Chronic total occlusion in non-ST elevation myocardial infarction - A multi-centre observational study.

OBJECTIVES: To evaluate the characteristics and outcomes of patients with a chronic total occlusion (CTO) in a Non-ST Elevation Myocardial Infarction (NSTEMI) cohort. BACKGROUND: There is limited data on the clinical characteristics, revascularisation strategies and outcomes of patients presenting with a NSTEMI and a CTO. METHODS: Retrospective analysis of a six-centre percutaneous coronary intervention (PCI) registry in the UK between January 2015 and December 2020 was performed. Patients with a NSTEMI with and without a CTO were compared for baseline characteristics and outcomes. RESULTS: There were 17,355 NSTEMI patients in total of whom 1813 patients had a CTO (10.4 %). Patients with a CTO were more likely to be older (CTO: 67.8 (±11.5) years vs. no CTO: 67.2 (±12) years, p = 0.04), male (CTO: 81.1 % vs.71.9 %, p < 0.0001) with a greater prevalence of cardiovascular risk factors. All-cause mortality at 30 days: HR 2.63, 95 % CI 1.42-4.84, p = 0.002 and at 1 year: HR: 1.87, 95 % CI 1.25-2.81, p = 0.003 was higher in the CTO cohort. CTO patients who underwent revascularisation were younger (Revascularisation 66.4 [±11.7] years vs. no revascularisation 68.4 [±11.4] years, p = 0.001). Patients with failed CTO revascularisation had lower survival (HR 0.21, 95 % CI 0.10-0.42, p < 0.0001). The mean time to revascularisation was 13.4 days. There was variation in attempt at CTO revascularisation between the 6 centres for (16 % to 100 %) with success rates ranging from 65 to 100 %. CONCLUSIONS: In conclusion, the presence of a CTO in NSTEMI patients undergoing PCI was associated with worse in-hospital and long-term outcomes.

Iatrogenic Dissection of the Left Internal Mammary Artery During Percutaneous Coronary Intervention of Jump Radial Artery Graft Bifurcation Disease: A Case Report.

Guide-catheter-induced ostial coronary artery dissection is a feared complication of percutaneous coronary intervention, but thankfully the incidence is low. We describe a case of catheter-induced ostial dissection of the left internal mammary artery (LIMA) with multiple radial jump grafts during percutaneous coronary intervention of radial graft bifurcation disease via the LIMA. The dissection led to loss of flow and profound haemodynamic compromise and cardiac arrest as the LIMA supplied the majority of the myocardium in this patient. Intravascular ultrasound was not immediately available, so an Export AP thrombus aspiration catheter (Medtronic) was used over the coronary wire in place to allow the injection of contrast while simultaneously pulling back on the catheter to delineate the extent of the dissection and guide accurate drug-eluting stent placement. The report is a cautionary tale to the reader to treat the LIMA with respect and think long and hard before considering any interventional procedure that uses the LIMA as a conduit.

Effects of late, repetitive remote ischaemic conditioning on myocardial strain in patients with acute myocardial infarction.

Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied (38 receiving 4 weeks' daily CRIC, 35 controls receiving sham conditioning). Patients underwent cardiovascular magnetic resonance at baseline (5-7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain (longitudinal/circumferential, in infarct-related and remote territories). At both timepoints, there were no significant between-group differences in global indices (LV ejection fraction, infarct size, longitudinal/circumferential strain). However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group (from - 16.2 ± 5.2 at baseline to - 18.7 ± 6.3 at follow up, p = 0.0006) but not in corresponding segments of the control group (from - 15.5 ± 4.0 to - 15.2 ± 4.7, p = 0.81; for change: - 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively, p = 0.027). In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls (- 1.2 ± 4.4 versus - 2.5 ± 4.0, p = 0.038). In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: http://clinicaltrials.gov/show/NCT01664611 .

