Background Radial artery occlusion ( RAO ) may occur posttransradial intervention and limits the radial artery as a future access site, thus precluding its use as an arterial conduit. In this study, we investigate the incidence and factors influencing the RAO in the current literature. Methods and Results We searched MEDLINE and EMBASE for studies of RAO in transradial access. Relevant studies were identified and data were extracted. Data were synthesized by meta‐analysis, quantitative pooling, graphical representation, or by narrative synthesis. A total of 66 studies with 31 345 participants were included in the analysis. Incident RAO ranged between <1% and 33% and varied with timing of assessment of radial artery patency (incidence of RAO within 24 hours was 7.7%, which decreased to 5.5% at >1 week follow‐up). The most efficacious measure in reducing RAO was higher dose of heparin, because lower doses of heparin were associated with increased RAO (risk ratio 0.36, 95% CI 0.17–0.76), whereas shorter compression times also reduced RAO (risk ratio 0.28, 95% CI 0.05–1.50). Several factors were found to be associated with RAO including age, sex, sheath size, and diameter of radial artery, but these factors were not consistent across all studies. Conclusions RAO is a common complication of transradial access. Maintenance of radial patency should be an integral part of all procedures undertaken through the radial approach. High‐dose heparin along with shorter compression times and patent hemostasis is recommended in reducing RAO .

Hybrid surgical approaches are gaining popularity. Minimally invasive aortic valve replacement and percutaneous coronary intervention [PCI] is well documented. We wanted to explore the feasibility of trans-catheter aortic valve implantation [TAVI] and off pump coronary artery bypass grafts [OPCAB].

Objectives: The aim of this study is to review the available literature on the efficacy and safety of agents used for prevention of RAS.Background: Different vasodilator agents have been used to prevent radial artery spasm(RAS) in patients undergoing transradial cardiac catheterization.Methods: Weincluded studies that evaluated any intra-arterial drug administered in the setting cardiac catheterization that was undertaken through the transradial access site (TRA). We also compared studies for secondary outcomes of major bleeding, procedure time, and procedure failure rate in setting of RAS prevention, patent hemostasis and radial artery occlusion.Results: 22 clinical studies met the inclusion criteria. For placebo, RAS rate was 12% (4 studies, 638 participants), which was similar to 2.5 mg of verapamil 12% (3 studies, 768 participants) but greater than 5 mg of verapamil (4%, 2 studies, 497 participants). For nicorandil, there was a much higher RAS rate compared to placebo (16%, 3 studies, 447 participants). The lowest rates of RAS was found for nitroglycerin at both 100 mu g (4%) and 200 mu g (2%) doses, isosorbide mononitrate (4%) and nicardipine (3%). We found no information regarding the procedure failure rates, patent hemostasis, and radial artery occlusion in these studies.Conclusions: In this largest and up-to-date review on intra-arterial vasodilators use to reduce RAS, we have found that the verapamil at a dose of 5 mgor verapamil in combination with nitroglycerine are the best combinations to reduce RAS. (C) 2015 Elsevier Inc. All rights reserved.

Primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infarction (STEMI) represents the current gold standard reperfusion therapy. Recent advances in antiplatelet and anticoagulant therapy have reduced the risk of ischemic complications and mortality in PPCI although this has been at the expense of major bleeding complications. Access site-related bleeding complications account for up to 50 % of major peri-procedural bleeding complications in PCI. Increasing adoption of the radial artery as the default access site has been shown to markedly reduce such major bleeding complications and mortality in selected patient cohorts. Recent data has suggested that adoption of the transradial access site in STEMI PCI procedures is associated with significant reductions in major bleeding complications and mortality in both national registry data and randomised controlled trials. We provide an overview of this data and discuss the remaining uncertainties around the synergy between access site and contemporary antithrombotic and antiplatelet therapy in such patients. Finally, whilst adoption of the radial artery as the default access site in PPCI has yielded a similar reduction in mortality as observed in the switch from thrombolysis to PPCI in the past, its adoption as a default access site is not universal. We discuss the remaining obstacles and challenges for more widespread adoption of the radial access site as the default access site in PPCI.

