Clinical articles

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 Noisy cumbersome pulsatile devices have been replaced by smaller silent rotary blood pumps that are much more patient friendly.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.

Atrial fibrillation (AF) is a major cause of recurrent stroke and transient ischaemic attack (TIA) in the UK. As many patients can have asymptomatic paroxysmal AF, prolonged arrhythmia monitoring is advised in selected patients following a stroke or TIA. This service evaluation assessed the clinical and potential health economic impact of prolonged arrhythmia monitoring post-stroke using R-TEST monitoring devices.

This was a prospective, case-controlled, service evaluation in a single health board in the North of Scotland. Patients were included if they had a recent stroke or TIA, were in sinus rhythm, and did not have another indication for, or contraindication to, oral anticoagulation. A health economic model was developed to estimate the clinical and economic value delivered by the R-TEST monitoring. Approval to use anonymised patient data in this service evaluation was obtained.

During the evaluation period, 100 consecutive patients were included. The average age was 70 ± 11 years, 46% were female. Stroke was the presenting complaint in 83% of patients with the other 17% having had a TIA. AF was detected in seven of 83 (8.4%) patients who had had a stroke and one of 17 (5.9%) patients with a TIA. Health economic modelling predicted that adoption of R-TEST monitoring has a high probability of demonstrating both clinical and economic benefits.

In conclusion, developing a post-stroke arrhythmia monitoring service using R-TEST devices is feasible, effective at detecting AF, and represents a probable clinical and economic benefit

Total ischaemic time in ST-elevation myocardial infarction (STEMI) has been shown to be a predictor of mortality. The aim of this study was to assess the total ischaemic time of STEMIs in an Irish primary percutaneous coronary intervention (pPCI) centre. A single-centre prospective observational study was conducted of all STEMIs referred for pPCI from October 2017 until January 2019.

There were 213 patients with a mean age 63.9 years (range 29–96 years). The mean ischaemic time was 387 ± 451.7 mins. The mean time before call for help (patient delay) was 207.02 ± 396.8 mins, comprising the majority of total ischaemic time. Following diagnostic electrocardiogram (ECG), 46.5% of patients had ECG-to-wire cross under 90 mins as per guidelines; 73.9% were within 120 mins and 93.4% were within 180 mins. Increasing age correlated with longer patient delay (Pearson’s r=0.2181, p=0.0066). Women exhibited longer ischaemic time compared with men (508.96 vs. 363.33 mins, respectively, p=0.03515), driven by a longer time from first medical contact (FMC) to ECG (104 vs. 34 mins, p=0.0021).

The majority of total ischaemic time is due to patient delay, and this increases as age increases. Women had longer ischaemic time compared with men and longer wait from FMC until diagnostic ECG. This study suggests that improved awareness for patients and healthcare staff will be paramount in reducing ischaemic time.

The assessment of the prognostic value of the admission electrocardiography (ECG) (specifically of the duration of the PR and QTc intervals, the QRS complex and the heart rate [HR]) in COVID-19 patients on the basis of nine observational studies (n=1,424) indicates that relatively long duration of the QTc interval and QRS complex, as well as higher HR, are linked to a severe course of COVID-19, which may be of use in risk stratification. Since there are important differences in suggested indicators of adverse prognosis between observational studies, further research is necessary to clarify high-risk criteria.

Cardiac transthyretin amyloidosis (ATTR) is an often underdiagnosed disease that can lead to significant morbidity and mortality for patients. In recent years, technetium-99m pyrophosphate scintigraphy (PYP) imaging has become a standard of care diagnostic tool to help clinicians identify this disease. With newly emerging therapies for ATTR cardiomyopathy, it is critical to identify patients who are eligible for therapy as early as possible. At our institution, we sought to describe the frequency of PYP scanning and how it has impacted the management of a patient suspected to have amyloid cardiomyopathy.

Between 1 January 2017 and 31 December 2020, we identified 273 patients who completed PYP scanning for evaluation of cardiac amyloidosis at Tufts Medical Center, a tertiary care centre. We reviewed pertinent clinical data for all study subjects. A PYP scan was considered positive when the heart to contralateral lung ratio was greater than or equal to 1.5, with a visual grade of 2 or 3, and confirmation with single-photon emission computerised tomography (SPECT) imaging.

