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Dilated cardiomyopathy represents a common phenotype expressed in individuals with a family of overlapping myocardial diseases due to acquired and/or genetic susceptibility. Disease trajectory, response to therapy and outcomes vary widely; therefore, further refinement of the diagnosis can help guide therapy and inform prognosis. Multimodality imaging plays a key role in this process, as well as excluding alternative causes which may mimic a primary myocardial disease. The following article discusses the role of different imaging modalities as well as what the future may look like in the context of recent research innovations.

Background: Myocarditis may predispose to dilated cardiomyopathy (DCM) and sudden cardiac death (SCD). Familial data indicate a potential genetic susceptibility shared with arrhythmogenic cardiomyopathy (ACM). We present the first large-scale genotype-phenotype study of adults with acute myocarditis. Methods: A cohort comprising 336 consecutive patients with acute myocarditis was enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterised cardiomyopathy-associated genes. The burden of rare protein altering variants (PAV) in ACM genes, DCM genes, and TTN specifically, were compared with local healthy controls sequenced on the same platform (n=1053). Case ascertainment was assessed against national hospital admission data. Results: We identified rare protein-altering variants in 23% of cases compared to 16% in controls (Δ+6.8%; p=0.021), with rare truncating variants (tv) in 6% of cases compared to Conclusion: We identified enrichment of cardiomyopathy gene variants in acute myocarditis patients, dominated by DSP-tv in those with normal LVEF and TTN-tv in those with reduced LVEF. Incorporation of genetic testing may be beneficial to identify such high-risk individuals and guide family screening in acute myocarditis patients.

Introduction: Acute myocarditis has been reported in patients infected with COVID-19 in case series and imaging-based studies. We sought to assess this link by evaluating trends in hospital admissions due to acute myocarditis and COVID-19 on a national level during the pandemic. Methods: Data on all NHS England hospital admissions with a primary or secondary diagnosis of acute myocarditis were acquired and curated from the NHS Digital hospital episode statistics dataset from 2019-2020. COVID-19 data was obtained from the UK government daily statistics. Rolling averages over 28-day periods are presented. Results: Across all ages, there were 1,894 hospital admissions due to myocarditis in 2019 compared with 1,610 in 2020 (15% reduction). During the first national lockdown (23 rd Mar-19 th Jun 2020), myocarditis admissions were 32% lower than the same period in 2019. During the second lockdown (5 th Nov-2 nd Dec), myocarditis admissions were 9% greater than in 2019, although this increase was not sustained throughout December despite the subsequent surge in COVID-19 admissions. In general, patients admitted in 2020, compared to 2019, were older (median age 46 years, interquartile range 28-61 vs 41 years, IQR 26-58; p Discussion: As COVID-19 admissions peaked in early 2020, there was a sharp decline in myocarditis admissions, probably attributed to profound disruptions in healthcare provision, but possibly due to reduced transmission of other viruses during lockdown. Whilst myocarditis admissions increased during the second lockdown, there was no clear association between COVID-19 and myocarditis admission numbers. Further research may identify delayed presentations or sequelae of myocarditis, particularly following the larger COVID-19 peak in January 2021, as well as the impact of the vaccination programme.

Objective The aim of the current study was to identify predictors of paraprosthetic aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and examine its influence on short/medium-term mortality using the UK TAVI Registry. TAVI is an effective treatment for high-risk patients with severe symptomatic aortic stenosis (AS), but paraprosthetic AR has been associated with increased in-hospital and mid-term mortality. Methods Between January 2007 and December 2011, 2584 TAVI procedures were performed in the UK. Patients undergoing ‘valve-in-valve’ procedures, patients with aortic regurgitation as the primary pathology and with no recorded severity of AR were excluded from this analysis (n=144). In total, therefore, 2440 patients were included. Balloon-expandable and self-expanding devices were implanted in 52.7 and 47.2%, respectively, using either transfemoral (67.7%) or non-transfemoral, surgical access (32.3%). Results Postprocedural AR was observed in 68%, mild AR in 57% and moderate-severe in 10%. A large aortic annulus, high preprocedural transaortic gradient, and use of self-expanding valve were independent predictors of moderate-severe AR. Moderate-severe (but not mild) AR was associated with increased mortality, and this relationship appeared significant for the balloon-expandable but not the self-expanding device. Conclusions Our data suggest that a large aortic annulus, high preprocedural transaortic gradient, and use of the self-expanding valve predict moderate-severe AR after TAVI. Such a degree of AR is associated with a significantly worse outcome with the balloon-expandable, but not with the self-expanding valve. Further studies are needed to verify this and explore potential mechanisms.

