Loss of troponin-T labelling in endomyocardial biopsies of cardiac transplant patients is associated with increased rejection grading.

Acute cellular rejection after cardiac transplantation surgery is routinely monitored by pathological assessment of haematoxylin and eosin (H&E) histology of endomyocardial biopsies (EMB). Unfortunately, there is considerable variation in the diagnosis of rejection that has been attributed to the subjectivity involved in assessing the degree of (a) inflammatory infiltrate and (b) myocyte damage. In this work, we sought to investigate the potential of high contrast confocal microscopy for numerically assessing inflammatory infiltrate and myocyte damage in EMB histology. Confocal microscopy was used to capture images from EMB fluorescently labelled for nuclei (DAPI), f-actin (phalloidin), troponin-T (anti-body), and extracellular matrix and cell border (wheat germ agglutinin). Images from 28 biopsy procedures were captured. Standard pathological grading of H&E histology identified the following rejection gradings: 6 0R, 16 1R, 6 2R and no 3R. Confocal imaging was able to identify equivalent features of rejection provided by H&E histology but at higher contrast facilitating quantification. Lymphocytic infiltrate was calculated as the ratio of non-myocyte nuclei to total nuclei. This metric was found to be significantly higher in the biopsies from 2R patients compared to both 1R and 0R patients (P < .05). Myocyte damage was quantified as the loss of troponin-T labelling normalised to f-actin labelling. This metric of myocyte damage found significantly lower amounts of troponin-T in the biopsies from 2R patients compared to those with a 0R rejection grading (P < .05). Confocal imaging and simple image processing routines show potential for numerically assessing both inflammatory infiltrate and myocyte damage in endomyocardial biopsy.

Socio-Economic Disparity is Not Linked to Outcome Following Heart Transplantation in New Zealand.

BACKGROUND: Socio-economic deprivation (SED) is emerging as a risk factor for acute graft rejection (AR) and reduced survival of heart transplant (HT) recipients. The study aim was to evaluate any association between SED status of HT recipients and the development of early AR and long-term survival in New Zealand. METHODS: This was a retrospective cohort study. Over a 30-year period, 329 HT recipients were identified from the Australian and New Zealand Heart Transplant Registry. All patients were divided into two groups according to the 2013 New Zealand Deprivation Index (NZDep2013) Score. Heart transplant recipients with NZDep2013 scores of 1,030 and above that corresponded to the eighth, ninth and tenth NZDep2013 deciles were allocated to the higher SED group and those with NZDep2013 scores below 1,030 to the lower SED group. RESULTS: The incidence of early AR in the higher SED group was 1.158/person-years and in the lower SED group 1.156/person-years. The crude incidence rate ratio was 1.0 (95% CI: 0.71-1.44; p = 0.9997). The prevalence of early AR in the higher SED group was 1.13/person-years and 1.15/person-years in the lower SED group. The crude prevalence rate ratio was 0.98/person-year (95% CI: 0.68-1.41/person-years; p = 0.468). In the higher SED group, mortality was 5.6/100 person-years (95% CI: 4.3-7.4/100 person-years) and 5.2/100 person-years (95% CI: 4.3-6.3/100 person-years) in the lower SED group. The adjusted mortality rate ratio estimate was 1.2 (95% CI: 0.8-1.7; p = 0.426). The higher and lower SED groups had similar survival (p = 0.196). CONCLUSION: Socio-economic disparity in New Zealand HT recipients has no negative impact on the development of AR or survival.

