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Health care is currently showing a fall in heart failure (HF) incidence and prevalence, particularly in developed countries, but with only a subset receiving appropriate therapy to protect the heart against maladaptive processes such as fibrosis and hypertrophy. Appropriate markers of advanced HF remain unidentified, which would help in choosing the most suitable therapy and avoid major compliance problems. Speckle tracking echocardiography (STE) is a good choice, being a non-invasive imaging technique which is able to assess cardiac deformation in a variety of conditions. Several multicenter studies and meta-analyses have demonstrated the clinical application and accuracy of STE in early and late stages of HF, as well as its association with both left ventricular (LV) filling pressures and myocardial oxygen consumption. Furthermore, STE assists in assessing right ventricular free-wall longitudinal strain (RVFWLS), which is a solid predictor of right ventricle failure (RVF) following LV assist device (LVAD) implantation. However, STE is known for its limitations; despite these, it has been shown to explain symptoms and signs and also to be an accurate prognosticator. The aim of this review is to examine the advantages of STE in the early evaluation of myocardial dysfunction and its correlation with right heart catheterization (RHC) parameters, which should have significant clinical relevance in the management of HF patients.

Health care is currently showing a fall in heart failure (HF) incidence and prevalence, particularly in developed countries, but with only a subset receiving appropriate therapy to protect the heart against maladaptive processes such as fibrosis and hypertrophy. Appropriate markers of advanced HF remain unidentified, which would help in choosing the most suitable therapy and avoid major compliance problems. Speckle tracking echocardiography (STE) is a good choice, being a non-invasive imaging technique which is able to assess cardiac deformation in a variety of conditions. Several multicenter studies and meta-analyses have demonstrated the clinical application and accuracy of STE in early and late stages of HF, as well as its association with both left ventricular (LV) filling pressures and myocardial oxygen consumption. Furthermore, STE assists in assessing right ventricular free-wall longitudinal strain (RVFWLS), which is a solid predictor of right ventricle failure (RVF) following LV assist device (LVAD) implantation. However, STE is known for its limitations; despite these, it has been shown to explain symptoms and signs and also to be an accurate prognosticator. The aim of this review is to examine the advantages of STE in the early evaluation of myocardial dysfunction and its correlation with right heart catheterization (RHC) parameters, which should have significant clinical relevance in the management of HF patients.

Health care is currently showing a fall in heart failure (HF) incidence and prevalence, particularly in developed countries, but with only a subset receiving appropriate therapy to protect the heart against maladaptive processes such as fibrosis and hypertrophy. Appropriate markers of advanced HF remain unidentified, which would help in choosing the most suitable therapy and avoid major compliance problems. Speckle tracking echocardiography (STE) is a good choice, being a non-invasive imaging technique which is able to assess cardiac deformation in a variety of conditions. Several multicenter studies and meta-analyses have demonstrated the clinical application and accuracy of STE in early and late stages of HF, as well as its association with both left ventricular (LV) filling pressures and myocardial oxygen consumption. Furthermore, STE assists in assessing right ventricular free-wall longitudinal strain (RVFWLS), which is a solid predictor of right ventricle failure (RVF) following LV assist device (LVAD) implantation. However, STE is known for its limitations; despite these, it has been shown to explain symptoms and signs and also to be an accurate prognosticator. The aim of this review is to examine the advantages of STE in the early evaluation of myocardial dysfunction and its correlation with right heart catheterization (RHC) parameters, which should have significant clinical relevance in the management of HF patients.

Health care is currently showing a fall in heart failure (HF) incidence and prevalence, particularly in developed countries, but with only a subset receiving appropriate therapy to protect the heart against maladaptive processes such as fibrosis and hypertrophy. Appropriate markers of advanced HF remain unidentified, which would help in choosing the most suitable therapy and avoid major compliance problems. Speckle tracking echocardiography (STE) is a good choice, being a non-invasive imaging technique which is able to assess cardiac deformation in a variety of conditions. Several multicenter studies and meta-analyses have demonstrated the clinical application and accuracy of STE in early and late stages of HF, as well as its association with both left ventricular (LV) filling pressures and myocardial oxygen consumption. Furthermore, STE assists in assessing right ventricular free-wall longitudinal strain (RVFWLS), which is a solid predictor of right ventricle failure (RVF) following LV assist device (LVAD) implantation. However, STE is known for its limitations; despite these, it has been shown to explain symptoms and signs and also to be an accurate prognosticator. The aim of this review is to examine the advantages of STE in the early evaluation of myocardial dysfunction and its correlation with right heart catheterization (RHC) parameters, which should have significant clinical relevance in the management of HF patients.

The objective of the study was to investigate the safety profile of high-risk micro-endomyocardial biopsy (micro-EMB) compared to conventional EMB in a large animal model. Twenty pigs were subjected to a maximum of 30 consecutive biopsies, including sampling from the free ventricular wall, with either micro-EMB (n = 10) or conventional EMB (n = 10). There were no major complications in the micro-EMB group (0/10), compared to six major complications in the EMB group (6/10; p = 0.003). Survival analysis further highlighted these differences (p = 0.004). There were significantly higher volumes of pericardial effusion in the EMB group (p = 0.01). The study shows a safety advantage of micro-EMB compared to standard EMB in the experimental high-risk circumstances investigated in this animal study. These results indicate enhanced possibilities to collect samples from sensitive areas by using the micro-EMB technique instead of standard EMB., QC 20220607

Disturbed fetal haemodynamics often affects cardiac development and leads to congenital cardiac defects. Reduced left ventricular (LV) preload in the fetus may result in hypoplastic LV, mitral and aortic valve, mimicking a moderate form of hypoplastic left heart complex. We aimed to induce LV hypoplasia by occluding the foramen ovale (FO) to reduce LV preload in the fetal sheep heart, using percutaneous trans-hepatic catheterisation. Under maternal anaesthesia and ultrasound guidance, hepatic venous puncture was performed in six fetal lambs (0.7-0.75 gestation). A coronary guidewire was advanced into the fetal inferior vena cava, right and left atrium. A self-expandable stent was positioned across the FO. An Amplatzer Duct Occluder was anchored within the stent for FO occlusion. Euthanasia and post-mortem examination was performed after 3 weeks. Nine fetuses were used as age-matched controls. Morphometric measurements and cardiac histopathology were performed. Compared with controls, fetal hearts with occluded FO had smaller LV chamber, smaller mitral and aortic valves, lower LV-to-RV ratio in ventricular weight and wall volume, and lower number of LV cardiomyocyte nuclei. We conclude that fetal FO occlusion leads to a phenotype simulating LV hypoplasia. This large animal model may be useful for understanding and devising therapies for LV hypoplasia.

