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Summary This case describes an unusual presentation of prosthetic valve endocarditis (PVE): an acute coronary syndrome. A 67-year-old male presented with cardiac sounding chest pain on a background of a short history of night sweats, weight loss and general malaise. Four months previously, he had undergone bio-prosthetic aortic valve replacement for severe aortic stenosis and single vessel bypass grafting of the obtuse marginal. Whilst having chest pain, his ECG showed infero-lateral ST depression. Early coronary angiography revealed a new right coronary artery (RCA) lesion that was not present prior to his cardiac surgery. Using multi-modality cardiac imaging, the diagnosis of PVE was made. An aortic root abscess was demonstrated that was causing external compression of the RCA. Learning points: PVE accounts for up to 20% of all cases of infective endocarditis. High clinical suspicion and early blood cultures before empirical antibiotics are key as the presentation of PVE can often be atypical. PVE rarely presents as an acute coronary syndrome. Potential mechanisms by which PVE may result in an ACS include coronary embolization, obstruction of coronary ostia by a large mobile vegetation and external coronary artery compression from an infective aneurysms/abscess. Repeat cardiac surgery is often required for high-risk PVE such as those caused by staphylococcal infection or severe prosthetic dysfunction.

Patients with CC-TGA entail long-term follow-up as they are at risk of developing high-degree AV block, systemic AV valve regurgitation and systemic ventricular failure. ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease).

Summary A 69-year-old male, an ex-smoker, was admitted with ongoing chest pain of 11 h duration. Past medical history included treated hypertension and gastro-oesophageal reflux disease. He delayed seeking medical attention as he assumed the pain to be due to indigestion and kept taking antacids without much symptomatic relief. Clinical examination on arrival was unremarkable. Admission 12 lead electrocardiogram (ECG) was diagnostic of a recent anterolateral myocardial infarction (MI) (Fig. 1A). Bedside trans-thoracic echocardiogram (TTE) confirmed an established anterolateral MI (Fig. 1B and Video 1). Unfortunately, en route to the cardiac catheter laboratory for a primary percutaneous coronary intervention (PPCI), he suffered a cardiac arrest, due to pulseless electrical activity. An urgent repeat TTE confirmed significant pericardial effusion due to myocardial rupture with thrombus in the left ventricular apex (Fig. 1C and Video 2). Attempts at resuscitating him were unsuccessful. It is rare to see and confirm a diagnosis of early myocardial rupture outside the autopsy room, as it is an extremely serious and lethal mechanical complication of acute MI. PEA in a patient with a first MI and without overt heart failure has a high predictive accuracy for this diagnosis. Anterior location of MI, age >70 years, and female sex are risk factors for myocardial rupture, while a patent infarct-related artery, either after PPCI or fibrinolytic therapy appears to be protective. As in this case, when time allows, TTE plays an invaluable role in diagnosing this condition

Infective endocarditis (IE) is a life-threatening condition with adverse consequences and increased mortality, despite improvements in treatment options. Diagnosed patients usually require a prolonged course of antibiotics, with up to 40–50% requiring surgery during initial hospital admission. We report a case of a 42-year-old intravenous drug user who presented feeling generally unwell, with lethargy, rigours, confusion and a painful swollen right leg. He was subsequently diagnosed with Proteus mirabilis endocarditis (fulfilling modified Duke criteria for possible IE) and deep vein thrombosis (DVT). He was successfully treated with single antibiotic therapy without needing surgical intervention or requiring anticoagulation for his DVT. Proteus endocarditis is extremely uncommon, with a limited number of case reports available in the literature. This case illustrates how blood cultures are invaluable in the diagnosis of IE, especially that due to unusual microorganisms. Our case also highlights how single antibiotic therapy can be effective in treating Proteus endocarditis.

Cardiac magnetic resonance (CMR) imaging demonstrated marked hypokinesia of the interventricular septum and right ventricular outflow tract free wall. [...]18F-fluorodeoxyglucose positron emission tomography (FDG-PET) was performed (figure 1D). (A) 12-lead ECG on admission (B) Cardiac magnetic resonance short axis late gadolinium enhancement image (C) 12-lead ECG recorded during palpitations, and (D) fluorodeoxyglucose positron emission tomography image.

