Gavin Blake

Contemporary management of and outcomes from cardiac device related infections

AIMS To describe the incidence and management of cardiac device infection. Infection is a serious, potentially fatal complication of device implantation. The numbers of device implants and infections are rising. Optimal care of device infection is not well defined. METHODS AND RESULTS We retrospectively identified cases of device infection at our institution between 2000 and 2007 by multiple source record review, and active surveillance. Device infection was related to demographics, clinical, and procedural characteristics. Descriptive analysis was performed. From 2000 to 2007, a total of 2029 permanent pacemakers and 1076 biventricular/implantable cardioverter-defibrillators (ICDs) or ICDs were implanted. Thirty-nine cases of confirmed device infections were identified--27 pacemaker and 12 bivent/ICD or ICD infections, giving an infection rate of 1.25%. Median time from implant or revision to presentation was 150 days (range 2915 days, IQR25% 35-IQR75% 731). Ninety percent of patients presented with generator-site infections. The most common organism was methicillin-sensitive Staphylococcus aureus (30.8%), followed by coagulase negative Staphylococcus (20.5%). Complete device extraction occurred in 82%. Of these, none had relapse, and mortality was 7.4% (n = 2/27). With partial removal or conservative therapy (n = 13), relapse occurred in 67% (n = 8/12), with mortality of 8.4% (n = 1/12). Median duration of antibiotics was 42 days (range 47 days, IQR25% 28-IQR75% 42 days). Re-implantation of a new device occurred in 54%, at a median of 28 days (range 73 days, IQR25% 8.5-IQR75% 35 days). Methicillin-Resistant Staphylococcus Aureus infection predicted mortality (P < 0.004, RR 37, 95% CI 5.3-250). Median follow-up was 36 months. CONCLUSION Cardiac device infection is a rare complication, with significant morbidity and mortality. Complete hardware removal with appropriate duration of antimicrobial therapy results in the best outcomes for patients.

Antiplatelet Agents in the Perioperative Period

OBJECTIVE To determine the use of the 3 major classes of antiplatelet drugs (aspirin, thienopyridines, and glycoprotein IIb/IIIa inhibitors), their management in the perioperative period, and the risks associated with premature withdrawal. DATA SOURCES We reviewed the PubMed, EMBASE, and Cochrane databases using the terms antiplatelet agents in the perioperative period, antiplatelet agents and management of bleeding, drug-eluting stents and stent thrombosis, substitutes for antiplatelet agents, and premature withdrawal of antiplatelet agents. STUDY SELECTION Randomized, double-blind, placebo-controlled trials; prospective observational studies; review articles; clinical registry data; and guidelines of professional bodies pertaining to antiplatelet agents were included. DATA EXTRACTION AND SYNTHESIS Two researchers independently read the selected abstracts and selected the studies that matched the inclusion criteria. Any discordance between the 2 researchers was resolved by discussion so that 99 articles were finally included. CONCLUSIONS Aspirin use should not be stopped in the perioperative period unless the risk of bleeding exceeds the thrombotic risk from withholding the drug. With the exception of recent drug-eluting stent implantation, clopidogrel bisulfate use should be stopped at least 5 days prior to most elective surgery. Use of glycoprotein IIb/IIIa inhibitors must be discontinued preoperatively for more than 12 hours to allow normal hemostasis. Premature withdrawal of antiplatelet agents is associated with a 10% risk of all vascular events. Following drug-eluting stent implantation, withdrawal is associated with stent thrombosis and potentially fatal consequences. No definitive guidelines exist to manage patients who are actively bleeding while taking these drugs.

A global perspective on psychosocial risk factors for cardiovascular disease.

Worldwide, there is variation in the incidence CVD with the greater burden being borne by low and middle-income countries. Traditional risk factors do not fully explain the CVD risk in populations, and there is increasing awareness of the impact the social environment and psychological factors have on CVD incidence and outcomes. The measurement of psychosocial variables is uniquely complex as variables are difficult to define objectively and local understanding of psychosocial risk factors may be subject to cultural influences. Notwithstanding this, there is a growing evidence base for the independent role they play in the pathogenesis of CVD. Consistent associations have been seen for general psychological stress, work-related stress, locus of control and depression with CVD risk. Despite the strength of this association the results from behavioural and pharmacological interventions have not clearly resulted in improved outcomes.

