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The small aortic annulus is a surgical challenge in patients undergoing aortic valve replacement which may lead to patient prosthesis mismatch. Management options include aortic root enlargement, aortic root replacement, and the use of sutureless valves. In this case series, we report our results with aortic root enlargement, sutureless valve implantation, and benchtop modelling of the radial forces exerted. Five patients underwent aortic root enlargement and insertion of the Perceval valve as part of the management strategy to enlarge their effective orifice area. We further investigate this strategy with a benchtop model to quantify the radial forces exerted by the Perceval valve on the aortic annulus. Radial and hoop forces on the aortic annulus and inner ring of the Perceval valve were recorded using a Mylar force tester. Five female patients with native annulus between 18mm–20mm underwent root enlargement and insertion of a Perceval S valve. The postoperative course was uncomplicated for all patients except for one who required a permanent pacemaker insertion. Transvalvular pressure gradients remained low at up to 4 years of follow-up (12 mmHg–21 mmHg), with no evidence of paravalvular leak. Benchtop testing demonstrated radial forces exerted at the annulus in all-size Perceval S valves to be within physiological variables, whereas compressive forces required to deform the valves were supraphysiological. The deployment of a sutureless valve within a surgical enlarged aortic root is a feasible solution in patients with a small aortic root. [ABSTRACT FROM AUTHOR]

Background: With the introduction of beating heart surgery, there has been a renewed interest in the incidence of postoperative atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG). A small number of studies have reported markedly decreased incidences of postoperative AF in patients undergoing off-pump CABG. Aims: The aim of the present study was to review the incidence of AF in patients undergoing off-pump CABG at Royal Melbourne Hospital. Methods: A retrospective review was undertaken of 80 patients who had elective first-time CABG off-pump over a 16-month period. These patients were matched with 80 patients who underwent CABG with cardiopulmonary bypass (CPB). Data on preoperative and operative variables were collected. Incidences of postoperative AF in both groups were recorded. Results: The incidence of AF in the off-pump group was 27 of 80 patients (34%) and in the CPB group it was 25 of 80 patients (31%; NS). Increasing age was a significant risk factor for developing postoperative AF, and beta-blockade was identified as a protective factor. Conclusions: Off-pump CABG does not decrease the incidence of postoperative atrial fibrillation. A randomised prospective trial has been commenced at Royal Melbourne Hospital to further investigate postoperative outcomes of off-pump CABG. (Heart, Lung and Circulation 2002; 11: 102-106). [ABSTRACT FROM AUTHOR]

We summarise recent advances in transfusion medicine applicable to cardiac surgery and cardiac transplantation. It is important that clinicians know the risks of blood transfusion in Australia. They should also be aware of the different types of transfusion reaction so that there is early recognition and investigation. Blood conservation strategies including acceptance of normovolaemic anaemia in clinically stable patients are important in reducing the requirement for red cell transfusion. Cytomegalovirus (CMV) seronegative blood products are recommended for heart transplant recipients with no evidence of prior CMV infection. Leucodepletion of units of unknown CMV status reduces the risk of CMV infection and are an acceptable alternative when seronegative units are unavailable. Leucodepletion of cellular blood products has been shown to reduce infection rates postoperatively in a large trial involving cardiac surgical patients. Further studies are needed to confirm this promising finding. Irradiation of blood products eliminates the risk of transfusion-associated graft versus host disease. Routine preoperative screening for cold agglutinins is no longer recommended. (Heart, Lung and Circulation 2002; 11: 42-51). [ABSTRACT FROM AUTHOR]

Implantation of bioprosthetic valves is more common as the population ages and there is a shift towards implanting bioprosthetic aortic valves in an increasingly younger surgical population. Bioprosthetic heart valve insertion, however, carries the long-term risk of valve failure through structural valve degeneration. Re-operative surgical aortic valve replacement has historically been the only definitive management option for patients with prosthetic valve dysfunction, however, data on the short- and long-term outcomes following re-operative surgery in Australia and New Zealand is limited. Data on all patients who underwent redo aortic valve surgery, over a 20-year period (up to 2021) was obtained from the Australian and New Zealand Society of Cardiothoracic Surgery Registry. A total of 1,199 patients (770 males; 64.2% and 429 females; 35.8%) were included in the overall analysis. The 30-day mortality was 6.4% with operative urgency status the most important risk factor for peri-operative mortality. The long-term survival rate of 1,145 patients was 90.5% (95% confidence interval [CI] 88.8%–92.3%), 77% (95% CI 73.9%–80.2%) and 57.2% (95% CI 55.2%–62.8%) at 1-, 5- and 10-years post-procedure, respectively, with a median survival of 12.7 years. Pre-existing chronic kidney disease was strongly associated with poorer long-term survival. For patients under 70 years of age the 1-, 5- and 10-year survival rates were 92.9% (95% CI 90.9%–95.1%), 83.6% (95% CI 80.1%–87.3%) and 73.1% (95% CI 67.4%–79.3%), respectively. The results from this registry study indicate that in Australia and New Zealand, a repeat surgical aortic valve replacement can result in a relatively low mortality rate, serving as a reference point for medical procedures in these regions. [ABSTRACT FROM AUTHOR]

