Rebecca Lane

Culprit Vessel Versus Multivessel Intervention at the Time of Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction and Multivessel Disease: Real-World Analysis of 3984 Patients in London

Background—It is estimated that up to two thirds of patients presenting with ST-segment–elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment–elevation myocardial infarction. Methods and Results—We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32–0.75; P<0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47–0.91; P=0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32–0.76; P=0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45–0.90; P=0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15–0.96; P=0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21–0.93; P=0.033). Conclusions—In this observational analysis of patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines.

Percutaneous coronary intervention of a circumflex chronic total occlusion using an epicardial collateral retrograde approach

Antegrade disobliteration of a chronic total coronary occlusion (CTO) may be technically difficult in spite of the use of customized equipment. Retrograde approaches via intramyocardial septal or bypass grafts have been described. We report a successful Percutaneous intervention of a proximal circumflex CTO using a retrograde approach via an epicardial collateral.

Achieving routine sub 30 minute door-to-balloon times in a high volume 24/7 primary angioplasty center with autonomous ambulance diagnosis and immediate catheter laboratory access

BACKGROUND In primary angioplasty (primary percutaneous coronary intervention [PPCI]) for acute myocardial infarction, institutional logistical delays can increase door-to-balloon times, resulting in increased mortality. METHODS We moved from a thrombolysis (TL) service to 24/7 PPCI for direct access and interhospital transfer in April 2004. Using autonomous ambulance diagnosis with open access to the myocardial infarction center catheter laboratory, we compared reperfusion times and clinical outcomes for the final 2 years of TL with the first 3 years of PPCI. RESULTS Comparison was made between TL (2002-2004, n = 185) and PPCI (2004-2007, n = 704); all times are medians in minutes (interquartile range): for TL, symptom to needle 153 (85-225), call to needle 58 (49-73), first professional contact (FPC) to needle 47 (39-63), door to needle 18 (12-30) (mortality: 7.6% at 30 days, 9.2% at 1 year); for interhospital transfer PPCI (n = 227), symptom to balloon 226 (175-350), call to balloon 135 (117-188), FPC to balloon 121 (102-166), first door-to-balloon 100 (80-142) (mortality: 7.0% at 30 days, 12.3% at 1 year); for direct-access PPCI (n = 477), symptom to balloon 142 (101-238), call to balloon 79 (70-93), FPC to balloon 69 (59-82), door to balloon 20 (16-29) (mortality: 4.6% at 30 days, 8.6% at 1 year). There was no difference between direct-access PPCI and TL times for symptom to needle/balloon. Direct-access PPCI was significantly quicker for the group than in-hospital thrombolysis for door to needle/balloon times due to the lack of any long wait patients (P < .001). CONCLUSIONS Interhospital transfer remains slow even with rapid institutional door-to-balloon times. With autonomous ambulance diagnosis and open access direct to the catheter laboratory, a median door-to-balloon time of <30 minutes day and night was achieved, and >95% of patients were reperfused within 1 hour.

High incidence of acute coronary occlusion in patients without protocol positive ST segment elevation referred to an open access primary angioplasty programme.

Background Primary percutaneous coronary intervention (PPCI) programmes vary in admission criteria from open referral to acceptance of electrocardiogram (ECG) protocol positive patients only. Rigid criteria may result in some patients with acutely occluded coronary arteries not receiving timely reperfusion therapy. Objective To compare the prevalence of acute coronary occlusion and, in these cases, single time point biomarker estimates of myocardial infarct size between patients presenting with protocol positive ECG changes and those presenting with less diagnostic changes in the primary angioplasty cohort of an open access PPCI programme. Methods We retrospectively performed a single centre cross sectional analysis of consecutive patients receiving PPCI between January and August 2008. Cases were categorised according to presenting ECG—group A: protocol positive (ST segment elevation/left bundle branch block/posterior ST elevation myocardial infarction), group B: ST segment depression or T-wave inversion, or group C: minor ECG changes. Clinical characteristics, coronary flow grades and 12 h postprocedure troponin-I levels were reviewed. Results During the study period there were 513 activations of the PPCI service, of which 390 underwent immediate angiography and 308 underwent PPCI. Of those undergoing PPCI, 221 (72%) were in group A, 41 (13%) in group B and 46 (15%) in group C. Prevalence of coronary occlusion was 75% in group A compared with 73% in group B and 63% in group C. Median 12 h postintervention troponin-I (25th–75th percentile) for those with coronary occlusion was significantly higher in group A patients; 28.9 μg/l (13.2–58.5) versus 18.1 μg/l (6.7–32.4) for group B (p=0.03); and 15.5 μg/l (3.8–22.0) for group C (p<0.001), suggesting greater infarct size in group A. Conclusions A number of patients referred to an open access PPCI programme have protocol negative ECGs but myocardial infarction and acute coronary artery occlusion amenable to angioplasty.

