Optimal Conduit Diameter Selection in Coronary Bypass Grafting Using Saphenous Vein.

BACKGROUND: Predictors of long-term saphenous vein graft (SVG) patency following coronary artery bypass grafting (CABG) include harvesting technique, degree of proximal coronary stenosis, and target vessel diameter and runoff. The objective of this study was to evaluate the association between vein graft diameter and long-term survival. METHODS: Patients undergoing primary CABG (2000-2017) at Flinders Medical Centre, Adelaide, Australia, were categorised into three groups according to average SVG diameter (<3.5 mm [small], 3.5-4 mm [medium], >4 mm [large]). Survival data was obtained from the Australian Institute of Health and Welfare National Death Index. To determine the association of SVG diameter with long-term survival we used Kaplan-Meier survival analysis and Cox proportional hazard models adjusted for preoperative variables associated with survival. RESULTS: Vein graft diameter was collected in 3,797 patients. Median follow-up time was 7.6 years (interquartile range, 3.9-11.8) with 1,377 deaths. SVG size >4 mm was associated with lower rates of adjusted survival up to 4 years postoperatively (hazard ratio 1.48; 95% confidence interval 1.05-2.1; p=0.026). CONCLUSIONS: Vein graft diameter >4mm was found to be associated with lower rates of survival following CABG.

Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery.

INTRODUCTION: Acute ischemic stroke (AIS) can be a catastrophic complication of cardiac surgery previously without effective treatment. Endovascular thrombectomy (EVT) is a potentially life-saving intervention. We examined patients at our institution who had EVT to treat AIS post cardiac surgery. METHODS: We retrospectively reviewed a stroke database from January 1, 2016 to October 31, 2021 to identify patients who had undergone EVT to treat AIS following cardiac surgery. Demographic data, operation type, stroke severity, imaging features, management and outcomes (mortality and modified Rankin Score (mRS)) were assessed. RESULTS: Of 5022 consecutive patients with AIS, 870 underwent EVT. Seven patients (0.8%) had EVT following cardiac surgery. Operations varied: two coronary artery bypass grafting (CABG), two transcatheter AVR, one redo surgical aortic valve replacement (AVR), one mitral valve repair and one patient with combined aortic and mitral valve replacements and CABG. Meantime postsurgery to stroke symptoms onset was 3 days (range 0-9 days). Median NIHSS was 26 (range 10-32). Five patients had middle cerebral artery occlusion and two internal carotid artery (n = 2). Median time between onset of symptoms and recanalization was 157 min (range 97-263). Two patients received Intra-arterial Thrombolysis. All patients survived and were discharged to another hospital (n = 3), home (n = 2), or rehabilitation facility (n = 2). Median 3-month mRS was 3 (range 0-6). CONCLUSION: We report the largest case series of EVT after cardiac surgery. EVT can be associated with excellent outcomes in these patients. Close neurological monitoring postoperatively to identify patients who may benefit from intervention is key.

Brian Fowell Buxton (15/04/1940-20/05/2022)-Outstanding Achievements and Personal Memories.

Brian F. Buxton, one of Australia's greatest cardiac surgeons, died in May 2022, aged 82 years. In June 2022, a memorial celebration of Brian's life was held in Melbourne, Australia, attended by 550 colleagues and friends from many walks of life-not only "medical people" but also friends involved in Brian's sailing and hiking activities. This Special Article includes an introduction from Professor Jayme Bennetts, President of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS), an abridged version of a memorial address by Professor James Tatoulis and contributions from two other long-term professional colleagues and personal friends of Buxton, Professor Jaishankar Raman and Professor Franklin Rosenfeldt, founding editor of Heart, Lung and Circulation. Buxton was an outstanding and pioneering surgeon, clinical leader, and good friend to many. The Brian F. Buxton Cardiac and Thoracic Aortic Surgery Unit in Melbourne, Australia, is now so named in honour of his outstanding achievements and as a legacy. Vale Brian F. Buxton.

