In the most recent recommendations of the European Society of Cardiology and European Association of Cardio-Thoracic Surgery, both Optical Coherence Tomography (OCT) and Intravascular ultrasound (IVUS) are classified as class IIa for procedural optimization. In a comparison of OCT and IVUS measurement in the phantom model, OCT data corresponded to the real lumen area of the model, but IVUS readings were inflated and less repeatable.

Abstract Background Left Main Stem Disease (LMS) has historically been treated with coronary artery bypass surgery (CABG). However, not all patents with LMS are candidates for CABG due to co-morbidities. There is limited long-term follow-up of patients undergoing PCI in the real world. The primary objective of this study was to investigate the long-term mortality following LMS PCI. Methods We conducted a retrospective study of patients who had undergone PCI for LMS disease at our hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records and analyzed using Kaplain-Meier survival analysis. Follow-up was obtained through linkage with the Office of National Statistics. Results 498 patients underwent LMS PCI (5.1% of the total PCI cases). The overall survival rate was 70%. Median survival following PCI was 1,196 days (IQR = 1,796). The mean age of the patients was 70.7 years; 70.5% were males. 70.9% of patients underwent PCI for Acute Coronary Syndrome (ACS), and 15.3% had STEMI. 33.7% of patients had a history of diabetes, 8% had stroke, 8.2% had COPD, and 8.8% had PVD. 51 patients went into cardiogenic shock, and 25 died prior to discharge. Survival of the ACS group was significantly lower than the stable group (67% vs 77%, p<0.01); the STEMI group did not significantly differ from rest of the ACS group (62% vs 66%, p=0.87). Survival in those <60 years of age was significantly higher than in those >60 years (80% vs 68%; p<0.01). The presence of one or more co-morbidities was associated with higher survival compared to zero co-morbidities (74% vs 65%, p<0.01). Patients with a history of diabetes had a significantly lower survival rate than those without diabetes (63% vs 73%, p<0.01). Patients with an LV ejection fraction ≤35% had a significantly lower survival than those with an ejection fraction >35% (22% vs 29%, p<0.01); only 259 patients had data on LV function. Patients who developed cardiogenic shock had a significantly lower survival rate than those who did not develop shock (38% vs 70%; p<0.01). When these patients were excluded from the data set, the overall survival rate increased from 70% to 74%. Lastly, a multinomial analysis showed that the only independent predictors of mortality were age (p<0.01) and cardiogenic shock (p<0.01). Conclusion Our results show that the real world 10-year mortality rate following LMS PCI is influenced by multiple factors including age, shock, and LV function. The high mortality rate was potentially due to the significant number of acute cases (70.1%) in non-operable patients. While factors such as age and past medical history are considered in the decision-making process regarding CABG vs PCI, we saw that specific subgroups within these factors may have decreased the effectiveness of PCI as a treatment for LMS disease, suggesting that deeper analysis into these risk factors is required when deciding between CABG and PCI for LMS disease management. Funding Acknowledgement Type of funding sources: None.

