A 78-year-old male with a history of hypertension and hypercholesterolaemia was admitted to hospital with acute left eye visual loss and diagnosed with retinal artery occlusion. Magnetic resonance imaging (MRI) revealed multiple, bilateral cerebral infarcts involving supra- and infra-tentorial brain consistent with acute ischaemic stroke from a central embolic source. Extended ambulatory electrocardiographic monitoring displayed sinus rhythm with no evidence of atrial flutter or fibrillation. Transthoracic echocardiography (TTE) revealed a cystic structure associated with the mitral valve, with no restriction or regurgitation. Left ventricular function was preserved with no evidence of apical thrombus. Characterisation with transesophageal echocardiography (TOE) demonstrated the cystic mass encapsulated within the anterior leaflet of the mitral valve at the posteromedial commissure which was well circumscribed with no independent motion or surface irregularities (Figure 1). Infective endocarditis or abscess were thought unlikely given there were no systemic infective symptoms and normal inflammatory markers. TOE, in conjunction with arterial phase computerised tomography (CT) imaging, additionally revealed mild–moderate aortic arch atheroma but no other abnormalities of possible embolic source.

A 59-year-old male was incidentally diagnosed with a left atrial mitral valve chordae involving the junction of the A1 and A2 mitral valve leaflets and resulting in moderate mitral regurgitation. The recognition of this extremely rare congenital malformation prevented over diagnosis and overtreatment.

The East Timor Hearts Fund has provided cardiac services in Timor‐Leste since 2010, conducting three clinics yearly.

The prevalence of rheumatic heart disease in Timor-Leste, a lower middle income country of about 1.3 million people and one hour from Australia, is among the highest in the world.1 The East Timor Hearts Fund (ETHF; https://easttimorheartsfund.org.au) is the primary facilitator of access to cardiac procedures for people in Timor-Leste.2 At the start of the coronavirus disease 2019 (COVID-19) pandemic, both Australia and Timor-Leste closed their international borders, and no Timorese patients have undergone cardiac surgery in Australia since March 2020. However, the ETHF has continued to provide remote care in the form of telehealth clinics. In March 2020 and August 2021, we assessed the status of East Timorese people on the ETHF waiting list for cardiac procedures in Australia. If we could not contact a patient, we sought information about their status from the Hospital Nacional Guido Valadares and the two largest community medical centres in Dili (Bairo Pite Clinic Lanud and Maluk Timor). The St Vincent’s Hospital Melbourne Human Research Ethics Committee approved our study (QA 21037). On 1 March 2020, 35 Timorese people were waiting for cardiac procedures in Australia, including 26 with rheumatic heart disease and nine with congenital cardiac disease (Box 1). By 31 August 2021, three people had died, and thirteen had been admitted to hospital with decompensated heart failure. The median New York Heart Association score declined from II (mild limitation of physical activity) in March 2020 to III (marked limitation) for the 15 people who attended ETHF online telehealth clinics during 2020 or 2021 (seven with lower, eight with stable scores). Of thirteen people who could not be contacted for follow-up, three had died suddenly; the status of ten whose phone numbers were no longer current was unknown (Box 2). Characteristic Age (years), median (IQR) 27 (19–34) Sex (men) 11 (31%) Rheumatic heart disease 26 (74%) Located in Dili 23 (66%) NYHA class, median (IQR): most recent face-to-face review in March 2020 II (I–II) NYHA class, median (IQR): 15 people who attended online clinics in 2020 or 2021 III (II–III) Time on waiting list (to 1 March 2020; months), median (IQR) 4 (4–13) Confirmed major adverse cardiovascular event 9 (26%) The COVID-19 border closures delayed cardiac interventions for our young patients by at least 18 months. Systemic delays in usual health care during the pandemic have increased morbidity and mortality in Australia, and not just for people with COVID-19.3 In the case of Timor-Leste, international border closures abruptly removed access to cardiac procedures for an entire nation. The poor outcomes for many East Timorese people with cardiac disease during the pandemic also highlight the inherent uncertainty of fly-in/fly-out volunteer medical services. Over the past decade, ETHF has supported the development of local expertise, and the Timor-Leste medical system has expanded markedly since independence in 2002. However, the COVID-19 pandemic cut access to overseas cardiac procedures. About 60 non-governmental organisations have cardiac surgery programs in low and middle income countries, with short term mission approaches similar to that of ETHF;4 it is likely that border closures also reduced access to cardiac surgery in other countries. The COVID-19 pandemic further restricted the access of low and middle income countries to surgical services, “with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic.”5 One-quarter of our young patients waiting for cardiac surgery experienced major adverse cardiovascular events during the pandemic, including three who died. Sudden border closures that remove access to humanitarian surgery highlight the vulnerabilities of short term medical mission models, and raise concerns that levels of undiagnosed disease in Timor-Leste may be higher after the COVID-19 pandemic has ended. We acknowledge the contributions by the other East Timor Hearts Fund members (Will Wilson, Virag Kushwaha, Simon Eggleton, David Marlow, Nicki Mock, Diana Marques, Louise Creati, Sarah Gutman, Peter Barlis, Ari Horton) and by the Maluk Timor staff (Jess Harries, Anary dos Santos da Silva, Sergio da Silva, Juliana Saramento). No relevant disclosures.

