Age is not a bar to PCI: Insights from the long-term outcomes from off-site PCI in a real-world setting.

OBJECTIVES: We sought to analyze the percutaneous coronary intervention (PCI) outcomes of very elderly patients (V. Eld. group, age >80 years) and compare their outcomes to a less elderly cohort (Eld. group, age 75-80 years) traditionally reported in the literature. BACKGROUND: Limited data exist on peri-procedural and long-term outcomes following PCI in the V. Eld. (age >80 years), with under-representation of this cohort in randomized controlled trials. These patients present with advanced complex coronary disease and multiple comorbidities. METHODS: All 580 consecutive patients aged ≥75 years (age 80 ± 4.9 years, 57.4% males) undergoing PCI between April 2006 and November 2011 were included. A total of 624 consecutive lesions were identified and analyzed. All V. Eld. patients (n = 253) were subsequently selected, and their outcomes compared to Eld. patients (n = 327). Mean follow-up was 30.8 ± 2.7 months with 98% clinical follow-up achieved. RESULTS: All comparative data are expressed as (V. Eld. vs Eld.) unless otherwise specified. All-cause mortality was significantly higher in the V. Eld. group (11.9% vs 6.1%), although this did not translate into a significant difference in cardiac mortality (6.3% vs 3.7%) or major adverse cardiac and cerebrovascular events (16.2% vs 12.5%). The composite incidence of myocardial infarction (MI), stroke, definite/probable stent thrombosis, and TIMI major bleed was 4.7%, 1.4% 1.9%, and 6.4%, respectively with no significant difference between both cohorts. CONCLUSIONS: This study demonstrates an acceptable occurrence of MI, death, repeat intervention, and stent thrombosis in a high-risk group of V. Eld. patients with de novo lesions. Age alone in the absence of other non-cardiac factors should not prohibit a patient from access to PCI.

Economic analysis of the use of coronary calcium scoring as an alternative to stress ECG in the non-invasive diagnosis of coronary artery disease.

OBJECTIVE: To conduct an economic analysis (EA) of coronary calcium scoring (CCS) using a 0 score, as alternative to stress electrocardiography (sECG) in diagnosing coronary artery disease (CAD). METHOD: A decision tree was constructed to compare four strategies for investigation of suspected CAD previously assessed in the formulation of clinical guidelines for the United Kingdom (UK) to two new strategies incorporating CCS. Sensitivity (96%; 95% CI 95.4-96.4%) and specificity (40%; 95% CI 38.7-41.4%) values for CCS were derived from a meta-analysis of 10,760 patients. Other input variables were obtained from a previous EA and average prices for hospital procedures in the UK. A threshold of £30,000/Quality-adjusted Life Year (QALY) was considered cost-effective. RESULTS: Using net monetary benefit calculations, CCS-based strategies were found to be cost-effective compared to sECG equivalents at all assessed prevalence of CAD. Using CCS prior to myocardial perfusion scintigraphy (MPS) and catheter angiography (CA) was found to be cost-effective at pre-test probabilities (PTP) below 30%. CONCLUSIONS: Adoption of CCS as an alternative to sECG in investigating suspected stable angina in low PTP population (<30%) would be cost-effective. In patients with PTP of CAD >30%, proceeding to MPS or CA would be more cost-effective than performing either CCS or sECG. KEY POINTS: Coronary calcium scoring (CCS) is useful for assessing coronary artery atherosclerosis It can be performed with multi-detector CT, which is now widely available It plays a role in excluding disease in suspected stable angina Our study assesses its role in this setting as alternative to stress-ECG Adoption of CCS as an alternative to sECG could prove cost-effective.

'Biting the hand that feeds': fever and altered sensorium following a dog bite.

Capnocytophaga canimorsus infection is the most severe and rapidly progressive bacterial infection transmitted by dog bite and fortunately is very rare. The authors describe a 68-year-old gentleman who presented in an acute confusional state 2 days after having been bitten on the left hand by a dog. Despite immediate broad-spectrum intravenous antibiotics, he developed significant sequelae including disseminated intravascular coagulopathy, microvascular emboli leading to peripheral necrosis, widespread local tissue destruction and septic arthritis. Our case illustrates a life-threatening presentation of infection with C canimorsus, which is known as 'the dog bite organism'. Early diagnosis and aggressive treatment is key to survival.

