Clinical articles

Transcatheter aortic valve implantation (TAVI) is a routine procedure for patients with symptomatic severe aortic stenosis who are deemed inoperable or high-risk surgical candidates. The aim of this study was to examine real-world data on death and readmission rates in patients following the procedure.

Electronic health records for patients who underwent TAVI between April 2015 and November 2018 were reviewed. Details of the procedure, complications, length of initial hospital stay and outcomes of interest (subsequent admissions and mortality) were recorded.

In our cohort of 124 patients, the mean age was 80.8 years and 43% were male. Cardiac comorbidities were common, more than 30% had myocardial infarction (MI) and 15% had a previous coronary artery bypass graft (CABG). One in five suffered from chronic obstructive pulmonary disease (COPD), with similar prevalence of diabetes mellitus and cerebrovascular accident (CVA). In-hospital mortality was low at 3.3%, however, 30-day readmission rates were high at 14.6%; 44.4% were readmitted to hospital within one year.

TAVI is a successful procedure in Scotland with good outcome data. The potential benefit of the procedure in many patients is limited by comorbidities, which shorten life-expectancy and lead to hospital readmission. These data highlight the importance of effective multi-disciplinary discussion in a time of realistic medicine.

In a cardiology department, there are some patients that require long-term antibiotics, such as those with infective endocarditis or infected prosthetic devices. We describe our experience with intravenous antibiotic therapy for patients with cardiology diagnoses who require a period of antibiotics in our outpatient service during the period of the COVID-19 pandemic. A total of 15 patients were selected to have outpatient antibiotic therapy (age range 36 to 97 years, 60% male). A total of nine patients had infective endocarditis, four patients had infected valve prosthesis or transcatheter aortic valve implantation (TAVI) endocarditis, one patient had infected pericardial effusion while another had infected pericarditis. For these 15 patients there was a total of 333 hospital bed-days, on average 22 days per patient. These patients also had a total of 312 days of outpatient antibiotic therapy, which was an average of 21 days per patient. The total cost, if patients were admitted for those days, assuming a night cost £400, was £124,800, which was on average £8,320 per patient. Three patients were readmitted within 30 days. One had ongoing endocarditis that was managed medically and another had pulmonary embolism. The last patient had a side effect related to daptomycin use. In conclusion, outpatient antibiotic therapy in selected patients with native or prosthetic infective endocarditis appears to be safe for a selected group of patients with associated cost savings.

Radial artery access has transformed cardiac catheterisation, allowing it to be performed in a daycase setting, saving both hospital beds, and nursing care costs. However, there are two common and seemingly diametrically opposite complications. These are radial artery occlusion and forearm haematoma; the former could be reduced by heparin, but at the expense of precipitating the latter. These complications increase proportionally to the size of radial artery sheath used. Interestingly, by cannulating the radial artery more distally beyond its bifurcation in the hand, the distal radial approach appears to be the ‘one stone, two birds’ or the synchronous Chinese idiom, ‘yīshí’èrniǎo’s’ solution, reducing both complications at the same time. Extending this further and downsizing to a 4Fr catheter system, heparin use could be spared altogether, without complications, and haemostasis achieved with short manual pressure at the puncture site. Hence, further cost savings by foregoing commercial compression bands, and abolishing access site care for nurses. We illustrate the above strategy in a patient with challenging radial anatomy, made simple and easy.

Two cases of orthostatic hypotension associated with weight loss following cancer treatment are described. Conventional treatments for orthostatic hypotension proved ineffective. A hypothesis of association with skeletal muscle wasting is discussed.

Stent edge dissection is one of the procedural complications concerning percutaneous coronary intervention (PCI). We present a clinical case of multi-vessel PCI where the patient had to return with recurring symptoms within two weeks of a seemingly successful PCI, only to teach us a valuable lesson in the more frequent and judicious use of intracoronary imaging.

