Single Australian Centre Research Articles

Percutaneous Coronary Intervention (PCI) for Spontaneous Coronary Artery Dissection (SCAD) Induced Acute Coronary Syndrome (ACS): 21 Year Experience in a Single Australian Centre

Percutaneous Coronary Intervention (PCI) for Spontaneous Coronary Artery Dissection (SCAD) Induced Acute Coronary Syndrome (ACS): 21 Year Experience in a Single Australian Centre

Transcatheter Mitral Valve-In-Valve Replacement for Degenerated Bio-Prosthetic Valves: A Single Australian Centre Experience

Transcatheter mitral valve-in-valve replacement for degenerated bioprosthetic valves has emerged as an alternative therapy for high-surgical-risk patients. There is limited Australian data to evaluate the outcomes. We seek to examine this further at our centre.

Prevalence of Frailty and Prehabilition Uptake Amongst Waitlisted Cardiac Transplant Patients: A Western Australian Single Centre Experience

Frailty is a novel risk factor which is associated with prolonged hospitalisation and death post cardiac transplantation [1–2]. Recent data suggest at least partial reversibility of pre-transplant frailty [1]. Prehabilitation programs may help reduce frailty prior to surgery and prevent post-operative complications [3]. We report the burden of frailty and uptake of prehabilitation in a contemporary Australian cohort.

Streptococcus anginosus group infections in hospitalised children and young people.

The Streptococcus anginosus group (SAG) comprises three bacterial species colonising the mouth and gastrointestinal and genitourinary tracts and capable of serious pyogenic infections. Although well-described in adults, studies in children are limited. Here, we characterise paediatric SAG infections from a single Australian centre. Hospitalised patients aged ≤18 years with positive SAG cultures from January 2009 to December 2019 were identified from Pathology Queensland's Gold Coast Laboratory database and their medical records were reviewed. Two-hundred children (62% male), median age 12 years (interquartile range 6-16), with positive SAG cultures were identified. Overall, 90% received intravenous antibiotics, 89% underwent surgical drainage, 23% were readmitted and 15% required additional surgery. The most common sites were the abdomen (39%), soft tissues (36%) and head and neck regions (21%). Since 2011, Pathology Queensland reported SAG at the species level (n=133). Of these, S. anginosus was the most prevalent (39%), then S. constellatus (34%) and S. intermedius (27%). Compared with the other two species, S. intermedius was most commonly associated with head and neck infections (relative risk (RR)=2.2, 95% confidence interval (CI) 1.4-3.5), while S. constellatus (RR=1.7, 95% CI 1.2-2.4) and S. anginosus (RR=1.5, 95% CI 1.0-2.0) were each associated with a higher risk of intra-abdominal infection than S. intermedius. Since February 2015, the number of children admitted with SAG-associated intra-abdominal infection per 1000 hospitalisations increased by 29% annually compared with an annual decline of 8% in previous years. SAG infections occur at various anatomical sites. Despite antibiotics and surgical management, almost one-quarter are re-hospitalised for further treatment.

Prescribing in a pediatric hospital setting – Lost in translation?

ObjectivesTo determine parental understanding of directions on common pediatric prescription pharmacy labels and to identify enablers and barriers that affect interpretation of these labels. MethodsProspective qualitative descriptive study (July to August 2020) of 20 parents in post-surgical wards at a single Australian tertiary pediatric center. ResultsFour key themes emerged through inductive analysis of the interview transcripts: 1) the addition of specific directions, such as administration with/without food and treatment course duration were perceived to be beneficial; 2) explicit phrasing of dosing intervals and times were more easily interpreted; 3) the use of simpler and common terminology enhanced understanding of the directions; and 4) presentation of multiple-step directions (e.g. tapering regimens) in a simplified and more organized manner was identified as an enabler and was thought to reduce confusion. ConclusionDifferences in wording and presentation of pediatric prescription medication label directions led to variable interpretation by parents. Practise ImplicationsTherefore, there is a need for guidelines to standardize the wording of prescription medication advice labels. Findings from this study can be used to achieve this goal.

Resource implications following expansion of computed tomography coronary angiography: An Australian experience.

To determine the downstream utilisation of Computed Tomography Coronary Angiography (CTCA) in a single Australian tertiary centre. A single-centre retrospective study analysed 1460 patients undergoing CTCA between 1st January 2015 to 31st December 2018 at a tertiary hospital in Victoria, Australia, with a catchment area of 500,000 people. The coronary stenosis grading, plaque characteristics and coronary calcium score were identified. The downstream impact was assessed by measuring the number of stress echocardiograms, myocardial perfusion scans (MPS), invasive coronary angiograms and subsequent revascularisations. The number of CTCA's performed steadily increased from 59 in 2015 to 395, 461 and 545 in 2016, 2017 and 2018 respectively. Seven hundred and fifty-seven (52%) were females, and 703 (48%) males with 724 (50%) normal CTCA studies. The number of downstream stress echocardiogram performed each year was 2, 60, 46 and 16, respectively, accompanied by MPS numbers of 0, 21, 29, and 18. There were 9, 37, 57 and 64 invasive coronary angiograms with 1, 13, 19 and 22 corresponding revascularisations. Despite small increases in absolute numbers of patients presenting with chest pain (from 2678 in 2015 to 3660 in 2018), there was a significant increase in downstream further testing from 11 in 2015 to 98 in 2018. The use of CTCA expansion has resulted in an increase in downstream testing. Therefore, resource planning with regards to CTCA expansion will have to account for increased rates of functional testing, invasive angiography and revascularisation.

