Search

Background: The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV‐GLS) and LV ejection fraction (LVEF). Methods: We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all‐cause mortality. Results: Mean age was 65 ± 15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV‐GLS. During a median follow‐up period of 5.8 years, 65 patients (34%) of 192 patients with follow‐up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF <50% (P <.001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV‐GLS worse than –15% and those with postoperative LV‐GLS better than ‐15% (P <.001). Conclusions: In patients with MAVD who underwent AVR, the mean postoperative LV‐GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV‐GLS and LVEF were both independently associated with higher mortality in this population. [ABSTRACT FROM AUTHOR]

Guidelines recommend using the CHA₂DS₂‐VASc score to determine anticoagulation decisions in atrial fibrillation (AF) patients, including those who undergo pulmonary vein isolation (PVI), however this may not consistently occur in the real‐world setting because of other clinical factors. We sought to evaluate the anticoagulation prescription rates patterns in AF patients 1 year PVI at our institution. Consecutive AF patients undergoing PVI in our prospective registry during 2014−2018 who were alive at 1‐year post‐PVI were studied. Anticoagulation prescription rates at this time‐point were adjudicated, and correlated to CHA₂DS₂‐VASc score, sex, and heart rhythm status at 1 year. Amongst 4596 patients undergoing PVI, mean age was 64.2 ± 10.0 years, 1328 (28.9%) were female, and based on CHA₂DS₂‐VASc score anticoagulation was not indicated, can be considered and indicated in 872 (19.0%), 1183 (25.7%), and 2541 (55.3%) patients, respectively. At 1‐year after PVI, 3504 (76.2%) patients were on anticoagulation, and 792 (17.2%) had recurrence of AF. Anticoagulation was continued in over half of AF patients without classic CHA₂DS₂‐VASc indication particularly in those with AF recurrence and women, while they were mildly under‐prescribed in those with indication, especially for those without AF recurrence and men. In a large real world cohort of patients after PVI, anticoagulation prescription is not solely depending on the CHA₂DS₂‐VASc score and sex, but also heart rhythm status and other clinical or imaging factors. [ABSTRACT FROM AUTHOR]

Transthoracic echocardiography (TTE) grading of aortic stenosis (AS) is challenging when parameters are discrepant, and four-dimensional cardiac computed tomography (4D-CCT) is increasingly utilized for transcatheter intervention workup. We compared TTE and 4D-CCT measures contributing to AS quantification. AS patients (n = 80, age 86 ± 10 years, 71% men) referred for transcatheter replacement in 2014–2017 were retrospectively studied, 20 each with high-gradient AS (HG-AS), classical and paradoxical low-flow low-gradient AS (CLFLG-AS and PLFLG-AS), and normal-flow low-gradient AS (NFLG-AS). Correlation and Bland–Altman analyses were performed between TTE and 4D-CCT parameters. There were moderate-to-high TTE versus 4D-CCT correlations for left ventricular volumes, function, mass, and outflow tract dimensions (r = 0.51–0.88), though values were mostly significantly higher by 4D-CCT (p < 0.001). Compared with 4D-CCT planimetry of aortic valve area (AVA), TTE estimates had modest correlation (r = 0.37–0.43) but were significantly lower (by 0.15–0.32 cm2). The 4D-CCT estimate of LVSVi lead to significant reclassification of AS subtype defined by TTE. In conclusion, 4D-CCT quantified values were higher than TTE for the left ventricle and AVA, and the AS subtype was reclassified based on LVSVi by 4D-CCT, warranting further research to establish its clinical implications and optimal thresholds in severe AS management. [ABSTRACT FROM AUTHOR]

Cardiovascular risk factors, biomarkers, and diseases are associated with poor prognosis in COVID-19 infections. Significant progress in artificial intelligence (AI) applied to cardiac imaging has recently been made. We assessed the utility of AI analytic software EchoGo in COVID-19 inpatients. Fifty consecutive COVID-19+ inpatients (age 66 ± 13 years, 22 women) who had echocardiography in 4/17/2020–8/5/2020 were analyzed with EchoGo software, with output correlated against standard echocardiography measurements. After adjustment for the APACHE-4 score, associations with clinical outcomes were assessed. Mean EchoGo outputs were left ventricular end-diastolic volume (LVEDV) 121 ± 42 mL, end-systolic volume (LVESV) 53 ± 30 mL, ejection fraction (LVEF) 58 ± 11%, and global longitudinal strain (GLS) −16.1 ± 5.1%. Pearson correlation coefficients (p-value) with standard measurements were 0.810 (<0.001), 0.873 (<0.001), 0.528 (<0.001), and 0.690 (<0.001). The primary endpoint occurred in 26 (52%) patients. Adjusting for APACHE-4 score, EchoGo LVEF and LVGLS were associated with the primary endpoint, odds ratios (95% confidence intervals) of 0.92 (0.85–0.99) and 1.22 (1.03–1.45) per 1% increase, respectively. Automated AI software is a new clinical tool that may assist with patient care. EchoGo LVEF and LVGLS were associated with adverse outcomes in hospitalized COVID-19 patients and can play a role in their risk stratification. [ABSTRACT FROM AUTHOR]

