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More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

The Getting It Right First Time (GIRFT) process is designed to improve the care of patients in the National Health Service (NHS) in England through in-depth review of services, benchmarking and presenting a data-driven evidence base to support change. Although it started as a pilot project targeting unwarranted variation in elective orthopaedic surgery, it rapidly became apparent that the approach of clinically led deep dives to review the activity in individual orthopaedic units was effective in improving standards of care and resulted in substantial cost savings that could be reinvested in the clinical service. GIRFT has now expanded to encompass 40 clinical specialties and is funded nationally by the NHS in England. The purpose of this article is to describe its application and benefit to cardiology.

ObjectivesBullying of trainee doctors has been shown to be associated with detrimental outcomes for both doctors and patients. However, there is limited evidence regarding the level of bullying of trainees within medical specialties.MethodsAn annual survey of UK cardiology trainees was conducted through the British Junior Cardiologists’ Association between 2017 and 2020 and asked questions about experiencing and witnessing bullying, and exposure to inappropriate language/behaviour in cardiology departments. Fisher’s exact tests and univariable logistic regression models were used to describe associations between trainee characteristics, and reports of bullying and inappropriate language/behaviour.ResultsOf 1358 trainees, bullying was reported by 152 (11%). Women had 55% higher odds of reporting being bullied (OR: 1.55 95% CI (1.08 to 2.21)). Non-UK medical school graduates were substantially more likely to be bullied (European Economic Area (EEA) OR: 2.22 (1.31 to 3.76), non-EEA/UK OR: 3.16 (2.13 to 4.68)) compared with those graduating from UK-based medical schools. Women were more likely than men to report sexist language (14% vs 4%, pDiscussionBullying and inappropriate language are commonly experienced by cardiology trainees and disproportionately affect women and those who attended non-UK medical schools. Consultants both in cardiology and other specialties are the most commonly reported perpetrators.

There is a growing expectation that information about the performance of clinical services and individual doctors is made publicly available. Patients have a legitimate interest in knowing the care they receive is of high quality, but there are some potential risks in public reporting of these data, not least that of risk-averse behaviour by clinicians concerned about loss of reputation and livelihood that potentially denies patients appropriate treatment. The development of reliable metrics to assess clinical performance is complex, evolving and often controversial. In the USA, the Society of Thoracic Surgeons and the American College of Cardiology (ACC) have published principles for public reporting of outcomes central to which is the use of high-quality, robust and validated clinical data.1 National registries such as the National Cardiovascular Data Registries (NCDR) in the USA and the National Institute for Cardiovascular Outcomes Research audits in the UK are fundamental to the quality of clinical data used for performance reporting as is the involvement and oversight of the respective professional societies who are best placed to define what good looks like. Approaches to publication differ. In the UK, National Health Service England has published individual consultant outcomes for 11 specialties including interventional cardiology and cardiac surgery.2 In the USA, the ACC and NCDR have launched a voluntary programme of public reporting of performance data by institution.3 Although in its infancy, it is gaining considerable professional and public support. For interventional cardiology and adult cardiac surgery in the UK, there are two levels of negative outlier on the basis of 3-year rolling analysis of national audit data: alert and alarm. An alert means that observed survival is 2 SD below the expected mean and an alarm that survival is 3 SD below the expected mean. Data review and validation is rigorous, but …

To the Editor, We thank Dr San Roman and colleagues for their comment1 on our editorial.2 They suggest that all cases with endocarditis should be referred to a reference centre because the specialist expertise to monitor their progress may not be available at general hospitals. The typical length of intravenous antibiotic therapy for patients with endocarditis is 4–6 weeks, and beds in …

To evaluate the usefulness of velocity ratio (VR) in patients with low gradient severe aortic stenosis (LGSAS) and preserved EF.LGSAS despite preserved EF represents a clinically challenging entity. Reliance on mean pressure gradient (MPG) may underestimate stenosis severity as has been reported in the context of paradoxical low flow, LGSAS. On the other hand, grading of stenosis severity by aortic valve area (AVA) may overrate stenosis severity due to erroneous underestimation of LV outflow tract (LVOT) diameter, small body size or inconsistencies in cut-off values for severe stenosis. We hypothesised that VR may have conceptual advantages over MPG and AVA, predict clinical outcomes and thereby be useful in the management of patients with LGSAS.Patients from the prospective Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study with an AVA1.0 cm(2), MPG≤40 mm Hg and EF≥55% and asymptomatic at baseline were stratified according to VR with a cut-off value of 0.25. Outcomes were evaluated according to aortic valve-related events and cardiovascular death.Of 435 patients with LGSAS, 197 (45%) had VR0.25 suggesting severe and 238 (55%) had VR≥0.25 suggesting non-severe stenosis. Aortic valve-related events (mean follow-up 42±14 months) were more frequent in patients with VR0.25 (57% vs 41%; p0.001) as was cardiovascular death within the first 24 months (p0.05). In multivariable Cox regression analysis, MPG was the strongest independent predictor of aortic valve events (p0.001) followed by VR (p0.02). Adjusting AVA by VR increased predictive accuracy for aortic valve events (area under the receiver operating curve 0.62 (95% CI 0.57 to 0.67) vs 0.56 (95% CI 0.51 to 0.61) for AVA, p=0.02) with net reclassification improvement calculated at 0.36 (95% CI 0.17 to 0.54, p0.001). VR did not improve the prediction of clinical events by MPG.In the difficult setting of LGSAS, VR shows a strong association with valve-related events and-although not outperforming MPG-may be particularly useful in guiding clinical management.NCT00092677.

