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Abstract Background The relationship between cardiac enzyme (CE) release following coronary artery bypass surgery (CABG) and medium term outcome is unclear. We sought to determine the relationship between post-operative CE release and one-year survival following isolated CABG. Methods Over three years 3,024 consecutive patients underwent isolated CABG. Patient characteristics were prospectively recorded in a cardiac surgical database. CE release, taken as the highest single measurement recorded in the first 24 hours post-op, was abstracted from an electronic archive. All cause mortality was taken from a national registry of deaths. Results Data were complete for 2,860 (94.6%) patients. CK-MB isoenzyme (reference range 5–24 U/l) was recorded in 2,568 (89.8%), total CK in 292 (10.2%). CE release three or more times the upper limit of the reference range (ULR) were recorded in 498 (17.4%) patients, 163 (5.7%) patients had CE more than six times ULR. There were 122 deaths (4.3%). Cox proportional hazards analysis showed that CE release 3–6 times ULR (adjusted HR 2.1 [95% CI: 1.6 to 2.6], p = 0.002) and CE release six or more times the ULR (adjusted HR 5.0 [95% CI: 4.5 to 5.4], p < 0.001) were independently associated with increased one-year mortality. Conclusion Cardiac enzyme release following CABG is associated with increased one-year all-cause mortality. The definition of peri-operative myocardial infarction following CABG should include elevation of CK-MB three or more times the upper limit of normal.

Objective: QT peak prolongation is associated with left ventricular hypertrophy (LVH) in patients with hypertension. This study tests the hypothesis that QT peak prolongation correlates with LV mass index in apparently healthy young football players.Methods: QT peak and other ECG criteria for LVH were assessed in 117 male professional footballers (mean age 16.4 years +/- SD 0.76). Their left ventricular mass index (LVMI) was assessed by transthoracic echocardiography. Heart rate-corrected QT peak (QTpc) interval was measured in lead I using Bazett's formula. Spearman (2-tailed) test and UNIANOVA was used to assess if there were correlations between QT peak and the various echocardiographic and ECG indices of LVH.Results: Echocardiographic LVH, defined as LVMI > or = 134 g/m(2), was seen in 79 (70.5%) subjects. ECG-defined LVH was present in 54 (50 %) players by Sokolow-Lyon criteria, in 19 (16 %) players by Romhilt Score, in 5 (4 %) players by Cornell voltage criteria, and in 7 (6 %) players by Cornell product >2436 mm ms. There was no correlation between QT peak (QTpc) and LVMI on echocardiography (Spearman r = 0.058, 2-tailed P = 0.54). In addition, there was no relation between LVH and QTpc of lead I using any of the following ECG criteria: Sokolow-Lyon (P = 0.6), Romhilt (P = 0.3), Cornell voltage (P = 0.8), or Cornell product (P = 0.6).Conclusion: QT peak interval, which is associated with pathological LVH in hypertensive patients and is a measure of risk of cardiac death, does not correlate with LVH characterized by myocyte hypertrophy in young apparently healthy professional footballers. [ABSTRACT FROM AUTHOR]

Objective: To assess physiological cardiac adaptation in adolescent professional soccer players.Subjects and Design: Over a 32 month period 172 teenage soccer players were screened by echocardiography and ECG at a tertiary referral cardiothoracic centre. They were from six professional soccer teams in the north west of England, competing in the English Football League. One was excluded because of an atrial septal defect. The median age of the 171 players assessed was 16.7 years (5th to 95th centile range: 14-19) and median body surface area 1.68 m(2) (1.39-2.06 m(2)).Main Outcome Measures: Standard echocardiographic measurements were compared with predicted mean, lower, and upper limits in a cohort of normal controls after matching for age and surface area. Univariate regression analysis was used to assess the correlation between echocardiographic variables and the age and surface area of the soccer player cohort. ECG findings were also assessed.Results: All mean echocardiographic variables were greater than predicted for age and surface area matched controls (p < 0.001). All variables except left ventricular septal and posterior wall thickness showed a modest linear correlation with surface area (r = 0.2 to 0.4, p < 0.001); however, left ventricular mass was the only variable that was significantly correlated with age (r = 0.2, p < 0.01). Only six players (3.5%) had structural anomalies, none of which required further evaluation. All had normal left ventricular systolic function. Sinus bradycardia was found in 65 (39%). The Solokow-Lyon voltage criteria for left ventricular hypertrophy were present in 85 (50%) and the Romhilt-Estes points score (five or more) in 29 (17%). Repolarisation changes were present in 19 (11%), mainly in the inferior leads.Conclusions: Chamber dimensions, left ventricular wall thickness and mass, and aortic root size were all greater than predicted for controls after matching for age and surface area. Sinus bradycardia and the ECG criteria for left ventricular hypertrophy were common but there was poor correlation with echocardiographic left ventricular hypertrophy. The type of hypertrophy found reflected the combined endurance and strength based training undertaken. [ABSTRACT FROM AUTHOR]

