The Association of Incidental Radiation Dose to the Heart Base with Overall Survival and Cardiac Events after Curative-intent Radiotherapy for Non-small Cell Lung Cancer: Results from the NI-HEART Study

AIMS

Cardiac disease is a dose-limiting toxicity in non-small cell lung cancer radiotherapy. The dose to the heart base has been associated with poor survival in multiple institutional and clinical trial datasets using unsupervised, voxel-based analysis. Validation has not been undertaken in a cohort with individual patient delineations of the cardiac base or for the endpoint of cardiac events. The purpose of this study was to assess the association of heart base radiation dose with overall survival and the risk of cardiac events with individual heart base contours.

MATERIALS AND METHODS

Patients treated between 2015 and 2020 were reviewed for baseline patient, tumour and cardiac details and both cancer and cardiac outcomes as part of the NI-HEART study. Three cardiologists verified cardiac events including atrial fibrillation, heart failure and acute coronary syndrome. Cardiac substructure delineations were completed using a validated deep learning-based autosegmentation tool and a composite cardiac base structure was generated. Cox and Fine-Gray regressions were undertaken for the risk of death and cardiac events.

RESULTS

Of 478 eligible patients, most received 55 Gy/20 fractions (96%) without chemotherapy (58%), planned with intensity-modulated radiotherapy (71%). Pre-existing cardiovascular morbidity was common (78% two or more risk factors, 46% one or more established disease). The median follow-up was 21.1 months. Dichotomised at the median, a higher heart base Dmax was associated with poorer survival on Kaplan-Meier analysis (20.2 months versus 28.3 months; hazard ratio 1.40, 95% confidence interval 1.14-1.75, P = 0.0017) and statistical significance was retained in multivariate analyses. Furthermore, heart base Dmax was associated with pooled cardiac events in a multivariate analysis (hazard ratio 1.75, 95% confidence interval 1.03-2.97, P = 0.04).

CONCLUSIONS

Heart base Dmax was associated with the rate of death and cardiac events after adjusting for patient, tumour and cardiovascular factors in the NI-HEART study. This validates the findings from previous unsupervised analytical approaches. The heart base could be considered as a potential sub-organ at risk towards reducing radiation cardiotoxicity.

Simulation CT Features and Radiation Cardiotoxicity in Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Radiation cardiotoxicity is a significant clinical dilemma in non-small cell lung cancer (NSCLC) radiation therapy (RT). Baseline cardiovascular (CV) status may influence the risk of cardiotoxicity, and may be ascertainable from the appearance of the heart on simulation computed tomography (CT). We examined the association of CT features with incidental heart dose and risk of cardiac events in NSCLC.

MATERIALS/METHODS

Patients treated with curative-intent RT between 2015 and 2020 at a regional center were identified. Clinical notes were interrogated for baseline patient and CV health details, and follow-up CV events. Cardiac events were verified by a cardiologist. A deep learning-based auto-segmentation tool was applied, allowing extraction of a pre-specified list of volume parameters in a programming environment. CAC was graded as none, mild, moderate and severe in patients with a non-contrast scan. The craniocaudal relationship of the PTV and heart (Feng atlas) were annotated.

