Aortic valve replacement rates in Australia from 2004 to 2019.

BACKGROUND: Several surgical and percutaneous treatments are available for patients with aortic valve disease. AIM: To establish whether trends in aortic valve replacements (AVR) in Australia reflect recent evidence. METHODS: Using the Australian Institute of Health and Welfare data, this study calculated all AVR and balloon aortic valvuloplasty (BAV) procedures conducted in all Australian hospitals from 2004 to 2019. Linear regression analysis was performed to determine whether age-adjusted rates had changed over the study period. RESULTS: There were 80 883 AVR performed. Of these, 66% were men and 64% were aged >70 years. Absolute rates of AVR increased from 3631 to 7277 with a significant 22% age-adjusted rise seen (1.9% increase per year (+0.26 per 100 000 per year; 95% confidence interval 0.19-0.34); P < 0.001). This trend was more pronounced in men than women and in those aged >80 years (+0.23 per 100 000 per year; P < 0.001). Proportion of mechanical AVR implanted fell from 38.4% to 8.6% (P < 0.001). A total of 2683 transcatheter aortic valve implantation (TAVI) procedures was performed in 2019, representing a 52% annual increase from 2014. BAV increased from 66 procedures in 2004 to 862 in 2019. CONCLUSION: Rates of AVR have increased significantly over the past 16 years, particularly in the elderly. Despite international guideline recommendations, fewer mechanical AVR are being used in younger cohorts. The uptake in TAVI rates might reflect evidence that suggests it is a safe alternative, at least in the medium term. BAV has also seen a resurgence during this time period.

Absorbable Suture Embolization in Distal Coronary Perforation.

Coronary artery perforation is a rare but serious complication during percutaneous coronary intervention. Distal or small vessel perforation is usually treated by coil, fat, or microsphere embolization. We describe 5 cases of distal coronary perforation that were managed successfully by a novel technique that uses absorbable sutures. (Level of Difficulty: Advanced.).

Association of hypertension with mortality in patients hospitalised with COVID-19.

OBJECTIVE: To assess whether hypertension is an independent risk factor for mortality among patients hospitalised with COVID-19, and to evaluate the impact of ACE inhibitor and angiotensin receptor blocker (ARB) use on mortality in patients with a background of hypertension. METHOD: This observational cohort study included all index hospitalisations with laboratory-proven COVID-19 aged ≥18 years across 21 Australian hospitals. Patients with suspected, but not laboratory-proven COVID-19, were excluded. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs. RESULTS: 546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (adjusted OR (aOR) 1.09, 95% CI 1.07 to 1.12, p<0.001), heart failure or cardiomyopathy (aOR 2.71, 95% CI 1.13 to 6.53, p=0.026), chronic kidney disease (aOR 2.33, 95% CI 1.02 to 5.32, p=0.044) and chronic obstructive pulmonary disease (aOR 2.27, 95% CI 1.06 to 4.85, p=0.035). Hypertension was the most prevalent comorbidity (49.5%) but was not independently associated with increased mortality (aOR 0.92, 95% CI 0.48 to 1.77, p=0.81). Among patients with hypertension, ACE inhibitor (aOR 1.37, 95% CI 0.61 to 3.08, p=0.61) and ARB (aOR 0.64, 95% CI 0.27 to 1.49, p=0.30) use was not associated with mortality. CONCLUSIONS: In patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality.

Cardiac Complications in Patients Hospitalised With COVID-19 in Australia.

OBJECTIVES: Describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. DESIGN: Observational cohort study. SETTING: Twenty-one (21) Australian hospitals. PARTICIPANTS: Consecutive patients aged ≥18 years admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. MAIN OUTCOME MEASURES: Incidence of cardiac complications. RESULTS: Six-hundred-and-forty-four (644) hospitalised patients (62.5±20.1 yo, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (20) (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (3) (0.5%) patients developed high grade atrioventricular (AV) block. Two (2) (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p<0.001). New onset atrial fibrillation or flutter (6.4% vs 1.0%, p=0.001) and troponin elevation above the ULN (50.3% vs 16.4%, p<0.001) were more common in patients 65 years and older. There was no significant difference in the rate of cardiac complications between males and females. CONCLUSIONS: Among patients with COVID-19 requiring hospitalisation in Australia, troponin elevation was common but clinical cardiac sequelae were uncommon. The incidence of atrial arrhythmias and troponin elevation was greatest in patients 65 years and older.

