Amerjeet Banning

Driving and arrhythmia: a review of scientific basis for international guidelines

In patients with arrhythmias, the most feared complication while driving is of driver incapacity resulting in a road traffic accident. Patients with implantable cardioverter-defibrillators (ICDs) may suffer incapacity as a result of device therapy itself. The aim of this review article was to examine the types of arrhythmia that occur while driving, the impact of arrhythmia on driving as well as evidence to support that driving itself can precipitate arrhythmias. We will also review the postulated mechanisms by which driving can precipitate arrhythmias. Finally, we will compare guidelines from the USA, Europe, and UK in fitness to drive in patients with arrhythmias and ICDs.

A propensity matched comparison of return to work and quality of life after stenting or coronary artery bypass surgery

Objectives We sought to determine (1) return to work (RTW) rates, (2) long-term employment (>12 months postprocedure), (3) time taken to RTW, and (4) quality of life (QoL), in patients treated with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Methods Questionnaires regarding RTW were sent to 689 PCI and 169 CABG patients who underwent PCI or CABG at University Hospitals of Leicester Trust, UK, from May 2012 to May 2013. QoL was also measured using the European QoL 5-dimensions questionnaire (EQ-5D). Responses from patients employed preprocedure were analysed using multivariate logistic regression. Propensity score-matching was further used to compare similar patient populations receiving PCI or CABG. Results The response rate was 38% (235 PCI and 88 CABG patients). 241 respondents (75%) were employed preprocedure. Of these 162 (93%) PCI and 51 (77%) CABG patients returned to work, whereas 147 (85%) PCI and 41 (62%) CABG patients were still employed at >12 months postprocedure. After propensity analysis, there was no significant difference between PCI and CABG patients in RTW, long-term employment, nor QoL. The median time taken to RTW was 6 weeks after PCI and 13 weeks after CABG (p=0.001). The effect remained significant after multivariate analysis (p=0.001) and propensity analysis (p=0.001). Conclusions In this first propensity score-matched study comparing RTW and QoL after PCI or CABG strict propensity matching indicates that RTW or QoL, is similar for PCI or CABG, albeit the number of matched pairs was small. There are differences, however, in delay in RTW.

A risk scoring system to predict coronary stent thrombosis

Abstract Objective: Stent thrombosis (ST) is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We aimed to develop a scoring system to predict the risk of ST following PCI. Research design and methods: Odds ratios (ORs) for risk factors associated with ST were identified from a meta-analysis based on a systematic literature review, and through consensus expert opinion (Delphi–RAND method). The combined ORs were used to calculate risk scores for acute (within 24 hours), early (within 30 days) and late (31 days to 1 year) ST. Risk scores were validated against patient-level data from the TRITON-TIMI 38 study. Twenty risk factors were identified. Results: The most highly predictive factor for early and late ST was “incomplete duration of dual antiplatelet therapy”. Derived total risk scores ranged from 0 to 22 for acute and early ST, and from 0 to 20 for late ST. Increasing scores were associated with an increasing risk of ST when applied to trial data. Model discrimination was 0.60 (p = .0028), 0.67 (p < .0001) and 0.66 (p < .0001) for acute, early and late ST respectively, indicating good discriminatory power for predicting ST. Key limitations included a lack of published data on acute ST, resulting in a risk score for this time point being based predominantly on expert opinion, and that it was not possible to map all risk factors to variables collected in the TRITON-TIMI 38 study. Conclusion: Our weighted scoring system may help to stratify ST risk and individualize antiplatelet therapy in patients undergoing PCI.

