London Chest Hospital Research Articles

PO-04-147 LEADLESS PACING IN ADULT CONGENITAL HEART DISEASE PATIENTS: MULTI-CENTRE UK EXPERIENCE

A significant number of Adults with Congenital Heart Disease (ACHD) require cardiac rhythm management devices. Implantation of endocardial or epicardial pacemakers presents specific challenges in this population. The Micra leadless pacemakers have potential to overcome some of these challenges. To assess the utility of Micra implant in ACHD population. A retrospective analyses of Micra implants undertaken at Barts Heart Centre, London and Liverpool Heart and Chest Hospital in the ACHD population between 2020-2022. Data was collected from a prospective registry and electronic health records. Patients were contacted for follow-up data where necessary. 26 AV Micras were implanted across the two centres over two years. 52% females with mean age of 37 yrs. 42% were anticoagulated with warfarin or a DOAC. Underlying etiology – Figure 1. Micra indication – Table 1. Mean procedure and fluoroscopy times were 57±21min and 7±1 min. Access site was femoral in 77% and transjugular in 23%. Mean sensing and thresholds were 11±0.4mV and 0.6±0.09V at 0.24ms respectively. There were no acute procedural complications. Over a mean follow-up of 13 months there were no significant programming issues or change in pacing parameters. One patient had high thresholds and one died of non-cardiac causes. Micra implants should be considered in cases where endocardial or epicardial implants are contraindicated or represent an otherwise suboptimal approach. They have advantages in ACHD patients with complex cardiac anatomy, difficult venous access and need for repeat procedures. Larger multicentre studies and longer follow-ups are required.Tabled 1Table 1Micra Indicationn, %Failed endocardial system6,23Failed epicardial system6,23Bridge to CRTP3,12SVC occlusion3,12Other8,30 Open table in a new tab

31 Clinical outcomes of transfemoral vs transapical tavi: uk single-centre early tavi experience

Background Transcather Aortic Valve Replacement (TAVI) started at Barts Health NHS Trust (London Chest Hospital) in 2008. It was the beginning of a new era for patients with severe aortic stenosis who were not fit enough for surgery; giving another treatment opportunity to our patients. Methods Data was collected on patients who underwent TAVI between January 2009-January 2015, comparing transapical (TA) and transfemoral (TF) approaches using appropriate statistical tests. The clinical outcomes included 30 day mortality, mean Log-EuroScore, renal function and complications. Results Over the 6 years, there was a total of 79 TA (39.1%) and 123 TF (60.9%) TAVI procedures. 30 day mortality included TA 3.8% Vs TF 4.1% (p=0.213); with Mean Log-EuroScore being 19.68 TA and 20.07 TF (p=0.879), which improved over the years. Mean hospital stay for TA was 13 days and TF was 11 days. Patients who had an eGFR 150 ml was 36.8% in TA patients and 35.8% in TF patients. With the former patient group, TA patients had a statistically significant post-TAVI AKI with worsening eGFR than TF (p=0.0013). Also, these TA patients had a longer hospital admission (mean=18.14 days) compared to TF (mean=10.32 days). Those patients with eGFR The complications during TAVI procedures included major bleeding (TA 6.33% Vs TF 9.76% p=0.081), arrhythmia/cardiac arrest (TA 3.80% Vs TF 0.81% p=0.408) and cardiac tamponade (TA 0% Vs TF 4.07% p=0.185). Other complications like para-prosthetic leak accounted for TA 8.47% Vs TF 14% (p=0.700), and intra-operative regurgitation TA 11.43% Vs 21.28%TF (p=0.589). Conclusions Both TA and TF approaches were observed to have similar clinical outcomes over those 6 years, except for those TA patients with poor renal function (eGFR

Ellis Jacob Epstein

Ellis Jacob Epstein was born to Dora and Charles Epstein, who lived in Broughton, Salford. He had an older sister, Evelyn, and a younger brother, Bernard. He went to school...

An audit on the documentation of the interpretation of chest radiographs following thoracic surgery

