Heart, Lung and Circulation最新文献

Background: The prevalence and predictors of right ventricular (RV) dysfunction before and after transcatheter aortic valve implantation (TAVI) are not known. We aimed to document this and sought to identify specific RV echo thresholds, below which RV improvement was unlikely to occur.

Method: Consecutive patients who underwent TAVI between 2017 and 2021 at Macquarie University Hospital (MUH) were included if ≥2 RV functional parameters were available on baseline echo; tricuspid annular plane systolic excursion, tissue Doppler (S') and/or RV fractional area change. Prevalence and predictors of baseline RV dysfunction were documented. Patients with a repeat echo performed at MUH at 1-3 months post-TAVI were included in further analyses to assess serial changes in RV function.

Results: Overall, 343 patients had an eligible baseline echo and 97 of these patients (28.2%) had RV dysfunction, pre-TAVI. These patients had significantly higher rates of atrial fibrillation, ischaemic heart disease, and chronic lung disease, than those without (p<0.05 for all). Of 239 patients with 1-3 month follow-up echo data, 66 of these had had baseline RV dysfunction; of these, 20 (30.3%) patients showed improvement and 46 (69.7%) patients showed persistent RV dysfunction. Thresholds with a greater than 90% predictive value for persistent RV dysfunction were identified for each baseline RV functional parameter: tricuspid annular plane systolic excursion <1.4 cm, S'<6, fractional area change <25%.

Conclusions: Baseline RV dysfunction was present in over a quarter of pre-TAVI patients and persisted at short-term follow-up in over two-thirds of such patients. There were clear thresholds to identify patients where RV recovery was unlikely, after TAVI.

Background: Ischaemic mitral regurgitation (IMR) results from dysfunctional myocardial remodelling, which portends a poor clinical prognosis. This study assessed the surgical treatment of IMR and its associations with clinical and echocardiographic outcomes in the context of 2014 reports suggesting non-surgical management of non-severe IMR.

Method: Patients who underwent mitral valve (MV) procedures for IMR at Liverpool Hospital (Sydney, Australia) between 2008 and 2020 were included based on coronary disease and echocardiographic criteria. Data were obtained from patient records and linkage with the Australian Institute of Health and Welfare National Death Index. The primary outcome was the type of MV surgery performed in 2008-2014 and 2015-2020. Secondary outcomes were survival and freedom from combination of mortality and congestive heart failure (CHF) readmission, comparing MV repair and MV replacement and the outcomes for two periods by MV procedure.

Results: Of 106 patients treated surgically for IMR, 78 had MV repair (59 in 2008-2014, 19 in 2015-2020) and 28 had MV replacement (14 in 2008-2014, 14 in 2015-2020). Patients were followed up for 7.2 years (interquartile range 5.2-9.1). Compared to 2008-2014, there was a reduced proportion of MV procedures for IMR (4.2% and 2.0%; p<0.001) and MV repair for IMR (80.8% and 57.6%; p=0.012) post-2014. Freedom from a combination of mortality and CHF readmission over 10 years was significantly better in the MV repair than in the MV replacement group (log rank p<0.001). Over 5 years, freedom from mortality and the combination of mortality and CHF readmission were similar in both periods (log rank p=0.675 and p=0.433). In the earlier period, freedom from combined outcome was better in the MV repair group than the MV replacement group (log rank p<0.001) but not different in the second period (log rank p=0.149). Mitral regurgitation recurrence was less in the later period (25.8% and 3.6%; p=0.013).

Conclusions: The proportion of MV procedures and MV repairs performed for IMR declined significantly after 2014, indicating a significant change in practice towards conservative surgical correction of IMR. The combined long-term outcomes were unchanged after the change in practice, but the incidence of mitral regurgitation recurrence was significantly improved.

Background: Psychosocial well-being and nutritional counselling are important components of cardiac rehabilitation endorsed by national and international guidelines. However, both areas can be complex for cardiac rehabilitation practitioners to navigate. This study aimed to examine whether practitioners have implemented standardised program content for psychosocial well-being and healthy eating and explore attitudes to these components.

Method: Cardiac rehabilitation practitioners were recruited to complete a 32-item cross-sectional survey via convenience sampling. The survey was developed by a team of researchers and practitioners to assess practices, practitioner approaches, and any barriers to implementation. Quantitative results were explored using descriptive statistics, and qualitative responses were coded and classified.

Results: Participants (n=98) represented approximately 89 (22%) cardiac rehabilitation services across Australia. Results suggested that most participants were familiar with standardised program content (92.3%). However, there were inconsistencies about the implementation. For example, although 93.9% of practitioners stated that their programs routinely screen for psychosocial well-being, only 47.2% repeat screening at program completion. On healthy eating, 99% of practitioners report providing healthy dietary advice-however, just over half offered individualised consultations with an expert professional such as an Accredited Practising Dietitian. Practitioners considered psychosocial well-being and healthy eating important components of the program.

Conclusions: Practitioners reaffirm the importance of psychosocial well-being and nutritional counselling in cardiac rehabilitation programs. However, practitioners inconsistently assess psychosocial well-being at cardiac rehabilitation completion, and individualised dietary counselling by experts is uncommon.

Background: With widespread adoption of high-sensitivity troponin assays, more individuals with myocardial injury are now identified, with type 1 myocardial infarction (T1MI) being less common despite having the most well-established evidence base to inform care. This study assesses the temporal time course of cardiovascular events among various forms of myocardial injury.

