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Background Transcatheter aortic valve implantation (TAVI) has proven efficacy in the treatment of aortic stenosis (AS). Understandably, there is increasing enthusiasm for its use to treat aortic regurgitation (AR). However, there are significant anatomical differences between AS and AR which make TAVI for AR more complex. Case summary We present the case of technically challenging TAVI for severe AR, which was complicated by a traumatic ventricular septal defect (VSD) that required percutaneous closure. To our knowledge, this is the first published case of VSD post-TAVI for AR. Discussion This unanticipated complication highlights anatomical differences between TAVI use in AS and AR. Lack of aortic valve calcification and excessive annular compliance made stable deployment of a self-expanding valve extremely challenging. Despite device oversizing, repeated embolization of the prosthesis into the left ventricular outflow tract traumatized the interventricular septum.

Funding Acknowledgements Type of funding sources: None. Introduction Coronavirus disease 2019 (COVID-19) infection can have multisystem involvements. The inflammation sequelae can cause myocarditis. The COVID-19 pandemic has impacted Ireland significantly. Understanding of myocardial involvement in COVID-19 is not fully elucidated but has been reported. The Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic in Ireland is a high volume CMR centre with approximately 4500 cases per year and accepting referral from all hospital in Ireland. These analyses are to describe the CMR findings in COVID-19 positive and probable cases attending the centre. Methods Consecutive 65 referrals with mention of "COVID-19" from March 2020 to December 2020 was assessed. 56 cases were included in this analysis. Cases were categorised as COVID-19 positive cases or probable (viral illness like symptoms) cases. The demography and CMR parameters were collected. Serial imaging of selected cases was included. Descriptive analyses methods were applied. Results In the period of 10 months, there was 49 COVID-19 positive cases (65.3% male; median age 49 [32 : 61] years) and 7 COVID-19 probable cases (42.9% male; median age 39 [37 : 59] years). In the COVID-19 positive cases, 25 had normal CMR, 11 has evidence of myocarditis, 1 with pericarditis, 2 with infarction/ischaemia, 3 with dilated cardiomyopathy, 2 with hypertrophic cardiomyopathy and 5 with other findings. There were 3 COVID-19 positive cases with serial imaging showing resolving myocarditis (100% female; median age 41 [30 : 47] years). 2 professional athletes with COVID-19 positive test showed no evidence of myocarditis. There are no significant differences in the age of male COVID-19 positive versus female group (p= 0.0752). Different demography and CMR parameters and tissue characterisation are described in Table 1 and Table 2. Conclusions The prevalence of myocarditis in this cohort is approximately 1 in 5 (21.4%). Within the COVID-19 positive cases, the prevalence is 22.4%. These observations may reflect selection bias for CMR referral in those with cardiac symptoms or cardiac enzymes leak.

Background Delayed hospital presentation with STEMI during the SARS-CoV-2 pandemic can lead to increased incidence of typically rare mechanical sequelae Intramyocardial dissecting hematoma (IDH) is one such complication of myocardial infarction Case A 51 year-old male patient with a background of hypertension presented with a 7 hour history of typical chest pain His initial ECG showed anterolateral ST segment elevation with reciprocal ST depression in the inferior leads, consistent with STEMI Urgent angiography revealed a 100% acute occlusion in the mid-LAD TIMI 3 flow was restored using a Xience 3 00 x 18mm stent, with resolution of pain and interval ECG improvement Laboratory investigations revealed new significant anaemia Decision-making Post-procedural transthoracic echocardiography revealed severely impaired systolic function and moderate concentric biventricular hypertrophy, and raised the suspicion of a mechanical complication (see image) This was further supported by his delayed presentation and extensive infarct area His anaemia was suggestive of active haemorrhage Endoscopic investigation failed to show a gastrointestinal source Cardiac MRI (CMR) confirmed the presence of IDH Conclusion This case highlights the need for a heightened index of suspicion for typically rare mechanical complications post-STEMI due to delayed hospital presentation during the current pandemic, as well as the growing utility of multimodality imaging such as CMR [Formula presented]

