Successful valve-in-valve transcatheter intervention to treat severe stenosis of a 38-year-old tricuspid bioprosthesis.

A 60-year-old man presented with breathlessness. Nearly four decades previously, he had required three operations for Staphylococcus aureus infective endocarditis of the tricuspid valve and had received a bioprosthetic valve. He had critical tricuspid bioprosthesis stenosis which was treated successfully by valve-in-valve transcatheter tricuspid valve replacement using a balloon-expandable transcatheter heart valve. One year after intervention, the patient is well with no tricuspid valve stenosis or regurgitation.

Prevalence, characteristics and clinical impact of work-related musculoskeletal pain in echocardiography.

BACKGROUND: Work-related musculoskeletal pain (WRMSP) is increasingly recognised in cardiac ultrasound practice. WRMSP can impact workforce health, productivity and sustainability. We sought to investigate the prevalence, characteristics and clinical impact of WRMSP. METHODS: Prospective electronic survey of 157 echocardiographers in 10 institutions. Data acquired on demographics, experience, working environment/pattern, WRMSP location, severity and pattern, the impact on professional, personal life and career. RESULTS: 129/157 (82%) echocardiographers completed the survey, of whom 109 (85%) reported WRMSP and 55 (43%) reported work taking longer due to WRMSP. 40/129 (31%) required time off work. 78/109 (60%) reported sleep disturbance with 26/78 (33%) of moderate or severe severity. 56/129 (45%) required medical evaluation of their WRMSP and 25/129 (19%) received a formal diagnosis of musculoskeletal injury. Those with 11+ years of experience were significantly more likely to receive a formal diagnosis of WRMSP (p = 0.002) and require medication (p = 0.006) compared to those with 10 years or less experience. CONCLUSION: WRMSP is very common amongst echocardiographers, with a fifth having a related musculoskeletal injury. WRMSP has considerable on impact on personal, social and work-related activities. Strategies to reduce the burden of WRMSP are urgently required to ensure sustainability of the workforce and patient access to imaging.

Impact of gender, ethnicity and social deprivation on access to surgical or transcatheter aortic valve replacement in aortic stenosis: a retrospective database study in England.

OBJECTIVE: To assess gender, ethnicity, and deprivation-based differences in provision of aortic valve replacement (AVR) in England for adults with aortic stenosis (AS). METHODS: We retrospectively identified adults with AS from the English Hospital Episode Statistics (HES) between April 2016 and March 2019 and those who subsequently had an AVR. We separately used HES-linked Clinical Practice Research Datalink (CPRD) to identify people with AVR and evaluate the timeliness of their procedure (CPRD-AVR cohort). ORs for AVR in people with an AS diagnosis were estimated using multivariable logistic regression adjusted for age, region and comorbidity. AVR was considered timely if performed electively and without evidence of cardiac decompensation before AVR. RESULTS: 183 591 adults with AS were identified in HES; of these, 31 436 underwent AVR. The CPRD-AVR cohort comprised 10 069 adults. Women had lower odds of receiving AVR compared with men (OR 0.65; 95% CI 0.63 to 0.66); as did people of black (OR 0.70; 95% CI 0.60 to 0.82) or South Asian (OR 0.75; 95% CI 0.69 to 0.82) compared with people of white ethnicities. People in the most deprived areas were less likely to receive AVR than the least deprived areas (OR 0.8; 95% CI 0.75 to 0.86). Timely AVR occurred in 65% of those of white ethnicities compared with 55% of both those of black and South Asian ethnicities. 77% of the least deprived had a timely procedure compared with 58% of the most deprived; there was no gender difference. CONCLUSIONS: In this large, national dataset, female gender, black or South Asian ethnicities and high deprivation were associated with significantly reduced odds of receiving AVR in England. A lower proportion of people of minority ethnicities or high deprivation had a timely procedure. Public health initiatives may be required to increase clinician and public awareness of unconscious biases towards minority and vulnerable populations to ensure timely AVR for everyone.

Ethnicity-dependent performance of the Global Registry of Acute Coronary Events risk score for prediction of non-ST-segment elevation myocardial infarction in-hospital mortality: nationwide cohort study.

