Feasibility of 5 Fr Contralateral Radial Access for Hybrid Chronic Total Occlusion Percutaneous Coronary Intervention: Experience From a Single Tertiary Center in the United Kingdom.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid algorithm has traditionally been performed femorally using 8 Fr sheaths. Antegrade dissection and re-entry (ADR) has facilitated procedures using 6 and 7 Fr guides via the radial artery. Radial artery dysfunction and occlusion is a recognized complication preventing future radial procedures, but is significantly less common with 5 Fr sheaths. Five Fr contralateral radial access (48% left, 52% right) was used in 33 consecutive patients undergoing elective CTO-PCI in a single United Kingdom (UK) center over a 2-year period. Procedural data were recorded in the UK Hybrid CTO registry. Antegrade access was via contralateral radial in 26 cases and via femoral access in 5 cases. Single 5 Fr access was used in 2 cases treated by antegrade wire escalation. The mean J-CTO score was 2.1 ± 1.2, with an overall success rate of 91%. A retrograde approach was used in 9 cases and ADR was used in 9 cases. The mean fluoroscopy and procedure times were 45.2 ± 30.6 min and 172.5 ± 118.1 min, respectively, and the mean volume of contrast use was 218.5 ± 83.0 mL. There was 1 radial artery complication, 1 case of periprocedural myocardial infarction, and 1 case of tamponade. In this series, 5 Fr contralateral access provided adequate visualization in all cases. A 5 Fr guide provided adequate support in all retrograde cases to cross with a microcatheter after wire passage. Down-sizing contralateral access to 5 Fr routinely is feasible and may lead to a reduction in radial artery dysfunction and occlusion, as well as a reduction in the volume of contrast used.

Daily remote ischaemic conditioning following acute myocardial infarction: a randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning (rIC) is a cardioprotective tool which has shown promise in preclinical and clinical trials in the context of acute ischaemia. Repeated rIC post myocardial infarction may provide additional benefits which have not previously been tested clinically. METHODS: The trial assessed the role of daily rIC in enhancing left ventricular ejection fraction (LVEF) recovery in patients with impaired LVEF (<45%) after ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (P-PCI). Patients were recruited from four UK hospitals and randomised to receive either 4 weeks of daily rIC or sham conditioning using the autoRIC Device (CellAegis) starting on day 3 post P-PCI. The primary endpoint was the improvement in LVEF over 4 months assessed by cardiac MRI (CMR). Seventy-three patients (38 cases, 35 controls) completed the study. RESULTS: The treatment and control groups were well matched at baseline including for mean LVEF (42.8% vs 44.3% respectively, p=0.952). There was no difference in the improvement in LVEF over 4 months between the treatment and control groups (4.8%±7.8% vs 4.6%±5.9% respectively, p=0.924). No differences were seen in the secondary outcome measures including changes in infarct size and left ventricular end-diastolic and systolic volumes, major adverse cardiac and cerebral event, mean Kansas City Cardiomyopathy Questionnaire score and change in N-terminal pro-brain natriuretic peptide levels. CONCLUSIONS: Daily rIC starting on day 3 and continued for 4 weeks following successful P-PCI for STEMI did not improve LVEF as assessed by CMR after 4 months when compared with a matched control group. TRIAL REGISTRATION NUMBER: NCT0166461.

Pacemaker leads and cardiac perforation.

This case series highlights the rare but potentially life threatening complication of ventricular perforation caused by pacemaker leads and discusses appropriate investigations and management strategies.

Validity of electrocardiographic classification of left ventricular hypertrophy across adult ethnic groups with echocardiography as a standard.

AIMS: To assess the validity of the electrocardiogram (ECG) as a diagnostic tool for left ventricular hypertrophy (LVH) for different ethnic groups with echocardiography as a standard. METHODS: Systematic review of the literature using the Cornell and Sokolow-Lyon voltage criteria for LVH. RESULTS: Five studies were identified. Pooled data from these studies demonstrated low sensitivity using both types of ECG criteria for white and African-origin groups, but with slightly higher sensitivity values for the African-origin group (Cornell, 31.2%; 95% confidence interval [CI], 28%-34.8%; Sokolow-Lyon, 32.9%; 95% CI, 29.5%-36.4%) compared with the white group (Cornell, 26.5%; 95% CI, 25.2%-27.8%; Sokolow-Lyon, 18.2%; 95% CI, 17.2%-19.3%). Specificity was high using both types of criteria in the white group (Cornell, 87.4%; 95% CI, 86.4%-88.4%; Sokolow-Lyon, 88.9%; 95% CI, 88%-90%) but was much lower in the African-origin group using the Sokolow-Lyon criteria (72.1%; 95% CI, 68.7%-75.3%). Specificity was high however for the African-origin group using the Cornell criteria (86.2%, 95% CI, 83.4%-88.5%). CONCLUSIONS: Both types of criteria are more sensitive in African-origin populations. The Sokolow-Lyon criteria are less specific for LVH in people of African origin. The evidence favors the Cornell criteria in research and service contexts involving African-origin and white populations. Further research is needed to adapt ECG criteria to take into account ethnicity to a greater degree. The issue needs to be studied in a broader range of ethnic groups.