Explore the vast range of titles available.

BackgroundHypertension and aortic stenosis(AS) are the commonest causes of left ventricular hypertrophy (LVH) and share similar pathophysiological features. Whilst an increase in resting coronary blood flow (per gram of LV) has been observed in AS, reduced resting coronary blood flow (per gram of LV) has been observed in hypertension.AimWe aimed to compare coronary flow patterns in subjects with left ventricular hypertrophy and aortic stenosis, in subjects with left ventricular hypertrophy and hypertension, and in subjects without left ventricular hypertrophy or hypertension.MethodsWe recruited 31 subjects (mean age 63, 18 female). 10 subjects had LVH and severe AS, 11 had LVH and hypertension and 10 had no LVH and no AS, with LVH defined on echocardiography.Simultaneous invasive pressure and Doppler velocity measurements in each of the left coronary arteries were taken. We performed ‘wave intensity analysis’, which is a method for separating the coronary flow pattern in terms of ‘waves’ that are generated proximally (by the aorta and systemic arteries) and distally (by the myocardial microcirculation).ResultsMean resting coronary flow per gram of tissue (figure 1) was increased in participants with LVH secondary to AS (1.62±0.60ml/min/g) and reduced in participants with LVH secondary to HT(0.49±0.27ml/min/g), compared to participants with no LVH and no AS (1.47±0.73ml/min/g).Wave 6 (figure 2) is the backwards decompression wave (BDW) and is particularly important for myocardial perfusion. The BDW corresponds to the diastolic ’suction’ of blood down the coronary arteries during myocardial relaxation.The energy of the BDW was increased in LVH secondary to AS (31.1 x103Wm-2s-2) but was reduced in LVH secondary to HT (12.3x103Wm-2s-2) (p<0.05), compared to participants with no LVH and no AS (14.3x103Wm-2s-2).The energy of the BDW correlated with LV cavity pressure (r=0.84, p<0.001) and diastolic time (r=-0.62, p<0.001) only in LVH secondary to AS participants. In contrast, the BDW correlated with LV mass (r=-0.49, p=0.03) in participants with LVH secondary to HT and with no LVH and no AS, but not in participants with LVH secondary to AS.Abstract 2 Figure 1Mean coronary flow per gram of LV for each groupAbstract 2 Figure 2Intracoronary wave intensity in a participant with LVH secondary to hypertension (left) and in a participant with LVH secondary to aortic stenosis (right)ConclusionsIn hypertension, LVH is associated with reduced mean coronary flow and reduced myocardial ‘suction’ during diastole.However, in AS, the large pressure gradient between the LV cavity pressure and the aorta results in a large contractile force which is generated in systole and then released in diastole. This large diastolic force overwhelms any local impairment caused by the hypertrophied myocardium and contributes to high resting coronary flow in LVH that is secondary to AS, compared to LVH that is secondary to hypertension.Conflict of InterestNone

Aims: To assess left ventricular (LV) function before and after transcatheter aortic valve implantation (TAVI) using conventional echocardiographic parameters and global longitudinal LV strain (GLS) and compare outcomes between Edwards S3 and Evolut R valves. Methods and results: Data were collected for consecutive patients undergoing TAVI at Hammersmith hospital between 2015 and 2018. Of the 303 patients, those with coronary artery disease and atrial fibrillation were excluded leading to a total of 85 patients, which constituted our study group. The mean follow-up was 49 ± 39 days. In total, 60% of patients were treated with Edwards S3 and 40% Evolut R. TAVI resulted in an early improvement of GLS (−13.96 to −15.25%, P = 0.01) but not ejection fraction (EF) (47.6 to 50.1%, P = 0.09). LV mass also improved, especially in patients with marked baseline LV hypertrophy (P < 0.001). There were no appreciable differences of LV function improvement and overall LV remodelling after TAVI between the two types of valves used (P = 0.14). Conclusions: TAVI results in reverse remodelling and improvement of GLS, especially in patients with impaired baseline LV function. There were no differences in the extent of LV function improvement between Edwards S3 and Evolut R valves but there was a greater incidence of aortic regurgitation with Evolut R.

