Background:Cardiac arrest and cardiogenic shock are medical emergencies with poor survival rates despite improvements in advanced life support and resuscitation techniques. Case summary:We present the case of a 44-year-old woman with ischaemic cardiomyopathy who suffered a prolonged out-of-hospital cardiac arrest due to ventricular tachycardia. Despite high-dose catecholamines and vasopressin, the patient had persistent hypotension and elevated vasoactive-inotropic requirements. Haemodynamic monitoring revealed features consistent with post-arrest vasoplegia. Two low-dose boluses of methylene blue (0.25 mg/kg) were administered, resulting in a rapid and sustained improvement in cardiac output, index, and blood pressure, alongside a marked reduction in vasoactive support. The patient made a full neurological recovery and was discharged home. Discussion:While already established in vasopressor resistant septic shock and post-cardiopulmonary bypass vasoplegia, this case highlights the potential role of methylene blue as an adjunct therapy in post out of hospital cardiac arrest vasoplegia, particularly when conventional therapies fail. The dose of methylene blue used was substantially lower than that reported in prior studies of sepsis and cardiac surgery. Further studies are warranted to define the timing, dosing, and clinical impact of methylene blue in this setting.

Background: Invasive coronary angiography has historically been the reference standard for coronary, valvular, and structural heart disease. Over the past decade, coronary computed tomography angiography (CCTA), CT-derived fractional flow reserve (CT-FFR), photon-counting detector computed tomography (PCCT), and cardiac magnetic resonance (CMR) have expanded the range of clinical questions answerable without an intra-arterial catheter, but this shift has been uneven across clinical domains. Methods: We performed a narrative review and synthesis of randomized trials, registries, society guidelines, and consensus documents (2009-2026) identified through PubMed and major cardiovascular guideline databases, written from a joint cardiology and cardiac-surgical standpoint. Results: The boundary has shifted asymmetrically, by which we mean a domain-dependent rather than uniform displacement of invasive angiography. Non-invasive imaging is now established as the first-line approach for stable chest pain at low-to-moderate pretest probability, for pre-transcatheter aortic valve replacement (TAVR) and structural procedural planning, and for aortic disease. It remains contested for stable multivessel disease and pre-coronary artery bypass grafting (CABG) planning, where CCTA- or CT-FFR-only planning is still investigational. Invasive angiography stays first-line for ST-elevation myocardial infarction (STEMI), cardiogenic shock, and complex percutaneous coronary intervention (PCI), where diagnosis and therapy are inseparable. Conclusions: Invasive and non-invasive modalities are complementary rather than competing. The appropriate first-line investigation depends on the disease domain, pretest probability, anatomical complexity, imaging quality, and whether diagnosis and treatment can be separated. We propose a complexity-stratified, heart-team framework and identify the surgical research gaps that remain.

BACKGROUND:Vasoactive medications constitute an integral component of the hemodynamic support strategy in patients with cardiogenic shock (CS). However, there is an emerging signal of harm associated with the commonly used catecholamine, epinephrine (adrenaline), when used in the treatment of CS. The PAramedic randomized trial of Noradrenaline (norepinephrine) versus Adrenaline in the management of patients with cardiogenic shock (PANDA) was therefore designed to determine if the initial treatment with norepinephrine, compared with epinephrine, improves outcomes in patients with CS. METHODS AND DESIGN:The PANDA trial is a prehospital, open-label, single-blind, randomized controlled trial designed to assess the efficacy and safety of two commonly used catecholaminergic agents, norepinephrine and epinephrine, in the initial resuscitation of patients with suspected CS. Patients aged 18 years and older are eligible for recruitment by paramedics if there is clinical evidence of hypoperfusion, a measured systolic blood pressure of ≤90 mmHg despite adequate volume resuscitation with intravenous fluids, and the shock etiology is of a suspected cardiac cause (including cardiac arrest of an estimated duration of less than 30-minutes). Paramedics will randomize an anticipated 1,155 patients over an estimated 5-year period in a 1:1 ratio to receive an infusion of epinephrine or norepinephrine, which will be titrated to achieve a target systolic blood pressure of 100 mmHg. The primary efficacy outcome will be all-cause 28-day mortality. Recruitment commenced on February 28, 2024 and a total of 450 patients have been recruited thus far. IMPLICATIONS:The PANDA trial will determine if norepinephrine, compared to epinephrine, for the initial hemodynamic support in CS improves outcomes. The results will help inform future treatment recommendations for the management of patients with CS. TRIAL REGISTRATION:ACTRN12621000805875.

