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Clinical articles

November 2023 Br J Cardiol 2023;30:158–60 doi :10.5837/bjc.2023.045

Brachial artery approach for managing retroperitoneal bleed following coronary intervention for STEMI

Muhammad Usman Shah, Krishna Poudyal, Ramy Goubran, Adnan Ahmed, Syed Yaseen Naqvi

Abstract

Primary percutaneous coronary intervention (PPCI) remains the gold-standard treatment for ST-elevation myocardial infarction (STEMI). Femoral arterial access for the procedure may be an ideal option in patients who are haemodynamically unwell. However, it is associated with rare, but life-threatening, complications such as perforation, leading to retroperitoneal haemorrhage. We present the case of a man in his 50s, admitted with cardiac arrest secondary to inferolateral STEMI. Successful PPCI was performed via right femoral artery, with access gained under ultrasound guidance. However, the patient deteriorated and was diagnosed to have a retroperitoneal haematoma secondary to femoral artery perforation. Additional arterial access via left brachial artery was obtained, and a covered stent was deployed successfully in the right femoral artery with satisfactory haemostasis. The patient recovered successfully and was discharged two weeks later. Early recognition of such complications is imperative to adequate management and percutaneous treatment is a viable option for such situations, in comparison with open surgical repair.

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November 2023 Br J Cardiol 2023;30:128–31 doi :10.5837/bjc.2023.035

Personal recording devices for arrhythmia detection

Gabriele Volucke, Guy A Haywood

Abstract

Persistent cardiac arrhythmias are readily amenable to detection by performing a standard electrocardiogram (ECG), but detection of transient (paroxysmal) arrhythmias has long been a significant cause of frustration to both doctors and patients. Often a significantly symptomatic arrhythmia is experienced by the patient but terminates before an ECG can be recorded to allow diagnosis. Prognostically important treatment is often delayed, and recurrent symptomatic attacks represent a high morbidity in patients’ lives and result in a burden on emergency services, who often arrive after the arrhythmia has terminated with no resultant progress in making a diagnosis.

Another area of concern has been the presence of asymptomatic, but clinically important, arrhythmias that can go unnoticed by people experiencing them and may result in permanent harm; asymptomatic paroxysmal atrial fibrillation in patients with high CHA2DS2-VASc scores being the most common example.

Both these issues are now being importantly addressed by the widespread availability of portable ECG recording devices, which patients can either manually activate themselves or program to automatically detect abnormal arrhythmias. Information on the range of devices available and their strengths and weaknesses is limited. This article aims to provide a helpful overview for patients and doctors advising them.

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November 2023 Br J Cardiol 2023;30:149 doi :10.5837/bjc.2023.037

Stent, balloon and hybrid in de novo PCI: could the whole be greater than the sum of its parts?

Pitt O Lim

Abstract

Andreas Grüntzig, an ardent angiologist crafted an indeflatable sausage-shaped dual-lumen balloon-catheter, designed its delivery to the heart, launched minimally invasive coronary intervention and taught by beaming live demonstration. Subsequent advances are just incremental tweaks and tinkers around this fully formed framework from 1978. The near-immediate or instant feedback learning process by which the heart responds to any new invasive procedural variation facilitates each new change; be it drug-eluting stent, drug-coated balloon, or both in different combinations and permutations. Now with Grüntzig’s balloon armed with an antiproliferative drug, it could dominate the field once more, as he originally envisaged.

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October 2023 Br J Cardiol 2023;30:152 doi :10.5837/bjc.2023.030

Type of thrombus, no reflow and outcomes of coronary intervention in ACS patients: OCT-guided study

Mostafa Abdelmonaem, Mohamed Farouk, Ahmed Reda

Abstract

Thrombus is the main finding in most patients with acute coronary syndrome (ACS), the type of which potentially impacts the end result of the interventional procedure in terms of no reflow and edge dissection. Optical coherence tomography (OCT) is considered a precise intra-vascular tool to image thrombi and characterise its properties. We aimed to study the impact of thrombus type, as defined by OCT, on procedural outcome in ACS patients. In this retrospective study we enrolled 100 patients who were treated by percutaneous coronary intervention (PCI) with the guidance of OCT. We recorded demographic and clinical data of the whole studied cohort. Angiographic details and procedural data were noted. Baseline OCT study was performed before intervention and repeated post-intervention. Plaque characterisation was identified, and thrombi were defined as red or white thrombi. Acute angiographic outcome was defined with special emphasis on no reflow.

