Clinical articles

Presentation of an interrupted aortic arch in adulthood is rare, and, up until, recently the only treatment strategy was through surgical repair. Advances in percutaneous interventions for congenital heart disease have included the percutaneous repair of coarctation of the aorta – from straightforward luminal narrowing through to full aortic interruption.^1-3 We present a case of a 28-year-old man who was diagnosed with a complete aortic interruption and successfully percutaneously treated.

Open-heart surgery is a major surgical procedure that requires intensive patient monitoring. Clinicians require prompt laboratory test results to assist them in this monitoring. Timeliness of result delivery is of great importance in taking prompt clinical decisions. We set out to evaluate the performance of the support laboratory before and after domiciliation at the cardiac centre using turnaround time (TAT) of electrolytes and liver function tests as benchmarks.

This hospital-based descriptive study was carried out at the University of Nigeria Teaching Hospital (UNTH), Enugu. The authors conducted a desk review of laboratory records for electrolytes and liver function tests from March 2013 to July 2017. Relevant laboratory personnel were also interviewed to ascertain types of equipment used and possible causes of delay at different stages of transition during the period under review. The TAT was calculated as the time from sample reception to time of dispatch of results.

Between 2013 and 2014, TAT for electrolytes and liver function tests were ~2 and ~6 hours, respectively. In 2015, TAT reduced to ~1 hour for electrolytes and ~1½ hours for liver function tests. Between 2016 and July 2017, TAT further reduced to ~10 minutes for electrolytes and ~30 minutes for liver function tests.

In conclusion, we were able to demonstrate improvement in performance of the support laboratory as shown by a reduction in TAT following the transition from the main laboratory to being domiciled in the cardiac centre.

Myocardial perfusion scintigraphy (MPS) is a non-invasive method that can be used to assess reversible left ventricular myocardial perfusion defect (<20% indicates limited and ≥20% indicates extensive ischaemia), and left ventricular ejection fraction (LVEF) at rest and at stress. Data on the utility of MPS used to stratify cardiac risk prior to abdominal aortic aneurysm (AAA) repairs are limited. We evaluated MPS as a stratification tool for patients scheduled for endovascular aneurysm repair (EVAR) or open repair, between 2013 and 2016 at Ashford and St Peter’s NHS Foundation Trust, and 4.9 years (median 2.8 years, interquartile range [IQR] 2.1–3.8) cardiovascular events (n=15, 17.9%) all-cause mortality (n=17, 22.6%). Of the 84 patients recruited (median age 75.7 years, IQR 69.4–79.6), 57 (67.9%) had limited and 27 (32.1%) extensive ischaemia, 62 (73.8%) underwent EVAR and 22 (26.2%) open repair. Compared with open repair patients, EVAR patients were older (median age 70.6 years vs. 76.4 years, p=0.015), had higher rates of extensive ischaemia (13.6% vs. 38.7%, p=0.025), and abnormal LVEF reserve (LVEF at stress minus LVEF at rest ≤0: 40.0% vs. 76.6%, p=0.011), while having lower rates of 30-day postoperative major adverse cardiac events (13.6% vs. 3.3%, p=0.040) but no difference for cardiovascular events (p=0.179) or 4.9 year all-cause mortality (22.7% vs. 22.6%, adjusted hazard ratio 0.80, 95% confidence interval [CI] 0.22 to 3.20, p=0.799). Our findings indicate that MPS provides valuable information for AAA repair procedure.

This is a case series of 10 patients who presented with the same electrocardiogram (ECG) manifestation of new-onset giant T-wave inversion and QT prolongation over a period of 24 months in a district general hospital. This unique ECG manifestation has been described with several cardiac and non-cardiac conditions.

Stunned myocardium is a rare, but serious, medical condition, and requires emergency intervention. Short periods of hypoperfusion may lead to a prolonged cardiac hypokinesia (hours to days), even though the perfusion is retained eventually. In other words, although the coronary circulation is retained, the hypokinesia remains. It might be considered as a case of prolonged post-ischaemic dysfunction.

In this case, a 60-year-old woman, visiting her siblings, presented with severe dyspnoea and cyanosis to the emergency department. Pulmonary oedema was diagnosed, and transthoracic echocardiography (TTE) showed general hypokinesia and reduced ejection fraction (15%), nevertheless, sequential TTE monitoring after the required medical intervention revealed a continuous improvement, with a 45% ejection fraction three days later and a specific anterior wall hypokinesia, solely.

