Sex-based treatment and outcomes for coronary bifurcation stenting: A report from the e-ULTIMASTER registry.

BACKGROUND: Percutaneous coronary intervention (PCI) for bifurcation lesions can be technically challenging and is associated with higher risk. There is little data on sex-based differences in strategy and outcomes in bifurcation PCI. AIMS: We sought to assess whether differences exist between women and men in the treatment and outcomes of bifurcation PCI. METHODS: We collected data on 4006 patients undergoing bifurcation PCI, from the e-ULTIMASTER study, a prospective, multicentre study enrolling patients from 2014 to 2018. We divided the bifurcation cohort according to sex, with 1-year follow-up of outcomes (target lesion failure [TLF], target vessel failure [TVF], and patient-oriented composite endpoint [POCE]). FINDINGS: Women were older (69.2 ± 10.9 years vs. 64.4 ± 11.0 years), with a greater burden of cardiovascular comorbidities. For true and non-true bifurcation lesions, women and men were equally likely to undergo a single stent approach (true: 63.2% vs. 63.6%, p = 0.79, non-true: 95.4% vs. 94.3%, p = 0.32), with similar rates of final kissing balloon (FKB) (37.2% vs. 35.5%, p = 0.36) and proximal optimization (POT) (34.4% vs. 34.2%, p = 0.93) in cases where two stents were used. Lastly, after propensity score matching, there was no difference between women and men in the incidence of the composite endpoints of TLF (5.5% vs. 5.2%, RR 1.05 [95% CI 0.77-1.44], p = 0.75), TVF (6.2% vs. 6.3%, RR 0.99 [95% CI 0.74-1.32], p = 0.96), and POCE (9.9% vs. 9.5%, RR 1.05 [95% CI 0.83-1.31], p = 0.70). CONCLUSION: In this contemporary, real-world study of bifurcation PCI, we report no difference in stent strategy between women and men, with similar outcomes at 1-year.

What do we mean by complex percutaneous coronary intervention? An assessment of agreement amongst interventional cardiologists for defining complexity.

BACKGROUND: In the last decade, percutaneous coronary intervention (PCI) has evolved toward the treatment of complex disease in patients with multiple comorbidities. Whilst there are several definitions of complexity, it is unclear whether there is agreement between cardiologists in classifying complexity of cases. Inconsistent identification of complex PCI can lead to significant variation in clinical decision-making. AIM: This study aimed to determine the inter-rater agreement in rating the complexity and risk of PCI procedures. METHOD: An online survey was designed and disseminated amongst interventional cardiologists by the European Association of Percutaneous Cardiovascular Intervention (EAPCI) board. The survey presented four patient vignettes, with study participants assessing these cases to classify their complexity. RESULTS: From 215 respondents, there was poor inter-rater agreement in classifying the complexity level (k = 0.1) and a fair agreement (k = 0.31) in classifying the risk level. The experience level of participants did not show any significant impact on the inter-rater agreement of rating the complexity level and the risk level. There was good level of agreement between participants in terms of rating 26 factors for classifying complex PCI. The top five factors were (1) impaired left ventricular function, (2) concomitant severe aortic stenosis, (3) last remaining vessel PCI, (4) requirement fort calcium modification and (5) significant renal impairment. CONCLUSION: Agreement among cardiologists in classifying complexity of PCI is poor, which may lead to suboptimal clinical decision-making, procedural planning as well as long-term management. Consensus is needed to define complex PCI, and this requires clear criteria incorporating both lesion and patient characteristics.

COVID-19 and its cardiovascular effects: a systematic review of prevalence studies.

