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Background In 2016, the NICE clinical guideline 95 (’Chest pain of recent onset: assessment and diagnosis’) was updated to include coronary CT angiography (CCTA) as the first-line imaging modality for stable chest pain, and to suggest that fractional flow reserve CT (FFRCT) should also be considered as an option. NICE state FFRCT reduces cath lab utilisation due to better diagnostic performance at detecting significant coronary artery disease (CAD) compared to CCTA, and does not involve additional CT scanner time, radiation or contrast. This technology is not currently available at City Hospitals Sunderland. Local and international data suggest that CCTA overestimates disease severity compared to findings at invasive cardiac catheterisation (ICC). We investigated the role of including FFRCT in investigation of stable chest pain, including theoretical cost and service utilisation savings, and identified the concordance in grading of CAD between CCTA and ICC. Method Data on disease grading were collected from reports of CCTAs done between 1 st January 2016 and 31 st December 2017. Data were also collected for those patients who subsequently underwent ICC. For the patients who underwent both CCTA and ICC, the CCTA reports and images were individually reviewed by a consultant cardiologist with experience in CCTA to assess concordance between both studies. A financial model was then created, using cost data quoted by NICE. Results A total of 163 patients underwent CCTA in the time period. Of these, 113 (68%) had mild-moderate CAD and so were managed medically. The remaining 50 (32%) patients underwent ICC due to either findings of moderate-severe CAD; anatomical aberrancies; or artefact. Of these 50 ICCs, 33 (66%, showing normal arteries or mild CAD) could have been avoided if there was a more sensitive test. 8 patients went on to undergo revascularisation. Financial modelling estimated that using FFRCT prior to referral for ICC would lead to a cost saving of £22 290 per year (£136.74 per patient per year) and result in more efficient utilisation of the angiography suite, reducing waiting list lengths. CCTA and ICC agreed on disease grading in 37/47 of cases, which correlates with data in the literature showing high sensitivity but relatively poor specificity. Conclusion CCTA is the NICE-recommended fist-line investigation for stable chest pain, and is sensitive and clinically useful. However, poor specificity causes unnecessary cardiac catheterisation. This relates to overestimation of luminal stenoses (e.g. due to arterfact from calcium). Use of FFRCT at City Hospitals Sunderland would reduce unnecessary angiograms and the risks associated with these, and would provide better utilisation of the angiography suite for interventional procedures, at a cost saving to the Trust. Introduction of guidelines such as CAD-RADS (coronary artery disease reporting and data system) would standardise terminology used in reporting and further improve reliability and specificity.

Objective Assessment of the feasibility and outcomes of the 2.5 L and 3.8 L Impella cardiac pump in patients with severe aortic stenosis (AS) and left ventricular impairment undergoing percutaneous revascularization (PCI) with or without balloon aortic valvuloplasty (BAV). Methods We reviewed the clinical and procedural findings from a consecutive series of unselected patients with severe AS who underwent PCI during Impella support. In addition, we describe novel “balloon-assist” techniques that allowed implantation of Impella into the left ventricle (LV) when initial unassisted attempts failed. Results Five patients with severe AS were identified (four males, age 78.2 years, aortic valve area (AVA) 0.6 cm2, left ventricular ejection fraction (LVEF) 24 ± 5%, mean Society of Thoracic Surgeons (STS) mortality 11% (range 3–17%)). The Impella catheter traversed the aortic valve (AV) unassisted in only one patient, with four cases requiring balloon-assist techniques. All patients underwent planned revascularisation; mean procedure time 177 min (range 135–252 min), mean number of stents 3.4 (range 1–8), with three patients requiring rotational atherectomy. All procedures were well tolerated, with absence of arrhythmia, hypotension, pulmonary edema, stroke, or myocardial infarction. One patient died 48 hr post-PCI of multi-organ failure. The four remaining patients were well at 30 days. Conclusion Implantation of the 2.5 and 3.8 L Impella appears feasible in patients with severe AS and left ventricle (LV) impairment. A balloon-assist technique may be used to facilitate device implantation when initial unassisted attempts fail. Improved hemodynamic stability may enhance the tolerability of lengthy and complex procedures. © 2014 Wiley Periodicals, Inc. © 2014 Wiley Periodicals, Inc.