Background: Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure., Methods: In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3-5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518., Findings: Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09-2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70-1·89, p=0·59)., Interpretation: Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially., Funding: Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK)., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: A 41-year-old female with 90 minutes of severe chest pain and ST-elevation in leads V1-V2 underwent emergency coronary angiography with a view to primary angioplasty., Investigations: Physical examination, electrocardiography, coronary angiography., Diagnosis: ST-segment elevation anterior myocardial infarction., Management: Coronary angiography, antiplatelet and antithrombotic therapy, statin, angiotensin-converting enzyme inhibitor, beta blocker, IVUS and percutaneous coronary intervention (PCI)

Pericardial cysts are rare. We provide high-quality imagery demonstrating a giant cyst using plain radiography, ultrasound and magnetic resonance imaging (MRI).

Background: Data on effectiveness and safety following the implantation of very long segments of drug-eluting stents (DES) are lacking., Aim: To describe our experience of consecutive patients undergoing implantation of very long segments of DES (> 50 mm) in de novo coronary lesions., Methods: We evaluated major in-hospital complications, target lesion revascularization (TLR) rates and long-term outcomes in 88 consecutive patients (91 procedures) who underwent a single-vessel intervention with implantation of > 50 mm of overlapping DES to de novo lesions between October 2002 and October 2007. An additional 14 patients with long segments of in-stent restenosis, 10 receiving both DES and bare-metal stents for long-segment disease and 1 with long-segment disease in a saphenous vein graft were excluded from the study. Baseline clinical data, procedural outcomes and completed follow up were collected prospectively., Results: Follow up was 100% complete up to April 30, 2008. The mean follow up was 26.5 months (6-60 months). The mean stent length was 70.6 mm (51-135 mm) and the average number of stents per vessel was 2.7 (2-5 stents). Acute complications included 1 case of acute stent thrombosis which was treated successfully, 1 case of aortic root dissection, and 1 case of retroperitoneal hemorrhage. The rate of non-Q-wave myocardial infarction (CKMB > 3 times normal) was 8%. During follow up, the rate of TLR was 6.5%. Five patients died, 4 of them due to noncardiac conditions. One death was attributed to possible late stent thrombosis (18 months) occurring suddenly 2 days post keloid repair. Two patients had definite very late stent thrombosis at 14 and 17 months., Conclusion: In our experience, the use of very long segments of DES is effective in treating diffuse de novo coronary artery lesions. However, longer-term follow up is necessary and more data are required to determine the optimum duration of dual antiplatelet therapy.

A 38-year-old man underwent coronary artery bypass graft surgery for angina pectoris following myocardial infarction. During the following 28 years, he required two repeat coronary artery bypass graft surgical procedures, nine percutaneous coronary interventions and 17 coronary angiograms. His treatment included saphenous vein, left internal mammary artery and gastroepiploic artery grafting, percutaneous transluminal coronary angioplasty and intragraft thrombolytic therapy, directional coronary atherectomy, cutting balloon angioplasty, intracoronary stenting with bare-metal and drug-eluting stents, treatment for in-stent restenosis, stenting of the left main and circumflex coronary arteries and saphenous vein graft as well as intracoronary pressure wire diagnostics. In addition to his statin therapy, antiplatelets and angiotensin-converting enzyme inhibitors, he also underwent biventricular automatic implantable cardioverter-defibrillator implantation and atrioventricular node radiofrequency ablation for his impaired left ventricular function, ventricular tachycardia and rapid atrial fibrillation. The present unusual case represents almost 'the whole nine yards' of treatment that has become available to patients with coronary artery disease during the past 30 years of technological development.