Background: Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. Method(s): Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. Result(s): Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51+/-11 and 51+/-10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in

Background: Left ventricular thrombus (LVT) has a 5% incidence after anterior ST-elevation myocardial infarction (STEMI). Multiple risk factors predispose to LVT formation, including left ventricular systolic dysfunction and infarct size, however measurable predictors during index left heart catheterization (LHC) have not been determined. Method(s): We performed a retrospective analysis of patients presenting between January 2010 and September 2017 with anterior STEMI who had in-hospital transthoracic echocardiography (TTE). LHC variables that were assessed included coronary anatomy, location of culprit stenosis, presence of diffuse stenosis, number of severely diseased vessels, apical akinesis on left ventriculogram (LVG), left ventricular end diastolic pressure, and success of percutaneous coronary intervention (PCI). Result(s): Of 598 consecutive anterior STEMI patients, records and inpatient TTE results were available in 425 patients. The incidence of LVT was 6.8% (n = 29). After multivariate adjustment, severe triple vessel coronary disease (OR = 8.27, CI = 2.97-23.00, p <=0.001), apical akinesis on LVG (OR = 6.74, CI = 1.48-30.73, p = 0.014), wrap-around left anterior descending (LAD) anatomy (OR = 5.10, CI = 1.97-13.23, p = 0.001), and failure of recanalization after PCI (OR = 3.94, CI = 1.06-14.66, p = 0.04) were predictors for LVT formation. The combined negative predictive value (NPV) for the absence of these four indices was 99.2%. Conclusion(s): Severe triple vessel disease, apical akinesis on LVG during index admission, wrap-around LAD, and failure of recanalization after PCI are associated with increased risk of LVT formation after anterior STEMI. The high NPV for the absence of these indices could serve as a risk stratification tool for LVT risk to guide early TTE utilization.Copyright © 2021 Elsevier Inc.

Pulmonary hypertension (PH) is common in infants with severe bronchopulmonary dysplasia (BPD) and increases the risk of death. The objectives of this preliminary study were to compare responses of pulmonary circulation parameters to 100% oxygen (O2) and inhaled nitric oxide (iNO) in infants with BPD and PH using echocardiography. Responses between fetal growth restriction (FGR) and appropriate for gestational age infants were compared. Ten infants <28 weeks GA at birth were assessed at >=36 weeks corrected gestation. Baseline echocardiography1 was performed which was repeated (echocardiography2) after 30 minutes of O2. After a gap of 2-3 hours, iNO was administered for 15 minutes and echocardiography3 was performed, followed by iNO weaning. The gestation and birthweight of the cohort were 25.9 +/- 1.6 weeks and 612 +/- 175 g. Assessments were performed at 38.7 +/- 1.4 weeks corrected gestational age. Baseline time to peak velocity: right ventricular ejection time (TPV/RVETc) increased from 0.24 +/- 0.02 to 0.27 +/- 0.02 (O2, p =.01) and 0.31 +/- 0.03 (iNO, p <.001), indicating a decrease in pulmonary vascular resistance [PVR]. Baseline tricuspid annular plane systolic excursion (TAPSE) increased from 8.1 +/- 0.6 mm to 9.3 +/- 0.7 mm (O2, p =.01) and 10.5 +/- 1.1 mm (iNO, p =.0004), indicating improved ventricular systolic performance. Percentage change for all parameters was greater with iNO. Significant correlations between cardiac performance and PVR were noted. FGR infants noted higher baseline PVR (TPV/RVETc, 0.21 +/- 0.02 vs. 0.25 +/- 0.01, p =.002), lower ventricular performance (TAPSE, 7 +/- 1.2 mm vs. 8.6 +/- 6 mm, p =.003), and lower percentage change with O2 and iNO. A reactive component of pulmonary circulation provides real-time physiological information, which could rationalize treatment decisions.Copyright © 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological S

Disturbed fetal haemodynamics often affects cardiac development and leads to congenital cardiac defects. Reduced left ventricular (LV) preload in the fetus may result in hypoplastic LV, mitral and aortic valve, mimicking a moderate form of hypoplastic left heart complex. We aimed to induce LV hypoplasia by occluding the foramen ovale (FO) to reduce LV preload in the fetal sheep heart, using percutaneous trans-hepatic catheterisation. Under maternal anaesthesia and ultrasound guidance, hepatic venous puncture was performed in six fetal lambs (0.7-0.75 gestation). A coronary guidewire was advanced into the fetal inferior vena cava, right and left atrium. A self-expandable stent was positioned across the FO. An Amplatzer Duct Occluder was anchored within the stent for FO occlusion. Euthanasia and post-mortem examination was performed after 3 weeks. Nine fetuses were used as age-matched controls. Morphometric measurements and cardiac histopathology were performed. Compared with controls, fetal hearts with occluded FO had smaller LV chamber, smaller mitral and aortic valves, lower LV-to-RV ratio in ventricular weight and wall volume, and lower number of LV cardiomyocyte nuclei. We conclude that fetal FO occlusion leads to a phenotype simulating LV hypoplasia. This large animal model may be useful for understanding and devising therapies for LV hypoplasia.

Background: Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. Method(s): Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. Result(s): Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51+/-11 and 51+/-10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in

Background: Left ventricular thrombus (LVT) has a 5% incidence after anterior ST-elevation myocardial infarction (STEMI). Multiple risk factors predispose to LVT formation, including left ventricular systolic dysfunction and infarct size, however measurable predictors during index left heart catheterization (LHC) have not been determined. Method(s): We performed a retrospective analysis of patients presenting between January 2010 and September 2017 with anterior STEMI who had in-hospital transthoracic echocardiography (TTE). LHC variables that were assessed included coronary anatomy, location of culprit stenosis, presence of diffuse stenosis, number of severely diseased vessels, apical akinesis on left ventriculogram (LVG), left ventricular end diastolic pressure, and success of percutaneous coronary intervention (PCI). Result(s): Of 598 consecutive anterior STEMI patients, records and inpatient TTE results were available in 425 patients. The incidence of LVT was 6.8% (n = 29). After multivariate adjustment, severe triple vessel coronary disease (OR = 8.27, CI = 2.97-23.00, p <=0.001), apical akinesis on LVG (OR = 6.74, CI = 1.48-30.73, p = 0.014), wrap-around left anterior descending (LAD) anatomy (OR = 5.10, CI = 1.97-13.23, p = 0.001), and failure of recanalization after PCI (OR = 3.94, CI = 1.06-14.66, p = 0.04) were predictors for LVT formation. The combined negative predictive value (NPV) for the absence of these four indices was 99.2%. Conclusion(s): Severe triple vessel disease, apical akinesis on LVG during index admission, wrap-around LAD, and failure of recanalization after PCI are associated with increased risk of LVT formation after anterior STEMI. The high NPV for the absence of these indices could serve as a risk stratification tool for LVT risk to guide early TTE utilization.Copyright © 2021 Elsevier Inc.

