Severe Left Ventricular Impairment Research Articles

Percutaneous coronary intervention in octogenarians – a real-world experience from a large non-surgical centre in the UK

Abstract Background With an ageing population, the demand for percutaneous coronary intervention (PCI) in the elderly is on the rise. Technical advances, better peri-procedural pharmacology and greater operator experience have led to improved outcomes after PCI. Octogenarians as a group, however, have been underrepresented in randomised clinical trials of coronary revascularisation. Observational studies therefore provide useful insights into the safety and efficacy of PCI in this patient population in a real-world clinical practice. Aim The aim of this study was to examine the trends in patient characteristics and clinical outcomes after PCI in octogenarians over a 10-year period in a large non-surgical PCI centre and to determine the predictors of mortality in this high risk patient cohort. Methods A total of 782 consecutive octogenarians were identified from a prospectively collected database of all patients undergoing PCI at our centre between 2007 and 2016. We analysed the characteristics of the cohort with respect to all-cause in-hospital and 1-year mortality, in-hospital Major Adverse Cardiovascular Events (MACE) rates, complexity of coronary artery disease and major comorbidities. The patients were stratified into three chronological tertiles to assess differences over time. A multivariate analysis was performed to determine predictors of mortality. Results The number of octogenarians undergoing PCI was found to have increased nearly ten-fold, from 19 in 2007 to 178 in 2016. Despite this, there were no significant differences in adverse clinical outcomes. A greater use of radial access was noted (p<0.0001). Increasing age, the presence of cardiogenic shock, severe left ventricular impairment, peripheral vascular disease, diabetes mellitus and low creatinine clearance were identified as independent predictors of mortality after PCI (Table 1). Conclusion PCI in octogenarians is a safe and effective revascularisation option, the use of which is increasing in the real-world clinical practice. Future PCI randomised clinical trials should include this challenging cohort to enhance the evidence base. Funding Acknowledgement Type of funding source: None

P710 Nivolumab-induced takotsubo syndrome: a case report

Abstract Background Nivolumab is a monoclonal antibody targeting programmed cell death protein 1 (PD-1), with a demonstrated clinical efficacy against metastatic cancer. Immunotherapy cardiovascular toxicity is rare, but recent scientific literature demonstrated possible and different cardiovascular side effects. Nivolumab was found to be associated with fatal acute myocarditis with diffuse myocardial necrosis and heart failure. To our knowledge no case of Nivolumab induced Tako-tsubo syndrome has ever been reported. Case presentation A 76-year-old woman was admitted to the emergency department for dyspnoea with electrocardiographic evidence of extensive anterior ST segment elevation (Figure 1A); the patient was hemodynamically unstable with increasing shortness of breath and oxygen desaturation (arterial blood pressure 90/50 mmHg, heart rate 120 beats/min, O2 Sat. 87%). She was scheduled for urgent coronary angiography which eventually demonstrated no significant coronary artery disease. The ventriculography revealed dyskinesis of the left apex and peri-apical segments and basal hyperkinesis (Figure 1B). The final diagnosis was stress cardiomyopathy or Tako-tsubo syndrome. The echocardiogram performed in the acute setting revealed severe left ventricular impairment (ejection fraction, EF = 30%) confirming the typical apical ballooning pattern of the syndrome (Figure 1C). Left ventricular outflow tract obstruction was not found. At admission, the level of TroponinT was mildly elevated (745 ng/L) and NT-proBNP was 35 000 pg/ml. The patient was treated with optimal heart failure medical therapy with gradual and complete left ventricular function recovery (EF at discharge = 55%). Of note, the patient had a history of primary lung adenocarcinoma firstly treated in 2017 with carboplatin; due to cancer progression she had undergone Nivolumab therapy in October 2018 with a total of three cycles, the last one interrupted one month before the cardiovascular event due to ipokaliemia and mild renal impairment. At that time the patient was defined as having a good functional status. Apart from the oncologic treatment, patient’s history did not reveal any "acute" stressful event. Conclusions To the best of our knowledge this is the first Takotsubo cardiomyopathy ever detected after Nivolumab therapy. Stress cardiomyopathy is a rare but possibly severe complication that could appear in the course of oncological treatment and, in this backdrop, its aetiology is not well understood. As a matter of fact, cardiac function monitoring and strict clinical follow-up for early detection of complications is mandatory in these patients. Favourable outcomes may be achieved with early diagnosis and prompt treatment introduction. Abstract P710 Figure. Diagnostic evaluation of Takotsubo Sdr

