Cardiomyocyte energy production during ischemia depends upon anaerobic glycolysis inefficiently yielding two ATP per glucose. Substrate augmentation with fructose 1,6-diphosphate (FDP) bypasses the ATP consuming steps of glucokinase and phosphofructokinase thus yielding four ATP per FDP. This study evaluated the impact of FDP administration on myocardial function after acute ischemia.
Male Wistar rats, 250-300 g, underwent 30 min occlusion of the left anterior descending coronary artery followed by 30 min reperfusion. Immediately prior to both ischemia and reperfusion, animals received an intravenous bolus of FDP or saline control. After 30 min reperfusion, myocardial function was evaluated with a left ventricular intracavitary pressure/volume conductance microcatheter. For bioenergetics studies, myocardium was isolated at 5 min of ischemia and assayed for ATP levels.
Compared to controls (n=8), FDP animals (n=8) demonstrated significantly improved maximal left ventricular pressure (100.5+/-5.4 mmHg versus 69.1+/-1.9 mmHg; p<0.0005), dP/dt (5296+/-531 mmHg/s versus 2940+/-175 mmHg/s; p<0.0028), ejection fraction (29.1+/-1.7% versus 20.4+/-1.4%; p<0.0017), and preload adjusted maximal power (59.3+/-5.0 mW/microL(2) versus 44.4+/-4.6 mW/microL(2); p<0.0477). Additionally, significantly enhanced ATP levels were observed in FDP animals (n=5) compared to controls (n=5) (535+/-156 nmol/g ischemic tissue versus 160+/-9.0 nmol/g ischemic tissue; p<0.0369).
The administration of the glycolytic intermediate, FDP, by intravenous injection, resulted in significantly improved myocardial function after ischemia and improved bioenergetics during ischemia.
Pre-hospital ECG is one strategy to improve door to balloon times (D2BT), however its long term effectiveness to sustain reductions in D2BT has not been evaluated.
From 2007 to 2011 we conducted a prospective interventional study involving 1000 patients undergoing primary PCI (PPCI) at a single tertiary referral institution to determine the long term impact of pre-hospital 12 lead ECG on D2BT.
The median D2BT of patients (n=414) who underwent PPCI following field 12-lead ECG was 54min [IQR: 37-71min] compared to the median time of a contemporary group (n=586) undergoing PPCI during the same period but not presenting via field triage of 100min [74-134] (p<0.001). The proportion of patients who achieved a D2BT of ≤90min in the pre-hospital ECG group was greater than that in the contemporary group (90% vs 42%, p<0.001). A comparison of the first 250 patients compared to subsequent 250 patient blocks showed no change in D2BT.
Introduction of pre-hospital ECG in the triage of STEMI resulted in a sustained reduction in D2BT.
The aims of this study were to (1) compare the release of S-100 beta and NSE in off-pump coronary artery bypass grafting (CABG) versus on-pump surgery; (2) investigate whether the S-100 beta and NSE serum concentrations correlate with cardiopulmonary bypass (CPB) duration.
Between October 2002 and May 2004, 42 patients undergoing first time CABG surgery were enrolled in the study. The exclusion criteria were: LVEF<35%, age>70 years, previous myocardial infarction, REDO surgery, the presence of valvular heart disease and/or cerebrovascular disease, abnormal preoperative carotid vessels angiography, coronary artery disease involving the distal circumflex artery, renal dysfunction, coagulopathy. The patients were randomly assigned either to undergo on-pump CABG surgery [group I, n=24 patients] or off-pump CABG [group II, n=18 patients]. Blood was not re-transfused from the cardiotomy suction. All patients presenting haemolysis were excluded from the study.
The preoperative S-100beta was 0.13+/-0.08 (microg/l) and NSE 7+/-1.5 (microg/l) in group I and 0.12+/-0.1 (microg/l) and 6.9+/-2.7 (microg/l), respectively in group II. Six hours after the surgery, S-100beta in patients of group I reached a maximum level of 1.38+/-0.4 (microg/l) and NSE of 17.7+/-6.5 (microg/l) compared to 0.5+/-0.11 (microg/l) [S-100B] and NSE 8.6+/-4.2 (microg/l) in group II (p=0.001). Three (12%) patients in group I and none (0%) in group II suffered postoperative delirium, p=0.247. No strokes occurred linear regression analysis revealed a strong correlation between cardiopulmonary bypass duration and S-100beta and NSE peak levels, p<0.0021 (r(2)=0.36) and p<0.0001 (r=0.81), respectively.
Coronary artery bypass surgery with CPB causes a significantly greater increase in NSE and S-100beta serum levels than off-pump surgery and correlates with CPB duration.
