The Journal of Heart and Lung Transplantation, 2006
A Fontan operation will eventually fail in many patients. Fontan conversion to extracardiac condu... more A Fontan operation will eventually fail in many patients. Fontan conversion to extracardiac conduit has been recommended but is not always successful. We present a case of a patient who went into intractable heart failure after reoperation, was rescued by left ventricular assist device implantation, and was finally bridged to heart transplantation.
The Journal of thoracic and cardiovascular surgery, 2013
Surgical aortic valve replacement is being increasingly performed in elderly patients with good p... more Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly. A systematic review of clinical studies after January 2000 was performed to identify health-related quality of life in the elderly after aortic valve replacement. Strict inclusion and exclusion criteria were applied. Quality appraisal of each study also was performed using predefined criteria. Health-related quality of life results were synthesized through a narrative review with full tabulation of the results of all included studies. Health-related quality of life improvements were shown across most or all domains in different health-related quality of life instruments. Elderly patients experienced marked symptomatic improvement. Health-related quality of life was equivalent or superior to b...
The mitral annulus can be rendered hostile by several uncommon clinical situations such as infect... more The mitral annulus can be rendered hostile by several uncommon clinical situations such as infective endocarditis, calcification, or previous valve surgery. These can all lead to difficulties seating a prosthesis or annuloplasty ring. The posterior mitral annulus or anteriorly the intervalvar fibrous body can be affected. These situations continue to pose a formidable technical challenge to the cardiac surgeon in the operating room. We review the evidence around solutions for these problems with the intent of giving surgeons an overview of techniques to address these issues.
Background: Surgical aortic valve replacement is being increasingly performed in elderly patients... more Background: Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly.
PLT from 11% to 39%, one or more FFP from 11% to 48% and one or more cryoprecipitate from 1% to 2... more PLT from 11% to 39%, one or more FFP from 11% to 48% and one or more cryoprecipitate from 1% to 20%. Similar variation was still present when the analysis was limited to isolated first-time CABG. Hospital-characteristics, including state or territory, private versus public and teaching versus non-teaching, were not associated with variation in transfusion rates.
Aims: To assess outcomes with a new fully repositionable and retrievable valve for transcatheter ... more Aims: To assess outcomes with a new fully repositionable and retrievable valve for transcatheter aortic valve replacement (TAVR).
Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasio... more Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasionally necessary when noninvasive imaging and Doppler echocardiographic data are inconclusive or differ from the clinical findings for specific scenarios, such as diagnosing constrictive or restrictive physiology. We present a case in which we safely and effectively replicate the previous successful application of a PressureWire in diagnosing constrictive pericarditis in a patient with a bileafltet mechanical aortic and mitral valves.
The collection of fluid in the mediastinum after cardiac surgery is traditionally prevented using... more The collection of fluid in the mediastinum after cardiac surgery is traditionally prevented using underwater seal drains that may be connected to low-pressure suction. High-vacuum drains (redivac drains) are a potential alternative to this arrangement and have previously been utilized in areas of general surgery, as well as in the treatment of post-sternotomy mediastinitis. There has been no study to date addressing the safety and efficacy of these drains following pediatric cardiac surgery. Five hundred and forty-six patients were prospectively randomised to receive either the redivac drains or the conventional underwater-seal drains attached to low-pressure wall suction. We sought to test the null hypothesis that there was no difference in the incidence of residual pericardial or pleural collections requiring drainage between the 2 drainage systems. Secondary endpoints included time to drain removal, volume of drainage and drain size. Analysis was performed on an intention to treat basis. Two hundred and thirty-seven patients were allocated to the redivac group, while 241 were allocated to the conventional drain group. Age and gender distribution, the use of cardiopulmonary bypass, numbers of patients with univentricular morphology and number of drains utilized were similar in the 2 groups. The use of redivac drains resulted in a significantly lower incidence of residual pleural effusions requiring drainage (4 vs. 18, P=0.003). There was no difference in the incidence of pericardial effusion requiring drainage. Redivac drains drained an equivalent volume through smaller calibre tubes (12 Ch vs. 16 Ch, P<0.0001) over a shorter period of time (42h (IQR 22-45) vs. 43h (IQR 27-52), P<0.01) than the conventional drainage system. Redivac drains are as safe and effective as conventional drains in the pediatric setting, and resulted in a lower incidence of residual pleural effusions requiring drainage. Together with their ease of care, earlier mobilisation of patients and greater cost-effectiveness, the routine use of high-vacuum drains can be recommended following pediatric heart surgery.