Impact of Surgical and Transcatheter Aortic Valve Replacement on Frailty Score.

OBJECTIVE: Frailty is common in the aortic stenosis (AS) population and impacts outcomes after both transcatheter and surgical aortic valve replacement (TAVR and sAVR, respectively). Frailty can significantly impact the decision regarding the suitability of a patient for aortic valve intervention, with frail patients often excluded. Since many frailty tools use indicators which may be influenced by AS itself, some of which are subjectively symptom driven, we sought to determine the impact of intervention on frailty scores. METHODS: A prospective, observational cohort study included patients being assessed for aortic valve (AV) intervention with either TAVR or sAVR due to severe aortic stenosis. Patients were assessed for symptoms at baseline, and 1- and 6-months post intervention subjectively, using the New York Heart Association (NYHA) class and the Kansas City Cardiomyopathy Questionnaire (KCCQ), and objectively, using a 6-minute walk test (6MWT). These were compared with frailty at baseline and final review using the Fried Frailty Scale (FFS). RESULTS AND CONCLUSIONS: Sixty-six (66) patients completed pre- and post-intervention reviews. The mean FFS score was significantly lower, indicating less frailty, at 6 months relative to pre procedure (1.18 vs 1.73, p=0.002). This correlated with the change in symptoms (p<0.001). Between intervention groups, the final mean FFS of both groups decreased significantly, with TAVR to 1.33 (p=0.030) and sAVR to 0.8 (p=0.015). There was no difference in the degree of improvement between interventions (p=0.517). Aortic valve intervention improves frailty scores in both TAVR and sAVR treated patients.

COVID-19 safety: aerosol-generating procedures and cardiothoracic surgery and anaesthesia - Australian and New Zealand consensus statement.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a contagious disease that is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Health care workers are at risk of infection from aerosolisation of respiratory secretions, droplet and contact spread. There are a number of procedures that represent a high risk of aerosol generation during cardiothoracic surgery. It is important that adequate training, equipment and procedures are in place to reduce that risk. RECOMMENDATIONS: We provide a number of key recommendations, which reduce the risk of aerosol generation during cardiothoracic surgery and help protect patients and staff. These include general measures such as patient risk stratification, appropriate use of personal protective equipment, consideration to delay surgery in positive patients, and careful attention to theatre planning and preparation. There are also recommended procedural interventions during airway management, transoesophageal echocardiography, cardiopulmonary bypass, chest drain management and specific cardiothoracic surgical procedures. Controversies exist regarding the management of low risk patients undergoing procedures at high risk of aerosol generation, and recommendations for these patients will change depending on the regional prevalence, risk of community transmission and the potential for asymptomatic patients attending for these procedures. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: This statement reflects changes in management based on expert opinion, national guidelines and available evidence. Our knowledge with regard to COVID-19 continues to evolve and with this, guidance may change and develop. Our colleagues are urged to follow national guidelines and institutional recommendations regarding best practices to protect their patients and themselves. ENDORSED BY: Australian and New Zealand Society of Cardiac and Thoracic Surgeons and the Anaesthetic Continuing Education Cardiac Thoracic Vascular and Perfusion Special Interest Group.

Prognostic Value of High-Sensitivity Troponin T After On-Pump Coronary Artery Bypass Graft Surgery.