Postcardiac arrest syndrome is a complex multisystem disorder that evolves after return of spontaneous circulation and remains a major determinant of morbidity and mortality following out-of-hospital cardiac arrest. Beyond anoxic brain injury and transient myocardial dysfunction, many patients develop a systemic ischemia/reperfusion response with endothelial and microvascular dysfunction, vasoplegia, and immune dysregulation-features that contribute to shock and organ failure. Hemodynamic instability is often mixed with low systemic vascular resistance despite preserved or recovering cardiac output, but management is still largely supportive and centered on achieving a target mean arterial pressure. An increasing understanding of the central role of inflammation, including gastrointestinal barrier disruption, cytokine release, complement activation, nitric oxide-cGMP signaling, and immune phenotypic heterogeneity has prompted evaluation of targeted adjunctive therapies. However, randomized trials of immunomodulators and other vasoactive strategies have yielded mixed results, reflecting biological heterogeneity and limited phenotypic stratification. This review synthesizes contemporary understanding of the inflammatory and hemodynamic mechanisms underpinning postcardiac arrest syndrome, examines current and emerging pharmacologic strategies, and highlights priorities for future investigation, including mechanistic phenotyping, prospective biobanking, and prospective trial requirements to guide more precise management strategies in postcardiac arrest care.

BACKGROUND:Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains a time-critical emergency with persistently high mortality despite advances in reperfusion and mechanical circulatory support. Clinical outcomes may be influenced by the timing of percutaneous coronary intervention (PCI), with after-hours procedures potentially affected by logistical and staffing constraints. The impact of PCI timing on AMI-CS outcomes remains unclear. METHOD:A retrospective cohort study was conducted using data from the Victorian Cardiac Outcomes Registry including all adults undergoing PCI for ST-elevation myocardial infarction (STEMI) or non-STEMI complicated by CS. PCI timing was classified as procedure start time in-hours (0800-1759 weekdays) or after-hours (all other times). Baseline, procedural, and outcome data were compared. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. Long-term mortality was determined through linkage with the Australian National Death Index. RESULTS:CS PCI cases were undertaken from 2013 to 2024; with 58.5% occurring after. CONCLUSIONS:hours, with in-hospital mortality remaining high over the past decade irrespective of procedure timing. These findings underscore the need for the continued development of shock management paradigms and strategic deployment of emerging treatments in AMI-CS.

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are the two dominant revascularisation strategies for obstructive coronary artery disease, yet their relative roles continue to shift because they address coronary pathophysiology differently with ever-evolving techniques. PCI has advanced through iterative improvements, including balloon angioplasty, bare-metal stents, and drug-eluting stents, with contemporary outcomes increasingly driven by procedural optimisation using intracoronary imaging and physiology-guided lesion selection rather than device category alone. CABG has progressed through perioperative management, improvements in operative safety, and, critically, conduit durability. Recognition of progressive saphenous vein graft failure has underpinned a conduit-optimisation era in which the left internal mammary artery to left anterior descending artery remains the gold standard. Further, broader arterial grafting (including radial artery use, multiple arterial grafting, and selected total-arterial strategies) has been increasingly applied, albeit with deliverability and competing-risk constraints highlighted in randomised evidence. This perspective review reframes the CABG versus PCI comparison not as a binary contest, but as a context-dependent assessment in which the relative value of each strategy depends on the specific technologies, techniques, and conduits available at the time of comparison. We summarise comparative effectiveness where evidence is most consistent and where it remains sensitive to anatomy, comorbidity, and endpoint definitions. In diabetes with multivessel disease, trial data favour CABG for long-term survival and clinical outcomes despite higher stroke risk. In left main disease, outcomes depend on lesion pattern and overall complexity, with trial-era stent technology and composite endpoint definitions influencing conclusions. In ischaemic left ventricular dysfunction, a long-term survival benefit is established for CABG added to medical therapy, while multi-vessel PCI has not demonstrated comparable prognostic modification in contemporary data. We then examine hybrid coronary revascularisation as territory-specific allocation, highlighting its physiological rationale, program dependence, and limited, adequately powered randomised evidence. Finally, we outline how artificial intelligence (AI) and robotics may accelerate a precision revascularisation paradigm by standardising lesion assessment, supporting procedural planning, improving procedural reproducibility, and enabling more patient-specific selection among PCI, contemporary CABG with optimised conduits, and hybrid pathways.

