Background:Emergency chest pain presentations represent a substantial burden on healthcare resources. The use of coronary computed tomography angiography (CCTA) has been shown to be safe and associated with reduced costs in stable outpatients referred for invasive coronary angiography (ICA). The history, electrocardiogram, age, risk factors, troponin (HEART) risk assessment score is used to risk-stratify patients with undifferentiated chest pain. We sought to evaluate the cost impact of an accelerated outpatient CCTA-based diagnostic pathway compared with inpatient ICA for the investigation of patients presenting acutely to the emergency department (ED) with symptoms suggestive of coronary artery disease (CAD) at a tertiary referral centre. Methods:We performed a comparative cost analysis based on retrospective observational data including stable adult ED patients who presented in 2023.Results:369 patients underwent outpatient CCTA and 376 were admitted for ICA. The median time to outpatient CCTA was 14 days (interquartile range (IQR) 5–24). Use of the CCTA-based pathway was associated with a 78% reduction in diagnostic pathway costs (€2990 per patient), when compared to admission for ICA, for the investigation of lower-risk individuals, with no increase in 30-day mortality or myocardial infarction. Patients referred for outpatient CCTA had a significantly shorter median length-of-stay compared with those admitted for ICA (6.5 hours (IQR 5.0–9.0) vs. 5 days (IQR 3.0–14.9); p < 0.05). Conclusions:Use of an accelerated outpatient CCTA-based diagnostic pathway for low-risk chest pain patients in the ED was associated with substantial cost savings and reduced hospital utilization without evidence of compromised short-term safety.

Background Device embolization after left atrial appendage occlusion (LAAO) is rare (∼0.1%) but may be life-threatening. Case Summary A 72-year-old man presented with a left frontal stroke 2 years after Amplatzer Amulet LAAO device implantation. Computed tomography angiography showed the occluder lodged across the left subclavian artery ostium in the transverse aortic arch. After heart team review and Health Products Regulatory Authority compassionate-use approval, an ONO basket retrieval system (Onocor) was used to capture the device under fluoroscopic and transesophageal echocardiography guidance. Repeated attempts to resheath it into a 26-F DrySeal sheath failed because the device could not be adequately compressed. The device was withdrawn to the right common iliac artery, where evolving limb ischemia prompted surgical device extraction via an infrarenal aortotomy. Extensive tissue ingrowth was evident on device retrieval. Discussion Review of 18 published reports describing 20 cases of late LAAO device embolization showed retrieval intervals up to 18 months, almost all successfully managed percutaneously. This case extends that experience to 2 years and highlights how chronic tissue incorporation can hinder resheathing, emphasizing the role of hybrid retrieval strategies when percutaneous extraction fails. Take-Home Messages Embolized LAAO devices that remain in situ for prolonged periods may develop tissue ingrowth, making percutaneous removal technically challenging. When full percutaneous extraction is not achievable, hybrid percutaneous-surgical retrieval via an infrarenal aortotomy offers a safe bailout that avoids sternotomy.

Background Percutaneous patent foramen ovale (PFO) closure typically uses femoral venous access. Congenital or acquired inferior vena cava (IVC) interruption precludes this route and presents a significant technical challenge. Case Summary A 54-year-old man was referred for PFO closure following cryptogenic embolic stroke. Femoral access failed; intraprocedural venography confirmed IVC interruption. The case was reattempted via the right internal jugular vein. A 30-mm PFO closure device was deployed using a preshaped transcatheter aortic valve replacement guidewire anchored in the left ventricle for support. Review Summary Fifteen published cases detail PFO closure via transjugular, transhepatic, and upper-limb access. The transjugular approach requires specific strategies to overcome the unfavorable crossing angle, including preformed or steerable catheters and distal wire anchoring in the pulmonary veins, left atrium, or left ventricle. Take-Home Messages Congenital or acquired IVC interruption necessitates alternative access strategies for percutaneous PFO closure. While technically demanding, transjugular and transhepatic routes are feasible alternatives.

