Clinical articles

This review focuses on the role of CytoSorb® (CytoSorbents Corporation, Monmouth Junction, New Jersey, USA), a technology for purifying extracorporeal blood. The technology is designed for several indications to prevent bleeding complications during on-pump cardiac surgery, including removal of the antiplatelet agent, ticagrelor, and the oral anticoagulant, rivaroxaban, from the blood. Recent clinical studies are briefly reviewed.

Cardiac implantable electronic device (CIED)-related complications and infections typically lead to prolonged hospital stays and, very occasionally, death. A new CIED insertion protocol was implemented in a district general hospital. The primary objective of this study was to determine whether a significant reduction in complication and infection rates occurred after implementation of the new protocol. Medical records were reviewed for patients who had a CIED inserted in the two years pre- and post-protocol implementation, and any complications were identified in a one-year follow-up period.

An increase in the complexity of the devices implanted after introduction of the protocol was observed. The number of complications was significantly reduced from 6.86% to 3.95% (p<0.0001). In the two years prior to protocol implementation, 14 of 871 (1.6%) patients suffered a CIED-related infection. In contrast, four of 683 (0.44%) patients suffered a CIED-related infection in the two years post-implementation. This was not statistically significant (p=0.093).

In conclusion, implementing a standardised protocol for CIED insertion significantly reduced the rate of complications, and also reduced the rate of infection, but this was not statistically significant.

The Fontan procedure provides a palliative surgical repair for complex congenital heart disease, but it is associated with many long-term problems, including liver cirrhosis, and hepatocellular carcinoma. The current suggestion from international guidance is that end-organ surveillance should be carried out, with a particular focus on regular blood tests and imaging for liver function.

In this study, retrospective analysis was performed on adult patients who had previously had a Fontan operation performed to determine the regularity of end-organ surveillance in regards to their liver function covering the three calendar years from 2016 to 2018, and the first six months of 2019.

Eighty-six patients were identified in South Wales monitored by the adult congenital heart disease unit. We found that the number of investigations performed in the first six months of 2019 was comparable to other calendar years in their entirety. Liver function tests had been performed in 57% of patients throughout 2018, with only 8% having had an alpha-fetoprotein taken, and only 9% having had imaging of the liver performed. Over the course of their lifetime, 97% of patients had had a liver function blood test performed at some point, with 17% having had an alpha-fetoprotein taken, and 49% having their liver imaged.

In conclusion, end-organ surveillance is an important follow-up for patients with a Fontan circulation, with guidelines proposing yearly blood test and imaging investigations. This study shows the opportunities to improve surveillance in this group of patients to highlight the development of liver cirrhosis, and/or hepatocellular carcinoma.

Exercise prevents and aids treatment of coronary heart disease, hypertension, heart failure, diabetes mellitus, obesity and depression, reduces cardiac events and improves survival. However, evidence suggests that the relationship between exercise and mortality may be curvilinear, with modest additional benefit at higher levels. Intensive exercise has also been associated with increased atrial fibrillation risk, although its clinical implications are not well understood. Other proposed adverse effects of exercise on the heart, including reduced right ventricular function, elevated cardiac biomarkers, myocardial fibrosis and coronary artery calcification, are less substantiated. Current evidence cannot affirm that extreme exercise is dangerous and future studies should combine large cohorts to obtain a statistically reliable limit. Associations between features of the athlete’s heart and cardiovascular morbidity and mortality should also be explored.

Control of hypercholesterolaemia is an effective way of reducing cardiovascular events in patients at elevated risk of cardiovascular disease. Repeat cholesterol measurement is a good practice, but is rarely performed, with clinicians often adopting a ‘fire and forget’ policy.

A retrospective audit at two cardiac centres in the West Midlands was performed to evaluate performance in lipid measurement following initiation of lipid therapy, and to evaluate whether all patients with an indication for a proprotein convertase subtisilin/kexin 9 inhibitor (PCSK9i) following acute coronary syndrome (ACS) were identified according to National Institute for Health and Care Excellence (NICE) recommendations.

We identified 167/7,048 patients with a total cholesterol of ≥7.2 mmol/L, of which 33 patients had previous vascular disease affecting more than one territory (polyvascular disease). Total cholesterol threshold ≥7.2 mmol/L was chosen in order to achieve a sufficient number of samples for the audit to be completed successfully. Low-density lipoprotein (LDL) level was performed in 93 patients on admission and repeated within three months in 20 patients (13%). Overall, 48 patients (30%) had any repeat LDL recorded. Of this group, 10 patients met the NICE criteria for PCSK9i.

