Results: In total, 91 patients had adequate image quality for analysis (mean age 64 ± 13 years; 6... more Results: In total, 91 patients had adequate image quality for analysis (mean age 64 ± 13 years; 63 males). Four-dimensional AutoRVQ-derived TAPSE strongly correlated with 2D RV S' and 2D TAPSE (Figure A, r = 0.43 [p < 0.0001]; Figure B r = 0.44 [p < 0.0001]). Four-dimensional EF correlated well with 4D FAC (r = 0.77, p < 0.001). Four-dimensional TAPSE correlated well with 4D FAC (r = 0.26, p = 0.01). However, no significant correlation was found between 4DAutoRVQ-derived RVEF and RVFAC and 2D RV S' and TAPSE. Conclusion: Four-dimensional AutoRVQ-derived TAPSE significantly correlated with conventional RV S' and TAPSE. Correlations between 4DEF, 4DFAC, and 4DTAPSE were strong.
Background: Angiotensin converting enzyme inhibitor (ACEi) and beta-blocker (BB) medications are ... more Background: Angiotensin converting enzyme inhibitor (ACEi) and beta-blocker (BB) medications are indicated in patients with impaired left ventricular (LV) systolic function. These medications result in improved prognosis, quality of life and LV function, with a proportion of complete recovery of LV systolic function. The proportion of patients who require lifelong medication use for indications other than previous LV dysfunction is unclear. Methods: We conducted a retrospective analysis of 1400 cardiology patients treated at Princess Alexandra Hospital, Brisbane, up to 2014. Data collected include, patient demographics, medical history, medication use, imaging results and clinical outcomes. Results: 1400 cardiology medical records were evaluated. Significantly impaired LV systolic function (LV EF ≤ 40%) was noted in 559 patients (39.9%) at the beginning of their medical treatment, of which 173 patients had no coronary artery disease and were still alive in 12 months. In the nonischaemic cases, recovery of LV systolic function was noted in 27.7%, the majority of which had indications for ACEi and BB use other than previous cardiomyopathy. Only 18 out of 559 patients (3.2%) with history of LV impairment has previous non-ischaemic cardiomyopathy as sole indications for ongoing ACEi and BB use. Conclusion: Only a very small proportion of patients have previous non-ischaemic cardiomyopathy as sole indication for ongoing ACEi and BB use. Most other patients have additional disease indications for continuing these medications.
spatial resolution we hypothesised that the dose delivered with CTCA would be less than delivered... more spatial resolution we hypothesised that the dose delivered with CTCA would be less than delivered by ICA. Methods: We reviewed our ICA database to identify severely obese patients (defined by BMI>34 kg/m2) who had undergone both diagnostic ICA and CTCA between January 2013 and February 2016. Patients who proceeded to PCI or had right heart catheters were excluded. Image quality and diagnostic accuracy were not part of this analysis. The dose length product (DLP) from CTCA and dose area product (DAP) from ICA were recorded and converted to mSv to estimate the effective radiation dose for each modality. Results: Twenty-six patients met the inclusion criteria. Mean age was 60 years, mean weight was 110 kg and mean BMI was 39 kg/m 2. The mean and median radiation doses from CTCA were significantly lower than those for ICA (p<.001). The maximum radiation dose for CTCA was 8.1mSv and for ICA was 38.1mSv (Table 1)
Degenerative aortic stenosis is the most common valvular heart disease in the elderly, and many p... more Degenerative aortic stenosis is the most common valvular heart disease in the elderly, and many patients are not suitable for aortic valve replacement surgery. Transcatheter aortic valve implantation (TAVI) is a new therapeutic option for selected patients at high risk for surgery. To evaluate the safety and efficacy of TAVI in Australian patients. A prospective study of patients undergoing TAVI for severe symptomatic aortic stenosis at The Prince Charles Hospital, Brisbane, Australia between August 2008 and July 2013. Patients were at high risk of surgical aortic valve replacement, or inoperable, as deemed by a multidisciplinary 'heart team'. Outcomes include procedural success and complications; 30-day and 1-year mortality and stroke; combined endpoints as outlined by the Valve Academic Research Consortium 2 (VARC-2) consensus document. 209 patients underwent TAVI during the study period. The mean age was 83.7±6.7 years and 101 (48%) were males. The valve systems utilised ...
