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Cardiac transplantation remains the gold standard therapy for select patients with end-stage heart failure and outcomes have improved significantly over the past few decades. We report the 5-year contemporary experience of cardiac transplantation in Western Australia, one of the most remote transplant centres worldwide.Patients undergoing isolated cardiac transplant at Fiona Stanley Hospital (FSH) from February 2015 until April 2021 were included. Donor details were collected using donor electronic records (Donate Life, Australia). Recipient data was collated from electronic medical records at FSH and the Australia and New Zealand Society of Cardiothoracic Surgery database. The primary outcome measure was all-cause mortality. Secondary outcome measures included postoperative intensive care and total hospital length of stay and rates of acute kidney injury, rejection, serious infections, and cardiac allograft vasculopathy. Frailty indices were also assessed.A total of 60 patients were included (mean age 53±14 yrs, 66.7% male). The commonest indication for transplant was a non-ischaemic cardiomyopathy (46.7%). Mean donor age was 35±12 years and median donor ischaemia time was 171 minutes (IQR=138-240). After median follow-up of 3.7 years, there were no mortalities. Postoperative renal failure occurred in 21 (35.0%) patients, pneumonia in four (6.7%), deep sternal wound infection in three (5.1%), acute rejection in 17 (28.3%) and cardiac allograft vasculopathy (CAV) in 23 (38.3%).With recipient and donor criteria comparable to national and international standards, compounded by the challenges of geographic isolation, we report the first published data on contemporary outcomes post isolated cardiac transplantation in Western Australia.

Stress hyperglycaemia is common following cardiac surgery. Its optimal management is uncertain and emerging literature suggests that flexible glycaemic control in diabetic patients may be preferable. This study aims to assess the relationship between maximal postoperative in-hospital blood glucose levels (BSL) and the morbidity and mortality outcomes of diabetic and non-diabetic cardiac surgery patients.A retrospective cohort analysis of all patients undergoing cardiac surgery at a tertiary single centre institution from 2015 to 2019 was undertaken. Early management and outcomes of hyperglycaemia following cardiac surgery were assessed via multivariable regression modelling. Follow-up was assessed to 1 year postoperatively.Consecutive non-diabetic patients (n=1,050) and diabetic patients (n=689) post cardiac surgery were included. Diabetics with peak BSL ≤13.9 mmol/L did not have an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. In non-diabetics, stress hyperglycaemia with peak BSL10.0 mmol/L was associated with overall wound complications (5.7% vs 8.8%, OR 1.64 [1.00-2.69], p=0.049) and postoperative pneumonia (2.7% vs 7.3%, OR 2.35 [1.26-4.38], p=0.007). Diabetic patients with postoperative peak BSL13.9 mmol/L were at an increased risk of overall wound complication (7.4% vs 14.8%, OR 2.47 [1.46-4.16], p0.001), graft harvest site infection (3.7% vs 11.8%, OR 3.75 [1.92-7.30], p0.001), and wound-related readmission (3.1% vs 8.8%, OR 3.11 [1.49-6.47], p=0.002) when compared to diabetics with peak BSL ≤13.9 mmol/L.In non-diabetics, stress hyperglycaemia with peak BSL10.0 mmol/L is associated with morbidity. In diabetic patients, hyperglycaemia with peak BSL ≤13.9 mmol/L was not associated with an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. Further investigation of flexible glycaemic targets (target BSL ≤13.9 mmol/L) in diabetic patients is warranted.

BACKGROUND Guidelines advocate multifactorial cardiovascular risk management in patients with diabetes and atherosclerotic cardiovascular disease. In hospitalised patients with diabetes following coronary artery bypass graft (CABG) we evaluated the impacts of decision-support algorithms for optimising glycaemia and lipid-lowering. We also assessed the safety of initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors near time of hospital discharge. METHODS This was a single-site, pre- and post-intervention analysis of glucose and lipid management in consecutive hospitalised patients with diabetes undergoing CABG surgery. The intervention involved education and decision-support algorithms designed by a multidisciplinary committee to guide cardiac surgery unit clinicians. RESULTS A total of 200 patients were included in the study. The pre- and post-intervention groups had similar baseline characteristics (HbA1c 7.9 ± 1.9% versus 8.1 ± 1.8%). Of 4092 blood glucose measurements the incidence of levels between 5 to 10 mmol/L was not different post-intervention (55.5% versus 57.0%, p = 0.441). Fewer endocrinology consultations occurred (59.0% versus 45.0%, p = 0.048) and rates of hypoglycaemia remained low. High-intensity statin was prescribed in >90% pre- and post-intervention although non-statin lipid-lowering agents remained

