Clinical Utility and Prognostic Value of Coronary Computed Tomography Angiography in Patients With Cancer.

There is growing interest in the role of coronary computed tomography angiography (CTA) in cardio-oncology. However, there is a paucity of real-world experience and outcome data for patients with cancer. This study sought to determine the clinical utility and prognostic value of coronary CTA in patients with cancer. In this prospective, single-center study, we recruited patients with cancer who underwent coronary CTA. Coronary artery disease (CAD) extent was classified as normal, nonobstructive (1% to 49% stenosis), and potentially obstructive (≥50% stenosis). Patients were followed up for a median of 9 months (interquartile range 3 to 30 months) for cancer-related deaths and major adverse cardiovascular events (MACEs) defined as nonfatal myocardial infarction, urgent unplanned revascularization, or cardiovascular death. The mean age of patients (n = 113) was 61 ± 12 years, and 68 were female (60%). The most common underlying cancers were breast (29%) and lymphoma (13%). A total of 25 patients had potentially obstructive CAD, most commonly of the left anterior descending artery. After coronary CTA, 88% statin-naive patients with potentially obstructive CAD were initiated on statin therapy. A total of 28/32 patients who were taking fluoropyrimidine chemotherapy (5-fluorouracil or capecitabine) continued therapy, of whom none had MACEs. Overall, there were no episodes of MACEs in this cohort and 11% had cancer-related deaths. Coronary CTA has an important role in the clinical decision-making in patients with cancer to detect CAD, initiate primary preventative therapy, and guide coronary revascularization. No MACEs occurred. Using this coronary CTA-guided approach, preventative therapy was initiated, and most patients continued prognostically important cancer therapy.

Intracardiac shunt assessment using CT coronary angiography.

BACKGROUND: Detection of intracardiac shunts using CT Coronary Angiography (CTCA) is currently based on anatomical demonstration of defects. We assessed a novel technique using a standard CTCA test bolus in detecting shunts independent of anatomical assessment and to provide an estimate of Qp/Qs. METHODS: We retrospectively reviewed 51 CTCAs: twenty-one from patients with known simple left to right intracardiac shunts with contemporaneous functional assessment (using CMR) within 6 months, 20 controls with structurally normal hearts, and 10 patients with shunt repairs. From the dynamic acquisition of a test bolus, we measured mean Hounsfield Units (HU) in various anatomical structures. We created time/density curves from the test bolus data, and calculated disappearance time (DT) from the ascending aorta (deriving a Qp/Qs), peak ascending aortic HU, and mean coefficient of variation of the arterial curves, and compared these with the Qp/Qs from the respective CMR. RESULTS: Patients with intracardiac shunts had significantly higher test bolus derived Qp/Qs compared with both the controls, and the repaired shunt comparator group. There was a very strong agreement between the test bolus derived Qp/Qs, and Qp/Qs as measured by CMR (Intraclass correlation 0.89). Mean bias was 0.032 â€‹± â€‹0.341 (95% limits of agreement -0.64 to 0.70). Interobserver, and intraobserver agreement of the disappearance time was excellent (0.99, 0.99 (reader 1) and 1.00 (reader 2) respectively). CONCLUSION: In this proof-of-concept study, we demonstrate a novel technique to detect, and to estimate severity of left to right intracardiac shunts on routine Cardiac CT.

Updates in heart failure.

This review provides a contemporary overview of HF management and highlights the key studies which have informed recent European HF guidelines.

Mechanical Non-ST-Segment Elevation Myocardial Infarction Secondary to Left Ventricular Outflow Tract Pseudoaneurysm: A Unique Entity.

We present a unique case of acute coronary syndrome (ACS) secondary to external coronary artery compression from a left ventricular outflow tract pseudoaneurysm in a postsurgical aortic valve replacement (AVR) patient, subsequently sealed with a pericardial patch. We highlight this rare presentation of ACS in postsurgical AVR patients and the importance of multimodality imaging and treatment of this unique, potentially serious sequela. (Level of Difficulty: Intermediate.).

Impaired autonomic function after incomplete revascularisation.

INTRODUCTION: Incomplete cardiac revascularisation (ICR) assessed by residual SYNTAX score (rSs) is associated with increased 5-year mortality. Furthermore, in the general population, our group has demonstrated that impaired autonomic function determined by heart rate recovery time between 10 and 20 s (HRR10-20) following an active stand is associated with increased all-cause mortality. PURPOSE: We hypothesised that ICR would be associated with impaired autonomic function determined by HRR10-20. METHODS: After ethical approval and informed consent, consecutive patients attending cardiac rehabilitation in a tertiary referral centre were enrolled. All patients had percutaneous coronary revascularisation. During an active stand, real-time heart rate, blood pressure and ECG recordings were taken using non-invasive digital photoplethysmography and HRR10-20 determined. Assessment of autonomic function was performed by determining speed of HRR10-20 post-orthostatic challenge.Patients with an rSs >0 were considered incompletely revascularised and those with an rSs of 0 fully revascularised. Demographic data were recorded and statistical analysis performed. RESULTS: Patients (n=53) comprised those with complete revascularisation (CR) (n=37) and ICR (n=16). In the ICR group, mean rSs was 9.4.HRR10-20 was impaired in the ICR group (-3±0.60) compared with the CR cohort (-6.56±0.52) (p<0.0001). Completeness of revascularisation was strongly associated with HRR10-20 (Pearson's correlation coefficient 0.529; p<0.0001). Baseline demographics did not differ significantly. Use of rate-limiting medication was similar between cohorts (beta blockers, calcium channel blockers, ivabradine). CONCLUSIONS: Our data confirm significant correlation between ICR and impaired autonomic function determined by speed of heart rate recovery. Thus, determining autonomic dysfunction post-ICR may identify those at increased mortality risk.