OBJECTIVES: Preoperative atrial fibrillation (PAF) has been associated with poorer early and mid-... more OBJECTIVES: Preoperative atrial fibrillation (PAF) has been associated with poorer early and mid-term outcomes after isolated valvular or coronary artery bypass graft surgery. Few studies, however, have evaluated the impact of PAF on early and mid-term outcomes after concomitant aortic valve replacement and coronary aortic bypass graft (AVR-CABG) surgery.
Background: Preoperative atrial fibrillation (preop-AF) has been associated with poorer early and... more Background: Preoperative atrial fibrillation (preop-AF) has been associated with poorer early and late outcomes after cardiac surgery. Few studies, however, have evaluated the impact of preop-AF on early and late outcomes after isolated aortic valve replacement (AVR). Methods: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program was retrospectively analyzed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients undergoing isolated AVR who presented with preop-AF and those in sinus rhythm. The independent effect of preop-AF on 12 short-term complications and long-term survival was determined using binary logistic and cox regression, respectively. Results: Isolated AVR surgery was performed in 2789 patients; 380 (13.6%) presented with preop-AF. Preop-AF patients were generally R ESUM E
percent, range 45-66 percent). The median peak gradient was 66 mmHg (range 64-70 mmHg), while the... more percent, range 45-66 percent). The median peak gradient was 66 mmHg (range 64-70 mmHg), while the median mean gradient was 41 mmHg (range 40-41 mmHg). The median cardiopulmonary bypass time was 97 min (range 75-119 min) and median cross-clamp time was 57 min (range 57-66 min). There was no mortality, no incidence of ITA graft injury and no significant post-operative cardiac complications. All patients have been followed up with satisfactory outcomes.
The Journal of Thoracic and Cardiovascular Surgery, 2013
Objective: No previous studies have specifically addressed the effect of training on outcomes aft... more Objective: No previous studies have specifically addressed the effect of training on outcomes after concomitant aortic valve replacement and coronary artery bypass grafting. This study evaluated the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training.
Background: Type 2 diabetes and the metabolic syndrome are associated with impaired diastolic fun... more Background: Type 2 diabetes and the metabolic syndrome are associated with impaired diastolic function and increased heart failure risk. Animal models and autopsy studies of diabetic patients implicate myocardial fibrosis, cardiomyocyte hypertrophy, altered myocardial microvascular structure and advanced glycation end-products (AGEs) in the pathogenesis of diabetic cardiomyopathy. We investigated whether type 2 diabetes and the metabolic syndrome are associated with altered myocardial structure, microvasculature, and expression of AGEs and receptor for AGEs (RAGE) in men with coronary artery disease. Methods: We performed histological analysis of left ventricular biopsies from 13 control, 10 diabetic and 23 metabolic syndrome men undergoing coronary artery bypass graft surgery who did not have heart failure or atrial fibrillation, had not received loop diuretic therapy, and did not have evidence of previous myocardial infarction. Results: All three patient groups had similar extent of coronary artery disease and clinical characteristics, apart from differences in metabolic parameters. Diabetic and metabolic syndrome patients had higher pulmonary capillary wedge pressure than controls, and diabetic patients had reduced mitral diastolic peak velocity of the septal mitral annulus (E'), consistent with impaired diastolic function. Neither diabetic nor metabolic syndrome patients had increased myocardial interstitial fibrosis (picrosirius red), or increased immunostaining for collagen I and III, the AGE Nε-(carboxymethyl)lysine, or RAGE. Cardiomyocyte width, capillary length density, diffusion radius, and arteriolar dimensions did not differ between the three patient groups, whereas diabetic and metabolic syndrome patients had reduced perivascular fibrosis. Conclusions: Impaired diastolic function of type 2 diabetic and metabolic syndrome patients was not dependent on increased myocardial fibrosis, cardiomyocyte hypertrophy, alteration of the myocardial microvascular structure, or increased myocardial expression of Nε-(carboxymethyl)lysine or RAGE. These findings suggest that the increased myocardial fibrosis and AGE expression, cardiomyocyte hypertrophy, and altered microvasculature structure described in diabetic heart disease were a consequence, rather than an initiating cause, of cardiac dysfunction.