This study evaluates the early and mid-term outcomes, predictors of mortality and morbidity and quality of life of patients operated for infective endocarditis. Data on 108 patients undergoing 113 surgical procedures during October 1998 to January 2010 was prospectively collected. NYHA Class was >III in 49 (43.4%) cases. Thirty-seven (33%) patients had isolated mitral valve procedures, 58 (51%) had aortic valve, two had tricuspid valve and 16 had multivalvular procedures. Active endocarditis was noted in 86 (76%) procedures, native valve endocarditis in 105 (93%) and prosthetic valve endocarditis in eight procedures. Logistic EuroSCORE at presentation was >14 in 18 (17%) patients. Staphylococcus aureus was the most common organism isolated. Follow-up was carried out in 76/85 (88.37%) of surviving patients, and the mean follow-up time was 37.2 months. Functional class and quality of life (using EQ-5D Health Questionnaire) were assessed by telephone interviews. NYHA Class on follow-up was I-II in 62/76 (83%). Multivariate predictor of 30-day mortality was peripheral vascular disease (p = 0.025) whilst multivariate predictors of long-term survival were male sex (p = 0.01), peripheral vascular disease (p = 0.02) and bypass time (p = 0.006). The overall survival was 87% at one year and 80% at five years. Thirty-three percent (25/76) patients reported a score reflecting full health. Optimal antibiotic therapy and timely surgical intervention were associated with improved functional class, quality of life and mid-term survival.
The use of plasma levels of B-type natriuretic peptides (BNPs) to guide treatment of patients with chronic heart failure (HF) has been investigated in a number of randomised controlled trials (RCTs). However, the benefits have been variable. We therefore performed a meta-analysis to examine the overall effect of BNP-guided drug therapy on all-cause mortality and HF rehospitalisation in patients with chronic HF.
We identified RCTs by systematic search of MEDLINE, EMBASE and the Cochrane Controlled Clinical Trials Register Database. Eligible RCTs were those that enrolled more than 40 patients and involved comparison of BNP-guided versus guideline-guided drug therapy of the patients with chronic HF in the outpatient setting.
Eleven RCTs with a total of 2414 patients and with a mean duration of 12 months (range, 3-36 months) were included in the meta-analysis. Overall, there was a significantly decreased risk of all-cause mortality (relative risk [RR], 0.83; 95% confidence interval [CI], 0.69-0.99; P=0.035; I(2)=0%) and HF rehospitalisation (RR, 0.75; 95% CI, 0.62-0.91; P=0.004; I(2)=62.2%) in the BNP-guided therapy group. Age, baseline BNP are the major dominants of HF rehospitalisation when analysed using meta-regression. In the subgroup analysis, HF rehospitalisation was significantly decreased in the patients younger than 70 years (RR, 0.45; 95% CI, 0.33-0.61; P=0.000; I(2)=0.0%), or with baseline higher BNP (≥2114pg/mL) (RR, 0.53; 95% CI, 0.39-0.72; P=0.000; I(2)=21.8%).
Compared with usual clinical care, B-type natriuretic peptide-guided therapy reduces all-cause mortality and HF rehospitalisation, especially in patients younger than 70 years or with higher baseline BNP.
To prevent infective endocarditis (IE), Australian guidelines recommend providing prophylactic antibiotics to Indigenous patients with rheumatic heart disease (RHD) prior to procedures which may cause bacteremia. In northern Australia RHD remains prevalent. We aimed to determine whether RHD is associated with an increased risk of IE, which risk factors are associated with IE, and the incidence and aetiology of IE.
A retrospective review of IE patients who fulfilled modified Duke criteria at two tertiary centres in northern Australia.
89 patients were reviewed. The rate of IE was 6.5/100,000 person-years. IE was more common in people with RHD (relative risk (RR) 58), Indigenous Australians (RR 2.0) and men (RR 1.7). RHD-associated IE was not confined to Indigenous Australians with 42% being non-Indigenous. The commonest risk factors for IE were intracardiac prosthetic material, injecting drug use and previous IE. One in five patients died.
In northern Australia the principle risk factor for IE is not RHD. Whilst RHD increased the risk of IE it was not restricted to Indigenous Australians. Current Australian recommendations of providing prophylactic antibiotics to Indigenous patients with RHD prior to procedures which may cause bacteremia may need to be broadened to include non-Indigenous patients.
new technologies for computed tomography coronary arteries imaging aim to reduce the radiation dose whilst maintaining image quality. The purpose of our study was to compare radiation dose and image quality parameters of Coronary Computed Tomography Angiography (CCTA) performed with retrospective 64-MDCT and prospective 128-MDCT.
a series of 77 consecutive patients were first randomised to either retrospective 64-MDCT (n=37) or prospective 128-MDCT (n=40) for CCTA. All patients in the retrospective 64-MDCT group were scanned with tube current modulation as strategy for reduction dose. Data regarding acquisition time and radiation dose were recorded. Two blinded radiologists independently assessed image quality of all coronary segments by using a four-point scale (1, excellent; 4, poor). Discrepancies were settled by consensus.
No significant differences were found regarding sex, age, body weight and heart rate. CTTA effective radiation dose was 2.1 ± 0.9 vs. 8.2 ± 4mSv in prospective and retrospective ECG-gating MDCT groups, respectively. Mean image quality score was 2.2 ± 0.9 for prospective 128-MDCT group and 1.4 ± 0.7 points for retrospective 64-MDCT representing a mean difference of 0.8 points (CI: 0.9 to 0.7).
in selected patients, CCTA using a 128-MDCT with prospective ECG-gating provides higher image quality with significant lower radiation dose when compared to 64-MDCT using retrospective ECG-gating.
