Use of the Sheathless Eaucath Is an Effective Strategy to Overcome Resistant Severe Radial Spasm.

Objectives: We aimed to assess the effectiveness of the sheathless Eaucath guiding catheter (SEGC) in overcoming severe spasm. Background: Radial spasm is a frequent challenge in transradial access (TRA) and can be difficult to manage. Methods: We performed a prospective observational study of 1000 consecutive patients undergoing coronary angiography with or without percutaneous coronary intervention. Patients with primary transfemoral access (TFA) or primary use of a sheathless guide catheter were excluded. Patients who developed angiographically confirmed severe spasm were treated with further sedation and vasodilators. If the conventional catheter would still not advance, it was exchanged for a SEGC. The primary endpoint was the successful passage of the SEGC through the radial with successful engagement of the coronary artery in patients with resistant severe spasm. Results: Primary TFA access was used in 58 (5.8%) and primary radial access with a SEGC in 44 (4.4%) patients. Of the remaining 898 patients, 888 (98.9%) had a radial sheath successfully inserted. Of these, 49 (5.5%) developed severe radial spasm with inability to advance the catheter. Following treatment with additional sedation and vasodilators, the severe spasm resolved in 5 (10.2%) patients. Passage of a SEGC was attempted in the remaining 44 patients with resistant severe spasm. Passage of the SEGC and engagement of coronary arteries were successful in all cases. There were no complications related to use of the SEGC. Conclusions: Our findings suggest that use of the SEGC for resistant severe spasm is highly effective, safe, and may reduce the need for conversion to TFA.

Cholesterol treatment in patients with acute coronary syndromes: does stating a target improve management?

AIM: Previous research in New Zealand has demonstrated high rates of statin prescription in patients with acute coronary syndromes (ACS), but how widely a treat to target approach is adopted is unclear. METHODS: We retrospectively examined cholesterol management in 100 consecutive patients admitted with confirmed ACS. The primary end point was reaching low-density lipoprotein-cholesterol (LDL-C) target of <1.8 mmol/L within six months. Following this a change in practice was implemented, documenting patients' current LDL-C and the LDL-C target of <1.8mmol/L in the discharge summary. A prompt to arrange a follow-up lipid test was also added to the discharge process. A second cohort of 100 patients with confirmed ACS was prospectively examined and the same endpoints reassessed. RESULTS: Lipid testing increased post intervention, both in-hospital (70% vs 98%, P<0.001) and during outpatient follow-up (60% vs 82%, P=0.01). In the intervention group, the primary outcome was achieved in more frequently (47% vs. 64% P=0.02) and follow-up LDL-C was lower (2.01.1 mmol/L vs 1.730.77 mmol/L, P=0.002). Non-statin cholesterol medication was rarely used. CONCLUSION: At baseline a treat to target approach was infrequent. Stating a target in discharge documentation was associated with significant improvements in lipid testing and patients achieving LDL-C targets.

First Experience Using the Sheathless Hyperion Guiding Catheter System Designed for Direct Insertion.

Background: Use of sheathless guiding catheters for transradial PCI has the potential to reduce radial trauma and allow use of larger catheters to facilitate complex PCI. The new sheathless Hyperion guide catheter (SHGC) system allows direct insertion of the SHGC using a 20G needle or IV cannula, a 0.025″ Silverway wire, and a dilator. We report the first clinical experience. Methods: We prospectively evaluated outcomes in consecutive patients undergoing PCI using radial access and the SHGC catheter at our institution between June 2020 and June 2021. There were no exclusion criteria. Results: The study included 120 patients, mean age 67 ± 12.6 years, 79.2% male. Insertion of a SHGC was attempted in 128 radial arteries and was successful in all cases. The SHGC was inserted directly in 74 (57.8%), following initial sheath removal in 24 (20.5%) and through the initial sheath in 30 (26.2%). Coronary artery engagement with a SHGC was successful in 126 (98.4%). A total of 150 lesions were treated, the majority being complex: 16.1% chronic total occlusions, 37.1% calcified, 30.6% bifurcation, and 43.5% long lesions. Angiographic success was achieved in 149 (99.2%) lesions. Periprocedural myocardial infarction occurred in 5 (4.2%) patients. There was no in-hospital urgent revascularisation or death and no major bleeding or vascular complications. Occlusion occurred in 2 (1.6%) radial arteries. Conclusion: This first clinical experience with the SHGC demonstrates that direct insertion is safe and effective and that the use of the SHGC allows complex interventions to be undertaken transradially with a high success rate.

An unusual case of spontaneous obstructive thrombus complicating rheumatic mitral stenosis.

