Prospective multicentre cohort study of transthoracic echocardiography provision in the South West of the UK during the first wave of SARS-CoV-2 pandemic.

AIMS: It was predicted internationally that transthoracic echocardiography (TTE) would be vital during the SARS-CoV-2 outbreak. We therefore, designed a study to report the demand for TTE in two large District General Hospitals during the rise in the first wave of the SARS-CoV-2 pandemic in the UK. A primary clinical outcome of 30-day mortality was also assessed. METHODS: The TTE service across two hospitals was reconfigured to maximise access to inpatient scanning. All TTEs of suspected or confirmed SARS-CoV-2 patients over a 3-week period were included in the study. All patients were followed up until at least day 30 after their scan at which point the primary clinical outcome of mortality was recorded. Comparative analysis based on mortality was conducted for all TTE results, biochemical markers and demographics. RESULTS: 27 patients with confirmed SARS-CoV-2 had a TTE within the inclusion window. Mortality comparative analysis showed the deceased group were significantly older (mean 68.4, SD 11.9 vs 60.5, SD 13.0, p=0.03) and more commonly reported fatigue in their presenting symptoms (29.6% vs 71.4%, p=0.01). No other differences were identified in the demographic or biochemical data. Left ventricular systolic dysfunction was noted in 7.4% of patients and right ventricular impairment or dilation was seen in 18.5% patients. TTE results were not significantly different in mortality comparative analysis. CONCLUSION: This study demonstrates an achievable approach to TTE services when under increased pressure. Data analysis supports the limited available data suggesting right ventricular abnormalities are the most commonly identified echocardiographic change in SARS-CoV-2 patients. No association can be demonstrated between mortality and TTE results.

Diagnosis and Prognosis in Sudden Cardiac Arrest Survivors Without Coronary Artery Disease: Utility of a Clinical Approach Using Cardiac Magnetic Resonance Imaging.

BACKGROUND: Determining the pathogenesis of sudden cardiac arrest or periarrest without significant coronary artery disease is crucial for management and prognosis. Cardiovascular magnetic resonance (CMR) can detect morphological, functional, or tissue abnormalities, and we sought to evaluate the role of CMR in determining sudden cardiac arrest pathogenesis and prognosis in survivors. METHODS AND RESULTS: We retrospectively reviewed cardiac investigations and clinical outcomes in consecutive survivors of potentially fatal arrhythmias without coronary artery disease admitted to our institutions from 2008 to 2014. After coronary angiography and echocardiography, all underwent CMR and, when indicated, electrophysiology studies. Major adverse cardiac events (MACE), comprising significant nonfatal ventricular arrhythmia or death, was the primary outcome. Of 164 included subjects (65% men; mean age 48 [18-80] years), CMR contributed to the diagnosis in 80 (49%) and was decisive in 50 cases (30%). Dilated cardiomyopathy (n=27), myocarditis or sarcoidosis (n=22), occult myocardial infarction (n=13), and hypertrophic cardiomyopathy (n=9) were most frequent. Arrhythmic causes were found in 14% while no cause was identified in 36%. MACE occurred in 31% of subjects during a median follow-up of 32 months. MACE associated with presence of a CMR diagnosis, extent of late gadolinium enhancement, and left and right ventricular ejection fractions. Right ventricular ejection fraction was an independent predictor of MACE. CONCLUSIONS: CMR identified a likely pathogenesis for sudden cardiac arrest in nearly half of survivors in whom coronary artery disease had been excluded. One in 3 subjects had MACE; risk doubled in those with a CMR diagnosis and some CMR parameters-late gadolinium enhancement, left ventricular ejection fraction, and especially right ventricular ejection fraction-associated with prognosis.

Pacing in congenital heart disease - A four-decade experience in a single tertiary centre.

BACKGROUND: The increased risk of brady- and tachy-arrhythmias in the congenital heart disease (CHD) population means that cardiac rhythm management devices are often required at an early age and expose patients to device-related complications. The present study drew upon four decades of experience at a tertiary adult congenital heart disease ACHD center and aimed to investigate the indication for cardiac implantable electronic devices (CIEDs) and predictors of late device-related complication requiring re-intervention. METHODS: A retrospective review of pacing records of ACHD patients over forty years was carried out. The primary outcome measure was device related complication requiring re-intervention. RESULTS: Between 1970 and 2009, 238 structural CHD patients who received CIEDs with follow-up data were identified (structural group). As a comparator group, 98 patients with congenital conduction disease or long QT syndrome with a structurally normal heart (electrical group) were included in the study. During a mean follow-up of 9.6±8.5years, 72 (21%) patients (44 structural group, 28 electrical group) required ≥1 re-intervention due to device related complications. Multivariate analysis showed that age at the time of device implant was an independent predictor of late device-related complications (HR 0.77, 95% CI 0.60-0.98, p=0.04). Sub-analysis of the structural group showed that ACHD complexity (Bethesda guideline) was the only predictor late device-related complication in the structural group (HR 2.96, 95% CI: 1.67-5.26, p<0.01). CONCLUSION: Increasing age at device implant was inversely associated with late device-related complications. ACHD patients with complex anatomy are at increased risk of device-related complications at mid and long-term follow-up.

Simulation of cardiac emergencies with real patients.

BACKGROUND: Simulation training with manikin simulators for medical emergencies is increasingly used in medical training. The assessment of a manikin, in particular history and examination, is very different to that of a real patient. We sought to combine aspects of traditional simulation training with the assessment of real hospital in-patients. STUDY DESIGN: In-patients who had recently experienced a cardiac emergency were asked to recall their symptoms as if they were still present. Medical students assessed these patients in the role of foundation year-1 (FY1) doctors, supervised by core medical trainee (CMT) doctors, and were encouraged to formulate a differential diagnosis and initial management plan. The students filled in a questionnaire prior to, immediately after and 1 week after each simulation session. This included a self-assessment of confidence in managing cardiac emergencies, as well as knowledge-based questions on aspects of assessment and management of cardiac emergencies. We sought to combine aspects of traditional simulation training with the assessment of real hospital in-patients RESULTS: Confidence in managing cardiac emergencies was initially low, but significantly increased after one simulation training session (p < 0.001). This increase was sustained on re-assessment 1 week after the training session (p < 0.001). In addition to the increase in confidence, a significant and sustained increase in knowledge score was also observed (p < 0.001). CONCLUSION: Simulation training with real patients led to an immediate and sustained increase in self-assessed confidence. There was also an increase in medical knowledge of the assessment and management of cardiac emergencies. This simulation technique is inexpensive, easily reproducible and can be used to complement learning from traditional simulation training with manikins.

Macrophage differentiation and function in atherosclerosis: opportunities for therapeutic intervention?

The macrophage is exquisitely sensitive to its microenvironment, as demonstrated primarily through in vitro study. Changes in macrophage phenotype and function within the atherosclerotic plaque have profound consequences for plaque biology, including rupture and arterial thrombosis leading to clinical events such as myocardial infarction. We review the evidence for dynamic changes in macrophage numbers and macrophage differentiation within the atherosclerotic plaque microenvironment and discuss potential approaches to target macrophage differentiation for therapeutic benefit in cardiovascular disease.