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Background In aortic stenosis (AS), overestimation of pressure gradients by Doppler compared to catheter-based measurement can be adjusted for by accounting for the pressure-recovery, expressed as an energy-loss index (ELI). However, evidence of improved risk assessment by ELI instead of aortic valve area indexed by body-surface area (AVAi) is scarce. Purpose We aimed to evaluate the prognostic performance of ELI and AVAi in a head-to-head comparison using large-scale, real-world data. Methods In the multi-center, mortality-data linked National Echocardiography Database of Australia (NEDA), patients with AS and requisite aortic area measurements were identified. The prognostic value of AVAi and ELI, respectively, was analyzed using Cox regression and compared by difference in C statistics. Results In patients with mild AS (n=3,179), moderate AS (n=4,194), and severe AS (n=3,120), there were 4,229 deaths of which 2,359 were cardiovascular deaths (median [interquartile range] follow-up 2.5 [1.1–4.5] years). There was an association with increased mortality risk per 0.1 cm2/m2 decrement for both AVAi (hazard ratio CV mortality [95% confidence interval] 1.18 [1.16–1.20]) and ELI (1.10 [1.09–1.12]). Prognostic performance for 5-year CV mortality did not improve by using ELI compared to AVAi (C statistic 0.626 vs 0.626, p=0.96). Conclusions In aortic stenosis, ELI was not associated with improved prognostic performance compared to AVAi using large-scale, real-world clinical data. These data do not support routine calculation of pressure recovery in echocardiographic reporting. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Swedish Heart and Lung Foundationthe Swedish Cardiac Society

Background We sought, for the first time, to quantify the societal to healthcare burden associated with the entire spectrum of aortic stenosis (AS) - the most common cardiac valve disorder requiring clinical management. Methods In this observational clinical cohort study with individual data linkage to all-cause mortality, we examined the distribution of progressive stenosis in the native aortic valves of 98,565 men and 99,357 women aged ≥65 years within a multicentre cohort across 24 sites internationally. Individuals were grouped according to their peak aortic valve velocity on last electrocardiogram investigation: 1.0–1.99 m/s (no AS/reference groups) and then 0.5 m/s increments up to ≥4.0 m/s (severe AS). Sex-specific premature mortality and years of life-lost (YLL) during 5-year follow-up were calculated, along with willingness-to-pay (WTP) to regain quality-adjusted life-years (QALYs) and healthcare costs associated with concurrent heart failure (HF). Results Overall, 20,701 men (21.0%; 95% CI 20.8–21.3) and 18,576 women (18.7%; 95% CI 18.5–18.9) had AS at baseline. Five-year mortality in men and women with no AS was 38.6% and 36.8%, respectively. In both sexes, mortality rose from 46.8–49.0% to 59.5–65.7% in the least- to most-severe cases of AS. Premature mortality (53.5–59.1% in the no AS group) declined from 42.4–50.9% to 34.8–35.2% of all deaths. Per 1,000 individuals, AS in men and women was associated with 8 and 13 more premature deaths resulting in 36 and 62 more QALYs (societal cost of $AU1.54 and $AU2.68 million respectively) when compared to no AS. The additional 5-year cost of healthcare utilisation for the 25 and 35 more men and women with concurrent HF and AS was estimated to be $AU1.27 and $AU1.91 million, respectively. Conclusions The presence of any degree of aortic valve stenosis is associated with higher levels of premature mortality coupled with excess healthcare costs that impose a heavy societal burden. These findings indicate the need for proactive and cost-effective strategies to promptly detect this common condition. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Edwards LifeSciences: Investigator-initiated grant

