Animation-supported consent for urgent angiography and angioplasty: a service improvement initiative.

OBJECTIVE: Patient understanding of angiography and angioplasty is often incomplete at the time of consent. Language barriers and time constraints are significant obstacles, particularly in the urgent setting. We introduced digital animations to support consent and assessed the effect on patient understanding. METHODS: Multi-language animations explaining angiography and angioplasty (www.explainmyprocedure.com/heart) were introduced at nine district hospitals for patients with acute coronary syndrome before urgent transfer to a cardiac centre for their procedure. Reported understanding of the reason for transfer, the procedure, its benefits and risks in 100 consecutive patients were recorded before introduction of the animations into practice (no animation group) and in 100 consecutive patients after their introduction (animation group). Patient understanding in the two groups was compared. RESULTS: Following introduction, 83/100 patients reported they had watched the animation before inter-hospital transfer (3 declined and 14 were overlooked). The proportions of patients who understood the reason for transfer, the procedure, its benefits and risks in the no animation group were 58%, 38%, 25% and 7% and in the animation group, 85%, 81%, 73% and 61%, respectively. The relative improvement (ratio of proportions) was 1.5 (95% CI 1.2 to 1.8), 2.1 (1.6 to 2.8), 2.9 (2.0 to 4.2) and 8.7 (4.2 to 18.1), respectively (p<0.001 for all comparisons). CONCLUSION: Use of animations explaining angiography and angioplasty is feasible before urgent inter-hospital transfer and was associated with substantial improvement in reported understanding of the procedure, its risks and its benefits. The approach is not limited to cardiology and has the potential to be applied to all specialties in medicine.

Evaluation of ECG Imaging to Map Hemodynamically Stable and Unstable Ventricular Arrhythmias.

BACKGROUND: ECG imaging (ECGI) has been used to guide treatment of ventricular ectopy and arrhythmias. However, the accuracy of ECGI in localizing the origin of arrhythmias during catheter ablation of ventricular tachycardia (VT) in structurally abnormal hearts remains to be fully validated. METHODS: During catheter ablation of VT, simultaneous mapping was performed using electroanatomical mapping (CARTO, Biosense-Webster) and ECGI (CardioInsight, Medtronic) in 18 patients. Sites of entrainment, pace-mapping, and termination during ablation were used to define the VT site of origin (SoO). Distance between SoO and the site of earliest activation on ECGI were measured using co-registered geometries from both systems. The accuracy of ECGI versus a 12-lead surface ECG algorithm was compared. RESULTS: A total of 29 VTs were available for comparison. Distance between SoO and sites of earliest activation in ECGI was 22.6, 13.9 to 36.2 mm (median, first to third quartile). ECGI mapped VT sites of origin onto the correct AHA segment with higher accuracy than a validated 12-lead ECG algorithm (83.3% versus 38.9%; P=0.015). CONCLUSIONS: This simultaneous assessment demonstrates that CardioInsight localizes VT circuits with sufficient accuracy to provide a region of interest for targeting mapping for ablation. Resolution is not sufficient to guide discrete radiofrequency lesion delivery via catheter ablation without concomitant use of an electroanatomical mapping system but may be sufficient for segmental ablation with radiotherapy.

Comparison of a high throughput day case atrial fibrillation ablation service in a local hospital with standard regional tertiary cardiac centre care.

