Heart, Lung and Circulation最新文献

Background: Atrial fibrillation (AF) significantly contributes to rising healthcare costs in Australia, with inpatient care accounting for most expenses. Recent literature has explored the use of a "wait-and-see" approach to managing patients presenting to emergency departments with primary AF given the high rate of spontaneous cardioversion (SCV), thereby avoiding invasive cardioversion and costly hospital admission. Limited adoption of this model of care may stem from challenges in identifying patients who truly need admission. To address this, predictive models for SCV are being explored. Our study aims to determine the accuracy threshold at which such models achieve cost savings by preventing unnecessary AF admissions.

Method: A decision-analytic model was used alongside Monte Carlo simulations to estimate the variability in cost per patient with changes in prediction model accuracy and expected rates of SCV. Estimated costs were derived from a sample of patients presenting to Flinders Medical Centre or Noarlunga Hospital, South Australia in 2022-2023 with primary AF.

Results: There were 669 admissions at Flinders Medical Centre or Noarlunga Hospital for primary AF in 2022-2023. SCV occurred in 240 (35.9%) cases, representing potentially avoidable admissions. The base case cost per admission was AUD$5,793.94, further increasing to $7,009.42 if interhospital transfer was required. The point at which cost benefit would be observed in our patient cohort was between 60% and 70% accuracy. There was an incremental reduction in cost in relation to increasing prediction model accuracy or population SCV rate.

Conclusions: Predicting SCV with an accuracy of 60%-70% in patients presenting with primary AF results in cost savings and reduced hospital bed utilisation through avoiding unnecessary admissions.

Background: Patients with end-stage heart failure experience a significant symptom burden that is often poorly controlled. Although palliative care can improve symptom management and reduce hospital admissions, many patients still die in acute care settings. The unpredictable course of end-stage heart failure complicates the identification of patients who would benefit from early palliative care referral. To address this challenge, an integrated cardiac supportive care service was developed to engage these patients early, optimise symptom control, and ensure timely access to palliative care.

Aim: The aim of this study is to document the symptom burden, using Patient-Reported Outcome Measures, for patients with end-stage heart failure on admission to the cardiac supportive care service.

Method: A prospective observational study was undertaken in a tertiary hospital service in Sydney, Australia between January 2020 and July 2022. Patients were included if they had a recent admission for heart failure or had heart failure with breathlessness or chest pain at rest or on minimal effort. The cardiac supportive care service, consisting of initial home visits and follow-up reviews conducted by a palliative care physician and cardiac nurse practitioner, collected information using the Dyspnoea-12 (D-12) Questionnaire and the Integrated Palliative Care Outcome Scale (IPOS). Symptom scores from these tools were analysed in relation to patient mortality, with Kaplan-Meier survival curves and Cox regression used to assess the association between symptom burden and time to death.

Results: A total of 114 patients were included in this study. Both the IPOS and D-12 scores indicated a substantial and clinically relevant symptom burden for this cohort of patients. High mean scores on the IPOS were observed for weakness (2.6, standard deviation [SD] 1.2), shortness of breath (2.6, SD 1.2), and sore/dry mouth (2.5, SD 1.3). Sore/dry mouth was the most frequent severe or overwhelming symptom (59%). The D-12 showed that descriptors of breathlessness most commonly rated as severe were "My breathing is exhausting" (40%), "My breathing is distressing" (39%), and "I feel short of breath" (38%). Patients with an IPOS score in the highest quartile had an elevated mortality risk. The survival of patients in this cohort was 17.1 months.

Conclusions: Patients with end-stage heart failure experience a substantial and frequently severe symptom burden, including breathlessness, dry mouth, and weakness. This study demonstrates the significant unmet need in this patient population and highlights the opportunity for integrated and proactive palliative care, delivered through a cardiac supportive care service. This model of care can optimise symptom management, facilitate advance care planning, and ensure timely referral to palliative care.

Aim: This study aimed to evaluate long-term outcomes of mitral valve surgery for rheumatic heart disease (RHD) in Indigenous Australians, comparing survival and revision rates between valve repair and replacement, and between mechanical and bioprosthetic prostheses.

Method: We conducted a retrospective analysis of 365 consecutive Indigenous Australian patients who underwent mitral valve surgery for RHD at a single tertiary centre from 1992 to 2023. Patients were grouped by procedure type: mitral valve repair, mechanical replacement, or bioprosthetic replacement. The primary outcomes were all-cause mortality and need for revision surgery. Multivariate Cox regression was used to identify independent predictors of outcomes. Kaplan-Meier survival analysis compared event-free survival between groups.

Results: During a mean follow-up of 8.5±6.0 years, 85 patients (23.3%) died and 59 (16.2%) required revision surgery. No significant difference in all-cause mortality was observed between repair and replacement (p=0.70), or between mechanical and bioprosthetic prostheses (p=0.24). Valve repair was associated with a higher unadjusted risk of revision (p=0.01), but this was not significant after adjustment (hazard ratio [HR] 1.41; p=0.30). Bioprosthetic valves were associated with a significantly increased risk of revision compared with mechanical valves (HR 7.22; p<0.001).

Conclusions: In this cohort of young Indigenous Australians with RHD, mitral valve repair and bioprosthetic valves were associated with increased revision rates but showed no survival advantage over mechanical prostheses. These findings support the consideration of mechanical valves in appropriately selected patients to optimise long-term durability.

Background: It is well-established that postoperative atrial fibrillation (POAF) can lead to adverse clinical outcomes after major cardiovascular operations. The current study was performed to investigate the occurrence of new-onset POAF after successful surgical repair of post-infarction ventricular septal rupture (VSR) and the association between POAF and in-hospital mortality.