Atherosclerosis is widely appreciated to involve a chronic lipid-induced inflammatory reaction of the arterial wall in response to haemodynamic stress and dyslipidaemia. The dysfunction of resident vascular cells and recruitment of infiltrating leukocyte cells orchestrate a complex interplay in the initiation and development of atherosclerosis. Despite a great many advances in recent years, the detailed mechanisms modulating the inflammation in atherosclerosis have not been fully elucidated. MicroRNAs (miRNAs) are small non-coding RNA (ncRNA) molecules that regulate gene expression post-transcriptionally by degradation and translational repression of target messenger RNAs (mRNAs). Substantial evidence demonstrates that miRNAs play a vital role in the physiological control of gene expression and in the pathogenesis of malignant, infectious, and cardiovascular disorders. MiR-155, a typical multi-functional miRNA, has recently emerged as a novel component of inflammatory signal transduction in the pathogenesis of atherosclerosis. MiR-155-mediated regulation is extensively involved in endothelial cells (ECs), macrophages, dendritic cell (DCs), vascular smooth muscle cells (VSMCs) and differentiation of leukocyte subsets. MiR-155 can modulate the expression of genes correlated with inflammation in different cell types in vitro and also affect the atherogenesis in vivo. However, miR-155 appears to play a conflicting role in the disease pathogenesis. Besides, miR-155 is potentially applied as a novel disease biomarker and therapeutic target in diagnosing and treating atherosclerosis. This article reviews the pertinent literature and mechanisms of action of miR-155 that have thus far been associated with atherosclerosis. Here we first introduce in brief the basic knowledge of the miRNA regulation and later discuss with emphasis the regulatory role of miR-155 in various cell types involved in atherosclerosis.
Loeys-Dietz syndrome (LDS) is a rare genetic disorder with an autosomal dominant inheritance due to mutations in the transforming growth factor beta-receptor type 1 or type 2. The disease is characterised by the triad of hypertelorism, bifid uvula or cleft palate, arterial tortuosity and aortic aneurysms. These phenotypic characteristics distinguish LDS from other connective tissue disorders related to transforming growth factor beta-receptor. Patients with LDS have a high risk of aortic dissection or rupture at a younger age and smaller aortic diameters. So, clinical suspicion of LDS followed by genotyping is important to prevent aortic dissection, leading cause of death, by surgical treatment.
Elevated levels of inflammatory markers are associated with incident coronary heart disease (CHD), but it remains controversial whether these markers provide incremental predictive value to conventional risk factors. We investigated the relationship between C-reactive protein (CRP) and interleukin-18 (IL-18) levels and risk of CHD in men and women without initial cardiovascular disease.
A prospective case-cohort design over the period 1981-2001 involving 253 incident CHD cases and a random sub-cohort of 441 subjects was used. Cox proportional hazards regression was used to estimate the relative risks (RRs) of CHD for continuous and tertiles of CRP and IL-18 after controlling for conventional risk factors.
The multivariate-adjusted RR of CHD associated with one unit increase in log CRP in the overall population was 1.29 (1.07, 1.55; trend P=0.008). Men and women in the top compared to bottom third of CRP distribution had an adjusted RR for CHD of 1.65 (1.03-2.65; P=0.036). The multivariate RR for continuous log IL-18 was 1.34 in men, 1.63 in women and 1.36 overall, and none reached statistical significance.
Baseline CRP but not IL-18 levels are independently predictive of future CHD. However CRP provides only modest additional predictive value over conventional risk factors and the benefit of a prevention strategy based on CRP still needs to be established.
This article advances an hypothesis that there is duplication of the heart rhythmogenesis system.
Methods and results:
The following article reviews available data and advances an hypothesis to suggest new ideas about the mechanisms of cardiac rhythm generation. The hypothesis is that along with the existence of an intracardiac pacemaker, the generator of cardiac rhythm exists in the central nervous system - in the efferent structures of the cardiac centre of the medulla oblongata. Originating in the medulla oblongata, neural signals in the form of brief bursts of pulses are conducted to the heart along the vagus nerves and, by interacting with the cardiac pacemaker structures, cause generation excitement in the heart in exact accordance with the frequency of the bursts. The intracardiac rhythm generator is a life-providing factor that maintains the heart pumping function when the central nervous system is in a stage of deep inhibition (e.g. under anaesthesia or when unconscious). The central generator is the factor that provides the heart with adaptive reactions in natural conditions of the organism.
Multi-leveled organisation of the mechanisms responsible for rhythmogenesis guarantees reliability and functional perfection of the cardiac rhythm generation system.
In the Australian Medical Journal of March 1883, there is a report entitled, "Valvular incompetency of pulmonary artery, with regurgitation", presented by Dr. William Pegus. Dr. Pegus presented this paper about his own peculiar heart problem, which was different from any in the textbooks of that time, to a group of doctors in 1882. He described his symptoms, the progress of the condition and the treatment he received, the most helpful of which was the use of Turkish baths. There was discussion on the possible diagnosis but at the conclusion of the presentation it was felt that all the symptoms could not be explained and therefore the diagnosis was uncertain. In the light of present day knowledge, the clinical picture is typical of a rupture of aneurysm of a sinus of Valsalva into the right ventricle. Rupture of such an aneurysm was first described by Hope in 1839 in his book on diseases of the heart and great vessels, the diagnosis being made at autopsy. Dr. Pegus was probably the first person in Australia to publish a detailed description of the symptoms and clinical signs and to give an account of the progress of the condition with his own thoughts about the treatment available at the time.