Guidelines advocate for intensive lipid-lowering in patients with atherosclerotic cardiovascular disease (ASCVD). In May 2020, evolocumab, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor, became government subsidised in Australia for patients with ASCVD requiring further low-density lipoprotein cholesterol (LDL-C) lowering.To identify barriers to prescribing PCSK9 inhibitors in hospitalised patients with ASCVD.A retrospective 3-month, single-site, observational analysis was conducted in consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Lipid-lowering therapy prescriptions, including PSCK9 inhibitors, were assessed using electronic medical records, compared against the Australian Pharmaceutical Benefits eligibility criteria, and barriers to PCSK9 inhibitor use identified.Of 331 patients, 244 (73.7%) underwent PCI and 87 (26.3%) underwent CABG surgery. A lipid profile during or within 8 weeks of admission was measured for 202 (82.8%) patients undergoing PCI and 59 (67.8%) undergoing CABG surgery. In patients taking high-intensity statins on admission (n = 109), LDL-C ≥1.4, ≥1.8 and2.6mmol/L was seen in 64 (58.7%), 44 (40.4%) and 19 (17.4%) patients respectively. High-intensity statin prescribing at discharge was high (80%); however, ezetimibe was initiated in zero patients with LDL-C ≥1.4 mmol/L. There was variable advice given by clinicians for LDL-C targets. No patients met the criteria for subsidised PSCK9 inhibitor therapy, largely due to lack of qualifying lipid levels following combined statin and ezetimibe therapy.Prescribing of non-statin LDL-C-lowering therapies remains low in patients with ASCVD. Underprescribing of ezetimibe and suboptimal lipid testing rates are barriers to accessing subsidised PCSK9i therapy using current Australian eligibility criteria.

The role of intra-aortic balloon pumps (IABP) in high-risk patients undergoing coronary artery bypass graft (CABG) surgery remains controversial. We report the 5-year experience from a new Australian centre.We retrospectively analysed 690 patients undergoing urgent isolated CABG surgery at a Western Australian tertiary centre from February 2015 to May 2020. De-identified data was obtained from the AustraliaNew Zealand Society of Cardiothoracic Surgeons database. Patients were stratified according to preoperative IABP use. A propensity score was created for the probability of IABP use and a propensity adjusted analysis was performed using logistic regression. The primary outcome was 30-day mortality. Secondary outcomes were postoperative inhospital outcomes.Preoperative IABP was used in 78 patients (11.3%). After propensity score adjustment, in a subgroup of patients with reduced ejection fraction or left main disease, 30-day mortality (7.0% vs 2.0%, OR 6.03, 95% CI 1.89-19.28, p=0.002) was significantly higher in the IABP group. Red blood cell transfusions (19.7% vs 12.6%, OR 1.86, 95% CI 1.02-3.35, p=0.039), prolonged inotrope use (78.9% vs 50.9%, OR 6.11, 95% CI 2.77-13.48, p0.001), prolonged invasive ventilation (28.2% vs 3.4%, OR 20.2, 95% CI 8.24-49.74, p0.001), mesenteric ischaemia (2.8% vs 0%, OR 4.52, 95% CI 1.15-17.77, p=0.031) and multisystem organ failure (1.3% vs 0.7%, OR 25.68, 95% CI 2.55-258.34, p=0.006) were significantly higher in the IABP group.In patients undergoing isolated CABG surgery, preoperative IABP use was associated with increased 30-day mortality and adverse outcomes. Large randomised controlled trials are required to confirm our findings.

Background Infective endocarditis (IE) is associated with significant morbidity and mortality. Non-adherence to IE guidelines and recommendations is frequent, and may adversely impact patient outcomes. Aim To assess the impact of non-adherence to components of existing IE guidelines and recommendations on a composite outcome consisting of any of the following: mortality, unplanned cardiac surgery, embolic event or relapse of positive blood culture within six months of diagnosis. Methods A single centre, retrospective cohort study. Results Amongst 157 patients, there was inconsistent adherence to: initial diagnosis of an infective condition (87%), timely administration of antimicrobial therapy (82%), appropriateness of predominant antimicrobial regime (94%), appropriate management of the portal of entry (86%), multidisciplinary input (75%), end of antimicrobial therapy repeat echocardiography (60%) and adherence to indications for surgery (76%). Inpatient mortality was 12.1% (n = 19) and the composite adverse outcome occurred in 36 (22.9%) patients. In multivariate logistic regression analysis, infection of prosthetic device (adjusted odds ratio [95% confidence interval]; 2.43 [1.07–5.50]) and non-adherence to surgical guidelines (aOR 3.67 [1.60–8.47]) were significantly associated with an adverse outcome. Conclusions Our data suggests that adherence to differing components of IE management guidelines and recommendations varies and that non-adherence to surgical aspects of guidelines has the biggest impact in determining outcomes.

Outcomes after coronary artery bypass graft (CABG) surgery have improved due to advances in surgical technique and post-operative care. We aimed to describe contemporary clinical characteristics and short-term post-operative outcomes in diabetic patients undergoing CABG surgery.A retrospective analysis of patients who underwent CABG surgery over a 4.5-year period in a Western Australian tertiary hospital was performed in September 2019. The cohort was stratified according to pre-operative diabetes status.A total of 1327 patients underwent CABG surgery, of which 572 (43.1%) had diabetes. Diabetic patients were more likely to be female (24.7% vs. 13.9%, p 0.001) and have dyslipidaemia (83.0% vs. 68.1%, p 0.001), hypertension (82.0% vs. 68.7%, p 0.001), raised body mass index (29.8 ± 5.6 vs. 28.7 ± 5.1 kg/mDiabetic patients continue to represent a higher-risk cohort, highlighting the need for further strategies to reduce short-term adverse outcomes following CABG surgery.