Characteristics and Outcomes of Patients With Severe Aortic Stenosis Discussed by the Multidisciplinary "Heart Team" According to Treatment Allocation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an alternative and effective contemporary intervention to surgical aortic valve replacement (SAVR) for patients with severe aortic valve disease at increased surgical risk. Guidelines recommend a multidisciplinary "Heart Team" (MHT) review of patients considered for a TAVI procedure, but this has been little studied. We reviewed the characteristics, treatments and outcomes of such patients reviewed by the MHT at our centre. METHODS: Data on consecutive patients with severe aortic valve stenosis discussed by the Auckland City Hospital MHT from June 2011 to August 2016 were obtained from clinical records. Patient characteristics, treatment and outcomes were analysed using standard statistical methods. RESULTS: Over the 5-year period 243 patients (mean age 80.2 ± 8.0 years, 60% male) were presented at the MHT meeting. TAVI was recommended for 200, SAVR for 26 and medical therapy for 17 patients, with no significant difference in mean age (80.2 ± 8.3, 80.4 ± 6.1, 80.4 ± 7.3 years, respectively) or EuroSCORE II (6.5 ± 4.7%, 5.3 ± 3.6%, 6.7 ± 4.3%, respectively). Over time, there was an increase in the number of patients discussed and treated, with no change in their mean age, but the mean EuroSCORE II significantly decreased (TAVI p = 0.026, SAVR p = 0.004). Survival after TAVI and SAVR was similar to that of the age-matched general population, but superior to medical therapy p = 0.002 (93% (n = 162), 84% (n = 21) and 73% (n = 18) at one year and 85% (n = 149), 84% (n = 21) and 54% (n = 13) at 2 years, respectively). CONCLUSIONS: An increasing number of patients were discussed at the MHT meeting with the majority undergoing TAVI, with a similar age and EuroSCORE II to those allocated SAVR or medical therapy. Survival following TAVI and SAVR was superior to medical therapy and similar to the age-matched general population. These findings suggest that the MHT process is robust, consistent and appropriately allocating a limited treatment resource.

Natural history of a systemic right ventricle.

The natural history of a systemic right ventricle after an atrial switch procedure has yet to be fully characterised. We describe the case of the longest surviving patient at our institution who underwent a Mustard Baffle correction for dextro-transposition of great arteries in childhood. Over following decades he was reviewed regularly with deteriorating systemic right ventricle function. At around 50 years of age he developed worsening heart failure on maximal medical therapy. He was subsequently assessed for cardiac transplantation which he underwent successfully at the age of 55 years.

Patent Foramen Ovale Closure Versus Medical Therapy for Cryptogenic Stroke: Meta-Analysis of Randomised Trials.

BACKGROUND: Patent foramen ovale (PFO) is a common anatomic variant associated with cryptogenic stroke. Percutaneous PFO closure in these patients to prevent recurrent neurological events has been controversial for decades, and mixed results have been reported from past and recent observational and randomised studies. This meta-analysis of randomised trials aims to compare the efficacy and safety of PFO closure with medical therapy for cryptogenic stroke patients. METHODS: Medline, PubMed, EMBASE, Scopus and Cochrane were searched from January 1980 to September 2017 by two authors independently to include original randomised trials comparing PFO closure with medical therapy for secondary stroke prevention. Relevant study and baseline characteristics and outcomes were extracted and pooled using random-effects models. RESULTS: Amongst 619 articles searched giving 10 full-texts assessed, six studies reporting five randomised trials and totalling 1,829 PFO closure and 1,611 medical therapy patients were included. Pooled hazards ratios (95% confidence interval, p-value) ischaemic stroke, transient ischaemic attack (TIA) and composite neurovascular or mortality events were 0.41 (0.19-0.90, p=0.03), 0.77 (0.51-1.14, p=0.19) and 0.60 (0.44-0.81, p<0.001) for PFO closure compared to medical therapy. Any adverse events, major bleeding and all-cause mortality were similar between modalities (p=0.37-0.95), however PFO closure had higher rates of new onset atrial fibrillation at 4.6 times (p<0.001). CONCLUSION: Our meta-analysis found that, in patients with cryptogenic stroke, percutaneous PFO closure is beneficial at reducing ischaemic stroke and composite neurovascular or mortality events, with a higher incidence of new atrial fibrillation, compared to medical therapy.

Cardiomyopathy as presenting sign of glycogenin-1 deficiency-report of three cases and review of the literature.

