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A challenging technical scenario frequently encountered in a percutaneous coronary intervention of a coronary bifurcation lesion (CBL) is stent implantation of only the stenosed segment without compromising the other two normal segments in non-true bifurcation lesions. Another is precise stent implantation covering the side branch ostium without leaving excessive stent metal at the other two segments of a bifurcation lesion in complex true bifurcation lesions. The aim of this study was to describe a novel stenting technique for both non-true and true CBLs by using a guide extension catheter (GuideLiner). With the assistance of a guide extension catheter mounted on both the main and the side-branch guidewires and with its intubation down to the bifurcation carina, a stent can be implanted in the side branch segment or distal main segment of the bifurcation lesion appropriately without compromising the other two segments of the coronary bifurcation. Stent implantation is described in three bifurcation lesions in three cases and shown in detail with illustrative figures. The technique facilitates side-branch only stenting in side-branch mono-ostial (medina 0, 0, 1) CBL or only the distal main segment in distal mono-ostial (medina 0, 1, 0) CBL without compromising the other two remaining segments when using the one-stent technique in non-true CBLs without leaving unnecessary excessive stent metal at the bifurcation site and when using a two-stent technique in complex true bifurcation lesions (tri-ostial or medina 1, 1, 1). Consequently, through optimizing stent deployment, the technique may have the potential to reduce the risk of subacute stent thrombosis and future in-stent restenosis. The most appropriate lesions suitable for the technique, and some other practical tips are also described.

Background Capnocytophaga canimorsus, a bacterium found in the oral cavities of healthy cats and dogs, is rarely reported as a cause of infective endocarditis. In this report we describe such a case in a young, male dog owner who presented acutely unwell in heart failure. Case summary A 47-year-old male presented with a subacute onset of fever, night sweats, weight loss, dyspnoea, and peripheral oedema. On clinical examination typical features of infective endocarditis, heart failure, and aortic regurgitation were found. The patient had no conventional risk factors for infective endocarditis but was a dog owner. Transthoracic echocardiography revealed vegetations on the right coronary and non-coronary cusps of the aortic valve causing severe eccentric aortic regurgitation and left ventricular dilatation. Initial blood cultures taken prior to the initiation of antimicrobial therapy showed no growth. The patient underwent aortic valve and root replacement and a 16S ribosomal RNA polymerase chain reaction (16S rRNA PCR) of the resected aortic valve tissue, using the additional primer set 785F/1175R targeting the V5–7 region of 16S rRNA, identified C. canimorsus. The patient was treated post-operatively with a 6-week course of meropenem and made a good recovery. Discussion Suspicion of C. canimorsus causing infective endocarditis should be considered in culture-negative infective endocarditis in individuals who have close contact with dogs or cats. Those who are immunocompetent can be susceptible to this infection and so this diagnosis should not be disregarded in healthy individuals. A 16S rRNA PCR can help identify this bacterium and should be used early in cases of culture-negative infective endocarditis.

Objectives To evaluate the feasibility of fully percutaneous closure using a novel collagen-based vascular closure device after transfemoral aortic valve replacement (TAVR). Background TAVR is utilized increasingly for the treatment of severe symptomatic aortic stenosis. Vascular complications related to access and closure dominate the adverse event profile of the procedure despite progressively reducing arteriotomy caliber. The advent of a novel collagen-based device (MANTATM ) and preliminary data suggest this could be used as a routine percutaneous closure device. Methods A prospective observational study of unselected consecutive patients undergoing TAVR in a single center. Data were collected via hospital electronic records and the SWEDEHEART registry. The primary clinical outcome was closure success and time to hemostasis. Secondary outcomes included VARC-2 defined major and minor vascular and bleeding complications within 30 days using suture-based closure with Prostar-XL within the same center. Results A consecutive cohort of 346 patients underwent TAVR via the transfemoral approach. Vascular closure with MANTATM was successful in all with a mean time to hemostasis of 42 sec (SD 115.5, range 0-600). The composite of all-cause mortality and major complications related to the main access site was similar between the groups (1.1% vs 1.9%, P = .61). Major bleeding occurred less frequently with MANTA TM (1.1% vs 7.8%, P = .02). Conclusion The novel use of a collagen-based vascular closure device for large caliber arteriotomy is feasible in an unselected population undergoing transfemoral TAVR and appears efficacious compared to percutaneous suture-based closure. These data should prompt larger studies to evaluate efficacy and safety.