Pulmonary hypertension (PH) is common in infants with severe bronchopulmonary dysplasia (BPD) and increases the risk of death. The objectives of this preliminary study were to compare responses of pulmonary circulation parameters to 100% oxygen (O2) and inhaled nitric oxide (iNO) in infants with BPD and PH using echocardiography. Responses between fetal growth restriction (FGR) and appropriate for gestational age infants were compared. Ten infants <28 weeks GA at birth were assessed at >=36 weeks corrected gestation. Baseline echocardiography1 was performed which was repeated (echocardiography2) after 30 minutes of O2. After a gap of 2-3 hours, iNO was administered for 15 minutes and echocardiography3 was performed, followed by iNO weaning. The gestation and birthweight of the cohort were 25.9 +/- 1.6 weeks and 612 +/- 175 g. Assessments were performed at 38.7 +/- 1.4 weeks corrected gestational age. Baseline time to peak velocity: right ventricular ejection time (TPV/RVETc) increased from 0.24 +/- 0.02 to 0.27 +/- 0.02 (O2, p =.01) and 0.31 +/- 0.03 (iNO, p <.001), indicating a decrease in pulmonary vascular resistance [PVR]. Baseline tricuspid annular plane systolic excursion (TAPSE) increased from 8.1 +/- 0.6 mm to 9.3 +/- 0.7 mm (O2, p =.01) and 10.5 +/- 1.1 mm (iNO, p =.0004), indicating improved ventricular systolic performance. Percentage change for all parameters was greater with iNO. Significant correlations between cardiac performance and PVR were noted. FGR infants noted higher baseline PVR (TPV/RVETc, 0.21 +/- 0.02 vs. 0.25 +/- 0.01, p =.002), lower ventricular performance (TAPSE, 7 +/- 1.2 mm vs. 8.6 +/- 6 mm, p =.003), and lower percentage change with O2 and iNO. A reactive component of pulmonary circulation provides real-time physiological information, which could rationalize treatment decisions.Copyright © 2021 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological S

Background: Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure (mPAP) >=25mmHg at right heart catheterisation (RHC) Liver transplant (LT) society consensus guidelines recommend routine screening for PH with echocardiography in patients undergoing LT assessment, with RHC used to confirm the diagnosis. In severe cases PH remains a contraindication to LT PH can be classified into precapillary or postcapillary at RHC; this differentiation is important in determining etiology and optimal treatment Portopulmonary hypertension (POPH) is a wellrecognised precapillary cause of PH in patients with cirrhosis and portal hypertension, with a prevalence of 2-10% in LT candidates. POPH is defined by mPAP >=25 mmHg, elevated pulmonary vascular resistance (PVR) >3 Woods units (WU) and normal pulmonary artery wedge pressure (PAWP) <15mmHg There is a paucity of literature relating to the prevalence and etiology of PH in LT candidates Methods: Consecutive adult patients completing LT assessment workup in Melbourne, Australia were prospectively included from 2010 to 2017 Patients were screened with transthoracic echocardiography or dobutamine stress echocardiography with routine measurement of estimated pulmonary artery pressure (ePAP). Suspected PH was defined as ePAP >=25 mmHg and patients with ePAP >=37 mmHg proceeded to RHC. Primary outcome was the prevalence of PH and secondary outcome to determine the distribution of pre-and postcapillary PH Results: 569 patients were included Median age was 57 (IQR 50-62), 68% were male and median MELD score was 18 (IQR 12-21) Common indications for LT were Hepatitis C (37%), hepatocellular carcinoma (37%) and alcohol (29%) 246 (43%) patients had suspected PH, of whom 43 (7 6%) proceeded to RHC. 15 (2.6%) patients had confirmed PH with a median mPAP of 34 mmHg (IQR 31 5-38) 12 (80%) patients were classified as mild PH (25-40 mmHg) and 3 (20%) as moderate PH (41-55mmHg) 6 (40%) patients had precapillary PH and met criteria

Left ventricular thrombus (LVT) has a 5% incidence after anterior ST elevation myocardial infarction (aSTEMI) in the primary percutaneous coronary intervention (PCI) era. Numerous risk factors predispose to LVT formation, including history of left ventricular dysfunction and infarct size, however measurable predictors during left heart catheterisation (LHC) have not been determined. We sought to investigate the predictive utility of LHC indices for LVT formation. We performed a dual-centre retrospective analysis of patients presenting between January 2010 and September 2017 with aSTEMI who had inpatient transthoracic echocardiography (TTE). LHC indices that were assessed on index LHC included location of culprit stenosis, presence of focal or diffuse stenosis, number of severely diseased vessels, presence of apical akinesis on left ventriculogram, left ventricular end diastolic pressure (LVEDP), and whether PCI was performed. Analysis was performed using multivariate analysis with results reported as odds ratios (OR) with 95% confidence intervals (CI). Of 514 consecutive aSTEMI patients, TTE results were available in 425 patients. The incidence of LVT was 6.8% (n=29). After multivariate adjustment, severe triple vessel disease (OR=6.82, CI=2.73-17.02, p=<0.001), apical akinesis (OR=4.58, CI=1.31-16.08, p=0.02), and LVEDP >20mmHg (OR=2.88, CI=1.03-8.05, p=0.04) were predictors of LVT formation. Negative predictive values for triple vessel disease, apical akinesis and LVEDP >20mmHg were 95.3%, 97.7%, and 97% respectively. Triple vessel disease, apical akinesis, and LVEDP >20mmHg are associated with increased risk of LVT in patients with aSTEMI. The high NPV for these indices could serve as a stratification tool for LVT risk to guide inpatient TTE utilisation.Copyright © 2020

Background: Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure (mPAP) >=25mmHg at right heart catheterisation (RHC) Liver transplant (LT) society consensus guidelines recommend routine screening for PH with echocardiography in patients undergoing LT assessment, with RHC used to confirm the diagnosis. In severe cases PH remains a contraindication to LT PH can be classified into precapillary or postcapillary at RHC; this differentiation is important in determining etiology and optimal treatment Portopulmonary hypertension (POPH) is a wellrecognised precapillary cause of PH in patients with cirrhosis and portal hypertension, with a prevalence of 2-10% in LT candidates. POPH is defined by mPAP >=25 mmHg, elevated pulmonary vascular resistance (PVR) >3 Woods units (WU) and normal pulmonary artery wedge pressure (PAWP) <15mmHg There is a paucity of literature relating to the prevalence and etiology of PH in LT candidates Methods: Consecutive adult patients completing LT assessment workup in Melbourne, Australia were prospectively included from 2010 to 2017 Patients were screened with transthoracic echocardiography or dobutamine stress echocardiography with routine measurement of estimated pulmonary artery pressure (ePAP). Suspected PH was defined as ePAP >=25 mmHg and patients with ePAP >=37 mmHg proceeded to RHC. Primary outcome was the prevalence of PH and secondary outcome to determine the distribution of pre-and postcapillary PH Results: 569 patients were included Median age was 57 (IQR 50-62), 68% were male and median MELD score was 18 (IQR 12-21) Common indications for LT were Hepatitis C (37%), hepatocellular carcinoma (37%) and alcohol (29%) 246 (43%) patients had suspected PH, of whom 43 (7 6%) proceeded to RHC. 15 (2.6%) patients had confirmed PH with a median mPAP of 34 mmHg (IQR 31 5-38) 12 (80%) patients were classified as mild PH (25-40 mmHg) and 3 (20%) as moderate PH (41-55mmHg) 6 (40%) patients had precapillary PH and met criteria

