Multiprofessional heart failure self-development framework

OBJECTIVE

Heart failure remains a key public health priority across the globe. The median age of people with heart failure admitted to hospital in the UK is 81 years old. Many such patients transcend the standard interventions that are well characterised and evidenced in guidelines, into holistic aspects surrounding frailty, rehabilitation and social care. Previous published competency frameworks in heart failure have focused on the value of doctors, nurses and pharmacists. We aimed to provide an expert consensus on the minimum heart failure-specific competencies necessary for multiple different healthcare professionals, including physiotherapists, occupational therapists, dietitians and cardiac physiologists.

METHODS

The document has been developed focussing on four main parts, (1) establishing a project working group of expert professionals, (2) a literature review of previously existing published curricula and competency frameworks, (3) consensus building, which included developing a structure to the framework with ongoing review of the contents to adapt and be inclusive for each specialty and (4) write up and dissemination to widen the impact of the project.

RESULTS

The final competency framework displays competencies across seven sections; knowledge (including subheadings on heart failure syndrome, diagnosis and clinical management); general skills; heart failure-specific skills; clinical autonomy; multidisciplinary team working; teaching and education; and research and development.

CONCLUSION

People with heart failure can be complex and have needs that require input from a broad range of specialties. This publication focuses on the vital impact of wider multidisciplinary groups and should help define the generic core heart failure-specific competencies needed to support future pipelines of professionals, who regularly interact with and deliver care for patients with heart failure.

Detection of pyridine derivatives by SABRE hyperpolarization at zero field

Nuclear magnetic resonance (NMR) spectroscopy is a powerful analytical tool used in modern science and technology. Its novel incarnation, based on measurements of NMR signals without external magnetic fields, provides direct access to intramolecular interactions based on heteronuclear scalar J-coupling. The uniqueness of these interactions makes each zero-field NMR spectrum distinct and useful in chemical fingerprinting. However, the necessity of heteronuclear coupling often results in weak signals due to the low abundance of certain nuclei (e.g., ¹⁵N). Hyperpolarization of such compounds may solve the problem. In this work, we investigate molecules with natural isotopic abundance that are polarized using non-hydrogenative parahydrogen-induced polarization. We demonstrate that spectra of hyperpolarized naturally abundant pyridine derivatives can be observed and uniquely identified whether the same substituent is placed at a different position of the pyridine ring or different constituents are placed at the same position. To do so, we constructed an experimental system using a home-built nitrogen vapor condenser, which allows for consistent long-term measurements, crucial for identifying naturally abundant hyperpolarized molecules at a concentration level of ~1 mM. This opens avenues for future chemical detection of naturally abundant compounds using zero-field NMR.

Echocardiographic description and outcomes in a heterogeneous cohort of patients undergoing mitral valve surgery with and without mitral annular disjunction: a health service evaluation

Background

Mitral annular disjunction (MAD) is a structural abnormality characterized by the distinct separation of the mitral valve annulus/left atrium wall and myocardium. Little is known about the significance of MAD in patients requiring mitral valve surgery. This evaluation evaluates the echocardiographic characteristics and patient outcomes for patients with and without MAD who require mitral valve surgery.

Methods

All patients who underwent mitral valve surgery and who had a pre-surgical transthoracic echocardiogram between 2013 and 2020 were included. Patient demographics and clinical outcomes were collected on review of patient electronic records.

Results

A total of 185 patients were included in the analysis of which 32.4% had MAD (average MAD length 8.4 mm). MAD was seen most commonly in patients with mitral valve prolapse and myxomatous mitral valves disease (90% and 60% respectively). In the patients with MAD prior to mitral valve surgery, only 3.9% had MAD post mitral valve surgery. There were no significant difference in the severity of post-operative mitral regurgitation, arrhythmic events or major adverse cardiovascular events in patients with and without MAD.

Conclusions

MAD is common in patients who undergo mitral valve surgery. Current surgical techniques are able to correct the MAD abnormality in the vast majority of patients. MAD is not associated with an increased risk of adverse clinical outcomes post mitral valve surgery.

Mid-term follow-up and outcomes of patients with prosthetic heart valves: a single-centre experience

Background

Patients with prosthetic heart valves (PHV) require long-term follow-up, usually within a physiologist led heart valve surveillance clinic. These clinics are well established providing safe and effective patient care. The disruption of the COVID-19 pandemic on services has increased wait times thus we undertook a service evaluation to better understand the patients currently within the service and PHV related complications.