Male patients and ST-elevation myocardial infarction (STEMI) patients more often had white thrombi (58.1% and 71.2%, respectively). Cases with red thrombi had longer pain duration, which was statistically significant. Edge dissection was more frequent with red thrombus, 44.7% versus 32.1% with white thrombus, but the difference is not statistically significant, while 17% of patients with white thrombi were complicated by no-reflow phenomenon versus only 4.3% in patients with red thrombi, and this difference was statistically significant.

In conculsion, OCT-guided PCI is feasible and safe in ACS settings. OCT-guided intra-procedural differentiation of thrombus type is potentially beneficial in predicting acute procedural outcome.

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October 2023 Br J Cardiol 2023;30:151 doi :10.5837/bjc.2023.031

A survey of digital access, digital confidence and rehabilitation delivery preferences of patients referred for CR

Helen Alexander, Andrew D’Silva, Christopher Tack, Aynsley Cowie

Abstract

Remote delivery of cardiovascular rehabilitation (CR) has been vital during the COVID pandemic when restrictions have been placed on face-to-face services. In the future, CR services are likely to offer alternatives to centre-based CR, including digital options. However, little is known about the digital access and confidence of CR service users, or their CR delivery preferences.

A telephone survey was conducted of those referred for CR in the London boroughs of Lambeth and Southwark (n=60) in which questions were asked about digital access and confidence, as well as current and future delivery preferences for their CR.

Between March and July 2021, 60 service-users met the inclusion criteria and were recruited for a telephone survey (mean age 60 ± 11.2 years). Of those, 82% had regular access to a smartphone, 60% to a computer or laptop and 43% to a tablet device. A high proportion of service users perceived themselves to be ‘extremely’ or ‘somewhat’ confident to use their devices. Thirty-nine (65%) service users would currently prefer a face-to-face assessment, rising to 82% once the perceived COVID-19 threat and restrictions are less. Preferences for accessing exercise were equally split between face-to-face and remotely supported independent exercise, with low interest in digital options. Delivery preferences for education, relaxation and peer support were more heterogeneous with interest in all delivery options.

In conclusion, digital access and confidence in CR service users was good. Redesigning CR services to offer more rehabilitation delivery options, aligned with patient choice may increase uptake and further trials are needed to assess the impact.

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October 2023 Br J Cardiol 2023;30:157 doi :10.5837/bjc.2023.032

Investigating infective endocarditis: teaching hospitals to choose wisely

Jake Williams, Megan Rawcliffe, Mark T Mills, David R Warriner

Abstract

Transthoracic echocardiography (TTE) is used to assess for evidence of infective endocarditis (IE). Inappropriate patient selection leads to significant burden on healthcare services. We aimed to assess effectiveness of cardiology consultant vetting of TTE requests for suspected IE in reduction of unnecessary scans. All inpatient TTE requests querying IE over a six-month period were vetted. Clinical information and pathology results were reviewed, and requests were either accepted, deferred, or rejected. A total of 103 patients had TTE requested: 39 (38%) were accepted for scan; four cases of IE were confirmed on TTE. There were 62% of patient requests rejected and not scanned, and no cases of IE subsequently diagnosed. Thus, consultant vetting of TTE requests for suspected IE is an effective way to safely reduce unnecessary scans and enables cost-effective streamlining of echocardiography services.

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October 2023 Br J Cardiol 2023;30:138 doi :10.5837/bjc.2023.033

Share The Pressure

Michaela Nuttall, Mark Cobain, Shaantanu Donde, Joanne Haws

Abstract

This paper summarises ‘Share The Pressure’, a project that developed and piloted a scalable model for engaging patients on the benefits of risk factor control for healthy ageing; training healthcare professionals (HCPs) in cardiovascular disease (CVD) risk communication; and improving the shared decision-making process between nurses, pharmacists and patients. The study features the use of a CVD risk tool called Heart Age, which has been shown to effectively motivate risk factor reduction in individuals.

The study team engaged virtually with patients and HCPs through established relationships within the community, third sector, charities, and social media. In addition, patients living with high blood pressure (hypertension) participated via online focus groups and surveys, which provided insight into patients’ preferences for conveying CVD risk, quantification of intervention benefits, side effects and processes to facilitate shared decision-making.

This insight gained from the focus group and survey data informed adaptations made to the Heart Age tool to provide ‘years off’ – or lowering of heart age – benefits for different aspects of blood pressure lowering, focusing on the independent and joint benefits of medication management and lifestyle.

The study piloted a training programme for nurses and pharmacists to support them in communicating and framing risk and intervention benefits.

The study trained 1,148 HCPs from 37 countries over 17 sessions. Post-training survey results of HCPs indicated an increase in self-rated knowledge and a strong likelihood of applying information learned to their clinical practice. In addition, the Heart Age users found the personalised report and Heart Age test results very motivating for patients with high blood pressure.

