AIMS:Guidelines recommend initial rate control in haemodynamically stable patients with atrial fibrillation (AF) or atrial flutter (AFL) and acute decompensated heart failure (ADHF). There is limited data on early inpatient rhythm control. We investigated the outcomes of patients managed with early TOE-guided DC cardioversion (DCCV) or ablation. METHODS:We retrospectively analysed patients admitted to a single centre with AF or AFL and ADHF with LVEF≤40% that underwent inpatient TOE-guided DCCV or ablation. The primary endpoint was the one year composite outcome of mortality or rehospitalisation for heart failure. RESULTS:We identified 79 patients, including 33 with AF (32 DCCV, one ablation) and 46 with AFL (22 DCCV, 24 ablation). The primary endpoint occurred in 20%. One-year mortality was 2.5%. There were significantly fewer rehospitalisations for arrhythmia or heart failure with AFL-ablation compared to AFL-DCCV (21% vs 64%, p=<0.01). Clinical recurrence of AF or AFL was 43%. At follow-up LV assessment, LVEF>40% was found in 75% (p=<0.01), including 87% of patients without known cardiomyopathy and 82% of patients in sinus rhythm. CONCLUSION:Early inpatient DCCV or ablation for AF or AFL and ADHF had low mortality rates and rehospitalisation for heart failure with substantial improvement in LV function at follow-up.

The diagnosis of cardiac tumours is often based on images without tissue diagnosis or tissue obtained at surgery. Percutaneous myocardial biopsy via a transvenous approach has been described in literatures but this technique is not feasible with left atrial tumours. We report a patient presenting with heart failure and left atrial tumour. The diagnosis of spindle cell neoplasm was established pre-operatively via successful transseptal fine needle aspiration of cells from a left atrial tumour. We believe this technique worth consideration to aid pre-surgery diagnosis. (Heart, Lung and Circulation 2010;19:438-439) (C) 2009 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.

A 66-year-old woman presented with a 40-year history of a slowly enlarging erythematous patch on the left thenar eminence. Histopathology showed a sharp 'step' between the uninvolved and involved skin. Epidermal dysplasia and a cornoid lamella were not seen. These are the typical features of circumscribed palmar hypokeratosis.

AIM:To assess physician compliance (at South Auckland's Middlemore Hospital) with two international guidelines on the prevention of thromboembolic complications of atrial fibrillation (AF). The two guidelines are The American College of Cardiology/American Heart Association/European Society of Cardiology consensus group (ACC/AHA/ESC guidelines-2001) and the American College of Chest Physicians guidelines (ACCP guidelines-2001).METHOD:A retrospective review of patients who presented to the emergency department with AF between 1 December 2001 and 28 February 2002. Antithrombotic treatment was compared with that recommended by the above stated international guidelines. It was hypothesised that 20% variance from guideline recommended treatment was clinically significant. The incidence of stroke in the study group was followed over a 12-month period.RESULTS:Eighty patients were included in the study. The proportion of patients managed in accordance with the ACC/AHA/ESC and ACCP guidelines was 47.5% (95% CI 36.2-59.0) and 31.2% (95% CI 21.3-42.6) respectively. This was significantly different from that hypothesised (p<0.0001). Only 47.4% (95% CI 34.0-61.0) and 47.3% (95% CI 33.6-61.2) of eligible patients, according to ACC/AHA/ESC and ACCP guidelines respectively, received warfarin. This was also less than hypothesised; p<0.0001. High-risk patients were less likely to be given warfarin if they were older (p<0.03). Four patients had a stroke at follow-up. These patients were not on warfarin, although recommended by the guidelines.CONCLUSION:Warfarin is significantly underutilised in patients with AF at our institution.