Methods

A clinical service evaluation of the heart valve surveillance clinic was undertaken to assess patient demographics, rates of complications and patient outcomes in patients who had undergone a PHV intervention at our institute between 2010 and 2020.

Results

A total of 294 patients (mean age at time of PHV intervention: 71 ± 12 years, 68.7% male) were included in this service evaluation. Follow-up was 5.9 ± 2.7 years (range: 10 years). 37.1% underwent baseline transthoracic echo (TTE) assessment and 83% underwent annual TTE follow-up. Significant valve related complications were reported in 20 (6.8%) patients. Complications included a change in patient functional status secondary to significant PHV regurgitation (0.3%) or stenosis (0.3%), PHV thrombosis (0.3%) or infective endocarditis (3.7%). Significant valve related complications resulted in ten hospital admission (3.4%), two re-do interventions (0.6%), and four deaths (1.3%).

Conclusions

This service evaluation highlights the large number of patients requiring ongoing surveillance. Only a small proportion of patients develop significant PHV related complications resulting in a low incidence of re-do interventions and deaths.

Clinical indications and triaging for adult transthoracic echocardiography: a consensus statement by the British Society of Echocardiography in collaboration with British Heart Valve Society

Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice.

Challenges of remote consultations: a delayed diagnosis of aortic valve endocarditis complicated by recurrent intracranial events

Embolic events causing stroke and intracranial haemorrhage are among the most catastrophic complications of infective endocarditis (IE).A female patient presented with acute unilateral weakness following a 3-month history of fever, for which she had multiple remote consultations with her general practitioner. A brain MRI confirmed a left sided infarct with haemorrhagic transformation. Blood cultures grew Streptococcus mitis and her cardiac imaging showed an aortic valve vegetation with severe aortic regurgitation. Following 2 weeks of antibiotics she developed a new cerebral haemorrhage associated with a mycotic aneurysm which was treated with two coils. After discussions within the multidisciplinary meeting, she underwent aortic valve replacement 3 weeks later. She made a remarkable recovery and was discharged.Our case highlights the importance of face-to-face clinical review in the post-COVID era. It stresses that the management of patients with infective endocarditis and neurological complications is challenging and requires a multidisciplinary approach.

Definition, prevalence, and clinical significance of mitral annular disjunction in different patient cohorts: A systematic review

BACKGROUND

Mitral annular disjunction (MAD) is a structural abnormality involving a distinct separation of the left atrium/mitral valve annulus and myocardium continuum. The literature around MAD has increased over recent years, thus we sought to review the current data on the definition, prevalence, and clinical outcomes of MAD.

METHODS

A search of MEDLINE and EMBASE was conducted to identify studies which evaluated MAD in any patient cohort. The study results were synthesized narratively.

RESULTS

A total of 12 studies were included with 3925 patients (average age 62 years, 63% male). The pooled prevalence of MAD in patients with mitral valve prolapse and/or Barlow's disease was 30.1%. In a general population, MAD prevalence was 8.7%. The definition of MAD was not consistent across all studies. In terms of clinical outcomes, only one study reported MAD to be associated with ventricular arrhythmias.

CONCLUSIONS

MAD is an increasingly recognized finding amongst patients undergoing cardiac imaging. This review highlights the need for agreed definitions for clinically significant MAD and how identified MAD should be managed. At present, there is insufficient evidence that MAD is associated adverse clinical outcomes.

The prevalence and significance of mitral annular disjunction on clinical outcomes in patients undergoing mitral valve surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Mitral annular disjunction (MAD) is a common structural abnormality involving a distinct separation of the left atrium/mitral valve annulus and myocardium continuum. MAD is commonly associated with altered mitral valve annular dynamics, increased left ventricular and mitral valve apparatus stress and potentially life threatening arrhythmias. At present there is limited data on the prevalence and significance of MAD in patients requiring mitral valve surgery.

Purpose

To ascertain the prevalence, extent and significance of MAD on a general cohort of patients with mitral valve disease who required mitral valve surgery. Primary outcomes included: duration of surgery, need for re-do operation (any cause), neurological and gastro-intestinal complications, cardiogenic shock and mortality. These were assessed during the surgical hospitalisation period.