AIMS: We investigated safety and efficacy of a high throughput atrial fibrillation (AF) ablation service within a local non-cardiac centre compared with matched patients at the regional tertiary cardiac centre. METHODS AND RESULTS: Patients were consented in clinic and pre-assessed by clerical staff. Locally, other than physicians, staff had no experience of ablation and were trained with simulations. Pulmonary vein isolation (PVI) was performed with conscious sedation, on uninterrupted anticoagulation for at least 4 weeks. No transoesophageal echocardiogram (TOE) was performed. A 28 mm Arctic Front Advance Cryoballoon was used. A 20 mm Achieve wire demonstrated PVI on a portable laptop-based EP recording system. Phrenic nerve function was monitored during right PVI. Finally, a transthoracic echocardiogram excluded a pericardial effusion. A Femostop was applied. Two hundred and seventy-six patients were matched. Average age was 61 ± 0.7 years, 39% female. CHA2DS2 VASc score varied from 0 to 7. Procedure time was significantly shorter at the local hospital (63.5 ± 1.1 vs. 101.7 ± 2.9 min, P < 0.0001). Fluoroscopy time (5.5 ± 0.2 vs. 12.6 ± 0.6 min, P < 0.0001) and fluoroscopy dose were lower (17.2 ± 2.1 vs. 97.6 ± 14.6 mGy, P < 0.0001). Successful PVI was achieved in all. The complication rate was low (5.4% vs. 6.3%, P = not significant). Four (1.4%) patients were not day case discharges. At 3 month follow-up, 54.3% had complete resolution, and 26.1% had improvement of symptoms. A total of 16.6% patients requested repeat procedures for ongoing symptoms. CONCLUSION: In experienced hands, cryoballoon for paroxysmal AF is delivered safely and effectively in a local centre. Outcomes remain excellent. These short, day case procedures allow utilization of non-cardiac centres. The service provides a model to meet increasing demands.

Infective endocarditis due to Atopobium vaginae: a rare association between genital infection and endocarditis of the tricuspid valve.

Atopobium vaginae is an anaerobic gram-positive organism associated with genitourinary infections. Bacteraemia is rare, with only two cases reported in the literature. This case describes an 18-year-old type 1 diabetic, presenting with sepsis and haemoptysis, on a background of poor dental hygiene and recurrent hospital admissions. Blood cultures grew A. vaginae and echocardiogram revealed a large tricuspid valve lesion. Despite medical therapy, symptoms of pulmonary emboli continued and she therefore underwent surgical resection of the lesion. Histopathological findings were of a vegetation; culture of the lesion was negative but 16S ribosomal PCR was positive, detecting 16S rRNA of A. vaginae The patient was treated with 4 weeks of vancomycin and made a good recovery. To our knowledge, this represents the first report of infective endocarditis due to this organism. We also provide a review of the literature, including comparing published drug susceptibility data with consensus breakpoints for antimicrobial agents.

Predictors of change in bodily pain in early rheumatoid arthritis: an inception cohort study.

OBJECTIVE: To investigate possible predictors for lack of pain improvement after 1 year of treatment for early rheumatoid arthritis (RA). METHODS: The Early Rheumatoid Arthritis Network (ERAN) database was used for analysis of baseline and 1-year pain data. The ERAN is a hospital-based inception cohort of 1,189 people. Short Form 36 questionnaire bodily pain scores were used to calculate change in pain at 1 year as the outcome. The proportion of the Disease Activity Score in 28 joints (DAS28) attributable to patient-reported components (joint tenderness and visual analog scale score; DAS28-P) at baseline was derived as a predictor. Predictors of less improvement in pain were investigated using adjusted odds ratios (OR(adj) ) generated by logistic regression, adjusting for 14 additional clinical and demographic covariates. RESULTS: Greater pain at baseline was associated with sex, high DAS28, worse mental health, and smoking. Most patients with early RA reported incomplete improvement in bodily pain after 1 year. The DAS28-P index did not significantly change in the patients whose disease remained active. Less improvement in pain was predicted by female sex (OR(adj) 3.41, 95% confidence interval [95% CI] 1.35-8.64) and a high DAS28-P index at baseline (OR(adj) for tertiles 2.09, 95% CI 1.24-3.55). Other conventional RA risk factors did not predict pain changes. CONCLUSION: The factors most likely to predict less improvement in pain in early RA are female sex and a high DAS28-P index. A high DAS28-P index may reflect greater contributions of noninflammatory factors, such as central sensitization, to pain. Strategies in addition to inflammatory disease suppression may be required to adequately treat pain.