Combined Heart-Lung-Liver Transplantation for Patients With Cystic Fibrosis: The Australian Experience

Combined multivisceral transplantation has emerged as a therapeutic option for a select patient cohort; however, clinical decision-making remains complex and controversial. The aim of this study was to examine patient characteristics, operative complications, and long-term outcomes of all patients who have undergone combined heart-lung-liver transplantation (HLLTx) in Australia. In this study, we performed a retrospective analysis of all adult patients who have undergone combined HLLTx in Australia to date. Recipient clinical characteristics, waitlist, and transplant outcomes are described. Eight adult patients have received HLLTx at a single Australian transplant center. Recipients of HLLTx have typically been young (median age, 30.1 years; range, 24-37), underweight (median body mass index, 19.8 kg/m2; range, 16.2-30.4) patients with cystic fibrosis (n=8, 100%) with severe airflow obstruction (median forced expiratory volume in the first second of expiration, 24% predicted; range, 17%-48%) accompanied by liver cirrhosis confirmed on histopathology (n=8, 100%). Despite relative preservation of synthetic function and low model for end-stage liver disease scores (median, 8; range, 6-17), all recipients had complications of portal hypertension prior to transplantation, with many patients having suffered life-threatening variceal hemorrhage. In this cohort, HLLTx was associated with overall posttransplant survival of 87.5% at 30 days, 71.4% at 1 year, and 42.9% at 5 years. Listing for combined HLLTx was associated with prolonged waitlist times relative to bilateral sequential single-lung transplantation (median 556 vs 56 days, respectively), however waitlist mortality and/or delisting was comparable between groups. Taken together, these findings highlight the opportunities and challenges facing combined (heart-) lung and liver transplantation in patients with multiorgan failure.

Absolute cardiovascular disease risk score and pharmacotherapy at the time of admission in patients presenting with acute coronary syndrome due to coronary artery disease in a single Australian tertiary centre: a cross-sectional study

ObjectivesTo describe (1) absolute cardiovascular disease risk (ACVDR) scores in patients presenting to hospital with acute coronary syndrome (ACS) and (2) proportions of these patients on guideline-recommended pharmacotherapy according to...

Blunt thoracic aorta injuries, an Australian single centre's perspective

Blunt thoracic aortic injuries (BTAI) are potentially life-threatening emergencies. The management paradigm has shifted from open repair to a predominantly endovascular approach. We evaluated the trends in managing BTAI at our centre over the last decade and compared them to current international guidelines. We retrospectively reviewed all patients who presented with BTAI to our level one trauma centre, Westmead Hospital, New South Wales, Australia between 1 January 2010 and 31 December 2019. Patient demographics, injury grade and location, imaging features, management details and outcomes were analysed. BTAI is rare, with 39 patients identified at our institute over the last 10 years. Of these, seven died in the emergency department from their associated injuries (17.9%). Of the 32 survivors, 27 underwent surgical management with an endovascular stent-graft placement, and the remaining five patients were treated non-operatively. No patients were treated via an open surgical approach. All patients were diagnosed via computed tomography angiography. There were one death and two endoleaks amongst patients who underwent Thoracic endovascular aortic repair (TEVAR). The death occurred secondary to severe traumatic brain injury. Two patients illustrated neurological changes however these were associated with the original injury. No patients failed non-operative management. This study demonstrates that at our level one trauma centre, patients with BTAI are managed in accordance with international guidelines. All patients underwent computed tomography angiography for diagnosis and grading of injury. All patients requiring surgical management underwent TEVAR. Furthermore, our data support that select patients with grade I injuries can safely be managed non-operatively.

A Mediterranean lifestyle is associated with favourable cardiometabolic markers in people with non-dialysis dependent chronic kidney disease.

Adherence to a Mediterranean lifestyle may be a useful primary and secondary prevention strategy for chronic kidney disease (CKD). This cross-sectional study aimed to explore adherence to a Mediterranean lifestyle and its association with cardiometabolic markers and kidney function in 99 people aged 73⋅2 ± 10⋅5 years with non-dialysis dependant CKD (stages 3-5) at a single Australian centre. Adherence was assessed using an a priori index, the Mediterranean Lifestyle (MEDLIFE) index. Cardiometabolic markers (total cholesterol, LDL-cholesterol, HbA1c and random blood glucose) and kidney function (estimated GFR) were sourced from medical records and blood pressure measured upon recruitment. Overall, adherence to a Mediterranean lifestyle was moderate to low with an average MEDLIFE index score of 11⋅33 ± 3⋅31. Adherence to a Mediterranean lifestyle was associated with employment (r 0⋅30, P = 0⋅004). Mediterranean dietary habits were associated with cardiometabolic markers, such as limiting sugar in beverages was associated with lower diastolic blood pressure (r 0⋅32, P = 0⋅002), eating in moderation with favourable random blood glucose (r 0⋅21, P = 0⋅043), having more than two snack foods per week with HbA1c (r 0⋅29, P = 0⋅037) and LDL-cholesterol (r 0⋅41, P = 0⋅002). Interestingly, eating in company was associated with a lower frequency of depression (χ2 5⋅975, P = 0⋅015). To conclude, Mediterranean dietary habits were favourably associated with cardiometabolic markers and management of some comorbidities in this group of people with non-dialysis dependent CKD.