In conclusion, rapid diagnosis and treatment are essential for stunned myocardium, as these could change the progress of the clinical condition.

The introduction of such digital technologies as robotic implants, home monitoring devices, wearable sensors and mobile apps in healthcare have produced significant amounts of data, which need to be interpreted and operationalised by physicians and healthcare systems across disparate fields.¹ Most often, such technologies are implemented at the patient level, with patients becoming their own producers and consumers of personal data, something which leads to them demanding more personalised care.²

This digital transformation has led to a move away from a ‘top-down’ data management strategy, “which entailed either manual entry of data with its inherent limitations of accuracy and completeness, followed by data analysis with relatively basic statistical tools… and often without definitive answers to the clinical questions posited”.³ We are now in an era of a ‘bottom-up’ data management strategy that involves real-time data extraction from various sources (including apps, wearables, hospital systems, etc.), transformation of that data into a uniform format, and loading of the data into an analytical system for final analysis.³

A recent survey of healthcare professionals confirms that hyperkalaemia is considered as a common and important clinical issue for patients receiving renin-angiotensin-aldosterone-system (RAAS) inhibitors in particular. Successful interventions to manage hyperkalaemia appear beneficial rather than avoidance or dose reduction of these RAAS inhibitors in patients with chronic heart failure, diabetic nephropathy or prior myocardial infarction.

Two newer potassium exchange resins, patiromer and sodium zirconium cyclosilicate (ZS-9), may offer improved predictability, tolerability, and efficacy for managing patients with hyperkalaemia.

A 55-year-old man with suspected community-acquired pneumonia and atrial fibrillation was found to have a very large left atrial myxoma complicated with a pulmonary triad – pulmonary hypertension, pulmonary infarction, and pulmonary lymphadenopathy. The myxoma was successfully removed and complete resolution of all three pulmonary complications followed. He re-presented two weeks post-surgery with atrial flutter, which was medically treated and considered for ablation. We have taken the opportunity to undergo a mini-literature review on myxoma and its pulmonary complications.

The National Institute for Health and Care Excellence (NICE) released an updated guideline on stable chest pain in 2016. They recommended that all patients with chest pain, typical or atypical, should be investigated with computed tomography coronary angiography (CTCA) in the first instance. Functional imaging tests were reserved for the assessment of patients with chest pain and known coronary artery disease (CAD) and for patients where the CTCA is equivocal or has shown CAD of uncertain significance. The European Society of Cardiology (ESC) guidelines on stable chest pain, however, recommend functional imaging tests for all stable chest pain patients, with CTCA as an alternative in patients with low-to-intermediate likelihood of CAD. The ESC guidelines also allow for the use of the exercise electrocardiogram (ECG) as an alternative to functional imaging tests in patients with low-to-intermediate likelihood of CAD, if functional imaging tests are not available.

Furthermore, traditionally, the aetiology of heart failure or left ventricular (LV) dysfunction was investigated with diagnostic invasive coronary angiography. More recently, cardiac magnetic resonance imaging (MRI) tissue characterisation was proposed as an effective alternative test. We conducted a survey of UK cardiologists’ opinions on the use of CTCA in patients with stable chest pain and in the investigation of the aetiology of heart failure.

The study sought to evaluate the indications, image quality, safety and impact on patient management of cardiac magnetic resonance imaging (CMR) in a district general hospital setting.  The database was developed using retrospective analysis of patient records from the start of the local CMR service in January 2014 until January 2017. All 791 consecutive patients were included in the dataset.

The most important indications were the investigation of myocarditis/cardiomyopathies (54.5%), work-up of suspected coronary artery disease (CAD)/ischaemia (27.1%), and assessment of viability (9.1%). Image quality was diagnostic in 99.9% of cases. Mild adverse effects were reported for 3.8% of patients for stress CMR and in 1.1% of non-stress CMR. No serious adverse events were reported in this study population. In 26.5% of cases, CMR findings resulted in therapeutic modifications. In 18.1%, the final diagnosis based on CMR was different to that suspected before the CMR.

In conclusion, the findings of this study emphasise that CMR is a safe procedure with high image quality. In many cases, CMR can be shown to change a patient’s management plan.