Perforation of right ventricular free wall by pacemaker lead detected by multidetector computed tomography.

Pacemaker lead perforation is a recognized complication of lead implantation, particularly with active fixation leads. Multidetector computed tomography (MDCT) is emerging as the imaging modality of choice in diagnosing lead perforation, identifying associated sequelae such as pericardial effusion and planning extraction. We present a case illustrating the use of MDCT in a case of right ventricular (RV) lead perforation manifesting 5 days after cardiac resynchronization therapy pacing.

Obtaining a follow-up appointment before discharge protects against readmission for patients with acute coronary syndrome and heart failure: A quality improvement project.

BACKGROUND: Cardiac patients have a high risk of readmission following hospital discharge. The aim of our project was to examine the factors associated with increased readmission rate, with a view to eventually decrease the rate of readmission for patients admitted to the hospital due to acute coronary syndrome (ACS) or heart failure. METHODS: Patients admitted to the cardiac step-down unit at a single private hospital from 2015 to 2016 were included in our study. Interventions that were employed included: (1) improved pre-discharge follow-up appointment scheduling, (2) medication education by a pharmacist, and (3) timely discharge planning. Our primary outcome of interest was all-cause rate of hospital readmission within 30days. We conducted a multivariate analysis to determine the factors that were predictive of readmission rate. RESULTS: 578 patients were included in the study and 402 were diagnosed with ACS (69.9%). The rate of readmission was 14.2% for patients with heart failure, compared to 7.5% for patients with ACS. Following the bundle of interventions, patients were significantly more likely to receive an appointment (45.6% vs. 75.4%, p<0.001), medication education from a pharmacist (38.5% vs. 56.7%, p=0.006), and a timely discharge (47.1% vs. 76.0%, p<0.001). Readmission rate was comparable following the intervention (8.6% vs. 9.7%), but patients that received an appointment had 0.374 times lower odds of being readmitted (p=0.004). CONCLUSIONS: While our package of interventions did not lead to a significant decline in our readmission rate, patients who received a follow-up appointment prior to discharge were strongly protected against readmission.

An unusual shadow above the aortic valve.

CLINICAL INTRODUCTION: A 55-year-old West African man was referred for routine echocardiography. He was completely asymptomatic, a non-smoker, working out at the gym several times weekly. He was taking hydrochlorothiazide for hypertension.Clinical examination revealed a blood pressure of 156/74 mm Hg and systolic and diastolic murmurs suggestive of aortic insufficiency. Pulses were equal bilaterally and he had no marfanoid features or hyperelasticity. ECG showed mild left ventricular hypertrophy and chest X-ray revealed a normal cardiac shadow and mediastinum.Transthoracic echocardiography demonstrated an unusual appearance above the aortic valve (figure 1A), moderate aortic regurgitation and a shadow in the aortic arch. Transoesophageal echocardiography was performed to evaluate the dilated aorta, arch and aortic valve further (figure 1B, C). The native aortic valve was trileaflet with moderate regurgitation. CT was also performed (figure 1D). QUESTION: What is the most likely diagnosis? Acute type A aortic dissectionWilliams syndromeLoa loa worm infectionIntimo-intimal intussusceptionGiant cell aortitis.

Asystole in alternating hemiplegia with de novo ATP1A3 mutation.

Alternating hemiplegia is a rare condition presenting with episodes of hemiplegia, epileptic seizures and, at times, dysautonomic attacks. De novo ATP1A3 (Na(+)/K(+) ATPase subunit) mutations were recently found to be the most common cause. We report a patient with alternating hemiplegia with de novo ATP1A3 mutation who experienced new-onset episodes of collapse in early adulthood unrelated to seizures. An implantable cardiac loop recorder documented episodes of asystole up to 5 s long. Subsequently a permanent pacemaker was implanted. ATP1A3 heart expression may be the explanation for the association of alternating hemiplegia and asystole episodes. Alternating hemiplegia has been associated with an increased risk of sudden death and lethal cardiac arrhythmias may be causative. Patients may need referral for appropriate cardiac investigations, especially if there is a change in symptoms. This case highlights the importance of clinical vigilance in patients with alternating hemiplegia.

