Tahir Hamid

Aortic balloon valvuloplasty: is there still a role in high-risk patients in the era of percutaneous aortic valve replacement?

OBJECTIVES To assess procedural and clinical outcomes in adults with severe aortic stenosis (AS) undergoing percutaneous aortic balloon valvuloplasty (PABV), who are considered unsuitable on initial assessment for surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI). BACKGROUND Surgical valve replacement provides better outcomes than conservative treatment for patients with severe symptomatic AS; however, patients with multiple comorbidities or hemodynamic instability carry a high operative risk. While TAVI offers an alternative to surgery, not all patients are suitable. This study looks at medium-term outcomes in a series of high-risk patients undergoing PABV. METHODS Pre- and postprocedure aortic valve gradients were measured by catheterization and echocardiography. Patients were assessed for symptomatic benefit and clinical outcomes. RESULTS Over 4 years, 42 patients underwent PABV. Mean clinical follow-up was 8 +/- 5.8 months and survival was 63%. Mean echocardiographic aortic valve gradient fell from 84.6 +/- 27 mmHg to 51.3 +/- 16 mmHg (p < 0.05). In 29% (12/42) patients, PABV was performed as a bridge to definitive AVR. Four had surgical AVR and six had TAVI. Two had successful noncardiac surgery. Four patients died in the periprocedural period and all were in cardiogenic shock. Patients were in New York Heart Association (NYHA) class IV decreased from 60% to 5% postprocedure (p < 0.05). CONCLUSION PABV is useful as a palliation or bridge to definitive therapy for treatment of patients with severe AS unsuitable for surgery. It is associated with good medium-term cardiac outcomes and enables some patients to receive definitive therapy.

Does the CHA2DS2-Vasc score predict procedural and short-term outcomes in patients undergoing transcatheter aortic valve implantation?

Background Transcatheter aortic valve implantation (TAVI) is associated with periprocedural and postprocedural morbidity and mortality. Currently, there is a paucity of risk stratification models for potential TAVI candidates. We employed the CHA2DS2-Vasc score to quantify the risk of 30-day mortality and morbidity in patients undergoing TAVI. Methods and results A retrospective analysis of registry data for consecutive patients undergoing TAVI at 3 tertiary centres in Northwest England between 2008 and 2013. The CHA2DS2-Vasc score and its modification—the R2CHA2DS2-Vasc score, which includes pre-existing renal impairment and pre-existing conduction abnormality (right bundle branch block/left bundle branch block, RBBB/LBBB)—were calculated for all patients. A total of 313 patients with a mean age of 80 (79.1–80.8) years underwent TAVI. The implanted devices were either the CoreValve or the Edwards-SAPIEN prosthesis. The 30-day mortality was 14.3% in those with a CHA2DS2-Vasc score ≥6, whereas it was only 6.2% in those with a score <6 (p=0.04). Using the R2-CHA2DS2-Vasc score, the difference was more pronounced with a 30-day mortality of 22.6% in those patients with an R2-CHA2DS2-Vasc score ≥7 compared to 6.0% in those with a R2-CHA2DS2-Vasc score <7 (p=0.001). In multivariable Cox regression analyses, there was a significant and independent relationship between the CHA2DS2-Vasc score (hazard ratio (HR)= 2.71, (1.01 to 7.31); p<0.05) and the modified R2CHA2DS2-Vasc score (HR=4.27 (1.51 to 12.07); p=0.006) with 30-day mortality. Conclusions Our study demonstrates the potential use of the CHA2DS2-Vasc or the R2CHA2DS2-Vasc score to quantify the risk of mortality in patients undergoing TAVI. This could have significant implications in terms of clinical as well as patients’ decision-making.

Use of the Impella Left Ventricular Assist Device as a Bridge to Recovery in a Patient with Cardiogenic Shock Related to Takotsubo Cardiomyopathy

The Impella Recover LP 2.5® (Abiomed Inc, Danvers, Massachusetts, USA) is an effective and minimally invasive left ventricular assist device and a useful tool in the treatment of patients undergoing high risk percutaneous coronary interventions and critically ill patients with poor left ventricular function. We present the use of the revised Impella Recover LP 2.5® left ventricular assist device, in a patient with acute heart failure and cardiogenic shock secondary to severe Takotsubo cardiomyopathy. The revised Impella Recover LP 2.5® left ventricular assist device is able to provide cardiac output of up to 2.5 l/min. The patient was weaned off the Impella device in 48 hours and was discharged on day 6 of admission without sequelae.

