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Preliminary study to assess the risk profile and outcomes of patients aged over 90years at the time of percutaneous coronary intervention.A database search was performed to identify patients 90years or over at the time of percutaneous coronary intervention. Risk profile scores (Charlson Comorbidity Index, SYNTAX, Logistic clinical SYNTAX, New York PTCA score and frailty indices) were evaluated on 24 consecutive patients in order to determine the best predictor for survival. Between both groups (survivors and non-survivors) unpaired Student's t-test was used to determine statistical significance.The New York PTCA score was significantly higher in those patients that died in hospital (n=5) when compared to those who survived to discharge (n=19) (NY PTCA score of 20.9±5.4 vs. 4.5±0.8, p0.001) and this was also seen with mortality at 12months. The level of co-morbidity (Charlson index) was similar in patients who died in hospital (n=5) compared with those who survived to discharge (n=19, Charlson comorbidity index of 3.4±0.7 vs.3.9±0.6, p=0.70). This trend was also observed at 1year. The average level of frailty (by the CSHA Clinical Frailty Scale), SYNTAX score and logistic clinical SYNTAX were not significantly different between the two groups both at discharge and at 12months. Choosing an arbitrary New York PTCA score of 9%, nearly two thirds of patients above this level died, whereas no patient below this level of risk died in hospital.This small observational study found that nonagenarians who underwent PCI had relatively low comorbidity and SYNTAX scores. The specific coronary intervention (New York PTCA) risk score appears to have more predictive power in this small group of patients than the other three scores. Crucially, the factors that determine risk by New York PTCA score - haemodynamic instability, shock, pulmonary oedema, renal failure, etc. - are commonly encompassed by an "end-of-bed" assessment of the patient and these patients that pass this test ought not to be denied PCI on the basis of their advanced years.

Interventions to treat coronary artery disease are available but they must be targeted at the correct individuals (and indeed lesions), in order to gain maximal benefit with the minimal adverse effects. Coronary contrast angiography is not able to provide all the information required for the assessment of the effects of artery disease. Other imaging modalities are of growing importance as they can reduce radiation exposure and invasiveness of screening, as well as providing important extra information. The ideal 'multiparametric' imaging technique would assess anatomy, viability and lesion activity in a single quick scan. Currently, MRI is the technology closest to achieving this ideal, although the existing technology still has some limitations. This review discusses the currently available techniques for the imaging of coronary anatomy and of myocardial viability, and considers their benefits and limitations. We also discuss the developing field of imaging molecularly targeted to active coronary lesions. Finally we provide a 5-year view of the current and likely future optimal imaging strategies.

Objective: To review the procedures, results and follow-up of patients who underwent percutaneous device closure of a patent foramen ovale (PFO) during pregnancy. We report modifications made to the established technique that allowed absolute minimization of radiation exposure. Relevant management issues of this unusual presentation of cardiac disease in pregnancy are discussed. Background: Stroke during or immediately prior to pregnancy is a catastrophic event. Paradoxical embolism may be more frequent due to the hypercoagulable state and increased incidence of venous thromboembolism. Treatment strategies must take into account the competing risks to mother and fetus. Methods: Three patients, aged 34, 27, and 39, presented with ischemic neurological events during or immediately preceding pregnancy. Due to evidence of recurrent events or relative contraindication to anticoagulation they proceeded to percutaneous device closure during the second trimester. The Helex device (WL Gore and Associates) was used in all patients. Procedures were performed with local anesthesia under intra-cardiac echocardiography guidance. Results: Successful closure was achieved with the Helex device in all three patients. Radiation doses, as assessed by dose area product, were 260, 58, and 19 cGy/cm2, with estimated uterine (fetal) dose of

A 43-year-old woman having significant risk factors for ischaemic heart disease was admitted with an acute coronary syndrome (ACS). Coronary angiography revealed a non-flow limiting lesion in her right coronary artery with the rest of her arteries unremarkable. Risk stratification of the culprit lesion in the right coronary artery through intravascular ultrasound virtual histology demonstrated that the rupture plaque had less than 5% necrotic core with low vulnerability indices. This important finding suggested that the re-rupture risk was low so aggressive pharmacological treatment that can influence the plaque characteristics was instigated in preference to mechanical plaque sealing with a coronary stent. At a year of follow-up the patient was well and had no further events.

Sixteen years after a long admission for a serious occupational accident, a 38-year-old man presented with intermittent atypical chest pain. Upon investigations a retained fragment of a pulmonary artery catheter was found in the right ventricle. Throughout the years between his accident and the current presentation he did not have any symptoms or signs of complications associated with the retained catheter such as arrhythmia, sepsis or thromboembolism. Upon presenting his case at the medical/surgical multidisciplinary meeting it was decided that the probability of complications occurring at this stage was low as the catheter fragment would have endothelialised and the risk of retrieval would outweigh the benefits. This scenario highlighted the importance of understanding the possible long-term complications of retained catheter fragments, the importance of being aware of the limitation of these devices and the need to be more vigilant in the emergency setting.

The National Institute for Health and Care Excellence (NICE) CG95 clinical guideline on chest pain of recent onset was published in 2010. There is debate over whether the proposed strategy improves patient care and its implications on service costs. Following a six-month pilot, 472 consecutive patient records were audited for pre-test probability of significant coronary artery disease, investigations performed and outcomes. Low- and moderate-risk patients had an unexpectedly low rate of coronary disease and revascularisation. Computerised tomography coronary angiography (CTCA) and stress echocardiography performed similarly, though the latter was more resource intensive. High-/very high-risk patients frequently required revascularisation and greater than 10% of each group had prognostically significant disease, going against the recommendation that very high risk patients do not undergo angiography. There were frequent protocol deviations and training clinic staff in the new approach was challenging. In conclusion, implementing NICE CG95 is feasible but presents challenges. Staff require training to follow the protocol consistently. Functional testing had no benefits over anatomical testing with CTCA, which may allow cost savings in some departments.