Abstract A number of guidelines exist with recommendations for diagnosis and management of mitral stenosis (MS). We systematically reviewed existing guidelines for diagnosis and management of MS, highlighting their similarities and differences, in order to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (5/4/2011–5/9/2021), the Guidelines International Network, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two independent reviewers screened titles and abstracts, and the full text of potentially relevant articles where needed. Selected guidelines were assessed for rigor of development; only guidelines with Appraisal of Guidelines for Research and Evaluation II instrument score >50% were included in the final analysis. Four guidelines were retained for analysis. There was consensus for percutaneous mitral balloon commissurotomy as first-line treatment of symptomatic severe rheumatic MS with suitable anatomy. In patients with unfavourable anatomy, surgical intervention should be considered. Exercise testing is indicated if discrepancy exists between symptoms and echocardiographic measurements. There was no clear divide between rheumatic MS and degenerative MS for their respective diagnoses and management. Pregnancy in severe MS is discouraged and the stenosis should be treated before conception. Long-term antibiotic prophylaxis is recommended for patients with rheumatic MS. Recommendations for the management of patients with mixed valvular diseases are lacking.

IntroductionAtrial fibrillation (AF) is one of the top ten reasons for hospital admissions. Failure to recognise this arrhythmia and risk stratify patients early on diagnosis can have detrimental consequences including high risk of thromboembolic events, stroke, heart failure and death. An audit conducted in our hospital (2011–2012) revealed that patients with AF stay an average 5.6 days in hospital. It has been estimated that billions of pounds are spent each year from health and social care budgets due to AF and AF related strokes.1 To address this, a new service “Rapid access AF clinic (RAAFC)” was developed in our hospital in June 2012. This retrospective study explores the role of RAAFC on clinical outcomes since its introduction.Methods210 patients were seen in our clinic between 01/06/2012 and 30/10/2015. 56 patients were excluded from the analysis - – 41 due to lack of access to records, 1 found to be in CHB and 14 in sinus rhythm. 154 patients were included in the final analysis. Patients were divided in to 2 groups depending on the duration of their symptoms. Group A (symptoms <48 h, n = 49) were seen in clinic on the same day. After clinical assessment, patients were cardioverted with flecanide and if failed underwent electrical cardioversion. Group B (symptoms >48 h, n = 105) were advised rate control medications, anticoagulants and arranged for cardioversion after 6 weeks when maintained in therapeutic INR. Those with poor rate control or early signs of instability, underwent TOE guided cardioversion. Follow-up ranged from 3 months to a year.ResultsThe mean age of the patients was 63.8 ± 13.8 years and 67.5% were male. Patients characteristics at baseline are shown in Table 1 and final outcomes in Table 2. Worryingly 57.1% of the patients scored 2 or above on CHADS2Vasc risk assessment of which 61.4% were not on anticoagulants. During follow-up, a high proportion of patients (63.9%) were asymptomatic and 66.7% maintained in sinus rhythm. The average length of stay was 2.72 ± 8.44 h. Only 4 patients (0.04%) were readmitted prior to their initial follow-up due to recurrence of AF. Two patients in group B developed complications related to thromboembolism. One had left femoral artery embolism requiring embolectomy and the other had TIA 2 days following TOE guided cardioversion. The patient who had embolic event had CHADS2Vasc score of 2 and developed symptoms 3 days after commencing warfarin when INR was subtherapeutic.Abstract 49 Table 1Baseline characteristics clinical outcomesVariable (n = =154)< 48 h (n = 49) (%)> 48 h (n = 105) (%) Female14 (28.6%)34 (32.3%)Source of referralPrimarySecondarySelf15 (30.6%)20 (40.8%)14 (28.6%)70 (66.7%)18 (17.1%)17 (16.2%)CHA2DS2-VASc score0123+28 (57.1%)7 (14.3%)8 (16.3%)6 (12.2%)19 (18.1%)14 (13.3%)22 (21.0%)50 (47.6%)HASBLED 137 (75.5%)12 (24.5%)37 (35.2%)68 (64.8%)AnticoagulationAlready establishedWarfarinNOACNone11 (22.4%)9 (81.8%)2 (18.2%)38 (77.6%)41 (39.0%)40 (97.6%)1 (2.4%)64 (61.0%)Abtract 49 Table 2Clinical outcomesVariablenPercentage Maintaining Sinus RhythmIn AF723666.7%33.3%Readmissions prior to first follow up40.04%ComplicationStrokeTIAVTE0110.01%0.01%SymptomaticAsymptomatic396936.1%63.9%ConclusionsRAAFC appear very effective in preventing hospital admissions, reduce length of stay and also helpful in identifying high risk patients who benefit from anticoagulation. We recommend RAAFC initiated in each trust to lower morbidity, mortality and also costs to NHS.ReferenceCamm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation. The task force for the management of atrial fibrillation of the European Society of Cardiology. Eur Heart J. 2010;31(19):2369-–429

