BACKGROUND & AIMS:Destination ventricular assist device (VAD) is a newly approved upfront therapy for advanced heart failure in Australia, presenting a therapeutic option for patients who are unsuitable candidates for cardiac transplantation. This study investigated the mortality and morbidity of patients who underwent VAD implantation for advanced heart failure and subsequently determined destination therapy (DT) in the Australian healthcare context. METHOD:We conducted a retrospective analysis of VAD recipients at a statewide advanced heart failure centre between 2012 and 2024. Patient and VAD characteristics, right-sided heart catheter indices, quality of life, and survival outcome data were collected for analysis. RESULTS:A total of 18 patients were included in the study. The median Interagency Registry for Mechanically Assisted Circulatory Support profile was 2 (interquartile range [IQR] 1.25-3). The median survival from discharge was 5.9 years (IQR 4.1-8.3). Symptoms improved at 6 months (p=0.00016), and Kansas City Heart Failure Questionnaire, EuroQol-5 Dimensions-5 Levels, and Depression in the Medically Ill screening scores improved through to 12 months (p=0.0042, 0.01 and 0.017, respectively) after implantation. The 6-minute walk distance improved from 247.7±149.8 m to 526.9±165.5 m at 12 months after implantation (p=0.003). Right-sided heart catheter indices also improved: mean pulmonary artery pressure (36.6±10.8 to 26.1±14.4 mmHg; p=0.04), pulmonary capillary wedge pressure (25.3±7.6 to 14.1±9.1 mmHg; p=0.02), and cardiac output (3.5±1.3 to 5.5±1.2 L/min; p=0.0005). The median time to confirm DT strategy was 621 days (IQR 314-916); transplant ineligibility was attributed to a range of biopsychosocial factors. CONCLUSION:Destination therapy (DT) VAD for advanced heart failure is a feasible therapeutic option for transplant-ineligible patients in Australia, associated with substantial improvements in survival and quality of life. Future studies should focus on optimising remote monitoring and patient selection to further improve long-term outcomes in this complex cohort.

BACKGROUND:The need to improve biomedical research for the safe inclusion of Indigenous peoples is well documented. However, how one achieves this improvement, particularly in multisite, hospital-based research, is largely absent from the published literature. We aimed to conduct a reflexive dialogue to examine the challenges faced when adapting a hospital-based, biomedical acute rheumatic fever project in response to First Nations community feedback, thereby identifying possible areas for advancement in this type of research. METHODS:This study used co-autoethnography, a qualitative methodology in which multiple researchers collaboratively reflect on and analyse their personal experiences related to a shared topic. We used this approach to reflect on the challenges of incorporating Indigenous knowledges into a biomedical acute rheumatic fever project, and to explore how the project itself evolved in response to feedback from First Nations stakeholders. Aboriginal coauthors used the First Nations' Yarning method to generate data for co-autoethnography until data saturation was reached (ie, once no new challenges were identified), at which point an all-author meeting led by an Aboriginal coauthor was held to present and further reflect on the tensions that had been encountered. Briefing and debriefing sessions between Aboriginal coauthors were held before and after the all-author meeting. The resulting data were additionally analysed through a collective writing process involving multiple revision cycles and further Yarning and discussions until every coauthor was satisfied that the findings were consistent with their ideas and experiences. FINDINGS:18 Yarns and meetings involving six researchers as participants were held between March, 2023, and November, 2024. Seven key challenges were encountered in honouring First Nations knowledge: barriers to community engagement; poorly suited project design; complications with biomedical funding structures; inappropriate research ethics documents; poor engagement with other biomedical research groups; the impact of the hospital setting on cultural safety; and anticipated disagreements and top-down team dynamics within the biomedical research team. We identified four major aspects of the acute rheumatic fever project that underwent adaptation in response to local First Nations stakeholder feedback: community consultation, project design, consent processes, and research team structure. INTERPRETATION:In responding to First Nations knowledge and wisdoms, we were able to incorporate Indigenous ways of knowing, being, and doing into an acute rheumatic fever project while simultaneously retaining the biomedical conventions necessary for a robust scientific design. However, although we adapted the project (with difficulty), we do not recommend that researchers use the same process. Our adaptations to the ill-fitting biomedical research model placed unnecessary burden on First Nations stakeholders and created lengthy delays. Instead, we propose that biomedical research systems require remodelling and innovation to ensure fitness-for-purpose and safe expansion with First Nations peoples. FUNDING:National Health and Medical Research Council of Australia and National Heart Foundation of Australia.