BACKGROUND:Percutaneous coronary intervention (PCI) is one of the most frequently performed procedures and is being undertaken in increasingly complex patient populations. International studies have suggested an association between operator or institutional procedural volume and PCI outcomes, largely reflecting differences in experience and performance. METHODS:All adult procedures registered in the Victorian Cardiac Outcomes Registry undergoing PCI in Victoria, Australia between 1 January 2015 and 31 December 2024 were included. Operators were classified as low (<50 PCI/year), medium (50-99), or high (≥100), and institutions as low (<200), medium (200-399), or high (≥400) annual PCI volume. Multivariable logistic regression clustered at the hospital level assessed associations between operator volume and in-hospital mortality. RESULTS:Across 34 institutions and 157 operators, 117,237 PCI procedures were analysed. High-volume operators performed 72.0% of all procedures, compared with 21.9% by medium-volume and 6.1% by low-volume operators. Similarly, high-volume institutions accounted for 71.2% of PCI, with 21.8% and 7.0% performed at medium- and low-volume centres, respectively. High-volume operators and institutions managed greater proportions of high-risk presentations (STEMI, out-of-hospital cardiac arrest, cardiogenic shock) and demonstrated comparable adjusted outcomes. Key PCI quality indicators such as radial access, coronary imaging use, and faster door-to-balloon times were more common among high-volume operators and institutions. After multivariable adjustment, neither operator nor institutional volume was independently associated with in-hospital mortality. CONCLUSION:In contemporary Australian PCI practice, important differences in PCI care metrics were observed between high- and low-volume operators and institutions. Although a substantial proportion of PCI is performed by operators not meeting current national volume standards, adjusted survival was not independently associated with operator or institutional volume. Consistent with European data, these findings highlight the importance of performance monitoring and suggest that minimum PCI standards in Australia and comparable mixed public-private systems may need to be reviewed to focus more on quality metrics, rather than procedural volume alone.

PURPOSE:Pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality. However, population-level data describing the prehospital presentation and outcomes of emergency medical service (EMS)-treated patients remain limited. We aimed to determine the incidence, clinical characteristics, and outcomes of patients with EMS-treated PE in Victoria, Australia. METHODS:This population-based cohort study included adults attended by a single statewide EMS provider between January 1, 2015, and November 28, 2020, with an in-hospital primary diagnosis of PE. Prehospital electronic patient care records were linked with statewide hospital and death registry datasets. The primary outcome was 30-day all-cause mortality. Multivariable analyses were performed to assess predictors of 30-day mortality. RESULTS:Among 3,976,574 EMS-attended patients (29.6 million person-years), 6,769 had a confirmed PE, yielding an incidence of 22.9 per 100,000 person-years (95% CI, 22.3-23.4), which increased over the study period from 22.86 in 2015-22.84 per 100,000 person years in 2020 (Ptrend = 0.04). The mean (SD) age was 64.7 (17.3) years. The 30-day mortality was 7.0%, ranging from 0.5% in very low-risk to 19.3% in very high-risk Pulmonary Embolism Severity Index (PESI) categories (P < 0.001). Independent predictors of 30-day mortality included older age, pre-hospital cardiac arrest, pre-existing malignancy, diabetes, and altered vital signs (low systolic blood pressure, hypoxia, and tachypnea). Only 4.2% of patients were discharged directly from the emergency department. CONCLUSIONS:PE treated by EMS is increasingly common and carries a substantial short-term mortality risk. These findings suggest that established risk stratification tools may help optimize prehospital triage and improve systems of care, however, further dedicated studies are required.

