Introduction:While most pacemaker implantations occur in older individuals, younger patients also receive pacemakers. In these, degenerative conduction system disease is less likely to be the cause of atrioventricular block (AVB), with other diseases being more common. There is, however, a paucity of data on this group as well as on younger pacemaker recipients that have undergone pacemaker implantation for reasons other than AVB. The aim of this study was to perform an audit of young adult permanent pacemaker recipients.Method:This was a retrospective record review, conducted in the Division of Cardiology at Tygerberg Hospital, Cape Town, South Africa. We included 169 adult patients between the ages of 18 and 60, who received permanent pacemakers between 2010 and 2020. A subgroup analysis of patients 55 years and younger was also performed.Results:Third degree AVB was the most common indication for pacemaker implantation (n = 115; 68%), followed by high degree AVB (n = 23; 13.6%) and sick sinus syndrome (SSS; n = 14; 8.3%). A specific underlying cause for conduction system abnormalities was found in only 25.4% of patients (n = 43), with most of them being 55 years or younger (n = 32; 30.8% of patients ≤ 55 years). Specific causes that were identified included prosthetic valve implantation and/or valve repair (n = 14; 8.3%), myocardial infarction (n = 6; 3.6%), cardiac sarcoidosis (n = 5; 3.0%), coronary artery bypass grafting (n = 3; 1.8%), cardiomyopathy (n = 2; 1.2%), muscular dystrophy (n = 2; 1.2%), congenital heart disease (ventricular septal defect; atrioventricular septal defect; Tetralogy of Fallot; bicuspid aortic valve; n = 6; 3.6%), acute myocarditis (n = 1; 0.6%), atrial myxoma removal (n = 1; 0.6%), planned AV node ablation (n = 2; 1.2%), and following a previous stab in the chest (n = 1; 0.6%).Conclusion:Given that the mean age of our study population was high, the low number of identified underlying causes in the whole cohort (≤60 years) may reflect some AVB due to age related degeneration of the conductions system in the patients 56 to 60 years age, but also raises the possibility that these patients may be less likely to be extensively investigated for an underlying cause than those ≤55 years, where diseases such as sarcoidosis were more readily confirmed. As access to advanced diagnostic tools improves, the percentage of young pacemaker recipients with an underlying cause identified may increase.

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Heart failure with reduced ejection fraction (HFrEF) is a growing problem worldwide and is associated with significant morbidity and mortality. Angiotensin receptor neprilysin inhibitors (ARNI) and sodium-glucose cotransporter 2 inhibitors (SGLT2-i) are now seen as disease modifying agents with growing evidence to support their early initiation in order to prolong lives of patients with HFrEF. However, most of these trials were conducted in the developed world involving older patients with ischaemic cardiomyopathies, in contrast to younger patients with idiopathic dilated cardiomyopathies (DCMO) typically seen in Africa. Further, these drugs are expensive and remain out of reach for most patients in the developing world. Purpose To determine the effects of early initiation of comprehensive heart failure (HF) therapy consisting of ARNI, SGLT2-i, β-blocker and mineralocorticoid receptor antagonist on transthoracic echocardiography (TTE) parameters of patients with newly diagnosed idiopathic DCMO. Methods This is prospective cohort study. All patients presenting to a single tertiary centre in South Africa between January and July 2021 with newly diagnosed idiopathic DCMO that were initiated on a regimen of comprehensive heart failure therapy as first line therapy were included. TTE were performed at initiation and at monthly follow up visits. Results Eight patients (mean age 35.4 ± 7 years, 25% females) were included. At baseline, the mean left ventricular ejection fraction (LVEF) was 17.1 ± 3.2%, mean left ventricular end diastolic diameter (LVEDD) was 68.0 ± 7.6mm, mean E’ (average) 4.0 ± 1.9m/s, mean LV global longitudinal strain (GLS) -4.5 ± 1.9%, mean LVOT VTI 10.9 ± 3.2cm and mean TAPSE 14.3 ± 4.1mm. The patients were followed up for an average of 4 months (range 1 – 5 months). TTE performed at the latest follow up visit showed a significant increase in LVEF (21.3%; 95% CI 13.5 - 29.0; p = 0.01), average E’ (2.5m/s; 95% 0.3 - 4.7; p = 0.05), GLS (-6.7%; 95% CI -1.0 - 8.9; p = 0.01), LVOT VTI (5.0cm; 95% CI 1.4 - 8.5; p = 0.03) and TAPSE (7mm; 95% CI 2.6 - 11.4; p = 0.02), and a significant reduction in LVEDD (6.5mm; 95% CI 1.1 - 11.9; p = 0.03). Conclusion Early initiation of comprehensive HF therapy including ARNI and SGLT2-i is associated with significant improvements in left and right ventricular function and LV reverse remodelling in a small cohort of young South African patients with newly diagnosed idiopathic DCMO. This supports the widespread adoption of this therapeutic strategy, even in a resource limited setting, in a population of patients with limited access to other therapeutic options such as mechanical circulatory support and cardiac transplantation. Abstract Table 1 Abstract Figure 1

