Left Atrial Appendage Occlusion: British Cardiovascular Intervention Society and British Heart Rhythm Society Position Statement.

Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described. Standards regarding procedure volume for implant centres and physicians, the role of multidisciplinary teams and audits are highlighted.

Left Atrial Appendage Occlusion: British Cardiovascular Intervention Society and British Heart Rhythm Society Position Statement.

Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described. Standards regarding procedure volume for implant centres and physicians, the role of multidisciplinary teams and audits are highlighted.

Changes to transcatheter aortic valve replacement (TAVR) services during the first wave of the COVID-19 pandemic: A single centre experience from United Kingdom tertiary hospital.

AIMS: COVID-19 had a devastating impact on patients with severe aortic stenosis (AS). Like many cardiac procedures, transcatheter aortic valve replacement (TAVR) services were suspended during the first wave of COVID-19. We took the opportunity to evaluate the clinical outcomes and identify any delays at different stages of the TAVR pathway during the COVID-19 pandemic. METHODS: Prospectively collected data on 210 consecutive TAVR patients between March 2019 and March 2021 were analysed. We compared the clinical outcomes and 30-day mortality rates of TAVR cases pre-pandemic and during the pandemic. We also looked to identify any time lags from the initial referral to respective stages of the TAVR workup. RESULTS: A total of 134 patients underwent TAVR prior to the national lockdown (March 2019-March 2020), compared to 76 patients during COVID-19 (April 2020-April 2021). Success rates of TAVR were similar (99% prior to the pandemic and 97.4% during COVID-19). The 30-day survival rates were 98.6% and 94.7%, respectively. Median length of stay post TAVR was 2 days during COVID-19 and 2.5 days prior to the pandemic (p = 0.064). Patients were seen quicker in clinic (median of 33 days) during COVID-19, compared to 51 days before COVID-19 (p = 0.044). No significant difference in times from referral to discussion at TAVR multidisciplinary team (MDT) meetings, CT Aortogram and TAVR implantation, in both groups. CONCLUSIONS: Reconfiguring the patient pathway during COVID-19 allowed TAVR to be performed safely, with a similar success rate and no excess complications or increased 30-day mortality. There proved to be no delay in the respective stages of patient TAVR workup, during the pandemic.

The impact of learning-curve-experience on transcatheter aortic valve replacement outcomes: Insights from the United Kingdom and Ireland all-comers second-generation ACURATE neo™ transcatheter aortic heart valve registry.

BACKGROUND: The ACURATE neo™ is a novel, second-generation self-expanding supra-annular transcatheter heart valve (THV). The objective of this multi-centre registry is to assess the safety, clinical utility, and impact of 'learning-curve-experience' (LCE) on transcatheter aortic valve replacement outcomes in the United Kingdom (UK) and Ireland. METHODS: We prospectively collected data from seven ACURATE neo™ THV implanting centres (n = 484) between February 2016 and November 2020. We compared mortality rates and outcomes in the LCE group (n = 120) compared to next successive 120 cases. RESULTS: The mean age of the cohort was 81.9(SD: 6.1) years and the majority were in the moderate risk category (EuroSCORE-II):3.3(SD: 3). The 97.5% of cases were performed under local anesthetic. The valve was successfully deployed in 98.8% of cases. The survival rate at 30 days was 97.9%. The incidence of stroke was 2.5%. Life threatening bleeding occurred in 0.6% of cases and vascular access complications occurred in 21 (4.3%) patients. Implantation-related conduction abnormalities occurred in 8.3% but only 5.6% required a PPM. The successful valve deployment occurred in 96% of the patients in the LCE group compared to 100% in the other group (p = 0.04; OR-2[CI 1.7-2.3]). The mortality rates at 30 days (1.7% vs. 1.7%) and 1 year (1.9% vs. 2.7%) were comparable between the two groups. CONCLUSIONS: This study represents the largest published UK and Ireland real-world experience of the ACURATE neo™ valve. The procedural success rates and safety outcomes were excellent and endorse its utility in clinical practice. The LCE appears to have an impact on the successful valve deployment but without translating into short-term or long-term outcomes.

