acute hospitals.

Initial experience of a large, self-expanding, and fully recapturable transcatheter aortic valve: The UK & Ireland Implanters' registry

OBJECTIVES

The UK & Ireland Implanters' registry is a multicenter registry which reports on real-world experience with novel transcatheter heart valves.

BACKGROUND

The 34 mm Evolut R transcatheter aortic valve is a self-expanding and fully recapturable transcatheter aortic valve, designed to treat patients with a large aortic annulus.

METHODS

Between January 2017 and April 2018, clinical, procedural and 30-day outcome data were prospectively collected from all patients receiving the 34 mm Evolut R valve across 17 participating centers in the United Kingdom and Ireland. The primary efficacy outcome was the Valve Academic Research Consortium-2(VARC-2)-defined endpoint of device success. The primary safety outcome was the VARC-2-defined composite endpoint of early safety at 30 days.

RESULTS

A total of 217 patients underwent attempted implant. Mean age was 79.5 ± 8.8 years and Society of Thoracic Surgeons Predicted Risk of Mortality Score 5.2% ± 3.4%. Iliofemoral access was used in 91.2% of patients. Device success was 79.7%. Mean gradient was 7.0 ± 4.6 mmHg and effective orifice area 2.0 ± 0.6 cm² . Paravalvular regurgitation was more than mild in 7.2%. A new permanent pacemaker was implanted in 15.7%. Early safety was demonstrated in 91.2%. At 30 days, all-cause mortality was 3.2%, stroke 3.7%, and major vascular complication 2.3%.

CONCLUSIONS

Real-world experience of the 34 mm Evolut R transcatheter aortic valve demonstrated acceptable procedural success, safety, valve function, and incidence of new permanent pacemaker implantation.

Balloon assisted retraction of a migrated CoreValve Evolut R bioprosthesis during cardiac arrest

We describe a case of balloon assisted retraction of a migrated CoreValve Evolut R bioprosthesis during trans-femoral TAVI.

Off-pump coronary artery bypass in poland syndrome with dextrocardia: case report

Poland Syndrome is a congenital disorder characterised by hypoplasia of the pectoral muscles along with upper extremity deformities. We encountered a patient with Poland syndrome associated with dextrocardia and also failed pectus excavatum repairs who presented to us with symptomatic ischaemic heart disease requiring intervention. He underwent successful off-pump coronary artery bypass surgery (OPCABG). As far as we are aware, this is the first case report of OPCABG in a case of Poland syndrome with dextrocardia. We describe here the management of this complex patient and wish to emphasise that the off-pump option is feasible in dextrocardia with some technical modifications.

Tongue swelling complicating management of a ventilated patient with acute respiratory distress syndrome secondary to novel influenza A (H1N1)

The recently emerged novel influenza A H1N1 virus continues to spread globally. The use of oseltamivir for treatment and prophylaxis of infection is recommended and its use has climbed steeply although there is little data available on its benefit in critically unwell patients with H1N1 influenza. A rare side-effect of oseltamivir treatment reported in post-marketing surveillance is tongue and lip swelling/angioedema. This case report describes the management of a critically ill ventilated patient with severe acute respiratory distress syndrome who developed clinically significant tongue and lip swelling during treatment with oseltamivir.

Development of a multipurpose vacuum chamber for serial optical and diffraction experiments with free electron laser radiation

In this paper we present a development of a multipurpose vacuum chamber which primal function is to be used in pump/probe experiments with free electron laser (FEL) radiation. The chamber is constructed for serial diffraction and serial spectroscopy allowing a fast exchange of samples during the measurement process. For the fast exchange of samples, liquid jet systems are used. Both applications, utilizing soft x-ray FEL pulses as pump and optical laser pulses as probe and vice versa are documented. Experiments with solid samples as well as the liquid jet samples are presented. When working with liquid jets, a system of automatically refilled liquid traps for capturing liquids has been developed in order to ensure stable vacuum conditions. Differential pumping stages are placed in between the FEL beamline and the experimental chamber so that working pressure in the chamber can be up to four orders of magnitude higher than the pressure in the FEL beamline.

Percutaneous coronary intervention in a patient with von Willebrand's disease presenting with an acute coronary syndrome

The optimal management strategy for patients with von Willebrand's disease presenting with acute coronary syndromes is unclear. We present a clinical case of percutaneous coronary intervention following an acute coronary syndrome in a man with von Willebrand's disease. Other published case reports are reviewed. The central role of von Willebrand factor in the pathophysiology of acute coronary syndrome and the possible cardioprotective effects of low levels of the protein are discussed. Practical considerations regarding hemostasis and antiplatelet therapy are addressed. Finally, recommendations for the management of patients with von Willebrand's disease presenting with acute coronary syndromes are suggested.