HaemophiliaVolume 21, Issue 6 p. e494-e496 Letter to the Editor Management of a myocardial infarction in a patient with classical acquired haemophilia patient in partial remission D. J. M. Routledge, Corresponding Author D. J. M. Routledge Clinical Haematology, Central Manchester NHS Foundation Trust, Manchester, UK Correspondence: David J. M. Routledge, Clinical Haematology, Central Manchester NHS Foundation Trust, Oxford Road, M13 9WL Manchester, UK. Tel.: 01612761234; fax: 01612768085; e-mail: daveroutledge@doctors.org.ukSearch for more papers by this authorD. Fraser, D. Fraser Haematology Manchester Royal Infirmary, Manchester, UKSearch for more papers by this authorJ. Thachil, J. Thachil Haematology Manchester Royal Infirmary, Manchester, UKSearch for more papers by this authorM. J. Nash, M. J. Nash Haematology Manchester Royal Infirmary, Manchester, UKSearch for more papers by this author D. J. M. Routledge, Corresponding Author D. J. M. Routledge Clinical Haematology, Central Manchester NHS Foundation Trust, Manchester, UK Correspondence: David J. M. Routledge, Clinical Haematology, Central Manchester NHS Foundation Trust, Oxford Road, M13 9WL Manchester, UK. Tel.: 01612761234; fax: 01612768085; e-mail: daveroutledge@doctors.org.ukSearch for more papers by this authorD. Fraser, D. Fraser Haematology Manchester Royal Infirmary, Manchester, UKSearch for more papers by this authorJ. Thachil, J. Thachil Haematology Manchester Royal Infirmary, Manchester, UKSearch for more papers by this authorM. J. Nash, M. J. Nash Haematology Manchester Royal Infirmary, Manchester, UKSearch for more papers by this author First published: 20 July 2015 https://doi.org/10.1111/hae.12757Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume21, Issue6November 2015Pages e494-e496 RelatedInformation

Women have a higher risk of adverse outcomes after percutaneous coronary intervention (PCI) than men. However, in acute coronary syndrome (ACS), long-term outcomes after contemporary PCI with drug-eluting stent (DES) have not been fully investigated. We aimed to test the impact of gender on outcomes in patients with ACS after PCI with DES. We analyzed all patients with ACS from the prospective NOBORI-2 trial who underwent PCI with a Nobori DES from 2008 through 2009 in 125 centers worldwide. End points of the study were target lesion failure, cardiac death, myocardial infarction (MI), and clinically driven target lesion revascularization, and major adverse cardiac events (composite of cardiac death, MI, and target vessel revascularization) at 1 year and yearly up to 5 years. There were 1,640 patients with ACS, 1,268 men (77%) and 372 women (23%). Compared to men, women were 5 years older and more frequently had co-morbidities such as diabetes mellitus and hypertension. There were no gender differences for cardiac death (1.3% vs 2.7%), MI (2.1% vs 3.2%), or target lesion revascularization (2.6% vs 3.8%) at 1 year after the procedure for men and women, respectively. The trend was the same at 2 years (cardiac death 2.0% vs 2.3%, MI 2.5% vs 3.5%, target lesion revascularization 3.2% vs 4.6%). Target lesion failure rates were 4.5% and 5.9% at 1 year and 5.7% and 7.3% at 2 years in men and women, respectively (p = NS). Multivariate analysis, which included age, hypertension, diabetes mellitus, and number of diseased vessels, showed that gender was not a predictor for outcome. There were no differences in bleeding or stent thrombosis rates. Relief from anginal symptoms was similar. The same rate of adherence to dual antiplatelet therapy was observed and reached 73% at 1 year and 31% at 2 years after the ACS event and PCI. In conclusion, although women had worse baseline characteristics, no differences in outcomes were observed between men and women treated for ACS with contemporary DES.

