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Objectives: The aim of the study was to evaluate mortality and morbidity outcomes following open-heart isolated tricuspid valve surgery (TVSx) with medium to long-term follow-up., Design: Retrospective cohort study., Setting: New South Wales public and private hospital admissions between 1 January 2002 and 30 June 2018., Participants: A total of 537 patients underwent open isolated TVSx during the study period., Primary and Secondary Outcome Measures: Primary outcome was all-cause mortality tracked from the death registry to 31 December 2018. Secondary morbidity outcomes, including admission for congestive cardiac failure (CCF), new atrial fibrillation (AF), infective endocarditis (IE), pulmonary embolism (PE) and insertion of a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD), were tracked from the Admitted Patient Data Collection database. Independent mortality associations were determined using the Cox regression method., Results: A total of 537 patients underwent open isolated TVSx (46% male): median age (IQR) was 63.5 years (43.9-73.8 years) with median length of stay of 16 days (10-31 days). Main cardiovascular comorbidities were AF (54%) and CCF (42%); 67% had rheumatic tricuspid valve. In-hospital and total mortality were 7.4% and 39.3%, respectively (mean follow-up: 4.8 years). Cause-specific deaths were evenly split between cardiovascular and non-cardiovascular causes. Predictors of mortality included a history of CCF (HR=1.78, 95% CI 1.33 to 2.38, p<0.001) and chronic pulmonary disease (HR=2.66, 95% CI 1.63 to 4.33, p<0.001). In-hospital PPM rate was 10.0%. At 180 days, 53 (9.9%) patients were admitted for CCF, 25 (10.1%) had new AF, 7 (1.5%) had new IE and <1% had PE, post-discharge PPM or ICD insertion., Conclusion: Open isolated TVSx carries significant mortality risk, with decompensated CCF and new AF the most common morbidities encountered after surgery. This report forms a benchmark to compare outcomes with newer percutaneous tricuspid interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background:  Contemporary Australian epidemiological data on acute pulmonary embolism (PE) are lacking., Objectives:  To determine the admission rates of acute PE in Australia, and to assess the temporal trends in short- and medium-term mortality following acute PE., Methods:  Retrospective population-linkage study of all New South Wales residents admitted with a primary diagnosis of PE between January 1, 2002 and December 31, 2018 using data from the Centre for Health Record Linkage databases. Main outcome measures included temporal trends in total PE admissions and all-cause mortality at prespecified time points up to 1 year, stratified by gender., Results:  There were 61,607 total PE admissions between 2002 and 2018 (mean ± standard deviation: 3,624 ± 429 admissions per annum; 50.42 ± 3.70 admissions per 100,000 persons per annum). The mean admission rate per annum was higher for females than for males (54.85 ± 3.65 vs. 44.91 ± 4.34 admissions per 100,000 persons per annum, respectively) and remained relatively stable for both genders throughout the study period. The main study cohort, limited to index PE admission only, comprised 46,382 persons (mean age: 64.6 ± 17.3 years; 44.4% males). The cumulative in-hospital, 30-day, 3-month, and 1-year mortality rates were 3.7, 5.6, 9.6, and 16.8%, respectively. When compared with 2002 as the reference year, there was a significant reduction in in-hospital (odds ratio [OR] = 0.34; 95% confidence interval [CI] = 0.25-0.46), 30-day (OR = 0.58, 95% CI = 0.46-0.73), and 1-year (hazard ratio = 0.74, 95% CI = 0.66-0.84) (all p  < 0.001) mortality risk by 2017 after adjusting for age, gender, and relevant confounders. The survival improvements were seen in both genders and were greater for females than for males., Conclusion:  Mortality following PE has improved with reductions observed in both short- and medium-term follow-ups between 2002 and 2018 with greater reductions in females despite their higher admission rates over time., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Aortic valve surgery (AVS) is the gold standard treatment for symptomatic aortic valve (AV) disease patients. We report the temporal trends in the incidence of patients requiring isolated AVS in an unselected statewide population and their mortality outcomes over 17-years., Methods: Patients were identified from the New South Wales, Australia, Admitted-Patient-Data-Collection registry between 1-July-2001 and 31-December-2018. Annual case-volumes and survival outcomes, adjusted for age, sex, referral source, endocarditis, concomitant coronary-artery-bypass-grafting, comorbidities including atrial fibrillation, hypertension and Charlson comorbidity index, were compared across calendar years., Results: The study cohort comprised 16436 patients who underwent isolated AVS (mean age: 72.2 ± 11.3y; 67.5% males). Annual case-volume increased from 768 to 1048 cases between 2002 and 2017 (r 2  = 0.82; p < 0.0001). Surgical AV replacement (SAVR) with mechanical