Heart, Lung and Circulation最新文献

Background: Historically, high-risk percutaneous coronary intervention (PCI) procedures such as rotational atherectomy (RA) required on-site surgical backup. However, advancements in PCI techniques, coupled with the geographic realities of Australia's dispersed population, warrant a reassessment of RA in the context of contemporary clinical practice.

Aim: We aimed to establish the safety and outcomes after RA at non-surgical centres.

Method: Consecutive RA PCI cases from September 2012 to February 2024 at seven Australian hospitals without on-site cardiac surgery were analysed. Primary outcomes were referrals for emergency cardiac surgery (bailout) and 30-day mortality.

Results: A total of 943 patients (1,010 lesions) were included, with a mean age of 74.4±9.6 years. A total of 72.6% were male and the average body mass index was 28.7±7.1 kg/m². Common comorbidities included diabetes (35.1%), a history of smoking (48.7%), and acute coronary syndrome or emergency presentation (32.9%). Off-site surgical bailout was necessary for four patients (0.4%) (temporary pacing wire-related right ventricular perforation with tamponade [n=2]; burr entrapment not retrievable percutaneously [n=2]). Major coronary perforations occurred in 0.8% (n=8; Ellis III). Minor perforations occurred in 2.3% (n=22). Tamponade occurred in eight (0.8%) patients. Burr entrapment occurred in six (0.6%) patients. A total of 32 patients (3.4%) died within 30 days of the procedure; 13 cases (1.4%) were PCI-related, but only eight of these (0.8%) were directly attributable to RA (significant ischaemia, e.g., no/slow reflow [n=4]; perforation with tamponade unable to be temporised percutaneously [n=2]; burr entrapment [n=1]; extensive coronary dissection [n=1]). Female sex and acute coronary syndrome presentation were predictors of poorer outcome.

Conclusions: RA can be safely conducted without on-site surgical backup, including in regional Australian areas. In geographically dispersed populations, regional access to RA-assisted PCI is critical. Immediate percutaneous management remains the mainstay of management of rare but potentially severe complications such as tamponade, perforations, and burr entrapment.

Background: Dual antiplatelet therapy (DAPT) is frequently prescribed to patients with acute coronary syndromes on presentation. If these patients require inpatient surgical revascularisation, current guidelines suggest they await several days' DAPT washout prior to proceeding to operation. However, the rate of non-response to DAPT is significant, and there is minimal research available to assess if patients who are non-responders can safely proceed to surgery without waiting for washout.

Method: A retrospective cohort study of prospectively collected data was undertaken, examining patients who proceeded to surgery before the guideline-recommended washout time compared to those with no DAPT exposure.

Results: One hundred patients had Thromboelastogram (TEG) assessment of response to DAPT. There was a high rate of DAPT non- and low-response, 56% (n=56). Thirty-five non- and low-response patients proceeded to theatre prior to the guideline-recommended waiting time following DAPT. There was no statistically significant increase in bleeding or transfusion requirements (any transfusion, p=0.79), and no difference in morbidity and mortality (p=0.46). Non-responders proceeding early to surgery had a significantly shorter length of stay - non-responder 8.8±3.3 vs no DAPT 10.7±4.7 vs awaited washout 12.1±4.7 days (p<0.01).

Conclusions: There is a high rate of non-/low-response to DAPT, particularly clopidogrel. Non-responder patients do not have significant increase in overall morbidity and mortality, bleeding outcomes or transfusion requirements, and have the advantage of a significantly shorter length of hospital stay.

Aim: Increasing evidence supports the use of fractional flow reserve (FFR) to accurately identify which coronary artery lesions are appropriate for intervention. We aim to describe the use of FFR-guided percutaneous coronary intervention (PCI) in a large Australian PCI registry.

Method: We assessed data from consecutive patients in the Victorian Cardiac Outcomes Registry from 2014 to 2020 who presented with stable coronary artery disease or non-ST-elevation acute coronary syndrome and underwent FFR-guided PCI in a single procedure. They were compared with a cohort who underwent standard angiographically guided PCI over the same period.