We describe a new type of cardiomyopathy caused by a mutation in the glycogenin-1 gene (GYG1). Three unrelated male patients aged 34 to 52 years with cardiomyopathy and abnormal glycogen storage on endomyocardial biopsy were homozygous for the missense mutation p.Asp102His in GYG1. The mutated glycogenin-1 protein was expressed in cardiac tissue but had lost its ability to autoglucosylate as demonstrated by an in vitro assay and western blot analysis. It was therefore unable to form the primer for normal glycogen synthesis. Two of the patients showed similar patterns of heart dilatation, reduced ejection fraction and extensive late gadolinium enhancement on cardiac magnetic resonance imaging. These two patients were severely affected, necessitating cardiac transplantation. The cardiomyocyte storage material was characterized by large inclusions of periodic acid and Schiff positive material that was partly resistant to alpha-amylase treatment consistent with polyglucosan. The storage material had, unlike normal glycogen, a partly fibrillar structure by electron microscopy. None of the patients showed signs or symptoms of muscle weakness but a skeletal muscle biopsy in one case revealed muscle fibres with abnormal glycogen storage. Glycogenin-1 deficiency is known as a rare cause of skeletal muscle glycogen storage disease, usually without cardiomyopathy. We demonstrate that it may also be the cause of severe cardiomyopathy and cardiac failure without skeletal muscle weakness. GYG1 should be included in cardiomyopathy gene panels.

Performance of contemporary surgical risk scores for mitral valve surgery.

BACKGROUND: Risk stratification for mitral valve repair or replacement (MVR) is important in the decision-making for treating several mitral valve disease but is rarely studied. We compared the prognostic utility of EuroSCORE, EuroSCORE II, and Society of Thoracic Surgeons (STS) Score for MVR. METHODS: The three scores were retrospectively calculated for consecutive patients undergoing isolated MVR at Auckland City Hospital during 2005-2012 and their discrimination and calibration for mortality and morbidities assessed. RESULTS: There were 408 patients (mitral valve repair 48.1% and replacement 51.9%) followed-up for 6.0 ± 2.6 years. The operative mortality was 2.5%. Mean EuroSCORE, EuroSCORE II, and STS Score were 7.6%, 3.4%, and 3.5%. C-statistics were 0.844, 0.817, and 0.850 for operative mortality. Hosmer-Lemeshow test p values were 0.076, 0.541, and 0.306, and Brier scores 0.0246, 0.0035, and 0.0075, respectively, for operative mortality. The numerically highest c-statistic for predicting complications include EuroSCORE for return to the operating room (c = 0.673); EuroSCORE II for stroke (c = 0.669) and mediastinitis (c = 0.801); and STS for renal failure (c = 0.828), ventilation >24 hours (c = 0.789), and composite morbidity (c = 0.732). The individual STS complication models for MVR had a numerically higher c-statistic only for stroke (c = 0.737). CONCLUSIONS: All scores discriminated mortality and most morbidities after MVR, although EuroSCORE over-estimated operative mortality. The STS Score was the best overall predictor of mortality and morbidity in the MVR cohort.

Transcatheter closure of secundum atrial septal defects: has fear of device erosion altered outcomes?

BACKGROUND: Transcatheter device closure has become the established standard of care for suitable atrial septal defects. Device erosion has been a recent focus and has prompted changes in the Instructions for Users documentation released by device companies. We reviewed our entire local experience with atrial septal defect device closure, focussing on the evolution of this procedure in our centre and particularly on complications. METHODS: We carried out a retrospective review of 581 consecutive patients undergoing attempted transcatheter device closure of an atrial septal defect in Auckland from December 1997 to June 2014. We reviewed all complications recorded and compared our outcomes with the current literature. We sought to understand the impact of the evolution in recommendations and clinical practice on patient outcomes in our programme. RESULTS: There were a total of 24 complications (4.1%), including 10 device embolisations (1.7%), nine arrhythmias (1.5%), two significant vascular access-related complications (0.3%), one device erosion (0.2%), one malposed device (0.2%), and one probable wire perforation of the left atrial appendage (0.2%). There was one mortality related to device embolisation. All device embolisations occurred following the change in Instructions for Users after publication of the first device erosion report in 2004. This increase in embolisation rate was statistically significant (p-value 0.015). CONCLUSIONS: In our series, the incidence of device embolisation was higher than that anticipated, with a significant increase following changes to the Instructions for Users. This highlights the need for ongoing data collection on complication incidence and for ongoing review of the impact of changes in clinical practice on complication rates.

Aortic Valve Replacement With or Without Concurrent Coronary Artery Bypass Grafting in Octogenarians: Eight-Year Cohort Study.