valves declined from 271 to 104 (r 2  = 0.87; p < 0.0001) between 2002 and 2017. In contrast, bioprosthetic SAVR increased from 342 to 729 cases (r 2  = 0.93; p < 0.0001). The 30-day, 6-month, and 1-year mortality rates improved progressively from 4.39%, 7.72%, and 9.19% in 2002, to 1.89%, 3.49%, and 4.68% by 2017. The adjusted odds ratio for 30-day mortality and hazard ratio for 1-year mortality were 0.33 (95% confidence interval [CI] 0.16-0.69, p < 0.01) and 0.09 (95% CI 0.07-0.12, p < 0.01), respectively. Similar improvements in outcomes were observed after implantation of mechanical or bioprosthetic aortic valves. Heart failure and sepsis were the most common cardiovascular-related and noncardiovascular-related causes death., Conclusion: The volume of AVS has increased progressively over time and has been associated with increased use of bioprosthetic valves and markedly improved 30-day and 1-year survival., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Right atrial (RA) and right ventricular (RV) parameters assessed by traditional echocardiography lack sensitivity to identify pulmonary embolism (PE). We sought to determine if alterations in RV free wall longitudinal strain (FWS) would be present in PE patients and improve evaluation. This retrospective study comprised of 84 consecutive PE patients from 2 centres, with adequate transthoracic echocardiography (TTE) images for RV FWS analysis. PE patients were compared to 66 healthy controls. Compared to controls, PE patients had increased RV parasternal long-axis diameter (RVPLAX) (33.4 ± 5.8 mm vs 39.9 ± 4.1 mm) and RA area (17.4 ± 5.6 cm 2 vs 14.5 ± 3.1 cm 2 ) (p < 0.001 for both). RV function was reduced in PE patients (RV fractional area change 31.1 ± 13.2% vs 41.7 ± 9.1%, TAPSE 17.0 ± 4.5 vs 21.3 ± 2.2 mm; p < 0.001 for both). RV FWS was reduced in PE patients (-14.4 ± 7.2% vs - 26.0 ± 4.4%, p < 0.001). RV FWS was the best discriminator for PE (AUC 0.912). In comparative multiple logistic regression models for PE, the model which included traditional measures of RV size and function and RV FWS, produced a powerful classifier (AUC 0.966, SE 0.013) with significantly better performance (p < 0.022) than the model without RV FWS (AUC 0.921, SE 0.024). RV FWS is a discriminator of PE patients; addition of RV FWS to existing parameters of RV size and function, significantly improves sensitivity and specificity for diagnosis of PE, and may play a role in diagnosis and guiding therapy. Validation in other PE groups is required to confirm these observations and its prognostic value needs evaluation.

Background: Temporary-transvenous-cardiac-pacing (TTCP) is a potentially lifesaving procedure, however trends in its utilization and outcomes in unselected contemporary populations are all unknown., Methods: Consecutive patients requiring TTCP between July-1, 2000 and December-31, 2013 were identified from a statewide registry of admitted patients. In addition, all patients who underwent other cardiac procedures including permanent-pacemaker (PPM) implantation, automated-implantable-cardiac-defibrillator (AICD) implantation, percutaneous-coronary-intervention (PCI), or coronary-artery-bypass-graft (CABG) surgery were identified for comparative outcome analyses. Survival was tracked from a statewide death registry., Results: A total of 4838 patients (mean age [±standard deviation] 74.7 ± 12.7 years; 58.0% males) requiring TTCP were identified. The incidence for TTCP was 5.86 ± 1.06 cases per-100,000-persons-per-annum, declining by 46% between 2003 and 2013. During 4.2 ± 3.7 years of follow-up, 2594 (53.6%) patients died, of whom 569 (11.8%) died during the index admission. Weekend admission was associated with increased mortality compared to weekdays (hazard ratio: 1.15, 95% confidence interval [CI] 1.06-1.26, p = 0.002) and independently predicted all-cause death. After adjusting for age, gender, comorbidities, and referral source for admission, patients requiring TTCP had worse survival than those undergoing PPM (n = 17,988) or AICD (n = 5264) implantation, PCI (n = 46,859), or CABG surgery (n = 50,992) (adjusted hazard ratio [aHR]: 2.14, 95% CI 1.94-2.37; aHR: 1.61, 95% CI 1.41-1.83; aHR: 1.76, 95% CI 1.61-1.93; aHR: 2.09, 95% CI 1.98-2.21 respectively, all p < 0.001)., Conclusion: TTCP utilization is decreasing and is associated with substantial in-hospital and long-term mortality with weekend-weekday variation in outcome. Further studies are needed to develop strategies to better understand the determinants of adverse outcomes of these patients, as well as appropriate strategies for outcome improvement., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Long-term studies following acute pulmonary embolism (PE) remain limited in the current era. A recent study from our collaborative group, in a contemporary adult population, showed substantially increased cardiovascular mortality following PE. We sought to evaluate the contribution of cardiovascular mortality to long-term outcomes in a different demographic that comprised of a significantly younger PE cohort., Methods