NIHR Bristol Cardiovascular Biomedical Research Unit

Routine monitoring of surgical outcomes can improve service quality. Risk-adjusted monitoring tools for adults with congenital heart disease (CHD) in England and Wales are lacking. Using national audit data of all adult CHD surgical procedures in public hospitals from 2015 to 2022, we developed logistic regression models for mortality at 30 days and 90 days and a 30-day complications outcome. Risk factors included patient demographics and categorical derived variables for case complexity and procedure risk. Model performance was assessed by area under the receiver operating characteristic curve and calibration errors for in-sample and cross-validation data sets. Average 30-day and 90-day mortality were 1.4% (49/3502) and 1.7% (58/3493). Moderate and severe CHD complexity were strong predictors of 30-day mortality (odds ratio [95% CI], 3.5 [0.8-15.8], 8.6 [2.4-30.9]), as was high-risk procedure (OR, 3.6 [2.1-6.0]). Average 30-day complication rate was 7.5% (242/3223). Procedure risk groups (OR, 2.4 [0.9-6.0] to 12.2 [4.0-36.8]) and procedure complexity (OR, 2.5 [1.5-4.3]) were the strongest predictors. In cross-validation, 30-day and 90-day mortality models had median discrimination (interquartile range in parentheses) of 0.844 (0.84-0.85) and 0.866 (0.86-0.87), calibration slopes of 1.05 (0.60-1.13) and 1.11 (0.61-1.21), and calibration-in-the-large of 0.00 (-0.12 to 0.19) and -0.07 (-0.17 to 0.30). The 30-day complications model had cross-validation discrimination of 0.760 (0.76-0.76), calibration slope of 0.93 (0.74-1.18), and calibration-in-the-large of -0.07 (-0.13 to 0.22). The adult CHD risk models perform well for short-term mortality despite a low number of events. The risk model for 30-day complications showed reduced performance, suggesting that important risk factors are not captured by routinely collected data.

Intracoronary (IC) imaging-guided percutaneous coronary intervention (PCI) improves clinical outcomes in patients with high clinical and anatomical risk when compared to interventions guided by angiography alone. Recent Class I recommendations for the use of IC imaging guidance when performing PCI in left main stem or complex lesions may result in a significant uptake as the technology is embraced as standard of care. Routine application of IC imaging will provide interventional cardiologists with a wealth of high-fidelity intracoronary data on plaque composition and distribution. When paired with emerging data regarding the importance of plaque anatomical characteristics, developments in artificial intelligence and computational fluid dynamics, lesion stratification with IC imaging may herald the next paradigm shift in this field. In this review, we will explore this important emerging application of IC imaging to inform morphology-guided PCI, identify high-risk lesions for targeted therapies, and consider the prospects of harnessing automated image interpretation with artificial intelligence technologies to achieve an integrated physiological and morphological assessment. Lesion stratification with IC imaging has the potential to shape the future of interventional cardiology practice to guide therapies within and beyond the confines of the cardiac catheterisation laboratory.

Abstract Background Cardiovascular magnetic resonance imaging (CMR) is a Class 1 diagnostic tool for suspected myocardial infarction with no obstructive coronary artery disease (MINOCA). However, time-sensitive conditions like myocarditis or Takotsubo syndrome,may become undetacable if imaging is delayed. Thus, scan timimg is crucial for optimizing diagnostic yield and clinical value. We evaluated the impact of scan timing on the diagnostic performance of cardiac magnetic resonance (CMR) in patients presenting with acute coronary syndrome (ACS) and nonobstructed coronary arteries. Methods Patients enrolled in the local MINOCA CMR Registry were identified and included. All participants underwent a 1.5-T CMR examination using a comprehensive protocol incorporating cine imaging, T2-weighted, and late gadolinium enhancement sequences. Based on CMR findings, patients were categorized into five diagnostic groups: MINOCA (embolic/spontaneous recanalization, coronary artery dissection), myocarditis, Takotsubo syndrome, cardiomyopathy, and unremarkable or normal CMR. The diagnostic rate was calculated as the proportion of non-normal CMR studies out of all CMR studies performed. Logistic regression analysis was conducted to assess the relationship between the probability of diagnosis and time to CMR. To account for potential non-linearity in the effect of scan timing, restricted cubic splines with four knots were employed. Results A total of 888 consecutive patients presenting with ACS and nonobstructed coronary arteries were included in the study (51% females). CMR identified an underlying cause in 672 (75.68%). The diagnostic yield was highest when CMR was performed within 7 days following acute presentation, subsequently declining at an average rate of 1% per day up to 15 days. Notably, while the detection rate of myocardial infarction remained relatively stable over time, the diagnosis of Takotsubo syndrome decreased from 24% within the first week to only 6% beyond 3 months post presentation. Conclusion CMR should be performed within 15 days of acute presentation to optimize diagnostic yield, as delayed imaging may miss up to 20% of cases. Conditions like Takotsubo syndrome are particularly time-sensitive, and CMR availability must be considered when interpreting results in suspected MINOCA.Scan timing and probability of diagnosis Adjudicated diagnosis by time to CMR

