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Takotsubo syndrome (TS), an increasingly recognized acute cardiac disease entity, is characterized by a unique pattern of circumferential and typically regional left ventricular wall motion abnormality resulting in a conspicuous transient ballooning of the left ventricle during systole. The mechanism of the disease remains elusive. However, the sudden onset of acute myocardial stunning in a systematic pattern extending beyond a coronary artery territory; the history of a preceding emotional or physical stress factor in two thirds of cases; the signs of sympathetic denervation at the regions of left ventricular dysfunction on sympathetic scintigraphy; the finding of myocardial edema and other signs consistent with (catecholamine-induced) myocarditis shown by cardiac magnetic resonance imaging; and the contraction band necrosis on histopathological examination all argue strongly for the involvement of the cardiac sympathetic nervous system in the pathogenesis of TS. In this narrative review, extensive evidence in support of local cardiac sympathetic nerve hyperactivation, disruption and norepinephrine spillover causing TS in predisposed patients is provided.

Objectives To evaluate the efficacy and safety of a double Prostar XL suture-based closure technique compared to a conventional single Prostar XL technique in elective transcatheter aortic valve implantation (TAVI) via the common femoral artery. Background TAVI is recommended as a treatment for symptomatic severe aortic stenosis for those who are at high or prohibitive risk of surgical valve replacement. Vascular complications remain the most frequent category of procedural complication. The most efficacious and safest percutaneous suture-based closure technique is unknown. Methods Prospective observational study of Prostar XL device closures used in 126 consecutive patients between 2012 and 2014. Single Prostar XL closure was used in 63 patients and double Prostar XL closure in a further 63 patients. Outcomes from the groups were compared. All patients were treated transfemorally through an 18Fr sheath. Technical success was defined as hemostasis not requiring interventional or surgical repair during hospital admission. Bleeding and vascular complications were defined using the second consensus of the valvular academic research consortium (VARC-2) criteria. Results The cohort was aged 83+/-6 and 48% were female with a logistic Euroscore of 24+/-11.6. Technical success was 86% and 98% respectively (P = 0.017) with systematic single and double Prostar XL closure. Composite VARC-2 vascular and bleeding complications occurred more frequently in the single Prostar XL group compared to the double Prostar XL group (10 [16%] v 3 [5%] P

Aim Primary percutaneous coronary intervention (PPCI) produces more effective coronary reperfusion and allows immediate risk stratification compared with fibrinolysis. We investigated the safety and feasibility of very early discharge at 2 days following PPCI in selected low-risk cases. Methods This was a prospective observational cohort study of 2779 patients who underwent PPCI between 2004 and 2011. Patients meeting the following criteria were deemed suitable for very early discharge; TIMI III flow, left ventricle (LF) ejection fraction >40%, and rhythmic and haemodynamic stability out to 48 h. Higher-risk patients who did not fulfil these criteria were discharged later according to physician preference. All patients were offered outpatient review by a multidisciplinary team. Endpoints included 30 day readmission rates and major adverse cardiac events (MACE) out to a median of 2.8 years (IQR range: 1.3–4.4 years). Results 1309 (49.3%) PPCI patients met very early discharge criteria, of whom 1117 (85.3%) were actually discharged at 2 days. 620 (23.4%) were discharged at 3 days, and 916 (34.5%) >3 days after admission (median 5, IQR: 4–8) days). Patients discharged at 2 days were younger, and had lower rates of diabetes, renal dysfunction, multivessel coronary artery disease, previous myocardial infarction, and previous coronary artery bypass surgery, compared with patients discharged later. 30-day readmission rates for non-MACE events were 4.8%, 4.9% and 4.6% for patients discharged 2 days, 3 days and >3 days after admission, respectively. MACE rates were lowest in patients discharged at 2 days (9.6%, 95% CI 4.7% to 16.6%) compared with patients discharged at 3 days (12.3% 95% CI 6.0% to 19.2%) and >3 days (28.6% 95% CI 22.9% to 34.7%, p Conclusions Our data suggest that discharge of low-risk patients 2 days after successful PPCI is feasible and safe. Over 40% of all patients with ST-elevation myocardial infarction may be suitable for early discharge with important implications for healthcare costs.

Purpose To estimate and assess the lens doses to the heart team performing transcatheter aortic valve implementation (TAVI) from latest generation of interventional x-ray equipment and to establish correlations between the equivalent lens dose for each profession and the patient dose (dose-area product, DAP). Methods Thermoluminescence dosimeters (TLD) have been used to measure the lens dose without lead glasses, to the medical staff, in a cohort of 24 TAVI procedures. Detailed exam-specific dose-related data from radiation dose structured reports (RDSR) was used to analyze the components contributing to the operator’s eye lens dose. Results The mean annual dose (150 TAVI procedures) to the lens of the eye for the whole heart team (primary operator, secondary operator, anesthesiologist and the nurse) was 4.3 ± 1.5, 1.9 ± 0.68, 3.9 ± 1.4 and 1.1 ± 0.40 mSv. The mean DAP-value per procedure was 27 ± 19 Gycm2. The primary operator is exposed to the highest radiation dose with a conversion coefficient (equivalent dose to the lens/DAP) of 1.1 ± 0.27 μSv/Gycm2 of the left eye lens followed by the anesthesiologist, who was exposed for almost equally high lens doses but in both lenses, and the secondary operator with 0.48 ± 0.12 μSv/Gycm2 of the left eye lens. The nurse is located at a safe distance with the lowest conversion factor for the left eye lens (0.27 ± 0.069 μSv/Gycm2). Conclusions In modern interventional x-ray equipment, the TAVIs will contribute to radiation dose levels below the threshold value for cataract as long as a ceiling mounted shield is used. The information from the RDSR shows that the highest dose contribution to the primary operator’s lens is from the second half of the procedure due to the aortography section consisting of image acquisitions.

Objective To assess the prevalence and long-term prognostic value of a dynamic (rise/fall) pattern of cardiac troponin T (hs-cTnT) elevation during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) compared with a stable hs-cTnT elevation. Methods Prospective cohort study of unselected patients admitted with AECOPD to the emergency room of a university hospital. Serial hs-cTnT measurements were made during admission. Survival after a median of 1.8 years was recorded. Results 83 patients with a mean age of 72 years and a mean forced expiratory volume in 1 s (FEV1) of 0.9 L. The mortality rate was 62%. The median hs-cTnT at admission was 27 ng/L (IQR 13.4–51)). 65 patients (78%) had at least one hs-cTnT measurement ≥14 ng/L, and among these the median change in hs-cTnT was 50.7% (IQR 25.2–89.4). Of the patients with serial hs-cTnT measurements, 53 (82%) had a dynamic pattern (ie, ΔTnT ≥20%). In multivariate analysis, stable hs-cTnT elevation was associated with increasing age (OR per 5 years with 95% CI 1.9 (1.01 to 3.7), p=0.045) and low Hb (OR 7.3 (1.1 to 49), p=0.039). Stable hs-cTnT elevation was associated with increased mortality with an HR of 2.4 (95%CI 1.1 to 5.3, p=0.027) in the multivariate Cox regression analysis. Conclusions Among the patients with at least one hs-cTnT above the 99th centile, 82% had a rise/fall pattern, as requested to make a diagnosis of myocardial infarction. Compared to a dynamic rise/fall pattern of hs-cTnT, a stable and moderately elevated hs-cTnT during AECOPD is associated with poor long-term prognosis.