RESULTS

A total of 478 patients were included, with a median age of 70 and Charlson Index of 5. The median mean heart dose was 6.3 Gy (IQR 2.7-11.4). The median lung V20 was 20.0% (IQR 14.8-27.1). Cardiovascular risk factors were common, with most patients having 2 (39%) or 3 (31%). A history of previous cardiac events was common, including myocardial infarction (14%), arrhythmia (11%) or heart failure (9%). A total of 6.9% and 7.1% patients developed a new atrial arrhythmia (AA) or heart failure (HF) after completing RT. The volume metrics with the highest AUC for AA and HF events were the left atrium (LA) (AUC 0.67, p = 0.0002) and left ventricle:right ventricle (LV:RV) ratio (AUC 0.66, p = 0.0021). Kaplan-Meier analysis for cardiac events dichotomizing at the optimal cut-point for maximum sensitivity and specificity demonstrated significantly different rates for both AA (LA 109cc, HR 3.35, 95% CI 1.64-6.83, p = 0.0009) and HF (LV:RV ratio 1.61, HR 2.37, 95% CI 1.19-4.74, p = 0.0143). Only 2 patients with non-contrast scans developed a myocardial infarction, both had mild CAC. The incidence of pooled cardiac events was not significantly different between patients with no (n = 2/21, 9.5%), mild (n = 10/38, 26.3%), moderate (n = 8/53, 15.1%) and severe (n = 7/24, 29.2%) CAC (p = 0.3916). Where the inferior border of the PTV was above the superior border of the heart, mean heart dose was significantly lower than compared with overlap of levels (1.9 Gy v 9.7 Gy, p<0.0001), and this was true for 3DCRT (n = 139, p<0.001), IMRT (n = 94, p<0.001) and VMAT (n = 145, p<0.001) patients.

CONCLUSION

LA volume and LV:RV volume ratio are predictive for the development of AA and HF respectively. CAC grade did not differentiate patients by risk of cardiac events. Where the craniocaudal level of the PTV doesn't overlap with the level of the heart, the cardiac dose is likely to be very low. Several simulation CT features are associated with cardiac events following treatment for NSCLC and prospective evidence of cardiac risk could enable medical optimization prior to RT.

Patient-Level and Endpoint-Specific Clinico-Dosimetric Analysis of the Cardiac Base as a Mediator of Radiation Cardiotoxicity in Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

Cardiac disease is a dose-limiting toxicity in non-small cell lung cancer (NSCLC) radiation therapy. Radiation dose to the cardiac base is associated with poor overall survival in several clinical studies, but has not been validated in a non-dose escalated cohort, or with individual patient delineations. In this study we examined the impact of cardiac base dose on overall survival (OS) and cardiac events (CEs), and interrogated the relationships of the substructures comprising the heart base with OS and CEs.

MATERIALS/METHODS

Patients with stage I-III NSCLC treated with curative-intent radiation therapy between 2015 and 2020 at a regional cancer center were identified. Clinical notes were examined for baseline patient, tumor and cardiac details, and both cancer and cardiac outcomes. Three cardiologists verified CEs. Cardiac delineations were completed using a validated deep learning-based autosegmentation tool. Cox and Fine and Gray regressions were undertaken for the risk of death and CEs respectively, accounting for pre-specified evidence-based dose metrics and clinically relevant cardiac covariates.

RESULTS

Most patients received 55 Gy/20# (n = 461/478, 96%) without chemotherapy (58%), planned with VMAT (51%) or IMRT (20%). Pre-existing cardiovascular morbidity was common, with 78% having ≥2 risk factors, and 46% having >1 established cardiac disease. The median follow-up was 21.1 months. Dichotomized at the median, higher heart base Dmax was associated with poorer survival on Kaplan-Meier analysis (21.6 months (95% CI 19.3-24.9) versus 29.4 months (95% CI 21.6-36.6), p = 0.021), and remained significant when statistically compared in published multivariate models. In a multivariate analysis for pooled acute CEs, heart base Dmax was associated with CEs (HR 1.75, 95% CI 1.01-1.06, p = 0.04), but this was not the case for individual CEs. Using Fine and Gray models to account for the competing risk of death, left main coronary maximum dose was associated with atrial fibrillation (p = 0.024), proximal right coronary artery V15 (p = 0.023) and mean dose (p = 0.032), and the right atrium mean dose (p = 0.029) were associated with heart failure. No dose-volume metrics were significantly associated with acute coronary syndrome. None of the constituent base substructures dose were significantly associated with death.

