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Clinical articles

July 2020 Br J Cardiol 2020;27:83–6 doi :10.5837/bjc.2020.021

Coronary lithotripsy: a novel approach to intra-coronary calcification with ‘cracking’ results?

Paula Finnegan, John Jefferies, Ronan Margey, Barry Hennigan

Abstract

This article is available as a BJC Learning CPD activity

Coronary lithotripsy is a novel approach to percutaneous coronary intervention (PCI). It is based on well-established technology dating back to 1980 when lithotripsy was first used to treat renal calculi. Its application in cardiovascular medicine is a more recent development that involves using a low-pressure lithotripsy balloon to deliver unfocused acoustic pulse waves in a circumferential mechanical energy distribution. This causes fracturing of calcification within the surrounding vasculature, facilitating optimal stent deployment.

This article aims to review recent clinical experience and the published data regarding intravascular lithotripsy (IVL). All relevant articles were identified via PubMed using keywords including “intravascular lithotripsy”, “shockwave” and “coronary”. All studies that contained published datasets regarding IVL with patient numbers >50 were included for review. There were 116 results found. After reviewing all the publications, articles were then tabulated and 17 were found to be relevant, including only four clinical studies.

In this review we found that intracoronary lithotripsy for heavily calcified arteries appears to be a safe, effective, easy-to-use method of dealing with an otherwise technically-challenging and high-risk scenario. It appears to carry low risk, uses low pressures, and exerts its effects on both superficial and deep intravascular calcium. Further prospective data with long-term follow-up will be required to explore both the off-label uses of IVL (such as post-stent dilatation), and the long-term patency of these vessels.

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July 2020 Br J Cardiol 2020;27:87–92 doi :10.5837/bjc.2020.022

Personalised external aortic root support (PEARS) to stabilise an aortic root aneurysm

John Pepper, Tal J Golesworthy, Cemil Izgi, Johanna J M Takkenberg, Tom Treasure

Abstract

Patients with congenitally determined aortic root aneurysms are at risk of aortic valve regurgitation, aortic dissection, rupture and death. Personalised external aortic root support (PEARS) may provide an alternative to aortic root replacement.

This was a multi-centre, prospective cohort of all consecutive patients who received ExoVasc mesh implants for a dilated aortic root between 2004 and 2017. Baseline and peri-operative characteristics, as well as early postoperative outcomes are described, and time-related survival and re-operation free survival are estimated using the Kaplan-Meier method.

From 2004 through 2017, 117 consecutive patients have received ExoVasc mesh implants for aortic root aneurysm. The inclusion criteria were an aortic root/sinus of Valsalva and ascending aorta with asymptomatic dilatation of between 40 and 50 mm in diameter in patients aged 16 years or more. Patients with more than mild aortic regurgitation were excluded. There was one early death. The length of stay was within seven days in 75% of patients.

In conclusion, the operation achieves the objectives of valve-sparing root replacement. PEARS may be seen as a low-risk conservative operation, which can be applied earlier on in the disease process, and which is complementary to more invasive procedures, such as valve-sparing root replacement or total root replacement.

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July 2020 Br J Cardiol 2020;27:93–6 doi :10.5837/bjc.2020.023

Shared decision-making for ICDs: a regional collaborative initiative

Honey Thomas, Mark Lambert, Chris Plummer, Craig Runnett, Richard Thomson, Anne Marie Troy-Smith, Andrew J Turley

Abstract

The National Institute for Health and Care Excellence (NICE) and NHS England have shown a commitment to embedding shared decision-making (SDM) in clinical practice and developing decision aids based on clinical guidelines. Healthcare policy makers are keen to enhance the engagement of patients in SDM in the belief that it improves the benefits accrued from healthcare interventions. This may be important for interventions such as implantable cardioverter-defibrillator (ICD) implantation, where cost-effectiveness is under scrutiny. NHS England invited the ICD implanters in the north of England to participate in a regional commissioning quality incentive (CQUIN) project to improve decision-making around a primary prevention ICD implant. A collaborative project included the development of a specific SDM tool, the first of its kind in the UK, followed by training and education of the clinical teams. The project illustrates that this approach is practical and deliverable and could be applied and used in other regions, and considered in additional clinical areas.

