The quality of care and long-term mortality of out of hospital cardiac arrest survivors after acute myocardial infarction: a nationwide cohort study

BACKGROUND

The long-terms outcomes of out of hospital cardiac arrest (OHCA) survivors are not well known.

METHODS

Using the Myocardial Ischaemia National Audit Project (MINAP) registry, linked to Office for National Statistics (ONS) mortality data, we analysed 661 326 England, Wales and Northern-Ireland AMI patients; 14 127 (2%) suffered OHCA and survived beyond thirty-days of hospitalisation. Patients dying within thirty-days of admission were excluded. Mean follow-up for patients included was 1 500 days. Cox regression models were fitted, adjusting for demographics and management strategy.

RESULTS

OHCA survivors were younger (in years) (64 (interquartile range [IQR] 54-72) vs. 70 (IQR 59-80), P < 0.001), more often underwent invasive coronary angiography (88% vs. 71%, P < 0.001) and percutaneous coronary intervention (72% vs. 45%, P < 0.001). Overall, risk of mortality for OHCA patients that survived past 30-days was lower than patients that did not suffer cardiac arrest (adjusted hazard ratio [HR] 0.91; 95% CI; 0.87-0.95, P < 0.001). 'Excellent care' according to the mean opportunity-based quality indicator (OBQI) score compared to 'Poor care', predicted reduced risk of long-term mortality post OHCA, for all-patients (HR: 0.77, CI; 0.76-0.78, P < 0.001), more for STEMI patients (HR: 0.73, CI; 0.71-0.75, P < 0.001), but less significantly in NSTEMI patients (HR: 0.79, CI; 0.78-0.81, P < 0.001).

CONCLUSIONS

Out of hospital cardiac arrest (OHCA) patients remain at significant risk of mortality in-hospital. However, if surviving over thirty-days post arrest, OHCA survivors have good longer-term survival up to ten-years compared to the general AMI population. Higher quality inpatient care appears to improve long-term survival in all OHCA patients, more so in STEMI.

Sex-based analysis of NSTEMI processes of care and outcomes by hospital: a nationwide cohort study

BACKGROUND

Contemporary studies demonstrate that non-ST-segment elevation myocardial infarction (NSTEMI) processes of care vary according to sex. Little is known regarding variation in practice between geographical areas and centers.

METHODS

We identified 305 014 NSTEMI admissions in the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP), 2010-2017, including female sex (110 209). Hierarchical, multivariate logistic regression models were fitted assessing for differences in primary outcomes according to sex. Risk standardized mortality rates (RSMR) were calculated for individual hospitals to illustrate correlation with variables of interest. 'Heat-maps' were plotted to show regional and sex-based variation in opportunity-based quality-indicator score (surrogate for optimal processes of care).

RESULTS

Women presented older (77y vs. 69y, P < 0.001) and were more often Caucasian (93% vs. 91%, P < 0.001). Women were less frequently managed with an invasive coronary angiogram (ICA) (58% vs. 75%, P < 0.001) or percutaneous coronary intervention (PCI) (35% vs. 49%, P < 0.001)). In our hospital-clustered analysis, we show positive correlation between the RSMR and increasing proportion of women treated for NSTEMI (R2 = 0.17, P < 0.001). There was clear negative correlation between proportion of women who had an optimum OBQI score during their admission and RSMR (R2 = 0.22, P < 0.001), with weaker correlation in men (R2 = 0.08, P < 0.001). Heat-maps according to clinical commissioning group (CCG) demonstrate significant regional variation in OBQI score, with women receiving poorer quality care throughout the UK.

CONLUSION

There was a significant in variation of the management of patients with NSTEMI according to sex, with widespread geographical variation. Structural changes are required to enable improved care for women.

Socioeconomic disparities in the management and outcomes of acute myocardial infarction

BACKGROUND

Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear.