Background We addressed the paucity of data describing the characteristics and natural history of incident pulmonary hypertension (PHT). Methods In this observational clinical cohort study, we examined 85,173 individuals undergoing routine echocardiography for heart disease without evidence of PHT (according to estimated right ventricular systolic pressure, eRVSP Results A total of 6,169 men (45.9%, mean age 61.4±16.7 years) and 7,279 women (60.8±16.9 years) with no initial evidence of PHT were identified (first echocardiogram). Subsequently, 5,412 (40.2%,) developed PHT (repeat echocardiogram) – comprising 4,125 (30.7%, 65.0±14.3 years), 928 (6.9%, 69.2±13.5 years), and 359 (2.7%, 69.8±12.7 years) cases of mild, moderate, and severe PHT, respectively. The incidence of all stages of PHT was 15.2 cases per million men/annum and 12.5 cases per million women/annum. Overall, median eRVSP increased by +7.4 (IQR +4.6 to +10.1) and +30.7 (IQR +26.0 to +37.3) mmHg; median E:e' ratio increased by +1.0 (IQR −0.4 to +3.2) and +3.6 (IQR +2.0 to +8.2); and median LA volume increased by +5.0 (IQR +0.0 to +12.0) and +19.5 (IQR +9.0 to +31.0) ml/m2, respectively, in mild and severe PHT groups between first and last echocardiograms. During subsequent median 8.1 years follow-up, 2,776/13,448 (20.6%) individuals died from all-cause. Compared to no PHT, the age- and sex-adjusted hazard ratios for all-cause mortality increased to 1.35 (95% confidence interval, CI 1.23–1.47) in mild PHT, 1.94 (95% CI 1.73–2.18) in moderate PHT, and 2.43 (95% CI 2.09–2.83) in severe PHT (all p Conclusions New onset of PHT is a common finding among individuals with heart disease followed-up with echocardiography. Even milder stage of PHT is associated with higher mortality, reinforcing the need for proactive evaluation for symptoms consistent with PHT. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Johnson & Johnson: Investigator-initiated grant

Background Sex‐specific differences in left ventricular ejection fraction (LVEF) and responses to neurohormonal modulating therapies are relevant to clinical trials of treatment for heart failure with preserved ejection fraction (HFpEF). Aims This study aimed to identify the proportion and characteristics of patients presenting with possible or confirmed HFpEF within the National Echo Database of Australia. Results A total of 237 046 women (48.1%) and 256 019 men (aged 61.0 ± 18.3 vs. 60.6 ± 17.1 years, respectively) had sex‐specific distributions of LVEF: 94.3% of women had LVEF ≥ 45% (mean LVEF 66.0 ± 8.6%), compared with 87.2% of men (mean LVEF 63.4 ± 8.7%). The presence of structural heart disease (SHD) according to the PARAGON‐HF criteria could be calculated in 93.8% of women and 93.4% of men with an LVEF ≥ 45%. Of these, 64 502 (30.8%) women and 104 344 (50.0%) of men had left ventricular hypertrophy, and 78 948 (35.3%) and 95 846 (42.9%), respectively, had left atrial enlargement. As a result, the proportion of women vs. men fulfilling echocardiographic criteria for HFpEF was very different: 111 497 (53.2%) vs. 146 359 (70.1%). SHD markedly increased with age, associated with a greater increase in women than men. The same signal was observed in those referred for suspected or previously confirmed HFpEF. Conclusions Double the number of men than women had LVEF

Background: There is a paucity of contemporary information regarding the prevalence and related health care expenditure of the most common cardiac conditions in Australian children, including congenital heart disease (CHD). Methods: The 10 most common cardiac conditions managed by Queensland Paediatric Cardiac Service during 2014–2015 were identified from an electronic database: ventricular septal defect (VSD), pulmonary stenosis, aortic stenosis, tetralogy of Fallot, atrioventricular septal defect, transposition, Ebstein's anomaly, long QT syndrome, dilated cardiomyopathy, and rheumatic carditis. Demographic data, clinic attendance, investigational procedures, and therapeutic interventions were extracted from the electronic health records to derive indicative population estimates and direct health care expenditure relating to CHD. Results: A total of 2,519 patients diagnosed with the 10 target conditions were being actively managed, including 456 (18.1%) new-born and 787 prevalent cases (2.5/1,000 population) aged

Background Although mild pulmonary hypertension is known to be associated with increased mortality, its impact on premature mortality is largely unknown. Methods We studied the distribution of estimated right ventricular systolic pressure (eRVSP) among a total of 154 956 adults with no evidence of left heart disease investigated with echocardiography. We then examined individually linked mortality, premature mortality and associated life-years lost (LYL) according to eRVSP levels. Results The cohort comprised 70 826 men and 84 130 women (aged 61.3±17.7 and 61.4±18.4 years, respectively). Overall, 85 173 (55.0%), 49 276 (31.8%), 13 060 (8.4%) and 7447 (4.8%) cases had eRVSP levels indicative of no (

