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Introduction Patients with repaired tetralogy of Fallot (RTOF) develop chronic pulmonary regurgitation and require monitoring for right ventricular dilatation. Pulmonary valve replacement can prevent irreversible right ventricular (RV) dilatation and dysfunction and cardiac magnetic resonance (CMR) is used to facilitate its optimal timing. There are however, different techniques published for measuring RV volumes. We sought to determine whether the choice of myocardial contouring technique affects preoperative RV volumetric thresholds for intervention. Methods Consecutive patients (n = 24, age 25.2±15.5 years, 42% male) with RTOF were identified retrospectively, having undergone CMR for clinical surveillance at a Level 1 ACHD surgical referral centre. Volumetric analysis was made by two experienced, independent observers blinded to clinical status. Right ventricular volumes were measured using three contouring techniques: 1) smooth, where the trabeculae were counted as part of the blood volume; 2) detailed, using semi-automated thresholding; 3) detailed, with manual contours. For 2) and 3), trabeculae and sub-valvar apparatus were counted as part of the myocardium. Inter-observer variability (F.L. & C.M.) was assessed blinded in 5 randomly selected patients. Results Right ventricular end-diastolic volume (EDV) was largest for smooth contours compared with thresholding and manual (table), as was end-systolic volume (ESV) (p Conclusions Smooth right ventricular contouring in RTOF creates larger RV volumes than detailed and may result in differences in management strategy. Smooth contouring is more reproducible than detailed methods using thresholding. Manual contouring was the least reproducible in this series. Our results are similar to studies of left ventricular contouring demonstrating larger volumes using smooth compared with detailed methods. The difference in right ventricular volume is accentuated in RTOF due to increased RV trabeculation. Consensus on contouring techniques in RTOF is vital to ensure standardisation of care. Conflict of Interest None

AimsBody composition (BC) is known to alter in heart failure. Cardiac resynchronisation therapy (CRT) improves left ventricular geometry but the impact on BC is unknown. Our aim was to evaluate BC in these patients before and after CRT implantation.MethodsProspective proof-of-concept pilot study of heart failure patients undergoing CRT between September 2014 and December 2015. Assessments performed pre-CRT and post-CRT (6 weeks and 6 months) were: BC parameters (using air-displacement plethysmography), New York Heart Failure classification for assessing symptom severity, echocardiography to assess left ventricular geometry, electrocardiography, Minnesota Heart Failure Questionnaire and N-terminal probrain natriuretic peptide (NT-pro-BNP). Repeated measures analysis of variance was performed to assess relative change over time and potential correlations.ResultsTwenty-five patients were recruited; mean-age (±SD) was 73.4±10.0 years, 23 males, 18 CRT defibrillators (remainder CRT pacemakers), 16 had ischaemic aetiology, 6 diabetics, 17 with left bundle-branch morphology on ECG and 10 had atrial fibrillation. Significant inverse correlations were observed in the first 6 weeks following CRT between fat mass and left ventricular end-diastolic volume (r=−0.69, pConclusionThis is the first study to observe interplay between BC and cardiac geometry/function following CRT; a trend in overall fat mass reduction was noted following CRT and merits further study.

The prevalence of heart failure is increasing and it is associated with significant mortality and morbidity. Optimal medical therapy improves outcome, but heart failure continues to have a substantial impact on both the individual patient and wider society. Over the last two decades, cardiac resynchronization therapy has revolutionized the treatment of selected patients who have heart failure. Cardiac resynchronization therapy significantly reduces mortality and hospitalization through reverse cardiac remodelling. This review informs non-specialists about cardiac resynchronization therapy and for which patients it should be considered.

The departmental journal club (JC) is a well-established form of continuing professional development (CPD). Social media offers a range of interactive online platforms, allowing the traditional JC to move from a formal educational meeting with local health professionals to a digital platform with users across the world. The authors created the General Internal Medicine JC (@GIMJClub) on Twitter and following a year of activity retrospectively analysed the participation and impact of this medium of JC delivery. There were 61 different participants across different continents, specialties and levels who participated in the 12 JC sessions and sent 1,543 tweets in total. Factors that appeared to influence the success of an individual JC session included choosing diverse, topical papers to discuss and a wide range of hosts. This work demonstrates the success of a Twitter-based general internal medicine JC for CPD. @GIMJClub facilitated unique and diverse interactions not otherwise available.