The management of in-stent restenosis (ISR) complicating bifurcation lesions is technically challenging and implant of further stents may not be feasible. The use of drug-eluting balloons provides an attractive option for treatment of such lesions allowing a technically simple procedure without the need for further complex stenting. The SeQuent Please paclitaxel-eluting balloon (B. Braun, Berlin, Germany) has been shown to be superior to a paclitaxel eluting stent or balloon angioplasty for ISR complicating a bare-metal stent. However, there is no data on the efficacy of the SeQuent Please in ISR complicating drug-eluting stents or bifurcation lesions. We report two cases where the SeQuent Please was used in this setting with angiographic success and freedom from target vessel failure and angina at 24 months. In both cases the Sheathless Eau Cath guide (Asahi Intecc, Japan) was employed to perform a kissing-balloon dilatation with the SeQuent Please, so allowing treatment via radial access.

Intramural hematoma in major coronary epicardial vessels is a rare cause of chest pain. Afflicted individuals may present with acute coronary syndrome (ACS) or even sudden cardiac death. Spontaneous, isolated intramural hematoma may occur in the absence of associated intimal dissection. In this situation, lesions may be angiographically indistinguishable from ruptured atherosclerotic plaque. Intravascular ultrasound is important in the accurate diagnosis of isolated intramural hematoma. Although coronary stenting may be required in the presence of ongoing ischemia, intramural hematoma may be successfully managed medically. We describe the case of a middle-aged woman who presented with ACS due to an intramural hematoma and discuss the diagnosis and management of this rare illness.

Iatrogenic coronary ostial stenosis after aortic valve replacement is a rare, life-threatening complication, which may follow implantation of either a mechanical or a biological prosthesis. Historically, this condition has been treated by urgent coronary bypass surgery but is associated with high morbidity and mortality, due to the hazards of early repeat sternotomy. We report a case of iatrogenic coronary ostial stenosis successfully treated with stenting and discuss the advantages of percutaneous intervention over coronary bypass surgery.

Assessment of the feasibility and outcomes of the 2.5 L and 3.8 L Impella cardiac pump in patients with severe aortic stenosis (AS) and left ventricular impairment undergoing percutaneous revascularization (PCI) with or without balloon aortic valvuloplasty (BAV).We reviewed the clinical and procedural findings from a consecutive series of unselected patients with severe AS who underwent PCI during Impella support. In addition, we describe novel "balloon-assist" techniques that allowed implantation of Impella into the left ventricle (LV) when initial unassisted attempts failed.Five patients with severe AS were identified (four males, age 78.2 years, aortic valve area (AVA) 0.6 cm(2) , left ventricular ejection fraction (LVEF) 24 ± 5%, mean Society of Thoracic Surgeons (STS) mortality 11% (range 3-17%)). The Impella catheter traversed the aortic valve (AV) unassisted in only one patient, with four cases requiring balloon-assist techniques. All patients underwent planned revascularisation; mean procedure time 177 min (range 135-252 min), mean number of stents 3.4 (range 1-8), with three patients requiring rotational atherectomy. All procedures were well tolerated, with absence of arrhythmia, hypotension, pulmonary edema, stroke, or myocardial infarction. One patient died 48 hr post-PCI of multi-organ failure. The four remaining patients were well at 30 days.Implantation of the 2.5 and 3.8 L Impella appears feasible in patients with severe AS and left ventricle (LV) impairment. A balloon-assist technique may be used to facilitate device implantation when initial unassisted attempts fail. Improved hemodynamic stability may enhance the tolerability of lengthy and complex procedures.

