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Background In 2016, the NICE clinical guideline 95 (’Chest pain of recent onset: assessment and diagnosis’) was updated to include coronary CT angiography (CCTA) as the first-line imaging modality for stable chest pain, and to suggest that fractional flow reserve CT (FFRCT) should also be considered as an option. NICE state FFRCT reduces cath lab utilisation due to better diagnostic performance at detecting significant coronary artery disease (CAD) compared to CCTA, and does not involve additional CT scanner time, radiation or contrast. This technology is not currently available at City Hospitals Sunderland. Local and international data suggest that CCTA overestimates disease severity compared to findings at invasive cardiac catheterisation (ICC). We investigated the role of including FFRCT in investigation of stable chest pain, including theoretical cost and service utilisation savings, and identified the concordance in grading of CAD between CCTA and ICC. Method Data on disease grading were collected from reports of CCTAs done between 1 st January 2016 and 31 st December 2017. Data were also collected for those patients who subsequently underwent ICC. For the patients who underwent both CCTA and ICC, the CCTA reports and images were individually reviewed by a consultant cardiologist with experience in CCTA to assess concordance between both studies. A financial model was then created, using cost data quoted by NICE. Results A total of 163 patients underwent CCTA in the time period. Of these, 113 (68%) had mild-moderate CAD and so were managed medically. The remaining 50 (32%) patients underwent ICC due to either findings of moderate-severe CAD; anatomical aberrancies; or artefact. Of these 50 ICCs, 33 (66%, showing normal arteries or mild CAD) could have been avoided if there was a more sensitive test. 8 patients went on to undergo revascularisation. Financial modelling estimated that using FFRCT prior to referral for ICC would lead to a cost saving of £22 290 per year (£136.74 per patient per year) and result in more efficient utilisation of the angiography suite, reducing waiting list lengths. CCTA and ICC agreed on disease grading in 37/47 of cases, which correlates with data in the literature showing high sensitivity but relatively poor specificity. Conclusion CCTA is the NICE-recommended fist-line investigation for stable chest pain, and is sensitive and clinically useful. However, poor specificity causes unnecessary cardiac catheterisation. This relates to overestimation of luminal stenoses (e.g. due to arterfact from calcium). Use of FFRCT at City Hospitals Sunderland would reduce unnecessary angiograms and the risks associated with these, and would provide better utilisation of the angiography suite for interventional procedures, at a cost saving to the Trust. Introduction of guidelines such as CAD-RADS (coronary artery disease reporting and data system) would standardise terminology used in reporting and further improve reliability and specificity.

Objective Assessment of the feasibility and outcomes of the 2.5 L and 3.8 L Impella cardiac pump in patients with severe aortic stenosis (AS) and left ventricular impairment undergoing percutaneous revascularization (PCI) with or without balloon aortic valvuloplasty (BAV). Methods We reviewed the clinical and procedural findings from a consecutive series of unselected patients with severe AS who underwent PCI during Impella support. In addition, we describe novel “balloon-assist” techniques that allowed implantation of Impella into the left ventricle (LV) when initial unassisted attempts failed. Results Five patients with severe AS were identified (four males, age 78.2 years, aortic valve area (AVA) 0.6 cm2, left ventricular ejection fraction (LVEF) 24 ± 5%, mean Society of Thoracic Surgeons (STS) mortality 11% (range 3–17%)). The Impella catheter traversed the aortic valve (AV) unassisted in only one patient, with four cases requiring balloon-assist techniques. All patients underwent planned revascularisation; mean procedure time 177 min (range 135–252 min), mean number of stents 3.4 (range 1–8), with three patients requiring rotational atherectomy. All procedures were well tolerated, with absence of arrhythmia, hypotension, pulmonary edema, stroke, or myocardial infarction. One patient died 48 hr post-PCI of multi-organ failure. The four remaining patients were well at 30 days. Conclusion Implantation of the 2.5 and 3.8 L Impella appears feasible in patients with severe AS and left ventricle (LV) impairment. A balloon-assist technique may be used to facilitate device implantation when initial unassisted attempts fail. Improved hemodynamic stability may enhance the tolerability of lengthy and complex procedures. © 2014 Wiley Periodicals, Inc. © 2014 Wiley Periodicals, Inc.