INTRODUCTION: High-sensitivity troponin T (hs-TnT), as a single or serial measurement to predict postoperative mortality and morbidity, appears to be attractive due to its direct relationship in assessing myocardial damage and the widespread availability of hs-TnT testing. Therefore, this study aimed to identify any prognostic value of hs-TnT in predicting in-hospital outcomes after coronary artery bypass graft (CABG) surgery. METHOD: We identified all consecutive patients who underwent on-pump CABG between July 2011 and December 2018. To evaluate the prognostic value of hs-TnT after CABG, we assessed the probability and odds ratio (OR) of adverse events concerning the maximum value of postoperative hs-TnT (measured within 24 hrs). TnT was routinely collected at 0, 6, 12 and 72 hours postoperatively. Values were categorised into intervals of 200 for analysis. A fully Bayesian logistic regression of the adverse event with the troponin T interval (0-200) as the reference level was used. A subgroup analysis was performed in patients with normal and elevated preoperative hs-TnT (< or ≥30 ng/L). The pre-specified primary outcome was a major adverse cardiac or cerebrovascular event (MACCE), defined as a composite of death within 30 days of operation for any cause, myocardial infection (MI), or stroke. RESULTS: 1,318 people underwent on-pump CABG during this period. One hundred and twenty-three (123) (9.3%) experienced MACCE, 14 (1.1%) experienced death within 30 days, 105 (8.0%) experienced MI and 14 (1.1%) experienced stroke. Compared to the reference category (hs-TnT ≤200 ng/L) we found there was an increase in OR with increasing level of hs-TnT for MACCE (p<0.001), 30-day mortality (p=0.003), MI (p<0.001) and ICU stay >48 hours (p<0.001). However, there was no statistically significant association present between hs-TnT and stroke, readmission to the intensive care unit (ICU), return to theatre for bleeding, or new-onset renal dysfunction. CONCLUSION: Peak hs-TnT level, greater than 400 ng/L, measured within 24 hours after CABG surgery is associated with MACCE, 30-day mortality, MI and ICU stay >48 hours. Prospectively designed trials, with clear prognostic and outcome variables, may provide further insight into the prognostic value of hs-TnT post-CABG.

2021 CSANZ and ANZSCTS Position Statement on the Operator and Institutional Requirements for a Transcatheter Aortic Valve Implantation (TAVI) Program in Australia.

This document establishes the minimum standard for accreditation of institutions and operators as endorsed by the Cardiac Society of Australia and New Zealand (CSANZ) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS). The original Joint Society Position Statement was ratified in August 2014. This 2021 update replaces the original and serves as a consensus within which the Conjoint Committee for Trancatheter Aortic Valve Implantation (TAVI) Accreditation will function, as recommended by Medical Services Advisory Committee (MSAC) Determination for TAVI. This is not a Guideline Statement but takes into consideration regional, legislative, and health system factors important to establishing requirements for TAVI accreditation in Australia.

Operator and Institutional Requirements for Transcatheter Mitral Valve Therapies in Australia: a CSANZ and ANZSCTS Position Statement.

This expert Position Statement is a description of the requirements for Accreditation for transcatheter mitral valve therapy (TMVT) in Australia. The requirements include the need for a multidisciplinary Heart Team review of individual cases, mandatory reporting of outcome data to a national TMVT Registry, and accreditation of individuals and institutions by the Conjoint Accreditation Committee, the assigned accreditation authority.

Transcatheter Transseptal Mitral Valve-in-Valve Replacement: An Early Australian Case Series and Literature Review.