Acoronary artery fistula (CAF) is an abnormal connection between a coronary artery and another structure. This rare condition has an incidence in the general population of 0.002%. A 57-year-old woman presented with angina, a normal electrocardiogram (ECG) and a peak troponin I of 0.22 µg/L (normal <0.04 µg/L). She was treated with a standard medical regimen for non-ST-elevation myocardial infarction. Coronary angiography revealed non-obstructed coronary arteries, with fistulae arising from the left anterior descending, left circumflex and right coronary arteries, all terminating in the pulmonary artery. Cardiac magnetic resonance (CMR) imaging was performed to investigate coronary steal syndrome. This confirmed there was no significant shunt or evidence of infarction. There was a small concentric pericardial effusion with a focal region of inferolateral epicardial fibrosis, suggesting a diagnosis of myopericarditis. The patient was treated with colchicine for three months. CAF can cause patients to present with a variety of symptoms or potentially life-threatening complications, including fistula rupture and myocardial infarction. Early recognition, characterisation and shunt analysis are imperative to facilitate management. Although left/ right heart catheterisation is considered the gold standard, CMR proved to be a useful diagnostic tool in our case, ruling out significant shunting and helping to identify a differential diagnosis.

Abstract Background Obstructive sleep apnoea (OSA) is present in 40–80% of patients with cardiovascular morbidity and is associated with adverse effects on cardiovascular health. Continuous positive airway pressure (CPAP) maintains airway patency during sleep and is hypothesised to improve cardiac function. In the present study, we report on the impact of 12 weeks of CPAP and improvements in echocardiographic parameters of the right ventricle (RV). Methods Nineteen newly diagnosed patients with OSA and a respiratory disturbance index (RDI) greater than 10 were enrolled. Echocardiography was performed before treatment and with a follow-up assessment after 12 weeks of CPAP. Echocardiographic and Doppler measurements were made following the American Society for Echocardiography guidelines. The primary outcome was isovolumetric acceleration (IVA). Secondary outcomes include tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), RV % strain, TEI index and RV dimension (RVD1). Results There was significant improvement in isovolumetric acceleration of 0.5ms2 (P = 0.0012 (95% CI -0.72, -0.20)) and significant improvement of 2.05 mm in TAPSE (p = 0.0379 (95% CI -3.98 - -0.13). There was no significant difference in FAC, RV % strain, TEI index or RVD1 with twelve weeks of CPAP therapy. Conclusion The present study highlights significant improvement in TAPSE and IVA with 12 weeks of CPAP treatment and no significant improvement in FAC, RVD1 and RV % strain. These data indicate favourable characteristics on both load dependent and load independent markers of RV function with CPAP.

OBJECTIVES:An accelerated diagnostic pathway is created to aid the management of low-risk patients presenting to the emergency room with chest pain. Records are taken of patient outcomes and factors influencing physician decision-making between inpatient invasive angiography versus early outpatient cardiac CT angiography. METHODS:A cohort study at 30 days post discharge is undertaken over 1 year. Differences are observed between a population of patients who underwent early outpatient CT and a population of ambulatory haemodynamically stable patients who underwent inpatient fluoroscopic angiography. RESULTS:Totally, 369 patients underwent CT (F = 46%) and 37 underwent angiography (F = 30%). Median outpatient CT was at 14 days. At 30 days, 0 patients suffered mortality or myocardial infarction. Eleven percent were recommended for invasive angiography. Two percent of CT patients underwent coronary revascularization. Median calcium score was 0. Twenty percent of the CT population were commenced on high-potency statin or had their pre-existing statin dose intensified. Calcium score affected a composition of statin commencement, angiography, and revascularization (OR 59, P < .001). Age, troponin, vascular disease, and previous coronary revascularization appeared to influence choice between coronary computed tomography angiography (CCTA) and invasive angiography. CONCLUSION:An accelerated diagnostic pathway for outpatient cardiac CT for chest pain resulted in no mortality or myocardial infarction, with a low level of downstream testing and coronary revascularization. ADVANCES IN KNOWLEDGE:At a median time to CCTA of 14 days post discharge from the emergency department, there is no effect on patient major adverse cardiac events.

