Healthcare exposures and associated risk of endocarditis after open-heart cardiac valve surgery.

BACKGROUND: Infective endocarditis (IE) following cardiac valve surgery is associated with high morbidity and mortality. Data on the impact of iatrogenic healthcare exposures on this risk are sparse. This study aimed to investigate risk factors including healthcare exposures for post open-heart cardiac valve surgery endocarditis (PVE). METHODS: In this population-linkage cohort study, 23,720 patients who had their first cardiac valve surgery between 2001 and 2017 were identified from an Australian state-wide hospital-admission database and followed-up to 31 December 2018. Risk factors for PVE were identified from multivariable Cox regression analysis and verified using a case-crossover design sensitivity analysis. RESULTS: In 23,720 study participants (median age 73, 63% male), the cumulative incidence of PVE 15 years after cardiac valve surgery was 7.8% (95% CI 7.3-8.3%). Thirty-seven percent of PVE was healthcare-associated, which included red cell transfusions (16% of healthcare exposures) and coronary angiograms (7%). The risk of PVE was elevated for 90 days after red cell transfusion (HR = 3.4, 95% CI 2.1-5.4), coronary angiogram (HR = 4.0, 95% CI 2.3-7.0), and healthcare exposures in general (HR = 4.0, 95% CI 3.3-4.8) (all p < 0.001). Sensitivity analysis confirmed red cell transfusion (odds ratio [OR] = 3.9, 95% CI 1.8-8.1) and coronary angiogram (OR = 2.6, 95% CI 1.5-4.6) (both p < 0.001) were associated with PVE. Six-month mortality after PVE was 24% and was higher for healthcare-associated PVE than for non-healthcare-associated PVE (HR = 1.3, 95% CI 1.1-1.5, p = 0.002). CONCLUSIONS: The risk of PVE is significantly higher for 90 days after healthcare exposures and associated with high mortality.

Trends in Isolated Mitral Valve Repair or Replacement Surgery in Australia: A Statewide Cohort Linkage Study.

BACKGROUND: Global trends in mitral valve surgery (MVSx) suggest increasing repair compared with replacement, especially in the United States and European countries. The relative use, and outcomes of, MV repair and replacement in Australia are unknown. METHODS: New South Wales residents who underwent isolated MVSx between 2001 and 2017 were identified from the Admitted-Patient-Data-Collection database. Mortality outcomes were tracked to 31 Dec 2018 and adjusted based on age, sex, urgency of operation, and comorbidity status. RESULTS: The study cohort comprised 5,693 patients: 2020 (35%) underwent repair (MVr), 1,656 (29%) underwent mechanical replacement (mech.MVR), and 2017 (35%) underwent bioprosthetic replacement (bio.MVR). Respective median ages [interquartile range] were 67 yo [59-75 yo], 64 yo [55-71 yo], and 75 yo [68-80 yo] (p<0.001 across groups). Between 2001 and 2017, total MVSx increased steadily with population growth. Whereas the relative use of MVr remained static (34% to 38%), that for bio.MVR (22% to 50%) and mech.MVR (45% to 13%) changed significantly. MVr had the best outcome with 1.2% in-hospital, 2.5% 1-year, and 21.6% total cumulative mortality during a median follow-up of 6.5 years. Compared to MVr, the adjusted hazard ratio (aHR) for mech.MVR and bio.MVR for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) and 1.73 (95% CI=1.53-1.95), respectively. Heart failure and sepsis were the main cardiovascular and noncardiovascular causes of death in all groups. CONCLUSION: In this statewide Australian cohort examined over 17 years, MVr is potentially underutilised despite having superior outcomes to MVR. Access to quality dataset which provides the indication for MVSx and quantitative clinical factors is critical to further improve MVr coverage and outcome MVSx.

Outcomes Following Triple Cardiac Valve Surgery Over 17-years: A Multicentre Population-Linkage Study.