Methods

The local cardiothoracic database within a large tertiary centre was used to identify all patients who underwent mitral valve surgery between 2013 and 2020. From this, patients who were found to have a transthoracic echocardiogram (TTE) pre and post mitral valve surgery were included. Two experienced sonographers retrospectively reviewed and analysed each TTE. The data collected included: presence, location and extent of MAD (pre and post-surgery). The local cardiothoracic database and electronic patient records were reviewed for primary outcomes.

Results

A total of 187 patients were included (age: 65.6 ± 13.7 years, 74.2% males). The most common reason for mitral valve surgery was mitral valve prolapse (31.6%), remaining aetiologies included functional MR, ischemic MR, infective endocarditis, rheumatic mitral stenosis and congenital abnormalities. Surgical intervention included: leaflet repair ± annuloplasty ring (57.2%), bio-prosthesis (19.8%) or mechanical prosthesis (23.0%). Pre surgery, MAD was present in 32.6% of all patients and was most commonly seen in patients with mitral valve prolapse (21.3%). In patients with MAD, the averaged MAD length was 8.4 ± 3.9mm (median 7 [IQR: 5-11]). Post-surgery, MAD was only identified in 2 patients, both of whom had mitral valve repair± annuloplasty ring. As seen in Table 1, there were no significant differences in clinical outcomes in patients with or without MAD.

Conclusion

MAD is common in a cohort of patients requiring mitral valve surgery. Surgical intervention is able to correct MAD in the vast majority of patients and its presence does not affect immediate post-surgical outcomes. Abstract Table 1.

Spinal abscess in a patient with undiagnosed Gerbode defect: a case report

Background

Gerbode defect (GD) is a rare cardiac defect in which an abnormal communication occurs between the left ventricle and right atrium. The aetiology is usually congenital but acquired defects can occur.

Case summary

We report on a 47-year-old male with atrioventricular block prior to decompression of an epidural abscess extending from the skull base to the 7th thoracic vertebrae. Following positive blood cultures for Staphylococcus aureus, a transoesophageal echocardiogram performed revealed a small GD with associated endocarditis. In our case, the defect was small and there was no evidence of heart failure, there was little guidance or literature available on how to best manage our patient. A multidisciplinary decision was taken to treat the endocarditis medically and to not close the defect in the acute setting. He recovered well and did not suffer any further cardiac complications. A repeat transthoracic echocardiogram did not reveal any evidence of endocarditis.

Conclusion

Gerbode defects are rare but have been known to increase the risk of developing endocarditis. It is important to have a high clinical suspicion of endocarditis in patients with evidence of conduction disorders and systemic infection.

Patient, Clinician, and Healthcare Perspectives in Evaluating Care Pathways for Stable Chest Pain

Chest pain is one of the most common reasons for patients to present to healthcare professionals. One of the main challenges with the management of chest pain is the wide differential diagnosis, ranging from minor chest trauma to potentially life-threatening acute myocardial infarction. In a patient-centered health service pathway, the aim is to assess, investigate, diagnose, and treat patients in the safest and most accurate, time, and cost-efficient manner. This report describes the concept of clinical pathways and their importance. It iterates different perspectives of the investigation of chest pain and the barriers to understanding the clinical sequence of events. By considering the patient, clinician, and healthcare service perspective, it is possible to critically evaluate the current stable chest pain pathway. This exercise gives consideration into the way in which patient care could be improved.

Outpatient parenteral antimicrobial therapy (OPAT) service is associated with inpatient-bed cost savings

In a cardiology department, there are some patients that require long-term antibiotics, such as those with infective endocarditis or infected prosthetic devices. We describe our experience with intravenous antibiotic therapy for patients with cardiology diagnoses who require a period of antibiotics in our outpatient service during the period of the COVID-19 pandemic. A total of 15 patients were selected to have outpatient antibiotic therapy (age range 36 to 97 years, 60% male). A total of nine patients had infective endocarditis, four patients had infected valve prosthesis or transcatheter aortic valve implantation (TAVI) endocarditis, one patient had infected pericardial effusion while another had infected pericarditis. For these 15 patients there was a total of 333 hospital bed-days, on average 22 days per patient. These patients also had a total of 312 days of outpatient antibiotic therapy, which was an average of 21 days per patient. The total cost, if patients were admitted for those days, assuming a night cost £400, was £124,800, which was on average £8,320 per patient. Three patients were readmitted within 30 days. One had ongoing endocarditis that was managed medically and another had pulmonary embolism. The last patient had a side effect related to daptomycin use. In conclusion, outpatient antibiotic therapy in selected patients with native or prosthetic infective endocarditis appears to be safe for a selected group of patients with associated cost savings.

