BACKGROUND AND AIM OF THE STUDY:Severe aortic stenosis in pregnancy creates several challenges for the physician. In recent years, balloon valvuloplasty has become more widely used, though the indications for its use in this setting are unclear. A review of the available evidence is presented, and a suggested management strategy illustrated.METHODS AND RESULTS:Available literature on the subject was reviewed via Medline search and reference lists from the identified articles. Particular attention was paid to prediction of risk, management options and outcome. The data suggest the importance of early symptoms in determining management, as there is a high risk of complications if left untreated. This group should be considered for valvuloplasty, whereas asymptomatic patients are at low risk, and can be managed expectantly. This is illustrated with two contrasting cases from the authors' practice: the symptomatic patient underwent aortic balloon valvuloplasty as a palliative procedure, using transesophageal and minimal fluoroscopic guidance, with good medium-term results. Both patients required aortic valve replacement in the medium to long-term.CONCLUSION:The use of aortic balloon valvuloplasty in pregnancy is useful as a palliative procedure, allowing deferral of valve replacement until after birth. Echocardiographic features alone are not enough to decide on management, and symptoms play a vital role in determining risk. The use of transesophageal echocardiography during the procedure significantly reduces fluoroscopy time.

With current stent technology and potent antiplatelet drugs, the results of percutaneous coronary intervention (PCI) are increasingly predictable. Kiemeneij and colleagues1 first described PCI as a daycase procedure done via the radial artery, though nearly 50% of these patients were considered unsuitable for same day discharge post-procedure. Subsequently, Koch and colleagues2 performed PCI on > 1000 patients via the femoral artery, transferring more than 90% the same day, back to their referring non-interventional hospital for overnight observation. In the UK, pressure on elective beds causes procedure cancellations and long waiting lists. Performing PCI as a day case procedure minimises the problems of bed availability and reduces overall cost. In 1999 we initiated a policy of elective PCI using coronary stenting and femoral artery access with same day discharge from hospital. During a two year period, 487 patients underwent day case PCI and we report on their immediate and six month outcomes. Between 1 February 1999 and 1 February 2001, our institution performed 1964 PCI procedures. A total of 487 patients with stable angina were admitted electively for PCI with planned same day discharge. Cases not considered for day case procedures included patients with acute coronary syndromes, patients with adverse angiographic appearances including bifurcations, small vessels (< 3 mm), diffuse disease, and lesions unsuitable for stenting. Cases where glycoprotein IIb/IIIa …

Background: The “warm up” effect in angina may represent ischaemic preconditioning, which is mediated by adenosine A1 receptors in most models. Objective: To investigate the effect of a selective A1 agonist, GR79236 (GlaxoSmithKline), on exercise induced angina and ischaemic left ventricular dysfunction in patients with coronary artery disease. Design: A double blind crossover study. Patients: 25 patients with multivessel coronary artery disease. Interventions: On mornings one week apart, patients received intravenous GR79236 10 μg/kg or placebo, and then carried out two supine bicycle exercise tests separated by 30 minutes. Equilibrium radionuclide angiography was done before and during exercise. Results: The onset of chest pain or 1 mm ST depression was delayed and occurred at a higher rate–pressure product during the second exercise test following either placebo or GR79236. Compared with placebo, GR79236 did not affect these indices during equivalent tests. GR79236 reduced resting global ejection fraction from (mean (SD)) 63 (7)% to 61 (5)% (p < 0.05) by a selective reduction in the regional ejection fraction of “ischaemic” left ventricular sectors (those where the ejection fraction fell during the first exercise test following placebo). Ischaemic sectors showed increased function during the second test following placebo (72 (21)% v 66 (20)%; p = 0.0001), or during the first test following GR79236 (69 (21)% v 66 (20)%; p = 0.0001). Sequential exercise further increased the function of ischaemic sectors even after drug administration. Conclusions: GR79236 failed to mimic the warm up effect, and warm up occurred even in the presence of this agent. This suggests that ischaemic preconditioning is not an important component of this type of protection. The complex actions of the drug on regional left ventricular function at rest and during exercise suggest several competing A1 mediated actions.