s / International Journal of Surgery 11 (2013) 589e685 614 ABSTRACTS Conclusions: Whilst discharge documentation has improved, significant deviation from local guidelines remains and is principally due to use of antiplatelet therapy after mitral repair. 0941: AN AUDIT ON THE DOCUMENTATION OF THE INTERPRETATION OF CHEST RADIOGRAPHS FOLLOWING THORACIC SURGERY Daron Nazari , Kapil Sugand , Martin Yates , Ian Hunt . 1 St George's University of London, London, UK; 2 Imperial College London, London, UK. Aims: All patients undergoing thoracic surgery at our institution undergo post-operative and post-drain removal chest radiographs (CXR). General Medical Council (GMC) Good Medical Practice guidelines state that the interpretation of all investigations should be documented by the requesting physician. The aim of this audit was to assess compliance with GMC standards. Methods: A prospective audit was carried out of all patients who underwent thoracic surgery between 1st November and 7th December 2012. Quality of documentation within the patient record was assessed by a single investigator for both the post-operative and the post-drain removal CXR's. For each CXR, basic demographics (date, patient details and physician identification) and the presence or absence of post-operative pulmonary complications were assessed. Results: During the period of study 63 patients underwent thoracic surgery. 49(78%) patients had documentation of post-operative and 46(73%) post-drain removal CXRs. However, more detailed clinical information was included in only 9(14%) and 12(19%) of records respectively. Conclusions: There is a suboptimal level of documentation of routine CXRs post-thoracic surgery. Improvement, therefore, is crucial in recording the presence or absence of radiographic post-operative complications in patient records. A pro forma for CXR documentation has been introduced and re-audit is currently in progress. 0982: THE EUROSCORE II IS A BETTER PREDICTOR OF MORTALITY THAN LOGISTIC EUROSCORE FOR PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE IMPLANTATION Ashok Kar, Daniel Moffat, Simon Kennon, Anne Malecki, Wael Awad. London Chest Hospital, London, UK. Objectives: Patient selection for transcatheter aortic valve implantation (TAVI) is critical because of proven efficacy for conventional aortic valve surgery (AVR). Currently available risk scoring systems are known to be inadequate; logistic Euroscore (LES) over predicts mortality for AVR. This study compared predictive ability of the new EuroSCORE II (ES2) with LES in patients undergoing TAVI. Methods: All patients undergoing TAVI (January 2009 September 2012) were identified from our registers. LES and ES2 scores were calculated and predicted mortalities for the 2 scoring systems compared with that observed. Results: 124 patients underwent TAVI: 3 cases were excluded due to insufficient data. Mean age of patients (n1⁄4121) was 81.9 years (75 e 91). Mean predicted LES was 21.6 12.6 compared to 7.7 6.2 for ES2; paired student t-test showed ES2 to be significantly lower (p 60kg. This may contribute to longer hospital admissions and more patients being discharged in AF. Other cardiac units should be encouraged to audit local practice and initiate change to guidelines. 1225: PRE-OPERATIVE TOPICAL ANTISEPTICS AND POST-OPERATIVE INFECTION RATES IN CARDIOTHORACIC SURGERY: META-ANALYSES OF PROSPECTIVE STUDIES Sudeep Das De. University of Cambridge, Cambridge, UK. Aim: To investigate the role of routine pre-operative topical antiseptic agents in cardiothoracic surgery. Background: Staphylococcus aureus is a major cause of post-operative infection after open-heart surgery, with the patient's endogenous flora as the principal source. However the routine use of pre-operative topical antiseptics in all cardiothoracic patients has not been established. In a meta-analysis, we quantitatively assessed the associations reported in prospective studies of routine use of preoperative topical antiseptics. Methods and Results: Studies were identified by computer-assisted searches of the published literature and scanning of relevant reference lists. The following was abstracted: size and type of cohort, mean age, mean duration of follow-up, and the relative risk ratio of developing a post-operative infection when using topical antiseptic agents. There were 5 studies reporting the use of pre-operative chlorhexidine and 4 studies on topical mupirocin. The combined relative risk ratio of developing a postoperative infection when using topical chlorhexidine versus the control armwas 0.47 (CI 0.39-0.63, p<0.05). The combined relative risk ratio when using topical mupirocin of developing an infection was 0.43 (CI 0.32-0.72, p<0.05). Conclusion: Published prospective studies provide good evidence to support the routine use of preoperative topical antiseptic agents.