Adult congenital heart disease (ACHD) services increasingly encounter heart failure (HF) in the ageing ACHD population. Optimal timing of referral for heart transplant (HTx) evaluation in this heterogeneous population is complex and ill-defined. We aim to outline the characteristics and outcomes of ACHD patients referred for HTx from a large Australian ACHD centre. Retrospective review of ACHD patients referred for HTx from a primary ACHD centre (1992–2021). Database analysis of patient demographics, characteristics, wait-listing, and transplantation outcomes was performed. A total of 45 patients (mean age 37±9.9 years old; 69% male) were referred for HTx with a mean follow-up of 5.9±6.3 years. Of these, 22 of 45 (49%) were listed and transplanted, including one heart–lung transplant. The commonest diagnosis was dextro-transposition of the great arteries (13/45, 29%). Most patients, 33 of 45 (73.3%) had undergone at least one cardiac surgery in childhood. Indications for HTx referral included HF in 34 of 45 (75%), followed by pulmonary hypertension in 7 of 45 (11%). Median transplant wait-list time was 145 days (interquartile range, 112–256). Of the 23 patients not wait-listed, the reasons included clinical stability in 13 of 45 (29%), psychosocial factors in 2 of 45 (4.4%) and prohibitive surgical risk, including multiorgan dysfunction, in 8 of 45 (17.7%). Transplant was of a single organ in most, 21 of 22 (95.5%). Overall mortality was 5 of 22 (22.7%) in those after HTx, and 14 of 23 (60.9%) in those not listed (p=0.0156). Increasingly, ACHD patients demonstrate the need for advanced HF treatments. HTx decision-making is complex, and increased mortality is seen in those not wait-listed. Ultimately, the referral of ACHD patients for HTx is underpinned by local decision-making and experience, wait-list times and outcomes. [ABSTRACT FROM AUTHOR]

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF. [ABSTRACT FROM AUTHOR]

There is an ever increasing demand for donor lungs in patients waiting for transplantation. Lungs of many potential donors will be rejected if the standard criteria for donor assessment are followed. We have expanded our donor lung pool by accepting marginal donors and establishing a donation after circulatory death program. We have achieved comparable results using marginal donors and accepting donor lungs following donation after circulatory death. We present our assessment and technical guidelines on lung procurement taking into consideration an increasingly complex cohort of lung donors. These guidelines form the basis of the lung procurement training program involving surgical Fellows at the Alfred Hospital in Melbourne, Australia. [ABSTRACT FROM AUTHOR]

The correct management of ischaemic mitral regurgitation (IMR) in patients presenting for coronary artery bypass grafting (CABG) remains contentious. Although it is generally agreed that severe MR in patients presenting for CABG should be corrected and that mild MR can be left alone, there is no consensus as to the correct treatment for those patients with moderate MR undergoing CABG. Further, there has never been a prospective randomised trial looking at this issue. The data from retrospective reviews is conflicting. The available evidence clearly shows an increase in cardiac morbidity in those patients undergoing revascularisation who are left with significant MR. However, those retrospective studies comparing patients who have a mitral valve procedure with their CABG to those who undergo CABG alone have not consistently shown a benefit. This may be due to the retrospective nature of these reports. But it may also be due to the type of repairs being performed which may not be adequately addressing the specific pathology involved. The aim of this paper therefore is to evaluate the available evidence to help guide decision making in the treatment of ischaemic MR. The underlying pathophysiology of this condition is outlined and the various types of repair being advocated are reviewed. Although there is no clear answer to the question of optimal management of IMR at present, what is clear is that a prospective trial is urgently needed to guide us with the treatment of this clinical problem. [Copyright &y& Elsevier]

Mechanical circulatory support has evolved markedly over recent years. ECMO (extra corporeal membrane oxygenation) is instituted for the management of life threatening pulmonary or cardiac failure (or both), when no other form of treatment has been or is likely to be successful. Most commonly, it is instituted in an emergency or urgent situation after failure of other treatment modalities. It is used as temporary support, usually awaiting recovery of organs, or can be used as a bridge to a more permanent device or cardiac transplantation. ECMO can be deployed in a veno-arterial configuration (either peripheral or central cannulation) for the treatment of cardiogenic shock. This is usually seen post-cardiotomy, post-heart transplant and in severe cardiac failure due to almost any other cause (e.g. cardiomyopathy, myocarditis, acute coronary syndrome with cardiogenic shock). Veno-venous ECMO is used for respiratory failure and usually involves peripheral cannulation using the femoral veins±internal jugular vein if required. The indications for veno-venous ECMO are respiratory failure, most commonly due to adult respiratory distress syndrome (ARDS), pneumonia, trauma or primary graft failure following lung transplantation. ECMO is also used for neonatal and paediatric respiratory support. Its use in premature neonates is the mainstay of treatment for immature lungs and insufficient surfactant. In this review, the technical aspects of ECMO cannulation, maintenance and weaning are outlined. Complication rates and outcomes are reviewed and our experience at The Epworth Hospital is summarized. [Copyright &y& Elsevier]

