Heart valve service provision in the United Kingdom and the effect of the COVID 19 pandemic; improved but must do better. A British Heart Valve Society national survey.

BACKGROUND: Outpatient care for patients with heart valve disease (HVD) is best provided by valve clinics delivered by specialists. Modern day practice in the United Kingdom (UK) is currently poorly understood and has not been evaluated for nearly a decade. Furthermore, the COVID 19 pandemic changed the management of many chronic diseases, and how this has impacted patients with heart valve disease is unclear. METHODS: A British Heart Valve Society survey was sent to 161 hospitals throughout the UK. RESULTS: There was a general valve clinic in 46 of the 68 hospitals (68%), in 19 of 23 Heart Centres (83%) and 29 of 45 DGHs (64%). Across all settings, 3824 new patients and 17,980 follow up patients were seen in valve clinics per annum. The mean number of patients per hospital were 197 (median 150, range 48-550) for new patients and 532 (median 400, range 150-2000) for follow up. On the day echocardiography was available in 55% of valve clinics. In patients with severe HVD, serum brain natriuretic peptide (BNP) was measured routinely in 39% of clinics and exercise testing routinely performed in 49% of clinics. A patient helpline was available in 27% of clinics. 78% of centres with a valve clinic had a valve multidisciplinary team meeting (MDT). 45% centres had an MDT co-ordinator and MDT outcomes were recorded on a database in 64%. COVID-19 had a major impact on valve services in 54 (95%) hospitals. CONCLUSIONS: There has been an increase in the number of valve clinics since 2015 from 21 to 68% but the penetration is still well short of the expected 100%, meaning that valve clinics only serve a small proportion of patients requiring surveillance for HVD. COVID-19 had a major impact on the care of patients with HVD in the majority of UK centres surveyed.

Impacts of valve intervention on the Functional REServe of the Heart: The FRESH-valve pilot study.

PURPOSE: Severe valve lesions require corrective interventions to avoid progression to heart failure (HF) and premature demise. We tested the hypothesis that despite operative risks, corrective valvular interventions will lead to significant improvements in overall cardiac pump function, especially before the onset of cardiac decompensation. METHODS: We compared the cardiopulmonary exercise performance and non-invasive haemodynamics of 46 consecutive patients with severe valvular disease before and after valvular intervention with reference to 101 healthy male and 139 female controls without cardiovascular disease. Cardiac and physical functional reserves were measured with standard respiratory gas analyses and CO2 rebreathing to measure cardiac output non-invasively during peak treadmill exercise. Data are given as mean ± SD and statistical significance accepted at P<0.05. RESULTS: The entire patient cohort showed no significant improvement in peak O2 consumption (V˙O2max, P=0.74) or in peak cardiac power (CPOmax, P=0.34) after valvular intervention, but we found instead a dichotomous outcome depending on preoperative cardiac function: (i) the pre-operative cardiac decompensatory subgroup (LoW, n=26) showed increased CPOmax (2.63 ± 0.67 to 3.42 ± 0.98 W, P<0.0001) and V˙O2max (1.38 ± 0.55 to 1.56 ± 0.59 L·min(-1), P<0.01); and (ii) the pre-operative non-decompensatory subgroup (HiW) showed reduced CPOmax (4.58 ± 0.96 to 3.84 ± 0.92 W, P<0.001) and V˙O2max (2.29 ± 0.72 to 1.97 ± 0.75 L·min(-1), P<0.01). Changes in NYHA class were found to be discrepant with these objective measurements. CONCLUSION: This investigation found an unexpected finding that valvular interventions performed in routine clinical practice do not consistently improve cardiac function, especially in those without pre-operative cardiac decompensation. Assessing cardiac functional gains would open up new avenues for future trials of valvular interventions.

Development Of A Novel Scoring System That Determines The Success Of Atrial Fibrillation Ablation As Part Of Cardiac Surgery.

BACKGROUND: Radiofrequency ablation therapy for the treatment of atrial fibrillation (AF) can be performed as a concomitant procedure alongside cardiac surgery, but carries the risks of increased bypass time and damage to the sinoatrial node. This study aims to assess the efficacy of concomitant surgical AF ablation and develop a novel scoring system to predict post-procedural return to sinus rhythm. METHODS: A review of the Leeds General Infirmary surgical database was conducted to list all patients who had undergone valvular or coronary bypass surgery with concomitant AF ablation between Jan 2012 - Dec 2013 (n = 76). Follow-up was obtained retrospectively using patient notes, clinic letters and echocardiographic data. Primary outcome was freedom from AF at median follow up (383 days). A novel scoring system was created through analysis of previous literature and evaluated using a receiver operating characteristic (ROC) curve. RESULTS: At median follow up 50.9% of patients undergoing the procedure were free from AF. The novel scoring system was shown to adequately predict post-procedural return to sinus rhythm (ROC AUC = 0.7708). CONCLUSION: A novel scoring system was shown to predict procedural success in patients undergoing concomitant AF ablation alongside cardiac surgery. These results can be further validated using larger patient cohorts.

