Durable ventricular assist devices for patients with advanced heart failure: the New Zealand experience.

AIMS: The prevalence of heart failure in New Zealand is increasing. A small number of select patients with predicted poor short-term survival are candidates for advanced heart failure therapies such as transplantation and durable mechanical circulatory support (MCS). The aim of our study was to introduce left ventricular assist devices (LVADs) to the wider clinicians and highlight their role in managing patients with advanced heart failure in New Zealand. METHOD: A retrospective audit of all ventricular assist device (VAD) recipients from January 2005 to December 2022 was conducted. Data were collated using electronic medical and paper records. The primary outcome was survival to transplantation or successful explant of VAD. RESULTS: Thirty-nine patients received VADs; 32 were male and seven female. Mean age was 45 years (range 10-64 years). Most recipients were NZ European (25), six were Maori, four were Pacific peoples and four were of other ethnicities. The majority of LVADs were implanted for those with dilated cardiomyopathy (67%). At the time of data collection, 24 (62%) had survived to heart transplantation, seven (18%) died while on VAD support, five from right ventricular failure and two from strokes, one patient had their VAD explanted due to recovery and seven (18%) VAD recipients continue on support awaiting transplant. CONCLUSION: This audit has provided an opportunity to inform New Zealand clinicians of our durable MCS programme and the expanding role of VAD support in patients with advanced heart failure. The programme will need to continue to audit and report its practice in order to provide equitable allocation of this very limited resource to a growing population in need.

The not so innocent heart murmur: a 5-year experience.

BACKGROUND: Auckland City Hospital (ACH) established a Heart Murmur Clinic (HMC) with the aim of providing prompt assessment of patients with asymptomatic systolic murmurs. This may lead to early intervention and improved outcomes if significant structural heart disease is detected and reassurance if no significant findings are found. Similar clinics for children have proven beneficial; the benefit of a HMC in an adult population has been difficult to determine. AIM: To review the clinical demographics and echocardiographic information of patients presenting to our HMC, to assess what proportion of significance structural heart disease had and determine the common structural abnormalities in this population. METHODS: This is a retrospective review of patients aged ≥15 years presenting to our HMC between March 2010 and December 2015 with an asymptomatic systolic murmur. Patients with previous cardiac surgery or known congenital or valvular heart disease were excluded. RESULTS: A total of 1221 patients was reviewed over the 5-year period; 980 underwent echocardiography. Significant cardiac disease was detected in 156 patients, with 23 patients requiring surgical intervention over the 5-year period. Significant aortic stenosis (n = 43) and mitral regurgitation (n = 48) were the most common pathologies. Patients > 65 years were more likely to have structural heart disease (16% vs 11%, P < 0.05). CONCLUSION: Establishing a HMC has allowed the screening of a large number of patients who would otherwise have low priority for assessment. We have identified a large proportion with significant structural disease, which has allowed for early surgical intervention when appropriate and may potentially result in improved patient outcomes.

Left Radial Versus Femoral Access for Coronary Angiography in Post-Coronary Artery Bypass Graft Surgery Patients.

It has been recently demonstrated that coronary angiography of native coronary arteries via the radial artery results in reduced morbidity and mortality, when compared with a femoral approach. However, the efficacy and safety of the transradial approach in patients with coronary grafts is relatively unknown. We performed a retrospective audit of all patients with a history of previous coronary artery bypass graft (CABG) surgery who underwent diagnostic angiography at our institution from 2008-2012. The primary efficacy endpoint was procedure time (minutes), while the secondary efficacy measure was patient radiation exposure (µGy/m²). There were 326 post-CABG patients studied during the defined period, with 254 via femoral approach and 72 via left radial artery. There was no significant difference between the two approaches in procedure time (37 minutes in radial group vs 35 minutes in femoral group; t-test, P=.43). There was also no difference in radiation exposure (7855 µGy/m² in femoral group vs 6825 µGy/m² in radial group; Satterthwaite t-test, P=.08). This study shows the validity of a left radial approach in patients who have undergone angiography post CABG. It suggests that transradial angiography can be safely performed in these patients, without significant increase in procedural time or radiation exposure.

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.

Basing musculoskeletal curriculum changes on the opinions of practicing physicians.

AIM: To establish which musculoskeletal conditions are deemed to be the most important in clinical practice. To use this information to inform the development of a new musculoskeletal curriculum, with emphasis on common and relevant conditions. METHODS: A survey listing 29 musculoskeletal conditions was sent to 150 doctors in Auckland, New Zealand. Doctors from 5 specialties, including general practice, were asked to score each condition on a rating scale from 0 to 7, to determine which conditions were perceived to be the most important as encountered in day-to-day clinical practice. RESULTS: The overall response rate to the survey was 36% and this was predominantly due to the low response rate from general practitioners. Fifteen conditions were given average ratings of 4.5/7 or greater and the top 5 of these were as follows: prolapsed intervertebral disc, hip fracture, mechanical back pain, gout at the great toe and osteoarthritis of the hip. CONCLUSION: This study has used a consensus approach to identify specific musculoskeletal conditions deemed to be the most important in clinical practice. The information obtained can be used for designing a contemporary and relevant musculoskeletal medical curriculum.

Characteristics of University of Auckland medical students intending to work in the regional/rural setting.

AIMS: To assess the level of interest in regional/rural (RR) practice in final year Auckland medical students and to investigate the demographic characteristics and speciality intentions of these students. METHODS: A questionnaire was distributed to all graduating students from The University of Auckland's School of Medicine (SOM) in 2006 and 2007. Students intending to work in a RR setting had their demographic data and intended specialty compared with students intending to work in the city. RESULTS: There were 186 respondents, with a response rate of 71%. Of this cohort, 58% stated an intention to work in a city, 15% in an RR setting, and 27% were undecided. RR-destined students were more likely to be Maori and less likely to be Asian then their city-destined counterparts. RR students were more likely to have strong interests in general practice than students intending to work in the city. CONCLUSION: Prior to the introduction of a specific rural selection pathway, Auckland medical students have shown a similar level of interest in RR medicine when compared to previous studies. However the proportion of students interested in RR health is significantly below the current proportion of people living in RR areas. The large proportion of students undecided on career setting at graduation suggests there may be room to increase the proportion further through formative early postgraduate experiences, or other incentives.