A 24 year old man presented with a 10 day history of fever, night sweats, weight loss, and a productive cough with occasional haemoptysis. He had a history of injecting drug use. He was on a community methadone replacement programme for opiate dependency. On examination, he had a fever (39.4°C), hypotension, and tachycardia. He had a few needle track marks in both antecubital fossae. Coarse crackles were heard throughout both lung fields, although oxygen saturation was 97% on room air.
Blood tests showed: white cell count 19.8×109/L (reference range 4-11), C reactive protein 186 mg/L (<10), urea 15.5 mmol/L (2.5-6.7), and creatinine 210 μmol/L (70-100). Urine dipstick was positive for blood.
Plain chest radiography showed multiple, round, ill defined areas of consolidation throughout both lung fields, with loss of the cardiac silhouette at both the right and left heart borders, as well as bilateral blunting of both costophrenic angles to the lower zones. No hilar or mediastinal lymphadenopathy was noted. He was started empirically on intravenous benzylpenicillin and oral clarithromycin for presumed severe community acquired pneumonia (as per local hospital guidance). His methadone prescription was confirmed with community drug services and the dose corrected for his renal function. Sputum culture was unremarkable and was negative for acid and alcohol fast bacilli. Serology for HIV and autoantibodies was negative. Two consecutive blood cultures grew Staphylococcus aureus .
### 1 What is your differential diagnosis from the history and examination alone?
#### Short answer
Acute constitutional symptoms with cough and haemoptysis suggest an acute infection of the respiratory system, probably community acquired pneumonia from a typical or atypical micro-organism. …
BackgroundThe ganglionated plexuses (GPs) of the intrinsic cardiac autonomic system may play a role in atrial fibrillation (AF).ObjectiveWe hypothesized that ablating the ectopy-triggering GPs (ET-GPs) prevents AF.MethodsGANGLIA-AF (ClinicalTrials.gov identifier NCT02487654) was a prospective, randomized, controlled, 3-center trial. ET-GPs were mapped using high frequency stimulation, delivered within the atrial refractory period and ablated until nonfunctional. If triggered AF became incessant, atrioventricular dissociating GPs were ablated. We compared GP ablation (GPA) without pulmonary vein isolation (PVI) against PVI in patients with paroxysmal AF. Follow-up was for 12 months including 3-monthly 48-hour Holter monitors. The primary end point was documented ≥30 seconds of atrial arrhythmia after a 3-month blanking period.ResultsA total of 102 randomized patients were analyzed on a per-protocol basis after GPA (n = 52; 51%) or PVI (n = 50; 49%). Patients who underwent GPA had 89 ± 26 high frequency stimulation sites tested, identifying a median of 18.5% (interquartile range 16%–21%) of GPs. The radiofrequency ablation time was 22.9 ± 9.8 minutes in GPA and 38 ± 14.4 minutes in PVI (P < .0001). The freedom from ≥30 seconds of atrial arrhythmia at 12-month follow-up was 50% (26 of 52) with GPA vs 64% (32 of 50) with PVI (log-rank, P = .09). ET-GPA without atrioventricular dissociating GPA achieved 58% (22 of 38) freedom from the primary end point. There was a significantly higher reduction in antiarrhythmic drug usage postablation after GPA than after PVI (55.5% vs 36%; P = .05). Patients were referred for redo ablation procedures in 31% (16 of 52) after GPA and 24% (12 of 50) after PVI (P = .53).ConclusionGPA did not prevent atrial arrhythmias more than PVI. However, less radiofrequency ablation was delivered to achieve a higher reduction in antiarrhythmic drug usage with GPA than with PVI. The ganglionated plexuses (GPs) of the intrinsic cardiac autonomic system may play a role in atrial fibrillation (AF). We hypothesized that ablating the ectopy-triggering GPs (ET-GPs) prevents AF. GANGLIA-AF (ClinicalTrials.gov identifier NCT02487654) was a prospective, randomized, controlled, 3-center trial. ET-GPs were mapped using high frequency stimulation, delivered within the atrial refractory period and ablated until nonfunctional. If triggered AF became incessant, atrioventricular dissociating GPs were ablated. We compared GP ablation (GPA) without pulmonary vein isolation (PVI) against PVI in patients with paroxysmal AF. Follow-up was for 12 months including 3-monthly 48-hour Holter monitors. The primary end point was documented ≥30 