P6456Role of cardiac imaging in the prediction of ventricular arrythmias, heart failure and death in dilated non-ischemic cardiomyopathy with severe left ventricular systolic disfunction

Abstract Background and purpose Dilated non-ischemic cardiomyopathy (DCM) is associated with an increased risk of cardiac events. Implantable Cardioverter Defibrillator (ICD) is recommended in DCM with severe left ventricular ejection fraction impairment, but the evidence of its usefulness is somewhat controversial. We evaluated the predictive value of myocardial fibrosis measured by cardiac magnetic resonance (CMR) and of global longitudinal strain (GLS) in the incidence of adverse cardiac events. Methods From 2009 to 2019, sixty-six patients with DCM were evaluated. CMR with a 1.5 Tesla scanner was performed, and the presence and extent of late gadolinium enhancement (LGE) was blindly assessed. GLS was measured using speckle-tracking 2D echocardiography. We examined the incidence of sustained ventricular arrhythmias (SVA, including appropriate anti-tachycardia pacing and shocks), admissions due to heart failure (HF) and all-cause mortality. Results 62.1% of the patients were male, with a median age of 63.8 years. 50.0% had cardiac resynchronization therapy and 73.9% had ICD as primary prevention therapy. Median LVEF was 25.7%. Median follow-up was 32 months. In that period, 10.6% of patients died, 25.8% had hospital admissions due to HF, and 9.2% had SVA. A burden of LGE over 14% was independently associated with higher risk of SVA (3.0% vs 19.2%, p=0.041). This cut-off value had a sensitivity of 83.3% and a negative predictive value of 97.0%. LGE was not associated with higher risk of HF admissions (27.3% vs 23.1%, p=0.731) or death (9.1% vs 11.5%, p=0.757). On the other hand, GLS was not associated with higher risk of SVA (8.7% vs 4.55% for a cut-off value of −10.6%, p=0.577), HF admissions (26.1% vs 30.4%, p=0.743) or death (8.7% vs 8.7%, p=1.00). Table 1. Main etiologies of DCM Causes N (%) Idiopathic 43 (65.2) Alcoholic 6 (9.1) Chemotherapy 4 (6.1) Non-compaction 4 (6.1) Familiar 3 (4.6) Thoracic radiotherapy 2 (3.0) Chagas disease 2 (3.0) Conclusions The burden of myocardial fibrosis measured by LGE is a high sensitive marker for the development of SVA. However, is not a predictive tool for HF admissions or all-cause mortality. GLS was not associated with the incidence of cardiac events in this population.

Alternative left ventricular pacing approaches for optimal cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) improves mortality, morbidity, and quality of life in selected heart failure patients with severe left ventricular (LV) ejection fraction impairment. However, between 20% and 40% of device recipients do not benefit clinically from CRT. Indeed, some anatomic and technical difficulties are related to the coronary venous implantation site via the coronary sinus (CS). Additionally, electrical constraints have been described, and CS does not always correspond to the optimal LV lead position. In the last decade, engineers and physicians have worked together to overcome the challenging LV lead implantation, and various biventricular pacing alternatives have been developed to improve CRT response. Inthis review, we discuss the evolution from CS pacing to wireless LV stimulation and His-bundle pacing.

Magnestic resonance conditional cardiac implantable electronic devices: are they the standard of care?

Cardiac implantable electronic devices (CIEDs) are the mainstay of care in patients with life-threatening ventricular arrhythmia, severe left ventricular impairment or symptomatic pauses. Magnetic resonance imaging (MRI) is the gold standard diagnostic tool for a wide variety of conditions however,

100.49 Mechanical Circulatory Support Prior to Elective High-Risk Percutaneous Coronary Intervention

High-risk percutaneous coronary intervention (HRPCI) carries an elevated mortality risk, for which mechanical circulatory support (MCS) is often required. Severe left ventricular (LV) impairment was the primary risk surrogate for HRPCI defined by the two main prospective randomized trials on MCS in

Extracorporeal membrane oxygenation for pheochromocytoma-induced cardiogenic shock.