METHODS

Using the UK Myocardial Ischaemia National Audit Project (MINAP) registry, we divided 370 064 patients with AMI into quintiles based on Index of Multiple Deprivation (IMD) score, comprising seven domains including income, health, employment and education. We compared white and 'ethnic-minority' patients, comprising Black, Asian and mixed ethnicity patients (as recorded in MINAP); further analyses compared the constituents of the ethnic-minority group. Logistic regression models examined the role of the IMD, ethnicity and their interaction on the odds of in-hospital mortality.

RESULTS

More patients from the most deprived quintile (Q5) were from ethnic-minority backgrounds (Q5; 15% vs Q1; 4%). In-hospital mortality (OR 1.10, 95% CI 1.01 to 1.19, p=0.025) and major adverse cardiovascular event (MACE) (OR 1.07, 95% CI 1.00 to 1.15, p=0.048) were more likely in Q5, and MACE was more likely in ethnic-minority patients (OR 1.40, 95% CI 1.00 to 1.95, p=0.048) versus white (OR 1.05, 95% CI 0.98 to 1.13, p=0.027) in Q5. In subgroup analyses, Black patients had the highest in-hospital mortality within the most affluent quintile (Q1) (Black: 0.079, 95% CI 0.046 to 0.112, p<0.001; White: 0.062, 95% CI 0.059 to 0.066, p<0.001), but not in Q5 (Black: 0.065, 95% CI 0.054 to 0.077, p<0.001; White: 0.065, 95% CI 0.061 to 0.069, p<0.001).

CONCLUSION

Patients with a higher deprivation score were more often from an ethnic-minority background, more likely to suffer in-hospital mortality or MACE when compared with the most affluent quintile, and this relationship was stronger in ethnic minorities compared with White patients.

Temporal analysis of non-ST segment elevation-acute coronary syndrome (NSTEACS) outcomes in 'young' patients under the age of fifty: A nationwide cohort study

BACKGROUND

The characteristics and risk factor profile of young patients presenting with non-ST segment elevation acute coronary syndrome (NSTEACS) and how they may have changed over time is not well reported.

METHODS

We identified 26,708 NSTEACS patients aged under 50 presenting to United Kingdom (UK) hospitals between 2010 and 2017 from Myocardial Ischaemia National Audit Project (MINAP). We calculated incidence of NSTEACS per 100,000 UK population, using Office of National Statistics (ONS) population estimates, prevalence of comorbidities, ethnicity, and in-hospital mortality. We formed biennial groups to enable comparison, 2010-2011, 2012-2013, 2014-2015 and 2016-2017.

RESULTS

The incidence of NSTEACS per 100,000 population showed minimal change between 2010 and 2017 (2010: 5.4 per 100,000 and 2017; 4.9 per 100,000). Rates of smoking (2010-11; 58% and 2016-17; 53%), and family history of coronary artery disease (CAD) (2010-11; 51% and 2016-17; 44%) fell, but the proportion of patients from an ethnic minority background (2010-11; 12% and 2016-17; 20%), with diabetes mellitus (DM) (2010-11; 14%, and 2016-17; 18%) and female patients (2010-11; 22% and 2016-17; 24%) increased over the study period. Mortality from NSTEACS remained unchanged (2010-11; 1% and 2016-17; 1%).

CONCLUSIONS

The incidence of NSTEACS in patients aged under fifty has not reduced despite reduction in prevalence of risk factors such as smoking hypercholesterolaemia in those admitted to UK hospitals. Despite improved rates of early invasive coronary angiography and percutaneous coronary intervention in 'young' NSTEACS patients, in-hospital mortality remains unchanged.

Trends In ST-elevation Myocardial Infarction Hospitalisation Among Young Adults: A Binational Analysis

BACKGROUND

ST-segment myocardial infarction (STEMI) is typically associated with increased age, but there is an important group of patients that suffer STEMI under the age of fifty, that are not well characterized in studies.