AIMS: The Global Registry of Acute Coronary Events (GRACE) score was developed to evaluate risk in patients with the acute coronary syndrome with or without ST-segment elevation. Little is known about its performance at predicting in-hospital mortality for ethnic minority patients. METHODS AND RESULTS: We identified 326 160 admissions with non-ST-segment elevation myocardial infarction (NSTEMI) in the Myocardial Infarction National Audit Project (MINAP), 2010-17, including White (n = 299 184) and ethnic minorities (excluding White minorities) (n = 26 976). We calculated the GRACE score for in-hospital mortality and assessed ethnic group baseline characteristics by low, intermediate and high risk. The performance of the GRACE risk score was estimated by discrimination [area under the receiver operating characteristic curve (AUC)] and calibration (calibration plots). Ethnic minorities presented younger and had increased prevalence of cardiometabolic risk factors in all GRACE risk groups. The GRACE risk score for White [AUC 0.87, 95% confidence interval (CI) 0.86-0.87] and ethnic minority (AUC 0.87, 95% CI 0.86-0.88) patients had good discrimination. However, whilst the GRACE risk model was well calibrated in White patients (expected to observed (E : O) in-hospital death rate ratio 0.99; slope 1.00), it overestimated risk in ethnic minority patients (E : O ratio 1.29; slope: 0.94). CONCLUSION: The GRACE risk score provided good discrimination overall for in-hospital mortality, but was not well calibrated and overestimated risk for ethnic minorities with NSTEMI.

Impact of the admitting ward on care quality and outcomes in non-ST-segment elevation myocardial infarction: insights from a national registry.

AIMS: Little is known about the association between the type of admission ward and quality of care and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI). METHODS AND RESULTS: We analysed data from 337 155 NSTEMI admissions between 2010 and 2017 in the UK Myocardial Ischaemia National Audit Project (MINAP) database. The cohort was dichotomised according to receipt of care either on a medical (n = 142,876) or cardiac ward, inclusive of acute cardiac wards and cardiac care unit (n = 194,279) on admission to hospital. Patients admitted to a cardiac ward were younger (median age 70 y vs. 75 y, P < 0.001), and less likely to be female (33% vs. 40%, P < 0.001). Independent factors associated with admission to a cardiac ward included ischaemic ECG changes (OR: 1.20, 95% CI: 1.18-1.23) and prior percutaneous coronary intervention (PCI) (OR: 1.19, 95% CI: 1.16-1.22). Patients admitted to a cardiac ward were more likely to receive optimal pharmacotherapy with statin (85% vs. 81%, P < 0.001) and dual antiplatelet therapy (DAPT) (91% vs. 88%, P < 0.001) on discharge, undergo invasive coronary angiography (78% vs. 59%, P < 0.001), and receive revascularisation in the form of PCI (52% vs. 36%, P < 0.001). Following multivariable logistic regression, the odds of inhospital all-cause mortality (OR: 0.75, 95% CI: 0.70-0.81) and major adverse cardiovascular events (MACE) (OR: 0.84, 95% CI: 0.78-0.91) were lower in patients admitted to a cardiac ward. CONCLUSION: Patients with NSTEMI admitted to a cardiac ward on admission were more likely to receive guideline directed management and had better clinical outcomes.

Analysis of conflicts of interest among authors and researchers of European clinical guidelines in cardiovascular medicine.

OBJECTIVES: We aimed to assess the frequency and nature of financial conflicts of interest among both the guideline committee authors and the authors of research studies used to support the European Society of Cardiology (ESC) guidelines. DESIGN: We evaluated the competing interests of the doctors that write five of the key ESC clinical practice guidelines (CPG): valvular heart disease (VHD), atrial fibrillation (AF), pericardial diseases (PD), heart failure (HF) and myocardial revascularisation (IHD). In addition, we examined the funding sources of studies cited in the recommendations that were related to pharmaceutical agents. If a study was sponsored by industry, the disclosures of all authors were reviewed to assess whether there was a financial conflict of interest with the study funder. RESULTS: In total, there were 603 recommendations (PD 112, VHD 111, HF 169, IHD 97 and AF 114) across the five guidelines, of which, 271 (45% (PD 26, VHD 23, HF 72, IHD 84 and AF 66)) related to pharmaceutical agents. At least 80% of guideline committee authors, except for the PD guidelines, had a relevant financial conflict of interest, with the most frequent being a direct personal payment (68-82%). Industry support for studies varied across the guidelines from 5% (PD) to 65% (IHD). If a study was funded by industry, authors were frequently (55-90%) conflicted with the industry sponsor. CONCLUSIONS: The majority of the doctors that write clinical guidelines have a relevant financial conflict of interest. In addition, industry sponsorship of studies is frequent, and authors are often conflicted with the study funder. We propose that physicians that write clinical guidelines should be free of such financial conflicts of interest to maintain scientific integrity and independence in the clinical guidelines.

Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography.

The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.

Tropheryma whipplei endocarditis.

Tropheryma whipplei is a bacterium that causes a rare infection called Whipple's disease and can cause devastating effects if left untreated. It is important to recognize that patients with this infection may present with atypical symptoms and are often apyrexial with normal inflammatory markers. Moreover, routine blood cultures often do not isolate these bacteria in conventional growth media. Therefore, it requires a high level of clinical suspicion to make this diagnosis. Here, we present two cases of Tropheryma whipplei aortic valve endocarditis, with atypical presentation and similar unusual but striking echocardiographic images.

Premature Structural Failure of Trifecta Bioprosthesis in Midterm Follow-up: A Single-Center Study.

BACKGROUND: A cluster of aortic bioprosthetic valve failures, most of which were Trifecta bioprostheses, was observed in Southampton General Hospital, Southampton, United Kingdom. This study was performed to assess whether the cluster represents a significant failure of this valve model or whether there is a selection bias that can explain the failure of these valves. METHODS: This retrospective study evaluated all bioprosthetic aortic valve replacement operations performed between 2011 and 2016 inclusive in our center. The study compared the performance of the Trifecta valve (Abbott, Abbott Park, IL) with that of Perimount (Edwards Lifesciences, Irvine, CA), Perimount Magna Ease, and Mitroflow (LivaNova, London, United Kingdom) bioprostheses. In addition, the study analyzed patient-related and valve-related risk factors for early failure in the failed valves. RESULTS: A total of 2807 bioprosthetic aortic valve replacements were performed. Of these, 836 were Trifecta valves, 1031 were Perimount, 449 were Perimount Magna Ease, and 351 were Mitroflow valves. A total of 24 Trifecta valves had premature structural failure, a number significantly higher than seen with Perimount or Perimount Magna Ease (no failure, P < .001 and P < .005, respectively) valves and the Mitroflow valve (1 failure, P < .05). There was no difference in the incidence of endocarditis or death. At the time of valve failure, 17 (71%) of the failed Trifecta valves had moderate or severe regurgitation, and the average peak gradient was 61 ± 29 mm Hg. The median failed prosthetic size was 23 mm. One failed valve had severe patient-prosthesis mismatch. The mean time to failure was 4.5 ± 1.7 years. CONCLUSIONS: The Trifecta bioprosthesis has an increased incidence of early structural valve failure, which is significantly higher than that of Perimount, Perimount Magna Ease, or Mitroflow. No patient-related or valve-related cause for the failure could be identified.

Machine learning detection of Atrial Fibrillation using wearable technology.

BACKGROUND: Atrial Fibrillation is the most common arrhythmia worldwide with a global age adjusted prevalence of 0.5% in 2010. Anticoagulation treatment using warfarin or direct oral anticoagulants is effective in reducing the risk of AF-related stroke by approximately two-thirds and can provide a 10% reduction in overall mortality. There has been increased interest in detecting AF due to its increased incidence and the possibility to prevent AF-related strokes. Inexpensive consumer devices which measure the ECG may have the potential to accurately detect AF but do not generally incorporate diagnostic algorithms. Machine learning algorithms have the potential to improve patient outcomes particularly where diagnoses are made from large volumes or complex patterns of data such as in AF. METHODS: We designed a novel AF detection algorithm using a de-correlated Lorenz plot of 60 consecutive RR intervals. In order to reduce the volume of data, the resulting images were compressed using a wavelet transformation (JPEG200 algorithm) and the compressed images were used as input data to a Support Vector Machine (SVM) classifier. We used the Massachusetts Institute of Technology (MIT)-Beth Israel Hospital (BIH) Atrial Fibrillation database and the MIT-BIH Arrhythmia database as training data and verified the algorithm performance using RR intervals collected using an inexpensive consumer heart rate monitor device (Polar-H7) in a case-control study. RESULTS: The SVM algorithm yielded excellent discrimination in the training data with a sensitivity of 99.2% and a specificity of 99.5% for AF. In the validation data, the SVM algorithm correctly identified AF in 79/79 cases; sensitivity 100% (95% CI 95.4%-100%) and non-AF in 328/336 cases; specificity 97.6% (95% CI 95.4%-99.0%). CONCLUSIONS: An inexpensive wearable heart rate monitor and machine learning algorithm can be used to detect AF with very high accuracy and has the capability to transmit ECG data which could be used to confirm AF. It could potentially be used for intermittent screening or continuously for prolonged periods to detect paroxysmal AF. Further work could lead to cost-effective and accurate estimation of AF burden and improved risk stratification in AF.