Background Conventionally, stroke volume index (SVI) ≤35ml/m2 is considered as “low-flow” in severe aortic stenosis (AS). Recent evidence suggests a lower threshold SVI (30ml/m2) may be more prognostically informative. Objectives To assess the association between SVI and survival in patients with low-gradient severe AS, with either preserved (LVEF ≥50%) or reduced (LVEF Methods Data were derived from the National Echocardiography Database of Australia (NEDA). Of 192,060 adults (aged 62.8±17.8 years) with comprehensive aortic valve profiling between 2000–2019, 12,013 (6.3%) had severe AS. Based on standard echocardiographic parameters, 1,623 patients had severe low-gradient AS with preserved LVEF and 744 patients had severe low-gradient AS with reduced LVEF. All-cause and cardiovascular-related mortality were assessed for each low-gradient group on an adjusted basis (age, sex, BMI, AVA indexed and RVSP), according to SVI. Mean follow-up was 81±42 months. Results Compared to patients with “normal” flow (SVI >35ml/m2), those with “low-flow” (SVI ≤35ml/m2) had significantly higher BMI, smaller AVA index and lower AV mean gradient and peak velocity (p≤0.001). In low-gradient with preserved LVEF patients, adjusted survival at 1- and 3-years was significantly lower only for SVI ≤30ml/m2 compared with SVI>35ml/m2 (p35ml/m2 (p=0.015 and p=0.018, respectively). Conclusions Taken together with previous data, our results suggest that a SVI threshold of ≤30ml/m2 (rather than ≤35 ml/m2) is prognostically significant in severe low-gradient AS with preserved LVEF. Funding Acknowledgement Type of funding sources: None. Survival plots LGAS with preserved EFSummary of results

Background The prevalence and outcomes of low-gradient severe aortic stenosis (AS), in particular low-flow low-gradient (LFLG) severe AS, have not been well characterized. Objectives We sought to delineate the relative prevalence and outcomes of patients with low-gradient severe AS in routine clinical cardiology practice. Methods Data were derived from the National Echocardiography Database of Australia (NEDA), a national multicentre clinical registry with data linkage to mortality. A total of 192,060 adults with native aortic valve profiling from 2000–2019 were identified, of whom 12,013 (6.3%) had severe AS (aged 75.3±13.1 years, 53.5% men). Severe AS subtypes were determined using standard echocardiographic criteria. All-cause and cardiovascular-related mortality were assessed on an adjusted basis (age and sex) in 8,162 patients with classifiable severe AS subtypes, during mean follow-up of 88±45 months. Additionally, rates of recorded Aortic Valve Replacement (AVR) during follow-up were compared between AS groups. Results 5,601 patients (47%) had high-gradient and 6,412 patients (53%) had low-gradient severe AS. In the low-gradient group, Stroke Volume Index data was recorded in 2,741 patients; 1,750 (64%) had LFLG and 991 (36%) had normal-flow low-gradient (NFLG). For LFLG patients, 1,570 had LV ejection fraction recorded; 959 (61%) had paradoxical LFLG and 651 (39%) had classical LFLG. Adjusted 5-year cardiovascular mortality rates were 28% in high-gradient, 24% in NFLG, 27% in paradoxical LFLG and 50% in classical LFLG patients (p Conclusions Approximately half the subjects with echocardiographic features of severe AS in routine clinical practice have low-gradient haemodynamics, associated with long-term mortality comparable to or worse than high-gradient severe AS. The poorest survival was associated with classical LFLG severe AS. Funding Acknowledgement Type of funding sources: None. Summary illustration5 year mortality curves