Background: Problematic mitral regurgitation (MR) may develop following lung transplantation (LTx). There is limited information on the management of MR in LTx patients, as such we sought to evaluate our centre's experience.Methods: From 2000 to 2019, 1,054 patients underwent LTx at our centre (896 bilateral, 158 single). We identified patients in whom significant MR developed at any point post-LTx. The aetiology of MR, management and outcome were retrospectively analysed.Results: Eight (8) patients developed severe MR post-LTx, six following bilateral LTx and two following single LTx. Lung transplantation indications included interstitial lung disease (n=5), chronic obstructive pulmonary disease (n=2) and pulmonary arterial hypertension (n=1). Severe MR occurred intraoperatively (n=1), postoperative day 1 (n=1) with the remaining six cases between 80 and 263 days post-LTx. The aetiology was noted to be due to severe left ventricular dysfunction following unmasking of a chronically pulmonary hypertension-related under-preloaded left ventricle in one case, and in the remaining seven patients causes included myxomatous degeneration, ischaemic MR, and functional MR due to annular dilatation. In the patient with intraoperative severe MR, the MR became mild with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and in the remaining seven patients a variety of procedures were used, including mitral valve repair, valve replacement and transcatheter edge-to-edge mitral valve repair. All patients survived the mitral procedure. Two (2) deaths occurred at 12.9 years (stroke) and 5 years (cancer) from mitral valve surgery.Conclusions: Development of significant mitral valve regurgitation is a rare but morbid complication after lung transplantation. This may represent the progressive natural history of pre-existing degenerative mitral valve disease and rarely, early after transplantation may be related to changes in ventricular geometry. Management of severe MR can follow the same management approach as in the non-transplant community, with the expectation of similarly good results. [ABSTRACT FROM AUTHOR]

There are many challenging problems related to bleeding and anticoagulation in cardiac surgery. Practical guidelines, which are based on available evidence, can help to direct management issues of post-bypass bleeding, perioperative anticoagulation and the use of haemostatic agents. The patient’s bleeding history is the most useful preoperative screening test of haemostasis. The input of a haematologist is often valuable in a number of areas, such as preoperative assessment of patients with a significant history of bleeding, or past history of heparin-induced thrombocytopenia, a lupus anticoagulant, or recent venous thromboembolism. Cardiothoracic surgeons, anaesthetists, perfusionists and haematologists can ensure ‘best practice’ by being actively involved in the development of ‘local’ transfusion and anticoagulation guidelines, hospital transfusion committee policies, and audits. (Heart, Lung and Circulation 2001; 10: 142–153). [ABSTRACT FROM AUTHOR]

Background: Over the last two decades, technological advancements in the delivery of extra corporeal membrane oxygenation (ECMO) have seen its use broaden and results improve. However, in the post cardiotomy ECMO patient group, survival remains very poor without significant improvements over the last two decades. Our study aims to report on the Australian experience, with the intention of providing background data for the formation of guidelines in the future.Methods: Retrospective analysis of prospectively collected data from the Australian and New Zealand Society of Cardiothoracic Surgeons (ANZSCTS) Database was performed. The ANZSCTS database captures at least 60% of cardiac surgical data in Australia, annually. Data was collected on adult patients who received ECMO post cardiotomy from September 2016 to November 2017 inclusive. Transplant and primary cardiomyopathy patients were excluded.Results: Of the 16,605 adult patients undergoing cardiac surgery in the 15-month period of the study, 87 patients required post cardiotomy ECMO (0.52%). The average age of the entire cohort was 56 years. Overall survival to discharge was 43.7% (n=38). Multivariable logistic regression analysis demonstrated that multiorgan failure (MOF), increasing age and longer cardiopulmonary bypass time were significant predictors of in hospital mortality.Conclusions: Post cardiotomy ECMO support is an uncommon condition. Survival in this study appears to be better than historical reports. Identification of poor prognostic indicators in this study may help inform the development of guidelines for the most appropriate use of this support modality. [ABSTRACT FROM AUTHOR]

Traditionally, patients presenting with symptoms of coronary artery disease (CAD) were managed medically. If medical treatment proved unsuccessful, patients were referred for coronary artery bypass surgery (CABG). However, in recent years, increasing numbers of patients have received percutaneous coronary intervention (PCI), usually a coronary stent, for primary treatment. PCI is attractive because it is minimally invasive, has proven success in the immediate treatment of acute myocardial infarction and is well-accepted for poor surgical candidates in selected cases. However, evidence from emerging and ongoing clinical trials and registries suggests that compared to PCI, CABG offers superior long-term prognostic benefits in many, if not most, patients with significant CAD. We present an analysis of recent evidence showing that patients with complex atherosclerotic lesions, multivessel disease, left main stem disease, left ventricular dysfunction and diabetes mellitus derive more benefit from surgical revascularisation than from PCI. We conclude that PCI should be restricted to patient groups where superiority or equivalence to CABG has been demonstrated and that the decision-making process in allocating treatment should be made by a multidisciplinary team to ensure that every patient receives balanced advice and therapy that is most effective in the long term. [ABSTRACT FROM AUTHOR]