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Background and Aims: The optimal revascularization strategy in patients with ischaemic cardiomyopathy remains unclear with no contemporary randomized trial data to guide clinical practice. This study aims to assess long-term survival in patients with severe ischaemic cardiomyopathy revascularized by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)., Methods: Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group registries (from January 2005 to 2018), patients with severe ischaemic cardiomyopathy [left ventricular ejection fraction (LVEF) <35%] undergoing PCI or isolated CABG were included in the analysis. Those with ST-elevation myocardial infarction and cardiogenic shock were excluded. The primary outcome was long-term National Death Index-linked mortality up to 10 years following revascularization. Risk adjustment was performed to estimate the average treatment effect using propensity score analysis with inverse probability of treatment weighting (IPTW)., Results: A total of 2042 patients were included, of whom 1451 patients were treated by CABG and 591 by PCI. Inverse probability of treatment weighting-adjusted demographics, procedural indication, coronary artery disease extent, and LVEF were well balanced between the two patient groups. After risk adjustment, patients treated by CABG compared with those treated by PCI experienced reduced long-term mortality [adjusted hazard ratio 0.59, 95% confidence interval (CI) 0.45-0.79, P = .001] over a median follow-up period of 4.0 (inter-quartile range 2.2-6.8) years. There was no difference between the groups in terms of in-hospital mortality [adjusted odds ratio (aOR) 1.42, 95% CI 0.41-4.96, P = .58], but there was an increased risk of peri-procedural stroke (aOR 19.6, 95% CI 4.21-91.6, P < .001) and increased length of hospital stay (exponentiated coefficient 3.58, 95% CI 3.00-4.28, P < .001) in patients treated with CABG., Conclusions: In this multi-centre IPTW analysis, patients with severe ischaemic cardiomyopathy undergoing revascularization by CABG rather than PCI showed improved long-term survival. However, future randomized controlled trials are needed to confirm the effect of any such benefits., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Cardio-cutaneous fistula is a very rare complication of cardiac surgery, and the optimal management strategy is unclear. We present a case of a right ventricle-to-pulmonary artery conduit (RV-PA) forming a cutaneous fistulate that was successfully surgically repaired. A 43-year-old male presented for an elective RV-PA conduit replacement with a cutaneous skin lesion and associated sub-sternal collection. The patient underwent redo-sternotomy for the previous surgical replacement RV-PA conduit, of pulmonary atresia, ventricular septal defect, and ligation of main aorto-pulmonary collateral arteries in childhood, with the subsequent upgrade of the RV-PA conduit using pulmonary homograft. Upon entry into the thoracic cavity, it was clear that there was a direct fistula formed from the RV-PA conduit that was responsible for the skin lesion and hence a direct communication to the PA. We discuss the surgical method and surrounding discussions regarding Cardio-cutaneous fistula in a successful surgical repair when the pathology is difficult to truly identify preoperatively., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to investigate the long-term outcomes following right ventricle-to-pulmonary artery (RV-to-PA) conduit insertion of Medtronic Freestyle® porcine valve (MFV) or pulmonary allograft valve (PAV) in adult patients with congenital heart disease., Methods: Retrospective medical record review of consecutive RV-to-PA conduit insertion, using either PAV or MFV from 1991 to 2017. Perioperative data and clinic reports were collected. Cause and date of death were obtained from the Australian National Death Index to obtain survival function., Results: In total, 232 patients (median age 31.5 years, interquartile range 25-41 years) underwent RV-to-PA conduit insertion (PAV = 84 and MFV = 148) and were eligible for inclusion [63.8% tetralogy of Fallot (TOF); 11.6% congenital pulmonary stenosis (PS); 24.6% other diagnoses]. The overall median follow-up time was 9.1 years (interquartile range 5.3-12.6 years). The mean gradient was 11.8 ± 7.1 mmHg in PAV and 16.6 ± 9.6 mmHg in MFV patients. Congenital PS patients had 100% survival at 20 years, TOF patients at 5, 10, 15 and 20 years had 99%, 97%, 96% and 96% survival, respectively. Patients with other primary diagnoses at 5, 10, 15 and 20 years had 93%, 91%, 87% and 87% respectively. Freedom from reintervention did not differ significantly at 5 and 10 years between pulmonary allograft (98.6%, 98.6%) and Freestyle® porcine bioprosthesis (97.5%, 93%)., Conclusions: Both valves perform equally well with regard to patients' freedom from reoperation, although transvalvular gradient was higher for Freestyle® patients. Congenital PS and TOF patients had better survival than patients with other primary diagnoses., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The Ross procedure has demonstrated excellent results when performed