BACKGROUND:Admission with heart failure (HF) is a milestone in the progression of the disease, often resulting in higher intensity medical care and ensuing readmissions. Whilst there is evidence supporting enrolling patients in a heart failure disease management program (HF-DMP), not all reported HF-DMPs have systematically enrolled patients with HF with preserved ejection fraction (HFpEF) and there is a scarcity of literature differentiating costs based on HF-phenotype.METHODS:1292 consenting, consecutive patients admitted with a primary diagnosis of HF were enrolled in a hospital based HF-DMP and categorized as HFpEF (EF≥45%) or HFrEF (EFRESULTS:The total average annual cost per patient was marginally higher in patients with HFrEF €13,011 (12,011, 14,078) than HFpEF, €12,206 (11,009, 13,518). However, emergency non-cardiovascular admission rates and average cost per patient were higher in the HFpEF vs HFrEF group (0.46 vs 0.31 per patient/12months) & €655 (318, 1073) vs €584 (396, 812). In the first 3months of the outpatient HF-DMP the HFrEF population cost more on average €791 (764, 819) vs €693 (660, 728).CONCLUSION:There are greater short-term (3-month) costs of HFrEF versus HFpEF as part of a HF-DMP following an admission. However, long-term (3-12month) costs of HFpEF are greater because of higher non-cardiovascular rehospitalisations. As HFpEF becomes the dominant form of HF, more work is required in HF-DMPs to address prevention of non-cardiovascular rehospitalisations and to integrate hospital based HF-DMPs into primary healthcare structures.

Background and objective Acute exacerbations of cystic fibrosis (CF) occur frequently throughout the course of the disease. Dyspnoea is the most common and distressing symptom experienced by patients during these episodes. We tested the hypothesis that pulmonary hyperinflation is an important determinant of dyspnoea severity during acute exacerbations. Methods We studied patients during an acute exacerbation of CF. Lung volumes, spirometry and dyspnoea scores were measured at Day 0, Day 7, at the end of treatment (EOT) and 14 days following the EOT. Results At the start of treatment, mean residual volume (RV)/total lung capacity (TLC) was 54.9%, which decreased significantly with treatment, as did vital capacity (VC), inspiratory capacity (IC) and dyspnoea scores. IC was the only independent predictor of dyspnoea severity. Conclusion Our study demonstrates significant improvements in hyperinflation, spirometry and dyspnoea scores with treatment of acute exacerbations of CF. Hyperinflation, rather than airflow limitation, may contribute towards the increased dyspnoea during exacerbations.

Introduction The prognosis and treatment of the two main types of cardiac amyloidosis, immunoglobulin light chain (AL) and transthyretin (ATTR) amyloidosis, are substantially influenced by cardiac involvement. Focal myocardial fibrosis is best detected and quantified by cardiovascular magnetic resonance (CMR) and late gadolinium enhancement (LGE) technique. Diffuse subendocardial and transmural LGE is a marker of late cardiac amyloidosis. This report describes the use of CMR to detect early cardiac manifestations in amyloidosis and to evaluate its progression over a five-year period. Methods Mr GS is a 77 year old gentleman who was diagnosed with cardiac amyloidosis in 2012. He attends follow-up annual review appointments at the National Amyloid Centre in University College London. He has undergone annual CMR at Blackrock clinic Dublin from 2014 until 2017. GS underwent LGE imaging for myocardial scar using a segmented Inversion recovery-technique 10 to 15 min after injection of 0.1 mmol/kg of gadolinium. Myocardial enhancement was assessed visually and interpreted by two cardiac CMR-trained physicians. Results A short axis of LGE imaging from GS is shown in figure 1 which demonstrates significant, confluent myocardial fibrosis throughout the myocarium. Figure 2 highlights the evolution of amyloidosis from 2014–2017 which shows a gradual increase in LGE uptake throughout the vertical long axis (VLA), horizontal long axis (HLA) and short axis (SA) images. There has been a clear deterioration in appearances with the most striking images of LGE seen in November 2017. The findings correspond with functional deterioration in heart failure symptoms and increasing B-type natriuretic peptide (BNP), peaking at 7,500 pg/ml. Conclusion LGE is a sensitive parameter for the early diagnosis of cardiomyopathy in amyloidosis and can be used to show progression of disease.

