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Background The World Heart Federation (WHF) criteria, published in 2012, provided an evidence-based guideline for the minimal diagnosis of echocardiographically-detected RHD. Primary aim of the study was to determine whether use of the WHF criteria altered the threshold for the diagnosis of echocardiographically-detected RHD compared with the previous WHO/NIH criteria. A secondary aim was to explore the utility of a three reviewer reporting system compared to a single or two reviewer reporting structure. Methods 144 de-identified echocardiograms (RHD, congenital valvar abnormality, physiological valvar regurgitation) were independently reported using the WHF criteria by two reviewers blinded to the previous WHO/NIH diagnosis. If there was discordance between the two reviewers, a third cardiologist independently performed a tie-breaker review. Results There was a 21% reduction of cases classified as RHD using the WHF criteria compared to the modified WHO/NIH criteria (68 cases compared to 86, p = 0.04). There was a 60% consensus across the different diagnostic categories with 2 reviewers, 89% majority agreement with 3 reviewers. 11% required an open label discussion. There was moderate agreement between 2 reviewers for any RHD, kappa 0.57 (CI 0.44–0.70), with no significant difference in agreement between the different categories. Conclusion The WHF criteria have raised the threshold for the diagnosis of RHD compared to the WHO/NIH criteria. However, inter-reporter variability of the WHF criteria is high. A three reviewer system is likely more accurate than a single or two reporter system for the diagnosis of mild RHD. This has resource implications for echocardiographic screening programmes.

Background Cardiac resynchronization therapy (CRT) has been shown to improve morbidity and mortality for heart failure (HF) patients. Little is known about the trends in CRT use and outcomes of these patients in New Zealand. Method Mortality, hospitalization events and complications in HF patients in the Northern Region of New Zealand implanted with CRT devices from Jan‐2007 to June‐2015 were reviewed. Results Two‐hundred patients underwent CRT implantation during the study period. There was a gradual increase in CRT‐D implantation (n = 157) but the number remained static for CRT‐P (n = 43). Patients who received CRT‐P were older (mean age 65.9 ± 14.0 years vs 61.5 ± 10.2 years, P

ObjectiveDifferent definitions have been used for screening for rheumatic heart disease (RHD). This led to the development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria. The objective of this study is to determine the intra-rater and inter-rater reliability and agreement in differentiating no RHD from mild RHD using the WHF echocardiographic criteria.MethodsA standard set of 200 echocardiograms was collated from prior population-based surveys and uploaded for blinded web-based reporting. Fifteen international cardiologists reported on and categorised each echocardiogram as no RHD, borderline or definite RHD. Intra-rater and inter-rater reliability was calculated using Cohen’s and Fleiss’ free-marginal multirater kappa (κ) statistics, respectively. Agreement assessment was expressed as percentages. Subanalyses assessed reproducibility and agreement parameters in detecting individual components of WHF criteria.ResultsSample size from a statistical standpoint was 3000, based on repeated reporting of the 200 studies. The inter-rater and intra-rater reliability of diagnosing definite RHD was substantial with a kappa of 0.65 and 0.69, respectively. The diagnosis of pathological mitral and aortic regurgitation was reliable and almost perfect, kappa of 0.79 and 0.86, respectively. Agreement for morphological changes of RHD was variable ranging from 0.54 to 0.93 κ.ConclusionsThe WHF echocardiographic criteria enable reproducible categorisation of echocardiograms as definite RHD versus no or borderline RHD and hence it would be a suitable tool for screening and monitoring disease progression. The study highlights the strengths and limitations of the WHF echo criteria and provides a platform for future revisions.