INTRODUCTION: Studies have reported increasing triple valve surgery (TVS, defined as concomitant aortic, mitral and tricuspid valves surgery) incidence and improved postoperative survival. The epidemiology and outcome of TVS is not known in Australia. METHODS: From the Admission-Patient-Data-Collection registry, all New South Wales residents who underwent cardiac valve surgery between 1 July 2001 and 31 December 2018 were identified, with cause-specific mortality tracked from the death registry. RESULTS: Triple valve surgery comprised 1.2% (347/28,667 cases) of all valvular surgeries. Volumes rose from eight cases-per-annum in 2002 to a peak of 37 in 2012, and between 23 and 30 cases-per-annum since. Mean (±SD) age of study cohort (n=340 persons) was 68.2±15.2 years (50% male); 20.3% had concomitant coronary-artery-bypass-surgery (males vs females: 29.4% vs 11.2%, p<0.001). Main surgery on aortic and mitral valves was replacement (95.9% and 70.6% respectively). Tricuspid valve annuloplasty was performed in 90.6% of patients. Cumulative in-hospital, 180-day, and total mortality (mean follow-up=4.9±4.0 yrs) was 7.4%, 11.8% and 42.6%, respectively. Heart failure (24.0% in-hospital, 22.5% post-discharge) and sepsis (24.0% in-hospital, 20.0% post-discharge) were the main cause-specific deaths. There was no in-hospital stroke-related death. Age (median >72 yrs; hazard ratio [HR]=1.95, 95%CI=1.37-2.79), malignancy (HR=6.35, 95%CI=2.21-18.26), heart failure (HR=1.79, 95%CI=1.25-2.57) and chronic kidney disease (CKD) (HR=2.21, 95%CI=1.39-3.51) (all p<0.005) were independent predictors during intermediate-term follow-up. CONCLUSIONS: Triple valve surgery remains rare in Australia and is associated with high mortality. Multi-centred collaboration and access to comprehensive clinical data are required to identify the drivers of poor outcome.

Outcomes of 1,098 Patients Following Transcatheter Aortic Valve Implantation: A Statewide Population-Linkage Cohort Study.

BACKGROUND: The increasing implementation of transcatheter aortic valve implantation (TAVI) in Australia warrants real-world data on the prevalence and outcomes of these patients. The aim of this study is to describe trends in case-volumes of TAVI in New South Wales (NSW), Australia and associated mortality outcomes. METHODS: From the Centre of Health Record Linkage registry, all NSW residents who underwent TAVI between 5 June 2013 and 30 June 2018 were identified. Cause-specific mortality was tracked from the statewide death registry. Temporal trends in case-volumes between 2013 and 2018 were assessed by linear regression. Binary logistic regression was used to compare differences in in-hospital and 30-day mortality, while Cox proportional hazards regression was used to compare mortality beyond 30 days. RESULTS: Case-volumes increased from 30 in 2013 to 345 by 2017. The cohort comprised 1,098 persons (mean[±SD] age: 83.3±7.7 yrs). Cumulative in-hospital, 180-day and at end-of-study (mean: 1.8±1.2 yrs) all-cause mortality were 1.3% (n=14), 4.9% (n=54) and 20.3% (n=224) respectively. Heart failure (14.3%, n=2), myocardial infarction (14.3%, n=2), and sepsis (14.3%, n=2) were the primary causes of in-hospital death. Post-discharge, sepsis (25.2%, n=53) was the main cause-specific death, while combined cardiovascular deaths accounted for 46% (n=97), mostly from heart failure (n=35). Heart failure, chronic kidney disease, and requirement for ventilation post-TAVI were independent predictors of in-hospital death and at 180 days. TAVI procedure in low-volume public centres was a predictor of mortality at 180 days. CONCLUSION: The number of TAVI procedures increased 10-fold between 2013 and 2017 state-wide, with mortality rates comparable to international cohorts at short and medium-term follow-up. Pre-existing comorbidities and site-specific caseloads may be important determinants of outcome, emphasising the importance of appropriate patient selection and treating centre.

Long-Term Follow-Up of Mortality and Heart Failure Hospitalisation in Patients With Intracardiac Device-Related Tricuspid Regurgitation.