Left ventricular thrombus (LVT) has a 5% incidence after anterior ST elevation myocardial infarction (aSTEMI) in the primary percutaneous coronary intervention (PCI) era. Numerous risk factors predispose to LVT formation, including history of left ventricular dysfunction and infarct size, however measurable predictors during left heart catheterisation (LHC) have not been determined. We sought to investigate the predictive utility of LHC indices for LVT formation. We performed a dual-centre retrospective analysis of patients presenting between January 2010 and September 2017 with aSTEMI who had inpatient transthoracic echocardiography (TTE). LHC indices that were assessed on index LHC included location of culprit stenosis, presence of focal or diffuse stenosis, number of severely diseased vessels, presence of apical akinesis on left ventriculogram, left ventricular end diastolic pressure (LVEDP), and whether PCI was performed. Analysis was performed using multivariate analysis with results reported as odds ratios (OR) with 95% confidence intervals (CI). Of 514 consecutive aSTEMI patients, TTE results were available in 425 patients. The incidence of LVT was 6.8% (n=29). After multivariate adjustment, severe triple vessel disease (OR=6.82, CI=2.73-17.02, p=<0.001), apical akinesis (OR=4.58, CI=1.31-16.08, p=0.02), and LVEDP >20mmHg (OR=2.88, CI=1.03-8.05, p=0.04) were predictors of LVT formation. Negative predictive values for triple vessel disease, apical akinesis and LVEDP >20mmHg were 95.3%, 97.7%, and 97% respectively. Triple vessel disease, apical akinesis, and LVEDP >20mmHg are associated with increased risk of LVT in patients with aSTEMI. The high NPV for these indices could serve as a stratification tool for LVT risk to guide inpatient TTE utilisation.Copyright © 2020

Background: To quantify the financial cost of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc). Method(s): Healthcare use was captured through data linkage, wherein clinical data for SSc patients enrolled in the Australian Scleroderma Cohort Study were linked with hospital, emergency department (ED) and ambulatory care databases (MBS) for the period 2008-2015. PAH was diagnosed on right heart catheter according to international criteria. Determinants of healthcare cost were estimated using logistic regression. Result(s): Total median (25th-75th) healthcare cost per patient (including hospital, ED and MBS cost but excluding medication cost) for our cohort during 2008-2015 was AUD$37,685 (18,144-78,811) with an annual per patient healthcare cost of AUD$7506 (5273-10,654). Total healthcare cost was higher for SSc-PAH patients compared with those without PAH with a total cost per patient of AUD$70,034 (37,222-110,814) vs AUD$34,325 (16,093 - 69,957), p < 0.001 respectively with an annual excess healthcare cost per PAH patient of AUD$2463 (1973-1885), p < 0.001. The cost of SSc-PAH occurs early post PAH diagnosis with 89.4% utilizing a healthcare service within the first 12 months post PAH diagnosis with an associated cost per patient of AUD$4125 (0-15,666). PAH severity was the main significant determinant of increased healthcare cost (OR 2.5, p = 0.03) in our PAH cohort. Conclusion(s): Despite SSc-PAH being a low prevalence disease, it is associated with significant healthcare resource utilization and associated economic burden, predominantly driven by the severity of PAH.Copyright © 2019 The Author(s).

Background Coronary computed tomography angiography (CCTA) is often avoided in elderly patients due to a presumption that a high proportion of patients will have heavily calcified plaque limiting an accurate assessment. We sought to assess the image quality, luminal stenosis and utility of CCTA in elderly patients with suspected coronary artery disease (CAD) and stable chest pain. Methods Retrospective analysis of elderly patients (> 75 years) who underwent 320-detector row CCTA between 2012-2017 at MonashHeart. The CCTA was analysed for degree maximal coronary stenosis by CAD-RADS classification, image quality by a 5-point Likert score (1-poor, 2-adequate, 3-good, 4-very good, 5-excellent) and presence of artefact limiting interpretability. Results 1011 elderly patients (62% females, 78.8 +/- 3.3 years) were studied. Cardiovascular risk factor prevalence included: hypertension (65%), hyperlipidaemia (48%), diabetes (19%) and smoking (21%). The CCTA was evaluable in 68% of patients which included 52% with non-obstructive CAD (< 50% stenosis), 48% with obstructive CAD (> 50%) stenosis. Mean Likert score was 3.1 +/- 0.6 corresponding to good image quality. Of the 323 (32%) of patients with a non-interpretable CCTA, 80% were due to calcified plaque and 20% due to motion artefact. Male gender (P = 0.009), age (P = 0.02), excess motion (P < 0.01) and diabetes mellitus (P = 0.03) were associated with non-interpretable CCTA. Conclusion Although CCTA is a feasible non-invasive tool for assessment of elderly patients with stable chest pain, clinicians should still be cautious about referring elderly patients for CCTA. Patients who are male, diabetic and >78 years of age are significantly less likely to have interpretable scans.Copyright © 2019 JGC All rights reserved

Background: The incidence of anomalous coronary anatomy is about 1%. The embryonic cause is unknown. Method(s): We searched cardiac catheterisation cases over 5 years (2013-2017) for the words "anomaly", "anomalous", "aberrant", and common spelling mistake variations. For duplicates, only a patient's earliest procedure was included. A cardiologist reviewed the report and angiogram of each potential case to confirm coronary anomaly. We excluded cases of high take-off anterior right coronary origin, separate origin of LAD and circumflex, and coronary artery fistulae, because our methodology was unlikely to detect all such cases. Result(s): The incidence was 0.8% (109 of 14295) including: (1) Circumflex origin from right cusp or as proximal branch of right coronary (n = 61, 56%), (2) Right coronary origin from left cusp (n = 36, 33%), (3) Left coronary origin from right cusp (n = 8, 7.3%), and single cases (n = 1, 0.9%) of (4) single coronary from right cusp, (5) single coronary from left cusp, (6) right, circumflex and LAD coronaries with separate ostia from right cusp, and (7) LAD origin from right cusp. There was no difference between cases and non-cases regarding age, procedure duration, screening time, height, weight or gender. Conclusion(s): 0.8% proportion with coronary anomaly is similar to previous series. The commonest anomaly is circumflex arising from the right cusp or as a branch of the right coronary. Our cohort could be leveraged to perform GWAS or whole genome sequencing to investigate genetic contributions to anomalous coronary anatomy. Genetic studies of this phenotype do not yet appear to have been conducted.Copyright © 2019

Background: To quantify the financial cost of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc). Method(s): Healthcare use was captured through data linkage, wherein clinical data for SSc patients enrolled in the Australian Scleroderma Cohort Study were linked with hospital, emergency department (ED) and ambulatory care databases (MBS) for the period 2008-2015. PAH was diagnosed on right heart catheter according to international criteria. Determinants of healthcare cost were estimated using logistic regression. Result(s): Total median (25th-75th) healthcare cost per patient (including hospital, ED and MBS cost but excluding medication cost) for our cohort during 2008-2015 was AUD$37,685 (18,144-78,811) with an annual per patient healthcare cost of AUD$7506 (5273-10,654). Total healthcare cost was higher for SSc-PAH patients compared with those without PAH with a total cost per patient of AUD$70,034 (37,222-110,814) vs AUD$34,325 (16,093 - 69,957), p < 0.001 respectively with an annual excess healthcare cost per PAH patient of AUD$2463 (1973-1885), p < 0.001. The cost of SSc-PAH occurs early post PAH diagnosis with 89.4% utilizing a healthcare service within the first 12 months post PAH diagnosis with an associated cost per patient of AUD$4125 (0-15,666). PAH severity was the main significant determinant of increased healthcare cost (OR 2.5, p = 0.03) in our PAH cohort. Conclusion(s): Despite SSc-PAH being a low prevalence disease, it is associated with significant healthcare resource utilization and associated economic burden, predominantly driven by the severity of PAH.Copyright © 2019 The Author(s).

