R. Markham

Coronary computed tomography angiography and its increasing application in day to day cardiology practice.

Coronary artery disease (CAD) is the leading single cause of death in Australia affecting around 1.4 million people. Coronary computed tomography angiography has an established role in the assessment of patients with low to intermediate pretest probability for CAD who have chest pain and is typically used with the aim to rule out significant coronary artery stenosis. Use was initially limited because of concerns over radiation exposure, a Medicare rebate restricted to specialist referrals and an absence of data supporting its use as an alternative to functional testing in patients with chest pain. Recent advances in scanner technology and image sequencing, along with data from randomised control trials, have addressed these issues and indicate that coronary computed tomography angiography will play a greater role in the assessment of CAD in the coming years.

Multimodality imaging of cor triatriatum sinistrum diagnosed in an adult female

A 66-year-old female with a history of hypertension presented for an elective transthoracic ultrasound. The study revealed normal left and right ventricular size and function and an echogenic band running along a normally sized left atrium. Subsequently a transesophageal echocardiogram (TEE) was organised which revealed a thin partial membrane arising from the roof of the left atrium (LA) and extending across to the interatrial septum (IAS) ( Fig. 1A, B, C and D ). Colour Doppler imaging revealed unidirectional, laminar flow through the membrane ( Fig. 1E and F). The remainder of the study was unremarkable, with normal left and right ventricular function and absent valvular pathology.

Outcomes Following Melody Transcatheter Pulmonary Valve Implantation for Right Ventricular Outflow Tract Dysfunction in Repaired Congenital Heart Disease: First Reported Australian Single Centre Experience

BACKGROUND Transcatheter pulmonary valve implantation (TPVI) with the Melody® transcatheter pulmonary valve (TPV) has demonstrated good haemodynamic and clinical outcomes in the treatment of right ventricular outflow tract (RVOT) conduit dysfunction in patients with repaired congenital heart disease CHD. We present the first Australian single centre experience of patients treated with Melody TPV. METHOD A prospective, observational registry was developed to monitor clinical and haemodynamic outcomes in patients with RVOT dysfunction treated with the Melody TPV (Medtronic Inc, Minneapolis, United States). RESULTS Seventeen patients underwent TPVI with Melody TPV at The Prince Charles Hospital between January 2009 and February 2016 with a median (range) age of 34 (R: 15-60). Fifteen (88%) were NYHA Class 2 dyspnoea and 11 (59%) had corrected Tetralogy of Fallot. Indication for TPVI was stenosis in eight (47%), regurgitation in two (12%) and mixed dysfunction in seven (41%). Device implantation was successful in all patients. Peak RVOT gradient was significantly reduced and there was no significant regurgitation post procedure. There was one (6%) major procedural adverse event and two (12%) major adverse events at last recorded follow-up. There were no patient deaths. Follow-up cardiac magnetic resonance imaging revealed a significant reduction in indexed right ventricular end diastolic volume. CONCLUSION This study confirms the safety and effectiveness of TPVI with Melody TPV for RVOT dysfunction in repaired CHD.

Myocardial infarction from isolated coronary artery vasculitis in a young patient: a rare case.

Symptomatic coronary artery disease (CAD) primarily occurs in patients over the age of 40, however younger men and women can also be affected. The pathophysiology of CAD in this group is often not due to atherosclerotic plaque rupture, except for those with genetically predetermined risk such as familial hypercholesterolaemia. In an autopsy study of victims aged 15–34 years, advanced coronary atheromas were seen only in 2% of males aged 15–19 years, and none in females [ 1 ]. Many of these cases may have had severe heterozygous familial hypercholesterolaemia (FH), which occurs with a frequency of 1:300–1:500 of the general population, and in which total cholesterol levels are very high (usually > 8 mmol/L) [ 2 ].

