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BACKGROUND Patients with acute severe aortic regurgitation (AR) due to infective endocarditis can progress rapidly from the hemodynamically stable patient to pulmonary edema and cardiogenic shock. We sought to identify patients at risk of decompensation where emergent surgery should be undertaken. METHODS We identified 90 patients with acute severe AR from the echocardiography laboratory database. Baseline clinical, hemodynamic (heart rate (HR) and blood pressure (BP)), and echocardiographic data including mitral filling, premature mitral valve closure (PMVC), and diastolic mitral regurgitation (DMR) were identified. The primary endpoint was subsequent development of pulmonary edema or severe hemodynamic instability. RESULTS Patients who met the primary endpoint had a higher HR (98.5 bpm vs 80.5 bpm), lower diastolic BP (54 mm Hg vs 61.5 mm Hg), higher mitral E-wave velocity (113 cm/s vs 83 cm/s), higher E/e' ratio (12.4 vs 8), higher proportion of DMR (27.8% vs 7.4%), and PMVC (25% vs 9.3%) than patients who did not meet the endpoint. The proportion of patients with the primary endpoint increased as HR increased ((≤81 bpm) 3/30 (10%), (81-94 bpm) 11/31 (35.5%), (≥94 bpm) 22/29 (75.9%), P

Introduction It is well documented that part-task trainers are highly effective in practical skills training, including pericardiocentesis.1 2 However, the use of immersive simulation to create high-fidelity clinical scenarios for summative assessment of pericardiocentesis is a novel approach. Cardiology trainees in the UK are expected to demonstrate Level 3 competency (perform the procedure unsupervised and deal with complications) in pericardiocentesis in order to meet the curriculum requirements to achieve their Certificate of Completion of Training (CCT). Given the high risk of complications associated with pericardiocentesis, it is now increasingly performed by interventional cardiologists in specialist centres, resulting in fewer opportunities for trainees to observe and practice this procedure during their training. This has become more apparent during the COVID-19 pandemic when normal clinical activities were largely put on hold, resulting in an increase in demand for simulation-based training and assessment of practical procedures. Methods Four cardiology trainees attended a series of two teaching sessions held 1 month apart which involved an immersive simulated scenario on the management of a patient with life-threatening cardiac tamponade. This included a period of teaching from a qualified trainer, followed by an observed assessment whereby trainees attended to a simulated patient and initiated relevant treatment, including successfully performing pericardiocentesis whilst interacting with colleagues and the patient. The procedure was performed using an ‘Ultrasound Guided Pericardiocentesis Simulator’ and a patient actor. Trainees were assessed using the Joint Royal Colleges Physician Training Board (JRCPTB) Directly Observed Procedures (DOPS) proforma for pericardiocentesis. The assessment comprised of 9 different domains graded (A-F), and a point score (1-6) was assigned according to their level of competency, generating an overall assessment score out of 54 points and mean score out of 6 points. Results Three out of the 4 trainees improved their mean assessment scores by an average of 22% in subsequent sessions (figure 1). Trainee 1 was already fully competent on initial assessment (initial mean score 6/6), demonstrated sustained competency throughout subsequent assessments and consequently fulfilled their training requirements for pericardiocentesis. Conclusion Immersive simulation is an effective, low-risk and high-fidelity method of training and assessment of pericardiocentesis for cardiology trainees. Although additional trainee data will be required to comprehensively validate it as an effective assessment tool for pericardiocentesis, during times where clinical experience is limited, immersive simulation can be an essential alternative training tool to allow trainees to meet requirements for their training and maintain clinical competencies. Conflict of Interest None References Diederich E, et al. The effect of model fidelity on learning outcomes of a simulation-based education programme for central venous catheter insertion. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 2015 December;10(6):360–367. Spurr L, Barron A, Butcher C, et al. P14 Part-task training with low-fidelity simulation is an effective method of pericardiocentesis training. BMJ Simulation and Technology Enhanced Learning 2017;3:A50. https://stel.bmj.com/content/3/Suppl_2/A50.1

