Contraception and Pre-Conception Counselling in Cardiac Patients: We Can Do Better. Experience From a Tertiary Centre in New Zealand.

BACKGROUND: Physiological changes in pregnancy can precipitate decompensation in women with pre-existing cardiac disease leading to suboptimal fetal outcome in addition to maternal risk. Many women born with congenital heart disease are living into childbearing years, and rheumatic heart disease (RHD) remains a significant problem within Maori and Pasifika communities in New Zealand. AIMS: To assess documentation of contraception advice and pre-conception counselling in women with pre-existing cardiac disease of childbearing potential and to explore potential barriers to these conversations. METHODS: We conducted a retrospective review of electronic clinic letters of 194 women with modified World Health Organization (mWHO) class 2 or above heart disease. This was followed by a survey of our cardiology team. RESULTS: Fifty-one (51) women with RHD and 143 women with non-RHD were identified. Thirty-eight per cent (38%) of women had documented discussions about contraception and pre-conception counselling. Women with RHD were less likely to receive discussions about contraception than women with non-RHD. All surveyed members of our cardiology team agreed that women with cardiac disease should have planned pregnancies and the majority reported always or usually discussing contraception. Factors such as lack of time, cultural barriers and presence of family members were identified. Many felt that the subject was outside of their expertise or admitted that they simply did not think about it. CONCLUSIONS: Advice regarding contraception in addition to pre-pregnancy counselling should be given to all patients with pre-existing cardiovascular disease of potential child-bearing potential. Our study shows much room for improvement.

Routine Use of Fluoroscopic-Guided Femoral Arterial Puncture to Minimise Vascular Complication Rates in CTO Intervention: Multi-centre UK Experience.

BACKGROUND: Chronic total occlusion (CTO) revascularisation has a crucial role in contemporary percutaneous coronary intervention (PCI). Procedural success is influenced by disease complexity, calcific burden and patient characteristics but has substantially improved with the implementation of novel hybrid strategies. However, vascular-access related complications remain a cause of morbidity and mortality. This study aimed to assess the effectiveness of fluoroscopic-guided femoral arterial puncture to minimise this risk during CTO PCI. METHODS: Standardised data were retrospectively collected from four high-volume UK CTO centres between September 2011 and November 2013. Demographic, clinical and procedural data (vascular access site, sheath size, anticoagulation use) was collated. The anatomical location of the femoral puncture in relation to the femoral bifurcation, femoral head position and inferior epigastric artery were recorded. Adverse events related to vascular access were documented. RESULTS: A total of 528 patients were included (676 femoral punctures) with the majority being male (n=432, 81.8%). Large sheaths (8F) were used in 81.2% of cases. Fluoroscopy-enabled punctures were made in the 'safe zone' in over > 93% of cases. Vascular closure devices (VCD) were used in 88.3% of cases. The adverse event rate per puncture was 0.89%. CONCLUSIONS: This study demonstrates an extremely low incidence of vascular-access complications in CTO PCI when fluoroscopic guidance is used to obtain femoral arterial access by default radial operators.

Early experience of implantation of the new CoreValve(®) Evolut(™) in degenerated bioprosthetic aortic valves.

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis in high-risk patients. The PARTNER trial demonstrated equivalent 1-year survival rates between patients randomized to TAVI versus conventional surgery (Leon et al., N Engl J Med 2010;363:1597-1607), with sustained benefit up to 2 years (Makkar et al., NEJM 2012;366:1696-1704). Recently, the ADVANCE registry cited all-cause mortality rates of 4.5%, 12.8%, and 17.9% at 30-days, 6 months, and 1-year following TAVI in 1,015 high-risk patients (Linke, TCT 2012, 2012). In addition, TAVI was demonstrated to be a feasible treatment for severe native valve regurgitation in a series of 31 high-risk patients. The all-cause 30-day mortality rate was 6.4%, with a 30-day major stroke rate of 6.4%. At 1-year, the all-cause mortality rate was 12.5% (Roy et al., J Am Coll Cardiol 2012;60(17S):B264). We report the successful transcatheter implantation of the new CoreValve(®) Evolut(™) in two patients with regurgitant aortic bioprostheses.

Acute Inferior ST-Elevation Myocardial Infarction Caused by Occlusion of a Giant Coronary Artery Aneurysm.

An approach to the treatment of a giant aneurysm of the proximal right coronary artery with thrombotic occlusion is described.