AIMSCoronary perforation during percutaneous coronary intervention (PCI) is associated with a high risk of mortality and morbidity. However there has been little data on perforation in the current era despite significant changes in PCI practice. We set out to identify incidence, risk factors and management strategies of coronary perforation in the current era.METHODS AND RESULTSWe performed a retrospective analysis of the Manchester Heart Centre PCI database from June 2004 to May 2008. Detailed analysis of all cases of suspected perforation was undertaken by case note and angiographic review. Demographic data was collected regarding all patients undergoing intervention. A total of 12,729 coronary lesions were treated in 7,903 patients over four years, during which drug-eluting stent (DES) uptake was 77%. The incidence of perforation was 0.56% (44/12,729). Perforation was associated with an inpatient mortality of 15.9% (7/44). Factors associated with perforation were female sex (p=0.003), increasing age (p<0.01), coronary calcification (p=0.003), use of a cutting balloon (p<0.001) or atheroablation (p<0.001), and treatment of a chronic total occlusion (p<0.01). Factors associated with death after perforation were non-elective procedure (p=0.036) and pericardial drain insertion (p<0.001).CONCLUSIONSDespite treatment of more complex disease, the incidence of coronary perforation has not increased. Major perforations (Ellis class III) are associated with a high rate of emergency coronary artery bypass graft (CABG) and death. Endovascular treatments allow sealing of the perforation in most cases and deaths occur primarily as a result of cardiogenic shock due to occlusion of the culprit artery. Patient risk factors associated with perforation should be considered when planning or performing PCI.

AIMSThe Sideguard® stent (Cappella Medical Devices Ltd, Galway, Ireland), is a novel nitinol self-expanding dedicated bifurcation stent that flares proximally at the ostium of the side branch (SB) into a trumpet shape thereby achieving full ostial coverage. The aim of this study is to report the utility and limitations of this stent in patients undergoing treatment to bifurcation coronary lesions in a real-world setting.METHODS AND RESULTSWe prospectively identified 20 successive patients admitted over a 6-month period in whom there was significant SB disease and who were suitable for a bifurcation procedure. The Sideguard® stent was successfully used in all 20 cases including several that would have been technically difficult using conventional bifurcation techniques. We highlight use of this system using five illustrative cases that illustrate its utility and limitations in the treatment of bifurcation lesions.CONCLUSIONSThe Sideguard® stent can be used to treat complex bifurcation lesions in a straight forward manner and is not subject to the limitations associated with conventional bifurcation PCI techniques including jailing of the SB ostium and inability to fully cover/scaffold the ostium of the SB.

Introduction PCI treatment of bifurcation disease is technically challenging. Dedicated bifurcation stents have been developed to address some of the challenges associated with bifurcation lesions. The aim of this study is to report clinical utility and outcomes of the Sideguard stent in patients undergoing treatment to bifurcation coronary lesions in a real world setting in a large tertiary UK centre. Methods Retrospective study of 61 consecutive patients treated with the Sideguard Stent for bifurcation PCI at the Manchester Heart Centre from March 2010 to October 2011. Patient demographics and PCI procedural data were obtained from the in-house, cross validated PCI database. Mortality data were obtained from National Office of Statistics. Interim 6 month and 1 year data were obtained from clinical review. Clinical end point studied included death, subsequent myocardial infarction, stent thrombosis and target lesion/vessel revascularisation (TLR/TVR). Results A total of 61 consecutive patients underwent bifurcation PCI using the Sideguard stent during this study. Mean age 57.1±11.5 years (range 30–76) of which 50/61 were male (81.9%). Bifurcation site was in LAD in 44 (72.2%), Cx in 14 (22.9%) and RCA in 3 (4.9%) of cases. Medina classification was 1:1:1 in 38 (62.3%), 1:0:1 in 10 (16.3%) and 0:1:1 in 6 (9.9%) of cases. Moderate or severe calcification was present in 27 (44.3%) of cases. Mean main vessel (MV) diameter was 3.36±0.39 mm, mean MV stent length was 35±18.4 mm and mean number of stents in MV was 1.54±0.77. Mean Side branch vessel (SB) diameter was 2.93±0.33 mm, mean SB stent length was 13.4±8.5 mm and mean number of stents in SB was 1.24±0.43. Final kissing balloon was attempted in 57 (93.4%) and successful in all cases attempted. Procedural complications occurred in 4/61 (6.6%) cases. Complications included 1 case of limited perforation of the MB which was treated conservatively, 1 case of clot formation related to IVUS examination (neither of these complications were thought to be related to sidegurad stent, directly) and 2 cases of stent displacement. Local deployment techniques have been modified to combat displacement. Operators now wait for 30 s and take a frame shot after stent deployment to confirm placement before removing the stent balloon. In our interim analysis 43 of these 61 patients have been followed up for at least 6 months (70.5%) and 37 patients for at least 1 year (60.7%). There were no deaths or stent thromboses. There was no TLR at 6 month and only 2 (3.3%) at 1 year. TVR was 1 (1.6%) at 6 month with no further cases at 1 year. Conclusions In one of the largest clinical experiences to date, the Sideguard stent can be used to treat complex bifurcation lesions in a straight forward manner, with excellent short and long term clinical outcomes.