We describe the first case of successful management of left ventricular outflow tract obstruction developing late after transcatheter aortic valve replacement with right ventricular apical pacing. The possible mechanisms of obstruction resolution are described. (Level of Difficulty: Advanced.)

Aims: The aim of this study was to explore the use of prolonged occlusion flow-mediated dilatation (PO-FMD) to dilate the radial artery prior to cannulation to increase cannulation success, reduce puncture attempts and reduce access-site complications in transradial coronary angiography. Methods and results: A total of 1,156 patients undergoing transradial coronary angiography were randomised into PO-FMD and sham PO-FMD groups. PO-FMD was achieved by a 10-minute inflation of a blood pressure cuff on the arm to above systolic pressure, followed by deflation with resultant radial artery dilation. In the sham PO-FMD group the cuff was not inflated. Operators were blinded to the intervention. Five hundred and eighty (580) patients were randomised to the sham PO-FMD group and 576 to the PO-FMD group. Cannulation failure was reduced with PO-FMD, with cannulation failure rates of 2.7% in the PO-FMD group and 5.8% in the sham PO-FMD group (p=0.01).The number of puncture attempts was reduced with the use of PO-FMD, with a median of one attempt in the PO-FMD group and two in the sham PO-FMD group (p<0.001). Radial artery pulsation loss (RAPL) was reduced with PO-FMD, with 1.4% in the PO-FMD group and 3.8% in the sham PO-FMD group (p=0.02). Conclusions: PO-FMD reduces cannulation failure rates, decreases puncture attempts, and decreases RAPL during transradial coronary angiography.

A 27-year-old healthy woman with a history of childhood asthma (currently well controlled) and no other known comorbidities presents with a history of acute-onset palpitations. She reports associated light-headedness and sweating, with no history of chest pain and no other associated symptoms. There is no history of recent use of inhaled beta-agonist, or recent stimulant or drug use. The patient also does not report any family history of known cardiovascular disease. She is haemodynamically stable, and other than being markedly tachycardic examines well. Urgent ECG with standard calibration done at the time is depicted in figure 1. Figure 1 Urgent standardised 12-lead ECG taken at the time of palpitations. RBBB, …

Arrhythmias can be a clinical manifestation of COVID-19 infection. COVID-19 infection can also be a precipitant of known arrhythmias which can increase the risk of morbidity and mortality. Management of arrhythmias should generally follow standard guidelines of arrhythmia management. Catheter ablation in the midst of the COVID-19 pandemic should be limited to arrhythmias that are immediately life-threatening or which may affect prognosis in the short-term. Some novel treatments like chloroquine, hydroxychloroquine and azithromycin can prolong the QT interval and predispose patients to life-threatening arrhythmias.

