2022, Volume 29, Issue 3, pages 81–120

Significant pharmacologic, interventional and surgical strategies in the management of coronary syndromes, together with evolving surgical and non-surgical innovations for valvular disease and improved care of congenital heart disease, have ensured that patients live longer and better lives. With these advancing therapies for cardiac disease, the number of patients surviving to develop end-stage heart failure continues to increase exponentially. While the heart as an organ has evolved to demonstrate remarkable resilience in the setting of disease, death from cardiovascular causes remains the most common cause of death in many parts of the world. Given the significant morbidity and mortality associated with end-stage heart failure, the last half century has been notable for a concentrated effort on developing therapies for the failing heart.

In this issue, Professor Stephen Westaby (see https://doi.org/10.5837/bjc.2022.021) provides an insightful personal perspective on a laudable life-long pursuit in the development of mechanical circulatory support with the ultimate goal of a fully implantable device. His long career has been punctuated by a number of seminal achievements, which have led to incremental improvements in a challenging area.

Disparities in cardiovascular morbidity and mortality are among the leading health and social care concerns in the UK. The disruption of the COVID-19 pandemic to health services has further placed cardiovascular care and the respective patient communities at the sharp end, not least in exacerbating existing health inequalities across service interfaces and patients’ health outcomes. While the pandemic engenders unprecedented constraints within established cardiology services, it conduces to a unique opportunity to embrace novel transformative approaches within the way we deliver patient care in maintaining best practices during and beyond the crisis. As the first step in navigating toward the ‘new norm’, a clear recognition of the challenges inherent in cardiovascular health inequalities is critical, primarily in preventing the widening of extant inequalities as cardiology workforces continue to build back fairer. We may consider the challenges through the lens of health services’ diverse facets, including the aspects of universality, interconnectivity, adaptability, sustainability, and preventability. This article explores the pertinent challenges and provides a focused narration concerning potential measures to foster equitable and resilient cardiology services that are patient centred in the post-pandemic landscape.

This audit compared the management of patients with heart failure with reduced ejection fraction (HFrEF) admitted to a district general hospital (DGH) during comparative eight month periods before and during the COVID-19 pandemic. The periods studied were from 1 February 2019 to 30 September 2019 and between the same dates in 2020. We investigated differences in mortality and patient characteristics (age, gender and new or prior diagnosis). For patients who survived to discharge and who were not referred to palliative care, we also investigated whether there were differences in rates of echocardiography and prescription of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists and beta blockers.

We found that the number of cases was lower during the pandemic and there was a lower mortality rate that was not statistically significant. There was a higher proportion of new cases (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.24 to 3.94, p=0.008) and of female patients (OR 2.03, 95%CI 1.14 to 3.61, p=0.019). For survivors, there was a non-significant decrease in prescription rates for ACE inhibitors and angiotensin II receptor antagonists (81.6% vs. 71.4%, p=0.137) that was not seen for beta blockers. The length of stay was increased and there was also an increase in the interval between admission and echocardiography in patients who were newly diagnosed. Regardless of time period, the time before echocardiography was significantly associated with length of stay.

SARS-CoV-2 is an emerging cause of viral myocarditis that generates multiple complications, such as dilated cardiomyopathy. We describe a young, obese male patient with severe myocardial involvement by the SARS-CoV-2 virus, who presented with chest pain, elevated cardiac enzymes, non-specific electrocardiographic findings, echocardiogram with evidence of dilated heart disease with reduced ejection fraction, and subsequent verification using magnetic resonance imaging (MRI). The results of the cardiac MRI were typical of viral myocarditis. The patient did not respond to a short course of systemic steroids and the standard management for heart failure, had multiple re-admissions, and, unfortunately, died.

The coronary artery calcium (CAC) score is a marker of advanced coronary atherosclerosis. Numerous prospective cohorts have validated CAC as an independent marker that improves prognostication in atherosclerotic cardiovascular disease (ASCVD) beyond traditional risk factors. Accordingly, CAC is now incorporated into international cardiovascular guidelines as a tool to inform medical decision-making. Particular interest concerns the significance of zero CAC score (CAC=0). While many studies report CAC=0 to virtually exclude obstructive coronary artery disease (CAD), non-negligible rates of obstructive CAD despite CAC=0 are reported in certain populations. Overall, the current literature supports the power of zero CAC as a strong downward risk classifier in older patients, whose CAD burden predominantly involves calcified plaque. However, with their higher burden of non-calcified plaque, CAC=0 does not reliably exclude obstructive CAD in patients under 40 years. Illustrating this point, we present a cautionary case of a 31-year-old patient found to have severe two-vessel CAD despite CAC=0. We highlight the value of coronary computed tomography angiography (CCTA) as the gold-standard non-invasive imaging modality when the diagnosis of obstructive CAD is in question.

A retrospective study of 322 patient experiences of post-operative pain, short term and long term, following a cardiac implantable electronic device (CIED) procedure. Pain from pacemaker and ICD (implantable cardioverter-defibrillator) implant surgery remains a problem both in terms of severity and longevity. There is a subset of patients receiving implants that have severe pain that may be of a long duration. Patient advice needs to be appropriate to these findings.

This study illustrates a need for better pain management by physicians, support, and realistic communication with their patients.

Cutibacterium acnes (C. acnes), previously known as Propionibacterium acnes, is a rare cause of infective endocarditis (IE). We provide a review of the literature and describe two recent cases from a single centre to provide insight into the various clinical presentations, progression and management of patients with this infection.

The primary objective of our review is to highlight the difficulty in the initial assessment of these patients with an aim to improve the time and accuracy of diagnosis and expedite subsequent treatment. There are currently no guidelines in the literature specific to the management of IE caused by C. acnes. Our secondary objectives are to disseminate information about the indolent course of the disease and add to the growing body of evidence around this rare, yet complex, cause of IE.

High-output heart failure (HF) is an uncommon condition. This occurs when HF syndrome patients have a cardiac output higher than eight litres per minute. Shunts, such as fistulas and arteriovenous malformations are an important reversible cause. We present the case of a 30-year-old man who presented to the emergency department due to decompensated HF. Echocardiogram showed dilated myocardiopathy with high cardiac output (19.5 L/min calculated on long-axis view). He was diagnosed with arteriovenous malformation by computed tomography (CT) and subsequent angiography, and a multi-disciplinary team decided to perform endovascular embolisation with ethylene vinyl alcohol/dimethyl sulfoxide at different times. The transthoracic echocardiogram showed a significant decrease in cardiac output (9.8 L/min) and his general condition improved significantly.

Implantable mechanical circulatory support systems have evolved dramatically over the last 50 years. The objective has been to replace or support the failing left ventricle with a device that pumps six litres of blood each minute, a massive 8,640 litres per day. Noisy cumbersome pulsatile devices have been replaced by smaller silent rotary blood pumps that are much more patient friendly. Nonetheless, the tethering to external components, together with the risks of power line infection, pump thrombosis and stroke, must be addressed before widespread acceptance. Infection predisposes to thromboembolism, so elimination of the percutaneous electric cable has the capacity to transform outcomes, reduce costs and improve quality of life.

Developed in the UK, the Calon miniVAD is powered by an innovative coplanar energy transfer system. As such, we consider it can achieve those ambitious objectives.