Increased mortality has been observed in those with cardiovascular diseases who are of normal body mass index (BMI) compared to the overweight and the obese. A similar association has been demonstrated in patients undergoing transcatheter aortic valve (TAVI) implantation. However, it still remains unclear whether low or normal BMI itself is unfavourable or whether this is merely a reflection of cardiac cachexia due to severe aortic stenosis. The hypothesis for the study was that weight change prior to TAVI may be associated with increased mortality following the procedure.Single centre retrospective analysis using the SWEDEHEART registry, national mortality statistics and local hospital database. Body mass index was used as the anthropomorphic measurement and patients grouped by WHO categories and weight change trajectory before and at TAVI. Kaplan-Meier survival was constructed and a Cox proportional hazard model used to evaluate predictors of outcome.Consecutive data on 493 patients with three year follow-up between 2008-2015 were evaluated. Overweight and obese body mass index categories (BMI25) were associated with improved mortality compared to normal and underweight patients (BMI25) (log rank p=0.02), hazard ratio of 0.68 (0.50-0.93). Weight loss trajectory was associated with increased mortality compared to stable weight (log rank p=0.01), hazard ratio 1.64 p=0.025.The pre-procedural weight trajectory of patients undergoing TAVI is an important predictor of clinical outcome after TAVI. Patients with stable weight trajectories are associated with improved mortality outcome compared to those with decreasing weight.

Percutaneous aortic valve replacement is performed predominantly via the transfemoral approach. The transaxillary (subclavian) approach may be utilized if an alternative route access is required. Conventional access and closure for this approach necessitates open surgical techniques. We report a nonsurgical fully percutaneous axillary TAVR using a collagen-based vascular closure device.

The goal was to evaluate published data on the incidence, diagnosis, and management of symptomatic combined mitral and aortic valvular disease. Furthermore, to identify the role of treatment using contemporary transcatheter techniques. Up to a quarter of symptomatic adult valvular disease is caused by multiple left-sided valvular lesions. The etiologic spectrum of this combined disease has shifted from rheumatic to degenerative. Both presentation and diagnosis of lesions are modified compared with isolated disease. Based upon narrative review, there are only limited observational experiences, insufficient to provide robust guidance. These data, however, indicate the feasibility of interventions such as transcatheter aortic valve replacement and edge-to-edge mitral valve repair to treat such disease and mitigate the risks of open surgery. Combined aortic and mitral valve disease is commonly encountered. There is a role for transcatheter interventions based on limited data; however, more research is needed.

The impact of a change in mitral regurgitation (MR) following TAVR is unknown. We studied the impact of baseline MR and early post-procedural change in MR on survival following TAVR.The SWEDEHEART registry included all TAVRs performed in Sweden. Patients were dichotomized into no/mild and moderate/severe MR groups. Vital status, echocardiographic data at baseline and within 7 days after TAVR were analyzed.1712 patients were included. 1404 (82%) had no/mild MR and 308 (18%) had moderate/severe MR. Baseline moderate/severe MR conferred a higher mortality rate at 5-year follow-up (adjusted HR 1.29, CI 1.01-1.65, p = 0.04). Using persistent ≤mild MR as the reference, when moderate/severe MR persisted or if MR worsened from ≤mild at baseline to moderate/severe after TAVR, higher 5-year mortality rates were seen (adjusted HR 1.66, CI 1.17-2.34, p = 0.04; adjusted HR 1.97, CI 1.29-3.00, p = 0.002, respectively). If baseline moderate/severe MR improved to ≤mild after TAVR no excess mortality was seen (HR 1.09, CI 0.75-1.58, p = 0.67). Paravalvular aortic regurgitation (PVL) was inversely associated with MR improvement after TAVR (OR 0.4, 95%: CI 0.17-0.94; p = 0.034). Atrial fibrillation (OR 2.1, 95% CI: 1.27-3.39, p = 0.004), self-expanding valve (OR 3.8, 95% CI: 2.08-7.14, p 0.0001), and PVL (4.3, 95% CI 2.32-7.78. p 0.0001) were associated with MR worsening.Moderate/severe baseline MR in patients undergoing TAVR is associated with a mortality increase during 5 years of follow-up. This risk is offset if MR improves to ≤mild, whereas worsening of MR after TAVR is associated with a 2-fold mortality increase.

