Search

Background/Aims Most transcatheter aortic valve implantation procedures are now performed under conscious sedation, rather than general anaesthetic. This study evaluated nurse-led conscious sedation, compared with anaesthetist-led sedation, to determine the feasibility of the former. Methods Consecutive patients undergoing transcatheter aortic valve implantation under either nurse-led or anaesthetist-led sedation between July 2018 and September 2021 were reviewed. Assessed outcomes were analysed and compared, including 30-day mortality rate, major vascular access site bleeding, moderate or severe aortic regurgitation, stroke, new pacemaker implantation, duration of procedure and length of stay. Results A total of 212 patients who underwent nurse-led sedation and 412 who underwent anaesthetist-led sedation were identified. There were no significant differences in risk scores between the two groups. In both groups, incidence of conversion to general anaesthetic was low, with nurse sedatitionists seeking anaesthetist support in 13 (6.2%) cases. Cases with nurse-led sedation had a significantly lower average duration of the procedure (90 minutes vs 111 minutes; P=0.001) and length of stay (2 days vs 3 days, P=0.0002). Conclusions Nurse-led sedation can be safely incorporated into transcatheter aortic valve implantation practice. Nurse-led sedation delivered similar outcomes to anaesthetist-led sedation, but with shorter procedural times and legnth of stay. This could allow more flexible scheduling, increased capacity and improved access for patients.

Introduction Transcatheter Aortic Valve Implantation (TAVI) is an established treatment option for severe aortic stenosis (AS), with over 5000 procedures performed in the UK in 2019. Given the high morbidity and mortality associated with delay to treatment, the British Cardiovascular Intervention Society proposes a diagnosis to procedure window of 18 weeks. However, in the UK TAVI Survey (2019), over 50% of centres reported difficulty in increasing capacity to meet this demand and the average timescale to TAVI was far longer than this target at 155 days. Streamlining patients to a dedicated structural clinic, a model proposed by Valve for Life UK, is therefore desirable to achieving these targets. Methods To improve the timeline to TAVI at a district general hospital (DGH), we optimised the referral process in 3 key areas. Firstly, direct triage to TAVI clinic by physiologists at the time of echo diagnosis, negating the need for initial assessment by a general cardiologist. We utilised specialist CT analysis software (3-Mensia), allowed CT images to be analysed locally rather than during MDT meetings, increasing capacity to discuss more cases in the time saved. Lastly, the procedure was often completed by the same structural interventionalist that had initially assessed the patient, eliminating the need for further clinic review in a specialist centre and providing continuity of care. We compared 2 pathways of patient care: pathway 1, representing existing processes, and pathway 2, representing this novel way of working.Data was collected retrospectively over a 2-year period (pathway 1 duration 16 months, pathway 2 duration 7 months) for all patients with severe aortic stenosis who were intended for TAVI procedure. We considered death whilst waiting for procedure or admission with progressive AS symptoms as adverse events. Results A total of 65 cases were reviewed, 44 were managed as outpatients and 15 inpatients. We excluded 5 cases treated along both pathways and 1 deemed clinically not suitable for TAVI after initial investigation. Of the 44 outpatients, 28 patients were managed in pathway 1 (1.8 patients per month) and 16 in pathway 2 (2.3 patients per month). The mean time from entry to pathway to procedure was 221 days in pathway 1 and 87 days in pathway 2 (p Conclusions Improving our local TAVI pathway has led to a significant reduction in the time to treatment. Most outpatients now undergo TAVI well within the BCIS 18-week target and 68 days faster than the UK average. Though the numbers are small, we also demonstrated an associated reduction in adverse events. These findings suggest that adopting a dedicated structural clinic model has led to significant improvements at DGH level, ultimately resulting in reducing the time to TAVI and improving patient care. Conflict of Interest None