Background: Post-systolic shortening index (PSI) is defined as myocardial shortening that occurs after aortic valve closure, and is an emerging measure of regional LV contractile dysfunction. PSI measurement variability amongst software vendor and its relationship with mechanical dyssynchrony and mechanical dispersion index (MDI) remains unknown. We evaluated PSI by speckle-tracking echocardiography from several vendors in patients with increased left ventricular wall thickness, and associations with MDI. Methods: This is a prospective cross-sectional study of 70 patients (36 hypertrophic cardiomyopathy [HCM], 18 cardiac amyloidosis and 16 healthy controls) undergoing clinically indicated echocardiography. PSI was measured using QLAB/aCMQ (Philips), QLAB/LV auto-trace (Philips), EchoPAC (GE), Velocity Vector Imaging (Siemens), and EchoInsight (EPSILON) software packages, and calculated as 100%×(post systolic strain–end-systole strain)/post systolic strain. Results: There was a significant difference in mean PSI among controls 2.1±0.6%, HCM 6.1±2.6% and cardiac amyloidosis 6.8±2.7% (p <0.001). Variations between software vendors were significant in patients with pathologic increases in LV wall thickness (for HCM p = 0.03, for amyloidosis p = 0.008), but not in controls (p = 0.11). Furthermore, there were moderate correlations between PSI and both MDI (r = 0.77) and left ventricular global longitudinal strain (r = 0.69). Conclusion: PSI was greater in HCM and cardiac amyloidosis patients than controls, and a valuable tool for dyssynchrony evaluation, with moderate correlations to MDI and strain. However, there were significant variations in PSI measurements by software vendor especially in patients with pathological increase in LV wall thickness, suggesting that separate vendor-specific thresholds for abnormal PSI are required. [ABSTRACT FROM AUTHOR]

Background: Rheumatic heart disease remains one of the leading causes of heart valve disease worldwide despite being a preventable condition. Mitral valve repair is superior to replacement in severe degenerative mitral valve disease, however its role in rheumatic valve disease remains controversial. This meta-analysis compared mitral valve repair and replacement in rheumatic heart disease.Methods: Medline, EMBASE, Cochrane and Scopus were searched from January 1980 to June 2016 for original studies reporting outcomes of both mitral valve repair and replacement in rheumatic heart disease in adults, children or both. Two (2) authors independently assessed studies for inclusion, followed by data extraction and analysis.Results: The search yielded 930 articles, with 98 full-texts reviewed after initial screening and 13 studies subsequently included for analysis, totalling 2,410 mitral valve repairs and 3,598 replacements. Pooled rates and odds ratio (95% confidence interval) for operative mortality of repair versus replacement was 3.2% versus 4.3%, 0.68 (0.50-0.92; p=0.01). Pooled odds ratios (95% confidence interval) were for long-term mortality 0.41 (0.30-0.56; p<0.001); reoperation 3.02 (1.72-5.31; p<0.001); and bleeding 0.26 (0.11-0.63; p=0.003). There was a trend towards lower thrombo-embolism 0.42 (0.17-1.03; p=0.06), and no significant difference in endocarditis (p=0.76), during follow-up.Conclusion: Mitral valve repair is associated with reduction in operative and long-term mortality and bleeding, so is recommended in rheumatic mitral valve disease where feasible, but it does entail a higher rate of reoperation during follow-up. [ABSTRACT FROM AUTHOR]

Background: Risk models play important roles in stratification and decision‐making towards cardiac surgery. Isolated tricuspid valve surgery is a high risk but increasingly performed the operation, however, the performance of risk models has not been externally evaluated in these patients. We compared the prognostic utility of contemporary risk scores for isolated tricuspid valve surgery. Methods: Consecutive patients undergoing isolated tricuspid valve surgery at Cleveland Clinic during 2004–2018 were evaluated in this cohort study. EuroSCORE II, Society of Thoracic Surgeon's tricuspid (STS‐TVS) score, and the Model for End‐stage Liver Disease (MELD) score were retrospectively calculated, and their performance for predicting operative mortality, postoperative complications, and mortality during follow‐up was assessed. Results: Amongst 207 patients studied, the mean age was 54.1 ± 17.9 years, 116 (56.0%) were female, 92 (44.4%) had secondary tricuspid regurgitation, and 151 (72.9%) had a surgical repair. Mean EuroSCORE II, STS‐TVS, and MELD scores were 6.3 ± 6.6%, 5.5 ± 6.2%, and 9.8 ± 4.7, respectively. C‐statistics (95% confidence intervals) for operative mortality were 0.83 (0.74–0.93) for EuroSCORE II, 0.60 (0.45–0.75) for STS‐TVS score, and 0.74 (0.58–0.89) for MELD score, while observed/expected ratios were 0.78 and 0.89 for the first two scores. All three scores were associated with mortality during follow‐up and discriminated most postoperative complications. Conclusion: EuroSCORE II was superior to STS‐tricuspid score for isolated TVS risk assessment. Although surgical risk scores traditionally underestimated operative mortality after isolated tricuspid valve surgery, they did not in our cohort, reflecting the excellent surgical results. The simple MELD score performed similarly to the EuroSCORE II, especially for discriminating morbidities. [ABSTRACT FROM AUTHOR]