Conduction Abnormalities and Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement Using the Repositionable LOTUS Device: The United Kingdom Experience.

OBJECTIVES: The authors report the incidence of pacemaker implantation up to hospital discharge and the factors influencing pacing rate following implantation of the LOTUS bioprosthesis (Boston Scientific, Natick, Massachusetts) in the United Kingdom. BACKGROUND: Transcatheter aortic valve replacement (TAVR) is associated with a significant need for permanent pacemaker implantation. Pacing rates vary according to the device used. The REPRISE II (Repositionable Percutaneous Replacement of Stenotic Aortic Valve Through Implantation of Lotus Valve System) trial reported a pacing rate of 29% at 30 days after implantation of the LOTUS device. METHODS: Data were collected retrospectively on 228 patients who had the LOTUS device implanted between March 2013 and February 2015 across 10 centers in the United Kingdom. Twenty-seven patients (12%) had pacemakers implanted pre-procedure and were excluded from the analysis. RESULTS: Patients were aged 81.2 ± 7.7 years; 50.7% were male. The mean pre-procedural QRS duration was 101.7 ± 20.4 ms. More than one-half of the cohort (n = 111, 55%) developed new left bundle branch block (LBBB) following the procedure. Permanent pacemakers were implanted in 64 patients (32%) with a median time to insertion of 3.0 ± 3.4 days. Chief indications for pacing were atrioventricular (AV) block (n = 46, 72%), or LBBB with 1st degree AV block (n = 11, 17%). Amongst those who received a pacemaker following TAVR the pre-procedural electrocardiogram findings included: No conduction disturbance (n = 41, 64%); 1st degree AV block (n = 10, 16%); right bundle branch block (n = 6, 9%) and LBBB (n = 5, 8%). LBBB (but not permanent pacemaker) occurred more frequently in patients who had balloon aortic valvuloplasty before TAVR (odds ratio [OR]: 1.25; p = 0.03). Pre-procedural conduction abnormality (composite of 1st degree AV block, hemiblock, right bundle branch block, LBBB) was independently associated with the need for permanent pacemaker (OR: 2.54; p = 0.048). The absence of aortic valve calcification was also associated with a higher pacing rate (OR: 0.55; p = 0.031). Multivariate regression analysis did not show an independent association between depth of implant, valve oversizing, balloon post-dilatation, and the need for pacing post-procedure. CONCLUSIONS: Following implantation of the repositionable LOTUS valve, 55% of patients developed LBBB and 32% of patients required a pacemaker during their index hospital admission. Patients with pre-procedural conduction disturbance and non-calcified aortic valves were more likely to need pacing. No other anatomic features were identified with increased pacing requirement with the LOTUS device.

Initial Experience of a Second-Generation Self-Expanding Transcatheter Aortic Valve: The UK & Ireland Evolut R Implanters' Registry.

OBJECTIVES: The authors present the UK and Irish real-world learning curve experience of the Evolut R transcatheter heart valve. BACKGROUND: The Evolut R is a self-expanding, repositionable, and fully recapturable second-generation transcatheter heart valve with several novel design features to improve outcomes and reduce complications. METHODS: Clinical, procedural, and 30-day outcome data were prospectively collected for the first 264 patients to receive the Evolut R valve in the United Kingdom and Ireland. RESULTS: A total of 264 consecutive Evolut R implantations were performed across 9 centers. The mean age was 81.1 ± 7.8 years, and the mean logistic European System for Cardiac Operative Risk Evaluation score was 19.9 ± 13.7%. Procedural indications included aortic stenosis (72.0%), mixed aortic valve disease (17.4%), and failing aortic valve bioprostheses (10.6%). Conscious sedation was used in 39.8% of patients and transfemoral access in 93.6%. The procedural success rate was 91.3%, and paravalvular leak immediately after implantation was mild or less in 92.3%. Major complications were rare: cardiac tamponade in 0.4%, conversion to sternotomy in 0.8%, annular rupture in 0.0%, coronary occlusion in 0.8%, major vascular in 5.3%, acute kidney injury in 6.1%, new permanent pacemaker implantation in 14.7%, and procedure-related death in 0.0%. At 30-day follow-up, survival was 97.7%, paravalvular leak was mild or less in 92.3%, and the stroke rate was 3.8%. CONCLUSIONS: This registry represents the largest published real-world experience of the Evolut R valve. The procedural success rate was high and safety was excellent, comparable with previous studies of the Evolut R valve and other second-generation devices. The low rate of complications represents an improvement on first-generation devices.