BACKGROUND: A small minority of people with coronavirus disease 2019 (COVID-19) develop a severe illness, characterised by inflammation, microvascular damage and coagulopathy, potentially leading to myocardial injury, venous thromboembolism (VTE) and arterial occlusive events. People with risk factors for or pre-existing cardiovascular disease may be at greater risk. OBJECTIVES: To assess the prevalence of pre-existing cardiovascular comorbidities associated with suspected or confirmed cases of COVID-19 in a variety of settings, including the community, care homes and hospitals. We also assessed the nature and rate of subsequent cardiovascular complications and clinical events in people with suspected or confirmed COVID-19. SEARCH METHODS: We conducted an electronic search from December 2019 to 24 July 2020 in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, covid-19.cochrane.org, ClinicalTrials.gov and EU Clinical Trial Register. SELECTION CRITERIA: We included prospective and retrospective cohort studies, controlled before-and-after, case-control and cross-sectional studies, and randomised controlled trials (RCTs). We analysed controlled trials as cohorts, disregarding treatment allocation. We only included peer-reviewed studies with 100 or more participants, and excluded articles not written in English or only published in pre-print servers. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results and extracted data. Given substantial variation in study designs, reported outcomes and outcome metrics, we undertook a narrative synthesis of data, without conducting a meta-analysis. We critically appraised all included studies using the Joanna Briggs Institute (JBI) checklist for prevalence studies and the JBI checklist for case series. MAIN RESULTS: We included 220 studies. Most of the studies originated from China (47.7%) or the USA (20.9%); 9.5% were from Italy. A large proportion of the studies were retrospective (89.5%), but three (1.4%) were RCTs and 20 (9.1%) were prospective. Using JBI's critical appraisal checklist tool for prevalence studies, 75 studies attained a full score of 9, 57 studies a score of 8, 31 studies a score of 7, 5 studies a score of 6, three studies a score of 5 and one a score of 3; using JBI's checklist tool for case series, 30 studies received a full score of 10, six studies a score of 9, 11 studies a score of 8, and one study a score of 5 We found that hypertension (189 studies, n = 174,414, weighted mean prevalence (WMP): 36.1%), diabetes (197 studies, n = 569,188, WMP: 22.1%) and ischaemic heart disease (94 studies, n = 100,765, WMP: 10.5%)  are highly prevalent in people hospitalised with COVID-19, and are associated with an increased risk of death. In those admitted to hospital, biomarkers of cardiac stress or injury are often abnormal, and the incidence of a wide range of cardiovascular complications is substantial, particularly arrhythmias (22 studies, n = 13,115, weighted mean incidence (WMI) 9.3%), heart failure (20 studies, n = 29,317, WMI: 6.8%) and thrombotic complications (VTE: 16 studies, n = 7700, WMI: 7.4%). AUTHORS' CONCLUSIONS: This systematic literature review indicates that cardiometabolic comorbidities are common in people who are hospitalised with a COVID-19 infection, and cardiovascular complications are frequent. We plan to update this review and to conduct a formal meta-analysis of outcomes based on a more homogeneous selected subsample of high-certainty studies.

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission.

BACKGROUND: In recent years, there has been a growing interest in outcomes of patients with acute myocardial infarction (AMI) using large administrative datasets. The present study was designed to compare the characteristics, management strategies and acute outcomes between patients with primary and secondary AMI diagnoses in a national cohort of patients. METHODS: All hospitalisations of adults (≥18 years) with a discharge diagnosis of AMI in the US National Inpatient Sample from January 2004 to September 2015 were included, stratified by primary or secondary AMI. The International Classification of Diseases, ninth revision and Clinical Classification Software codes were used to identify patient comorbidities, procedures and clinical outcomes. RESULTS: A total of 10 864 598 weighted AMI hospitalisations were analysed, of which 7 186 261 (66.1%) were primary AMIs and 3 678 337 (33.9%) were secondary AMI. Patients with primary AMI diagnoses were younger (median 68 vs 74 years, P < .001) and less likely to be female (39.6% vs 48.5%, P < .001). Secondary AMI was associated with lower odds of receipt of coronary angiography (aOR 0.19; 95%CI 0.18-0.19) and percutaneous coronary intervention (0.24; 0.23-0.24). Secondary AMI was associated with increased odds of MACCE (1.73; 1.73-1.74), mortality (1.71; 1.70-1.72), major bleeding (1.64; 1.62-1.65), cardiac complications (1.69; 1.65-1.73) and stroke (1.68; 1.67-1.70) (P < .001 for all). CONCLUSIONS: Secondary AMI diagnoses account for one-third of AMI admissions. Patients with secondary AMI are older, less likely to receive invasive care and have worse outcomes than patients with a primary diagnosis code of AMI. Future studies should consider both primary and secondary AMI diagnoses codes in order to accurately inform clinical decision-making and health planning.