Background: Cardiorespiratory fitness (CRF) varies with sex and is an independent predictor of mortality. We sought to investigate sex differences in the exercise protocol selected, CRF levels, and their relationships with long term all-cause mortality. Methods: In a 25-year stress testing registry spanning from 1991 to 2014, consecutive all-comer patients who underwent exercise stress testing at Cleveland Clinic were categorized by sex, stress protocol and imaging modality. All tests were conducted by one or more of stress test technicians, sonographers and nuclear medicine technologists, and interpreted by cardiologists. The primary outcome all-cause mortality was analyzed in using multivariable Cox regression. Results: In 120,705 patients, the mean age was 53.3 ± 12.5 years, and 41% were female. Females were more commonly referred for non-Bruce exercise protocols (modified Bruce, Cornell 0, 5 and 10, Naughton and modified Naughton) with odds ratio of 2.62; 95% confidence interval (95%CI) (2.54–2.70) after adjusting for age and comorbidities. When also adjusting for the protocol chosen, females achieved lower CRF with beta −1.40, 95% CI (−1.43, −1.37). There were 8426 (6.9%) deaths during a mean follow-up of 8.7 years. Both female sex and CRF were independently associated with lower all-cause mortality with hazards ratio (95%CI) of 0.44 (0.41–0.46) and 0.41 (0.39–0.42) respectively, after adjusting for age, co-morbidities and protocol chosen. Conclusions: Women were more likely referred for less demanding exercise protocols, more imaging protocols and achieved lower CRF than men. Despite this, female sex was associated with significantly lower long term mortality for equivalent CRF level in adjusted analyses. • This large 25-year exercise test registry included 120,705 patients and 8426 deaths. • Females were more often referred for non-Bruce exercise and imaging protocols. • Female sex and higher CRF are independently associated with greater survival. • Regardless of stress test modality, females had better prognosis at equivalent CRF. [ABSTRACT FROM AUTHOR]

Background: Right ventricular (RV) systolic strain has recently demonstrated prognostic value in various cardiovascular diseases. Despite this, the reference range including the lower limit of normal (LLN) and factors associated with RV strain measurements are not well-established. This meta-analysis aimed to determine the mean and LLN of two- (2D) and three-dimensional (3D) right ventricular global (RVGLS), free wall (RVFWLS) and interventricular septal wall (IVSLS) longitudinal strains in healthy individuals and factors that affect strain measurements. Methods: In this meta-analysis, Pubmed, Embase and Cochrane databases were searched until 31 July 2020 for eligible studies reporting RVGLS, RVFWLS and/or IVSLS in at least 30 healthy subjects. We pooled the means and LLNs of RV strains by two- (2D) and three- (3D) dimensional echocardiography, and performed meta-regression analyses. Results: From 788 articles screened, 45 eligible studies totaling 4439 healthy subjects were eligible for analysis. Pooled means and LLNs with 95% confidence intervals for 2D- RV strains were RVGLS -23.4% (-24.2%, -22.6%) and -16.4% (-17.3%, -15.5%) in 27 studies; RVFWLS -26.9% (-28.0%, -25.9%) and -18.0% (-19.2%, -16.9%) in 32 studies; and IVSLS –20.4% (-22.0%, -18.9%) and -11.5% (-13.6%, -9.6%) in 10 studies, and similar results for 3D- RV strains. Right ventricular fractional area change and vendor software were associated with 2D-RVGLS and RVFWLS means and LLNs. Conclusion: We reported the pooled means and LLNs of RV systolic strains in healthy subjects, to define thresholds for abnormal, borderline and normal strains. Important factors associated with RV systolic strains include right ventricular fractional area change and vendor software. [ABSTRACT FROM AUTHOR]

Background: International guidelines recommend early discharge for uncomplicated acute coronary syndrome (ACS) patients within 3 days; however, there is a paucity of contemporary literature regarding the safety of this strategy. Aims: To report the trends in the proportion of ACS hospitalisations discharged within 3 days and their outcomes in New Zealand. Methods: ACS hospitalisations 2006–2015 using national routinely collected data were categorised by length of stay (LOS) into ≤3, 4–5 and >5 days, excluding deaths during the index admission. Trend analysis of death, cardiovascular and bleeding events and their composites (net adverse clinical events) at 30‐day and 1‐year post‐discharge were performed using generalised linear mixed regression models adjusting for covariates by LOS subgroups. Results: Among 130 037 ACS hospitalisations, LOS ≤ 3 days increased from 32% in 2006 to 44% in 2016. This trend was observed for all demographics, ACS subtypes and management strategies. Event rates at 30 days and 1 year were the lowest for the LOS ≤3 days subgroup (all‐cause mortality 1.6% and 9.1% respectively). Thirty‐day and 1‐year all‐cause mortality rates were unchanged over time for this subgroup (adjusted odds ratio (95% confidence interval) of 1.011 (0.985–1.038) and 0.991 (0.979–1.003)), while net adverse clinical event rates significantly decreased (0.962 (0.950–0.973) and 0.972 (0.964–0.980) respectively). Conclusion: There was a substantial increase in early discharge post‐ACS over 10 years. These patients were associated with reduction in adverse clinical events up to 1 year and no increase in all‐cause mortality. These findings from a comprehensive national register suggest that guideline recommendations on early discharge after uncomplicated ACS are safe and appropriate. [ABSTRACT FROM AUTHOR]