Abstract Background Transradial catheterization has become the preferred access site for coronary angiography. The transradial approach is however not without challenges and complications. Cannulation is technically challenging and may require multiple cannulation attempts or access may fail. Local access site complications may occur postprocedurally. Purpose To explore the use of prolonged occlusion flow mediated dilatation (PO-FMD) to dilate the radial artery prior to cannulation to reduce puncture attempts, increase cannulation success and reduce access site complications in transradial coronary angiography. Methods 1156 patients undergoing transradial coronary angiography were randomized into PO-FMD and sham PO-FMD groups. PO-FMD was achieved by a 10 minute inflation of a blood pressure cuff on the arm to above systolic pressure, followed by deflation with resultant radial artery dilation. In the sham PO-FMD group the cuff was not inflated. The operators were blinded to the intervention. Results 580 patients were randomized to the sham PO-FMD group and 576 to the PO-FMD group. The number of puncture attempts were reduced with the use of PO-FMD, with a median number of attempts of 1 in the PO-FMD group and 2 in the sham PO-FMD group (p<0.001). Cannulation failure was reduced with PO-FMD FMD with cannulation failure rates of 2.7% in the PO-FMD group and 5.8% in the sham PO-FMD group (p=0.01). Radial artery pulsation loss (RAPL) was reduced with PO-FMD with 1.4% in the PO-FMD group and 3.8% in the sham PO-FMD group (p=0.02). Conclusion PO-FMD decreases puncture attempts, reduces cannulation failure rates and decreases RAPL during transradial coronary angiography.

Rapid identification and treatment of the causative organism is key in the successful treatment of bacterial infection. This can be difficult in conditions such as infective endocarditis when the organisms are circulating in low concentrations. In such conditions a delay in identifying the organism and initiating appropriate antimicrobial treatment is associated with a worse outcome. Blood culture yields may be improved by the development of a blood culture device (BCD) specifically for this purpose. This study aimed to develop a BCD and test it in vivo on a sheep model for function and safety. A blood culture device (BCD) was designed to allow an increased volume of blood (100mL) to circulate under turbulent conditions over a large surface area to optimize bacterial exposure. To prevent clotting during sampling the BCD was preloaded with heparin saline. The efficacy and safety of the developed BCD was tested on an animal model of five sheep. All five developed BCDs functioned well when tested on the sheep model. A volume of 100mL of blood was circulated through each device without clotting. The sheep did not display any clinical or biochemical evidence of bleeding or bleeding risk during or after sampling. This study confirms that a BCD can be developed through which an increased volume of blood can be circulated under turbulent conditions over a large surface area without clotting during sampling and without exposing the subject to a hemorrhagic risk.

Coronary interventions: vascular accessPurpose: To evaluate efficacy and safety of trans ulnar access for coronary angiography and interventions.Methods: A prospective cohort study was conducted in 73 patients who underwent coronary angiography and/or percutaneous coronary intervention at thammasat university hospital from May 2016 to July 2017.Transulnar access was done in patient with normal Allen's test.Procedure was performed by single operator.Primary endpoint was a success rate of vascular access.Secondary endpoints was fluoroscopy time, vascular access time, procedure time for diagnostic coronary angiography, contrast volume during diagnostic coronary angiography ulnar spasm, hematoma of access site, ulnar artery occlusion after procedure Results: Of 73 patients (age 63±14 year, 42.5% Female), 79% (58 patients) was successful transulnar access.The mean vascular access time was 4.8± 5.7 minutes and mean procedural time was 67.17± 57.08 minutes which 54.8% (40 patients) underwent percutaneous coronary intervention.Nine patients (12%) developed ulnar artery spasm during procedure and five patients (6.8%) had significant access site hematoma.No ulnar artery occlusion was demonstrated by Doppler colour ultrasound within one week.Conclusion: Transulnar access was safe and efficacy for patients undergo coronary intervention.This supports the safety and efficacy of transulnar access as an alternative access to transradial approach in patients who had radial access site limitation.

