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Background Published data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear. Objectives The purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre–COVID-19 cohorts. Methods From March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re–myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre–COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019). Results In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p, Central Illustration

Plaque rupture leads to a cascade of events culminating in collagen disruption, tissue factor release, platelet activation and thrombus formation. Pro-inflammatory conditions, hyperglycemia and smoking predispose to high thrombus burden (HTB) which is an independent predictor of slow or no-reflow. In patients with acute myocardial infarction (AMI), glycoprotein IIb/IIIa inhibitors (GPI) reduce thrombus burden and improve myocardial perfusion. These agents are typically administered systemically via the intravenous route or locally via an intracoronary (IC) route. However, as higher local concentrations of GPI are associated with enhanced platelet inhibition, intralesional (IL) GPI administration may be particularly effective in cases of HTB. Modest-sized randomized trials comparing IL and IC GPI delivery have reported conflicting outcomes. Some trials have demonstrated improved coronary flow and myocardial perfusion with reduced major adverse cardiac events with IL compared with IC GPI administration, whereas others have shown no significant benefits. Furthermore, although no direct comparison has been made between IL delivery using an aspiration catheter, microcatheter or a dedicated balloon-based "weeping" infusion-catheter, improved outcomes have been most consistent following GPI administration at the site of the lesion and thrombus with the dedicated infusion catheter. This review provides an update on the role and outcomes of IL GPI administration in patients with AMI and HTB. Based on the evidence we offer an algorithm demonstrating when to consider IL administration in patients with AMI undergoing intervention. We conclude with a perspective on the management of patients with STEMI and COVID-19 in whom a prothrombotic state often results in HTB.

Severe Acute Respiratory Syndrome coronavirus-2 has rapidly spread and emerged as a pandemic. Although evidence on its pathophysiology is growing, there are still issues that should be taken into consideration, including its effects on pre-existing peripheral vascular disease. The aim of this review is to describe the thrombotic and endothelial dysfunctions caused by SARS-CoV-2, assess if cardiovascular comorbidities render an individual susceptible to the infection and determine the course of pre-existing vascular diseases in infected individuals. A search through MEDLINE, PubMed and EMBASE was conducted and more than 260 articles were identified and 97 of them were reviewed; the rest were excluded because they were not related to the aim of this study. Hypertension, cardiovascular disease, diabetes mellitus and cerebrovascular diseases comprised 24.30% ± 16.23%, 13.29% ± 12.88%, 14.82% ± 7.57% and 10.82% ± 11.64% of the cohorts reviewed, respectively. Arterial and venous thrombotic complications rocketed up to 31% in severely infected individuals in some studies. We suggest that hypertension, cardiovascular diseases, diabetes and cerebrovascular diseases may render an individual susceptible to severe COVID-19 infection. Pre-existing vascular diseases are expected to deteriorate with SARS-CoV-2 infection as a consequence of its increased thrombotic burden and the development of endothelial dysfunction. COVID-19 has emerged only a few months ago and it is premature to predict the long-term effects to the vascular system. Its disturbances of the coagulation mechanisms and effects on vascular endothelium will likely provoke a surge of vascular complications in the coming months.

Objectives: To describe outcomes following percutaneous coronary intervention (PCI) in patients who would usually have undergone coronary artery bypass grafting (CABG). Background: In the United Kingdom, cardiac surgery for coronary artery disease (CAD) was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with “surgical disease” instead underwent PCI. Methods: Between 1 March 2020 and 31 July 2020, 215 patients with recognized “surgical” CAD who underwent PCI were enrolled in the prospective UK-ReVasc Registry (ReVR). 30-day major cardiovascular event outcomes were collected. Findings in ReVR patients were directly compared to reference PCI and isolated CABG pre-COVID-19 data from British Cardiovascular Intervention Society (BCIS) and National Cardiac Audit Programme (NCAP) databases. Results: ReVR patients had higher incidence of diabetes (34.4% vs 26.4%, P =.008), multi-vessel disease with left main stem disease (51.4% vs 3.0%, P

Disordered coagulation, endothelial dysfunction, dehydration and immobility contribute to a substantially elevated risk of deep venous thrombosis, pulmonary embolism (PE) and systemic thrombosis in coronavirus disease 2019 (Covid-19). We evaluated the prevalence of pulmonary thrombosis and reported RV (right ventricular) dilatation/dysfunction associated with Covid-19 in a tertiary referral Covid-19 centre. Of 370 patients, positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 39 patients (mean age 62.3 ± 15 years, 56% male) underwent computed tomography pulmonary angiography (CTPA), due to increasing oxygen requirements or refractory hypoxia, not improving on oxygen, very elevated D-dimer or tachycardia disproportionate to clinical condition. Thrombosis in the pulmonary vasculature was found in 18 (46.2%) patients. However, pulmonary thrombosis did not predict survival (46.2% survivors vs 41.7% non-survivors, p = 0.796), but RV dilatation was less frequent among survivors (11.5% survivors vs 58.3% non-survivors, p = 0.002). Over the following month, we observed four Covid-19 patients, who were admitted with high and intermediate-high risk PE, and we treated them with UACTD (ultrasound-assisted catheter-directed thrombolysis), and four further patients, who were admitted with PE up to 4 weeks after recovery from Covid-19. Finally, we observed a case of RV dysfunction and pre-capillary pulmonary hypertension, associated with Covid-19 extensive lung disease. We demonstrated that pulmonary thrombosis is common in association with Covid-19. Also, the thrombotic risk in the pulmonary vasculature is present before and during hospital admission, and continues at least up to four weeks after discharge, and we present UACTD for high and intermediate-high risk PE management in Covid-19 patients.