Background Coronary computed tomography angiography (CCTA) is often avoided in elderly patients due to a presumption that a high proportion of patients will have heavily calcified plaque limiting an accurate assessment. We sought to assess the image quality, luminal stenosis and utility of CCTA in elderly patients with suspected coronary artery disease (CAD) and stable chest pain. Methods Retrospective analysis of elderly patients (> 75 years) who underwent 320-detector row CCTA between 2012-2017 at MonashHeart. The CCTA was analysed for degree maximal coronary stenosis by CAD-RADS classification, image quality by a 5-point Likert score (1-poor, 2-adequate, 3-good, 4-very good, 5-excellent) and presence of artefact limiting interpretability. Results 1011 elderly patients (62% females, 78.8 +/- 3.3 years) were studied. Cardiovascular risk factor prevalence included: hypertension (65%), hyperlipidaemia (48%), diabetes (19%) and smoking (21%). The CCTA was evaluable in 68% of patients which included 52% with non-obstructive CAD (< 50% stenosis), 48% with obstructive CAD (> 50%) stenosis. Mean Likert score was 3.1 +/- 0.6 corresponding to good image quality. Of the 323 (32%) of patients with a non-interpretable CCTA, 80% were due to calcified plaque and 20% due to motion artefact. Male gender (P = 0.009), age (P = 0.02), excess motion (P < 0.01) and diabetes mellitus (P = 0.03) were associated with non-interpretable CCTA. Conclusion Although CCTA is a feasible non-invasive tool for assessment of elderly patients with stable chest pain, clinicians should still be cautious about referring elderly patients for CCTA. Patients who are male, diabetic and >78 years of age are significantly less likely to have interpretable scans.Copyright © 2019 JGC All rights reserved

Background: The incidence of anomalous coronary anatomy is about 1%. The embryonic cause is unknown. Method(s): We searched cardiac catheterisation cases over 5 years (2013-2017) for the words "anomaly", "anomalous", "aberrant", and common spelling mistake variations. For duplicates, only a patient's earliest procedure was included. A cardiologist reviewed the report and angiogram of each potential case to confirm coronary anomaly. We excluded cases of high take-off anterior right coronary origin, separate origin of LAD and circumflex, and coronary artery fistulae, because our methodology was unlikely to detect all such cases. Result(s): The incidence was 0.8% (109 of 14295) including: (1) Circumflex origin from right cusp or as proximal branch of right coronary (n = 61, 56%), (2) Right coronary origin from left cusp (n = 36, 33%), (3) Left coronary origin from right cusp (n = 8, 7.3%), and single cases (n = 1, 0.9%) of (4) single coronary from right cusp, (5) single coronary from left cusp, (6) right, circumflex and LAD coronaries with separate ostia from right cusp, and (7) LAD origin from right cusp. There was no difference between cases and non-cases regarding age, procedure duration, screening time, height, weight or gender. Conclusion(s): 0.8% proportion with coronary anomaly is similar to previous series. The commonest anomaly is circumflex arising from the right cusp or as a branch of the right coronary. Our cohort could be leveraged to perform GWAS or whole genome sequencing to investigate genetic contributions to anomalous coronary anatomy. Genetic studies of this phenotype do not yet appear to have been conducted.Copyright © 2019

Rationale/Background: Pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) secondary to interstitial lung disease (ILD) are recognized complications of scleroderma, but the possibility of PH being secondary to left heart disease in scleroderma has received relatively little attention. The aim of this study was to identify individuals with scleroderma who had the potential for either a left heart cause or contribution to PH or dyspnea based on an echocardiogram performed for either screening or investigation of symptoms. Methods/Materials: Diastolic function and left atrial (LA) pressure were assessed using American Society of Echocardiography (ASE) 2016 criteria which included consideration of LA volume index (LAVI), transmitral E, E/A, mitral annular tissue Doppler velocity (e'), calculated E/e' , and whether the tricuspid regurgitation (TR) velocity was >2.8 m/s. A LAVI of>34 mL/m2 was assumed to indicate chronic elevation of LA pressure. Elevation of pulmonary artery pressure (PAP) was assumed if the TR velocity was>=3.0 m/s. Right heart catheterization was performed on symptomatic patients in which PAH was suspected. Result(s): There were 194 individuals (30 men; age 58+/-15 years); three had atrial fibrillation, three had pacemakers, and four had a reduced left ventricular ejection fraction (40-50%). LA dilatation (LAVI>34 mL/m2) was present in 88/194 and a LAVI>40 mL/m2 was present in 56/194. Only 100 participants were classed as having normal diastolic function. The TR velocity could not be obtained in 20 individuals and was>=3.0 m/s in 23 participants, of whom ten had a dilated left atrium and 11 met the ASE criteria for elevation of LA pressure. Summary/Conclusions: LA dilatation is a common finding in scleroderma, implying that PH can be secondary to left heart disease in scleroderma and that PAH and PH secondary to ILD could also have a PH component secondary to LA pressure elevation. Furthermore, individuals with LA dilatation but a norm

Background: We aimed to evaluate the construct validity of the Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) in Australian systemic sclerosis (SSc) patients. Method(s): SSc patients, identified through the Australian Scleroderma Cohort Study database, completed two quality-of-life instruments concurrently, the PROMIS-29 and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The construct validity of the PROMIS-29 was assessed by the correlations between the PROMIS-29 and the SF-36 and Health Assessment Questionnaire Disability Index (HAQ-DI). Cronbach's alpha was used to test the internal reliability of all instruments in Australian SSc patients and non-parametric correlation, including Spearman's correlation, was used to test the construct validity of PROMIS-29 against the SF-36 and HAQ-DI. Result(s): A total of 477 completed questionnaires were returned, equating to a response rate of 59.6%. The mean (+/-SD) age of respondents at the time of the survey was 64.1 (+/-11.1) years. They were predominantly female (87.4%), with limited disease subtype (lcSSc) (77.8%) and long disease duration from onset of first non-Raynaud's phenomenon symptom at the time of survey (10.9 +/- 11.1 years). For the correlation analysis between the PROMIS-29 and the legacy instruments, all Spearman correlation coefficients were in the logical direction and highly significant suggesting that the PROMIS-29 is a good alternative to other validated measures of disease burden. Conclusion(s): Our study indicates that the PROMIS-29 questionnaire is a valid instrument for measuring healthrelated quality of life in Australian females with lcSSc of long duration.Copyright © 2017 Wichtig International.