BACKGROUND Transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy is unsuccessful in 5-10% of reported cases. These patients may benefit from isolated surgical placement of an epicardial LV lead via minithoracotomy approach. AIM To evaluate the success of this approach at long-term follow-up. METHODS Retrospective evaluation of all consecutive patients undergoing isolated epicardial LV lead placement after failed transvenous attempt over a 6-year period. Data collected on baseline parameters, procedural details, and outcome at follow-up (hospital stay, complications, mortality, and clinical response). RESULTS Forty-two patients underwent epicardial lead implant. Five died within 1 year (11.9%): two (4.8%) died within 30-days post op (one from intraoperative hemorrhage, the other from multiple organ failure); 39 (95.1%) were admitted to the high dependency unit and transferred to the ward

AimsCardiac resynchronisation therapy (CRT) is effective treatment for selected patients with heart failure (HF) but has ~30% non-response rate. We evaluated whether specific biomarkers can predict outcome.MethodsA prospective single-centre pilot study of consecutive unselected patients undergoing CRT for HF between November 2013 and December 2015 evaluating cardiac extracellular matrix biomarkers and micro-ribonucleic acid (miRNA) expression before and after CRT assessing ability to predict functional response and survival. Each underwent three assessments (pre-implant, 6 weeks and 6 months postimplant) including: New York Heart Association (NYHA) class, echocardiography, electrocardiography, 6 min walk test (6MWT), Minnesota Living with Heart Failure Questionnaire (MLHFQ) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP). Plasma markers of cardiac fibrosis assessed were: N-terminal pro-peptides of collagen I and III, collagen I C-terminal telopeptides (CTx) and matrix metalloproteinases (MMP-2 and MMP-9) as well as a panel of miRNAs (miRNA-21, miRNA-30d, miRNA-122, miRNA-133a, miRNA-210 and miRNA-486).ResultsA total of 52 patients were recruited; mean age (±SD) was 72.4±9.4 years; male=43 (82.7%), ischaemic aetiology=30 (57.7%), mean QRS duration=166.4±23.5 ms, left bundle branch block (LBBB) morphology = 39 (75.0%), mean NYHA=2.7±0.6, 6MWT=238.8±130.6 m, MLHFQ=46.4±21.3 and left ventricular ejection fraction (LVEF)=24.3%±8.0%. Mean follow-up=1.7±0.3 and 5.8±0.7 months. There were 27 (55.1%) functional responders (3 no definable 6-month response; 2 missed assessments and 1 long-term lead displacement). No marker predicted response, however, CTx and LBBB trended most towards predicting functional response.ConclusionNo specific biomarkers reached significance for predicting functional response to CRT. CTx showed a trend towards predicting response and warrants further study.Trial registration numberNCT02541773.

Objective Cardiac resynchronisation therapy (CRT) is an effective therapy for selected patients with heart failure (HF); however, a significant non-response rate exists. We examined current evidence on extracellular cardiac matrix (ECM) biomarkers in predicting response following CRT. Methods Complete literature review of PubMed, Ovid SP MEDLINE, Cochrane Library and TRIP, reference lists, international cardiology conferences and ongoing studies between December 1999 and December 2015 conducted according to prospectively registered study selection and analysis criteria (PROSPERO:CRD42016025864) was performed. All observational and randomised control trials (RCT) were included if they tested prespecified ECM biomarkers’ ability to predict CRT response. Risk of bias assessment and data extraction determined pooling of included studies was not feasible due to heterogeneity of the selected studies. Results A total of 217 studies were screened; six (five prospective cohort and one RCT substudy) were included in analysis with 415 participants in total. Study sizes varied (n=55–260), cohort characteristics contrasted (male: 67.8%–83.6%, ischaemic aetiology: 40.2%–70.3%) and CRT response definitions differed (three clinical/functional, three echocardiographic). Consistent observation in all ECM biomarker behaviour before and after CRT implantation was not observed between studies. Lower type I and type III collagen synthesis biomarkers (N-terminal propeptides of type I and III procollagens) expression demonstrated replicated ability to predict reverse left ventricular remodelling. Conclusion Collagen synthesis biomarkers offer the most potential as ECM biomarkers for predicting CRT response. Heterogeneity between these studies was large and limited the ability to pool and compare results numerically. Use of different response definitions was one of the biggest challenges.