CONCLUSION

Dose to the heart base was associated with increased mortality and an increased pooled cardiac event rate. Accounting for endpoint-specific clinical covariates, only select constituent substructures of the heart base were associated with CEs and no substructures were independently associated with survival. Together, these findings are suggestive of possible interplay between the constituent base substructures in their mediation of radiation cardiotoxicity.

Association between statin therapy dose intensity and radiation cardiotoxicity in non-small cell lung cancer: Results from the NI-HEART study

INTRODUCTION

Radiation cardiotoxicity is a dose-limiting toxicity and major survivorship issue for patients with non-small cell lung cancer (NSCLC) completing curative-intent radiotherapy, however patients' cardiovascular baseline is not routinely optimised prior to treatment. In this study we examined the impact of statin therapy on overall survival and post-radiotherapy cardiac events.

METHODS

Patients treated between 2015-2020 at a regional center were identified. Clinical notes were interrogated for baseline patient, tumor and cardiac details, and both follow-up cancer control and cardiac events. Three cardiologists verified cardiac events. Radiotherapy planning scans were retrieved for application of validated deep learning-based autosegmentation. Pre-specified Cox regression analyses were generated with varying degrees of adjustment for overall survival. Fine and Gray regression for the risk of cardiac events, accounting for the competing risk of death and cardiac covariables was undertaken.

RESULTS

Statin therapy was prescribed to 59% of the 478 included patients. The majority (88%) of patients not prescribed a statin had at least one indication for statin therapy according to cardiovascular guidelines. In total, 340 patients (71%) died and 79 patients (17%) experienced a cardiac event. High-intensity (HR 0.68, 95%CI 0.50-0.91, p = 0.012) and medium-intensity (HR 0.70, 95%CI 0.51-0.97, p = 0.033) statin therapy were associated with improved overall survival after adjustment for patient, cancer, treatment, response and cardiovascular clinical factors. There were no consistent differences in the rate or grade of cardiac events according to statin intensity.

CONCLUSIONS

Statin therapy is associated with improved overall survival in patients receiving curative-intent radiotherapy for NSCLC, and there is evidence of a dose-response relationship. This study highlights the importance of a pre-treatment cardiovascular risk assessment in this cohort. Further studies are needed to examine if statin therapy is cardioprotective in patients undergoing treatment for NSCLC with considerable incidental cardiac radiation dose and a low baseline cardiac risk.

Sex-based difference in fractional flow reserve and its impact on clinical outcomes

BACKGROUND

Obesity is a real public health problem and is of growing concern. People are resorting to surgical or endoscopic means to fight against overweight and obesity. In recent years, there has been a marked increase in the use of these means and in particular the insertion of a gastric balloon which seems to present less risk than surgical methods. Renal complications from intragastric balloon placement are extremely rare. We report here the case of compression of the left renal vein revealed by lumbar pain and hematuria in an overweight 39-year-old woman who benefited from the balloon gastric placement one month before symptoms. The scanner made the diagnosis and showed a good evolution after the withdrawal of the balloon.

METHODS

This was a prespecified and retrospective analysis of all consecutive patients who underwent FFR assessment for intermediate coronary lesions between January 2014 and December 2015. The primary endpoint was defined as the 1-year composite of cardiac death, vessel-related myocardial infarction, and clinically-driven target vessel revascularization.

RESULTS

In 1554 lesions (23% in women), FFR was lower in men [0.83 ±0.09 vs 0.85 ±0.08, P = .004] driven by LAD values (for LAD P < .001, LCx or RCA P> .40). In proximal lesions (PLs), FFR was lower in men [0.83 ±0.10 vs 0.85 ±0.08, P = .004] with comparable values in non-PLs [0.84 ±0.09 vs 0.85 ±0.08, P = .36]. In PLs, the primary endpoint was higher in women [HR_(adjusted) 3.18 (1.08-9.37), P = .035] with comparable outcomes in non-PLs (P = .032 for interaction). In deferred lesions, the primary endpoint was higher in women [HR_(adjusted) 2.73 (1.10-6.74), P = .03] with no differences in revascularized lesions across sex (P = .02 for interaction). Results were consistent when using propensity score matching analysis.