Regional systems of care after out-of-hospital cardiac arrest in the UK: premier league care saves lives

Out-of-hospital cardiac arrest (OHCA) is a common condition in the UK with an estimated annual incidence of 60,000.1 Clinical outcomes for this group can only be described as awful. Not only is the condition usually fatal, with survival to hospital admission/hospital discharge rates of 24% and 8%, respectively,2 but the cost of survival is frequently significant morbidity with the largest observational study ever assembled of over 400,000 OHCA victims recently reporting severe cerebral disability in the majority of survivors.3 Predictors of survival include time to first emergency response; witnessed arrest; effective bystander cardiopulmonary resuscitation; initial shockable rhythm; early defibrillation and prehospital return of spontaneous circulation (ROSC).2 Such variables demonstrate how survival is largely determined by the actions of the general public and immediate access to automated defibrillation equipment. Despite national public awareness campaigns, wide geographical variations in survival to discharge rates of between 1% and 8% are reported in the UK.4 The post-cardiac arrest care pathway for OHCA victims successfully resuscitated in the field varies, and may in part account for this observation. Highlighting the positive end of the survival spectrum, a Premier League football player who collapsed on the field in cardiac arrest ultimately survived with no reported neurological disability after total cardiac arrest duration of more than 70 minutes. The player concerned was transported to a tertiary cardiac centre bypassing two district hospitals en-route, while apparently in sustained cardiac arrest.5 Coronary artery disease accounts for between 40% and 90% of OHCA,6 with rarer cardiac causes including cardiomyopathies, channelopathies, systemic and infiltrative diseases and acute myocarditis. Currently, specialist cardiac facilities are routinely only made immediately available for those whose ROSC electrocardiogram clearly demonstrates ST-segment elevation (STE). This would implicate acute coronary artery occlusion as the culprit pathology, with the patient standing to benefit from primary percutaneous coronary intervention (PPCI). In 2010, the London Ambulance Service introduced a pathway of care to convey these patients directly to one of eight heart attack centres, where survival to discharge rates of up to 80% have been reported in those with ROSC on arrival.7 Data from the PROCAT – (Parisian out-of-hospital cardiac arrest) registry looking at coronary intervention and OHCA, would however suggest that PCI may confer a mortality benefit to a group beyond those displaying electrocardiographic STE.8 In 301 ROSC patients without STE routinely taken to coronary angiography, 78 had successful PCI with survival correspondingly increasing from 31% to 47% in this group. Importantly, this group only included OHCA of presumed cardiac origin. Such a group may be difficult to identify in the prehospital setting when other clinical data such as presence of chest pain and risk factor profile is not readily available, practically it may thus be easier to define them as those in whom a non-cardiac cause for the arrest is not immediately forthcoming. PROCAT findings would support previous work9 demonstrating that absence of STE does not exclude acute coronary occlusion, thus surely limiting its sensitivity and specificity as a selection tool to identify OHCA survivors who stand to benefit from immediate coronary angiography. Indeed, in a large Australian cohort of 2900 unselected ROSC patients, transfer to hospitals with 24-hour cardiac interventional facilities10 was shown to improve survival, although improved survival here is likely multifactorial with access to cardiac critical care facilities making a contribution. Optimal post-cardiac arrest care is resource intensive, requiring input from a variety of specialties: cardiologists with a special interest in intervention and dysrrhythmias; intensivists; neurologists; specialist nurses and a variety of therapists. Such complex care may be best delivered by a smaller number of experienced hospitals dealing with a higher volume of patients. Indeed, hospitals treating more than 40 such patients annually have been shown to have higher rates of survival to discharge11 and supports the evolution of designated ‘cardiac arrest centres’; a concept already endorsed by the American Heart Association.12 Within such centres, specialist treatments such as PPCI and therapeutic hypothermia (shown to improve neurological outcomes and survival13) can be instituted in a timely and well-rehearsed fashion by teams regularly treating survivors of OHCA. The development of such regional organization will inevitably raise concerns regarding longer transfer times for critically ill patients, though data exist to refute such fears.14 Furthermore, regional systems of care have been successfully instituted in the treatment of other time sensitive conditions such as STEMI, stroke and more recently trauma. Although providing only anecdotal evidence, the recent case of the professional footballer demonstrates how access to specialized care in selected cases can provide astounding results. Here, although likely non-ischaemic, the underlying cause of arrest was undoubtedly cardiac. With coronary interventional and other specialist facilities seemingly offering wide ranging benefit, it would seem attractive to suggest that access to specialist centres may benefit a broader subgroup of OHCA cardiac patients, beyond those in whom STE myocardial infarction after ROSC is clearly evident. However, exactly who stands to benefit the most from a routine admission policy, beyond this well-defined group, remains poorly understood. Routine admission of all OHCA patients to specialist centres would no doubt impose too large a burden on tertiary intensive care resources and in most cases would be of little benefit to the victim, even admission limited to those attaining ROSC, would present novel problems. Here, ROSC attained in a district hospital would warrant interhospital transfer (IHT), when in most of these cases ROSC would not imply meaningful survival is possible, indeed, many resuscitation attempts are terminated after a successful restoration of circulation. IHT in those deemed suitable would mean transferring critically ill patients long distances, placing an unpredictable burden on high-dependency ambulance crews, as well as receiving centres. Prehospital ROSC is however among the strongest predictors of survival.2 Those in this group in whom a non-cardiac cause to the arrest is not immediately forthcoming may indeed stand to benefit the most from routine access to specialist care. Comparing clinical outcomes in OHCA patients is fraught with difficulty. The population is heterogeneous with a broad variety of clinical factors impacting upon survival. National standardized data collection would afford an understanding of how these factors interact with admitting institution, to ascertain which subgroup of the total OHCA cohort beyond those displaying electrocardiographic STE stand to benefit the most from routine access to specialist care. A national database of OHCA patients will allow the identification of appropriate selection criteria for those most likely to benefit, on which feasibility for the development of a national network of designated ROSC centres can be assessed.

