Latest articles

Conduction system pacing (CSP) ― encompassing His-bundle pacing (HBP) and left bundle-branch area pacing (LBBAP) ― delivers more physiological ventricular pacing compared with traditional right ventricular (RV) pacing. It is gaining traction beyond tertiary centres, however, evidence from district general hospitals (DGHs) remains limited. We aimed to evaluate the feasibility, electrical performance, and early clinical outcomes of CSP implemented in a UK DGH.

We performed a retrospective single-centre study of consecutive patients who underwent successful CSP at Chesterfield Royal Hospital. HBP implants (n=20) were performed between June 2019 and August 2022; LBBAP implants (n=71) between January 2023 and May 2025. Baseline demographics, procedural metrics, pacing parameters, complications, heart-failure (HF) readmissions, and echocardiographic data to 12 months were obtained from electronic records.

Ninety-one patients (mean age 76 ± 10 years; 69% male) received CSP, most commonly for left ventricular systolic dysfunction (LVSD) (40%) or anticipated high right-ventricular pacing burden (42%). LBBAP demonstrated lower implant thresholds than HBP (0.92 ± 0.44 V vs. 1.50 ± 0.77 V) and remained stable to 12 months (0.68 ± 0.25 V). HBP thresholds rose to 2.11 ± 1.49 V at 12 months. Screening time was shorter with LBBAP (9.6 ± 5.9 min) than HBP (14.4 ± 6.8 min, p<0.01). No infections or septal haematomas occurred. Lead revision was required in two HBP recipients and none with LBBAP (hazard ratio 17.14, p=0.067). Nine patients (9.9%) were readmitted with HF, occurring between 56 and 1,500 days post-implant.

In conclusion, CSP can be implemented safely and effectively in a DGH setting. LBBAP offers superior electrical stability, shorter procedure time, and less lead revisions, supporting its preferential adoption as the default pacing strategy for CSP.

We present a case involving the discovery of an extracardiac mass during a routine ablation procedure for typical atrial flutter. Using multiple imaging modalities it was possible to assess the mass during the procedure, leading to successful completion of the ablation.

“There’s a ghost in the library”

Documentation in medicine has transformed in the last 10 years: notes no longer scatter across the floor to reveal hurriedly scribbled ward rounds without signature or ownership. In the digital era, we can proudly say that ‘if it wasn’t written down it didn’t happen’. By extension, in the modern world of acute echocardiography, if it wasn’t ‘uploaded and reported’, it didn’t happen. These ‘ghost studies’ roam hospital corridors ready to interfere with patient care in maverick ways. All we are left with clinically is a rumour that a study possibly happened. There should be zero ‘ghost studies’ in our library. But, evidently, the ghosts are yet to be busted.

Historically, young people with genetic heart diseases were discouraged from active sport due to concerns about the increased risk of sudden cardiac death during competitive or intensive exercise. The shock resulting from the sudden death of a young athlete, an event often highly publicised, tends to generate concern in the general population, and fear of litigation in a low-evidence area: both influence decision-making by the medical profession when discussing ‘restrictions’, especially in patients with genetic heart diseases, who by definition, are at increased risk of sudden cardiac death. In recent years, however, we have moved to a point where many athletes with certain genetic heart diseases can, with optimal medical therapy, be considered for involvement in various sporting and athletic pursuits. We are cautiously moving away from the assumption that exercise is contraindicated; we are factoring in the wishes of the patient-athlete (shared decision-making), and we are encouraging optimal protection for these athletes during their sporting endeavours (easily available automated external defibrillators [AEDs], and club personnel trained in basic life support [BLS]), while ensuring regular medical assessment to identify alterations in risk status. With dedicated follow-up of all such patient-athletes, we can refine our understanding of how best to advise (and protect) them in terms of exercise for enhanced quality of life.

Cardiomyopathies are diseases of the heart muscle (ICD‑10 chapter IX, code I42). This study compared the health profiles of individuals with cardiomyopathy to age- and sex-matched controls in the UK Biobank prospective cohort to better understand health behaviours. Historical advice for patients to avoid exercise may have contributed to earlier heart failure; addressing these outdated perceptions could guide future recommendations to improve outcomes and reduce cardiovascular mortality.

Data from the UK Biobank were analysed, including physical activity behaviours, body mass index (BMI), waist circumference, body composition, hand-grip strength, and lifestyle factors, such as intake of fruit, processed/red meat, oily fish, alcohol and smoking, as well as PC-sitting and TV-viewing time. Linear and logistic regression assessed associations between these exposures and cardiomyopathy, adjusting for age, sex, and deprivation index.

The cohort comprised 442 individuals with cardiomyopathy and 173,429 matched controls. Significant differences were noted in age, deprivation index, alcohol intake, BMI, waist and hip circumference, physical activity levels, TV viewing, and sedentary time. Males had higher odds of cardiomyopathy than females (odds ratio [OR] 2.5, 95% confidence interval [CI] 2.04 to 3.05, p<0.0001). Obesity was strongly associated with cardiomyopathy (OR 3.7, 95%CI 2.88 to 4.76, p<0.0001). Sleep risk scores and type of physical activity risk scores were also significantly associated with cardiomyopathy.