Acute coronary syndrome secondary to cardiac infiltration and coronary occlusion of chronic lymphocytic leukemia - A case report

A 72-year-old male with a history of chronic lymphocytic leukemia (CLL) was admitted to hospital with a productive cough and an episode of diarrhea and vomiting. He was initially treated for pneumonitis and sepsis. On the 12th day of his admission, he reported chest pain. Changes on his electrocardiogram were suggestive of myocardial ischemia and an elevated troponin rise was detected from his blood tests. A diagnosis of acute coronary syndrome was made but due to his frailty, he was medically managed. His echocardiogram revealed an external echogenic mass which invaded the anterolateral left ventricular wall. Further imaging with cardiac magnetic resonance imaging (MRI) and computed tomography (CT) thorax demonstrated external encasement of left circumflex coronary artery with mediastinal mass, leading into downstream myocardial ischemia and subsequent necrosis. He was considered suitable for aggressive radiotherapy/chemotherapy but passed away 7 days later. This case highlights the unusual case where an acute myocardial infarction can be attributed to direct infiltration and external compression of coronary artery by mediastinal tumor and the value of multi-modality imaging (echocardiogram, CT, and MRI) in identifying the cause of myocardial ischemia in patients with CLL in the end stages of the disease. .

Misdiagnosis of Heart Failure: A Systematic Review of the Literature

BACKGROUND

Heart failure (HF) is a chronic disease associated with a significant burden to patients, families, and health services. The diagnosis of HF can be easily missed owing to similar symptoms with other conditions especially respiratory diseases.

METHODS AND RESULTS

We conducted a systematic review to determine the rates of HF and cardiomyopathy misdiagnosis and explored the potential causes. The included studies were narratively synthesized. Ten studies were identified including a total of 223,859 patients. There was a lack of definition of HF misdiagnosis in the studies and inconsistent diagnostic criteria were used. The rates of HF misdiagnosis ranged from 16.1% in hospital setting to 68.5% when general practitioner referred patients to specialist setting. The most common cause for misdiagnosis was chronic obstructive pulmonary disease (COPD). One study using a COPD cohort showed that HF was unrecognized in 20.5% of patients and 8.1% had misdiagnosis of HF as COPD. Another study suggests that anemia and chronic kidney disease are associated with an increase in the odds of unrecognized left ventricular systolic dysfunction. Other comorbidities such as obesity, old age, atrial fibrillation, and ischemic heart disease are prevalent in patients with a misdiagnosis of HF.

CONCLUSIONS

The misdiagnosis of HF is an unfortunate part of everyday clinical practice that occurs with a variable rate depending on the population studied. HF is frequently misdiagnosed as COPD. More research is needed to better understand the missed opportunities to correctly diagnose HF so that harm to patients can be avoided and effective treatments can be implemented.

The role of the Tei index in assessing for cardiotoxicity from anthracycline chemotherapy: a systematic review

Background

Anthracycline agents are known to be effective in treating tumors and hematological malignancies. Although these agents improve survival, their use is associated with cardiotoxic effects, which most commonly manifests as left ventricular systolic dysfunction (LVSD). As such, guidelines recommend the periodic assessment of left ventricular ejection fraction (LVEF). However, as diastolic dysfunction likely proceeds systolic impairment in this setting, the role of Tei index may offer additional benefit in detecting subclinical LVSD.

Methods

We conducted a systematic review to investigate the evidence for the use of Tei index in assessing subclinical cardiotoxicity in patients receiving anticancer agents. A search of Medline and EMBASE was performed and relevant studies were reviewed and narratively synthesized.

Results

A total of 13 studies were included with a total of 800 patients (mean age range 46–62 years, percentage of male participants ranged from 0–86.9%). An increase in Tei index was observed in 11 studies, which suggested a decline in cardiac function following chemotherapy. Out of these, six studies indicated that the Tei index is a useful parameter in predicting cardiotoxic LVSD. Furthermore, five studies indicated Tei index to be superior to LVEF in detecting subclinical cardiotoxicity.

Conclusions

Though there are some studies that suggest that Tei index may be a useful indicator in assessing subclinical anthracycline-related cardiotoxicity, the findings are inconsistent and so more studies are needed before the evaluation of Tei index is performed routinely in patients receiving chemotherapy.