Background: Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS). It is critical to evaluate in the current era of ACS management involving invasive strategies and potent anti-thrombotics. Risk models remain under-utilised in this setting but may guide the choice and duration of therapy. We compared their performances for predicting bleeding in ACS patients in this meta-analysis.Methods: Medline, EMBASE, Cochrane and Scopus were searched for relevant articles from 1980 to 31 December 2017 assessing external validation of risk scores for bleeding after ACS. Two (2) authors independently reviewed the searched studies for eligibility, followed by pooled analyses using random effects models.Results: Amongst 1,843 articles searched, 73 full-texts were reviewed and 17 studies totalling 18,155 patients were included for analysis. C-statistics (95% confidence interval) for predicting in-hospital major bleeding by risk model were Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) 0.714 (0.659-0.779), Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) 0.711 (0.626-0.797), Acute Coronary Treatment and Intervention Outcomes Network (ACTION) 0.767 (0.737-0.797), Global Registry of Acute Coronary Events (GRACE) 0.689 (0.473-0.905) and HAS-BLED 0.636 (0.460-0.812). CRUSADE also predicted bleeding during medium-term follow-up c=0.704 (0.644-0.765). It performed better for radial versus femoral access (c=0.826 and 0.734), invasive versus non-invasive strategy (c=0.752 and 0.625) and similarly for ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) (c=0.791 and 0.760). Heterogeneities of studies and paucity of studies assessing risk scores beyond CRUSADE were important limitations.Conclusions: Acute coronary syndrome-specific bleeding scores had moderate discrimination for bleeding, while the GRACE and HAS-BLED scores could not. The ACTION score had the highest pooled c-statistic, while the CRUSADE score was the most widely studied, and also performed better for invasive strategy and radial access subgroups. [ABSTRACT FROM AUTHOR]

Background: Mitral annular calcification (MAC) is prevalent in the aging population, with recent renewed interest regarding its associations with cardiovascular risk factors, outcomes, and influence on valvular heart disease and interventions. This meta‐analysis aimed to report the relationships between MAC and cardiovascular mortality and morbidity events. Methods: Relevant studies were searched from PubMed, Cochrane, and Embase databases until November 30, 2019. Associations between MAC as a binary variable with death and cardiovascular events were pooled using random‐effects models. The main outcomes of interest were all‐cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, atrial fibrillation, and procedural outcomes. Results: Among 799 article abstracts and 122 full‐text articles screened, 26 (16 prospective and 10 retrospective) studies totaling 35 070 subjects were analyzed. MAC was associated with higher all‐cause death, hazard ratio (95% confidence interval) 1.76 (1.43‐2.22), and cardiovascular mortality 1.85 (1.45‐23.5). It also positively correlated with myocardial infarction 1.48 (1.22‐1.79), stroke 1.51 (1.22‐2.05), incidental heart failure 1.55 (1.30‐1.84), atrial fibrillation 1.75 (1.43‐2.15), and their composite, major adverse cardiovascular events (MACE). Finally, conversion to mitral valve replacement at time of cardiac surgery was more in patients with MAC than without MAC, with odds ratio (95% confidence interval) 2.82 (1.28‐6.18). Conclusion: Mitral annular calcification was overall associated with higher rates of death, and both individual and composite cardiovascular events. The presence of increasingly encountered MAC has significant clinical implications for cardiovascular risk assessment and valvular interventions. [ABSTRACT FROM AUTHOR]

Background: Evaluating trends in acute coronary syndrome (ACS) and invasive coronary procedures, including coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) can identify areas for improvement in clinical care and inform future health planning. This national data-linkage study reports trends in ACS hospitalisations and procedure rates in New Zealand between 2006 and 2016.Methods: All adult ACS hospitalisations and associated angiography and revascularisation procedures were identified from hospital discharge codes. Crude and age-standardised ACS incidence and procedure rates were calculated for each calendar year.Results: Between 2006 and 2016 there were 188,264 ACS admissions. During this time, there was a steady decline in hospitalisation rates, from 685 to 424 per 100,000 per year. This decline was observed in both sexes and in all age groups. There were also significant increases in coronary angiography and revascularisation rates, from 29.8% to 54.3% and 20.6% to 37.3%, respectively, between 2006 and 2016. The rate of revascularisation by PCI increased from 16.0% to 31.0%, a greater increase than revascularisation by CABG, which increased from 4.6% to 6.5%. Increases in procedures were observed in all age groups and both sexes. The proportions of coronary angiograms that resulted in revascularisation each year consistently ranged from 67 to 70% throughout the period.Conclusions: Acute coronary syndrome hospitalisation rates in New Zealand decreased by nearly 40% between 2006 and 2016, while the use of coronary angiography and revascularisation after ACS nearly doubled. The similar proportions of angiograms that resulted in revascularisation each year suggests that, despite the doubling of angiograms over the 10-year study period, they are not over-utilised. [ABSTRACT FROM AUTHOR]

Background: Type A aortic dissection is a fatal condition warranting emergency surgery to prevent complications and death. We reviewed the contemporary trends, characteristics, outcomes and predictors of this operation at our centre over a 14-year period.Methods: Consecutive patients undergoing type A aortic dissection surgery at Auckland City Hospital during March 2003-March 2017 were studied, and relevant characteristics and outcomes collected prospectively for statistical analyses.Results: There were 327 patients included, and the number of operations each year remained similar from 2003-2010, and steadily increased thereafter. Median age was 60.6 years, with 124 (37.9%) females, 136 (41.6%) Maori or Pacific ethnicity, 319 (97.6%) emergency surgeries, 62 (19.0%) in a critical preoperative state and 154 (47.1%) having a malperfusion syndrome. Operative mortality occurred in 65 (19.9%), although this has decreased from 23.3% before 2014 to 14.0% since. Composite morbidity occurred in 212 (65.0%), predominantly acute kidney injury 134 (41.0%), ventilation >24 hours (129 (39.6%), return to theatre 94 (28.8%) and stroke 63 (19.3%). Survival at 1, 5 and 10 years was 79.0%, 71.7% and 57.8% respectively. Critical preoperative state and malperfusion syndrome were independent predictors of operative and long-term mortality and composite morbidity.Conclusion: Surgery for acute type A aortic dissection has been increasing since 2011 and continues to have high rates of operative mortality and morbidities, although the former has decreased since 2014. Critical preoperative state and malperfusion were the key predictors of adverse outcomes. After surviving the perioperative period, prognosis was good with low rates of late mortality. [ABSTRACT FROM AUTHOR]