INTRODUCTION:Cardiogenic shock and cardiac arrest are associated with high risk of mortality despite advances in resuscitation techniques and supportive care. A growing body of evidence implicates a systemic inflammatory response syndrome (SIRS) in the pathogenesis of post-arrest vasoplegia and end-organ injury. Methylene blue (MB), a nitric oxide pathway inhibitor, has shown efficacy in vasoplegic and septic shock, yet its role in cardiogenic shock or cardiac arrest is not well established. METHODS:We conducted a systematic review of peer-reviewed studies examining methylene blue in cardiogenic shock or cardiac arrest. Electronic databases MEDLINE, EMBASE, CENTRAL, Scopus, and Web of Science were searched in March 2025. Preclinical randomised trials and clinical studies in adult humans or animal models were included. RESULTS:Out of 676 screened records, seven studies met inclusion criteria: six preclinical randomised animal studies and one retrospective human cohort study. Early porcine studies using electrically induced ventricular fibrillation and continuous MB infusion during CPR demonstrated improved survival, haemodynamic profile, and neurologic outcomes. In contrast, more recent, well conducted bolus-only studies using infarct-induced models reported minimal or no benefit associated with MB administration. The single human study lacked a comparator group and provided limited cardiogenic shock-specific outcome data. CONCLUSIONS:This systematic review highlights the lack of data available for MB in cardiogenic shock and cardiac arrest, especially in humans. There was a potential therapeutic signal for methylene blue in some animal models of cardiogenic shock and cardiac arrest. Prospective studies with clinically relevant models of cardiac injury are warranted to determine whether MB can improve outcomes in this high-risk population.

BACKGROUND:Coronary allograft vasculopathy (CAV) remains a significant cause of morbidity and mortality after heart transplantation. The use of aspirin for CAV prophylaxis has recently garnered interest as a possible therapeutic adjunct in this setting. METHODS:This 2-center retrospective cohort study included 372 patients who underwent heart transplantation between January 2009 and March 2018 and were stratified according to the commencement of aspirin during their index transplant admission. The primary outcome was the development of moderate or severe CAV (International Society for Heart and Lung Transplantation grade ≥2) at surveillance coronary angiography. Secondary endpoints included mortality at follow-up. RESULTS:There were no differences in age, sex, and cause of heart failure. In the early aspirin group, the preponderant risk factors included use of ventricular assist devices, pretransplant smoking, and mild or moderate rejection. Multivariable analyses to assess for independent predictors of CAV development and mortality demonstrated that aspirin was associated with reduced mortality (adjusted hazard ratio = 0.19; 95% confidence interval, 0.08-0.47, P  < 0.01) and a trend toward a protective effect against the development of moderate or severe CAV (adjusted hazard ratio = 0.24; 95% confidence interval, 0.54-1.19; P  = 0.08). CONCLUSIONS:In this retrospective risk-adjusted 2-center cohort study, early aspirin administration was associated with reduced risk of death and a trend toward a protective effect against CAV development. These findings warrant validation in prospective randomized trials.

BACKGROUND:Despite the evidence of clinical benefit, total arterial revascularization (TAR) remains underutilized in elderly patients undergoing coronary artery bypass grafting due to concerns about perceived surgical complexity and limited life expectancy. OBJECTIVES:The objective of the study was to evaluate long-term survival of TAR vs conventional non-TAR grafting strategies in elderly (≥70 years) and younger (<70 years) patients using a binational cardiac surgery registry. METHODS:The study included patients who underwent primary isolated coronary artery bypass grafting with at least 2 grafts between 2001 and 2020. The endpoint was long-term all-cause mortality. Patients were stratified into 2 age groups, <70 years and ≥70 years. Within each cohort, survival outcomes were compared between those who received TAR, and those who received non-TAR involving at least 1 saphenous vein graft. Secondary analyses further divided the non-TAR group into patients receiving multiple arterial grafting or single arterial grafting. Baseline differences were adjusted using inverse probability treatment weighting, followed by Cox proportional hazard modeling. RESULTS:Among 59,641 patients, TAR was associated with significantly improved survival compared to non-TAR in both elderly (HR: 0.87; 95% CI: 0.81-0.92; P < 0.001) and younger age groups (HR: 0.80; 95% CI: 0.73-0.88; P < 0.001). A clear hierarchy in survival was also demonstrated, with the highest survival observed in patients undergoing TAR, followed by non-TAR-multiple arterial grafting, and the lowest in those receiving non-TAR-single arterial grafting. CONCLUSIONS:TAR improves long-term survival in both elderly and younger patients. These findings challenge the assumption that limited life expectancy precludes arterial grafting and support broader implementation of TAR in appropriately selected older patients. Randomized clinical trials evaluating TAR are warranted to validate these observational findings.

