Bruce Bastian

Peri-operative Levosimendan in Patients Undergoing Cardiac Surgery: An Overview of the Evidence.

Levosimendan, a calcium sensitiser, has recently emerged as a valuable agent in the peri-operative management of cardiac surgery patients. Levosimendan is a calcium-sensitising ionodilator. By binding to cardiac troponin C and reducing its calcium-binding co-efficient, it enhances myofilament responsiveness to calcium and thus enhances myocardial contractility without increasing oxygen demand. Current evidence suggests that levosimendan enhances cardiac function after cardiopulmonary bypass in patients with both normal and reduced left ventricular function. In addition to being used as post-operative rescue therapy for low cardiac output syndrome, a pre-operative levosimendan infusion in high risk patients with poor cardiac function may reduce inotropic requirements, the need for mechanical support, the duration of intensive care admissions as well as post-operative mortality. Indeed, it is these higher-risk patients who may experience a greater degree of benefit. Larger, multicentre randomised trials in cardiac surgery will help to elucidate the full potential of this agent.

Acquired Gerbode Defects Associated with Infective Endocarditis.

Infective endocarditis is associated with a high risk of mortality and complications. A very rare complication is the development of an acquired left ventricle to right atrium (Gerbode) defect secondary to bacterial invasion of the membranous septum. We report two complex cases of infective endocarditis complicated by acquired Gerbode defects, outlining the role of two-dimensional (2D) and three-dimensional (3D) transoesophageal imaging.

Heart Failure Hospitalisations in the Hunter New England Area Over 10 years. A Changing Trend

BACKGROUND Heart failure carries a major burden on our health system, mainly related to the high rate of hospital admission. An understanding of the recent trends in heart failure hospitalisation is essential to the future allocation of health resources. Our aim is to analyse the temporal trends in heart failure hospitalisation. METHODS We extracted all separations in the Hunter New England Local Health District between 2005-2014 (n=40,119) with an ICD 10 code for heart failure (I-50) in the first four diagnoses on discharge. The numbers of hospitalisations were age-standardised to the 2001 Australian population and compared based on gender and remoteness. RESULTS There was a decline in the age-standardised hospitalisation. However, there was a clear inflection point between 2009-2010, after which the decline levelled off. The absolute number of hospitalisations increased between 2010 and 2014. Heart failure hospitalisation was higher in males compared to females and rural compared to metropolitan inhabitants. CONCLUSION The gains in heart failure treatment noted in recent years seem to have come to an end. Patients aged 75 years and older are contributing the majority of age-standardised hospitalisations.

Disparities in the incidence of acute myocardial infarction: long-term trends from the Hunter region

Trends in the incidence of acute myocardial infarction (AMI) provide important information for healthcare providers and can allow for accurate planning of future health needs and targeted interventions in areas with an excess burden of cardiovascular disease.

Effect of wetting the mouth on aortic blood pressure just before taking sublingual nitrates

The absorption of sublingual nitrate tablets is sometimes variable. We performed a randomized controlled trial to determine whether wetting the mouth improved the decrease in aortic systolic blood pressure (BP) from sublingual nitrate tablet or spray. The 100 patients undergoing routine diagnostic cardiac catheterization were allocated to control (no nitrate), 0.3 mg sublingual nitrate tablet, 0.4 mg sublingual nitrate spray, water + 0.3 mg sublingual nitrate tablet, or water + 0.4 mg sublingual nitrate spray. Aortic systolic and diastolic BP were recorded using a fluid-filled catheter and measured off-line blind to the treatment group. Compared with control subjects, there were significant decreases in aortic systolic BP with both nitrate preparations (tablet = -7.1 mm Hg, 95% confidence interval [CI] = -12.5 to -1.6 mm Hg; spray = -8.0 mm Hg, 95% CI = -13.4 to -2.5 mm Hg). On average, water significantly increased the fall in aortic systolic BP with nitrate tablets (-5.5 mm Hg, 95% CI = -10.9 to -0.1 mm Hg, p = 0.044) but did not significantly enhance the effect of nitrate spray (-2.8 mm Hg, 95% CI = -8.3 to 2.6 mm Hg). Water significantly increased the fall in aortic diastolic BP with tablets only (-2.9 mm Hg, 95% CI = -5.5 to -0.2), and had no significant effect on heart rate. Water had a consistently larger influence on the hemodynamic effects of nitrate tablets than on the effects of nitrate spray. Patients with a dry mouth will have an increased effect from sublingual nitrate tablets if they wet their mouth before using sublingual nitrate tablets. Water does not appear to assist in the action of sublingual spray.