Robotic percutaneous coronary intervention (R-PCI) is a novel approach to performing percutaneous coronary intervention (PCI) whereby the operator can utilise remotely controlled technology to manipulate guidewires and catheter devices. This enables the procedure to be undertaken from within a radiation-shielded cockpit. Success in early trials has led to the release of commercially available robotic platforms which have now received regulatory approval and are available for use in clinical practice. Recent trials evaluating R-PCI have demonstrated high technical success rates with low complication rates. Despite this, a significant number of cases, particularly those with complex anatomy, still require at least partial conversion to a manual procedure. Advantages of R-PCI include accurate stent placement, reduced operator radiation exposure and a presumed reduction in orthopedic injuries. Limitations include current incompatibility with certain intravascular imaging catheters and the inability to manipulate multiple guidewires and stents simultaneously. Patients presenting with ST-elevation myocardial infarction requiring primary-PCI have also largely been excluded from existing R-PCI studies. Given these caveats, R-PCI remains a novel technology and has yet to become commonplace in cardiac catheterisation laboratories, however with increasing safety and feasibility data emerging, it is possible that R-PCI may form part of standard practice in the future.

Introduction: The COVID-19 pandemic has restricted availability of ICU resources. Symptomatic patients with coronary artery disease (CAD) normally considered surgical candidates have therefore required alternative revascularization with percutaneous coronary intervention (PCI). The UK-REVASC registry describes the demographics and in-hospital clinical outcomes of this novel patient cohort. Methods: From 1 st March to 31 st May 2020, anonymised data of 171 patients from 38 UK centres were enrolled in a prospective, observational registry. All were on surgical waiting lists or considered for surgery. Results: The demographics, procedural characteristics and outcomes are shown in Tables 1-3. A comparison with routine PCI British Cardiovascular Intervention Society (BCIS) data and UK isolated coronary bypass surgical data are listed, where available and appropriate. The median age was 68 (IQR 60-76) years. There was significantly more previous MI, PCI and CABG in the routine PCI database than in ReVasc Registry patients, perhaps suggesting a more acute presentation with accelerated symptoms in the test group. These were however complex patients with a mean SYNTAX Score (SS) of 27.8 (range 9-65) and >20x the number of LMS plus multi-vessel disease compared to the routine PCI group, which is reflected in a high use of adjunctive imaging. Radial access was very high at 94.1%. PCI success was 97.0%. Complete revascularization was achieved in 52% with the mean residual SS 1.42 (0-20) in these. There were 2 deaths, however the mortality rate was comparable with published surgical data. Furthermore, a 50% reduction in in-patient stay was observed. Conclusion: In this multi-centre UK registry, in-hospital outcomes following PCI for patients with complex coronary disease, who would typically be treated with CABG, compared well with the surgical data. This suggests that the role of PCI could be extended. Future longer term follow-up however is required and planned.

ObjectivesTo understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19.MethodsWe systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomesResultsThere was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62–118) min in 2020 vs 75 (57–95) min in 2019, pConclusionThese findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

AimsLate stent thrombosis and delayed vessel wall healing remain an important issue in coronary vessels treated with drug-eluting stents (DES), especially when long-vessel segments need to be covered, like in chronic total occlusions (CTO). Avoiding polymer use to avoid chronic inflammatory responses is a potential solution to reduce target vessel failure (TVF). We aimed to validate the clinical safety and efficacy at 1 year of the polymer-free Cre8 DES vs. nonpolymer-free DES for the percutaneous treatment of CTO.MethodsBetween September 2011 and August 2016, patients were prospectively enrolled in three CTO centres. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), including cardiac death, any myocardial infarction, stent thrombosis, TVF and target vessel revascularization.ResultsA total of 102 Cre8 and 133 non-Cre8 patients were enrolled. At 1 year, a low cumulative MACCE was observed in the Cre8 group (6.9%, respectively). Moreover, a numerical trend towards better MACCE was observed in the Cre8 group vs. the non-Cre8 group (6.9 vs. 14.3%; P=0.065). The clinically driven TVF rate was not statistically different between Cre8 and non-Cre8 patients (6.9 vs. 9.8%; P=0.373). A borderline significant difference regarding mortality was observed in favour of Cre8 patients (0 vs. 3.8%; P=0.049).ConclusionLow rates of MACCE and TVF up to 1 year were observed in the Cre8 group, supportive of the use of polymer-free DES for lesions with high complexity.

Percutaneous coronary intervention relieves symptoms in patients with chronic ischemic heart disease resistant to optimal medical therapy and alters the natural history of acute coronary syndromes. However, adverse procedural outcomes may occur during the intervention. Knowledge of possible complications and their timely management are essential for the practicing cardiologist and can be life-saving for the patient. In this review, the authors summarize potential complications of percutaneous coronary intervention focusing on their practical management.

Objective To investigate the effect of left atrial appendage (LAA) occlusion device positioning upon periprocedural and long-term outcomes. Background The Amulet device is designed to cover the ostium of the LAA. Prolapse of the device into the neck of the LAA is not uncommon resulting in incomplete coverage of the ostium. The clinical consequences of this remain uncertain. Methods Outcomes of 87 patients with successful LAA closure were analyzed according to Amulet disc position: group A (n = 45) had complete LAA ostium coverage; group B (n = 42) had incomplete ostium coverage because of disc prolapse. Periprocedural major adverse events (MAE) (composite of all cause death, tamponade, device/air embolization, cerebrovascular events, myocardial infarction, and major bleeding not related to vascular access complications) and total device-related periprocedural adverse events (defined as MAE and pericardial effusion) were evaluated. All patients were followed up longitudinally with long-term events defined as a composite of: cardiovascular death, cerebrovascular events, systemic embolization, and major bleeding requiring transfusion or intervention. Results Median follow-up was 234 days (IQR 150-436 days). There was a trend toward more periprocedural MAE in group B (P = 0.07) with deep implantation of the Amulet device associated with significantly more periprocedural adverse events (P = 0.03). There were no differences in reposition attempts (P = 0.9) or long-term events (P = 0.57). Conclusions Our data suggest that suboptimal device positioning may be associated with worse periprocedural outcomes but no difference in long-term clinical outcomes. The results of this relatively small cohort does not seem to be affected by repositioning attempts during the index procedure.