The prognostic significance of incomplete revascularization and untreated coronary anatomy following percutaneous coronary intervention: An analysis of 6,755 patients with multivessel disease

More than half of the patients undergoing percutaneous coronary intervention (PCI) have multivessel disease. Whether complete revascularization impacts long‐term mortality or whether selected patients or those with specific coronary anatomy benefit from complete revascularization is unclear.

No place like home: A case study of a patient discharged from an Intensive Care Unit for end of life care at home:

Introduction Both in the UK and internationally, discharge from an intensive care unit to home for end of life care is a rare and challenging occurrence. These challenges include clinicians’ ability to identify appropriate patients in whom it is possible to communicate with about their wishes and preferences, the critical nature of their condition and the interface between hospital and community services. Method We present a case report of a patient who had been admitted to hospital with a myocardial infarction and subsequently suffered a cardiac arrest, from which he was successfully resuscitated. Subsequently, he suffered multi-organ failure, but despite treatments, the ceiling of care was reached. With a poor prognosis, medical and nursing staff engaged in advance care planning to determine his wishes and preferences at the end of life and to facilitate his discharge from the intensive care unit to his home. Conclusion This case study has highlighted that through good communication amongst patients, families and professionals and collaborative working across boundaries and organisations, appropriate patients in the critical care setting can have a real choice regarding where they wish to be cared for and die at the end of their life.

Mid-to-long term mortality following surgical versus percutaneous coronary revascularization stratified according to stent subtype: An analysis of 6,682 patients with multivessel disease