The Dublin cardiac arrest registry: temporal improvement in survival from out-of-hospital cardiac arrest reflects improved pre-hospital emergency care

AIMS Out-of-hospital cardiac arrest (OOHCA) survival remains poor, estimated at 3-7%. We aim to describe the incidence of OOHCA, survival from OOHCA, and the impact of improved pre-hospital care on survival from OOHCA. METHODS AND RESULTS A retrospective registry was established using multi-source information to assess survival from cardiac arrest following the introduction of several improvements in pre-hospital emergency medical care from 2003. Survival from OOHCA, from asystole/pulseless electrical activity, and from ventricular tachycardia/ventricular fibrillation was estimated. Adjusted per 100 000 population annual incidence rates from national population census data were calculated. Mean and median emergency medical services (EMS) response times to OOHCA calls were assessed. A total of 962 OOHCAs occurred from 1 January 2003 until 31 December 2008. Sixty-nine per cent (69%, n = 664) were male. Seventy-two per cent (72%, n = 693) occurred at home with 28% occurring in a public venue. Of these public venues, 33.9% (91 of 268) had an automated external defibrillator available. Bystander cardiopulmonary resuscitation (CPR) was in progress when emergency services arrived in 11% (n = 106) of the cases. Nineteen per cent (19.4%, n = 187) had a known prior cardiac history or chest pain prior to circulatory collapse. Overall survival to hospital discharge improved significantly from 2.6 to 11.3%, P = 0.001. Survival from ventricular fibrillation (VF) to hospital admission, rose from 28.6 to 86.3%, P = 0.001. Survival to hospital discharge from VF improved from 21.4 to 33%, P = 0.007. Mean EMS response times to the scene of arrest decreased from 9.18 to 8.34 min. Emergency medical services scene time, reflecting acute pre-hospital medical care, rose from 14.46 to 18.12 min. The adjusted incidence of OOHCA for our catchment population declined from 109.4 to 88.2 per 100,000 population between 2003 and 2008. CONCLUSIONS The incidence of OOHCA has declined but importantly, survival to hospital discharge has improved dramatically. Reduction in ambulance response time, resulting in earlier initiation of basic and advanced life support and earlier defibrillation, was associated with an increase in the proportion of victims found in VF rather than asystole and likely accounted for most of the improvement. Further improvements in response times and public education to improve bystander CPR rates should remain a priority.

MicroRNA Expression in Coronary Artery Disease.

The pathogenesis of atherosclerosis involves the interplay of inflammation, altered cellular activity, angiogenesis, and neointima formation. The main cellular participants in atherosclerosis include vascular endothelial cells, smooth muscle cells, and monocytes. The recent discovery of small, non-coding RNAs, microRNAs (miRNAs), and their influence on these processes has provided a greater molecular insight into atherosclerosis. This in turn has led to increase focus on the potential utility of miRNA subtypes as biomarkers for coronary artery disease. Furthermore miRNAs could potentially provide therapeutic targets for the treatment of atherosclerosis and its complications. In this review, we discuss the experimental and clinical evidence for the role of miRNAs in the pathogenesis of coronary artery disease, the limitations of the data and challenges facing the field.

The Brady Bunch? New evidence for nominative determinism in patients’ health: retrospective, population based cohort study

Objective To ascertain whether a name can influence a person’s health, by assessing whether people with the surname “Brady” have an increased prevalence of bradycardia. Design Retrospective, population based cohort study. Setting One university teaching hospital in Dublin, Ireland. Participants People with the surname “Brady” in Dublin, determined through use of an online telephone directory. Main outcome measure Prevalence of participants who had pacemakers inserted for bradycardia between 1 January 2007 and 28 February 2013. Results 579 (0.36%) of 161 967 people who were listed on the Dublin telephone listings had the surname “Brady.” The proportion of pacemaker recipients was significantly higher among Bradys (n=8, 1.38%) than among non-Bradys (n=991, 0.61%; P=0.03). The unadjusted odds ratio (95% confidence interval) for pacemaker implantation among individuals with the surname Brady compared with individuals with other surnames was 2.27 (1.13 to 4.57). Conclusions Patients named Brady are at increased risk of needing pacemaker implantation compared with the general population. This finding shows a potential role for nominative determinism in health.

The risks in risk prediction.