CTFFR the SWindon Evaluation of Emerging Technology (CTFFR SWEET) Aims To see how adding routine CT Fractional Flow Reserve (CTFFR) to CT Coronary Angiography (CTCA) altered the care pathway of patients with chest pain of recent onset. Setting Rapid Access Chest Pain Clinic (RACPC) in a secondary care hospital in the South West of England supported by a well-established CT programme (since 2006). CTFFR was started in July 2018 as part of the NHS ITP programme, CTFFR was requested routinely for patients with CT scans of sufficient quality with visible stenoses of 30-90% in a major epicardial coronary arteries. The NICE cost model for CTFFR predicts a 50% reduction in subsequent angiography and reduced downstream costs. Measurements Patient journey(s), costs, resource use. Methods The RACPC database helped identify 2 consecutive 12 month patient cohorts and their initial testing strategy. Using hospital database searches the care of patients undergoing CTCA as a first test was examined in more detail. Codes of all care were obtained to estimate costs. Results The initial testing strategy for each cohort is shown in Table 1. Downstream testing, cath lab procedures and revascularisation by cohort that had CTCA as the first test are shown in table 2. Patients who underwent CTCA as a first test had less steps (cath lab, revascularisation, stress imaging) in care following the introduction of CTFFR (Figure 1). CTFFR helped identify patients likely to receive same day PCI, 51/276 patients had images sent for analysis. 41 were analysed successfully. 17 of these patients were scheduled for angiography. Of these there were 4 false positives. In the remaining 13, 8 underwent same day PCI and 1 was referred for CABG, Revascularisation Rate (RR) 69%. The RR was 66% in the 6/10 patients for whom CTFFR analysis was not possible referred for angiography, 1 same day PCI and 3 CABG. 12 other patients in the post CTFFR cohort were referred for angiography with a revascularisation rate of 42%, 2/4 PCI patients had same day procedures 1 had CABG. In the CTCA only cohort 54% of PCI procedures were same day compared to 84% in the CTFFR group. A rough estimate of costs using CTCA, DSE, CTFFR, Angiography and PCI per patient across the 2 cohorts showed £310 per patient pre and £471 per patient post CTFFR (AHSN cost model). There was no appreciable difference in cath lab admissions in the CTCA first groups before and after the introduction of routine CTFFR, 35/363 (9.6%) vs 36/276 (13%). Conclusion This single centre observational study showed in our practice that CTFFR identified patients with significant coronary disease suitable for coronary intervention and streamlined care. The reductions in costs and angiography in the NICE model were not seen. Conflict of Interest NIL

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.

Vascular and bleeding complications after transfemoral transcatheter aortic valve implantation (TF-TAVI) are associated with significant morbidity and mortality. Whether percutaneous approach (PC) or surgical cut-down (SC) is superior is still widely debated. PubMed, EMBASE and Cochrane library

Background Ischaemic mitral regurgitation (MR) is a known complication of ST elevation myocardial infarction (STEMI). There is a paucity of evidence on the impact of acutely revascularised STEMI on the mitral valve. The current ESC and ACC guidelines do not specifically advise a management strategy in this cohort. The aim of this study is to delineate the effect of STEMI on the mitral valve, identify predictors of MR and compare mortality between these groups. Methods In this observational registry study, we analysed 1122 consecutive patients presenting with STEMI who underwent primary PCI between April 2014 and April 2016. We identified predictors of significant MR (moderate or severe) and compared the mortality risk in MR group vs no MR group. Statistical analysis was done on SPSS. Results Of the 1122 patients identified at baseline (mean age 64±13 years, and 76% male), 94 were excluded due to missing echo data. 62 patients (6%) were found to have significant MR. Patients’ with significant MR were on average 10 years older than patients with no MR (95% CI=6.7–−13.13; p 40% (p Although 76% of the sample population were male, females were shown to have a proportionally higher prevalence of MR and higher all-cause mortality (p=0.0179; p=0.0048) compared with males. All-cause mortality at the time of data collection was 19% in MR group vs 5% in no MR group. On a multivariate analysis; age, LV ejection fraction, renal impairment and non-smoker status were all shown to be significant predictors for ischaemic MR. Over a mean follow up of 2.3 years, 8% of the patients died, with significantly higher mortality in moderate-severe MR group compared with no MR group (Log rank 13.4, p Conclusion Acute MR was found to be a significant predictor of mortality following STEMI. 3% of patients with LVEF >40% were found to have significant MR and may benefit from a repeat echocardiogram at follow-up thereby guiding future management. Prospective multicenter trials are warranted to confirm the finding.