METHODS & RESULTS

We analysed results from Myocardial Ischemia National Audit Project (MINAP) from the United Kingdom (UK) between 2010-2017 and the National Inpatient Sample (NIS) from the United States (US) between 2010-2018. After exclusion criteria, there were 32,719 STEMI patients aged ≤50 from MINAP, and 238,952 patients' ≤50 from the NIS. We analysed temporal trends in demographics, management, and mortality. The proportion of females increased, 15.6% (2010-2012) to 17.6% (2016-2017) (UK) and 22.8% (2010-2012) to 23.1% (2016-2018) (US). The proportion of white patients decreased, from 86.7% (2010) to 79.1% (2017) (UK) and 72.1% (2010) to 67.1% (2017) (US). Invasive coronary angiography (ICA) rates increased in UK (2010-2012: 89.0%, 2016-2017: 94.3%), while decreased in US (2010-2012: 88.9%, 2016-2018: 86.2% (US). After adjusting for baseline characteristics and management strategies, there was no difference in all-cause mortality in the UK in 2016-2017 compared to 2010-2012 (OR:1.21, 95% CI:0.60-2.40), but there was a decrease in the US in 2016-2018 compared to 2010-2012 (OR: 0.84, 95% CI: 0.79-0.90).

CONCLUSION

The demographics of young STEMI patients have temporally changed in the UK and US, with increased proportions of females and ethnic minorities. There was a significant increase in the frequency of diabetes mellitus over the respective time periods in both countries.

Ethnic Disparities in ST-Segment Elevation Myocardial Infarction Outcomes and Processes of Care in Patients With and Without Standard Modifiable Cardiovascular Risk Factors: A Nationwide Cohort Study

Trials suggest patients with ST-elevation myocardial infarction (STEMI) without 'standard modifiable cardiovascular risk factors' (SMuRFs) have poorer outcomes, but the role of ethnicity has not been investigated. We analyzed 118,177 STEMI patients using the Myocardial Ischaemia National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analyzed using hierarchical logistic regression models; patients with ≥1 SMuRF (n = 88,055) were compared with 'SMuRFless' patients (n = 30,122), with subgroup analysis comparing outcomes of White and Ethnic minority patients. SMuRFless patients had higher incidence of major adverse cardiovascular events (MACE) (odds ratio, OR: 1.09, 95% CI 1.02-1.16) and in-hospital mortality (OR: 1.09, 95% CI 1.01-1.18) after adjusting for demographics, Killip classification, cardiac arrest, and comorbidities. When additionally adjusting for invasive coronary angiography (ICA) and revascularisation (percutaneous coronary intervention (PCI) or coronary artery bypass grafts surgery (CABG)), results for in-hospital mortality were no longer significant (OR 1.05, 95% CI .97-1.13). There were no significant differences in outcomes according to ethnicity. Ethnic minority patients were more likely to undergo revascularisation with ≥1 SMuRF (88 vs 80%, P < .001) or SMuRFless (87 vs 77%, P < .001. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status.

Impact of pre-existing vascular disease on clinical outcomes

AIMS

Little is known about the outcomes and processes of care of patients with non-ST-segment myocardial infarction (NSTEMI) who present with 'polyvascular' disease.

METHODS AND RESULTS

We analysed 287 279 NSTEMI patients using the Myocardial Ischaemia National Audit Project registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed-coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD)-with comparison to a historically disease-free control group, comprising 167 947 patients (59%). After adjusting for demographics and management, polyvascular disease was associated with increased likelihood of major adverse cardiovascular events (MACEs) [CAD odds ratio (OR): 1.06; 95% confidence interval (CI): 1.01-1.12; P = 0.02] (CeVD OR: 1.19; 95% CI: 1.12-1.27; P < 0.001) (PVD OR: 1.22; 95% CI: 1.13-1.33; P < 0.001) and in-hospital mortality (CeVD OR: 1.24; 95% CI: 1.16-1.32; P < 0.001) (PVD OR: 1.33; 95% CI: 1.21-1.46; P < 0.001). Patients without vascular disease were less frequently discharged on statins (PVD 88%, CeVD 86%, CAD 90%, and control 78%), and those with moderate [ejection fraction (EF) 30-49%] or severe left ventricular systolic dysfunction (EF < 30%) were less frequently discharged on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) (CAD 82%, CeVD 77%, PVD 77%, and control 74%). Patients with polyvascular disease were less likely to be discharged on dual antiplatelet therapy (DAPT) (PVD 78%, CeVD 77%, CAD 80%, and control 87%).