BACKGROUND: Transcatheter mitral valve implantation for degenerated bioprostheses has recently emerged as an alternative to redo mitral valve surgery, particularly in patients at high risk for reoperative cardiac surgery. We sought to examine our early experience of transcatheter transseptal mitral valve-in-valve procedures. METHODS: Prospectively collected data was retrospectively reviewed in patients undergoing transcatheter transseptal mitral valve-in-valve implantation using the Edwards Sapien 3 balloon expandable bioprosthesis (Edwards Lifesciences, Irvine, CA, USA). RESULTS: Seven (7) patients underwent the procedure between December 2017 and November 2018. Three (3) patients were young Indigenous Australians (age range 33-41years) who were not suitable for mechanical prostheses; four patients were elderly (age range 82-92 years) and considered high risk for reoperative surgery. The median (maximum, minimum) EuroSCORE II of the group was 7.32 (4.81, 19.89). Procedural success was obtained in six of the seven patients; these six patients had no significant complications and had a median hospital stay of 3 days. In one patient, the device displaced towards the left ventricle on inflation, resulting in left ventricular outflow tract obstruction and haemodynamic instability. Urgent redo mitral valve surgery and explantation of the transcatheter prosthesis was undertaken, however, this patient died postoperatively of multi-organ failure. Of the successfully deployed valves, the median (maximum, minimum) gradient across the new mitral prosthesis was 5.5 mmHg (4, 7) and only one patient had mild mitral regurgitation, all others had no or trivial regurgitation. At 30 days, these six patients are well and all are in New York Heart Association (NYHA) Class I. CONCLUSIONS: Our early experience with transcatheter transseptal mitral valve-in-valve implantation demonstrates this procedure to be feasible in our institution with acceptable early results. Further follow-up is necessary to determine the longevity of valves implanted in this manner, especially in the younger population.

Effect of Balloon Aortic Valvuloplasty on Mortality in Patients With Severe Aortic Stenosis Prior to Conservative Treatment and Surgical or Transcatheter Aortic Valve Replacement.

BACKGROUND: Outcomes following an initial strategy of balloon aortic valvuloplasty (BAV) prior to medical therapy or intervention with surgical or transcatheter aortic valve replacement (SAVR or TAVR) are unclear in the modern transcatheter intervention era. METHODS: A retrospective, observational cohort study of the echocardiography, cardiothoracic surgery and TAVR databases between 1 January 2006 and 31 December 2016 was performed to compare outcomes between all patients with severe aortic stenosis (AS) treated with or without BAV prior to medical or invasive therapy. RESULTS: 3,142 patients were available for analysis. 223 BAV treated patients had lower mortality relative to medically treated patients, particularly early (20.1% v. 7.6% at 6 months, 58.1% v. 52.5% at 5 years). Over 5 years, the adjusted hazard ratio (HR) was 0.62 (95% CI 0.48-0.80, p < 0.001). Compared with 630 patients proceeding directly to intervention, 75 patients receiving BAV experienced a higher mortality (HR = 2.76, 95% CI 2.07-3.66, p < 0.001). No subsequent excess perioperative mortality was observed with BAV compared with those receiving surgery directly (HR = 1.45, 95% CI 0.91-2.31, p = 0.117). CONCLUSIONS: The risk associated with BAV is low, and improves mortality compared with medical therapy. Balloon aortic valvuloplasty treated patients have poorer outcomes, but treatment with BAV does not increase perioperative mortality and may lessen it.

Intrathoracic shoulder dislocation causing rupture of the right main bronchus.

An intrathoracic shoulder dislocation is a rare injury, usually the result of high-energy trauma [Hawkes et al. in Am J Orthop 43(4):E74-E78, 2014; Tsai et al. in Ann Thorac Cardiovasc Surg 20:592-594, 2014, in Rupprecht et al. Bull Emerg Trauma 5(3):212-214, 2017; Abellan et al. J Orthop Surg (Hong Kong)18(2):254-257, 2010]. It often occurs in conjunction with thoracic, pelvic, and long bone injuries. In addition, there is often significant injuries to the shoulder girdle and chest wall associated with neurovascular compromise [Abellan et al. J Orthop Surg (Hong Kong)18(2):254-257, 2010; Lin et al. JBJS Case Connect 6(1):e61, 2016]. Following a literature review, it appears that no cases have been reported of an intrathoracic shoulder dislocation associated with a rupture of the ipsilateral main bronchus. We present a case of a rupture of the right main bronchus that occurred due to high-energy impact and an associated intrathoracic right-shoulder fracture dislocation. Computed tomography identified diastasis of the ipsilateral first intercostal space, humeral head indentation in the hilum of the lung, and a pneumoarthrogram of the right glenohumeral joint.