Out-of-hospital cardiac arrest (OOHCA) is the leading mode of death in Europe and the United States. Emergency coronary angiography has a role in patients with OOHCA and ST-segment elevation, but outside of this group, its role is unclear. Intensive treatment of patients with an inevitably

The second generation STENTYS Xposition S self-expanding stent with a novel balloon delivery system was launched in May 2015. The stents unique properties are well suited for the treatment of left main stem disease where large diameters, coverage of diameter differences and precise positioning are required. We report the first consecutive experience of using this device in the treatment of left main stem lesions.20 consecutive patients with a mean age of 73.9±10.1 years were treated over a period of 8 months at our institution and were assessed on the parameters of technical, angiographic and procedural success.Technical success was achieved in 95% of cases and angiographic success in 80% of cases. There was no incidence of geographical miss. Side branch access was straightforward, with no failure to recross stent struts, dilate or deploy a second stent if required. In this unselected clinical cohort, 2 critically ill patients with cardiogenic shock on presentation died despite successful revascularisation. There was no incidence of early stent related complications up to 30-day follow up.This first consecutive series of left main lesions treated with STENTYS Xposition S documents high acute technical and procedural success rates.

Background The evidence for benefits of bivalirudin over heparin has recently been challenged. We aimed to analyse the safety and cost-effectiveness following reintroduction of heparin instead of bivalirudin as the standard anticoagulation for primary percutaneous coronary intervention (PPCI) in a high-volume centre. Methods and results This analysis was an open-label, prospective registry including all patients admitted to our centre for PPCI from April 2014 to April 2016. Heparin was reintroduced as standard anticoagulant in April 2015. During the 2 years, 1291 patients underwent a PPCI, 662 in the Bivalirudin protocol period (Cohort B) and 629 in the Heparin protocol period (Cohort H). Baseline and procedural characteristics were not significantly different, except for a higher use of thromboaspiration and femoral access in the earlier Cohort B. Glycoprotein 2b3a (Gp2b3a) antagonists were used in 24% of the patients in Cohort B versus 28% in Cohort H (P

Background and purpose Complex cardiac pacing with either an implantable cardiovertor defibrillator (ICD) or a biventricular pacemaker with pacing only (CRT-P) or biventricular pacemaker with implantable cardiovertor defibrillator (CRT-D) plays an important role in the management of patients with heart failure. However, device implantation is associated with rare but significant complications which may limit the number of centres offering this treatment. The aim of this study is to define procedural success and complication rates associated with implantation of complex implantable cardiac devices in a district general hospital. Methods and subjects The pacing records of all the patients who underwent complex cardiac pacing (ICD, CRT-P and CRT-D) between January 2010 and December 2011 were reviewed. Information on clinical characteristics, pacing indications, venous access, implantation data, lead stability at follow-up, and procedure-related complications were obtained. Results A total of 151 devices (60 CRT-Ds, 55 CRT-Ps and 36 ICDs), were implanted between January 2010 and December 2011 with a median follow-up of 12 months. Overall transvenous procedural success rate was 99.3%. 14 (9.3%) out of the 151 patients suffered a complication. There were no procedure-related deaths, and lead displacement (5.3%) was the most common complication. Other complications included pocket haematoma and phrenic nerve stimulation (1.3% and 3.4%, respectively). There were no cases of pneumothorax, cardiac tamponade, device-related infection, symptomatic venous thrombosis and stroke. Lead thresholds, in particular that of the left ventricular lead, remained stable during the follow-up period indicating persistent delivery of cardiac resynchronisation therapy in the group receiving CRT systems. Conclusions In the presence of necessary clinical expertise, complex cardiac devices can be implanted successfully and with a high degree of safety in the setting of a district general hospital.

