Matthew Jackson

Coronary access following TAVI – Selective coronary engagement using balloon-assisted tracking of a guide catheter extension

performing percutaneous coronary intervention (PCI) following transcatheter aortic valve implantation (TAVI) will become more frequent with the increasing use of TAVI in lower surgical risk populations. The ideal management strategy for coronary artery disease (CAD) in the setting of TAVI is not well defined and CAD is often left untreated prior to TAVI. Engaging the coronary ostia through the TAVI side cells can be challenging; techniques for rapid coronary cannulation, especially in the acute setting, need to be developed. We present a case demonstrating balloon-assisted tracking of a GuideLiner guide catheter extension to selectively cannulate the left coronary ostium and facilitate successful PCI for an acute coronary syndrome.

Transradial Secondary Access to Guide Valve Implantation and Manage Peripheral Vascular Complications During Transcatheter Aortic Valve Implantation

BACKGROUND Vascular complications from transfemoral (TF) secondary access during transcatheter aortic valve implantation (TAVI) are common. We compare our experience of transradial (TR) versus transfemoral secondary access during TAVI and describe techniques for performing iliofemoral arterial intervention from the transradial approach. METHODS All TAVI procedures with a single secondary access were included. Demographics, procedural details and 30-day outcomes were recorded. VARC-2 criteria were used for procedural complications. Procedures with TF primary access were stratified by the site of secondary arterial access. RESULTS Single secondary access was used in 199 cases, of which 20 were performed via non-TF access. Of the 179 TF primary access cases, 115 (64%) used TR secondary access and 64 (36%) used TF secondary access. In the TR cohort percutaneous vascular intervention was performed from the transradial approach in 19 cases (17%). Emergent TF secondary access was not required in any case. There were no differences in procedural time, radiation dose, contrast use, bleeding complications, stroke or mortality between the groups. There was one secondary access complication in the TF cohort and none in the TR cohort. CONCLUSIONS Transradial (TR) secondary access during TAVI is safe and feasible and may reduce the secondary access site vascular complication rate. With appropriate equipment, most peripheral vascular complications can be managed entirely via TR access avoiding unplanned femoral arterial access. TR secondary access should be considered the default approach for non-TF TAVI cases and can be considered for all TF cases as long as dedicated equipment is available.

The impact of diabetes on the prognostic value of left ventricular function following percutaneous coronary intervention: Insights from the British Cardiovascular Intervention Society

To study the relationship between diabetes mellitus (DM) and left ventricular (LV) function on outcomes following percutaneous coronary intervention (PCI).

97 Can pre-operative troponin levels predict post-operative mortality following non-cardiac surgery?

Introduction Despite advances in surgical and anaesthetic techniques, non-cardiac surgery still has a significant mortality. We hypothesised that pre-operative troponin levels might predict post-operative mortality. Methods Patients undergoing elective and urgent/emergency non-cardiac surgery excluding minor procedures were retrospectively assessed for known vascular disease (defined by diagnostic imaging or previous intervention rather than clinical assessment) and vascular risk factors including hypertension, treatment with lipid-modifying agents (irrespective of agent or dose) and chronic lung disease. Pre-operative high-sensitivity troponins and routine pre-operative bloods were recorded. Six- and twelve-month mortality data were collected; independent predictors of mortality and associations between pre-operative patient characteristics and pre-operative troponin were determined. Results 993 patients were assessed; 13% had an elevated pre-operative troponin with 3%>50 ng/L. 825 (83%) were elective patients; 8.6% had an elevated pre-operative troponin. Six-month mortality was 4.2% and 5.9% at twelve months. Elevated pre-operative troponin was associated with higher post-operative mortality; 2.5%, 12.5% and 25% for a troponin <17 ng/L, 17 – 49 ng/L and >50 ng/L respectively (figure?1). This trend was also evident at twelve months; 3.7%, 16.3% and 37% for the same troponin bands (figure 2). Lipid-modifying agents were independently associated with a lower rate of pre-operative troponin release (HR 0.446 (0.232 – 0.857) p=0.015). Impaired renal function (assessed as a continuous variable), emergency presentation and pre-operative troponin levels were independent predictors of six- and twelve-month mortality with emergency presentation the strongest predictor by hazard ratio (table 1). Age over 75 independently predicted twelve-month mortality only. Conclusion The role of pre-operative troponin monitoring and the prevalence of pre-operative troponin has not previously been established on an all-comer population. Pre-operative troponin level greater than 50 ng/L is an independent predictor of six and twelve-month mortality following non-cardiac surgery in an all-comers cohort although the mechanism of troponin release is not clear. The lower rate of troponin release associated with lipid-modifying medication has been seen in other studies (1). We hypothesise the known anti-inflammatory effects of statins may indicate a systemic inflammatory process responsible for the troponin release rather than unstable coronary disease. Further studies to assess this in the elective population may be useful to target pre-operative interventions. Reference Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. ?Berwanger O, Le Manach Y, Suzumura EA, et al. Eur Heart J2016Jan 7;37(2):177?–?85Abstract 97 Table 1Abstract 97 Figure 1Abstract 97 Figure 2