Acute coronary syndromes in patients with cancer: Recent advances.

Coronary artery disease is presently one of the leading causes of death among cancer survivors. Due to the number of cancer survivors projected to reach 26 million by 2040 managing coronary disease in this population presents a unique challenge. Cancer patients face an elevated risk of atherosclerotic disease due to shared cardiovascular risk factors and the cardiotoxic effects of cancer therapies, predisposing them to acute coronary syndromes. Challenges in treating cancer patients presenting with acute coronary syndromes include atypical presentations, obscured symptoms, and the impact of cancer-related processes on traditional biomarkers. This review explores the complexities of acute coronary syndrome management in cancer patients, addressing challenges involved, recent advances in percutaneous strategies, pharmacology, and considerations for these high-risk individuals. This review discusses a balance between invasive vs. medical strategy, technical advances in multimodal imaging, intravascular physiology, intracoronary imaging, and evolving stent options, highlighting the need for tailored approaches in this complex patient population.

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry.

BACKGROUND: Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI). METHODS: Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators). RESULTS: LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047). CONCLUSIONS: Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

Revolutionising Acute Cardiac Care With Artificial Intelligence: Opportunities and Challenges.

This article reviews the application of artificial intelligence (AI) in acute cardiac care, highlighting its potential to transform patient outcomes in the face of the global burden of cardiovascular diseases. It explores how AI algorithms can rapidly and accurately process data for the prediction and diagnosis of acute cardiac conditions. The review examines AI's impact on patient health across various diagnostic tools such as echocardiography, electrocardiography, coronary angiography, cardiac computed tomography, and magnetic resonance imaging, discusses the regulatory landscape for AI in health care, and categorises AI algorithms by their risk levels. Furthermore, it addresses the challenges of data quality, generalisability, bias, transparency, and regulatory considerations, underscoring the necessity for inclusive data and robust validation processes. The review concludes with future perspectives on integrating AI into clinical workflows and the ongoing need for research, regulation, and innovation to harness AI's full potential in improving acute cardiac care.

Evaluation of stenoses using AI video models applied to coronary angiography.

The coronary angiogram is the gold standard for evaluating the severity of coronary artery disease stenoses. Presently, the assessment is conducted visually by cardiologists, a method that lacks standardization. This study introduces DeepCoro, a ground-breaking AI-driven pipeline that integrates advanced vessel tracking and a video-based Swin3D model that was trained and validated on a dataset comprised of 182,418 coronary angiography videos spanning 5 years. DeepCoro achieved a notable precision of 71.89% in identifying coronary artery segments and demonstrated a mean absolute error of 20.15% (95% CI: 19.88-20.40) and a classification AUROC of 0.8294 (95% CI: 0.8215-0.8373) in stenosis percentage prediction compared to traditional cardiologist assessments. When compared to two expert interventional cardiologists, DeepCoro achieved lower variability than the clinical reports (19.09%; 95% CI: 18.55-19.58 vs 21.00%; 95% CI: 20.20-21.76, respectively). In addition, DeepCoro can be fine-tuned to a different modality type. When fine-tuned on quantitative coronary angiography assessments, DeepCoro attained an even lower mean absolute error of 7.75% (95% CI: 7.37-8.07), underscoring the reduced variability inherent to this method. This study establishes DeepCoro as an innovative video-based, adaptable tool in coronary artery disease analysis, significantly enhancing the precision and reliability of stenosis assessment.