Background Emergency coronary angiography in comatose survivors of out of hospital cardiac arrest (OHCA), in the absence of STEMI criteria on a post-resuscitation ECG, is controversial. High mortality and the implications on resource use, without robust criteria for the selection of appropriate candidates, has prevented clear guidance from the national societies. Our institution has adopted early involvement of a specialist team, consisting of an interventional cardiologist, emergency care physician and intensive-care anaesthetist, to initiate early assessment of patients. All survivors of OHCA, without an obvious non-cardiac aetiology, are transferred to the cardiac catheterisation laboratory for emergent angiography and intervention, if indicated, irrespective of presenting ECG, before admission to intensive care. We report the outcomes of this pathway with particular emphasis on the predictive value of the post-resuscitation ECG. Methods We retrospectively reviewed the clinic data, ECG characteristics and angiographic images of all survivors of OHCA admitted to our institution between 1 October 2012 and 31 July 2015. Results We obtained data for 192 patients (80% male, average age 62 years). 24% patients were transferred from neighbouring hospitals. The median time interval from admission to the emergency department and transfer to the catheter laboratory was 76 min for local patients compared to 176 min for transferred patients. The prevalence of significant coronary artery disease (>70% stenosis in at least one coronary artery) was 77% in our patient cohort. 69 (36%) patients had an acute coronary occlusion whereas 55 (29%) cases were chronic total occlusions. Immediate PCI was undertaken in 109 (57%) cases and of these 46 (42%) did not have ST elevation on the post-resuscitation ECG. Our overall rate of survival to discharge was 58%, with higher rates of survival observed in those undergoing PCI (63% v 52% in conservatively managed patients (non-significant p = 0.1)). Conclusion Clinical criteria and electrocardiographic data are poor predictors of significant coronary artery disease and acute coronary occlusion. In our experience early involvement of a specialist team to facilitate prompt assessment and immediate coronary angiography is associated with a favourable outcome in this unselected population of comatose survivors of out of hospital cardiac arrest.

The uroguanylin system is a newly discovered endocrine/paracrine system that may have a role in the regulation of salt balance, appetite and gut health. The precursor pro-uroguanylin is predominantly synthesized in the gut, although there may be other sites of synthesis, including the kidney tubules. Products from pro-uroguanylin may mediate natriuresis following oral consumption of a salt load through both GC-C (guanylate cyclase C)-dependent and -independent mechanisms, and recent evidence suggests a role in appetite regulation. Local paracrine effects in the gut through GC-C stimulation may have tumour-suppressing actions through the regulation of cell proliferation and metabolism. Although most information on this system has been derived from knockout models, recent human studies have indicated possible roles in heart failure and renal failure. An improved understanding of the nature of its natriuretic, appetite and tumour-suppressing actions may facilitate the discovery of new therapies for heart failure, obesity and cancer prophylaxis.

Background We sought to summarize and critically appraise the literature on the epidemiology of infective endocarditis (IE) in the general population. Methods We retrieved population-based IE surveys by searching MEDLINE and EMBASE. Two reviewers independently extracted relevant data. We performed a metaregression to determine if temporal trends of IE characteristics exist. Results Fifteen population-based investigations with 2,371 IE cases from seven countries (Denmark, France, Italy, the Netherlands, Sweden, United Kingdom, and United States) from 1969 to 2000 were eligible. Different case definitions and procedures were used to capture all IE cases, including census of existing diagnoses, record-linkage system, and direct contact survey. In the unadjusted regression, there was a decline in the proportion of IE patients with underlying rheumatic heart disease (RHD; 12%; 95% confidence interval [CI], − 21 to − 3%; p = 0.01) and an increase in the proportion of patients undergoing valve surgery (9%; 95% CI, 3 to 16%) per decade. After adjusting for country, the decline in IE cases with underlying RHD became nonsignificant, but the proportions of IE patients undergoing valve surgery increased 7% per decade (95% CI, − 4 to 14%; p = 0.06), and those with underlying prosthetic valve increased 7% per decade (95% CI, − 1 to 16%; p = 0.07). There were no significant temporal trends in the causative organisms. Conclusion Evidence from well-planned, representative IE epidemiologic surveys is scarce in many countries. Available studies suggest a changing distribution of underlying valvular heart disease in patients with IE and an increase in its surgical treatment.