Complications of cardiac implantable electronic device placement in public and private hospitals.

BACKGROUND: Few safety data exist comparing clinical outcomes in Australian public and private hospitals. We hypothesised that differences could exist between public and private hospitals due to differences in acuity and patient-level co-morbidities. AIMS: To report comparative complications of cardiac implantable electronic device (CIED) placement in public and private hospitals. METHODS: We conducted an observational cohort study of outcomes of patients aged >18 years from 2010 to 2015 undergoing a new permanent pacemaker (PPM), implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy pacemaker or defibrillator (CRT-D/P) implant in NSW and Queensland public and private hospitals. The primary endpoint was major CIED-related complications occurring in-hospital or within 90 days of discharge. The independent effect of hospital sector was determined using multiple logistic regression, adjusting for covariates, including age, sex, co-morbidities and procedural acuity. RESULTS: A total of 32 364 new CIED implants (PPM 23 845, ICD 5361 and CRT-D/P 3158) were included (49% in private hospitals). Overall, 8.0% of private hospital procedures and 9.6% public hospital procedures experienced at least one complication. After adjustment, the overall risk of CIED complications was similar in private and public hospitals (OR: 0.92, 95% CI: 0.84-1.00, P = 0.06). In analysis of individual complications, adjusted all-cause in-hospital mortality was higher in private hospitals, (OR: 1.49, 95% CI: 1.03-2.16, P = 0.036) primarily driven by an excess mortality in acute cases. The adjusted risk of in-hospital generator operation (OR: 0.53, 95% CI: 0.30-0.94, P = 0.03) and post-discharge infection (OR: 0.61, 95% CI: 0.46-0.81, P < 0.001) was lower in private hospitals. CONCLUSIONS: These data identify important similarities and differences in safety outcomes of CIED implantation between Australian public and private hospitals.

Challenges in transformation of the "traditional block rotation" medical student clinical education into a longitudinal integrated clerkship model.

BACKGROUND: Longitudinal integrated clerkships (LIC) in the first major clinical year in medical student training have been demonstrated to be at least equivalent to and in some areas superior to the "traditional block rotation" (TBR). Flinders University School of Medicine is starting a pilot changing the traditional teaching at the major Academic Medical Centre from TBR to LIC (50% of students in other locations in the medical school already have a partial or full LIC programme). METHODS: This paper summarises the expected challenges presented at the "Rendez-Vous" Conference in October 2012: (a) creating urgency, (b) training to be a clinician rather than imparting knowledge, (c) resistance to change. RESULTS: We discuss the unexpected challenges that have evolved since then: (a) difficulty finalising the precise schedule, (b) underestimating time requirements, (c) managing the change process inclusively. DISCUSSION: Transformation of a "block rotation" to "LIC" medical student education in a tertiary academic teaching hospital has many challenges, many of which can be anticipated, but some are unexpected.

Sex Differences in Acute Complications of Cardiac Implantable Electronic Devices: Implications for Patient Safety.

Background To date, limited population-level studies have examined the impact of sex on the acute complications of cardiac implantable electronic devices ( CIED) , including permanent pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy devices. Methods and Results We studied all patients aged >18 years from 2010 to 2015 who were a resident of Australia or New Zealand, undergoing a new permanent pacemaker, implantable cardioverter defibrillator, or cardiac resynchronization therapy implant. Standardized variables were collected including patient demographic characteristics, primary and secondary diagnoses, procedures performed and discharge status. Diagnoses and procedures were coded as per the International Classification of Diseases, Tenth Revision ( ICD-10) and the Australian Classification of Health Interventions. The primary end point was the incidence of major CIED -related complications in-hospital or within 90 days of discharge, with the effect of sex evaluated using multiple logistic regression. A total of 81 304 new CIED (61 658 permanent pacemakers, 12 097 implantable cardioverter defibrillators, 7574 cardiac resynchronization therapy) implants were included (38% women). Overall, 8.5% of women and 8.0% of men experienced a CIED complication ( P=0.008). Differences between women and men remained significant after adjustment for age, procedural acuity, and comorbidities (odds ratio 1.10, 95% CI: 1.04-1.16, P<0.001). Differences in CIED complication rates were primarily driven by excess rate of in-hospital pleural drainage (1.2% women versus 0.6% men, P<0.001; adjusted odds ratio 1.86, 95% CI: 1.59-2.17, P<0.001) and pericardial drainage (0.3% women versus 0.1% men, P<0.001; adjusted odds ratio 2.17, 95% CI: 1.48-3.18, P<0.001). Conclusions Women are at higher risk of acute CIED complications. Improvements in implant technique and technologies are required to minimize the risk of implant-related complications in women.

The Australian Intervention Randomized Control of Rate in Atrial Fibrillation Trial (AIRCRAFT).

OBJECTIVES: The Australian Intervention Randomized Control of Rate in Atrial Fibrillation Trial was a multicenter trial of atrioventricular junction ablation and pacing (AVJAP) compared with pharmacologic ventricular rate control (medication [MED]) in patients with mild to moderately symptomatic permanent atrial fibrillation (AF). BACKGROUND: There have been very few prospective randomized trials, undertaken in highly symptomatic patients, comparing AVJAP with pharmacologic methods of ventricular rate control for patients with permanent AF. METHODS: There were 99 patients (70 men, mean age 68 +/- 8.6 years) at five centers. Forty-nine patients were randomized to AVJAP while 50 patients were randomized to pharmacologic control. The primary end point was cardiac function measured by echocardiography and exercise tolerance. The secondary end points were ventricular rate control, evaluated by 24-h ambulatory electrocardiographic monitoring, and quality of life. Data were collected at randomization and then at one month, six months, and 12 months post-randomization. RESULTS: At 12 months follow-up there was no significant difference in left ventricular ejection fraction (AVJAP: 54 +/- 17%; MED: 61 +/- 13% [p = ns]) or exercise duration on treadmill testing (AVJAP: 4.1 +/- 2 min; MED: 4.6 +/- 2 min [p = ns]); however, the peak ventricular rate was lower in the AVJAP group during exercise (112 +/- 17 beats/min vs. 153 +/- 36 beats/min, p < 0.05) and activities of daily life (117 +/- 16 beats/min vs. 152 +/- 37 beats/min, p < 0.05). The CAST quality-of-life questionnaire revealed that patients in the AVJAP group had fewer symptoms at six months (p = 0.003) and at 12 months (p = 0.004). The observed relative risk reduction in symptoms at 12 months was 18%. Global subjective semiquantitative measurement of quality of life using the "ladder of life" revealed that the AVJAP group reported a 6% better quality of life at six months (p = 0.011). CONCLUSIONS: In this trial, AVJAP for patients with mild to moderately symptomatic permanent AF did not worsen cardiac function during long-term follow-up, and quality of life was improved.

Wolf in wolf's clothing--a case of prosthetic aortic valve thrombosis presenting as an acute coronary syndrome.

Mechanical prosthetic valve thrombosis (PVT) is a potentially life threatening event that occurs with an incidence of 0.2% per patient year following aortic valve replacement [Lengyel M, Fuster V, Keltal M, et al. Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. J Am Coll Cardiol 1997;30:1521-6]. We present the case of a middle-aged man with thrombosis of his aortic valve prosthesis mimicking an acute coronary syndrome. The patient received thrombolytic therapy with subsequent embolism of thrombotic debris to the leg.