Background: The indication for percutaneous closure of patent foramen ovale (PFO) has recently changed, following evidence that closure is superior to medical treatment alone in preventing recurrent stroke in cryptogenic stroke patients aged ≤60 years. We aimed to determine the impact of updated criteria on the management of stroke or transient ischaemic attack (TIA) at our institution. Methods: We performed a retrospective record review using ICD-10-AM codes for patients presenting with stroke/TIA between 2015 and 2018. Patients >60 years old or presenting with primary haemorrhagic stroke were excluded. Demographic, clinical, brain imaging and echocardiographic data were collected. Transthoracic and transoesophageal echocardiograms (TOE) were independently reviewed by a cardiologist and stroke aetiology classified by a stroke neurologist. Suitability for closure was evaluated against recent clinical trial inclusion criteria. Results: There were 241 presentations of stroke/TIA ≤60 years (58% male, mean age 49 ± 9). TOE was performed in 46/241 (19.1%), PFO was identified in 16/46 (34.8%). Stroke was classified as embolic stroke of undetermined source (ESUS) in 10/16 (62.5%) and 8/10 (80%) met inclusion criteria for closure (large shunt size (>30 microbubbles passing to left atrium within three cardiac cycles) (n = 5) and/or atrial septal aneurysm (n = 7)). PFO closure was performed in 3/8 (37.5%) Conclusions: Recent trial results indicate that an increased proportion of patients with cryptogenic stroke may benefit from PFO closure. Within the limitation of small numbers, we predict at least a doubling in the number of patients for PFO closure consideration at our centre.

Background: As a clinical quality registry, the Victorian Cardiac Outcomes Registry (VCOR) collects episodic data relating to percutaneous coronary intervention (PCI) to monitor and report on the quality of care delivered. Linkage with administrative datasets is known to enhance the utility, quality and breadth of a registry's output. This study aimed to assess the feasibility of data linkage between VCOR and the Victorian Admitted Episodes Dataset (VAED) and Victorian Emergency Minimum Dataset (VEMD) provided by Victorian Data Linkage (VDL).

An eighty-three year-old woman presented to the emergency department with a painful breast lump. Her medical history included coronary artery bypass with mitral valve replacement and permanent pacemaker insertion ten years ago. Twelve months earlier, her pacemaker was upgraded to a biventricular automatic implantable cardioverter-defibrillator (BiV-AICD). Ultrasonography revealed her right ventricular (RV) pacing lead was within the left breast, and sited within a 26 x 12 x 17 mm fluctuant collection moving with apical impulse. Computed tomography confirmed bipolar lead erosion through the right ventricular apex, the pericardium and the intercostal space into the subcutaneous fat of the left breast. Our patient proceeded to surgery, performed via submammary incision with dissection down to the lead. Thirty millilitres of purulent fluid was drained and cultured Staphylococcus epidermidis. The RV lead was successfully repositioned and the apex repaired. Our patient was discharged nineteen days later on lifelong antibiotics, and remains well. There are multiple case reports of pacing lead perforation, with varying degrees of fatality. Our case represents one of the most extreme survivable lead perforations ever reported. Lead perforation has been variously reported into the right coronary artery, the lungs, the pleural cavity, the breast, the diaphragm, and even the colon. AICD leads, older age and female gender have all been consistently identified as higher-risk features for late lead perforation.

An 83-year-old woman presented to the emergency department with a painful mammary hematoma. Her medical history included coronary artery bypass surgery with mitral valve replacement and permanent pacemaker insertion 10 years previously. Twelve months earlier, her pacemaker had been upgraded to a

Background: Unplanned readmission to hospital after percutaneous coronary intervention (PCI) is an important problem, which results in a significant burden to the healthcare system. We sought to determine the incidence and predictors of unplanned cardiac readmission within 30 days of PCI, in a large contemporary Australian cohort. Methods: We prospectively collected data on 17,153 PCI cases between January 2014 and December 2015 in the multi-centre Victorian Cardiac Outcomes Registry (VCOR). We identified patients with an unplanned cardiac readmission within 30 days of PCI, and determined demographic, clinical and procedural characteristics. Results: 644 (3.8%) patients had an unplanned cardiac readmission of which 94.7% had only 1 readmission. The 30-day unplanned readmission rate was higher in patients with acute coronary syndrome (ACS) compared to non-ACS patients (5.1% vs. 2.3%, p < 0.01), but similar in ST-elevation and non-ST-elevation ACS patients (5.0% vs. 5.1%, p = NS). Independent predictors of unplanned readmission included female gender, ACS presentation, severe left-ventricular systolic dysfunction, chronic kidney disease and being on chronic oral anticoagulant therapy (all p < 0.02). Patient age, low socioeconomic status and diabetes status were not associated with increased unplanned readmission (p = NS). There was also no difference in the readmission rate between public and private hospitals (3.8% vs. 3.6%, p = NS). Conclusion: While local unplanned readmission rates following PCI compare favourably with international data, over 300 patients per annum are still being unexpectedly readmitted in the first 30 days following PCI in Victoria. Targeted strategies for high-risk patients are needed to reduce this burden on both patients and the health system.