69 Development and Validation of a Stent Thrombosis Risk Scoring System

Introduction Coronary stent thrombosis (ST) is a rare but potentially lethal complication of percutaneous coronary intervention (PCI). Previous studies have identified various patient, lesion and procedure-related risk factors, but there are currently no risk scoring tools in clinical use. In this study, we aimed to develop a scoring system to predict the risk of ST at different time points following PCI, to help guide the potency and duration of antiplatelet treatment. Methods Two research methods were used to identify risk factors for acute (within 24 h), early (within 30 days), late (30 days to 1 year) and very late (more than 1 year after PCI) ST and their associated odds ratios (ORs). This included a systematic literature review and meta-analysis of studies that met certain pre-defined criteria, and a modified Delphi RAND panel to gain expert opinion from eight experienced interventional cardiologists (Figure 1). Abstract 69 Figure 1 A Bayesian model was used to combine the results of both methods to produce a list of risk factors for each time point with associated ORs and confidence intervals (CIs) (Figure 2). Abstract 69 Figure 2 The risk scores were validated by applying them to patient level data from the TRITON-TIMI 38 study and the discriminatory power was tested by developing receiver operator characteristic (ROC) curves for each time point. The ability of the risk scores to predict ST was tested using the Hosmer-Lemeshow goodness-of-fit test. Results In total, 20 risk factors (9 patient-, 3 lesion- and 8 PCI procedure-related) were found to significantly influence the risk of developing ST. The combined ORs with CIs for some of the risk factors common to all time points are shown in Table 1 below. Abstract 69 Table 1 Risk factor Acute STOR (95% CI) Early STOR (95% CI) Late STOR (95% CI) VLSTOR (95% CI) Discontinued dual antiplatelet therapy N/A 3.49 (2.17-5.30) 3.44 (2.09-5.36) 1.75 (0.97-2.92) Bifurcation lesion PCI 1.62 (1.17-2.19) 1.66 (1.18-2.26) 1.57 (1.00-2.34) 1.39 (0.92-2.01) Incomplete stent expansion 1.63 (1.08-2.38) 1.73 (1.14-2.55) 1.91 (1.19-2.94) 1.54 (0.98-2.31) Undersized stent relative to vessel 1.95 (1.18-3.03) 2.00 (1.24-3.07) 1.91 (1.17-2.96) N/A Diabetes mellitus 1.62 (1.24-2.07) 1.69 (1.29-2.18) 1.53 (1.08-2.10) 1.61 (1.04-2.36) The final weighted risk scores, divided into patient-, treated lesion- and PCI procedure-related factors ranged from 0 to 22, 0 to 22 and 0 to 20 for acute, early and late ST respectively. When applied to the patient cohort within the TRITON-TIMI 38 study, the related risk of ST was 0–1.53%, 0–3.85% and 0–0.96% for acute, early and late ST respectively. Model discrimination, measured by area under the ROC curve, was 0.60 (95% CI 0.54–0.67, p = 0.0028) for acute ST, 0.67 (0.61–0.73, p < 0.0001) for early ST and 0.66 (0.58–0.73, p < 0.0001) for late ST, indicating good discriminatory power for all 3 risk scores. Conclusions In conclusion, published data were combined with expert opinion to produce a weighted scoring system to predict the risk of acute, early, late and very late ST following PCI. This will be assessed prospectively in clinical practice. Use of such a tool will be invaluable in combination with established bleeding risk scores to tailor the potency and duration of antiplatelet therapy in patients undergoing PCI.

What Can We Do About Cardiogenic Shock

Cardiogenic shock (CGS) remains a significant clinical problem in cardiovascular medicine. Although history shows event rates have improved, they remain substantial. In 1942, the observations of Stead1 of shock syndrome resulting from failure of the heart were published, and death at this time in CGS was expected, that is, it was reported at 100%. Goldberg et al2 in 1977 to 1985 reported in-hospital mortality rates from CGS of 74% to 81%. Since the introduction of early percutaneous coronary intervention (P-PCI) for ST-segment–elevation myocardial infarction (STEMI), there has been a reduction in mortality from CGS. Even so, in the SHOCK trial (Should we Emergently Revascularise Occluded arteries for Cardiogenic Shock), the 30-day mortality of CGS patients randomized to early revascularization was 46.7%,3 and it has not changed in the past 16 years despite further pharmacological development (such as the TRIUMPH study4 [A Phase III International, Multi-Center, Prospective, Randomized, Double-Blind, Placebo-Controlled Study to Assess the Safety and Efficacy of Nitric Oxide Synthase Inhibition With Tilarginine Acetate Injection in Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction] testing the inducible nitric oxide synthase inhibitor tilarginine) and the introduction and testing of devices to support the myocardium such as the Intra Aortic Balloon Pump (eg, as in the IABP-II study5 [Intra-Aortic Balloon Pump]). Indeed to add to the problem, there have been data to suggest that CGS rates are rising. Kolte et al6 reported in 2014 that among 1,990,486 reviewed patients, the incidence of CGS rose from 6.5% in 2003 to 10.1% in 2010, which is likely to be because of improvements in very early mortality associated with P-PCI. Further insights come from Kunadian et al,7 who analyzed the data from the UK British Cardiovascular Intervention Society (BCIS) National Cardiovascular Outcomes Research (NICOR) database and also reported …

Chronic Total Occlusions

Chronic total occlusion (CTO) intervention remains a challenge in terms of percutaneous coronary intervention (PCI). Traditionally average success rates (60–70% British Cardiovascular Interventional Society—BCIS data), procedure duration, degree of radiation exposure, percieved and real procedural complications and need for specialized operator training and maintenance of procedure volume have led to negative perceptions on the value of CTO PCI. Absence of robust data proving hard end point clinical benefit also raise questions over cost efficacy when traditional markers such an incremental cost-effectiveness ratio (ICER) are used. However in the right patients with real-life debilitating symptoms despite medical therapy, CTO PCI can transform a patient’s quality of life—they being able to walk and exercise with friends and family without having to stop because of angina can be life changing. We know there are a significant number of patients who have life-limiting angina despite medication and who can languish with poor quality of life for many years. CTO PCI done properly so as to get good results can change that. Recent advances in techniques including the retrograde approach as well as newer generation stents have yielded better results and renewed interest in CTO treatment. Therefore, it is beholden to the trainee/new consultant or other interventionist becoming interested in CTO PCI to ensure the following: Learn the technique in a structured formal progressive manner, preferably under the mentorship of another more experienced CTO operator. Do cases in conjunction with experienced colleagues. Become totally familiar with antegrade techniques first. Audit their data including success rates. Look to proctorship when they consider techniques/kit they are not familiar with. Attend live interactive courses as part of their summative experiential learning curve. Understand the principles behind the various techniques and are aware of the complications associated with this sometimes technically demanding procedure. Are fully aware of the issues around contrast-induced nephropathy and especially around radiation protection. This chapter will detail ways of ensuring best practice with most likely chance of success for PCI-CTO. It will provide the evidence base where available and include tips and tricks for best clinical practice.