BackgroundIt remains unclear as to whether polycystic ovary syndrome (PCOS) is an additional risk factor in the development of left ventricular (LV) hypertrophy in obese women. In the current study, we provide clarity on this issue by rigorously analysing patient LV geometry beyond the basic clinical measures currently used. Importantly, the cohort contained only normotensive patients that would normally be deemed low risk with no further intervention required.MethodsThe study comprised 24 obese women with PCOS and 29 obese Control women. Transthoracic echocardiography was used to evaluate LV structure/function. Basic clinical and metabolic data were collected for each participant consisting of age, BMI, blood pressure, fasting glucose, LDL-C, HLD-C, cholesterol and triglyceride levels. Exclusion criteria; BMI < 30 g/m2, type 2 diabetes, hypertension.ResultsBoth groups exhibited concentric remodelling of the LV posterior wall at a prevalence of ~20%, this associated with grade 1 diastolic dysfunction. Estimated LV mass/height2.7was increased patients with PCOS (45 ± 2.2 vs 37 ± 1.6) with 33% exhibiting LV mass/height2.7above ASE guidelines, compared to 7% in Controls. Furthermore, 25% of patients with PCOS were characterised with concentric hypertrophy, an alteration in LV geometry that was not observed in the Control group.ConclusionsTo our knowledge, this is the first study to assess LV geometric patterns in obese women with PCOS. The results suggest that obese women with PCOS are at greater risk of concentric hypertrophy than obese only women and provide justification for additional cardiovascular risk assessment in normotensive obese/PCOS women.

Timor‐Leste is one of the poorest countries in the world. The East Timor Hearts Fund is a charitable organisation involving Australian cardiologists providing outreach screening and access to cardiac interventions.

BACKGROUND:The East Timor Hearts Fund (ETHF) is a charitable organisation of Australian cardiologists providing outreach screening in Timor-Leste. For patients requiring intervention, ETHF arranges logistics, procedures, and postoperative care. The aim of this project is to evaluate outcomes of patients requiring intervention.METHODS:The ETHF database of all patients was utilised to identify patients with disease warranting surgical or percutaneous intervention. Both patients who underwent intervention and those who did not proceed to intervention were included in this study. Patients who had intervention arranged by other organisations but have then had follow-up with ETHF were also included. Overall demographics and pre and postoperative factors were assessed, with sub-group analysis of adult and paediatric patients to identify any differences in care.RESULTS:Of 221 patients requiring intervention, 101 patients underwent intervention, receiving 22 different operations or procedures. Patients were predominantly young (median age 17.5 years) and female (64.7%), with rheumatic heart disease (63.8%). Twenty-four (24) (33.3%) women aged 15-45 years old with cardiac disease warranting intervention were documented as pregnant or breastfeeding at time of clinic assessment. Of patients who did not proceed to intervention, adults were more likely to be lost to follow-up (42.4% vs 18.5%) while paediatric patients were more likely to experience progression of disease (18.5% vs 7.5%, p=0.005). Median waitlist time was 5 months, with no significant difference between adults and children, correlating with a preoperative mortality rate of 5.4%. For patients who underwent intervention, post-procedure mortality was extremely low (0.9%) and attendance of at least one post-procedure review was excellent (99.0%). Eleven (11) (10.9%) patients have required repeat intervention, with no difference in rates between adult and paediatric patients. Length of follow-up extends up to 20 years for some patients.CONCLUSION:The Timor-Leste interventional cohort was predominantly a young female population with rheumatic and congenital cardiac disease. There were also high rates of pregnancy amongst female patients with severe cardiac disease. Delayed access to intervention may result in preoperative adverse events and mortality, and is a key target for improvement. Patients who undergo intervention have very low post-procedural mortality, good adherence to early medical follow-up and good long-term outcomes.