Emergency TAVI in cardiogenic shock and cardiorenal syndrome secondary to severe bicuspid aortic stenosis.

A 78-year man with severe aortic stenosis awaiting elective surgical aortic valve replacement presented with worsening New York Heart Association IV shortness of breath. Despite appropriate heart failure treatment, he deteriorated and developed cardiogenic shock and cardiorenal syndrome which progressed despite inotropic support. A non-contrast-gated CT coronary angiogram was arranged in light of acute renal failure which revealed a bicuspid aortic valve. Three-dimensional transoesophageal echocardiography guidance was used to assist annulus sizing. An emergency transcatheter aortic valve replacement (eTAVI) was carried out 5 days into admission with a 34 mm Core Valve Evolut Pro valve with a no contrast technique. The patient's blood pressure and urine output improved and no procedural complications were encountered. He was discharged after 21 days and has remained well subsequently. This case highlights the utility of eTAVI and demonstrates the feasibility of a no contrast approach.

CT coronary angiography and COVID-19: inpatient use in acute chest pain service.

OBJECTIVES: CT coronary angiography (CTCA) is a well-validated clinical tool in the evaluation of chest pain. In our institution, CTCA availability was increased in January 2020, and subsequently, expanded further to replace all exercise testing during the COVID-19 pandemic. Our objective was to assess the impact of increased utilisation of CTCA on length of stay in patients presenting with chest pain in the prepandemic era and during the COVID-19 pandemic. METHODS: Study design was retrospective. Patients referred for cardiology review between October 2019 and May 2020 with chest pain and/or dyspnoea were broken into three cohorts: a baseline cohort, a cohort with increased CTCA availability and a cohort with increased CTCA availability, but after the national lockdown due to COVID-19. Coronary angiography and revascularisation, length of stay and 30-day adverse outcomes were assessed. RESULTS: 513 patients (35.3% female) presented over cohorts 1 (n=179), 2 (n=182), and 3 (n=153). CTCA use increased from 7.8% overall in cohort 1% to 20.4% in cohort 3. Overall length of stay for the patients undergoing CTCA decreased from a median of 4.2 days in cohort 1 to 2.5 days in cohort 3, with no increase in 30 days adverse outcomes. Invasive coronary angiogram rates were 45.8%, 39% and 34.2% across the cohorts. 29.6% underwent revascularisation in cohort 1, 15.9% in cohort 2 and to 16.4% in cohort 3. CONCLUSIONS: Increased CTCA availability was associated with a significantly reduced length of stay both pre-COVID-19 and post-COVID-19 lockdown, without any increase in 30-day adverse outcomes.

New pharmacotherapy for heart failure with reduced ejection fraction.

INTRODUCTION: The European Society of Cardiology (ESC), Canadian Cardiovascular Society, and the American College of Cardiology Heart Failure (HF) guidelines all currently recommend the use of Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) and Beta Blockers (BB) in the treatment of HF with a reduced ejection fraction (HFrEF). Newer medications targeting combining an ARB with a neprilysin inhibitor (ARNI) sacubitril/valsartan have shown benefits in mortality and can be used in place of an ACE inhibitor or an ARB. Additionally, dapagliflozin, a medication targeting the sodium-glucose cotransporter 2 (SGLT2) can be used in addition to current therapies. AREAS COVERED: This review provides a comprehensive analysis of the evidence around the new pharmacotherapies for HFrEF, specifically, sacubitril/valsartan and dapagliflozin. A comprehensive review of the literature using keywords such as heart failure with reduced ejection fraction, angiotensin receptor, neprilysin inhibitor, and sodium glucose transporter was conducted within the National Centre for Biotechnology Information (NCBI) and Google Scholar databases. The reference sections of articles were also examined to find additional articles. EXPERT OPINION: Sacubitril/valsartan and dapagliflozin both show marked benefits on mortality in HFrEF patients. More research needs to be conducted on the mechanisms of action on disease modification.

Late ventricular standstill following an elective TAVI.

Transcatheter aortic valve implantations (TAVIs) may be complicated by a need for permanent pacemaker implantation post procedure, usually due to local trauma or compression on the conduction system. There are some features that might help predict that a patient is high risk for developing conduction disease following TAVI, for example, underlying right bundle branch block or use of certain types of TAVI. It might also become apparent during the procedure, or before temporary wire removal post procedure. Higher risk patients may undergo rhythm monitoring for longer periods post TAVI. We present a case where a patient required an unexpected emergency pacemaker following a TAVI, despite low risk clinical features, a low risk baseline ECG, and the use of a low risk TAVI valve. In addition, this very significant conduction disease only became apparent over 72 hours following implantation, despite normal resting ECGs and telemetry up to that point.