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The study aimed to determine the predictors of procedural failure (coronary cannulation) in patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) from the transradial (TR) approach.We conducted an observational study of 20,315 consecutive patients undergoing TR angiography between 2016 and 2020. TR failure was described as inability to cannulate the coronary arteries. Univariate and multivariate analyses were performed to determine independent predictors of TR failure.Out of the study population, TR failure was observed in 365 (1.8%) patients, out of which 281 (77%) crossed over successfully to the transfemoral (TF) route and 84 (23%) to left radial access (LRA). Unsuccessful procedures were most likely seen in patients who were elderly, female, BAME background, short stature or with a history of hypertension, diabetes, and renal disease. On regression analysis, age (OR: 1.024; 95% Cl: 1.014-1.035), female gender (OR: 0.729; 95% Cl: 0.555-0.957), BAME (OR: 0.786; 95% Cl: 0.612-0.959), height (OR: 0.988; 95% Cl: 0.977-0.999), hypertension (OR: 1.510; 95% Cl: 1.147-1.987) and RRA (OR: 1.977; 95% Cl: 1.105-3.538) were independent predictors of TR failure. On further analysis, these predictors of failure were not seen from the LRA approach.This study identifies that rates of TR failure are low and that predictors of failure differ between the RRA and LRA. The difference in predictors between the 2 routes suggests that in patients when coronary cannulation is unsuccessful via the RRA then the LRA could be considered as a second access site. Further study is needed to see if in selected patient groups the LRA could be used as the first-choice access route.

Objective We aimed to assess the use of enhanced stent visualisation (ESV) on outcomes, after PCI with overlapping stents, specifically using CLEARstent technology. Background Stent underexpansion and overlap are both significant risk factors for restenosis and stent thrombosis. Enhanced stent visualisation (e.g. CLEARstent) systems could provide important data to reduce under-expansion and stent overlap. Methods This was a cohort study based on this institution's percutaneous coronary intervention (PCI) registry. A total of 2614 patients who had PCI for stable angina or acute coronary syndromes (ACS, excluding cardiogenic shock) with overlapping 2nd generation drug eluting stents (DES) in the same vessel between May 2015 and January 2018 were included in the analysis. Patients were divided into ESV (n = 1354) and no ESV guided intervention (n = 1260). The primary end-point was major adverse cardiovascular events (MACE: target vessel revascularisation, target vessel myocardial infarction and all-cause mortality) recorded at a median follow up of 2.4 years. Results Groups were comparable for patient characteristics (age, diabetes mellitus, ACS presentation). A significant difference in MACE was observed between patients who underwent ESV-guided PCI (9.5%) compared with patients who underwent Standard PCI (14.4%, p = .018). This difference was mainly driven by reduced rates of target vessel revascularisation and recurrent myocardial infarction. Overall this difference persisted after multivariate Cox analysis (HR 0.86, 95% CI: 0.73–0.98) and propensity matching (HR = 0.88, 95% CI: 0.69–0.99). Conclusion We suggest that routine clinical use of ESV technology during PCI can be useful, and is associated with better medium-term angiographic and clinical outcomes. Further study is required to build on this promising signal.