Mitral valve surgery has undergone significant expansion and improvement in early in-hospital mortality over the last 20years. At the same time, a considerable decline seems to have occurred in reoperative mitral valve surgery, which remains a relatively high-risk procedure. We investigated the trends, early outcomes and predictors of complications in patients undergoing RMV over 20years in the United Kingdom. The UK National Adult Cardiac Surgery Audit database was used to retrospectively analyse patients who underwent reoperative mitral valve surgery (n=1239). These were then compared with a cohort of patients who underwent primary mitral valve surgery (n=47,213) during the same period, from November 1, 1998, to March 30, 2019. We investigated in-hospital outcomes and examined predictors of adverse outcomes in patients undergoing reoperative mitral valve surgery. The proportion of reoperative mitral valve surgery out of all mitral procedures decreased significantly between 1999 and 2001, from 7.31% to 3.44%. After this time point, the percentage remained relatively steady, ranging from 1.8% to 3.45%. Of the 1239 reoperative mitral valve surgery, most were replacements 1127 (91%). When compared to primary mitral valve surgery, reoperative mitral valve surgery were associated with a significantly increased mortality (13% vs 5.2%), requirement for dialysis (14% vs 5.2%), cerebrovascular event (CVE,2.4% vs 1.2%), return to theatre for bleeding (8.3% vs 5.3%) and increased length of stay (15 vs 11days) (all, p<0.001). After adjustment for baseline characteristics, reoperative mitral valve surgery was still associated with increased mortality (OR1.92; CI1.53-2.43; p<0.001), CVE (OR1.32, CI1.05-1.65; p=0.027) and dialysis (OR1.91; CI1.5-2.42, p<0.001), compared to primary mitral valve surgery. The predictors for increased in-hospital mortality in the reoperative mitral valve surgery cohort were old age (OR 1.4, CI 1.00-1.08), creatinine >200μmol/L (OR 3.86, CI 1.93-7.70, p<0.001), need for emergency surgery (OR 2.18, CI 1.06-4.47, p=0.034) and increased aortic cross-clamp time (OR 1.02, CI 1:00-1.03). The incidence of reoperative mitral valve surgery has decreased in the UK over the first decade, most notably after 2001. Despite some variations, the volume remained steady in the second decade. Reoperative mitral valve surgery mortality and associated morbidity remain relatively high.

Despite its use in patients awaiting heart transplant (HT), the impact of continuous inotropic support on short-term complications and long-term transplant outcomes remains unclear. This study evaluated inotrope use at the time of HT on perioperative complications and post-transplant survival, comparing outcomes at 30 days, 1 year, and 10 years with mechanical circulatory support (MCS) strategies including ECMO, IABP, and VADs. A retrospective analysis of the United Network for Organ sharing (UNOS) registry was performed, stratifying patients based on bridge strategy at the time of transplant: inotropes, ECMO, IABP, or VADs. Baseline characteristics, perioperative complications, and 30-day, 1-year, and 10-year post-transplant survival outcomes were analyzed across groups. Survival was assessed using Kaplan-Meier and Cox proportional hazards models. Among the 11,801 heart transplant patients included, 9330 were on inotropes, 372 were on ECMO, 1072 received an IABP, and 1027 had VADs. Inotrope-bridged patients had significantly lower 30-day and 1-year mortality rates compared to the ECMO, IABP, and VAD groups. They also experienced reduced incidences of post-transplant dialysis and stroke. At 10 years, the inotrope group demonstrated superior long-term survival, with significantly lower mortality risk compared to ECMO (HR: 1.81; CI: 1.49-2.20, p < 0.001), IABP (HR: 1.19; CI: 1.06-1.32, p = 0.005), and VAD (HR: 1.18; CI: 1.10-1.27, p < 0.001). Continuous use of inotropes after waitlisting is associated with lower short, intermediate, and long-term mortality and does not lead to worse outcomes compared to ECMO, IABP, and VAD support. When mechanical support is not an option, inotropic therapy remains a viable and effective strategy.