The development of the cardiology unit at Westmead Hospital occurred simultaneously with major advances in cardiology. Being the only teaching hospital built in New South Wales in the twentieth century, the hospital opened on 10 November 1978 on the site of the old Parramatta speedway. John Uther commenced in April 1979 and the electrophysiology laboratory opened in June, beginning an era of research and arrhythmia management that lead to the unit being a centre of excellence for arrhythmias. Cardiac surgery commenced in November 1981 with David Johnson as the initial surgeon, developing electrophysiological surgery. At the same time, Andreas Gruntzig was pioneering coronary angioplasty and this service commenced at Westmead in 1983. The early electrophysiology research culminated in the Ralph Reader prize being awarded to three Westmead fellows, David Richards, Robert Denniss and Lorraine Holley over the first three years with Mark Cooper awarded in 1986. Also in 1986, the era of thrombolytic therapy commenced for acute myocardial infarction. Dr Michel Mirowski implanted the first defibrillator in 1980 with approval by the FDA in 1985. Telectronics developed the first Australian defibrillator with considerable input from the unit, resulting in the first Australian made defibrillator inserted by the unit in 1987. The staffing at the unit has been a combination of staff specialists and visiting medical officers who have worked in all invasive and non invasive laboratories. This resulted in a unique and successful concept with the VMOs also attending the peripheral hospitals of the area resulting in the first successful example of clinical networking throughout the area. This has resulted in a full range of cardiac services available to all patients in all hospitals of the area.
Professor John Uther was the Director of Cardiology at Westmead Hospital from 1979 to 1990. Professor David Ross and Dr Pramesh Kovoor followed in this capacity subsequently. Networking between Westmead and metropolitan hospitals was established by conjoint appointment of cardiologists across the facilities. Westmead has maintained its excellence in electrophysiology with leadership in operative/catheter ablation of atrial fibrillation, development of catheter for mapping tricuspid annulus, multi-electrode mapping and intramural ablation of ventricular tachycardia and paediatric electrophysiology. Dr. Hugh Paterson became the Director of Cardiothoracic Surgery in 2006. The previous Directors were Dr. David Johnson, Dr. Graham Nunn and Associate Professor Richard Chard. Westmead established an area-wide acute infarct angioplasty service for all patients presenting to any facility in Western Sydney along with triage of chest pain in the ambulance in 2004. Collaborative sessions with vascular surgeons for non-coronary interventions commenced in 2005. In the future, Westmead will continue its excellence in vascular and electrophysiological interventions. Imaging (echocardiography, computerised tomography and magnetic resonance imaging) will be a major part of the service. Innovation in basic science is likely. Overall, it will be an exciting time to be a cardiologist, vascular surgeon or cardiothoracic surgeon at Westmead.
Methicillin resistant Staphylococcus aureus (MRSA) endocarditis is increasing in frequency and has a high mortality. This condition has not been specifically described in an Australian population previously.
To describe the characteristics, management and outcomes of patients with MRSA endocarditis in an Australian hospital and identify trends in this group over 16 years.
Retrospective case series of MRSA endocarditis patients between 1991 and 2006.
Between 1991 and 2006, 27 patients were managed for MRSA endocarditis. This group consisted of 18 males (67%). The median age was 64 years. Infection was related to a prosthetic valve or annular ring in 10 patients (37%). The most common comorbidities were diabetes mellitus 8 (30%) and malignancy 8 (30%). Nosocomial acquisition occurred in 16 (59%), non-nosocomial healthcare associated acquisition in 10 (37%) and community acquisition in 1 (4%). Management was with a single antimicrobial agent in 5 (19%) and combination antimicrobial therapy in 22 (81%). Surgery was undertaken in 16 patients (59%). The mortality was 66%. Over this time there was increased non-nosocomial acquisition and presentations to non-tertiary hospitals. There was no clear improvement in survival over the 16 years.
In this Australian setting, MRSA endocarditis was mostly nosocomial or healthcare associated. Common characteristics were older patients with multiple co-morbidities. Despite high rates of combination antibiotic therapy and surgery, mortality was very high. There is a need for randomised comparative antibiotic studies.
To report on the 'Operation Open Heart' (OOH) cardiac surgical program in Papua New Guinea (PNG). To document the short-term surgical outcome, the experience gained and the skill transfer from the visiting team members to their PNG counterparts.
Analysis of the database compiled from the records of the patients who were operated on by the visiting cardiothoracic surgical team.
Four hundred and seventy patients from all regions of the country received operations. Three hundred and thirty seven (72%) were children less than 12 years of age, 39 (8%) were between 12 and 18 years of age and 263 (56%) were females. One hundred and eighty five (40%) patients had open heart procedures. Complications were unremarkable and the short-term mortality was 1.9%. Clinical skills were transferred to, and experience was gained by national anaesthetists, surgeons, paediatricians, physicians and nurses from intensive and full nursing care units and the operating theatre.
The program not only achieved a higher annual operation rate than previous programs but also had a lower mortality rate. It achieved its objective of service delivery and, to a considerable extent, its objective of skill transfer. There now is an established and active group of PNG doctors and nurses with the skills, experience and confidence to perform patent ductus repair safely and efficiently. The program is cheaper than its predecessors, and is less disruptive for parents, patients and families.