Advances in coronary computed tomography angiography (CCTA) reconstruction algorithms are expected to enhance the accuracy of CCTA plaque quantification. We aim to evaluate different CCTA reconstruction approaches in assessing vessel characteristics in coronary atheroma using intravascular ultrasound (IVUS) as the reference standard.Matched cross-sections (n ​= ​7241) from 50 vessels in 15 participants with chronic coronary syndrome who prospectively underwent CCTA and 3-vessel near-infrared spectroscopy-IVUS were included. Twelve CCTA datasets per patient were reconstructed using two different kernels, two slice thicknesses (0.75 ​mm and 0.50 ​mm) and three different strengths of advanced model-based iterative reconstruction (IR) algorithms. Lumen and vessel wall borders were manually annotated in every IVUS and CCTA cross-section which were co-registered using dedicated software. Image quality was sub-optimal in the reconstructions with a sharper kernel, so these were excluded. Intraclass correlation coefficient (ICC) and repeatability coefficient (RC) were used to compare the estimations of the 6 CT reconstruction approaches with those derived by IVUS.Segment-level analysis showed good agreement between CCTA and IVUS for assessing atheroma volume with approach 0.50/5 (slice thickness 0.50 ​mm and highest strength 5 ADMIRE IR) being the best (total atheroma volume ICC: 0.91, RC: 0.67, p ​ ​0.001 and percentage atheroma volume ICC: 0.64, RC: 14.06, p ​ ​0.001). At lesion-level, there was no difference between the CCTA reconstructions for detecting plaques (accuracy range: 0.64-0.67; p ​= ​0.23); however, approach 0.50/5 was superior in assessing IVUS-derived lesion characteristics associated with plaque vulnerability (minimum lumen area ICC: 0.64, RC: 1.31, p ​ ​0.001 and plaque burden ICC: 0.45, RC: 32.0, p ​ ​0.001).CCTA reconstruction with thinner slice thickness, smooth kernel and highest strength advanced IR enabled more accurate quantification of the lumen and plaque at a segment-, and lesion-level analysis in coronary atheroma when validated against intravascular ultrasound.gov (NCT03556644).

Fractional flow reserve is the gold standard for assessing the haemodynamic significance of intermediate coronary artery stenoses. Cumulative evidence has shown that FFR-guided revascularisation reduces stent implantations and improves patient outcomes. However, despite the wealth of evidence and guideline recommendations, its use in clinical practice remains minimal. Patient and technical limitations of FFR as well as the need for intracoronary instrumentation, use of adenosine, and increased costs have limited FFR’s applicability in clinical practice. Over the last decade, several angiography-derived FFR software packages have been developed which do not require intracoronary pressure assessment with a guidewire or need for administration of hyperaemic agents. At present, there are 3 commercially available software packages and several other non-commercial technologies that have been described in the literature. These technologies have been validated against invasive FFR showing good accuracy and correlation. However, the methodology behind these solutions is different—some algorithms are based on solving the governing equations of fluid dynamics such as the Navier–Stokes equation while others have opted for a more simplified mathematical formula approach. The aim of this review is to critically appraise the methodology behind all the known angiography-derived FFR technologies highlighting the key differences and limitations.

Objectives: The clinical environment has been forced to adapt to meet the unprecedented challenges posed by the COVID-19 pandemic. Intensive care facilities were expanded in anticipation of the pandemic where the consequences include severe delays in elective procedures. Emergent procedures such as Percutaneous Coronary Intervention (PCI) in acute myocardial infarction (AMI) in which delays in timely delivery have well established adverse prognostic effects must also be explored in the context of changes in procedure and public behaviour associated with the COVID-19 pandemic. The aim for this single centre retrospective cohort study is to determine if door-to-balloon (D2B) times in PCI for ST Elevation Myocardial Infarction (STEMI) during the United Kingdom’s first wave of the COVID-19 pandemic differed from pre-COVID-19 populations. Methods: Data was extracted from our single centre PCI database for all patients that underwent pPCI for STEMI. The reference (Pre-COVID-19) cohort was collected over the period 01-03-2019 to 31-05-2019 and the exposure group (COVID-19) over the period 01-03-2020 to 31-05-2020. Baseline patient characteristics for both populations were extracted. The primary outcome measurement was D2B times. Secondary outcome measurements included: time of symptom onset to call for help, transfer time to first hospital, transfer time from non-PCI to PCI centre, time from call-to-help to PCI centre, time to table and onset of symptoms to balloon time. Categorical and continuous variables were assessed with Chi squared and Mann-Whitney U analysis respectively. Procedural times were calculated and compared in the context of heterogeneity findings. Results: 4 baseline patient characteristics were unbalanced between populations with statistical significance (P

The British Society of Echocardiography (BSE) highlights the importance of patient questionnaires as part of the quality improvement process, To this end, we implemented a novel system whereby paired surveys were completed by patients and physiologists for transthoracic echocardiography scans, allowing for parallel comparison of the experiences of service providers and end users. Anonymised questionnaires were completed for each scan by the patient and physiologist for outpatient echocardiographic scans in a teaching hospital. In 26% of the responses, patient found the scans at least slightly painful, and in 24% of scans physiologists were in discomfort. The most common reason given by physiologists for technically difficult or inadequate scans was patient discomfort. In 38% of the scans at least one person (the patient or the physiologist) was in at least some discomfort. Comparative data showed that the scans reported as most painful by patients were also reported by the physiologists as difficult and uncomfortable. In summary, these results demonstrate the feasibility of implementing paired surveys. Patient information leaflets by the BSE and National Health Service (NHS) describe echocardiography as painless but the results here indicate this is not always the case.