BACKGROUND Fibrosis plays a central role in hypertrophic cardiomyopathy (HCM), contributing to symptoms via impaired systolic and diastolic function and ventricular arrhythmias. OBJECTIVES The aim of this study was to determine if eplerenone has an antifibrotic effect in nonobstructive HCM (resting left ventricular outflow tract gradient <30 mm Hg). METHODS This was a randomized, double-blind, placebo-controlled trial of eplerenone in 61 patients with nonobstructive HCM over 12 months. The primary endpoint was native T1 time on cardiac magnetic resonance as an index of diffuse fibrosis. Secondary endpoints included changes in diastolic function. RESULTS Thirty patients were randomized to 50 mg eplerenone and 31 to placebo. There was a reduction in native T1 time within the eplerenone group (1,315 f 134 ms at baseline vs 1,259 f 92 ms at 12 months; P = 0.041), with no significant change in the placebo group (1,234 f 28 ms at baseline vs 1,238 f 70 ms at 12 months; P = 0.854). This represents a 3.7% f 9% reduction in native T1 with eplerenone compared with a 1.1% f 9% increase with placebo (P = 0.07). There was no significant change in functional status or markers of diastolic function (such as E/e' ratio or mitral E/A ratio). CONCLUSIONS In patients with nonobstructive HCM, there was a reduction in myocardial T1 time with eplerenone, consistent with a reduction in diffuse myocardial fibrosis. Larger and longer trials are needed to confirm this finding and explore whether it translates into improved exercise capacity or a reduction in mortality over time. (Anti-fibrotic role of eplerenone on diffuse myocardial fibrosis and diastolic function in patients with hypertrophic cardiomyopathy; ACTRN12613000065796) (JACC Heart Fail. 2025;13:102415) (c) 2025 by the American College of Cardiology Foundation.

BACKGROUND:Fibrosis plays a central role in hypertrophic cardiomyopathy (HCM), contributing to symptoms via impaired systolic and diastolic function and ventricular arrhythmias. OBJECTIVES:The aim of this study was to determine if eplerenone has an antifibrotic effect in nonobstructive HCM (resting left ventricular outflow tract gradient <30 mm Hg). METHODS:This was a randomized, double-blind, placebo-controlled trial of eplerenone in 61 patients with nonobstructive HCM over 12 months. The primary endpoint was native T1 time on cardiac magnetic resonance as an index of diffuse fibrosis. Secondary endpoints included changes in diastolic function. RESULTS:Thirty patients were randomized to 50 mg eplerenone and 31 to placebo. There was a reduction in native T1 time within the eplerenone group (1,315 ± 134 ms at baseline vs 1,259 ± 92 ms at 12 months; P = 0.041), with no significant change in the placebo group (1,234 ± 28 ms at baseline vs 1,238 ± 70 ms at 12 months; P = 0.854). This represents a 3.7% ± 9% reduction in native T1 with eplerenone compared with a 1.1% ± 9% increase with placebo (P = 0.07). There was no significant change in functional status or markers of diastolic function (such as E/e' ratio or mitral E/A ratio). CONCLUSIONS:In patients with nonobstructive HCM, there was a reduction in myocardial T1 time with eplerenone, consistent with a reduction in diffuse myocardial fibrosis. Larger and longer trials are needed to confirm this finding and explore whether it translates into improved exercise capacity or a reduction in mortality over time. (Anti-fibrotic role of eplerenone on diffuse myocardial fibrosis and diastolic function in patients with hypertrophic cardiomyopathy; ACTRN12613000065796).