Introduction There are currently no established prognostic models for low-flow, low-Gradient (LFLG) severe aortic stenosis (AS). The Cardiac Damage Staging Classification, has been validated as a clinically useful prognostic tool in high-gradient severe AS, but not specifically in LFLG severe AS. Objective To assess and confirm the prognostic utility of the Cardiac Damage Staging Classification, in LFLG severe AS patients. Methods We analysed data from the National Echocardiography Database of Australia (NEDA), a national multicentre registry with individual data linkage to mortality. Of 192,060 adults (aged 62.8±17.8 years) with comprehensive ultrasound profiling of the native aortic valve studied between 2000–2019, 12,013 (6.3%) had severe AS. Based on standard echocardiographic parameters, 611 classical and 959 paradoxical LFLG patients were identified. Mean follow-up was 70±41 months. All-cause and cardiovascular-related mortality were assessed for each LFLG group on an adjusted basis (age and sex), according to cardiac damage classification staging. Results Paradoxical LFLG patients were younger (mean age 74.3 vs 76.2, p=0.006) and more often female (62.8% vs 36.3%, p Conclusion In patients with LFLG severe AS identified by echocardiography, increasing severity denoted by the cardiac damage staging classification is strongly associated with increasing medium- to long-term mortality. Funding Acknowledgement Type of funding sources: None. Stages + Classical LFLG 5 year mortalityParadoxical LFLG 5 year mortality curves

There are currently no established prognostic models for "low-gradient" severe aortic stenosis (AS), including those with low-flow, low-gradient (LFLG) or normal-flow, low-gradient (NFLG) severe AS. The "cardiac damage staging classification" has been validated as a clinically useful prognostic tool for high-gradient severe AS but not yet for these other common subtypes of severe AS, LFLG and NFLG.The authors analyzed data from the National Echo Database of Australia, a large national, multicenter registry with individual data linkage to mortality. Of 192,060 adults (mean age, 62.8 ± 17.8 years) with comprehensive ultrasound profiling of the native aortic valve studied between 2000 and 2019, 12,013 (6.3%) had severe AS. On the basis of standard echocardiographic parameters, 5,601 patients with high-gradient, 611 with classical and 959 with paradoxical LFLG, and 911 with NFLG severe AS were identified. Mean follow-up was 88 ± 45 months. All-cause and cardiovascular-related mortality were assessed for each group on an adjusted basis (age and sex) and analyzed by cardiac damage stage.Patients with LFLG AS had greater associated cardiac damage at diagnosis (stages 3 and 4 in 34% of those with classical LFLG, 22.5% of those with paradoxical LFLG, 15.5% of those with NFLG, and 14% of those with high-gradient AS; P .001). For all four major subtypes of severe AS, there was a progressive increase in 1- and 5-year mortality with increasing cardiac damage score. For example, for paradoxical LFLG severe AS, compared with stage 0 patients, adjusted 1-year all-cause mortality was 22% higher in stage 1 patients, 55% higher in stage 2 patients (P = .095), and 155% higher in stage 3 and 4 patients (P .001). Among patients with classical LFLG severe AS, compared with stage 1 patients, adjusted 1-year all-cause mortality was 55% higher in stage 2 patients (P = .018) and 100% higher in stage 3 and 4 patients (P .001).Regardless of severe AS subtype, increasing severity denoted by the cardiac damage staging classification is strongly associated with increasing mortality risk.

During the USNS Comfort mobilization to New York City in response to the pandemic, the ship's medical team cared for over 35 mechanically ventilated corona virus disease 2019 (COVID-19) infected patients. Due to the better than expected mortality rates of these patients, tracheotomy for prolonged intubation or other indicated interventional bronchoscopies were performed on 7 COVID positive patients, as well as 2 with negative screening tests. No member of the health care team subsequently became symptomatic or tested positive for COVID-19. This was in part due to the formation of a dedicated surgical airway team, use of standardized procedural techniques and personal protective equipment (PPE), and construction of a negative pressure operating room within the COVID-19 isolation ward on the ship. This experience shows that tracheotomies and other aerosolizing procedures can be performed with due concern for patient and provider safety, regardless of patient's COVID status.

Drawing upon deep ethnographic fieldwork, and written in lively prose that weaves together story and evidence, the book explores contemporary homesteading in Appalachia as a means of resistance to capitalist modernity. It is framed around two questions: Why are people still pursuing rural subsistence? And why are they often divided into two main groups, known to each other--not always kindly--as “hicks” and “hippies”? These turn out to be urgent questions, considering that the cultural divide between these two groups is one instance of the dangerous and growing schism between “liberal” and “conservative” in the contemporary United States. Because the answer turns upon the distribution of literacy and literate education, these also turn out to be profound questions that cannot be answered without exploring the inner workings of class and capitalism. Thus, the narrative begins by telling the complex and often misunderstood histories of both groups of back-to-the-landers, but turns in the middle chapters to an analysis of the ways in which working-class people are rendered educationally dispossessed through schooling and jobs, as well as discussion of the often devastating consequences of that dispossession. In the final chapter, the book returns to homesteading as a form of resistance, to address the question of whether it provides, as practitioners hope, a measure of shelter from the machine.