Prasugrel hydrochloride for the treatment of acute coronary syndrome patients.

INTRODUCTION: Dual antiplatelet therapy (DAPT) with aspirin combined with either a thienopyridine (clopidogrel or prasugrel) or acyclopentyl-triazolo-pyrimidine (ticagrelor) plays a vital role in the management of acute coronary syndrome (ACS) especially in those undergoing percutaneous coronary intervention (PCI) but even those being managed medically. Observational studies and some formal studies have shown patients on the standard dual antiplatelet regimen (clopidogrel and aspirin) continue to have further ischemic events and can suffer stent thrombosis. It has been demonstrated that clopidogrel is associated with a delayed onset of action with a considerable inter-individual variation to treatment thus making it difficult to achieve an optimal level of platelet inhibition. Areas covered: This article will review the current evidence that is available regarding the effectiveness and safety of prasugrel in ACS patients undergoing percutaneous coronary intervention (PCI). Expert commentary: Prasugrel is an oral third-generation inhibitor of platelet activation and aggregation. Laboratory studies and early phase clinical trials show prasugrel has a faster onset of action, is more potent and has reduced inter-patient response variability compared to clopidogrel. The published studies so far demonstrated that prasugrel when compared to clopidogrel also shows a higher degree of effectiveness in the prevention of platelet-initiated thrombotic events in patients with ACS undergoing PCI, however these benefits are offset somewhat by an increased bleeding risk.

Data supporting the use of the radial approach as the default strategy in octogenarians undergoing primary-PCI?

BACKGROUND: There is a significant increase in the number of octogenarians undergoing Primary Percutaneous Intervention (PPCI) for ST elevation myocardial infarction Objective: To analyze one year all cause mortality in octogenarians who are admitted with a STEMI and received PPCI in a tertiary cardiac centre in the UK, and to observe the impact of the mode of vascular access on mortality. METHODS: We reviewed registry records of consecutive STEMI patients(N=2951), admitted between 2005 and 2011.Kaplan-Meier and Cox regression analyses were used to compare mortality between OG and Age group (50-79) years. RESULTS: Of the total population, 8.1% (n=241, Mean age: 85.3 yrs. (SD: 3.4)) were OG of whom 53.5% were male. Use of femoral arterial access (63%) was significantly higher among OG (P=0.04) compared to radial route. In univariate analysis, event free survival was significantly lower in OG (log rank test, P=0.001) compared to other age group. All cause mortality was significantly higher among patients who had femoral arterial access compared to radial route (log rank test, P=0.03) in OG. In Cox regression analysis conventional risk factors femoral access remained significantly associated with one year all cause mortality (Beta:-1.9(SE: 0.9, P=0.04). CONCLUSION: In our analysis, OG who received PPCI for STEMI have disproportionately higher one year all cause mortality compared to younger age group. Use of femoral arterial access appears to be independently associated with this excess mortality. Radial access preferred to be the safer and prime option in this high risk population and warrants further investigations.

Transcatheter Aortic Valve Replacement Using the Repositionable LOTUS Valve: United Kingdom Experience.