Frequency and impact of incidental findings on computed tomography during work-up for transcatheter aortic valve implantation: single centre experience and review of the literature.

OBJECTIVE: To assess the frequency and impact of incidental findings (IF) on CT during work-up for transcatheter aortic valve intervention (TAVI). METHODS: A consecutive cohort of patients referred for consideration of TAVI who underwent a CT scan between 2009 and 2018 were studied retrospectively. CT reports were reviewed for the presence of IFs and categorised based upon their clinical significance: (a) insignificant-findings that did not require specific treatment or follow-up; (b) intermediate-findings that did not impact on the decision-making process but required follow-up; (c) significant-findings that either required urgent investigation or meant that TAVI was clinically inappropriate. RESULTS: A total of 652 patients were included, whose median age was 82 years. One or more insignificant IF was found in 95.6% of patients. Intermediate IFs were documented in 5.4%. 91 (14%) patients had at least one significant IF. These included possible malignancy in 67 (74%). The ultimate decision to offer aortic valve intervention was only changed by the presence of an IF in 3.5% of cases. CONCLUSION: Clinically significant IFs are detected in more than 1 in 10 of patients undergoing CT as part of a TAVI work-up, although just over half of these patients still receive aortic valve intervention. ADVANCES IN KNOWLEDGE: This study is the largest UK cohort, which, when combined with a review of existing literature, provides a clear picture of the frequency and clinical impact of IFs found at CT for TAVI assessment.

Screening for Atrial Fibrillation Using Economical and Accurate Technology (From the SAFETY Study).

The prevalence of atrial fibrillation (AF) is estimated at more than 3% in the adult population and there has been increased interest in screening for AF. In the SAFETY trial we chose to evaluate if inexpensive, wearable, consumer electrocardiography (ECG) sensing devices (Polar-H7 [PH7] and Firstbeat Bodyguard 2 [BG2]), could be used to detect AF accurately. We undertook a case-control study of 418 participants aged >65 (82 with AF and/or flutter at the study visit and 336 without) attending 3 general practice surgeries in Hampshire, UK for a single screening visit. The PH7 and BG2 devices were tested alongside 2 established AF detection devices (AliveCor and WatchBP) in random order and the diagnosis of AF was confirmed by 12-Lead ECG interpreted by a panel of cardiologists. The sensitivity (95% confidence interval [CI] range), specificity (95% CI range), and overall accuracy (95% CI range) of the 4 devices were: AliveCor: 87.8% (78.7% to 94.0%), 98.8% (97.0% to 99.7%), 96.7% (94.4% to 98.2%); WatchBP: 96.3% (89.7% to 99.2%), 93.5% (90.3% to 95.9%), 94.0% (91.3% to 96.1%): PH7: 96.3% (89.7% to 99.2%), 98.2% (96.2% to 99.3%), 97.9% (96.0% to 99.0%). BG2: 96.3% (89.7% to 99.2%), 98.5% (96.6% to 99.5%), 98.1% (96.3% to 99.2%). The PH7 and BG2 devices were highly reliable (the devices acquired sufficient data and obtained a diagnostic result in all but 1 participant on the first attempt). In conclusion, inexpensive, consumer heart rate monitoring devices (PH7 and BG2) can be used to detect AF accurately with sensitivity and specificity >95%. The consumer devices performed as well or better than WatchBP and AliveCor and have the capability to store or transmit ECG data which could be used to confirm AF.

Clinical and echocardiographic follow-up of patients following surgical heart valve repair or replacement: a tertiary centre experience.