Outcomes of Redo Valve Surgery in Indigenous Australians.

BACKGROUND: Rheumatic heart disease often leads to valve surgery at a young age in our Indigenous population. Anticoagulation can be problematic and therefore repeat surgery to replace degenerated bioprosthetic valves is common. We sought to examine outcomes following redo valve surgery in this population. METHODS: Data from our institutional database was reviewed from 1992 to 2017. During this period, 82 redo valve surgeries were performed in 73 patients identifying as Aboriginal and Torres Strait Islander. We compared this study group to Indigenous patients undergoing primary valve surgery (n=389) and non-Indigenous patients undergoing redo valve surgery (n=154). RESULTS: Redo patients had a median age of 29.5 years (IQR 24, 44), 59% were female, and they had significant comorbidities. The 30-day mortality in this cohort was 6% (EuroSCORE II 3.57), and they had significant morbidity. The median time to repeat surgery in those who had previous mitral valve surgery was 6.3 years, with no difference between mitral valve repair or replacement at the index procedure. Compared to non-Indigenous patients undergoing redo valve surgery, the Indigenous patients were significantly younger with higher left ventricular function but a greater proportion of pulmonary hypertension. There were no significant differences in short-term outcomes. Compared to Indigenous patients undergoing primary valve surgery, the Indigenous redo patients were significantly younger with more co-morbidities. There was no difference in 30-day mortality, but the redo patients did have significantly greater resource utilisation (increased hospital and intensive care unit (ICU) lengths of stay, ventilation and blood transfusion) and poorer long-term survival. CONCLUSIONS: Indigenous patients presenting for redo valve surgery represent a complex and comorbid group of patients, with outcomes worse than expected in a young population, albeit comparable within study groups. Time from original surgery was short at 6 years, and thus a strategy must be in place in terms of planning future surgeries in this cohort of predominantly young rheumatic heart disease patients.

Public Health Costs for Northern Territory and South Australian Cardiac Surgery Patients.

BACKGROUND: The cost of performing cardiac surgery in the public health system in Australia is unclear. This paper analyses the cost of cardiac surgery performed at Flinders Medical Centre (FMC), South Australia, comparing cost by procedure, rheumatic valvular heart disease status, Aboriginality and location. METHODS: This study is a retrospective, population-based analysis of cardiac surgery data held in the Cardiac Surgery Registry cross-referenced to cost data provided by the FMC Department of Finance and Patient Travel, Accommodation and Transport Services at the Royal Darwin Hospital. Seven hundred ninety-five (795) patients who underwent cardiac surgery at FMC from 1 July 2014 to 30 June 2016 were included. RESULTS: Across all procedures, Northern Territory (NT) Aboriginal patients had a mean total cost of $78,506 which was $24,113 more than NT non-Aboriginal, $28,443 more than South Australian (SA) Aboriginal and $22,955 more than SA non-Aboriginal patients. The total cost of a patient undergoing a repeat sternotomy (reoperative procedure) was found to be significantly higher than a primary procedure ($85,797 versus $59,097). In patients undergoing valve surgery procedures, those identified with rheumatic heart disease had a higher mean total cost than those without (a difference of $25,094). Significantly, the rheumatic patient group showed a higher proportion of reoperative procedures (19% versus 5%). CONCLUSIONS: The cost of treating NT Aboriginal cardiac surgical patients remotely has a significant financial impact upon the health care delivery system, as does the impact of rheumatic heart disease. This study found that the cost for the NT Aboriginal patient group was substantially higher than the NT non-Aboriginal, SA Aboriginal and SA non-Aboriginal patient groups. The additional cost to family and dislocation of social structures is not able to be calculated, but would also clearly weigh heavily on both patient groups. These findings suggest that future health funding models should recognise Aboriginality, remoteness and rheumatic heart disease.

High-Sensitivity Troponin Release Profile After Cardiac Surgery.