INTRODUCTION: Tricuspid regurgitation (TR) is a known complication of cardiac implantable electronic devices (CIED). A better understanding of the patient population affected by this complication and their outcomes is needed. The aims of our study were to: 1) describe the incidence of CIED-related tricuspid regurgitation; 2) identify patient characteristics conferring risk; 3) assess the long-term risk of hospitalisation for heart failure and mortality in patients with this complication. METHODS: This was a retrospective cohort study of 2,265 patients that had a de novo device implantation at a tertiary referral centre between January 2010 and December 2017. Patients with echocardiograms prior to and at least 3 months after device implantation were included. Patients with moderate or severe TR at baseline were excluded. RESULTS: Following screening of medical records, 165 patients were analysed. Forty-four (44) (27%) patients developed new-onset moderate or severe device-related TR, without a significant difference between patients with permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD). Patients with CIED-related tricuspid regurgitation had a higher rate of hospitalisation for heart failure than those without (63.6% vs 34.7%, p=0.001) during a median follow-up of 29 months (IQR 13-60 months). Subsequent analyses showed that the association between CIED-related TR and heart failure hospitalisation only became significant in the period beyond 12 months following CIED implantation. Piecewise Cox regression analysis stratified at 12 months of follow-up showed that CIED-related TR was associated with an increased risk of heart failure hospitalisation beyond 12 months after adjustment for differences in baseline characteristics (HR 1.99, 95% CI 1.05-3.76, p=0.03). There was a higher mortality rate in the group with CIED-related TR; however, this did not reach significance (36.3% vs 22.3%, p=0.09). CONCLUSION: CIED-related TR is common and clinically significant with serious implications for long-term outcomes, especially congestive heart failure.

Incidence and Impact of Hypoalbuminaemia on Outcomes Following Acute Pulmonary Embolism.

BACKGROUND: Clinical features and outcomes of patients with hypoalbuminaemia in acute pulmonary embolism (PE) have never been studied. The present study investigated the incidence and determined the prognostic significance of hypoalbuminaemia in patients with confirmed acute PE. METHODS: From a dedicated tertiary-referral centre database involving 1,426 consecutive patients admitted with confirmed PE (2000-2012), 1,032 patients had serum albumin assessed on admission (day-1). Patients were stratified into hypoalbuminaemia (<35 g/L) or normal serum albumin (≥35 g/L). Multivariable logistic and Cox proportional-hazards regression methods were used to assess 30-day and 90-day all-cause mortality. RESULTS: Hypoalbuminaemia was present in 160 (15.5%) patients at day-1 and was associated with higher mean (±SD) heart rate (94.4 ± 21.8 vs 87.8 ± 21.5 bpm), lower systolic blood pressure (131.0 ± 24.7 vs 142.3 ± 24.7 mmHg), lower arterial oxyhaemoglobin saturation (93.3 ± 6.1% vs 95.6 ± 4.0%), lower day-1 serum sodium (137.0 ± 4.7 vs 138.8 ± 3.8 mmol/L) and haemoglobin levels (114.4 ± 20.7 vs 131.5 ± 18.7 g/L). Patients with hypoalbuminaemia had higher incidence of malignancy (44.4% vs 18.8%) and chronic renal disease (9.4% vs 5.2%), and at admission were less likely to be taking aspirin/clopidogrel (19.3% vs 27.7%) and more likely to be using enoxaparin (6.7% vs 3.0%). During a mean follow-up of 5.0 ± 4.0 years, patients with hypoalbuminaemia had higher 30-day (16.3% vs 3.6%) and 90-day (26.3% vs 6.2%) mortality. Multivariable analyses showed hypoalbuminaemia independently predicted both 30-day (odds ratio 2.57, 95% confidence interval [CI] 1.03-6.41) and 90-day (hazard ratio 2.42 95% CI 1.38-4.22) mortality. CONCLUSION: Hypoalbuminaemia is an independent predictor of mortality following PE and may improve risk stratification of patients in risk prediction models.

Morbidity and mortality outcomes of patients requiring isolated tricuspid valve surgery: a retrospective cohort study of 537 patients in New South Wales between 2002 and 2018.