OBJECTIVES: This study sought to present the U.K. experience to date with the second-generation LOTUS bioprosthesis (Boston Scientific, Natick, Massachusetts). BACKGROUND: First-generation transcatheter aortic valves have limitations. Second-generation repositionable valves may improve on some of those limitations. METHODS: Prospectively collected data relating to procedural and in-hospital outcome was analyzed from 10 implantation centers in the United Kingdom. RESULTS: Implants in 228 patients age 81.4 ± 7.6 years were studied; 53.5% were male. Mean logistic EuroScore was 17.5 ± 12.4. One hundred eighty-seven (82.0%) were undertaken for aortic stenosis, 7 (3.1%) for aortic regurgitation, and 34 (14.9%) for mixed aortic valve disease. A total of 67.1% of cases were done under local anesthetic and/or sedation with transfemoral access in 94.7% and transaortic in 5.3%. Three device sizes were used: 23 mm (n = 66, 28.9%), 25 mm (n = 39, 17.1%), and 27 mm (n = 123, 53.9%). The valve was successfully deployed in 99.1% of procedures. After implantation, the mean aortic gradient was 11.4 ± 5.4 mm Hg and aortic valve area 1.6 ± 0.5 cm(2). In-hospital mortality was 1.8% (n = 4). Complications included cardiac tamponade (1.8%), conversion to sternotomy (1.3%), stroke (3.9%), vascular access-related (7.0%), and acute kidney injury (7.9%). The incidence of moderate/severe aortic regurgitation was 0.8% (n = 2). A total of 31.8% of patients required new permanent pacemaker implantation. CONCLUSIONS: This analysis represents the largest published series on use of the LOTUS valve. Outcomes using this valve are excellent. In-hospital mortality is very low. Complication rates are low, and the LOTUS valve improves on first-generation valves, particularly with regard to residual aortic regurgitation.

Left atrial-oesophageal fistula: a very rare, potentially fatal complication of radiofrequency ablation for atrial fibrillation.

A 56-year-old man underwent radiofrequency ablation for atrial fibrillation. Four weeks later he presented with sepsis and neurological symptoms. Urine analysis demonstrated the presence of blood and protein. A CT scan showed pockets of air in the left atrium. An MRI brain scan revealed multiple cerebral abscesses. The patient developed a third heart sound and splinter haemorrhages. He was subsequently referred to cardiology for transoesophageal echocardiography after starting a course of intravenous meropenem. The cardiology team noted that this individual presented with a triad of infections, neurological sequelae and air in the left atrium after an ablation procedure and diagnosed atrio-oesophageal fistula. A decision to operate was made 9 days after admission. At surgery an area of caseous ulceration was found on the posterior wall of the left atrium overlying the oesophagus. PCR analysis revealed Mycoplasma salivarium, part of the oral flora.

Glycemic status underlies increased arterial stiffness and impaired endothelial function in migrant South Asian stroke survivors compared to European Caucasians: pathophysiological insights from the West Birmingham Stroke Project.

BACKGROUND: The pathophysiology of an increased risk of cerebrovascular disease mortality among South Asians (SA) remains unclear. Indices of arterial stiffness and endothelial dysfunction are independent markers of vascular disease, having both prognostic and diagnostic implications. We hypothesized that there are ethnic variations in indices of arterial stiffness and endothelial dysfunction between SA and European Caucasian (EC) stroke patients, which may underline a poorer prognosis in the former, and further investigated promoters of vessel wall abnormalities. METHODS: Using a cross-sectional approach, a total of 100 SA stroke survivors were prospectively recruited from the ongoing West Birmingham Stroke Project. Indices of vessel wall characteristics (arterial stiffness and endothelial function [change in reflective index]) were measured noninvasively using the digital volume pulse analysis technique in a temperature-controlled environment, using a direct standardized approach. SA stroke subjects were compared to 60 EC stroke survivors, 60 SA with risk factors, and 73 healthy controls. RESULTS: Among stroke patients, both ethnic groups were comparable for cardiovascular risk profile, except for more diabetes mellitus in SA (P=0.007) subjects and a higher prevalence of atrial fibrillation in EC (P=0.04) subjects. According to the TOAST and Bamford classifications, SA subjects had more small vessel (P=0.04) and lacunar infarctions (P=0.01). SA subjects had higher measurements of arterial stiffness (P<0.001) and impaired endothelial-dependent vascular function (change in reflective index %; P<0.001). On univariate analysis, endothelial function was negatively correlated with fasting plasma glucose (r=-0.4; P<0.001) and total cholesterol level (r=-0.2; P<0.001). On multivariate analysis, glycemic status was independently associated with impaired endothelial function (P=0.008) and increased arterial stiffness (P<0.001) among SA subjects. CONCLUSIONS: SA stroke survivors had more small vessel disease-related cerebrovascular events compared to EC subjects. Underlying glycemic status in SA subjects had an adverse impact on the vascular system, leading to abnormal vessel wall characteristics.