Method: Consecutive hospital encounters were identified. Using the first episode of care during the sampling period, myocardial injury classifications (i.e., T1MI, acute injury/type 2 myocardial infarction [T2MI], chronic injury, and no injury) were established via two machine learning algorithms. The temporal time course of increased hazard for mortality, recurrent myocardial infarction, heart failure, and arrhythmia over 3 years were explored.

Results: There were 176,787 index episodes; 6.9% were classified as T1MI, 6.0% as acute injury/T2MI, and 26.7% as chronic injury. Although each classification was associated with an early increased risk of all-cause mortality compared with no injury (incidence rate ratio [IRR]<30 days: T1MI: 19.97 [95% confidence interval 12.50-32.69]; acute injury/T2MI: 26.51 [16.80-42.97]; chronic injury: 15.37 [10.22-23.95]), the instantaneous relative hazard for recurrent myocardial infarction was highest in those with initial T1MI (IRR<30 days: T1MI: 28.81 [22.75-36.76]; acute injury/T2MI: 10.23 [7.60-13.77]; chronic injury:5.54 [4.34-7.41]). In contrast, the instantaneous hazard for heart failure in those with initial acute injury/T2MI and chronic injury remained increased over long-term follow up unlike in T1MI (IRR1 3 yrs: T1MI: 5.52 [4.99-6.09]; acute injury/T2MI: 10.36 [9.51-11.30]; chronic injury:7.40 [6.90-7.94]).

Conclusions: The substantial and persistent rate of late cardiac events highlights the need to establish an evidence base for the therapeutic management of "non-T1MI" diagnostic classifications and suggests opportunity to improve late outcomes using existing and emerging therapies.

Introduction: Anti-cancer treatments frequently have serious adverse effects on the cardiovascular system. Understanding the mechanisms underlying these cancer therapy-related cardiovascular toxicities is essential for their prevention and potential treatment. While research often centres on cardiomyocyte damage as the primary cause of cardiac injury, the roles of cardiac fibroblasts and endothelial cells are often neglected. In this study, we aimed to investigate the direct toxicity in cardiac fibroblast and endothelial cells of 35 FDA-approved anti-cancer drugs, of which the effects previously only had been explored in cardiomyocytes.

Methods and results: Metabolic cell viability in cardiac fibroblasts and endothelial cells was first determined using the CellTiter-Glo luminescence assay. If metabolic cell viability was reduced, lactate dehydrogenase was measured in the supernatant to assess cytotoxicity. Interestingly, certain anti-cancer treatments were able to increase metabolic cell viability. For these drugs, gene expression analysis assessing for myofibroblast differentiation and endothelial-to-mesenchymal transition was performed.

Conclusion: Our study demonstrates that anti-cancer therapies indeed exhibited different toxicity profiles in cardiac fibroblasts and endothelial cells compared to cardiomyocytes and triggers specific pathophysiological transformations in response to anti-cancer drug exposure.

Background: In Australia, the role of surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in patients who are suitable for both procedures remains controversial. In 2022, new Items were added to the Medicare Benefits Schedule (MBS) to allow patients at intermediate and low risk with appropriate private health insurance to undergo TAVI. The Cardiac Society of Australia and New Zealand supported these changes whereas the Australian and New Zealand Society of Cardiac and Thoracic Surgeons opposed them. The aim of this study was to document subsequent private TAVI activity in patients at intermediate and low risk, relative to both private TAVI activity in patients at high risk and private SAVR activity.

Method: A retrospective population-level descriptive study was undertaken, using Medicare claims data obtained from Services Australia.

Results: Among private patients who underwent TAVI, the groups at high, intermediate, and low risk all had a median age between 75 and 84 years. Only 1% were aged ≤64 years (86/6,586), and 80% of these were at high risk (69/86). Among private patients at intermediate and low risk who underwent TAVI and private patients who underwent SAVR, only 4% of patients aged 55-64 years chose private TAVI over private SAVR (8/211), and 63% of these were at intermediate risk (5/8).

Conclusions: The introduction of MBS Items for private TAVI in patients at intermediate and low risk without accompanying age exclusion criteria has not (yet) had a major impact on private SAVR activity. This suggests that the multidisciplinary heart team (TAVI case conference) approval process remains an effective mechanism for ensuring access to private TAVI is consistent with international guidelines.

Background & aim: Cardiogenic shock is a medical emergency that is associated with high mortality rates. It is a resource-intensive and costly condition that is complicated by comorbidities and clinical deterioration. However, the barriers and enablers to quality cardiogenic shock care are relatively unknown from the perspective of Australian clinicians. This study aimed to i) To explore clinicians' perspectives on the barriers to delivering these best practice care and optimal outcomes for patients with cardiogenic shock; and ii) To understand priorities to overcome these barriers, with the intent of using the findings to inform the development and implementation of a clinical trial for cardiogenic shock management-ESCAPE-CS: Evaluation of a Standardised ClinicAl Pathway to improve Equity and outcomes in Cardiogenic Shock (ESCAPE-CS).

Method: A qualitative focus group study was conducted via videoconference with experienced clinicians, and audio-recorded and transcribed verbatim. Data were analysed using thematic analysis in NVivo.

Results: Five focus groups were conducted, including 19 participants (11 male and eight female), comprising seven intensive care unit physicians, seven nurse consultants/educators, three cardiologists, and two emergency department physicians working in metropolitan and rural, regional, or remote health settings. Five themes were identified: CONCLUSIONS: This study provided critical insights into the barriers and possible enablers to delivering best practice care and optimal outcomes for patients with cardiogenic shock. There is scope for an improved model of care in cardiogenic shock management to address inequalities emerging from multifactorial complexities.