Variabilidad de la respuesta plaquetaria a la aspirina / Assessing platelet response to aspirin

Introducción y objetivos: A pesar de que el estudio Antiplatelet Trialists' Collaboration demostró una reducción del 25% de los eventos mayores con el uso de aspirina en enfermos de alto riesgo, un porcentaje de pacientes presentan eventos isquémicos recurrentes. Esto ha llevado a la descripción de la "resistencia a la aspirina" con una tasa muy variable, de 0.4% a 83%. Este estudio evaluó la variabiliad en la función plaquetaria basal, la prevalencia de la resistencia a la aspirina, y la efectividad y reproducibilidad de los estudios de función plaquetaria. Materiales y métodos: Se llevó a cabo un estudio aleatorizado y cruzado de mediciones repetidas, con sujetos saludables de entre 18 y 60 años. Luego de firmar el consentimiento informado, los pacientes fueron distribuidos en forma aleatorizada a recibir aspirina en dosis de 75 mg o 300 mg; fueron evaluados al inicio y luego de cuatro períodos de tres semanas mediante diferentes técnicas: Optical Platelet Aggregation (OPA), PFA-100™, VerifyNow™, y los niveles séricos y urinarios de tromboxano B2 (TXB2). Se obtuvo la aprobación del comité de ética local. El análisis estadístico fue realizado con el programa SPSS17. Resultados: El índice global de resistencia a la aspirina fue variable, entre 2.4% y 63.5% en función de la técnica utilizada. Se demostró una variabilidad interindividual e intraindividual significativa al inicio y con la administración de placebo en las diferentes técnicas. La sensibilidad de los ensayos varió entre 24% (OPA ADP10) y 87.8% (tromboxano sérico), y la especificidad varió entre 81% (PFA-100™) y 97.4% (tromboxano). La selección de "valores de corte" alternativos provocó tasas de prevalencia diferentes de resistencia bioquímica a la aspirina, con un mecanismo de compensación entre la sensibilidad y la especificidad. Conclusiones: La respuesta a la aspirina mostró una marcada variabilidad interensayo, interindividual y temporal. Se requieren varias evaluaciones con diferentes técnicas para diagnosticar en forma confiable la resistencia a la aspirina. La selección de valores discriminativos alternativos debería considerarse al evaluar formalmente esta entidad

Introduction: Despite the 25% reduction in major events with aspirin in high-risk patients reported by the Antiplatelet Trialists' Collaboration, a proportion of patients develop recurrent ischaemic events. This has led to the emergence of 'aspirin resistance' with rates between 0.4% and 83% reported. This study assessed variability in baseline platelet function, prevalence of aspirin resistance, and the performance and reproducibility of platelet function testing methods. Materials and Methods: A repeated-measures randomised crossover study was performed in healthy individuals aged 18-60 years. After informed consent, patients were randomised to aspirin dose (75 mg or 300 mg) and treatment sequence with testing at baseline and after each four 3-week treatment period via Optical Platelet Aggregation (OPA), PFA-100™, VerifyNow™, and serum and urinary thromboxane (TXB2) levels. Local ethical approval was granted. Statistical analysis was performed using SPSS17. Results: The overall rate of aspirin resistance varied from 2.4% to 63.5% depending on the assay used. Significant inter- and intra-individual variability existed at baseline and on placebo testing between assays. Assay sensitivities ranged from 24.0% (OPA ADP10) to 87.8% (serum TXB2), and specificities from 81.0% (PFA-100™) to 97.4% (serum TXB2). Selection of alternative "cut-off" values resulted in differing prevalence rates of biochemical aspirin resistance with a trade-off between sensitivity and specificity. Conclusions: Response to aspirin shows marked inter-assay, inter-individual and temporal variability. Testing on multiple occasions using several assays is necessary to reliably diagnose aspirin resistance. Selection of alternative assay "cut-off" values should be considered when formally assessing aspirin response

Uncorrected tetralogy of Fallot: adult presentation in the 61st year of life.

Tetralogy of Fallot (TOF) is the commonest form of cyanotic congenital heart defect after infancy [Brickner ME, Hillis LD, Lange RA. Congenital Heart Disease in Adults-Second of Two Parts. NEJM 2000; 342(5):334-342.]. There are few studies assessing the risk of surgical correction in adult patients and long-term survival into the fourth decade of life is rare. The case history is described of a 61-year old female presenting with probable viral myocarditis. Subsequent investigations revealed an underlying diagnosis of tetralogy of Fallot. The patient remains asymptomatic despite persistent hypoxia. Potential factors contributing to longevity in this case are relatively good pulmonary blood flow via large branch pulmonary arteries, and the possible gradual development of right ventricular outflow tract obstruction over a long time period.