OBJECTIVES: The aim of the study was to evaluate mortality and morbidity outcomes following open-heart isolated tricuspid valve surgery (TVSx) with medium to long-term follow-up. DESIGN: Retrospective cohort study. SETTING: New South Wales public and private hospital admissions between 1 January 2002 and 30 June 2018. PARTICIPANTS: A total of 537 patients underwent open isolated TVSx during the study period. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was all-cause mortality tracked from the death registry to 31 December 2018. Secondary morbidity outcomes, including admission for congestive cardiac failure (CCF), new atrial fibrillation (AF), infective endocarditis (IE), pulmonary embolism (PE) and insertion of a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD), were tracked from the Admitted Patient Data Collection database. Independent mortality associations were determined using the Cox regression method. RESULTS: A total of 537 patients underwent open isolated TVSx (46% male): median age (IQR) was 63.5 years (43.9-73.8 years) with median length of stay of 16 days (10-31 days). Main cardiovascular comorbidities were AF (54%) and CCF (42%); 67% had rheumatic tricuspid valve. In-hospital and total mortality were 7.4% and 39.3%, respectively (mean follow-up: 4.8 years). Cause-specific deaths were evenly split between cardiovascular and non-cardiovascular causes. Predictors of mortality included a history of CCF (HR=1.78, 95% CI 1.33 to 2.38, p<0.001) and chronic pulmonary disease (HR=2.66, 95% CI 1.63 to 4.33, p<0.001). In-hospital PPM rate was 10.0%. At 180 days, 53 (9.9%) patients were admitted for CCF, 25 (10.1%) had new AF, 7 (1.5%) had new IE and <1% had PE, post-discharge PPM or ICD insertion. CONCLUSION: Open isolated TVSx carries significant mortality risk, with decompensated CCF and new AF the most common morbidities encountered after surgery. This report forms a benchmark to compare outcomes with newer percutaneous tricuspid interventions.

Outcomes Following Implantable Cardioverter-Defibrillator Insertion in Patients 80 Years of Age or Older: A Statewide Population Cohort Study.

BACKGROUND: Patients ≥ 80 years of age are underrepresented in major implantable cardioverter-defibrillator (ICD) trials, and real-world data are lacking. In this study, we sought to assess ICD utilisation, outcomes, and their predictors, in an unselected statewide population including patients ≥ 80 years old. METHODS: We extracted details of ICDs implanted from 2009 to 2018 in New South Wales (NSW), Australia from the Centre for Health Record Linkage administrative data sets. Analysis was stratified into age groups of < 60 years, 60-79 years, and ≥ 80 years. RESULTS: A total of 9304 patients (mean age 66.1 ± 13.1 years; 12.1% ≥ 80 years) had de novo ICD placement at an average rate of 1163 ± 122 patients per annum, with more implants in men in all age groups. After adjusting for NSW population size by sex, age group, and calendar year, mean implantation rates were 5.5 ± 0.6, 63.2 ± 8.6, and 52.7 ± 10.8 per 100,000 persons per annum in patients aged < 60 years, 60-79 years, and ≥ 80 years, respectively. In-hospital mortality was 0.4% and did not differ among age groups. However, 1-year mortality was 2.1%, 5.9%, and 10.7%, in those < 60 years, 60-79 years, and ≥ 80 years of age, respectively (P < 0.001), with hazard ratios for those aged ≥ 80 years of 4.3 (95% confidence interval [CI] 3.1-6.0) and those aged 60-79 years of 2.6 (95% CI 1.9-3.5) relative to those aged < 60 years (both P < 0.001) after adjusting for ICD indications, sex, implantation year, referral source, and comorbidities. In those aged ≥ 80 years, age > 83 years, congestive cardiac failure, chronic renal failure, neurodegenerative disease, and a higher Charlson comorbidity index score were each independent predictors of 1-year mortality. CONCLUSIONS: ICD use in patients aged ≥ 80 years and 60-79 years was 10-fold that in patients aged < 60 years, and perioperative outcomes were good in all ages, but there was substantially increased 1-year mortality in those aged ≥ 80 years. Careful selection based on age and comorbidity may further reduce 1-year mortality in patients ≥ 80 years old receiving ICDs.

