Cardiovascular care

Cardiac rehabilitation for children and young people (CardioActive): protocol for a single-blind randomised feasibility and acceptability study of a centre-based cardiac rehabilitation programme versus usual care in 11-16 years with heart conditions (2024)

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Type of publication:
Journal article

Author(s):
Capobianco, Lora; Hann, Mark; McManus, Emma; Peters, Sarah; Doherty, Patrick Joseph; Ciotti, Giovanna; *Murray, Joanne; Wells, Adrian.

Citation:
BMJ Open. 14(2):e077958, 2024 Feb 24.

Abstract:
BACKGROUND: Congenital heart conditions are among the most common non-communicable diseases in children and young people (CYP), affecting 13.9 million CYP globally. While survival rates are increasing, support for young people adjusting to life with a heart condition is lacking. Furthermore, one in three CYP with heart conditions also experiences anxiety, depression or adjustment disorder, for which little support is offered. While adults are offered cardiac rehabilitation (CR) to support their mental and physical health, this is not offered for CYP.One way to overcome this is to evaluate a CR programme comprising exercise with
mental health support (CardioActive; CA) for CYP with heart conditions. The exercise and mental health components are informed by the metacognitive model, which has been shown to be effective in treating anxiety and depression in CYP and associated with improving psychological outcomes in adult CR. METHOD AND ANALYSIS: The study is a single-blind parallel randomised feasibility trial comparing a CR programme (CA) plus usual care against usual care alone with 100 CYP (50 per arm) aged 11-16 diagnosed with a heart condition. CA will include six group exercise, lifestyle and mental health modules. Usual care consists of routine outpatient management. Participants will be assessed at three time points: baseline, 3-month (post-treatment) and 6-month follow-up. Primary outcomes are feasibility and acceptability (ie, referral rates, recruitment and retention rates, attendance at the intervention, rate of return and level of completion of follow-up data). Coprimary symptom outcomes (Strength and Difficulties Questionnaire and Paediatric Quality of Life) and a range of secondary outcomes will be administered at each time point. A nested qualitative study will investigate CYP, parents and healthcare staff views of CR and its components, and staff's experience of delivering CA. Preliminary health economic data will be collected to inform future cost-effectiveness analyses. Descriptive data on study processes and clinical outcomes will be reported. Data analysis will follow intention to treat. Qualitative data will be analysed using thematic analysis and the theoretical framework of acceptability. ETHICS AND DISSEMINATION: Ethical approval was granted on 14 February 2023 by the Greater Manchester East Research Ethics Committee (22/NW/0367). The results will be disseminated through peer-reviewed journals, conference presentations and local dissemination. TRIAL REGISTRATION NUMBER: ISRCTN50031147; NCT05968521.

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Vesical Haemangioma in Klippel-Trenaunay-Weber Syndrome: A Clinical Case (2023)

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Type of publication:
Journal article

Author(s):
Mohamed, Ahmed; *Chin, Yew Fung; Farah, Mohamed; Mahmalji, Wasim

Citation:
Cureus. 15(12):e49952, 2023 Dec.

Abstract:
Klippel-Trenaunay-Weber (KTW) syndrome, a rare vascular disorder, often presents with cutaneous capillary malformations and soft tissue hypertrophy. However, urinary tract involvement in the form of vesical haemangiomas is a seldom-encountered clinical condition. We present a case of a 37-year-old male with KTW syndrome who exhibited recurrent gross haematuria, prompting clinical evaluation. Initial diagnostic assessments revealed erythematous changes in the bladder, consistent with haemangiomas. Despite an initial biopsy and diathermy, the patient's symptoms recurred, leading to a subsequent management strategy involving laser fulguration. This case underscores the significance of recognizing cutaneous haemangiomas as potential indicators of urinary tract involvement in KTW syndrome and highlights the challenges in managing vesical haemangiomas, where a multidisciplinary approach is essential for optimal care.

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Evidence-based frozen elephant trunk practice: a narrative review (2023)

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Type of publication:
Journal article

Author(s):
Kayali F.; Chikhal R.; Agbobu T.; Jubouri M.; *Patel R.; Chen E.P.; Mohammed I.; Bashir M.

Citation:
Cardiovascular Diagnosis and Therapy. 13(6) (pp 1104-1117), 2023. Date of Publication: 2023.