We aimed to evaluate the impact of incomplete revascularization (ICR) on long-term outcomes of patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Consecutive patients undergoing CTO PCI at 4 centers were included. Baseline SYNTAX score (bSS: low [≤ 22], intermediate [22 and33], high [≥33]), residual SYNTAX score (rSS: 0,0 and ≤8,8), and SYNTAX revascularization index (SRI: 100 × (bSS-rSS)/bSS: 100%, 50% to 99%,50%) were calculated. The primary end point was major adverse cardiac events (MACEs; cardiac death, any myocardial infarction, any revascularization) on follow-up. Multivariable Cox regression analysis was conducted to identify predictors of MACEs. Overall, 686 patients were included (low bSS: n = 437; intermediate bSS: n = 187; high bSS: n = 62). Occlusion complexity, crossing strategies, and procedural success rates were similar across groups. The degree of ICR increased with higher bSS categories (rSS was 2.5 ± 4.7 in low vs 6.2 ± 9.3 in intermediate vs 9.1 ± 12.2 in high bSS, p0.001). The SRI followed a similar pattern. Median follow-up was 781 (369 to 1,217) days. Three-year MACE rates increased with higher bSS and rSS, and decreasing SRI categories (bSS: low 19.4% vs intermediate 25.9% vs high 33.3%, p = 0.02), which was driven by a higher incidence of repeat revascularization. Compared with an rSS = 0, both an rSS0 and ≤8 (hazard ratio 2.06, p = 0.004) and an rSS8 (hazard ratio 3.19, p0.001) were independent predictors of MACEs. Similar findings were observed when the SRI was entered in a separate model. In conclusion, even a mild degree of ICR is associated with a higher incidence of MACEs on long-term follow-up after CTO PCI.

A 55-year-old male underwent percutaneous coronary intervention (PCI) for left anterior descending artery chronic total occlusion. After lesion preparation with non-compliant (NC) balloon, two bioresorbable vascular scaffolds (2.5/28 mm, 3.0/28 mm, Absorb BVS, Abbott Vascular, Santa Clara, CA, USA) were implanted followed by 1:1 sized NC balloon post-dilatation at 20 atm. Final intravascular ultrasound (IVUS) showed acceptable BVS expansion in diffusely calcified lesions. Twenty-one months’ follow-up coronary angiography revealed severe restenosis with reocclusion at the distal edge of the distal BVS. After recanalization with a 1.0 mm balloon, optical coherence tomography (OCT) was performed. Quantitative analysis comparing OCT and IVUS at the index procedure demonstrated that minimum scaffold area at follow-up became significantly smaller and with higher eccentricity, suggesting severe recoil at the lesions with thick calcium spot, whereas these changes were not observed at the lesion with relatively thin calcification. The lesions were successfully revascularized with drug-eluting stents and final OCT showed symmetric expansion of metallic stents. Our case demonstrates that different types of calcification can have an impact on BVS expansion and recoil. In calcified lesions, an optimal implantation technique is mandatory to achieve the best possible results, and characterization of calcified lesions with intravascular imaging may be helpful to decide PCI strategy with BVS.

Chronic total occlusions (CTO) percutaneous coronary intervention (PCI) is associated with high radiation dose. Our study aim was to evaluate the impact of the implementation of a noise reduction technology (NRT) on patient radiation dose during CTO PCI. A total of 187 CTO PCIs performed between February 2016 and May 2017 were analyzed according to the angiographic systems utilized: Standard (n = 60) versus NRT (n = 127). Propensity score matching (PSM) was performed to control for differences in baseline characteristics. Primary endpoints were Cumulative Air Kerma at Interventional Reference Point (AK at IRP), which correlates with patient’s tissue reactions; and Kerma Area Product (KAP), a surrogate measure of patient’s risk of stochastic radiation effects. An Efficiency Index (defined as fluoroscopy time/AK at IRP) was calculated for each procedure. Image quality was evaluated using a 5-grade Likert-like scale. After PSM, n = 55 pairs were identified. Baseline and angiographic characteristics were well matched between groups. Compared to the Standard system, NRT was associated with lower AK at IRP [2.38 (1.80–3.66) vs. 3.24 (2.04–5.09) Gy, p = 0.035], a trend towards reduction for KAP [161 (93–244) vs. 203 (136–363) Gycm2, p = 0.069], and a better Efficiency Index [16.75 (12.73–26.27) vs. 13.58 (9.92–17.63) min/Gy, p = 0.003]. Image quality was similar between the two groups (4.39 ± 0.53 Standard vs. 4.34 ± 0.47 NRT, p = 0.571). In conclusion, compared with a Standard system, the use of NRT in CTO PCI is associated with lower patient radiation dose and similar image quality.

We aimed to investigate the procedural and long-term outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients who had undergone previous coronary artery bypass grafting (CABG) vs those who had not, and to evaluate the role of the Registry of CrossBoss and Hybrid procedures in France, the Netherlands, Belgium, and United Kingdom (RECHARGE) score in predicting acute and long-term outcomes.We compiled a multicentre registry of consecutive patients undergoing CTO PCI at 7 centres between January 2009 and April 2017. The primary end point was target-vessel failure (TVF), a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization on follow-up.Overall, 2058 patients were included (patients who underwent CABG, n = 401; CABG-naïve patients, n = 1657). Patients who had undergone CABG were older and had a higher prevalence of comorbidities and higher occlusion complexity (RECHARGE score, 3.6 ± 1.3 vs 1.8 ± 1.2; P0.001). Antegrade dissection/re-entry techniques and the retrograde approach were used more frequently in patients who had undergone CABG. Procedural metrics were worse, and technical (82% vs 88%; P = 0.001) and procedural (81% vs 87%; P = 0.001) success was lower in patients who had undergone CABG. They also experienced a higher rate of major complications (3.7% vs 1.5%; P = 0.004). The RECHARGE score was inversely associated with technical success (P0.001). Median follow-up was 377 days (interquartile range, 277-766 days). The 24-month TVF rate was higher in patients who had undergone CABG than in CABG-naïve patients (16.1% vs 9.0%; P0.001). On multivariable analysis, the RECHARGE score (hazard ratio, 1.61; P0.001) remained an independent predictor of TVF, together with longer total stent length and not using a drug-eluting stent.Compared with CABG-naïve patients, CTO PCI in patients who had undergone CABG shows higher procedural complexity, worse success rates, and higher adjusted risk of TVF on follow-up.