Objectives: To determine the prevalence of rheumatic heart disease (RHD) in school-aged children and young people in Timor-Leste. Design: Prospective cross-sectional survey. Echocardiography was performed by Australian cardiologists to determine the presence of RHD. Demographic data were also collected. Patients in whom RHD was detected were entered into a register to allow monitoring of adherence to secondary prophylaxis; the first dose of benzathine penicillin G (BPG) was administered on the day of screening. Setting: Schools in urban (Dili) and rural (Ermera) Timor-Leste. Participants: School students aged 5-20 years. Outcome measures: Definite and borderline RHD, as defined by World Heart Federation echocardiographic criteria. Results: 1365 participants were screened; their median age was 11 years (IQR, 9-14 years), and 53% were girls. The estimated prevalence of definite RHD was 18.3 cases per 1000 population (95% CI, 12.3-27.0 per 1000), and of definite or borderline RHD 35.2 per 1000 (95% CI, 26.5-46.4 per 1000). Definite (adjusted odds ratio [aOR], 3.5; 95% CI, 1.3-9.4) and definite or borderline RHD (aOR, 2.7; 95% CI, 1.4-5.2) were more prevalent among girls than boys. Eleven children (0.8%) had congenital heart disease. Of the 25 children in whom definite RHD was identified, 21 (84%) received education and a first dose of BPG on the day of screening; all 25 have since received education about primary care for RHD and have commenced penicillin prophylaxis. Conclusions: The rates of RHD in Timor-Leste are among the highest in the world, and prevalence is higher among girls than boys. Community engagement is essential for ensuring follow-up and the effective delivery of secondary prophylaxis.

Background: It is unclear whether obesity and type 2 diabetes (T2D), either alone or in combination, induce left ventricular hypertrophy (LVH) independent of hypertension. In the current study, we provide clarity on this issue by rigorously analysing patient left ventricular (LV) structure via clinical indices and via LV geometric patterns (more commonly used in research settings). Importantly, our sample consisted of hypertensive patients that are routinely screened for LVH via echocardiography and normotensive patients that would normally be deemed low risk with no further action required.Methods: This cross sectional study comprised a total of 353 Caucasian patients, grouped based on diagnosis of obesity, T2D and hypertension, with normotensive obese patients further separated based on metabolic health. Basic metabolic parameters were collected and LV structure and function were assessed via transthoracic echocardiography. Multivariable logistic and linear regression analyses were used to identify predictors of LVH and diastolic dysfunction.Results: Metabolically healthy normotensive obese patients exhibited relatively low risk of LVH. However, normotensive metabolically non- healthy obese, T2D and obese/T2D patients all presented with reduced normal LV geometry that coincided with increased LV concentric remodelling. Furthermore, normotensive patients presenting with both obesity and T2D had a higher incidence of concentric hypertrophy and grade 3 diastolic dysfunction than normotensive patients with either condition alone, indicating an additive effect of obesity and T2D. Alarmingly these alterations were at a comparable prevalence to that observed in hypertensive patients. Interestingly, assessment of LVPWd, a traditional index of LVH, underestimated the presence of LV concentric remodelling. The implications for which were demonstrated by concentric remodelling and concentric hypertrophy strongly associating with grade 1 and 3 diastolic dysfunction respectively, independent of sex, age and BMI. Finally, pulse pressure was identified as a strong predictor of LV remodelling within normotensive patients.Conclusions: These findings show that metabolically non- healthy obese, T2D and obese/T2D patients can develop LVH independent of hypertension. Furthermore, that LVPWd may underestimate LV remodelling in these patient groups and that pulse pressure can be used as convenient predictor of hypertrophy status.

INTRODUCTION AND AIMS:Injecting drug use (IDU) is a major risk factor for infective endocarditis (IE). An understanding of the epidemiology of IE and IDU is vital for delivery of health care for this disease. Our aim was to examine the rates of IDU-associated IE (IDU-IE) in a single centre over the last 12 years.DESIGN AND METHODS:Retrospective analysis of two cohorts of consecutive patients (n = 226) admitted with IE from 2002 to 2013. Numbers of cases and rates of IE were compared between two cohorts (2002-2006 and 2009-2013). Rate ratios were calculated using Poisson distributions. Poisson regression was used to examine relationship over time.RESULTS:One hundred thirty cases of endocarditis were seen in the first observation period (6 IDU-IE) and 96 in the second observation period (15 IDU-IE). The estimated incidence rate of IE had fallen from 10.1 to 6.45 per 100, 000 person-years [rate ratio 0.64, 95% confidence interval (CI) 0.48, 0.85]. In contrast, the estimated incidence rate of IDU-E has risen from 0.48 to 0.79 per 100, 000 person-years (rate ratio 1.65, 95% CI 0.59, 4.57). Incidence rate regression suggests that the number of IDU-IE cases is expected to increase by a factor of 1.25 (95%CI 1.09-1.44) for each increase of 1 year.DISCUSSION AND CONCLUSIONS:Over the last decade, there has been a decrease in incidence rate and total number of cases of IE but a rise in rate and number of cases of IDU-IE. This may indicate increasing IDU or increased rates of endocarditis in intravenous drug users in this region. This finding may inform health-care planning in the area.