BACKGROUND Sternoclavicular joint septic arthritis (SCJ SA) is a rare infectious disease process with reported life-threatening complications such as mediastinal abscess and mediastinitis. The available literature reports variable success of medical management and a predominance of surgical management, with a 58% rate of surgical washout/debridement and high rates (47%) of resection of the SCJ and medial third of the clavicle. METHODS A retrospective case series of radiologically or microbiologically confirmed cases of bacterial SCJ SA at Fiona Stanley Hospital was analysed. Demographic data, investigations, management and outcomes were assessed. RESULTS Eleven cases of bacterial SCJ SA were identified. Eight cases were of primary SCJ SA, whilst three cases were secondary to haematogenous seeding. Recognized risk factors such as intravenous drug use, diabetes mellitus, trauma, smoking and immunosuppression were present. The most common complication was clavicular osteomyelitis (64%). Life-threatening complications included mediastinal abscess and rapidly progressive necrotizing myositis. Nine patients (82%) were managed with primary medical therapy, with two patients failing antibiotic therapy and requiring joint washout. Two patients were taken for urgent washout on presentation. Four cases (36%) resulted in operative SCJ washout. There were no cases requiring resection of the SCJ or clavicle. CONCLUSION This series suggests that SCJ SA can be primarily treated medically in the absence of life-threatening complications. In addition, medical management may be sufficient for cases complicated by clavicular osteomyelitis. Need for surgical resection of the SCJ and medial third of the clavicle may be less than previously reported.

Background: Perioperative statin therapy can have pleiotropic effects beyond reducing plasma cholesterol level. Whether perioperative statin therapy can reduce surgical infection after cardiac surgery remains unclear. We aimed to assess whether preoperative statin therapy is associated with a reduced risk of surgical site infections and pneumonia after cardiac surgery.Methods: This retrospective cohort study included 1902 adult patients who had cardiac surgery between February 2015 and April 2019 at a major cardiothoracic centre in Western Australia. The primary outcomes were surgical site infections and pneumonia; secondary outcomes were inotrope requirement, duration of mechanical ventilation, intensive care unit (ICU) and hospital stay, and 30-day mortality. We used propensity-score matching to minimise confounding.Results: Following propensity-score matching (N=1098), patients on preoperative statins (n=551) were associated with a reduced risk of postoperative wound infections (0.7% vs 13.9%, adjusted odds ratio [OR] 0.010, 95% confidence interval [CI] 0.001-0.075, PConclusions: Use of statin before cardiac surgery was associated with a reduced risk of postoperative surgical site infections and pneumonia.

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) improve cardiovascular outcomes in patients with type 2 diabetes (T2D). Diabetic ketoacidosis (DKA) is an uncommon, but well recognised, life-threatening complication of SGLT2i. In a retrospective study of patients with T2D undergoing cardiac surgery at our institution, DKA occurred in 15.3% of patients taking SGLT2i at the time of surgery, compared with 0.47% of non-SGLT2i-treated patients. Intravenous insulin in the first 24 h after surgery was associated with a significantly lower risk of DKA in SGLT2i patients. Use of an insulin infusion should be considered in these patients, especially in those who are unable to cease their SGLT2i pre-operatively.

Icosapent ethyl reduces cardiovascular events in high-risk patients with hypertriglyceridaemia on statin therapy. However, it is not widely available and the potential application following coronary artery bypass graft (CABG) surgery is not well-established. We aimed to determine the real-world percentage of CABG surgery patients who may be eligible for the therapy.A retrospective analysis was performed between February 2015 and August 2020 in an Australian hospital. Patients were included if a lipid profile was performed at least three weeks following CABG surgery. Data was extracted from electronic medical records. Eligibility for icosapent ethyl was defined according to inclusion criteria from the REDUCE-IT trial.Of 484 patients with follow-up lipid profiles, 21 (4.3%) were not eligible for icosapent ethyl based on age and 39 (8.1%) were not prescribed statin therapy or were prescribed a fibrate. After applying triglyceride and low-density lipoprotein cholesterol level criteria, 124 (25.6%) patients were potentially eligible for icosapent ethyl therapy. Of those eligible, high-intensity statin therapy were prescribed in 108 (87.1%).A substantial percentage of CABG surgery patients may be eligible for icosapent ethyl and could potentially benefit from its cardiovascular protection. Further research should evaluate the additional cardiovascular benefits of icosapent ethyl in this very high-risk group of patients who are already treated with high-intensity statins.

In this real-world study, the main barriers for not initiating SGLT2 inhibitor therapy early after an acute cardiac event are prescribing criteria around glycated haemoglobin and renal function. Initiation of SGLT2 inhibitors near to, or at, hospital discharge following the cardiac event was not associated with 30-day diabetic ketoacidosis readmissions.

Funding Acknowledgements Type of funding sources: None. Background Our hospital is one of the most remote transplant centres in the world. We evaluated the short- and long-term outcomes after cardiac transplantation at a new Tertiary Centre hospital in Western Australia. Methods A retrospective study of all patients undergoing cardiac transplantation since February 2015 until November 2020 was conducted. De-identified data was collected using hospital medical records and the ANZSCTS database. Primary outcome measure was mortality at any time point and acute rejection. Secondary outcome measures included new renal failure, post-operative blood product use and readmission rate. Results A total of 59 cardiac transplantations were conducted, with the mean age of recipients being 52 (±15) years and the majority being male (64.4%). Ischaemic cardiomyopathy and dilated cardiomyopathy were the most common indications for transplantation, accounting for 71.2% of all transplants. The mean age of donors was 35.29 (±11.11) years with the majority being male (69.5%). There were no mortalities and acute rejection within 3 months of transplant occurred in 16 (27.1%) patients. New renal failure was the most common complication occurring in 16 (27.1%) patients. After multivariate analysis, donor ischaemia time >200minutes was associated with an increased risk of renal failure (OR 1.2, P = 0.044). Conclusions Over a five-year period at a new cardiac transplant centre in one of the most remote locations of the world, we report no mortalities.