Mortality outcomes in 35,433 patients admitted for acute haemorrhagic stroke in Australia: A population-linkage study.

Background: Haemorrhagic stroke (HS) is an important cardiovascular cause of mortality worldwide. Trends in admission rates and outcomes, and predictors of outcomes, post-HS in Australia remain unclear. Methods: All New South Wales residents, Australia, hospitalized with HS from 2002 to 2017 were identified from the Admitted-Patient-Data-Collection database. Admission rates were adjusted to population size by sex, age-groups and calendar-year. Mortality was tracked from the death registry to 31-Dec-2018 and adjusted for admission calendar-year, age, gender, referral source, surgical evacuation following HS and comorbidities. Results: The cohort comprised 35,433 patients (51.1% males). Overall age-adjusted mean(±SD) admission rates were higher for males (63.6 ± 6.2 vs 49.9 ± 4.4 admissions-per-100,000-persons-per-annum). Annual admission rates declined for both sexes from 2002 to 2017 especially in those ≥60yo. In-hospital and 1-year mortality rates were higher for females than males (25.0% vs 20.0% and 40.6% vs 35.9% respectively, all p < 0.001). Adjusted in-hospital and 1-year mortality declined for men and women, overall decreasing by 45% (odds ratio 0.55, 95% confidence interval [CI] = 0.47-0.64), and 31% (hazard ratio 0.69,95%CI = 0.63-0.76) respectively between 2002 and 2017. Independent predictors of increased in-hospital and 1-year mortality included increasing age and Charlson comorbidity index, while male sex, a history of hyperlipidaemia and current smoking, and surgical evacuation following HS were associated with reduced mortality (all p < 0.001). Conclusion: HS incidence increases markedly with age. Although age-adjusted HS admission rates and post HS mortality have fallen, HS remains associated with high early and 1-year mortality, with females consistently associated with worse outcomes. Strategies to improve outcomes of these patients remain a clinical priority.

Prognostic impact of the Charlson comorbidity index on mortality following acute pulmonary embolism.

OBJECTIVES: It was the aim of this study to determine the prognostic significance of the Charlson Comorbidity Index (CCI) following acute pulmonary embolism (PE) and assess the prognosis of patients without comorbidities (defined as a CCI score of 0). METHODS: Outcomes of 1,023 consecutive patients admitted with confirmed PE were tracked after a median of 3.7 years (25-75th interquartile range 1.5-6.1 years). All were assigned a non-age-adjusted CCI score. RESULTS: The median CCI score was 1.0 (interquartile range 0.0-3.0). Three hundred and fifty-one (34%) patients had a CCI score of 0. Only 1 (0.3%) of 31 in-hospital deaths occurred in patients with a CCI score of 0. Long-term mortality for these patients was similar to the population-derived age- and sex-matched mortality rate, and was significantly better than for those with a CCI score ≥1 (12.5 vs. 47.5%; p < 0.0001 adjusted for age and sex). In multivariate analysis, CCI (per 1-score increase) independently predicted in-hospital (hazard ratio 1.27, 95% confidence interval 1.09-1.49; p = 0.003) and post-discharge (hazard ratio 1.35, 95% confidence interval 1.29-1.42; p < 0.0001) death. The c statistics for the multivariate prediction models for in-hospital (incorporating CCI score and serum sodium level) and post-discharge death (age, CCI score, hyperlipidemia, serum sodium and hemoglobin) were 0.738 and 0.788, respectively (both p < 0.0001). CONCLUSION: The CCI can be incorporated into risk models, with good discriminatory power, for predicting in-hospital and long-term outcomes following acute PE. Patients with a CCI score of 0 have a favorable long-term outcome following acute PE.

A novel parasternal transthoracic echocardiographic window for detecting coronary ostial dilation after modified Bentall surgery.