OBJECTIVES The goal of this study was to investigate whether the "warm-up" effect in angina protects against ischemic left ventricular (LV) dysfunction.BACKGROUND After exercise, patients with coronary disease demonstrate persistent myocardial dysfunction, which may represent stunning, as well as warm-up protection against further angina, which may represent ischemic preconditioning. The effect of warm-up exercise on LV function during subsequent exercise has not been investigated.METHODS Thirty-two patients with multivessel coronary disease and preserved LV function performed two supine bicycle exercise tests 30 min apart. Equilibrium radionuclide angiography was performed before, during and up to 60 min after each test. Global LV ejection fraction and volume changes and regional ejection fraction for nine LV sectors were calculated for each acquisition.RESULTS Onset of chest pain or 1 mm ST depression was delayed and occurred at a higher rate-pressure product during the second exercise test. Sectors whose regional ejection fraction fell during the first test showed persistent reduction at 15 min (68 +/- 20 vs. 73 +/- 20%, p < 0.0001). These sectors demonstrated increased function during the second test (71 +/- 20 vs. 63 +/- 20%, p = 0.0005). The reduction at 15 min and the increase during the second test were both in proportion to the reduction during the first test. Effects on global function were only apparent when the initial response to exercise was considered.CONCLUSIONS The warm-up effect is accompanied by protection against ischemic regional LV dysfunction. The degree of stunning and protection after exercise is related to the severity of dysfunction during exercise, consistent with results from experimental models. (J Am Coil Cardiol 2001; 37:705-10) (C) 2001 by the American College of Cardiology.

Introduction. For patients undergoing myocardial perfusion imaging (MPI), pharmacological stress is increasingly recommended when there is any doubt about exercise capacity. This approach is based on the observation that the sensitivity for detecting coronary disease is reduced when exercise stress is submaximal. This would be of little importance clinically if the sensitivity for predicting irreversible cardiac events were maintained. We investigated the prognostic value of a normal SPECT MPI study when exercise produced submaximal stress. Methods. Between 1995-1998, 1398 patients underwent SPECT MPI (73% 99mTc-tetrofosmin, 27% 201Tl), 1290 (92%) with exercise stress (72% treadmill, 28% upright bicycle). 574 (41%) failed to achieve 80% of the maximum predicted heart rate: age 60±10 years, 63% male, 5% diabetic, 19% previous myocardial infarction, 28% previous revascularisation, 18% angiographically documented coronary disease. 203 (35%) of these MPI studies were normal, and the patients were followed-up by GP questionnaire with review of the hospital notes. Cardiac events were cardiac death or nonfatal myocardial infarction. Results. Follow-up was complete for 155 patients, with a mean (±SD) duration of 2.2±0.8 years. 3 patients died, all of definite noncardiac causes. There was 1 cardiac event (nonfatal myocardial infarction) in a patient who had previously had coronary artery bypass surgery. Conclusion. A normal SPECT MPI study following submaximal exercise predicts a very low risk of cardiac events during follow-up in a relatively high risk population. Patients with reduced exercise capacity do not automatically require pharmacological stress for accurate risk assessment.

Over the past decade physicians treating patients with myocardial infarction have progressed from passive acceptance of the presence of coronary occlusion and merely managing its consequences to a strategy of actively attempting to secure reperfusion. Yet reperfusions fails in a significant proportion of patients. Whilst the benefits of thrombolysis are undeniable 1 Fibrinolytic Therapy Trialists' (FTT) Collaborative GroupIndications of fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet. 1994; 343: 311-322 Summary PubMed Scopus (2798) Google Scholar attempts to improve reperfusion, and thus survival, with more intensive protocols applied to the infarct population as a whole have not been successful. 2 The GUSTO InvestigatorsAn international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993; 329: 673-682 Crossref PubMed Scopus (3630) Google Scholar , 3 Neuhaus KL von Essen R Tebbe U et al. Safety observations from the pilot phase of the randomized r-Hirudin for Improvement of Thrombolysis (HIT-III) study: a study of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte (ALKK). Circulation. 1994; 90: 1638-1642 Crossref PubMed Scopus (299) Google Scholar Do we need to improve our current reperfusion strategies and is it possible to develop, on the basis of the current evidence, a rational approach to the patient in whom thrombolysis has been unsuccessful?