CONCLUSION

Polyvascular disease patients had a higher incidence of in-hospital mortality and MACEs. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Impact of pre-existing vascular disease on clinical outcomes in patients with non-ST-segment myocardial infarction: a nationwide cohort study

Aims

Little is known about the outcomes and processes of care of patients with non ST-segment myocardial infarction (NSTEMI) who present with “polyvascular” disease.

Methods

We analysed 287,279 NSTEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed; coronary artery disease (CAD), cerebrovascular disease (CeVD) and peripheral vascular disease (PVD), with comparison to a historically disease-free control group; comprising 167,947 patients (59%). Further analyses compared cumulative number of affected beds with our control.

Results

After adjusting for demographics and management, vascular bed disease was associated with increased likelihood of MACE (CAD OR: 1.06, 95% CI: 1.01–1.12, P=0.02) (CeVD OR: 1.19, 95% CI: 1.12–1.27, P&lt;0.001) (PVD OR: 1.22, 95% CI: 1.13–1.33, P&lt;0.001) and in-hospital mortality (CeVD OR: 1.24, 95% CI: 1.16–1.32, P&lt;0.001) (PVD OR: 1.33, 95% CI: 1.21–1.46, P&lt;0.001). Patients with no vascular disease were less likely to be discharged on statins (PVD 88%, CeVD 86%, CAD 90% and control 78%), and those with moderate (EF 30–49%) or severe left ventricular systolic dysfunction (LVSD) (EF&lt;30%) were less likely to be discharged on ACE inhibitors (CAD 82%, CeVD 77%, PVD 77%, control 74%). Patients with polyvascular disease were less likely to be discharged on DAPT (PVD 78%, CeVD 77%, CAD 80%, control 87%).

Conclusion

Polyvascular disease patients had a higher adjusted incidence of in-hospital mortality and MACE. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Funding Acknowledgement

Type of funding sources: None.

Ethnic disparities in ST-segment myocardial infarction outcomes and processes of care in patients with and without standard modifiable cardiovascular risk factors: a nationwide cohort study

Background

There is growing interest in patients presenting with ST-elevation myocardial infarction (STEMI) in the absence of `standard modifiable cardiovascular risk factors' (SMuRFs), which include current smoking, hypertension, diabetes and hypercholesterolaemia. Recent trials have demonstrated how these “SMuRFless” patients can have poorer outcomes after STEMI then those patients with SMuRFs, but these trials have not looked at the role of ethnicity in outcomes (1).

Methods

We analysed 118,177 STEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed using hierarchical logistic regression models according to the presence of ≥1 SMuRF (88,055) and compared to the “SMuRFless” cohort (30,122), with a subgroup analysis comparing the outcomes of white and ethnic minority patients (comprising Black, Asian, Mixed and other) depending on SMuRF status. Our primary outcomes were in-hospital mortality and major adverse cardiovascular events (MACE), and secondary outcomes were in-hospital cardiac mortality and major bleeding.

Results

SMuRFless patients had a higher incidence of MACE (OR 1.09, CI 1.02–1.16), in-hospital mortality (OR 1.09, CI 1.01–1.18), and cardiac-mortality (OR 1.08, CI 1.00–1.17) than those with SMuRFs after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. There were no statistically significant differences in our outcome measures between white and ethnic minority patients. Ethnic minority patients were more likely to undergo revascularisation by PCI or CABG (ethnic minority with SMuRFs 88%, ethnic minority SMuRFless 87%, white with SMuRFs 80%, white SMuRFless 77%).