There is some interest in long-term survival after various cardiac surgical strategies, including off-pump versus on-pump coronary artery surgery (CAG), mitral valve (MV) repair versus replacement, and aortic valve (AV) bioprosthetic versus mechanical replacement.We studied patients older than 49 years of age, recording risk factors and surgical details at the time of surgery. We classified procedures as: MV surgery with or without concurrent grafts or valves; AV surgery with or without concurrent CAG; or isolated CAG. Follow-up was through the state death register and state-wide hospital attendance records. Risk-adjusted survival was estimated using Cox proportional hazards. Observed survival was compared to the expected age- and sex- matched population survival.During a median follow-up of 14.8 years 5,807 of 11,718 patients died. The difference between observed and expected survival varied between 3.4 years for AV surgery and 9.6 years for females undergoing MV surgery. The risk-adjusted mortality hazard rate after off-pump CAG was 0.93 (95% CI 0.8-1.0, p=0.84), MV repair 0.67 (95% CI 0.6-0.8, p0.0001), MV bioprosthesis 0.82 (95% CI 0.81 (0.6-1.0, p=0.11) and bioprosthetic AV replacement 1.02 (95% CI 0.9-1.2, p=0.82).Compared to the general population, cardiac surgical patients have a shorter than expected life expectancy. We observed a survival benefit of mitral valve repair over replacement. We did not observe significant survival differences between off-pump and on-pump CAG, nor between bioprosthetic and mechanical replacement.

Background The presence of mitral annular calcification (MAC) in patients with mitral valve (MV) stenosis or regurgitation is a difficult scenario for surgeons and the heart team. Patients with MAC most often have a significant number of comorbidities that exclude them as surgical candidates. This review highlights the various contemporary techniques available to manage MAC during treatment of the MV. Methods This study is a focused review of the anatomy, pathology, and management of MAC. The review describes the surgical and transcatheter techniques with outcomes, where available. Results The incidence of MAC is between 5% and 42% in patients with severe MV disease. The pathophysiology underlying MAC is not yet clear, but it most likely is related to processes of inflammation and atherosclerosis. Surgical techniques can be grouped into those in which the MAC is completely resected en bloc and those in which the MAC is incompletely resected or left in situ. Transcatheter therapies are feasible in some patients, but they have been limited by the anatomic constraints of MAC; most importantly left ventricular outflow tract obstruction and paravalvular regurgitation. Conclusions Surgeons as part of the heart team now have a range of techniques to manage MAC in those patients with severe MV disease. Transcatheter therapies may increase the options for patients whose surgical risk is too high.

Background: The paucity of available hearts for transplantation means that more patients remain on durable left ventricular support for longer periods of time. The Registry to Evaluate the HeartWare Left Ventricular Assist System was an investigator-initiated multicenter, prospective, single-arm database established to collect post-Conformité Européene mark clinical information on patients receiving the HeartWare ventricular assist device system as a bridge to transplantation. This registry represents the longest multicenter follow-up of primary left ventricular assist device outcomes. Methods: Data were collected on 254 commercial implants performed between February 2009 and March 2012 from 9 centers in Europe (7) and Australia (2). Patients were followed to device explant, heart transplantation, or death. The outcomes of patients through July/August 2018 were analyzed. Summary statistics were used to describe patient demographics, adverse events, length of support, and outcomes for this extended-term cohort. Results: A total of 122 patients were on support for >2 years, and 34 patients were on support for >5 years. Twenty nine patients are still alive on support (support ranging from 1213 to 3396 days), and 23 of those are on their original HeartWare ventricular assist device system. Kaplan–Meier survival through 7 years was 51%. Through 6 years, freedom from any stroke was 82%, while freedom from severely disabling stroke was 89%. Conclusions: Low rates of heart transplant now require longer periods of left ventricular assist device support in patients. This analysis demonstrates that long-term support using a HeartWare ventricular assist device system offers survival of 51% through 7 years.

Patients undergoing coronary artery bypass graft (CABG) surgery remain at high cardiovascular risk; however, few studies have evaluated lipid management and attainment of lipid targets in these patients. We investigated the proportion of CABG surgery patients who attained low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (HDL-C) targets.Data were retrospectively obtained from patients undergoing CABG surgery at an Australian tertiary hospital between February 2015 and August 2020. The most recent lipid profile was recorded (at least 3 weeks post-operatively). We studied patients with electronically available data to ensure accuracy. Target LDL-C was defined as1.4 (54 mg/dL) and1.8 mmol/L (70 mg/dL), and target non-HDL-C as2.2 (85 mg/dL) and2.6 mmol/L (100 mg/dL), as per the 2019 and 2016 European dyslipidaemia guidelines, respectively.Follow-up lipid results were available for 484 patients (median post-operative follow-up, 483 days; interquartile range, 177.5-938.75 days). The mean age was 62.7±10.5 years and 387 (80.1%) were male. At discharge, 469 (96.9%) patients were prescribed statins, 425 (90.6%) high-intensity. Ezetimibe was prescribed for 62 (12.8%) patients and a proprotein convertase subtilisin-kexin type 9 inhibitor for 1. LDL-C levels1.4 and1.8 mmol/L were attained in 118 (24.4%) and 231 (47.7%) patients, respectively, and non-HDL-C levels2.2 and2.6 mmol/L in 140 (28.9%) and 237 (49.0%) patients, respectively.The use of non-statin lipid-lowering therapies was limited, and many CABG surgery patients did not attain lipid targets despite high-intensity statins. Further studies are required to optimise lipid management in this very high-risk population.