BACKGROUND: During the modified Bentall surgery (aortic root replacement), a cuff of native aorta is implanted, together with the coronary ostium, into the aortic graft. Multi-detector computed tomography (MDCT) imaging can accurately assess the coronary ostial anastomosis site post-surgery. In this study, we assessed the feasibility of imaging the coronary ostial anastomosis site using transthoracic echocardiography (TTE). METHODS: Patients (n = 14, mean age 65 ± 12 years, 79% males) with previous Bentall surgery underwent TTE study, with MDCT (64-slice) as the reference standard. TTE used conventional and novel acoustic windows to interrogate the coronary ostia. RESULTS: All coronary ostia (n = 28) were well-visualized with MDCT. The optimum TTE acoustic window for visualizing the coronary ostia was a superiorly positioned parasternal short-axis view with the probe tilted towards the left shoulder, medially angulated for the right coronary artery ostia (RCAos) and laterally angulated for the left main coronary artery (LMAos). In this off-axis position, 10 (71%) LMAos and 13 (93%) RCAos could be visualized. In the conventional parasternal views, only 5 (36%) RCAos and no LMAos could be visualized. TTE underestimated the diameter of the LMAos (10.0 ± 2.4 mm TTE vs. 13.4 ± 2.7 mm MDCT, p = 0.007), but was similar to MDCT for the RCAos (9.8 ± 3.1 mm TTE vs. 11.1 ± 3.2 mm MDCT, p = 0.10). CONCLUSIONS: We report a novel TTE acoustic window to image the coronary ostia of post-Bentall surgery patients. Although TTE underestimates the left coronary ostium size, recognition of the ostial dilation with TTE appears feasible in most patients. Those that cannot be imaged will require alternative imaging modality such as MDCT.

Right atrial to left atrial area ratio on early echocardiography predicts long-term survival after acute pulmonary embolism.

BACKGROUND: Current guidelines recommend that transthoracic echocardiography (TTE) should be performed for acute risk stratification following acute pulmonary embolism (PE), but it is unclear whether the initial TTE can predict long-term outcome beyond six months. We sought to assess the potential of the initial right atrial (RA) to left atrial (LA) area ratio (RA/LA ratio) on TTE to predict long-term mortality in survivors of submassive PE. METHODS: A derivation cohort comprised a previously reported group of 35 consecutive patients with acute PE who were intensively studied by serial TTE at 1, 2, 5 days, 2, 6, 12 and 26 weeks and RA/LA ratio related to long-term outcome. The Day 1 RA/LA ratio findings were then further related to long-term outcome in 158 patients followed for 3.6 ± 2.3 years. RESULTS: In the derivation cohort, total mortality was 28.6% (n = 10) following a mean (±standard deviation) follow-up of 4.3 ± 1.9 years. The RA/LA ratio was highly dynamic, being increased at day 1, but normalised rapidly within 2-5 days of presentation and this was most marked amongst long-term non-survivors. A RA/LA ratio > 1.0 on day 1 was independently associated with a three-fold increase in long-term mortality on Kaplan-Meier analysis. Pooled analysis of 158 patient indicated that age, Charlson Comorbidity Index (CCI), simplified Pulmonary Embolism Severity Score (PESI), troponin T, day 1 RA/LA Ratio and pulmonary arterial systolic pressure (PASP) were univariate predictors of long-term mortality. Multivariate analysis identified Day 1 RA/LA Ratio (HR 1.7 per 10% increase, p = 0.002), CCI (HR 2.2 per 1 unit increase, p = 0.004) and age (HR 1.1, p = 0.03) as the only independent predictors of long-term mortality. CONCLUSION: A RA/LA Ratio >1.0 at presentation with acute PE was associated with a three-fold increased risk of long-term mortality. The RA/LA ratio on presentation with an acute PE is a simple, novel predictor of long-term survival.

Sex differences in rates of permanent pacemaker implantation and in-hospital complications: A statewide cohort study of over 7 million persons from 2009-2018.

