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1.  The changing face of infective endocarditis 
Heart  2005;92(7):879-885.
Infective endocarditis (IE) is an evolving disease with a persistently high mortality and morbidity, even in the modern era of advanced diagnostic imaging, improved antimicrobial chemotherapy, and potentially curative surgery. Despite these improvements in health care, the incidence of the disease has remained unchanged over the past two decades and may even be increasing. Chronic rheumatic heart disease is now an uncommon antecedent, whereas degenerative valve disease of the elderly, mitral valve prolapse, intravenous drug misuse, preceding valve replacement, and vascular instrumentation have become increasingly common, coinciding with an increase in staphylococcal infections and those caused by fastidious organisms. The current understanding of this difficult condition is reviewed and recent developments in medical and surgical management are updated.
PMCID: PMC1860698  PMID: 16216860
infective endocarditis; valve disease
2.  Multivariate prediction of major adverse cardiac events after 9914 percutaneous coronary interventions in the north west of England 
Heart  2005;92(5):658-663.
To develop a multivariate prediction model for major adverse cardiac events (MACE) after percutaneous coronary interventions (PCIs) by using the North West Quality Improvement Programme in Cardiac Interventions (NWQIP) PCI Registry.
All NHS centres undertaking adult PCIs in north west England.
Retrospective analysis of prospectively collected data on 9914 consecutive patients undergoing adult PCI between 1 August 2001 and 31 December 2003. A multivariate logistic regression analysis was undertaken, with the forward stepwise technique, to identify independent risk factors for MACE. The area under the receiver operating characteristic (ROC) curve and the Hosmer‐Lemeshow goodness of fit statistic were calculated to assess the performance and calibration of the model, respectively. The statistical model was internally validated by using the technique of bootstrap resampling.
Main outcome measures
MACE, which were in‐hospital mortality, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accidents.
Independent variables identified with an increased risk of developing MACE were advanced age, female sex, cerebrovascular disease, cardiogenic shock, priority, and treatment of the left main stem or graft lesions during PCI. The ROC curve for the predicted probability of MACE was 0.76, indicating a good discrimination power. The prediction equation was well calibrated, predicting well at all levels of risk. Bootstrapping showed that estimates were stable.
A contemporaneous multivariate prediction model for MACE after PCI was developed. The NWQIP tool allows calculation of the risk of MACE permitting meaningful risk adjusted comparisons of performance between hospitals and operators.
PMCID: PMC1860907  PMID: 16159983
major adverse cardiac events; percutaneous coronary interventions; risk prediction
3.  Needle embolism in an intravenous drug user 
Heart  2006;92(3):315.
PMCID: PMC1860824  PMID: 16501192
Images in cardiology
4.  Transoesophageal echocardiographic assessment of mitral valve commissural morphology predicts outcome after balloon mitral valvotomy 
Heart  2006;92(1):52-57.
To investigate the value of transoesophageal echocardiography in the assessment of commissural morphology and prediction of outcome after balloon mitral valvotomy (BMV).
Prospective study.
Tertiary cardiac referral centre.
72 consecutive patients (mean age 61.3 years, range 38–89 years) referred for BMV.
Transoesophageal echocardiography was performed immediately before BMV and the mitral commissures were scanned systematically. Anterolateral and posteromedial commissures were scored individually according to whether non‐calcified fusion was absent (0), partial (1), or extensive (2). Calcified commissures usually resist splitting and scored 0. Scores for each commissure were combined giving an overall commissure score for each valve of 0–4, higher scores reflecting increased likelihood of commissural splitting. Valve anatomy was also graded by the method of Wilkins et al, which does not include commissural assessment.
Main outcome measures
Patients were divided into outcome groups: A (good) and B (suboptimal). “Good” was defined as final valve area > 1.5 cm2 with a > 25% increase in area and absence of severe mitral regurgitation judged by echocardiography.
Valve area increased from a mean (SD) of 1.1 (0.28) cm2 to 1.8 (0.46) cm2. Commissure scores were higher in group A than in group B (p < 0.01), scores ⩾ 2 predicting a good outcome with positive and negative accuracy of 67% and 82%, respectively (p < 0.001). Commissure score was the strongest independent predictor of outcome.
Transoesophageal echocardiographic assessment of commissural morphology predicts outcome after BMV, adding significantly to the Wilkins score.