Results: A total of 59,401 patients were included in the study with 2,455 (4.1%) undergoing FFR-guided PCI. Patients who underwent FFR-guided PCI less often presented with a non-ST-elevation acute coronary syndrome (22% vs 39%, p<0.001), were less probable to have their procedure out of hours (4.8% vs 10.6%, p<0.001), and more probable to have radial access (70% vs 59%, p<0.001). The use of FFR increased over the study period (2.8% of all cases in 2014 vs 4.7% in 2020, p<0.001). FFR-guided PCI was more often performed on the left anterior descending artery (65% of all cases vs 42%, p<0.001). The 30-day mortality was less in the FFR-guided group (0.2% vs 0.6%, p=0.005) but the overall mortality was very low.

Conclusions: This observational study demonstrates that the frequency of use of FFR to guide PCI was low in the Australian context; however, use is increasing. Patients in the FFR-guided group had lower 30-day mortality, although the overall rates of mortality in the study were very low.

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: 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: The Australian Cardiovascular (CVD) Disease Risk Calculator is used to estimate the individual risk of developing cardiovascular disease in the next 5 years. A new version was recently published (July 2023), with the aim of improving on the predictive performance of its predecessor (released in 2012). We present the findings of an external validation study comparing the predictive performance of the 2023 and 2012 Australian CVD risk calculators using data prospectively collected in the Hunter Community Study (HCS; NSW Australia), a longitudinal community-based cohort of people aged 55-85 years.

Methods: We compared the risk predicted by the two calculators to the observed 5-year events in the HCS, in terms of discrimination (using area under the receiver operator characteristic curve, AUROC), calibration (using observed vs expected, O/E, ratio), sensitivity, and specificity.

Results: Discrimination was very similar for the 2023 and 2012 calculators, with AUROC measured to be 0.71 95% confidence interval (CI; 0.66, 0.75) and 0.71 95% CI (0.67, 0.75), respectively. With the updated calculator, sensitivity was better in males, while specificity was better in females; there were also modest improvements in positive likelihood ratios for both males and females. The 2023 calculator was found to overpredict risk for males (O/E ratio 0.57, p<0.001), but was better calibrated for females (O/E ratio 1.02, p=0.46).

Conclusions: We conclude that the 2023 calculator provides some improvements in the prediction of CVD, specifically the positive likelihood ratios. However, there are also benefits in observing the old 2012 calculator for some purposes and specific population groups. We find that there is a need for a larger, nationwide cohort to allow further external validation of the 2023 Australian CVD Risk Calculator.

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.

Background: The long-term mortality of patients undergoing linear ventriculoplasty (LVP) for ischaemic left ventricular aneurysm (LVA) varies. This study aimed to develop a risk prediction model for mortality after LVP.

Method: A total of 741 patients with an ischaemic anterior-wall LVA who underwent LVP between January 1999 and March 2021 at Fuwai Hospital were retrospectively enrolled, and 22 clinical features were assessed. The entire cohort was randomly grouped into training and validation cohorts in a ratio of 8:2. Backward stepwise elimination approach and the least absolute shrinkage and selection operator regression were used for feature selection. A nomogram was developed based on a multivariable Cox regression model. The performance of the model was evaluated using discrimination and calibration. Decision curve analysis was performed to test the clinical usefulness.

Results: The mean age was 58.6 (standard deviation 9.6) years, and 15.8% of the patients were female. The mean ejection fraction was 42.8% (8.5%). Coronary artery bypass grafting was performed in 93.4% of the patients. During a median follow-up of 60 months, 105 patients died. Eight features were selected and included in the multivariable Cox regression-based nomogram. The model achieved good calibration and discriminative ability as indicated by the concordance index (training 0.71; validation 0.77). Decision curve analysis showed the model had good clinical usefulness.

Conclusions: In this study, a nomogram with relatively good performance was developed to predict individualised long-term mortality after LVP in patients with an ischaemic anterior-wall LVA. However, external validation is needed.

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.