BACKGROUND: With the introduction of transcatheter aortic valve implantation (TAVI), there is increasing interest in evaluating outcomes of aortic valve replacement (AVR) with or without (+/-) concurrent coronary artery bypass grafting (CABG) particularly in high-risk patients. We reviewed the characteristics and outcomes of octogenarians undergoing isolated AVR and AVR+CABG. METHODS: All patients 80 years of age or older undergoing AVR+/-CABG at Auckland City Hospital during 2005-2012 were included, and their characteristics and outcomes analysed. RESULTS: There were 93 and 104 octogenarians respectively undergoing isolated AVR and AVR+CABG with mean follow-up of 4.4+/-2.2 years and 4.1+/-2.3 years. Significant differences in baseline and operative characteristics contributed to higher EuroSCORE II (5.9 vs 6.4%, P=0.016) and STS Score (4.9 vs 6.9%, P<0.001) for AVR+CABG patients. They also had a significantly higher rate of 30-day mortality (0.0% vs 6.7%, P=0.015) and prolonged ventilation>24hours (10.7% vs 23.1%, P<0.001), but not composite morbidity (P=0.248) or stroke (P=0.709). Long-term survival was similar at one, three and five years; 94.6%, 82.6% and 73.0% for AVR and 91.3%, 86.1% and 67.6% for AVR+CABG. Independent predictors of 30-day mortality included reduced creatinine clearance and history of myocardial infarction. CONCLUSION: AVR+CABG had significantly higher but acceptable 30-day mortality in octogenarians than AVR. We have identified prognostic factors important in the decision-making of treatment modality, where age alone should not preclude surgery.

Comparing Performance of Risk Scores for Combined Aortic Valve Replacement and Coronary Bypass Grafting Surgery.

BACKGROUND: Aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) make up the majority of cardiac surgery with increasing demand as the population ages. Accuracy of risk stratification is important, in predicting adverse outcomes and selecting modality of intervention, but has been rarely studied for the combined AVR+CABG operation. We compared the prognostic utility of EuroSCORE, EuroSCORE II and Society of Thoracic Surgeons' (STS) Score for AVR+CABG. METHODS: All patients (n=450) undergoing AVR+CABG at Auckland City Hospital during 2005-2012 with mean follow-up of 4.7+/-2.5 years were included. The three risk scores were calculated and their discrimination and calibration for mortality and morbidities assessed. RESULTS: Operative mortality was 6.4% (29), and mean scores were EuroSCORE 12.5+/-11.1%, EuroSCORE II 6.6+/-6.1% and STS Score 5.5+/-4.4%. C-statistics were 0.587, 0.669 and 0.699 respectively for operative mortality, Hosmer-Lemeshow test P-values were 0.064, 0.718 and 0.567, and Brier Score 0.716, 0.585 and 0.588. Independent predictors of operative mortality were history of myocardial infarction and impaired renal function. Society of Thoracic Surgeons' score also was the most accurate score for predicting mortality during follow-up (c=0.663), composite morbidity (c=0.627), stroke (c=0.642), prolonged ventilation>24hours (c=0.642), and return to theatre (c=0.612). CONCLUSION: The STS score has the best discriminative ability for mortality and the majority of complications after AVR+CABG, while its calibration was similar to EuroSCORE II and superior to EuroSCORE. It should therefore be used for risk stratification and when considering surgical versus percutaneous intervention in those with concurrent aortic valve and coronary artery disease.

T-tubule disease: Relationship between t-tubule organization and regional contractile performance in human dilated cardiomyopathy.

Evidence from animal models suggest that t-tubule changes may play an important role in the contractile deficit associated with heart failure. However samples are usually taken at random with no regard as to regional variability present in failing hearts which leads to uncertainty in the relationship between contractile performance and possible t-tubule derangement. Regional contraction in human hearts was measured by tagged cine MRI and model fitting. At transplant, failing hearts were biopsy sampled in identified regions and immunocytochemistry was used to label t-tubules and sarcomeric z-lines. Computer image analysis was used to assess 5 different unbiased measures of t-tubule structure/organization. In regions of failing hearts that showed good contractile performance, t-tubule organization was similar to that seen in normal hearts, with worsening structure correlating with the loss of regional contractile performance. Statistical analysis showed that t-tubule direction was most highly correlated with local contractile performance, followed by the amplitude of the sarcomeric peak in the Fourier transform of the t-tubule image. Other area based measures were less well correlated. We conclude that regional contractile performance in failing human hearts is strongly correlated with the local t-tubule organization. Cluster tree analysis with a functional definition of failing contraction strength allowed a pathological definition of 't-tubule disease'. The regional variability in contractile performance and cellular structure is a confounding issue for analysis of samples taken from failing human hearts, although this may be overcome with regional analysis by using tagged cMRI and biopsy mapping.