BackgroundPheochromocytoma, a rare catecholamine-producing tumor, might provoke stress-induced Takotsubo-like cardiomyopathy and severe cardiogenic shock. Because venoarterial-extracorporeal membrane oxygenation (VA-ECMO) rescue of pheochromocytoma-induced refractory cardiogenic shock has rarely been reported, we reviewed our ICU patients’ presentations and outcomes.MethodsAll pheochromocytoma-induced refractory cardiogenic shock cases managed with VA-ECMO (January 2007–March 2015) were prospectively included and reviewed. We also performed a systematic review on this topic.ResultsNine patients (7 women, 2 men; 31–51 [median, 43 (IQR 36–49) years old]) were included; none had a previously known pheochromocytoma. Six of them had medical histories suggestive of the diagnosis: palpitations and headaches for several months for four, multiple endocrine neoplasia syndrome type 1 for one and recurrent Takotsubo disease for one; at hospital admission, all were hypertensive despite cardiogenic shock. Three others had an identified surgical triggering factor. All nine patients rapidly developed refractory cardiogenic shock with very severe left ventricular (LV) impairment (LV ejection-fraction range 5–20%; LV outflow-tract velocity–time integral range 3–8 cm). Seven patients’ abdominal computed tomography scans showed pheochromocytoma-suggestive adrenal gland tumors (no scan during ICU stay for 2). Despite VA-ECMO implantation, three patients died of refractory multiple organ failure. For the six others, myocardial function improved and ECMO was removed 3–7 days post-implantation; α- and β-blockers were progressively introduced. Five survivors underwent pheochromocytoma excision 3 weeks–4 months post-ICU discharge, with satisfactory outcomes. One patient, whose pheochromocytoma was diagnosed 1 year after the index event, underwent uneventful surgical adrenalectomy. Systematic review retrieved 40 cases of pheochromocytoma-induced cardiogenic shock requiring mechanical support (mostly ECMO), with a mortality rate of 7%. Pheochromocytoma was removed surgically after mechanical support weaning in 31 patients and during mechanical support in 5. Four were not operated.ConclusionsPheochromocytoma is a rare but reversible cause of cardiogenic shock amenable to VA-ECMO rescue. Adrenal gland imaging should be obtained for all patients with unexplained cardiogenic shock. Lastly, it might be safer to perform adrenalectomy several weeks after the initial catastrophic presentation, once recovery of LV systolic function is complete.

Predictive power of late gadolinium enhancement for myocardial recovery in chronic ischaemic heart failure: a HEART sub-study.

The amount of myocardial scar measured by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging predicts regional recovery in wall motion following revascularization. Previous studies have been conducted in patients with a relatively recent myocardial insult and relatively preserved left ventricular (LV) function. In this sub-study of a clinical trial, the predictive value of LGE, and other CMR-derived data, for myocardial recovery in patients with chronic severe ischaemic cardiomyopathy was assessed. Twenty-two patients with severe LV impairment of ischaemic origin were enrolled as a sub-study of a trial that randomly assigned patients to revascularization or not in addition to guideline-indicated pharmacological therapy. Patients underwent a CMR study at baseline and 6 months. Scans were qualitatively and quantitatively assessed for wall motion, rest/stress myocardial perfusion, and LGE. The median duration of heart failure was 13 (inter-quartile range 5-21) months. Patients had severe LV dilatation [end-diastolic volume (EDV) 280 ± 77 mL] and reduction in LV ejection fraction (LVEF) (29 ± 10%). The percentage scar burden by LGE was 17 ± 9%. Patient characteristics of those undergoing revascularization (n = 7) or not (n = 14) were similar. Myocardial perfusion reserve index (MPRI) improved following revascularization (MPRI 1.17 vs. 1.57, P < 0.0001) but not following medical therapy (1.39 vs. 1.32, P = 0.54). However, LVEF improved in patients whether or not they had revascularization. In the revascularization group, 14% of dysfunctional segments with LGE <25% and 22% of dysfunctional segments with LGE <50% had improved contractile function. However, the transmural extent of LGE did not predict contractile recovery following revascularization or pharmacological therapy (P = 0.19, P = 0.42). LVEDV improved overall (280 ± 77 to 269 ± 83 mL, P = 0.05); improvement was associated with heart failure duration (P = 0.04). In patients with chronic severe LV impairment of ischaemic origin, duration of heart failure is a better predictor of recovery than transmural extent of LGE, following medical therapy or successful revascularization. This suggests that the extent of myocardial remodelling is more important for LV recovery than the presence and extent of prior infarction alone and that LGE should not be the sole determinant of treatment method in severe LV systolic dysfunction of ischaemic origin.