Transcatheter mitral valve intervention: an emerging treatment for mitral regurgitation

Mitral regurgitation (MR) is a valvular heart disease associated with significant morbidity and mortality. Transcatheter mitral valve intervention (TMVI) repairs or replaces the mitral valve through small arterial and venous entry sites and so avoids risks associated with open heart surgery. Transcatheter devices targeting components of the mitral apparatus are being developed to repair or replace it. Numerous challenges remain including developing more adaptable devices and correction of multiple components of the mitral annulus to attain durable results. The mitral valve apparatus is a complex structure and understanding of the mechanisms of MR is essential in the development of TMVI. There will likely be a complementary role between surgery and TMVI in the near future.

Right Heart Catheterisation: How To Do It

Right heart catheterisation (RHC) is a minimally invasive procedure that provides direct haemodynamic measurement of intracardiac and pulmonary pressures. It is the gold standard investigation for the diagnosis and management of pulmonary hypertension. This article will describe how to perform right heart catheterisation, indications and contraindications.

Percutaneous valve in valve in the tricuspid position in a patient with Tetralogy of Fallot

Here, we describe a case of a successful percutaneous insertion of a transcatheter 29 mm Edwards Sapien XT valve into a tricuspid valve in a patient with repaired tetralogy of fallot. Similar procedures have been performed with the Edwards Sapien valve and Melody valves; however, this is the first case described in the literature of an Edwards Sapien valve used in a patient with Tetralogy of Fallot. With procedural safety being demonstrated, this case illustrates an important alternative treatment option for patients with congenital heart disease. Although long-term data is required to compare its efficacy with surgically replaced valves, percutaneous procedures can serve as a delay to surgical valve replacement which over a patients’ lifetime with congenital heart disease, can minimise the amount of invasive surgeries and potential complications.

Point-of-care INR compared to laboratory INR in patients supported with a continuous flow left ventricular assist device

Fig. 1. Correlation between INR as measured by CoaguChek® XS and the laboratory. Continuous-flow left ventricular assist devices (CF-LVAD) are utilised in patients with end-stage heart failure (ESHF) as a bridge to cardiac transplantation or in some countries, as destination therapy [1]. Thrombotic and bleeding events are the most frequent and serious complications in patients with CF-LVAD [2]. As such, warfarinisation and a daily reported international normalised ratio (INR) value between 2.0 and 3.0 are required to reduce the thrombotic risk [3]. The CoaguChek® XS (Roche Diagnostics, Indiana, North America) has been approved for use as a form of anticoagulation monitoring. However there is limited data in its use formonitoring anticoagulation in patients with a CF-LVAD [4]. We analysed 230 INR values, as measured by CoaguChek® XS and the laboratory (Stagos STA-R Evolution, Leicester, United Kingdom), from 15 patients with CF-LVAD for ESHF as a bridge to transplant at The Prince Charles Hospital (Brisbane, Australia) between December 2013 and August 2015. Blood samples for each of the testing methods were taken on the same day and within a 4-hour window of each other. Mean age of 40 ± 14 years. 10 (67%) were male and target INR was 2–3 for all patients. 4 (27%) were on amiodarone, mean creatinine was 89±53 μmol/L,meanhaematocrit 0.32 (+/−0.05) and nopatients had hepatic synthetic or thyroid dysfunction. There was amoderate correlation between laboratory and CoaguChek® XS INR values with a correlation coefficient of 0.86 (r2= 0.75, p b 0.001) shown in Fig. 1. Mean INR was significantly different between the laboratory and CoaguChek® XS

Transcatheter aortic valve implantation using the Lotus valve system in severe aortic stenosis in an orthotopic heart transplant patient

A 68-year-old male presented with increasing breathlessness (NYHA Class III) and reduced exercise tolerance to approximately 150 m. An orthotopic heart transplant had been performed twelve years previously for ischaemic cardiomyopathy. Transthoracic and transoesophageal echocardiography (TOE) revealed a calcified aortic valve with severe stenosis (maximum trans-aortic velocity 4.0 m/s, mean pressure gradient 44 mm Hg, aortic valve area 0.7 cm) and

'Coronary computed tomographic arteriography is anatomical and a myocardial perfusion is functional, detecting ischaemia - hence they are complementary': Reply

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