Cardiac surgery is a relatively young specialty and is undergoing many changes presently. The advent of catheter-based technology, minimally invasive surgery and better information regarding the roles of cardiac surgery in the management of common cardiac disease is changing the way we provide services. In Australia, attention must be turned to the way cardiac surgical services are provided to enable delivery of modern procedures. This has implications for the provision of training. We explore the face of modern cardiac surgery and how this may be taken up in Australia.

PURPOSE Left ventricular assist devices (LVAD) are associated with an increased aerobic capacity in patients with chronic heart failure (CHF). However, studies evaluating the impact of LVAD implantation on physical activity (PA) are lacking. The aim of this study was to compare daily PA levels in participants with LVAD with well-matched CHF participants. METHODS Sixteen participants with an LVAD (age, 59.1 ± 10.8 yr) were case-matched to 16 participants with advanced CHF (age, 58.3 ± 8.7 yr), who were listed or being considered for cardiac transplantation. Participants underwent a cardiopulmonary exercise test to determine peak oxygen consumption (V˙O2 peak). Physical activity was monitored continuously for seven consecutive days with an Actiheart monitor. RESULTS V˙O2 peak in the CHF group (12.3 ± 3.5 mL·kg·min) was not significantly different to the LVAD group before LVAD implantation (10.4 ± 2.1 mL·kg·min), but was lower than in the LVAD group after implantation (15.8 ± 4.3 mL·kg·min; P < 0.05). Physical activity was higher in the LVAD (19.7 ± 6.4 kJ·kg·d) compared with the CHF group (11.6 ± 6.9 kJ·kg·d; P = 0.001). The LVAD participants spent more time performing moderate-intensity PA than their CHF counterparts (median, 26 min·d; interquartile range, 24-40 min·d vs median, 12 min·d; interquartile range, 9-16 min·d; P < 0.001). Physical activity was correlated with V˙O2 peak (r = 0.582; P = 0.001) across participants in the CHF and LVAD groups. CONCLUSIONS Higher levels of PA were observed in participants with LVAD compared with patients with advanced CHF. This may be due to a higher V˙O2 peak, resulting in an improved capacity to perform activities of daily living with less symptoms.

Deep sternal wound infections (DSWI) after cardiac surgery impose a significant burden to patient outcomes and health care costs. The objective of this study is to identify risk factors, microbiological characteristics and protective factors for deep sternal wound infections following cardiac surgery in an Australian hospital.We performed a retrospective study on 1,902 patients who underwent cardiac surgery at Fiona Stanley Hospital, a tertiary hospital in Western Australia from February 2015 to April 2019. Patients were grouped into having either deep sternal wound infections or no wound infections.Of 1,902 patients, 26 (1.4%) patients had DSWI. On multivariate analysis, male gender was associated with DSWI with an adjusted odds ratio of 7.390 (95% CI 1.189-45.918, p=0.032). Increased body mass index (BMI) had an odds ratio of 1.101 (95% 1.03-1.18, p=0.008). Increased length of stay (LOS) had an odds ratio of 1.05 (95% CI 1.02-1.08, p=0.002). Left main disease had an odds ratio of 3.076 (95% CI 1.204-7.86, p=0.019). The presence of hypercholesterolaemia had an odds ratio of 0.043 (95% CI 0.009-0.204, p0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most common organisms found in deep sternal wound infections (23.1% and 26.9% respectively). Polymicrobial growth occurred in 19.2% of patients. One gram of topical cephazolin was applied in 315 patients. None of these patients developed a deep sternal wound infection (p=0.022).In a large Australian tertiary centre, male gender, increased BMI, presence of left main coronary artery disease, and increased length of hospital stay are significantly associated with the risk of deep sternal wound infections. Staphylococcus aureus and Staphylococcus epidermidis are common organisms in deep sternal wound infections. Topical antibiotics such as cephazolin are useful in preventing deep sternal wound infections. The presence of hypercholesterolaemia is a protective factor and we hypothesise that this is due to long-term statin use.

A 22-year-old man underwent mediastinal metastasectomy for a testicular germ cell tumour via median sternotomy. Intraoperatively, the tumour was massive, measuring 88 mm in anterior-posterior (AP) diameter. It was densely adherent to the trachea and aggressive debulking resulted in tracheal injury. Therefore, the patient was kept nil by mouth for 3 days postoperatively and was discharged uneventfully. He represented only 2 days later with a large right-sided chylothorax. His chylothorax was managed conservatively with insertion of an intercostal catheter (ICC) and a low-fat diet. Over the course of 9 days, the ICC drained approximately 5 L of fluid. His admission was further complicated by severe gastroparesis requiring feeding Nasojejunal (NJ) tube placement. The delayed feeding in this case resulted in late detection of the occult thoracic duct injury. This case illustrates that conservative and multidisciplinary management of a postoperative chylothorax from a suspected thoracic duct injury achieves favourable outcomes avoiding further surgical intervention.

Cardiac surgery is a relatively young specialty and is undergoing many changes presently. The advent of catheter-based technology, minimally invasive surgery and better information regarding the roles of cardiac surgery in the management of common cardiac disease is changing the way we provide services. In Australia, attention must be turned to the way cardiac surgical services are provided to enable delivery of modern procedures. This has implications for the provision of training. We explore the face of modern cardiac surgery and how this may be taken up in Australia.