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July 2020 Br J Cardiol 2020;27:97–9 doi :10.5837/bjc.2020.024

Computed tomography artefact finding of pacing lead perforation

Holly Morgan, Christopher Williams, Robert A Bleasdale

Abstract

Computed tomography (CT) is a widely available imaging modality and artefactual findings are not uncommon, particularly in the presence of foreign bodies.

We conducted a retrospective analysis of all CT scans carried out in our trust in a 12-month period, identifying all reports containing the word “pacemaker”. There were 88 scans identified, six of which reported findings related to the pacemaker. In five cases right ventricular lead perforation was reported. All patients underwent further investigations, which did not show any evidence of true lead perforation.

In conclusion, it is important that both cardiologists and radiologists are aware of the possibility of artefactual lead perforation on CT.

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June 2020 Br J Cardiol 2020;27:51–54 doi :10.5837/bjc.2020.017

Impact of COVID-19 on primary percutaneous coronary intervention centres in the UK: a survey

Ahmed M Adlan, Ven G Lim, Gurpreet Dhillon, Hibba Kurdi, Gemina Doolub, Nadir Elamin, Amir Aziz, Sanjay Sastry, Gershan Davis

Abstract

During the coronavirus disease (COVID-19) pandemic, the British Cardiovascular Society/British Cardiovascular Intervention Society and the British Heart Rhythm Society recommended to postpone non-urgent elective work and that primary percutaneous coronary intervention (PCI) should remain the treatment of choice for patients with ST-segment elevation myocardial infarction (STEMI). We sought to determine the impact of COVID-19 on the primary PCI service within the United Kingdom (UK).

A survey of 43 UK primary PCI centres was performed and a significant reduction in the number of cath labs open was found (pre-COVID 3.6±1.8 vs. post-COVID 2.1±0.8; p<0.001) with only 64% of cath labs remained open during the COVID-19 pandemic. Primary PCI remained first-line treatment for STEMI in all centres surveyed.

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June 2020 Br J Cardiol 2020;27:55–9 doi :10.5837/bjc.2020.018

COVID-19: the heart and other issues

Cormac T O’Connor, David Mulcahy

Abstract

From the time that the first cases were reported from Wuhan, China on the 31st December 2019,1 our knowledge of the clinical and virological associations of the novel coronavirus (COVID-19) has been evolving at a rapid pace. On 18th May 2020, COVID-19 had caused over 4.82 million cases worldwide and resulted in 316,959 deaths.2 Whilst the primary focus of management for patients with COVID-19 remains close monitoring of respiratory function, there have been high levels of cardiac dysfunction in emerging cross-sectional and observational analyses, suggesting the need for heightened awareness in patients who may require cardiac input as part of a multidisciplinary approach. We review the current data on the association of COVID-19 and the heart.

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June 2020 Br J Cardiol 2020;27:67–70 doi :10.5837/bjc.2020.020

An exercise-based cardiac rehabilitation programme for AF patients in the NHS: a feasibility study

Mark Mills, Elizabeth Johnson, Hamza Zafar, Andrew Horwood, Nicola Lax, Sarah Charlesworth, Anna Gregory, Justin Lee, Jonathan Sahu, Graeme Kirkwood, Nicholas Kelland, Andreas Kyriacou

Abstract

There is increasing evidence for the role of exercise-based cardiac rehabilitation in the management of patients with atrial fibrillation (AF). However, this intervention has not yet been widely adopted within the National Health Service (NHS).

We performed a feasibility study on the utilisation of an established NHS cardiac rehabilitation programme in the management of AF, and examined the effects of this intervention on exercise capacity, weight, and psychological health. We then identified factors that might prevent patients from enrolling on our programme.

Patients with symptomatic AF were invited to participate in an established six-week exercise-based cardiac rehabilitation programme, composed of physical activity and education sessions. At the start of the programme, patients were weighed and measured, performed the six-minute walk test (6MWT), completed the Generalised Anxiety Disorder Questionnaire (GAD-7), and the Patient Health Questionnaire (PHQ-9). Measurements were repeated on completion of the programme.

