Subtle aortic dissection in a patient with severe aortic regurgitation and undiagnosed bicuspid aortic valve: A case report with a literature review.

BACKGROUND AND AIM OF THE STUDY: A subtle aortic dissection can be challenging to detect despite the availability of multiple diagnostic modalities. Whilst rare, the inability to detect this variant of aortic dissection can lead to a dismal prognosis. We present an extremely rare case of a subtle aortic dissection with supra-annular aortic root intimal tear and acute severe aortic regurgitation in a patient with a bicuspid aortic valve. METHODS: Case report and literature review conserning subtle aortic dissection is provided. RESULTS: Initial concerns were either aortic dissection or infective endocarditis. Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and a Bentall procedure with a mechanical aortic valve was performed. CONCLUSIONS: Our case along with the review of current literature emphasizes that current imaging techniques may be inadequate for diagnosis of this rare variant of aortic dissection.

Long-Term Follow-Up of Isolated Epicardial Left Ventricular Lead Implant Using a Minithoracotomy Approach for Cardiac Resynchronization Therapy.

BACKGROUND: Transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy is unsuccessful in 5-10% of reported cases. These patients may benefit from isolated surgical placement of an epicardial LV lead via minithoracotomy approach. AIM: To evaluate the success of this approach at long-term follow-up. METHODS: Retrospective evaluation of all consecutive patients undergoing isolated epicardial LV lead placement after failed transvenous attempt over a 6-year period. Data collected on baseline parameters, procedural details, and outcome at follow-up (hospital stay, complications, mortality, and clinical response). RESULTS: Forty-two patients underwent epicardial lead implant. Five died within 1 year (11.9%): two (4.8%) died within 30-days post op (one from intraoperative hemorrhage, the other from multiple organ failure); 39 (95.1%) were admitted to the high dependency unit and transferred to the ward <24 hours. Median hospital stay was 3.4 ± 1.9 days. The overall complication rate was 17.5% (n = 7): 15.0% (n = 6) short term and 2.5% (n = 1) long term; these included three (7.5%) LV noncapture events all treated with reprogramming. There were two (5.0%) wound infections requiring oral antibiotics and two (5.0%) device infections requiring intravenous antibiotics (one had device resiting, the other developed septic shock requiring intensive care admission). Assessment of clinical response was possible in 34 (81.0%) at follow-up: 21 (61.8%) were responders and 13 (28.2%) nonresponders with no significant differences between these groups; no clinical predictors of response were identified. CONCLUSION: Isolated epicardial LV lead implant using minithoracotomy is relatively safe and effective at successful LV pacing. Response rate and postoperative recovery at long-term follow-up are reasonable in these high-risk patients.

Body composition in heart failure and the impact of cardiac resynchronisation therapy: a proof-of-concept study.

Aims: Body composition (BC) is known to alter in heart failure. Cardiac resynchronisation therapy (CRT) improves left ventricular geometry but the impact on BC is unknown. Our aim was to evaluate BC in these patients before and after CRT implantation. Methods: Prospective proof-of-concept pilot study of heart failure patients undergoing CRT between September 2014 and December 2015. Assessments performed pre-CRT and post-CRT (6 weeks and 6 months) were: BC parameters (using air-displacement plethysmography), New York Heart Failure classification for assessing symptom severity, echocardiography to assess left ventricular geometry, electrocardiography, Minnesota Heart Failure Questionnaire and N-terminal probrain natriuretic peptide (NT-pro-BNP). Repeated measures analysis of variance was performed to assess relative change over time and potential correlations. Results: Twenty-five patients were recruited; mean-age (±SD) was 73.4±10.0 years, 23 males, 18 CRT defibrillators (remainder CRT pacemakers), 16 had ischaemic aetiology, 6 diabetics, 17 with left bundle-branch morphology on ECG and 10 had atrial fibrillation. Significant inverse correlations were observed in the first 6 weeks following CRT between fat mass and left ventricular end-diastolic volume (r=-0.69, p<0.01) and NT-pro-BNP and fat mass (r=0.41, p=0.05). No significant differences were noted over 6 months. There was an observed trend towards reduced fat mass in the first 6 weeks post-CRT implant driven by non-responders. There was no significant difference between responders and non-responders in BC over 6 months. Conclusion: This is the first study to observe interplay between BC and cardiac geometry/function following CRT; a trend in overall fat mass reduction was noted following CRT and merits further study.

Characterisation of circulating biomarkers before and after cardiac resynchronisation therapy and their role in predicting CRT response: the COVERT-HF study.