Background Studies comparing coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) have largely been performed in the bare-metal stent (BMS) and first-generation drug eluting stent (F-DES) era. Second-generation DES (S-DES) have shown improved outcomes when compared to F-DES, but data comparing CABG with PCI using S-DES is limited. We compared mortality following CABG versus PCI for patients with multivessel disease and analyzed different stent types. Methods A total of 6,682 patients underwent multivessel revascularization at Harefield Hospital, UK. We stratified CABG patients into single arterial graft (SAG) or multiple arterial grafts (MAG); and PCI patients into BMS, F-DES or S-DES groups. We analyzed all-cause mortality at 5 years. Results 4,388 patients had CABG (n[SAG] = 3,358; n[MAG] = 1,030) and 2,294 patients had PCI (n[BMS] = 416; n[F-DES] = 752; n[S-DES] = 1,126). PCI had higher 5-year mortality with BMS (HR = 2.27, 95% CI:1.70–3.05, p<0.001); F-DES (HR = 1.52, 95% CI:1.14–2.01, p = 0.003); and S-DES (HR = 1.84, 95% CI:1.42–2.38, p<0.001). This was confirmed in inverse probability treatment weighted analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI had higher 5-year mortality with BMS (Δ = 15.5, 95% CI:3.6,27.5, p = 0.011) and FDES (Δ = 16.5, 95% CI:6.6,26.4, p<0.001), but had comparable mortality with CABG for PCI with SDES (Δ = 0.9, 95% CI: -9.6,7.9, p = 0.844), and when exclusively compared to CABG patients with SAG (Δ = 0.4, 95% CI: -8.0,8.7, p = 0.931) or MAG (Δ = 4.6, 95% CI: -0.4,9.6, p = 0.931). Conclusions In this real-world analysis, when adjusting for measured and unmeasured confounding, PCI with SDES had comparable 5-year mortality when compared to CABG. This warrants evaluation in adequately-powered randomized controlled trials.

Acute fulminant necrotizing eosinophilic myocarditis: early diagnosis and treatment

Necrotizing eosinophilic myocarditis is a rare but potentially fatal condition that requires prompt recognition and treatment. We describe a case of a young athlete presenting with chest pain and breathlessness, with evidence of rapidly deteriorating cardiac function. The condition was successfully treated with corticosteroids, with no evidence of residual myocardial damage. This is the first reported case to demonstrate the utility of cardiac magnetic resonance imaging for diagnosis and monitoring response to treatment. It also highlights the value of endomyocardial biopsy in establishing a tissue diagnosis in cases of fulminant myocarditis, in order to direct treatment appropriately.

P14 Part-task training with low-fidelity simulation is an effective method of pericardiocentesis training

Background Pericardiocentesis is a core skill for cardiologists. For those in UK training, a formative Direct Observation of Practical Skills (DOPS) assessment is mandated; however, the availability of practical pericardiocentesis training in clinical practice remains a challenge. The use of part-task trainers in practical skill training is well documented and allows trainees to learn in a safe environment away from the clinical setting.1 Their use specifically in teaching pericardiocentesis is less well reported. We present our experience of a novel practical ultrasound-guided pericardiocentesis training course. Summary of Work A half-day course was developed encompassing part-task training, and interactive lectures based on the European Society of Cardiology guidelines including indications, complications and the interpretation of echocardiographic appearances of pericardial effusions and tamponade. Part-task training was performed using an ‘Ultrasound-Guided Thoracentesis/Pericardiocentesis Simulator’ (Kyoto Kagaku co. ltd., model MW17) and Vivid-i (GE) echocardiography machine. The skill was demonstrated first by a Consultant cardiologist and was subsequently performed by each delegate. Each delegate repeated the procedure in the context of a clinical vignette, where the part-task trainer was accompanied by a patient monitor (Laerdel) to simulate changes in patient haemodynamic status during and after the procedure. This provided a framework for semi-structured debrief on skill performance and discussion of potential causes, complications and management of pericardiocentesis. All candidates completed matched pre- and post-course assessments involving Extended Matching and Multiple Choice Questions, and an evaluation form. All candidates on GMC-approved training schemes were able to complete DOPS assessments using the NHS e-portfolio system. Results Two half-day courses were each attended by six cardiology trainees and clinical fellows at ST3 +level. 100% (n=12) and 92% (n=11) rated the practical skills session as ‘very good’ or ‘good’ in usefulness and presentation respectively. 100% (n=12) of attendees reported the course met their educational needs ‘very well’ or ‘well’. Thematic analysis of feedback supported the use of practical part-task training for pericardiocentesis which met delegates’ expectations and training objectives. Quantitative analysis demonstrated significant improvement in assessment scores following the course (p<0.01; CI 3.37–6.46). Discussion Part-task training with low-fidelity simulation is a viable and effective method of pericardiocentesis training. It offers a valuable opportunity to develop this core practical skill in accordance with local and national training requirements, without compromising patient safety. Important limitations of the pericardiocentesis model used include the initial cost, damage to skin pads during training, and the lack of ventricular contraction which reduces echocardiographic fidelity. Reference 1. E Diederich, et al. The effect of model fidelity on learning outcomes of a simulation-based education programme for central venous catheter insertion. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare December 2015;10(6):360–367.