BACKGROUND: Whether a bias exists in the implantation of permanent pacemakers (PPI) and complications according to sex and age in the Australian population is unclear. HYPOTHESIS: Population rate of PPI and its complications differed between men and women. METHODS: We examined the prevalence of PPI from January-2009 to December-2018 from datasets held by the New South Wales (NSW) Centre-for-Health-Record-Linkage, including patient's characteristics and in-hospital complications. All analysis was stratified by sex and age by decade. RESULTS: A total of 28,714 admissions involved PPI (40% women). The mean PPI rate (±standard-deviation) and median age (interquartile range) was 2,871±242 per-annum and 80yrs (73-86yrs), respectively. At the same time-period, the mean NSW population size was 7,487,393±315,505 persons (50% women; n = 3,773,756±334,912). The mean annual age-adjusted rate of PPI was 125.5±11.6 per-100,000-men, compared to 63.4±14.3 per-100,000-women (P<0.01). The mean annual rate of PPI increased from 2009-2017 by 0.9±3.3% in men, compared to 0.4±4.4% in women (P<0.01) suggesting a widening disparity. Total non-fatal in-hospital complications was higher in women compared to men (8.2% vs 6.6%, P<0.01), and this persisted throughout study period even after adjusting for multiple covariates. Overall, in-hospital mortality was low (0.73%) and similar between sexes. CONCLUSION: In a statewide Australian population exceeding 7 million, PPI rates were consistently nearly two-fold higher for men compared to women over 10-years, with an apparently widening disparity, that was not explained by age. Overall complication rates were higher in women. Future studies should examine the aetiology behind this disparity in PPI rates, as well as its complications.

Trends in Acute Pulmonary Embolism Admission Rates and Mortality Outcomes in Australia, 2002-2003 to 2017-2018: A Retrospective Cohort Study.

BACKGROUND: Contemporary Australian epidemiological data on acute pulmonary embolism (PE) are lacking. OBJECTIVES: To determine the admission rates of acute PE in Australia, and to assess the temporal trends in short- and medium-term mortality following acute PE. METHODS: Retrospective population-linkage study of all New South Wales residents admitted with a primary diagnosis of PE between January 1, 2002 and December 31, 2018 using data from the Centre for Health Record Linkage databases. Main outcome measures included temporal trends in total PE admissions and all-cause mortality at prespecified time points up to 1 year, stratified by gender. RESULTS: There were 61,607 total PE admissions between 2002 and 2018 (mean ± standard deviation: 3,624 ± 429 admissions per annum; 50.42 ± 3.70 admissions per 100,000 persons per annum). The mean admission rate per annum was higher for females than for males (54.85 ± 3.65 vs. 44.91 ± 4.34 admissions per 100,000 persons per annum, respectively) and remained relatively stable for both genders throughout the study period. The main study cohort, limited to index PE admission only, comprised 46,382 persons (mean age: 64.6 ± 17.3 years; 44.4% males). The cumulative in-hospital, 30-day, 3-month, and 1-year mortality rates were 3.7, 5.6, 9.6, and 16.8%, respectively. When compared with 2002 as the reference year, there was a significant reduction in in-hospital (odds ratio [OR] = 0.34; 95% confidence interval [CI] = 0.25-0.46), 30-day (OR = 0.58, 95% CI = 0.46-0.73), and 1-year (hazard ratio = 0.74, 95% CI = 0.66-0.84) (all p < 0.001) mortality risk by 2017 after adjusting for age, gender, and relevant confounders. The survival improvements were seen in both genders and were greater for females than for males. CONCLUSION: Mortality following PE has improved with reductions observed in both short- and medium-term follow-ups between 2002 and 2018 with greater reductions in females despite their higher admission rates over time.

Outcomes of 16,436 patients requiring isolated aortic valve surgery: A statewide cohort study.