We describe a rare case of native mitral valve thrombosis in a patient with rheumatic mitral valve disease without predisposing thrombophilia. The patient presented in heart failure with a new diagnosis of mitral stenosis. After a period of intravenous diuresis there was a sudden cardiovascular collapse. Trans-oesophageal echocardiogram identified an atrial mass obstructing the mitral valve. The patient proceeded to emergent mitral valve replacement. A coagulopathy was identified in the form of thrombus-induced disseminated intravascular coagulation (DIC). Mitral valve thrombosis is a rare cause of morbidity and mortality in rheumatic heart disease and is not readily identifiable on transthoracic echocardiography.

Noninvasive Myocardial Work Index: Characterizing the Normal and Ischemic Response to Exercise.

BACKGROUND: Myocardial work index (MWI) and work efficiency are new parameters for assessing left ventricular function. We aim to characterize the normal response to exercise in a mixed population and determine whether MWI can identify patients with inducible ischemia. METHODS: Patients were retrospectively enrolled from an existing database of exercise stress echocardiography. Inclusion criteria were a clinical indication of possible ischemia and technical suitability to calculate MWI. Exclusion criteria were abnormal baseline left ventricular function or inadequate image quality. Echocardiograms positive for ischemia were defined by independent visual assessment and compared with angiographic findings where available. Myocardial work index was determined using a proprietary algorithm and efficiency calculated as constructive work divided by the sum of constructive and wasted work. RESULTS: A total of 177 patients met inclusion criteria; 117 were excluded, leaving 40 normal and 20 positive tests. During normal exercise, global MWI increased 54% (from 2,296 to 3,523 mm Hg%) and efficiency remained at 96%. However, in patients with inducible ischemia, MWI decreased in affected segments, global MWI did not increase (2,069-2,070 mm Hg%), and global efficiency fell from 93% to 87%. The receiver operating characteristic curve for MWI had an area under the curve of 0.94. CONCLUSIONS: During normal exercise, MWI increases and efficiency remains unchanged. However, during exercise-induced ischemia, MWI paradoxically decreases in affected segments, while globally MWI fails to increase and efficiency decreases. We have demonstrated that MWI can be applied to stress echocardiography to identify ischemia, but its utility remains uncertain. Further research that makes comparisons with an objective measure of functional ischemia is needed.

Idarucizumab for dabigatran reversal: the first 6 months in a tertiary centre.

This retrospective audit reviews patients on dabigatran presenting with bleeding or requiring urgent surgery in the Wellington region, whether they received idarucizumab appropriately and the outcome of episodes. Eighty patients were identified with bleeding or need for urgent surgery, 14 of which received idarucizumab. In patients who received idarucizumab, use was safe, effective and overall appropriate. Idarucizumab was underutilised with patients who could have benefited not receiving it; however, some patients who were treated may not have required it. Increased awareness and use may improve outcomes.

Outcomes of surgical ablation for atrial fibrillation: a 10-year experience.

AIM: Surgical ablation for atrial fibrillation has been performed at Wellington hospital for 10 years. This audit aims to evaluate the outcomes from surgical intervention for atrial fibrillation and identify variables affecting clinical results. METHOD: A retrospective audit of clinical outcomes was performed including all patients who had received surgical intervention for atrial fibrillation from 2004 to 2013. RESULTS: Forty-seven patients who underwent surgical intervention for atrial fibrillation were identified and reviewed. There were no deaths prior to discharge. At 6 months, 81.4% of patients were in sinus rhythm, this dropped to 58.7% at late follow-up (average of 48 months). Procedure type had a statistically significant effect on outcome. Over 288 patient-years of follow-up, 2 strokes and 7 deaths occurred. CONCLUSIONS: The surgical treatment of atrial arrhythmias in Wellington hospital is a safe and effective management option, although the antiarrhythmic effects do appear to diminish with time. There were lower rates of mortality and stroke long-term than would be expected with simple anticoagulation. It is important that the formal Cox-Maze procedure lesion set is performed to maximise the surgical interventions effectiveness. Atrial size predicts success, and should be considered in patient selection.

Temporal pattern analysis and its applicability in sport: an explanation and exemplar data.

Quantitative analysis of sports performance has been shown to produce information that coaches can use within the coaching process to enhance performance. Traditional methods for quantifying sport performances are limited in their capacity to describe the complex interactions of events that occur within a performance over time. In this paper, we outline a new approach to the analysis of time-based event records and real-time behaviour records on sport performance known as T-pattern detection. The relevant elements of the T-pattern detection process are explained and exemplar data from the analysis of 13 soccer matches are presented to highlight the potential of this form of analysis. The results from soccer suggest that it is possible to identify new profiles for both individuals and teams based on the analysis of temporal behavioural patterns detected within the performances.