CONCLUSIONS

There is a sex-based difference in FFR, particularly in stenoses subtending large myocardium, and more evident in deferred lesions.

Clinical Outcomes of Deferred Revascularisation Using Fractional Flow Reserve in Diabetic Patients

BACKGROUND

Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery lesions. Diabetic patients are associated with high burden of atherosclerosis and microvascular dysfunction. We studied the clinical outcomes of diabetic patients who underwent FFR-guided deferred revascularisation.

METHODS

Consecutive patients from a single large volume centre who underwent FFR assessment were included. Clinical endpoints were prospectively collected using the national electronic care records system. The primary endpoint was defined as the four-year risk of the vessel-oriented composite outcome of cardiac death, vessel-related myocardial infarction (VMI), and vessel-related urgent revascularisation (VUR). Absolute FFR values groups (0.81 to 0.85; 0.86 to 0.90; and >0.90) were used to further stratify patient outcomes.

RESULTS

FFR-guided deferred revascularisation occurred in 860 patients (63%), of whom 159 were diabetic. The primary endpoint was significantly higher in the diabetic compared to the non-diabetic group [HR 1.76 (95%CI 1.08 to 2.88), P = 0.024]. The difference was driven from cardiac death (6.3% vs. 3.0%, P = 0.044) and VMI (5.0% vs. 1.7%, P = 0.012) but not VUR (8.8% vs. 5.1%, P = 0.07). There was a significant decrease in the incidence of the primary endpoint in the diabetic group according to FFR groups (23.6%, 12.3%, 2.4%, P = 0.001) with comparable clinical outcomes in the non-diabetic group (11.8%, 6.4%, 7.4%, P = 0.085).

CONCLUSIONS

Our study demonstrated an increased risk of death and target vessel MI in diabetic patients undergoing FFR-guided deferred revascularisation compared to non-diabetic group. Nonetheless, FFR remained a useful tool to identify those at future risk, mainly in diabetic patients.

The evolution of coronary stents

INTRODUCTION

Percutaneous coronary intervention (PCI) is 40 years old this year. From its humble beginnings of experimental work, PCI has transitioned over years with coronary artery stenting now a standard medical procedure performed throughout the world. Areas covered: The conversion from plain old balloon angioplasty (POBA) to the present era of drug eluting stents (DES) has been driven by many technological advances and large bodies of clinical trial evidence. The journey to present day practice has seen many setbacks, such as acute vessel closure with POBA; rates of instant restenosis with bare metal stents (BMS) and more recently, high rates of stent thrombosis with bioabsorbable platforms. This work discusses POBA, why there was a need for BMS, the use of inhibiting drugs to create 1^st generation DES, the change of components to 2^nd generation DES, the use of absorbable drug reservoirs and platforms, and possible future directions with Prohealing Endothelial Progenitor Cell Capture Stents. Expert commentary: This paper reviews the evolution from the original pioneering work to modern day practice, highlighting landmark trials that changed practice. Modern day contemporary practice is now very safe based on the latest drug eluting stents and supported by large datasets.

Management and Prevention of Saphenous Vein Graft Failure: A Review

Coronary artery bypass grafting (CABG) remains a vital treatment for patients with multivessel coronary artery disease (CAD), especially diabetics. The long-term benefit of the internal thoracic artery graft is well established and remains the gold standard for revascularization of severe CAD. It is not always possible to achieve complete revascularization through arterial grafts, necessitating the use of saphenous vein grafts (SVG). Unfortunately, SVGs do not have the same longevity, and their failure is associated with significant adverse cardiac outcomes and mortality. This paper reviews the pathogenesis of SVG failure, highlighting the difference between early, intermediate, and late failure. It also addresses the different surgical techniques that affect the incidence of SVG failure, as well as the medical and percutaneous prevention and treatment options in contemporary practice.