BACKGROUND Aortic stenosis (AS) and mitral regurgitation (MR) result in different patterns of left ventricular remodeling and hypertrophy. OBJECTIVES We characterized left ventricular wall stress (LVWS) profiles in pressure and volume-overloaded systems, examined the relationship between baseline LVWS and cardiac remodeling, and assessed the acute effects of valve intervention on LVWS using invasive pressures combined with cardiac magnetic resonance (CMR) imaging measures of left ventricular volumes/mass. METHODS A total of 47 patients with severe AS undergoing transcatheter aortic valve replacement (TAVR) and 15 patients with severe MR undergoing MitraClip (MC) underwent a 6-minute walk test (6MWT), transthoracic echocardiogram, and CMR before their procedures. Catheters in the left ventricle were used to record hemodynamic changes before and after valve/clip deployment. This was integrated with CMR data to calculate LVWS before and after intervention. RESULTS The TAVR group demonstrated significant reductions in systolic LVWS post procedure (median 24.7 Pa [IQR: 14 Pa] pre vs median 17.3 Pa [IQR: 12 Pa] post; P < 0.001). The MC group demonstrated significant reductions in diastolic LVWS (median 6.4 Pa [IQR: 5 Pa] pre vs median 4.3 Pa [IQR: 4.1 Pa] post; P = 0.021) with no significant change in systolic LVWS (30.6 +/- 1.61 pre vs 33 +/- 2.47 Pa post; P = 0.16). There was an inverse correlation between baseline systolic LVWS and 6MWT in the TAVR group (r = -0.31; P = 0.04). CONCLUSIONS TAVR results in significant reductions in systolic LVWS acutely. MC results in significant reductions in diastolic LVWS. Higher baseline systolic LVWS in TAVR is associated with shorter 6MWT suggesting that in AS, LVWS may be a useful marker of early decompensation. (c) 2024 by the American College of Cardiology Foundation.

Abstract Continuous ambulatory intravenous inotropes can be successfully used as a bridge to decision or heart transplant in patients with end-stage heart failure. The traditional model at our institute involved the Hospital in the Home (HITH) team, with daily nurse-led visits to the patients’ home, to safely maintain this treatment, which is otherwise largely restricted to the intensive care setting. In response to the COVID-19 pandemic, delivery of healthcare underwent a paradigm shift. Our model was changed to a patient led continuous intravenous inotrope program at home which obviated the need for a daily nurse visit. We describe our process and our early outcomes. Fifteen patients were deemed suitable for the Independent at Home program. All patients needed to complete ambulatory intravenous inotrope education, pass competency testing and have implantable cardioverter-defibrillators inserted prior to discharge. Competencies included proficiency for troubleshooting the inotrope ambulatory delivery pump, monitoring of vital signs and ability to report decompensated heart failure symptoms. Weekly outpatient visits to our heart failure clinic with nursing, medical and pharmacy reviews were scheduled. Emergency action plans were provided to patients. 73.3% of our cohort were male. The average age was 51 years. 46.6% had a diagnosis of dilated cardiomyopathy. 53.3% were listed for heart transplant and were bridge to transplant (BTT) and 46.7% were bridge to decision (BTD) for heart transplant. Over a study period of 35 months, seven (46.7%) patients were weaned off inotropes, three (20.0%) were escalated to durable mechanical circulatory support (one due to decompensated heart failure and two due to persistently elevated pulmonary pressures), four (26.7%) were transplanted and one (6.7%) chose to be palliated. Six patients had one admission, five patients had two admissions. Five readmissions were due to decompensated heart failure, four admissions were planned to optimize pulmonary hypertension following a right heart catheterization, three had peripherally inserted central catheter (PICC) line complications and two had non-cardiac admissions (refer to table 1). The median length of days on the Independent at Home program was 112 days with an interquartile range of 120 days. A comparative group consisting of consecutive patients treated under the previous Hospital in the Home model are presented in table 2; the Independent at Home cohort shows reduced unplanned admissions. The independent at home inotrope program is an effective and safe option to bridge to decision or bridge to cardiac transplantation.HITH vs Independent admission reasonHITH vs Independent admissions

We thank Dr. Yu et al. for their interest in our manuscript. As the authors state, there are a variety of statistical methods that may be used to assess inter-operator agreement – in this case between the Risk-SCD and ACC/AHA scores used to stratify risk of sudden cardiac arrest in hypertrophic cardiomyopathy (HCM) [1].