International best practice guidelines recommend lifelong follow-up of patients that have undergone valve repair or replacement surgery and provide recommendations on the utilization of echocardiography during follow-up. However, such follow-up regimes can vary significantly between different centres and sometimes within the same centre. We undertook this study to determine the patterns of clinical follow-up and use of transthoracic echocardiography (TTE) amongst cardiologists in a large UK tertiary centre. In this retrospective study, we identified patients that underwent heart valve repair or replacement surgery in 2008. We used local postal codes to identify patients within our hospital's follow-up catchment area. We determined the frequency of clinical follow-up and use of transthoracic echocardiography (TTE) during the 9-year follow-up period (2009-2016 inclusive). Of 552 patients that underwent heart valve surgery, 93 (17%) were eligible for local follow-up. Of these, the majority (61/93, 66%) were discharged after their 6-week post-operative check-up with no further follow-up. Of the remaining 32 patients, there was remarkable heterogeneity in follow-up regimes and use of TTE. This variation did not correlate with the prosthesis type. In summary, the frequency of clinical follow-up and use of echocardiography is highly variable in contemporary practice. Many patients are inappropriately discharged back to their family doctor with no plans for hospital follow-up. These data further support the creation of dedicated specialist heart valve clinics to optimize patient care, ensure rational use of TTE and optimize adherence with best practice guidelines.

Stress echocardiography in contemporary clinical cardiology: practical considerations and accreditation.

Stress echocardiography is a widely utilised test in patients with known or suspected coronary artery disease (CAD), valvular heart disease and cardiomyopathies. Its advantages include the ubiquitous availability of echocardiography, lack of ionising radiation, choice of physiological or pharmacological stressors, good diagnostic accuracy and robust supporting evidence base. SE has evolved significantly as a technique over the past three decades and has benefitted considerably from improvements in overall image quality (superior resolution), machine technology (e.g. digital cine-loop acquisition and side-by-side image display) and development of second-generation ultrasound contrast agents that have improved reader confidence and diagnostic accuracy. The purpose of this article is to review the breadth of SE in contemporary clinical cardiology and discuss the recently launched British Society of Echocardiography (BSE) Stress Echocardiography accreditation scheme.

Incremental Prognostic Value of Stress Echocardiography With Carotid Ultrasound for Suspected CAD.

OBJECTIVES: This study hypothesized that ischemia and atherosclerosis assessment by ultrasound (US) may provide incremental prognostic information in patients with new-onset chest pain who do not have coronary artery disease (CAD). BACKGROUND: The clinical significance of atherosclerosis assessment by carotid US in patients undergoing stress echocardiography (SE) in such patients is unknown. METHODS: Consecutive patients with suspected angina but no history of CAD underwent simultaneous SE and US prospectively to assess myocardial ischemia and carotid plaque burden (CPB), respectively. Patients were followed up for major adverse events (MAEs)-all-cause mortality, nonfatal myocardial infarction, and unplanned coronary revascularization. RESULTS: Of 591 recruited patients, 580 (men, 46%; mean age 59 ± 11 years) patients were available for follow-up. SE demonstrated myocardial ischemia in 12%, but prevalence of carotid plaques was 59%. During a mean follow-up of 1,117 ± 361 days, 40 first MAEs occurred. In the multivariable regression model, pre-test probability (PTP) of CAD (p = 0.001), abnormal SE (p < 0.0001), and CPB (p < 0.0001) predicted MAEs. MAE rates per year increased from 0.9% versus 1.97% versus 4.3% versus 9.7% in patients with no carotid plaque and normal SE versus patients who had plaque and normal SE versus those with no plaque and abnormal SE versus patients with plaque and abnormal SE, respectively (p < 0.0001). In hierarchical analysis, plaque burden provided incremental prognostic value over PTP of CAD and SE; likewise, SE was incremental to PTP-CAD and CPB (p < 0.0001 for both). CONCLUSIONS: In patients with suspected stable angina without known CAD, simultaneous SE (for ischemia) and US (for atherosclerosis) provided incremental prognostic value.

Lesson of the month 1: Obesity hypoventilation (Pickwickian) syndrome: a reversible cause of severe pulmonary hypertension.

Obesity hypoventilation syndrome (OHS) is a condition in which an individual with a body mass index >30 kg/m2 develops daytime alveolar hypoventilation (defined as a resting PaCO2 >45 mmHg) that cannot be attributed to other pathologies. It is a condition with increasing prevalence and rising cost to healthcare systems worldwide. Right heart failure and pulmonary hypertension are well-known complications of this syndrome. Here, we present the case of a female patient with OHS who presented to our centre with severe pulmonary hypertension, which resolved with appropriate treatment. We also review this clinical condition and its diagnosis and management.