Objective We sought to describe the prevalence, management strategies and evaluate the prognosis of patients with iatrogenic catheter‐induced ostial coronary artery dissection (ICOCAD). Background ICOCAD is a rare but potentially devastating complication of cardiac catheterisation. The clinical manifestations of ICOCAD vary from asymptomatic angiographic findings to abrupt vessel closure leading to myocardial infarction and death. Methods 55,968 patients who underwent coronary angiography over a 10‐year period were screened for ICOCAD as defined by the National Heart, Lung, and Blood Institute. The management and all‐cause mortality were retrieved from local and national databases. Results The overall prevalence of ICOCAD was 0.09% (51/55,968 patients). Guide catheters accounted for 75% (n = 37) of cases. Half of the ICOCAD cases involved the right coronary artery while the remaining were related to left main stem (23/51; 45%) and left internal mammary artery (2/51; 4%). Two‐thirds of ICOCAD were high grade (type D, E, and F). The majority of cases were type F dissections (n = 18; 66%), of which two third occurred in females in their 60s. The majority of ICOCAD patients (42/51; 82%) were treated with percutaneous coronary intervention while the remaining underwent coronary artery bypass grafting (3/51; 6%) or managed conservatively (6/51; 12%). Three deaths occurred during the index admission while 48/51 patients (94.1%) were safely discharged without further mortality over a median follow‐up of 3.6 years. Conclusions ICOCAD is a rare but life‐threatening complication of coronary angiography. Timely recognition and prompt bailout PCI is a safe option for majority of patients with good clinical outcomes.

Background: More than half of the patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have multi-vessel coronary artery disease. This is associated with worse outcomes compared with single vessel disease. Whilst evidence now exists to support complete revascularisation for bystander disease the optimal timing is still debated. This study aimed to compare clinical outcomes in patients with STEMI and multi-vessel disease who underwent complete revascularisation as inpatients in comparison to patients who had staged PCI as early outpatients. Methods and results: We conducted an observational cohort study consisting of 1522 patients who underwent primary PCI with multi-vessel disease from 2012 to 2019. Exclusions included patients with cardiogenic shock and previous CABG. Patients were split into 2 groups depending on whether they had complete revascularisation performed as inpatients or as staged PCI at later outpatient dates. The primary outcome of this study was major adverse cardiac events (consisting of myocardial infarction, target vessel revascularisation and all-cause mortality). 834 (54.8%) patients underwent complete inpatient revascularisation and 688 patients (45.2%) had outpatient PCI (median 43 days post discharge). Of the inpatient group, 652 patients (78.2%) underwent complete revascularisation during the index procedure whilst 182 (21.8%) patients underwent inpatient bystander PCI in a second procedure. Overall, there were no significant differences between the groups with regards to their baseline or procedural characteristics. Over the follow-up period there was no significant difference in MACE between the cohorts ( P = .62), which persisted after multivariate adjustment (HR 1.21 [95% CI 0.72-1.96]). Furthermore, in propensity-matched analysis there was no significant difference in outcome between the groups (HR: 0.86 95% CI: 0.75-1.25). Conclusions: Our study demonstrated that the timing of bystander PCI after STEMI did not appear to have an effect on cardiovascular outcomes. We suggest that patients with multi-vessel disease can potentially be discharged promptly and undergo early outpatient bystander PCI. This could significantly reduce length of stay in hospital.