BACKGROUND: Postoperative serum troponin levels and perioperative myocardial infarction (MI) rates correlate with mortality and morbidity following cardiac surgery. The objective of this study was to document the release profile of high sensitivity troponin T (hsTnT) following different cardiac operations. METHODS: Patients undergoing one of five different isolated cardiac surgical procedures (eligible preoperative hsTnT <29ng/L, serum creatinine < 0.2mmol/L) were recruited prospectively. Serum hsTnT was measured at 0, 4, 6, 8, 10, 12, 24 and 72hours after the first surgical insult to myocardium, together with daily electrocardiographs. RESULTS: There were 10 patients in the on-pump coronary artery bypass group and 5 each in the remaining groups (off-pump coronary artery bypass, open aortic valve replacement, transcutaneous aortic valve implantation and mitral valve replacement). Five additional patients were excluded due to perioperative MI or renal failure. Median [range] of peak hsTnT was 241[99-566], 64[50-136], 353[307-902], 115[112-275], and 918[604-1166] ng/L, respectively. Operations with the lowest peak hsTnT values peaked earliest (four hours) while those with highest values peaked latest (eight hours). CONCLUSION: After cardiac surgery, the hsTnT profile peaks four to eight hours after the initial surgical insult. The magnitude and timing of the peak correlates to the expected degree of surgically-induced myocardial injury.

Quantitative assessment of paravalvular regurgitation following transcatheter aortic valve replacement.

BACKGROUND: Paravalvular aortic regurgitation (PAR) following transcatheter aortic valve implantation (TAVI) is well acknowledged. Despite improvements, echocardiographic measurement of PAR largely remains qualitative. Cardiovascular magnetic resonance (CMR) directly quantifies AR with accuracy and reproducibility. We compared CMR and transthoracic echocardiography (TTE) analysis of pre-operative and post-operative aortic regurgitation in patients undergoing both TAVI and surgical aortic valve replacement (AVR). METHODS: Eighty-seven patients with severe aortic stenosis undergoing TAVI (56 patients) or AVR were recruited. CMR (1.5 T) and transthoracic echocardiography (TTE) were carried out pre-operatively and a median of 6 days post-operatively. The CMR protocol included regurgitant aortic flows using through-plane phase-contrast velocity. None/trivial, mild, moderate and severe AR by CMR was defined as ≤8%, 9-20%, 21-39%, >40% regurgitant fractions respectively. RESULTS: Pre- and post-operative left ventricular ejection fraction (LVEF) was similar. Post-procedure aortic regurgitant fraction using CMR was higher in the TAVI group (TAVI 16 ± 13% vs. AVR 4 ± 4%, p < 0.01). Comparing CMR to TTE, 27 of 56 (48%) TAVI patients had PAR which was at least one grade more severe on CMR than TTE (Z = -4.56, p <0.001). Sensitivity analysis confirmed the difference in PAR grade between TTE and CMR in the TAVI group (Z = -4.49, p < 0.001). CONCLUSION: When compared to CMR based quantitative analysis, TTE underestimated the degree of paravalvular aortic regurgitation. This underestimation may in part explain the findings of increased mortality associated with mild or greater AR by TTE in the PARTNER trial. Paravalvular aortic regurgitation post TAVI assessed as mild by TTE may in fact be more severe.

A review of outcome following valve surgery for rheumatic heart disease in Australia.