Dietzia species pacemaker pocket infection: an unusual organism in human infections.

An 87-year-old man presented 10 months following permanent pacemaker insertion with cellulitis-like inflammation around the impulse generator. Symptoms improved with oral flucloxacillin, but only days after stopping, the infection recurred, and he was admitted from clinic for intravenous antibiotics. Suspecting the source was likely Staphylococcal, intravenous flucloxacillin was started, and the patient's inflammatory markers responded adequately. Two samples of fluid were aspirated from the pacemaker site. These showed no bacterial growth using routine microbiological culture techniques. The samples were sent for 16S rDNA PCR and Dietzia species was detected in both samples. Dietzia species is an Actinomyces-like organism, which is not commonly associated with human infection, but is reported to have been isolated from clinical specimens and thus presumptively associated with human disease. The pacemaker was explanted and the pocket debrided with no complications. He made a full recovery after a prolonged course of flucloxacillin.

'Biting the hand that feeds': fever and altered sensorium following a dog bite.

Capnocytophaga canimorsus infection is the most severe and rapidly progressive bacterial infection transmitted by dog bite and fortunately is very rare. The authors describe a 68-year-old gentleman who presented in an acute confusional state 2 days after having been bitten on the left hand by a dog. Despite immediate broad-spectrum intravenous antibiotics, he developed significant sequelae including disseminated intravascular coagulopathy, microvascular emboli leading to peripheral necrosis, widespread local tissue destruction and septic arthritis. Our case illustrates a life-threatening presentation of infection with C. canimorsus, which is known as 'the dog bite organism'. Early diagnosis and aggressive treatment is key to survival.

Transient loss of consciousness in a patient with a Brugada like ECG.

Syncope in a patient with a Brugada syndrome channelopathy carries significant prognostic implications and warrants consideration of implantable cardioverter defibrillator (ICD) implantation. We report a case of a 62-year-old gentleman who presented with a transient loss of consciousness and an electrocardiogram (ECG) suggestive of type 1 Brugada syndrome. Further investigation revealed evidence of a silent myocardial infarction and negative ventricular tachycardia stimulation and Ajmaline testing. Careful review of the ECG's subsequently showed the type 1 pattern was present in only V1.

Aortic root abscess: multimodality imaging with computed tomography and gallium-67 citrate single-photon emission computed tomography/computed tomography hybrid imaging.

Culture negative endocarditis and aortic root abscess can prove difficult diagnostic challenges. Computed tomography can be extremely useful in this setting. We report a case of an aortic root abscess 3 months after elective aortic valve replacement in which cardiac CT and hybrid imaging with Gallium-67 SPECT complemented workup with transesophageal echocardiography in establishing the diagnosis of an abscess.

Right atrial mass in patient undergoing chemotherapy.

A 58-year-old lady, with a Hickman line in situ for chemotherapy for invasive ductal breast carcinoma, presented with fever. Blood cultures grew coagulase negative staphylococci. Transoesophageal echocardiography revealed a mass in the right atrium in the region of the Eustachian apparatus. The Hickman line was removed and the patient was treated for right-sided endocarditis. However, the mass persisted after prolonged intravenous antibiotics and a decision was made to remove it surgically. Histology revealed organised thrombus. The differential investigation of a right atrial mass in this position is discussed.

Chest pain, dyspnoea and elevated D-dimer in a recent air traveller.

A previously asymptomatic 69-year-old lady, who recently travelled on a 4 h flight, presented with acute left-sided pleuritic pain, dyspnoea and calf pain. Blood gases revealed hypoxaemia and D-dimer was significantly elevated. She also had low-grade fever, leukocytosis and a small left-sided pleural effusion on chest x-ray. The working diagnosis was pulmonary embolism and chest infection and she received low molecular weight heparin and antibiotics. A subsequent CT pulmonary angiogram ruled out pulmonary embolism but revealed an abnormal finding in the ascending aorta, suggestive of a penetrating aortic ulcer. Urgent transoesophageal echocardiography was consistent with an intramural haematoma and the patient underwent emergency aortic root replacement with imminent aortic rupture confirmed at surgery. This case highlights the fact that acute aortic syndromes may have atypical presentations and also emphasises the fact that D-dimer levels are elevated in aortic syndromes.