The management of in-stent restenosis (ISR) complicating bifurcation lesions is technically challenging and implant of further stents may not be feasible. The use of drug-eluting balloons provides an attractive option for treatment of such lesions allowing a technically simple procedure without the need for further complex stenting. The SeQuent Please paclitaxel-eluting balloon (B. Braun, Berlin, Germany) has been shown to be superior to a paclitaxel eluting stent or balloon angioplasty for ISR complicating a bare-metal stent. However, there is no data on the efficacy of the SeQuent Please in ISR complicating drug-eluting stents or bifurcation lesions. We report two cases where the SeQuent Please was used in this setting with angiographic success and freedom from target vessel failure and angina at 24 months. In both cases the Sheathless Eau Cath guide (Asahi Intecc, Japan) was employed to perform a kissing-balloon dilatation with the SeQuent Please, so allowing treatment via radial access.

Intramural hematoma in major coronary epicardial vessels is a rare cause of chest pain. Afflicted individuals may present with acute coronary syndrome (ACS) or even sudden cardiac death. Spontaneous, isolated intramural hematoma may occur in the absence of associated intimal dissection. In this situation, lesions may be angiographically indistinguishable from ruptured atherosclerotic plaque. Intravascular ultrasound is important in the accurate diagnosis of isolated intramural hematoma. Although coronary stenting may be required in the presence of ongoing ischemia, intramural hematoma may be successfully managed medically. We describe the case of a middle-aged woman who presented with ACS due to an intramural hematoma and discuss the diagnosis and management of this rare illness.

Iatrogenic coronary ostial stenosis after aortic valve replacement is a rare, life-threatening complication, which may follow implantation of either a mechanical or a biological prosthesis. Historically, this condition has been treated by urgent coronary bypass surgery but is associated with high morbidity and mortality, due to the hazards of early repeat sternotomy. We report a case of iatrogenic coronary ostial stenosis successfully treated with stenting and discuss the advantages of percutaneous intervention over coronary bypass surgery.

There are little data on the efficacy and safety of the Edwards Sapien valve (Edwards Lifesciences, Irvine, California, USA) in congenital, bicuspid aortic valve stenosis. Patients with bicuspid valves were excluded from the randomised PARTNER trial.1 Bicuspid valves differ from tricuspid aortic valves in that the orifice is elliptical and the leaflets are typically bulky and very heavily calcified. Bicuspid valves are considered …

The Edwards Sapien transcatheter heart valve (THV) is available for treatment of severe symptomatic aortic stenosis via transfemoral access or trans-apical access when ilio-femoral vessels are considered unsuitable. Some patients, however, may be unsuitable for access via either of these routes. We describe successful implantation of an Edwards Sapien THV via direct access of the ascending aorta in a patient with previous right pneumonectomy and pulmonary disease who was considered unsuitable for implantation via femoral vessels or via trans-apical approach. The potential advantages of this novel access route over trans-apical approach are discussed.

Undilatable coronary lesions, due to coronary calcification, are encountered with increasing frequency. Percutaneous intervention of such lesions comes with the risk of stent underexpansion, which increases the risk of stent thrombosis and restenosis. A variety of techniques and devices are available to assist the interventionist in the treatment of calcified lesions. The OPN NC (SIS-Medical AG, Winterthur, Switzerland) is a high-pressure balloon (rated burst pressure 35 atm) that uses a novel, twin-layer balloon technology to ensure uniform balloon expansion, eliminating "dog-boning." We report four cases of successful treatment of calcified lesions with the OPN NC balloon after dilatation with standard noncompliant balloons to high-pressure failed.

Pacemaker insertion causing contact dermatitis is a rare but recognized complication. We report a 60-year-old gentleman, who presented 2 years after his pacemaker implantation with erythema and itching at site of pacemaker insertion. He was initially treated with antihistamines; however, the erythema persisted over the pacemaker site as shown in Figure …

Lipomatous hypertrophy of the interatrial septum is a rare condition and it does not require any specific treatment. We present the transoesophageal echocardiogram findings of a 70-year-old lady demonstrating the appearances that were typical of lipomatous hypertrophy of the interatrial septum.