and Results: Demographic and clinical characteristics were retrospectively collected for this cohort, and similar methods and outcome measures were applied as detailed in the original study. We compared a population from a different metropolitan area (LH: Liverpool Hospital) to that from the original study (CRGH: Concord Hospital) over a similar time period. A total of 815 patients comprised this cohort with mean 5.3±3.8year follow-up. There were similar demographics between the two cohorts, though the mean age was significantly younger in LH group (60 vs 68years, p<0.001). Prior history of cardiovascular disease in the LH group was half of that present in the CRGH cohort. The overall mortality was 7.4% per patient-year. Patients with underlying cardiovascular disease when presenting with an acute PE had a 2.3-fold increased risk of death during follow-up compared to those without. Multivariate analysis showed that older age, male gender, malignancy, diabetes, cardiovascular disease and chronic pulmonary disease were independent predictors of post-discharge mortality., Conclusions: Despite our cohort being significantly younger with a lower incidence of pre-existing cardiovascular disease, cardiovascular disease was still a significant contributor to long-term outcomes and an important predictor of mortality following acute PE., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are known to have poorer short-term prognosis compared to stable coronary artery (CAD) patients undergoing elective PCI. Few studies have made direct comparison of long-term mortality between ACS and stable CAD patients undergoing PCI. The aim of our study was to compare the long-term mortality following PCI between patients with ACS and those with stable CAD., Methods: We examined consecutive patients undergoing PCI with stenting at a tertiary referral hospital. Clinical, angiographic and biochemical data were collected and analysed. The primary outcome was all-cause mortality retrieved from the Statewide Death Registry database., Results: Included were 1923 consecutive PCI patients (970 stable CAD and 953 ACS). The mean follow-up time was 4.1 years ± 1.8 years. In-hospital mortality was 1.4% overall, seen exclusively in patients with ACS (n=28, 2.9%). Post-discharge mortality was 6.7% among patients with stable CAD and 10.5% for ACS (P<0.01). Multivariate predictors of post-discharge deaths for both groups included age (HR 1.08 per year, P<0.001) and impaired renal function (HR 2.49, P<0.001). Following adjustment for these factors, an ACS indication for PCI was not associated with greater post-discharge mortality (adjusted HR 1.18: 0.85-1.64, P=0.32)., Conclusions: Patients undergoing PCI following an ACS have higher long-term mortality to those with stable CAD, which is potentially explained by a greater prevalence of comorbidities. This suggests that for the ACS population, contemporary interventional and medical management strategies may effectively and specifically counter the adverse prognostic impact of coronary instability and myocardial damage., (Copyright © 2012. Published by Elsevier Ireland Ltd.)

Background: Current guidelines recommend that transthoracic echocardiography (TTE) should be performed for acute risk stratification following acute pulmonary embolism (PE), but it is unclear whether the initial TTE can predict long-term outcome beyond six months. We sought to assess the potential of the initial right atrial (RA) to left atrial (LA) area ratio (RA/LA ratio) on TTE to predict long-term mortality in survivors of submassive PE., Methods: A derivation cohort comprised a previously reported group of 35 consecutive patients with acute PE who were intensively studied by serial TTE at 1, 2, 5 days, 2, 6, 12 and 26 weeks and RA/LA ratio related to long-term outcome. The Day 1 RA/LA ratio findings were then further related to long-term outcome in 158 patients followed for 3.6 ± 2.3 years., Results: In the derivation cohort, total mortality was 28.6% (n = 10) following a mean (±standard deviation) follow-up of 4.3 ± 1.9 years. The RA/LA ratio was highly dynamic, being increased at day 1, but normalised rapidly within 2-5 days of presentation and this was most marked amongst long-term non-survivors. A RA/LA ratio > 1.0 on day 1 was independently associated with a three-fold increase in long-term mortality on Kaplan-Meier analysis. Pooled analysis of 158 patient indicated that age, Charlson Comorbidity Index (CCI), simplified Pulmonary Embolism Severity Score (PESI), troponin T, day 1 RA/LA Ratio and pulmonary arterial systolic pressure (PASP) were univariate predictors of long-term mortality. Multivariate analysis identified Day 1 RA/LA Ratio (HR 1.7 per 10% increase, p = 0.002), CCI (HR 2.2 per 1 unit increase, p = 0.004) and age (HR 1.1, p = 0.03) as the only independent predictors of long-term mortality., Conclusion: A RA/LA Ratio >1.0 at presentation with acute PE was associated with a three-fold increased risk of long-term mortality. The RA/LA ratio on presentation with an acute PE is a simple, novel predictor of long-term survival.