Over two years, 77 patients were invited to join the programme. Twenty-two patients (28.5%) declined participation prior to initial assessment and 22 (28.5%) accepted and attended the initial assessment, but subsequently withdrew from the programme. In total, 33 patients completed the entire programme (63.9 ± 1.7 years, 58% female). On completion, patients covered longer distances during the 6MWT, had lower GAD-7 scores, and lower PHQ-9 scores, compared with their baseline results. Compared with patients that completed the entire programme, those who withdrew from the study had, at baseline, a significantly higher body mass index (BMI), covered a shorter distance during the 6MWT, and had higher PHQ-9 and GAD-7 scores.

In conclusion, enrolling patients with AF into an NHS cardiac rehabilitation programme is feasible, with nearly half of those invited completing the programme. In this feasibility study, cardiac rehabilitation resulted in an improved 6MWT, and reduced anxiety and depression levels, in the short term. Severe obesity, higher anxiety and depression levels, and lower initial exercise capacity appear to be barriers to completing exercise-based cardiac rehabilitation. These results warrant further investigation in larger cohorts.

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May 2020 Br J Cardiol 2020;27:64–6 doi :10.5837/bjc.2020.011

Hypertrophic cardiomyopathy and exercise restrictions: time to let the shackles off?

Yuen W Liao, James Redfern, John D Somauroo, Robert M Cooper

Abstract

The health benefits of physical activity are well documented. Patients with hypertrophic cardiomyopathy (HCM) are often discouraged from participating in physical activity due to a perceived increase in the risk of sudden cardiac death (SCD). As a result, only 45% of patients with HCM meet the minimum guidelines for physical activity, and many report an intentional reduction in exercise following diagnosis. Despite most SCD being unrelated to HCM, guidelines traditionally focused on the avoidance of potential risk through restriction of exercise, without clear recommendations on how to negate the negative health impact of inactivity. Retrospective reviews have demonstrated that the majority of cardiac arrests in patients with HCM occurred at rest or on mild exertion and that the overall incidence of HCM-related SCD is significantly lower than previously reported. We will discuss current international guidelines and recommendations and consider the outcomes of various studies that have investigated the effects of exercise of different intensities on patients with HCM. In light of the growing evidence suggesting that carefully guided exercise can be both beneficial and safe in patients with HCM, we ask whether it is time to let the shackles off exercise restriction in HCM.

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May 2020 Br J Cardiol 2020;27:60–3 doi :10.5837/bjc.2020.012

A multi-disciplinary care pathway improves symptoms, QoL and medication use in refractory angina

Kevin Cheng, Ranil de Silva

Abstract

Refractory angina (RA) is a growing clinical problem. Long-term mortality is better than expected and focus has shifted to improving symptoms, quality of life and psychological morbidity. We established a dedicated multi-disciplinary care pathway for patients with RA and assessed its effect on psychological outcomes, quality of life and polypharmacy. We reviewed electronic health records to capture demographics, changes in medication use, and patient-related outcome measures (Seattle Angina Questionnaire [SAQ] and Hospital Anxiety and Depression Scale) before and after enrolment.

One hundred and ninety patients were referred to our service. Pre- and post-questionnaire data were available in 83 patients. Anxiety and depression scores significantly improved (p<0.05) as well as quality of life and all subcategories of the SAQ (p<0.0001). Patients were most commonly on three or four anti-anginal drugs. In patients with no demonstrable reversible ischaemia, there was a significant reduction in anti-anginal usage (mean reduction of two drugs) after completion of our pathway (p<0.025).

In conclusion, a dedicated multi-disciplinary pathway for RA is associated with improvements in quality of life, mental health and polypharmacy. An ischaemia-driven method to rationalise medication may reduce polypharmacy in patients with RA, particularly in patients with no demonstrable ischaemia.

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May 2020 Br J Cardiol 2020;27:71 doi :10.5837/bjc.2020.013

Ezekiel’s heart

JJ Coughlan, Max Waters, David Moore, David Mulcahy

Abstract

“I will give you a new heart and put a new spirit in you; I will remove from you your heart of stone and give you a heart of flesh” – Ezekiel 36:26

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