Introduction: Despite increasing prevalence of cardiovascular disease in the elderly, they are often excluded from clinical revascularisation trials. Data on outcomes of contemporary PCI in the elderly is lacking. Objectives: To describe the clinical characteristics and outcomes of elderly patients undergoing PCI at St Vincent's Hospital Melbourne. Methods: We analysed 140 patients >80 years old who underwent PCI between September 2012 and December 2015, representing 9.7% of total PCIs performed over the same period of time. Clinical and procedural characteristics, in-hospital and 30-day outcomes are described. Results: The cohort had a mean age of 82.9±2.7 years and 59% were males. Medical comorbidities were diabetes (37%), previous MI (9%), cerebrovascular disease (12%) and peripheral vascular disease (10%). Mean baseline creatinine was 100±40 mmol/L. Presentation with STEMI, NSTEMI, and unstable angina were 10%, 32% and 57% respectively. Cardiogenic shock was present in 6%; 1 out of hospital cardiac arrest; 62% had multivessel disease. Procedural success rate was 99% with mean 1.5 stents per patient deployed and 80% received drug-eluting stents. 4% received glycoprotein IIb/IIIa inhibitors; 41% femoral approach; 9% suffered from periprocedural bleeding complications; and 4% developed contrast-induced nephropathy. In-hospital mortality was 3% (2 cardiac deaths, 1 anuric renal failure, 1 haemorrhagic stroke). There was no additional mortality or MACE event at 30 days. Conclusion: In a selected group of elderly patients, high PCI success rates can be achieved with favourable short-term outcomes. Further studies are warranted to examine the long-term outcomes of management strategies in this population.

Background: The VCOR PCI registry has grown to become the primary method of measuring and benchmarking the performance and safety of PCI in Victoria. Methods: Thirteen public and ten private PCI hospitals contribute baseline, procedural, in-hospital and 30-day outcomes via a secure web-based system. Patients are included via an opt-out consent model. All sites receive quarterly reports providing individualised and comparative results and outcomes. We report on the last 24 months of VCOR PCI data. Results: 16,467 PCI procedures were performed in 14,389 patients through 2014-15. The mean age was 65±12 years. Males predominated (77%); 22% were diabetic and 53% were treated for acute coronary syndromes. Over the 2 years, increases were seen in use of radial access (38% vs 46%) and implantation of DES (74% vs 78%). Overall procedural success rate remained high at 94%. The 30-day follow up rate was 98%. Overall unadjusted outcomes included-:Tabled 1N (%)2014 (n= 8293)2015 (n=8174)In-hospital mortality171 (2.1)136 (1.7)In-hospital major bleeding60 (0.7)101 (1.2)30-day mortality202 (2.4)168 (2.1)30-day mortality (excludes shock / cardiac arrest)90 (1.1)70 (0.9)30-day stroke34 (0.4)23 (0.3)30-day unplanned revascularisation110 (1.3)115 (1.4)30-day MACCE395 (4.8)362 (4.4) Open table in a new tab There were no significant differences in key performance measures among the participating hospitals. Conclusion: VCOR has identified high-quality PCI outcomes in Victoria across a 2-year period, with notable trends towards increased use of radial access and drug-eluting stents, and no performance outliers among participating hospitals.

A 77 year-old man presented with dyspnoea. A left sternal edge systolic ejection murmur was noted. He underwent coronary artery bypass grafting with a vein graft(SVG) to the LAD 34 years prior, complicated by graft degeneration 10 years later, necessitating repeat surgery (LIMA to LAD). A rest/exercise echocardiogram demonstrated normal rest and exercise left ventricular function with no ischaemia demonstrated. The right ventricle(RV) was mildly dilated at rest with mild systolic impairment and further dilatation and hypokinesis with exercise. The resting RV systolic pressure was 50 mmHg + right atrial pressure(RAP), increasing to 100 mmHg + RAP with exercise, falling to 60 mmHg + RAP post exercise. The PA systolic pressure gradients at rest and exercise were 50mmHg and 95mmHg respectively. Invasive investigations revealed a PA gradient 20 mmHg, RV systolic pressure 40 mmHg, PA pressure 20/4 mmHg and a large, partially thrombosed aneurysm of the original vein graft. The LIMA graft to the LAD was patent. Computed tomography (figure) confirmed a 6.3 cm graft aneurysm compressing the PA (arrow). Accordingly, he had the aneurysm coiled with abolition of flow. Breathlessness subsequently improved. Exercise echocardiography seventeen months later revealed normal resting RV systolic pressure (21 mmHg + RAP), increasing to 32 mmHg + RAP with exercise and a peak systolic PA gradient at maximum exercise of only 22 mmHg. This case represents a rare example of a SVG aneurysm causing dynamic PA compression as arterial pressure within the aneurysm rose with exercise.