Abstract Multiple guidelines exist for the diagnosis and management of mitral regurgitation (MR), the second most common valvular heart disease in high-income countries, with recommendations that do not always match. We systematically reviewed guidelines on diagnosis and management of MR, highlighting similarities and differences to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (1 June 2010 to 1 September 2021), the Guidelines International Network, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two reviewers independently screened the abstracts and identified articles of interest. Guidelines that were rigorously developed (as assessed with the Appraisal of Guidelines for Research and Evaluation II instrument) were retained for analysis. Five guidelines were retained. There was consensus on a multidisciplinary approach from the heart team and for the definition and grading of severe primary MR. There was general agreement on the thresholds for intervention in symptomatic and asymptomatic primary MR; however, discrepancies were present. There was agreement on optimization of medical therapy in severe secondary MR and intervention in patients symptomatic despite optimal medical therapy, but no consensus on the choice of intervention (surgical repair/replacement vs. transcatheter approach). Cut-offs for high-risk intervention in MR, risk stratification of progressive MR, and guidance on mixed valvular disease were sparse.

Abstract Guidelines for the diagnosis and management of aortic regurgitation (AR) contain recommendations that do not always match. We systematically reviewed clinical practice guidelines and summarized similarities and differences in the recommendations as well as gaps in evidence on the management of AR. We searched MEDLINE and Embase (1 January 2011 to 1 September 2021), Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed as assessed by the Appraisal of Guidelines for Research and Evaluation II tool. Three guidelines met our inclusion criteria. There was consensus on the definition of severe AR and use of echocardiography and of multimodality imaging for diagnosis, with emphasis on comprehensive assessment by the heart valve team to assess suitability and choice of intervention. Surgery is indicated in all symptomatic patients and aortic valve replacement is the cornerstone of treatment. There is consistency in the frequency of follow-up of patients, and safety of non-cardiac surgery in patients without indications for surgery. Discrepancies exist in recommendations for 3D imaging and the use of global longitudinal strain and biomarkers. Cut-offs for left ventricular ejection fraction and size for recommending surgery in severe asymptomatic AR also vary. There are no specific AR cut-offs for high-risk surgery and the role of percutaneous intervention is yet undefined. Recommendations on the treatment of mixed valvular disease are sparse and lack robust prospective data.

ObjectivesTo investigate the association of the CharlsonComorbidity Index (CCI) with clinical outcomes after transcatheter aortic valve implantation (TAVI).BackgroundPatients undergoing TAVI have high comorbid burden; however, there is limited evidence of its impact on clinical outcomes.MethodsData from 1887 patients from the UK, Canada, Spain, Switzerland and Italy were collected between 2007 and 2016. The association of CCI with 30-day mortality, Valve Academic Research Consortium-2 (VARC-2) composite early safety, long-term survival and length of stay (LoS) was calculated using logistic regression and Cox proportional hazard models, as a whole cohort and at a country level, through a two-stage individual participant data (IPD) random effect meta-analysis.ResultsMost (60%) of patients had a CCI ≥3. A weak correlation was found between the total CCI and four different preoperative risks scores (ρ=0.16 to 0.29), and approximately 50% of patients classed as low risk from four risk prediction models still presented with a CCI ≥3. Per-unit increases in total CCI were not associated with increased odds of 30-day mortality (OR 1.09, 95% CI 0.96 to 1.24) or VARC-2 early safety (OR 1.04, 95% CI 0.96 to 1.14) but were associated with increased hazard of long-term mortality (HR 1.10, 95% CI 1.05 to 1.16). The two-stage IPD meta-analysis indicated that CCI was not associated with LoS (HR 0.97, 95% CI 0.93 to 1.02).ConclusionIn this multicentre international study, patients undergoing TAVI had significant comorbid burden. We found a weak correlation between the CCI and well-established preoperative risks scores. The CCI had a moderate association with long-term mortality up to 5 years post-TAVI.