Introduction Interstitial myocardial fibrosis is best detected and quantified by cardiovascular magnetic resonance (CMR). It may be accurately detected by late gadolinium enhancement (LGE) and T1 relaxation mapping. Duchenne muscular dystrophy (DMD) is an X-linked recessive disease that occurs in males leading to cardiomyopathy and death in early adulthood. This report describes the use of CMR to detect early cardiac manifestations in DMD and to evaluate its progression over a five-year period in two young patients. Methods Yearly CMR was performed on two brothers (patient one aged 16 and patient two aged 14) from 2013 until 2017. All patients underwent LGE imaging for myocardial scar using a segmented Inversion recovery-technique 10 to 15 min after injection of 0.1 mmol/kg of gadolinium. Myocardial enhancement was assessed visually and interpreted by two cardiac CMR-trained physicians. T1 mapping techniques were used on the latest scan in November 2017. Results A short axis stack of LGE imaging from patient one is shown in figure 1 which demonstrates significant, confluent myocardial fibrosis in the anterolateral, lateral and inferolateral walls from base through to the distal LV segments. The total gadolinium volume was 15 g (24% of the total myocardium), with a T1 mapping value of 1105 ms (normal local mean 957 ms), figure 2. Figure 3 highlights the evolution of DMD in these two patients from 2013–2017 which shows a gradual increase in LGE throughout the horizontal long axis (HLA) and short axis (SA) images of each patient. There has been a clear deterioration in appearances with the most striking images of LGE seen in November 2017. Conclusion LGE is a sensitive parameter for the early diagnosis of cardiomyopathy in DMD and can be used to show progression of disease.

Background Two-dimensional Doppler-echocardiography (2 DE) remains the primary modality in assessing left ventricular diastolic dysfunction (LVDD) due to its widespread availability. In asymptomatic LVDD (ALVDD), the putative precursor of diastolic heart failure, 2 DE imaging of cardiac volume and mass has been reported to be prognostically significant. However, the consistency of such measures is not fully known with limited data on sequential imaging. We aimed to compare reproducibility of cardiac volumes and mass by sequential 2 DE against cardiac magnetic resonance imaging (CMR), the gold standard in evaluating volumes and mass, in patients with ALVDD. Methods We sub-analysed imaging data from a prospective randomized clinical study (EudraCT 2010-021664-16) evaluating the impact of chronic doxycycline therapy on cardiac remodeling in patients with ALVDD, using 2 DE and CMR. Both modalities were performed by independent blinded observers at baseline, 6 months and 12 months. Cardiac volumes and mass were indexed to body surface area at each timepoint for all patients. Pearson’s correlation was performed between measurements of both modalities at (baseline, 6 months, 12 months) respectively. Results were reported as mean ± SD. Results All patients (n=48) had mean age 69.8 ± 8.5 years and ejection fraction (EF) 67 ± 7% at baseline. Sequential correlations in EF (0.20, 0.15, 0.34), p = 0.17, 0.32, 0.02 respectively; and left ventricular end-diastolic volume index (LVEDVi) (0.37 , 0.17 , 0.07), p = 0.01, 0.27, 0.65 respectively, were compared between both modalities. Modest but significant correlations were observed between 2 DE and CMR for left atrial volume index (LAVi) (0.39, 0.50, 0.45), left ventricular mass index (LVMi)(0.46, 0.30 , 0.45) and left ventricular end-systolic volume index (LVESVi) ( 0.43, 0.58 , 0.48 ); all p Conclusion 2 DE-measured EF and LVEDVi demonstrated a predominantly poor correlation with CMR. However, 2 DE demonstrated modest correlation in LAVI, LVMI and LVESVi. The reproducibility of these sequential measurements against CMR supports their use as durable targets for measuring impact of therapies for ALVDD.