Primary systemic amyloidosis presenting as idiopathic inflammatory colitis.

A 75-year old-female was referred with chest pain. She was fully investigated and it was felt that her symptoms were non-cardiac. Four months later, she was seen in gastroenterology outpatients with bloody diarrhoea and abdominal pain. Colonoscopy demonstrated inflammation up to the splenic flexure and histology confirmed inflammatory colitis. Later, she developed dyspepsia and weight loss. An oesophagogastroduodenoscopy (OGD) showed Helicobacter pylori negative erosive gastritis with a benign duodenal ulcer. Whole body CT scan was normal. Ten months later, she was admitted with dyspnoea due to severe heart failure. The admission ECG had significantly changed, now showing low voltage complexes and repeat echocardiography showed restrictive cardiomyopathy. Specific congo red staining on the biopsy specimens from the previous OGD and colonoscopy confirmed amyloid deposits. Further investigations detected an underlying light chain myeloma causing systemic (AL) amyloidosis. Unfortunately, her condition deteriorated rapidly and she died shortly afterwards.

Myocardial infarction induced by spontaneous pneumothorax.

Chest pain is a very common condition. Patients may have a benign condition or present with a potentially lethal condition such as acute myocardial infarction, aortic dissection or tension pneumothorax. It is important to remember that patients may present with more than one serious pathology and that other serious conditions may potentially precipitate an acute coronary syndrome in a susceptible individual. We report the case of an elderly man with a background of chronic obstructive pulmonary disease who presented with sudden onset of chest pain and severe dyspnoea. Pneumothorax was diagnosed promptly and a chest drain inserted. His electrocardiogram (ECG) was abnormal and it is known that ECG changes do occur with spontaneous pneumothorax that have on occasions led to the incorrect diagnosis of acute myocardial infarction. Our patient had ongoing chest pain and it became evident that he also had developed an acute myocardial infarction.

Native valve infective endocarditis due to Achromobacter xylosoxidans in an apparently immunocompetent individual.

A 79-year-old woman presented with fever, lethargy and weight loss. Clinically, the patient was confused, frail and had a systolic murmur. Her temperature was 38 °C and she remained persistently febrile. Initial investigations revealed neutrophilia with an elevated C reactive protein level. Multiple peripheral blood cultures grew Achromobacter xylosoxidans, a Gram-negative rod, which is a very rare cause of infection in patients who are immunocompetent. Subsequent transoesophageal echocardiography confirmed endocarditis with obvious vegetations on the mitral valve. The patient was treated with intravenous meropenem and cotrimoxazole in line with microbiology guidance. Surgical intervention in the form of mitral valve replacement was considered, but the patient was felt to be at prohibitive risk. After 6 weeks of intravenous antibiotics, a repeat transoesophageal echocardiogram showed no improvement in the mitral valve vegetation, which had increased in size. At this stage, her clinical course was complicated by major upper gastrointestinal bleeding requiring transfusion, multiorgan failure and ultimately death.

Right atrial mass in the context of recurrent non-Hodgkin's lymphoma: atrial myxoma presenting with atrial flutter.

A case is described of a 57-year-old man with a background of low-grade bronchus-associated lymphoid tissue (BALT) non-Hodgkin's lymphoma presenting with dyspnoea and palpitations. Diagnostic work-up revealed paroxysmal atrial flutter and the presence of a mass in the right lower lobe at bronchoscopy, with histology confirming recurrent BALTOMA. Transthoracic echocardiography (TTE) revealed a mass in the right atrium. Transoesophageal echocardiography (TOE) confirmed the presence of a fleshy, mobile pedunculated right atrial mass adherent to the interatrial septum, with features more in keeping with an atrial myxoma rather than intracardiac lymphoma. He proceeded to cardiotomy and excision of the mass with histology confirming an atrial myxoma. The clinical and echocardiographic features of atrial myxomas and intracardiac lymphomas are briefly discussed.