Intra-aortic balloon pump for high-risk percutaneous coronary intervention.

The intra-aortic balloon pump (IABP) was first introduced into clinical practice in 1968.1 Early experimental and clinical trials suggested that intra-aortic balloon counterpulsation could provide circulatory assistance to a failing left ventricle.2,3 Counterpulsation—balloon inflation during diastole and deflation in systole—augments the intrinsic Windkessel effect, whereby potential energy stored in the aortic root during systole is converted to kinetic energy with the elastic recoil of the aortic root. Counterpulsation leads to a decline in afterload, a reduction in cardiac work, and therefore myocardial oxygen requirements of the ventricle. Augmentation of diastolic pressure when the balloon is fully inflated together with reduction in left ventricular (LV) filling pressures contribute to improved coronary perfusion (Figures 1 and 2).4 This proposed improvement in myocardial energetics has been further supported by a significant reduction in systemic lactate.5 These physiological enhancements are thought to be of particular benefit after acute myocardial infarction (AMI), supported by animal studies, which have shown a reduction in infarct size when counterpulsation is used.6,7 Figure 1. Coronary perfusion. Coronary flow is predominantly diastolic and further enhanced by counterpulsation, which augments diastolic blood flow and thus coronary perfusion. In addition, aortic recoil during diastole further improves efficiency of the left ventricle. Figure 2. Systemic arterial pressure waveform on introduction of intra-aortic balloon pump–assisted diastolic augmentation. The intra-aortic balloon pump inflates at the dicrotic notch, leading to peak-augmented diastolic pressure. As the balloon deflates, assisted end diastolic pressure is seen to be lower than unassisted end diastolic pressure and assisted systolic pressure is lower than unassisted systolic pressure. Peak diastolic augmentation should be greater than the unassisted systolic pressure and both assisted pressures should be less than the unassisted pressures. Intra-aortic balloon counterpulsation was initially used as a means of supporting patients undergoing surgical revascularization. Percutaneous delivery …

Tako-tsubo Cardiomyopathy on the First Day After Renal Transplantation — Case Report and Literature Review

BackgroundThe etiology of tako-tsubo cardiomyopathy, defined as a transient left ventricular dysfunction in the absence of significant coronary artery stenosis, still remains unclear. This syndrome mainly occurs in postmenopausal women and is often associated with emotional stress or miscellaneous diagnostic and therapeutic procedures. Estimated prevalence of tako-tsubo cardiomyopathy is found in 1% to 2% of patients presenting with suspected acute coronary syndrome. So far there has been only one case report of tako-tsubo cardiomyopathy in a renal transplant recipient. Case reportWe describe the case of a 68-year-old woman with a history of coronary artery disease and coronary artery bypass grafting in whom unspecific transient chest pain and hypotension were observed on the first day after renal transplantation. After transplantation, the patient was anuric with pulmonary congestion and toxic tacrolimus concentrations were observed. Electrocardiogram showed sinus rhythm with left bundle branch block (LBBB) that has not been described before. Plasma cardiac necrosis markers troponin I and creatine kinase MB were mildly elevated. Echocardiography showed severe left ventricular function impairment with characteristic shape of left ventricle. Subsequent cardiac catheterization revealed the absence of angiographic evidence of acute plaque rupture within both coronary arteries and bypass grafts. During the next few days there was marked clinical improvement with resolution of LBBB and full recovery of all biochemical parameters. On discharge, full functional recovery of the left ventricle in echocardiography was observed. Postulated mechanisms of tako-tsubo cardiomyopathy include catecholamine excess, coronary artery spasm, and microvascular dysfunction. On the other hand calcineurin inhibitors are known factors causing coronary epicardial endothelial dysfunction and negatively affecting vasomotor function. ConclusionsTako-tsubo cardiomyopathy in patients after renal transplantation may be at least in part a manifestation of calcineurin inhibitor cardiotoxicity.

Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival

We sought to evaluate our experience with total arterial revascularization and compare it with the traditional approach of a single internal thoracic artery supplemented by saphenous veins. From 1995 to 2010, 6059 patients with triple-vessel coronary artery disease underwent primary isolated coronary artery bypass grafting at 8 centers. A study cohort of 3774 patients was formed, with 2988 (79%) undergoing total arterial revascularization and 786 (21%) receiving only saphenous veins to supplement a single in situ internal thoracic artery. In the total arterial revascularization group, bilateral internal thoracic arteries were used in 1079 patients (36%) and at least 1 radial artery was used in 2916 patients (97%). Propensity score matching was used for risk adjustment. Patients undergoing total arterial revascularization were younger (65.0±10.4 years vs 71.3±7.9 years, P<.001) and less likely to have diabetes, cerebrovascular disease, recent myocardial infarction, and severe left ventricular impairment. At 15 years, patients who underwent total arterial revascularization experienced superior unadjusted survival (62%±1.1% vs 35%±1.9%, P<.001). Multivariable Cox regression in the entire study cohort showed the total arterial group had improved survival with a hazard ratio of 0.79 (95% confidence interval, 0.70-0.90; P<.001). After propensity score matching yielded 384 patient pairs, patients who underwent total arterial revascularization showed improved survival at 15 years than patients who underwent single arterial revascularization (54%±3.3% vs 41%±3.0%, P=.0004). This large multicenter study suggests that a strategy of total arterial revascularization is associated with improved long-term survival compared with the use of only a single arterial and saphenous vein grafts. Total arterial revascularization should be encouraged in patients with a reasonable life expectancy.

Feasibility and efficacy of the 2.5 L and 3.8 L impella percutaneous left ventricular support device during high‐risk, percutaneous coronary intervention in patients with severe aortic stenosis

Assessment of the feasibility and outcomes of the 2.5 L and 3.8 L Impella cardiac pump in patients with severe aortic stenosis (AS) and left ventricular impairment undergoing percutaneous revascularization (PCI) with or without balloon aortic valvuloplasty (BAV). We reviewed the clinical and procedural findings from a consecutive series of unselected patients with severe AS who underwent PCI during Impella support. In addition, we describe novel "balloon-assist" techniques that allowed implantation of Impella into the left ventricle (LV) when initial unassisted attempts failed. Five patients with severe AS were identified (four males, age 78.2 years, aortic valve area (AVA) 0.6 cm(2) , left ventricular ejection fraction (LVEF) 24 ± 5%, mean Society of Thoracic Surgeons (STS) mortality 11% (range 3-17%)). The Impella catheter traversed the aortic valve (AV) unassisted in only one patient, with four cases requiring balloon-assist techniques. All patients underwent planned revascularisation; mean procedure time 177 min (range 135-252 min), mean number of stents 3.4 (range 1-8), with three patients requiring rotational atherectomy. All procedures were well tolerated, with absence of arrhythmia, hypotension, pulmonary edema, stroke, or myocardial infarction. One patient died 48 hr post-PCI of multi-organ failure. The four remaining patients were well at 30 days. Implantation of the 2.5 and 3.8 L Impella appears feasible in patients with severe AS and left ventricle (LV) impairment. A balloon-assist technique may be used to facilitate device implantation when initial unassisted attempts fail. Improved hemodynamic stability may enhance the tolerability of lengthy and complex procedures.