The purpose of this study is to define the long-term patency of the radial artery (RA) graft and review the current literature.
Two hundred and eighty-six RA symptom-directed graft angiograms were studied in 209 patients. The preoperative patient characteristics and intraoperative variables were collected prospectively from patients who had primary coronary artery bypass grafting between 1995 and 2002. A total of 166 (79%) patients were male with a mean age of 65 years. The mean period from operation to re-angiogram was 35 months. Actuarial techniques are not valid in graft patency studies as the time when the graft occluded is not known. Therefore, RA patency was analyzed at four categorical time intervals. The RA was grafted to the left anterior descending artery (LAD) in six patients (2%), diagonal (DIAG) in 29 (10%), obtuse marginal (OM) in 166 (58%), right coronary artery (RCA) in 9 (3%) and posterior descending artery (PDA) in 76 (27%) cases. The graft failure was defined as >or=80% stenosis.
A total of 259 (91%) grafts were patent and 26 (9%) had failed. Most grafts were widely patent or occluded. The LAD/DIAG patency was 30/35 (86%), OM patency 154/166 (93%) and RCA/PDA patency 79/84 (94%). The interval from surgery to angiogram did not affect the RA graft patency (86% at <1 year, 95% at 1-3 years, 89% at 4-5 years, 96% at >5 years).
Even in a patient cohort with adverse symptoms, excellent RA patency was achieved that remained almost constant through all time intervals studied. Better selection, harvesting and preservation may further improve early patency.
As there is no current information regarding the fate of abstracts presented at annual scientific meetings of the Cardiac Society of Australia and New Zealand (CSANZ), we examined the publication rate and indexed impact of original articles arising from these abstracts.
Conference abstracts from 1999 to 2005 were evaluated as these were accessible in electronic file form. Searches were conducted for abstract authors and keywords were searched for in journal publication citations (to November 30, 2007) in the National Library of Medicine (NIH, USA) PubMed database. A match of abstract to retrieve full article was identified on the basis of authorship, similarities in titles and study design. The ISI Web of Knowledge citation database (Philadelphia, USA) was accessed for Journal Citation Reports impact factors (IF).
A total of 2172 abstract presentations resulted in 648 original publications (30%, mean IF = 4.4). Most publications were published within 1 (61%) or 2 years (84%), with a mean lag of 1.5 years. The proportions of abstract presentations represented by Clinical, Basic Science and Surgical categories were 70.6%, 26.9%, and 2.5%, respectively. Subsequent publication rates (and IF) arising from within these categories were 25.8% (IF = 4.8), 34.4% (IF = 5.1) and 97.9% (IF = 3.1), respectively.
(1) Almost a third of CSANZ abstract presentations result in publication of an original article. (2) Most are published within 1-2 years. (3) The average IF is mid-range, with 32% of publications having an IF above 4.4. Despite the limitations to publication faced by CSANZ members, a high quality and timely publication rate is nonetheless evident.
c-kit-positive cardiac progenitor cells (CPCs) have been proven suitable for stem cell therapy. CPCs marker c-kit and its ligand, the stem cell factor (SCF), are associated with the functions of proliferation and differentiation. In our previous study, we found that stromal cell-derived factor-1α (SDF-1α) could enhance the expression of c-kit. However, the mechanism is unknown.
CPCs were isolated from adult mouse hearts, and c-kit-positive CPCs were purified by magnetic-activated c-kit cell sorting magnetic beads. The cells were cultured with SDF-1α, c-kit expression was measured by western blotting and qPCR, the proliferation and migration of cells were measured by CCK-8 and transwell assay, DNA methyltransferase (DNMT) mRNA were measured by qPCR, global DNMT activity was measured by DNMT activity assay kit, and DNA methylation was analysed using Sequenom's MassARRAY platform. Results showed that SDF-1α could enhance the expression of c-kit, which results in the promoting of c-kit-positive CPCs proliferation and migration. SDF-1α stimulation inhibited the expression of DNMT1, DNMT3β, and global DNMT activity, which led to significant demethylation in c-kit-positive CPCs.
SDF-1α signalling, via CXCR4 activation, up-regulated c-kit expression by inhibiting DNMT1 and DNMT3β expression and global DNMT activity, and by subsequent demethylation of the c-kit gene.
To investigate the effect of basic fibroblast growth factor (bFGF) on myocardial expression of hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) following acute myocardial infarction (AMI) in rats.
Eighty male Sprague-Dawley rats were divided into sham operation (n=20), AMI control (n=20), bFGF50 (intravenous bFGF 50 μg/kg/d, n=20) and bFGF200 (intravenous bFGF 200 μg/kg/d, n=20) groups. The left ventricular ejection fraction (LVEF) was measured by echocardiography. The expression of HIF-1α mRNA and VEGF mRNA in the ischaemic tissues was analysed by reverse transcription-polymerase chain reaction.