Coronary heart disease remains one of the leading causes of mortality and morbidity in New Zealand (NZ) and globally. The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) programme includes the CathPCI registry which records all those referred for diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) in NZ. We present the methods and three-years of data from the ANZACS-QI CathPCI registry. The data was extracted from the ANZACS QI CathPCI registry from 01/09/2014 to 24/09/2017. The ANZACS-QI data dictionary defines all the clinical, procedural and outcomes variables collected, and standard statistical analyses were applied. 40,870 patients underwent cardiac catheterisation, with a mean age of 65 years, and males making up 67% of the cohort. Indications included acute coronary syndrome 55%, angina with suspected stable coronary disease 28%, valve surgery workup 8%, planned PCI 3%, heart failure/cardiomyopathy 3%, arrhythmia 1% and other 2%. For those undergoing DCA alone, radial access was used in 85% and two-thirds had at least one major artery with >50% stenosis. PCI was performed in 39% of patients. Drug-eluting stents were used in 97%. The CathPCI registry records the characteristics and outcomes of all patients undergoing DCA and PCI in NZ hospitals. As part of the ANZACS-QI programme the registry provides an important platform for quality improvement, research and to inform clinical practice. • The CathPCI registry records all cardiac catheterisation procedures in New Zealand. • It is a platform of ANZACS-QI and its methodology and 3-year practice is reported. • There were 43,097 diagnostic coronary angiograms, with 15,482 (37%) PCIs. • The registry allows quality improvement, research and informs clinical practice. [ABSTRACT FROM AUTHOR]

Infective endocarditis is a heterogeneous disease with a wide array of pathological lesions. We present a 55‐year‐old man with severe mitral and aortic regurgitation on transthoracic echocardiography. Transesophageal echocardiogram characterized the mechanisms detecting a windsock mitral valve perforation, aortic root abscess, and Gerbode ventricular septal defect, with the deep transgastric view showing all three pathologies concurrently. The etiologies of mitral valve perforation and Gerbode defects are discussed. Transesophageal echocardiography remains a critical imaging modality to diagnose and evaluate the extent of infective endocarditis with superior sensitivity to transthoracic echocardiography. [ABSTRACT FROM AUTHOR]

Background: Approximately 5% of coronary angiographies detect LMS disease >50%. Recent randomized trials showed PCI has comparable outcomes to coronary artery bypass grafting (CABG) in low or intermediate risk candidates. In clinical practice, PCI is frequently utilized in those with prohibitive surgical risk. We reviewed contemporary national results of percutaneous coronary intervention (PCI) for left main coronary disease (LMS) disease in New Zealand.Methods: All patients undergoing PCI for LMS disease from 01/09/2014-24/09/2017 were extracted from the All New Zealand Acute Coronary Syndrome-Quality Improvement registry with national dataset linkage, analyzing characteristics and in-hospital outcomes.Results: The cohort included 469 patients, mean age 70.8 ± 10.7 years, male 331 (71%), and the majority 339 (72%) were unprotected LMS. Indications include ST-elevation myocardial infarction (STEMI) 83 (18%) and NSTEMI or unstable angina 229 (49%). Compared with protected LMS, unprotected LMS were more likely to present with an acute coronary syndrome (73% versus 48%, P < 0.001), and to die in-hospital (9.4% versus 3.9%, P = 0.045). In those with unprotected LMS, in-hospital mortality after acute STEMI PCI was higher than for other indications (21.1% versus 6.1%, P < 0.001). Independent predictors of in-hospital death and major adverse cardiovascular events included STEMI, femoral access and worse renal function.Conclusion: Our LMS PCI cohort had high mortality rates, especially those presenting with STEMI and an unprotected LMS. This reflects the contemporary real-world practice of LMS PCI being predominantly performed in high risk patients which differs from randomized trial populations, and this should be considered before comparing with CABG outcomes. [ABSTRACT FROM AUTHOR]