Previous studies of the incidence and severity of mitral regurgitation (MR) following acute myocardial infarction (MI) were limited by the study population (ST-elevation MI only), by diagnostic methods (lack of multiparametric quantification), or by the time-frame of study (late assessment post-MI). The true incidence of ischaemic MR (IMR) immediately following type 1 MI [non-ST-elevation (NSTEMI) and ST-elevation (STEMI)] patients in the modern era of universal early revascularisation remains unclear. Since even mild IMR confers a poor prognosis, factors which promote or protect against the development of MR require further evaluation. To determine the incidence, clinical and angiographic characteristics of patients with IMR following type 1 MI treated with PCI. This was a single-centre study of 1000 consecutive, prospectively recruited patients admitted to the Queen Elizabeth Hospital Birmingham with type 1 MI who underwent PCI. Early inpatient transthoracic echocardiography (TTE) was performed by accredited echocardiographers using standard multiparametric quantification. MR was observed in 294/1000 patients (29.4%) post-MI, graded as mild (76%), moderate (21%) and severe (3%). Median time from symptom onset to PCI was 1 day (IQR 0–4) and to TTE 2 days (IQR 1–3). Compared to patients without MR (MR-), those with MR (MR+) were older (73±12 years vs 66±13 years; p<0.001), male (75% vs 64%; p<0.001) and more likely to have a history of hypertension (HTN) (63% vs 55%; p=0.0117), heart failure (HF) (3.4% vs 1.1%; p=0.0140) and previous MI (28% vs 20%; p<0.005). MR+ patients more frequently presented with HF (8.5% vs 4.2%; p=0.0075), lower LV ejection fraction (LVEF) (50±14% vs 55±11%; p<0.001) and higher peak high sensitivity troponin T (765ng/L, IQR 170–3032 vs 400ng/L, IQR 51–1966; p<0.0001). MR+ patients were more likely to have severe disease in the left circumflex (LCx) (50% vs 33%; p<0.0001) or right coronary artery (RCA) (51% vs 43%; p=0.0135). Incidence of severe disease in the left main stem and left anterior descending artery (LAD) did not significantly differ between the two groups. Incidence of MR was equal (29%) amongst STEMI (126/431) and NSTEMI (168/569) patients. While the time to revascularisation did not affect the prevalence of MR following STEMI (linear regression analysis of door-to-balloon time in MR+ and MR- patients p=0.843), NSTEMI patients were more likely to develop MR if revascularisation was delayed (linear regression analysis of symptom onset to PCI time MR+ vs MR- p=0.061). Almost 1/3 of patients with type 1 MI undergoing revascularisation have MR evident on pre-discharge TTE. Factors promoting MR include older age, male sex, HTN, HF, larger non-LAD territory infarct, and depressed LVEF. The incidence of MR following STEMIs and NSTEMIs is equal. Earlier revascularisation is unlikely to reduce MR in STEMI patients but may improve MR prevalence following NSTEMI. Type of funding source: None

Objectives: The Impella® percutaneous systems (Abiomed, Danvers, USA) are temporary ventricular assist devices, approved for use in high-risk percutaneous coronary intervention (PCI). Impella use in the United Kingdom (UK) is limited by cost, reimbursement, lack of operator experience and paucity of long-term outcome data. We investigated 10-year outcomes of Impella circulatory support in a large quaternary UK hospital. Methods: Consecutive patients undergoing Impella-assisted PCI between 2008 and 2018 were retrospectively identified and outcome data collected. Results: Eighty patients underwent Impella-assisted PCI and were predominantly male (73.8%) with a mean age of 71.2 + 13.7 years. Fifty-three (66.3%) presented with non-ST segment elevation myocardial infarction (MI) and 7.5% with ST-segment elevation MI. The majority of patients had severe left ventricular systolic dysfunction (58.8%), multivessel disease (83.8%) and unprotected left main stem disease (52.5%). Ten (12.5%) patients had pre-procedural cardiogenic shock. In-hospital major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality occurred in 21.3% and 18.8% respectively. Post-procedure stroke and bleeding occurred in 2.5% and 13.8% of patients respectively, with one vascular complication (conservatively managed pseudoaneurysm). Median time to first follow-up visit was 105 (64.5; 282.0) days, at which point MACCE occurred in 18.8% of patients. Pre-procedural cardiogenic shock was a significant predictor of in-hospital MACCE (OR 9.0, C.I. 2.1-37.6, p=0.003). Conclusion: When used to support high-risk PCI, Impella has an excellent safety profile. These data support the practice of Impella use in this cohort; however a randomised controlled trial is required to determine the efficacy of Impella against unsupported PCI.