The Journal of Thoracic and Cardiovascular Surgery, 2013
Background: Surgical aortic valve replacement is being increasingly performed in elderly patients... more Background: Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly.
Intravenous leiomyomatosis with intracardiac extension is an uncommon pathologic progression of u... more Intravenous leiomyomatosis with intracardiac extension is an uncommon pathologic progression of uterine leiomyomata. It is a histologically benign condition, however due to interfence with right sided cardiac function patients may present with marked cardiovascular compromise and present a diagnostic dilemma to clinicians who are unfamiliar with this condition. Given the rarity of this condition, experience in individual institutions is usually limited to a few cases. We present an illustrative case and provide a review of the clinical presentation, preoperative assessment, operative approach, pathology and postoperative issues. The importance of a multidisciplinary approach to diagnosis and management is highlighted. Operative management aims to completely resect all tumour in the safest manner for the patient, most commonly via single or two stage operation. Where complete resection is achieved, recurrence appears to be a rare event.
Background. Undiagnosed glycometabolic dysfunction is prominent amongst nondiabetic cardiac surgi... more Background. Undiagnosed glycometabolic dysfunction is prominent amongst nondiabetic cardiac surgical patients, whereas perioperative dysglycemia is associated with adverse outcomes. This study assessed whether the preoperative level of insulin resistance predicts the degree of perioperative dysglycemia in nondiabetic, normoglycemic cardiac surgical patients.
The Journal of Heart and Lung Transplantation, 2006
A Fontan operation will eventually fail in many patients. Fontan conversion to extracardiac condu... more A Fontan operation will eventually fail in many patients. Fontan conversion to extracardiac conduit has been recommended but is not always successful. We present a case of a patient who went into intractable heart failure after reoperation, was rescued by left ventricular assist device implantation, and was finally bridged to heart transplantation.
The Journal of thoracic and cardiovascular surgery, 2013
Surgical aortic valve replacement is being increasingly performed in elderly patients with good p... more Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly. A systematic review of clinical studies after January 2000 was performed to identify health-related quality of life in the elderly after aortic valve replacement. Strict inclusion and exclusion criteria were applied. Quality appraisal of each study also was performed using predefined criteria. Health-related quality of life results were synthesized through a narrative review with full tabulation of the results of all included studies. Health-related quality of life improvements were shown across most or all domains in different health-related quality of life instruments. Elderly patients experienced marked symptomatic improvement. Health-related quality of life was equivalent or superior to b...
The mitral annulus can be rendered hostile by several uncommon clinical situations such as infect... more The mitral annulus can be rendered hostile by several uncommon clinical situations such as infective endocarditis, calcification, or previous valve surgery. These can all lead to difficulties seating a prosthesis or annuloplasty ring. The posterior mitral annulus or anteriorly the intervalvar fibrous body can be affected. These situations continue to pose a formidable technical challenge to the cardiac surgeon in the operating room. We review the evidence around solutions for these problems with the intent of giving surgeons an overview of techniques to address these issues.
Background: Surgical aortic valve replacement is being increasingly performed in elderly patients... more Background: Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly.
PLT from 11% to 39%, one or more FFP from 11% to 48% and one or more cryoprecipitate from 1% to 2... more PLT from 11% to 39%, one or more FFP from 11% to 48% and one or more cryoprecipitate from 1% to 20%. Similar variation was still present when the analysis was limited to isolated first-time CABG. Hospital-characteristics, including state or territory, private versus public and teaching versus non-teaching, were not associated with variation in transfusion rates.