Next-generation endomyocardial biopsy: the potential of confocal and super-resolution microscopy.

Confocal laser scanning microscopy and super-resolution microscopy provide high-contrast and high-resolution fluorescent imaging, which has great potential to increase the diagnostic yield of endomyocardial biopsy (EMB). EMB is currently the gold standard for identification of cardiac allograft rejection, myocarditis, and infiltrative and storage diseases. However, standard analysis is dominated by low-contrast bright-field light and electron microscopy (EM); this lack of contrast makes quantification of pathological features difficult. For example, assessment of cardiac allograft rejection relies on subjective grading of H&E histology, which may lead to diagnostic variability between pathologists. This issue could be solved by utilising the high contrast provided by fluorescence methods such as confocal to quantitatively assess the degree of lymphocytic infiltrate. For infiltrative diseases such as amyloidosis, the nanometre resolution provided by EM can be diagnostic in identifying disease-causing fibrils. The recent advent of super-resolution imaging, particularly direct stochastic optical reconstruction microscopy (dSTORM), provides high-contrast imaging at resolution approaching that of EM. Moreover, dSTORM utilises conventional fluorescence dyes allowing for the same structures to be routinely imaged at the cellular scale and then at the nanoscale. The key benefit of these technologies is that the high contrast facilitates quantitative digital analysis and thereby provides a means to robustly assess critical pathological features. Ultimately, this technology has the ability to provide greater accuracy and precision to EMB assessment, which could result in better outcomes for patients.

Intra-aortic balloon counterpulsation in contemporary practice - where are we?

The intra-aortic balloon pump (IABP) remains the most widely used form of mechanical circulatory support in current clinical practice. This article will review the current evidence to guide IABP use, focussing on large registry and prospective, randomised data, and seek to establish appropriate roles for the IABP in contemporary practice. Despite a paucity of clinical evidence, the IABP remains a useful clinical tool in selected settings, although its routine, up-front use in relatively unselected MI populations is not supported by data. Although current evidence no longer supports routine use in certain high-risk groups, further studies of appropriately selected high-risk patients may yet demonstrate benefit in patients with moderate-severe degrees of shock.

Comparison of Risk Scores for Prediction of Complications following Aortic Valve Replacement.

BACKGROUND: Risk models play an important role in stratification of patients for cardiac surgery, but their prognostic utilities for post-operative complications are rarely studied. We compared the EuroSCORE, EuroSCORE II, Society of Thoracic Surgeon's (STS) Score and an Australasian model (Aus-AVR Score) for predicting morbidities after aortic valve replacement (AVR), and also evaluated seven STS complications models in this context. METHODS: We retrospectively calculated risk scores for 620 consecutive patients undergoing isolated AVR at Auckland City Hospital during 2005-2012, assessing their discrimination and calibration for post-operative complications. RESULTS: Amongst mortality scores, the EuroSCORE was the best at discriminating stroke (c-statistic 0.845); the EuroSCORE II at deep sternal wound infection (c=0.748); and the STS Score at composite morbidity or mortality (c=0.666), renal failure (c=0.634), ventilation>24 hours (c=0.732), return to theatre (c=0.577) and prolonged hospital stay >14 days post-operatively (c=0.707). The individual STS complications models had a marginally higher c-statistic (c=0.634-0.846) for all complications except mediastinitis, and had good calibration (Hosmer-Lemeshow test P-value 0.123-0.915) for all complications. CONCLUSION: The STS Score was best overall at discriminating post-operative complications and their composite for AVR. All STS complications models except for deep sternal wound infection had good discrimination and calibration for post-operative complications.

A review of a regional primary percutaneous coronary intervention service, with a focus on door to reperfusion times: the 2012 Auckland/Northland experience.