Extreme angulation of coronary artery takeoff represents a challenge for wiring and device advancement in percutaneous coronary intervention (PCI). This anatomic feature is particularly adverse in cases of chronic total occlusion (CTO) of the ostial-proximal segment of the target vessel. In this setting, the retrograde approach can help getting access to the occlusion. However, difficulties might arise at the critical step of wire externalization, due to the need to overcome the extreme ostial angle. Here, we describe a case of successful CTO PCI of the proximal circumflex artery, which presented an extreme angle at its takeoff. Due to inability to perform antegrade wiring of the occlusion, the retrograde approach was undertaken via epicardial collaterals from the right coronary artery. Since conventional attempts at re-entering the antegrade guiding catheter failed due to the aforementioned extreme angle, the retrograde wire was snared in the mid left anterior descending artery, and externalization was performed. This case demonstrates the usefulness of coronary snares in the CTO operator's toolkit and shows how such devices can be used to safely and successfully complete challenging retrograde procedures.

Background: The coronavirus disease-2019 pandemic has restricted availability of intensive care unit resources Symptomatic patients with coronary artery disease considered surgical candidates have therefore needed revascularization with percutaneous coronary intervention (PCI) We describe demographics/in-hospital clinical outcomes of this novel cohort Methods: From March 1, 2020, to May 31, 2020, anonymized data of 171 patients in 38 U K centers were enrolled in a prospective registry All were considered surgical candidates Results: Tables 1-3 show demographics, procedural characteristics, and outcomes A comparison with routine PCI (British Cardiovascular Intervention Society data) and U K coronary bypass surgical data are listed if available and appropriate There was significantly more prior myocardial infarction, PCI, and coronary artery bypass graft in the routine PCI database than in ReVasc Registry patients, suggesting more acute presentation in latter group However, these were complex patients — mean SYNTAX score of 27 8 (range 9 to 65);and >20 times the number of LMS plus multivessel disease compared to the routine PCI group, with high use of adjunctive imaging Radial use was high at 94 1% PCI success was 97 0% Complete revascularization was 52% and residual SYNTAX score 1 42 (0 to 20) The 2 deaths were acute, and mortality rate comparable to published surgical data A 50% reduction in in-patient stay was observed [Formula presented] Conclusion: In this multicenter U K registry, in-hospital outcomes with PCI for patients with complex coronary disease, normally treated with coronary artery bypass graft, compared well with surgical data suggesting the role of PCI could be extended Future long-term follow-up is planned Categories: CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP)

Introduction NHS England announced a new nurse angiographer role with the purpose of reducing hospital waiting lists for elective angiography. Methods Development of a standardised operating procedure for training in Radial Arterial Access (RAA), guidance on how to minimise the risk and recognise complications and post procedural limb management. Obtaining approval at the new procedures committee. Training program 50 consultant supervised nurse led procedures for (RAA), establishing expertise in 100 further procedures, followed by roll out of the program to other nursing staff. Results During training (RAA) cannulation was successful on 1st attempt in 42 out of 50 (success rate allowing for two attempts 84%), with no complications recorded. Successful access by a more experienced operator N = 7, failed (RAA) N = 1. The following 100 were performed independently on unselected patients (success rate 81%; (1st pass 70)), with no complications, need for alternate access routes, N = 1. The following table details the success rate and patient comfort score recorded during 104 procedures performed by a nurse specialist and trainee registrars. Conclusion Nurse-led (RAA) is safe and feasible and has the potential to improve catheter laboratory efficiency, patient satisfaction, standardise procedure training and improve staff retention. Our next steps will be to train more nurses in radial access and progress to nurse led angiography. Conflict of Interest None

A 70-year-old man underwent percutaneous coronary intervention for proximal right coronary artery (RCA) chronic total occlusion with implantation of 3 bioresorbable vascular scaffolds (Absorb, Abbott Vascular, Santa Clara, California) to the distal to proximal RCA and a 4.0/18-mm Ultimaster (Terumo

Background: Coronavirus disease-2019 (COVID-19) poses a risk for health care workers necessitating modifications to existing medical pathways In particular, managing patients with suspected COVID-19 represents a risk to the delivery of a primary percutaneous coronary intervention (PPCI) pathway where time-dependent revascularization is key Methods: We sought to evaluate the effect of the COVID-19 pandemic on an established ambulance-triggered PPCI program involving 2 high-volume heart attack centers in London, United Kingdom A systematic analysis was performed in patients with ST-segment elevation myocardial infarction undergoing PPCI comparing the COVID-19 pandemic period March 1, 2020, to April 30, 2020, with a control group from the previous year Results: During the study period, admissions through the PPCI pathway decreased by 34% The time from symptoms onset to first call for help (2020: 11 min vs 2019: 12 min;p = 0 90) and from symptom onset to arrival at PPCI center (2020: 183 min vs 2019: 178 min;p = 0 99) were comparable;however, the time from arrival at PPCI center to revascularization decreased (2020: 44 min vs 2019: 53 min;p = 0 0004) In-hospital mortality during the study period was significantly lower (5% vs 15%;p = 0 04) COVID-19–positive patients (n = 8) had higher rates of cardiogenic shock (25%), intensive care unit admission (50%), and inpatient mortality (38%) [Formula presented] Conclusion: Our data show that the modifications to the existing PPCI pathway were not associated with treatment delay or adverse outcome The reduction in ST-segment elevation myocardial infarction presentations raises concern that patients may not be seeking appropriate medical attention for chest pain Importantly, we demonstrate that PPCI can be delivered safely and efficiently during the COVID-19 pandemic Categories: OTHER: COVID-19

Coronary angiography is routinely used to assess the extent and severity of coronary artery disease and for decision-making during percutaneous coronary interventions (PCI). However, it is sometimes inadequate for deciding a strategy and defining optimal stenting outcomes. In this review, we present a comprehensive and practical approach to PCI using intravascular ultrasound or optical coherence tomography to optimize stent deployment and assess procedural complications after stent implantation.