We present a 52-year-old woman who was admitted to the emergency department with a short history of palpitations, sweating and nausea. An electrocardiogram (ECG) that was performed suggested inferolateral ischaemia with a significant troponin rise. The patient underwent an invasive coronary angiogram that showed mild non-obstructive coronary disease. She was thus given a provisional diagnosis of myocardial infarction with non-obstructive arteries (MINOCA), treated as an acute coronary syndrome (ACS) and subsequently discharged home. The patient represented within 72 hours with a recurrence of symptoms and a further troponin rise. While on the ward severe recurrent orthostatic hypertensive episodes were noted. Further investigations revealed increased urinary and plasma metanephrines, increased plasma catecholamines and imaging revealed a left adrenal 5.7 cm mass, demonstrating probable pheochromocytoma. The patient was treated with curative surgery. This case highlights the importance of thorough history-taking in patients with atypical symptoms for acute coronary syndrome and diagnosed with MINOCA.

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

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

To evaluate the feasibility of fully percutaneous closure using a novel collagen-based vascular closure device after transfemoral aortic valve replacement (TAVR).TAVR is utilized increasingly for the treatment of severe symptomatic aortic stenosis. Vascular complications related to access and closure dominate the adverse event profile of the procedure despite progressively reducing arteriotomy caliber. The advent of a novel collagen-based device (MANTAA prospective observational study of unselected consecutive patients undergoing TAVR in a single center. Data were collected via hospital electronic records and the SWEDEHEART registry. The primary clinical outcome was closure success and time to hemostasis. Secondary outcomes included VARC-2 defined major and minor vascular and bleeding complications within 30 days using suture-based closure with Prostar-XL within the same center.A consecutive cohort of 346 patients underwent TAVR via the transfemoral approach. Vascular closure with MANTAThe novel use of a collagen-based vascular closure device for large caliber arteriotomy is feasible in an unselected population undergoing transfemoral TAVR and appears efficacious compared to percutaneous suture-based closure. These data should prompt larger studies to evaluate efficacy and safety.

Objective: This study aimed to investigate the predictive value of circumferential iliofemoral calcifications and current manufacturer recommendations, which are not evidence-based, in transfemoral (TF) transcatheter aortic valve implantation (TAVI) Methods: A patient cohort with a broad range of iliofemoral anatomies undergoing TF TAVI (n=132) were retrospectively divided as “suitable” (n=76, 58%) and “unsuitable” (n=56, 42%) candidates according to current recommendations. Iliofemoral angiography and reconstructed mul- tislice CT (MSCT) images were used for access screening in the majority of patients. Results: Vessel properties were significantly worse in the “unsuitable group.” The sheath-to-iliofemoral artery ratio (SIFAR) and calcium score were 1.35±0.2 and 1.7±0.8 in the unsuitable group, compared to 1.0±0.12 (p

Percutaneous valve implantation is a recognized therapy for calcific aortic stenosis in those patients who are inoperable or at high surgical risk. The transfemoral approach is the most frequently used method for device delivery, but a tortuous calcific aorta and the inflexibility of large-caliber endovascular equipment can impede progress or even cause the procedure to be abandoned. Herein, the use of a technique employing a snare to safely overcome device obstruction in the aortic arch of an elderly female patient is described. The technique may be of practical value whenever any large-caliber device is obstructed in the circulation.