Accuracy and Prognostic Value of Physiologist-Led Stress Echocardiography for Coronary Disease

BACKGROUND

We demonstrated that physiologist-led stress echocardiography (PLSE) is feasible for coronary artery disease (CAD) assessment. We sought to extend our work by assessing its accuracy and prognostic value.

METHODS

Retrospective study of 898 subjects undergoing PLSE (n=393) or cardiologist-led stress echocardiography (CLSE) (n=505) for CAD assessment using exercise or dobutamine. For accuracy assessment, the primary outcome was the ability of stress echocardiography to identify significant CAD on invasive coronary angiography (ICA). Incidence of 24-month non-fatal MI, total and cardiac mortality, revascularisation and combined major adverse cardiac events (MACE) were assessed.

RESULTS

Demographics, comorbidities, CAD predictors, CAD pre-test probability and cardiac medications were matched between the PLSE and CLSE groups. PLSE had high sensitivity, specificity, positive and negative predictive value and accuracy (85%, 74%, 69%, 88%, 78% respectively). PLSE accuracy measures were similar and non-inferior to CLSE. There was a similar incidence of individual and combined outcomes in PLSE and CLSE subjects. Negative stress echocardiography conferred a comparably low incidence of non-fatal MI (PLSE 1.4% vs. CLSE 0.9%, p=0.464), cardiac mortality (0.6% vs. 0.0%, p=0.277) and MACE (6.8% vs. 3.1%, p=0.404).

CONCLUSION

This is the first study of the accuracy compared with gold standard of ICA, and prognostic value of PLSE CAD assessment. PLSE demonstrates high and non-inferior accuracy compared with CLSE for CAD assessment. Negative PLSE and CLSE confer a similarly very low incidence of cardiac outcomes, confirming for the first time the important prognostic value of PLSE.

The prognostic value of Tei index in acute myocardial infarction: a systematic review

Background

Echocardiographic evaluation of left ventricular ejection fraction (LVEF) is used in the risk stratification of patients with an acute myocardial infarction (AMI). However, the prognostic value of the Tei index, an alternative measure of global cardiac function, in AMI patients is not well established.

Methods

We conducted a systematic review, using MEDLINE and EMBASE, to evaluate the prognostic value of the Tei index in predicting adverse outcomes in patients presenting with AMI. The data was collected and narratively synthesised.

Results

A total of 16 studies were including in this review with 2886 participants (mean age was 60 years from 14 studies, the proportion of male patients 69.8% from 14 studies). Patient follow-up duration ranged from during the AMI hospitalisation stay to 57.8 months. Tei index showed a significant association with heart failure episodes, reinfarction, death and left ventricular thrombus formation in 14 out of the 16 studies. However, in one of these studies, Tei index was only significantly predictive of cardiac events in patients where LVEF was <40%. In two further studies, Tei index was not associated with predicting adverse outcomes once LVEF, left ventricular end-systolic volume index and left ventricular early filling time was taken into consideration. In the two remaining studies, there was no prognostic value of Tei index in relation to patient outcomes.

Conclusions

Tei index may be an important prognostic marker in AMI patients, however, more studies are needed to better understand when it should be used routinely within clinical practice.

P1247 Bilateral endogenous endophthalmitis as the initial presentation of hacek prosthetic valve infective endocarditis

Summary

A 75 year old lady with a prosthetic aortic valve (St Jude mechanical AVR) presented to ophthalmology with a one month history of black spots in the vision of her left eye with a further episode in her right eye two weeks later, leading to a diagnosis of bilateral endogenous endopthalmitis and was admitted to hospital. There was no history of trauma and the chest and abdominal examination was normal. The erythrocyte sedimentation rate (40) and C reactive protein (45.8) were elevated. She had several sets of blood cultures, which were positive for Aggregatibacter actinomycetemcomitans, a HACEK organism and was started on empirical Ceftriaxone. The transthoracic echocardiography was normal. However, the suspicion of Infective Endocarditis (IE) was high, therefore a transoesophageal echocardiography was performed and showed an aortic root abscess (Image 1). An urgent computerised aortogram was performed. Following a planned two week period of intravenous antibiotics the patient was taken to theatre to have a redo AV valve replacement and root repair. Following a prolonged period on intensive care and a six week course of pathogen directed antibiotic therapy she was then fit enough to be discharged.