Abstract:
Background and Objective: The frozen elephant trunk (FET) allows a single-stage repair of complex arch pathologies due to its stented and non-stented hybrid prosthesis (HP) features. FET inherently has its own related complications including distal stent graft-induced new entry (dSINE), failure of aortic remodelling, endoleak, reintervention, and kinking of the stent. The aim of this narrative review is to discuss the latest evidence regarding the postoperative clinical outcomes of the FET procedure. Another aim is to provide an overview of results achieved using different FET devices on the global arch prostheses market. <Method(s): A comprehensive literature search was conducted using multiple electronic databases to identify and extract the relevant data and information. Key Content and Findings: This review found that the literature reported a 5-12% mortality rate post- FET, with varying figures depending on the prosthesis type. Between 0-18.2% of patients developed dSINE, while 0.1-28% developed endoleak. Reintervention occurred in 0-28% of patients and the incidence of kinking has been quoted between 0-8% in the literature. Reporting aortic remodelling rates was challenging due to the lack of standardisation and various measurements reported; however, all studies included in this review reported relative increase in true lumen diameter, reduction in the false lumen diameter, and/or false lumen thrombosis. Conclusion(s): In conclusion, FET can achieve a favourable postoperative profile in terms of survival, complications and aortic remodelling, and remains the gold-standard treatment for thoracic aortic pathologies implicating the arch and descending thoracic aorta.

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Five historical innovations that have shaped modern cardiothoracic surgery (2023)

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Type of publication:
Journal article

Author(s):
Mainwaring E.; *Patel R.; Desai C.; Acharya R.; Raveshia D.; *Shah S.; *Panesar H.; Patel N.; Singh R.

Citation:
Journal of Perioperative Practice. (pp 17504589231212967), 2023. Date of Publication: 27 Dec 2023. [epub ahead of print]

Abstract:
Throughout history, many innovations have contributed to the development of modern cardiothoracic surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern cardiothoracic surgery: cardiopulmonary bypass, surgical pacemakers, video assisted thoracic surgery, robotic surgery and mechanical circulatory support. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of cardiothoracic surgery and their ongoing relevance in contemporary and perioperative practice.

Improving the Outcome of Patients With Heart Failure: Assessment of Iron Deficiency and Intravenous Iron Replacement (2023)

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Type of publication:Journal article

Author(s):*Yera, Hassan O; Khan, Ahsan; Akinlade, Olawale M; Champsi, Asgher; Glouzon, Van Nam J; Spencer, Charles.

Citation:Cureus. 15(10):e47027, 2023 Oct.

Abstract:Background Iron deficiency (ID) has been shown to be a significant co-morbidity in patients with heart failure (HF), independent of their anaemia status. Correction of ID has been shown to improve quality of life, recurrent heart failure hospitalizations and morbidity. A quality improvement project was designed to improve the assessment and treatment of iron deficiency in HFatients in our tertiary care centre. Methods and results An initial baseline dataset was collected, followed by two cycles of interventions to help improve the care of HF patients admitted to our hospital over a two-month period. The Plan-Do-Study-Act (PDSA) cycle approach was applied, with the first intervention involving raising awareness of the importance and need to assess the iron status of HF patients through education provided to doctors, nurses and patients. Furthermore, information leaflets were produced and disseminated across the medical wards and through social media forums. The post-intervention datasets were collected and compared to the baseline outcomes. Baseline data showed that only four (20%) of heart failure patients had their iron status checked. Following the interventions, screening for ID increased to 80% (16), of which 85% (11) of those who identified as iron deficient received intravenous iron replacement. Conclusion The project was successful in improving the practice of screening for iron deficiency and intravenous replacement of iron in patients with HF.

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Effects of a transoceanic rowing challenge on cardiorespiratory function and muscle fitness (2024)

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Type of publication:Journal article

Author(s):*Ellis, Chris; *Ingram, Thomas; Kite, Chris; Taylor, Sue; Howard, Liz; Pike, Joanna; *Lee, Eveline; Buckley, John.

Citation:International Journal of Sports Medicine.  2024 Feb 24.

Abstract:Ultra-endurance sports and exercise events are becoming increasingly popular for older age groups. We aimed to evaluate changes in cardiac function and physical fitness in males aged 50-60 years who completed a 50-day transoceanic rowing challenge. This case account of four self-selected males included electro- and echo-cardiography (ECG, echo), cardiorespiratory and muscular fitness measures recorded nine-months prior to and three weeks after a transatlantic team-rowing challenge. No clinically significant changes to myocardial function were found over the course of the study. The training and race created expected functional changes to left ventricular and atrial function; the former associated with training, the latter likely due to dehydration, both resolving towards baseline within three weeks post-event. From race-start to finish all rowers lost 8.4-15.6 kg of body mass. Absolute cardiorespiratory power and muscular strength were lower three weeks post-race compared to pre-race, but cardiorespiratory exercise economy improved in this same period. A structured programme of moderate-vigorous aerobic endurance and muscular training for >6 months, followed by 50-days of transoceanic rowing in older males proved not to cause any observable acute or potential long-term risks to cardiovascular health. Pre-event screening, fitness testing, and appropriate training is recommended, especially in older participants where age itself is an increasingly significant risk

Echocardiographic Assessment of the Left Ventricle in Young Prehypertensive Nigerians (2023)

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Type of publication:Journal article

Author(s):Oboirien, Isa O; *Yera, Hassan O; Akinlade, Olawale M; Omoniyi, Oluwamayowa N; Umar, Hayatu; Sani, Mahmoud U.

