Comorbidities and Ventricular Dysfunction Drive Excess Mid-Term Morbidity in an Indigenous Australian Coronary Revascularisation Cohort.

BACKGROUND: There is a paucity of data in regards to longer term morbidity outcomes in Indigenous Australian patients undergoing coronary artery bypass grafting (CABG). No comparative data on re-infarction, stroke or reintervention rates exist. Outcome data following percutaneous coronary intervention (PCI) is also extremely limited. Addressing this gap in knowledge forms the major aim of our study. METHODS: This was a single centre cohort study conducted at the Townsville Hospital, Australia which provides tertiary adult cardiac surgical services to the northern parts of the state of Queensland. It incorporated consecutive patients (n=350) undergoing isolated CABG procedures, 2008-2010, 20.9% (73/350) of whom were Indigenous Australians. The main outcome measures were major adverse cardiac or cerebrovascular events (MACCE) at mid-term follow-up (mean 38.9 months). RESULTS: The incidence of MACCE among Indigenous Australian patients was approximately twice that of non-Indigenous patients at mid-term follow-up (36.7% vs. 18.6%; p=0.005; OR 2.525 (1.291-4.880)). Following adjustment for preoperative and operative variables, Indigenous Australian status itself was not significantly associated with MACCE (AOR 1.578 (0.637-3.910)). Significant associations with MACCE included renal impairment (AOR 2.198 (1.010-4.783)) and moderate-severe left ventricular impairment (AOR 3.697 (1.820-7.508)). An association between diabetes and MACCE failed to reach statistical significance (AOR 1.812 (0.941-3.490)). CONCLUSIONS: Indigenous Australians undergoing CABG suffer an excess of MACCE when followed-up in the longer term. High rates of comorbidities in the Indigenous Australian population likely play an aetiological role.

A Review of Coronary Artery Bypass Grafting in the Indigenous Australian Population.

INTRODUCTION: Indigenous Australians experience poorer health outcomes than non-Indigenous Australians. Ischaemic heart disease is a leading contributor to the mortality gap which exists between Indigenous and non-Indigenous Australians. METHODS: We reviewed the literature in regards to Indigenous Australians undergoing coronary artery bypass grafting (CABG) for management of ischaemic heart disease. RESULTS: Younger patients with higher rates of preventable risk factors constitute the Indigenous Australian CABG population. Indigenous Australian females are over-represented in series to date. High rates of left ventricular dysfunction are seen in the Indigenous CABG cohorts potentially reflecting barriers to medical care or the influence of high rates of diabetes observed in the Indigenous Australian population. The distribution of coronary artery disease appears to differ between Indigenous Australian and non-Indigenous CABG cohorts likely reflecting a difference in the referral patterns of the two population groups with diabetes again likely influencing management decisions. Reduced utilisation of arterial conduits in Indigenous Australian cohorts has been identified in a number of series. This is of particular concern given the younger age structure of the Indigenous Australian cohorts. Indigenous Australian patients suffer excess morbidity and mortality in the longer term after undergoing CABG. Ventricular dysfunction and excess comorbidities in the Indigenous Australian CABG population appear largely responsible for this. CONCLUSION: Excess morbidity and mortality endured by Indigenous Australians in the longer term following CABG appears largely contributed to by higher rates of ventricular dysfunction and comorbidities in the Indigenous Australian CABG population. Maximising internal mammary artery use and continued focus on strategies to reduce the impact of diabetes, renal impairment and heart failure in the Indigenous Australian population is essential to reduce the mortality gap experienced by Indigenous Australians secondary to ischaemic heart disease.

An Overview of Indigenous Australian Disadvantage in Terms of Ischaemic Heart Disease.

BACKGROUND: Indigenous Australians experience poorer health outcomes than non-Indigenous Australians and a significant life expectancy gap exists. Ischaemic heart disease (IHD) represents the leading specific cause of death in Indigenous Australians and is a significant, if not the most significant, contributor to the mortality gap. With this narrative review we aim to describe the burden of IHD within the Indigenous Australian community and explore the factors driving this disparity. METHODS: A broad search of the literature was undertaken utilising an electronic search of the PubMed database along with national agency databases-the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS). RESULTS: A complex interplay between multiple factors contributes to the excess burden of IHD in the Indigenous Australian population: CONCLUSIONS: In terms of IHD, Indigenous Australians experience disadvantage at multiple stages of the disease process. Ongoing efforts are needed to continue to inform clinicians of both this disadvantage and strategies to assist negating it. Further research is needed to develop evidence based practices which may help reduce this disparity in outcomes.

