Risk of infective endocarditis after surgical and transcatheter aortic valve replacement.

OBJECTIVE: To define the incidence and risk factors for infective endocarditis (IE) following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). METHODS: All patients who underwent first SAVR or TAVI in England between 2007 and 2016 were identified from the NICOR databases. Hospital admissions with a primary diagnosis of IE were identified by linkage with the NHS Hospital Episode Statistics database. Approval was obtained from the NHS Research Ethics Committee. RESULTS: 2057 of 91 962 patients undergoing SAVR developed IE over a median follow-up of 53.9 months-an overall incidence of 4.81 [95% CI 4.61 to 5.03] per 1000 person-years. Correspondingly, 140 of 14 195 patients undergoing TAVI developed IE over a median follow-up of 24.5 months-an overall incidence of 3.57 [95% CI 3.00 to 4.21] per 1000 person-years. The cumulative incidence of IE at 60 months was higher after SAVR than after TAVI (2.4% [95% CI 2.3 to 2.5] vs 1.5% [95% CI 1.3 to 1.8], HR 1.60, p<0.001). Across the entire cohort, SAVR remained an independent predictor of IE after multivariable adjustment. Risk factors for IE included younger age, male sex, atrial fibrillation, and dialysis. CONCLUSIONS: IE is a rare complication of SAVR and TAVI. In our population, the incidence of IE was higher after SAVR than after TAVI.

Comparison of general anaesthesia and non-general anaesthesia approach in transfemoral transcatheter aortic valve implantation.

OBJECTIVE: Performing transfemoral transcatheter aortic valve implantation (TAVI) without general anaesthesia (GA) has been increasingly adopted. We sought to study the impact of GA and non-GA approaches on procedural outcome and 30-day and 1-year mortality in transfemoral TAVI. METHODS: The UK TAVI registry holds information for every TAVI procedure in the UK. We analysed the data for patients implanted during 2013-2014 using either an Edwards Sapien or a Medtronic CoreValve prosthesis. Propensity score-matching analysis was performed to adjust for confounding factors. RESULTS: 2243 patients were studied (aged 81.4±7.5 years, 1195 males). 1816 (81%) underwent TAVI with GA and 427 (19%) without GA. Transoesophageal echocardiography (TOE) was used in 92.3% of GA and 12.4% of non-GA cases (p<0.001). There was no significant difference in the rate of successful valve deployment (GA 97.2% vs non-GA 95.7%, p=0.104) and in the incidence of more than mild aortic regurgitation (AR) at the end of the procedure (GA 5.6% vs non-GA 7.0%, p=0.295). However, procedure time was longer (131±60 vs 121±60mins, p=0.002) and length of stay was greater (8.0±13.5 vs 5.7±5.5 days, p<0.001) for GA cases. 30-day and 1-year mortality rates did not differ between the GA and non-GA cases. After propensity matching, these results remained unchanged. A second propensity analysis (adjusted for mode of anaesthesia) did not show an association between use of TOE and rate of successful valve deployment or frequency of significant AR. Neither was TOE associated with a longer procedural time or greater length of stay. CONCLUSION: Procedure outcome, and 30-day and 1-year mortality are not influenced by mode of anaesthesia. However, GA is associated with longer procedure duration and greater length of stay.

Association of different antiplatelet therapies with mortality after primary percutaneous coronary intervention.

OBJECTIVES: Prasugrel and ticagrelor both reduce ischaemic endpoints in high-risk acute coronary syndromes, compared with clopidogrel. However, comparative outcomes of these two newer drugs in the context of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unclear. We sought to examine this question using the British Cardiovascular Interventional Society national database in patients undergoing primary PCI for STEMI. METHODS: Data from January 2007 to December 2014 were used to compare use of P2Y12 antiplatelet drugs in primary PCI in >89 000 patients. Statistical modelling, involving propensity matching, multivariate logistic regression (MLR) and proportional hazards modelling, was used to study the association of different antiplatelet drug use with all-cause mortality. RESULTS: In our main MLR analysis, prasugrel was associated with significantly lower mortality than clopidogrel at both 30 days (OR 0.87, 95% CI 0.78 to 0.97, P=0.014) and 1 year (OR 0.89, 95% CI 0.82 to 0.97, P=0.011) post PCI. Ticagrelor was not associated with any significant differences in mortality compared with clopidogrel at either 30 days (OR 1.07, 95% CI 0.95 to 1.21, P=0.237) or 1 year (OR 1.058, 95% CI 0.96 to 1.16, P=0.247). Finally, ticagrelor was associated with significantly higher mortality than prasugrel at both time points (30 days OR 1.22, 95% CI 1.03 to 1.44, P=0.020; 1 year OR 1.19 95% CI 1.04 to 1.35, P=0.01). CONCLUSIONS: In a cohort of over 89 000 patients undergoing primary PCI for STEMI in the UK, prasugrel is associated with a lower 30-day and 1-year mortality than clopidogrel and ticagrelor. Given that an adequately powered comparative randomised trial is unlikely to be performed, these data may have implications for routine care.