AIMS: Primary percutaneous coronary intervention (PCI) is the optimal management for ST segment elevation myocardial infarction (STEMI) patients. We reviewed the largest primary PCI regional service in New Zealand: the Auckland/Northland service based at Auckland City Hospital, to assess patient management, in particular the door to reperfusion times (DTRTs), and predictors of death in hospital. METHODS: We obtained patient details from a comprehensive prospective database of all primary PCI patients admitted with STEMI from 1/1/12 to 31/12/12 to the Auckland City Hospital cardiac catheterisation laboratory. Of four District Health Boards (DHBs) within the region, two accessed this regional service at all times, and two accessed the Auckland City Hospital cardiac catheterisation laboratory 'after hours': all times except for 08:00 to 16:00 hours on Monday to Friday. RESULTS: A total of 401 adult patients underwent a primary PCI at the Auckland City Hospital Regional centre for a STEMI presentation, over the 12 months period. The median patient age was 61 years, 77% were male. Overall 183 (46%) (95% CI 41, 51) patients achieved a DTRT of < 90 mins, and 266 (66%) (95% CI 61, 71) a DTRT of < 120 mins, with a clear geographical influence to these times. Of 27 patients with direct transfer to the catheter laboratory from the community, the DTRT was < 120 mins in 24 (92%) (95% CI 72, 96) patients. In-hospital mortality was 24 (6%) patients (95% CI 4, 9). CONCLUSIONS: The 2012 Auckland/Northland primary PCI service delivers good outcomes consistent with current Australasian standards. Although geographical isolation complicates door to reperfusion times, these may potentially be improved by more focus on direct transfer to the cardiac catheterisation laboratory, especially directly from the community.

B-type natriuretic peptide forms within the heart, coronary sinus, and peripheral circulation in humans: evidence for degradation before secretion.

BACKGROUND: The B-type natriuretic peptides (BNP and N-terminal pro-BNP) are secreted by the heart and, in the case of BNP, serve to maintain circulatory homeostasis through renal and vascular actions and oppose many effects of the renin-angiotensin system. Recent evidence suggests that in patients with severe heart failure, circulating immunoreactive BNP is made up mainly of metabolites that may have reduced bioactivity. We hypothesized that BNP may be degraded before it even leaves the heart. METHODS: Peripheral venous plasma plus atrial and ventricular tissue, obtained from explanted hearts at the time of transplantation, were collected from 3 patients with end-stage heart failure. In a separate study, plasma was collected from the coronary sinus and femoral artery of 3 separate patients undergoing cardiac catheterization. Plasma C18 reverse-phase extracts were separated on reverse-phase HPLC, and the collected fractions were subjected to RIAs with highly specific antisera directed to the amino- and carboxy-terminal ends of BNP(1-32). RESULTS: ProBNP, BNP(1-32), and 2 major BNP metabolites were present in atrial and ventricular tissue, where BNP(1-32) represented 45% and 70% of total processed BNP, respectively. Neither BNP(1-32) nor the 2 metabolites were detected in peripheral venous plasma. Nor was BNP(1-32) detected in matching coronary sinus and femoral artery plasma from the 3 patients undergoing cardiac catheterization. CONCLUSIONS: BNP(1-32) is partly degraded within the hearts of patients with end-stage heart failure, and even in patients with relatively well-preserved left ventricular systolic function, only BNP metabolites enter the systemic circulation.

Initial clinical experience with the Coherex FlatStent™ and FlatStent™ EF PFO closure system for in-tunnel PFO closure: results of the Coherex-EU study.

OBJECTIVE: The Coherex-EU Study evaluated the safety and efficacy of PFO closure utilizing novel in-tunnel PFO closure devices. BACKGROUND: Transcatheter closure of patent foramen ovale (PFO) followed the development of transcatheter closure devices designed to patch atrial septal defects (ASDs). The Coherex FlatStent™ and FlatStent™ EF devices were designed specifically to treat PFO anatomy. METHODS: A total of 95 patients with a clinical indication for PFO closure were enrolled in a prospective, multicenter first in man study at six clinical sites. Thirty-six patients received the first-generation FlatStent study device, and 57 patients received the second-generation FlatStent EF study device, which was modified based on clinical experience during the first 38 cases. Two patients enrolled to receive the first generation did not receive a device. RESULTS: At 6 months post-procedure, 45% (17/38) of the intention-to-treat (ITT) cohort receiving the first-generation FlatStent device had complete closure, 26% (10/38) had a trivial residual shunt, and 29% (11/38) had a moderate to large residual shunt. In the ITT cohort receiving the second-generation FlatStent EF device, 76% (43/57) had complete closure, 12% (7/57) had a trivial shunt, and 12% had a moderate to large shunt. Five major adverse events occurred, all without sequelae. CONCLUSION: This initial study of the Coherex FlatStent/FlatStent EF PFO Closure System demonstrated the potential for in-tunnel PFO closure. The in-tunnel Coherex FlatStent EF may offer an alternative to septal repair devices for PFO closure in appropriately selected patients; however, further investigation will be necessary to establish the best use of this device.