Concerns are often raised regarding the credibility of patients' report of pain and this concern is heightened among individuals with AIDS, where many patients have a history of injection drug use. This study compared the pain experience, adequacy of pain management and psychological well-being among patients with AIDS who reported a history of injection drug use (IDU) as their HIV transmission risk factor and patients with other HIV transmission risk factors. Five hundred and sixteen ambulatory AIDS patients participating in a quality of life study completed a series of self-report instruments including the Brief Pain Inventory, the Beck Depression Inventory, the Brief Symptom Inventory, the Functional Living Inventory and the Social Support Questionnaire. Results demonstrated that IDU and non-IDU subjects did not differ significantly in their report of pain prevalence, pain intensity or pain-related functional interference. However, IDU patients were significantly more likely to receive inadequate analgesic medications, reported lower levels of pain relief and a greater degree of psychological distress. There was also no difference in report of pain intensity, pain relief or functional interference among patients who acknowledged continued drug use, those who denied any recent drug use and patients participating in a methadone maintenance program. These data support the validity of AIDS patients' report of pain, at least in research settings, and suggest that undertreatment of pain is not restricted to patients who actively abuse drugs.

Staphylococcus aureus bacteraemia (SAB) is an important cause of community and nosocomial sepsis, with a significant mortality rate. Infective endocarditis (IE) is a serious complication, occurring in up to 25 % of cases. Transoesophageal echocardiography (TOE) significantly improves the sensitivity of diagnosis. We compared the sensitivity and specificity of clinical evaluation alone in diagnosing IE. We evaluated all adult patients with SAB at our centre from 1998 to 2006 in order to determine what proportion of clinically unsuspected cases were diagnosed with IE on TOE. IE was defined according to modified Duke criteria. The median age of the patients was 68 years, 77 % were male and the majority of cases did not have a known pre-existing condition. Twenty-one percent were methicillin-resistant Staphylococcus aureus (MRSA). Intravascular device was the most common cause of bacteraemia. TOE was performed in 144 (100 %) of the cases. IE was suspected clinically in 15 % of cases, and the overall prevalence of possible or definite IE on TOE-inclusive Duke criteria was 29 % (n = 41). Following TOE, 22 (15 %) cases were reclassified as either possible or definite endocarditis. TOE detected a vegetation in 37 (90 %) of the 41 cases of IE. Nineteen (46 %) were not suspected clinically by Duke criteria. Sensitivity improved in the presence of pre-existing valve lesion or community acquisition. The overall in-hospital mortality was 10 %. There is a high incidence of endocarditis in SAB and a large percentage of cases are not evident on clinical grounds. TOE evaluation is indicated for all medically suitable adult patients with SAB in order to improve the detection of endocarditis.

Background: Stress induced cardiomyopathy (SIC) is increasingly recognised in patients presenting with features of an acute coronary syndrome. Associated left ventricular thrombosis has been described with an incidence of up to 9% when magnetic resonance imaging is utilised. The incidence as detected by conventional transthoracic echocardiography is unclear. Method: We retrospectively assessed all cases of SIC presenting to two large Victorian tertiary referral centres over a six-year period (July 2006 to January 2012). Patients with typical, transient echocardiographic features, new ECG abnormalities and no angiographic evidence of coronary occlusion or plaque rupture were included in the analysis in accordance with published Mayo Clinic criteria. Patients presenting with intracranial bleeding were excluded, as the detection of thrombus in these patients would not have altered subsequent management. We calculated rates of LV thrombosis, as detected by echocardiography, mortality and ischaemic stroke at 60 days following initial diagnosis. Results: Thirty-eight patients (36 or 95% women) met criteria for SIC, with mean age 67 years. An acute emotional trigger was identified in 61% of patients. One death was recorded (2.6%) with one stroke identified (2.6%) coincident with the diagnosis of SIC. Two patients (5.3%) demonstrated echocardiographic evidence of apical thrombus. Both patients were therapeutically anticoagulated and neither subsequently experienced a clinically evident thrombotic event. Conclusion: This pilot study suggests left ventricular apical thrombosis may represent an under-recognised and under-treated complication of SIC. Consideration of prophylactic anticoagulation whilst myocardial function remains depressed or close echocardiographic monitoring may be warranted in patients presenting with SIC.