Conclusion

SMuRFless patients have a higher incidence of MACE, in-hospital mortality, and cardiac-mortality than those with SMuRFs, which persists after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status but did not have poorer outcomes when compared to white patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of QRS Duration on Non-ST-Segment Elevation Myocardial Infarction (from a National Registry)

QRS duration (QRSd) is ill-defined and under-researched as a prognosticator in patients with non-ST-segment myocardial infarction (NSTEMI). We analyzed 240,866 adult (≥18 years) hospitalizations with non-ST-segment elevation myocardial infarction using data from the United Kingdom Myocardial Infarction National Audit Project. Clinical characteristics and all-cause in-hospital mortality were analyzed according to QRSd, with 38,023 patients presenting with a QRSd >120 ms and 202,842 patients with a QRSd <120 ms. Patients with a QRSd >120 ms were more frequently older (median age of 79 years vs 71 years, p <0.001), and of white ethnicity (93% vs 91%, p <0.001). Patients with a QRSd <120 ms had higher frequency of use of aspirin (97% vs 95%, p <0.001), P2Y12 inhibitor (93% vs 89%, p <0.001), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (82% vs 81%, p <0.001) and β blockers (83% vs 78%, p <0.001). Invasive management strategies were more likely to be used in patients with QRSd <120 ms including invasive coronary angiography (72% vs 54%, p <0.001), percutaneous coronary intervention (46% vs 33%, p <0.001) and coronary artery bypass graft surgery (8% vs 6%, p <0.001). In a propensity score matching analysis, there were no differences between the 2 groups in the adjusted rates of in-hospital all-cause mortality (odds ratio 0.94, 95% confidence interval 0.86 to 1.01) or major adverse cardiac events (odds ratio 0.94, 95% confidence interval 0.85 to 1.02) during the index admission. In conclusion, prolonged QRSd >120 ms in the context of non-ST-segment myocardial infarction is not associated with worse in-hospital mortality or the outcomes of major adverse cardiac events.

Kolkata-Coventry comparative registry study of acute heart failure: an insight into the impact of public, private and universal health systems on patient outcomes in low-middle income cities (KOLCOV HF Study)

Introduction

Survival gaps in acute heart failure (AHF) continue to expand globally. Multinational heart failure (HF) registries have highlighted variations between countries. Whether discrepancies in HF practice and outcomes occur across different health systems (ie, private, public or universal healthcare) within a city or between countries remain unclear. Insight into organisational care is also scarce. With increasing public scrutiny of health inequalities, a study to address these limitations is timely.

Method

KOLCOV-HF study prospectively compared patients with AHF in public (Nil Ratan Sircar Hospital (NRS)) versus private (Apollo Gleneagles Hospital (AGH)) hospitals of Kolkata, India, and one with universal health coverage in a socioeconomically comparable city of Coventry, England (University Hospitals Coventry & Warwickshire (UHCW)). Data variables were adapted from UK’s National HF Audit programme, collected over 24 months. Predictors of in-hospital mortality and length of hospitalisation were assessed for each centre.

Results

Among 1652 patients, in-hospital mortality was highest in government-funded NRS (11.9%) while 3 miles north, AGH had significantly lower mortality (7.5%, p=0.034), similar to UHCW (8%). This could be attributed to distinct HF phenotypes and differences in clinical and organisational care. As expected, low blood pressure was associated with a significantly greater risk of death in patients served by public hospitals UHCW and NRS.

Conclusion

Marked differences in HF characteristics, management and outcomes exist intra-regionally, and between low–middle versus high-income countries across private, public and universal healthcare systems. Physicians and policymakers should take caution when applying country-level data locally when developing strategies to address local evidence-practice gaps in HF.

Heart failure with preserved ejection fraction (HFpEF) pathophysiology study (IDENTIFY-HF): rise in arterial stiffness associates with HFpEF with increase in comorbidities

Background

There has been a shift in paradigm proposing that comorbidities play a significant role towards the pathophysiology of the heart failure with preserved ejection fraction (HFpEF) syndrome. Further, HFpEF patients have abnormal macrovascular function, potentially contributing significantly in altered ventricular-vascular coupling in these patients. However, our full understanding of the role of comorbidities, arterial stiffness and it relationship with HFpEF remains incomplete.