This chapter evaluates contemporary homesteading and rural subsistence in eastern Kentucky as a form of activism and resistance. It argues that homesteading alone is not a particularly effective means of changing larger socioeconomic structures, such as capitalism and plutocracy. However, homesteading, when pursued with skill, is capable of surprising achievements: it can be an effective means of reducing a household’s reliance upon the mainstream economy; shifting work away from wage labor; fostering frugality; bringing homesteaders into closer interaction with the natural world; and serving as a living laboratory for appropriate technologies. These are real accomplishments that explain the continued attraction of this particular form of activism.

The first of a three-chapter sequence exploring “cultural division in a capitalist society,” chapter 5 addresses the question--raised by the previous chapter on the back-to-the-land movement--of why some adults in eastern Kentucky are highly literate and book educated, while most are not. Drawing upon ethnographic fieldwork, the chapter argues that many people experience a kind of “make-believe,” lecture-based schooling that renders them disinterested in reading and book-based learning. Some are raised in literate households, which may offset the limitations of the classroom; most, however, grow up in households with limited literacy and have little opportunity to access this crucial set of educational resources. The chapter recognizes the worth of practical skills and knowledge, while also discussing the real impacts of pedagogical dispossession.

The first of three chapters exploring the history of homesteading in the area around Berea, Kentucky, chapter 2 gives a lively overview of the initial wave of white colonization and Native American displacement in the late 1700s. Because the Wilderness Road and Boonesborough are both within the research area, the life of Daniel Boone is used to illustrate the ways in which--although the labor of colonization was performed by working-class and enslaved people--the project of colonization was controlled by elites, and the land engrossed into vast estates. Despite popular images of this first United States frontier as a space of smallholder independence, the society that was created was aristocratic and defined by exploitation, a theme carried forward through the rest of the book.

The previous chapter focused on the role of literacy and schooling in creating “cultural division in a capitalist society”; this chapter focuses upon the role of labor and jobs. Beginning with an ethnographic description of work in a factory in eastern Kentucky, the chapter explores lower-tier jobs as a source of damage and limitation for workers, and poses the question of whether such jobs are inevitable in an industrial society. In answering that question, the chapter offers a primer on the political economy of capitalism and exploitation; contrasts low-quality jobs with professional, high-quality jobs; and discusses real-world alternatives to capitalism. The conclusion is that damaging jobs are mostly a side-effect of the ownership architecture of capitalism; they are not an unavoidable feature of industrial society.

The second of three chapters exploring the history of homesteading in the area around Berea, Kentucky, chapter 3 presents the story of rural subsistence from the late 1800s up to the economic boom generated by World War II. The chapter is framed in terms of the “parable of enclosure”--the idea that yeoman farmers would not voluntarily trade independent livelihood for capitalist wage labor--and argues that as industry and technology generated ever more advanced consumer goods (for example, refrigerators, radios, antibiotics), the peasant way of life became outmoded; once wage labor became available in the factories of the north, millions of Appalachians left the mountains. But, as the chapter documents, some chose to return to a homesteading life, forming an overlooked back-to-the-land movement.

The third of three chapters exploring the history of homesteading, this chapter analyzes the counterculture back-to-the-land movement in the area around Berea, Kentucky. Drawing upon ethnographic fieldwork, the chapter illustrates that this is a major social movement, far more enduring and robust than stereotypes of “hippie” back-to-the-landers would suggest. The chapter shows that participants represent a multistranded left with diverse backgrounds, including a high proportion who are from rural Appalachia; that they take subsistence production seriously; and that homesteading represents a specific, “prefigurative” form of social activism. The chapter also explores the complex relationship between counterculture homesteaders and their rural neighbors, and argues the former are unified as a group by high levels of literacy and educational attainment; they represent, in effect, a rural intelligentsia.