Feasibility of 5 Fr Contralateral Radial Access for Hybrid Chronic Total Occlusion Percutaneous Coronary Intervention: Experience From a Single Tertiary Center in the United Kingdom.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid algorithm has traditionally been performed femorally using 8 Fr sheaths. Antegrade dissection and re-entry (ADR) has facilitated procedures using 6 and 7 Fr guides via the radial artery. Radial artery dysfunction and occlusion is a recognized complication preventing future radial procedures, but is significantly less common with 5 Fr sheaths. Five Fr contralateral radial access (48% left, 52% right) was used in 33 consecutive patients undergoing elective CTO-PCI in a single United Kingdom (UK) center over a 2-year period. Procedural data were recorded in the UK Hybrid CTO registry. Antegrade access was via contralateral radial in 26 cases and via femoral access in 5 cases. Single 5 Fr access was used in 2 cases treated by antegrade wire escalation. The mean J-CTO score was 2.1 ± 1.2, with an overall success rate of 91%. A retrograde approach was used in 9 cases and ADR was used in 9 cases. The mean fluoroscopy and procedure times were 45.2 ± 30.6 min and 172.5 ± 118.1 min, respectively, and the mean volume of contrast use was 218.5 ± 83.0 mL. There was 1 radial artery complication, 1 case of periprocedural myocardial infarction, and 1 case of tamponade. In this series, 5 Fr contralateral access provided adequate visualization in all cases. A 5 Fr guide provided adequate support in all retrograde cases to cross with a microcatheter after wire passage. Down-sizing contralateral access to 5 Fr routinely is feasible and may lead to a reduction in radial artery dysfunction and occlusion, as well as a reduction in the volume of contrast used.

Daily remote ischaemic conditioning following acute myocardial infarction: a randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning (rIC) is a cardioprotective tool which has shown promise in preclinical and clinical trials in the context of acute ischaemia. Repeated rIC post myocardial infarction may provide additional benefits which have not previously been tested clinically. METHODS: The trial assessed the role of daily rIC in enhancing left ventricular ejection fraction (LVEF) recovery in patients with impaired LVEF (<45%) after ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (P-PCI). Patients were recruited from four UK hospitals and randomised to receive either 4 weeks of daily rIC or sham conditioning using the autoRIC Device (CellAegis) starting on day 3 post P-PCI. The primary endpoint was the improvement in LVEF over 4 months assessed by cardiac MRI (CMR). Seventy-three patients (38 cases, 35 controls) completed the study. RESULTS: The treatment and control groups were well matched at baseline including for mean LVEF (42.8% vs 44.3% respectively, p=0.952). There was no difference in the improvement in LVEF over 4 months between the treatment and control groups (4.8%±7.8% vs 4.6%±5.9% respectively, p=0.924). No differences were seen in the secondary outcome measures including changes in infarct size and left ventricular end-diastolic and systolic volumes, major adverse cardiac and cerebral event, mean Kansas City Cardiomyopathy Questionnaire score and change in N-terminal pro-brain natriuretic peptide levels. CONCLUSIONS: Daily rIC starting on day 3 and continued for 4 weeks following successful P-PCI for STEMI did not improve LVEF as assessed by CMR after 4 months when compared with a matched control group. TRIAL REGISTRATION NUMBER: NCT0166461.

Pacemaker leads and cardiac perforation.

This case series highlights the rare but potentially life threatening complication of ventricular perforation caused by pacemaker leads and discusses appropriate investigations and management strategies.

Remote ischemic conditioning: from experimental observation to clinical application: report from the 8th Biennial Hatter Cardiovascular Institute Workshop.

In 1993, Przyklenk and colleagues made the intriguing experimental observation that 'brief ischemia in one vascular bed also protects remote, virgin myocardium from subsequent sustained coronary artery occlusion' and that this effect'... may be mediated by factor(s) activated, produced, or transported throughout the heart during brief ischemia/reperfusion'. This seminal study laid the foundation for the discovery of 'remote ischemic conditioning' (RIC), a phenomenon in which the heart is protected from the detrimental effects of acute ischemia/reperfusion injury (IRI), by applying cycles of brief ischemia and reperfusion to an organ or tissue remote from the heart. The concept of RIC quickly evolved to extend beyond the heart, encompassing inter-organ protection against acute IRI. The crucial discovery that the protective RIC stimulus could be applied non-invasively, by simply inflating and deflating a blood pressure cuff placed on the upper arm to induce cycles of brief ischemia and reperfusion, has facilitated the translation of RIC into the clinical setting. Despite intensive investigation over the last 20 years, the underlying mechanisms continue to elude researchers. In the 8th Biennial Hatter Cardiovascular Institute Workshop, recent developments in the field of RIC were discussed with a focus on new insights into the underlying mechanisms, the diversity of non-cardiac protection, new clinical applications, and large outcome studies. The scientific advances made in this field of research highlight the journey that RIC has made from being an intriguing experimental observation to a clinical application with patient benefit.

The time-of-day variation in vascular smooth muscle contractility depends on a nitric oxide signalling pathway.