A user-assisted multi-camera tracking system employing several key novel methodologies has previously been shown to be highly effective in assisting human users in tracking targets of interest through industry-standard i-LIDS multi-camera benchmark data. 1 A prototype system was developed in order to test and evaluate the effectiveness of this approach. In this paper, we develop this system further in order to improve tracking accuracy and further facilitate scalability to arbitrary numbers of camera views across much larger spatial areas and different locations. Specifically, we describe the following three areas of improvement: (1) dynamic learning mechanisms apply user feedback in adapting internal models to improve performance over time; (2) modular design and hardware acceleration techniques are explored with a view to real-time performance, extensive configurability to leverage available hardware and scalability to larger datasets; and (3) re-design of the user interface for deployment as a secure asynchronous remote web-based service. We conduct an extensive evaluation of the system in terms of: (1) tracking performance; and (2) the speed of the system in computation and in usage over a network. We use a newly collected real-world dataset significantly more challenging than i-LIDS, which comprises six cameras covering two London Underground stations. We show that: (1) dynamic learning is effective; (2) the user-assisted paradigm retains its effectiveness with this significantly more challenging dataset; (3) large-scale deployment and real-time computation is feasible due to linear scalability; (4) context-aware user search strategies and external non-visual information can aid search convergence; and (5) storage and querying of meta-data is a bottleneck to be overcome.

Acquired left ventricle (LV) to left atrial (LA) fistula is a very rare complication following aortic valve replacement (AVR). This can usually be surgically repaired but the risk of re-operation is high due to repeat sternotomy and also due to other comorbidities usually seen in this population. We report a case presenting with recurrent episodes of left ventricular failure 10 years following bioprosthetic aortic valve replacement and who was diagnosed to have a communication between the LV and the LA on transesophageal echocardiography (TEE). This was treated percutaneously with an Amplatzer duct occluder (ADO) device (AGA Medical Corp.) as she was considered to be a high surgical risk.

Human CCTV operators face several challenges in their task which can lead to missed events, people or associations, including: (a) data overload in large distributed multi-camera environments; (b) short attention span; (c) limited knowledge of what to look for; and (d) lack of access to non-visual contextual intelligence to aid search. Developing a system to aid human operators and alleviate such burdens requires addressing the problem of automatic re-identification of people across disjoint camera views, a matching task made difficult by factors such as lighting, viewpoint and pose changes and for which absolute scoring approaches are not best suited. Accordingly, we describe a distributed multi-camera tracking (MCT) system to visually aid human operators in associating people and objects effectively over multiple disjoint camera views in a large public space. The system comprises three key novel components: (1) relative measures of ranking rather than absolute scoring to learn the best features for matching; (2) multi-camera behaviour profiling as higher-level knowledge to reduce the search space and increase the chance of finding correct matches; and (3) human-assisted data mining to interactively guide search and in the process recover missing detections and discover previously unknown associations. We provide an extensive evaluation of the greater effectiveness of the system as compared to existing approaches on industry-standard i-LIDS multi-camera data.

There are little data on the efficacy and safety of the Edwards Sapien valve (Edwards Lifesciences, Irvine, California, USA) in congenital, bicuspid aortic valve stenosis. Patients with bicuspid valves were excluded from the randomised PARTNER trial.1 Bicuspid valves differ from tricuspid aortic valves in that the orifice is elliptical and the leaflets are typically bulky and very heavily calcified. Bicuspid valves are considered …

The Edwards Sapien transcatheter heart valve (THV) is available for treatment of severe symptomatic aortic stenosis via transfemoral access or trans-apical access when ilio-femoral vessels are considered unsuitable. Some patients, however, may be unsuitable for access via either of these routes. We describe successful implantation of an Edwards Sapien THV via direct access of the ascending aorta in a patient with previous right pneumonectomy and pulmonary disease who was considered unsuitable for implantation via femoral vessels or via trans-apical approach. The potential advantages of this novel access route over trans-apical approach are discussed.