Purpose

The IDENTIFY-HF study aims to shed light on the HFpEF pathophysiology and investigates whether gradually increase in arterial stiffness (in addition to ageing) due to increasing common comorbidities, such as hypertension and diabetes, is associated with HFpEF.

Methods

Arterial compliance was assessed in five groups (Groups A to E) matched for age, (≥70 years), sex and renal function: Group A; normal healthy volunteers without major comorbidities (control). Group B; patients with hypertension only. Group C; patients with hypertension and diabetes mellitus only. Group D; patients with HFpEF. Group E; patients with heart failure and reduced ejection fraction (HFrEF); the parallel group. Arterial compliance was assessed using pulse wave velocity (PWV), as the primary outcome measure and was compared between Group A to D. A separate comparison was made between Groups D and E. To avoid confounding factors, participants were asked to omit their morning blood pressure medication and abstain from caffeine for 12 hours prior to the study.

Results

From the 95 volunteers recruited, PWV was obtained in 94 subjects. The mean PWV in group A, B, C, D and E was 10.2-, 12.2-, 13.0-, 13.7- and 10.0 m/s respectively. After adjusting for covariance (age, sex, BMI and renal function), the mean difference between Group A (healthy volunteers) and D (HFpEF) was 2.14 m/s (p=0.023). Whilst the mean difference between the HFpEF and HFrEF group D and E respectively was 2.68 m/s (p=0.003).

Conclusion

Rise in comorbidities increases arterial stiffness, as measured by pulse wave velocity, which in turn significantly associates with HFpEF (p=0.023). It is therefore possible that the HFpEF syndrome may not be due to a primary cardiac pathology but rather an end-result of non-cardiac comorbidities affecting vascular resistance with perhaps some secondary cardiac involvement.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): 1)West Midlands Clinical Research Network, National Institute of Health Research, UK2)Research, Development & Innovation department of the University Hospitals Coventry & Warwickshire NHS Trust (RDI, UHCW), UK.

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

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&lt;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

The utility of 18F-fluorodeoxyglucose positron emission tomography with computed tomography in Mycobacterium chimaera endocarditis: a case series

Background

Infective endocarditis secondary to Mycobacterium chimaera can present with classical constitutional symptoms of infective endocarditis but can be blood culture negative and without vegetations on transthoracic or transoesophageal echocardiogram. Patients with prosthetic valves are at particularly high risk.

Case summary

We present two patients who were diagnosed with infective endocarditis secondary to M. chimaera infection. They presented similarly with pyrexia of unknown origin and night sweats. Both patients had previously undergone aortic valve replacement; one with a tissue valve and the other with a metallic valve. New cardiac murmurs were evident on auscultation, but clinical examination showed no peripheral stigmata of endocarditis. Transoesophageal echo and transthoracic echo were both unremarkable, as were serial blood cultures. FDG PET CT scan was the key investigation, which showed increased uptake in the spleen beside other areas. Histopathology and mycobacterial cultures confirmed the diagnosis of M. chimaera infection in both cases. The first patient completed medical therapy and is now fit and well. However, the second patient unfortunately developed disseminated infection causing death.

Discussion

The management of M. chimaera infective endocarditis is challenging, often with delayed diagnosis and poor outcomes. In the context of negative blood cultures and inconclusive echocardiograms where there remains a high index of suspicion for endocarditis, FDG PET CT scanning can be a crucial diagnostic importance and should be considered early in patients with prosthetic valves.

Safety and cost-effectiveness of same-day complex left atrial ablation

Background

Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation.

Method

Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed.

Results

A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450.

Conclusions

Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.

•

We have previously reported same-day standard catheter ablation is safe, feasible and cost-effective. Data on same-day complex left-atrial ablation are limited.