non-fatal coronary event. Secondary end points included nonischaemia-related death and image qual... more non-fatal coronary event. Secondary end points included nonischaemia-related death and image quality. Results: 2063 coronary segments from 145 patients were analysed with 2043 considered diagnostic (97%). Mean age was 54.0 ± 14.5 years; mean time after transplantation was 7.5 ± 7.2 years. Median follow up was 384 days. 129 segments (6.3%) were considered diseased with 14 intermediate and 18 severe stenoses. By CAV grading, there were 86, 44, 3 and 2 with grade 0, 1, 2, and 3. One coronary event occurred (suspected coronary dissection). No ischaemia-related deaths were reported. One non-ischaemic death occurred. 8 patients underwent subsequent ICA resulting in 2 stents. Immune therapy was changed based on CTCA results in 20% of patients who were not on everolimus. Conclusion: Majority of CTCA studies achieved diagnostic quality. The prevalence of significant CAV detected on routine surveillance CTCA is low but appreciable. Early detection led to appropriate therapy. Majority of patients had no visible coronary disease and had no subsequent ischaemic events. CTCA is an effective tool in identifying low risk CAV patients who have a good prognosis.
Transcatheter aortic valve replacements lower mortality in patients not suitable for surgical val... more Transcatheter aortic valve replacements lower mortality in patients not suitable for surgical valve replacement compared to conservative treatment. Transcatheter valve-in-valve implants have been shown to be feasible in failed bioprostheses in aortic, mitral, pulmonary and tricuspid positions. We report the first Australasian experience of a transapical mitral valve-in-valve placement with an Edwards Sapien(®) transcatheter valve for a failed mitral bioprosthesis, focussing on the technical aspects of this novel procedure. Whilst the evidence for this niche indication is limited currently to case reports and case series, further evaluation of its long term outcomes may justify its use in this particularly high risk group of re-do sternotomy patients.
Background: Hypertrophic cardiomyopathy (HCM) is a disease characterized by an initial preservati... more Background: Hypertrophic cardiomyopathy (HCM) is a disease characterized by an initial preservation of left ventricular ejection fraction (LVEF) in the setting of a morphologically abnormal ventricle. Myocardial onedimensional strain imaging is a relatively new method of quantifying regional myocardial function. Methods: 21 patients with HCM with normal ejection fraction and 23 age matched control patients were included in the study. 268 segments were able to be studied out of a possible 276 in the patient group and 250 out of a possible 252 segments were able to be studied in the control group. Peak systolic strain and peak strain rate, was collected for the basal, mid and apical segments in the apical four chamber and the apical two chamber views. Results: Despite there being no difference in ejection fraction between patients and controls (68% vs. 62% p = ns), there was a significant difference (p < 0.001) in peak systolic strain and peak strain rate in the basal inferoseptal, mid inferoseptal, basal anterolateral, mid-inferolateral segments. Paradoxical positive strain (systolic lengthening) was found either in the basal septum or in the mid septum of 100% of HCM patients. A significant difference (p < 0.001) for post-systolic shortening between normal and diseased segments was found in the apical anterior, midinferoseptum, mid-inferolateral and apical inferolateral segments. Conclusion: In spite of a preserved global LVEF, regional myocardial function in HCM may be markedly abnormal. The prevalence of multiple pathological markers of abnormal function such as reduced strain and strain rate, PPS and PSS promotes the role of a comprehensive examination of the left ventricle.
Aim: Transthoracic echocardiography (TTE) is the commonest method to assess ventricular function ... more Aim: Transthoracic echocardiography (TTE) is the commonest method to assess ventricular function and for presence of thrombus. However, in up to 25% of cases, images may be technically difficult, limiting accuracy of this technique. Compounding this problem is the presence of numerous echocardiographic equivalents that may mimic thrombus. This study sought to assess the impact of contrast echocardiography (CE) in assessment of ventricular thrombi in patients with sub-optimal images. Method: Over a 42 month period, all CE and simultaneous unenhanced TTE (UTTE) performed to assess for ventricular thrombus were evaluated for LVEF, presence/absence of thrombus, unenhanced TTE mimickers if negative, thrombus location/size/morphology and associated regional wall motion (RWM). Results: 234 simultaneous UTTE and CE studies were performed. Unenhanced TTE negative for thrombus (n = 77), suspicious (n = 77), non-diagnostic images (n = 57) and positive (n = 24). Using CE, thrombus was excluded in 185, suspicious in five and visualised in 44 cases. Thrombi were laminar (18), protruding (26) and mobile (11). In 75/101 cases suspicious or diagnosed on UTTE, CE demonstrated no thrombus, due to presence of trabeculation (n = 50), near field artifact (n = 11), false tendons (n = 3), other (n = 11). LVEF if thrombus present = 33.0%, LVEF if thrombus absent = 34.4% (p = ns).