The use of radial artery for vascular access for cardiac catheterization and intervention has gained increasing acceptance over the last few years as result of the lower risk of vascular complications compared to use of the femoral artery. The strong evidence showing that major bleeding (commonly access site related) is an independent predictor of mortality in acute coronary syndrome patients undergoing intervention has only accelerated this change. This case highlights that although the risk of access site complications is reduced with the radial approach there remains a risk of spontaneous bleeding elsewhere due to the use of multiple potent antiplatelet and anticoagulant therapy in the treatment of acute coronary syndromes. Early recognition of bleeding is of the utmost importance as delay increases the likelihood complications of bleeding including death.

Undilatable coronary lesions, due to coronary calcification, are encountered with increasing frequency. Percutaneous intervention of such lesions comes with the risk of stent underexpansion, which increases the risk of stent thrombosis and restenosis. A variety of techniques and devices are available to assist the interventionist in the treatment of calcified lesions. The OPN NC (SIS-Medical AG, Winterthur, Switzerland) is a high-pressure balloon (rated burst pressure 35 atm) that uses a novel, twin-layer balloon technology to ensure uniform balloon expansion, eliminating "dog-boning." We report four cases of successful treatment of calcified lesions with the OPN NC balloon after dilatation with standard noncompliant balloons to high-pressure failed.

Colour cues were used to obtain robust detection and tracking of people in relatively unconstrained dynamic scenes. Gaussian mixture models were used to estimate probability densities of colour for skin, clothing and background. These models were used to detect, track and segment people, faces and hands. A technique for dynamically updating the models to accommodate changes in apparent colour due to varying lighting conditions was used. Two applications are highlighted: (1) actor segmentation for virtual studios, and (2) focus of attention for face and gesture recognition systems. A system implemented on a 200 MHz PC tracks multiple objects in real time.

We use colour mixture models for real-time colour-based object localisation, tracking and segmentation in dynamic scenes, motivated by applications such as virtual studios and recognition of human faces, gestures and actions. We address the issues of model order selection, modelling scene background and model adaptation in time. Experimental results are given to demonstrate our approach under varying viewing and lighting conditions.

The use of adaptive Gaussian mixtures to model the colour distributions of objects is described. These models are used to perform robust, real-time tracking under varying illumination, viewing geometry and camera parameters. Observed log-likelihood measurements were used to perform selective adaptation.

A system is described that provides robust and real-time focus-of-attention for tracking and segmentation of multi-coloured objects. Gaussian mixture models were used to estimate the probability densities of object foreground and scene background colours. Tracking was performed by fitting dynamic bounding boxes to image regions of maximum probability. Two scenarios are presented: (1) real-time face tracking based upon a skin colour model and (2) dynamic body segmentation for virtual studios based upon combined foreground and background models.

Pacemaker insertion causing contact dermatitis is a rare but recognized complication. We report a 60-year-old gentleman, who presented 2 years after his pacemaker implantation with erythema and itching at site of pacemaker insertion. He was initially treated with antihistamines; however, the erythema persisted over the pacemaker site as shown in Figure …

Lipomatous hypertrophy of the interatrial septum is a rare condition and it does not require any specific treatment. We present the transoesophageal echocardiogram findings of a 70-year-old lady demonstrating the appearances that were typical of lipomatous hypertrophy of the interatrial septum.

The use of adaptive Gaussian mixtures to model the colour distributions of objects is described. These models are used to perform robust, real-time tracking under varying illumination, viewing geometry and camera parameters. Observed log-likelihood measurements were used to perform selective adaptation.

An integrated system for the acquisition, normalisation and recognition of moving faces in dynamic scenes is introduced. Four face recognition tasks are defined and it is argued that modelling person-specific probability densities in a generic face space using mixture models provides a technique applicable to all four tasks. The use of Gaussian colour mixtures for face detection and tracking is also described. Results are presented using data from the integrated system.