Background/objectives: Acute coronary syndrome (ACS) is a major global health issue primarily caused by the rupture or erosion of vulnerable coronary plaques. Non-invasive identification of these plaques through coronary computed tomography angiography (CCTA) can be improved with radiomics, which extracts and analyses quantitative features from medical images. This systematic review aims to comprehensively evaluate the literature surrounding the role of radiomics in assessing coronary plaques via CCTA. Methods: A systematic search of Medline, EMBASE, and Web of Science was conducted up to July 2024. Nine studies met the inclusion criteria, and their methodological quality was assessed using the radiomic quality score (RQS) and the QUADAS-2 tool. Results: All studies that evaluated radiomic models for plaque vulnerability reported area under the curve (AUC) values exceeding 0.7, indicating at least modest diagnostic performance. In the four studies that made direct comparisons, radiomic models consistently outperformed conventional CCTA markers. However, RQS scores ranged from 2.7% to 41.7%, reflecting variability in study quality and underscoring the need for more robust validation. Conclusions: Radiomics has the potential to enhance CCTA-based identification of vulnerable coronary plaques, offering a promising non-invasive approach to predicting major adverse cardiovascular events. However, the current body of research is limited by the lack of external validation, reliance on small, single-centre retrospective studies, and methodological inconsistencies, which impact the generalisability and reproducibility of findings. Future research should prioritise prospective, multi-centre studies with standardised protocols and rigorous validation frameworks to effectively incorporate radiomics into clinical practice.

Background Deformation imaging represents a method of measuring myocardial function, including global longitudinal strain (GLS), peak atrial longitudinal strain (PALS) and radial strain. This study aimed to assess subclinical improvements in left ventricular function in patients undergoing transcatheter aortic valve implantation (TAVI) by comparing GLS, PALS and radial strain pre and post procedure. Methods We conducted a single site prospective observational study of 25 patients undergoing TAVI, comparing baseline and post-TAVI echocardiograms. Individual participants were assessed for differences in GLS, PALS and radial strain in addition to changes in left ventricular ejection fraction (LVEF) (%). Results Our results revealed a significant improvement in GLS (mean change pre-post of 2.14% [95% CI 1.08, 3.20] p = 0.0003) with no significant change in LVEF (0.96% [95% CI − 2.30, 4.22], p = 0.55). There was a statistically significant improvement in radial strain pre and post TAVI (mean 9.68% [95% CI 3.10, 16.25] p = 0.0058). There was positive trend towards improvements in PALS pre and post TAVI (mean change of 2.30% [95% CI − 0.19, 4.80] p = 0.068). Conclusion In patients undergoing TAVI, measuring GLS and radial strain provided statistically significant information regarding subclinical improvements in LV function, which may have prognostic implications. The incorporation of deformation imaging in addition to standard echocardiographic measurements may have an important role in guiding future management in patients undergoing TAVI and assessing response.

Introduction Cancer-related fatigue is a common symptom whose pathophysiology may involve dysfunction of cardiac muscle & autonomic nervous system (ANS). Aim Assess feasibility of objective measurement of fatigue, cardiac muscle & ANS function in a palliative population. Methods Consecutive participants with cancer recruited from palliative outpatient clinic. Fatigue measured subjectively (brief fatigue inventory [BFI]) & objectively (grip strength, timed-up-and-go [TUG], sit-to-stand [STS]). A 2D transthoracic echocardiogram assessed cardiac function (systolic: ejection fraction [EF]; diastolic: isovolumic relaxation time [IVRT], LV filling velocities [E/A]. Myocardial strain analysed using EchoPAC software. Heart rate variability (HRV) recorded for five minutes each of spontaneous & paced breathing. SDNN: standard deviation of RR intervals; RMSSD: Root mean square of successive differences. Active stand identified postural hypotension. Participants completed an acceptability questionnaire. Results 10 participants, 7 female. Mean age: 66 years (57–71). Cancer types: Lung, colorectal, breast, gastric, ovarian. Metastatic disease: n=10. BFI ≥3 (indicating fatigue): n=7 Median (Range) BFI 4.2 (0–8.9). Grip strength (kg force) 18 (9–39). TUG (s) 9 (7–23). STS (no. in 30s) 10 (0–15) Ejection fraction normal 67.5%. Grade I diastolic dysfunction present (E/A 0.8, IVRT 96ms). HRV reduced SDNN & RMSSD very low: 21.3, 11.5ms spont; 27.2, 19.2ms paced, normal >50, >42 respectively Strain significantly different (19.1, 24.3, p=0.02) in groups with/without fatigue. BFI correlated with HRV, TUG with Strain (0.875, p=0.001), & HRV. All found study acceptable No participant withdrew. One participant each: • unable to complete STS • felt echo interfered with privacy • found paced breathing 'bothersome' Conclusions 1. Objective assessment of fatigue, cardiac muscle & ANS feasible, acceptable & warranted in palliative populations 2. Majority of participants fatigued subjectively & objectively 3. Significant diastolic dysfunction & loss of HRV present 4. Correlations between subjective & objective fatigue, myocardial strain & HRV 5. These bedside tests can be used in palliative populations to guide symptom management