Fixing Hearts and Protecting Minds

Ischemic heart disease is a significant cause of mortality and morbidity in Western populations. Consistent with this, coronary artery bypass graft (CABG) surgery remains one of the most frequently performed major surgeries. Improved survival rates mean that our research focus now extends beyond surgical technique to include quality of postoperative outcome. Postoperative cognitive dysfunction (POCD) has emerged as one of the most challenging and hotly debated issues, with increasing impetus to answer the unresolved question: does fixing the heart come at a cost to the brain? CABG surgery is associated with neurological events including stroke in 1.6%1 and delirium in 5.8%2 of patients. Beyond these severe and marked alterations to neurological function, there has been a widely held belief that CABG surgery is associated with POCD, which may presage a decline toward dementia. Research has been influenced by the 1995 Consensus Statement3 into the study of POCD in patients undergoing CABG surgery. Although the methods of investigation set forth by the Consensus Statement achieved widespread acknowledgment, its specific recommendations have not always been followed.4 Despite significant methodological issues, it seems that the balance of interpretation has historically been in favor of CABG surgery as a cause of significant POCD. More recently, however, a review of a series of publications from a well-controlled longitudinal cohort study conducted at Johns Hopkins5 and a meta-analysis6 suggested that cognition is in fact stable or may even show some improvement after CABG surgery in the majority of patients, at least within the first year (Figures 1 and 2). There is little doubt that POCD affects some patients in the short term, but the pathophysiological mechanisms underlying this and the influence on longer-term cognitive function remain uncertain. For research to progress, we require a paradigmatic shift in our focus from …

OP0112 Cystic fibrosis related arthritis in adults in south east england

BackgroundAlthough bone and joint manifestations are common in children with cystic fibrosis (CF), they have received little attention in adults. CF-related arthropathy (CFA) is a relatively infrequent complication previously reported...

Christopher Patrick Silver

Christopher Patrick Silver was educated at King’s School, Bruton and Hertford College, Oxford. He was a house officer in Sheffield, where it is reported that, when not tending patients, he...

132 The utilisation of non-cardiac services by a heart attack centre

Introduction Most patients with ST-elevation myocardial infarction (STEMIs) within the London area are transferred to Heart Attack Centres (HAC) for primary percutaneous coronary intervention. HACs may be stand-alone centres, combined with cardiac surgery and cardiac ITU or part of a large single site acute hospitals. It is not clear whether these different models impact on patient pathways and care. We investigated the utilisation of non-cardiology services (including cardiac surgery and ITU) of patients admitted to a single London HAC. Methods We undertook a retrospective data analysis of 300 consecutive patients presenting with ST-elevation myocardial infarction to the London Chest Hospital, Barts and The London NHS Trust between January and June 2009. The cardiology databases and hospital care record systems were examined to identify all episodes and encounters generated by non-cardiology clinical activity. We also assessed use of cardiac surgery and intensive care during the index admission. Results Twelve (4%) of patients with STEMIs presenting to a HAC required clinical services outside the HAC infrastructure. 6 (2%) required either telephone advice or visit from a non-cardiac specialist and 6 (2%) required in-patient transfer to another clinical service. Inpatient transfer was due to complications of coronary intervention 3 (1%) or for management of newly diagnosed/ chronic non-cardiac conditions 3 (1%). No adverse outcomes were recorded due to delays in accessing non-cardiac care. ITU admission was required in 13 (4%) of HAC patients. The mean length of ITU stay was 11 days and the HAC service required an average of 0.8 ITU beds/day. Eighteen (5%) of HAC patients required inpatient CABG, 8/18 as emergency procedures. Conclusion Almost all STEMI patients can be managed within a HAC, and the utilisation of non-cardiac services is minimal suggesting that HACs can be located separately from acute general hospitals. However the importance of ITU and cardiac surgical services suggests that patient pathways are safer and more efficient if these services are on-site with the HAC. The greater risks of adverse outcomes following emergency surgery is another implication for surgical centres attached to the HAC.

Brenda Moffat Dudley (née MacAdam)

Brenda Moffat Dudley (nee MacAdam) followed the family tradition of entering into a medical career, and, after qualifying, worked at the Whittington Hospital, London Chest Hospital, …

Peter McAllister Elder

After qualifying, Peter McAllister Elder worked at the London Chest Hospital, meeting his future wife, Margaret, during an air raid. Wartime service included Bomber Command, South Africa, …

Raphael Balcon MD FRCP (1936–2008)

Raphael Balcon was a major influence on cardiology in the UK for 40 years. His work for the British Cardiac Society as treasurer and later as president built on the...

Hypertrophic pulmonary osteoarthropathy and the vagus nerve: an historical note

Hypertrophic pulmonary osteoarthropathy and the vagus nerve: an historical note

Effect of Interactions Between Lower Airway Bacterial and Rhinoviral Infection in Exacerbations of COPD