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

Collateral pathways in vascular disease are important natural "bypass" conduits that protect against ischemia. Endovascular diagnostic and therapeutic procedures via peripheral access sites are performed frequently. This case report underlines the importance of being aware of collateral circulation in patients with chronic aortoiliac occlusive disease undergoing subclavian transcatheter aortic valve implantation to avoid acute limb ischemia. (©) RSNA, 2016.

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

Moderate renal impairment (RI) with a glomerular filtration rate (GFR)60 ml/min/1.73 m2 is known to predict survival. The authors investigated whether mild RI with an estimated GFR of 60-89 ml/min/1.73 m2 independently predicts survival in a contemporary population with ST segment elevation myocardial infarction (STEMI).This is a single-centre, observational, retrospective cohort study. Patients 601 patients with STEMI who underwent emergency catheter laboratory admission met the inclusion criteria for this study.Estimated glomerular filtration rate (eGFR) was obtained by the Modified Diet in Renal Disease equation, and preprocedure renal function was subdivided into chronic kidney disease stages. Univariate and multivariate Cox regression analyses were performed to assess which of 17 patient or procedural variables were independent risk factors for death.Longitudinal data were collated for 576 patients (96.3%). Median follow-up time was 2.6 years. 30-day and long-term death rates were 5.7% and 12.5%, respectively. Following multivariable analysis, mild RI with an eGFR of 60-89 ml/min/1.73 m2 was a strong independent predictor of death, compared with an eGFR ≥90 ml/min/1.73 m2 (HR 2.79, 95% CI 1.98 to 3.92, p0.001), and increasing chronic kidney disease stage was a strong predictor of death after both 30 days and long-term follow-up. An eGFR of 60-89 ml/min/1.73 m2 had a greater independent effect on short- and long-term mortality than the presence of diabetes mellitus (HR 2.0, 95% CI 1.2 to 3.33).Mild RI (eGFR=60-89 ml/min/1.73 m2) on admission is strongly predictive of short- and long-term mortality in patients with STEMI admitted to the catheter laboratory. A redefined threshold of clinically significant impairment is now required (GFR90 ml/min/1.73 m2).

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

Multi-vessel coronary artery disease (MVD) in patients presenting with ST-segment elevation myocardial infarction (STEMI) is associated with poor outcomes. Percutaneous coronary intervention (PCI) of all lesions (complete) as compared with culprit lesion only appears to result in improved long-term

Aims Poor prognosis in chronic heart failure (HF) is linked to endothelial dysfunction for which there is no specific treatment currently available. Previous studies have shown reproducible improvements in endothelial function with cocoa flavanols, but the clinical benefit of this effect in chronic HF has yet to be determined. Therefore, the aim of this study was to assess the potential therapeutic value of a high dose of cocoa flavanols in patients with chronic HF, by using reductions in N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) as an index of improved cardiac function. Methods and results Thirty‐two patients with chronic HF, stable on guideline‐directed medical therapy, were randomized to consume 50 g/day of high‐flavanol dark chocolate (HFDC; 1064 mg of flavanols/day) or low‐flavanol dark chocolate (LFDC; 88 mg of flavanols/day) for 4 weeks and then crossed over to consume the alternative dark chocolate for a further 4 weeks. Twenty‐four patients completed the study. After 4 weeks of HFDC, NT‐proBNP (mean decrease % ± standard deviation) was significantly reduced compared with baseline (−44 ± 69%), LFDC (−33 ± 72%), and follow‐up (−41 ± 77%) values. HFDC also reduced diastolic blood pressure compared with values after LFDC (−6.7 ± 10.1 mmHg). Conclusions Reductions in blood pressure and NT‐proBNP after HFDC indicate decreased vascular resistance resulting in reduced left ventricular afterload. These effects warrant further investigation in patients with chronic HF.

