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Background The management of heart failure (HF) patients who are CRT non-responders (symptomatic and have no evidence of reverse LV remodelling following epicardial CRT) remains limited. Endocardial LV pacing is potentially superior to epicardial LV pacing as it allows faster electrical activation, more physiological and provides a greater selection of pacing sites enabling operators to avoid myocardial scar. The WiSE-CRT system was developed to provide endocardial LV pacing and may be particularly useful in CRT non-responders. Objectives To determine whether WiSE-CRT would improve patient outcomes in CRT non-responders. Method CRT non-responders who successfully had the WiSE-CRT system implanted were analysed. Patients were followed up for 6 months. Results 17 patients were analysed, baseline demographics: 68.2±7.9 years, 94.1% male, 41.1% ischaemic, NYHA 2.8±0.4, QRS 169.1±23.8ms and LVEF 25.6±8.0%. There were no acute complications and 1 patient developed a pocket haematoma during follow-up. 58.8% of patients had an improvement in their clinical composite score (alive, no HF hospitalisations, improvement in NYHA or patient global assessment), 53.3% had an improvement in LVESV of≥15% and 64.7% had an absolute increase in LVEF of ≥5% or improvement in LVESV of ≥15%. Conclusion The management of CRT non-responders remains difficult with limited treatment options. Our analysis has shown that in this high-risk patient group, the WiSE-CRT system results in a considerable improvement in the clinical composite score and leads to reverse left ventricular remodelling. These encouraging results suggest an important role for the WiSE-CRT system in the management of CRT non-responders.

Background Heart failure (HF) patients undergoing CRT upgrades are more symptomatic and have lower rates of reverse LV remodelling compared with de novo implants. WiSE-CRT delivers endocardial LV pacing and has many advantages over epicardial CRT which can be particularly useful in this upgrade population. Currently, WiSE-CRT is reserved for patients considered high risk for epicardial CRT such as venous occlusion, risk of pocket infection and multiple co-morbidities placing patients at an increased risk. Objectives To determine whether patients undergoing high-risk CRT upgrades with WiSE-CRT had at least comparable outcomes to epicardial CRT upgrades. Methods Consecutive patients undergoing epicardial CRT upgrades at Guy's and St Thomas’ between 2014-2018 were compared with patients undergoing high-risk CRT upgrades with a WiSE-CRT. Results 95 patients were included; 58 epicardial and 37 endocardial CRT. Baseline demographics for epicardial vs. endocardial CRT upgrades include: 71.2±12.2 vs. 67.9±11.4 years (p=0.098), 77.6±0.4 vs. 83.8±0.4% (p=0.023) male, 39.7±0.5 vs. 37.8±0.5% (p=0.859) ischaemic, QRS 176.3±27.5 vs. 182.4±29.0ms (p=0.315) and LVEF 30.2±8.2 vs. 29.7±7.9% (p=0.796). At 6 month follow-up, epicardial CRT upgrades had an 81% improvement in clinical composite score (alive, no HF hospitalisations, improvement in NYHA or global assessment) and 78% had improvement following WiSE-CRT (p=0.784). There was a trend towards a non-significant improvement in LV remodelling following WiSE-CRT compared with epicardial CRT; 73.5±0.4 vs. 66.0±0.5% (p=0.367) of patients had an absolute change in LVEF≥5% and 69.0±0.5 vs. 52.8±0.5% (p=0.185) of patients had improvement in LVESV≥15%. Conclusion Patients undergoing high-risk CRT upgrades with WiSE-CRT have comparable outcomes with those patients undergoing epicardial CRT upgrades. There is a tendency towards improved LV remodelling following WiSE-CRT, however further studies are required to determine if this reaches significance in a larger patient cohort.

Introduction: Indwelling urinary catheters cause a variety of complications including infections, pain and bleeding. Sometimes, the catheter becomes encrusted and blocked. Case Report: A 66-year-old male was presented with increasing suprapubic pain for about two months because of a poorly draining Foley catheter. Two years earlier, the patient had undergone a transurethral resection of the prostate (TURP) gland. He was given a Foley catheter and asked to follow-up in a week. He did not follow-up or change the catheter for two years. The catheter could not be removed. A computed tomography scan of the abdomen showed a large encrustation of 5.0x5.2x5.5 cm surrounding the Foley. The patient underwent open suprapubic cystostomy with intact retrieval of stone along with the catheter. Conclusion: Indwelling Foley catheters frequently become encrusted and may become difficulty to remove. The developments of giant encrustations are unusual. Such giant encrustations usually need surgery for removal.

A 28-year-old Gurkha soldier presented with signs of severe chest sepsis and respiratory distress. High-flow oxygen, broad-spectrum intravenous antibiotics and intravenous fluids were started immediately. Bedside thoracic ultrasound demonstrated a moderate right pleural effusion suggestive of an empyema. A pleural aspirate was borderline for pleural infection, therefore, a chest drain was inserted and the patient was transferred to high dependency. Within 48 h the patient clinically improved. Three weeks later, a persistently raised C reactive protein and indeterminate right lower lobe radiographic changes was observed. Video-assisted thorascopic surgery was subsequently performed. Although technically difficult, a large amount of pus was drained from the pleural cavity. The patient was discharged, returning to normal army duties 8 weeks later. Follow-up chest radiographs showed complete resolution of the empyema and no evidence of scarring. The CRP normalised to

A 50-year-old Chinese woman, non-smoker, presented with a 6-month history of increased sweating on the right side of her face, exertional chest tightness and breathlessness. Although the patient presented with increased sweating on the right, further history and examination revealed unilateral, left-sided anhidrosis, left partial ptosis and miosis consistent with Horner's syndrome. The patient was subsequently investigated with thoracic CT to assess for an apical lung mass (Pancoast tumour). A CT chest ruled out a mediastinal tumour, however, it revealed a large 60×41 mm soft tissue mass arising from the left atrium, protruding across the mitral valve into the left ventricle, suspicious of an intracardiac tumour. The patient was referred urgently for cardiothoracic assessment at a tertiary referral centre and successful open resection was performed. Histology confirmed an atrial myxoma. The patient developed postoperative atrial fibrillation but otherwise made a full recovery.