Trends in the Incidence of First Acute Myocardial Infarction in Metropolitan and Regional Areas of the Hunter Region

INTRODUCTION There is conflicting information regarding the contemporary incidence of first acute myocardial infarction (AMI) in Australia. We sought to document the regional variations in first AMI incidence in a large health district. METHODS We identified all patients presenting with first AMI in the Hunter region of New South Wales from 2004 to 2013. We calculated age and gender adjusted incidence of AMI and evaluated differences between patients from regional and metropolitan areas. We assessed 30-day and 12-month outcomes, including mortality, through linkage with the NSW Registry of Births Deaths and Marriages. RESULTS The incidence of first AMI in regional areas was persistently higher throughout the study compared to metropolitan areas (IRR 1.244; 95% CI 1.14-1.35; p≤0.001). There were no significant differences between regional and metropolitan areas in 30-day and 12-month outcomes following presentation with first AMI. CONCLUSIONS The study demonstrates persistently higher rates in regional compared to metropolitan areas, supporting the need for implementation of targeted intervention and prevention strategies.

Outcomes following heart failure hospitalization in a regional Australian setting between 2005 and 2014: HF in regional Australia

The aim of the current study is to examine 10 year trends in mortality and readmission following heart failure (HF) hospitalization in metropolitan and regional Australian settings.

Mortality and Readmission Following Hospitalisation for Heart Failure in Australia: A Systematic Review and Meta-Analysis

BACKGROUND Heart failure (HF) is a common, costly condition with an increasing burden on Australian health care system resources. Knowledge of the burden of HF on patients and on the health system is important for resource allocation. This study is the first systematic review to estimate the mortality and readmission rates after hospitalisation for HF in the Australian population. METHODS We searched for studies of HF hospitalisation in Australia published between January 1990 and May 2016, using a systematic search of PubMed, Medline, Scopus, Web of Science, EMBASE and Cochrane Library databases. Studies reporting 30-day and/or 1-year outcomes for mortality or readmission following hospitalisation were eligible and included in this study. RESULTS Out of 2889 articles matching the initial search criteria, a total of 13 studies representing 67,255 patients were included in the final analysis. The pooled mean age of heart failure patients was 76.3 years and 51% were male (n=34,271). The pooled estimated 30-day and 1-year all-cause mortality were 8% and 25% respectively. The pooled estimated 30-day and 1-year all-cause readmission rates were 20% and 56% respectively. There is a high prevalence of comorbidities in heart failure patients. There were limited data on readmission and mortality in rural patients and Indigenous people. CONCLUSIONS Heart failure hospitalisations in Australia are followed by substantial readmission and mortality rates.

Percutaneous Retrieval of an Embolised Vascular Stent

© 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) a Inc. All rights reserved. *Corresponding author at: Cardiovascular Unit, John Hunter Hospital, Newcastle, N Email: Nicholas.Collins@hnehealth.nsw.gov.au ventricular outflow tract (RVOT)(Fig. 1a and1b), with the stent position confirmed on 2D and 3D transoesophageal echocardiography (Fig. 1c and 1d). Percutaneous device retrieval was planned, with stent position confirmed on fluoroscopy (Fig. 2a). A 6 JR4 guide was positioned into the RVOT with a loop snare capturing the embolised stent (Fig. 2b).

Audit of the aetiology and prevalence of pulmonary hypertension in a tertiary hospital setting

Appropriate diagnosis and initiation of disease‐specific treatment is an important therapeutic goal in idiopathic pulmonary arterial hypertension. We evaluated the prevalence and aetiology of moderate‐to‐severe pulmonary hypertension in a cohort of patients referred for inpatient echocardiography, with significant pulmonary hypertension documented in 4.6%. Pulmonary hypertension complicating left heart disease was the most common aetiology, with idiopathic pulmonary arterial hypertension less frequent.