Archive for August, 2015

Management guide to use of Novel Oral Anticoagulants

A useful guide to use of novel oral anticoagulants is available here.

Categories: Uncategorized

Journal Club 19 August 2015


Arrhythmic Mitral Valve Prolapse and Sudden Cardiac Death





Mitral valve prolapse (MVP) may present with ventricular arrhythmias and sudden cardiac death (SCD) even in the absence of hemodynamic impairment. The structural basis of ventricular electric instability remains elusive.

Methods and Results

The cardiac pathology registry of 650 young adults (≤40 years of age) with SCD was reviewed, and
cases with MVP as the only cause of SCD were re-examined. Forty-three patients with MVP (26 females; age range,19–40 years; median, 32 years) were identified (7% of all SCD, 13% of women). Among 12 cases with available ECG, 10 (83%) had inverted T waves on inferior leads, and all had right bundle-branch block ventricular arrhythmias. A bileaflet involvement was found in 70%. Left ventricular fibrosis was detected at histology at the level of papillary muscles in
all patients, and inferobasal wall in 88%. Living patients with MVP with (n=30) and without (control subjects; n=14) complex ventricular arrhythmias underwent a study protocol including contrast-enhanced cardiac magnetic resonance. Patients with either right bundle-branch block type or polymorphic complex ventricular arrhythmias (22 females; age range, 28–43 years; median, 41 years), showed a bileaflet involvement in 70% of cases. Left ventricular late enhancement
was identified by contrast-enhanced cardiac magnetic resonance in 93% of patients versus 14% of control subjects (P<0.001), with a regional distribution overlapping the histopathology findings in SCD cases.


MVP is an underestimated cause of arrhythmic SCD, mostly in young adult women. Fibrosis of the
papillary muscles and inferobasal left ventricular wall, suggesting a myocardial stretch by the prolapsing leaflet, is the structural hallmark and correlates with ventricular arrhythmias origin. Contrast-enhanced cardiac magnetic resonance may help to identify in vivo this concealed substrate for risk stratification.

Supplementary Material

The editorial is available here.

Journal Club 5 August 2015


Outcomes of Percutaneous Coronary Intervention Performed at Offsite Versus Onsite Surgical Centers
in the United Kingdom





Percutaneous coronary intervention (PCI) is increasingly being performed at centers with offsite surgical support. Strong guideline endorsement of this practice has been lacking, in part because outcome data are limited to modest-size populations with short-term follow-up.


The aim of this study was to compare the outcomes of PCI performed at centers with and without surgicalsupport in the United Kingdom between 2006 and 2012.


A retrospective analysis was performed of centrally tracked outcomes from index PCI procedures entered in the British Cardiovascular Intervention Society database between 2006 and 2012, stratified according to whether procedures were performed at centers with onsite or offsite surgical support. The primary endpoint was 30-day all-cause
mortality, with secondary endpoints of mortality at 1 and 5 years.


Outcomes at a median of 3.4 years follow-up were available for 384,013 patients, of whom 31% (n ¼ 119,096) were treated at offsite surgical centers. In an unadjusted analysis, crude mortality rates were lower in patients treated at centers with offsite versus onsite surgical coverage (2.0% vs. 2.2%; p < 0.001). On multivariate adjustment, there were no between-group differences in survival between the naive and imputed populations at 30 days (naive population hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.71 to 1.06; p ¼ 0.16; imputed population HR:0.99; 95% CI: 0.89 to 1.09; p ¼ 0.82), 1 year (naive population HR: 0.92; 95% CI: 0.79 to 1.07; p ¼ 0.26; imputed population HR: 0.99; 95% CI: 0.92 to 1.06; p ¼ 0.78), or 5 years (naive population HR: 0.92; 95% CI: 0.84 to 1.01; p ¼ 0.10; imputed population HR: 0.97; 95% CI: 0.92 to 1.03; p ¼ 0.29). Results were consistent irrespective of procedural indication. No differences in mortality were seen in sensitivity analyses performed using a propensity-matched population of 74,001 patients.


PCI performed at centers without onsite surgical backup is not associated with any mortality hazard.

Supplementary Material

The editorial is available here.