A Review of the Key Clinical Trials of 2015: Results and Implications

Introduction

Multiple significant, potentially practice changing clinical trials in cardiology have been conducted and subsequently presented throughout the past year.

Methods

In this paper, the authors have reviewed and contextualized significant cardiovascular clinical trials presented at major international conferences of 2015 including American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, American Diabetes Association, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics, Heart Rhythm Congress, and the American Heart Association Scientific Sessions.

Results

The authors describe new trial data for heart failure (including eplerenone, finerenone, patiromer, sacubitril/valsartan, the beta 3 agonist mirabegron, sitagliptin, empagliflozin, alginate-hydrogel LV epicardial implant), anticoagulation (idarucizumab and andexanet alfa reversal agents, adherence programmes, practice in ablation), transcatheter aortic valve replacement (long-term data, valve-in-valve use, the TriGuard embolic deflecting device), patent foramen ovale closure, cardiovascular prevention (PCSK9 inhibitors, hypertension treatment) and antiplatelets strategies (extended duration therapy with clopidogrel or ticagrelor). Trial data are also described for contemporary technologies including the Biofreedom polymer-free drug coated stent, bioabsorbable stents, PCI strategies, left main treatment, atrial fibrillation ablation techniques, leadless pacemakers and the role of coronary computed tomographic angiography.

Conclusions

This paper summarizes and contextualizes multiple pertinent 2015 clinical trials and will be of interest to both clinicians and cardiology researchers.

Serum- and HDL3-serum amyloid A and HDL3-LCAT activity are influenced by increased CVD-burden

BACKGROUND

High density lipoproteins (HDL) protect against cardiovascular disease (CVD). However, increased serum amyloid-A (SAA) related inflammation may negate this property. This study investigated if SAA was related to CVD-burden.

METHODS

Subjects referred to the rapid chest pain clinic (n = 240) had atherosclerotic burden assessed by cardiac computerised tomography angiography. Subjects were classified as: no-CVD (n = 106), non-obstructive-CVD, stenosis<50% (n = 58) or moderate/significant-CVD, stenosis ≥50% (n = 76). HDL was subfractionated into HDL2 and HDL3 by rapid-ultracentrifugation. SAA-concentration was measured by ELISA and lecithin cholesterol acyltransferase (LCAT) activity measured by a fluorimetric assay.

RESULTS

We illustrated that serum-SAA and HDL3-SAA-concentration were higher and HDL3-LCAT-activity lower in the moderate/significant-CVD-group, compared to the no-CVD and non-obstructive-CVD-groups (percent differences: serum-SAA, +33% & +30%: HDL3-SAA, +65% and +39%: HDL3-LCAT, -6% & -3%; p < 0.05 for all comparisons). We also identified a positive correlation between serum-SAA and HDL3-SAA (r = 0.698; p < 0.001) and a negative correlation between HDL3-SAA and HDL3-LCAT-activity (r = -0.295; p = 0.003), while CVD-burden positively correlated with serum-SAA (r = 0.150; p < 0.05) and HDL3-SAA (r = 0.252; p < 0.001) and negatively correlated with HDL3-LCAT-activity (r = -0.182; p = 0.006). Additionally, multivariate regression analysis adjusted for age, gender, CRP and serum-SAA illustrated that HDL3-SAA was significantly associated with modifying CVD-risk of moderate/significant CVD-risk (p < 0.05).

CONCLUSION

This study has demonstrated increased SAA-related inflammation in subjects with moderate/significant CVD-burden, which appeared to impact on the antiatherogenic potential of HDL. We suggest that SAA may be a useful biomarker to illustrate increased CVD-burden, although this requires further investigation.