Reduction of ICD indications after optimization of heart failure treatment in patients with severe left ventricular systolic dysfunction

Background: Patients with LVEF≤35% and NYHA class II or III heart failure under optimal medical treatment have an indication of an ICD in primary prevention. Data regarding the magnitude of improvement of LVEF after intensive optimization of heart failure medical treatment are scarce. Purpose: To assess the clinical, echocardiographic and biological impact of intensive optimization of heart failure medical treatment in patients with severe left ventricular systolic dysfunction. Methods: This is an observational prospective study in which patients visited in a heart failure unit with LVEF≤35%, without an ICD, with heart failure and non-optimal heart failure medical treatment are included. Up-titration of beta blockers, ACE inhibitors/ARB and aldosterone antagonist are gradually performed in the day hospital of the heart failure unit up to 100% of the target dose or the maximum tolerated dose. At 6 month after completion of drug up-titration the echocardiography is repeated and clinical follow-up assessed again. Results: 85 patients have been already included. 34/85 are still being up-titraded. 3/85 died during follow-up. The 6 month follow-up has been accomplished in 48/85 patients, age 65±14 years, 9 (19%) female, 20 (42%) with ischemic heart disease. Patients on 100% of target dose of beta blockers, ACE inhibitors/ARB and aldosterone antagonists increased from 8%, 23% and 17% to 81%, 77% and 72%, respectively, with up-titration. NYHA class diminished at 6 month: 2,1±0,6 vs 1,5±0,6, p 35% in 25/48 (52%) patients at 6 month after up-titration. Consequently, patients with an ICD indication were reduced: 44 (92%) vs 12 (25%) when comparing before and after 6 month of completion of optimization of heart failure medical therapy. Moreover, pro-BNP levels were also reduced: 2676±227 vs 1754±1804 pg/ml before and after 6 month of up-titration completion. Conclusions: Intensive optimization of heart failure medical therapy in patients with severe systolic left ventricular impairment improves symptoms and quality of life and reduces hospital admissions. Furthermore LVEF increases in the majority of patients and ICD indications are accordingly reduced.

029 PREDICTORS OF SURVIVAL AND NEUROLOGICAL RECOVERY IN ST-ELEVATION MYOCARDIAL INFARCTION COMPLICATED BY OUT OF HOSPITAL CARDIAC ARREST

<h3>Background</h3> Recent UK epidemiological data suggests that while incidence and mortality of myocardial infarction (MI) is in decline, mortality associated with out of hospital cardiac arrest (OOHCA) in the setting of MI is still a significant problem now constituting 70% of its total fatality. Small studies have shown survival benefit with primary percutaneous coronary intervention (pPCI) in OOHCA in the setting of ST elevation myocardial infarction (STEMI). There is little contemporary outcome data in this population. We sought to identify predictors of survival in STEMI complicated by OOHCA in a large, contemporary cohort in the era of pPCI. <h3>Methods</h3> Between January 2008 and October 2011, 1836 consecutive STEMI admissions to a high volume pPCI centre were retrospectively analysed. 132 patients were identified as having OOHCA. Clinical and procedural data was collected from the UK Myocardial Ischaemia National Audit Project (MINAP) database and patient notes. Endpoints were all cause mortality to 4 years (mean: 559 days, median: 380 days) and neurological recovery at discharge (Cerebral Performance Score/CPS 1). Mortality data was collected using the Office of National Statistics mortality database. <h3>Results</h3> 132 out of 1836 consecutive STEMI patients were identified with OOHCA (7.2%). The mean age of patients was 59.4±14years, 78.8% were male and 55% were directly conveyed to the pPCI centre; the remaining were transferred from district hospitals. Survival to discharge was 76.5% (101/132 patients). 86 patients had full neurological recovery (65% of the whole cohort). Long term follow-up revealed only one further death making the overall survival rate 75.8%. Survivors had significantly higher incidence of witnessed arrest (p&lt;0.0001) and immediate cardiopulmonary resuscitation (CPR)/advanced life support (ALS) (p&lt;0.0001), a shorter time to return of spontaneous circulation (ROSC) (p&lt;0.0001) and were more likely to be alert post ROSC (p&lt;0.0001). Shorter call to balloon time (p=0.0117) and time from arrest to arrival at pPCI centre (p&lt;0.0001) were strongly associated with improved survival as was successful pPCI (p=0.0004) defined as TIMI 2–3 flow. Patient factors associated with poor outcome included three-vessel disease (p=0.0007), severe left ventricular impairment (p=0.0179), cardiogenic shock (p=0.0023) and renal dysfunction (p&lt;0.0001) on admission. Improved neurological outcome in survivors was strongly associated with witnessed arrest (p&lt;0.0001), immediate CPR/ALS (p=0.0186), shorter time to ROSC (p&lt;0.0001), patient being alert post ROSC (p&lt;0.0001) and shorter call to balloon (p=0.0028) and arrest to arrival times (p&lt;0.0001). <h3>Conclusions</h3> To our knowledge, this is the first reported series of STEMI complicated by OOHCA of this size in UK contemporary practice. This data shows a 76% survival rate, 65% rate of full neurological recovery and supports the emergent transfer of this patient group to a cardiac centre for pPCI.