Aims: Cardiac resynchronisation therapy (CRT) is effective treatment for selected patients with heart failure (HF) but has ~30% non-response rate. We evaluated whether specific biomarkers can predict outcome. Methods: A prospective single-centre pilot study of consecutive unselected patients undergoing CRT for HF between November 2013 and December 2015 evaluating cardiac extracellular matrix biomarkers and micro-ribonucleic acid (miRNA) expression before and after CRT assessing ability to predict functional response and survival. Each underwent three assessments (pre-implant, 6 weeks and 6 months postimplant) including: New York Heart Association (NYHA) class, echocardiography, electrocardiography, 6 min walk test (6MWT), Minnesota Living with Heart Failure Questionnaire (MLHFQ) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP). Plasma markers of cardiac fibrosis assessed were: N-terminal pro-peptides of collagen I and III, collagen I C-terminal telopeptides (CTx) and matrix metalloproteinases (MMP-2 and MMP-9) as well as a panel of miRNAs (miRNA-21, miRNA-30d, miRNA-122, miRNA-133a, miRNA-210 and miRNA-486). Results: A total of 52 patients were recruited; mean age (±SD) was 72.4±9.4 years; male=43 (82.7%), ischaemic aetiology=30 (57.7%), mean QRS duration=166.4±23.5 ms, left bundle branch block (LBBB) morphology = 39 (75.0%), mean NYHA=2.7±0.6, 6MWT=238.8±130.6 m, MLHFQ=46.4±21.3 and left ventricular ejection fraction (LVEF)=24.3%±8.0%. Mean follow-up=1.7±0.3 and 5.8±0.7 months. There were 27 (55.1%) functional responders (3 no definable 6-month response; 2 missed assessments and 1 long-term lead displacement). No marker predicted response, however, CTx and LBBB trended most towards predicting functional response. Conclusion: No specific biomarkers reached significance for predicting functional response to CRT. CTx showed a trend towards predicting response and warrants further study. Trial registration number: NCT02541773.

Cardiac resynchronization therapy and its role in the management of heart failure.

The prevalence of heart failure is increasing and it is associated with significant mortality and morbidity. Optimal medical therapy improves outcome, but heart failure continues to have a substantial impact on both the individual patient and wider society. Over the last two decades, cardiac resynchronization therapy has revolutionized the treatment of selected patients who have heart failure. Cardiac resynchronization therapy significantly reduces mortality and hospitalization through reverse cardiac remodelling. This review informs non-specialists about cardiac resynchronization therapy and for which patients it should be considered.

Journal clubs in the digital age: Twitter for continuing professional development.

The departmental journal club (JC) is a well-established form of continuing professional development (CPD). Social media offers a range of interactive online platforms, allowing the traditional JC to move from a formal educational meeting with local health professionals to a digital platform with users across the world. The authors created the General Internal Medicine JC (@GIMJClub) on Twitter and following a year of activity retrospectively analysed the participation and impact of this medium of JC delivery. There were 61 different participants across different continents, specialties and levels who participated in the 12 JC sessions and sent 1,543 tweets in total. Factors that appeared to influence the success of an individual JC session included choosing diverse, topical papers to discuss and a wide range of hosts. This work demonstrates the success of a Twitter-based general internal medicine JC for CPD. @GIMJClub facilitated unique and diverse interactions not otherwise available.

Extracellular cardiac matrix biomarkers in patients with reduced ejection fraction heart failure as predictors of response to cardiac resynchronisation therapy: a systematic review.

OBJECTIVE: Cardiac resynchronisation therapy (CRT) is an effective therapy for selected patients with heart failure (HF); however, a significant non-response rate exists. We examined current evidence on extracellular cardiac matrix (ECM) biomarkers in predicting response following CRT. METHODS: Complete literature review of PubMed, Ovid SP MEDLINE, Cochrane Library and TRIP, reference lists, international cardiology conferences and ongoing studies between December 1999 and December 2015 conducted according to prospectively registered study selection and analysis criteria (PROSPERO:CRD42016025864) was performed. All observational and randomised control trials (RCT) were included if they tested prespecified ECM biomarkers' ability to predict CRT response. Risk of bias assessment and data extraction determined pooling of included studies was not feasible due to heterogeneity of the selected studies. RESULTS: A total of 217 studies were screened; six (five prospective cohort and one RCT substudy) were included in analysis with 415 participants in total. Study sizes varied (n=55-260), cohort characteristics contrasted (male: 67.8%-83.6%, ischaemic aetiology: 40.2%-70.3%) and CRT response definitions differed (three clinical/functional, three echocardiographic). Consistent observation in all ECM biomarker behaviour before and after CRT implantation was not observed between studies. Lower type I and type III collagen synthesis biomarkers (N-terminal propeptides of type I and III procollagens) expression demonstrated replicated ability to predict reverse left ventricular remodelling. CONCLUSION: Collagen synthesis biomarkers offer the most potential as ECM biomarkers for predicting CRT response. Heterogeneity between these studies was large and limited the ability to pool and compare results numerically. Use of different response definitions was one of the biggest challenges.