BackgroundPatients with ischemic left ventricular dysfunction have higher operative risk with coronary artery bypass graft surgery (CABG). However, those whose early risk is surpassed by subsequent survival benefit have not been identified.ObjectivesThis study sought to examine the impact of anatomic variables associated with poor prognosis on the effect of CABG in ischemic cardiomyopathy.MethodsAll 1,212 patients in the STICH (Surgical Treatment of IsChemic Heart failure) surgical revascularization trial were included. Patients had coronary artery disease (CAD) and ejection fraction (EF) of ≤35% and were randomized to receive CABG plus medical therapy or optimal medical therapy (OMT) alone. This study focused on 3 prognostic factors: presence of 3-vessel CAD, EF below the median (27%), and end-systolic volume index (ESVI) above the median (79 ml/m2). Patients were categorized as having 0 to 1 or 2 to 3 of these factors.ResultsPatients with 2 to 3 prognostic factors (n = 636) had reduced mortality with CABG compared with those who received OMT (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.56 to 0.89; p = 0.004); CABG had no such effect in patients with 0 to 1 factor (HR: 1.08; 95% CI: 0.81 to 1.44; p = 0.591). There was a significant interaction between the number of factors and the effect of CABG on mortality (p = 0.022). Although 30-day risk with CABG was higher, a net beneficial effect of CABG relative to OMT was observed at >2 years in patients with 2 to 3 factors (HR: 0.53; 95% CI: 0.37 to 0.75; p

Background The post-market Registry to Evaluate the HeartWare Left Ventricular Assist System (ReVOLVE) is an investigator-initiated registry established to collect post–CE Mark Trial clinical data on patients receiving a HeartWare ventricular assist device (HVAD) in the European Union and Australia. Methods The ReVOLVE is a multi-center, prospective, single-arm registry performed at seven centers in Europe and two in Australia. Herein we describe a total of 254 commercial HVAD implants according to labeled indications between February 2009 and November 2012. Summary statistics included patients’ demographics, adverse events, length of support and outcomes. Results Compared with the clinical trial supporting the CE Mark of the HeartWare system, patient selection differed in that patients were older, and there were higher proportions of females and patients with idiopathic cardiomyopathies in the ReVOLVE cohort. Duration of support ranged from 1 to 1,057 days, with a mean of 363 ± 280 days (median 299.5 days). Transplantation was done in 56 patients (22%), explant for recovery was performed in 3 patients (1%), 43 died while on support (17%), and 152 (60%) remain on the device. Success in patients with the HeartWare system was 87% at 6 months, 85% at 1 year, 79% at 2 years and 73% at 3 years. Adverse event rates were low, comparable or improved when compared to the CE Mark Trial. Conclusion Real-world use of the HeartWare system continues to demonstrate excellent clinical outcomes in patients supported with the device.

Background We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edwards SAPIEN™ Transcatheter Heart Valve (THV) in the Australian and New Zealand (ANZ) clinical environment. Methods This single arm registry of select patients treated in eight centres, represent the initial experience within ANZ with the balloon expandable Edwards SAPIEN THV delivered by transfemoral (TF) and transapical (TA) access. Results The total enrolment for the study was 132 patients, 63 patients treated by TF, 56 by TA, and 2 patients were withdrawn from the study. The mean ages: 83.7 (TF) and 81.7 (TA), female: 34.3% (TF) and 61.3% (TA), logistic EuroSCORE: 26.8% (TF) and 28.8% (TA), and with procedural success (successful implant without conversion to surgery or death): 92.4% (TF) and 87.1% (TA) (p=0.32). Outcomes were not significantly different between TF and TA implants. These included one year mortality of 13.6% (TF) and 21.7% (TA) (p=0.24), MACCE: 16.7% (TF) and 28.3% (TA) (p=0.12), pacemaker: 4.6% (TF) and 8.3% (TA) (p=0.39), and VARC major vascular complication of 4.6% (TF) and 5.0% (TA) (p=0.91). Conclusion TAVI in the ANZ clinical environment has demonstrated excellent outcomes for both the TA and TF approaches in highly selected patients. These results are consistent with those demonstrated in European, Canadian registries and the pivotal US clinical trials. ACTRN12611001026910.

A 50-year-old Indigenous woman, on home haemodialysis, was found to have a large mycotic aneurysm of the proximal left anterior descending coronary artery at the site of a previous drug-eluting stent. Blood cultures grew methicillin-sensitive Staphylococcus aureus bacteraemia. She underwent a complex operation involving resection of the mycotic aneurysm, removal of the stent and a coronary artery bypass graft to the distal left anterior descending (LAD) coronary artery using the left internal mammary artery. She had a complicated intensive care unit admission with pericardial tamponade on day 1 postoperatively requiring reopening and removal of clot and type 1 respiratory failure requiring reintubation on day 10 postoperatively. Once extubated, she developed prolonged hyperactive delirium and a significant decline in mobility. Over the course of a 6-week hospital admission, she received extensive multidisciplinary care and was discharged for rehabilitation to a peripheral hospital. She was discharged home after rehabilitation with ongoing follow-up with infectious diseases.

Infections of proximal aortic vascular grafts are a catastrophic complication of aortic surgery. Despite aggressive antimicrobial and surgical intervention, mortality and reinfection rates remain significant. Here, we describe a man aged 71 years with a medical history of bioprosthetic aortic valve with aortic arch replacement (modified Bentall’s procedure), who developed a large periprosthetic abscess due to Staphylococcus aureus 7 years after his initial surgery. The patient’s preference was to avoid redo surgery, however despite high-dose intravenous flucloxacillin and oral rifampicin therapy, there was rapid progression of the abscess, necessitating urgent surgery. Notwithstanding the burden of infection, the patient underwent successful surgical excision and graft re-implantation and remains independent and well, almost 2 years postoperatively.