Inferior ST-segment elevation following transseptal puncture for balloon mitral valvuloplasty is atropine-responsive.

ST-segment elevation in the inferior leads has been previously described following transseptal puncture for balloon mitral valvuloplasty. The mechanism, however, is obscure, and immediate left and right coronary angiography has not suggested that embolism or vascular spasm is the cause. We hypothesized that a neurally-mediated mechanism was responsible and have since treated 3 further patients with inferior ST-segment elevation following transseptal puncture for balloon valvuloplasty with intravenous atropine, with rapid resolution of ST-segment elevation in each case.

Transradial coronary angiography in patients with contraindications to the femoral approach: an analysis of 500 cases.

The transradial approach to coronary angiography is considered by some to be a route of choice, by others to be a route that should be used only where there are relative contraindications to the femoral approach. We present the largest series to date of patients in whom transradial coronary angiography was undertaken specifically because of contraindications to the femoral approach. Since 1995, patients at this cardiothoracic center have been considered for a transradial approach to coronary angiography if there were relative contraindications to the femoral route. Data from 500 patients was prospectively collected. Patients were aged 66 +/- 9 years; 72% were male. Indications for the radial approach included peripheral vascular disease (305), therapeutic anticoagulation (77), musculoskeletal (59), and morbid obesity (32). Sixty-eight patients (14%) required a radial procedure following a failed femoral approach. Access was right radial 291 (58%), left radial 209 (42%). Eighteen operators were involved, but two operators undertook 355 (71%) of the cases. Catheter gauge was 6 Fr (n = 243; 49%), 5 Fr (219; 43%), and 4 Fr (29; 6%). The procedure was successful in 463 cases [92.6%; 88.2% for nonmajority vs. 94.4% (P < 0.05) for the two majority operators]. Success in males (93.6%) significantly exceeded that in females (90.1%; P < 0.05). In-catheter-laboratory duration was 45 +/- 17 min; fluoroscopy time, 7.5 +/- 6 min; radiation dose, 40 +/- 23 CGy. The procedure was without incident in 408 cases (82%). There were procedural difficulties in 18% of cases, including radial artery spasm (12%) and vasovagal response (5%). The incidence was higher with 6 Fr catheters (23%) than with 5/4 Fr (15%; P < 0.05). Major procedural complications occurred in three cases: brachial artery dissection in one and cardiac arrest in two. Postprocedure major vascular complications numbered three: claudicant pain on handgrip in one, ischemic index finger (with subsequent terminal phalanx amputation due to osteomyelitis) in one, and ischemic hand for 4 hr in one. Patients with contraindications to the femoral approach form a high-risk group. In these patients, transradial cardiac catheterization can be performed successfully and with a low risk of major complications. Minor adverse features remain frequent, occurring in one in five cases, though difficulties are minimized both with increasing operator experience and smaller sheath diameter.

Permanent pacemakers: should straightened atrial leads be repositioned?

The aim of this study was to assess if atrial leads whose "J" configuration has straightened significantly on the postprocedural chest X ray should be repositioned. Between January 1996 and December 1997, 445 patients underwent dual chamber pacemaker implantation at the Papworth Hospital. Postprocedural chest X rays were available in 410 of these. The degree of straightening of the tip of the atrial lead was assessed from the lateral chest X ray and was graded as mild (-10 to +10 degrees from the horizontal), moderate (+10 to +30 degrees), or severe (> or = +30 degrees). Patients were followed with regard to atrial sensing and pacing characteristics, lead displacements, and lead revisions. Fifty-two (12%) patients had some degree of straightening (graded mild, moderate, severe) of the atrial lead on the postprocedure chest X ray (passive fixation in 48, active 4). Of these, 12 patients underwent next day lead repositioning, 5 of whom had abnormalities of pacing and/or sensing parameters. Seven patients therefore underwent repositioning of the atrial lead despite normal pacing parameters in view of lead straightening alone. Of the 12 patients who underwent repositioning, 3 still had lead straightening after the second procedure. The cohort for follow-up consisted of 43 patients (24 [56%] men, age 69 +/- 11 years at the time of implant) who were left with significant atrial lead straightening but adequate atrial parameters. Straightening was mild in 26 patients, moderate in 10, and severe in 7 patients. At implant the P wave amplitude was 4.8 +/- 2.4 mV. Follow-up was for 4.8 +/- 2.1 years, a total of 178 patient years. At final follow-up, the P wave amplitude was 2.7 +/- 1.3 (P < 0.05 vs implant). Censoring events occurred in 16 cases, comprising 11 deaths (none suspected to be pacemaker or lead related), 3 cases of persistent atrial fibrillation, 1 system extraction for infection, and 1 lead extraction for erosion. There were no cases of inadequate atrial lead sensing or pacing in the remaining patients. Irrespective of the degree of lead straightening on the postoperative lateral chest X ray, atrial leads should not be repositioned unless there are abnormalities of pacing or sensing parameters.

Coronary angiography in the fully anticoagulated patient: the transradial route is successful and safe.