Objectives To evaluate the impact of incomplete revascularisation (ICR) on long-term outcomes following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background ICR is associated with worse post-PCI outcomes. Methods We included consecutive patients undergoing CTO PCI at 4 centres (07/2011 to 01/2017). Baseline SYNTAX score (bSS: low [≤22], intermediate [23–32], high [≥33]), residual SYNTAX score (rSS: 0–4, 4.5–8,>8), and SYNTAX Revascularisation Index (SRI: 100×(bSS-rSS)/bSS: 100%, 50%–99%, Results We included 686 patients (low bSS: n=437; intermediate bSS: n=187; high bSS: n=62). Mean bSS was 14.0±4.7 vs 26.0±2.6 vs 39.7±6.0 (p 8 (HR 3.00, 95% CI: 1.85 to 4.86, p Conclusions Even a mild degree of ICR is associated with worse long-term outcomes following CTO PCI.

Objectives The aim of this study was to assess adenosine infusion via a cannula in the back of the hand compared with central venous access to achieve peak hyperemia during fractional flow reserve (FFR). Background Adenosine is often used to induce maximal hyperemia when measuring FFR. The gold standard is continuous infusion via a large central vein; however, the increasing use of the transradial route for angiography makes it desirable to have an alternative route for adenosine. Peripheral venous access is frequently obtained in the hand, but concern exists as to whether adenosine delivery from this site can achieve adequate vasodilation for accurate FFR measurement. Our aim was to address this. Methods Subjects were selected from patients presenting for coronary angiography/intervention who required a pressure-wire study. Subjects received intravenous adenosine infusion sequentially via 2 routes: first, via a 20-gauge hand cannula, and then, after a washout period, via a 5- or 6-F femoral venous sheath. Adenosine was administered at 140 μg/kg/min from each site. Data interpretation was blinded. Minimal FFR achieved with intravenous adenosine from each infusion site was recorded as was the time to peak hyperemia. Results Paired (hand and femoral adenosine) recordings taken from 84 vessels in 61 patients were suitable for blinded analysis. The mean FFR measured using adenosine administered via hand and femoral routes was 0.85 with an SD of 0.08 (intraclass correlation = 0.986). Time to peak hyperemia was longer on average with hand-administered adenosine compared with femoral adenosine administration (63 s vs. 43 s; mean difference, 22 s with a 95% confidence interval: 18 s to 27 s; p Conclusions Hand vein adenosine infusion produced FFR values very similar to those obtained using central femoral vein adenosine administration, with no systematic bias toward higher or lower reading from 1 site. This has important practical implications for radial access cases involving pressure-wire studies.

Human Immunodeficiency Virus (HIV) infection affects 36.7 million people worldwide, it accounted for 1.1 million deaths in 2015. The advent of combined antiretroviral therapy (cART) has been associated with a decrease in HIV-related morbidity and mortality. However, there are increasing concerns about long-lasting effects of chronic inflammation and immune activation, leading to premature aging and HIV-related mortality. Cardiovascular diseases, especially coronary artery disease, are among the leading causes of death in HIV-infected patients, accounting for up to 15% of total deaths in high income countries. Furthermore, as cART availability expands to low-income countries, the burden of cardiovascular related mortality is likely to rise. Hence, over the next decade HIV-associated cardiovascular disease burden is expected to increase globally. In this review, we summarize our understanding of the pathogenesis and risk factors associated with HIV infection and cardiovascular disease, in particular coronary artery disease. (c) 2018 Elsevier B.V. All rights reserved.

Stent loss during percutaneous coronary intervention (PCI) is a rare event, which however has been associated with devastating consequences. Adequate management of this complication requires an exact understanding of the location of the lost stent and underlying mechanisms. Our case reports on a 55-year-old man who underwent PCI to a chronic total occlusion of the left anterior descending artery, complicated by stent loss. Successful management involved crushing and trapping of the stent behind a newly implanted stent. The use of optical coherence tomography proved invaluable, clarifying the relationship of the lost stent with side branches, allowing choosing a larger balloon for stent crushing, and suggesting a possible cause for stent loss. Finally, we provide a review on recent literature on stent loss during PCI and offer an algorithm to guide its management.

Contrast-induced acute kidney injury (CI-AKI) is the acute impairment of renal function further to the intravascular administration of iodinated contrast media, and occurs most frequently after coronary angiography, percutaneous coronary intervention, and contrast-enhanced computed tomography. CI-AKI has been associated with the development of acute renal failure, worsening of chronic kidney disease, requirement for dialysis, prolonged hospital stay, and higher mortality rates and health care costs. Recently, a number of studies suggested that contrast media exposure might not be the causative agent in the occurrence of acute kidney injury, particularly in stable patients who receive small to moderate amounts of contrast media. However, those who undergo coronary angiography and intervention are indeed subject to an increased hazard of CI-AKI, in view of a more significant contrast media exposure as well as the presence of concomitant risk factors. Solid randomized clinical trials are therefore required to identify preventative strategies to reduce the risk of CI-AKI and its complications in these patients.

Objectives Remote ischaemic preconditioning (RIPC), using brief cycles of limb ischaemia/reperfusion, is a non-invasive, low-cost intervention that may reduce perioperative myocardial injury (PMI) in patients undergoing cardiac surgery. We investigated whether RIPC can also improve short-term clinical outcomes. Methods One hundred and eighty patients undergoing elective coronary artery bypass graft (CABG) surgery and/or valve surgery were randomised to receive either RIPC (2–5 min cycles of simultaneous upper arm and thigh cuff inflation/deflation; N=90) or control (uninflated cuffs placed on the upper arm and thigh; N=90). The study primary end point was PMI, measured by 72 h area under the curve (AUC) serum high-sensitive troponin-T (hsTnT); secondary end point included short-term clinical outcomes. Results RIPC reduced PMI magnitude by 26% (−9.303 difference (CI −15.618 to −2.987) 72 h hsTnT-AUC; p=0.003) compared with control. There was also evidence that RIPC reduced the incidence of postoperative atrial fibrillation by 54% (11% RIPC vs 24% control; p=0.031) and decreased the incidence of acute kidney injury by 48% (10.0% RIPC vs 21.0% control; p=0.063), and intensive care unit stay by 1 day (2.0 days RIPC (CI 1.0 to 4.0) vs 3.0 days control (CI 2.0 to 4.5); p=0.043). In a post hoc analysis, we found that control patients administered intravenous glyceryl trinitrate (GTN) intraoperatively sustained 39% less PMI compared with those not receiving GTN, and RIPC did not appear to reduce PMI in patients given GTN. Conclusions RIPC reduced the extent of PMI in patients undergoing CABG and/or valve surgery. RIPC may also have beneficial effects on short-term clinical outcomes, although this will need to be confirmed in future studies. Trial registration number ClinicalTrials.gov ID: NCT00397163.