Background Bentall's procedure and its modifications have been used for over 40 years for the treatment of ascending aortic disease. This study reviewed 10 years of experience with Aortic Root Replacement (ARR) in a major cardiac surgical centre. Methods Eighty-nine patients underwent ARR between 1999 and 2009. The records were scrutinised by retrospective chart review. Results The mean age was 54 years. Seventy-nine percent of patients were male and 21% female. The indications for the procedure were Aortic Root Aneurysm (ARA) (65%), type A dissection (28%), infective endocarditis (4.4%) and prosthetic valve regurgitation (2.2%). Fifty-seven percent of these were performed electively and 43% as an emergency. A bicuspid aortic valve was present in 37%. Arch surgery was required in 15.7%, bypass grafting in 12.3% and mitral valve surgery in 5.6%. The descending aorta was involved in 16.8%. Operative mortality was 3.3% and in-hospital mortality 12.3%. Mean follow-up was 67.05 months (range 2–143). No patients required re-operation. Conclusions The factors associated with increased in-hospital mortality were pre-operative haemodynamic instability, concommitant coronary artery disease and acute renal failure. The presence of a bicuspid valve may be associated with lower rates of complications, but no difference in mortality.

Objectives Deep sternal wound infection is a devastating complication of cardiac surgery. In the current era of increasing patient comorbidity, newer techniques must be evaluated in attempts to reduce the rates of deep sternal wound infection. Methods A randomized controlled trial comparing sternal closure with traditional sternal wires in figure-8 formation with the Pioneer cabling system® from Medigroup after adult cardiac surgery was performed. Results A total of 273 patients were enrolled with 137 and 135 patients randomized to sternal wires and cables group, respectively. Baseline characteristics between the two groups were well balanced. Deep sternal wound infection occurred in 0.7% of patients in the wires group and 3.7% of patients in the cables group (absolute risk difference = -3.0%, 95% confidence interval: -7.7 to 0.9%; P = 0.12). Patients in the cables group were extubated slightly earlier than those in the sternal wires group postoperatively (9.7 vs 12.8 h; P = 0.03). There was, however, no significant difference in hospital and follow-up pain scores or analgesia requirements. Conclusions The Pioneer sternal cabling system appears to facilitate early extubation after adult cardiac surgery, but it does not reduce the rate of deep sternal infectionAustralian New Zealand Clinical Trials Registry: ANZCTR-ACTRN12615000973516.

Gastrointestinal (GI) bleeding in ventricular assist devices (VADs) has been reported with rotary devices. The pathophysiological mechanisms and treatments are in evolution. We performed a retrospective review of GI bleeding episodes for all VADs implanted at our institution. Five male patients experienced GI bleeding-age 63.6 ± 3.64 years. VAD type VentrAssist n = 1, Jarvik 2000 n = 2, and HeartWare n = 2. All patients were anticoagulated as per protocol with antiplatelet agents (aspirin and/or clopidogrel bisulfate [Plavix] and warfarin (therapeutic international normalized ratio 2.0-3.5). There was no prior history of gastric bleeding in this group. Ten episodes of bleeding requiring blood transfusion occurred in five patients. Some patients had multiple episodes (1 × 5, 1 × 2, 3 × 1). The events occurred at varying times post-VAD implantation (days 14, 21, 26, 107, 152, 189, 476, 582, 669, and 839). Octreotide (a long-acting somatostatin analogue that reduces splanchnic arterial and portal blood flow) was administered subcutaneously or intravenously. Three patients received infusions of adrenaline at 1 µg/min to enhance pulsatility. Anticoagulation was interrupted during bleeding episodes but successfully introduced post bleeding event. GI bleeding is a significant complication of VAD therapy. In this article, we discuss diagnosis and management options.

Background The increasing prevalence of chronic heart failure has stimulated the ongoing development of left ventricular assist devices (LVADs) for both bridge-to-transplant (BTT) and destination therapy (DT). The aim of this prospective, multicenter clinical trial was to determine the efficacy and safety of a third-generation LVAD, the VentrAssist, in a BTT cohort. Methods Patients (n = 33) with end-stage chronic heart failure who required circulatory support as BTT therapy were implanted with a VentrAssist device. The primary outcome was survival until transplant or transplant eligibility with the device in situ at trial end-point (Day 154 after implant). The secondary outcomes were pump flow index and end-organ function. Safety, patient functional status and resource use were also assessed. Results At trial end-point, the success rate was 82% (39.4% transplanted, 42.4% transplant-eligible). The LVAD pump flow index (median ≥2.7 liters/min/m 2 ) was sufficient to maintain an adequate circulation and significantly improve end-organ function. Of the 77 protocol-defined serious adverse events, most occurred within 30 days of implantation. No patients died as a direct result of pump failure or malfunction. After implantation, patient functional status improved, with 70% of patients achieving hospital discharge, and resource use was reduced. Conclusions This trial demonstrated a favorable efficacy and safety profile for use of the VentrAssist LVAD in BTT patients.