Background: We report the late outcomes in 411 consecutive patients undergoing drug-eluting stent (DES) implantation by a single operator between 2003-2006., Methods: Prospective registry with continuous follow up. Patients with stable angina (SA) or acute coronary syndrome (ACS) received DES for long lesions, small vessels, chronic total occlusion, bifurcation, aorto-ostial, left main, post atherectomy or saphenous vein graft lesions, multivessel/multilesion single-vessel (V) disease, in-stent restenosis (ISR) or diabetes., Results: Age range: 34-86 years. One hundred sixty-six (40.3%) had ACS, 98.3% hypercholesterolemia and 14.6% diabetes. Two hundred sixty-one (63.5%) had percutaneous coronary intervention (PCI) to 1V and 150 (36.5%) to >1V. Six hundred seven V were treated. Two hundred fifty-nine patients (63%) had multilesion PCI, and 109 (26.5%) 1V multilesion PCI. Two hundred ninety-three (71.3%) patients had long lesions and 224 had Vs < 2.75 mm diameter. 75.5% of lesions were Type B2/C. 1-8 stents were implanted/patient. Eight hundred twenty-two of 883 stents were DES. One hundred eight patients received > or = 1 stent of < or = 2.5 mm diameter and 246 patients received stents greater than or equal to 20 mm long. Twenty-five patients developed late complications. ISR occurred in 23, 3.5-38 months after DES implantation. Three had sudden late DES thrombosis (LST). One-third also had ISR. Twenty of twenty-five required PCI, 1 CABG and 4 medical treatment. Subsequently, 3 of the 20 required further PCI for recurrent ISR and 1 CABG. 9 patients died during 1-5-year follow up., Conclusions: In "real-world" patients at increased risk of ISR after bare-metal stenting (BMS), "off-label" DES implantation has a low incidence of late complications. The most common is ISR which presents later than after BMS. Acute LST is serious but unusual and may be accompanied by ISR.

Background: The electrocardiogram (ECG) remains a simple, universally available, and prognostically powerful investigation in heart failure, and acute coronary syndromes. We sought to assess the prognostic utility of clinical, angiographic, and simple ECG parameters in a large cohort of patients undergoing elective cardiac catheterization (CC) for known or suspected coronary artery disease., Methods: Consecutive consenting patients undergoing CC for coronary disease were enrolled at a single tertiary center. Patient data, drug therapy, catheter reports, and ECG recordings were prospectively recorded in a validated electronic archive. The primary outcome measure was death or nonfatal myocardial infarction (MI) over 1 year or until percutaneous or cardiac surgical intervention. Independent prognostic markers were identified using the Cox proportional hazard model., Results: A total of 682 individuals were recruited of whom 17(2.5%) died or suffered a nonfatal MI in 1 year. In multivariate analysis QRS duration (ms) (HR 1.03 95% CI 1.01-1.05, P = 0.003), extent of coronary disease (HR 2.01 95% CI 1.24-3.58, P = 0.006), and prolonged corrected QT peak interval in lead I (HR 1.02 95% CI 1.00-1.03, P = 0.044) were independently associated with death or nonfatal MI. Receiver-operator characteristic (ROC) analysis for the multivariate model against the primary end point yielded an area under the curve of 0.759 (95% CI 0.660-0.858), P < 0.001., Conclusions: QRS duration and QT peak are independently associated with increased risk of death or nonfatal MI in stable patients attending for coronary angiography.

Background: There are limited data on the impact of successful chronic total occlusion (CTO) revascularization by percutaneous coronary intervention (PCI) on survival. We performed a retrospective study comparing the survival between patients with a successful and a failed CTO revascularization by PCI., Methods: Between January 1, 2000 and June 30, 2004, 543 of 5803 (9.4%) patients underwent PCI for a CTO at our center. A CTO was defined as an occlusion of the artery present for at least 3 months with Thrombolysis in Myocardial Infarction flow grade 0 or 1. Patient records were linked to a national database to monitor all deaths during follow up. Propensity matching was used to balance out case mix differences., Results: Technical success for CTO was 377 of 543 (69.4%). In-hospital mortality was 0.3% and 1.2% for the CTO success and CTO failure patients, respectively. During a mean (SD) follow up of 1.7 (0.5) years, the mortality rate was 2.5% in the CTO success patients and 7.3% in the CTO failure patients. The crude hazard ratio for death with CTO failure was 3.92 (95% confidence intervals 1.56-10.07; P = 0.004). The rates of coronary artery bypass were 3.2% vs. 21.7% (P < 0.001) for the CTO success and CTO failure patients, respectively. Our propensity matched 157 CTO success to CTO failure patients and the associated hazard ratio for death with CTO failure was 4.63 (95% confidence interval 1.01-12.61; P = 0.049). Multivariate analysis showed that CTO failure was an independent predictor of death., Conclusion: Patients with a successful revascularization of a CTO by PCI have an increased survival rate compared to patients with a failed CTO procedure., ((c) 2007 Wiley-Liss, Inc.)