A 69-year-old woman with a subacute history of dyspnoea and orthopnoea, presented for coronary angiography, on a background of hypertension and COPD. Examination revealed an elevated jugular venous pressure and bibasal crepitations. Sinus rhythm with a left bundle branch block was evident on 12-lead electrocardiography, with a troponin rise of 303ng/L (normal range <16ng/L) on bloods. Transthoracic echocardiography findings included preserved systolic function, concentric left ventricular hypertrophy, and diastolic parameters consistent with an elevated left atrial pressure. Coronary angiography with a Judkins right 4F catheter demonstrated a single coronary artery (SCA) arising from the anterior right sinus of Valsalva. The SCA trifurcated to a dominant right coronary artery, large calibre left circumflex artery and small left anterior descending artery (see diagram). There was significant tortuosity of all three arteries without flow limiting stenosis. Aortogram confirmed the absence of a left main. An anomalous SCA is extremely rare with registry studies suggesting a prevalence of 0.014%-0.066%. SCA is associated with congenital cardiac defects in up to 40% of cases including bicuspid aortic valve, hypertrophic cardiomyopathy and coronary artery fistulas. SCA may be associated with symptomatic transient transmural myocardial ischaemia, arrhythmias and sudden cardiac death in the presence or absence of coronary atherosclerosis.

Background: The transradial approach is increasing in popularity worldwide for coronary procedures. However, when right heart catheterisation is required, the femoral approach is often still used due to the proximity of the femoral artery and vein. We sought to examine the feasibility of left and right heart catheterisation entirely via the arm using the radial artery and an antecubital fossa vein. Methods: Fifty-eight consecutive patients underwent planned right and left heart catheterisation via the right arm. The indication for right heart catheterisation was: heart failure (19%); pulmonary hypertension (12%); severity valve disease (29%); shunt (5%); research study (34%). The clinical presentation was: elective (76%); NSTEMI (10%); STEMI (7%); heart failure (7%). Results: All patients were anticoagulated with heparin. Transradial arterial access was successful in all patients. Right heart catheterisation via the antecubital fossa vein was successful in 54 patients (93%). The reasons for procedural failure were venous dissection (1), venous tortuosity (2), and undiagnosed subclavian vein occlusion (1). A diagnostic study only was performed in 69% of patients and PCI was performed in 31%. Fourteen percent of patients underwent coronary sinus sampling as part of a research study. The only complication was a venous forearm haematoma (1.7%) which was managed conservatively. Conclusion: Right and left heart catheterisation can be performed routinely via the arm in a broad range of patients, including acute coronary syndrome cases and those undergoing PCI, with a high success rate. This approach can be considered for all patients in which right and left heart catheterisation is planned.

Objectives-To determine the rate of failure of patient reassurance after a normal test result and study the determinants of failure.Design-Replicated single case study with qualitative and quantitative data analysis.Setting-University teaching hospital.Subjects-40 consecutive patients referred for echocardiography either because of symptoms (10 patients) or because of a heart murmur (30), 39 were shown to have a normal heart.Interventions-Medical consultations and semistructured patient interviews were tape recorded. Structured interviews with consultant cardiologists were recorded in survey form.Main outcome measures-Patient recall of the explanation and residual understanding, doubt, and anxiety about the heart after the test and post-test consultation.Results-All 10 patients presenting with symptoms were left with anxiety about the heart despite a normal test result and reassurance by the consultant. Of 28 patients referred because of a murmur but shown to have no heart abnormality, 20 became anxious after detection of the murmur; 11 had residual anxiety despite the normal test result.Conclusions-Reassurance of the ''worried well''-anxious patients with symptoms or patients concerned by a health query resulting from a routine medical examination or from screening-constitutes a large part of medical practice, It seems to be widely assumed that explaining that tests have shown no abnormality is enough to reassure, The results of this study refute this and emphasise the importance of personal and social factors as obstacles to reassurance.

Recent advances in electronic engineering have allowed Doppler echocardiography to be presented in the form of a real-time two-dimensional image. The resulting image of blood flow has been described as a 'non-invasive angiogram', but the analogy with angiography should not be pushed too far since the technical determinants of these images are entirely different. Nevertheless, the colour flow map does allow rapid and direct exclusion, detection and quantitation of regurgitant and stenotic lesions, and semi-quantitative assessment of valvular regurgitation and shunts. To achieve optimum results, it is necessary to standardise recording procedure, to take account of patient variables which influence the image appearance and quality and to be aware of the possibility of artefact. As for all investigations, results which are not coherent with other echocardiographic data, with other investigations and with the clinical assessment should be subjected to particular scrutiny with the possibility of false diagnosis in mind.

We prospectively studied the impact of echocardiography on a cardiologist's diagnosis and management plan and on patient anxiety for 300 consecutive referrals. There was an impact on diagnosis in 90% of patients. Most common was confirmation of diagnosis usually with the addition of information pertinent to management (81 %); change of disease category or resolution of diagnostic doubt was uncommon (9%). The consultant cardiologist believed the heart to be normal in 48 patients who did not have any associated disease; none had any echocardiography abnormality. The cardiologist reported increased diagnostic confidence in 74% of all patients but management changed in only 9%. One-third. of all patients reported reduced anxiety when this was an important clinical issue but in less than half of them did the cardiologist consider that echocardiography information was essential for reassurance. Anxiety was increased in 6%, and in 12% the anxiety response was inconsistent with the test result.