Cobaltism related to athroplasty implants has been anecdotally documented in at least six cases presenting with a combination of neurological, endocrine and cardiac symptoms with improvement in most symptoms after revision. Causality however has not been well established.This report documents the case of a 75 year-old male farmer who presents with possible cobalt cardiomyopathy from severe cobalt poisoning in the setting of arthroprosthetic cobaltism with symptomatic improvement upon revision of the hip. (Heart, Lung and Circulation 2012;21:759-760) (C) 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.

Transthoracic echocardiography plays a central role in diagnosing a variety of cardiac and pericardial disorders. However its use in identifying extra-cardiac thoracic pathology is less well recognised. We describe an unusual case of intrathoracic intestinal strangulation detected by transthoracic echocardiography. The recognition of bowel loops within the left hemithorax enabled rapid confirmatory computed tomographic imaging and subsequent life-saving surgery This case demonstrates the utility of bedside echocardiography in the assessment of intrathoracic pathology and emphasises the need for cardiologists to be familiar with the echocardiographic appearance of these disorders. (Heart, Lung and Circulation 2012;21:831-835) (C) 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.

Background: The clinical profile of endocarditis has changed over the past four decades with studies showing trends towards increasing age, more nosocomial and prosthetic valve infection and increasing rates of Staphylococcus aureus infection. However, these studies have been biased by referral patterns. Methods: We reviewed data collected at three hospitals in the Barwon-South-West region in Victoria, Australia. All cases identified between 1994 and 1999 were reviewed according to the Duke criteria. Results: During this period, 58 patients were diagnosed as having endocarditis. The incidence rate during this time was 3.0 per 100 000 with a rise in the rate of admissions from 0.15 to 0.26 per 1000 from 1995 to 1999. Sixteen (28%) were nosocomial with the majority from line-related sepsis. No intravenous drug users were identified. Eighteen (31%) involved endovascular prosthetic material. S. aureus was the causative pathogen in 23 (40%), with 'viridans' streptococci contributing 12 (21%) and other organisms accounting for 12 (21%). Attributable mortality in this series was 17%. Conclusions: We have seen a rise in the rate of endocarditis during this time. The proportions of endocarditis due to S. aureus and 'viridans' streptococci, as well as rates of nosocomial and prosthetic valve infection, are consistent with more recent series at referral hospitals and district hospitals, representing a change since studies performed in the 1960s and 1970s. Our findings confirm a trend towards a clinical profile seen at referral centres and reinforce the emerging importance of S. aureus, nosocomial bacteraemia and prosthetic valve endocarditis.

Background-Unstable angina and non-Q-wave myocardial infarction involve coronary arterial plaque rupture, platelet activation, and thrombus formation. This study tested the benefit of different doses of lamifiban (a platelet IIb/IIIa antagonist) alone and in combination with heparin in patients with these conditions to select the most promising lamifiban regimen for subsequent evaluation.Methods and Results-At 273 hospitals in 20 countries, 2282 patients were randomly assigned to lamifiban (2x2 factorial design: low-dose [1 mu g/min] with and without heparin versus high-dose [5 mu g/min] with and without heparin) or to standard therapy (placebo and heparin). All patients received aspirin. The composite primary end point of death or nonfatal myocardial infarction at 30 days occurred in 11.7% of those receiving standard therapy, 10.6% receiving low-dose lamifiban, and 12.0% receiving high-dose lamifiban (P=0.668). By 6 months, this composite was lowest for those assigned to low-dose lamifiban (P=0.027) and intermediate for those assigned to high-dose lamifiban (P=0.450) compared with control (13.7%, 16.4%, and 17.9%, respectively). Compared with control, the combination of high-dose lamifiban and heparin resulted in more intermediate or major bleeding (12.1% versus 5.5%; P=0.002) and a similar rate of ischemic events. Conversely, low-dose lamifiban and heparin yielded similar bleeding rates as in the control group but fewer ischemic events at 6 months (12.6% versus 17.9%; P=0.025).Conclusions-In unstable angina and non-Q-wave infarction, platelet IIb/IIIa antagonism with lamifiban reduces adverse ischemic events at 6 months beyond that of aspirin and heparin therapy. The role of conjunctive heparin remains uncertain but appears more favorable with low-dose IIb/IIIa antagonism. Larger-scale study is needed to more reliably estimate these effects.

The purpose of this study was to examine the accuracy, determine the spectrum of aortic disease and the effect that transesophageal echocardiography has on the clinical management in a consecutive series of patients referred for assessment of aortic disease.