The Essentials of Cardiac Computerized Tomography

Cardiac computerized tomography (CT) has evolved from a research tool to an important diagnostic investigation in cardiology, and is now recommended in European, US, and UK guidelines. This review is designed to give the reader an overview of the current state of cardiac CT. The role of cardiac CT is multifaceted, and includes risk stratification, disease detection, coronary plaque quantification, defining congenital heart disease, planning for structural intervention, and, more recently, assessment of ischemia. This paper addresses basic principles as well as newer evidence.

A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients

The elderly constitute a sizeable proportion of the acute coronary syndrome (ACS) population, and this population is continually increasing in number. Guideline-directed therapy is frequently underutilized in the elderly due to concerns about patient safety. However, studies suggest that this subgroup could benefit from many of the conventional and newer therapies available. This paper reviews current literature in the context of contemporary American and European guidance.

Addressing discrepancies: personal experience of a cardiac mission programme in Africa

The worldwide incidence of cardiovascular disease (CVD) is increasing, reflecting a combination of ongoing infective diseases and a rapid rise in traditional 'western' risk factors. It is estimated that in the next 20 years that CVD be the leading cause of death in developing nations. There are high incidences of rheumatic heart disease, coronary artery disease, cardiomyopathies, uncorrected congenital heart disease and human immunodeficiency virus (HIV) associated disease in many low-income countries. Such high levels combined with a lack of diagnostic tests and therapeutic options means mortality and morbidity rates are high. A number of charities and organizations have tried to address the discrepancy of cardiac care within developing areas although the needs remain great. However there is no one global cardiac organization that coordinates such humanitarian work. The challenges of missionary work include the need for appropriate facilities, financial constraints of clinical consumables, and lack of education of local healthcare staff, making the move away from the mission model difficult. The strategy for delivery of care in developing countries should be long term educational and technical support, so that local case volumes increase. However it must be realized that there are many different levels of local services within developing nations with different health and educational needs, including some countries with very high facilities and skills levels, yet high case loads. This paper highlights the personal experience of our organization and the types of diseases encountered in developing countries.

Abstract 461: Compositional Changes to High-Density Lipoproteins That Are Related to Increased Cardiocascular Disease Burden

Atherosclerosis is a vascular disease characterized by the build up of lipid derived plaques, and an individual’s risk of acute coronary syndrome is related to plaque burden and composition. Multiple risk markers for atherosclerosis and CVD act in a synergistic way through inflammatory pathways. One such inflammatory marker is serum amyloid A (SAA), which associates with HDL, negating its antiatherogeinc properties, which may have a causal role in atherosclerosis development.

This study examined if SAA was related to CVD burden, and if this influenced the antiatherogenic properties of HDL.

Subjects (n=240) referred to the rapid chest pain clinic at the Ulster Hospital UK, had atherosclerotic burden assessed by cardiac computerised tomography (CCT) and were classified as no CVD; mild CVD stenosis <50% and moderate/severe CVD stenosis >50%. HDL 2 and HDL 3 were isolated from serum by rapid ultracentrifugation. SAA was measured by an ELISA procedure, lipids by a colorimetric method and CETP activity by a fluorimetric assay.

Results: Although lipids were similar in HDL 2 across the groups, lipids decreased in HDL 3 with increasing CVD burden. In addition, the concentration of SAA and the activity of CETP increased with increasing CVD burden (see table). Additionally, ordinal regression analysis illustrated that HDL 3 -SAA and HDL 2 -CETP where independently related to CVD burden (p=0.001).

Conclusions: This study has shown that SAA was associated with increased CVD burden and that HDL had altered lipid composition and increased CETP activity. Thus, SAA and CETP may be useful biomarkers for the detection and assessment of CVD.