Long-term high-intensity physical activity is associated with morphological changes, termed as the 'athlete's heart'. The differentiation of physiological cardiac adaptive changes in response to high-level exercise from pathological changes consistent with an inherited cardiomyopathy is imperative. Cardiovascular magnetic resonance (CMR) imaging allows definition of abnormal processes occurring at the tissue level, including, importantly, myocardial fibrosis. It is therefore vital in accurately making this differentiation. In this review, we will review the role of CMR imaging of fibrosis, and detail CMR characterisation of myocardial fibrosis in various cardiomyopathies, and the implications of fibrosis. Additionally, we will outline advances in imaging fibrosis, in particular T1 mapping. Finally we will address the role of CMR in pre-participation screening.

The requirement for nodal analysis currently confounds the oncological propriety of focused purely endoscopic resection for early-stage colon cancer and complicates the evolution of innovative alternatives such as natural orifice transluminal endoscopic surgery (NOTES) and its hybrids. Adjunctive sentinel node biopsy (SNB) deserves consideration as a means of addressing this shortfall.Data from two prospectively maintained databases established for multicentric studies of SNB in colon cancer that employed similar methodologies were pooled to establish technique potency selectively in T1/T2 disease (both overall and under optimized conditions) and to project potential clinical impact.Of 891 patients with T1-4, M0 intraperitoneal colon cancer, 225 had T1/T2 disease. Sentinel nodes were either not found or were falsely negative in 18 patients with T1/T2 cancers (8%) as compared with 17% (112/646) in those with T3/T4 disease (P = 0.001). Negative predictive value (NPV) in the former exceeded 95%, while sensitivity [including immunohistochemistry (IHC)] was 81%. In the 193 patients with T1/T2 disease recruited from those centers contributing22 patients, sensitivity was 89% and NPV 97%. Thus, in this cohort, SNB could have correctly prompted localized resection (obviating en bloc mesenteric dissection) in 75% (144) of patients, including 59 with T1 lesions potentially amenable to intraluminal resection alone as their definitive treatment. Forty-four patients (23.4%) would still have conventional resection, leaving three patients (1.6% overall) understaged (11% false-negative rate).These findings support the further investigation of SNB as oncological augment for localized resective techniques. Specific prospective study should pursue this goal.

Background Population screening for abdominal aortic aneurysm (AAA) can be cost-justified by its impact on the incidence of emergency presentations with rupture. The objective of this prospective, cohort study was to determine whether the proposed framework can be further evolved to address all-cause cardiovascular mortality in the community by integrating full risk factor assessment. Methods Male volunteers aged >60 years attending for AAA screening by ultrasound also underwent full cardiovascular assessment via physician-administered health questionnaire, sphygmomanometry, anthromorphometry, and fasting phlebotomy for lipid and glucose profiling. Framingham and SCORE project evaluations were used to calculate 10-year risk of ischemic heart disease and all-cause fatal cardiovascular disease, respectively. Results A total of 481 men were screened, and 23 (4.8%) had an AAA detected (22% of which were >4 cm). Obesity, smoking, hypertension, impaired glucose metabolism, and hypercholesterolemia were notably frequent in those without an AAA. Mean 10-year cardiovascular risk in the population without AAA (6.89 and 6.74 by SCORE and Framingham estimations, respectively) was similar to those with AAA (7.78 and 7.04, respectively). Supplementary screening increased total costs by 2.5%. Reserving concomitant atherosclerotic testing for those with elevated systolic blood pressure at presentation allowed identification of 96%/95% of those with Framingham/SCORE risks >10%, respectively, thus saving 162 (33%) individuals from additional investigation and conserving the cost increment to 1.8% overall. Conclusion The proven framework of population sifting for AAA provides a unique opportunity to also confront latent cardiovascular malady. Sphygmomanometry during ultrasonographic screening for AAA seems both cost-effective and readily incorporated within the current paradigm.