BACKGROUND: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects younger Indigenous and older non-Indigenous Australians. Despite its impact there is limited understanding of the factors influencing outcome following surgery for RHD. METHODS: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to assess outcomes following surgical procedures for RHD and non-RHD valvular disease. The association with demographics, co-morbidities, pre-operative status, valve(s) affected and operative procedure was evaluated. RESULTS: Outcome of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients had longer ventilation, experienced fewer strokes and had more readmissions to hospital and anticoagulant complications. Mortality following RHD surgery at 30 days was 3.1% (95% CI 2.2 - 4.3), 5 years 15.3% (11.7 - 19.5) and 10 years 25.0% (10.7 - 44.9). Mortality following non-RHD surgery at 30 days was 4.3% (95% CI 3.9 - 4.6), 5 years 17.6% (16.4 - 18.9) and 10 years 39.4% (33.0 - 46.1). Factors independently associated with poorer longer term survival following RHD surgery included older age (OR1.03/additional year, 95% CI 1.01 - 1.05), concomitant diabetes (OR 1.7, 95% CI 1.1 - 2.5) and chronic kidney disease (1.9, 1.2 - 2.9), longer invasive ventilation time (OR 1.7 if greater than median value, 1.1- 2.9) and prolonged stay in hospital (1.02/additional day, 1.01 - 1.03). Survival in Indigenous Australians was comparable to that seen in non-Indigenous Australians. CONCLUSION: In a large prospective cohort study we have demonstrated survival following RHD valve surgery in Australia is comparable to earlier studies. Patients with diabetes and chronic kidney disease, were at particular risk of poorer long-term survival. Unlike earlier studies we did not find pre-existing atrial fibrillation, being an Indigenous Australian or the nature of the underlying valve lesion were independent predictors of survival.

Position statement for the operator and institutional requirements for a transcatheter aortic valve implantation (TAVI) program.

The Cardiac Society of Australia and New Zealand (CSANZ) and the Australia and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) have joined together to provide recommendations for institutions and individual operators to assess their ability to initiate and maintain a transcatheter valve program. Transcatheter aortic valve replacement has been developed as an alternative to traditional surgical replacement of the aortic valve in high risk patients, particularly the frail elderly. The position paper has endorsed the important role of a multi-disciplinary "Heart Team" in selecting patients for TAVI as fundamental to the establishment of a successful program. The paper outlines recommendations for the cardiologist to have a background in structural intervention and the surgeon to have experience in high-risk aortic valve replacement. It is further recommended that TAVI programs be established in high volume cardiac surgical centres where on site valve surgery is performed. The paper is intended to provide guidance to individual operators and prospective institutions considering the establishment of a successful TAVI program.

A review of valve surgery for rheumatic heart disease in Australia.

BACKGROUND: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects older non-Indigenous Australians and Aboriginal Australians and/or Torres Strait Islander peoples. Factors associated with the choice of treatment for advanced RHD remain variable and poorly understood. METHODS: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed. Demographics, co-morbidities, pre-operative status and valve(s) affected were collated and associations with management assessed. RESULTS: Surgical management of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients were younger, more likely to be female and Indigenous Australian, to have atrial fibrillation (AF) and previous percutaneous balloon valvuloplasty (PBV). Surgery was performed on one valve in 64.5%, two valves in 30.0% and three valves in 5.5%. Factors associated with receipt of mechanical valves in RHD were AF (OR 2.69) and previous PBV (OR 1.98) and valve surgery (OR 3.12). Predictors of valve repair included being Indigenous (OR 3.84) and having fewer valves requiring surgery (OR 0.10). Overall there was a significant increase in the use of mitral bioprosthetic valves over time. CONCLUSIONS: RHD valve surgery is more common in young, female and Indigenous patients. The use of bioprosthetic valves in RHD is increasing. Given many patients are female and younger, the choice of valve surgery and need for anticoagulation has implications for future management of RHD and related morbidity, pregnancy and lifestyle plans.

Twenty percent human albumin solution fluid bolus administration therapy in patients after cardiac surgery-II: a multicentre randomised controlled trial.