PMCID: PMC1860992  PMID: 16365352
transoesophageal echocardiography; balloon valvotomy; commissure; mitral stenosis
5.  Diagnostic criteria and problems in infective endocarditis 
Heart  2004;90(6):611-613.
PMCID: PMC1768277  PMID: 15145855
infective endocarditis; Duke criteria; Staphylococcus aureus; Coxiella burnetti
6.  Clinical and haemodynamic profiles of young, middle aged, and elderly patients with mitral stenosis undergoing mitral balloon valvotomy 
Heart  2003;89(12):1430-1436.
Objective: To compare the clinical characteristics, haemodynamic findings, and symptomatic outcome in four age groups of patients in the UK undergoing percutaneous mitral balloon valvotomy.
Design: A review of patients with mitral stenosis treated by balloon dilatation.
Setting: Western General Hospital, Edinburgh, a cardiac referral centre.
Results: Of 405 patients who had mitral balloon valvotomy, 19 were aged under 40 years, 101 aged 40–54, 173 aged 55–69, and 112 were 70 years old or more. Medical co-morbidity and Parsonnet score for risk at surgery increased notably with age. Older patients had greater symptomatic limitation and a more severe degree of mitral stenosis, with more valve degenerative change. The incidence of atrial fibrillation, mitral reflux, left ventricular impairment, coronary artery disease, and aortic valve disease increased progressively with age. Before balloon dilatation the right ventricular systolic and left atrial pressures were similar in all age groups, but younger patients had a higher transmitral gradient and cardiac output. After balloon dilatation the younger patients achieved a greater increase in valve area. Complications of balloon valvotomy were more common in the older patients. At five years after balloon dilatation the percentages of patients in each age group who were in New York Heart Association classes I and II were 87%, 63%, 36%, and 19%, respectively. Mortality at five years was 0%, 5%, 31%, and 59%.
Conclusions: Percutaneous balloon valvotomy gives a good haemodynamic and symptomatic result in patients under 55. In older patients improvement is often less pronounced and less sustained, but the procedure is a well tolerated palliative treatment for those unsuitable for surgery.
PMCID: PMC1767985  PMID: 14617555
mitral stenosis; mitral balloon valvotomy; haemodynamics; outcome
7.  Pacemaker lead fracture  
Heart  2003;89(7):783.
PMCID: PMC1767738  PMID: 12807857
Images in cardiology
Heart  2003;89(7):793-800.
PMCID: PMC1767745  PMID: 12807864
acquired immunodeficiency virus; human immunodeficiency virus; HIV; endocarditis; dilated cardiomyopathy
9.  Contemporary criteria for the selection of patients for percutaneous balloon mitral valvuloplasty 
Heart  2002;87(5):401-404.
PMCID: PMC1767103  PMID: 11997400
balloon valvuloplasty; echocardiography; mitral stenosis
10.  Spontaneous "regression" of enhanced immune function in a photoperiodic rodent Peromyscus maniculatus. 
Short days inhibit reproduction and enhance immune function in deer mice (Peromyscus maniculatus). Their reproductive inhibition is sustained by an endogenous timing mechanism: after ca. 20 weeks in short days, reproductive photorefractoriness develops, followed by spontaneous recrudescence of the reproductive system. It is unknown whether analogous seasonal timing mechanisms regulate their immune function or whether enhanced immune function is sustained indefinitely under short days. In order to test this hypothesis, we housed adult male deer mice under long (16 h light day(-1)) or short (8 h light day(-1)) day conditions for 32 weeks or under long day conditions for 20 weeks followed by 12 weeks of short days. Mice under the long day conditions remained photostimulated over the 32 weeks, whereas mice housed under the short day conditions exhibited gonadal regression followed by photorefractoriness and spontaneous recrudescence. Mice transferred to short days at week 20 were reproductively photoregressed at week 32. Total splenocytes, relative splenic mass and mitogen-activated splenocyte proliferation were greater in those mice transferred to short days at week 20 than in those mice housed under either long or short day conditions for 32 consecutive weeks, and immune function in mice exposed to short days for 32 weeks was comparable with that of long day animals. These data suggest that short day enhancement of immune function is not indefinite. With prolonged (< or = 32 weeks) exposure to short days, several measures of immune function exhibit "spontaneous" regression, restoring long day-like immunocompetence. The results suggest that formal similarities and, possibly, common substrates exist among the photoperiodic timekeeping mechanisms that regulate seasonal transitions in reproductive and immune function.