Objective To determine whether the instantaneous wave-free ratio (iFR) can detect improvement in stenosis significance after percutaneous coronary intervention (PCI) and compare this with fractional flow reserve (FFR) and whole cycle Pd/Pa. Design A prospective observational study was undertaken in elective patients scheduled for PCI with FFR ≤0.80. Intracoronary pressures were measured at rest and during adenosine-mediated vasodilatation, before and after PCI. iFR, Pd/Pa and FFR values were calculated using the validated fully automated algorithms. Setting Coronary catheter laboratories in two UK centres and one in the USA. Patients 120 coronary stenoses in 112 patients were assessed. The mean age was 63±10 years, while 84% were male; 39% smokers; 33% with diabetes. Mean diameter stenosis was 68±16% by quantitative coronary angiography. Results Pre-PCI, mean FFR was 0.66±0.14, mean iFR was 0.75±0.21 and mean Pd/Pa 0.83±0.16. PCI increased all indices significantly (FFR 0.89±0.07, p<0.001; iFR 0.94±0.05, p<0.001; Pd/Pa 0.96±0.04, p<0.001). The change in iFR after intervention (0.20±0.21) was similar to ΔFFR 0.22±0.15 (p=0.25). ΔFFR and ΔiFR were significantly larger than resting ΔPd/Pa (0.13±0.16, both p<0.001). Similar incremental changes occurred in patients with a higher prevalence of risk factors for microcirculatory disease such as diabetes and hypertension. Conclusions iFR and FFR detect the changes in coronary haemodynamics elicited by PCI. FFR and iFR have a significantly larger dynamic range than resting Pd/Pa. iFR might be used to objectively document improvement in coronary haemodynamics following PCI in a similar manner to FFR.

Symptomatic relief is the primary goal of percutaneous coronary intervention (PCI) in stable angina and is commonly observed clinically. However, there is no evidence from blinded, placebo-controlled randomised trials to show its efficacy. ORBITA is a blinded, multicentre randomised trial of PCI versus a placebo procedure for angina relief that was done at five study sites in the UK. We enrolled patients with severe (≥70%) single-vessel stenoses. After enrolment, patients received 6 weeks of medication optimisation. Patients then had pre-randomisation assessments with cardiopulmonary exercise testing, symptom questionnaires, and dobutamine stress echocardiography. Patients were randomised 1:1 to undergo PCI or a placebo procedure by use of an automated online randomisation tool. After 6 weeks of follow-up, the assessments done before randomisation were repeated at the final assessment. The primary endpoint was difference in exercise time increment between groups. All analyses were based on the intention-to-treat principle and the study population contained all participants who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02062593. ORBITA enrolled 230 patients with ischaemic symptoms. After the medication optimisation phase and between Jan 6, 2014, and Aug 11, 2017, 200 patients underwent randomisation, with 105 patients assigned PCI and 95 assigned the placebo procedure. Lesions had mean area stenosis of 84·4% (SD 10·2), fractional flow reserve of 0·69 (0·16), and instantaneous wave-free ratio of 0·76 (0·22). There was no significant difference in the primary endpoint of exercise time increment between groups (PCI minus placebo 16·6 s, 95% CI −8·9 to 42·0, p=0·200). There were no deaths. Serious adverse events included four pressure-wire related complications in the placebo group, which required PCI, and five major bleeding events, including two in the PCI group and three in the placebo group. In patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure. The efficacy of invasive procedures can be assessed with a placebo control, as is standard for pharmacotherapy. NIHR Imperial Biomedical Research Centre, Foundation for Circulatory Health, Imperial College Healthcare Charity, Philips Volcano, NIHR Barts Biomedical Research Centre.

It has been recognised for nearly 200 years that the human pressure waveform changes in shape with ageing and disease. The shape of the pressure waveform has been explained in terms of two fundamental models: the Windkessel (reservoir) and wave theory. In its simplest form the Windkessel model satisfactorily explains the pressure waveform in diastole but cannot model pressure changes in systole. Wave theory satisfactorily models the pressure waveform but predicts the existence of ‘self-cancelling’ forward and backward waves in diastole which are difficult to explain in biological terms. We propose that a hybrid reservoir–wave model better describes the pressure waveform and may enable assessment of aortic function from pressure measurements made at any large systemic artery.

IntroductionHeartFlow is a non-invasive technique for estimating fractional flow reserve (FFRCT) from computer tomography coronary angiography (CTCA). HeartFlow has been made available via an NHS England funded program since September 2018 and is now fully embedded within our stable chest pain pathway. The aim of this work was to evaluate the impact of HeartFlow, which replaced previous practice of stress testing for patients with moderate coronary lesions, and invasive angiography for those with severe stenoses on CTCA.MethodsWe reviewed 360 consecutive patients who underwent CTCA and FFRCT between September 2018 and June 2019. CT coronary angiograms and HeartFlow models were read by a cardiologist and radiologist. Clinical records of all patients were reviewed.ResultsAll patients referred for FFRCT had coronary stenoses greater than 50%. 72% had FFRCT≥0.8 and were discharged. 26% had FFRCT<0.80 and underwent invasive coronary angiography. 1% were unsuitable. Of the patients referred for invasive angiography, 39% underwent PCI, 14% were referred for bypass surgery, 5% had chronic total occlusions and 4% had no suitable targets for revascularization. 34% of patients with FFRCT<0.80 had discordant findings on invasive pressure wire assessment, and revascularization was deferred.ConclusionOur study demonstrates the impact of HeartFlow in a high-volume CTCA service. Two thirds of patients referred for HeartFlow, who would previously have undergone downstream testing, had negative results and the pathway stopped at that point. Of the patients referred for invasive assessment, significant disease was found in two thirds, and in one third significant stenoses were not identified.