Accurate risk stratification is important in pregnant women including the growing population with congenital heart disease (CHD). We meta‐analysed the performance of risk models for CHD women. Six studies with 3426 pregnancies were studied, with cardiac complication rates of 6.7–20.6%. Pooled c‐statistics (95% confidence interval) for scores were mWHO 0.71 (0.65–0.76), CARPREG 0.66 (0.61–0.71) and ZAHARA 0.71 (0.65–0.76). Current risk models had at best moderate discrimination for CHD women with significant room for improvement. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Mitral annular disjunction (MAD) is an increasingly recognized entity associated with mitral valve prolapse (MVP), ventricular arrhythmias and death. Few studies have investigated the utility of myocardial deformation analysis in MAD. We compared chamber quantification including strain by transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) between MVP patients with and without MAD. Forty-two patients with MVP (21 with MAD, 21 without MAD) and 21 controls were studied. Global, basal and basal inferolateral (BIL) segmental strains were measured and compared using velocity-vector imaging TTE and feature-tracking CMR. Mean age was 54 ± 17 years, 19 (46%) were female, and 19 (46%) underwent surgical mitral valve repair with no deaths during follow-up in the 2 groups with MVP. Patients with MAD and MVP had lower basal longitudinal strain by TTE than those with MVP without MAD. Those with MAD and MVP had lower magnitude in BIL and basal segments by circumferential and radial strain by CMR compared to those with MVP without MAD and controls. Amongst global strain parameters, CMR-derived global circumferential strain was independently associated with MAD diagnosis odds ratio 1.49 (per 1%), 95% confidence interval 1.09–2.05, P = 0.014, with optimal threshold of −18.0% having 76% sensitivity and specificity for MAD. Abnormal circumferential and radial strain patterns in the basal segments by CMR may be useful for identifying regional LV dysfunction associated with MAD. • This study compared TTE and CMR strain of subjects with MVP with/without MAD and controls. • Subjects with MAD had lower magnitude of circumferential and radial strains in the basal segments by CMR. • Strain imaging especially by CMR appears to be a valuable tool for evaluating regional LV dysfunction associated with MADrefe. [ABSTRACT FROM AUTHOR]

Background: Patent foramen ovale (PFO) is a common anatomic variant associated with cryptogenic stroke. Percutaneous PFO closure in these patients to prevent recurrent neurological events has been controversial for decades, and mixed results have been reported from past and recent observational and randomised studies. This meta-analysis of randomised trials aims to compare the efficacy and safety of PFO closure with medical therapy for cryptogenic stroke patients.Methods: Medline, PubMed, EMBASE, Scopus and Cochrane were searched from January 1980 to September 2017 by two authors independently to include original randomised trials comparing PFO closure with medical therapy for secondary stroke prevention. Relevant study and baseline characteristics and outcomes were extracted and pooled using random-effects models.Results: Amongst 619 articles searched giving 10 full-texts assessed, six studies reporting five randomised trials and totalling 1,829 PFO closure and 1,611 medical therapy patients were included. Pooled hazards ratios (95% confidence interval, p-value) ischaemic stroke, transient ischaemic attack (TIA) and composite neurovascular or mortality events were 0.41 (0.19-0.90, p=0.03), 0.77 (0.51-1.14, p=0.19) and 0.60 (0.44-0.81, p<0.001) for PFO closure compared to medical therapy. Any adverse events, major bleeding and all-cause mortality were similar between modalities (p=0.37-0.95), however PFO closure had higher rates of new onset atrial fibrillation at 4.6 times (p<0.001).Conclusion: Our meta-analysis found that, in patients with cryptogenic stroke, percutaneous PFO closure is beneficial at reducing ischaemic stroke and composite neurovascular or mortality events, with a higher incidence of new atrial fibrillation, compared to medical therapy. [ABSTRACT FROM AUTHOR]

Background Transcatheter aortic valve implantation (TAVI) is considered for severe aortic valve disease at high and now intermediate risk for surgical aortic valve replacement. Risk stratification plays a critical role decision-making for intervention and modality. We compared the prognostic utility of surgical risk scores for TAVI in this meta-analysis. Methods MEDLINE, Embase, Cochrane and Web of Science databases from 1 January 1980 to 31 December 2015 were searched. Studies were systematically reviewed for inclusion, and data extracted for pooled analyses. Results Amongst 1688 articles searched, 47 full-text articles were screened and 24 studies (12,346 TAVI cases) included for analyses. Pooled c-statistics (95% confidence interval) for operative mortality were EuroSCORE 0.62 (0.57–0.67), EuroSCORE II 0.62 (0.59–0.66), STS Score 0.62 (0.59–0.65). Pooled calibration odds ratios (95%CI) were EuroSCORE 0.31 (0.25–0.38), EuroSCORE II 1.26 (1.06–1.51), STS 0.95 (0.72–1.27). C-statistics (95%CI) for 1-year mortality were EuroSCORE 0.62 (0.57–0.67), EuroSCORE II 0.66 (0.61–0.71) and STS Score 0.58 (0.53–0.64). Conclusion Surgical risk scores at most modestly discriminated operative and 1-year mortality. The EuroSCORE grossly over-estimated operative mortality while the EuroSCORE II and STS Scores fitted better to TAVI outcomes with their own limitations. There is a need for the development and validation of TAVI-specific risk models. [ABSTRACT FROM AUTHOR]

Background: Nearly half of the patients undergoing coronary artery bypass grafting (CABG) have diabetes. There is mixed data as to whether preoperative (haemoglobin A1c{HbA1c}) and/or perioperative diabetes control is associated with mortality and morbidity after CABG. We reviewed the characteristics and outcomes of diabetic patients undergoing CABG with a focus on HbA1c, perioperative glucose levels and diabetic treatment regimens.Methods: Diabetic patients undergoing CABG during July 2010 to June 2012 were studied (n=306). The last preoperative HbA1c levels, and perioperative glucose levels (mean and coefficient of variation {CV}) were retrospectively recorded, as well as the pre-existing and perioperative diabetes treatment regimens for analyses.Results: Mean HbA1c was 7.7+/-1.6%, and 11.1% (34), 56.2% (172), and 32.7% (100) of patients were managed preoperatively with diet only, oral diabetic medications and insulin respectively. For operative mortality which occurred in 2.0%, C-statistics (95% confidence interval) was only significant for HbA1c, 0.855 (0.757-0.975), and glucose CV on the day of surgery, 0.722 (0.567-0.877). HbA1c also detected postoperative renal failure, C-statistic 0.617 (0.504-0.730), but not other complications or mortality during follow-up. In multivariate analysis, HbA1c was the only diabetes-related independent predictor of operative mortality, hazards ratio 4.13 (1.04-16.4), and none of the diabetes-related variables predicted mortality during follow-up or other postoperative complications.Conclusion: Preoperative HbA1c was the only diabetic variable to independently predict operative mortality after CABG, suggesting medium-term preoperative diabetes control is more important and prognostic of operative outcomes than perioperative diabetes control. [ABSTRACT FROM AUTHOR]