Background: Hypertension (HT) is associated with left ventricular (LV) diastolic dysfunction and ... more Background: Hypertension (HT) is associated with left ventricular (LV) diastolic dysfunction and increased left atrial (LA) volume. We sought to investigate changes in LA size and function by decade in mild HT patients. Methods: Mild HT patients (31-84 years; n = 115) with blood pressure of >140/90 mm Hg but < 160/100 mmHg were compared to a case controlled normal cohort. Subjects were divided by age deciles. LA maximum, minimum and pre 'a' wave volumes were measured using the biplane method of discs. LA passive emptying and active emptying volumes and fractions were calculated. Results: The HT group had higher LA maximum volumes compared to Normals until decade 8. There was no difference between HT and Normal groups for passive emptying volumes, whilst active emptying volumes were higher in all decades in the HT group.
Five cases of exercise induced pure vasodepressor syncope in patients without significant structu... more Five cases of exercise induced pure vasodepressor syncope in patients without significant structural heart disease are reported. Hypotension and symptoms of syncope or presyncope were induced by treadmill exercise testing and in each case limited exercise performance. Evidence of inappropriate peripheral vasodilatation, probably as a consequence of ventricular mechanoreceptor stimulation, was shown in all five patients. Head up tilt testing resulted in hypotension in four patients and isoprenaline infusion in the supine position resulted in hypotension in the fifth. These patients had a new condition of exercise induced neurally mediated (vasodepressor) syncope without appreciable structural cardiac abnormalities.
Results: In total, 91 patients had adequate image quality for analysis (mean age 64 ± 13 years; 6... more Results: In total, 91 patients had adequate image quality for analysis (mean age 64 ± 13 years; 63 males). Four-dimensional AutoRVQ-derived TAPSE strongly correlated with 2D RV S' and 2D TAPSE (Figure A, r = 0.43 [p < 0.0001]; Figure B r = 0.44 [p < 0.0001]). Four-dimensional EF correlated well with 4D FAC (r = 0.77, p < 0.001). Four-dimensional TAPSE correlated well with 4D FAC (r = 0.26, p = 0.01). However, no significant correlation was found between 4DAutoRVQ-derived RVEF and RVFAC and 2D RV S' and TAPSE. Conclusion: Four-dimensional AutoRVQ-derived TAPSE significantly correlated with conventional RV S' and TAPSE. Correlations between 4DEF, 4DFAC, and 4DTAPSE were strong.
Background: Angiotensin converting enzyme inhibitor (ACEi) and beta-blocker (BB) medications are ... more Background: Angiotensin converting enzyme inhibitor (ACEi) and beta-blocker (BB) medications are indicated in patients with impaired left ventricular (LV) systolic function. These medications result in improved prognosis, quality of life and LV function, with a proportion of complete recovery of LV systolic function. The proportion of patients who require lifelong medication use for indications other than previous LV dysfunction is unclear. Methods: We conducted a retrospective analysis of 1400 cardiology patients treated at Princess Alexandra Hospital, Brisbane, up to 2014. Data collected include, patient demographics, medical history, medication use, imaging results and clinical outcomes. Results: 1400 cardiology medical records were evaluated. Significantly impaired LV systolic function (LV EF ≤ 40%) was noted in 559 patients (39.9%) at the beginning of their medical treatment, of which 173 patients had no coronary artery disease and were still alive in 12 months. In the nonischaemic cases, recovery of LV systolic function was noted in 27.7%, the majority of which had indications for ACEi and BB use other than previous cardiomyopathy. Only 18 out of 559 patients (3.2%) with history of LV impairment has previous non-ischaemic cardiomyopathy as sole indications for ongoing ACEi and BB use. Conclusion: Only a very small proportion of patients have previous non-ischaemic cardiomyopathy as sole indication for ongoing ACEi and BB use. Most other patients have additional disease indications for continuing these medications.