Pacing Over the Guidewire in Cardiac Structural Intervention: A Practical Guide.

Left ventricular access for aortic valve intervention provides the opportunity to deliver rapid pacing over the guidewire for device positioning and deployment. Temporary pacing delivered via the left ventricle can obviate the need for venous access and has been shown to be a safe alternative to temporary right ventricular pacing. The technique requires some basic knowledge and experience in temporary cardiac pacing. We outline safe practical steps and common pitfalls in using this technique.

Targeting elevated left ventricular end-diastolic pressure following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction - a phase one safety and feasibility study.

INTRODUCTION: Elevated left ventricular end diastolic pressure (LVEDP) is an independent predictor of mortality and heart failure in patients with ST-segment elevation myocardial infarction (STEMI). Whether lowering elevated LVEDP improves outcomes remains unknown. METHODS: This non-randomized, single blinded study with prospective enrolment and sequential group allocation recruited patients undergoing primary percutaneous coronary intervention for STEMI with LVEDP ⩾ 20 mmHg measured immediately after primary percutaneous coronary intervention. The intervention arm (n=10) received furosemide 40 mg intravenous bolus plus escalating doses of glyceryl trinitrate (100 µg per min to a maximum of 1000 µg) during simultaneous measurement of LVEDP. The control group (n=10) received corresponding normal saline boluses with simultaneous measurement of LVEDP (10 readings over 10 min). Efficacy endpoints were final LVEDP achieved, and the dose of glyceryl trinitrate needed to reduce LVEDP by ⩾ 20%. Safety endpoint was symptomatic hypotension (systolic blood pressure < 90 mmHg). RESULTS: From 1 April 2017 to 23 August 2017 we enrolled 20 patients (age: 64±9 years, males: 60%, n=12, anterior STEMI: 65%, n=13). The mean LVEDP for the whole cohort (n=20) was 29±4 mmHg (intervention group: 28±3 mmHg vs. control group: 31±5 mmHg; p=0.1). The LVEDP dropped from 28±3 to 16±2 mmHg in the glyceryl trinitrate + furosemide group (p <0.01) but remained unchanged in the control group. The median dose of glyceryl trinitrate required to produce ⩾ 20% reduction in LVEDP in the intervention group was 200 µg (range: 100-800). One patient experienced asymptomatic decline in systolic blood pressure to below 90 mmHg. There was no correlation between LVEDP and left ventricular ejection fraction. CONCLUSION: The administration of glyceryl trinitrate plus furosemide in patients with elevated LVEDP following primary percutaneous coronary intervention for STEMI safely reduces LVEDP.

Contemporary Management of Coronary Artery Perforation.

While coronary artery perforation remains an uncommon complication of percutaneous coronary intervention, appropriate recognition, early stabilisation and definitive treatment are essential. The immediate goals are to prevent progressive haemodynamic deterioration complicating cardiac tamponade, avoid the need for surgical intervention and limit accompanying mortality. Understanding the role and utility of newer devices that may influence procedural planning and improve procedural results when these complications occur is essential to minimise morbidity and mortality.

Trends in the Incidence of First Acute Myocardial Infarction in Metropolitan and Regional Areas of the Hunter Region.