BACKGROUND:Attenuation-compensated (AC) technique was recently introduced to improve the plaque characterization of optical coherence tomography (OCT). Histological validation demonstrated promising results but the efficacy and reproducibility of this technique for assessing in-vivo tissue composition remains unclear.Methods and Results:OCT images portraying native (n=200) and stented (n=200) segments and 31 histological cross-sections were analyzed. AC-OCT appeared superior to conventional (C)-OCT in detecting the external elastic lamina (EEM) borders (76% vs. 65.5%); AC-OCT enabled larger EEM arc detection compared with C-OCT (174.2±58.7° vs. 137.5±57.9°; P

Fractional flow reserve (FFR) is regarded as the gold standard for the physiological assessment of intermediate coronary artery stenoses. However, FFR does not allow assessment of plaque morphology and lesion geometry. Intracoronary imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) can help treatment planning by optimising stent implantation, which can improve patient outcomes. The aim of this meta-analysis is to compare the efficacy of IVUS and OCT-derived metrics in detecting flow limiting stenoses in non-left main stem lesions.A systematic review of PubMed, Medline, and Cochrane databases was performed and identified studies examining the diagnostic accuracy of IVUS and OCT in detecting significant stenoses when compared to FFR.A total of 33 (7537 lesions) studies (24 IVUS, 7 OCT and 2 IVUSOCT studies) were included in the meta-analysis. Pooled analysis showed that IVUS- and OCT-derived minimum lumen area (MLA) had a similar sensitivity in predicting haemodynamically significant lesions (IVUS-MLA: 0.747 vs OCT-MLA 0.732, p = 0.519). However, OCT-MLA had a higher specificity (0.763 vs 0.665, p 0.001) and diagnostic accuracy in detecting flow-limiting stenoses than IVUS-MLA (AUC 0.810 vs 0.754, p = 0.045). Sub-analysis of the studies with the clinically significant FFR cut-off value of 0.80 yielded similar results demonstrating that OCT-MLA has a better accuracy than IVUS-MLA in detecting haemodynamically significant stenoses (AUC 0.809 vs 0.750, p = 0.034).OCT with its superior image resolution appears to be the preferable intravascular imaging modality for the detection of haemodynamically significant stenoses in non-left main stem lesions.

Background Cardiac MR stress perfusion remains a qualitative technique in clinical practice due to technical and postprocessing challenges. However, automated inline perfusion mapping now permits myocardial blood flow (MBF, ml/g/min) quantification on‐the‐fly without user input. Purpose To investigate the diagnostic performance of this novel technique in detecting occlusive coronary artery disease (CAD) in patients scheduled to undergo coronary angiography. Study Type Prospective, observational. Subjects Fifty patients with suspected CAD and 24 healthy volunteers. Field Strength 1.5T. Sequence "Dual" sequence multislice 2D saturation recovery. Assessment All patients underwent cardiac MR with perfusion mapping and invasive coronary angiography; the healthy volunteers had MR with perfusion mapping alone. Statistical Tests Comparison between numerical variables was performed using an independent t‐test. Receiver operator characteristic (ROC) curves were generated for transmyocardial, endocardial stress MBF, and myocardial perfusion reserve (MPR, the stress:rest MBF ratio) to diagnose severe (>70%) stenoses as measured by 3D quantitative coronary angiography (QCA). ROC curves were compared by the method of DeLong et al. Results Compared with volunteers, patients had lower stress MBF and MPR even in vessels with 70%), MBF and MPR decreased. To diagnose occlusive (>70%) CAD, endocardial and transmyocardial stress MBF were superior to MPR (area under the curve 0.92 [95% CI 0.86–0.97] vs. 0.90 [95% CI 0.84–0.95] and 0.80 [95% CI 0.72–0.87], respectively). An endocardial threshold of 1.31 ml/g/min provided a per‐coronary artery sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 90%, 82%, 50%, and 98%, with a per‐patient diagnostic performance of 100%, 66%, 57%, and 100%, respectively. Data Conclusion Perfusion mapping can diagnose occlusive CAD with high accuracy and, in particular, high sensitivity and NPV make it a potential "rule‐out" test. Level of Evidence: 1 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019;50:756–762.