seconds of atrial arrhythmia after a 3-month blanking period. A total of 102 randomized patients were analyzed on a per-protocol basis after GPA (n = 52; 51%) or PVI (n = 50; 49%). Patients who underwent GPA had 89 ± 26 high frequency stimulation sites tested, identifying a median of 18.5% (interquartile range 16%–21%) of GPs. The radiofrequency ablation time was 22.9 ± 9.8 minutes in GPA and 38 ± 14.4 minutes in PVI (P < .0001). The freedom from ≥30 seconds of atrial arrhythmia at 12-month follow-up was 50% (26 of 52) with GPA vs 64% (32 of 50) with PVI (log-rank, P = .09). ET-GPA without atrioventricular dissociating GPA achieved 58% (22 of 38) freedom from the primary end point. There was a significantly higher reduction in antiarrhythmic drug usage postablation after GPA than after PVI (55.5% vs 36%; P = .05). Patients were referred for redo ablation procedures in 31% (16 of 52) after GPA and 24% (12 of 50) after PVI (P = .53). GPA did not prevent atrial arrhythmias more than PVI. However, less radiofrequency ablation was delivered to achieve a higher reduction in antiarrhythmic drug usage with GPA than with PVI.
Abstract Background Pulsed field ablation (PFA) is a new modality for pulmonary vein isolation (PVI) for atrial fibrillation (AF). PFA is performed under general anaesthetic (GA) or deep sedation with propofol, but this requires anaesthetic support in many countries, restricting use. No study has tested the feasibility of PFA under mild conscious sedation (MCS). Methods We prospectively recruited patients undergoing PFA PVI, offered the option of MCS delivered by electrophysiologists, and compared these with patients who opted for GA. MCS comprised intravenous midazolam and fentanyl. All procedures were performed under anaesthetic supervision in case of requirement to convert to GA, which formed the primary outcome. Results Twenty-three patients were recruited (8 MCS, 15 GA). One patient (1/8 [12.5%]) required conversion from MCS to GA. Total procedural times were similar between groups (MCS 92 ± 12.4 min vs. GA 101 ± 17.3 min; p = 0.199). High mean sedative doses were required in the MCS group (5.12 ± 0.83 mg midazolam and 209 ± 40 mcg fentanyl). Median intraprocedural pain perception by the patient, rated from 0 to 100 was 45 (IQR 22.5–72.5) in the MCS group. Post-procedural groin pain (0 [0–0] vs. 5 [0–35]; p = 0.027) and throat pain (0 [0–0] vs. 10 [5–40]; p = 0.001) were lower in the MCS group. Conclusion PFA under MCS is feasible in selected patients but pain and tolerance may be suboptimal, and high sedative doses are required. Graphical abstract
Abstract Background Ablation of autonomic ectopy-triggering ganglionated plexuses (ET-GP) has been used to treat paroxysmal atrial fibrillation (AF). It is not known if ET-GP localisation is reproducible between different stimulators or whether ET-GP can be mapped and ablated in persistent AF. We tested the reproducibility of the left atrial ET-GP location using different high-frequency high-output stimulators in AF. In addition, we tested the feasibility of identifying ET-GP locations in persistent atrial fibrillation. Methods Nine patients undergoing clinically-indicated paroxysmal AF ablation received pacing-synchronised high-frequency stimulation (HFS), delivered in SR during the left atrial refractory period, to compare ET-GP localisation between a custom-built current-controlled stimulator (Tau20) and a voltage-controlled stimulator (Grass S88, SIU5). Two patients with persistent AF underwent cardioversion, left atrial ET-GP mapping with the Tau20 and ablation (Precision™, Tacticath™ [ n = 1] or Carto™, SmartTouch™ [ n = 1]). Pulmonary vein isolation (PVI) was not performed. Efficacy of ablation at ET-GP sites alone without PVI was assessed at 1 year. Results The mean output to identify ET-GP was 34 mA ( n = 5). Reproducibility of response to synchronised HFS was 100% (Tau20 vs Grass S88; [ n = 16] [kappa = 1, SE = 0.00, 95% CI 1 to 1)][Tau20 v Tau20; [ n = 13] [kappa = 1, SE = 0, 95% CI 1 to 1]). Two patients with persistent AF had 10 and 7 ET-GP sites identified requiring 6 and 3 min of radiofrequency ablation respectively to abolish ET-GP response. Both patients were free from AF for > 365 days without anti-arrhythmics. Conclusions ET-GP sites are identified at the same location by different stimulators. ET-GP ablation alone was able to prevent AF recurrence in persistent AF, and further studies would be warranted.