Abstract Background Ischaemic mitral regurgitation (IMR) confers a poor prognosis. Transcatheter intervention may improve survival but benefit is likely to depend on severity of IMR relative to LV remodelling following myocardial infarction (MI). In theory, those with “discordant” IMR (significant regurgitant volume without severe LV dilatation or impairment), are expected to benefit most from mitral intervention. While subcategorization may help to inform treatment, there are no data on post-MI patients in this respect. Purpose To determine the incidence of discordant & concordant IMR categorised on echocardiography post-MI and impact on outcomes. Methods 1000 consecutive patients admitted to our hospital with myocardial infarction who underwent coronary angioplasty were included. Early inpatient TTE was performed by accredited echocardiographers using standard multiparametric quantification. Using TTE parameters, 4 subgroups were identified (figure) according to the degree of MR relative to LV remodelling. Thresholds were based on European guidelines (± 2SD from normal) and median value among survivors for vena contracta (VC): – LVEF: 52% (♂), 54% (♀) – Indexed LV end diastolic volume (LVEDVi): 74ml/m2 (♂), 61ml/m2 (♀) – Effective regurgitant orifice area (EROA) ≥0.2cm2 – Regurgitant volume (RVol) ≥30ml – VC ≥0.5cm Results MR was seen in 294/1000 patients (29.4%) with a severity of mild (76%), moderate (21%) and severe (3%). Concordant and discordant IMR were each seen in 16/294 (5%) of IMR patients post-MI. After a mean follow up of 3.2 years, IMR patients had a 3% rate of heart failure (HF) within 1 year and 19% mortality. Non-survivors had significantly worse IMR (PISA 0.65±0.25cm vs 0.54±0.19cm; p=0.033; VC 0.63±0.25cm vs 0.49±0.18cm; p=0.014), worse LV function (LVEF 44±17% vs 51±13%; p<0.001), larger LV (LVEDVi 67±23ml/m2 vs 60±22ml/m2; p=0.032) and larger indexed LA volume (LAVi) (44±22ml vs 35±15ml; p<0.001). Those with concordant IMR had the worst survival (50%) although almost 1 in 5 of those with discordant MR died within the follow up period (19%). Using multivariable Cox regression, significant predictors of mortality included LVEF (p<0.001; HR 0.96, 0.94–0.98) and LAVi (p<0.001; HR 1.02, 1.01–1.03) but not LVEDVi. Conclusion 1) Significant predictors of mortality in IMR include LA dilatation and decline in LVEF, but not LV dilatation. 2) Although discordant severe IMR is uncommon following MI, mortality if left untreated remains high. Attention should be paid to early selection of this cohort for intervention. Funding Acknowledgement Type of funding source: None

Abstract Background National Institute of Clinical Excellence guideline (NICE, CG95) recommends CTCA as a 1st line diagnostic test for evaluation of ambulatory patients with suspected stable angina based on its high sensitivity and low cost. This has led to increasing demand for CTCA across the National Health Service (NHS) in order to comply with the NICE recommendation. Purpose We studied the utility and effectiveness of CTCA in the evaluation of ambulatory patients with suspected stable angina attending rapid access chest pain clinic (RACPC) in a large tertiary hospital in the UK. Methods The study included consecutive patients attending RACPC over a pre-specified period of 6-months who were suspected of having stable angina and hence, referred for CTCA. The data were collected on demographics, CTCA results including incidental finding and downstream investigations. All patients had a minimum of 12-months follow up for clinical outcomes. Results A total of 170 patients were referred for CTCA (mean age = 56.8 years, male = 53.5%) out of the 388 consecutive patients who were reviewed in the RACPC during the 6-month period. CTCA was non-diagnostic in 48/170 (28.2%) cases (Breathing artefact 35%, Severe Coronary Calcification 31%, Elevated heart rate/Ectopy 30%) while 63/170 (37.1%) of patients had incidental extra-cardiac findings. Amongst patients with incidental findings, 17/63 (27.0%) underwent further investigations. A total of 54/170 (31.7%) of patients were recommended to have downstream cardiac investigations such as a stress test (DSE/MRI/MPS) (23/170, 15.8%) while 31/170 (18.2%) were referred for invasive coronary angiography. Revascularisation procedures (PCI n=7.6%, CABG n=4.7%) were required in 21/170 (12.4%) patients. Based on 2017 NHS tariffs, overall average cost-per-patient with the initial CTCA approach was £122.11 excluding downstream investigations and £548.43 including the cost of downstream cardiac investigations. Incidental Findings after CTCA Conclusions Our study suggests that a CTCA based approach is associated with non-diagnostic information in at least 1:4 patients and incidental extracardiac findings in 1:3 patients. Further downstream cardiac investigations are required in around 1:3 patients after a CTCA carried out for evaluation suspected stable angina. The NICE recommendation is based on the low initial cost of CTCA and high sensitivity, however, taking in to account the additional cost of downstream investigations, the average cost per patient of this approach is significantly (4.5 times) higher. Acknowledgement/Funding None