In total there were 55 positive, 202 negative, and 16 equivocal PYP scans. Endomyocardial biopsies were rarely performed following PYP results. Of the seven patients with a positive PYP scan who underwent biopsy, five were positive for ATTR amyloid; of the patients with a negative scan who were biopsied, none were positive for ATTR amyloidosis and two were positive for amyloid light-chain (AL) amyloidosis. The biomarkers troponin I, B-type naturietic peptide (BNP), and N-terminal pro-BNP (NT-proBNP), as well as the interventricular septal end-diastolic thickness (IVSd) seen on echocardiogram, were all found to be statistically higher in the PYP positive cohort than in the PYP negative cohort using Mann-Whitney U statistical analysis. In total, 27 out of the 55 patients with a positive PYP scan underwent therapy specific for cardiac amyloid.

In conclusion, this study reinforces the clinical significance of the PYP scan in the diagnosis and management of cardiac amyloidosis. A positive scan allowed physicians to implement early amyloid-directed treatment while a negative scan encouraged physicians to pursue an alternative diagnosis.

We report a case of a patient that presented with typical angina pain and associated risk factors for coronary artery disease (CAD). Subsequent cardiac catheterisation led to the discovery of an isolated R-IIP modified Lipton classification coronary artery anomaly with follow-up coronary computed tomography angiography (CCTA) confirmation. This case report includes images of the CCTA and left heart catheterisation results, along with a discussion of the potential for increased risk of atherosclerosis in our patient, and a proposed explanation of his presentation with prototypical angina pain, despite lack of apparent atherosclerosis.

Though coronary artery disease primarily occurs in those over the age of 40 years, younger individuals who use recreational drugs may be afflicted with coronary events. Cannabis is one such perilous agent that can cause myocardial infarction (MI) and is one of the most common psychoactive drugs used worldwide. Cannabis (also known as marijuana, weed, pot, dope or grass) is the most widely used illegal drug in the UK. The desired euphoric effects are immediate, as are life-threatening hazardous ones.

In this article, we briefly describe a case series of two unique but similar cases of cannabis-induced ST-elevation MI witnessed at our hospital in quick succession. We will analyse the composite pathophysiology in acute coronary syndromes provoked by cannabis and discuss the evolving legality around the use of the drug.

Ambulatory electrocardiogram (AECG) monitoring is a common cardiovascular investigation. Traditionally, this requires a face-to-face appointment. In order to reduce contact during the COVID-19 pandemic, we investigated whether drive-by collection and self-fitting of the device by the patient represents an acceptable alternative.

A prospective, observational study of consecutive patients requiring AECG monitoring over a period of one month at three hospitals was performed. Half underwent standard (face-to-face) fitting, and half attended a drive-by service to collect their monitor, fitting their device at home. Outcome measures were quality of the recordings (determined as good, acceptable or poor), and patient satisfaction.

A total of 375 patients were included (192 face-to-face, 183 drive-by). Mean patient age was similar between the two groups. The quality of the AECG recordings was similar in both groups (52.6% good in face-to-face vs. 53.0% in drive-by; 34.9% acceptable in face-to-face vs. 32.2% in drive-by; 12.5% poor in face-to-face vs. 14.8% in drive-by; Chi-square statistic 0.55, p=0.76). Patient satisfaction rates were high, with all patients in both groups satisfied with the care they received.

In conclusion, drive-by collection and self-fitting of AECG monitoring yields similar AECG quality to conventional face-to-face fitting, with high levels of patient satisfaction.

Imagine that it is possible to know, the actual coronary blood flow. Would this not remove any doubt, if a chest pain is the heart’s fault?

Aortic dissection is a rare and potentially fatal complication of coronary angiography. We report a case of a woman in her late 80s who underwent a left femoral approach coronary angiogram for evaluation of a transcatheter aortic valve replacement (TAVR). Following the procedure, she had a cardiac arrest and was found to have a descending aortic dissection on transoesophageal echocardiogram. Autopsy showed an acute intimal tear of the descending aorta, most likely related to catheter manipulation. Patients undergoing evaluation for TAVR, who tend to be elderly with concomitant atherosclerosis, are at risk for complications following cardiac catheterisation including aortic dissection.