Background A paradigmatic clash exists between biomedical and Indigenous research frameworks. Problematically, when ill-fit biomedical research frameworks are applied Indigenous peoples can experience exclusion from biomedical studies and consequent potential health benefits. To overcome these issues, community based participatory research methodologies are often recommended. However, these can prove difficult to apply in tertiary healthcare research where prospective Indigenous peoples and families participating in research will come from unforeseen and numerous Indigenous communities. Adding further complexity, there appears a dearth of information for achieving incorporation of decolonising and Indigenous research frameworks into this type of prospective research. Methods We sought to reflect on and describe inclusion of an Indigenous Research Paradigm into the establishment of a prospective multi-site tertiary healthcare study on improving diagnosis and treatment of acute rheumatic fever. To generate reflection, the First Nations Yarning method was employed allowing qualitative findings to be generated via Indigenous epistemology and ontology. Findings Four main areas were identified as requiring significant change to align with an Indigenous Research Paradigm: stakeholder engagement, project design, consent processes, and multi-site approach. Multi-layered Indigenous leadership was recognised as a crucial component of the transformation and of the project success more broadly. Interpretation With extensive local First Nations involvement and a First Nations-led research team, a multi-site institution-based biomedical research project can be successfully adapted to be more in keeping with an Indigenous Research Paradigm. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committees of Menzies School of Health Research and Far North Queensland gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript

Background: Hypertrophic cardiomyopathy (HCM) is the commonest genetic cardiomyopathy and may result in sudden cardiac death (SCD). Clinical risk stratification scores are utilised to estimate SCD risk and determine potential utility of a primary prevention implantable cardioverter defibrillator (ICD).Methods: Patients with a confirmed diagnosis of HCM from a quaternary HCM service were defined according to clinical characteristics, genetic profiles and cardiac imaging results. European Risk-SCD score and American Heart Association / American College of Cardiology (AHA/ACC) Score were calculated. The primary outcome was cardiac arrest.Results: 380 patients with HCM were followed up for a median of 6.4 years. 18 patients (4.7%) experienced cardiac arrest, with predictive factors being younger age (37.2 vs 54.4 years, p = 0.0041), unexplained syncope (33.3% vs 9.4%, p = 0.007), non-sustained ventricular tachycardia (50.0% vs 12.7%, p < 0.0001), increased septal thickness (21.5 vs 17.5 mm, p = 0.0003), and presence of a sarcomeric gene mutation (100.0% vs 65.8%, p = 0.038). The Risk-SCD and AHA/ACC scores had poor agreement (kappa coefficient 0.38). Risk-SCD score had poor sensitivity (44.4%), classifying 55.6% of patients with cardiac arrest as low-risk but was highly specific (93.7%). AHA/ACC risk score did not discriminate between groups significantly. 20 patients (5.3%) died, with most >60-year-olds having a non-cardiac cause of death (p = 0.0223).Conclusion: This study highlights limited (38%) agreement between the Risk-SCD and AHA/ACC scores. Most cardiac arrests occurred in ostensibly low or medium-risk patients under both scores. Appropriate ICD selection remains challenging. Incorporating newer risk markers such as HCM genotyping and myocardial fibrosis quantification by cardiac MRI may assist future risk refinement.

Background Worldwide, the cardiology profession has an under-representation of women. We assessed medical students' perceptions of cardiology as a career choice with the aim of identifying barriers to gender diversity.Method An anonymous survey was distributed to medical students studying at three Australian medical universities. Questions pertained to demographics, year and stage of medical training, desire to pursue cardiology, and perceived barriers to a cardiology career.Results were analysed according to identified gender and desire to pursue or not pursue a cardiology career. Multivariable logistic regression evaluated for independent associations. The primary outcome were barriers identified to pursuing a career in cardiology.Results From 127 medical student respondents (86.6% female, mean age 25.964.8 years), 37.0% stated they wanted to pursue a career in cardiology (39.1% of women versus 23.5% of men, p=0.54). The top four perceived barriers to a cardiology career included: poor work-life balance (92/127, 72.4%), physician training process (63/127, 49.6%), on-call requirements (50/127, 39.4%) and lack of flexibility (49/127, 38.6%), with no gender differences. Women were more likely to report gender-related barriers (37.3% versus 5.9%, p=0.01) and less likely to identify procedural aspects as a barrier (5.5% women versus 29.4% men, p=0.001). Stu-dents in their pre-clinical years were more likely to want a career in cardiology (odds ratio 3.0, 95% con-fidence interval 1.2-7.7, p=0.02).Conclusions A high proportion of female and male medical students want to pursue a career in cardiology with both genders identifying major barriers of poor work-life balance, lack of flexibility, on-call requirements and the training process.

In Timor-Leste, cardiac interventions and surgical procedures are largely provided by the East Timor Hearts Fund. Since March 2020, no Timorese patients have been able to travel to Australia for humanitarian cardiac procedures.

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