A 50-year-old hypertensive female presented to us with her first episode of anginal sounding chest discomfort at rest. Her 12-lead ECG demonstrated sinus rhythm with evolving antero-lateral T-wave inversion. Twelve-h Troponin-I was raised at 11.14 ng/ml (normal range 0–0.08 ng/ml).
Coronary angiography revealed two-vessel spontaneous coronary artery dissection (SCAD) involving the right coronary artery extending into the postero-lateral artery (figure 1), and the proximal segment of the first diagonal of the left anterior descending artery (figure 2).
Figure 1
Reveals a dissection within the …
Atrial fibrillation (AF) ablation services were significantly affected by the COVID-19 pandemic. We aimed to evaluate a symptom-based clinician prioritisation scheme for waiting list management compared with patient-completed quality of life (QoL) scores. We also sought to understand factors influencing QoL, particularly the impact of COVID-19, on patients awaiting AF ablation, via a bespoke questionnaire.Patients awaiting AF ablation were sent two QoL questionnaires (Atrial Fibrillation Effect on QualiTy of Life (AFEQT) and EuroQol 5D (EQ5D-5L)) and the bespoke questionnaire. At a separate time point, patients were categorised as C1-urgent, C2-priority or C3-routine by their cardiologist based on review of clinic letters.There were 118 patients included with priority categorisation available for 86 patients. Median AFEQT scores were lower in C2 (30.4; 17.2-51.9) vs C3 patients (56.5; 32.1-74.1; p<0.01). Unplanned admission occurred in 3 patients in C3 with AFEQT scores of <40. Although 65 patients had AF symptoms during the pandemic, 43.1% did not seek help where they ordinarily would have. An exercise frequency of ≥3-4 times a week was associated with higher AFEQT (56.5; 41.2-74.1; p<0.001) and EQ5D (0.84; 0.74-0.88; p<0.0001) scores.The QoL of patients awaiting AF ablation is impaired and AFEQT helps to identify patients at risk of admission, over and above physician assessment. COVID-19 influenced patients seeking medical attention with symptomatic AF when they normally would. Regular exercise is associated with better QoL in patients awaiting AF ablation.
In April 2020, formal face-face cardiology training was put on pause due to COVID-19. We adapted by utilising a video-conferencing platform to continue some form of Cardiology education on a national scale, and maintain morale. This programme, known as CardioWebinar, has continued ever since. We looked to study the effectiveness of delivering virtual Cardiology education 1 year into the COVID pandemic.
Methods
Expert speakers throughout the UK were sought after via social media and 'word of mouth.' Weekly webinars were organised and advertised (Canva posters) on social media (Twitter), as well as via the British Cardiovascular Society and British Junior Cardiologists' Association (BJCA) media links. Each webinar was scheduled mid-week at 17:30 (UK). Interested attendees registered for free using an online ticketing platform (Eventbrite). Webinars were delivered using an online video conferencing platform (Zoom) which required a £14.99 monthly subscription. Each webinar consisted of a 40-minute presentation followed by Q&A (20mins). All webinars were recorded and later accessible for free on the BJCA TV Gallery. A Learning Management System (LMS) was used to collect feedback after each session and generate certificates of attendance for attendee appraisal. We systematically reviewed the LMS feedback of live attendees from 6 consecutive webinars delivered between Jan-Feb 2021. We further surveyed our most recent (March 2021) attendees (145 participants) via an extended questionnaire through the LMS exploring their experiences of our virtual education.