Conclusion

We present the first case in the literature of a HACEK Prosthetic Valve endocarditis presenting with bilateral endogenous endophthalmitis.

Abstract P1247 Figure. TOE image of Absess

1673 Accuracy and prognostic value of physiologist-led stress echocardiography for coronary disease

Funding Acknowledgements

No funding sources

Background

Cardiac physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There is no published data on the accuracy or prognostic value of PLSE.

Purpose

To assess and compare the accuracy and prognostic value of PLSE and cardiologist-led stress echocardiography (CLSE) for CAD assessment

Methods

Retrospective study of 898 subjects undergoing PLSE (n = 393) or CLSE (n = 505) for CAD assessment using exercise or dobutamine. For accuracy assessment, the primary outcome was the ability of stress echocardiography to identify significant CAD on invasive angiography (ICA). Incidence of 24-month non-fatal myocardial infarction (MI), total and cardiac mortality, revascularisation and combined major adverse cardiac events (MACE) were assessed.

Results

Demographics, comorbidities, CAD predictors and cardiac medications were matched between the PLSE and CLSE groups. PLSE had high sensitivity, specificity, positive and negative predictive value and accuracy (85%, 74%, 69%, 88%, 78% respectively). PLSE accuracy measures were similar and non-inferior to CLSE. There was a similar incidence of individual and combined outcomes in PLSE and CLSE subjects. Negative stress echocardiography conferred a low incidence of non-fatal MI (PLSE 1.4% vs. CLSE 0.9%, p = 0.464), cardiac mortality (0.6% vs. 0.0%, p = 0.277) and MACE (6.8% vs. 3.1%, p = 0.404).

Conclusion

This is the largest study of PLSE accuracy and first study of the prognostic value of PLSE. PLSE demonstrates high and non-inferior accuracy compared with CLSE for CAD assessment. Negative PLSE and CLSE confer a similarly very low incidence of cardiac outcomes, confirming for the first time the important prognostic value of PLSE.

Accuracy of PLSE and CLSE for CAD Marker of diagnostic test Total (n = 72) PLSE (n = 32) CLSE (n = 40) p Significant CAD present (n, %) 20 (27.8%) 12 (37.5%) 8 (20.0%) 0.167 * Single-vessel CAD 12 (60.0%) 7 (58.3%) 5 (62.5%) 0.325 * Multi-vessel CAD 8 (40.0%) 5 (41.7%) 3 (37.5%) 0.325 Sensitivity 76% (66-76%) 85% (73-97%) 63% (48-78%) Non-significant Specificity 73% (63-73%) 74% (59-89%) 72% (58-86%) Non-significant Positive predictive value (PPV) 53% (42-64%) 69% (53-85%) 29% (15-43%) Significant Negative predictive value (NPV) 88% (80-96%) 88% (77-99%) 88% (78-98%) Non-significant Overall accuracy 74% (64-84%) 78% (64-92%) 70% (56-84%) Non-significant Accuracy data expressed as value (95% confidence interval). CAD= coronary artery disease. Differences in values between PLSE and CLSE considered statistically significant if no crossover in 95% confidence intervals

Abstract 1673 Figure. Predicted coronary artery lesion from SE

Early Unplanned Readmissions After Admission to Hospital With Heart Failure

Hospital readmissions remain a continued challenge in the care of patients with heart failure (HF). This study aims to examine the rates, temporal trends, predictors and causes of 30-day unplanned readmissions after admission with HF. Patients hospitalized with a primary or secondary diagnosis of HF in the U.S. Nationwide Readmission Database were included. We examined the incidence, trends, predictors and causes of unplanned all-cause readmissions at 30-days. A total of 2,635,673 and 8,342,383 patients were included in the analyses for primary and secondary diagnoses of HF, respectively. The 30-day unplanned readmission rate was 15.1% for primary HF and 14.6% for secondary HF. Predictors of readmission in primary HF included renal failure (OR 1.27 (1.25 to 1.28)), cancer (OR 1.26 (1.22 to 1.29)), receipt of circulatory support (OR 2.81 (1.64 to 4.81)) and discharge against medical advice (OR 2.29 (2.20 to 2.39)). In secondary HF, the major predictors were receipt of circulatory support (OR 1.43 (1.12 to 1.84)) and discharge against medical advice (OR 2.01 95%CI (1.95 to 2.07)). In primary HF 52.4% of patients were readmitted for a noncardiac cause while for secondary HF 73.9% were readmitted for a noncardiac cause. For secondary HF, the strongest predictor of readmission was discharge against medical advice (OR 2.06 95%CI 2.01 to 2.12, p < 0.001). Early unplanned readmissions are common among patients hospitalized with HF, and a majority of readmissions are due to causes other than HF. Our results highlight the need to better manage comorbidities in patients with HF.