Method: All consecutive patients who followed surgical repair of VSR from two medical centres in China from January 2008 to December 2023 were finally enrolled in this study (n=113). Patients who developed new-onset POAF after VSR repair were assigned to the POAF group, and those who did not develop POAF were assigned to the non-POAF group. The unadjusted and adjusted odds ratio (OR) for in-hospital mortality was derived by logistic regression. Then, multivariate logistic regression analyses were used to assess the risk of POAF, ORs and corresponding 95% confidence intervals (CIs) were reported.

Results: POAF was diagnosed in 31.9% (36/113) of this cohort population, and was related to age (OR 1.06; 95% CI 1.05-1.07; p<0.001), male sex (OR 0.46; 95% CI 0.25-0.66; p=0.034), Killip class III/IV (OR 1.37; 95% CI 1.07-1.84; p=0.003), size of VSR (OR 1.54; 95% CI 1.26-1.63; p=0.015), systolic pulmonary artery pressure >45 mmHg (OR 1.65; 95% CI 1.36-1.92; p=0.001), and operation time (OR 1.13; 95% CI 1.12-1.29; p<0.001). Patients with POAF exhibited a significantly higher in-hospital mortality than those without POAF (52.7% vs 19.5%; p<0.001).

Conclusions: POAF following surgical repair of VSR was related to significantly higher rates of in-hospital mortality. More careful attention should be given to POAF after surgical repair of VSR. The older female patient who had Killip class III/IV, a larger size of VSR, systolic pulmonary artery pressure >45 mmHg, and experienced longer surgery time was at the highest risk for POAF.

Background: Postoperative atrial fibrillation (AF) after video-assisted thoracoscopic surgery (VATS) is the most prevalent form of secondary AF in older patients, which is likely to recur or even cause persistent AF and may receive long-term clinical treatment in clinically. We aimed to analyse the preoperative and intraoperative risk factors for the recurrence of paroxysmal postoperative AF.

Method: Data were collected from patients who underwent VATS and experienced paroxysmal postoperative AF at Peking Union Medical College Hospital between June 2013 and December 2022. We studied the incidence of AF recurrence within 1 year after initial occurrence and the potential preoperative and intraoperative risk factors using multivariable logistic regression analyses.

Results: Of the 2,920 patients who underwent VATS in this study, 122 (4.2%) suffered paroxysmal postoperative AF within 30 days after surgery. The recurrence incidence of paroxysmal postoperative AF was 21.3% (26 of 122) within 1 year. Multiple logistic regression analysis revealed that left atrial diameter (odds ratio [OR] 1.13; 95% confidence interval [CI] 1.01-1.27; p=0.040), left ventricular ejection fraction (OR 0.91; 95% CI 0.83-0.98; p=0.013), and intraoperative hypotension (OR 5.04; 95% CI 1.20-21.69; p=0.025) were significant risk factors for paroxysmal postoperative AF recurrence.

Conclusions: Larger left atrial diameter, lower left ventricular ejection fraction, and intraoperative hypotension may be associated with AF recurrence in older patients with paroxysmal postoperative AF after thoracoscopic surgery. It could be helpful to identify patients at high risk of AF recurrence and advise active monitoring.

Background: Pulmonary embolism is associated with significant mortality and remarkably often subject to misdiagnosis, which further adversely affects prognosis. Disease severity and corresponding prognosis are strongly dependent on the risk constellation and determine the therapy. Therefore, we sought to analyse how mechanical thrombectomy influences short term clinical, laboratory, and haemodynamic findings in patients with symptomatic pulmonary artery embolism.

Method: In this study, we retrospectively analysed clinical, laboratory, and haemodynamic parameters in 32 patients with symptomatic pulmonary embolism who underwent mechanical thrombectomy using the FlowTriever device. Only patients with pulmonary embolism confirmed by computed tomography pulmonary angiography and classified as intermediate-high or high risk according to the current European Society of Cardiology guidelines were included. The main outcome measures were periprocedural changes in troponin, lactate, pulmonary artery pressures, and vital signs.

Results: Reductions of increased heart rate, pulmonary arterial pressure, and right ventricle-to-left ventricle ratio were observed immediately after the procedure and in early clinical follow-up, as well as improvement in arterial oxygen saturation and demand. Interventional thrombectomy further resulted in a reduction of increased levels of high-sensitivity troponin and lactate. In summary, the analysis of this study shows consistent respiratory and haemodynamic improvements in line with other published data on mechanical thrombectomy with this device.

Conclusions: Mechanical thrombectomy in patients with pulmonary artery embolism at intermediate-high risk was associated with an immediate and significant decrease in both specific myocardial and systemic biomarkers, for which prognostic relevance has been repeatedly demonstrated.

Postural orthostatic tachycardia syndrome (POTS) is a complex disorder mainly of orthostatic intolerance, often accompanied by a spectrum of symptoms related to autonomic nervous system dysfunction. Although the diagnostic criteria require an orthostatic challenge test, the associated symptom burden can be broad and is often missed by treating healthcare professionals, resulting in significant diagnostic delay. Treatment of this highly heterogenous condition is nuanced and consists of non-pharmacologic and pharmacologic approaches. Availability of POTS care is limited, with a dearth of medical specialists or general practitioners specialising in autonomic medicine. The complexity of care for those with POTS necessitates a multidisciplinary approach due to the need for extended appointment times and frequent follow-ups to monitor therapeutic response and progress. This should include a primary team consisting of a general practitioner and trained autonomic physicians with specialist nurses, allied health professionals, and any other specialists required to manage the affected systems. This state-of-the-art review aims to cover the key aspects of diagnosing and managing POTS, including special neurological, gastroenterological, psychological, and paediatric considerations. There is an urgent need to provide services that meet the needs of the growing POTS population.