004 TELEMONITORING IN HEART FAILURE: EXPERIENCE OF A COMMUNITY-BASED HEART FAILURE SERVICE

IntroductionCommunity based models of heart failure (HF) care increasingly employ telemonitoring to improve care by reducing the risk of HF decompensation and hospitalisation. A new service was launched in Gloucestershire...

Abnormal glucose and lipid control in non-ischemic left ventricular dysfunction

BackgroundCardiovascular risk factors are classically associated with coronary atherosclerosis. We sought to investigate whether risk factors are also associated with left ventricular (LV) dilatation, contractile impairment and reduced myocardial blood flow (MBF) in patients with non-ischemic LV dysfunction. MethodsWe studied 81 patients (59 males, age 60 ± 9 years) with mild-to-severe LV dysfunction (mean ejection fraction 37%, range 19%-50%), no history of diabetes and normal coronary arteries. Absolute MBF was measured by positron emission tomography and 13N-ammonia at rest and after dipyridamole (0.56 mg/kg I.V. over 4 min). ResultsOvert LV dysfunction (LV end-diastolic diameter >60 mm associated with LV ejection fraction <45%) was present in 42 patients (52%); severely depressed hyperemic MBF (<1.09 mL · min−1 · g−1) was present in 41 patients (51%). Using multivariate logistic regression analysis, low high-density lipoprotein cholesterol (HDL-C, P < .036), newly diagnosed non-insulin-dependent diabetes or insulin-resistance (NIDD/IR, P < .019) and the use of diuretics (P = .001) were independently associated with overt LV dysfunction. Low HDL-C (P = .015) and NIDD/IR (P = .048) were also independently associated with severely depressed hyperemic MBF. ConclusionsLow HDL-C and NIDD/IR are associated with more severe LV impairment and reduced hyperemic MBF in non-ischemic LV dysfunction.

A PATIENT WITH CHOREA-ACANTHOCYTOSIS AND DILATED CARDIOMYOPATHY

We discuss the case of a 43-year-old male with a 20-year history of a slowly progressive neurodegenerative syndrome. He first presented with epilepsy at the age of 26 but over...

TCT-521 Predictors Of Outcome In Patients With ST-elevation Myocardial Infarction Presenting With Out Of Hospital Cardiac Arrest

confirmed using the Office of National Statistics database with follow-up ranging from 3 to 44 months. Results: The mean age was 60 14years and 80.3% patients were male. The incidence of previous coronary disease in the cohort was 27.8%, 32.8% patients were hypertensive, 37.7% smokers, 24.6% hypercholesterolaemic and 8.2% had known diabetes. 45% patients had a witnessed arrest and 43.4% were directly conveyed to the pPCI centre. Mean arrest-to-arrival time in the cohort was 115 24mins with a mean call-to-balloon time of 168 24mins. The rate of successful pPCI in the cohort was 85% with 21.7% having 3-vessel disease. Shock was present in 16% and severe left ventricular impairment in 25% patients. The in-hospital mortality within the cohort was 21%. Of the patients who died 14 were cardiovascular deaths, 3 being shortly after return of spontaneous circulation in the catheterisation laboratory, and 6 of all deaths were secondary to hypoxic brain injury in Intensive Care. 79% of all patients survived to discharge. Of the patients who survived 92% were discharged with no neurological deficit. At follow-up (12-44 months in 62% patients) 100% of patients who survived to discharge were still alive. Conclusions: Here we present descriptive data of a large, contemporary cohort of STEMI admissions for pPCI that are complicated by OOHCA. Here we show a 79% survival rate to discharge, a higher proportion than previously reported, with good long term prognosis after discharge.