e14602 Background: Type 1 Diabetes Mellitus (T1DM) is a serious side effect of Immune Checkpoint Inhibitors (ICIs), which typically presents as Diabetic Ketoacidosis (DKA) in 70% of cases. The majority of cases of ICI-Induced DKA are in older patients, with a high morbidity and mortality. Recent data shows that the incidence of ICI-induced DKA is rising, and as a unique clinical entity, it is still not yet fully understood. The purpose of this study is to gain further understanding about the typical onset of ICI-Induced DKA, the association with HbA1c, C-peptide, and Islet autoantibodies, and the challenges of identifying DKA and complications associated with treating DKA in the older patient. Methods: This study is a multi-centre case series of patients with a diagnosis of solid tumours who received ICIs, and subsequently presented with Diabetic Ketoacidosis. Results: Twelve patients were identified at centres across the United Kingdom. The median age was 68 years (range 45-86), and seven of the patients were female. No patients had a background of diabetes. Eight patients were treated with pembrolizumab, and four patients were treated with a combination of Ipilimumab and Nivolumab. The median time to onset of DKA from starting ICIs was 21 weeks (range 3-117). The mean pH level at presentation of DKA was 7.01, mean glucose level was 33mmol/L and mean HbA1c was 80mmol/mol. Seven of the patients required ICU admission, with complications including acute kidney injury (AKI) and fluid overload. C-peptide level was only tested in six patients; three of the six patients had an undetectable C-peptide level at presentation. One patient had positive T1DM-associated autoantibodies, and interestingly had the shortest onset to DKA at 3 weeks after ICI initiation. For nine of the twelve patients, this was their only presentation of ICI toxicity to date. All patients were subsequently diagnosed with insulin-dependent diabetes after their DKA presentation. Conclusions: This demonstrates the rapid and often unpredictable onset of DKA presenting as a new phenomenon in older patients , with a sharp rise in glucose levels and fall in C-peptide level. The presentation of DKA in this older population was found to be associated with likely requirement for ICU admission, resistant blood sugars requiring higher insulin doses, high risk of fluid overload, and acute kidney injury. This study helps to enlighten clinicians regarding this unique clinical presentation of DKA following ICI treatment, and the importance of patient education and recommended diagnostic tests and management for best clinical practice.

This study reports a rare case of acute myocardial infarction due to double coronary artery occlusion in a 53-year-old woman who presented with acute chest pain, elevated troponin levels, and ST-elevation myocardial infarction (STEMI). Coronary angiography revealed simultaneous occlusions in the left anterior descending artery (LAD) and circumflex artery (Cx). Complete resolution and restoration of coronary perfusion were achieved through aspiration thrombectomy using the Penumbra CAT RX system and percutaneous coronary intervention (PCI), with one drug-eluting stent (DES) in each artery.

ABSTRACTBackgroundFrailty, marked by increased vulnerability and reduced physiological reserve, is common in end‐stage heart failure patients. Continuous flow left ventricular assist devices (LVADs) have improved outcomes, but the impact of frailty on these outcomes is unclear. This systematic review and meta‐analysis investigate the effect of frailty on clinical outcomes in patients undergoing LVAD therapy.MethodsFollowing PRISMA guidelines, we searched PubMed, Cochrane, EMBASE, MEDLINE, and Google Scholar up to September 2023 for studies comparing frail and non‐frail patients undergoing LVAD implantation. Data on mortality, hospital length of stay, intubation duration, bleeding, infection, and readmission rates were extracted and analyzed using the Mantel–Haenszel random‐effects model, with heterogeneity assessed by the I2 statistic.ResultsFifteen studies involving 3458 patients were included. Frailty was significantly associated with higher long‐term mortality (OR: 2.12; 95% CI: 1.17–3.83; p = 0.01), but not with short‐term mortality (OR: 1.61; 95% CI: 0.71–3.65; p = 0.26), hospital length of stay (MD: 1.93; 95% CI: −9.83 to 13.68; p = 0.75), or intubation duration (MD: 34.28; 95% CI: −1.15–69.71; p = 0.06). No significant differences were found in bleeding (OR: 1.76; 95% CI: 0.76–4.10; p = 0.19), infection (OR: 0.44; 95% CI: 0.11–1.84; p = 0.26), or readmission rates (OR: 1.07; 95% CI: 0.78–1.46; p = 0.68).ConclusionFrail patients with LVADs have higher long‐term mortality but similar short‐term outcomes, hospital stays, intubation times, bleeding, infection, and readmission rates compared to non‐frail patients. These findings highlight the need for tailored strategies to improve outcomes in frail LVAD patients and suggest further research on frailty interventions.