Intravascular imaging has enabled in vivo assessment of coronary artery pathology and detection of plaque characteristics that are associated with increased vulnerability. Prospective invasive imaging studies of coronary atherosclerosis have demonstrated that invasive imaging modalities can detect lesions that are likely to progress and cause cardiovascular events and provided unique insights about atherosclerotic evolution. However, despite the undoubted value of the existing imaging techniques in clinical and research arenas, all the available modalities have significant limitations in assessing plaque characteristics when compared with histology. Hybrid/multimodality intravascular imaging appears able to overcome some of the limitations of standalone imaging; however, there are only few histology studies that examined their performance in evaluating plaque pathobiology. In this article, we review the evidence about the efficacy of standalone and multi-modality/hybrid intravascular imaging in assessing plaque morphology against histology, highlight the advantages and limitations of the existing imaging techniques and discuss the future potential of emerging imaging modalities in the study of atherosclerosis.

Background The international healthcare response to COVID-19 has been driven by epidemiological data related to case numbers and case fatality rate. Second order effects have been less well studied. This study aimed to characterise the changes in emergency activity of a high-volume cardiac catheterisation centre and to cautiously model any excess indirect morbidity and mortality. Method Retrospective cohort study of patients admitted with acute coronary syndrome fulfilling criteria for the heart attack centre (HAC) pathway at St. Bartholomew’s hospital, UK. Electronic data were collected for the study period March 16th – May 16th 2020 inclusive and stored on a dedicated research server. Standard governance procedures were observed in line with the British Cardiovascular Intervention Society audit. Results There was a 28% fall in the number of primary percutaneous coronary interventions (PCIs) for ST elevation myocardial infarction (STEMI) during the study period (111 vs. 154) and 36% fewer activations of the HAC pathway (312 vs. 485), compared to the same time period averaged across three preceding years. In the context of ‘missing STEMIs’, the excess harm attributable to COVID-19 could result in an absolute increase of 1.3% in mortality, 1.9% in nonfatal MI and 4.5% in recurrent ischemia. Conclusions The emergency activity of a high-volume PCI centre was significantly reduced for STEMI during the peak of the first wave of COVID-19. Our data can be used as an exemplar to help future modelling within cardiovascular workstreams to refine aggregate estimates of the impact of COVID-19 and inform targeted policy action.

Cardiac troponins are established markers of myocardial injury, with Troponin I (cTnI) having higher specificity compared to Troponin T (TnT). An 80 year-old female with previous tissue aortic valve replacement (tAVR) and hypertension experienced a collapse in the context of generalised muscle

We describe our technique for reconstructing the free right atrial wall and superior vena cava using CorMatrix (CorMatrix Alpharetta, GA, USA) extracellular matrix following resection of a large leiomyosarcoma.

AIM The aim of this study was to investigate the effects of baseline anaemia on the outcome in patients treated by primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction. METHODS This study was a retrospective cohort study of 2418 patients with ST-elevation myocardial infarction treated by PPCI between January 2004 and August 2010 at a single centre. We investigated the outcome in patients with anaemia compared with that in patients with a normal haemoglobin (Hb) level. Anaemia was defined according to the WHO definition as an Hb level less than 12 g/dl for female individuals and less than 13 g/dl for male individuals. We also calculated hazard ratios using a stratified model according to the Hb level. RESULTS A total of 471 (19%) patients were anaemic at presentation. The anaemic cohort was older (72.2 vs. 62.4 years, P

We describe our technique for reconstructing the free right atrial wall and superior vena cava using CorMatrix (CorMatrix Alpharetta, GA, USA) extracellular matrix following resection of a large leiomyosarcoma.