Results
55 CardioWebinars have been delivered since April 2020. The speakers have been predominantly Consultant Cardiologists from the UK. Some of the recordings have had >1000 views. Other than the video platform subscription, no cost was incurred in the delivery of this entire programme.We collected feedback from 392 respondents (~65 live attendees per webinar) from each session between Jan-Feb 2021. The sessions were rated as 'very good-excellent' by 97%. We collected a further 145 responses from March 2021 attendees to an extended questionnaire. 90% rated the whole series as 'very good –excellent' in supporting their cardiology education during the Covid pandemic, and 84% felt the programme sufficiently covered even the more challenging areas of the Cardiology curriculum (e.g aortopathies). 90% of the respondents felt that their work-life schedule allowed them to join the live webinars at this time. The respondents where predominantly from the UK (91%), though included an international audience (9%). Whilst 74% of attendees were cardiology trainees, the remaining 26% included physiologists, nursing staff, consultants and other junior doctors. 99% felt that virtual education should continue to play a formal part in their training after the COVID pandemic.
Conclusion
Webinars allow everyone interested in cardiac care across the world the opportunity to hear experts teach, and without a travel cost. They are cheap and easy to organise. Whilst the 'social' aspect of training is limited, this study suggests that webinars will remain an integral part of the post-Covid era.
Conversations considering the benefits and risks of invasive procedures, including their alternatives, are a key part of many patient consultations in Cardiology. However, patients absorb only a fraction of the information shared during a single encounter, often due to time constraints, leading to an incomplete understanding. Video animation tools were designed to better facilitate communication and consolidate patient (and family members) understanding in advance of their procedure. We aimed to assess real-world patient feedback having introduced online cardiac video animations into our high-volume tertiary cardiac centre.
Methods
In July 2022, we obtained unlimited patient access to a digital tool that offers short, multi-language narrated video animations covering the breadth of cardiac procedures (cardiac intervention, electrophysiology, structural and cardiac surgery). These animations are accessible on any device, including a desktop, laptop, or mobile phone. Specifically, we purchased password protected access to 31 video animations in three local languages. Web-links and QR codes for each video animation were designed. These were shared with patients and family members during different stages of the patients' journey through the hospital. We sampled qualitative feedback from a cohort of patients attending pre-assessment clinic, measured on our electronic patient record via a 3-point Likert scale.
Results
As summarised in figure 1, we adapted our patient pathway to integrate use of this resource in the patient journey by 1) informing patients during their out-patient cardiologist consultation; 2) emailing video links integrated within an e-consent process; 3) sharing video links as QR codes in patient letters; 4) reminding patients during their nurse-led pre-assessment clinic; 5) via hospital poster advertisements; 6) and on the front page of the hospital website. Since its implementation 18 months ago, 20,607 animation views have occurred, with 90% watched to completion. The three most popular animations were "angiogram/angioplasty" (4135), atrial fibrillation ablation (1415), and TAVI (1243). Between July 2022 to December 2023, 1,878 patients have attended our nurse led pre-assessment clinic, and we sampled qualitative feedback from about 20% (342 patients). As demonstrated in figure 2, 84% of patients felt the procedural video animations were quite helpful/very helpful. The remaining 16% found it "not helpful", with anecdotal reasons being "feeling already adequately informed", "inability to access the technology", or "not wanting to know".
Conclusion
In our high-volume tertiary centre, online narrated video animations discussing cardiac procedures were successfully implemented into our patient pathway and deemed helpful by the majority of our patients.
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