Background: This systematic review and meta-analysis compares long-term outcomes follow-up data comparing drug-eluting balloons (DEBs) and drug-eluting stents (DESs) in interventional treatment of small coronary artery disease (<3 mm). Methods: A systematic review was undertaken along with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome was 1-3-year performance of DEB versus DES in major adverse cardiac events. Secondary outcomes include all-cause mortality, MI, cardiac death, vessel thrombosis, major bleeding, target vessel revascularisation and target lesion revascularisation. Two independent reviewers extracted data. All outcomes used the Mantel-Haenszel and random effects models. ORs are presented with a 95% CI. Results: Of 4,661 articles, four randomised control trials were included (1,414 patients). DEBs demonstrated reduced rates of non-fatal MI at 1 year (OR 0.44; 95% CI [0.2-0.94]), and BASKET-SMALL 2 reported a significant reduction in 2-year bleeding rates (OR 0.3; 95% CI [0.1-0.91]). There was no significant difference in all other outcomes. Conclusion: Long-term follow-up of DEB and DES use in small coronary arteries demonstrates DEBs be comparable with DESs in all outcomes at 1, 2 and 3 years of follow-up. A significant reduction was found in rates of non-fatal MI at 1 year in the DEB arm, and a reduction in major bleeding episodes at 2 years in the BASKET-SMALL 2 trial. These data highlight the potential long-term utility of novel DEBs in small coronary artery disease revascularisation.

Cardio-oncology is a dynamic field. Research has suggested that cancer itself can damage the heart, independent of cancer treatment-related cardiac dysfunction (CTRCD). The aim of this study was to establish the nature of cardiovascular abnormalities reported in cancer, excluding CTRCD. Scoping review search included cardiovascular abnormalities in adults with solid tumour malignancies, and excluded CTRCD and thrombotic events. Three databases (CINAHL, Embase, Medline) were searched, supplemented by a handsearch. All screening and data extraction was done by two researchers with consensus reached for any conflicts. Given the heterogeneous nature of the studies identified, data synthesis was narrative. The search identified 42 366 studies. Following deduplication and title/abstract screening, 195 studies were assessed for full-text eligibility. Forty-four studies are included in the final analysis. There are 19 prospective observational studies, 13 retrospective studies, 9 case reports and 3 cross-sectional studies. Types of abnormality identified include cardiomyopathy (16, including Takotsubo (9)), autonomic nervous system (ANS) dysfunction (10), biomarker disturbances (9), reduced myocardial strain (6) and others (3). Due to variable study design, the prevalence was not determined. Cardiovascular abnormalities were associated with morbidity (chest pain, dyspnoea, fatigue) and shortened prognosis. In conclusion: (1) There is evidence for cardiovascular dysfunction in patients with solid tumour malignancies, distinct from CTRCD. People with solid tumours have higher rates of cardiac disease, even when newly diagnosed and treatment naïve. (2) Abnormalities manifest mainly as cardiomyopathies, ANS dysfunction and raised biomarker levels and are associated with significant symptoms. (3) Treatment plans need to take account of these risks, and widen criteria for screening.