Pulmonary hypertension (PH) is common in heart failure with preserved ejection fraction (HFpEF), driven in many patients by a combination of elevated left atrial pressure and pulmonary vascular remodelling. Whether local biomarker release contributes to pulmonary remodelling in HFpEF is unknown. We, therefore, aimed to compare the transpulmonary inflammatory biomarker release profile in healthy control subjects and HFpEF patients and to investigate the contribution of biomarkers to adverse pulmonary vascular remodelling as reflected via invasive haemodynamics. Thirty-four participants (20 HFpEF, 14 healthy controls) underwent exercise hemodynamic testing and concurrent target organ blood sampling (pulmonary artery & systemic arterial). A panel of 157 inflammatory biomarkers were analysed via OLink proteomics using proximity extension assay technology and subsequent polymerase chain reaction. Transpulmonary gradient (TPG) was calculated as [pulmonary artery]-[systemic arterial]. HFpEF patients were older (70±9 vs 53±8 years, p<0.001) with higher BMI (34±9 vs 26±9 kg/m², p=0.004). While no healthy controls had PH, 55% of HFpEF patients did. Pulmonary vascular resistance was higher (1.95±0.83 vs 0.93±0.50WU, p<0.001), and pulmonary artery compliance (PAC) lower (4.2±1.7 vs 7.1±2.4ml/mmHg, p<0.001) in HFpEF at rest as well as at peak exercise. From 157 biomarkers, 22 demonstrated significantly different TPGs between groups, with 12 demonstrating association with invasive haemodynamics, Figure 1. Principal coordinate analysis revealed significantly different transpulmonary biomarker release profiles between HFpEF and controls (p=0.002), Figure 2. Correlations between PAC and the TPG of follistatin, agouti-related protein, lipoprotein lipase, and thrombomodulin were significantly different (p<0.05) between groups, as were correlations for exercise mean pulmonary artery pressure and TPG of thrombomodulin, leptin, ADAMTS13, adrenomedullin, CCL11, decorin, GDF-2, and PD-L2 (all p<0.05). TPGs for lipoprotein lipase, adrenomedullin, leptin, agouti-related protein, thrombomodulin, ADAMTS13, decorin and PD-L2 were also associated with differences in exercise pulmonary vasodilatory capacity between HFpEF and controls, as assessed by ΔPVR or ΔPAC (all p<0.05). We identified a significantly altered transpulmonary flux profile of inflammatory biomarkers in HFpEF compared to healthy controls. These locally generated biomarkers demonstrated association with adverse pulmonary remodelling in HFpEF and may thereby be targets for therapeutic intervention.Figure 1 Figure 2

Importance:Multiarterial coronary bypass procedures offer improved clinical outcomes compared with single arterial grafting with supplementary saphenous vein grafts. However, the survival advantage of multiarterial grafting across varying levels of left ventricular impairment remains uncertain. Objective:To compare long-term survival outcomes of patients undergoing multiple vs single arterial grafting, stratified by preoperative ejection fraction. Design, Setting, and Participants:A complete-case retrospective cohort study was conducted using data from a multicenter population-based cardiac registry established by the Australian & New Zealand Society of Cardiac & Thoracic Surgeons with linkage to the National Death Index. Participants were individuals who underwent primary isolated coronary bypass surgery between June 1, 2001, and January 31, 2020. Exclusion criteria were nonadults, reoperations, concomitant or previous cardiac surgical procedures, single-graft procedure, and cases without any arterial grafts. Statistical analyses were conducted in September 2024. Exposures:Patients underwent either multiple or single arterial grafting, stratified by their preoperative left ventricular ejection fraction. Main Outcomes and Measures:Long-term all-cause mortality. Results:The study included 59 641 patients (mean [SD] age at the time of surgery, 65.8 [10.2] years; 48 321 men [81.0%]). The median follow-up duration was 5.0 years (IQR, 2.3-8.6 years). Multiarterial grafting was associated with a 19.0% relative reduction in all-cause mortality compared with single arterial grafting among patients with a normal left ventricular ejection fraction (hazard ratio [HR], 0.81; 95% CI, 0.75-0.87; P < .001). Similar survival benefits were observed among patients with mild (HR, 0.83; 95% CI, 0.77-0.90; P < .001), moderate (HR, 0.82; 95% CI, 0.74-0.90; P < .001), and severe left ventricular impairment (HR, 0.82; 95% CI, 0.71-0.96; P = .01). A multivariable Cox proportional hazards regression interaction-term analysis indicated no significant differences in the multiarterial survival benefit by ejection fraction stratification (P = .75). Multiarterial grafting with exclusively arterial conduits was associated with enhanced survival benefits compared with other multiarterial procedures with saphenous vein grafts, except when the left ventricular ejection fraction was below 30% (HR, 0.87; 95% CI, 0.67-1.13; P = .30). Conclusions and Relevance:In this retrospective cohort study using data from a binational database, multiarterial procedures were associated with reduced long-term mortality risk compared with single arterial grafting across the spectrum of preoperative left ventricular ejection fractions. Total arterial revascularization was associated with incrementally improved survival, particularly among patients with preserved ejection fraction. Because most coronary surgery practice continues to use single arterial grafting, consideration to alter grafting strategy to multiarterial procedures may be indicated.