INTRODUCTION: There is conflicting information regarding the contemporary incidence of first acute myocardial infarction (AMI) in Australia. We sought to document the regional variations in first AMI incidence in a large health district. METHODS: We identified all patients presenting with first AMI in the Hunter region of New South Wales from 2004 to 2013. We calculated age and gender adjusted incidence of AMI and evaluated differences between patients from regional and metropolitan areas. We assessed 30-day and 12-month outcomes, including mortality, through linkage with the NSW Registry of Births Deaths and Marriages. RESULTS: The incidence of first AMI in regional areas was persistently higher throughout the study compared to metropolitan areas (IRR 1.244; 95% CI 1.14-1.35; p≤0.001). There were no significant differences between regional and metropolitan areas in 30-day and 12-month outcomes following presentation with first AMI. CONCLUSIONS: The study demonstrates persistently higher rates in regional compared to metropolitan areas, supporting the need for implementation of targeted intervention and prevention strategies.

Disparities in the incidence of acute myocardial infarction: long-term trends from the Hunter region.

BACKGROUND: Trends in the incidence of acute myocardial infarction (AMI) provide important information for healthcare providers and can allow for accurate planning of future health needs and targeted interventions in areas with an excess burden of cardiovascular disease. AIM: To investigate the regional variations in AMI incidence in the Hunter region. METHODS: Incident cases of AMI identified between 1996 and 2013 from the Hunter New England Health Cardiac and Stroke Outcomes Unit were prospectively collected for this study. We calculated crude and age-adjusted incidence of AMI over an 18-year period and explored differences in remoteness, age, sex and indigenous status. RESULTS: During 1996-2013, a total of 15 480 cases of AMI were identified. There was a significantly higher incidence of AMI in patients from regional areas compared to patients from metropolitan areas. More importantly, while rates of AMI declined by 28% in metropolitan patients, they increased by 8% in regional patients. Males had higher rates of AMI throughout the study period than females, however there was trend over time towards a reduction in AMI incidence in males that was not seen in females. The age-adjusted incidence of AMI for indigenous patients increased by 48% from 2007 to 2013, compared to a 23% decrease in non-indigenous patients. CONCLUSION: Between 1996 and 2013 in the Hunter region, the adjusted incidence of AMI increased for regional patients compared to metropolitan patients with a trend towards a higher adjusted incidence of AMI in the indigenous population.

Multidisciplinary Assessment in Optimising Results of Percutaneous Patent Foramen Ovale Closure.

BACKGROUND: Percutaneous patent foramen ovale (PFO) closure is a therapeutic option to prevent recurrent cerebral ischaemia in patients with cryptogenic stroke and transient cerebral ischaemia (TIA). The apparent lack of benefit seen in previous randomised trials has, in part, reflected inclusion of patients with alternate mechanisms of stroke. The role of formal neurology involvement in accurately delineating the likely aetiology of stroke or TIA is crucial in appropriate identification of patients for device closure. Furthermore, as the benefits of device closure may accrue over time, long-term follow-up is essential to define the role of device closure in management of presumed cryptogenic stroke. METHODS: We retrospectively reviewed our experience with percutaneous PFO device closure since 2005. All subjects who underwent PFO closure at John Hunter and Lake Macquarie Private Hospitals were included in the study. All patients referred for device closure following cryptogenic stroke or TIA had first undergone formal neurology review with appropriate imaging and exclusion of paroxysmal atrial arrhythmia. Patients with a history of transient ischaemic attack (TIA) are frequently referred to a specialised clinic, aimed to identify patients with conditions not referable to cerebral ischaemia, with investigations initiated by the specialist clinic to elucidate an underlying aetiology. Outcome data was derived from the Hunter New England Area Local Health District Cardiac and Stroke Outcomes Unit, in addition to review of the medical record. The Cardiac and Stroke Outcomes Unit prospectively identified all patients presenting with stroke, TIA and atrial fibrillation. RESULTS: One hundred and twelve consecutive patients undergoing percutaneous patent foramen ovale closure between 2005 and 2015 were identified. The average age was 42.7 years and 57 (50.9%) patients were male. Cryptogenic stroke (68.8%) and transient cerebral ischaemia (23.2%) were the most common indications for PFO closure, with the Amplatzer device used in 83 cases (74.1%). Early residual shunting was visible in seven patients (6.3%), however on follow-up agitated saline study only two patients had residual shunt (1.8%). The annual risk of recurrent stroke or TIA was 0.21%. CONCLUSIONS: Percutaneous patent foramen ovale closure can be performed safely and effectively in patients with paradoxical embolism. In selected patients, following appropriate multidisciplinary specialist pre-procedural assessment, excellent long-term results with low incidence of recurrent events may be achieved.