Deirdre F Waterhouse1, Ronan A Cahill2, Frances Sheehan2, CJ McCreery11Department of Cardiovascular Medicine, St Vincent’s University Hospital, Dublin, Ireland; 2Department of Preventative Medicine, Blackrock Clinic, Dublin, IrelandIntroduction: Although atherogenesis is clearly entwined with systemic inflammation, the risk-predictive relationship between preclinical and overt cardiovascular disease (CVD) and systemic white blood cell (WBC) subtypes remains unclear. Implication of an association would greatly facilitate cardiac risk prediction, assessment and monitoring.Methods: 1383 asymptomatic individuals (795 men, 588 women) attending for executive health screening were examined clinically as well as with phlebotomy and exercise stress testing to determine their ten-year risk of developing overt cardiovascular disease (as estimated by both Framingham and SCORE calculations). The significance of their association with overall WBC and subtypes were determined using both univariate and multiple regression modeling.Results: Of all WBC subtypes, monocyte count was found to have the strongest, independentrelationship with overall CVD risk by backwards linear regression modeling (Framingham: β = 0.057; p = 0.03; SCORE: β = 0.128; p =

Acute exacerbations of cystic fibrosis (CF) occur frequently throughout the course of the disease. Dyspnoea is the most common and distressing symptom experienced by patients during these episodes. We tested the hypothesis that pulmonary hyperinflation is an important determinant of dyspnoea severity during acute exacerbations.We studied patients during an acute exacerbation of CF. Lung volumes, spirometry and dyspnoea scores were measured at Day 0, Day 7, at the end of treatment (EOT) and 14 days following the EOT.At the start of treatment, mean residual volume (RV)/total lung capacity (TLC) was 54.9%, which decreased significantly with treatment, as did vital capacity (VC), inspiratory capacity (IC) and dyspnoea scores. IC was the only independent predictor of dyspnoea severity.Our study demonstrates significant improvements in hyperinflation, spirometry and dyspnoea scores with treatment of acute exacerbations of CF. Hyperinflation, rather than airflow limitation, may contribute towards the increased dyspnoea during exacerbations.

Although population screening for abdominal aortic aneurysm (AAA) has/had a significant impact on disease-specific mortality, coexisting systemic atherosclerosis represents the major impediment to improved longevity. We examined the feasibility and yield of full cardiovascular assessment concomitant with screening for AAA detection. A total of 1032 asymptomatic men over the age of 50 years (328 were >60 years) underwent a detailed cardiac health questionnaire, sphygmomanometry, body mass index calculation, fasting lipid profiling, ultrasonographic (US) examination of their infrarenal aorta and carotid arteries, and treadmill exercise stress testing. Framingham and SCORE project estimations of the 10-year risk of ischemic heart disease (IHD) and fatal cardiovascular disease (CVD) of any cause were calculated for the men with an AAA and in those >60 years but with neither AAA nor known cardiac disease. Overall, we detected an AAA >3 cm in 30 men (2.9%). Unaddressed obesity, smoking, hypertension, impaired glucose metabolism, and hypercholesterolemia were commonly identified in individuals both with and without an AAA, being notably frequent in those >60 years without an AAA. The 10-year risk of IHD and CHD in those >60 years was similar regardless of whether an AAA was present. Doppler screening for significant carotid stenosis had detection rates similar to those for aortic US scanning, being most useful in those >65 years of age. Exercise stress testing, however, was of only limited value when used nonselectively. Modifiable atherosclerotic disease and cardiovascular risk can be readily detected in individuals presenting for AAA screening and are present to a significant degree at an earlier age. Consideration of selected, additional investigations is required to maximize the value of generalized screening programs.

Purpose This case illustrates an acute myocardial infarction with occlusion of the left anterior descending coronary artery complicated by apical ventricular rupture and apical thrombus. Procedures An electrocardiogram, transthoracic echocardiogram (TTE), coronary angiography and cardiac magnetic resonance imaging (CMR) guided optimal management of the patient. Findings Coronary angiography revealed multivessel disease with an ostial occlusion of the LAD. Echocardiography showed apical dilatation of the left ventricle with a large, echogenic mass at the apex. Contrast echocardiography confirmed the presence of a large apical thrombus, separated from the LV cavity by myocardium. A CMR showed a completed LAD infarct and a filling thrombus was noted in the aneurysmal apical region inferring a contained rupture of the LV apex. Principle Conclusions Accurate and definitive delineation of unusual cardiac anatomy is best provided by complementary multimodality cardiac imaging, echocardiography and CMR. TTE can miss LV thrombi, particularly when they are large, aneurysmal and apical in nature. CMR provides the cardiac surgeon the ability to visualise in 3D the functional and morphological abnormalities, helping guide necessary intervention. Optimal management of patients with ventricular rupture remains controversial both in terms of timing and choice of intervention.