Ischemic stroke in South Asians: a review of the epidemiology, pathophysiology, and ethnicity-related clinical features.

BACKGROUND AND PURPOSE: Within the United Kingdom, mortality from stroke is higher among South Asians compared to European whites. The reasons for this excess cerebrovascular risk in South Asians remain unclear. The aim of this review is to present a comprehensive and systematic overview of the available literature relating to ischemic stroke among South Asian populations identifying distinct features of stroke epidemiology in this group. SUMMARY OF REVIEW: A high frequency of lacunar strokes is a familiar pattern among South Asians, which suggests a greater prevalence of small-vessel disease in South Asians. This may be a consequence of abnormal metabolic and glycemic processes. In addition, stroke mortality among South Asians appears to be explained by glycemic status, which is an independent predictor of long-term stroke mortality. Within India, there is a perceptible rural-urban gradient in stroke prevalence, underlying the dangers of the rapid transition in socioeconomic circumstances seen across the Indian subcontinent. CONCLUSIONS: This review emphasizes the importance of further research into ischemic stroke for South Asians given their higher cardiovascular disease burden and necessity for targeted healthcare approaches.

Impact of mean arterial blood pressure on higher arterial stiffness indices in South Asians compared to white Europeans.

BACKGROUND: The pathophysiology of excessive premature coronary heart disease mortality among South Asians living in Britain remains unclear. We hypothesized that higher measures of arterial stiffness among South Asians compared with their white European counterparts would reflect an earlier progression of atherosclerosis, even in the absence of established coronary heart disease risk indices. METHODS: Arterial stiffness was measured by digital volume pulse photoplethysmography in 90 healthy South Asians and compared with 62 matched white Europeans in a temperature-controlled environment using a direct, standardized approach. RESULTS: Both ethnic groups were comparable for coronary heart disease risk profiles and had similar 10-year coronary heart disease risk estimates, but South Asians had a greater mean (SD) stiffness index compared with white Europeans [9.39 (0.22) vs. 8.43 (0.23) m/s; P = 0.007]. On linear regression analysis, mean arterial blood pressure (beta = 0.06; P = 0.03) and age (beta = 0.11; P = 0.002) were independent predictors of arterial stiffness in South Asians. Among white Europeans, age was an independent predictor of arterial stiffness (beta = 0.05; P = 0.01). CONCLUSION: Healthy South Asians have increased systemic arterial stiffness measured by stiffness index compared with white Europeans. There was an adverse and disproportional impact of age and mean arterial pressure on the vascular system in South Asians. Increased indices of arterial stiffness may explain their increased susceptibility to coronary heart disease.

Measurement of stiffness index by digital volume pulse analysis technique: clinical utility in cardiovascular disease risk stratification.

BACKGROUND: Indices of arterial stiffness are accepted as independent markers of cardiovascular disease (CVD), having both positive prognostic and diagnostic implications. The utility of stiffness index (SI) derived from digital volume pulse (DVP) analysis in CVD risk screening is not established. METHODS: Using a representative sample of individuals from local communities (West Midlands, UK), we determined the performance of SI in the discrimination of increasing CVD risk. Arterial stiffness was measured by DVP photoplethysmography (PCA 2; Micro Medical) using a direct, standardized approach. CVD risk assessment was performed in accordance with the Joint British Society guidelines (JBS2). RESULTS: Of our cohort of 247 individuals (51% male; mean age 55.2 (s.d. 10.3) years), 187 were apparently healthy and 60 had established CVD risk factors (diabetes mellitus: 33%, hypertension: 77.8%, hypercholesteremia: 61%). On univariate analysis, SI was strongly associated with CVD risk (the European Society of Cardiology (ESC) based HeartScore) (Pearson correlation coefficient (R): 0.56, P < or = 0.001) and increased in an ordinal fashion from "low risk" to "medium risk" to "high risk" to "very high risk" (pseudo R2 = 0.30; P < 0.001). In receiver operator characteristic curve analysis, SI was the best discriminator between low to medium risk and high-risk categories (area under curve (AUC): 0.76 (95% CI 0.64-0.88), P < 0.001) when compared to total cholesterol, plasma glucose, systolic blood pressure, and waist-to-hip ratio and had the utility to discriminate the individuals with known CVD risk factors such as diabetes and hypertension. CONCLUSION: Noninvasive measurements of arterial stiffness may aid the optimal stratification of CVD risk in an apparently healthy population.