Citation:Cureus. 15(10):e46740, 2023 Oct

Abstract:BACKGROUND: Prehypertension is associated with an increased risk of cardiovascular morbidity and mortality. This risk could partly be explained by the early compromise in left ventricular (LV) structure and function. This study investigated the LV geometry and function in young black prehypertensive subjects. METHODS AND RESULTS: This cross-sectional descriptive study was conducted at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Echocardiography-derived LV geometry and function were assessed using standardized methods. Prehypertensive subjects had higher mean systolic blood pressure (BP) (130.78 +/- 3.57 mmHg vs 111.42 +/- 3.54 mmHg, P<0.001), diastolic BP (79.32 +/- 4.13 mmHg vs 66.39 +/- 4.42 mmHg, P<0.001), body mass index (BMI) (26.24 +/- 3.45 kg/m2 vs 22.20 +/- 2.21 kg/m2, P<0.001), waist circumference (WC) (86.93 +/- 8.73 cm vs 76.73 +/- 6.66 cm, P<0.001), fasting blood glucose (FBG) (93.84 +/- 7.28 mg/dl vs 90.08 +/- 6.26 mg/dl, P<0.001), and dyslipidemia (21.5% vs 6%. P<0.001) compared to normotensive subjects. LV mass index (LVMI) was greater in prehypertensive subjects compared to normotensive subjects {male (106.84 +/- 12.34 g/m2 vs 76.07 +/- 10.25 g/m2, P<0.001); female (92.06 +/- 8.80 g/m2 vs 66.53 +/- 7.21 g/m2, P<0.001)}, with abnormal LV geometry recorded in 17.5%. Linear regression analysis showed that waist circumference, systolic BP, serum creatinine level, and urea level were determinants of LVMI. The prevalence of LV diastolic dysfunction was higher in prehypertensive subjects than in normotensive subjects (14.5% vs. 0.5%, P<0.001), with systolic BP {odds ratio (OR) 0.928, confidence interval (CI) 0.834 – 0.969; P=0.016)} and diastolic BP (OR 0.832, CI 0.722 – 0.958; P=0.011) being independent predictors. CONCLUSION: This study showed that prehypertension in young Black subjects was associated with altered LV geometry and impaired diastolic function, and these changes demonstrated linear progression with increasing systolic BP

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Correlative effect between sac regression and clinical outcomes following endovascular repair in abdominal aortic aneurysm: fact or myth? (2023)

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Type of publication:
Journal article

Author(s):
Al-Tawil, Mohammed; Muscogliati, Eduardo; Jubouri, Matti; Saha, Priyanshu; *Patel, Ravi; Mohammed, Idhrees; Bailey, Damian M; Williams, Ian M; Bashir, Mohamad

Citation:
Expert Review of Medical Devices. 1-8, 2023 Jun 16

Abstract:
INTRODUCTION: Endovascular aneurysm repair (EVAR) has rapidly become the preferred management of abdominal aortic aneurysm (AAA). Sac regression status post-EVAR has been linked to clinical outcomes as well as the choice of EVAR device. The aim of this narrative review is to investigate the relationship between sac regression and clinical outcomes post-EVAR in AAA. Another aim is to compare sac regression achieved with the main EVAR devices. AREAS COVERED: We carried out a comprehensive literature search on multiple electronic databases. Sac regression was usually defined as a decrease in the sac diameter (>10 mm) over follow-up. This revealed that individuals who had sac regression post-EVAR had significantly lower mortality, and higher event-free survival rates. Further, lower rates of endoleak and reintervention were observed in patients with regressing aneurysm sacs. Sac regression patients also had significantly lower odds of rupture compared to counterparts with stable or expanded sacs. The choice of EVAR device was also shown to impact regression, with the Fenestrated Anaconda showing favorable results. EXPERT OPINION: Sac regression post-EVAR in AAA is an important prognostic factor as it translates to improved mortality and morbidity. Therefore, this relationship must be seriously taken into consideration during follow-up.