OBJECTIVES The Registry to Evaluate the HeartWare Left Ventricular Assist System (ReVOLVE) is an investigator-initiated multicentre, prospective, single-arm database established to collect post-Conformite Europeenne Mark clinical information on patients receiving the HeartWare® Ventricular Assist System (HVAD®). The number of patients requiring longer periods of mechanical circulatory support is ever increasing and so further investigation into long-term outcomes in bridge-to-transplant populations is necessary. METHODS Data were collected on 254 commercial implants performed between February 2009 and March 2012 from nine centres in Europe (7 centres) and Australia (2 centres). Patients were followed to device explant, heart transplant or death, and the outcomes of patients who remained on support longer than 2 years were analysed. Summary statistics were used to describe patient demographics, adverse events, length of support and outcomes for this long-term cohort. RESULTS A total of 124 patients (49% of the original ReVOLVE population) were on support for more than 2 years (range: 731-2108 days), 76 of whom are still alive on support. Overall survival through 5 years was 59%. CONCLUSIONS Owing to the low rate of heart transplants, a significant number of patients receiving a left ventricular assist device as a bridge to transplant remain on support for prolonged periods, often exceeding 2, 3 and even 4 years. Real-world use of the HVAD system continues to show excellent outcomes for patients on the device, including those on support beyond 2 years.

OBJECTIVES Ventricular blood stasis is a concern for continuous flow mechanical support devices and might contribute to the formation of thromboembolic events. The HeartWare® Ventricular Assist System (HVAD®) is equipped with the Lavare™ cycle that is a periodic speed modulation feature designed to alter flow patterns within the left ventricle and reduce areas of potential blood stasis. Here, we report in vitro and clinical findings on the effects of the Lavare cycle. METHODS The effect of pump speed changes on the intraventricular flow field was examined with an in vitro particle image velocimetry model. The clinical impact of the Lavare cycle was evaluated through a retrospective review of the ReVOLVE study which includes 248 patients implanted with the HVAD following Conformite Europeenne Mark in nine centres in Europe and Australia. Baseline characteristics, adverse event profiles and Kaplan-Meier survival estimates were stratified by patients using/not using the Lavare cycle. RESULTS Particle image velocimetry showed increased ventricular washout with an active Lavare cycle as measured by the fluid velocities and angular dispersion parameters. With the Lavare cycle on, there was also a 22% decrease in the stagnation index compared with when the Lavare cycle was off. In the ReVOLVE registry, patients with the Lavare cycle turned on (n = 215) were supported for 497 patient-years, whereas patients who did not use the speed modulation (n = 33) were supported for 39.3 patient-years. The Lavare cycle did not significantly affect patient survival as both groups had approximately an 80% survival after 1 year. Patients using the Lavare cycle had significantly fewer rates of stroke [0.06 vs 0.20 events per patient-year (EPPY), P = 0.0008], sepsis (0.03 vs 0.15 EPPY, P = 0.0003) and right heart failure (0.03 vs 0.18 EPPY, P < 0.0001) with no difference in the transplant or recovery rates among the two cohorts. CONCLUSIONS The Lavare cycle effectively generates ventricular washout and the adverse event profiles of ReVOLVE patients with the Lavare cycle on were better than those with the Lavare cycle off. Larger studies are warranted to verify the positive effect of the Lavare cycle and to optimize speed modulation settings, so additional clinically relevant improvements can be realized.

Right ventricular failure (RVF) is common after left ventricular assist device (LVAD) implantation and a major determinant of adverse outcomes. Optimal perioperative right ventricular (RV) management is not well defined. We evaluated the use of pulmonary vasodilator therapy during LVAD implantation. We performed a retrospective analysis of continuous-flow LVAD implants and pulmonary vasodilator use at our institution between September 2004 and June 2013. Preoperative RVF risk was assessed using recognized variables. Sixty-five patients (80% men, 50 ± 14 years) were included: 52% HeartWare ventricular assist device (HVAD), 11% HeartMate II (HMII), 17% VentrAssist, 20% Jarvik. Predicted RVF risk was comparable with contemporary LVAD populations: 8% ventilated, 14% mechanical support, 86% inotropes, 25% BUN39 mg/dL, 23% bilirubin ≥2 mg/dL, 31% RV : LV (left ventricular) diameter ≥0.75, 27% RA : PCWP (right atrium : pulmonary capillary wedge pressure)0.63, 36% RV stroke work index6 gm-m/m(2)/beat. The majority (91%) received pulmonary vasodilators early and in high dose: 72% nitric oxide, 77% sildenafil (max 200 ± 79 mg/day), 66% iloprost (max 126 ± 37 μg/day). Median hospital stay was 26 (21) days. No patient required RV mechanical support. Of six (9%) patients meeting RVF criteria based on prolonged need for inotropes, four were transplanted, one is alive with an LVAD at 3 years, and one died on day 35 of intracranial hemorrhage. Two-year survival was 77% (92% for HMII/HVAD): transplanted 54%, alive with LVAD 21%, recovery/explanted 2%. A low incidence of RVF and excellent outcomes were observed for patients treated early during LVAD implantation with combination, high-dose pulmonary vasodilators. The results warrant further investigation in a randomized controlled study.

A 42-year-old woman presented to a regional hospital emergency room with palpitations and was found to be in ventricular tachycardia. Chest radiography demonstrated a massively enlarged cardiac silhouette. Echocardiography and cardiac magnetic resonance imaging demonstrated a mass within the left ventricular free wall, consistent with a cardiac fibroma. The patient proceeded to have surgical resection of the mass. Left ventricular function was preserved postoperatively.