The LVEF in the bFGF50 and bFGF200 group was higher than in the AMI control group (p<0.05) seven and 14 days after the treatment. There was no difference in HIF-1α mRNA expression between the bFGF50 and AMI control group (p>0.05). However, the HIF-1α mRNA expression in the bFGF200 group was higher than in the AMI control group seven days (1.13 ± 0.18 vs 0.90 ± 0.14, p<0.01) and 14 days (1.31 ± 0.18 vs 0.93 ± 0.09, p<0.01) after the treatment. The VEGF mRNA expression in the bFGF200 group was also higher than in the AMI control group seven days (1.10 ± 0.17 vs 0.86 ± 0.14, p<0.01) and 14 days after the AMI (1.28 ± 0.19 vs 0.89 ± 0.14, p<0.01).
bFGF therapy was associated with an improvement in left ventricular function and an increase in myocardial expression of HIF-1α mRNA and VEGF mRNA following AMI. bFGF may exert its cardioprotective effect through upregulating HIF-1α mRNA and VEGF mRNA in the ischaemic myocardium.
To establish a national profile of the current cardiothoracic surgery workforce and advise the Australian Government on workforce requirements to 2011, the Cardiothoracic Surgery Workforce Working Party brought down a report in May 2001 to The Australian Medical Workforce Advisory Committee. The survey data were taken from half the current Fellows of the Royal Australian College of Surgeons engaged in cardiothoracic surgery. Australian cardiothoracic surgeons are typically middle-aged males working more than 60 h per week. Their work has both private and public sector components and most surgeons provide services in both cardiac and thoracic surgery to an average catchment of 180 000 people. Concentrated in the capital cities, mainly on the eastern seaboard, they devote 90% of their working hours to service delivery, with little time spent in research and developmental aspects of their profession, or in administrative roles. The committee provided 10-year projections for surgical services, predicting an annual growth in service requirements of 1.8% in Australia to 2011. The report concludes that maintenance of the present intake of surgical trainees at five per year - offset by the projected retirements of 2.7 surgeons annually - will be sufficient to meet demand. This conclusion is based on an assumption of a decade of unchanged national health structures and patterns of workforce participation and service delivery.
Despite Coronary Heart Disease exacting a heavy toll among Aboriginal Australians, accurate estimates of its epidemiology are limited. This study compared the incidence of acute myocardial infarction (AMI) and 28-day case fatality (CF) among Aboriginal and non-Aboriginal Western Australians aged 25-74 years from 2000-2004.
Incident (AMI hospital admission-free for 15 years) AMI events and 28-day CF were estimated using person-based linked hospital and mortality data. Age-standardised incidence rates and case fatality percentages were calculated by Aboriginality and sex.
Of 740 Aboriginal and 6933 non-Aboriginal incident events, 208 and 2352 died within 28 days, respectively. The Aboriginal age-specific incidence rates were 27 (males) and 35 (females) times higher than non-Aboriginal rates in the 25-29 year age group, decreasing to 2-3 at 70-74 years. The male:female age-standardised incidence rate ratio was 2.2 in Aboriginal people 25-54 years compared with 4.5 in non-Aboriginal people. Aboriginal age-standardised CF percentages were 1.4 (males) and 1.1 (females) times higher at age 25-54 years and 1.5 times higher at age 55-74 years.
These data suggest higher CF and, more importantly, AMI incidence contribute to the excess ischaemic heart disease mortality in Aboriginal Western Australians. The poorer cardiovascular health in Aboriginal women, particularly in younger age groups, should be investigated.
A pacemaker (PM) and implantable cardioverter-defibrillator (ICD) survey was undertaken in Australia (Au) and New Zealand (NZ) for calendar year 2001.
Results and conclusions:
Compared to the 1997 survey, significant increases in implantation numbers were recorded. For 2001, the total new PMs implanted was 9498 Au (6405 in 1997) and 914 NZ (823 in 1997). The number of new PM implants per million population was 486 Au (345 in 1997) and 245 NZ (228 in 1997). There were also significant increases in PM replacements between surveys with 1536 in Au (735 in 1997) and 195 in NZ (126 in 1997). Dual chamber implants were 71% Au (65% in 1997) and 56% NZ (55% in 1997). Pacing leads were overwhelmingly transvenous and bipolar with an increase in the use of active fixation leads in preference to tined leads, particularly in the atrium. There was a marked increase in the use of ICDs. The implants were 956 Au (449 in 1997) and 86 NZ (31 in 1997) with new implants per million population being 49 Au and 23 NZ. A breakdown of data for the six Au States and well as comparisons of similar surveys from other countries is presented.
The Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) have established a database for the collection and analysis of the results of cardiac surgery in Australia and New Zealand. Initially data has been collected only in Victoria public hospitals. This report covers the first 12 months of data collection from 1st August 2001 to 1st July 2002.
Whilst cardiac surgical performance in Australia is considered to be of a high standard equivalent to other developed countries, there is currently no systematic approach to data collection in order to provide performance indicators and benchmarks. The development of an Australasian cardiac surgical database and performance indicators will enable benchmarking and comparison with international standards which should lead to performance improvements.
A database definition set and standardised data collection form was developed by the ASCTS for all participating cardiac surgery units in public hospitals in Victoria. Opt-off consent for subject inclusion in the database was approved by each participating institutional ethics review committee. An electronic database and reporting application was developed. Data included in this analysis is from the initial 12 months collection from all hospitals participating in the project from 1st August 2001 to 31st July 2002.