CRT improves the exercise capacity and functional reserve of the failing heart through enhancing the cardiac flow- and pressure-generating capacity.

BACKGROUND: While information on how cardiac resynchronisation therapy (CRT) affects cardiac performance at rest is readily available, the mechanisms whereby CRT alters cardiac function during maximal exercise are unclear. AIMS: We examined the medium-term effects of CRT on cardiac and physical functional reserve of patients with severe heart failure (CHF) and prolonged QRS duration. METHODS: Seventeen consecutive patients with severe CHF (NYHA III-IV) and widened QRS underwent maximal cardiopulmonary exercise testing with non-invasive central haemodynamic measurements before and 6-8 weeks after CRT pacemaker implantation. RESULTS: After CRT there were significant increases in exercise cardiac output by 19.3% (P=0.0048) from 9.5+/-3.4 l min(-1), peak mean arterial blood pressure by 14.1% (P=0.0001) from 91.3+/-13.6 mm Hg, and peak cardiac power output by 37.2% (P=0.0008) from 1.92+/-0.74 W. There were no significant changes in these variables at rest. Exercise duration (+42.3%, P=0.0002), NYHA functional class (P=0.0001) and SF-36 symptom score (P=0.0006) were also significantly improved. Powerful surrogate indicators of prognosis were also significantly improved with CRT: peak O(2) consumption (+20.9%, P=0.0007), VE/VCO(2) slope (-20.0%, P=0.005) and circulatory power (+42.0%, P=0.0012). CONCLUSION: In this cohort of patients, post-implant CRT significantly improved the flow-, pressure- and power-generating capacity of the failing hearts. This may be causally related to the improvements observed in exercise capacity, functional class and symptom scores.

The benefits of valsartan in the treatment of heart failure: results from Val-HeFT.

Angiotensin II receptor blockers (ARBs) are the most recent class of anti-hypertensive drug to enter clinical use for chronic heart failure (CHF). In the landmark Valsartan Heart Failure Trial (Val-HeFT), valsartan reduced the risk of the combined endpoint of all-cause mortality and morbidity by 13.2% over a 2-year follow-up. Although it significantly improved a pre-specified primary endpoint, it did not improve the endpoint of all-cause mortality. Valsartan administered to patients not receiving angiotensin-converting enzyme inhibitors (ACEI) at baseline reduced the endpoint of all-cause mortality by 33% and the combined endpoint of mortality and morbidity by 44%, compared with placebo. Based on these findings, valsartan became the first ARB to be approved by the US Food and Drug Administration for the treatment of New York Heart Association class II-IV HF in patients who are intolerant of ACEIs. This review provides a summary of the key Val-HeFT results and their implications in the treatment of CHF patients.

Sleep . 3: Clinical presentation and diagnosis of the obstructive sleep apnoea hypopnoea syndrome.

Patients with OSAHS may present to a sleep clinic or to other specialists with symptoms that are not immediately attributable to the condition. The diagnostic methods available are reviewed.

A novel SP-1 site in the human interleukin-1 beta promoter confers preferential transcriptional activity in keratinocytes.

To investigate the mechanisms of transcriptional activation of interleukin-1beta (IL-1beta) in non-monocytic cells, we constructed a series of reporter plasmids with the bacterial chloramphenicol acetyltransferase gene linked to various parts of the human IL-1beta promoter and performed transient transfection experiments. We identified a promoter segment that activates transcription most efficiently in keratinocytes. Electrophoretic mobility shift assays (EMSA) with a 43-mer oligonucleotide derived from the functionally identified cis-acting element revealed specific complexes. By competition analysis with transcription factor consensus sequence oligonucleotides and by immunosupershift, transcription factor SP-1 or a closely related protein was shown to bind to this regulatory element. The closest match to the known SP-1 consensus sequence within the respective region is a TCCCCTCCCCT motif. Mutation of this motif almost completely, and specifically, abolished the binding of two low-mobility complexes and led to a 95% decrease of constitutive transcriptional activation of a reporter construct IL-1beta (-170/+108). Likewise, activation of this reporter construct by tumor necrosis factor-alpha depended on the SP-1 site. These observations suggest that a so-far-unrecognized SP-1 site in the human IL-1beta promoter may participate in the transcriptional regulation of this gene in keratinocytes.