The UK cardiology specialist training programme utilises the National Health Service (NHS) e-Portfolio to ensure adequate progression is being made during a trainees’ career. The NHS e-portfolio has been used for 15 years, but many questions remain regarding its perceived learning value and usefulness for trainees and trainers. This qualitative study in the recent pre-COVID era explored the perceived benefits of the NHS e-Portfolio with cardiology trainees and trainers in two UK training deaneries. Questionnaires were sent to 66 trainees and to 50 trainers. 50% of trainees felt that their development had benefited from use of the ePortfolio. 61% of trainees found it an effective educational tool, and 25% of trainees and 39% of trainers found the ePortfolio useful for highlighting their strengths and weaknesses. 75% of trainees viewed workplace based assessments as a means to passing the ARCP. The results show that the NHS ePortfolio and workplace based assessments were perceived negatively by some trainees and trainers alike, with many feeling that significant improvements need to be made. In light of the progress and acceptance of digital technology and communication in the current COVID-19 era, it is likely to be the time for the development of a new optimal digital training platform for cardiology trainees and trainers. The specialist societies could help develop a more speciality specific learning and development tool.

Selexipag is an oral selective prostacyclin-receptor agonist that was approved for use in patients with World Health Organisation (WHO) functional class II–III pulmonary arterial hypertension (PAH). Treatment with individualised doses of selexipag resulted in significant reductions in the composite end point of death or a complication related to PAH in the phase III GRIPHON (Prostacyclin [PGI2] Receptor Agonist In Pulmonary Arterial Hypertension) study. In order to better understand the real-world approach to selexipag titration and to establish the individualised maintenance regimens used in our centre, we performed this retrospective study of the first 20 patients prescribed selexipag. Baseline characteristics differed from the GRIPHON study, with more combination therapy and comorbidities at drug initiation. Maintenance doses were stratified as low-dose in 10% (n=2), medium-dose in 70% (n=14) and high-dose in 20% (n=4). This study highlights that selexipag can be safely initiated, titrated and transitioned in an outpatient setting to achieve an individualised dosing regimen.

A 52-year-old woman, referred for transoesophageal echocardiography, developed acute Takotsubo cardiomyopathy during the examination as a result of emotional distress beforehand. Asymptomatic left ventricular apical ballooning with severe systolic dysfunction within minutes of the emotional trigger was the first sign of any abnormality.

This is an interesting case of wide complex tachycardia in a patient on flecainide for paroxysmal atrial fibrillation. Diagnostic possibilities were discussed, actual diagnosis revealed, and explanation provided.

The coronavirus disease 2019 (COVID-19) commonly involves the respiratory system but increasingly cardiovascular involvement is recognised. We assessed electrocardiogram (ECG) abnormalities in patients with COVID-19.

We performed retrospective analysis of the hospital’s COVID-19 database from April to May 2020. Any ECG abnormality was defined as: 1) new sinus bradycardia; 2) new/worsening bundle-branch block; 3) new/worsening heart block; 4) new ventricular or atrial bigeminy/trigeminy; 5) new-onset atrial fibrillation (AF)/atrial flutter or ventricular tachycardia (VT); and 6) new-onset ischaemic changes. Patients with and without any ECG change were compared.

There were 455 patients included of whom 59 patients (12.8%) met criteria for any ECG abnormality. Patients were older (any ECG abnormality 77.8 ± 12 years vs. no ECG abnormality 67.4 ± 18.2 years, p<0.001) and more likely to die in-hospital (any ECG abnormality 44.1% vs. no ECG abnormality 27.8%, p=0.011). Cox-proportional hazard analysis demonstrated any ECG abnormality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.12 to 3.47, p=0.019), age (HR 1.03, 95%CI 1.01 to 1.05, p=0.0009), raised high sensitivity troponin I (HR 2.22, 95%CI 1.27 to 3.90, p=0.006) and low estimated glomerular filtration rate (eGFR) (HR 1.73, 95%CI 1.04 to 2.88, p=0.036) were independent predictors of in-hospital mortality.

In conclusion, any new ECG abnormality is a significant predictor of in-hospital mortality.