Failure to repeat LDL levels in patients following hospital discharge with a diagnosis of ACS, is likely to explain the small number of patients identified as being eligible for PCSK9i. Underreporting of comorbid vascular disease also prevents the identification of patients at very high risk. We advocate re-establishing the practice of routine repeat fasting lipids measurement following discharge from hospital in order to correctly identify patients who may be eligible for optimal lipid-lowering therapy.

Patients with heart failure with reduced ejection fraction (HFrEF) who received the sodium-glucose co-transport 2 inhibitor, dapagliflozin, in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) study have a significant reduction in worsening heart failure (HF) and cardiovascular death. It is uncertain what proportion of patients admitted to a large regional cardiac centre with decompensated heart failure would be eligible for dapagliflozin post-discharge based on their characteristics at discharge.

The DAPA-HF study criteria were retrospectively applied to a cohort of 521 consecutive patients referred to the inpatient HF service in a tertiary cardiac centre in South West Wales between April 2017 and April 2018. Inclusion criteria: left ventricular ejection fraction (LVEF) <40%, New York Heart Association (NYHA) class II–IV symptoms and an elevated N-terminal pro-B-type naturietic peptide (NT-proBNP). Exclusion criteria: systolic blood pressure (SBP) <95 mmHg, estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m² or type 1 diabetes mellitus. We did not have complete NT-proBNP data for the cohort, as it was not routinely measured at the time in our institute.

There were 478 patients, mean age 78 ± 13 years, 57% male and 91% NYHA class II–IV symptoms, were included in the analysis. Of these, 247 patients had HFrEF, 219 (46%) patients met the inclusion criteria, 231 (48%) were excluded as LVEF was >40%, and 48 (10%) were excluded with NYHA class I symptoms. Of the 219 patients who met the inclusion criteria, 13 (5.9%) had a SBP <95 mmHg, 48 (22%) had eGFR <30 ml/min/1.73 m², leaving 136 (28.5% of total and 55% of those with HFrEF) who met DAPA-HF study criteria.

In our study, 28.5% of all heart failure admissions and 55% of patients with HFrEF would be eligible for dapagliflozin post-discharge according to the DAPA–HF study entry criteria.

Takotsubo cardiomyopathy (TCM) was first described about 30 years ago. It has been attributed to the sudden catecholamine surge in relation to severe stress, which can cause multi-vessel coronary spasms and myocardial apical ballooning. Football supporters are prone to develop severe stress due to sudden changes in match results. This case presents a football supporter of Sheffield United (the Blades) who was admitted to the hospital with cardiac sounding chest pain following a last minute goal by the opposing team. The necessary investigations were carried out including coronary angiogram and echocardiogram. He was diagnosed with TCM following a left ventricular angiogram demonstrating the typical appearance of the octopus pot.

Increased demand for transcatheter aortic valve implantation (TAVI) procedures for patients with severe aortic stenosis has not been matched with a proportional increase in available resources in recent years. This article highlights the importance of developing integrated care pathways for TAVI, which incorporate standardised protocols for permanent pacemaker implantation (PPI) to ensure best practice, increase service efficiency and reduce rates of PPI post-TAVI.

During the recent ‘first wave’ of the COVID-19 pandemic, the National Health Service (NHS) has triaged planned services to create surge capacity. The primary prevention implantable cardioverter-defibrillator (ICD) was in a grey area of triage guidance, but it was suggested as a procedure that could be reasonably stopped. Recent reports have highlighted deaths of patients awaiting ICDs who may have been deferred during the pandemic. In our trust we reorganised our device service and continued to implant primary prevention ICDs during the ‘first wave’ and, here, report that most patients wished to proceed and underwent uncomplicated implantations. One patient later died from COVID-19, although the transmission site cannot be definitively concluded. With strict adherence to public health guidance and infection prevention strategies, we believe that ICD implantation can be performed safely during the pandemic, and this should be standard practice during subsequent surges.

Papillary fibroelastomas (PFE) are rare benign cardiac tumours mainly originating on aortic and mitral valvular surfaces. Management is individualised, but most recommend surgical excision due to thromboembolic risk. We report a 75-year-old man with symptomatic severe aortic stenosis compounded by PFE. Redo sternotomy aortic valve replacement was deferred in favour of the trans-apical (TAVR) approach. This report highlights, for the first time, the application of TAVR as a strategy for aortic valve stenosis and PFE to mitigate risk posed by injury to patent internal mammary arterial graft in close proximity to the manubrium, and complications due to the patient’s multiple comorbidities.