Aims: To assess outcomes with a new fully repositionable and retrievable valve for transcatheter ... more Aims: To assess outcomes with a new fully repositionable and retrievable valve for transcatheter aortic valve replacement (TAVR).
Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasio... more Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasionally necessary when noninvasive imaging and Doppler echocardiographic data are inconclusive or differ from the clinical findings for specific scenarios, such as diagnosing constrictive or restrictive physiology. We present a case in which we safely and effectively replicate the previous successful application of a PressureWire in diagnosing constrictive pericarditis in a patient with a bileafltet mechanical aortic and mitral valves.
The collection of fluid in the mediastinum after cardiac surgery is traditionally prevented using... more The collection of fluid in the mediastinum after cardiac surgery is traditionally prevented using underwater seal drains that may be connected to low-pressure suction. High-vacuum drains (redivac drains) are a potential alternative to this arrangement and have previously been utilized in areas of general surgery, as well as in the treatment of post-sternotomy mediastinitis. There has been no study to date addressing the safety and efficacy of these drains following pediatric cardiac surgery. Five hundred and forty-six patients were prospectively randomised to receive either the redivac drains or the conventional underwater-seal drains attached to low-pressure wall suction. We sought to test the null hypothesis that there was no difference in the incidence of residual pericardial or pleural collections requiring drainage between the 2 drainage systems. Secondary endpoints included time to drain removal, volume of drainage and drain size. Analysis was performed on an intention to treat basis. Two hundred and thirty-seven patients were allocated to the redivac group, while 241 were allocated to the conventional drain group. Age and gender distribution, the use of cardiopulmonary bypass, numbers of patients with univentricular morphology and number of drains utilized were similar in the 2 groups. The use of redivac drains resulted in a significantly lower incidence of residual pleural effusions requiring drainage (4 vs. 18, P=0.003). There was no difference in the incidence of pericardial effusion requiring drainage. Redivac drains drained an equivalent volume through smaller calibre tubes (12 Ch vs. 16 Ch, P<0.0001) over a shorter period of time (42h (IQR 22-45) vs. 43h (IQR 27-52), P<0.01) than the conventional drainage system. Redivac drains are as safe and effective as conventional drains in the pediatric setting, and resulted in a lower incidence of residual pleural effusions requiring drainage. Together with their ease of care, earlier mobilisation of patients and greater cost-effectiveness, the routine use of high-vacuum drains can be recommended following pediatric heart surgery.
OBJECTIVES: Preoperative atrial fibrillation (PAF) has been associated with poorer early and mid-... more OBJECTIVES: Preoperative atrial fibrillation (PAF) has been associated with poorer early and mid-term outcomes after isolated valvular or coronary artery bypass graft surgery. Few studies, however, have evaluated the impact of PAF on early and mid-term outcomes after concomitant aortic valve replacement and coronary aortic bypass graft (AVR-CABG) surgery.
Background: Preoperative atrial fibrillation (preop-AF) has been associated with poorer early and... more Background: Preoperative atrial fibrillation (preop-AF) has been associated with poorer early and late outcomes after cardiac surgery. Few studies, however, have evaluated the impact of preop-AF on early and late outcomes after isolated aortic valve replacement (AVR). Methods: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program was retrospectively analyzed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients undergoing isolated AVR who presented with preop-AF and those in sinus rhythm. The independent effect of preop-AF on 12 short-term complications and long-term survival was determined using binary logistic and cox regression, respectively. Results: Isolated AVR surgery was performed in 2789 patients; 380 (13.6%) presented with preop-AF. Preop-AF patients were generally R ESUM E
percent, range 45-66 percent). The median peak gradient was 66 mmHg (range 64-70 mmHg), while the... more percent, range 45-66 percent). The median peak gradient was 66 mmHg (range 64-70 mmHg), while the median mean gradient was 41 mmHg (range 40-41 mmHg). The median cardiopulmonary bypass time was 97 min (range 75-119 min) and median cross-clamp time was 57 min (range 57-66 min). There was no mortality, no incidence of ITA graft injury and no significant post-operative cardiac complications. All patients have been followed up with satisfactory outcomes.