Frequency and sequelae of retained implanted cardiac device material post heart transplantation.

BACKGROUND: Cardiac implantable electronic devices (CIEDs) have now become common therapeutic adjuncts for patients prior to orthotopic heart transplantation (OHT). Removal of the generator and the intracardiac components occurs at time of transplantation but removal of the intravascular portion of leads may be unsuccessful without specialized extraction equipment. METHODS: We performed a retrospective audit of chest radiographs and clinical records of patients undergoing OHT at Green Lane and Auckland City Hospitals between 2002 and 2012. RESULTS: At the time of transplant surgery, 56 of 100 patients had a CIED in situ. Hardware was retained postoperatively in 22 (39%), and the CIED had been in situ for 47 (interquartile range [IQR] 16-68) months for these cases, compared to 14 (IQR 3-24) months in those without. In two (9%) patients, the device generator was electively explanted during the week following OHT. There were no subsequent procedures undertaken to remove retained lead fragments. One (4%) had lead fragment embolization, one (4%) had endoluminal fragment migration, and one (4%) had lead fragment erosion into the mediastinum; all were asymptomatic and without adverse clinical sequelae. There was no infection associated with this hardware. The presence of retained lead fragments was not associated with additional mortality. CONCLUSIONS: Retained lead fragments following OHT occur commonly, without adverse clinical events for this cohort; however, the long-term clinical implications remain uncertain. Complete removal of all CIED hardware should be attempted at the time of OHT, and when this is not possible leads should be left in a state that facilitates their removal at a later date if required.

Isolated aortic valve replacement in octogenarians before and after the introduction of trans-catheter aortic valve implantation.

BACKGROUND: Trans-catheter aortic valve implantation (TAVI) became available at Auckland City Hospital in 2011 for patients with severe aortic stenosis in whom surgical aortic valve replacement (AVR) was deemed at high risk. We assessed whether introduction of TAVI affected the characteristics and outcomes of octogenarians undergoing AVR. METHODS: Isolated AVR performed in patients ≥80 years of age during 2008-2012 were divided into two groups, pre- and post-TAVI introduction, for analyses. RESULTS: Isolated AVR was undertaken in 35 and 33 octogenarians pre- and post-TAVI introduction. The post-TAVI group were older (84.2 vs 82.3 years, P=0.003), had lower ejection fraction (P=0.026), more had inpatient surgery (76% vs 29%, P<0.001), with higher EuroSCORE II (5.4 vs 3.9%, P=0.033). Operative mortality was 0.0% in both groups. One-year survival was similar (97.6% vs 94.3%, P=0.613), but composite morbidity was lower in the post-TAVI group (9.1% vs 31.4%, P=0.035). Chronic respiratory disease (P=0.043) independently predicted mortality during follow-up, while number of coronary vessel>50% stenosis (P=0.050), creatinine clearance (P=0.016) and being in the pre-TAVI era group (P=0.022) predicted composite morbidity. CONCLUSIONS: Since TAVI was introduced, mean age and risk scores significantly increased in octogenarians undergoing AVR, while mortality rates remained similar and composite morbidity decreased.

Closure of a broncho-pleural fistula using an atrial septal defect occluder.

Broncho-pleural fistulae (BPF) are recognised as a rare complication following pneumonectomy. We describe a patient, who after failing conservative treatment, underwent closure of a persistent fistula with an atrial septal defect (ASD) occluder. Additionally we review the literature regarding management of BPF and the emerging role of cardiac defect closure devices as a possible treatment option.