Study objectivesThe inflammatory responses and associated clinical severity of COPD exacerbations are greatly variable, and the determinants of these factors are poorly understood. We examined the hypothesis that bacteria and viruses may modulate this heterogeneity and that interactions between bacterial and viral infection may affect changes in airway bacterial load and the clinical features and inflammatory responses of exacerbations in patients with COPD.DesignProspective cohort study.SettingOutpatient Department, London Chest Hospital, London, UK.PatientsThirty-nine patients with COPD.MeasurementsWe prospectively studied 56 COPD exacerbations, obtaining clinical data and paired sputum and serum samples at baseline and exacerbation. Qualitative and quantitative microbiology, polymerase chain reaction detection for rhinovirus, and estimation of cytokine levels by enzyme-linked immunosorbent assay were performed.ResultsA total of 69.6% of exacerbations were associated with a bacterial pathogen, most commonly Haemophilus influenzae. Rhinovirus was identified in 19.6% of exacerbations. The rise in bacterial load at exacerbation correlated with the rise in sputum interleukin (IL)-8 (r = 0.37, p = 0.022) and fall in FEV1 (r = 0.35, p = 0.048). Exacerbations with both rhinovirus and H influenzae had higher bacterial loads (108.56 cfu/mL vs 108.05cfu/mL, p = 0.018) and serum IL-6 (13.75 pg/mL vs 6.29 pg/mL, p = 0.028) than exacerbations without both pathogens. In exacerbations with both cold symptoms (a marker of putative viral infection) and a bacterial pathogen, the FEV1 fall was greater (20.3% vs 3.6%, p = 0.026) and symptom count was higher (p = 0.019) than those with a bacterial pathogen alone.ConclusionsThe clinical severity and inflammatory responses in COPD exacerbations are modulated by the nature of the infecting organism: bacterial and viral pathogens interact to cause additional rises in inflammatory markers and greater exacerbation severity.

Thoraic surgical management. Fourth edition. By J. R. Belcher, M. S., F.R.C.S., London Chest Hospital. 8¼ × 5½ in. Pp. 192, with 60 illustrations. 1972. London: Baillière Tindall. £ 2.20

Thoraic surgical management. Fourth edition. By J. R. Belcher, M. S., F.R.C.S., London Chest Hospital. 8¼ × 5½ in. Pp. 192, with 60 illustrations. 1972. London: Baillière Tindall. £ 2.20

Thoracic surgical management. By J. R. Belcher, M.S., F.R.C.S., Consultant Surgeon at the London Chest Hospital; and I. W. B. Grant, M.B., M.R.C.P. (Edin.), Assistant Physician, Edinburgh Northern Hospitals and Royal Victoria and Associated Hospitals. With a Foreword by Sir Clement Price Thomas, K.C.V.O. 5 3/8 × 8 in. Pp. 196 + xii, with 65 illustrations. 1953. London: Bailliére, Tindall&

Thoracic surgical management. By J. R. Belcher, M.S., F.R.C.S., Consultant Surgeon at the London Chest Hospital; and I. W. B. Grant, M.B., M.R.C.P. (Edin.), Assistant Physician, Edinburgh Northern Hospitals and Royal Victoria and Associated Hospitals. With a Foreword by Sir Clement Price Thomas, K.C.V.O. 5 3/8 × 8 in. Pp. 196 + xii, with 65 illustrations. 1953. London: Bailliére, Tindall&

John Hunter. By S. Roodhouse Gloyne, M.D. (Leeds), Consulting Pathologist, London Chest Hospital, and King Edward VII Sanatorium, Midhurst. 6¼ × 8⅝ in. Pp. 104 + x, with Frontispiece and 16 Plates. 1950. Edinburgh: E. &amp; S. Livingstone Ltd. 15s

John Hunter. By S. Roodhouse Gloyne, M.D. (Leeds), Consulting Pathologist, London Chest Hospital, and King Edward VII Sanatorium, Midhurst. 6¼ × 8⅝ in. Pp. 104 + x, with Frontispiece and 16 Plates. 1950. Edinburgh: E. &amp; S. Livingstone Ltd. 15s

Relationships Among Bacteria, Upper Airway, Lower Airway, and Systemic Inflammation in COPD