PMCID: PMC1088869  PMID: 11674869
11.  Normalisation of abnormal coronary fractional flow reserve associated with myocardial bridging using an intracoronary stent 
Heart  2000;83(6):705-707.
Although intracoronary stenting procedures have been advocated for the successful treatment of myocardial ischaemia associated with myocardial bridging, the physiological rationale for this approach remains unexplored. The case of a 70 year old man with symptoms of cardiac ischaemia associated with a left anterior descending coronary artery bridge is described, where use of an intracoronary stent abolished the angiographic abnormalities and also restituted pronounced abnormalities of coronary fractional flow reserve.

Keywords: angioplasty; myocardial bridge; coronary flow reserve; stent
PMCID: PMC1760858  PMID: 10814636
12.  Drug eluting coronary stents  
BMJ : British Medical Journal  2002;325(7376):1315-1316.
PMCID: PMC1124789  PMID: 12468460
13.  Early therapeutic experience with the endothelin antagonist BQ-123 in pulmonary hypertension after congenital heart surgery 
Heart  1999;82(4):505-508.
OBJECTIVE—To assess the effect of endothelin type A (ETA) receptor antagonism in infants with pulmonary hypertension following corrective surgery for congenital heart disease.
DESIGN—Open label, preliminary study.
SETTING—Tertiary paediatric cardiothoracic surgical centre.
PATIENTS—Three infants (aged 3 weeks, 7 weeks, and 8 months) with postoperative pulmonary hypertension unresponsive to conventional treatment, including inhaled nitric oxide.
INTERVENTIONS—Patients received incremental intravenous infusions (0.1 to 0.3 mg/kg/h) of the ETA receptor antagonist BQ-123.
MAIN OUTCOME MEASURES—The response to BQ-123 administration was determined using continuous invasive monitoring of cardiorespiratory variables.
RESULTS—BQ-123 infusion caused a reduction in the ratio of pulmonary to systemic pressures (0.62 (0.01) to 0.52 (0.03), mean (SEM)) with an accompanying decrease in right ventricular stroke work index (4.6 (0.4) to 2.5 (0.3) g/m) and a tendency for the cardiac index to rise (2.1 (0.2) to 2.7 (0.6) l/min/kg/m2). This was associated with a well tolerated fall in the arterial partial pressure of oxygen (16.5 (4.1) to 12.4 (3.3) kPa) and mean systemic arterial pressure (57 (3) to 39 (3) mm Hg).
CONCLUSIONS—ETA receptor antagonism in infants with postoperative pulmonary hypertension after corrective surgery for congenital heart disease led to significant improvement in pulmonary haemodynamic indices. However, these benefits were associated with reductions in systemic blood pressure and arterial oxygen saturation, the latter consistent with a ventilation-perfusion mismatch. On the basis of these results, studies in pulmonary hypertension will need to proceed with caution.

Keywords: endothelin-1; pulmonary hypertension; receptor antagonism; congenital heart disease
PMCID: PMC1760282  PMID: 10490569
16.  Hepatitis B immunisation among invasive cardiologists: poor compliance with United Kingdom guidelines. 
British Heart Journal  1995;74(6):685-688.
OBJECTIVES--To assess the compliance of invasive cardiologists in the United Kingdom with recently accepted national guidelines on the protection of health care workers and patients from hepatitis B. To determine levels of awareness of the infectivity and prevalence of the virus and current attitudes towards screening of patients before cardiac catheterisation and surgery. DESIGN--Anonymous postal survey by questionnaire from the University Hospital of Wales, Cardiff. The questionnaire established the respondent's position, knowledge of hepatitis B, current immunological state, and policy towards the routine screening of patients for hepatitis B carriage. PARTICIPANTS--All British cardiologists of consultant or senior registrar grade involved in invasive procedures. RESULTS--The response rate was 78% (211/271). 20% of respondents had never been vaccinated against hepatitis B and about a third of those vaccinated had not complied correctly with the recommended immunisation regimen. There was little uniformity in practices for screening patients for hepatitis B carriage before invasive procedures, and the level of knowledge concerning the prevalence of hepatitis B and the risks of inoculation was poor. CONCLUSIONS--Invasive cardiologists are at high risk of inoculation with hepatitis B. Nationally agreed guidelines are designed to protect both medical staff and patients against the risk of infection but currently they are ill heeded.
PMCID: PMC484132  PMID: 8541179

Results 1-17 (17)