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Cardiovascular disease morbidity is associated with social deprivation in subjects with familial hypercholesterolaemia (FH): a study comparing FH individuals in UK primary care and the UK Simon Broome register linked with secondary care records (2022)

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Type of publication:
Conference abstract

Author(s):
Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:
Atherosclerosis Plus. Conference: HEART UK 35th Annual Medical & Scientific Conference. Virtual. 49(Supplement 1) (pp S4-S5), 2022. Date of Publication: October 2022

Abstract:
Background: Measures of social deprivation are associated with higher cardiovascular diseases (CVD) morbidity and mortality. To determine if this is also seen in subjects with Familial Hypercholesterolaemia (FH), CVD morbidity has been examined in participants in the UK primary care database (CPRD) and in the UK Simon Broome (SB) register using linkage to the UK secondary care Hospital Episodes Statistics (HES). Method(s): A composite CVD outcome was analysed (first HES outcome of coronary heart disease, myocardial infarction, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG). The measure of socio-economic status/deprivation used was the English index of multiple deprivation (IMD). Cox proportional hazards regression estimated hazards ratios (HR) for incident CVD and mortality [95% CI] in each IMD quintile. <br/>Result(s): We identified 4,309 patients with FH in UK CPRD primary care database (followed from 1988 to 2020), free from CVD, and 2988 SB register participants, with linked secondary care HES records. In both groups, the prevalence of FH was considerably lower in the most deprived quintile (60% in CPRD and 52% in SB). CPRD patients in the most deprived quintile (IMD-5) had the highest prevalence of obesity and of smoking compared to those from IMD quintiles 1,2,3 and 4 (p-value for trend, all <0.001). Compared to least deprived, the most deprived individuals had the highest risk of composite CVD (unadjusted HR 1.71 [CI 1.22-2.40]), however, on adjustment for smoking and alcohol consumption, there were no statistical differences in CVD risk between socio-economic groups. In the FH Register patients there was an increase in the incidence rates and hazards ratios for composite CVD with increasing quintiles of deprivation. After adjustment for age, sex, smoking and alcohol consumption, this effect remained statistically significant (quintile 5 vs 1, HR = 1.83 [1.54-2.17]. Conclusion(s): Patients with FH are underdiagnosed in lower socio-economic groups. In both CPRD and the SB Register the most deprived FH patients had the highest risk of CVD and mortality, but in CPRD but not in the SB register this was largely explained by smoking and alcohol consumption. Clinicians should adopt more effective strategies to detect FH in lower socio-economic groups, and to optimise risk factor management and to support lifestyle changes and medication adherence for this group.

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Fate and Consequences of the False Lumen After Thoracic Endovascular Aortic Repair in Type B Aortic Dissection (2023)

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Type of publication:Journal article

Author(s):Jubouri M; *Patel R; Tan SZ; Al-Tawil M; Bashir M; Bailey DM; Williams IM

Citation:Annals of Vascular Surgery. 94:32-37, 2023 Aug.

Abstract:Background: Type B aortic dissection (TBAD) occurs due to an entry tear in the intimal layer of the aorta distal to the origin of the left subclavian artery where blood enters the newly formed false lumen (FL) and extends distally or proximally to form a dissection over an indeterminate length of the aorta which, over time, may eventually rupture. Thoracic endovascular aortic repair (TEVAR) aims to seal off the entry tear proximally with the stent-graft, occluding the origin of the dissection and excluding the FL. Nevertheless, in some cases, the perfusion to the FL is maintained, hindering the aortic remodelling process and increasing the risk of aneurysmal degeneration and rupture, particularly in the abdominal aorta where evidence suggest that remodelling is slower. This review examines the long-term effects of a patent or partially thrombosed FL on clinical outcomes following TEVAR in TBAD, also highlighting the pathological processes behind negative aortic remodelling. Another aim of this review is to provide an overview and appraisal of the currently available techniques for managing a patent or partially thrombosed FL to prevent long-term morbidity occurring. Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies. Results: Evidence in the literature show that a partially thrombosed FL is more dangerous than a patent FL due to the occlusion of the distal re-entry tears, impeding outflow and increasing mean arterial and diastolic pressures, whereas the latter is decompressed via distal re-entry sites. FL thrombosis and satisfactory remodelling is sometimes achieved in as few as 40% of patients after TEVAR due to the maintained perfusion of the FL either at the level of the thoracic or abdominal aorta. However, although the thoracic aorta is predominantly covered by the TEVAR stent-graft, poorer remodelling and more dilation is seen in the abdominal aorta. Several techniques are available to embolize the FL, including the Provisional Extension to Induce Complete Attachment, Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair, candy-plug, and Knickerbocker techniques. Conclusions: The management of TBAD is invariably TEVAR to seal off the proximal entry tear while extending the repair distally to completely exclude the FL. A risk of aortic wall dilatation distal to TEVAR stent-graft remains; hence, regular monitoring and accurate imaging are essential. At present, a patent FL can be treated using a range of different endovascular techniques.

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