OBJECTIVES:This paper describes cardiotoxicity and cancer treatment-related cardiac dysfunction (CTRCD). Long-term sequelae of treatment are important, and changing, and may manifest when a patient is under the care of a supportive care service.METHODS:Key messages for supportive and palliative care clinicians are outlined to facilitate identification and management of CTRCD.RESULTS:Not all cardiotoxicity is alike. Types of cardiotoxicity, cardiac complications of immunotherapy, the challenge of autonomic nervous system dysfunction in cancer and management of cardiotoxicity are highlighted.CONCLUSIONS:The key strategies are early detection of cardiotoxicity, monitoring for development of CTRCD during treatment and surveillance in survivorship.

Despite the increased uptake of intravascular lithotripsy (IVL) for treating severely calcified coronary lesions, there is limited patient-level data examining the effect of IVL on quality of life, symptomatology, and outcomes beyond 30 days. We sought to assess demographics, procedural characteristics, outcomes, and impact of IVL on patient-reported angina after a minimum of 6 months follow-up. A retrospective single-center study was conducted of patients treated with coronary IVL between January and October 2020. Baseline demographics were obtained from electronic patient records and SYNTAX scores were calculated from index coronary angiograms. Technical success and complications were assessed along with clinical outcomes, which included all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), and MACE (composite of death, stroke, MI, and TLR). Canadian Cardiovascular Society (CCS) angina classification was assessed at virtual clinical follow-up. Forty-seven consecutive patients were included. At a mean follow-up of 306 ± 74 days, the mean CCS angina score was reduced by 53% post-IVL-assisted PCI (2.9 vs 1.4, p < 0.001). Technical and procedural success were high (94% and 92%, respectively). One patient (2%) met the pre-specified criteria for in-hospital MACE and 4 (9%) met pre-specified MACE at follow-up, including 2 deaths and 2 TLR. Procedural complications included coronary dissection (11%) and coronary perforation (6%) and were managed either conservatively or with PCI. Coronary IVL is a safe and effective adjunctive therapy for treating heavily calcified coronary lesions. This cohort shows high procedural success and a significant reduction in CCS angina at follow-up.

A Caucasian man in his mid-50s presented to the emergency department with sudden onset right-sided weakness and dysarthria. CT angiogram demonstrated a small volume of left middle cerebral artery territory infarction after which the patient underwent successful thrombolysis. Initial ECG showed diffuse T wave inversion. He was admitted to an acute stroke ward where 72 hours of telemetry demonstrated normal sinus rhythm without arrhythmia. Transthoracic echocardiogram showed a reduced ejection fraction of 47% in the absence of any regional wall motion abnormality. An echogenic mass was noted in the apical inferior septal wall. Cardiac MRI demonstrated circumferential mid to apical endocardial thickening with characteristic appearances consistent with endomyocardial fibrosis (EMF). Furthermore, a visible hypointensity in the apex confirmed left ventricular thrombus adherent to the area of EMF. The patient was started on anticoagulation and heart failure therapy. He has recovered from the ischaemic stroke and is currently under outpatient surveillance.

The plasma multimeric glycoprotein von Willebrand factor (VWF) plays a critical role in primary hemostasis by tethering platelets to exposed collagen at sites of vascular injury. Recent studies have identified additional biological roles for VWF, and in particular suggest that VWF may play an important role in regulating inflammatory responses. However, the molecular mechanisms through which VWF exerts its immuno-modulatory effects remain poorly understood. In this study, we report that VWF binding to macrophages triggers downstream MAP kinase signaling, NF-κB activation and production of pro-inflammatory cytokines and chemokines. In addition, VWF binding also drives macrophage M1 polarization and shifts macrophage metabolism towards glycolysis in a p38-dependent manner. Cumulatively, our findings define an important biological role for VWF in modulating macrophage function, and thereby establish a novel link between primary hemostasis and innate immunity.

We present a unique case of acute coronary syndrome (ACS) secondary to external coronary artery compression from a left ventricular outflow tract pseudoaneurysm in a postsurgical aortic valve replacement (AVR) patient, subsequently sealed with a pericardial patch. We highlight this rare presentation of ACS in postsurgical AVR patients and the importance of multimodality imaging and treatment of this unique, potentially serious sequela. (Level of Difficulty: Intermediate.)