Purpose: European guidelines state that with the exception of cardiogenic shock, percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) should be limited to the culprit artery. Although there is no robust randomized controlled trial data available there is a general consensus that non culprit coronary artery lesions identified at the time of STEMI should be treated in a staged manner. Whilst there is general consensus on the above; currently neither guidelines nor evidence exist regarding the optimal time for staged PCI. Our aim was to compare outcomes in patients who underwent staged PCI either as an inpatient or as an outpatient within six weeks time. Methods: This was an observational cohort study of 983 patients with multi-vessel disease who underwent PPCI from 2007 to 2011. Patients with previous CABG, cardiogenic shock were excluded. 102 patients were managed with staged intervention. The primary outcome was major adverse cardiac events (all cause mortality, myocardial infarction, target vessel revascularisation and stroke). Follow-up was for a median of 3.2 years (IQR range 2.0-4.4 years). Results: 24 (23.5%) patients underwent inpatient staged PCI with 78 (76.5%) patients undergoing their intervention within 6 weeks of hospital discharge. Patients who underwent inpatient staged PCI were older compared to those having 6 week staged procedures. (66.1±10.4 vs 59.2±10.6, P=0.02). Otherwise there were no other differences in baseline characteristics. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 3-year event rates between patients undergoing in-patient and 6 week staged procedures. Un-adjusted Cox analysis demonstrated no difference in 3 year outcomes between inpatient and 6 week procedures (HR 0.84 [95% CI 0.27-2.61)), which persisted after multivariate adjustment ((HR 0.60 [95% CI 0.12-2.96)) (factors corrected for: previous MI, DM, access, age, EF, eGFR, DES use, gender, previous CVA, PVD). Conclusion: This observational data suggests that staged procedures performed as an in-patient or at 6 weeks post discharge are associated with similar outcomes in STEMI patients with MVD undergoing primary PCI.

Background European guidelines state that with the exception of cardiogenic shock, percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) should be limited to the culprit artery. Although there is no robust randomised controlled trial data available there is a general consensus that non-culprit coronary artery lesions identified at the time of STEMI should be treated in a staged manner. Whilst there is general consensus on the above; currently neither guidelines nor evidence exist regarding the optimal time for staged PCI. Our aim was to compare outcomes in patients who underwent staged PCI either as an in-patient or as an out-patient within 6 weeks time following a STEMI. Methods This was an observational cohort study of 983 patients with multi-vessel disease who underwent primary PCI from 2007 to 2011. Patients with previous CABG, cardiogenic shock were excluded. 102 patients were managed with staged intervention. The primary outcome was major adverse cardiac events (all cause mortality, myocardial infarction, target vessel revascularisation and stroke). Follow-up was for a median of 3.2 years (IQR range 2.0–4.4 years). Results 24 (23.5%) patients underwent in-patient staged PCI with 78 (76.5%) patients undergoing their intervention within 6 weeks of hospital discharge. Differences in baseline characteristics are outlined in table 1. Patients who underwent in-patient staged PCI were older compared to those having 6 week staged procedures. (66.1±10.4 vs 59.2±10.6, p=0.02). Otherwise there were no other differences in baseline characteristics. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 3-year event rates between patients undergoing in-patient and 6 week staged procedures (figure 1). Un-adjusted Cox analysis demonstrated no difference in 3 year outcomes between in-patient and 6 week procedures (HR 0.84 (95% CI 0.27 to 2.61)), which persisted after multivariate adjustment ((HR 0.60 (95% CI 0.12 to 2.96)) (factors corrected for: previous MI, DM, access, age, EF, eGFR, DES use, gender, previous CVA, PVD). Conclusions This observational data suggests that staged procedures performed as an in-patient or at 6 weeks post discharge are associated with similar outcomes in STEMI patients with multi-vessel disease undergoing primary PCI.

Background Previous studies have demonstrated a relationship between pre-existing anaemia and inpatient mortality after percutaneous coronary intervention (PCI). There is limited data looking at the impact of baseline Haemoglobin and long term outcome after primary PCI. Methods Clinical information was analysed from a prospective database on 2357 STEMI patients who underwent Primary PCI between January 2004 and May 2010 at a London centre. Information was entered at the time of procedure and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS/CCAD national audit. Anaemia was defined according to WHO definition of Hb greater than or equal to 12 g/dl for females and 13 g/dl for males. Results 471 (20%) patients were anaemic at presentation. The anaemic cohort, were older (72.2 vs 62.4, p Conclusion Patients presenting with anaemia undergoing primary PCI appear at significantly higher risk of an adverse outcome. This risk increases further in population receiving RBC transfusions during index hospitalisation.