Effects of transvenous pacing on cardiac troponin release

Cardiac troponins are invaluable tools for the detection of minimal myocardial injury. No study to date has analyzed the effect of permanent cardiac pacing on minimal myocardial injury detection by cardiac troponin I (cTnI) measurement. We investigated 76 clinically stable patients (mean age 75 years, range 31-93 years, 59% men) listed for elective endocardial permanent pacemaker insertion. Patients were required to have normal levels of cardiac cTnI, aspartate transaminase (AST) and creatinine kinase (CK) on a venous blood sample taken immediately prior to elective pacemaker implantation. Repeat measurements of AST, CK, and cTnI were performed at a mean of 19.2 post implantation. There was a detectable small rise in cTnI levels above normal in 21% of patients in a second blood sample taken 18-21 hours later (mean cTnI 0.39 +/- 0.37 microg/L, normal < 0.15 microg/L). The only factor that correlated with this rise was prolonged x ray screening time for lead implantation.

GPIIbIIIa inhibitors as adjunctive therapy in acute myocardial infarction

Thrombolytic therapy has proved useful in the treatment of acute myocardial infarction but is frequently associated with limited vessel reperfusion and early reocclusion. Local platelet aggregation and activation play a role in these pathological processes, explaining the benefit of aspirin, a weak antiplatelet agent. Recent interest has turned to GPIIbIIIa antagonists, a class of potent inhibitors of platelet aggregation. Their concomitant use with fibrinolytics, in rescue and primary angioplasty for acute myocardial infarction treatment is explored. Efficacy and safety issues are addressed and the potential pivotal role of these agents in the treatment of acute myocardial infarction is discussed.

Soluble adhesion molecules in reperfusion during coronary bypass grafting

OBJECTIVE

Adhesion of activated leukocytes to the endothelial cells as a result of myocardial ischaemia/reperfusion during open chest coronary artery surgery has been shown to be involved in the development of tissue damage. Activated leukocytes adhere to endothelium via adhesion molecules expressed by both cell types, resulting in the impairment of coronary capillary flow. Upon cell activation, adhesion proteins may be released in the soluble form to circulating blood. The purpose of our study was to verify whether myocardial ischaemia/reperfusion occurring during coronary artery bypass grafting results in release of the soluble adhesion molecules VCAM-1, ICAM-1, E-selectin and L-selectin into the circulation.

METHODS

Plasma levels of the soluble adhesion molecules were measured in vein, arterial and coronary sinus blood samples taken from 15 patients undergoing coronary artery bypass grafting (CABG). Blood samples for estimations were collected during the procedure: before aorta cross-clamping, at the beginning of reperfusion and 30 min after reperfusion. Soluble adhesion molecules levels were measured by standard ELISA assays.

RESULTS

Mean plasma levels of soluble VCAM-1 in arterial samples increased significantly at the beginning of reperfusion and 30 min after reperfusion. In contrast, soluble L-selectin plasma levels in arterial samples remained unchanged. In coronary sinus samples, levels of soluble ICAM-1 significantly increased 30 min after reperfusion. Moreover, in coronary sinus samples collected 30 min after reperfusion, soluble ICAM-1 levels were significantly higher than in arterial samples obtained at the same time. The mean concentration of soluble E-selectin in samples obtained from coronary sinus decreased significantly 30 min after reperfusion. Moreover, plasma levels of soluble E-selectin in coronary sinus samples obtained 30 min after reperfusion were significantly decreased compared with these observed in arterial samples collected at the same time.

CONCLUSIONS

The reperfusion of ischaemic myocardium during CABG results in a significant increase in plasma levels of the soluble endothelial adhesion molecules VCAM-1 and ICAM-1 and significant decrease in soluble E-selectin plasma levels. L-selectin plasma levels during CABG procedure remain unchanged. We propose that the increased plasma concentrations of soluble VCAM-1 and ICAM-1 are a result of endothelial cell activation during ischaemia/reperfusion following bypass surgery.

The release of soluble adhesion molecules ICAM-1 and E-selectin after acute myocardial infarction and following coronary angioplasty

Endothelial cells express surface adhesion molecules for leukocytes in response to myocardial ischaemia. These molecules may be released into plasma by activated cells and be detectable in soluble form. Samples were collected from the peripheral vein of 14 consecutive patients with acute myocardial infarction (AMI) at the time of admission, 6 h, and 1 and 5 days post-admission. Additionally, samples were drawn from the coronary sinus ostium and peripheral artery of seven patients undergoing coronary angioplasty (PTCA) before and after the first balloon inflation. We measured the plasma levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble E-selectin (sELAM-1). In patients with AMI plasma levels of sICAM-1 exceeded those observed in age and sex-matched healthy subjects, (mean+/-SEM; 220.6+/-18 ng/ml) at all the time intervals assessed (358.9+/-24.5; 330.9+/-24.4; 379.4+/-39.7 and 366.8+/-47.5 ng/ml, respectively, p<0.01). sELAM-1 levels, however, were normal on admission, increased at 6 h to 52.7+/-3.8 ng/ml, p<0.05, and at day 1 (56.0+/-4.6 ng/ml) before decreasing to normal levels on the fifth day. After brief myocardial ischaemia occurring during PTCA, an increased level of sICAM-1 was observed following balloon deflation in the coronary sinus (329.2+/-20 ng/ml; p<0.05) as compared to the subjects undergoing coronary angiography, but not in the peripheral artery. sELAM-1 levels remained unchanged during angioplasty. Thus, soluble adhesion molecules expressed by activated endothelial cells are released into peripheral blood during both AMI and brief myocardial ischaemia and measurement of such molecules may prove useful for monitoring vascular endothelium activation following myocardial ischaemia/necrosis.