Background: Risk stratification for mitral valve repair or replacement (MVR) is important in the decision-making for treating several mitral valve disease but is rarely studied. We compared the prognostic utility of EuroSCORE, EuroSCORE II, and Society of Thoracic Surgeons (STS) Score for MVR.Methods: The three scores were retrospectively calculated for consecutive patients undergoing isolated MVR at Auckland City Hospital during 2005-2012 and their discrimination and calibration for mortality and morbidities assessed.Results: There were 408 patients (mitral valve repair 48.1% and replacement 51.9%) followed-up for 6.0 ± 2.6 years. The operative mortality was 2.5%. Mean EuroSCORE, EuroSCORE II, and STS Score were 7.6%, 3.4%, and 3.5%. C-statistics were 0.844, 0.817, and 0.850 for operative mortality. Hosmer-Lemeshow test p values were 0.076, 0.541, and 0.306, and Brier scores 0.0246, 0.0035, and 0.0075, respectively, for operative mortality. The numerically highest c-statistic for predicting complications include EuroSCORE for return to the operating room (c = 0.673); EuroSCORE II for stroke (c = 0.669) and mediastinitis (c = 0.801); and STS for renal failure (c = 0.828), ventilation >24 hours (c = 0.789), and composite morbidity (c = 0.732). The individual STS complication models for MVR had a numerically higher c-statistic only for stroke (c = 0.737).Conclusions: All scores discriminated mortality and most morbidities after MVR, although EuroSCORE over-estimated operative mortality. The STS Score was the best overall predictor of mortality and morbidity in the MVR cohort. [ABSTRACT FROM AUTHOR]

Background: With the introduction of transcatheter aortic valve implantation (TAVI), there is increasing interest in evaluating outcomes of aortic valve replacement (AVR) with or without (+/-) concurrent coronary artery bypass grafting (CABG) particularly in high-risk patients. We reviewed the characteristics and outcomes of octogenarians undergoing isolated AVR and AVR+CABG.Methods: All patients 80 years of age or older undergoing AVR+/-CABG at Auckland City Hospital during 2005-2012 were included, and their characteristics and outcomes analysed.Results: There were 93 and 104 octogenarians respectively undergoing isolated AVR and AVR+CABG with mean follow-up of 4.4+/-2.2 years and 4.1+/-2.3 years. Significant differences in baseline and operative characteristics contributed to higher EuroSCORE II (5.9 vs 6.4%, P=0.016) and STS Score (4.9 vs 6.9%, P<0.001) for AVR+CABG patients. They also had a significantly higher rate of 30-day mortality (0.0% vs 6.7%, P=0.015) and prolonged ventilation>24hours (10.7% vs 23.1%, P<0.001), but not composite morbidity (P=0.248) or stroke (P=0.709). Long-term survival was similar at one, three and five years; 94.6%, 82.6% and 73.0% for AVR and 91.3%, 86.1% and 67.6% for AVR+CABG. Independent predictors of 30-day mortality included reduced creatinine clearance and history of myocardial infarction.Conclusion: AVR+CABG had significantly higher but acceptable 30-day mortality in octogenarians than AVR. We have identified prognostic factors important in the decision-making of treatment modality, where age alone should not preclude surgery. [ABSTRACT FROM AUTHOR]