To evaluate the efficacy and safety of a double Prostar XL suture-based closure technique compared to a conventional single Prostar XL technique in elective transcatheter aortic valve implantation (TAVI) via the common femoral artery.TAVI is recommended as a treatment for symptomatic severe aortic stenosis for those who are at high or prohibitive risk of surgical valve replacement. Vascular complications remain the most frequent category of procedural complication. The most efficacious and safest percutaneous suture-based closure technique is unknown.Prospective observational study of Prostar XL device closures used in 126 consecutive patients between 2012 and 2014. Single Prostar XL closure was used in 63 patients and double Prostar XL closure in a further 63 patients. Outcomes from the groups were compared. All patients were treated transfemorally through an 18Fr sheath. Technical success was defined as hemostasis not requiring interventional or surgical repair during hospital admission. Bleeding and vascular complications were defined using the second consensus of the valvular academic research consortium (VARC-2) criteria.The cohort was aged 83+/-6 and 48% were female with a logistic Euroscore of 24+/-11.6. Technical success was 86% and 98% respectively (P = 0.017) with systematic single and double Prostar XL closure. Composite VARC-2 vascular and bleeding complications occurred more frequently in the single Prostar XL group compared to the double Prostar XL group (10 [16%] v 3 [5%] P 0.04, and 17 [27%] v 6 [10%] P 0.004).A systematic double Prostar XL closure technique for large caliber arterial access sites during TAVI is feasible, safe and associated with fewer technical failures, fewer vascular complications, and less bleeding compared with single Prostar XL.

Non-ST-elevation acute coronary syndromes (NSTEACS) represent a growing challenge to cardiologists. While ST-elevation infarction (STEMI) has been attracting the focus of acute cardiovascular healthcare systems owing to the proliferation of 24-hour regional primary percutaneous coronary interventions (PCI) services, NSTEACS management has lagged behind. More numerous,1 and with a higher cumulative mortality than STEMI,2 this spectrum of conditions is threatening to be the “elephant in the room” of acute coronary syndromes. Access to diagnostic coronary angiography and, if necessary, revascularisation within 72 hours of presentation is a class 1A indication in North American and European guidelines for those with high or intermediate risk features for poor clinical outcome. This strong recommendation is based on contemporary randomised trials, including meta-analyses3 4 comparing a systematic invasive strategy against a default conservative medical strategy with intervention only in the event of refractory ischaemia. Cost-effectiveness analyses also indicate that targeting those at highest risk is of economic value.5 6 Early invasive strategies (

Diabetes mellitus (diabetes), in particular type 2 diabetes, constitutes one of the largest emerging threats to health in the 21st century. It is estimated that by 2030 as many as 360 million people world wide will be affected.1 The cause of death in those with diabetes is dominated by coronary heart disease, accompanied by increased rates of stroke and peripheral vascular disease: so called macrovascular complications. At least two‐thirds of deaths are attributable to these cardiovascular diseases and their sequelae.2 A true picture of the extent of macrovascular complications is obscured, however, by inaccurate death certification3 and diagnostic criteria4 based on the development of microvascular complications (retinopathy, neuropathy, nephropathy). The Euro Heart5 Survey demonstrated that if one applied oral glucose tolerance tests to those presenting with all forms of acute coronary syndrome, two‐thirds display impaired glucose regulation. In the USA, although the overall mortality rate associated with coronary heart disease has declined over the past 20 years, this trend has not been reflected in a decline of mortality rates in patients with diabetes.6 Results published in this issue of Heart from the Swedish registry on coronary care (RIKS‐HIA) confirm this trend (see article on page 1577).7 After a myocardial infarction (MI), patients with diabetes had an increased mortality rate compared with non‐diabetic patients. Moreover, despite the existence of treatments which may benefit diabetic patients disproportionately, the relative hazard of mortality in diabetic patients has improved little compared with non‐diabetic patients between the time periods 1995–8 and 1999–2002. These observations give us a glimpse of the vast epidemic that is approaching, if not upon us.