The radial approach to coronary angiography is intuitively attractive for fully anticoagulated patients (INR > 2) but no data exist concerning efficacy or safety of this procedure. The consensus view is that the femoral approach is contraindicated in fully anticoagulated patients, and though some operators undertake femoral catheterization in such patients and use closure devices, there are no data to suggest that it is safe to do so. At our institution, the radial approach for coronary angiography is reserved for patients in whom there is a relative contraindication to the femoral route. We have undertaken over 600 radial coronary angiograms in such patients since 1996, 66 of whom underwent transradial catheterization specifically because of anticoagulation status (INR > 2). Thirty-eight patients (58%) were male, average age 67 +/- 11 years. All 66 patients had an INR > 2 but < 4.5. The approach was left radial in 26 (39%), right radial in the remainder; sheath size was 4 Fr in 4 (6%), 5 Fr in 13 (20%), and 6 Fr in 49 (74%). Seven operators in total were involved, though two operators undertook the majority of cases (47; 71%). Success rate was 97%, with no failure of access, and only one minor postprocedural hemorrhage. Failures were due to radial artery atherosclerosis (1) and subclavian tortuosity (1). The radial approach to coronary angiography is safe and to be recommended in the fully anticoagulated patient.

Occasional-operator percutaneous brachial coronary angiography: first, do no arm.

The percutaneous brachial approach to coronary angiography is perceived, rightly or wrongly, to be the easiest of the arm approaches. Predominantly femoral operators may therefore be encouraged to use the percutaneous brachial approach as an occasional procedure. We decided to investigate prospectively whether this was a reasonable strategy by examining outcome in patients who underwent percutaneous brachial cardiac catheterization by occasional brachial operators. Between October 1997 and 2000, 55 patients underwent percutaneous brachial coronary angiography (0.6% of coronary angiographies), aged 66 +/- 10 years, of whom 40 (73%) were male. Chief indications for a brachial approach were peripheral vascular disease in 35 (64%), failed femoral approach in 10 (18%), and orthopnoea in 5 (9%). The procedure was completed successfully in 46 patients (84%). Reasons for failure were failure of access (two), brachial artery spasm (one), inability to negotiate brachial/subclavian tortuosity (two), dissection of the brachial artery (two), and inability to intubate a vein graft (two). Six patients required catheterization from an alternative site (brachial arteriotomy in two, percutaneous transradial in two, femoral in two), with success in all. There were complications of varying severity in 20 patients (36%). Major complications were false aneurysm requiring surgical repair (one), large brachial hematoma requiring surgical exploration and arterial repair (one), and hematoma with clinical median nerve dysfunction for one month. Minor complications included need for repeat coronary angiography via alternative approach (six), weakness of radial pulse < 24 hr (two), brachial artery dissection without clinical sequelae (two), brachial artery spasm terminating procedure (one), and wound oozing (three). Percutaneous brachial coronary angiography is a hazardous procedure when undertaken by occasional brachial operators. Complications are unacceptably frequent. As with all practical procedures, complication rates are likely to be inversely proportional to operator volumes. Patients requiring an arm approach should be referred to operators with high-volume brachial or radial experience.

Assessment of coronary flow reserve by adenosine transthoracic echocardiography: validation with intracoronary Doppler.

OBJECTIVE: Data on the accuracy of transthoracic echocardiographic (TTE) analysis of coronary flow reserve are scarce. We compared coronary flow reserve measurements assessed using TTE with those achieved using the gold standard of intracoronary Doppler. METHODS: Twenty-one patients admitted for elective coronary angioplasty to the circumflex or left anterior descending (LAD) coronary artery underwent TTE immediately before angioplasty, both at rest and during intravenous administration of adenosine 140 microg/kg/min. Transthoracic images of distal LAD coronary diameter and coronary flow were obtained in 14 patients (66%). These patients then underwent intracoronary Doppler analysis of coronary flow reserve in the distal LAD coronary artery. In 1 patient with a proximal LAD artery lesion, the narrowing could not be crossed with the Doppler guidewire. Paired data on coronary flow reserve were therefore available in 13 patients. RESULTS: Patients were aged 61.7 +/- 8.3 years. Ten were men. Body mass index was 26.3 +/- 4.6 kg/m(2). Resting distal LAD artery blood flow was 18.4 +/- 9.0 mL/min assessed by TTE versus 17.6 +/- 8.1 mL/min by intracoronary Doppler. Hyperemic flow was 36.3 +/- 23.4 versus 33.1 +/- 19.2 mL/min, respectively. Coronary flow reserve was therefore 1.89 +/- 0.66 by TTE compared with 1.83 +/- 0.62 by intracoronary Doppler. Limits of agreement for coronary flow reserve were -0.28 to +0.44, well within boundaries of clinical acceptability. CONCLUSION: Transthoracic echocardiography is capable of providing accurate data on coronary flow reserve in the distal LAD coronary artery. As a truly noninvasive modality, this technique offers advantages over traditional invasive procedures.