Alpha-1-antitrypsin deficiency (AATD) is associated with variable development of emphysema and other features of chronic obstructive pulmonary disease (COPD). Matrix metalloproteinases (MMPs) are believed to be important in the pathophysiology of COPD, and may therefore confer susceptibility to this phenotype in patients with AATD. Objectives: to assess the role of polymorphism of MMP1, MMP3 and MMP12 in AATD phenotypes. Methods: 424 PiZZ subjects from the UK AATD Registry were assessed for history of chronic bronchitis (CB), post-bronchodilator lung function impairment and decline of lung function. Tag single nucleotide polymorphisms (SNPs) for MMP1, MMP3 and MMP12 were chosen using HapMap (r2>0.8, MAF>0.05) and were genotyped using TaqMan® genotyping technologies. Quantitative genetic association was assessed using regression modelling to correct for covariates. Results: in patients with AATD, carriers of the G allele of rs678815 ( MMP3) had lower gas transfer (KCO) ( P = 0.025, B =-7.766) than the homozygous wild type, while carriers of the T allele of rs470358 ( MMP1) had higher KCO ( P = 0.025, B = 6.130). Conclusions: variations in MMP1 and MMP3 are associated with gas transfer in AATD, supporting a previous family study showing linkage of KCO to this gene region. Replication of these preliminary data is now required particularly if MMP inhibitors are to be considered as a therapeutic option.

A complex interplay exists between heart failure, metabolic status and body composition. The idiosyncrasies of these relationships are poorly understood, but they offer prognostic value and potential clinical utility. Current understanding of this relationship and known clinical value are discussed in this article.

The pattern and global burden of disease has evolved considerably over the last two decades, from primarily communicable, maternal, and perinatal causes to non-communicable disease (NCD). Cardiovascular disease (CVD) has become the single most important and largest cause of NCD deaths worldwide at over 50%. The World Health Organisation (WHO) estimates that 17.6 million people died of CVD worldwide in 2012. Proportionally, this accounts for an estimated 31.43% of global mortality, with ischaemic heart disease (IHD) accounting for approximately 7.4 million deaths, 13.2% of the total. IHD was also the greatest single cause of death in 2000, accounting for an estimated 6.0 million deaths. The global burden of CVD falls, principally, on the low and middle-income (LMI) countries, accounting for over 80% of CVD deaths. Individual populations face differing challenges and each population has unique health burdens, however, CVD remains one of the greatest health challenges both nationally and worldwide.

The pattern and global burden of disease has evolved considerably over the last two decades from primarily communicable, maternal, and perinatal causes to noncommunicable disease (NCD). Cardiovascular disease (CVD) has become the single most important and largest cause of NCD deaths worldwide, at over 50%. The World Health Organization (WHO) estimates that 17.6 million people died of CVD worldwide in 2012. Proportionally this accounts for an estimated 31.3% of global mortality, with ischemic heart disease (IHD) accounting for 7.4 million deaths, 13.2%. IHD was also the greatest single cause of death in 2000, accounting for an estimated 6.0 million deaths. The global burden of CVD falls, principally, on the lower- and middle-income countries, accounting for over 80% of CVD deaths. Individual populations face differing health challenges, and each specific population has unique health burdens, however, CVD continues to remain one of the greatest health challenges worldwide.

Transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy is unsuccessful in 5-10% of reported cases. These patients may benefit from isolated surgical placement of an epicardial LV lead via minithoracotomy approach.To evaluate the success of this approach at long-term follow-up.Retrospective evaluation of all consecutive patients undergoing isolated epicardial LV lead placement after failed transvenous attempt over a 6-year period. Data collected on baseline parameters, procedural details, and outcome at follow-up (hospital stay, complications, mortality, and clinical response).Forty-two patients underwent epicardial lead implant. Five died within 1 year (11.9%): two (4.8%) died within 30-days post op (one from intraoperative hemorrhage, the other from multiple organ failure); 39 (95.1%) were admitted to the high dependency unit and transferred to the ward24 hours. Median hospital stay was 3.4 ± 1.9 days. The overall complication rate was 17.5% (n = 7): 15.0% (n = 6) short term and 2.5% (n = 1) long term; these included three (7.5%) LV noncapture events all treated with reprogramming. There were two (5.0%) wound infections requiring oral antibiotics and two (5.0%) device infections requiring intravenous antibiotics (one had device resiting, the other developed septic shock requiring intensive care admission). Assessment of clinical response was possible in 34 (81.0%) at follow-up: 21 (61.8%) were responders and 13 (28.2%) nonresponders with no significant differences between these groups; no clinical predictors of response were identified.Isolated epicardial LV lead implant using minithoracotomy is relatively safe and effective at successful LV pacing. Response rate and postoperative recovery at long-term follow-up are reasonable in these high-risk patients.

Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator (ICD) implantation improve morbidity and mortality in selected patients. Many centers still admit patients overnight. We evaluated the safety, feasibility, and cost savings of same-day CRT/ICD device implantation by performing a retrospective study of all consecutive elective CRT/ICD implants at a tertiary center from January 2009 to April 2013. All emergency and/or inpatient cases were excluded. Data were collected on baseline demographics, implantation indication, procedure details, complications (categorized as immediate [≤24 hours], short term [24 hours to 6 weeks], medium term [6 weeks to 4 months], and long term [>4 months]), and mortality (30 day and 1 year). Comparisons were made between those having planned same-day versus overnight stay procedures. A cost analysis was performed to evaluate cost savings of the same-day policy. A total of 491 devices were implanted during this period: 267 were elective (54 planned overnight, 213 planned same-day) of which 229 were CRT pacemakers or CRT defibrillators and 38 ICDs. There were 26 total overall complications (9.7%) with no significant differences between planned same-day versus planned overnight stay cohorts (9.4% vs 11.1%, p = 0.8) and specifically no differences in immediate, short-, medium-, and long-term complications at follow-up. The 30-day and 1-year mortality rates did not differ between the two groups. An overnight stay at our hospital costs $450 (£300); our cost saving during this period was $91,800 (£61,200). Same-day CRT/ICD implantation is safe, feasible, and associated with significant cost savings. It provides significant advantages for patients and health care providers, especially given the current financial climate.

BACKGROUND Catheter ablation is a curative intervention for common arrhythmias such as supraventricular tachycardia and atrial flutter. Many centers still admit patients overnight after this procedure. OBJECTIVE This study was performed to evaluate the safety and cost-effectiveness of same-day standard catheter ablation. METHODS We conducted a retrospective study of all consecutive elective same-day procedures performed between 2010 and 2014. Data were collected on baseline parameters, procedure details and success, postoperative complications, unplanned overnight hospital admissions, and clinical outcome (including mortality) at 4-month follow-up. A cost analysis of potential savings was also performed. RESULTS A total of 1142 patients underwent planned same-day electrophysiological study with or without ablation. Radiofrequency ablation was performed in 897 of these patients (mean age ± standard error 56 ± 0.6 years, range 16-95 years, 467 males), with 921 arrhythmias ablated and with complete procedural success in 883 cases (96%). There were 92 unplanned admissions (10.3%): 50 for concealed pathways that required transseptal puncture, 19 for immediate complications (including 9 femoral bleeds and 5 pacemakers for heart block), 12 admitted at the operator's discretion, and 11 for other clinical reasons. All had transthoracic echocardiography after the procedure, and none had significant pericardial effusion. At 4-month follow-up, there were 16 readmissions (1 deep vein thrombosis, 3 pericarditic chest pain, 2 femoral hematomas, 7 palpitations, and 3 others) and 1 death (unrelated to ablation). An overnight stay at our center costs $450 (£300); same-day ablation over this period saved our institution $365,000 (£240,000). CONCLUSION Same-day standard catheter ablation is safe and cost-effective, with significant benefits for patients and health care providers. This is particularly important given the current financial climate.

Christopher McAloon and colleagues look at how using Twitter and other social media can help support doctors’ professional development.

Background Cardiac Resynchronisation Therapy (CRT) is known to improve morbidity and mortality in selected patients with heart failure. The left ventricular (LV) lead is commonly placed percutaneously via the coronary sinus with a 10–13% failure rate. Epicardial lateralLV lead placement via a left submammary incision is an alternative method when the percutaneous method fails. We report our experience from a large tertiary centre. Methods Retrospective study evaluating all patients having elective surgical epicardial LV lead placement via left submammary incision between November 2006 and November 2013. Data collected included baseline parameters, procedural and follow-up data, including NYHA class, hospital stay, 30 day readmission rate and mortality. Results Forty two patients underwent elective surgical epicardial LV lead placement. Table 1 demonstrates demographic and baseline data. All patients initially had an attempted transvenous procedure. Reasons for transvenous LV lead failure are outlined in Table 2. A further attempt at percutaneous placement was made in 12 patients. 30 day mortality was 2 patients (4.8%), both of whom died during their admission. One patient died from intra-operative haemorrhage. The other patient had intra-operative ventricular tachycardia, developing multiple organ failure and dying 7 days later. 39 patients spent one post-operative day on HDU and one patient was taken directly to the ward. The median hospital stay was 3 nights (range 1–13), with 4 patients transferred to another hospital. Other complications in 7 (16.7%) patients during follow-up included the LV lead not capturing requiring same day revision (n = 1), pneumonia/UTI treated with oral antibiotics (n = 1), pneumonia and wound infection treated with oral antibiotics (n = 1), wound infection treated with oral antibiotics (n = 1), box infection (n = 2, one requiring IV antibiotics), and late LV lead failure (n = 1). Two patients (4.8%) were readmitted within 30 days. 35 patients were followed up at a median of 7 weeks (range 1–32). 12 of these had a documented reduction in their NYHA class. 6 out of 25 patients who were on diuretics prior to lead placement had these reduced within this follow-up. Conclusion Epicardial LV lead placement is safe and effective when endocardial lead placement is not possible. Postoperative recovery in such high risk patients is good and has comparable outcomes. Precise anatomic placement could be considered for optimisation.