spatial resolution we hypothesised that the dose delivered with CTCA would be less than delivered... more spatial resolution we hypothesised that the dose delivered with CTCA would be less than delivered by ICA. Methods: We reviewed our ICA database to identify severely obese patients (defined by BMI>34 kg/m2) who had undergone both diagnostic ICA and CTCA between January 2013 and February 2016. Patients who proceeded to PCI or had right heart catheters were excluded. Image quality and diagnostic accuracy were not part of this analysis. The dose length product (DLP) from CTCA and dose area product (DAP) from ICA were recorded and converted to mSv to estimate the effective radiation dose for each modality. Results: Twenty-six patients met the inclusion criteria. Mean age was 60 years, mean weight was 110 kg and mean BMI was 39 kg/m 2. The mean and median radiation doses from CTCA were significantly lower than those for ICA (p<.001). The maximum radiation dose for CTCA was 8.1mSv and for ICA was 38.1mSv (Table 1)
Degenerative aortic stenosis is the most common valvular heart disease in the elderly, and many p... more Degenerative aortic stenosis is the most common valvular heart disease in the elderly, and many patients are not suitable for aortic valve replacement surgery. Transcatheter aortic valve implantation (TAVI) is a new therapeutic option for selected patients at high risk for surgery. To evaluate the safety and efficacy of TAVI in Australian patients. A prospective study of patients undergoing TAVI for severe symptomatic aortic stenosis at The Prince Charles Hospital, Brisbane, Australia between August 2008 and July 2013. Patients were at high risk of surgical aortic valve replacement, or inoperable, as deemed by a multidisciplinary 'heart team'. Outcomes include procedural success and complications; 30-day and 1-year mortality and stroke; combined endpoints as outlined by the Valve Academic Research Consortium 2 (VARC-2) consensus document. 209 patients underwent TAVI during the study period. The mean age was 83.7±6.7 years and 101 (48%) were males. The valve systems utilised ...
non-fatal coronary event. Secondary end points included nonischaemia-related death and image qual... more non-fatal coronary event. Secondary end points included nonischaemia-related death and image quality. Results: 2063 coronary segments from 145 patients were analysed with 2043 considered diagnostic (97%). Mean age was 54.0 ± 14.5 years; mean time after transplantation was 7.5 ± 7.2 years. Median follow up was 384 days. 129 segments (6.3%) were considered diseased with 14 intermediate and 18 severe stenoses. By CAV grading, there were 86, 44, 3 and 2 with grade 0, 1, 2, and 3. One coronary event occurred (suspected coronary dissection). No ischaemia-related deaths were reported. One non-ischaemic death occurred. 8 patients underwent subsequent ICA resulting in 2 stents. Immune therapy was changed based on CTCA results in 20% of patients who were not on everolimus. Conclusion: Majority of CTCA studies achieved diagnostic quality. The prevalence of significant CAV detected on routine surveillance CTCA is low but appreciable. Early detection led to appropriate therapy. Majority of patients had no visible coronary disease and had no subsequent ischaemic events. CTCA is an effective tool in identifying low risk CAV patients who have a good prognosis.
Transcatheter aortic valve replacements lower mortality in patients not suitable for surgical val... more Transcatheter aortic valve replacements lower mortality in patients not suitable for surgical valve replacement compared to conservative treatment. Transcatheter valve-in-valve implants have been shown to be feasible in failed bioprostheses in aortic, mitral, pulmonary and tricuspid positions. We report the first Australasian experience of a transapical mitral valve-in-valve placement with an Edwards Sapien(®) transcatheter valve for a failed mitral bioprosthesis, focussing on the technical aspects of this novel procedure. Whilst the evidence for this niche indication is limited currently to case reports and case series, further evaluation of its long term outcomes may justify its use in this particularly high risk group of re-do sternotomy patients.