Routine pre‐operative echocardiography for detection of aortic stenosis?

I read the recent article by Loxdale et al. [1] with interest and commend them for their study into the use of pre-operative echocardiography to detect aortic stenosis (AS). I wish to raise some methodological points for discussion. Firstly, it is surprising that the authors considered aortic sclerosis and mild AS as a single condition. Aortic sclerosis implies that the valve is calcified (i.e. sclerotic) but not obstructing blood flow (i.e. not stenotic). International consensus guidelines distinguish aortic sclerosis as having a peak velocity of <2.5 m.s and mild AS as 2.5– 3.0 m.s [2]. Secondly, although the authors state that 31% of patients with aortic sclerosis or AS did not have an audible murmur, it should also be noted that 7 ⁄ 8 (88%) of patients with severe AS and 16 ⁄ 24 (67%) patients with moderate AS did have audible murmurs (total 23 ⁄ 32, 72%). Mild AS is not of haemodynamic concern and is unlikely to alter significantly the anaesthetic management of most patients. However, moderate or severe AS is functionally important and the majority of cases are detectable clinically; it is noted that only one patient with severe AS did not have an audible murmur. It is surprising that 1 ⁄ 3 patients with moderate AS apparently did not have an audible murmur. Only two of these had severe left ventricular impairment, suggesting that in the majority (with normal stroke volume), a murmur should have been audible. Finally, although their title mentions the ‘role’ of echocardiography, the authors do not discuss how their results should be integrated into clinical practice or, if inconclusive, how their results could inform the design of future studies to determine the role of echocardiography. Their findings do not support routine use of echocardiography in all such patients, especially as in many centres a dedicated daily service may not be feasible and surgery in this cohort should not be delayed. There remains a clear role for careful cardiac auscultation and examination and, whilst Loxdale et al. [1] should be congratulated for their efforts, their results do not imply that restricting echocardiography to those patients with audible murmurs is a practice that should be changed.

Effects of Aging, Renal Dysfunction, Left Ventricular Systolic Impairment, and Weight on Steady State Pharmacokinetics of Perhexiline

Two hundred patients at steady-state on long-term perhexiline were identified retrospectively. The ratio of maintenance dose to steady-state plasma concentration (dose:[Px]) was correlated with the following putative determinants via simple and multiple linear regression analyses: age, weight, left ventricular ejection fraction (LVEF), and creatinine clearance (CrCl, Cockroft-Gault formula). A Mann-Whitney U test was performed to determine if severe left ventricular systolic impairment affected maintenance dose. Advanced age, left ventricular systolic impairment, and renal impairment were frequently encountered. Using simple linear regression, age was a negative correlate of dose:[P] (R = 0.23, P = 0.001), whereas weight (R = 0.27, P = 0.0001) and CrCl (R = 0.30, P < 0.0001) were positive correlates. Mann-Whitney U analysis showed no difference between dose: [Px] among patients with LVEF of less than 30% versus 30% or greater. Advancing age was strongly associated with decreasing weight (R = -0.45, P < 0.00001) and calculated CrCl varied directly with weight, as expected (R = 0.66, P < 0.0001). Stepwise multiple linear regression using age, LVEF, CrCl, and weight as potential predictors of dose:[P] yielded only weight as a significant determinant. Perhexiline has become a "last-line" agent for refractory angina as a result of complex pharmacokinetics and potential toxicity. Use has increased predictably in the aged and infirm who have exhausted standard medical and surgical therapeutic options. Beyond genotype, the effect of patient characteristics on maintenance dose has not been explored in detail. In this study, dose requirement declined with age in a frail and wasting population as a result of weight-related pharmacokinetic factors. LVEF had no apparent effect on maintenance dose and should not be considered a contraindication to use. A weight-adjusted starting dose may facilitate the safe and effective prescription of perhexiline and is calculated by 50 + 2 × weight (kg) mg/d, rounded to the closest 50 mg/day.