In-stent Thrombosis and COVID-19 Infection: Current Insights on the Mechanistic Relationship.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been demonstrated as a major risk factor in inducing coronary stent thrombosis due to its propensity to create a pro-thrombotic state. This review explores the mechanisms that may contribute to the increased thrombosis risk seen in COVID-19. Furthermore, we discuss the patient and haematological factors that predispose to an increased risk of stent thrombosis, as well as the role of certain antiplatelet and anticoagulation therapies, including ticagrelor and enoxaparin, that may reduce the likelihood and severity of in-stent thrombosis, in SARS-CoV-2 infection. To counter the proinflammatory and pro-thrombotic state shown in COVID-19, anti-thrombotic therapy in the future may be optimised using point-of-care platelet inhibition testing and inflammation-modifying therapies. Large-scale randomised trials with long-term follow-up are increasingly necessary to assess the intersection of COVID-19 and stent optimisation as well as the reduction of stent thrombosis after drug-eluting stent (DES) implantation.

Artificial Intelligence as a Diagnostic Tool in Non-Invasive Imaging in the Assessment of Coronary Artery Disease.

Coronary artery disease (CAD) remains a leading cause of mortality and morbidity worldwide, and it is associated with considerable economic burden. In an ageing, multimorbid population, it has become increasingly important to develop reliable, consistent, low-risk, non-invasive means of diagnosing CAD. The evolution of multiple cardiac modalities in this field has addressed this dilemma to a large extent, not only in providing information regarding anatomical disease, as is the case with coronary computed tomography angiography (CCTA), but also in contributing critical details about functional assessment, for instance, using stress cardiac magnetic resonance (S-CMR). The field of artificial intelligence (AI) is developing at an astounding pace, especially in healthcare. In healthcare, key milestones have been achieved using AI and machine learning (ML) in various clinical settings, from smartwatches detecting arrhythmias to retinal image analysis and skin cancer prediction. In recent times, we have seen an emerging interest in developing AI-based technology in the field of cardiovascular imaging, as it is felt that ML methods have potential to overcome some limitations of current risk models by applying computer algorithms to large databases with multidimensional variables, thus enabling the inclusion of complex relationships to predict outcomes. In this paper, we review the current literature on the various applications of AI in the assessment of CAD, with a focus on multimodality imaging, followed by a discussion on future perspectives and critical challenges that this field is likely to encounter as it continues to evolve in cardiology.

Impact of Sex on Clinical Outcomes in Patients undergoing Complex Percutaneous Coronary Angioplasty (from the e-ULTIMASTER Study).

Female gender has been shown to be associated with worse clinical outcomes after percutaneous coronary intervention (PCI). However, the impact of gender on the clinical outcomes of complex PCI is still poorly understood. This study examined the differences in patient and coronary lesion characteristics and longer-term clinical outcomes in male and female patients who underwent complex PCI. This was a sub-analysis of the e-ULTIMASTER study, which was a large, multicontinental, prospective, observational study enrolling 37,198 patients who underwent PCI with the Ultimaster stent. Patients who underwent complex PCI were stratified by gender. The primary outcome was target lesion failure at 12 months, defined as the composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target lesion revascularization at 12 months. A total of 13,623 patients underwent complex procedures, of which 35.7% were women. Women were twice as likely as men to be aged ≥80 years (17.6% vs 9%, p <0.0001) and had a higher prevalence of cardiovascular risk factors. Women had fewer lesions treated than men (1.5 ± 0.8 vs 1.6 ± 0.8, p <0.0001) and fewer stents implanted (2.0 ± 1.1 vs 2.1 ± 1.1, p <0.0001). There was no statistically significant difference in clinical outcomes at 12 months between women and men. Event rates were comparable in women and men for target lesion failure (4.7% vs 4.3%, p = 0.30), target vessel failure (5.1% vs 4.9%, p = 0.73), and cardiac death (1.8% vs 1.7%, p = 0.80).In conclusion, our findings suggest no significant differences in clinical outcomes between women and men who underwent complex PCI.

Percutaneous Coronary Angioplasty in Patients with Cancer: Clinical Challenges and Management Strategies.

The number of cancer survivors in the United States is projected to increase by 31% by 2030. With advances in early screening, diagnosis and therapeutic strategies, a steadily increasing number of patients are surviving cancer. Coronary artery disease (CAD) is now one of the leading causes of death amongst cancer survivors, with the latter group of patients having a higher risk of CAD compared to the general population. Our review covers a range of specific challenges faced by doctors when considering percutaneous coronary interventions (PCI) in cancer patients; clinical outcomes in cancer patients undergoing PCI, as well as some important technical considerations to be made when making decisions regarding the management strategy in this special population of patients.