Knowing, Anticipating, Even Facilitating but Still not Intending: Another Challenge to Double Effect Reasoning

A recent administrative law decision in Victoria, Australia, applied double effect reasoning in a novel way. Double effect reasoning has hitherto been used to legitimate treatments which may shorten life but where the intent of treatment is pain relief. The situation reviewed by the Victorian tribunal went further, supporting actions where a doctor agrees to provide pentobarbitone (Nembutal) to a patient at some time in the future if the patient feels at that time that his pain is unbearable and he wants to end his life. The offer to provide the drug was described as a palliative treatment in that it gave reassurance and comfort to the patient. Double effect reasoning was extended in this instance to encompass potentially facilitating a patient's death. This extension further muddies the murky double effect reasoning waters and creates another challenge to this concept.

Analysis of lead placement optimization metrics in cardiac resynchronization therapy with computational modelling

AIMS

The efficacy of cardiac resynchronization therapy (CRT) is known to vary considerably with pacing location, however the most effective set of metrics by which to select the optimal pacing site is not yet well understood. Computational modelling offers a powerful methodology to comprehensively test the effect of pacing location in silico and investigate how to best optimize therapy using clinically available metrics for the individual patient.

METHODS AND RESULTS

Personalized computational models of cardiac electromechanics were used to perform an in silico left ventricle (LV) pacing site optimization study as part of biventricular CRT in three patient cases. Maps of response to therapy according to changes in total activation time (ΔTAT) and acute haemodynamic response (AHR) were generated and compared with preclinical metrics of electrical function, strain, stress, and mechanical work to assess their suitability for selecting the optimal pacing site. In all three patients, response to therapy was highly sensitive to pacing location, with laterobasal locations being optimal. ΔTAT and AHR were found to be correlated (ρ < -0.80), as were AHR and the preclinical activation time at the pacing site (ρ ≥ 0.73), however pacing in the last activated site did not result in the optimal response to therapy in all cases.

CONCLUSION

This computational modelling study supports pacing in laterobasal locations, optimizing pacing site by minimizing paced QRS duration and pacing in regions activated late at sinus rhythm. Results demonstrate information content is redundant using multiple preclinical metrics. Of significance, the correlation of AHR with ΔTAT indicates that minimization of QRSd is a promising metric for optimization of lead placement.

Feasibility of physiologist-led stress echocardiography for the assessment of coronary artery disease

BACKGROUND

Physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There are however no published data on the feasibility of PLSE. We sought to assess the feasibility, safety and robustness of PLSE and cardiologist-led stress echocardiography (CLSE) for coronary artery disease (CAD) assessment.

METHODS

Retrospective analysis of 898 patients undergoing PLSE or CLSE for CAD assessment using exercise or dobutamine stress over 24 months. PLSE involved 2 cardiac physiologists (exercise) or 1 physiologist plus 1 cardiac nurse (dobutamine). A cardiology registrar was present in the echocardiography department during PLSE in case of medical complications. CLSE involved 1 physiologist and 1 trainee cardiologist who analysed the study and reviewed findings with an imaging cardiologist. Sixteen-segment wall motion scoring (WMS, WMSI) analysis was performed. Feasibility (stressor, image quality, proportion of completed studies, agreement with imaging cardiologist analysis) and safety (complication rate) were compared for PLSE and CLSE.

RESULTS

The majority of studies were CLSE (56.2%) and used dobutamine (68.7%). PLSE more commonly used exercise (69.2%). Overall, 96% of studies were successfully completed (>14 diagnostic segments in 98%, P = 0.899 PLSE vs CLSE). Commencement of PLSE was associated with an increase in annual SE's performed for CAD assessment. Complication rates were comparably very low for PLSE and CLSE (0.8% vs 1.8%, P = 0.187). There was excellent agreement between PLSE and CLSE WMS interpretation of 480 myocardial segments at rest (κ = 0.87) and stress (κ = 0.70) and WMSI (ICCs and Pearson's r >0.90, zero Bland-Altman mean bias).