Atrial fibrillation (AF) is the commonest cardiac arrhythmia both in the general population and in the intensive care unit (ICU) setting. Its incidence continues to rise, affecting up to 10% of patients admitted to a general ICU and up to 50% of those admitted to a cardiac ICU. Uncontrolled AF has detrimental effects on the cardiovascular system, including heart failure, thromboembolic events, reduced quality of life and prolonged hospital stay. This article reviews the risk factors for developing AF, possible underlying mechanisms, clinical features and diagnosis, and focuses particularly on its management according to the latest guidelines with a specific focus on the ICU patient. We also discuss novel anticoagulants that will revolutionise the management of antithrombotic therapy in AF patients by replacing warfarin.

BackgroundNovel cardioprotective strategies are required to improve clinical outcomes in higher-risk patients undergoing coronary artery bypass graft (CABG) with or without valve surgery. Remote ischaemic preconditioning (RIPC) in which brief episodes of non-lethal ischaemia and reperfusion are applied to the arm or leg has been demonstrated to reduce perioperative myocardial injury (PMI) following CABG with or without valve surgery.ObjectiveTo investigate whether or not RIPC can improve clinical outcomes in this setting in the Effect of Remote Ischaemic preconditioning on Clinical outcomes in patients undergoing Coronary Artery bypass graft surgery (ERICCA) study in patients undergoing CABG surgery.DesignMulticentre, double-blind, randomised sham controlled trial.SettingThe study was conducted across 30 cardiothoracic centres in the UK between March 2010 and March 2015.ParticipantsEligible patients were higher-risk adult patients (aged > 18 years of age; additive European System for Cardiac Operative Risk of ≥ 5) undergoing on-pump CABG with or without valve surgery with blood cardioplegia.InterventionsPatients were randomised to receive either RIPC (four 5-minute inflations/deflations of a standard blood pressure cuff placed on the upper arm) or the sham control procedure (simulated RIPC protocol) following anaesthetic induction and prior to surgical incision. Anaesthetic management and perioperative care were not standardised.Main outcome measuresThe combined primary end point was the rate of major adverse cardiac and cerebral events comprising cardiovascular death, myocardial infarction, coronary revascularisation and stroke within 12 months of randomisation. Secondary end points included perioperative myocardial and acute kidney injury (AKI), intensive care unit and hospital stay, inotrope score, left ventricular ejection fraction, changes in quality of life and exercise tolerance.ResultsIn total, 1612 patients (sham control group,n = 811; RIPC group,n = 801) were randomised in 30 cardiac surgery centres in the UK. There was no difference in the primary end point at 12 months between the RIPC group and the sham control group (26.5% vs. 27.7%; hazard ratio 0.95, 95% confidence interval 0.79 to 1.15;p = 0.58). Furthermore, there was no evidence for any differences in either adverse events or the secondary end points of PMI (72-hour area under the curve for serum high-sensitivity troponin T), inotrope score, AKI, intensive therapy unit and hospital stay, 6-minute walk test and quality of life.ConclusionsIn patients undergoing elective on-pump CABG with or without valve surgery, without standardisation of the anaesthetic regimen, RIPC using transient arm ischaemia–reperfusion did not improve clinical outcomes. It is important that studies continue to investigate the potential mechanisms underlying RIPC, as this may facilitate the translation of this simple, non-invasive, low-cost intervention into patient benefit. The limitations of the study include the lack of standardised pre-/perioperative anaesthesia and medication, the level of missing and incomplete data for some of the secondary end points and the incompleteness of the data for the echocardiography substudy.Trial registrationClinicalTrials.gov NCT01247545.FundingThis project was funded by the Efficacy and Mechanism Evaluation programme, a MRC and NIHR partnership, and the British Heart Foundation.

Summary Infective endocarditis is a rising problem in the intensive care setting. Patients admitted to the intensive care unit (ICU) are at a high risk of developing infective endocarditis because of the frequent use of invasive monitoring and therapeutic devices in the intensive care environment. In particular, cardiac surgery patients are at a high risk of developing nosocomial infective endocarditis in the ICU. Staphylococci and Streptococci are the predominant organisms causing infective endocarditis in this setting, while fungal endocarditis remains a less frequent condition that may be on the rise. Infective endocarditis in the intensive care can be challenging to diagnose and manage. Morbidity and mortality from infective endocarditis can be high in the intensive care setting because of pre-existing pathologies in patients as well as the more complex nature of the disease in patients who need admission to the ICU. A multidisciplinary team approach is essential to improve clinical outcomes of patients with this condition. Particular emphasis has to be placed on the prevention of nosocomial endocarditis in the ICU through the use of strict aseptic conditions during placement and manipulation of invasive devices as well as appropriate endocarditis prophylaxis in selected patients.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass graft (CABG) surgery is particularly challenging. We aimed to investigate the procedural and long-term outcomes in patients with vs. without prior CABG. We compiled a multicenter

OBJECTIVES: To evaluate the outcomes of subadventitial stenting (SS) around occluded stents for recanalizing in-stent chronic total occlusions (IS-CTOs).BACKGROUND: There is little evidence on the outcomes of SS for IS-CTO.METHODS: We examined the outcomes of SS for IS-CTO PCI at 14 centers between July 2011 and June 2017, and compared them to historical controls recanalized using within-stent stenting (WSS). Target-vessel failure (TVF) on follow-up was the endpoint of this study, and was defined as a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization.RESULTS: During study period, 422 IS-CTO PCIs were performed, of which 32 (7.6%) were recanalized with SS, usually when conventional approaches failed. The most frequent CTO vessel was the right coronary artery (72%). Mean J-CTO score was 3.1 ± 0.9. SS was antegrade in 53%, and retrograde in 47%. Part of the occluded stent was crushed in 37%, while the whole stent was crushed in 63%. Intravascular imaging was used in 59%. One patient (3.1%) suffered tamponade. Angiographic follow-up was performed in 10/32 patients: stents were patent in six cases, one had mild neointimal hyperplasia, and three had severe restenosis at the SS site. Clinical follow-up was available for 29/32 patients for a mean of 388 ± 303 days. The 24-month incidence of TVF was 13.8%, which was similar to historical controls treated with WSS (19.5%, P = 0.49).CONCLUSIONS: SS is rarely performed, usually as last resort, to recanalize complex IS-CTOs. It is associated with favorable acute and mid-term outcomes, but given the small sample size of our study additional research is warranted.