In conclusion, individuals with cardiomyopathy demonstrated poorer health profiles and more sedentary behaviours than controls. These findings highlight the need for targeted interventions and updated exercise advice to improve clinical outcomes and reduce cardiovascular mortality in this population.

Cardiovascular disease is a leading cause of mortality in patients with chronic kidney disease (CKD) and kidney transplant recipients (KTR). However, it remains uncertain whether KTR status predisposes patients to a heightened risk of major adverse cardiovascular events (MACE) following percutaneous coronary intervention (PCI). A systematic search was conducted using MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL), encompassing studies from inception to December 2024. The primary outcome was in-hospital mortality in KTR undergoing PCI compared with non-KTR cohorts. A random-effects model was used to analyse pooled data. A total of six studies with 13,287,090 patients were included. Four studies compared PCI outcomes in KTR with various degrees of renal dysfunction, revealing significantly lower in-hospital mortality in KTR compared with patients with CKD (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.35 to 0.55, p<0.001). No significant difference was seen in in-hospital mortality between KTR and patients without CKD (OR 1.12, 95%CI 0.75 to 1.68, I²=95.60%, p=0.57). Two studies compared KTR and patients on haemodialysis, both observed a lower incidence of MACE in the KTR group compared with the haemodialysis cohort (OR 0.43, 95%CI 0.20 to 0.92, I²=0%, p=0.03). In conclusion, PCI in KTR is associated with lower in-hospital mortality as compared with patients with CKD or those on dialysis. There was no mortality difference observed when comparing KTR with patients without CKD.

Measuring the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) can help to triage patients with suspected acute heart failure (HF), towards confirmatory transthoracic echocardiography. It has a high negative-predictive value, however, it is not specific due to the influence on its levels by comorbidities. The British Society of Echocardiography (BSE) have published criteria for the triage of those with suspected HF, for inpatient echocardiography, using age-specific NT-proBNP cut-off values.

This study aims to evaluate the diagnostic utility of these recommendations for triaging inpatient echocardiography requests to diagnose acute HF. We analysed data from consecutive inpatients who had an echocardiogram requested between 1 and 15 March 2024, at two secondary care hospitals in the East of England. NT-proBNP results were paired to these requests. Patients were then grouped into the three BSE NT-proBNP cut-off levels and compared. The main outcome of interest was the diagnostic yield for HF using these criteria.

There were 159 patients included in the final analysis: 100 (62.9%) met the NT-proBNP BSE threshold; 65 (65.0%) of these had an inpatient echocardiogram, of which 39 (60.0%) were diagnosed with HF. There were 59 (37.1%) who did not meet the BSE threshold: 29 (49.2%), however, had an inpatient echocardiogram, with nine (31.0%) subsequently diagnosed with HF. Review of these nine patients revealed other valid reasons for echocardiography request: therefore, no cases were truly missed. Patients who had atrial fibrillation (AF) had a similar diagnostic yield for HF compared with those who did not (AF + HF diagnosis 54.0% vs. no AF + HF 67.9%; p=0.385).

In conclusion, the BSE’s age-related NT-proBNP criteria for inpatient echocardiography provides a safe and viable framework for triaging inpatient requests towards a diagnosis of HF. This approach could reduce the burden on stretched services, allowing resources to be directed more appropriately.

Often considered benign, Takotsubo syndrome (TTS) could be life threatening. We present a 54-year-old female patient with a history of heterozygous beta-thalassaemia and Graves’ disease who came to the emergency department complaining of dizziness, atypical chest pain and an episode of collapse. The patient developed cardiac arrest due to ventricular fibrillation. After 45 minutes of cardiopulmonary resuscitation, return of spontaneous circulation was achieved. A transthoracic echocardiography revealed hypokinetic mid and apical left ventricular (LV) segments. Her coronary angiography showed significant stenosis in the left anterior descending coronary artery, for which she underwent percutaneous coronary intervention. In the subacute phase, she had episodes of polymorphic ventricular tachycardia in the context of QT-interval prolongation. Cardiac magnetic resonance imaging demonstrated diffuse myocardial oedema in the mid and apical segments of the LV. Finally, after 60 days of hospitalisation, an implantable cardioverter-defibrillator was implanted for secondary prevention of sudden cardiac death. This case study demonstrates some of the serious complications of TTS and the medical decisions that may need to be made regarding its treatment course.

Conventional management of out-of-hospital cardiac arrest (OOHCA) in patients with unusual cardiac anatomy may result in inferior outcomes. It is important that appropriate consideration of these patients is made when developing OOHCA resuscitation guidelines. Initiatives to improve outcomes following OOHCA, such as community training of resuscitation techniques, should take patients with unusual cardiac anatomy into account. We present a male in his twenties with heterotaxy syndrome, a congenital defect with abnormally arranged intrathoracic and intra-abdominal organs. He experienced an unwitnessed OOHCA with a downtime of approximately 20 minutes. He had complex congenital heart disease and had undergone previous palliative cardiac surgery resulting in a Fontan circulation. Despite maximal inotropic and vasopressor support, he developed multi-organ failure with diffuse hypoxic brain injury warranting care withdrawal. In this case report we discuss the important roles of appropriate community resuscitation in patients with unusual cardiac anatomy and of mechanical circulatory support in patients with single ventricle physiology.