Prognostic value of demographic factors, pre-test probability scoring, exercise test diagnosis, and inability to exercise in patients with recent onset suspected cardiac chest pain

Aims: To assess the prognostic value of an inconclusive exercise test or inability to exercise in patients with recent onset suspected cardiac chest pain and to determine the independent predictors of events in these patients. Methods: This was an observational follow-up study of patients presenting to a rapid access chest pain clinic with a history of recent-onset suspected cardiac chest pain as referred by the family practitioner. The main outcome measure was a composite endpoint of death and acute coronary syndrome hospital admission. Results: The study cohort consisted of 1851 patients in whom a total of 147 events were recorded during a mean follow-up period of 4.1 ± 1.1 years. Those with events were significantly older (65.1 ± 12.5 years versus 56.4 ± 13.2 years, p < 0.001), had higher mean pre-test probability of coronary artery disease (CAD), and had higher prevalence of diabetes (18.4% vs. 13.6%, p < 0.001), hypertension (55.8% vs. 38.7%, p < 0.001), and smoking (36.7% vs. 25.4%, p = 0.03) than those without events. These patients were also more likely to have a positive exercise electrocardiogram (ECG) (15.6% vs. 8.6%, p < 0.001) or not have a diagnostic exercise test because of an inconclusive result or inability to exercise (60.5% vs. 28.6%, p < 0.001). Cox multivariate regression analysis showed that age (hazard ratio, HR 1.03, p < 0.001), pre-test probability of CAD (HR 1.08, p = 0.04), positive exercise ECG (HR 2.94, p < 0.001), and an inconclusive test or inability to exercise (HR 3.45, p < 0.001) were independent predictors of events. Conclusions: In patients with recent onset suspected cardiac chest pain, not having a diagnostic exercise ECG because of an inconclusive test or inability to exercise is an independent predictor of events and has similar prognostic implications to a positive exercise ECG. In addition, pre-test probability estimation at baseline is a robust indicator of clinical outcome. Future models of care need to incorporate early and increased access to non-exercise cardiac imaging techniques in order to meet the needs of this high-risk subgroup of patients.

The pressure wire as a diagnostic tool in patients with congenital cardiac disease.

The pressure wire has emerged as a useful tool to assess the clinical severity of moderate coronary artery lesions. We report a novel use of the pressure wire in adult patients with complex congenital cardiac disease in whom it was used in assessing pressures beyond the stenosis in the distal pulmonary artery, aorto-pulmonary collaterals, and across prosthetic tricuspid valves, where conventional catheters were unable to reach. We used this in three of our patients for assessment of pulmonary artery pressures and in two patients for assessment of pressures across a prosthetic St Jude® valve. Out of the three patients referred for assessment, only two had significantly raised distal pulmonary pressures enabling them to receive appropriate therapy. Out of the two patients with a prosthetic tricuspid valve, only one required surgery based on this assessment. We describe a novel use of the pressure wire in the functional assessment of adults with congenital cardiac disease in whom conventional catheter techniques may not be able to provide adequate data. It can be a guide to provide appropriate therapy and avoid unnecessary interventions in this patient group.

Annular sizing using real-time three-dimensional intracardiac echocardiography-guided trans-catheter aortic valve replacement.

Objective Transcatheter aortic valve replacement (TAVR) has been established as an alternative therapy for patients with severe aortic stenosis who are unfit for the surgical aortic valve replacements. Pre and periprocedural imaging for the TAVR procedure is the key to procedural success. Currently transesophageal echocardiography (TOE), including real-time three-dimensional (RT-3D) imaging TOE, has been used for peri-interventional monitoring and guidance for TAVR. We describe our initial experience with real-time three-dimensional intracardiac echocardiography (RT-3DICE), imaging technology for the use in the TAVR procedure. Methods We used RT-3DICE using an ACUSON SC2000 2.0v (Siemens Medical Solution), and a 10F AcuNav V catheter (Siemens-Acuson, Inc, Mountain View, California, USA) in addition to preoperative multislice CT (MSCT) in total of five patients undergoing TAVR procedure. Results Aortic annulus and sinus of valsalva diameters were measured using RT-3DICE. Aortic valve measurements obtained using RT-3DICE are comparable to those obtained using MSCT with no significant difference in our patients. Conclusions This small study of five patients shows the safe use of RT-3DICE in TAVR Procedure and may help the procedures performed under local anaesthesia without the need for TOE.

Emergency percutaneous aortic balloon valvuloplasty in a nonagenarian

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Benefit of endovascular stenting for aortic coarctation on systemic hypertension in adults.