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October 2023 Br J Cardiol 2023;30:132–7 doi :10.5837/bjc.2023.034

Mitral valve TEER in the UK: what you need to know as TEER becomes routinely available in the NHS

Daniel J Blackman, Sam Dawkins, Robert Smith, Jonathan Byrne, Dominik Schlosshan, Philip A MacCarthy

Abstract

Transcatheter edge-to-edge repair (TEER) was first performed in 2003, and is now established across the developed world as an effective, minimally invasive treatment option for patients with mitral regurgitation (MR). Multiple large registries have established the efficacy of mitral TEER in patients with primary or degenerative MR in whom surgery is considered prohibitive or high risk, while ongoing randomised-controlled trials will determine its role in younger and lower-risk patients. In patients with secondary or functional MR, in whom mitral valve surgery is not routinely recommended, the pivotal COAPT trial showed a profound reduction in both mortality and heart failure hospitalisation in carefully selected patients.

NHS England approved the routine commissioning of mitral TEER in 2019, and following a substantial delay, due in large part to the COVID pandemic, the procedure is now widely available across the UK. This review article describes the TEER procedure, currently available devices, the underlying evidence base, and the key facts needed for clinicians to understand who, how, and where to refer patients for consideration of mitral TEER. The emerging role of TEER in patients with severe symptomatic tricuspid regurgitation is also considered.

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September 2023 Br J Cardiol 2023;30:95–8 doi :10.5837/bjc.2023.025

Screening for the vulnerable aorta: targeting high-risk groups in the population

Riccardo Proietti, Mark Field, Victoria McKay, Gregory Y H Lip, Manoj Kuduvalli, on behalf of UK Aortic Society

Abstract

Thoracic aortic aneurysms are often asymptomatic until patients present with a life-threatening acute aortic syndrome. The vulnerability of an aorta to an acute aortic syndrome is determined by cross-sectional diameter and underlying aetiological factors, such as genotype or acquired disease. Screening the general population for thoracic aneurysms presents multiple resource issues including the availability of imaging modalities. Targeted screening of high-risk groups provides the only currently pragmatic solution. Opportunistic imaging through lung cancer screening programmes could pick up a proportion. Until we have a comprehensive screening programme it is incumbent on all healthcare professionals to have a low threshold for considering acute aortic pathologies when reviewing patients presenting with chest pain.

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September 2023 Br J Cardiol 2023;30:105 doi :10.5837/bjc.2023.026

Where are we getting it wrong? Prevalence and causes of unplanned SAVR in a UK regional cardiac centre

Montasir H Ali, Amir Mushtaq, Abdul R A Bakhsh, Ahmed Salem, Kawan Abdulwahid, Adrian Ionescu

Abstract

Surgical aortic valve replacement (SAVR) prolongs life and improves its quality in patients with severe aortic stenosis (AS). Unplanned SAVR is a failure of AS screening and follow-up programmes. We identified all elective, first, isolated SAVRs performed between 1 January and 31 December 2019 in a Welsh tertiary cardiac centre, and documented the clinical and echocardiographic variables, and reasons for unplanned SAVR.

Of 140 isolated SAVR, 37 (26%) were unplanned (16 female, mean age 72.3 ± 8.4 years). Twenty had been on the SAVR waiting list and had expedited operations because of concerns about the severity of the AS (12 patients), or because of acute (four patients) or chronic (four patients) left ventricular failure (LVF). Of the 17 not on the waiting list, AS was known in seven: three had acute pulmonary oedema while under follow-up with ‘moderate AS’, one had been referred but developed pulmonary oedema while waiting for a surgical outpatient appointment, one refused SAVR but was subsequently admitted with acute pulmonary oedema and accepted SAVR, one was admitted directly from home because concerns about worsening AS, and one had infective endocarditis with severe aortic regurgitation. Of 10 patients with a new diagnosis of AS, five presented with LVF, four with angina and in three there was a history of syncope (p=0.003 vs. known AS; multiple symptoms). Survival, age, Canadian Cardiovascular Society (CCS) and New York Heart Association (NYHA) class, number of risk factors, peak and mean aortic valve (AV) gradients, AV area, and stroke volume index were not different between patients who had planned versus unplanned SAVR, or with known or new AS. Patients with a new diagnosis of AS had longer pre-operative wait (22.3 ± 9.3 vs. 6.0 ± 10.3 days, p<0.001).

In conclusion, a quarter of SAVRs are unplanned and half are in patients without a prior diagnosis of AS. Unplanned SAVR is associated with prolonged length of hospital stay and with a history of syncope, but other conventional clinical and echocardiographic parameters do not differ between patients undergoing planned versus unplanned SAVR.

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