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Aim To assess the clinical and echocardiographic outcomes in patients referred for device closure of atrial septal defects in a tertiary referral hospital in Australia. Methods A prospective follow-up study was performed on all patients who had device closure of a secundum atrial septal defect (ASD) from June 1999 to December 2007. Clinical and echocardiographic data at the time of implantation and follow-up is presented. Results 176 patients were referred for shunt closure of ASD. All patients had a significant shunt defined as a shunt with right heart dilatation and/or a shunt ratio of at least 1.5:1. The majority were female (67%) and the average age was 36.5 ± 22.7 years; age range 3–84. The average hospital admission time was 2.5 ± 1.7 days. The average follow-up occurred at 3.7 ± 3.6 months for the first follow-up and 26.3 ± 18.2 months (range 3 months–7.8 years) for the long-term follow-up. Baseline echocardiogram findings showed the majority had a normal left ventricular ejection fraction (99%); average LVEF = 63.2 ± 7.2% while the right ventricle was dilated in 61% of patients. Procedure information: The average procedure time was 94.8 ± 36.4 min. Procedural imaging was performed using Transoesophageal echocardiography (TOE) in 107 cases (61%); Intracardiac Echocardiography (ICE) in 69 (39%). Device use was as follows: Amplatzer = 156 cases, Helex = 18, and Starflex = 2. Postprocedure shunt assessment by transthoracic echocardiography showed successful closure (no shunt or trivial shunt) in 99% cases. Two patients were referred for inpatient surgery due to a significant residual shunt in one case and an unstable device in another. One patient who had an unstable device had their device repositioned successfully. Atrial arrhythmia was the most common complication occurring in the peri-implantation period in 12 cases (6%) with four further cases at final up. The high prevalence of right ventricular dilatation in 65% patients at baseline had improved significantly at the first and long term follow-up to 2% (p = 0.0001). Conclusion Device closure of secundum atrial septal defects in this large Australian cohort demonstrates a high procedural success rate with a low incidence of complications in the short and long term.

Prospective Audit of Coronary Care Unit Admissions by Nursing Staff: Implications for Patient Management and

Conclusion: Abnormal myocardial strain, detectable by 2D TTE, can improve after percutaneous AVR similar to that seen in the open AVR. Further trials are needed to look at long term TTE parameters in percutaneous valve replacement. doi:10.1016/j.hlc.2009.05.097

single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). We aimed to evaluate the application of AC in an Asian urban academic hospital setting. Methods: 300 consecutive patients referred for SPECT MPIwere analyzed in a prospectivemanner. Based onAC, indications of tests were scored as having an appropriate, uncertain or inappropriate indication. Imaging results were noted. Results: Overall, 235 (78.3%) tests were determined to be appropriate, 42 (14.0%) were inappropriate, 16 (5.3%) were uncertain and 7 (2.3%) were unclassifiable. Patients in the inappropriate groupwere younger than those in the appropriate group (p< 0.001). The most common indication for inappropriate testingwas thedetectionof coronary disease in asymptomatic low-risk patients. There is a higher proportion of normal test results obtained in the inappropriate group (81%) than in the appropriate group (60%) (p= 0.009). There remained a substantial proportion of abnormal results in the inappropriate group (19%), which occurred more frequently in men than in women (p= 0.003). Conclusion: In the application of AC in this single Asian academic hospital setting, a high proportion of testingwas appropriate. Theprospective use ofAC is feasible andmay improve quality of care, butmay lead tomisses in relevant findings in the inappropriate group. Future studies should be directed towards refining the inappropriate and uncertain categories of the AC, and identifying strategies aimed at reducing inappropriate testing. doi:10.1016/j.hlc.2009.05.075

Cardiac perforation and device erosion is an infrequent but potentially lethal complication of percutaneous occluder device insertion. Transthoracic and transesophageal echocardiography (TEE) and gated cardiac CT are useful in detecting this complication.Wepresent characteristic clinical and imaging findings of early and late cardiac perforation diagnosed at our institution, prior to surgical correction. Results: Echocardiograms from 230 device insertions were retrospectively reviewed. 2 cases of confirmeddevice erosion were identified, occurring from 2 weeks to 18 months after device insertion. Clinical and imaging features of device erosion were: (a) new cardiac symptoms of pericardial pain, dyspnoea or tamponade, (b) device size and geometry in relation to atrial size, particularly device extending >90% across the atrial septum, (c) relationship of device to aorta and posterior atrial wall, (d) deficient superior-anterior rim, (e) presence of pericardial fluid adjacent to device, (f) TEE or CT evidence of disc protrusion into or through the atrial/aortic wall. Discussion: Device erosion can be gradual and present with progressive symptoms of pericardial chest pain and/or dyspnoea in the early or late stages post percutaneous ASD or PFO closure. Cardiac perforation by the closure device can cause intermittent symptoms and pericardial fluid accumulation, due to intermittent occlusion of the puncture site by the device itself. Conclusion: Deficient superior-anterior rim and encroachment of the occluder device on the posterior atrial wall are important and under-recognised risk factors for device erosion. TEE should be performed prior to device insertion with heightened awareness of atrial geometry andmanufacturer’s guidelines for device sizing. This may reduce occurrence of this serious complication. TEE and cardiac CT are useful in confirming device erosion when present.