Background/Objectives: Acute ischemic stroke is an uncommon but potentially devastating complication of Transcatheter Aortic Valve Implantation (TAVI). Despite improvements in device technology and procedural techniques, stroke rates have remained stable, with cerebral embolic protection devices demonstrating only limited efficacy to date. Therefore, the management of acute ischemic stroke complicating TAVI (AISCT) remains a key priority. We conducted a systematic review of the management of AISCT and provided multidisciplinary consensus recommendations for optimal management. Methods: PubMed, Google Scholar, and Cochrane databases were searched from inception to October 2023. All the original studies focusing on the treatment of AISCT were included. Non-English language studies, review articles, and studies in pediatric populations were excluded. Consensus recommendations were made by a working group comprising experts in stroke medicine and structural interventional cardiology. Results: A total of 18 studies met the inclusion criteria, including 14 case reports/series and 4 observational studies. No clinical trials were identified. The included case reports and series suggest that tissue-type plasminogen activator (tPA) and mechanical thrombectomy (MT) might be effective strategies for managing AISCT. However, significant bleeding complications were reported in two out of the four patients receiving tPA. Four observational studies also suggest an association between tPA and/or MT and improved functional outcomes and survival compared to conservative management. Higher bleeding rates were reported following tPA. Observational data suggest that there is currently little real-world utilization of either reperfusion strategy. Conclusions: There is an absence of high-quality randomized data to guide clinical decision making in this important area. Observational data suggest reperfusion strategies are associated with improved clinical outcomes once important confounders such as stroke severity have been accounted for. While MT can be recommended as the standard of care in appropriately selected patients, significantly increased rates of bleeding with tPA following large-bore arterial access raise important safety concerns. We present simple clinical guidance for AISCT based on the limited available data. Close multidisciplinary work and patient-specific consideration of ischemic and bleeding risk is essential.

Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective treatment for severe aortic stenosis across the spectrum of surgical risk cohorts. Subsequently, the dramatic increase in procedural volume worldwide has placed significant financial and logistical pressures on healthcare institutions, particularly regarding hospital length of stay (LOS), which can adversely affect patient flow. In this review article, we discuss different peri-procedural strategies developed to reduce LOS and facilitate early discharge after TAVI.

Introduction The ORBITA trial of percutaneous coronary intervention (PCI) versus a placebo procedure for patients with stable angina was conducted across six sites in the United Kingdom via home monitoring and telephone consultations. Patients underwent detailed assessment of medication adherence which allowed us to measure the efficacy of the implementation of the optimization protocol and interpretation of the main trial endpoints. Methods Prescribing data were collected throughout the trial. Self‐reported adherence was assessed, and urine samples collected at pre‐randomization and at follow‐up for direct assessment of adherence using high‐performance liquid chromatography with tandem mass spectrometry (HPLC MS/MS). Results Self‐reported adherence was >96% for all drugs in both treatment groups at both stages. The percentage of samples in which drug was detected at pre‐randomization and at follow‐up in the PCI versus placebo groups respectively was: clopidogrel, 96% versus 90% and 98% versus 94%; atorvastatin, 95% versus 92% and 92% versus 91%; perindopril, 95% versus 97% and 85% versus 100%; bisoprolol, 98% versus 99% and 96% versus 97%; amlodipine, 99% versus 99% and 94% versus 96%; nicorandil, 98% versus 96% and 94% versus 92%; ivabradine, 100% versus 100% and 100% versus 100%; and ranolazine, 100% versus 100% and 100% versus 100%. Conclusions Adherence levels were high throughout the study when quantified by self‐reporting methods and similarly high proportions of drug were detected by urinary assay. The results indicate successful implementation of the optimization protocol delivered by telephone, an approach that could serve as a model for treatment of chronic conditions, particularly as consultations are increasingly conducted online. Medical therapy for patients with stable angina optimised over 6 weeks of tele‐ health clinic visits. Treatment titrated to home blood pressure and heart rate measurements. Medication adherence confirmed using HPLC MS/MS and patient self‐reporting. Patients subsequently randomised to PCI or placebo procedure in the ORBITA trial. Adherence reassessed at final follow‐up. Self‐reported adherence was >96% for all drugs in both treatment groups at both stages. Proportion of expected drug detected was >90% for all first‐choice, protocol‐directed medicines at both stages. No significant between group differences at pre‐ randomisation or at follow‐up and medication taking patterns did not change following treatment with PCI. The study uses a simple model for optimisation of medical therapy in clinical practice using a telehealth approach with high levels of adherence.

Cardiac failure due to rapidly progressive valve disease is a rare complication of rheumatoid arthritis (RA) that can be challenging to manage. A patient with severe heart failure secondary to RA who, after failing to respond to medical therapy, underwent high-risk valve surgery and did remarkably well, with dramatic symptomatic improvement and essentially normalised left ventricular size and function as seen on follow-up echocardiography.