Background: Aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) make up the majority of cardiac surgery with increasing demand as the population ages. Accuracy of risk stratification is important, in predicting adverse outcomes and selecting modality of intervention, but has been rarely studied for the combined AVR+CABG operation. We compared the prognostic utility of EuroSCORE, EuroSCORE II and Society of Thoracic Surgeons' (STS) Score for AVR+CABG.Methods: All patients (n=450) undergoing AVR+CABG at Auckland City Hospital during 2005-2012 with mean follow-up of 4.7+/-2.5 years were included. The three risk scores were calculated and their discrimination and calibration for mortality and morbidities assessed.Results: Operative mortality was 6.4% (29), and mean scores were EuroSCORE 12.5+/-11.1%, EuroSCORE II 6.6+/-6.1% and STS Score 5.5+/-4.4%. C-statistics were 0.587, 0.669 and 0.699 respectively for operative mortality, Hosmer-Lemeshow test P-values were 0.064, 0.718 and 0.567, and Brier Score 0.716, 0.585 and 0.588. Independent predictors of operative mortality were history of myocardial infarction and impaired renal function. Society of Thoracic Surgeons' score also was the most accurate score for predicting mortality during follow-up (c=0.663), composite morbidity (c=0.627), stroke (c=0.642), prolonged ventilation>24hours (c=0.642), and return to theatre (c=0.612).Conclusion: The STS score has the best discriminative ability for mortality and the majority of complications after AVR+CABG, while its calibration was similar to EuroSCORE II and superior to EuroSCORE. It should therefore be used for risk stratification and when considering surgical versus percutaneous intervention in those with concurrent aortic valve and coronary artery disease. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is the commonest cardiac arrhythmia including in end-stage renal failure patients, but controversy remains whether these patients benefit from anticoagulation. We reviewed the characteristics, management and outcomes of end-stage renal failure patients on dialysis with AF.Methods: All patients started on dialysis at Middlemore Hospital between January 2000 and December 2008 who had AF were studied. Data regarding demographics, co-morbidities, renal disease, AF and embolic, bleeding and/or mortality events were recorded.Results: There were 141 out of 774(18.2%) dialysis patients with AF followed-up for 4.4+/-2.5 years, and 41.8%(59) were on warfarin. Incidence of all embolic events, ischaemic stroke, all bleeding and intracranial bleed were 4.1, 3.1, 9.6 and 0.82/100 person years respectively. Warfarin anticoagulation was associated with increased risk of intracranial bleed (hazards ratio=11.1, P=0.038), but not total embolic, bleeding events or mortality during follow-up (P=0.317-0.980). All three scores (CHADS2, CHA2DS2-VASc and HAS-BLED) could detect all embolic events (c=0.808-0.838), but not bleeding events (c=0.459-0.498).Conclusions: Anticoagulation with warfarin didn't significantly reduce embolism or mortality in dialysis patients with AF, but increased the risk of intracranial bleeds. Convention risk scores predict embolic but not bleeding events in these patients. [ABSTRACT FROM AUTHOR]

Background Risk models play an important role in stratification of patients for cardiac surgery, but their prognostic utilities for post-operative complications are rarely studied. We compared the EuroSCORE, EuroSCORE II, Society of Thoracic Surgeon's (STS) Score and an Australasian model (Aus-AVR Score) for predicting morbidities after aortic valve replacement (AVR), and also evaluated seven STS complications models in this context. Methods We retrospectively calculated risk scores for 620 consecutive patients undergoing isolated AVR at Auckland City Hospital during 2005-2012, assessing their discrimination and calibration for post-operative complications. Results Amongst mortality scores, the EuroSCORE was the best at discriminating stroke (c-statistic 0.845); the EuroSCORE II at deep sternal wound infection (c=0.748); and the STS Score at composite morbidity or mortality (c=0.666), renal failure (c=0.634), ventilation>24 hours (c=0.732), return to theatre (c=0.577) and prolonged hospital stay >14 days post-operatively (c=0.707). The individual STS complications models had a marginally higher c-statistic (c=0.634-0.846) for all complications except mediastinitis, and had good calibration (Hosmer-Lemeshow test P-value 0.123-0.915) for all complications. Conclusion The STS Score was best overall at discriminating post-operative complications and their composite for AVR . All STS complications models except for deep sternal wound infection had good discrimination and calibration for post-operative complications. [ABSTRACT FROM AUTHOR]

In a recent study, early isolated TR surgery before symptoms onset was associated with improved survival and lower perioperative morbidity events.2 Identifying suitable asymptomatic TR patients may be challenging, and a multi-modality imaging approach is advised. Keywords: valve repair/replacement EN valve repair/replacement 469 469 1 01/07/22 20220201 NES 220201 We thank Dr. Al-Ebrahim for his interest in our original article and insightful comments.1 The tricuspid valve is no longer forgotten because tricuspid regurgitation (TR) is being increasingly encountered clinically, its adverse prognosis, and rapidly evolving transcatheter tricuspid interventions landscape. [Extracted from the article]

Background: Trans-catheter aortic valve implantation (TAVI) became available at Auckland City Hospital in 2011 for patients with severe aortic stenosis in whom surgical aortic valve replacement (AVR) was deemed at high risk. We assessed whether introduction of TAVI affected the characteristics and outcomes of octogenarians undergoing AVR. Methods: Isolated AVR performed in patients ≥80 years of age during 2008–2012 were divided into two groups, pre- and post-TAVI introduction, for analyses. Results: Isolated AVR was undertaken in 35 and 33 octogenarians pre- and post-TAVI introduction. The post-TAVI group were older (84.2 vs 82.3 years, P =0.003), had lower ejection fraction (P =0.026), more had inpatient surgery (76% vs 29%, P <0.001), with higher EuroSCORE II (5.4 vs 3.9%, P =0.033). Operative mortality was 0.0% in both groups. One-year survival was similar (97.6% vs 94.3%, P =0.613), but composite morbidity was lower in the post-TAVI group (9.1% vs 31.4%, P =0.035). Chronic respiratory disease (P =0.043) independently predicted mortality during follow-up, while number of coronary vessel>50% stenosis (P =0.050), creatinine clearance (P =0.016) and being in the pre-TAVI era group (P =0.022) predicted composite morbidity. Conclusions: Since TAVI was introduced, mean age and risk scores significantly increased in octogenarians undergoing AVR, while mortality rates remained similar and composite morbidity decreased. [Copyright &y& Elsevier]

Key Clinical Message: Our case depicts a challenging diagnosis of catastrophic antiphospholipid syndrome in a young patient with a heterogenous presentation with extensive clinical course, a wide range of investigations, including multimodality imaging, and multidisciplinary expertise, to initiate prompt treatment addressing multiorgan thrombotic injury. [ABSTRACT FROM AUTHOR]