Bleeding is a known predictor of poor outcome after a number of cardiac interventions. We investigated whether using the new bleeding definition of the Valve Academic Research Consortium predicts a poor outcome after transcatheter aortic valve implantation. In addition, we sought to identify those patient characteristics that predict periprocedural bleeding and investigated the effect of blood transfusion. This was a retrospective study of 101 patients undergoing transapical or transfemoral transcatheter aortic valve implantation at Kings College Hospital from August 2007 to November 2010. The association among bleeding, blood transfusion, and in-hospital and 6-month mortality was examined. Of the 101 patients, 5 (4.9%) had life-threatening periprocedural bleeding related to vascular or apical complications, 17 (17%) had major bleeding, and 79 (78%) had minor or no bleeding. The in-hospital mortality rate for the cohort was 9.9% (n = 10) and the 6-month mortality rate was 18.8% (n = 19). Those patients with life-threatening bleeding and those who were transfused had significantly greater in-hospital mortality rates than the patients without life-threatening bleeding or transfusion (60.0% vs 7.3%, p0.05; and 14.8% vs 4.3%, p0.05, respectively). Life-threatening bleeding, a decrease in hemoglobin5 g/dl, and a blood transfusion of2 U were associated with increased mortality at 6 months. In a logistic regression model, coexisting vascular disease, diabetes, and preprocedural anemia significantly affected the incidence of life-threatening or major bleeding. In conclusion, consistent with many other cardiac interventions, life-threatening periprocedural bleeding after transcatheter aortic valve implantation is associated with poorer outcomes.

Transportation services and projects are delivered by multiple organizations and therefore effective systems engineering on these projects must traverse organizational boundaries. Each of the organizations across this complex supply chain faces different issues – and therefore needs to tailor its systems engineering to cope with difficult problems. However, to deliver effective transport services to customers, this systems engineering needs to be integrated. So how do we systems engineer the supply chain to enable effective, cross-organizational systems engineering? What roles should customers and suppliers take in the overall SE program? What are the key challenges we need to address to deliver the low cost, reliable, environmentally-friendly, high capacity and safe transport services our customers want to use? The panelists will explore these questions from different perspectives – from designing national transportation infrastructure to building trains. We'll hear from five perspectives: For each perspective we'll explore: What are the primary systems challenges? Which aspects of systems engineering add most value? What aspects cause the greatest difficulty? What changes would make the supply chain more effective? Audience discussion is sought to explore: How does the experience of the transportation industry SE compare or contrast to other industries? Are the viewpoints of various contributors common? Are interdependencies being overlooked? National government's transport administration - focusing on keeping people moving in our major cities and getting a decent return from investment in major enhancements Rail agency – focusing on integrating infrastructure, vehicles and command and control to deliver effective transport services Major rail system upgrade program – focusing on delivering major enhancements with minimum cost and risk Systems consultant – focusing on specifying the procurement of integrated systems to meet agency's business needs while navigating sub-system supplier capabilities and systems integration risk Sub-system supplier – focusing on delivering vehicles, infrastructure or command and control solutions that meet the market and specific customers need

The drive for improved railway performance is a fundamental commitment of both UK Government and the railway industry. This drive is apparent in many of the initiatives involving collaboration, competition, investment, incentives and metrics. However, the experience of the last few years highlights the complexity of assessing train performance within a dynamic system, and demonstrates that performance forecasts can carry a significant margin of uncertainty. A further challenge for the industry is the need to effectively manage the often conflicting performance requirements of capacity, reliability and journey time at lowest life cycle cost, whilst maintaining acceptable levels of safety. An important contribution to meeting the performance challenge is the development and application of modelling techniques to improve the quantitative understanding of performance, and the complex system relationships that exist. Such understanding is supporting better decision-making at both strategic and tactical levels. Modelling techniques also enable the setting of meaningful performance related system requirements, thus ensuring that performance gets 'designed-in' from the outset. Looking forward, it is suggested that advances in system dynamics modelling might provide a means for better understanding of the complex interactions and trade-offs that characterise the railway system.

A previously asymptomatic, 16-year-old male from China presented following a cardiac arrest. He had a past medical history of Kawasaki's disease with no known sequelae. Following 6 min of bystander resuscitation, a 200J DC shock was delivered for VF, with return of circulation. An ECG …