Whether remote ischemic preconditioning (transient ischemia and reperfusion of the arm) can improve clinical outcomes in patients undergoing coronary-artery bypass graft (CABG) surgery is not known. We investigated this question in a randomized trial.We conducted a multicenter, sham-controlled trial involving adults at increased surgical risk who were undergoing on-pump CABG (with or without valve surgery) with blood cardioplegia. After anesthesia induction and before surgical incision, patients were randomly assigned to remote ischemic preconditioning (four 5-minute inflations and deflations of a standard blood-pressure cuff on the upper arm) or sham conditioning (control group). Anesthetic management and perioperative care were not standardized. The combined primary end point was death from cardiovascular causes, nonfatal myocardial infarction, coronary revascularization, or stroke, assessed 12 months after randomization.We enrolled a total of 1612 patients (811 in the control group and 801 in the ischemic-preconditioning group) at 30 cardiac surgery centers in the United Kingdom. There was no significant difference in the cumulative incidence of the primary end point at 12 months between the patients in the remote ischemic preconditioning group and those in the control group (212 patients [26.5%] and 225 patients [27.7%], respectively; hazard ratio with ischemic preconditioning, 0.95; 95% confidence interval, 0.79 to 1.15; P=0.58). Furthermore, there were no significant between-group differences in either adverse events or the secondary end points of perioperative myocardial injury (assessed on the basis of the area under the curve for the high-sensitivity assay of serum troponin T at 72 hours), inotrope score (calculated from the maximum dose of the individual inotropic agents administered in the first 3 days after surgery), acute kidney injury, duration of stay in the intensive care unit and hospital, distance on the 6-minute walk test, and quality of life.Remote ischemic preconditioning did not improve clinical outcomes in patients undergoing elective on-pump CABG with or without valve surgery. (Funded by the Efficacy and Mechanism Evaluation Program [a Medical Research Council and National Institute of Health Research partnership] and the British Heart Foundation; ERICCA ClinicalTrials.gov number, NCT01247545.).

Although the rate of procedural complications during transcatheter aortic valve implantation has decreased because of technological advancement and increased operator experience, device embolization remains a rare but potentially fatal complication, even with new generation devices. We report, to our knowledge, the first case of Portico valve (St Jude Medical, Minneapolis, MN) migration despite apparent optimal initial implantation depth, which was retrieved using a novel strategy after failure of a traditional retrieval technique. We also describe a mechanism of left coronary artery systolic perfusion with diastolic backflow, which led to myocardial ischemia.

Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Coronary artery bypass graft (CABG) surgery is the revascularisation strategy of choice in patients with diabetes mellitus and complex CAD. Owing to a number of factors, including the ageing population, the increased complexity of CAD being treated, concomitant valve and aortic surgery, and multiple comorbidities, higher-risk patients are being operated on, the result of which is an increased risk of sustaining perioperative myocardial injury (PMI) and poorer clinical outcomes. As such, new treatment strategies are required to protect the heart against PMI and improve clinical outcomes following cardiac surgery. In this regard, the heart can be endogenously protected from PMI by subjecting the myocardium to one or more brief cycles of ischaemia and reperfusion, a strategy called “ischaemic conditioning”. However, this requires an intervention applied directly to the heart, which may be challenging to apply in the clinical setting. In this regard, the strategy of remote ischaemic conditioning (RIC) may be more attractive, as it allows the endogenous cardioprotective strategy to be applied away from the heart to the arm or leg by simply inflating and deflating a cuff on the upper arm or thigh to induce one or more brief cycles of ischaemia and reperfusion (termed “limb RIC”). Although a number of small clinical studies have demonstrated less PMI with limb RIC following cardiac surgery, three recently published large multicentre randomised clinical trials found no beneficial effects on short-term or long-term clinical outcomes, questioning the role of limb RIC in the setting of cardiac surgery. In this article, we review ischaemic conditioning as a therapeutic strategy for endogenous cardioprotection in patients undergoing cardiac surgery and discuss the potential reasons for the failure of limb RIC to improve clinical outcomes in this setting. Crucially, limb RIC still has the therapeutic potential to protect the heart in other clinical settings, such as acute myocardial infarction, and it may also protect other organs against acute ischaemia/reperfusion injury (such as the brain, kidney, and liver).

A 17-year-old male patient presented to the emergency department with sudden onset of palpitations after drinking high caffeine preparations at the gym. He had no relevant medical history or family history of sudden cardiac death. He denied any use of regular medications, alcohol or illicit drugs. On arrival, he was tachycardic (ECG in figure 1—top) but haemodynamically stable. Cardiovascular examination was otherwise unremarkable; chest X-ray and routine blood tests were normal. He was given intravenous metoprolol with no significant effect. Subsequently, his blood pressure deteriorated (ECG in figure 1—bottom) and intravenous adenosine was administered followed by further blood pressure reduction. The on-call cardiologist was …

Organ or tissue dysfunction due to acute ischemia-reperfusion injury (IRI) is the leading cause of death and disability worldwide. Acute IRI induces cell injury and death in a wide variety of organs and tissues in a large number of different clinical settings. One novel therapeutic noninvasive intervention, capable of conferring multiorgan protection against acute IRI, is 'remote ischemic conditioning' (RIC). This describes an endogenous protective response to acute IRI, which is triggered by the application of one or more brief cycles of nonlethal ischemia and reperfusion to one particular organ or tissue. Originally discovered as a therapeutic strategy for protecting the myocardium against acute IRI, it has been subsequently demonstrated that RIC may confer protection against acute IRI in a number of different noncardiac organs and tissues including the kidneys, lungs, liver, skin flaps, ovaries, intestine, stomach and pancreas. The discovery that RIC can be induced noninvasively by applying the RIC stimulus to the skeletal tissue of the upper or lower limb has facilitated its application to a number of clinical settings in which organs and tissues are at high risk of acute IRI. In this article, we review the experimental studies that have investigated RIC in organs and tissues other than the heart, and we explore the therapeutic potential of RIC in preventing organ and tissue dysfunction induced by acute IRI.