Background Transcatheter aortic valve implantation (TAVI) is an alternative and effective contemporary intervention to surgical aortic valve replacement (SAVR) for patients with severe aortic valve disease at increased surgical risk. Guidelines recommend a multidisciplinary “Heart Team” (MHT) review of patients considered for a TAVI procedure, but this has been little studied. We reviewed the characteristics, treatments and outcomes of such patients reviewed by the MHT at our centre. Methods Data on consecutive patients with severe aortic valve stenosis discussed by the Auckland City Hospital MHT from June 2011 to August 2016 were obtained from clinical records. Patient characteristics, treatment and outcomes were analysed using standard statistical methods. Results Over the 5-year period 243 patients (mean age 80.2 ± 8.0 years, 60% male) were presented at the MHT meeting. TAVI was recommended for 200, SAVR for 26 and medical therapy for 17 patients, with no significant difference in mean age (80.2 ± 8.3, 80.4 ± 6.1, 80.4 ± 7.3 years, respectively) or EuroSCORE II (6.5 ± 4.7%, 5.3 ± 3.6%, 6.7 ± 4.3%, respectively). Over time, there was an increase in the number of patients discussed and treated, with no change in their mean age, but the mean EuroSCORE II significantly decreased (TAVI p = 0.026, SAVR p = 0.004). Survival after TAVI and SAVR was similar to that of the age-matched general population, but superior to medical therapy p = 0.002 (93% (n = 162), 84% (n = 21) and 73% (n = 18) at one year and 85% (n = 149), 84% (n = 21) and 54% (n = 13) at 2 years, respectively). Conclusions An increasing number of patients were discussed at the MHT meeting with the majority undergoing TAVI, with a similar age and EuroSCORE II to those allocated SAVR or medical therapy. Survival following TAVI and SAVR was superior to medical therapy and similar to the age-matched general population. These findings suggest that the MHT process is robust, consistent and appropriately allocating a limited treatment resource.

Background Implantable cardioverter‐defibrillator (ICD) therapy is indicated for selected heart failure patients for the primary prevention of sudden cardiac death. Little is known about the outcomes in patients selected for primary prevention device therapy in the northern region of New Zealand. Method Heart failure patients with systolic dysfunction who underwent primary prevention ICD/cardiac resynchronization therapy‐defibrillator (CRT‐D) implantation between January 1, 2007, and June 1, 2015, were included. Complications, mortality, and hospitalization events were reviewed. Results Three hundred and eighty‐five primary prevention devices were implanted (269 ICD, 116 CRT‐D). Mean age at implant was 59.1 ± 11.4 years. Mean duration of follow‐up was 3.64 ± 2.17 years. The commonest cause of death was heart failure (41.8%). Only 2 patients died from sudden arrhythmic death. The 5‐year heart failure mortality rate was 6%, whereas the 5‐year sudden arrhythmic death rate was 0.3%. Heart failure hospitalizations were commoner in those who received ICD than CRT‐D (67.7% vs 25.8%, P < .001). Maori patients have low implant rates (14%) with relatively high rates of admissions with heart failure and ventricular arrhythmia admissions, Conclusions Even in appropriately selected heart failure patients who received primary prevention devices, only a small percentage died as a result of sudden arrhythmic death. CRT‐D should be the device of choice where appropriate in heart failure patients. Significant challenges remain to improve access to device therapy and maximize benefit to those who do get implanted.

Objective We aimed to define the normal range of aortic and mitral valve thickness in healthy schoolchildren from a high prevalence rheumatic heart disease (RHD) region, using a standardised protocol for imaging and measurement. Methods Measurements were performed in 288 children without RHD. Anterior mitral valve leaflet (AMVL) thickness measurements were performed at the midpoint and tip of the leaflet in the parasternal long axis (PSLA) in diastole, when the AMVL was approximately parallel to the ventricular septum. Thickness of the aortic valve was measured from PSLA imaging in systole when the leaflets were at maximum excursion. The right coronary and non-coronary closure lines of the aortic valve were measured in diastole in parasternal short axis (PSSA) imaging. Results were compared with 51 children with RHD classified by World Heart Federation diagnostic criteria. Results In normal children, median AMVL tip thickness was 2.0 mm (IQR 1.7–2.4) and median AMVL midpoint thickness 2.0 mm (IQR 1.7–2.4). The median aortic valve thickness was 1.5 mm (IQR 1.3–1.6) in the PSLA view and 1.4 mm (IQR 1.2–1.6) in the PSSA view. The interclass correlation coefficient for the AMVL tip was 0.85 (0.71 to 0.92) and for the AMVL midpoint was 0.77 (0.54 to 0.87). Conclusions We have described a standardised method for mitral and aortic valve measurement in children which is objective and reproducible. Normal ranges of left heart valve thickness in a high prevalence RHD population are established. These results provide a reference range for school-age children in high prevalence RHD regions undergoing echocardiographic screening.

Disparities in health care access and outcomes between Maori (M) and Non-Maori (NM) New Zealanders have been reported but little is known about access to and outcomes following heart transplantation (HT).A retrospective analysis was performed of M and NM who underwent HT in New Zealand. Demographic, clinical and outcome data were collected.Of 253 patients transplanted, 176 were European, 47 M (19%) and 30 of other ethnicities. M and NM groups were compared. Median age (both 46 years), gender (17% vs 21% female), waiting time (90 vs 76 days) and diagnosis (dilated cardiomyopathy - 62% vs 58%) were similar for both groups. M were heavier (81 vs 71 kg, p0.0001) and more were blood group A (58% vs 39%). Five year survival was similar (79% vs 78%) but 10 year survival was significantly reduced in M (54% vs 67% p=0.02).The proportion of Maori who have undergone heart transplantation in New Zealand compares favourably with their proportion in the New Zealand population. The reasons for the adverse diverging outcomes after five years require further investigation.