Objective: To inform the design of a pivotal randomized controlled trial of prophylactic intra-aortic balloon counterpulsation (IABC) in patients undergoing coronary artery bypass graft (CABG) at high risk of postoperative low cardiac output syndrome (LCOS). Design(s): Inception cohort study. Setting(s): A total of 13 established cardiac centers in Australia, Canada, New Zealand, and the United Kingdom. Participant(s): Adult patients were eligible for inclusion if they were listed for CABG surgery and had 2 or more LCOS risk factors (low ejection fraction, severe left main coronary artery disease, redo sternotomy, unstable angina). Intervention(s): Outcomes of interest were a composite outcome of in-hospital mortality, postoperative acute myocardial infarction (AMI), acute kidney injury (AKI), or stroke as well as 6-month vital status and quality of life using the EuroQol 5-dimensional questionnaire (EQ5D). Measurements and Main Results: The study included 136 participants over a 29-month period. Overall, in-hospital and 6-month mortality occurred in 7 (5%) and 11 (8%) participants, respectively. The composite outcome occurred in 60 (44%). The mean increase in EQ5D summary index at 6 months was 0.10 (standard deviation 0.24, p = 0.01). Perioperative AMI, AKI, or stroke significantly decreased the odds of a clinically meaningful improvement in quality of life (odds ratio 0.32; 95% confidence interval 0.13-0.79; p = 0.014). Preoperative IABC was used in 39 participants and did not predict postoperative outcomes. Conclusion(s): The study identified a group of patients at risk of LCOS in whom CABG surgery was associated with a substantial burden of perioperative morbidity. Preoperative IABC use was variable, supporting the need for further research.Copyright © 2018 Elsevier Ltd

We present a rare case of polyarteritis nodosa coronary vasculitis with pericardial tamponade and severe ischaemic cardiomyopathy. A 34 year old lady presented with acute chest pain, dyspnoea and syncope. She had no previous medical conditions. She had a systolic blood pressure of 60mmhg on arrival. Examination revealed raised jugular venous pressure and pulsus paradoxus. Electrocardiogram revealed low voltage complexes. Urgent echocardiography showed moderate pericardial effusion (maximal 2 cm apically) with features of pericardial tamponade. Pericardiocentesis drained 250ml which normalised of her vitals. Subsequent echocardiography revealed dilated left ventricle with moderately reduced left ventricular ejection fraction and non-left anterior descending coronary artery territory hypokinesis. Left heart catheterisation revealed all coronary arteries were severely aneurysmal with features of intra-aneurysmal thrombus in the right coronary artery aneurysms. The first obtuse marginal and first diagonal branch had aneurysmal segments followed by chronic total occlusions. Laboratory analysis revealed that the pericardial fluid was exudative but had negative microbiology and cytology screen. Her erythrocyte sendiment rate was elevated at 50mm/hr but a c-reactive protein of 6mg/L and negative autoimmune screen. Subsequent computed tomography angiography confirmed liver and renal artery aneurysms, consistent with polyarteritis nodosa (ANCA-negative). She was treated with intravenous cyclophosphamide and high dose corticosteroids. Her erythrocyte sediment rate subsequently improved. A subcutaneous implantable cardioverter-defibrillator was inserted for primary prevention. Follow-up computed tomography coronary angiogram at 5months revealed persistence of coronary aneurysms and intra-aneurysmal thrombus. At 8 month review her immunosuppressants were successful weaned, her functional status improved with heart failure treatment and repeat echocardiography revealed mildly imp

Introduction: Coronary angiogram, while a powerful diagnostic tool in coronary artery disease, is not without an associated risk from ionising radiation. There are a number of factors that influence the amount of radiation the patient receives during the procedure, some of which are under the control of the operator. One of these is an adjustment of the fluoroscopic pulse rate. This study aims to assess the feasibility of using ultra-low pulse rate (3 pulses per second(pps)) fluoroscopy during routine diagnostic coronary angiogram procedures and the effect it has on fluoroscopy time, diagnostic clarity and radiation dose. Method(s): A retrospective study of three operators each undertaking 50 coronary angiogram procedures was performed. One of the operators used a pulse rate of 3 pps and 6 pps for fluoroscopic screening while the control groups used the standard 10 pps mode utilised at this centre. Result(s): Results demonstrated no reduction of diagnostic clarity, up to a 58% reduction in Dose Area Product and no increase in fluoroscopy time with the 3 pps setting. Conclusion(s): Findings from this pilot study suggest that utilisation of ultra-low pulse rate fluoroscopy in routine transfemoral diagnostic coronary angiography in the catheterisation laboratory is feasible.Copyright © 2018 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology

Introduction: Work disability is a significant consequence of chronic rheumatic disorders, impacting both the society through indirect costs and the individual and their family through loss of income and social activities, and a negative influence on quality of life. We sought to assess employment status, risk factors for unemployment, and the associations of unemployment with patients' health related quality of life (HRQoL). Method(s): Patients enrolled in a SSc longitudinal observational cohort were included. All patients completed an employment questionnaire on enrollment. Clinical manifestations were defined as present if present at the time of enrollment. Pulmonary arterial hypertension (PAH) was diagnosed on right heart catheterization (mPAP >25 and PAWP <15 mmHg). Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of different risk factors with employment. All statistical analysis were performed using STATA 14.0. Result(s): Among 1587 SSc patients, 160 (20%) were unemployed at the time of cohort enrolment. Of these 82.5% were female, 63% had limited disease subtype. Mean (+/- SD) age and disease duration at recruitment from first non-Raynaud's symptom were 51.9 (+/- 10.4) and 11.1 (+/- 10.9) years, respectively. Multivariable regression analysis revealed the presence of digital amputation (OR 3.9, 95% CI 1.7-9.1, p = 0.002) diffuse disease subtype (OR 2.2, 95% CI 1.3-3.5, p-value = 0.002), sicca symptoms (OR 2.7, 95% CI 1.6-4.4, p<0.001), physical job (OR 1.8, 95% CI 1.1-3.1, p = 0.03) and PAH (OR 2.2, 95% CI 1.1-4.5, p = 0.02) to be associated with unemployment. Unemployed patients had consistently poorer HRQoL scores in all domains (physical, emotional and mental health) of the SF-36 form than those who were employed. Conclusion(s): SSc is associated with substantial work disability and poor quality of life. Raising awareness, identifying modifiable risk factors and implementing emp

Background: We aimed to evaluate the construct validity of the Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) in Australian systemic sclerosis (SSc) patients. Method(s): SSc patients, identified through the Australian Scleroderma Cohort Study database, completed two quality-of-life instruments concurrently, the PROMIS-29 and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The construct validity of the PROMIS-29 was assessed by the correlations between the PROMIS-29 and the SF-36 and Health Assessment Questionnaire Disability Index (HAQ-DI). Cronbach's alpha was used to test the internal reliability of all instruments in Australian SSc patients and non-parametric correlation, including Spearman's correlation, was used to test the construct validity of PROMIS-29 against the SF-36 and HAQ-DI. Result(s): A total of 477 completed questionnaires were returned, equating to a response rate of 59.6%. The mean (+/-SD) age of respondents at the time of the survey was 64.1 (+/-11.1) years. They were predominantly female (87.4%), with limited disease subtype (lcSSc) (77.8%) and long disease duration from onset of first non-Raynaud's phenomenon symptom at the time of survey (10.9 +/- 11.1 years). For the correlation analysis between the PROMIS-29 and the legacy instruments, all Spearman correlation coefficients were in the logical direction and highly significant suggesting that the PROMIS-29 is a good alternative to other validated measures of disease burden. Conclusion(s): Our study indicates that the PROMIS-29 questionnaire is a valid instrument for measuring healthrelated quality of life in Australian females with lcSSc of long duration.Copyright © 2017 Wichtig International.