Background Delayed diagnosis of valvular heart disease carries a poor prognosis, and early identification is desirable. We undertook a retrospective analysis of echocardiographic and electronic health care record data from the largest single cardiovascular service in the UK, to identify the burden of acute presentations with previously undiagnosed valvular heart disease and to determine the geographical and demographic distribution. Methods and Results Automated text mining analysis was retrospectively applied to all echocardiographic examinations performed between 2015 and 2019 at Bart’s Health NHS trust, identifying 2043 reports containing text or numerical data indicating severe valvular lesions. Demographic and clinical data was integrated with the echocardiographic dataset, identifying the postcode and GP practices for with the highest proportion of patients with severe valvular disease that were diagnosed during acute inpatient admissions. 376 individuals had severe valvular lesions identified during acute admission, of which 269 (72%) had no previously documented echocardiogram. A cluster of 11 GP practices (9%, 11 of 117 practices) were identified as having a higher proportion of diagnoses of severe valvular disease on acute admissions [figure 1]. These 11 were plotted geographically, alongside correlating postcodes, to identify geographical hotspots [figure 2]. Analyses were undertaken using Matlab, R and ggplot2. Conclusions A geographical cluster of GP practices, centred around a single hospital, had a higher proportion of patients diagnosed with severe valvular disease during acute admissions without a previous echocardiogram. Outreach echocardiography provision in these regions could potentially identify patients with valvular disease before acute decompensation. Further work should focus on improving methodology to identify cases and investigating risk factors that predispose to diagnosis of severe valvular disease in extremis. Conflict of Interest none

Aim: To improve patient flow, patients should be discussed daily as part of SAFER patient care bundle. However, the National Early Warning Score (NEWS) was seldom mentioned as a trigger for patient discussion on our SAFER board rounds, potentially missing unwell patients. Our aim was to discuss all patients with a NEWS≥4 at morning board round on our 30-bedded respiratory ward. Methods: PDSA interventions were: i) display NEWS scores on whiteboard ii) introduce ward e-observations iii) improve nursing handover of sick patients iv) display oxygen(O2) saturation 88%-92% on whiteboard. Data was collected from whiteboards, nursing handover sheets and board round discussions. Process measures were i) record of NEWS/NEWS≥4 on whiteboard, ii) record of O2 range 88%-92%, and LTOT from whiteboard/nursing sheet. Results: We performed 21 measurement cycles and 4 PDSA interventions over 4 months. Baseline(B) = daily median value of cycles 1-6, Completion(C) = daily median value of cycles 16-21. NEWS score recordings on white board (B, n=14.5: C, n=30) and NEWS≥4 recordings (B, n=1.5: C, n=6.5) both improved. O2 88%-92% recording on whiteboard (B, n=0: C, n=9.5) and nursing sheet (B, n=3: C, n=7) were also better. More sick patients were discussed at board round, (B, n=1, C, n=2.5). Board round length rose from 28 to 30.5 minutes. Conclusion: We showed an improvement in discussion of unwell respiratory patients through displaying NEWS scores during morning board round. Patients with O2 range 88%-92% may have led to inappropriate escalation of high NEWS scores. Future PDSA cycles may include introduction of oxygen focused NEWS-2 and education bundle to the ward.

Objectives— Defective endothelial regeneration predisposes to adverse arterial remodeling and is thought to contribute to cardiovascular disease in type 2 diabetes mellitus. We recently demonstrated that the type 1 insulin-like growth factor receptor (IGF1R) is a negative regulator of insulin sensitivity and nitric oxide bioavailability. In this report, we examined partial deletion of the IGF1R as a potential strategy to enhance endothelial repair. Approach and Results— We assessed endothelial regeneration after wire injury in mice and abundance and function of angiogenic progenitor cells in mice with haploinsufficiency of the IGF1R (IGF1R +/− ). Endothelial regeneration after arterial injury was accelerated in IGF1R +/− mice. Although the yield of angiogenic progenitor cells was lower in IGF1R +/− mice, these angiogenic progenitor cells displayed enhanced adhesion, increased secretion of insulin-like growth factor-1, and enhanced angiogenic capacity. To examine the relevance of IGF1R manipulation to cell-based therapy, we transfused IGF1R +/− bone marrow–derived CD117 + cells into wild-type mice. IGF1R +/− cells accelerated endothelial regeneration after arterial injury compared with wild-type cells and did not alter atherosclerotic lesion formation. Conclusions— Haploinsufficiency of the IGF1R is associated with accelerated endothelial regeneration in vivo and enhanced tube forming and adhesive potential of angiogenic progenitor cells in vitro. Partial deletion of IGF1R in transfused bone marrow–derived CD117 + cells enhanced their capacity to promote endothelial regeneration without altering atherosclerosis. Our data suggest that manipulation of the IGF1R could be exploited as novel therapeutic approach to enhance repair of the arterial wall after injury.