Aims Heart failure has been demonstrated in previous studies to have a dismal prognosis. However, the modern-day prognosis of patients with new onset heart failure diagnosed in the community managed within a disease management programme is not known. The purpose of this study is to report on prognosis of patients presenting with new onset heart failure in the community who are subsequently followed in a disease management program. Methods and Results A review of patients referred to a rapid access heart failure diagnostic clinic between 2002 and 2012 was undertaken. Details of diagnosis, demographics, medical history, medications, investigations and mortality data were analysed. A total of 733 patients were seen in Rapid Access Clinic for potential new diagnosis of incident of heart failure. 38.9% (n=285) were diagnosed with heart failure, 40.7% (n=116) with HF-REF and 59.3% (n=169) with HF-PEF. There were 84 (29.5%) deaths in the group of patients diagnosed with heart failure; 41 deaths (35.3%) occurred in patients with HF-REF and 43 deaths (25.4%) occurred in patients with HF-PEF. In patients with heart failure, 52.4% (n=44) died from cardiovascular causes. 63.8% of HF patients were alive after 5 years resulting on average in a month per year loss of life expectancy over that period compared with aged matched simulated population. Conclusions In this community-based cohort, the prognosis of heart failure was better than reported in previous studies. This is likely due to the impact of prompt diagnosis, the improvement in therapies and care within a disease management structure.

This case is of a 29-year-old man with progressive familial intrahepatic cholestasis type 1 also known as Byler9s disease. At the age of 21, our patient developed non-ischaemic dilated cardiomyopathy. Cardiac MRI demonstrated global wall thinning, with significant areas of myocardial fibrosis in the mid and epicardial walls from base to apex on postgadolinium late contrast enhanced images. No shared genetic loci between dilated cardiomyopathy and Byler9s or cholestatic liver disease have yet been found. This presents the first documented case of non-ischaemic dilated cardiomyopathy, with evidence of mid wall fibrosis, in association with an established diagnosis of progressive familial intrahepatic cholestasis type 1 since childhood.

Summary To estimate the cost and diagnostic implications of using CMR alone instead of conventional TTE/TMET work-up to guide patient selection for angiography. Healthcare costs were derived from VHI’s hospital billing system. Background Patient selection for coronary angiography traditionally relies on clinical assessment, treadmill exercise testing (TMET) and transthoracic echocardiography (TTE). Cardiac Magnetic Resonance (CMR) is a relatively novel imaging study, which provides excellent non-invasive assessment of myocardial perfusion and is useful in risk stratification of patients with suspected coronary artery disease (CAD). Methods

Intracranial plasmacytomas are an uncommon presentation of extramedullary relapse of multiple myeloma. The optimal management of extramedullary plasmacytomas remains unclear, with initial reports of bortezomib showing promising clinical results. We describe a case of multiple extracellular, including intracranial, plasmacytoma, with no evidence of marrow involvement, in a patient with relapsed IgA multiple myeloma. To our knowledge, this is the first reported case of a patient with rapid extramedullary relapse of disease despite recent exposure to bortezomib and dexamethasone.

Background It is well established that muscle strength and exercise capacity are impaired in adults with cystic fibrosis (CF). Numerous factors have been implicated in this process including nutritional factors, disuse, and corticosteroid use. It is also known that serum testosterone levels are frequently low in adolescent male patients with CF. As testosterone is known to have an effect on peripheral muscle, we aimed to assess the relationship among circulating androgen levels, muscle strength, and exercise capacity in adults with CF. Methods A prospective observational study was performed. Participants underwent maximal exercise testing and peripheral muscle strength assessment (quadriceps, shoulder flexion, handgrip, maximal inspiratory pressure, and maximal expiratory pressure). Venous blood samples were obtained for the measurement of total testosterone, sex hormone-binding globulin, and albumin. The free testosterone (FT) level was calculated. Results A total of 15 subjects completed the study. The patients who were studied had impaired muscle strength and exercise capacity but normal mean androgen levels. Quadriceps strength, SF, and peak oxygen uptake (V o 2max) were 40.1 ± 9.4%, 59.3 ± 20.3%, and 77.4 ± 22.2% predicted, respectively. One patient had a low testosterone level, with low FT levels evident in two subjects. There was no correlation between testosterone or FT level with any of the muscle strengths calculated. Neither testosterone or FT level was correlated with exercise capacity or pulmonary function. Conclusions Male CF patients with impaired skeletal muscle strength and exercise capacity have normal testosterone levels. Hypogonadism was rare in this group of adult men with CF. These findings would not support the role of testosterone in muscle dysfunction or impaired exercise capacity in CF patients.