Cardiac surgery in Indigenous Australians--how wide is 'the gap'?

BACKGROUND: Cardiovascular disease remains the leading cause of mortality in the Indigenous Australian population. Limited research exists in regards to cardiac surgery in the Aboriginal and Torres Strait Islander (ATSI) population. We aimed to investigate risk profiles, surgical pathologies, surgical management and short term outcomes in a contemporary group of patients. METHODS: Variables were assessed for 557 consecutive patients who underwent surgery at our institution between August 2008 and March 2010. RESULTS: 19.2% (107/557) of patients were of Indigenous origin. ATSI patients were significantly younger at time of surgery (mean age 54.1±13.23 vs. 63.1±12.46; p=<0.001) with higher rates of preventable risk factors. Rheumatic heart disease (RHD) was the dominant valvular pathology observed in the Indigenous population. Significantly higher rates of left ventricular impairment and more diffuse coronary artery disease were observed in ATSI patients. A non-significant trend towards higher 30-day mortality was observed in the Indigenous population (5.6% vs. 3.1%; p=0.244). CONCLUSIONS: Cardiac surgery is generally required at a younger age in the Indigenous population with patients often presenting with more advanced disease. Despite often more advanced disease, surgical outcomes do not differ significantly from non-Indigenous patients. Continued focus on preventative strategies for coronary artery disease and RHD in the Indigenous population is required.

Early experience of transaortic TAVI--the future of surgical TAVI?

BACKGROUND: Trans-catheter aortic valve implantation (TAVI) is now a well recognised procedure for the high risk surgical patient with native or bioprosthetic aortic valve stenosis. Transfemoral and transapical implantation techniques are well described. With increasing referral of more marginal transapical patients, we describe our experience of a transaortic TAVI approach which we believe reduces the postoperative wound pain, respiratory complications, operative risk and hospital stay. METHODS: Patients referred for surgical TAVI underwent trans-catheter aortic valve implantation via an upper sternotomy and direct cannulation of the ascending aorta. RESULTS: Thirteen patients with a mean age of 81 years underwent transaortic Edwards SAPIEN valve implantation. There was no in hospital mortality in our series. One patient required insertion of a permanent pacemaker for complete heart block. There were no aortic cannulation complications. CONCLUSION: The transaortic TAVI approach provides good exposure of the distal ascending aorta, a familiar cannulation site for cardiac surgeons. Our initial experience demonstrates the approach to be a safe technique with the potential for faster and less complicated recovery in patients undergoing surgical TAVI procedures. With further experience and greater acceptance, the transaortic approach may ultimately become the procedure of choice for patients unsuitable for a transfemoral approach.

First Australian transapical mitral valve-in-valve implant for a failed mitral bioprosthesis: how to do it.

Transcatheter aortic valve replacements lower mortality in patients not suitable for surgical valve replacement compared to conservative treatment. Transcatheter valve-in-valve implants have been shown to be feasible in failed bioprostheses in aortic, mitral, pulmonary and tricuspid positions. We report the first Australasian experience of a transapical mitral valve-in-valve placement with an Edwards Sapien(®) transcatheter valve for a failed mitral bioprosthesis, focussing on the technical aspects of this novel procedure. Whilst the evidence for this niche indication is limited currently to case reports and case series, further evaluation of its long term outcomes may justify its use in this particularly high risk group of re-do sternotomy patients.

Management and midterm outcomes of post-infarction ventricular septal defect.

We assessed midterm outcomes, predictors of mortality, and residual defects after repair of post-infarction ventricular septal defect in 10 patients (mean age, 65.3 years; range, 50-78 years) who were operated on between 2000 and 2008. Mean time from onset of symptoms of myocardial infarction to diagnosis of ventricular septal defect was 3.5 days. Time from diagnosis to surgery ranged from 6 h to 84 days. The defects were located anteriorly in 4 patients and posteriorly in 6. Patch reconstruction of the septum was used in 6 patients and the infarct exclusion technique in 4. Hospital mortality was 60%. The only predictor of mortality was tricuspid valve competence (p = 0.048). There was no correlation between location of the defect or type of repair and operative mortality. Residual or recurrent ventricular septal defect was noted in 6 patients. Location of the defect and type of repair were not predictors of residual or recurrent defects. Residual ventricular septal defect was not associated with increased short-term mortality or reduction of functional status. Early mortality associated with post-infarction ventricular septal defect repair is significant. Discharged patients continue to have good functional capacity and quality of life, as well as favorable midterm survival.