The clinical care of patients with valve disease is best organised by multidisciplinary specialist valve teams.1 ,2 These supervise inpatient and outpatient care, design protocols and processes and coordinate training and education. However, valve disease may not be detected or, if detected, a referral to a specialist team may not be made. This leads to preventable premature death.3 ,4 A working group was therefore convened by the British Heart Valve Society with representatives of all interested national bodies and a panel of invited international commentators. The overall aim was to produce recommendations to improve the detection, conservative management and interventional treatment of valve disease. This document focuses on the detection of valve disease. This occurs principally, but not exclusively, in the community. In the USA, the estimated prevalence of moderate or severe valve disease is 2.5% using population screening.3 By contrast, it was only 1.8% in a separate population when echocardiography was performed according to clinical indications.3 Although the two populations were different geographically and racially, this difference still points to clinically and statistically significant underdetection of valve disease. Similarly, there is major variation between observed and expected rates of aortic valve replacement in the UK5 which is likely to be as a result of differences in rates of detection and referral by general practitioners. Early detection of asymptomatic moderate or severe disease allows planned surveillance and optimal timing of surgery. By contrast, the EuroHeart survey6 found that approximately 50% of all patients having surgery for valve disease were in NYHA class III or IV which unnecessarily increases morbidity and mortality. Just under a third of patients with heart failure have valve disease7 and heart failure complicated 25% of admissions with aortic valve disease in Scotland between 1997 and 2005.4 …

The population prevalence of moderate or severe valve disease in industrialised countries is as high as 13% in those aged 75 years or older.1 Undetected valve disease leads to premature death1 but valve surgery, when indicated, can prolong life.2 Access to medical care in industrialised countries is usually good, but limitations exist3 and better ways of organising care are needed.4 A working group was therefore convened by the British Heart Valve Society with representatives of all interested national bodies and a panel of invited international commentators. The aim was to produce recommendations to improve the detection, conservative management and interventional treatment of valve disease. This paper focusses on conservative management and proposes recommendations for overcoming limitations in care by means of a specialist valve clinic. The initial management of patients with valve disease is usually conservative and meticulous follow-up is then vital. However, accepted management guidelines are not followed adequately.5–7 Furthermore, the application of accepted guidelines requires specialist experience especially in determining whether a patient is genuinely asymptomatic. Most patients with valve disease are still cared for by general cardiologists or general physicians who may be less skilled than a valve disease specialist in making a diagnostic formulation. Furthermore, it is likely that advances in practice are more slowly assimilated by a generalist than by a cardiologist who undertakes specialist continuing education. As a result, patients are often referred for surgery too late. In the EuroHeart Survey,6 approximately one half of patients were in New York Heart Association class III or IV at the time of valve surgery. At least one third of elderly patients with severe aortic stenosis are not referred for surgery at all even when clinically indicated.8 Developing a percutaneous valve programme leads to increased rates of conventional surgery suggesting …

To assess the impact of introducing a transcatheter aortic valve implantation (TAVI) service on aortic valve surgical activity and outcomes.A retrospective analysis of prospectively collected data.University hospital of south Manchester.815 consecutive patients undergoing isolated aortic valve replacement (AVR) or coronary artery bypass grafting plus AVR from January 2006 to December 2009. Fifty consecutive patients who underwent TAVI from January 2008 to December 2009.Aortic valve surgical activity in the 2years before the introduction of a TAVI service and in the 2years following. Outcomes following conventional aortic valve surgery and TAVI.In the 2years following the introduction of TAVI at this centre, conventional AVR activity has increased by 37% compared with an 8% increase nationally (p0.001). Compared with the 2years before TAVI there was no change in the mean logistic EuroSCORE (7.4 vs 7.9 p=0.16) or crude mortality rate (2.9% vs 2.1% p=0.48). Fifty high-risk patients underwent TAVI with a 30-day mortality rate of 0%. The mean logistic EuroSCORE of the TAVI patients was 25.3.TAVI is an emerging alternative to AVR in high-risk patients. Since the introduction of a TAVI service at this centre, conventional AVR activity has increased. Despite a trend of increasing mean logistic EuroSCORE indicating that more complex cases are being undertaken, there has been a non-significant reduction in the crude mortality rate. Offering a TAVI service has a positive impact on the volume of conventional AVR surgical activity.

Objectives—To compare aortic valve replacement (AVR) using a minimally invasive approach through a transverse sternotomy with the established approach of median sternotomy. Design—Retrospective, case-control study. Patients—Fourteen high risk patients (median age 78, Parsonnet score of 18%) who underwent AVR performed through a minimally invasive transverse sternotomy were compared with a historical group of patients matched for age, sex, and Parsonnet score who underwent AVR performed through a median sternotomy by the same surgeon. Outcome measures—Cross clamp time, total bypass time, intensive care stay, postoperative in-hospital stay, morbidity, and mortality. Results—There were two deaths in the minimally invasive group and none in the control group (NS). The cross clamp and total bypass times were longer in the minimally invasive group (67 and 92 minutes v 46 and 66 minutes, p