Pre-hospital thrombolysis in ST-segment elevation myocardial infarction: a regional Australian experience.

OBJECTIVE: The system of care in the Hunter New England Local Health District for patients with ST-segment elevation myocardial infarction (STEMI) foresees pre-hospital thrombolysis (PHT) administered by paramedics to patients more than 60 minutes from the cardiac catheterisation laboratory (CCL), and primary percutaneous coronary intervention (PCI) at the CCL for others. We assessed the safety and effectiveness of the pre-hospital diagnosis strategy, which allocates patients to PHT or primary PCI according to travel time to the CCL. DESIGN, SETTING AND PARTICIPANTS: Prospective, non-randomised, consecutive, single-centre case series of STEMI patients diagnosed on the basis of a pre-hospital electrocardiogram (ECG), from August 2008 to August 2013. All patients were treated at the tertiary referral hospital (John Hunter Hospital, Newcastle). MAIN OUTCOME MEASURES: The primary efficacy endpoint was all-cause mortality at 12 months; the primary safety endpoint was bleeding. RESULTS: STEMI was diagnosed in 484 patients on the basis of pre-hospital ECG; 150 were administered PHT and 334 underwent primary PCI. The median time from first medical contact (FMC) to PHT was 35 minutes (IQR, 28-43 min) and to balloon inflation 130 minutes (IQR, 100-150 min). In the PHT group, 37 patients (27%) needed rescue PCI (median time, 4 h; IQR, 3-5 h). The 12-month all-cause mortality rate was 7.0% (PHT, 6.7%; PCI, 7.2%). The incidence of major bleeding (TIMI criteria) in the PHT group was 1.3%; no patients in the primary PCI group experienced major bleeding. CONCLUSION: PHT can be delivered safely by paramedical staff in regional and rural Australia with good clinical outcomes.

Percutaneous device closure of patent foramen ovale using the Premere occlusion device: initial experience, procedural, and intermediate-term results.

BACKGROUND: Percutaneous device closure is a therapeutic option in patients with presumed stroke complicating paradoxical emboli. Newer devices with lower profiles and potentially reduced thrombogenicity have emerged, such as the Premere PFO occlusion device (St Jude Medical, Inc.); there are limited data on the efficacy and procedural experience with this device. METHODS: We evaluated our initial experience with the Premere device in a contemporary patient cohort, comparing the procedural and intermediate follow-up characteristics with the currently utilized Amplatzer PFO occluder. RESULTS: Both devices were similarly effective in terms of immediate procedural success and defect closure. Procedures using the Premere device tended to be longer and required larger vascular access-sheath sizes; there were also significantly more adverse events in the Premere group (4/29) compared to the Amplatzer group (0/42; P=.02), including 1 retroperitoneal bleed, 2 hematomas, and 1 myocardial infarction. CONCLUSIONS: While the Amplatzer device may offer advantages in terms of safety and procedural simplicity, this in part reflects the early procedural experience with this new device. The Premere and Amplatzer PFO occlusion devices are similarly effective in achieving PFO closure when applied to appropriate anatomy and should be considered complementary when performing such procedures.

Pseudoaneurysm after transradial cardiac catheterization: case series and review of the literature.