BACKGROUND Endovascular stenting is a recognised treatment strategy for aortic coarctation (CoA) in adults. We assessed systemic hypertension control and the need for antihypertensive therapy after CoA stenting in adults. METHODS Data were collected prospectively on 54 patients (36 men; mean age: 34 ± 16 years) who underwent endovascular stenting for CoA over a 7-year period. Five patients were excluded as they did not attend follow-up appointments. Patients underwent clinical examination, including right arm systolic blood pressure (SBP) and 24-hour ambulatory blood pressure monitoring at baseline, 6-12 weeks and 9-12 months. RESULTS There was a significant fall in mean peak-to-peak systolic gradient (PG) across the CoA after stenting (26 ± 11 mmHg vs. 5 ± 4 mmHg; P<0.01). There were successive reductions in right arm SBP and ambulatory SBP at baseline, 6-12 weeks and 9-12 months post-procedure (right arm: 155 ± 18 mmHg vs. 137 ± 17 mmHg vs. 142 ± 16 mmHg, respectively; all P-values <0.01; ambulatory: 142 ± 14 mmHg vs. 132 ± 16 mmHg vs. 131 ± 15 mmHg, respectively; all P-values <0.01). Twenty-four patients had severe CoA (PG >25 mmHg before stenting); baseline SBP was significantly higher in severe versus non-severe patients (160 mmHg vs. 148 mmHg; P=0.02). The absolute reduction in PG after stenting was significantly higher in the severe group (31 ± 7 mmHg vs. 14 ± 5 mmHg; P<0.0001), but there was no significant difference in SBP between groups at 6-12 weeks (141 mmHg vs. 135 mmHg; P=0.21) or 9-12 months (139 mmHg vs. 139 mmHg; P=0.96). CONCLUSION Endovascular stenting of CoA results in a significant reduction in SBP at 6-12 weeks, which is sustained at 9-12 months, with similar outcomes in severe and non-severe CoA groups.

Prescription errors in the National Health Services, time to change practice.

Introduction Medication error is a major source of iatrogenic illness. Error in prescription is the most common form of avoidable medication error. We present our study, performed at two, UK, National Health Services Hospitals. Material and methods The prescription practice of junior doctor’s working on general medical and surgical wards in National Health Service District General and University Teaching Hospitals in the UK was reviewed. Practice was assessed against standard hospital prescription charts, developed in accordance with local pharmacy guidance. Results A total of 407 prescription charts were reviewed in both initial audit and re-audit one year later. In the District General Hospital, documentation of allergy, weight and capital-letter prescription was achieved in 31, 5 and 40% of charts, respectively. Forty-nine per cent of discontinued prescriptions were properly deleted and signed for. In re-audit significant improvement was noted in documentation of the patient’s name 100%, gender 54%, allergy status 51% and use of generic drug name 71%. Similarly, in the University Teaching Hospital, 82, 63 and 65% compliance was achieved in documentation of age, generic drug name prescription and capital-letter prescription, respectively. Prescription practice was reassessed one year later after recommendations and changes in the prescription practice, leading to significant improvement in documentation of unit number, generic drug name prescription, insulin prescription and documentation of the patient’s ward. Conclusion Prescription error remains an important, modifiable form of medical error, which may be rectified by introducing multidisciplinary assessment of practice, nationwide standardised prescription charts and revision of current prescribing clinical training.

Left Ventricular Angiography Post Primary Percutaneous Intervention-does it Predict Subsequent Left Ventricular Dysfunction?

Objectives: We aimed to assess whether LV dysfunction assessed by LV angiography (LVA) during PPCI for STEMI predicts subsequent LV dysfunction at follow up. Left ventricular (LV) function as assessed by echocardiography has been demonstrated to improve in the first 6 months following primary percutaneous coronary intervention (PPCI). Data regarding the predictive value of LV angiography (LVA) performed immediately following PPCI are limited. Methods: A retrospective analysis of our tertiary centre angiographic database was performed (2011-2013). Patients were divided into two groups based on LVA. Group 1: normal or mild LV dysfunction and group 2: moderate or severe LV dysfunction. Results: Complete dataset was available for 89 patients (of a total of 194). 28.1% (16 patients) in group 1 compared to 46.9% (15 patients) in group 2 failed to improve LV function from baseline as assessed by follow-up echocardiography. LV function on LVA correlated significantly with subsequent LV function at follow up (Spearman’s rho p=0.007). Binary regression analysis demonstrated that Symptom to Balloon Time (STB) was a significant predictor (OR 1.003, 95% CI 1.001-1.005, p=0.008) of lack of LV function recovery at a median follow up of 10 months. Patients in whom the thrombectomy catheter was used were less likely to have abnormal LV function at follow up (OR 0.214, 95% CI 0.063-0.730, p=0.014). Conclusions: Baseline abnormal LV function on LVA predicted LV dysfunction at follow up. Increased STB time and lack of thrombectomy catheter use are significant predictors of abnormal LV function at follow up. Condensed abstract: We aimed to assess whether LV dysfunction assessed by LV angiography (LVA) during PPCI for STEMI predicts subsequent LV dysfunction at follow up. A retrospective analysis of our tertiary centre angiographic database was performed (2011-2013). Patients were divided into two groups based on LVA - group 1: normal or mild LV dysfunction and group 2: moderate or severe LV dysfunction. Binary regression analysis demonstrated that Symptom to Balloon Time (STB) was a significant predictor (OR 1.003, 95% CI 1.001-1.005, p=0.008) of lack of LV function recovery at a median follow up of 10 months. Patients in whom the thrombectomy catheter was used were less likely to have abnormal LV function at follow up (OR 0.214, 95% CI 0.063-0.730, p=0.014). Baseline abnormal LV function on LVA predicted LV dysfunction at follow up. Increased STB time and lack of thrombectomy catheter use are significant predictors of abnormal LV function at follow up.