Objective To investigate the relationship between resting distal coronary pressure to aortic pressure ratio (Pd/Pa) and fractional flow reserve (FFR) obtained during maximal hyperemia Background. FFR is an invasive index of the functional severity of a coronary artery stenosis determined from coronary pressure measurements It is generally believed that there is little correlation between resting Pd/Pa and FFR obtained during maximal hyperemia We have therefore studied this relationship in a large cohort of patients who had undergone pressure-wire assessments Methods 528 consecutive pressure-wire studies performed in 483 patients over a 2-year period were retrospectively analyzed Results A linear correlation between resting Pd/Pa and FFR post-pharmacological hyperemia was observed (rho = 0 74, p < 0 0001) When a FFR of <= 0 75 (or <= 0 80 as per FAME) was defined as positive a resting Pd/Pa of <= 0 85 (<= 0 87) had a positive predictive value (PPV) of 95% (94 6%), while a resting Pd/Pa of >= 0 93 (>= 0 96) had a negative predictive value (NPV) of 95 7% (93%) Conclusions We demonstrate a strong correlation between resting Pd/Pa and FFR Resting values of Pd/Pa can be used to predict a positive FFR result with relatively high PPV and NPV This may potentially obviate the need for adenosine infusion in a proportion of pressure wire studies

AIMS:The Terumo Heartrail catheter (Terumo Corp., Tokyo, Japan) allows extra deep catheter intubation of coronary vessels and has been shown to be useful in CTO lesions. The aim of this study is to assess the safety and efficacy of using the Heartrail II catheter as a distal stent delivery system in PCI following failure of conventional techniques.METHODS AND RESULTS:We prospectively identified cases performed over a 15-month period in which a Heartrail catheter was used to facilitate stent delivery following failure of conventional techniques. Stent delivery using the Heartrail catheter was performed in 35 cases and was successful in 31 cases. Success rates of 100% in grafts, 95% in RCA, 80% in LAD and 60% in circumflex cases were recorded respectively. Successful stent delivery was associated with intubation depth, with 29/29 succeeding when the intubation depth was > 2 cm and failure in 4/5 cases when the intubation depth <or= 2 cm. There were no complications related to deep intubation of the catheter.CONCLUSIONS:Use of the Heartrail catheter is safe and highly effective for aiding stent delivery across proximal obstructions in both left and right coronary systems. The small number of unsuccessful cases were related to inability of the catheter to traverse stenotic proximal obstructions within 2 cm of the RCA and LCA origins.

Influenza accounts for 3 to 5 million cases of severe illness and up to 300,000 deaths annually. Cardiovascular involvement in acute influenza infection can occur through direct effects of the virus on the myocardium or through exacerbation of existing cardiovascular disease. Epidemiological studies have demonstrated an association between influenza epidemics and cardiovascular mortality and a decrease in cardiovascular mortality in high risk patients has been demonstrated following vaccination with influenza vaccine. Influenza is a recognised cause of myocarditis which can lead to significant impairment of cardiac function and mortality. With recent concerns regarding another potential global pandemic of influenza the huge potential for cardiovascular morbidity and mortality is discussed.

A case of influenza A myopericarditis is presented in a patient with cardiac tamponade and immunomediated cardiac failure. Myocarditis is a rare and potentially lethal complication of infection with influenza A, and may manifest with a wide spectrum of cardiac involvement, from mild myocarditis to cardiogenic shock. Even with full supportive therapy, mortality is significant, and normalization of left ventricular function may occur in up to 50% of cases. In the present report, previous literature regarding cardiac involvement following influenza A infection is reviewed, and potential immunological mechanisms involved in the progression of the cardiomyopathy following influenza A infection are discussed. Cardiovascular involvement in influenza infection should be considered in all patients presenting with hemodynamic compromise.