INTRODUCTION: Radial artery access for diagnostic and therapeutic procedures offers clear advantages in terms of vascular complications. While radial artery occlusion may occasionally complicate radial artery access, new methods of hemostasis are now utilized to avoid this complication. In contrast, pseudoaneurysm following radial artery access is an extremely uncommon complication. METHODS: We describe a series of patients who developed radial artery pseudoaneurysm after their procedure. RESULTS: Five patients developed radial pseudoaneurysm after diagnostic and interventional procedures, likely reflecting inadequate hemostasis following the procedure and delayed bleeding complicating systemic anticoagulation. CONCLUSIONS: While uncommon, radial artery pseudoaneurysm may complicate cardiac catheterization procedures, with anticoagulation an important contributor. The clinical presentation, likely precipitating mechanisms and treatment options are discussed.

Stroke during pregnancy: therapeutic options and role of percutaneous device closure.

Percutaneous device closure of patent foramen ovale has developed into a therapeutic option for patients with presumed cryptogenic stroke. The appropriate use of these therapies relies on appropriate clinical assessment, as well as an understanding of the potential advantages of certain closure devices. Pregnancy is an uncommon scenario for stroke, but nonetheless represents a hypercoaguable state which may predispose to thromboembolism. We describe a case of stroke during pregnancy treated with percutaneous device closure; the role of, and alternatives to, device closure are discussed, as are specific issues related to device selection and the interventional procedure.

Serial angiography in patients with acute coronary syndromes: effect of antithrombotic therapy on angiographic lesion severity.

BACKGROUND: Patients presenting with acute coronary syndromes (ACS) commonly have a responsible culprit coronary lesion. There is limited data on the natural history of this culprit lesion in the short term and whether there is a change in morphology of this lesion in the days following presentation. Furthermore, the effect of antithrombotic therapy on this process is unknown. METHODS: Sixty-eight patients presenting with ACS had their diagnostic study performed at our institution and had coronary angioplasty performed a few days later at a different hospital. Culprit lesion characteristics including minimum luminal diameter (MLD) and percentage diameter stenosis were determined on each occasion. RESULTS: Acute myocardial infarction patients (n=14) had improved culprit lesion characteristics at angioplasty compared to baseline (diameter stenosis 78.9% versus 62.4%, p<0.01). Similarly, patients presenting with unstable angina (UA) or non-ST elevation myocardial infarction (non-STEMI) (n=54) had improved diameter stenosis (78.0% versus 72.7%, p<0.001). The change in MLD was greater in MI patients than UAP/non-STEMI patients (0.6mm versus 0.16mm, p<0.01). CONCLUSION: Treatment of ACS patients with aspirin with anticoagulant therapy followed by delayed intervention results in angiographic improvement in lesion severity which may provide a more favourable environment in which to undertake percutaneous coronary intervention.

Septal ethanol ablation for hypertrophic obstructive cardiomyopathy: early and intermediate results of a Canadian referral centre.

BACKGROUND: Septal ethanol ablation (SEA) is a relatively new interventional nonsurgical treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM). This procedure involves targeted infarction of the basal interventricular septum to reduce left ventricular outflow tract (LVOT) obstruction. OBJECTIVES: To describe the experience with this technique in a large tertiary care centre. METHODS AND RESULTS: Since 1998, 40 HOCM patients with disabling symptoms refractory to medical treatment have undergone SEA. Procedural success was 88% (35 of 40 patients). The LVOT gradient decreased from 86+/-38 mmHg to 16+/-16 mmHg. There were two major complications: one patient died of respiratory failure at 30 days following SEA, and one patient developed a major coronary dissection during the procedure and required emergency myectomy and coronary bypass surgery. There were two late failures (6% of initially successful cases). In both patients, the LVOT gradient and symptoms reappeared some months after the procedure and further interventions were required. In the remaining patients, the gradient continued to decrease to one year; 86% were asymptomatic or have mild symptoms compared with 94% with severe symptoms before SEA. Septal thickness decreased from 20.8+/-2.9 mm to 13.2+/-3.3 mm (P<0.001) at the site of the targeted septal infarct. CONCLUSION: SEA is a feasible option for suitable patients with HOCM.