•

Our multi-centre cohort study of 967 consecutive elective complex left-atrial ablation procedures between January 2011 and December 2019 revealed same-day ablations using conscious sedation were safe and associated with very few complications and could have significant benefits to patients and cost-savings for healthcare providers worldwide.

•

Same-day complex left-atrial ablation procedures can be performed safely without the need for overnight-stay. This has major implications for both patients and healthcare providers, especially given the current financial challenges and Covid-19 pandemic.

P2837Day-case complex left atrial ablation is safe and cost-effective: experience from a UK tertiary centre

Background

Day-case standard catheter ablation is becoming routine. However, patients having complex left atrial ablation for atrial fibrillation (AF) or left atrial tachycardia (LAT) often stay overnight. We have been performing day-case complex left atrial ablation since 2015.

Purpose

To evaluate the safety, efficacy and cost-effectiveness of day-case complex left atrial ablation compared with those who stayed overnight.

Methods

A retrospective analysis of all consecutive complex left atrial ablations performed in a UK tertiary cardiac centre between 2010–2018. Data were collected on baseline parameters, procedure details including mapping technique, ablation strategy, immediate efficacy, and acute complications.

Results

A total of 830 complex left atrial catheter ablations were performed; mean age±SD=60±12 years, 63% male. The majority were AF ablation (n=804, 96.9%), with the rest being LAT/left-atrial flutter. Of the AF cases, 545 were paroxysmal (≤7 days), 212 persistent (>7 days) and 47 long-standing (>1yr); 98% of cases were elective. Pulmonary vein isolation was performed in all; additional LA lines were done in 163, CTI ablation in 129 and CFAEs in 33. 3D-mapping (Carto/Precision)=44.7% (with contact sensing=38.0%), PVAC=18.7%, PVI cryo-balloon=36.6%. Of the cohort 331 (39.9%) were done as day-case. Acute success= 94.9%, acute complications=4.58% (femoral site complications, n=12; pericardial effusion, n=19 (9 needing drain); stroke/cerebral embolus, n=3; phrenic nerve palsy, n=5; first degree heart block, n=1). Comparison of day-case vs non day-case revealed no significant difference in number of complications (Table 1). An overnight stay at out hospital costs £350. During the period of study our institution saved £115.850 (∼140,000 euros).

Day-case vs non day-case ablation Parameters Day-case (n=331) Non day-case (n=499) p-value Mean age ± SD (years) 61.2±11.6 59.1±11.9 0.009 Males (n, %) 205 (61.9%) 321 (64.3%) 0.484 Normal heart (n, %) 243 (73.4%) 383 (76.8%) 0.276 Paroxysmal AF (n, %) 218 (65.9%) 327 (65.5%) 0.928 Fluoroscopy time (mins) 23.8±13.9 27.0±14.5 0.001 Procedure time (mins) 150±89.6 163±68.2 0.025 % with 3D-mapping 30.8% 56.9% <0.001 Acute complications (n, %) 12 (3.63%) 26 (5.21%) 0.285

Conclusions

Day-case complex left atrial cardiac ablation is safe and effective. It is associated with good clinical outcomes and leads to significant cost savings as an overnight stay is not needed.

Technical Considerations in Transradial Unprotected Left Main Stem Rotational Atherectomy-Assisted and IVUS-Guided Percutaneous Coronary Intervention Using the 7.5F Eaucath Sheathless Guiding Catheter System

Rotational atherectomy-assisted percutaneous coronary intervention (PCI) on unprotected left main stem (LMS) bifurcation lesions is technically challenging. Intravascular ultrasound (IVUS) has become a standard part of the PCI procedure for the treatment of LMS disease. There is limited experience in performing these cases via a transradial approach using a sheathless guiding catheter (SGC) system. We report a case of a symptomatic octogenarian patient with restrictive angina and significant LMS bifurcation disease, who was successfully treated transradially with the use of the 7.5F Eaucath SGC system and we describe the technical challenges encountered with this strategy.