DEVELOPMENT OF A NOVEL SIDE-BRANCH STENT: IN-VITRO STUDY

Background: For coronary bifurcation lesions, provisional T-stent is the default strategy since two-stent strategies demonstrate worse outcomes in meta-analyses. An optimal side-branch stent design may prove otherwise. We have developed a totally novel user-friendly side branch stent with a

Contemporary considerations in left main stem treatment

Percutaneous interventional treatment for disease affecting the left main stem has historically been considered problematic for a number of reasons. Firstly its site, at the origin of the coronary tree, means that any percutaneous therapy has to be absolutely robust. A post-procedural occlusion of a mid or distal circumflex or right coronary artery, while less than ideal, carries far less risk than occlusive stent thrombosis affecting the left main stem. Only recently has stenting become predictably safe through advances in techniques, devices and adjunctive pharmacology. Secondly, left main stem disease is heterogeneous. Treating ostial/shaft disease is very different from treating complex distal bifurcation/trifurcation. Finally, and as a follow on, we have failed to develop standard strategies for bifurcation disease in general. Provisional crossover stenting appears to be the best there is currently, but for significant disease in the side branch (which may be the large circumflex) this procedure can be far from satisfactory. Despite some data on their value, bifurcation techniques such as double-kiss-crush appear to have failed to have been taken up. Unfortunately, up to 70% of LMS disease affects the distal bifurcation. Recent trial data have confirmed, however, that the role of PCI in LMS disease can be expanded. It remains essential that, if LMS intervention is being considered, the following basics are understood: one should know the published data, understand the angiogram in detail, consider the whole patient and their comorbidities, consider the risks; have a management strategy and specifically a PCI strategy (and especially be experienced in the various bifurcation techniques if appropriate), and be able to interpret intravascular imaging.

5 Developing a novel stent concept in the management of bifurcation disease

Introductions Provisional stenting is the accepted treatment for bifurcation disease, but techniques and stents for 1:1:1 disease can give sub-optimal results. We have developed a novel stent designed to be balloon modified in-situ to any bifurcation angle with no ingression of stent material into the main or side-branch lumen. Methods Following design discussions, and extensive Finite Element Analysis studies with our non-commercial Industry partner two prototype (ST04 and ST05) were laser cut from cobalt chromium. In-vitro testing included detailed quantitative Micro-CT and video evaluation in silicone bifurcation models of 2 shapes (λ, Y) and 3 angles (45o, 60o,75o), n = 36. Prototypes were assessed for crush resistance. Results Both prototypes showed successful longitudinally shortening (Figure 1). Mean distance from stent strut to vessel wall was 0.11+/-0.04mm (ST04), 0.09+/-0.02mm (ST05) in λ-60o indicating excellent apposition, with no protrusion into either lumen. Crush resistance in the malleable part was lower than the standard section (eg: ST04 malleable end = 0.13+/-0.01N/mm; regular part=0.32+/-0.01N/mm p < 0.001). Conclusions The results show proof-of-concept that a stent with a malleable end can be conformed to the side branch ostium with good apposition. This may translate into better outcomes for two-stent strategies in true bifurcation lesions. Abstract 5 Figure 1 Fly-through 3D reconstruction image viewing carina from the main branch (Y-45 angle, sample ST04 A9); there is complete coverage of the carina with no evidence of stent protrusion into the side branch lumen (*) or main branch lumen (+)

Complete revascularisation in patients with ST-segment elevation myocardial infarction and multivessel disease: contemporary data in context

Commentary on: Engstrom T, Kelbaek H, Helqvist S, et al. DANAMI-3—PRIMULTI Investigators. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet 2015;386:665–71.[OpenUrl][1][CrossRef][2][PubMed][3] Primary percutaneous coronary intervention is recommended in patients presenting with ST-segment Elevation Myocardial infarction (STEMI).1 In 40–60% of STEMI patients there is disease in non-infarct-related arteries (IRAs).2 Such patients have higher mortality rates and incidence of MI.3 Current guidelines suggest PCI should be undertaken to the IRA only.1 However, these were based on numerous, potentially selected-patient retrospective observational studies. The DANAMI-3-PRIMULTI investigators compared complete and culprit-only revascularisation in patients with STEMI and multivessel disease. PRIMULTI was a prospective multicentre open-label randomised controlled trial. Patients within 12 h of STEMI were initially … [1]: {openurl}?query=rft.jtitle%253DLancet%26rft.volume%253D386%26rft.spage%253D665%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0140-6736%252815%252960648-1%26rft_id%253Dinfo%253Apmid%252F26347918%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1016/S0140-6736(15)60648-1&link_type=DOI [3]: /lookup/external-ref?access_num=26347918&link_type=MED&atom=%2Febmed%2F21%2F2%2F73.atom