The Journal of Thoracic and Cardiovascular Surgery, 2013
Objective: No previous studies have specifically addressed the effect of training on outcomes aft... more Objective: No previous studies have specifically addressed the effect of training on outcomes after concomitant aortic valve replacement and coronary artery bypass grafting. This study evaluated the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training.
Background: Type 2 diabetes and the metabolic syndrome are associated with impaired diastolic fun... more Background: Type 2 diabetes and the metabolic syndrome are associated with impaired diastolic function and increased heart failure risk. Animal models and autopsy studies of diabetic patients implicate myocardial fibrosis, cardiomyocyte hypertrophy, altered myocardial microvascular structure and advanced glycation end-products (AGEs) in the pathogenesis of diabetic cardiomyopathy. We investigated whether type 2 diabetes and the metabolic syndrome are associated with altered myocardial structure, microvasculature, and expression of AGEs and receptor for AGEs (RAGE) in men with coronary artery disease. Methods: We performed histological analysis of left ventricular biopsies from 13 control, 10 diabetic and 23 metabolic syndrome men undergoing coronary artery bypass graft surgery who did not have heart failure or atrial fibrillation, had not received loop diuretic therapy, and did not have evidence of previous myocardial infarction. Results: All three patient groups had similar extent of coronary artery disease and clinical characteristics, apart from differences in metabolic parameters. Diabetic and metabolic syndrome patients had higher pulmonary capillary wedge pressure than controls, and diabetic patients had reduced mitral diastolic peak velocity of the septal mitral annulus (E'), consistent with impaired diastolic function. Neither diabetic nor metabolic syndrome patients had increased myocardial interstitial fibrosis (picrosirius red), or increased immunostaining for collagen I and III, the AGE Nε-(carboxymethyl)lysine, or RAGE. Cardiomyocyte width, capillary length density, diffusion radius, and arteriolar dimensions did not differ between the three patient groups, whereas diabetic and metabolic syndrome patients had reduced perivascular fibrosis. Conclusions: Impaired diastolic function of type 2 diabetic and metabolic syndrome patients was not dependent on increased myocardial fibrosis, cardiomyocyte hypertrophy, alteration of the myocardial microvascular structure, or increased myocardial expression of Nε-(carboxymethyl)lysine or RAGE. These findings suggest that the increased myocardial fibrosis and AGE expression, cardiomyocyte hypertrophy, and altered microvasculature structure described in diabetic heart disease were a consequence, rather than an initiating cause, of cardiac dysfunction.
The Journal of Thoracic and Cardiovascular Surgery, 2013
Background: Surgical aortic valve replacement is being increasingly performed in elderly patients... more Background: Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly.
Intravenous leiomyomatosis with intracardiac extension is an uncommon pathologic progression of u... more Intravenous leiomyomatosis with intracardiac extension is an uncommon pathologic progression of uterine leiomyomata. It is a histologically benign condition, however due to interfence with right sided cardiac function patients may present with marked cardiovascular compromise and present a diagnostic dilemma to clinicians who are unfamiliar with this condition. Given the rarity of this condition, experience in individual institutions is usually limited to a few cases. We present an illustrative case and provide a review of the clinical presentation, preoperative assessment, operative approach, pathology and postoperative issues. The importance of a multidisciplinary approach to diagnosis and management is highlighted. Operative management aims to completely resect all tumour in the safest manner for the patient, most commonly via single or two stage operation. Where complete resection is achieved, recurrence appears to be a rare event.
Background. Undiagnosed glycometabolic dysfunction is prominent amongst nondiabetic cardiac surgi... more Background. Undiagnosed glycometabolic dysfunction is prominent amongst nondiabetic cardiac surgical patients, whereas perioperative dysglycemia is associated with adverse outcomes. This study assessed whether the preoperative level of insulin resistance predicts the degree of perioperative dysglycemia in nondiabetic, normoglycemic cardiac surgical patients.
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Papers by Andrew Newcomb