The epilogue forms a coda to the previous chapter, which argues that contemporary homesteading in eastern Kentucky represents a serious form of activism and resistance to capitalist modernity, even though it does little to change the nature of capitalism itself. The epilogue suggests that homesteading should be seen as a form of anarchism, defined by James Scott as “cooperation without hierarchy or state rule.” The epilogue illustrates that anarchism is a foundational mode of human life--one that remains crucial today even as it is overlooked and eroded--and argues that the intentional practice of anarchism represents an important, capacity-building experience in “lived democracy,” which is too often lacking in our families, schools, churches, governments, and workplaces.

Drawing upon ethnographic fieldwork, this chapter deepens the questions raised in the introduction with visits to a “country” homestead (during a pig roast) and a “bohemian” homestead (during a work party on a strawbale house), describing the overlapping but contrasting cultures and practices of the two places. The chapter argues that contemporary homesteads represent anomalous and exotic spaces that differ markedly from those common in mainstream American life, and discusses the stereotypes, both positive and negative, of “hick” and “hippie” homesteaders. It closes with a discussion of the challenges of defining homesteading, which is predicated upon intensified household subsistence but takes many forms, such as a minimalist homestead relying more upon frugality than production, or a parcel with an owner-built home but no garden.

The third of three chapters that examine “cultural division in a capitalist society,” chapter 7 focuses upon behavioral and ideational differences and oppositions between country and bohemian homesteaders, which is a particular iteration of the larger cultural schism between left and right in the contemporary United States. Weaving together story and evidence, the chapter argues that this is a class division, but one in which literate education plays a more prominent role than occupation or monetary wealth. The argument is developed by examining the role of education in the lives of individual characters, in terms of issues such as diet, trash burning, attitudes toward non-straight sexualities, and susceptibility to mass-media propaganda.

Our understanding of the causes and consequences of pulmonary hypertension is limited. Consequently, its most distinctive forms with the worst prognosis have been the focus for diagnosis and treatment. We highlight the emerging challenge of reframing the prevalence and prognostic implications of pulmonary hypertension, focusing on the optimal therapeutic window to address the high mortality linked to this condition.

During the USNS Comfort mobilization to New York City in response to the pandemic, the ship's medical team cared for over 35 mechanically ventilated corona virus disease 2019 (COVID-19) infected patients. Due to the better than expected mortality rates of these patients, tracheotomy for prolonged intubation or other indicated interventional bronchoscopies were performed on 7 COVID positive patients, as well as 2 with negative screening tests. No member of the health care team subsequently became symptomatic or tested positive for COVID-19. This was in part due to the formation of a dedicated surgical airway team, use of standardized procedural techniques and personal protective equipment (PPE), and construction of a negative pressure operating room within the COVID-19 isolation ward on the ship. This experience shows that tracheotomies and other aerosolizing procedures can be performed with due concern for patient and provider safety, regardless of patient's COVID status.

Mortality with impaired left ventricular ejection fraction (LVEF) has been clearly demonstrated. However, the prevalence and significance of increased LVEF (beyond the guideline-recommended normal range) in the community is unclear. We used the National Echo Database Australia (NEDA) to compare mortality in patients with normal and high LVEF. Methods NEDA contains echo data (>530,000, years 1997–2017) from laboratories (N=14) across Australia, linked to the National Death Index (NDI). 331,344 individuals aged >18 years (n=172,251 [52%] men, age=60.8±18.0 years and 152,095 [48%] women, 60.9±19.2 years) had a mean follow up of 5.4 person-years and 63,142 fatal events. LVEF using Method Of Discs (MOD) could be calculated in 116,544 individuals. We compared mortality in those with normal LVEF (52–72% for males and 54–74% for females) compared with high LVEF (>72% and >74% for males and females, respectively). Results Mortality was 11% higher in females with high LVEF vs females with normal LVEF. On multivariable logistic regression, high ejection fraction remained an independent predictor of mortality after correction for age, gender and body mass index. High LVEF was positively associated with female gender, age and diastolic dysfunction. Of 96,033 individuals in the study population, there were 46,876 males (48.8%), mean age 61.19±17.09 years, not significantly different from their female counterparts. 44,282 males had normal LVEF (52–72%) as opposed to 2,594 with high LVEF (>72%). In females, 46,186 had normal LVEF (54–74%) and 2,971 had high LVEF.InCox proportional hazard models, the hazard ratio (HR) for mortality in males with normal EF was 1.105 for age (95% CI 1.102 to 1.07) and 1.074 (95% CI 0.988 to 1.167) for high LVEF (p Conclusion High LVEF, particularly in older women, is associated with increased mortality compared with an LVEF within the reference range. Further study is required to evaluate possible mechanisms for worse outcomes in patients with high LVEF.