Isolated tricuspid valve surgery is not commonly performed with few studies and limited numbers published. We reviewed the characteristics and outcomes, including survival, reoperation rates and their predictors of different types of isolated tricuspid surgery.Patients coded for isolated tricuspid valve surgery were identified from the Green Lane Hospital database. Relevant clinical characteristics were collected from both clinical and written clinical records. Mortality was checked against the national 'Births, Deaths and Marriages' database from the Ministry of Health.Seventy-two consecutive patients (48 ± 16 years; 71% women, body mass index 25 ± 6) underwent isolated tricuspid valve surgery from 1965 to 2011. Valve repair was performed in 53 and 47% had a valve replacement. The majority of these operations were performed in the last two decades. Early mortality within 30 days of operation was 7.9% for repair and 17.6% for replacement (P = 0.29). The 1-, 5-, 10- and 25-year survival rates were 83.8, 74.5, 63.6 and 32.8% for tricuspid repair and 81.8, 68.2, 61.4 and 15.2% for tricuspid replacement, respectively. Preoperative loop diuretic dose (P = 0.0120) and preoperative haemoglobin level (P = 0.0377) were independent predictors of survival for all isolated tricuspid surgery, while preoperative creatinine level (P = 0.04) independently predicted reoperation during the follow-up.Both isolated tricuspid replacement and repair were associated with significant but acceptable early and late mortality with no statistically significant difference in cumulative survival. Preoperative loop diuretic dose, haemoglobin and creatinine are individually associated with survival and/or reoperation after isolated tricuspid valve surgery.

Objective: To compare the efficiency of 20 and 40 µm arterial line filters during cardiopulmonary bypass for the removal of emboli from the extracorporeal circuit. Methods: Twenty-four adult patients undergoing surgery were perfused using a cardiopulmonary bypass circuit containing either a 20 µm or 40 µm arterial filter (n = 12 in both groups). The Emboli Detection and Classification system was used to count emboli upstream and downstream of the filter throughout cardiopulmonary bypass. The mean proportion of emboli removed by the filter was compared between the groups. Results: The 20 µm filter removed a significantly greater proportion of incoming emboli (0.621) than the 40 µm filter (0.334) (p=0.029). The superiority of the 20 µm filter persisted across all size groups of emboli larger than the pore size of the 40 µm filter. Conclusion: The 20 µm filter removed substantially more emboli than the 40 µm filter during cardiopulmonary bypass in this comparison.

Objective: To compare the emboli filtration efficiency of five integrated or non-integrated oxygenator-filter combinations in cardiopulmonary bypass circuits. Methods: Fifty-one adult patients underwent surgery using a circuit with an integrated filtration oxygenator or non-integrated oxygenator with a separate 20 µm arterial line filter (Sorin Dideco Avant D903 + Pall AL20 (n=12), Sorin Inspire 6 M + Pall AL20 (n=10), Sorin Inspire 6M F (n=9), Terumo FX25 (n=10), Medtronic Fusion (n=10)). The Emboli Detection and Classification quantifier was used to count emboli upstream and downstream of the primary filter throughout cardiopulmonary bypass. The primary outcome measure was to compare the devices in respect of the median proportion of emboli removed. Results: One device (Sorin Inspire 6 M + Pall AL20) exhibited a significantly greater median percentage reduction (96.77%, IQR=95.48 – 98.45) in total emboli counts compared to all other devices tested (p=0.0062 – 0.0002). In comparisons between the other units, they all removed a greater percentage of emboli than one device (Medtronic Fusion), but there were no other significant differences. Conclusion: The new generation Sorin Inspire 6 M, with a stand-alone 20 µm arterial filter, appeared most efficient at removing incoming emboli from the circuit. No firm conclusions can be drawn about the relative efficacy of emboli removal by units categorised by class (integrated vs non-integrated); however, the stand-alone 20 µm arterial filter presently sets a contemporary standard against which other configurations of equipment can be judged.