Objective: To establish the associations and prognostic utility of angiographic, clinical and HRV parameters in a large cohort of patients undergoing diagnostic cardiac catheterisation (CC)., Methods: Patients undergoing CC as elective day cases were enrolled at a single tertiary center from September 2001 to January 2003. Patient data, serum biochemistry, current drug therapy, catheter reports and five minute high resolution electrocardiograph (ECG) recordings were prospectively recorded and validated in an electronic archive. ECG recordings were used to generate time domain (SDNN (standard deviation of NN intervals)) and spectral HRV parameters (low frequency (LF) and high frequency (HF) power). Significant associations between dichotomized HRV variables and covariates were investigated using binary logistic regression. The independent prognostic ability of clinical markers was evaluated using the Cox proportional hazard model., Results: 841 consecutive consenting patients of mean age 61+/-10 years were recruited into the study with a mean follow-up period of 690+/-436 days. In multivariate analysis decreasing LF spectral power was independently associated with proximal right coronary stenosis OR (odds ratio)=1.65 (95% CI=1.16-2.36), P=0.006 and to all cause mortality OR=5.01 (95% CI=1.47-17.01), P=0.010. Increasing LF power was also independently associated with normal coronary angiograms in patients investigated suspected coronary disease without a confirmed prior history of a coronary ischaemic event OR=2.16 (95% CI=1.26-3.73), P=0.002., Conclusions: Reduced LF power independently predicts all cause mortality in a large cohort of patients receiving medical therapy after elective CC. LF power was also independently associated with >75% proximal RCA stenosis.

Valvular endocarditis after percutaneous coronary intervention is unusual. We report a new case of mitral valve endocarditis after stent implantation to a saphenous vein graft.

Background and Objective: Complex percutaneous coronary intervention (PCI) often requires introduction of numerous devices into and out of the arterial circulation and this may result in an increased risk of bacteraemia or even septicaemia. This study was undertaken to detect the frequency of bacteraemia that may be associated with such procedures., Methods: 147 patients undergoing complex PCI had blood culture tests immediately after and 12 hours after the procedure., Results: Of 147 patients, 26 (17.7%) had detectable bacteraemia immediately after PCI. Coagulase-negative staphylococcus was isolated most commonly. An additional 12% of patients yielded positive blood cultures in the next 12 hours with femoral sheaths still in-situ. There were no associated clinical sequelae., Conclusions: Uncomplicated bacteraemia is not uncommon as a result of complex PCI procedures. Although there are usually no clinical sequelae, these findings are important for those patients who are considered to be at moderate or high risk of infective endocarditis who require an invasive procedure such as PCI. This paper emphasizes the need for maximum sterility during PCI procedures if infective complications and stent infection are to be avoided.

Infective endocarditis (IE) is a life-threatening disease with substantial morbidity and mortality which affects individuals with underlying structural cardiac defects who develop bacteraemia, often as a result of dental, gastrointestinal, genitourinary, respiratory or cardiac invasive/surgical procedures. Prompt recognition of the clinical diagnosis by a wide variety of medical personnel, early involvement of specialist cardiologists, cardiac surgeon and a microbiologist, and prompt treatment with the most appropriate antimicrobial agents offer the greatest chance of improving the outcome for these patients. The guidance given here to clinicians involved in the management of patients with IE briefly covers diagnosis, antibiotic prophylaxis, medical treatment and the indications for surgery.

We evaluated the current short- and medium-term outcomes of complete revascularization, compared to culprit lesion percutaneous coronary intervention (PCI), in patients with multivessel coronary disease presenting with unstable angina. One hundred fifty-one patients with multivessel coronary disease presented to a tertiary cardiothoracic center with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) between January 2000 and September 2001. In group A (n=71), the intended strategy was complete revascularization by multivessel PCI. In group B (n=80), culprit lesion PCI was intended despite the presence of other lesions amenable to PCI (B1) or due to confounding anatomical factors (B2). Clinical variables and endpoints were collected from patient notes, a dedicated database and telephone follow-up, and included recurrent stable and unstable angina, need for repeat PCI or elective coronary artery bypass graft, incidence of non-fatal myocardial infarction (MI) and death. Baseline characteristics were similar in each group. Procedural success was achieved in over 95% of cases in both groups with high stent implantation rates (>96%). There was no observed difference in mortality or incidence of MI between the groups. Compared to group A, more patients in group B1 had residual angina [22.8% (13/57) versus 9.9% (7/71); p=0.041] and required further PCI [17.5% (10/57) versus 7.0% (5/71); p=0.045]. There was a non-significant trend toward fewer readmissions for UA and less long-term antianginal medication in group A [38.0% (27/71) versus 52.6% (30/57); p=0.043]. Complete and culprit lesion revascularization by PCI are safe methods of treating patients with multivessel coronary disease presenting with UA/NSTEMI. Reductions in residual angina, repeat PCI and need for antianginal therapies suggest that complete revascularization should be the strategy of choice when possible.

Both heavily calcified and ostial lesions are difficult to deal with by percutaneous transluminal coronary angioplasty (PTCA) alone. Acute results are often sub-optimal, complications are more frequent, and long-term results are disappointing. Optimal stent deployment may not be possible unless satisfactory lesion dilatation is achieved and the lesion made more compliant. The use of rotational atherectomy and cutting balloon angioplasty to a calcified ostial lesion in the left circumflex coronary artery prior to stent implantation is reported.