Overall, there were 2982 procedures performed in this period of which 2969 had sufficient data to be included in this analysis (99.5%). The majority of procedures 2017 (68%) being undertaken were isolated coronary artery bypass surgery (CABG). The mean age of all subjects undergoing procedures was 65 years (range: 18-91 years) and 70% were male. 64% of all procedures were elective and 6.1% emergency or salvage. Median post-procedure length of hospital stay for all procedures was 6.0 days and intensive care unit (ICU) stay was 23.0h. Re-operation for haemorrhage occurred in 2.1% of all cases and deep sternal infection in 0.4% of all cases. Crude 30-day operative mortality was 3.6% for all procedures; 2.1% for isolated CABG, 3.6% for valve procedures, 5.2% for valve and CABG and 11.4% for other cardiac surgical procedures. Mortality rates increased from 1.8% for elective procedures to 4.1% for urgent and 24.6% for emergency or salvage operations. In comparison to international figures from the USA and UK, mortality rates following isolated CABG were lower whilst average length of hospital stay post-procedure was higher.
The ASCTS database project is now well established and the electronic database and reporting module is in operation in all participating sites. The risk-adjusted isolated operative mortality suggests cardiac surgical performance in Victoria compares well with international standards. As the database develops, local risk-adjustment models for mortality and morbidity for each procedure will be developed to enable appropriate between hospital comparisons.
The cardiac surgical programme at Epworth Hospital has performed in excess of 13 000 open-heart surgical procedures between 1981 and 2003. During the audit period (2002) 411 patients underwent open-heart surgery. The 2002 Cardiac Surgical Audit confirms the very high standard of surgery. The goals for the future are to maintain the low complication rate and maintain an efficiency to reduce the financial burden on the hospital, the insurance companies and the health system. (Heart, Lung and Circulation 2003; 12: S39−S41)
In March 2001, the Victorian Heart Centre at Epworth Hospital implemented a database management system to improve the standard of data collection and analysis of procedures performed in our catheter laboratory. A retrospective analysis of procedures undertaken during 2000, together with prospective data collected during 2001/2002, has enabled us to achieve our goals of benchmarking performance and undertaking research on the outcomes of interventional cardiology procedures at Epworth. The figures reported in this year's cardiac catheterisation laboratory audit report confirm a continued high standard performance in our laboratory.
Although pacing and electrophysiology (EP) have been practised at the Epworth since the mid-1980s, they have enjoyed significant and continued growth since the opening of the J.G. Sloman dedicated EP laboratory 4 years ago. Nevertheless, there has not been a formal audit performed in these fields so far. This analysis sought to define the number and nature of the cases treated in the EP and pacing laboratory over a period of 18 months, so that recommendations might be made to improve our future practise in this area. Whilst it became apparent that the lack of a uniform and consistent data base (such as that which is used for the interventional cardiology laboratory) significantly hampered the process of this analysis, nevertheless the analysis revealed the high standard of performance and level of success attained in these cases over the given time period.
To describe monitoring of four years' isolated coronary artery bypass surgery outcomes and complications at The Prince Charles Hospital, Brisbane, Australia.
Analysis of Cardiac Surgical Register database using tabulations, funnel plots and random-effects (Bayesian shrinkage) analysis for aggregated data. Combined CUSUM and cumulative observed minus expected (modified VLAD) charts and combined CUSUM and cumulative funnel plots used for individual observation sequential data and binomial control charts and generalised additive models (GAMs) for quarterly sequential data. Risk adjustment employed re-calibrated EuroSCORE.
There were 2575 procedures with an unadjusted in-hospital mortality rate of 1.17%. Mean age was 65 years and 21% of patients were female; 43.6% were elective procedures. Median ventilation time was 10 hours and median length of stay in intensive care (ICU) was 23 hours. Return to theatre for bleeding occurred in 3% of cases. Return to theatre for surgical site infection occurred in 0.4% of cases; 4% were re-do procedures. Permanent stroke or neurological deficit occurred in 1%, perioperative myocardial infarction in 0.8%, arrest in 1.2%, renal failure in 1.6% and ICU return in 2.3% of cases.
Complication rates and mortality were comparable with similar units. Use of random-effects (Bayesian shrinkage) analysis for aggregated data is encouraged together with generalised additive models (GAMs) and combined CUSUM and cumulative observed minus expected (modified VLAD) charts for sequential data.
A pacemaker (PM) and implantable cardioverter-defibrillator (ICD) survey was undertaken in Australia (Au) and New Zealand (NZ) for 2005.
Results and conclusions:
Compared to the 2001 survey, significant increases in implantation numbers were recorded. For 2005, the total new PMs implanted was 11,850 in Au (9498 in 2001) and 1134 in NZ (914 in 2001). The number of new PM implants per million population was 590 in Au (486 in 2001) and 275 in NZ (245 in 2001). Biventricular PMs were documented for the first time with 461 implants in Au and 16 in NZ. Pulse generator types were predominantly dual chamber with 73% in Au (70% in 2001) and 51% in NZ (54% in 2001). Pacing leads were overwhelmingly transvenous and bipolar with an increase in the use of active fixation leads in preference to tined leads. There was a marked increase in the use of ICDs with 2864 new implants in Au (956 in 2001) and 134 in NZ (86 in 2001). The new ICD implants per million population were 142 in Au (49 in 2001) and 33 in NZ (23 in 2001). ICDs were 35% biventricular in Au and 10% in NZ. The Au Northern Territory is included for the first time.
