Acute coronary syndrome with intracranial haemorrhage is a management conundrum where the use of antiplatelet therapies potentiates haemorrhage expansion and subsequent neurological disability. This is a case of Takotsubo cardiomyopathy (TC), due traumatic subarachnoid haemorrhage (SAH), and critical left anterior descending (LAD) artery stenosis using cardiac magnetic resonance imaging (MRI) to guide therapy. A 70-year-old female presented following syncope and head strike post-postural change without prodrome. Her past medical history included smoking, hypertension, dyslipidaemia, and TC 2 years prior with non-obstructive mid-LAD stenosis. Electrocardiogram demonstrated widespread deep T-wave inversion and a prolonged QTc of 612 ms. High-sensitivity troponin I was elevated at 839 ng/L (female reference <16 ng/L) with a contrast-enhanced CT head illustrating a traumatic left-sided and inferior frontal SAH. Transthoracic echocardiography and left ventriculography demonstrated apex akinesis consistent with TC; however, coronary angiography also revealed critical proximal LAD stenosis and critical ostial disease of a large diagonal branch. Cardiac MRI 6 days after the event showed normalisation of ventricular function and no delayed gadolinium enhancement or oedema, consistent with a diagnosis of recurrent TC secondary to traumatic SAH. The patient was discharged on aspirin and proceeded to elective percutaneous intervention 4 weeks later, where she was commenced on clopidogrel, and had no complications at 6-month follow-up. Takotsubo cardiomyopathy uncommonly occurs following SAH; however, concomitant severe coronary artery disease is a rare scenario that confounds the diagnosis and risks catastrophic intracranial bleeding with revascularisation therapy. Cardiac MRI was used to exclude acute infarction and delay intervention until after stabilisation of the SAH.

Background and objective: Transcatheter Aortic Valve Implantation (TAVI) is a promising alternative to surgical aortic valve replacement (AVR) for treatment of patients with symptomatic severe aortic stenosis who are at high surgical risk due to age or comorbidities. We aim to evaluate the economic cost of hospitalisation for TAVI compared to surgical AVR in a cohort of octogenarians. Method and results: Since the 2008–2009 financial year in a single centre, 45 octogenarians (mean age 86.4) with severe aortic stenosis were treated with TAVI and 24 (mean age 84.1) were treated with surgical AVR. Direct cost and length of stay for the index hospitalisation for valve replacement were calculated. The median length of stay for TAVI was seven days (IQR 5, 13) compared to surgical AVR of 14 days (IQR 9.3, 27.5) (p < 0.001). The median direct cost of hospitalisation for TAVI was $47615 (IQR 39899, 59622) and for surgical AVR was $47795 (IQR 25839, 76581) (p = NS). Conclusion: In octogenarians, hospitalisation for TAVI is associated with similar cost to surgical AVR but significantly shorter length of stay.

Background: Two Transcatheter Aortic Valve Implant (TAVI) devices are currently in use under clinical trial in Australia – Edwards SAPIEN valve (SAPIEN) and Medtronic CoreValve (CoreValve). Anatomical suitability for SAPIEN include: aortic annulus dimension of 18–25 mm, iliac-femoral diameter >7–8 mm (transfemoral approach using 22–24 Fr RetroFlex system) or >6–6.5 mm (transfemoral approach using newer 18–19 NovaFlex system). Anatomical suitability for CoreValve include: aortic annulus dimension of 20–27 mm, ascending aorta diameter ≤40–43 mm, iliac-femoral diameter >6 mm (for transfemoral approach) or left subclavian diameter >6 mm (for transubclavian approach). We aim to assess the complementary anatomical suitability in a TAVI program with access to both valves. Methods and results: Fifty-five patients were treated with TAVI in a single centre with simultaneous access to both SAPIEN and CoreValve since February 2009. Twenty were implanted using CoreValve (all transfemoral) and 35 using SAPIEN (12 transapical, 15 transfemoral with RetroFlex system, 8 with NovaFlex system). Aortic annulus was measured using transoesophageal echocardiogram. Iliac-femoral, subclavian, ascending aortic and root anatomy were measured using invasive angiography. Fifty patients (91%) were suitable for SAPIEN valve, with 21 being suitable for transfemoral approach using RetroFlex system and 38 with NovaFlex system. Forty-four patients (80%) were suitable for CoreValve, with 36 being suitable for transfemoral approach. Overall 45 cases were suitable for a transfemoral approach using one or both valves. Conclusion: 9–20% of the patients treated in this centre with access to both transcatheter valves would be unsuitable for treatment if there was access to only one valve. 82% can be treated with a transfemoral approach.