Background— Permanent pacemaker (PPM) requirement is a recognized complication of transcatheter aortic valve implantation. We assessed the UK incidence of permanent pacing within 30 days of CoreValve implantation and formulated an anatomic and electrophysiological model. Methods and Results— Data from 270 patients at 10 centers in the United Kingdom were examined. Twenty-five patients (8%) had preexisting PPMs; 2 patients had incomplete data. The remaining 243 were 81.3±6.7 years of age; 50.6% were male. QRS duration increased from 105±23 to 135±29 milliseconds ( P <0.01). Left bundle-branch block incidence was 13% at baseline and 61% after the procedure ( P <0.001). Eighty-one patients (33.3%) required a PPM within 30 days. Rates of pacing according to preexisting ECG abnormalities were as follows: right bundle-branch block, 65.2%; left bundle-branch block, 43.75%; normal QRS, 27.6%. Among patients who required PPM implantation, the median time to insertion was 4.0 days (interquartile range, 2.0 to 7.75 days). Multivariable analysis revealed that periprocedural atrioventricular block (odds ratio, 6.29; 95% confidence interval, 3.55 to 11.15), balloon predilatation (odds ratio, 2.68; 95% confidence interval, 2.00 to 3.47), use of the larger (29 mm) CoreValve prosthesis (odds ratio, 2.50; 95% confidence interval, 1.22 to 5.11), interventricular septum diameter (odds ratio, 1.18; 95% confidence interval, 1.10 to 3.06), and prolonged QRS duration (odds ratio, 3.45; 95% confidence interval, 1.61 to 7.40) were independently associated with the need for PPM. Conclusion— One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a PPM within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction. It is known to occur in young women in the peripartum period. The exact aetiology is unknown. This report describes a 46 year old pre-menopausal woman without cardiac risk factors presenting with acute inferior myocardial infarction and SCAD angiographically. She was noted to be at the end of her menstrual cycle. We believe that her SCAD was directly related to the phase of menstrual cycle she was in.

Introduction Endorsed by international guidelines, risk stratification plays a central role in the optimal management of patients with non ST-elevation (NSTE-ACS). High risk patients benefit from an early invasive approach and admission biomarker levels may help to identify this cohort. Atrial natriuretic peptide (ANP) is a recognised prognostic marker in ST elevation myocardial infarction (STEMI) and in heart failure (HF) but has not been evaluated in NSTE-ACS. The precursor of ANP is N-terminal Pro-ANP whose mid regional epitope is more stable when compared to epitopes of N- or C- terminals of pro-ANP used in previous assays. Aims To assess the prognostic value, optimum time for sampling and a cut off value for mid regional proANP in unselected patients9 with non ST elevation ACS (NSTE-ACS). We use GRACE risk score and NTproBNP as benchmark comparators. Method and Results Plasma MRproANP was measured both on admission (taken within 36 h of symptoms) and discharge (3 to 5 days later) in 630 (437 men, median age 70.0±12.8 years) patients with NSTE-ACS. During follow up which ranged from 150 to 1059 days the primary end point of a major adverse cardiac event (MACE) was reached by 170 (27%) patients. This included 84 (13.3%) deaths, 56 (8.9%) readmissions with HF and 68 (10.8%) re-infarctions. Admission and discharge levels were entered into 2 separate multivariate Cox regression models adjusted for important clinical and biochemical factors and Receiver Operator Characteristic (ROC) analyses performed with results shown in Abstract 43 Table 1. Admission levels demonstrated a stronger association with MACE were therefore used for comparison against GRACE score and admission NTproBNP level in a further multivariate Cox model. This showed that MRproANP (HR 5.81 p<0.001) and GRACE score calculated pre-discharge (HR 1.01 p=0.024) continued to be independently associated with the primary end point but not admission NTproBNP (HR 1.00 p=0.99) or GRACE score if calculated on presentation (HR 1.01 p=0.057). The accuracy of MRproANP at prediction of the MACE (AUC 0.76 p<0.001) was not improved by combining with GRACE score (AUC 0.72 p<0.001) both (AUC 0.76 p<0.001). ROC analyses provided the optimum cut off value for MRproANP for prediction of MACE of 165 pmol/L which gave optimum survival stratification on Kaplan–Meier analysis (log rank 90.12 p<0.001). Conclusion MRproANP level is a potent prognostic marker of adverse events. Admission levels offer early identification of high risk NSTE-ACS patients and its role in optimising management requires further investigation.