Background CRT is an effective therapy in HF. Pacemakers and defibrillators are implanted for arrhythmogenic indications. Pacing dependency can induce HF and is an established CRT upgrade criterion [LVEF 40%]. We aimed to compare cardiovascular outcomes between upgraded and de-novo CRT’s. Methodology A retrospective study of all consecutive CRT implants over five years (Jan 2009 – Dec 2013) in a UK tertiary centre. Data was collected on baseline demographics, co-morbidities and indications (NYHA class, ECG, echocardiogram). Comparisons were made for these outcomes: acute response [ 2 mths], all-cause mortality and first hospitalisation. CRT response was defined as >1 NYHA class increase. Results 373 CRT implants were performed (79 upgrades). Upgrade and de-novo patients were matched for all comorbidities. [Table 1][1] demonstrates baseline demographics, indications and CRT response. A Kaplan-Meier analysis was performed on all-cause mortality and time to first hospitalisation, with three year rates demonstrated in the table. A significantly worse long-term response (p 0.002) and all-cause mortality (p 0.043) was demonstrated for upgrade patients. View this table: Abstract 57 Table 1 De-Novo vs. upgrade cardiac resynchronisation therapy device: Demographics, indications, response and outcomes Conclusion Upgraded CRT patients have a worse long-term response and higher all-cause mortality. The potential worse outcome for upgrade patients should be considered before implant. [1]: #T1

CRT is an effective therapy in HF. Pacemakers and defibrillators are implanted for arrhythmogenic indications. Pacing dependency can induce HF and is an established CRT upgrade criterion [LVEF%lt;35% and ventricular pacing >40%]. We aimed to compare cardiovascular outcomes between upgraded and de

Introduction The Electrocardiogram (ECG) is the most commonly used diagnostic test in modern medicine. 1 Competency in ECG interpretation is central to undergraduate and postgraduate clinical training and minimising potential adverse consequences on patient care. Several studies have demonstrated postgraduates interpret ECG’s sub-optimally. 2,3 Our study compares the effectiveness of two cost neutral learning strategies to improve competence and confidence in this core clinical skill. Method A prospective randomised study was carried out over a one-month period comparing the learning strategies in two cohorts: undergraduate 3 rd year medical students and postgraduate foundation year one (FY1) doctors.Both had blinded randomisation to one of these strategies; focused teaching program (FTP) and self-directed learning (SDL). All volunteers completed a confidence questionnaire on ECG interpretation before and after completing the intervention. Additionally, all undertook an ECG recognition multiple choice question (MCQ) paper at the end of the learning period to assess competence. Results A total of 21 FY1’s and 25 3rd year medical students participated. The undergraduates in the FTP group demonstrated a significant difference in successfully interpreting ‘Ventricular Tachycardia’ (p = 0.046) and ‘Narrow Complex Tachycardia’ (p = 0.009) than the SDL group. Overall, participant confidence increased in both groups in each cohort. The FTP group demonstrated a greater improvement in confidence compared to SDL in both cohorts. Conclusion A dedicated teaching program can improve trainee confidence and competence in ECG interpretation. A larger benefit is observed in those undertaking a focused teaching program. ECG interpretation can be improved at any training level, especially undergraduates with a dedicated teaching program. References Rubinstein J, Dhole A, Ferenchick G. Puzzle based teaching versus traditional instruction in electrocardiogram interpretation for medical students – a pilot study. BMC Medical Education 2009; 9(4):1–7 Sur D, Kaye L, Mikus M, Goad J, Morena A. Accuracy of electrocardiogram reading by family practice residents. Fam Med 2000; 32(5): 315–9 Jensen MSA, Thomasen JL, Jensen SE, Lauritzen T, Engberg M. Electrocardiogram interpretation in general practice. Family Practice 2005; 22:109–113