in patients with aortic stenosis or mixed aortic valve disease [aortic stenosis and aortic regurgitation (AR)]. However, due to its reported risk of late reoperation, it is not recommended under current guidelines for patients presenting with bicuspid aortic valve and pure AR. We have analysed our own results in light of this recommendation., Methods: Between 1993 and 2016, 129 consecutive patients with a mean age of 34.7 ± 10.6 years (range 16-64 years) presented with bicuspid aortic valve and pure AR and underwent the Ross procedure. Patients were reviewed annually and had 2nd yearly transthoracic echocardiograms during follow-up. The unit had a liberal reoperation policy where reoperation was performed if patients developed recurrent moderate or greater AR during follow-up., Results: There was 1 inpatient death, and 3 late deaths over a mean follow-up duration of 9.6 ± 6.8 years. Late survival at 10 and 20 years post-surgery were 99% [95% confidence interval (CI) 94-100] and 95% (95% CI 85-99), respectively. Eleven patients underwent redo aortic valve replacement (AVR) and 4 patients had redo pulmonary valve replacement. Freedom from reoperation for AVR and more-than-mild AR at 10 and 20 years post-surgery were 89% (95% CI 81-94) and 85% (95% CI 74-92), respectively. Having longer aortic cross-clamp (hazard ratio 1.03, 95% CI 1.00-1.06; P = 0.05) and cardiopulmonary bypass times (hazard ratio 1.02, 95% CI 1.00-1.05; P = 0.05), and having a larger preoperative sinotubular junction diameter (hazard ratio 1.15, 95% CI 1.03-1.30; P = 0.02) were significant predictors of having redo AVR or significant AR at follow-up., Conclusions: With a 20-year freedom from redo AVR and greater-than-mild residual AR of 85%, the utilization of the Ross procedure in bicuspid aortic valve patients with pure AR should be considered.

The purpose of this study is to describe the Australian experience with TSPV in the aortic position in 543 patients followed for up to 8 years. Prospectively collected data were reviewed. The average age was 73.5 years, with 74.4% older than 70 years. Eighty-five percent of valves were calcified and 79.5% stenotic. Most valves implanted (79.3%) were sizes 25, 27, or 29 mm. Concomitant coronary bypass was performed in 45.3% of patients. Total cumulative follow-up for the 543 patients was 2131 patient years. At 6 years, 82.1% and at 8 years, 76.3% were in New York Heart Association class I, 55% had no aortic insufficiency. The average mean systolic gradient for all valves at 6 years was 7.4 mmHg. The effective orifice area varied from 1.7 cm(2) (23-mm valve) to 1.96 cm(2) (29-mm valve). Actuarial survival at 8 years was 79.3%. Freedom from valve-related deaths was 93.2%. There was one instance of primary tissue valve failure during follow-up, with 93.3% freedom from explant. The early hemodynamic benefits of the TSPV are well maintained during more than 8 years of follow-up, without evident significant valvular dysfunction. Longer follow-up time is required to validate durability.

Objective: There is an important role for accurate risk prediction models in current cardiac surgical practice. Such models enable benchmarking and allow surgeons and institutions to compare outcomes in a meaningful way. They can also be useful in the areas of surgical decision-making, preoperative informed consent, quality assurance and healthcare management. The aim of this study was to assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model on the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) patient database., Methods: The additive and logistic EuroSCORE models were applied to all patients undergoing cardiac surgery at six institutions in the state of Victoria between 1st July 2001 and 4th July 2005 within the ASCTS database who have complete data. The entire cohort and a subgroup of patients undergoing coronary artery bypass grafting (CABG) only were analysed. Observed and predicted mortalities were compared. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. Model calibration was tested by the Hosmer-Lemeshow chi-square test., Results: Eight thousand three hundred and thirty-one patients with complete data were analysed. There were significant differences in the prevalence of risk factors between the ASCTS and European cardiac surgical populations. Observed mortality was 3.20% overall and 2.00% for the CABG only group. The EuroSCORE models over estimated mortality (entire cohort: additive predicted 5.31%, logistic predicted 8.76%; CABG only: additive predicted 4.25%, logistic predicted 6.19%). Discriminative power of both models was very good. Area under ROC curve was 0.83 overall and 0.82 for the CABG only group. Calibration of both models was poor as mortality was over predicted at nearly all risk deciles. Hosmer-Lemeshow chi-square test returned P-values less than 0.05., Conclusions: The additive and logistic EuroSCORE does not accurately predict outcomes in this group of cardiac surgery patients from six Australian institutions. Hence, the use of the EuroSCORE models for risk prediction may not be appropriate in Australia. A model, which accurately predicts outcomes in Australian cardiac surgical patients, is required.