QRISK is an improvement in risk estimation for UK practitioners, but caveats remain

Ruptured Noncoronary Sinus of Valsalva Aneurysm An Unusual Cause of Chronic Right-Sided Heart Failure

A 34-year-old woman was transferred to our hospital for further investigation of a 1-year history of shortness of breath, bilateral transudative pleural effusions, and marked peripheral edema. Previous extensive investigations had not revealed a cause. On examination, there were marked dependent edema and a large left-sided pleural effusion. A continuous murmur was heard along the left sternal edge. Transthoracic echocardiogram demonstrated a bicuspid aortic valve with mild stenosis and an aneurysm of the noncoronary sinus of Valsalva. The right ventricle and right …

7 Correlation of aortic valve annular plane assessment by pre-procedural computed tomography versus on-table 3-dimensional rotational angiography

Background Accurate assessment of the aortic valve annular plane (AVAP) is critical during transcatheter aortic valve Implantation (TAVI) procedures, particularly for placement of balloon-expandable TAVI valves. Pre-procedural computed tomography (CT) angiography has typically been used to determine the AVAP. However, this may differ from the in-lab AVAP determined during the TAVI procedure due to differences in patient position between the two assessments or compromised quality of the CT dataset. The aim of this study was to assess the correlation between the AVAP obtained by pre-procedural CT angiography with in-lab AVAP assessment using 3-dimensional rotational angiography (3DRA). Methods Using a prospective TAVI database, patients undergoing trans-femoral TAVI who had had both pre-procedural CT angiography and on-table 3DRA were identified. The AVAP assessment by CT angiography was performed using 3Mensio software (Pie Medical Imaging). 3DRA assessment was performed using DynaCT (Siemens). Correlation was reported according to the concordance correlation coefficient (ρc). Results From a total of 113 patients undergoing TAVI between June 2014 and August 2017 in the Mater Private Hospital, 100 patients were eligible for inclusion in the analysis. The mean AVAP as assessed by CT angiography was LAO 8.6°±10.5° and caudal 1.8°±10.7°. The mean AVAP as assessed by 3DRA was LAO 9.9°±9.2° and caudal 5.11°±8.7° (figure 1). The concordance correlation coefficients for the LAO/RAO and cranial/caudal planes of the AVAP were 0.52 (95% CI: 0.38 to 0.66) and 0.56 (95% CI 0.43 to 0.68), respectively. The proportion of patients in whom there was a≥5° and ≥10° discrepancy between the CT and 3DRA assessments of the AVAP for the LAO/RAO, the cranial/caudal, and both LAO/RAO and cranial/caudal planes is shown in figure 2. Conclusions In this large consecutive patient series, correlation between pre-procedural CT and on-table 3DRA in the prediction of the AVAP was moderate. In approximately one-quarter of patients, there was a≥10° discrepancy in either the LAO/RAO or cranial/caudal plane, while in 10% of patients there was a≥10° discrepancy in both planes. These data support the value of an in-lab assessment of the AVAP to optimize clinical outcomes during TAVI procedures.

40 Transcatheter paravalvular leak closure; a single centre experience

Introduction Significant paravalvular leak (PVL) is estimated to occur in at least 1–2% of patients undergoing surgical aortic and/or mitral valve replacement, and 3–4% of patients undergoing percutaneous aortic valve replacement (TAVR). Surgery for repair of PVL is associated with a 30-day mortality of approximately 10%. Percutaneous closure of PVL has emerged as an alternative to surgical repair. Methods Using a prospective registry, we sought to examine the clinical outcomes of patients treated with percutaneous closure of PVL at a tertiary referral hospital in Ireland. Results A total of 21 patients (mean age 68 ±13 years, 76% male) were treated for PVL. Heart failure (HF) and haemolysis (HL) were the presenting symptoms in 62% and 24% of patients, respectively. The remaining 14% of patients presented with both HF and HL. Of the 21 prosthetic valves treated, 9 were in the mitral position, and 12 were in the aortic position. A total of 26 PVL procedures were performed in the 21 patients (mean of 1.2 procedures/patient). The mean number of plugs used per patients was 1.9 (range 0–4). There was one (3.8%) major adverse procedural complication (stroke) and two minor (7.7%) procedural complications (both vascular access complication treated with endovascular techniques). Among patients with HF as the presenting symptom (n=16), the mean NYHA class before and after percutaneous PVL closure was 2.6 ±0.62 versus 1.5 ± 0.63. None of these patients have required repeat surgery over a median follow-up of 20 months (IQR 9.5–32). Among patients with HL, clinical success was achieved in 2 of 5 patients (40%). A total of 6 deaths (28%) occurred in the patient cohort over a mean follow-up of 22 ±13.4 months. Thirty-day mortality was 0%. Figure 1 shows the Kaplan Meier Estimate of survival. Conclusions Patients with PVL represent a high-risk patient cohort. Percutaneous PVL offers a safe alternative to surgical PVL repair, and appears particularly effective in those patients who present primarily with HF as their presenting symptom. Abstract 40 Figure 1 Kaplan-Meier curve showing survival free from death by any cause