The interplay between heart failure, metabolism and body composition.

A complex interplay exists between heart failure, metabolic status and body composition. The idiosyncrasies of these relationships are poorly understood, but they offer prognostic value and potential clinical utility. Current understanding of this relationship and known clinical value are discussed in this article.

The changing face of cardiovascular disease 2000-2012: An analysis of the world health organisation global health estimates data.

The pattern and global burden of disease has evolved considerably over the last two decades, from primarily communicable, maternal, and perinatal causes to non-communicable disease (NCD). Cardiovascular disease (CVD) has become the single most important and largest cause of NCD deaths worldwide at over 50%. The World Health Organisation (WHO) estimates that 17.6 million people died of CVD worldwide in 2012. Proportionally, this accounts for an estimated 31.43% of global mortality, with ischaemic heart disease (IHD) accounting for approximately 7.4 million deaths, 13.2% of the total. IHD was also the greatest single cause of death in 2000, accounting for an estimated 6.0 million deaths. The global burden of CVD falls, principally, on the low and middle-income (LMI) countries, accounting for over 80% of CVD deaths. Individual populations face differing challenges and each population has unique health burdens, however, CVD remains one of the greatest health challenges both nationally and worldwide.

Same-day cardiac catheter ablation is safe and cost-effective: Experience from a UK tertiary center.

BACKGROUND: Catheter ablation is a curative intervention for common arrhythmias such as supraventricular tachycardia and atrial flutter. Many centers still admit patients overnight after this procedure. OBJECTIVE: This study was performed to evaluate the safety and cost-effectiveness of same-day standard catheter ablation. METHODS: We conducted a retrospective study of all consecutive elective same-day procedures performed between 2010 and 2014. Data were collected on baseline parameters, procedure details and success, postoperative complications, unplanned overnight hospital admissions, and clinical outcome (including mortality) at 4-month follow-up. A cost analysis of potential savings was also performed. RESULTS: A total of 1142 patients underwent planned same-day electrophysiological study with or without ablation. Radiofrequency ablation was performed in 897 of these patients (mean age ± standard error 56 ± 0.6 years, range 16-95 years, 467 males), with 921 arrhythmias ablated and with complete procedural success in 883 cases (96%). There were 92 unplanned admissions (10.3%): 50 for concealed pathways that required transseptal puncture, 19 for immediate complications (including 9 femoral bleeds and 5 pacemakers for heart block), 12 admitted at the operator's discretion, and 11 for other clinical reasons. All had transthoracic echocardiography after the procedure, and none had significant pericardial effusion. At 4-month follow-up, there were 16 readmissions (1 deep vein thrombosis, 3 pericarditic chest pain, 2 femoral hematomas, 7 palpitations, and 3 others) and 1 death (unrelated to ablation). An overnight stay at our center costs $450 (£300); same-day ablation over this period saved our institution $365,000 (£240,000). CONCLUSION: Same-day standard catheter ablation is safe and cost-effective, with significant benefits for patients and health care providers. This is particularly important given the current financial climate.

Matrix metalloprotease polymorphisms are associated with gas transfer in alpha 1 antitrypsin deficiency.

UNLABELLED: Alpha-1-antitrypsin deficiency [AATD] is associated with variable development of emphysema and other features of chronic obstructive pulmonary disease [COPD]. Matrix metalloproteinases [MMPs] are believed to be important in the pathophysiology of COPD, and may therefore confer susceptibility to this phenotype in patients with AATD. OBJECTIVES: to assess the role of polymorphism of MMP1, MMP3 and MMP12 in AATD phenotypes. METHODS: 424 PiZZ subjects from the UK AATD Registry were assessed for history of chronic bronchitis [CB], post-bronchodilator lung function impairment and decline of lung function. Tag single nucleotide polymorphisms (SNPs) for MMP1, MMP3 and MMP12 were chosen using HapMap [r(2)>0.8, MAF>0.05] and were genotyped using TaqMan genotyping technologies. Quantitative genetic association was assessed using regression modelling to correct for covariates. RESULTS: in patients with AATD, carriers of the G allele of rs678815 [MMP3] had lower gas transfer [KCO] [P = 0.025, B =-7.766] than the homozygous wild type, while carriers of the T allele of rs470358 [MMP1] had higher KCO [P = 0.025, B = 6.130]. CONCLUSIONS: variations in MMP1 and MMP3 are associated with gas transfer in AATD, supporting a previous family study showing linkage of KCO to this gene region. Replication of these preliminary data is now required particularly if MMP inhibitors are to be considered as a therapeutic option.