A 36-year-old man with systemic lupus erythematosus (SLE) presented with chest pain, infero-lateral ST segment elevation on ECG and elevation of cardiac biomarkers and inflammatory markers. Coronary angiography ruled out obstructive coronary artery disease (CAD) but echocardiography showed impairment of regional and global left ventricular (LV) function. He was treated for SLE myocarditis but institution of aggressive immunosuppressant therapy only partially improved his condition, which followed a relapsing and remitting course in subsequent months, with progressive impairment of LV function. Cardiac MRI showed active inflammation and extensive transmural scarring. Endomyocardial biopsy (EMB) demonstrated patchy myocardial fibrosis and low-grade myocarditis and PCR assays excluded viral causes. The lack of response to immunosuppression and the detection of the sign of En coup de Sabre were suggestive of scleroderma as the underlying cause of the myocarditis.

Coronary artery disease (CAD) is the leading cause of death and disability worldwide, and early and successful restoration of myocardial reperfusion following an ischemic event is the most effective strategy to reduce final infarct size and improve clinical outcome. This process can, however, induce further myocardial damage, namely acute myocardial ischemia-reperfusion injury (IRI) and worsen clinical outcome. Therefore, novel therapeutic strategies are required to protect the myocardium against IRI in patients with CAD. In this regard, the endogenous cardioprotective phenomenon of “ischemic conditioning,” in which the heart is put into a protected state by subjecting it to one or more brief nonlethal episodes of ischemia and reperfusion, has the potential to attenuate myocardial injury during acute IRI. Intriguingly, the heart can be protected in this manner by applying the “ischemic conditioning” stimulus to an organ or tissue remote from the heart (termed remote ischemic conditioning or RIC). Furthermore, the discovery that RIC can be noninvasively applied using a blood pressure cuff on the upper arm to induce brief episodes of nonlethal ischemia and reperfusion in the forearm has greatly facilitated the translation of RIC into the clinical arena. Several recently published proof-of-concept clinical studies have reported encouraging results with RIC, and large multicenter randomized clinical trials are now underway to investigate whether this simple noninvasive and virtually cost-free intervention has the potential to improve clinical outcomes in patients with CAD. In this review article, we provide an update of recently published and ongoing clinical trials in the field of RIC.

Introduction Remote ischaemic preconditioning (RIPC) has emerged as a non-invasive, low-cost therapeutic intervention for reducing peri-operative myocardial injury (PMI) in patients undergoing coronary artery bypass graft (CABG) and/or valve surgery. However, some studies have been neutral, suggesting that the standard single limb RIPC stimulus may be ineffective under certain conditions. We investigated the effect of increasing the strength of the RIPC stimulus in patients undergoing elective cardiac bypass surgery. Methods and results 180 consecutive patients undergoing elective CABG and/or valve surgery were randomised to receive either RIPC (2–5 min cycles of simultaneous upper arm and thigh cuff inflation and deflation, N=90) or control (uninflated cuffs placed on the upper arm and thigh for 20 min, N=90). Patients randomised to RIPC had less PMI (26% reduction in 72 h area-under-the-curve high-sensitivity Troponin T; p=0.003), reduced incidence of post-operative atrial fibrillation (AF, 11% RIPC vs 24% control; p=0.031), decreased the incidence of acute kidney injury (AKI, 7% RIPC vs 17% control; p=0.036), and shortened the stay on the intensive care unit (ICU, 2 days RIPC vs 3 days control; p=0.043). Interestingly, we found that in those patients who received IV GTN during surgery sustained less PMI, and RIPC was ineffective. Conclusions Multi-limb RIPC induced by simultaneous upper arm and leg cuff inflation reduced PMI, decreased the incidence of post-operative AF, reduced the incidence of AKI and shortened the ITU stay, in patients undergoing CABG and/or valve surgery.

Introduction Remote ischaemic preconditioning (RIPC) using brief cycles of upper or lower limb ischaemia and reperfusion has been reported to protect the heart against ischaemia-reperfusion injury (IRI). Previous studies suggest that the diabetic heart is more resistant to the cardioprotective effects of myocardial ischaemic preconditioning. Whether the diabetic heart is amenable to RIPC is unknown and is investigated in this study. Methods Non-diabetic and diabetic patients undergoing elective coronary artery bypass graft (CABG) surgery were randomised to receive three different treatment protocols after the induction of anaesthesia: (1) Control—no RIPC; (2) RIPC1 comprising 3-five min cycles of upper arm cuff inflation/deflation; or (3) RIPC2 comprising 2-five min cycles of simultaneous upper and lower limb cuff inflations/deflations (total 4). A section of the right atrial appendage was harvested, from which atrial trabeculae were isolated and subjected to 90 min simulated ischaemia and 120 min simulated reperfusion, at the end of which the recovery of baseline contractile function was determined. Results Atrial trabeculae harvested from diabetic (N=13 patients) and non-diabetic control patients (N=20 patients) were demonstrated to recover 24.5%±2.4% and 29.3%±1.3% of baseline contractile function, respectively. Prior treatment of patients with RIPC1 increased the recovery of function in both non-diabetic (50.4%±1.9%; p 0.05) and diabetic (28.6%±0.9% U0126 and 30.0%±1.2% PD98059; p>0.05) atrial trabeculae. Conclusion We demonstrate for the first time that in vivo RIPC can protect ex vivo atrial trabeculae against simulated IRI. Both non-diabetic and diabetic atrial trabeculae were amenable to RIPC protection. Increasing the intensity of the RIPC stimulus resulted in greater functional recovery. The pro-survival kinase MEK-Erk1/2 appears to contribute to RIPC protection in human atria trabeculae.