Elevated angiogenin levels in chronic heart failure.

BACKGROUND: Abnormal indices of angiogenesis have been reported in chronic heart failure (CHF). We tested the hypothesis that circulating angiogenin (a potent inducer of neovascularization in vivo) is higher in CHF patients compared with controls and associated with indices of CHF severity: brain natriuretic peptide (BNP), Simpson's left ventricular ejection fraction (EF), and New York Heart Association (NYHA) class. METHODS: Using a cross-sectional approach, we measured serum angiogenin and BNP levels in 109 consecutive patients with CHF (85 males; mean age 60 (standard deviation (SD) 10 yrs) and 112 asymptomatic controls with normal cardiac function and related levels to echocardiographic parameters. RESULTS: Angiogenin was significantly higher in CHF patients compared to controls (P < 0.001). On univariate analysis, angiogenin was positively associated with age, plasma glucose, insulin, and BNP (all P < 0.001); and negatively correlated with diastolic blood pressure (P = 0.04) and EF (P = 0.002). Angiogenin levels increased in an ordinal fashion with NYHA class, exaggerated by the presence of diabetes mellitus (pseudo R2 = 0.15, P < 0.001). In multivariate analysis, angiogenin levels were only associated with deteriorating NYHA classification (beta = 0.14 (95% confidence interval (CI) 0.09-0.19), P < 0.001). Angiogenin was also a modest discriminator for the presence of CHF (area under the curve 0.72; 95% CI 0.62-0.82), P < 0.001). CONCLUSION: Angiogenin is related to worsening heart failure severity (NYHA classification), with the highest levels in NYHA class III. Further research is warranted to determine the validity of angiogenin in a diagnostic and prognostic capacity in CHF.

Widening access to cardiovascular healthcare: community screening among ethnic minorities in inner-city Britain - the Healthy Hearts Project.

BACKGROUND: The burden of cardiovascular disease (CVD) in Britain is concentrated in inner-city areas such as Sandwell, which is home to a diverse multi-ethnic population. Current guidance for CVD risk screening is not established, nor are there specific details for ethnic minorities. Given the disparity in equitable healthcare for these groups, we developed a 'tailored' and systematic approach to CVD risk screening within communities of the Sandwell locality. The key anticipated outcomes were the numbers of participants from various ethnic backgrounds attending the health screening events and the prevalence of known and undiagnosed CVD risk within ethnic groups. METHODS: Data was collected during 10 health screening events (September 2005 and July 2006), which included an assessment of raised blood pressure, overweight, hyperlipidaemia, impaired fasting glucose, smoking habit and the 10 year CVD risk score. Specific features of our approach included (i) community involvement, (ii) a clinician who could deliver immediate attention to adverse findings, and (iii) the use of an interpreter. RESULTS: A total of 824 people from the Sandwell were included in this study (47% men, mean age 47.7 years) from community groups such as the Gujarati Indian, Punjabi Indian, European Caucasian, Yemeni, Pakistani and Bangladeshi. A total of 470 (57%) individuals were referred to their General Practitioner with a report of an increased CVD score - undetected high blood pressure in 120 (15%), undetected abnormal blood glucose in 70 (8%), undetected raised total cholesterol in 149 (18%), and CVD risk management review in 131 (16%). CONCLUSION: Using this systematic and targeted approach, there was a clear demand for this service from people of various ethnic backgrounds, of whom, one in two needed review from primary or secondary healthcare. Further work is required to assess the accuracy and clinical benefits of this community health screening approach.