Population screening for abdominal aortic aneurysm (AAA) can be cost-justified by its impact on the incidence of emergency presentations with rupture. The objective of this prospective, cohort study was to determine whether the proposed framework can be further evolved to address all-cause cardiovascular mortality in the community by integrating full risk factor assessment.Male volunteers aged60 years attending for AAA screening by ultrasound also underwent full cardiovascular assessment via physician-administered health questionnaire, sphygmomanometry, anthromorphometry, and fasting phlebotomy for lipid and glucose profiling. Framingham and SCORE project evaluations were used to calculate 10-year risk of ischemic heart disease and all-cause fatal cardiovascular disease, respectively.A total of 481 men were screened, and 23 (4.8%) had an AAA detected (22% of which were4 cm). Obesity, smoking, hypertension, impaired glucose metabolism, and hypercholesterolemia were notably frequent in those without an AAA. Mean 10-year cardiovascular risk in the population without AAA (6.89 and 6.74 by SCORE and Framingham estimations, respectively) was similar to those with AAA (7.78 and 7.04, respectively). Supplementary screening increased total costs by 2.5%. Reserving concomitant atherosclerotic testing for those with elevated systolic blood pressure at presentation allowed identification of 96%/95% of those with Framingham/SCORE risks10%, respectively, thus saving 162 (33%) individuals from additional investigation and conserving the cost increment to 1.8% overall.The proven framework of population sifting for AAA provides a unique opportunity to also confront latent cardiovascular malady. Sphygmomanometry during ultrasonographic screening for AAA seems both cost-effective and readily incorporated within the current paradigm.

To investigate the relationship between thyrotropin concentrations within the accepted reference range and cardiovascular risk.Initially, 728 women aged 45-60 years were enrolled over a 12-month period. All participants underwent full cardiovascular assessment, including detailed health questionnaire, sphygomanometry, body mass index (BMI) calculation, fasting glucose and lipid profiling, and measurement of serum thyrotropin concentrations. Patients whose thyrotropin concentrations were within the reference range (0.5-4.5 mU/L) were divided into quartiles (n = 629). The means of cardiovascular risk parameters between the first (n = 158) and fourth (n = 157) quartile were compared. Subsequently, the relationships between thyrotropin concentration and risk parameters for cardiovascular disease were examined.This study demonstrates that, within the reference range, increasing thyrotropin concentrations are associated with increasing risk parameters for the development of cardiovascular disease. Subjects with thyrotropin concentrations within the uppermost quartile of the reference range had significantly increased waist circumference, BMI, glucose, triglyceride, and systolic blood pressure measurements when compared to those in the lowermost quartile. Furthermore, significant relationships between thyrotropin and waist circumference, BMI, and fasting glucose and triglycerides concentrations were demonstrated. Finally, independent relationships between thyrotropin and both fasting glucose and triglyceride concentrations were demonstrated.Within the reference range, increasing thyrotropin concentrations are associated with increasing cardiovascular risk parameters. Fasting glucose and triglycerides have been shown to be independently associated with thyrotropin concentration.