Funded by Heart-Research UK

A comparison of Diamond Forrester and coronary calcium scores as gatekeepers for investigations of stable chest pain

To determine if calcium scores (CS) could act as a more effective gatekeeper than Diamond Forrester (DF) in the assessment of patients with suspected coronary artery disease (CAD). A sub-study of the Cardiac CT for the Assessment of Chest Pain and Plaque (CAPP) study, a randomised control trial evaluating the cost-effectiveness of cardiac CT in symptomatic patients with stable chest pain. Stable pain was defined as troponin negative pain without symptoms of unstable angina. 250 patients undergoing cardiac CT had both DF scores and CS calculated, with the accuracy of both evaluated against CT coronary angiogram. Criteria given in UK national guidelines were compared. Of the 250 patients, 4 withdrew. 140 (57 %) patients were male. The mean DF was 47.8 and mean CS 172.5. Of the 144 patients with non-anginal pain 19.4 % had significant disease (>50 % stenosis). In general the DF over estimated the presence of CAD whereas the CS reclassified patients to lower risk groups, with 91 in the high risk DF category compared to 26 in the CS. Both receiver operating curve and McNemar Bowker test analysis suggested the DF was less accurate in the prediction of CAD compared to CS [Formula: see text] Projected downstream investigations were also calculated, with the cost per number of significant stenoses identified cheaper with the CS criteria. Patients with suspected stable CAD are more accurately risk stratified by CS compared to the traditional DF. CS was more successful in the prediction of significant stenosis and appears to be more effective at targeting clinical resources to those patients that are in need of them.

Evaluation of a final year work-shadowing attachment

The transition from medical student to junior doctor is well recognised to be a difficult and stressful period. To ease this transition, most UK universities have a work-shadowing period (WSP), during which students can learn practical skills needed for forthcoming employment. The aim of this study was to evaluate the WSP at Queen's University Belfast, and gain the views of both students and Foundation Programme Supervisors and Directors (FPSDs). The study utilised both qualitative (focus groups) and quantitative (questionnaires) approaches. The FPSDs completed a specific questionnaire designed for this study, while the students completed the university's internal quality assurance questionnaire. Twenty-eight of the 37 (76%) FPSDs and 106 / 196 (54%) students completed the questionnaires. Focus groups were conducted with up to 10 students in each group in both a regional centre and a district general hospital at the start and the end of the WSP as well as 8 weeks into working life. The transcripts of the focus groups were analysed and themes identified. A number of deficiencies with the current WSP were identified, including concerns about the use of log books, the timing of the attachment and relatively low levels of supervision provided by senior hospital staff members. As a result, students felt unprepared for commencing work, with particular mention given to medical emergencies, prescribing, and the emotional aspects of the job. A number of recommendations are made, including the need for more senior input to ensure better student attendance, participation and clinical interaction. Furthermore, students should be offered additional supervised responsibility for delivery of patient care and more experiential learning with respect to drug prescribing and administration. The study also suggests that more needs to be done to help ease the emotional and psychological stresses of the early FY1 period. These issues have been resolved to a large extent with the introduction of the new final year Student Assistantship module in the academic year 2010-2011.

Delayed cardiac perforation by defibrillator lead placed in the right ventricular outflow tract resulting in massive pericardial effusion

A 76-year-old man received a dual-chamber implantable cardioverter defibrillator (ICD), with the defibrillator lead positioned within the right ventricular outflow tract. The lead parameters at the time of implantation were satisfactory and the post-procedure chest X-ray showed the leads were in place. The patient was cardioverted from atrial fibrillation during defibrillation threshold testing and commenced on anticoagulation immediately. One month post implantation, he experienced multiple ventricular tachycardia episodes all successfully treated with antitachycardia pacing and shocks by his ICD, but he fell and hit his chest against a hard surface during one of these attacks. He developed a massive pericardial effusion and computed tomography confirmed cardiac perforation by the defibrillator lead. Pericardiocentesis was performed and the defibrillator lead replaced with a different model positioned at the right ventricular apex. The patient made an uneventful recovery. The management and avoidance of delayed cardiac perforation by transvenous leads were discussed.