Objective Women have been under-represented in randomised clinical trials for primary prevention implantable cardioverter defibrillators (ICDs), and there are concerns about the efficacy of devices between genders. Our study aimed to investigate gender differences in the use of primary prevention ICD in patients with heart failure from the northern region of New Zealand. Methods Patients with heart failure with systolic dysfunction who received primary prevention ICD/cardiac resynchronisation therapy-defibrillator (CRT-D) in the northern region of New Zealand from 1 January 2007 to 1 June 2015 were included. Complications, mortality and hospitalisation events were reviewed. Results Of the 385 patients with heart failure implanted with ICD/CRT-D, women comprised 15.1% (n=58), and no change in utilisation of these devices was observed over the study period among women. Women were more likely to have non-ischaemic cardiomyopathy and have higher perioperative complications (8.6% vs 2.5%, P=0.02), with non-significant higher trend towards increased lead displacement (5.2% vs 1.8%, P=0.12). Women appeared to have lower all-cause (10.3% vs 18.7%, P=0.12), cardiovascular (5.2% vs 11.9%, P=0.13) and heart failure (3.5% vs 7.9%, P=0.22) mortalities but was not statistically significant. There were no gender differences in all-cause (70.7% vs 67%, P=0.58) or heart failure (19% vs 25%, P=0.32) readmissions. Conclusion Perioperative complications were significantly more common in women referred for ICD/CRT-D. Although there has been a significant increase in ICD implantation rates, gender differences in the use of these devices still exist in New Zealand, in keeping with the demographics of ischaemic heart disease and systolic dysfunction between genders.

Central arterial pressure is a better predictor of adverse cardiovascular outcomes than brachial blood pressure, but noninvasive measurement by applanation tonometry is technically demanding.Pulsecor R6.5 is a novel device adapted from a standard sphygmomanometer which estimates the central aortic pressure from analysis of low-frequency suprasystolic waveforms at the occluded brachial artery. A physics-based model, which simulates the arterial system using elastic, thin-walled tube elements and Navier-Stokes equations, is used to calculate arterial pressure and flow propagation. To determine the reliability of the device, we compared 94 central systolic pressures estimated by Pulsecor to the simultaneous directly measured central aortic pressures at the time of coronary angiography in 37 individuals.There was good correlation in central SBP between catheter measurements and Pulsecor estimates by either invasive or noninvasive calibration methods (r = 0.99, P 0.0001 and r = 0.95, P 0.0001, respectively). The mean difference in central systolic pressure was 2.78 (SD 3.90) mmHg and coefficient of variation was 0.03 when the invasive calibration method was used.When the noninvasive calibration method was used, the mean difference in central systolic pressure was 0.25 (SD 6.31) mmHg and coefficient of variation was 0.05.We concluded that Pulsecor R6.5 provides a simple and easy method to noninvasively estimate central SBP, which has highly acceptable accuracy.

P. Gladding , F. Erogbogbo , M. Swihart , K. Smart , S. El-Jack , D. Korcyk , M. Webster , R. Stewart , I. Zeng , M. Jullig , K. Bakeev , M. Jamieson , N. Kasabov , L. Liang , R. Hu , S. Schliebs , B. Gopalan , S. Villas-Boas 7 Waitemata District Health Board, Auckland, NZ Institute for Lasers, Photonics and Biophotonics, Buffalo University, USA KEDRI, Auckland University of Technology, Auckland, NZ Princess Alexandria Hospital, Brisbane, Australia Green Lane Cardiovascular Service, Auckland, NZ CCRep, Middlemore Hospital, Auckland, NZ School of Biological Science, University of Auckland, Auckland, NZ CAMO software, New Jersey, USA Lerner Research Institute, Cleveland, Ohio, USA Corresponding author.

flow measurement in the main (MPA), right (RPA) and left (LPA) pulmonary arteries on a 1.5T Siemens Avanto MR scanner, using both the standard and the interleaved sequences, in a varying order. Internal consistency of the measurements was checked by the sum MPA flow (RPA + LPA flows). Flow measurements were analysed using Argus software (Siemens), statistical analysis with SPSS Statistics. Results: The mean MPA flow was 5.90 l/min using the standard sequence vs 5.47 l/min with the interleaved sequence (p=0.484). Mean RPA flow was 3.07 l/min vs. 2.75 l/min (p=0.249), and the mean LPA flow was 2.89 l/ min vs. 2.59 l/min (p=0.310). Internal consistency was comparable at 0.29 l/min standard vs. 0.28 l/min interleaved (p=0.959). Conclusion: The interleaved flow sequence produces similar results to the standard sequential method. No advantage for the interleaved sequence was demonstrated, but use thereof has no disadvantage either. In clinical situations where flow should be measured at multiple sites, eg shunt calculation, the interleaved sequence is preferable, with one source of potential error eliminated.