We describe five patients with severe unstable angina refractory to medical management in whom coronary angiography demonstrated a severe stenosis of the left main stem. Due to severe co-existing illnesses bypass surgery was deemed inappropriate. Angioplasty to the left main stem stenosis followed by stent deployment was performed. All five patients were successfully discharged from hospital.

To noninvasively assess the hemodynamic effects of VVI and DDD pacing modes we measured beat‐to‐beat arterial blood pressure during VVI and DDD pacing in 30 patients with complete heart block (CHB), using fingertip photoplethysmography. Of these patients, 15 undertook a double‐blind cross‐over comparison of the symptomatic effects of VVI versus DDD pacing to determine the relationship between blood pressure changes and the occurrence of symptoms suggestive of the pacemaker syndrome during ventricular pacing. Mean (SD) systolic blood pressure was 11.7 (15.4) mmHg lower during VVI pacing compared to DDD pacing (P < 0.0005). The mean (SD) beat‐to‐beat variability of systolic blood pressure was 5.20 (2.87%) in VVI mode versus 2.12 (1.07%) in DDD mode (P < 0.0000005). In comparison with DDD pacing, the excess of symptoms experienced by patients during VVI pacing did not correlate with the change in mean systolic blood pressure, but was significantly correlated with the increase in beat‐to‐beat systolic blood pressure variation during VVI pacing (r = 0.58, P = 0.024). We conclude that noninvasive measurement of fingertip arterial beat‐to‐beat blood pressure is a rapid and simple method of assessing the hemodynamic effect of VVI pacing. Beat‐to‐beat blood pressure variability was related to symptomatic intolerance of VVI pacing and may have potential utility as an aid to diagnosis or as a predictor of pacemaker syndrome.

OBJECTIVE: To establish the feasibility and safety of an appropriately trained clinical nurse specialist performing diagnostic cardiac catheterisation. DESIGN: Non-randomised retrospective comparison between the first 100 and second 100 consecutive investigations by a clinical nurse specialist and 200 consecutive patients investigated by two cardiology registrars over a similar period. SETTING: Regional cardiac centre performing 3200 catheterisation procedures per annum. PATIENTS: 200 patients undergoing routine (non-emergency) cardiac catheterisation for investigation of ischaemic heart disease. MAIN OUTCOME MEASURES: Procedural complications, image quality, fluoroscopy times. RESULTS: Satisfactory diagnostic images in all nurse specialist cases with no deaths and two complications (coronary artery dissection and femoral pseudoaneurysm). Procedure duration and fluoroscopy times slightly shorter for clinical nurse specialist by 3 and 1.6 minutes, respectively (P < 0.05). CONCLUSIONS: Non-medical practitioners can be trained to perform straightforward cardiac angiography in low risk patients with consultant supervision, as for cardiology registrars. With important restrictions such posts may have a limited role in supporting future consultant based services.