Acute Coronary Syndromes Due to Atherosclerotic Coronary Artery Disease in Young Patients.

Young patients represent about 4-10% of the population presenting with acute coronary syndrome. In this focused mini-review, we highlight the data regarding acute coronary syndromes in young patients with atherosclerotic coronary artery disease. Differences in the underlying pathologies and pathophysiological mechanisms should yield to different clinical management and treatment strategies.

Analysing functional implications of differences in left ventricular morphology using statistical shape modelling.

Functional implications of left ventricular (LV) morphological characterization in congenital heart disease are not widely explored. This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV), and healthy controls. A statistical shape modelling framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) data in isolated CoA (n = 25), CoA + BAV (n = 30), isolated BAV (n = 30), and healthy controls (n = 25). Average 3D templates and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters (i.e., sphericity, conicity) or global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture was also explored. The LV template was shorter and more spherical in CoA patients. Sphericity was overall associated with global and apical radial (p = 0.001, R2 = 0.09; p < 0.0001, R2 = 0.17) and circumferential strain (p = 0.001, R2 = 0.10; p = 0.04, R2 = 0.04), irrespective of the presence of aortic stenosis and/or regurgitation and controlling for age and hypertension status. LV strain was not associated with arch architecture. Differences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease.

Outcomes of acute myocardial infarction in patients with preexisting physical disability: a report in the United States.

BACKGROUND: A significant proportion of the world's population lives with physical disability (PD) requiring healthcare services. Risk factors for cardiovascular disease (CVD) such as hypertension and diabetes are more prevalent among patients with PD. Our study compares outcomes following acute myocardial infarction (AMI) between patients with preexisting PD and those without, using the National Inpatient Sample (NIS). METHODS AND RESULTS: We analyzed all adult inpatients having a diagnosis of AMI from 2015 to 2018. The main outcome measured was in-hospital all-cause mortality. Of 2,674,524 patients admitted with AMI, 5% had PD. Patients in the PD group were found to have higher mortality (aOR 1.13, CI 1.1-1.15 p < 0.001), with the musculoskeletal group showing the highest mortality. Patients with PD received lower rates of percutaneous coronary intervention (aOR 0.65, CI 0.64-0.66, <0.001), compared to the non-PD group, with the musculoskeletal group having the lowest rates of intervention. CONCLUSION: A diagnosis of PD was independently associated with significantly increased mortality following AMI. The prognostic impact of disability correlates with the nature of the disability, with musculoskeletal disability being associated with the worst mortality outcomes. Finally, patients with any type of PD are less likely to be offered invasive cardiac management following their AMI.

Differential Impact of Type 1 and Type 2 Diabetes Mellitus on Outcomes Among 1.4 Million US Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: The aim was to determine the impact of diabetes mellitus (DM) on outcomes after percutaneous coronary intervention (PCI). There is limited data on the impact of DM and its subtypes among patients who underwent PCI during hospitalization. METHODS: All PCI hospitalizations from the National Inpatient Sample (October 2015-December 2018) were stratified by the presence and subtype of DM. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in type 1 DM (T1DM) and type 2 DM (T2DM) compared to no-DM. RESULTS: Out of 1,363,800 individuals undergoing PCI, 12,640 (0.9%) had T1DM and 539,690 (39.6%) had T2DM. T1DM patients had increased aOR of major adverse cardiovascular and cerebrovascular events (MACCE) (1.26, 95%CI 1.17-1.35), mortality (1.56, 95%CI 1.41-1.72), major bleeding (1.63, 95%CI 1.45-1.84), and stroke (1.75, 95%CI 1.51-2.02), while T2DM patients had only increased aOR of MACCE (1.02, 95%CI 1.01-1.04), mortality (1.10, 95%CI 1.08-1.13) and stroke (1.22, 95%CI 1.18-1.27), compared to no-DM patients. However, both T1DM and T2DM had lower aOR of cardiac complications (0.87, 95%CI 0.77-0.97 and 0.87, 95%CI 0.85-0.89, respectively), in comparison to no-DM patients. When accounting for the indication, both DM subgroups had higher aOR of MACCE, mortality, and stroke compared to no-DM patients in the acute coronary syndrome setting (p < 0.001, for all), while only increased aOR of stroke (1.59, 95%CI 1.17-2.15 for T1DM and 1.12, 95%CI 1.05-1.20 for T2DM) persisted in the elective setting. CONCLUSIONS: Patients with DM who have undergone PCI during hospitalization are more likely to experience adverse in-hospital outcomes, and T1DM patients are a particularly high-risk cohort.