the understanding of rights needed for subjects to provide informed consent. Methods: A booklet designed to provide information on participants’ rights which used simple language was developed to replace this information in current ICF’s. 282 hospital inpatients were randomised to one of three ways to present research information; a standard ICF, the booklet combined with a short ICF, or the booklet combined with a simplified ICF. Comprehension of information related to the research proposal and to participant’s rights was assessed by questionnaire. Results: Information related to participants’ rights contributed an average of 44% of the words in standard ICFs, and was harder to read than information describing the clinical trial (FK 25 versus (vs.) 41 respectively, p= 0.0003). Comprehension assessed in inpatients was better for the booklet and short ICF 62%, (95% CI 56 to 67) correct, or simplified ICF 62% (CI 58 to 68) correct compared to 52%, (CI 47 to 57) correct for the standard ICF, p= 0.009. Thiswas due tobetterunderstandingofquestionson rights (62%vs. 49% correct, p= 0.0008). Comprehension of study related information was similar for the simplified and standard ICF (60% vs. 64% correct, p= 0.68). Conclusions: A booklet provides a simple, consistent approach to providing information on participant rights which is relevant to all research studies, and improves comprehension of patients who typically participate in clinical trials. http://dx.doi.org/10.1016/j.hlc.2013.04.012

Background: Atrial fibrillation (Afib) may first be diagnosed only after presentation with heart failure or stroke. Identification of Afib by non-medical staff when measuring blood pressure (BP) may improve its’ detection in asymptomatic patients in primary care. The Pulsecor CardioScope is a user friendly automated sphygmomanometer previously validated for estimating central BP. Analysis of beat-to-beat variation in the pulsewave amplitude or RR interval could also be used to diagnose Afib. Methods: Patients presented for pre-clinic BP measurement and electrocardiogram (ECG) were recruited. ECG technicians performed BP measurement using Pulsecor and an ECG simultaneously. Pulse wave parameters calculated by Pulsecor were tested for performance in correctly classifying rhythm as Afib and Sinus via pulse rate variability (PRV) using √ mean[(period2−period1)2], pulse amplitude variation (PAV) using [max(pulse amplitude)−min(pulse amplitude)]/mean(pulse amplitude) and signal to noise ratio (SNR). Pulsecor analysis was performed blind to ECG results. Diagnoses of arrhythmias were confirmedbyCardiologyRegistrars interpreting corresponding ECGs. Results:Forty-fivepatients (meanage 70± 12 years; 71% men) with Afib on ECG, and 55 patients (mean age 60± 17 years; 44% men) with normal sinus rhythm. One hundred percent sensitivity to Afib was associated with a 13% false positive rate; 96% sensitivity with 7% false positive rate when using PRV for rhythm classification. PRV demonstrated the highest accuracy [Area under the curve (AUC)= 0.953] to detect Afib when comparing with PAV (AUC=0.844) and SNR (AUC=0.857). Conclusions: Pulsecor device can diagnose Afib with high sensitivity, and can be used to screen for Afib with BP measurement in primary care.

Background: An implantable cardioverter-defibrillator (ICD) is a treatment associated with significant cost and risk of morbidity. Elderly patients (arbitrarily defined as age≥ 75 years old) were under-represented in large clinical trials (e.g. MADIT-II and SCD-HeFT) which showed a mortality benefit with ICD implantation in patients with reduced left ventricular function. Thenetmortality benefit for this age group is unclear and there is no New Zealand data available. Aim: The aim of this study was to ascertain survival in elderly patients who have had ICDs implanted. The secondary objective was to document device related morbidity. Methods: This was a descriptive study with retrospective data collection on 41 patients age≥ 75 years old living in the Auckland region who received ICDs between 1st January 2000 to 31st December 2010. Demographic, clinical and survival data were collected retrospectively from Auckland District Health Board (DHB), Counties Manukau DHB, Waitamata DHB and regional ICD databases. Results: The total number of deaths was 15 (37%), eight cardiac and seven non cardiac. One and two year mortality rates were 2.4% (1/41) and 14.6% (6/41) respectively. Twenty patients (48.8%) received appropriate therapy while fivepatients (12.2%) received inappropriate therapy. Other device relatedmorbidity includes five implant complications (12.2%), five generator complications (12.2%) and one lead complication (2.4%) during follow up. Conclusions:While the total numberofpatients is small, our data support the value of ICD implantation in carefully selected elderly patients. Device related morbidity is acceptable.