OBJECTIVE--To compare symptoms and exercise tolerance during dual chamber universal (DDD) and ventricular rate response (VVIR) pacing in elderly (> or = 75) patients. DESIGN--Randomised, double blind, crossover study. SETTING--Regional cardiac department. PATIENTS--Twenty elderly patients (mean age 80.5 (1) years) with high grade atrioventricular block and sinus rhythm. Patients with pre-existing risk factors for the pacemaker syndrome and chronotropic incompetence were excluded. INTERVENTION--After four weeks of VVI pacing following pacemaker implantation, patients underwent consecutive two week periods of VVIR and DDD pacing. MAIN OUTCOME MEASURES--Patient preference, symptom scores, "daily activity exercises," and perceived level of exercise (Borg score). RESULTS--Eleven patients preferred DDD mode to either VVI or VVIR mode. Mean (SE) total symptom scores during VVI, VVIR, and DDD pacing were 5.9 (1.1), 6.1 (1.0), and 3.5 (0.9) respectively (P < 0.01). The corresponding mean (SE) pacemaker syndrome symptom scores were 4.8 (0.7), 5.2 (0.8), and 2.9 (0.8) (P < 0.05). Symptom scores during VVI and VVIR pacing were not significantly different. Exercise performance and Borg scores were significantly worse during VVI pacing compared with VVIR or DDD pacing but did not significantly differ between VVIR and DDD modes. CONCLUSIONS--In active elderly patients with complete heart block both DDD and VVIR pacing are associated with improved exercise performance compared with fixed rate VVI pacing. The convenience and reduced cost of VVIR systems, however, may be offset by a higher incidence of the pacemaker syndrome. In elderly patients with complete heart block VVIR pacing results in suboptimal symptomatic benefit and should not be used instead of DDD pacing.

We studied 16 patients aged 77-88 years to determine whether elderly patients gain significant benefit from dual-chamber (DDD) compared with single-chamber ventricular demand (VVI) pacing. The study was designed as a double-blind randomized two-period crossover study--each pacing mode was maintained for 7 days. End points included: (i) overall symptoms scores; (ii) exercise tests related to daily activities; and (iii) perceived level of difficulty (Borg score). The mean symptom score in DDD mode was 7.07 (6.38) vs. 12.27 (7.29) in VVI mode (p < 0.006). Dizziness, breathlessness and fatigue were the most noticed symptoms during VVI pacing. One patient dropped out from follow-up and three patients requested early reprogramming, all from VVI mode. Overall, no patient preferred VVI mode, 11 preferred DDD mode and four expressed no preference. There were significant improvements in all objective test performances in DDD mode. Mean (SD) total Borg scores in DDD mode and VVI mode were 36.57 (5.85) and 41.93 (6.49), respectively (p < 0.002). Ventricular demand pacing in elderly patients with complete heart block is associated with higher symptom scores, reduced exercise ability and greater perceived exercise difficulty compared with dual-chamber pacing.

Journal Article Atrial systolic failure in cardiac amyloidosis Get access R.H. Stables, R.H. Stables Cardiac Department, John Radcliffe HospitalOxford Search for other works by this author on: Oxford Academic PubMed Google Scholar O.J.M. Ormerod O.J.M. Ormerod Cardiac Department, John Radcliffe HospitalOxford Search for other works by this author on: Oxford Academic PubMed Google Scholar QJM: An International Journal of Medicine, Volume 86, Issue 7, July 1993, Pages 465–466, https://doi.org/10.1093/oxfordjournals.qjmed.a068844 Published: 01 July 1993

We have studied before operation 156 patients aged more than 40 yr presenting for elective vascular or non-vascular surgery, using ambulatory ECG monitoring to detect silent myocardial ischaemia (SMI). The prevalence of SMI was 18.2% in the vascular group (n = 102) and 7.6% in the non-vascular group (n = 54). A history of ischaemic heart disease, or an abnormal ECG suggestive of a previous myocardial infarction, predicted a high risk of SMI (28% compared with 9% in the absence of these variables). However, a significant amount of SMI (36% of the total) occurred in patients without one of the defined risk factors. In addition, 24 of the patients with abdominal aortic disease underwent cardiac gated blood pool (MUGA) scans. Abnormal ventricular wall function was observed in 62.5% of the patients. Twenty-nine percent of the patients studied with MUGA scans had SMI and 21% had ejection fractions less than 40%. A significant association (P less than 0.05) existed between the presence of SMI and a ventricular ejection fraction of less than 40%.