Purpose Chronic thromboembolic pulmonary hypertension (CTEPH) is defined as pulmonary hypertension resulting from non-resolving fibro-thrombotic obstructions of pulmonary arteries. Pulmonary endarterectomy (PEA) remains the treatment of choice for disease that is technically operable. The epidemiology and long-term outcomes of CTEPH has not been previously described in Australia and New Zealand. Methods Using PHSANZ registry, data was extracted for all CTEPH patients diagnosed between January 2004 and March 2020. We analysed baseline characteristics, treatment strategies, outcome data, and long-term survival. Results A total of 404 patients were included with 146 (36.1%) undergoing PEA and 258 (63.9%) in the non-PEA group. PEA patients were younger (55±16yr vs. 62±16yr) with higher baseline 6MWD (405±122m vs. 323±146m), whilst both groups had similar baseline pulmonary haemodynamics. Pulmonary vasodilator therapy was used in 50% of patients post-PEA, and 76% in the non-PEA group. Actual 1, 5, and 10-yr transplant-free survivals were 93%, 84% and 74% for the PEA group compared to 87%, 63% and 42% for the non-PEA group (log rank test, p Conclusion In this first multicentre report of CTEPH in Australia and New Zealand, long-term survival is comparable to other contemporary registries. However, PEA was only offered to a minority of CTEPH patients and significantly less than overseas reports. Greater awareness and improved patient access to experienced CTEPH surgical centres are important priorities. Multivariate survival analysis showed baseline 6MWD was an independent predictor of survival in both operated and medically managed patients.

Pulmonary vascular resistance (PVR) >3 Wood units is a criterion of the haemodynamic definition of pulmonary arterial hypertension (PAH). However, this cut-off is conservative and arbitrarily defined. Data is lacking on the natural history, response to therapy and survival of patients diagnosed with precapillary pulmonary hypertension (PH) with mild or borderline elevation of PVR.In Australia, PAH therapy could be prescribed solely on mean pulmonary arterial pressure (PAP) and pulmonary arterial wedge pressure (PAWP) criteria. Using the Australian and New Zealand Pulmonary Hypertension Registry, we aimed to study a population diagnosed with PAH between January 2004 and December 2017 with the pre-defined haemodynamic characteristics of mean PAP ≥25 mmHg, PAWP ≤15 mmHg and PVR Eighty-two patients met the pre-defined haemodynamic inclusion criteria (mean age 63±11 years; 67 females). Underlying aetiologies included idiopathic disease (n=39), connective tissue disease (CTD; n=42) and HIV infection (n=1). At diagnosis, mean PAP was 27 mmHg (interquartile range (IQR) 25–30 mmHg), PAWP 13 mmHg (IQR 11–14 mmHg) and PVR 2.2 Wood units (IQR 1.9–2.7 Wood units). Baseline 6-min walk distance (6MWD) was 352 m (IQR 280–416 m) and 77% of subjects were in New York Heart Association (NYHA) functional class 3 or 4. All patients were commenced on initial monotherapy with an endothelin receptor antagonist (ERA; n=66) or phosphodiesterase type-5 inhibitor (PDE5i; n=16). At first re-evaluation, 6MWD increased by 46 m (IQR 7–96 m) and 35% of subjects demonstrated improvement in NYHA functional class. After a median follow-up of 65 months (IQR 32–101 months), 18 out of 82 subjects (22.0%) had died, with estimated 1-year and 5-year survival rates of 98% and 84%, respectively. Death attributed to PAH occurred in six out of these 18 patients (33.3%, 7% of total cohort).Patients with precapillary PH and “borderline” PVR falling outside the current definition have adverse outcomes. Such patients appear to respond to PAH therapy; however, this requires further study in randomised trials.