Purpose Many patients attending their primary care physician with symptoms suggestive of new onset heart failure, have a 12 lead electrocardiogram (ECG) as part of an initial triage work up. However, the role of ECG in predicting heart failure in the community is not yet defined. We thus examined the ability of ECG to predict heart failure in this patient population. Method All 733 patients attending the rapid access clinic for possible heart failure in St Vincent’s University Hospital, Dublin, from the period of 2000 till 2012 were included in this study. 12-lead ECG was performed using the Agilent Page Writer 100 ECG machine and interpreted by independent cardiologists. The ECGs were analysed along side the diagnosis of heart failure. ROC curves were performed to assess the robustness of the ECG in predicting heart failure. Result Heart failure patients had significant prolonged QRS duration, prolonged QT duration, prolonged QTc and more rightward T wave axis compared to the non heart failure group. They also had significant ECG evidence of prior myocardial ischaemia, intraventricular conduction disorder, abnormal axis, ventricular hypertrophy and atrial fibrillation. Using the ECG evidence of myocardial ischaemia, intraventricular conduction disorder, atrioventricular disorder, abnormal axis, atrial enlargement, ventricular hypertrophy, ventricular arrhythmia and atrial fibrillation as a predictive model, the ROC analysis showed that the ECG model is a reasonable test (AUC = 0.81) to help predict heart failure in the community. Adding BNP to the model increased the robustness of the model in predicting heart failure (AUC = 0.88). Conclusion The utility of the 12-lead ECG in predicting heart failure in the community is under appreciated. This study showed that this simple test is useful and can offer primary care physicians the ability to expedite the diagnosis of heart failure in order to start relevant further investigation and treatment in the community. In conclusion, ECG is a useful test in predicting heart failure in the community, however addition of BNP into the model helped to increase the robustness of the test.

We describe a patient with an aggressive soft tissue sarcoma masquerading as a profunda femoris pseudoaneurysm. A 73-year-old patient presented with a pulsatile swelling in her right groin. Femoral angiography demonstrated what appeared to be a pseudoaneurysm of the right profunda femoris artery and she underwent an open surgical repair. The patient represented 2 months later with an enlarging non-pulsatile, non-tender mass at the site of the wound. Open biopsy determined the diagnosis as malignant fibrous histiocytoma (MFH). An en bloc resection of the mass with reconstruction of the femoral artery and vein using PTFE grafts was performed.

Summary We performed a one year study to assess the impact of CMR imaging on the management of patients with suspected or confirmed cardiomyopathy. Background Investigation and risk stratification of suspected or confirmed cardiomyopathy traditionally involves correlation between electrocardiographic, echocardiographic and angiographic findings in an appropriate clinical setting. Cardiac Magnetic Resonance (CMR) is the new gold standard in assessment of cardiac structure, function and perfusion, provided in a single study. Aetiology and prognostic factors may be investigated concurrently. Methods This was a single centre, 12-month experience of patients referred for assessment of presumptive cardiomyopathy. Images were provided by a 1.5T GE Scanner and were reported by a Level 3 Reporter. Results 224 patients (145 male, 79 female) underwent CMR assessment of cardiomyopathy. 177 (79%) were outpatient referrals. The primary indications for CMR included 49 (21.9%) - Arrhythmia 42 (18.8%) - Abnormal echocardiogram with no cause found 35 (15.6%) - Cardiac symptoms with normal coronaries 32 (14.3%) - Screening for family history of CM/SCD 23 (10.3%) - Abnormal ECG/holter/stress test 18 (8%) - Follow-up of previously diagnosed CM 17 (7.6%) - Systemic illness 7 (3.1%) - ICD insertion CMR provided sufficient information to confirm or outrule cardiomyopathy in 68.2% of cases. A new diagnosis of cardiomyopathy was made in 25.4%. CMR also had an important role in ongoing assessment of patients with established diagnosis of cardiomyopathy, with 22.2% having their previous diagnosis outruled and 27.8% being recommended for device implantation as a direct result of CMR findings. Overall in cardiomyopathy assessment, CMR had an impact on management in 50% of patients, with a therapeutic consequence on 36.2%, including medication changes, angiography and device insertion. Conclusions Patients at all stages of the clinical spectrum of cardiomyopathy, from initial presentation to institution of therapy and long-term follow up may benefit from CMR. CMR should be implemented early in the diagnostis of suspected cardiomyopathy. Our data demonstrates the significant impact CMR consistently has on confirming diagnosis, guiding therapy and providing accurate prognosis in this patient group. Funding None.