PURPOSE: After cardiac surgery, fluid bolus therapy (FBT) with 20% human albumin may facilitate less fluid and vasopressor administration than FBT with crystalloids. We aimed to determine whether, after cardiac surgery, FBT with 20% albumin reduces the duration of vasopressor therapy compared with crystalloid FBT. METHODS: We conducted a multicentre, parallel-group, open-label, randomised clinical trial in six intensive care units (ICUs) involving cardiac surgery patients deemed to require FBT. We randomised 240 patients to receive up to 400 mL of 20% albumin/day as FBT, followed by 4% albumin for any subsequent FBT on that day, or to crystalloid FBT for at least the first 1000 mL, with use of crystalloid or 4% albumin FBT thereafter. The primary outcome was the cumulative duration of vasopressor therapy. Secondary outcomes included fluid balance. RESULTS: Of 480 randomised patients, 466 provided consent and contributed to the primary outcome (mean age 65 years; median EuroSCORE II 1.4). The cumulative median duration of vasopressor therapy was 7 (interquartile range [IQR] 0-19.6) hours with 20% albumin and 10.8 (IQR 0-22.8) hours with crystalloids (difference - 3.8 h, 95% confidence interval [CI] - 8 to 0.4; P = 0.08). Day one fluid balance was less with 20% albumin FBT (mean difference - 701 mL, 95% CI - 872 to - 530). CONCLUSIONS: In patients after cardiac surgery, when compared to a crystalloid-based FBT, 20% albumin FBT was associated with a reduced positive fluid balance but did not significantly reduce the duration of vasopressor therapy.

Effects of RBT-1 on preconditioning response biomarkers in patients undergoing coronary artery bypass graft or heart valve surgery: a multicentre, double-blind, randomised, placebo-controlled phase 2 trial.

Background: RBT-1 is a combination drug of stannic protoporfin (SnPP) and iron sucrose (FeS) that elicits a preconditioning response through activation of antioxidant, anti-inflammatory, and iron-scavenging pathways, as measured by heme oxygenase-1 (HO-1), interleukin-10 (IL-10), and ferritin, respectively. Our primary aim was to determine whether RBT-1 administered before surgery would safely and effectively elicit a preconditioning response in patients undergoing cardiac surgery. Methods: This phase 2, double-blind, randomised, placebo-controlled, parallel-group, adaptive trial, conducted in 19 centres across the USA, Canada, and Australia, enrolled patients scheduled to undergo non-emergent coronary artery bypass graft (CABG) and/or heart valve surgery with cardiopulmonary bypass. Patients were randomised (1:1:1) to receive either a single intravenous infusion of high-dose RBT-1 (90 mg SnPP/240 mg FeS), low-dose RBT-1 (45 mg SnPP/240 mg FeS), or placebo within 24-48 h before surgery. The primary outcome was a preoperative preconditioning response, measured by a composite of plasma HO-1, IL-10, and ferritin. Safety was assessed by adverse events and laboratory parameters. Prespecified adaptive criteria permitted early stopping and enrichment. This trial is registered with ClinicalTrials.gov, NCT04564833. Findings: Between Aug 4, 2021, and Nov 9, 2022, of 135 patients who were enrolled and randomly allocated to a study group (46 high-dose, 45 low-dose, 44 placebo), 132 (98%) were included in the primary analysis (46 high-dose, 42 low-dose, 44 placebo). At interim, the trial proceeded to full enrollment without enrichment. RBT-1 led to a greater preconditioning response than did placebo at high-dose (geometric least squares mean [GLSM] ratio, 3.58; 95% CI, 2.91-4.41; p < 0.0001) and low-dose (GLSM ratio, 2.62; 95% CI, 2.11-3.24; p < 0.0001). RBT-1 was generally well tolerated by patients. The primary drug-related adverse event was dose-dependent photosensitivity, observed in 12 (26%) of 46 patients treated with high-dose RBT-1 and in six (13%) of 45 patients treated with low-dose RBT-1 (safety population). Interpretation: RBT-1 demonstrated a statistically significant cytoprotective preconditioning response and a manageable safety profile. Further research is needed. A phase 3 trial is planned. Funding: Renibus Therapeutics, Inc.