Revascularization in ischaemic heart failure with preserved ejection fraction: a nationwide cohort study.

AIMS: Despite the common occurrence of coronary artery disease (CAD) and heart failure (HF) with preserved ejection fraction (HFpEF), there is limited evidence to guide revascularization. METHODS AND RESULTS: We investigated the long-term outcomes of coronary artery bypass grafting (CABG) in patients with HF and significant CAD across the spectrum of ejection fraction, using a large national cohort of patients from the Veteran Affairs (VA) Medical Centers in the US. Patients with HF were stratified into groups, HFpEF, HF with mid-range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF) and compared to patients with no preoperative HF. We analysed 10 396 patients. Despite an increased hazard in the first year following revascularization, the long-term survival (median follow-up 6.6 years; interquartile range 3.7-10.1) of HFpEF post-CABG was similar to controls (hazard ratio 0.85, 95% confidence interval 0.68-1.06), but survival progressively declined with HFmrEF and HFrEF. Similar trends were seen with recurrent HF hospitalization with lower risk with baseline HFpEF (43.9 ± 6.9/100 patient-years) compared to HFmrEF (65.9 ± 3.8/100 patient-years) and HFrEF (93.4 ± 4.8/100 patient-years). Although HFpEF patients had lower mortality and HF hospitalization post-CABG compared to patients with a lower ejection fraction, they experienced the highest rates of future myocardial infarction. CONCLUSION: Although HFpEF patients with CAD have greater short-term risk post-CABG, their long-term survival is comparable to controls. However, they are at increased risk for HF hospitalizations and myocardial infarction. These data support the safety of CABG in HFpEF patients and suggest continuum of mortality risk for ischaemic HF when stratified by baseline ejection fraction before revascularization.

Development and Validation of a Teaching Module for Echocardiographic Scoring of Rheumatic Mitral Stenosis.

BACKGROUND: The Wilkins score and commissural calcification scores predict outcomes after percutaneous balloon mitral valvuloplasty. However, many cardiologists are inadequately trained in their application-both in the United States where the incidence of rheumatic heart disease has fallen and in rheumatic heart disease endemic countries where training infrastructure is weak. OBJECTIVES: This study sought to develop a computer-based educational module teaching 2 scoring systems for rheumatic mitral stenosis and to validate the module among cardiology fellows in the United States and Uganda. METHODS: We developed a module organized into 3 sets of 10 echocardiograms each. The module was completed by 13 cardiology fellows from 2 academic centers in the United States and 1 in Uganda. Subject answers were compared with a score assigned by 2 experts in echocardiography. The primary outcome was change in subjects' accuracy from set 1 to set 3, measured by mean absolute deviation from expert scores. Secondary outcomes included change in interoperator variability and individual subject bias from set 1 to set 3. RESULTS: The mean absolute deviations from expert scores in sets 1 and 3 were 2.09 and 1.82 for the Wilkins score (possible score range 0 to 16) and 1.13 and 0.94 for the commissural calcification score (possible score range 0 to 4). The change from set 1 to set 3 was statistically significant only for 1 of the Wilkins component scores (leaflet calcification, p < 0.001.) No change was seen in the interoperator variability. Individual subject bias in assigning the total Wilkins score was reduced from set 1 to set 3. CONCLUSIONS: Use of this module has the potential to enhance the training of cardiologists in the echocardiographic assessment of mitral stenosis. Modified versions of this module or similar ones should be tested in targeted populations of cardiology trainees with the most exposure to mitral stenosis interventions.

Chest pain associated with moderator band pacing.

A 65-year-old man was evaluated for chronic chest pain that had been present for 8 years after placement of a dual-chamber implantable cardioverter-defibrillator to treat inducible ventricular tachycardia. Previous coronary angiography had revealed nonobstructive coronary artery disease and a left ventricular ejection fraction of 0.45 to 0.50, consistent with mild idiopathic nonischemic cardiomyopathy. Evaluation with chest radiography and transthoracic echocardiography showed the implantable cardioverter-defibrillator lead to be embedded within the right ventricle at the moderator band, which had mild calcification. Treatment included extraction of the dual-coil lead and placement of a new single-coil right ventricular lead at the mid septum. The patient had complete relief of symptoms after the procedure. This case shows that chest pain can be associated with the placement of a right ventricular implantable cardioverter-defibrillator lead in the moderator band and that symptomatic relief can occur after percutaneous lead extraction and the implantation of a new right ventricular lead to the mid septal region.

Small bowel capsule endoscopy in patients with cardiac pacemakers and implantable cardioverter defibrillators: Outcome analysis using telemetry review.

AIM: To determine if there were any interactions between cardiac devices and small bowel capsules secondary to electromagnetic interference (EMI) in patients who have undergone small bowel capsule endoscopy (SBCE). METHODS: Authors conducted a chart review of 20 patients with a cardiac pacemaker (CP) or implantable cardioverter defibrillator (ICD) who underwent continuous electrocardiographic monitoring during their SBCE from 2003-2008. authors searched for unexplained electrocardiogram (ECG) findings, changes in CP and ICD set parameters, any abnormality in transmitted capsule data, and adverse clinical events. RESULTS: There were no adverse events or hemodynamically significant arrhythmias reported. CP and ICD set parameters were preserved. The majority of ECG abnormalities were also found in pre- or post- SBCE ECG tracings and the CP behavior during arrhythmias appeared appropriate. Two patients seemed to have episodes of undersensing by the CP. However, similar findings were documented in ECGs taken outside the time frame of the SBCE. One patient was observed to have a low signal encountered from the capsule resulting in lack of localization, but no images were lost. CONCLUSION: Capsule-induced EMI remains a possibility but is unlikely to be clinically important. CP-induced interference of SBCE is also possible, but is infrequent and does not result in loss of images transmitted by the capsule.

A case report of vinorelbine monotherapy-related acute bronchospasm and non-ST elevation acute coronary syndrome.

Vinorelbine is a semi-synthetic vinca-alkaloid with a broad spectrum anti-tumor activity. The dose-limiting toxicity of vinorelbine is neutropenia and leucopenia which is seen in majority of the patients. The previous case reports on the cardiac toxicity occurred mainly in combination therapy of vinorelbine with cisplatin or carboplatin. We offer evidence that acute coronary syndrome and resultant diastolic heart failure developed as a result of acute bronchospasm due to intravenous vinorelbine monotherapy.