Background: Hypertrophic cardiomyopathy (HCM) is a disease characterized by an initial preservati... more Background: Hypertrophic cardiomyopathy (HCM) is a disease characterized by an initial preservation of left ventricular ejection fraction (LVEF) in the setting of a morphologically abnormal ventricle. Myocardial onedimensional strain imaging is a relatively new method of quantifying regional myocardial function. Methods: 21 patients with HCM with normal ejection fraction and 23 age matched control patients were included in the study. 268 segments were able to be studied out of a possible 276 in the patient group and 250 out of a possible 252 segments were able to be studied in the control group. Peak systolic strain and peak strain rate, was collected for the basal, mid and apical segments in the apical four chamber and the apical two chamber views. Results: Despite there being no difference in ejection fraction between patients and controls (68% vs. 62% p = ns), there was a significant difference (p < 0.001) in peak systolic strain and peak strain rate in the basal inferoseptal, mid inferoseptal, basal anterolateral, mid-inferolateral segments. Paradoxical positive strain (systolic lengthening) was found either in the basal septum or in the mid septum of 100% of HCM patients. A significant difference (p < 0.001) for post-systolic shortening between normal and diseased segments was found in the apical anterior, midinferoseptum, mid-inferolateral and apical inferolateral segments. Conclusion: In spite of a preserved global LVEF, regional myocardial function in HCM may be markedly abnormal. The prevalence of multiple pathological markers of abnormal function such as reduced strain and strain rate, PPS and PSS promotes the role of a comprehensive examination of the left ventricle.
Aim: Transthoracic echocardiography (TTE) is the commonest method to assess ventricular function ... more Aim: Transthoracic echocardiography (TTE) is the commonest method to assess ventricular function and for presence of thrombus. However, in up to 25% of cases, images may be technically difficult, limiting accuracy of this technique. Compounding this problem is the presence of numerous echocardiographic equivalents that may mimic thrombus. This study sought to assess the impact of contrast echocardiography (CE) in assessment of ventricular thrombi in patients with sub-optimal images. Method: Over a 42 month period, all CE and simultaneous unenhanced TTE (UTTE) performed to assess for ventricular thrombus were evaluated for LVEF, presence/absence of thrombus, unenhanced TTE mimickers if negative, thrombus location/size/morphology and associated regional wall motion (RWM). Results: 234 simultaneous UTTE and CE studies were performed. Unenhanced TTE negative for thrombus (n = 77), suspicious (n = 77), non-diagnostic images (n = 57) and positive (n = 24). Using CE, thrombus was excluded in 185, suspicious in five and visualised in 44 cases. Thrombi were laminar (18), protruding (26) and mobile (11). In 75/101 cases suspicious or diagnosed on UTTE, CE demonstrated no thrombus, due to presence of trabeculation (n = 50), near field artifact (n = 11), false tendons (n = 3), other (n = 11). LVEF if thrombus present = 33.0%, LVEF if thrombus absent = 34.4% (p = ns).
Background: Hypertension (HT) is associated with left ventricular (LV) diastolic dysfunction and ... more Background: Hypertension (HT) is associated with left ventricular (LV) diastolic dysfunction and increased left atrial (LA) volume. We sought to investigate changes in LA size and function by decade in mild HT patients. Methods: Mild HT patients (31-84 years; n = 115) with blood pressure of >140/90 mm Hg but < 160/100 mmHg were compared to a case controlled normal cohort. Subjects were divided by age deciles. LA maximum, minimum and pre 'a' wave volumes were measured using the biplane method of discs. LA passive emptying and active emptying volumes and fractions were calculated. Results: The HT group had higher LA maximum volumes compared to Normals until decade 8. There was no difference between HT and Normal groups for passive emptying volumes, whilst active emptying volumes were higher in all decades in the HT group.
Five cases of exercise induced pure vasodepressor syncope in patients without significant structu... more Five cases of exercise induced pure vasodepressor syncope in patients without significant structural heart disease are reported. Hypotension and symptoms of syncope or presyncope were induced by treadmill exercise testing and in each case limited exercise performance. Evidence of inappropriate peripheral vasodilatation, probably as a consequence of ventricular mechanoreceptor stimulation, was shown in all five patients. Head up tilt testing resulted in hypotension in four patients and isoprenaline infusion in the supine position resulted in hypotension in the fifth. These patients had a new condition of exercise induced neurally mediated (vasodepressor) syncope without appreciable structural cardiac abnormalities.
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