The GRACE (Global Registry of Acute Coronary Events) risk score has been shown to offer predictive power with regard to death and AMI (acute myocardial infarction) in patients with ACS (acute coronary syndromes). NT-proBNP (N-terminal pro-B-type natriuretic peptide) has also been found to be useful in predicting mortality following ACS. In the present study, we sought to investigate the use of the GRACE score and NT-proBNP levels at predicting risk of early and late deaths following ACS. We studied 1033 patients (740 men, mean age 66.5+/-12.7 years) with AMI. Blood was drawn once within 24 h following the onset of chest pain. The plasma concentration of NT-proBNP was determined using an in-house non-competitive immunoassay. Patients were GRACE risk scored. The 30-day mortality was 3.7% and the 6-month mortality was 7.8%, and all were related to higher GRACE risk scores (P=0.001 for trend). Higher NT-proBNP levels were also related to increased mortality (P<0.0001). In a Cox proportional hazards model, independent predictors of 30-day and 6-month mortality included NT-proBNP levels and the GRACE risk score. The receiver-operating curve for the GRACE risk score was complemented by NT-proBNP levels for prediction of 30-day mortality [AUC (area under the curve), 0.85] and 6-month mortality (AUC, 0.81). NT-proBNP gives complementary information to the GRACE risk score for predicting early and late mortality. The inclusion of the NT-proBNP blood test is useful in risk-stratifying patients after ACS.

Introduction Adrenomedullin is elevated in heart failure (HF) and post-acute coronary syndrome (ACS). Mid-regional pro-adrenomedullin (MRproADM) is more stable and has been shown to have prognostic value after ST elevation ACS. Aims To assess the prognostic value of admission (A) and discharge (D) MRproADM levels in unselected patients with non-ST elevation ACS (NSTE-ACS) for major adverse cardiac events (MACE) including all-cause mortality, readmission with HF or recurrent myocardial infarction (re-MI) both as a primary composite endpoint and separate secondary endpoints and then compare it with the well-established Grace clinical risk score (calculated on discharge) to evaluate its clinical utility as a risk marker. Method and Results Plasma MR-proADM was measured on admission and discharge in 745 (514 men, median age 70.0 ± 12.7 years) consecutive patients with NSTE-ACS. During follow-up (1–2837 days) 120 (16.1%) patients died, 65 (8.7%) were readmitted with HF and 77 (10.3%) had re-MI. A-MRproADM and D-MRproADM levels were entered into two separate multivariate Cox regression models adjusted for important clinical and biochemical factors to compare their predictive power. Receiver operator characteristic (ROC) analyses evaluating areas under the curve (AUC) were also performed, with the results shown in the table. Both were strong predictors of MACE along with age (hazard ratio 1.02, p = 0.019). A-MRproADM appears to be a more powerful predictor of death than D-MRproADM levels; however, D-MRproADM appears to predict readmission with HF more strongly, leading to a similar ability to predict MACE overall. For early mortality up to 30 days, Cox modelling yielded HR 116.88, p Conclusion Both admission and discharge MRproADM levels are strong prognostic markers of adverse events in NSTE-ACS and aid further risk stratification of patients when used in combination with the Grace score. A-MRproADM is a more potent predictor of early events than Grace scoring in this cohort and may represent an important clinical tool.