Introduction: Faster door to balloon (DTB) times are associated with improved survival in ST elevation myocardial infarction (STEMI). Key strategies in reducing DTB time are shortening the door to activation (DTA) time of the cardiac catheterisation laboratory (CCL) and earlier patient transfer to the CCL. Traditionally, the treating cardiologist performs CCL activation and patients are routinely transferred once the CCL staff call for the patient. We implemented a change in practice in February 2009 to ED activation of "Code STEMI" thereby decreasing activation and door to balloon times. We wanted to ensure the early good results were being reproduced. Aim: To study activation rates, the presence of false positives, and maintenance in DTB times, 12 months on from a very successful "Code STEMI" implementation. Methods: DTB and DTA times were prospectively recorded in all patients undergoing primary PCI between October 2009 and December 2010. This 14-month follow on data was reviewed and compared to the data from the original experience from February 2009 to October 2009. Results: The DTB and DTA times continue to improve (DTB: 77 minutes 2009 vs 69 minutes 2010). There have been transient increases in false positive CCL activations noted that have required ongoing emergency/cardiovascular medicine communication. Conclusion: Ongoing review and monitoring of ED activated STEMIs are required to ensure activation criteria are being adhered to, and to maintain door to balloon times and adherence to the activation protocol.

OBJECTIVES:To assess whether a collaborative interdepartmental pathway involving emergency department (ED) physicians activating the cardiac catheterisation laboratory (CCL) with immediate patient transfer to the CCL reduces door-to-balloon (DTB) times for patients with suspected ST-elevation myocardial infarction (STEMI).DESIGN, SETTING AND PARTICIPANTS:A quasi-experimental before-and-after observational study using a prospective database, supplemented by chart review, of consecutive patients transferred from the ED to the CCL for suspected STEMI, from January 2007 to October 2009, at Sir Charles Gairdner Hospital, an adult tertiary-care hospital, Western Australia.MAIN OUTCOMES MEASURES:Median DTB time and proportion of patients with DTB time of < 90 minutes. Secondary outcomes, based on analysis of predefined subgroups, included door-to-activation time, activation-to-balloon time and false-positive activations of the CCL.RESULTS:Two hundred and thirty-four patients underwent emergency coronary angiography for suspected STEMI, with 188 (80%) undergoing percutaneous coronary intervention (118 before and 70 after implementation of the new pathway). Following implementation of the new pathway, median DTB time reduced from 97 to 77 minutes (P < 0.001), median door-to-activation time from 28 to 15 minutes (P = 0.002) and median activation-to-balloon time from 66 to 53 minutes (P < 0.001). The proportion of patients with recommended DTB time of < 90 minutes increased from 41% to 77% (P < 0.001) with no change in false positive CCL activation rates (12% v 11%; P = 0.38).CONCLUSION:ED physician activation of CCL with immediate patient transfer is associated with highly significant improvements in DTB time without increased false positive rates.

Background: Faster door to balloon times are associated with lower mortality in STEMI and this has been achieved by pre hospital (ambulance mediated) activation of the cardiac catheterisation laboratory (CCL). Lower mortality should also be achievable by reducing pain to door (PTD) time and increasing the proportion of patients contacting ambulance services to enable earlier CCL activation.