BACKGROUND: Aortic valve surgery (AVS) is the gold standard treatment for symptomatic aortic valve (AV) disease patients. We report the temporal trends in the incidence of patients requiring isolated AVS in an unselected statewide population and their mortality outcomes over 17-years. METHODS: Patients were identified from the New South Wales, Australia, Admitted-Patient-Data-Collection registry between 1-July-2001 and 31-December-2018. Annual case-volumes and survival outcomes, adjusted for age, sex, referral source, endocarditis, concomitant coronary-artery-bypass-grafting, comorbidities including atrial fibrillation, hypertension and Charlson comorbidity index, were compared across calendar years. RESULTS: The study cohort comprised 16436 patients who underwent isolated AVS (mean age: 72.2 ± 11.3y; 67.5% males). Annual case-volume increased from 768 to 1048 cases between 2002 and 2017 (r2 = 0.82; p < 0.0001). Surgical AV replacement (SAVR) with mechanical valves declined from 271 to 104 (r2 = 0.87; p < 0.0001) between 2002 and 2017. In contrast, bioprosthetic SAVR increased from 342 to 729 cases (r2 = 0.93; p < 0.0001). The 30-day, 6-month, and 1-year mortality rates improved progressively from 4.39%, 7.72%, and 9.19% in 2002, to 1.89%, 3.49%, and 4.68% by 2017. The adjusted odds ratio for 30-day mortality and hazard ratio for 1-year mortality were 0.33 (95% confidence interval [CI] 0.16-0.69, p < 0.01) and 0.09 (95% CI 0.07-0.12, p < 0.01), respectively. Similar improvements in outcomes were observed after implantation of mechanical or bioprosthetic aortic valves. Heart failure and sepsis were the most common cardiovascular-related and noncardiovascular-related causes death. CONCLUSION: The volume of AVS has increased progressively over time and has been associated with increased use of bioprosthetic valves and markedly improved 30-day and 1-year survival.

Sleep disordered breathing in chronic heart failure.

Heart failure is a growing problem, placing an increasing burden on public health resources and continuing to exert a high toll in mortality and morbidity. Sleep disordered breathing (SDB) is also a major public health problem and is associated with an increased risk of fatal and non-fatal cardiovascular events. Current evidence suggests SDB, particularly central SDB, is more prevalent in patients with chronic heart failure (CHF) than in the general population, but is under-diagnosed as SDB symptoms are less prevalent in CHF. This is further hampered by the absence of a simple and accurate screening tool and limited access to sleep facilities to diagnose SDB in the large numbers of patients with CHF. The presence of SDB in patients with CHF imposes increased haemodynamic burdens and results in autonomic abnormalities. Central SDB is an independent marker of worse prognosis, and evidence is increasing that obstructive SDB is also associated with higher mortality in patients with CHF. Optimal treatment of central SDB in these patients remains uncertain. While evidence of efficacy of positive pressure ventilation is stronger in obstructive SDB, improvement in survival for patients with both CHF and SDB awaits definitive trials. This paper summarizes our current understanding of the pathophysiology of SDB in CHF, and the cardiovascular consequences, and reviews the evidence for the beneficial effects of treatment of SDB in patients with CHF.

Predictors for congestive heart failure hospitalization or death following acute pulmonary embolism: A population-linkage study.

BACKGROUND: Congestive heart failure (CHF) is a risk factor for pulmonary embolism (PE). PE is also an independent predictor of death or re-hospitalization among CHF patients. We assessed the incidence of CHF admission following acute PE using population-linkage analysis. METHODS: Patients were identified from a comprehensive single-center PE database and CHF admissions or death after their PE were tracked from the statewide Admitted Patient Data Collection and Death registries respectively. Patients were divided into two groups: Group-1 were patients without a history of CHF and left ventricular ejection fraction (LVEF) ≥50%; Group-2 were patients with a history of CHF and/or LVEF <50%. Cox regression was used to identify independent predictors for post-PE CHF admission or death. RESULTS: The study cohort comprised 515 patients (Group-1: n = 338 [65.6%]; Group-2: n = 177 [34.4%]). The incidence of first CHF hospitalization after discharge for acute PE over a mean (±SD) follow-up period of 4.7 ±â€¯3.7 years for the total cohort was 71 (13.8%), with the rate significantly higher in Group-2 than Group-1 (Group-2: [n = 58] 9.11 per-100-patient-years vs Group-1: [n = 13] 0.73 per-100-patient-years). Independent predictors for CHF admission or death after acute PE were older age, male gender, history of CHF or malignancy, low day-1 serum hemoglobin, on diuretics during index PE admission, LVEF <50%, and elevated right ventricular-atrial pressure gradient on echocardiography. CONCLUSION: We report a high incidence of CHF requiring hospital admission after acute PE. Surveillance for new-onset heart failure and close monitoring for heart failure decompensation following acute PE particularly in at-risk groups may be warranted.