New-Onset Heart Failure in a Patient With a Pacemaker: An Unusual Cause

Anelderlywomanpresentedwithgrossperipheral edemaextending to the abdominal wall 2 months after a tissue aortic valve replacement for severe symptomatic aortic stenosis. Her immediate postoperative recovery had been complicated by developing atrial fibrillation associated with an uncontrolled ventricular rate, which was treated with bisoprolol and amiodarone, achieving cardioversion to sinus rhythm on discharge. Echocardiography demonstrated normal biventricular function with a well-seated, normally functioning aortic valve replacementandmoderately severemitral and tricuspid regurgitation.Preoperatively, she had only mild mitral regurgitation and tricuspid regurgitation.Onexamination, shehada regular pulseof60beats/ minandherbloodpressurewas 120/80mmHg.Cannonwaveswere visible in the jugular venous pressure waveform. Ten years earlier, she had undergone single-chamber ventricular pacemaker implantation for episodesof sinusnodediseasewith syncope and was awaiting a generator change but was otherwise well. Despite intensive intravenousdiuretic therapy, shedidnot improve. Her admissionelectrocardiogram(ECG)wasobtained (Figure). Questions:WhatdoesthisECGshow?Howwouldthisalteryour management? Interpretation Thepatientdevelopedsignificant rightheart failure shortly afterher valve operation. It was unlikely that her mitral and tricuspid valve lesionswould have progressed as quickly as they did given her normal biventricular function. Similarly, there was no evidence of recurrent tamponade as evidenced by the rim of residual pericardial fluidandherhemodynamic stability. Primarypumpfailurewas ruled out by her normal right ventricular (RV) function. Theelectrocardiogramdemonstrates appropriateRVpacingat a rate of 60 beats/min. However, retrograde P waves can be seen within the T waves, indicating retrograde ventriculoatrial conduction following ventricular pacing. This is pacemaker syndrome, and the resulting atrioventricular dysychrony accounts for the sudden deterioration in mitral and tricuspid valve function and associated symptoms.

88 Routine Post-Operative Troponin Screening for Myocardial Injury after Noncardiac Surgery (MINS) Events – A Single Centre Experience

