Time to TAVI: streamlining the pathway to treatment.

INTRODUCTION: Severe aortic stenosis is a major cause of morbidity and mortality. The existing treatment pathway for transcatheter aortic valve implantation (TAVI) traditionally relies on tertiary Heart Valve Centre workup. However, this has been associated with delays to treatment, in breach of British Cardiovascular Intervention Society targets. A novel pathway with emphasis on comprehensive patient workup at a local centre, alongside close collaboration with a Heart Valve Centre, may help reduce the time to TAVI. METHODS: The centre performing local workup implemented a novel TAVI referral pathway. Data were collected retrospectively for all outpatients referred for consideration of TAVI to a Heart Valve Centre from November 2020 to November 2021. The main outcome of time to TAVI was calculated as the time from Heart Valve Centre referral to TAVI, or alternative intervention, expressed in days. For the centre performing local workup, referral was defined as the date of multidisciplinary team discussion. For this centre, a total pathway time from echocardiographic diagnosis to TAVI was also evaluated. A secondary outcome of the proportion of referrals proceeding to TAVI at the Heart Valve Centre was analysed. RESULTS: Mean±SD time from referral to TAVI was significantly lower at the centre performing local workup, when compared with centres with traditional referral pathways (32.4±64 to 126±257 days, p<0.00001). The total pathway time from echocardiographic diagnosis to TAVI for the centre performing local workup was 89.9±67.6 days, which was also significantly shorter than referral to TAVI time from all other centres (p<0.003). Centres without local workup had a significantly lower percentage of patients accepted for TAVI (49.5% vs 97.8%, p<0.00001). DISCUSSION: A novel TAVI pathway with emphasis on local workup within a non-surgical centre significantly reduced both the time to TAVI and rejection rates from a Heart Valve Centre. If adopted across the other centres, this approach may help improve access to TAVI.

Pulmonary embolism with coexistent incidental pulmonary cement embolism post vertebroplasty.

A 46-year-old woman presented with sudden onset of shortness of breath and pleuritic chest pain. A CT pulmonary angiogram identified a 5 cm cement pulmonary embolus within the right main pulmonary artery with a surrounding thrombus. She had undergone an L4 vertebroplasty 3 years prior to presentation for a benign lytic lesion. Cement embolus is a known complication of cement vertebroplasty with incidence rates of approximately 0.9%. Management is usually conservative and associated morbidity and mortality rates are low. It is not known whether a previous cement embolus could provide a nidus for thrombus formation.

A fateful kiss: the use of CT coronary angiogram in the diagnosis of non-cardiac chest pathology.

A 34-year-old dental nurse presented with a 2-day history of retrosternal chest pain that was constant and 'burning' in nature. She was otherwise fit and well, no significant prior medical history and no ischaemic heart disease risk factors. Clinical examination was entirely normal apart from pyrexia of 38.3°C. Admission ECG showed ST depression in the inferior and anterolateral leads suggestive of myocardial ischaemia, consequently a CT coronary angiogram (CTCA) was performed. This showed normal coronary arteries, incidental distal oesophageal thickening was seen. Further history taking revealed that her youngest daughter had recently suffered from cold sores. The patient went on to have a diagnostic procedure, an oesophagogastroduodenoscopy. Biopsies confirmed acute oesophagitis with features suggestive of herpes virus infection. The patient responded promptly to oral acyclovir. This case highlights the value of CT coronary angiogram in identifying non-cardiac pathology in patients with a low pretest probability of coronary artery disease.

Conservative treatment of a female collegiate volleyball player with costochondritis.

OBJECTIVE: This study was conducted to discuss the conservative care used to treat a female collegiate volleyball player with acute costochondritis. CLINICAL FEATURES: A 21-year-old collegiate volleyball player had right anterior chest pain and midthoracic stiffness of 8 months duration. INTERVENTION AND OUTCOME: High-velocity, low-amplitude manipulation was performed to the associated hypokinetic costovertebral, costotransverse, and intervertebral zygapophyseal thoracic joints. Instrument-assisted soft tissue mobilization was performed by using the Graston technique. Pain levels improved on numeric pain scale, as did functional status identified on Dallas Pain Questionnaire and Functional Rating Index. CONCLUSION: This athlete seemed to respond positively to manipulation, soft tissue mobilization, and taping.