Rationale/Background: Pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) secondary to interstitial lung disease (ILD) are recognized complications of scleroderma, but the possibility of PH being secondary to left heart disease in scleroderma has received relatively little attention. The aim of this study was to identify individuals with scleroderma who had the potential for either a left heart cause or contribution to PH or dyspnea based on an echocardiogram performed for either screening or investigation of symptoms. Methods/Materials: Diastolic function and left atrial (LA) pressure were assessed using American Society of Echocardiography (ASE) 2016 criteria which included consideration of LA volume index (LAVI), transmitral E, E/A, mitral annular tissue Doppler velocity (e'), calculated E/e' , and whether the tricuspid regurgitation (TR) velocity was >2.8 m/s. A LAVI of>34 mL/m2 was assumed to indicate chronic elevation of LA pressure. Elevation of pulmonary artery pressure (PAP) was assumed if the TR velocity was>=3.0 m/s. Right heart catheterization was performed on symptomatic patients in which PAH was suspected. Result(s): There were 194 individuals (30 men; age 58+/-15 years); three had atrial fibrillation, three had pacemakers, and four had a reduced left ventricular ejection fraction (40-50%). LA dilatation (LAVI>34 mL/m2) was present in 88/194 and a LAVI>40 mL/m2 was present in 56/194. Only 100 participants were classed as having normal diastolic function. The TR velocity could not be obtained in 20 individuals and was>=3.0 m/s in 23 participants, of whom ten had a dilated left atrium and 11 met the ASE criteria for elevation of LA pressure. Summary/Conclusions: LA dilatation is a common finding in scleroderma, implying that PH can be secondary to left heart disease in scleroderma and that PAH and PH secondary to ILD could also have a PH component secondary to LA pressure elevation. Furthermore, individuals with LA dilatation but a norm

We present a rare case of polyarteritis nodosa coronary vasculitis with pericardial tamponade and severe ischaemic cardiomyopathy. A 34 year old lady presented with acute chest pain, dyspnoea and syncope. She had no previous medical conditions. She had a systolic blood pressure of 60mmhg on arrival. Examination revealed raised jugular venous pressure and pulsus paradoxus. Electrocardiogram revealed low voltage complexes. Urgent echocardiography showed moderate pericardial effusion (maximal 2 cm apically) with features of pericardial tamponade. Pericardiocentesis drained 250ml which normalised of her vitals. Subsequent echocardiography revealed dilated left ventricle with moderately reduced left ventricular ejection fraction and non-left anterior descending coronary artery territory hypokinesis. Left heart catheterisation revealed all coronary arteries were severely aneurysmal with features of intra-aneurysmal thrombus in the right coronary artery aneurysms. The first obtuse marginal and first diagonal branch had aneurysmal segments followed by chronic total occlusions. Laboratory analysis revealed that the pericardial fluid was exudative but had negative microbiology and cytology screen. Her erythrocyte sendiment rate was elevated at 50mm/hr but a c-reactive protein of 6mg/L and negative autoimmune screen. Subsequent computed tomography angiography confirmed liver and renal artery aneurysms, consistent with polyarteritis nodosa (ANCA-negative). She was treated with intravenous cyclophosphamide and high dose corticosteroids. Her erythrocyte sediment rate subsequently improved. A subcutaneous implantable cardioverter-defibrillator was inserted for primary prevention. Follow-up computed tomography coronary angiogram at 5months revealed persistence of coronary aneurysms and intra-aneurysmal thrombus. At 8 month review her immunosuppressants were successful weaned, her functional status improved with heart failure treatment and repeat echocardiography revealed mildly imp

Objective: To inform the design of a pivotal randomized controlled trial of prophylactic intra-aortic balloon counterpulsation (IABC) in patients undergoing coronary artery bypass graft (CABG) at high risk of postoperative low cardiac output syndrome (LCOS). Design(s): Inception cohort study. Setting(s): A total of 13 established cardiac centers in Australia, Canada, New Zealand, and the United Kingdom. Participant(s): Adult patients were eligible for inclusion if they were listed for CABG surgery and had 2 or more LCOS risk factors (low ejection fraction, severe left main coronary artery disease, redo sternotomy, unstable angina). Intervention(s): Outcomes of interest were a composite outcome of in-hospital mortality, postoperative acute myocardial infarction (AMI), acute kidney injury (AKI), or stroke as well as 6-month vital status and quality of life using the EuroQol 5-dimensional questionnaire (EQ5D). Measurements and Main Results: The study included 136 participants over a 29-month period. Overall, in-hospital and 6-month mortality occurred in 7 (5%) and 11 (8%) participants, respectively. The composite outcome occurred in 60 (44%). The mean increase in EQ5D summary index at 6 months was 0.10 (standard deviation 0.24, p = 0.01). Perioperative AMI, AKI, or stroke significantly decreased the odds of a clinically meaningful improvement in quality of life (odds ratio 0.32; 95% confidence interval 0.13-0.79; p = 0.014). Preoperative IABC was used in 39 participants and did not predict postoperative outcomes. Conclusion(s): The study identified a group of patients at risk of LCOS in whom CABG surgery was associated with a substantial burden of perioperative morbidity. Preoperative IABC use was variable, supporting the need for further research.Copyright © 2018 Elsevier Ltd

Introduction: Work disability is a significant consequence of chronic rheumatic disorders, impacting both the society through indirect costs and the individual and their family through loss of income and social activities, and a negative influence on quality of life. We sought to assess employment status, risk factors for unemployment, and the associations of unemployment with patients' health related quality of life (HRQoL). Method(s): Patients enrolled in a SSc longitudinal observational cohort were included. All patients completed an employment questionnaire on enrollment. Clinical manifestations were defined as present if present at the time of enrollment. Pulmonary arterial hypertension (PAH) was diagnosed on right heart catheterization (mPAP >25 and PAWP <15 mmHg). Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of different risk factors with employment. All statistical analysis were performed using STATA 14.0. Result(s): Among 1587 SSc patients, 160 (20%) were unemployed at the time of cohort enrolment. Of these 82.5% were female, 63% had limited disease subtype. Mean (+/- SD) age and disease duration at recruitment from first non-Raynaud's symptom were 51.9 (+/- 10.4) and 11.1 (+/- 10.9) years, respectively. Multivariable regression analysis revealed the presence of digital amputation (OR 3.9, 95% CI 1.7-9.1, p = 0.002) diffuse disease subtype (OR 2.2, 95% CI 1.3-3.5, p-value = 0.002), sicca symptoms (OR 2.7, 95% CI 1.6-4.4, p<0.001), physical job (OR 1.8, 95% CI 1.1-3.1, p = 0.03) and PAH (OR 2.2, 95% CI 1.1-4.5, p = 0.02) to be associated with unemployment. Unemployed patients had consistently poorer HRQoL scores in all domains (physical, emotional and mental health) of the SF-36 form than those who were employed. Conclusion(s): SSc is associated with substantial work disability and poor quality of life. Raising awareness, identifying modifiable risk factors and implementing emp

Introduction: Coronary angiogram, while a powerful diagnostic tool in coronary artery disease, is not without an associated risk from ionising radiation. There are a number of factors that influence the amount of radiation the patient receives during the procedure, some of which are under the control of the operator. One of these is an adjustment of the fluoroscopic pulse rate. This study aims to assess the feasibility of using ultra-low pulse rate (3 pulses per second(pps)) fluoroscopy during routine diagnostic coronary angiogram procedures and the effect it has on fluoroscopy time, diagnostic clarity and radiation dose. Method(s): A retrospective study of three operators each undertaking 50 coronary angiogram procedures was performed. One of the operators used a pulse rate of 3 pps and 6 pps for fluoroscopic screening while the control groups used the standard 10 pps mode utilised at this centre. Result(s): Results demonstrated no reduction of diagnostic clarity, up to a 58% reduction in Dose Area Product and no increase in fluoroscopy time with the 3 pps setting. Conclusion(s): Findings from this pilot study suggest that utilisation of ultra-low pulse rate fluoroscopy in routine transfemoral diagnostic coronary angiography in the catheterisation laboratory is feasible.Copyright © 2018 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology

Right heart catheterization (RHC) is the gold standard for the diagnosis and classification of pulmonary hypertension. Significant expertise is required for safely performing a full RHC and for the acquisition of reliable and reproducible information. Physicians performing an RHC should have adequate training not only in vascular access, catheter insertion, and manipulation but also in the interpretation of waveforms, potential pitfalls, and strict quality control. This article describes the essential technical aspects of RHC as applied to the pulmonary circulation, the potential pitfalls, and areas of major controversy., SCOPUS: re.j, info:eu-repo/semantics/published

We report two patients with relapsing remitting multiple sclerosis (RRMS) on interferon (IFN) beta-1a treatment for more than 7 years who developed pulmonary arterial hypertension (PAH). Patient 1 developed severe PAH requiring lung transplantation. Histology showed typical proliferative lesions including plexiform lesions consistent with PAH. Patient 2 ceased IFN beta-1a, and their symptoms stabilised. Both cases highlight IFN beta-1a treatment as a potential risk factor for PAH. PAH needs to be considered as a diagnosis in patients on long-term IFN beta-1a treatment who develop new-onset respiratory symptoms.Copyright © The Author(s), 2015.

Introduction/Aim: Pulmonary hypertension (PH) in COPD is associated with increased disability and reduced survival. Detection of PH in COPD is challenging due to limitations of echocardiography and potential risks associated with right heart catheterization (RHC). The main pulmonary arteries (PA) become progressively less distensible in PH. Previous studies have shown PA distensibility to correlate well with measured mPAP at RHC. We assessed relationships between PA distensibility, cardiac function and emphysema index measured using dynamic ECGgated MDCT. Method(s): 34 patients with stable COPD (mean[SD] age 65.8[9.7], FEV1% 43.9[22.5], 18 male) underwent dynamic retrospective ECGgated MDCT. Emphysema was quantified by CT densitometry based upon a density threshold of <-950 Hounsfield Units (HU). The main pulmonary artery cross-sectional area (CSA) was measured at 10% intervals from 0-90% of the R-R interval. PA distensibility (%) was calculated as ((maximum CSA-minimum CSA)/minimum CSA) x 100. Cardiac function parameters were assessed using semi-automated software with manual correction if required. The relationship of PA distensibility with both emphysema index and right ventricular ejection fraction (RVEF) was tested via Pearson's r. Result(s): Mean[SD] PA distensibility was low (16.5[5.9]%). PA distensibility was significantly negatively correlated with emphysema index (r=-0.365, p = 0.031) and positively correlated with reduced RVEF (r=0.483, p=0.0025). Conclusion(s): Dynamic MDCT permits simultaneous evaluation of emphysema, PA pressure and right ventricular performance. Increased severity of emphysema appears associated with reduced PA distensibility. Impaired PA distensibility appears associated with decreased RVEF. Dynamic MDCT provides a valuable tool for assessment of heart-lung interaction in COPD.

A 79-year-old man with stable chronic obstructive pulmonary disease was found to have an abdominal aortic aneurysm and worsening dyspnoea. Echocardiography demonstrated critical aortic stenosis. Simultaneous endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR) was recommended due to high surgical risk. Procedural strategy was to perform balloon valvuloplasty (BAV), followed by EVAR then TAVR. The initial 25 mm Lotus valve adopted a barrel shape suggestive of an undersized valve and was thus replaced with a 27 mm valve. Post procedural echo revealed no regurgitation. We report here for the first time a successful simultaneous TAVR/EVAR using the fully retrievable Lotus Valve.Copyright © 2016, Japanese Association of Cardiovascular Intervention and Therapeutics.

Bronchopulmonary dysplasia (BPD) and BPD-associated pulmonary hypertension (BPD-PH) are chronic inflammatory cardiopulmonary diseases with devastating short- and long-term consequences for infants born prematurely. The immature lungs of preterm infants are ill-prepared to achieve sufficient gas exchange, thus usually necessitating immediate commencement of respiratory support and oxygen supplementation. These therapies are life-saving, but they exacerbate the tissue damage that is inevitably inflicted on a preterm lung forced to perform gas exchange. Together, air-breathing and necessary therapeutic interventions disrupt normal lung development by aggravating pulmonary inflammation and vascular remodelling, thus frequently precipitating BPD and PH via an incompletely understood pathogenic cascade. BPD and BPD-PH share common risk factors, such as low gestational age at birth, fetal growth restriction and perinatal maternal inflammation; however, these risk factors are not unique to BPD or BPD-PH. Occurring in 17-24% of BPD patients, BPD-PH substantially worsens the morbidity and mortality attributable to BPD alone, thus darkening their outlook; for example, BPD-PH entails a mortality of up to 50%. The absence of a safe and effective therapy for BPD and BPD-PH renders neonatal cardiopulmonary disease an area of urgent unmet medical need. Besides the need to develop new therapeutic strategies, a major challenge for clinicians is the lack of a reliable method for identifying babies at risk of developing BPD and BPD-PH. In addition to discussing current knowledge on pathophysiology, diagnosis and treatment of BPD-PH, we highlight emerging biomarkers that could enable clinicians to predict disease-risk and also optimise treatment of BPD-PH in our tiniest patients.Copyright © 2017 Hudson Institute of Medical Research

Background: Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc). Annual screening with echocardiogram (ECHO) is recommended. We present the methodological aspects of a PAH screening programme in a large Australian SSc cohort, the epidemiology of SSc-PAH in this cohort, and an evaluation of factors influencing physician adherence to PAH screening guidelines. Method(s): Patient characteristics and results of PAH screening were determined in all patients enrolled in a SSc longitudinal cohort study. Adherence to PAH screening guidelines was assessed by a survey of Australian rheumatologists. Summary statistics, chi-square tests, univariate and multivariable logistic regression were used to determine the associations of risk factors with PAH. Result(s): Among 1636 patients with SSc, 194 (11.9%) had PAH proven by right-heart catheter. Of these, 160 were detected by screening. The annual incidence of PAH was 1.4%. Patients with PAH diagnosed on subsequent screens, compared with patients in whom PAH was diagnosed on first screen, were more likely to have diffuse SSc (p = 0.03), be in a better World Health Organisation (WHO) Functional Class at PAH diagnosis (p = 0.01) and have less advanced PAH evidenced by higher mean six-minute walk distance (p = 0.03), lower mean pulmonary arterial pressure (p = 0.009), lower mean pulmonary vascular resistance (p = 0.006) and fewer non-trivial pericardial effusions (p = 0.03). Adherence to annual PAH screening using an ECHO-based algorithm was poor among Australian rheumatologists, with less than half screening their patients with SSc of more than ten years disease duration. Conclusion(s): PAH is a common complication of SSc. Physician adherence to PAH screening recommendations remains poor. Identifying modifiable barriers to screening may improve adherence and ultimately patient outcomes.Copyright © 2017 The Author(s).