BACKGROUND AND AIMS:The optimal revascularization strategy in patients with ischaemic cardiomyopathy remains unclear with no contemporary randomized trial data to guide clinical practice. This study aims to assess long-term survival in patients with severe ischaemic cardiomyopathy revascularized by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS:Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group registries (from January 2005 to 2018), patients with severe ischaemic cardiomyopathy [left ventricular ejection fraction (LVEF) <35%] undergoing PCI or isolated CABG were included in the analysis. Those with ST-elevation myocardial infarction and cardiogenic shock were excluded. The primary outcome was long-term National Death Index-linked mortality up to 10 years following revascularization. Risk adjustment was performed to estimate the average treatment effect using propensity score analysis with inverse probability of treatment weighting (IPTW). RESULTS:A total of 2042 patients were included, of whom 1451 patients were treated by CABG and 591 by PCI. Inverse probability of treatment weighting-adjusted demographics, procedural indication, coronary artery disease extent, and LVEF were well balanced between the two patient groups. After risk adjustment, patients treated by CABG compared with those treated by PCI experienced reduced long-term mortality [adjusted hazard ratio 0.59, 95% confidence interval (CI) 0.45-0.79, P = .001] over a median follow-up period of 4.0 (inter-quartile range 2.2-6.8) years. There was no difference between the groups in terms of in-hospital mortality [adjusted odds ratio (aOR) 1.42, 95% CI 0.41-4.96, P = .58], but there was an increased risk of peri-procedural stroke (aOR 19.6, 95% CI 4.21-91.6, P < .001) and increased length of hospital stay (exponentiated coefficient 3.58, 95% CI 3.00-4.28, P < .001) in patients treated with CABG. CONCLUSIONS:In this multi-centre IPTW analysis, patients with severe ischaemic cardiomyopathy undergoing revascularization by CABG rather than PCI showed improved long-term survival. However, future randomized controlled trials are needed to confirm the effect of any such benefits.

ABSTRACT Background Acute myocardial infarction complicated by cardiogenic shock (AMICS) confers short‐term mortality of 40%–50%. Protocolised network management of AMICS patients as part of a hub‐and‐spoke model supported by upstream mechanical circulatory support (MCS) is gaining traction globally to treat AMICS. Method We conducted a prospective multicenter study in Melbourne, Australia describing our 5‐year experience utilizing a protocolised hub‐and‐spoke model of care for patients with AMICS supported by planned upstream use of Impella CP (Abiomed, Danvers, MA). Results From December 2019 to August 2024, 31 patients were treated for AMICS with Impella MCS support. Median age was 60 years and 87% were males. ST‐elevation myocardial infarction accounted for 84% of presentations, and 29% were complicated by cardiac arrest. The majority of patients treated were in SCAI‐CSWG stage D (52%), and stage C (26%) shock. Upstream Impella prior to PCI occurred in 84% of patients. The 30‐day survival rate was 74%. An adverse event occurred in 39% of patients. Device‐related complications were due to hemolysis (32%) and arrhythmia (3%). Escalation of MCS support was required in five patients (16%). Multivariate analysis identified patients requiring transfer to the hub center prior to revascularisation as an independent predictor of mortality (OR 13.2 [1.34–129.3] p = 0.027). Conclusion In this first protocolised hub‐and‐spoke model of care for AMICS supported by planned upstream use of Impella in Australia, 30‐day survival was high compared to published historical rates. Patient and device‐related complication rates were low. Expansion of the hub‐and‐spoke model for the treatment of AMICS appears warranted.