Study objective: The upper and lower airways are continuous. While upper airway symptoms are common in COPD patients, with accumulating evidence to suggest increased nasal inflammation, the relationships among upper airway, lower airway, and systemic inflammatory indexes have not been studied. We aimed to confirm that there is heightened nasal inflammation in COPD patients, to test the hypothesis that the degree of upper airway inflammation relates to the degree of lower airway inflammation, and to investigate the underlying associations with bacterial carriage and the systemic inflammatory response. Design: Prospective cohort study. Setting: Outpatient Department, London Chest Hospital, London, UK. Participants: Forty-seven patients with COPD and 12 control subjects of similar age, sex, and smoking status. Measurements: Serum, nasal wash fluid, and sputum samples were obtained from 47 stable patients with COPD for the analysis of inflammatory indexes and bacterial colonization. Nasal wash fluid specimens were obtained from 12 control subjects. Results: COPD patients had an increased nasal interleukin (IL)-8 concentration compared to control subjects (difference, 97.2 pg/mL; p 0.009). The nasal IL-8 concentration in COPD patients correlated with that in sputum (r 0.30; p 0.039). In both the upper and lower airways of patients with COPD, the IL-8 concentration was associated with indexes of bacterial colonization. Patients colonized with a sputum potentially pathogenic microorganism had a higher total nasal bacterial load (difference, 1.5 log cfu/mL; p 0.016). We did not find significant relationships between the degree of upper or lower airway inflammation, or bacterial carriage, and the systemic inflammatory response. Conclusions: COPD is associated with an increased nasal concentration of the neutrophil chemoattractant protein IL-8, the degree of which reflects that present in the lower airway. A relationship between lower airway bacterial colonization, postnasal drip, and higher nasal bacterial load may suggest a mechanism underlying this finding. This study is the first to report a correlation between the degree of upper and lower airway inflammation in COPD. (CHEST 2005; 127:1219–1226)

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The upper and lower airways are continuous. While upper airway symptoms are common in COPD patients, with accumulating evidence to suggest increased nasal inflammation, the relationships among upper airway, lower airway, and systemic inflammatory indexes have not been studied. We aimed to confirm that there is heightened nasal inflammation in COPD patients, to test the hypothesis that the degree of upper airway inflammation relates to the degree of lower airway inflammation, and to investigate the underlying associations with bacterial carriage and the systemic inflammatory response. Prospective cohort study. Outpatient Department, London Chest Hospital, London, UK. Forty-seven patients with COPD and 12 control subjects of similar age, sex, and smoking status. Serum, nasal wash fluid, and sputum samples were obtained from 47 stable patients with COPD for the analysis of inflammatory indexes and bacterial colonization. Nasal wash fluid specimens were obtained from 12 control subjects. COPD patients had an increased nasal interleukin (IL)-8 concentration compared to control subjects (difference, 97.2 pg/mL; p = 0.009). The nasal IL-8 concentration in COPD patients correlated with that in sputum (r = 0.30; p = 0.039). In both the upper and lower airways of patients with COPD, the IL-8 concentration was associated with indexes of bacterial colonization. Patients colonized with a sputum potentially pathogenic microorganism had a higher total nasal bacterial load (difference, 1.5 log cfu/mL; p = 0.016). We did not find significant relationships between the degree of upper or lower airway inflammation, or bacterial carriage, and the systemic inflammatory response. COPD is associated with an increased nasal concentration of the neutrophil chemoattractant protein IL-8, the degree of which reflects that present in the lower airway. A relationship between lower airway bacterial colonization, postnasal drip, and higher nasal bacterial load may suggest a mechanism underlying this finding. This study is the first to report a correlation between the degree of upper and lower airway inflammation in COPD.

Specialisation in Cardiology

Peter C. Mills is a consultant and an interventional cardiologist at the London Chest Hospital. His “Letter From London,” reflecting his views on cardiovascular medicine and surgery from a British perspective, will appear from time to time in The American Heart Hospital Journal. My two favorite audio editorialists are Dr. Sylvan Weinberg and the late Mr. Alistair Cooke. It is, therefore, with considerable trepidation that I am responding to Sylvan's request for a “Letter From London” for The American Heart Hospital Journal. My literary style certainly doesn't compare with either of these greats, but Sylvan did ask me if I would write an occasional letter, and here is the first. It is, of course, an entirely unofficial comment on the cardiological world and shouldn't be taken to represent the views of anyone other than myself as an individual, rather than in any of my official capacities in the United Kingdom!

Validation of a Chronic Obstructive Pulmonary Disease screening questionnaire for population surveys

The Confronting Chronic Obstructive Pulmonary Disease (COPD) Survey in North America and Europe conducted during 1999–2000 aimed to identify international differences in the clinical management of COPD and the patients’ perspectives on their disease. Our aim was to validate the screening questionnaire used in this study in a sample of patients presenting at a respiratory clinic. Interviews were conducted at an outpatient clinic of the London Chest Hospital. Of the 136 patients contacted, 25 refused or were not able to participate. Questionnaire data were validated by comparison with medical records and spirometry on 104 patients. Overall, the questionnaire correctly identified 86.5% of patients with a diagnosis of COPD with a chance-corrected agreement ( κ=0.66, se 0.098), which indicates good agreement between the questionnaire α and the medical records. The questionnaire had a high sensitivity (92.0%) and specificity (72.4%) with respect to the diagnosis of COPD. The screening questionnaire used in The Confronting COPD Survey appears to be a valid screening tool to differentiate COPD from other respiratory diseases.