The dip in blood pressure during the resting-period is paradoxically associated with an increase in total peripheral resistance and occurs at a time when the vascular response to vasoconstrictor compounds is heightened, and to vasodilators reduced. However, the cellular mechanisms responsible for this time-of-day variation are not well defined. We have investigated the role of nitric oxide synthase (NOS) signalling in the control of contraction in mesenteric resistance arteries using wire myography, combined with quantitative PCR analysis of gene transcription and western blot analysis of protein. Small rings of mesenteric arteries, isolated from rats at two opposing time-points corresponding to the animal's active and resting-period, were mounted in a wire myograph. Vessels exhibited a time-of-day variation in their contractile-response to phenylephrine, with a reduced maximal contraction during the active- versus the resting-period (11.8±0.8 versus 18.6±1.2 mN P<0.001). Vessels preconstricted with phenylephrine were also more responsive to vasodilation with acetylcholine during the active-period, with an EC50 of 58.6±11 versus 232±31 nM in resting-period vessels (P<0.0001). These differences were abolished in the presence of l-NAME. Quantitative RT-PCR reveals a functioning peripheral circadian clock in mesenteric arteries and a 3.3-fold increase in endothelial NO synthase mRNA levels in active- versus resting-period vessels (P<0.001), which translated to a 1.7-fold increase in total eNOS protein (P<0.05). The time-of-day variation in the response of mesenteric resistance vessels to phenylephrine and acetylcholine is dependent on NOS signalling.

Pseudoaneurysm of the left ventricle following apical approach TAVI.

Symptomatic severe aortic stenosis carries a two year survival of only 50%. However many patients are unsuitable for conventional aortic valve replacement as they are considered too high risk due to significant co-morbidities. Transcatheter Aortic Valve Implantation (TAVI) offers a viable alternative for this high risk patient group, either by the femoral or apical route. This article reports a case of a pseudoaneurysm of the left ventricle following an apical approach TAVI in an elderly lady with severe aortic stenosis. To our knowledge pseduoaneuryms of the left ventricle have been reported infrequently in the literature and has yet to be established as a recognised complication of TAVI.

The cost of postgraduate training.

The Modernising Medical Careers and European Working Time Directive have led to significant changes in the working patterns and training of junior doctors. This article seeks to explore the hidden costs incurred by trainees of various specialties and grades for postgraduate training.

Spontaneous bowel perforation due to norovirus: a case report.

Norovirus is the leading cause of epidemic gastroenteritis worldwide but the disease is usually self-limiting and generally only causes serious health problems in the young, elderly and immunocompromised. The authors report a case of bowel perforation in an elderly Caucasian lady with confirmed infection with Norovirus genogroup II and no other presumptive cause. To the authors' knowledge this is the first such case of bowel perforation due to Norovirus. Viral gastroenteritis should be considered in the list of differentials when no obvious cause of bowel perforation can be identified to minimise morbidity and mortality.

Validity of electrocardiographic classification of left ventricular hypertrophy across adult ethnic groups with echocardiography as a standard.

AIMS: To assess the validity of the electrocardiogram (ECG) as a diagnostic tool for left ventricular hypertrophy (LVH) for different ethnic groups with echocardiography as a standard. METHODS: Systematic review of the literature using the Cornell and Sokolow-Lyon voltage criteria for LVH. RESULTS: Five studies were identified. Pooled data from these studies demonstrated low sensitivity using both types of ECG criteria for white and African-origin groups, but with slightly higher sensitivity values for the African-origin group (Cornell, 31.2%; 95% confidence interval [CI], 28%-34.8%; Sokolow-Lyon, 32.9%; 95% CI, 29.5%-36.4%) compared with the white group (Cornell, 26.5%; 95% CI, 25.2%-27.8%; Sokolow-Lyon, 18.2%; 95% CI, 17.2%-19.3%). Specificity was high using both types of criteria in the white group (Cornell, 87.4%; 95% CI, 86.4%-88.4%; Sokolow-Lyon, 88.9%; 95% CI, 88%-90%) but was much lower in the African-origin group using the Sokolow-Lyon criteria (72.1%; 95% CI, 68.7%-75.3%). Specificity was high however for the African-origin group using the Cornell criteria (86.2%, 95% CI, 83.4%-88.5%). CONCLUSIONS: Both types of criteria are more sensitive in African-origin populations. The Sokolow-Lyon criteria are less specific for LVH in people of African origin. The evidence favors the Cornell criteria in research and service contexts involving African-origin and white populations. Further research is needed to adapt ECG criteria to take into account ethnicity to a greater degree. The issue needs to be studied in a broader range of ethnic groups.