OBJECTIVES:To determine the influence of presenting electrocardiographic (ECG) changes on prognosis in acute coronary syndrome cardiogenic shock (ACS-CS) patients undergoing percutaneous coronary angiography (PCI). BACKGROUND:The effect of initial ECG changes such as ST-elevation myocardial infarction (STEMI) versus non-STEMI among patients ACS-CS on prognosis remains unclear. METHODS:We analysed data from consecutive patients with ACS-CS enrolled in the Victorian Cardiac Outcomes registry between 2014 and 2020. Inverse probability of treatment weighting analysis (IPTW) was used to assess the effect of ECG changes on 30-day mortality. RESULTS:Of 1564 patients with ACS-CS who underwent PCI, 161 had non-STEMI and 1403 had STEMI on ECG. The mean age was 66 ± 13 years, and 74 % (1152) were males. Patients with non-STEMI compared to STEMI were older (70 ± 12 vs 65 ± 13 years), had higher rates of diabetes (34 % vs 21 %), prior coronary artery bypass graft surgery (14 % vs 3.3 %), peripheral arterial disease (10.6 % vs 4.1 %, p < 0.01), and lower baseline eGFR (53.8 [37.1, 75.4] vs 65.3 [46.3, 87.8] ml/min/1.73m2), all p ≤ 0.01. Non-STEMI patients were more likely to have a culprit left circumflex artery (29 % vs 20 %) and more often underwent multivessel percutaneous coronary intervention (30 % vs 20 %) but had lower rates of out-of-hospital cardiac arrest (21 % vs 39 %), all p ≤ 0.01. Propensity score analysis with IPTW confirmed that non-STEMI ECG was associated with lower odds for 30-day all-cause mortality (OR 0.47 [0.32, 0.69], p < 0.001), and 30-day major adverse cardiovascular and cerebrovascular events (OR 0.48 [0.33, 0.70]). CONCLUSIONS:In patients undergoing PCI, Non-STEMI as compared to STEMI on index ECG was associated with approximately half the relative risk of both 30-day mortality and 30-day MACCE and could be a useful variable to integrate in ACS-CS risk scores.

Background Although postoperative atrial fibrillation (POAF) frequently occurs early after cardiac surgery, there is a paucity of data evaluating predictors and timing of late atrial fibrillation (AF) recurrence. Objectives The authors sought to evaluate predictors of late AF recurrence in patients undergoing cardiac surgery. Methods We retrospectively reviewed cardiac surgery patients from 2010 to 2018 with no preoperative diagnosis of AF or atrial flutter. We recorded incidence and timing of late AF recurrence, defined as occurring ≥12 months following surgery. Results 1,031 patients were included (mean age at surgery 64 ± 12 years, 74% male). Early POAF was recorded in 445 patients (43%). POAF was usually transient, with total AF duration <48 hours in 72% and reversion to sinus rhythm at discharge in 91%. At 4.7 ± 2.4 years follow-up, late AF occurred in 139 patients (14%). Median time to AF recurrence was 4.4 years post-surgery (Q1-Q3: 2.6-6.2 years). Late AF was significantly more likely among patients with early POAF than those without (23% vs 6%; P < 0.001), with highest incidence (38%) in those with POAF duration >48 hours. In a multivariable analysis, early POAF duration >48 hours was a significant predictor of late AF recurrence (HR: 5.9). Surgery type and CHA2DS2-VASc score were not predictive of late AF events. Conclusions Post-operative AF episodes of duration ≥48 hours predict recurrent AF episodes over long-term follow-up after cardiac surgery. Implications for arrhythmia surveillance and anticoagulation in patients with longer duration POAF episodes require further study.