BACKGROUND:Thus far, the topic hemostatic agent PerClot® is used for surgical procedures. Data about the use of PerClot® for cardiac-rhythm-devices (CRD) implantation are missing. The aim of this study was to evaluate the safety and efficacy of PerClot® in patients with high bleeding risk.METHODS AND RESULTS:In this prospective randomized study we planned to include 150 patients admitted for CRD-Implantation receiving anticoagulation and/or dual-antiplatelet-therapy. Participants were randomized to receive PerClot® versus standard-of-care. The primary endpoint was the incidence of pocket hematoma. Safety endpoint was pocket infection. After a planned safety-interim-analysis the study was terminated early because of safety concerns. 51 patients were included. The two groups were comparable with regard to age (73±11years vs. 74±10years; p=0.71), CHA2DS2VASc (3.6±1.5 vs. 4.0±1.5; p=0.27) and HASBLED-Score (2.4±1.1 vs. 2.5±1.0; p=0.98), CRD or procedure type, anticoagulant or anti-platelet therapy. The use of PerClot® resulted in a higher incidence of postoperative fever (7 (28%) vs. 0 (0%); p=0.004), higher C-Reactive Protein (66.1±50.5mg/l vs. 25.9±22.5mg/l; p=0.002); and higher postoperative white blood cell count (13.5±4.3/nl vs. 8.8±2.6/nl; p<0.001). Hematoma formation did not differ significantly (p=0.14). Reoperation was not necessary in any patient.CONCLUSION:This first randomized controlled study for the topical use of the hemostatic agent PerClot® in CRD implantation was terminated early by the safety monitoring board because of an augmented rate of fever and inflammatory markers in the PerClot® group. The addition of PerClot® does not suggest a benefit with regard to the frequency of pocket hematoma.

A persistant left superior vena cava (PLSVC) draining to the coronary sinus (CS) is the most common venous anomaly of the thorax, affecting approximately 0.5% - 2% of the general population, and is present in up to 10% of patients with other congenital cardiac anomalies. The embryological development of the thoracic venous system is complex and subject to significant variation. Usually, most of the left cardinal system involutes, leaving only the coronary sinus, which drains the cardiac veins, and the ligament of Marshall (a remnant of the left superior vena cava). The presence of a PLSVC is usually an incidental finding at either echocardiography, cardiac catheterisation or device implantation. The typical echocardiographic findings are that of a dilated CS, which can be appreciated on the parasternal long axis view, the parasternal short axis at mitral valve level, the apical 2 chamber view and a modified apical four chamber view scanning down to visualise the CS. A contrast study with agitated saline (bubble study) done via the left brachial vein will demonstrate the dilated CS draining into the right atrium.

BACKGROUND:Guidelines advise early angiography in non-ST elevation myocardial infarction (NSTEMI) to ensure an optimal outcome. Resource limitations in secondary hospitals in the Western Cape dictate a local guideline to treat NSTEMIs medically with out-patient assessment for angiography, unless mandatory indications for early angiography occur.METHODS:A retrospective cohort study assessed NSTEMIs at Tygerberg Hospital (TBH), Karl Bremer Hospital (KBH) and Worcester Hospital (WH) over one year. Two cohorts were analysed, secondary hospitals (KBH and WH; SH) and secondary service within a tertiary hospital (TBH). Where differences were found, sub-analysis compared WH and KBH.RESULTS:TBH and SH were similar at baseline and in clinical presentation. Cases at TBH were more likely to receive in-patient angiography (94 vs 51%, p < 0.0001), and had a lower in-patient mortality rate (6 vs 23%, p = 0.0326). There was no difference between KBH and WH in sub-analysis.CONCLUSION:This study confirmed that the management and mortality of NSTEMIs in the public health sector in the Western Cape, South Africa is not influenced by geography, but rather by the level of service available in the hospital of first presentation.