Background Myocardial strain-change in myocardial fibre length over the cardiac cycle-is a measure of cardiac muscle function. It is obtained using conventional techniques such as echocardiography and magnetic resonance imaging, adding additional clinical information to augment the current techniques. Methods A narrative review of the current relevant literature with respect to myocardial strain, with a focus on strain measured by echocardiography. Results Myocardial strain identifies global and regional abnormalities in myocardial function and differentiates types of cardiomyopathy. It is an earlier marker of myocardial disease than ejection fraction and is predictive of cardiovascular adverse events. Accurate measurement requires high-quality images and experienced practitioners. Conclusion This review explains advantages and disadvantages of myocardial strain imaging and explains why, through adding increased precision without additional burden, it should be a standard part of cardiac assessment.

BACKGROUND:High-sensitivity troponin-T (HS-cTnT) levels are often measured in patients presenting with atrial fibrillation (AF), with many subjected to unnecessary invasive assessments. The significance of a normal or mildly raised HS-cTnT in this context is poorly understood. This study aimed to determine the predictive value of HS-cTnT for significant coronary artery disease (CAD) in new AF with rapid ventricular response. We also compared the discriminative ability of HS-cTnT to suspected angina for significant CAD. METHODS:We examined patients presenting with new AF to two tertiary Irish centers in a defined period. Those included had HS-cTnT taken at presentation and subsequent ischemic evaluation. RESULTS:Of 5350 cases screened for inclusion, 281 were deemed eligible. Of these, 148 and 133 patients had a positive and negative index HS-cTnT, respectively. Of those with negative HS-cTnT, 13 (9.8%) had significant CAD versus 51 (34.5%) with positive HS-cTnT (P < 0.001). Positive Hs-cTnT status remained significant upon multivariate analysis (OR, 2.9; 95% CI, 1.37-6.14; P = 0.005). A similar model where HS-cTnT was replaced with suspected angina produced an OR of 1.64 (95% CI, 0.75-3.59; P = 0.213). A logistic model determined optimal cutoff value for HS-cTnT to be less than 30 ng/l, producing a negative predictive value of 91.8% and area under the receiver operative curve of 83.36. CONCLUSION:HS-cTnT exhibits potential as an effective screening biomarker to predict nonsignificant CAD in new rapid AF, allowing more targeted and rationalized ischemic testing. HS-cTnT may also be a more accurate predictor of significant CAD than clinically suspected stable angina.Graphical abstract: http://links.lww.com/MCA/A540.

Background: Iron-overload cardiomyopathy initially manifests with diastolic dysfunction and can progress to dilated cardiomyopathy if untreated. Previous studies have shown that patients with primary and secondary hemochromatosis can have subclinical left ventricle dysfunction with abnormalities on strain imaging. This study aimed to evaluate the relationship between cardiac T2* values and myocardial-wall strain in patients with hereditary hemochromatosis (HH) at the time of diagnosis and after a course of venesection treatment. Materials and Methods: Baseline cardiac magnetic resonance (CMR) at 3 T was performed in 19 patients with newly diagnosed HH with elevated serum ferritin levels and repeated after a course of treatment with venesection. Quantitative T2* mapping and strain analysis were performed offline using dedicated relaxometry fitting and feature-tracking software. Results: The majority (84%) of patients had normal baseline myocardial T2* values (mean 19.3 ms, range 8.9 to 31.2 ms), which improved significantly after venesection (mean 24.1 ms, range 11 to 38.1 ms) (P=0.021). Mean global radial strain significantly improved from 25.0 (range: 15.6 to 32.9) to 28.3 (range: 19.8 to 35.8) (P=0.001) and mean global circumferential strain improved, decreasing from −15.7 (range: −11.1 to −19.2) to −17.1 (range: −13.0 to −20.1) (P=0.001). Conclusion: Patients with HH may have normal T2* values in the presence of subclinical left ventricle dysfunction, which can be detected by abnormal radial and circumferential strain. As strain imaging improves following venesection in HH, it may serve as a useful biomarker to guide treatment.