Outcomes of Percutaneous Coronary Intervention in Patients With Acquired Immunosuppression.

There are limited data on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with acquired immunosuppression who are frequently underrepresented in clinical trials. All PCI procedures between October 2015 and December 2018 in the Nationwide Inpatient Sample were retrospectively analyzed, stratified by immunosuppression status. Multivariable logistic regression models were performed to examine (1) the association between immunosuppression status and in-hospital outcomes, expressed as adjusted odds ratio (aOR) with 95% confidence intervals (CIs) and (2) predictors of mortality among patients with severe acquired immunosuppression. In this contemporary analysis of nearly 1.5 million PCI procedures, approximately 4% of patients who underwent PCI had acquired immunosuppression. Of these, chronic steroid use accounted for approximately half of the cohort who underwent PCI who had acquired immunosuppression, with the remainder divided between hematologic cancer, solid organ active malignancy, and metastatic cancer, with the latter group having the highest rates of composite of in-hospital mortality or stroke (9.3%) (mortality 7.5% and acute ischemic stroke 2.4%). In conclusion, immunosuppression was independently associated with increased adjusted odds of adverse clinical outcomes, specifically mortality or stroke (aOR 1.11, 95% CI 1.06 to 1.15, p <0.001) and in-hospital mortality (aOR 1.21, 95% CI 1.13 to 1.29, p <0.001), with outcomes dependent on the cause of immunosuppression.

Assessment of Cardiac, Vascular, and Pulmonary Pathobiology In Vivo During Acute COVID-19.

Background Acute COVID-19-related myocardial, pulmonary, and vascular pathology and how these relate to each other remain unclear. To our knowledge, no studies have used complementary imaging techniques, including molecular imaging, to elucidate this. We used multimodality imaging and biochemical sampling in vivo to identify the pathobiology of acute COVID-19. Specifically, we investigated the presence of myocardial inflammation and its association with coronary artery disease, systemic vasculitis, and pneumonitis. Methods and Results Consecutive patients presenting with acute COVID-19 were prospectively recruited during hospital admission in this cross-sectional study. Imaging involved computed tomography coronary angiography (identified coronary disease), cardiac 2-deoxy-2-[fluorine-18]fluoro-D-glucose positron emission tomography/computed tomography (identified vascular, cardiac, and pulmonary inflammatory cell infiltration), and cardiac magnetic resonance (identified myocardial disease) alongside biomarker sampling. Of 33 patients (median age 51 years, 94% men), 24 (73%) had respiratory symptoms, with the remainder having nonspecific viral symptoms. A total of 9 patients (35%, n=9/25) had cardiac magnetic resonance-defined myocarditis. Of these patients, 53% (n=5/8) had myocardial inflammatory cell infiltration. A total of 2 patients (5%) had elevated troponin levels. Cardiac troponin concentrations were not significantly higher in patients with and without myocarditis (8.4 ng/L [interquartile range, IQR: 4.0-55.3] versus 3.5 ng/L [IQR: 2.5-5.5]; P=0.07) or myocardial cell infiltration (4.4 ng/L [IQR: 3.4-8.3] versus 3.5 ng/L [IQR: 2.8-7.2]; P=0.89). No patients had obstructive coronary artery disease or vasculitis. Pulmonary inflammation and consolidation (percentage of total lung volume) was 17% (IQR: 5%-31%) and 11% (IQR: 7%-18%), respectively. Neither were associated with the presence of myocarditis. Conclusions Myocarditis was present in a third patients with acute COVID-19, and the majority had inflammatory cell infiltration. Pneumonitis was ubiquitous, but this inflammation was not associated with myocarditis. The mechanism of cardiac pathology is nonischemic and not attributable to a vasculitic process. Registration URL: https://www.isrctn.com; Unique identifier: ISRCTN12154994.