"Paradoxical" Low flow, low gradient severe aortic valve stenosis (PLF-LG-AS) is characterized by reduced stroke volume despite preserved EF. If managed conservatively this entity of AS is associated with poor prognosis. Our observational single center study aimed to investigate the outcome of these

While outcomes for ST-segment-elevation myocardial infarction has significantly decreased over the last years, patients presenting with non-ST-segment-elevation acute coronary syndromes (NSTEACS) still have a rather high mortality. Longer term mortality over 4 years is about double the mortality after a ST-segment-elevation myocardial infarction. The reason for the poorer prognosis is unclear but is very likely to be partially explained by the generally older age of NSTEACS patients. The optimal therapy for NSTEACS is less well defined. In this review, the authors specifically discuss the role of coronary angiography, how to decide which patient should undergo this procedure and whether there is an optimal time point. The review provides an up-to-date discussion about the best treatment strategies for NSTEACS.

Background The role of drug-eluting balloons (DEB) is unclear. Increasing evidence has shown a benefit for the treatment of in-stent restenosis. Its effect on de novo coronary lesions is more controversial. Several smaller randomized trials found conflicting results. Methods This is a systematic review and meta-analysis of randomized controlled trials (RCT) evaluating the effect of local Paclitaxel delivery/drug eluting balloons (DEB) (+/− bare metal stent) compared to current standard therapy (stenting) to treat de novo coronary lesions. Data sources for RCT were identified through a literature search from 2005 through 28 December 2012. The main endpoints of interest were target lesion revascularization (TLR), major adverse cardiac events (MACE), binary in-segment restenosis, stent thrombosis (ST), myocardial infarction (MI), late lumen loss (LLL) and mortality. A random effects model was used to calculate the pooled relative risks (RR) with 95% confidence intervals. Results Eight studies (11 subgroups) and a total of 1,706 patients were included in this analysis. Follow-up duration ranged from 6 to 12 months. Overall, DEB showed similar results to the comparator treatment. The relative risk (RR) for MACE was 0.95 (0.64 to 1.39); P = 0.776, for mortality it was 0.79 (0.30 to 2.11), P = 0.644, for stent thrombosis it was 1.45 (0.42 to 5.01), P = 0.560, for MI it was 1.26 (0.49 to 3.21), P = 0.629, for TLR it was 1.09 (0.71 to 1.68); P = 0.700 and for binary in-stent restenosis it was 0.96 (0.48 to 1.93), P = 0.918. Compared to bare metal stents (BMS), DEB showed a lower LLL (− 0.26 mm (−0.51 to 0.01)) and a trend towards a lower MACE risk (RR 0.66 (0.43 to 1.02)). Conclusion Overall, drug-eluting balloons (+/− bare metal stent) are not superior to current standard therapies (BMS or drug eluting stent (DES)) in treating de novo coronary lesions. However, the performance of DEB seems to lie in between DES and BMS with a trend towards superiority over BMS alone. Therefore, DEB may be considered in patients with contraindications for DES. The heterogeneity between the included studies is a limitation of this meta-analysis; different drug-eluting balloons have been used.

Cardiovascular magnetic resonance (CMR) is a rapidly emerging non-invasive imaging technique free of X-Ray and offers higher spatial resolution than alternative forms of cardiac imaging for the assessment of left ventricular (LV) anatomy, function, and viability due to the unique capability of myocardial tissue characterization after gadolinium-chelates contrast administration. This imaging technique has clinical utility over a broad spectrum of heart diseases: ranging from ischaemic to non ischaemic aetiologies. Cardiomyopathies (CMP) are a heterogeneous group of diseases of the myocardium associated with architectural abnormalities and mechanical dysfunction. CMR can help excluding coronary artery disease and can provide positive diagnostic features for several CMP resulted in better diagnosis and management, Leading to improvements in mortality.

Coronary perforation is one of the most challenging and feared complications of percutaneous coronary intervention (PCI). The angiographic images of a large perforation are spectacular and are often debated during complication case review sessions at interventional cardiology meetings. Therefore

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