CONCLUSION

This to our knowledge is the first study of the feasibility of PLSE. PLSE performed by well-trained physiologists is feasible and safe in contemporary practice. PLSE and CLSE interpretation of stress echocardiography for CAD agree very closely.

The relative role of patient physiology and device optimisation in cardiac resynchronisation therapy: A computational modelling study

Cardiac resynchronisation therapy (CRT) is an established treatment for heart failure, however the effective selection of patients and optimisation of therapy remain controversial. While extensive research is ongoing, it remains unclear whether improvements in patient selection or therapy planning offers a greater opportunity for the improvement of clinical outcomes. This computational study investigates the impact of both physiological conditions that guide patient selection and the optimisation of pacing lead placement on CRT outcomes. A multi-scale biophysical model of cardiac electromechanics was developed and personalised to patient data in three patients. These models were separated into components representing cardiac anatomy, pacing lead location, myocardial conductivity and stiffness, afterload, active contraction and conduction block for each individual, and recombined to generate a cohort of 648 virtual patients. The effect of these components on the change in total activation time of the ventricles (ΔTAT) and acute haemodynamic response (AHR) was analysed. The pacing site location was found to have the largest effect on ΔTAT and AHR. Secondary effects on ΔTAT and AHR were found for functional conduction block and cardiac anatomy. The simulation results highlight a need for a greater emphasis on therapy optimisation in order to achieve the best outcomes for patients.

•

Ventricular conduction block indicates patient response to CRT.

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Placement of CRT pacing leads strongly affects response to therapy.

•

Improved treatment planning should be prioritised in order to maximise CRT outcomes.

Facing and Overcoming Sensitivity Challenges in Biomolecular NMR Spectroscopy

In the Spring of 2013, NMR spectroscopists convened at the Weizmann Institute in Israel to brainstorm on approaches to improve the sensitivity of NMR experiments, particularly when applied in biomolecular settings. This multi-author interdisciplinary Review presents a state-of-the-art description of the primary approaches that were considered. Topics discussed included the future of ultrahigh-field NMR systems, emerging NMR detection technologies, new approaches to nuclear hyperpolarization, and progress in sample preparation. All of these are orthogonal efforts, whose gains could multiply and thereby enhance the sensitivity of solid- and liquid-state experiments. While substantial advances have been made in all these areas, numerous challenges remain in the quest of endowing NMR spectroscopy with the sensitivity that has characterized forms of spectroscopies based on electrical or optical measurements. These challenges, and the ways by which scientists and engineers are striving to solve them, are also addressed.

A comprehensive cardiac motion estimation framework using both untagged and 3-D tagged MR images based on nonrigid registration

In this paper, we present a novel technique based on nonrigid image registration for myocardial motion estimation using both untagged and 3-D tagged MR images. The novel aspect of our technique is its simultaneous usage of complementary information from both untagged and 3-D tagged MR images. To estimate the motion within the myocardium, we register a sequence of tagged and untagged MR images during the cardiac cycle to a set of reference tagged and untagged MR images at end-diastole. The similarity measure is spatially weighted to maximize the utility of information from both images. In addition, the proposed approach integrates a valve plane tracker and adaptive incompressibility into the framework. We have evaluated the proposed approach on 12 subjects. Our results show a clear improvement in terms of accuracy compared to approaches that use either 3-D tagged or untagged MR image information alone. The relative error compared to manually tracked landmarks is less than 15% throughout the cardiac cycle. Finally, we demonstrate the automatic analysis of cardiac function from the myocardial deformation fields.

Developing a mandate for change: planning as a political process

The three main questions dealt with in this article are: 'why have community participation in planning?' 'what is community participation?' and 'how can community participation be practised?' Planning in this context should be understood in a strategic sense as social policy development and implementation at a regional level. In answer to the first question, two common approaches to social planning and their shortcomings are briefly discussed, with reference to a taxonomy from Alan Walker's book Social Planning, A Strategy for Socialist Welfare. Community participation in social planning is a key characteristic of an alternative approach which addresses or avoids altogether the fundamental shortcomings of the other two. Issues of the practice of community participation in regional planning are examined through a description and analysis of the planning process undertaken by the Western Metropolitan Region of the Health Department Victoria. Some general conclusions regarding current trends in policy formation and public sector administration are also drawn.