Introduction The VISION study demonstrated an association between 30-day mortality after surgery and raised post-operative troponin levels.1 Subsequently, diagnostic criteria for ‘ischaemic’ MINS were established excluding non-ischaemic aetiology.2 We evaluated our initial experiences with post-operative troponin monitoring, to look in-depth at patients who suffer MINS events. Methods Pre- and post-operative high-sensitive troponins were checked on all elective and emergency surgical patients over 45 years of age with an inpatient stay of more than 2 days between August 2014 and June 2015. A MINS event was defined as in the VISION (1) study as any positive post-operative troponin. Thirty-day mortality after surgery was determined via HES data. Notes, pathology reports and discharge letters were reviewed for evidence of sepsis, prolonged tachycardia, multi-organ failure or significant bleeding (Hb loss of >5 g/l and/or total Hb <8 g/dl). Events were classified as ‘non MINS’, ‘unexplained MINS’ or ‘secondary MINS’ due to one of these provoking factors. Cox regression analysis was performed to assess association between variables. Results 388 patients were studied. 196 were male with a mean age of 69 years (range 45–95). 132 (34%) were emergency admissions. 245 (63.1%) had normal post-operative troponins (i.e. non MINS), with 81 (20.9%), 49 (12.6%) and 13 (3.4%) recording troponin levels of 17–50, 51–1000 and more than 1000 respectively. 21 of the positive post-op values represented a downward trend from pre-op tests, with a further 17 positive pre-op values falling into the normal range post-operatively.Abstract 88 Table 1 Types of MINS and 30 day mortality Pathophysiology Emergency N = 132 (% of total MINS) Elective N = 256 (% of total MINS) All surgery N = 388 (% of total MINS) 30 day mortality N = 11 (% of total mortality) All MINS events 82 60 142 8 (72.7%) Unexplained MINS 31 (37.8%) 39 (65%) 70 (49.3%) 0 (0%) Secondary to Sepsis 41 (50%) 15 (25%) 56 (39.4%) 8 (72.7%) Secondary to Bleeding 9 (11%) 5 (8.3%) 14 (9.9%) 0 (0%) Secondary to Tachycardia 1 (1.2%) 1 (1.7%) 2 (1.4%) 0 (0%) No MINS event 50 196 246 3 (27.3%) All patients 132 256 388 11 The 30 day mortality rate was 2.8% compared to 1.9% in VISION. Of the 11 deaths, 10 (90.9%) were emergency admissions. Two (18.2%) deaths occurred in patients exhibiting a downward trend in troponin and 3 (27.3%) had a normal post-operative troponin (i.e. did not suffer a MINS event). Discussion A raised post-operative troponin was associated with poor prognosis as suggested in the VISION study (p = 0.022 HR 0.213 [0.057–0.803]). Sepsis was also associated with a poor prognosis (p < 0.001 HR 0.08 [0.021–0.305]) as is emergency admission for surgery (p = 0.004 HR 0.05 [CI 0.006–0.392]). However, there was no mortality from ‘ischaemic’ MINS events (unexplained events and events secondary to tachycardia and bleeding). Whether MINS events are a separate clinical entity related to unstable or significant coronary disease or a reflection of other poor prognostic factors remains unclear. Further studies assessing coronary anatomy may be useful in delineating this further. References Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between Post-operative Troponin Levels and 30-Day Mortality among Patients undergoing Noncardiac Surgery. JAMA. 2012;307(21) Myocardial Injury After Noncardiac Surgery. VISION Study Investigators. Anaesthesiology, 2014;120: 564-–78

30 Do PRAMI and CVLPRIT represent real-life experiences of culprit-only PPCI? - a single centre observational study

Introduction The RCTs, PRAMI1 and CVLPRIT,2 have suggested that preventative PCI for multi-vessel disease identified during PPCI improves outcomes with higher rates of cardiovascular events in the culprit-only cohorts. Methods 1143 consecutive STEMIs at our centre from August 2011–2013 were retrospectively assessed for eligibility to one or both trials. 343 patients would have been suitable for PRAMI and 196 for CVLPRIT; termed ‘observational’ cohorts. Outcomes were determined from clinic letters, procedure reports and regional blood result reporting with mortality outcomes compared to ONS data. Results Over 36 months, our observational PRAMI cohort experienced fewer combined primary outcomes (13.9% vs 22.9%), comparable to the preventative PRAMI (Figure 1A) arm with only 8.5% undergoing additional early planned revascularisation. Our observational CVLPRIT cohort experienced numerically fewer MACE primary outcomes over 12 months (16.8% vs 21.2% Figure 1B) with 30 day event rates comparable to the preventative PCI cohort, despite only 9.2% undergoing additional early planned revascularisation. Abstract 30 Figure 1 A – Primary outcomes from PRAMI (1) cohorts, B – Primary outcomes from CVLPRIT (2) cohorts. Original graphs reproduced with permission with observational cohort outcomes superimposed Conclusion Our all-comers culprit-only PCI cohorts have better outcomes than those seen in the published RCTs suggesting a high-risk population may have been selected for inclusion. Reference PRAMI trial. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Eng J Med. 2013, 369(12), 1115–1123 CVLPRIT trial. Gershlick AH. Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015 Mar 17;65(10):963–972. Figure A was originally published in N Eng J Med, 369(12):1115–1123, D. S. Wald et al, Randomised Trial of Preventive Angioplasty in Myocardial Infarction, Copyright