The Gerbode defect: a case series.

BACKGROUND: The Gerbode defect is a rare abnormal communication between the left ventricle (LV) and right atrium (RA). The lesion is either congenital or acquired. Acquired defects are largely iatrogenic or infective in origin. We present two cases of acquired Gerbode defects with similar clinical presentations but very different outcomes. CASE SUMMARIES: Patient 1 A 64-year-old male presented with features of decompensated cardiac failure and a low-grade temperature. Dehiscence of a recently implanted bioprosthetic aortic valve and high-velocity LV to RA jet (Gerbode defect) was found on echocardiography. Blood cultures grew Staphylococcus warneri and the diagnosis of infective endocarditis was established. The patient was treated with intravenous antibiotics and the aortic valve and Gerbode defect were successfully surgically repaired.Patient 2 An 81-year-old male presented after being found on the floor at home. On admission, he was clinically septic with evidence of decompensated heart failure. No clear infective focus was initially found. Transthoracic echocardiography revealed severe left ventricular impairment, with a normal bioprosthetic aortic valve. He was treated with intravenous antibiotics, but later deteriorated with evidence of embolic phenomena. Repeat echocardiography revealed a complex infective aortic root lesion with bioprosthetic valve dehiscence and flow demonstrated from the LV to RA. Unfortunately, the patient succumbed to the infection and cardiac complications. DISCUSSION: The Gerbode defect is a rare but important complication of infective endocarditis and valve surgery. Care needs to be taken to assess for Gerbode defect shunts on echocardiogram, especially in the context of previous cardiac surgery.

Impact of COVID-19 on inpatient referral of acute heart failure: a single-centre experience from the south-west of the UK.

AIMS: Healthcare services worldwide have been significantly impacted by the COVID-19 pandemic. Recent reports have shown a decline in hospitalization for emergency cardiac conditions. The impact of the COVID-19 pandemic on hospitalization and particularly mortality due to acute heart failure has not been thoroughly described. METHODS AND RESULTS: In this single-centre observational study, we examined referrals to the acute heart failure team over a period of 16 weeks (7 January to 27 April 2020) spanning the ongoing COVID-19 pandemic; 283 patients referred to our acute heart failure services over the study period were included on the basis of typical symptoms, raised BNP, and echocardiogram. There was a substantial but statistically non-significant drop in referrals with 164 referred in the 8 weeks before the first UK death due to COVID-19 on 2 March 2020 (BC), compared with 119 referred after (AC) in the subsequent 8 weeks, representing a 27% reduction overall (P = 0.06). The 30 day case fatality rate was increased from 11% in the BC group compared with 21% in the AC group (risk ratio = 1.9, 95% confidence interval 1.09-3.3). Age, gender, length of stay, left ventricular ejection fraction, and N-terminal pro-brain natriuretic peptide were similar between the groups. Admission creatinine, age, and AC cohort status were found to be univariable predictors of mortality. On multivariate Cox regression analysis, only age (hazard ratio 1.04, P = 0.03) and AC cohort status (hazard ratio 2.1, P = 0.017) remained significant predictors of mortality. On sensitivity analysis, this increased mortality was driven by COVID-19 positive status. CONCLUSIONS: There was a reduction in referral of patients with acute heart failure with significant increase in mortality in the 8 weeks following the first reported UK death due to COVID-19. The observation of increased mortality does not appear related to a change in population in terms of demographics, left ventricular ejection fraction, or N-terminal pro-brain natriuretic peptide. The observed increased mortality appears to be related to the coexistence of COVID19 infection with acute heart failure. The study highlights the need for widespread preventative and shielding measures particularly in this group of patients especially in the light of the second wave. Longer follow-up with inclusion of data from other centres and community heart failure services will be needed.