Delay times in the administration of thrombolytic therapy: the Brighton experience

We reviewed the effectiveness of a strategy involving paramedic ambulances and community education to reduce the delay to thrombolytic therapy in patients admitted with acute myocardial infarction, by analysing delay times recorded during routine treatment. Rapid identification and treatment of patients with acute myocardial infarction who were eligible for thrombolysis was carried out in the Accident and Emergency and Cardiac Care Units. Two hundred seventy-four patients were admitted with acute myocardial infarction over an 18-month period and treated with anistreplase (168) or streptokinase (106). The following median times were recorded: symptom onset to administration of thrombolytic therapy, 142 min (range 43-980 min); symptom onset to ambulance arrival, 60 min; ambulance with patient to arrival in hospital, 35 min; time to treatment in hospital ('door to needle time'), 25 min; in-hospital delays were notably shorter for patients given anistreplase as opposed to streptokinase. Shortened delays for the delivery of thrombolytic therapy can be achieved by a strategy involving public education, the availability of resuscitation ambulances, and close liaison with the Accident and Emergency Department.

Effect of intraluminal application of tissue-type plasminogen activator on the fibrinolytic activity of experimental vein grafts

OBJECTIVE

The aim was to quantify the effect of intraluminally applied tissue-type plasminogen activator (tPA) on the fibrinolytic activity of experimental vein grafts and assess the effect of pretreatment of the vein on early platelet and thrombus formation using histological techniques.

METHODS

A pig model of bilateral saphenous venin-carotid artery grafts was used. In each animal one side of the neck was grafted using vein distended to 230 mm Hg and pretreated with tPA (1 mg.ml-1) for a period of 15 min before grafting (treated graft). The perfused in situ for 2 h after implantation and before analysis. Changes in local fibrinolytic activity were quantified using fibrin plate techniques and specific chromogenic assays for tPA and urokinase (uPA) in tissue extract (n = 6 animals). Histological assessment was made using light and scanning microscopy (n = 4 animals).

RESULTS

Surgical preparation and distention significantly reduced the fibrinolytic activity of pig saphenous vein in terms of areas of lysis produced on fibrin plates (P < 0.05), tPA activity (P < 0.05), and uPA activity (P < 0.05). Pretreatment of distended vein with tPA before grafting significantly enhanced its fibrinolytic activity after 2 h perfusion compared to control (untreated) grafts, as assessed by areas of lysis on fibrin plates (P < 0.05) and specific tPA activity (P < 0.05). Treated grafts also showed qualitatively less platelet and thrombus formation on histological examination.

CONCLUSIONS

Pretreatment of surgically harvested vein by intraluminal application of tPA before grafting enhances its fibrinolytic activity after exposure to 2 h perfusion in vivo. This technique requires further investigation to validate its potential as a means of providing local anticoagulation to veins implanted as arterial grafts thereby reducing the incidence of early graft thrombosis.

Collagen fiber architecture of bovine pericardium

Small-angle light scattering (SALS) was used to quantify the collagen fiber architecture of 12 bovine pericardium (BP) specimens overlying the right and left anterior surfaces of the heart. The collagen fiber architecture was described in terms of preferred collagen fiber directions, volume fractions (Vf), and degree of orientation. To explore the relationship between BP collagen architecture and mechanical anisotropy, biaxial mechanical tests were performed on two specimens chosen for their extremes of collagen fiber architecture. About 38% of the SALS test locations showed the occurrence of two distinct collagen fiber populations, with the primary population Vf typically 90%. Structurally, the left anterior specimens appeared to be the most homogeneous, with an overall preferred direction close to the circumferential direction of the heart. The right side specimens were inconsistent, with a broad range of fiber orientations. The direction of greatest stiffness was consistent with the underlying collagen fiber architecture. Overall, these results suggest that 1) the mechanical behavior of BP is quantitatively consistent with its collagen fiber architecture; 2) the variability of BP mechanical anisotropy is caused by variations in collagen fiber preferred directions; and 3) the left anterior side of the bovine pericardial sac might be a good material selection site for bioprosthesis fabrication.