The cardiac catheterisation laboratory interventional audit for 2007 showed that 761 cases were performed, treating at total of 941 lesions. Unstable coronary syndromes accounted for 59% of all cases. Coronary stenting was performed in 93.3% of cases, with drug-eluting stents being utilised 88% of the time. Adjunctive therapies included intra-aortic balloon pumping in 3.1% of cases, & 19.5% of patients received a glycoprotein IIb/IIIa inhibitor. Procedural success was attained in 96.1% of cases, with an overall mortality rate of 0.53%, and a similar 0.53% of patients proceeded to surgical revascularisation in the same admission.
A total of 498 patients underwent open-heart surgery in 2007 with 5 deaths (1%).There was no mortality in 248 patients who had de novo isolated coronary bypass surgery. Major mortality and morbidities were almost exclusively confined to patients over the age of 80 years. The development of new catheter based procedures such as aortic valve replacement is likely to decrease the complication rate and length of hospital stay in this high risk group of patients.
A pacemaker (PM) and Implantable Cardioverter-Defibrillator (ICD) Survey was undertaken in Australia and New Zealand for the calendar year 2009.
Results and conclusions:
For 2009, the number of new implants for Australia was 12,523 (11,850 in 2005) and 1277 for New Zealand (1134 in 2005). The number of new PM implants per million population was 565 for Australia (590 in 2005) and 299 for New Zealand (275 in 2005). Both countries had substantial increases in PM replacements. There were 446 biventricular PMs implanted in Australia (461 in 2005) and 45 in New Zealand (16 in 2005). Pulse generator types were predominantly dual chamber with 71% for Australia (72% in 2005) and 54% for New Zealand (51% in 2005). Transvenous pacing leads were overwhelmingly bipolar with marked increases in the use of active fixation leads; Australia 80% atrium, 75% ventricle and New Zealand 65% atrium, 62% ventricle. There was also a marked increase in the number of new ICDs implanted; Australia 3555 (2864 in 2005) and New Zealand 329 (134 in 2005). The new ICD implants per million population were 160 for Australia (142 in 2005) and 77 for New Zealand (33 in 2005). The usage of biventricular ICDs was 33% for Australia and 13% for New Zealand.
Three priority areas in the prevention, diagnosis and management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) were identified and discussed in detail: 1. Echocardiography and screening/diagnosis of RHD - Given the existing uncertainty it remains premature to advocate for or to incorporate echocardiographic screening for RHD into Australian clinical practice. Further research is currently being undertaken to evaluate the potential for echocardiography screening. 2. Secondary prophylaxis - Secondary prophylaxis (long acting benzathine penicillin injections) must be seen as a priority. Systems-based approaches are necessary with a focus on the development and evaluation of primary health care-based or led strategies incorporating effective health information management systems. Better/novel systems of delivery of prophylactic medications should be investigated. 3. Management of advanced RHD - National centres of excellence for the diagnosis, assessment and surgical management of RHD are required. Early referral for surgical input is necessary with multidisciplinary care and team-based decision making that includes patient, family, and local health providers. There is a need for a national RHD surgical register and research strategy for the assessment, intervention and long-term outcome of surgery and other interventions for RHD. (Heart, Lung and Circulation 2012;21:632-638)
Traditionally, treatment options for patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) are limited. Bosentan has been shown to improve pulmonary haemodynamics and exercise tolerance short term but long term clinical studies are lacking.
To report long term efficacy and safety data with endothelin receptor antagonists (ERA) in patients with PAH associated CHD.
Prospective, open label, uncontrolled, single centre study of 53 patients (33 females, 17 Trisomy 21, mean age 34 ± 12 years) prescribed ERA (48 bosentan, 5 sitaxentan) from 2003 to August 2009. Outcome measurements of oxygen saturation (SaO2), WHO functional class, 6-minute walk test distance (6MWD) and adverse events were analysed.
Mean duration of therapy was 15 ± 13 months in 53 patients with CHD. Four patients failed ERA, seven died (five progressive RHF) and one delisted from transplantation. No abnormal liver transaminases occurred on bosentan, with one case on sitaxentan. After 3, 6, 12, 18 and 24 months of treatment a significant improvement was seen in WHO functional class (mean 3.15 vs 2.8 vs 2.5 vs 2.5 vs 2.4 vs 2.4; p<0.01) and 6MWD (344 ± 18 vs 392 ± 17 vs 411 ± 17 vs 420 ± 17 vs 442 ± 18 vs 417 ± 23: p<0.0005, p<0.01) compared with baseline. The Trisomy 21 and PAH-CHD showed a significant improvement in 6MWD at 6 and 12 months (263 ± 24 vs 348 ± 29 vs 360 ± 32, p<0.01, p<0.05) respectively. No changes in SaO2, BNP, RV or LV function were demonstrated during follow-up.
This large single centre study demonstrates that endothelin receptor antagonism is an effective and safe treatment in PAH associated CHD with or without Trisomy 21. The improvements in exercise tolerance are similar to reported benefits in other forms of PAH.