154 Has the Introduction of the Pryor Risk Score Affected Our use of Coronary Angiography

Background NICE guideline CG95 for investigating chest pain of new onset (http://www.nice.org.uk/guidance/cg95) recommends calculating the Pryor risk score to determine the risk of significant coronary artery disease (CAD). Significant CAD is defined as a lesion >70% in a major epicardial artery or >50% in the left main stem (box 1 of the guideline). Patients with a calculated risk score of 61–90% should be investigated using invasive coronary angiography. Aim This study evaluates how use of the Pryor risk score has altered the pickup rate of significant CAD on invasive coronary angiography. Design Retrospective analysis of clinical data and angiography reports covering a 12 month period before and after the introduction of the Pryor score (Sept 2009–Sept 2010 and Jan 2013–Dec 2013 respectively). Method Patients were identified using the chest pain clinic database and data collected from medical notes. Pryor risk scores were calculated by the nurse specialist in clinic using the standardised Pryor risk score calculator circulated by the Cardiovascular Network. Significant CAD detailed on the angiography report was recorded. Statistical analysis was performed using a two-tailed Z-test for population proportions. Exclusions Patients who underwent invasive angiography for a reason other than a Pryor score of 61–90% were excluded as were patients with symptoms secondary to known CAD. Results In the pre-Pryor score group, 34 patients underwent angiography with 27 undergoing Bruce protocol treadmill testing prior to listing. In the Pryor score group, 31 patients underwent angiography. Both groups had similar demographics including gender, age and cardiovascular risk factors. Angiograms were graded into normal, minor disease or significant disease in one, two or three vessels. The results are seen in Table 1. Only seven (20.6%) patients in the pre-Pryor score group had no significant disease compared to fourteen (45.2%) patients in the Pryor score group (p = 0.034). Abstract 154 Table 1 Sept 2009–Sept 2010 Jan 2013–Dec 2013 Significance Normal 3 (8.9%) 4 (12.9%) p = 0.596 Minor disease 4 (11.8%) 10 (32.3%) p = 0.044 Single vessel 12 (35.2%) 6 (19.4%) p = 0.153 Two vessel 8 (23.5%) 9 (29%) p = 0.617 Three vessel 7 (20.6%) 2 (6.5% p = 0.098 Total 34 31 For patients with a risk score greater than 91%, local Trust policy is to perform a diagnostic angiogram for risk stratification (NICE guidance would suggest medical treatment without further investigation). Including these patients (Table 2), 73 angiograms were performed in 2013 with 29 (39.7%) having no significant CAD. Compared to the pre-Pryor score cohort, this still approaches statistical significance with a p value of 0.05. Abstract 154 Table 2 Sept 2009–Sept 2010 Jan 2013–Dec 2013 Significance Normal 3 (8.9%) 7 (9.6%) p = 0.116 Minor disease 4 (11.8%) 22 (30.1%) p = 0.039 Single vessel 12 (35.2%) 19 (26%) p = 0.33 Two vessel 8 (23.5%) 15 (20.5%) p = 0.73 Three vessel 7 (20.6%) 10 (13.7%) p = 0.36 Total 34 73 Conclusion This study suggests that the Pryor risk score puts significantly more patients through invasive angiography who do not have significant coronary disease. Whilst coronary angiography remains ‘gold standard’, it is not without risk and we question whether using exercise testing to subdivide the patients into ‘high’ and ‘low’ risk groups based on exercise capacity could lead to first-line invasive or non-invasive testing respectively to maximise the incidence of significant CAD found at angiography.