Longer-Term Safety and Efficacy of Contemporary Percutaneous Coronary Intervention – Insights from 2-Year Follow-Up of a Single Australian Centre Registry

Non-Caucasian populations are under-represented in randomised controlled trials in interventional cardiology. Urban Australia is increasingly becoming ethnically diverse. There is little data assessing outcomes of non-Caucasian populations undergoing percutaneous coronary intervention (PCI) in the Australian setting.

Prevalence of internal carotid artery stenosis in ambulatory patients presenting for non-emergent percutaneous coronary angiogram in a single Australian centre.

Association between coronary artery disease (CAD) and internal carotid artery stenosis (ICAS) could prove clinically relevant. However, evidence defining this association is currently inconclusive. Our study investigates the prevalence of ICAS in non-emergent, ambulatory patients presenting for PCA with suspected CAD in an Australian context. Between February 2019 and June 2019, 121 consecutive participants were verbally consented and enrolled in our study. The data were analysed retrospectively. PCA and CUS were performed within 24h of each other. Multinomial logistic regression assessed independent predictors for ICAS, with statistical significance set at P value<0.05. Linear regression analysis correlated CAD and ICAS severity, with significance of a P-value<0.05. Analysis was conducted using IBM SPSS 26 software (Chicago, Illinois). The final study included 121 patients (age 73±9years, 76.9% male). ICAS on CUS was present in 55.4% of participants for PCA. CAD was an independent risk factor for ICAS on multinomial logistic regression odds ratio 3.87 (P=0.023). CAD severity (multi vessel disease) showed significant correlation with ICAS r=0.22 (P=0.014) using linear regression analysis. CAD is an independent predictor of ICAS, and severity of ICAS is correlated with CAD disease. However, most participants had only minor ICAS (16-49% diameter stenosis). Our findings are consistent with internationally published studies, suggesting their data are generalisable to the Australian population. Larger studies are needed to address the applicability of CUS screening in patients with advanced CAD.

Correlation between computed tomography volumetry and nuclear medicine split renal function in live kidney donation: a single-centre experience.

Potential live renal donors undergo both renal computed tomography angiogram (CTA) and nuclear imaging dimercaptosuccinic acid (DMSA) scans. Each kidney's renal function and vascular anatomy influences the choice of donor side. Although DMSA measures differential blood flow, it is a surrogate for renal function and nephron mass. Computed tomography techniques can provide volumetry information. The aim of this study was to determine the relationship between measured split renal volumes on computed tomography versus renal volumes derived from DMSA split function in live donors. Prospective data of live kidney donors assessed at a single Australian centre from 2014 to 2017 were reviewed. All patients had pre-operative CTA and DMSA imaging. Renal volume was determined via semi-automated software calculation from CTA three-dimensional image reconstructions by one investigator. Measured split renal volume was compared against calculated renal volume using measured DMSA split function (percentage split function multiplied by total renal volume). Fifty-three patients were included in the study. Split renal volumes on three-dimensional CTA images correlate to calculated split volumes determined from DMSA (Pearson coefficient 0.95 for right renal volume, 0.95 for left). The decision of which kidney to remove can be achieved with CTA only. Omitting a DMSA scan would reduce the radiation load by 0.70 mSv (35 chest X-rays) and potential cost saving of AU$1062.00 per donor. CTA technology allows accurate assessment of renal volumes that correlate well with DMSA split function. Avoiding a DMSA scan results in cost and radiation reduction in the assessment of a live kidney donor.

Management of pleomorphic dermal sarcoma.

Pleomorphic dermal sarcoma (PDS) is a rare, poorly defined skin neoplasm with features similar to atypical fibroxanthoma, but with adverse histopathological characteristics indicating metastatic potential such as tumour necrosis, invasion beyond superficial subcutis or vascular and/or perineural infiltration. Optimal treatment for PDS is uncertain and reported outcomes vary due to the rarity of this diagnosis and uncertainty over histopathological categorization. The aim of this study was to review the clinical and histopathological features of PDS in a single Australian centre. A retrospective review of all patients managed at the Peter MacCallum Cancer Centre with PDS between 2003 and 2017 was performed by a search of electronic records and histories reviewed. A total of 27 patients were identified, mostly elderly males (85.2%, mean age 79.8 years). Lesions were seen most commonly on the head and neck region (96.3%), predominantly on the scalp (63%). Mean tumour radial surgical excision margin was 12.8 mm. Eighteen patients (66.7%) underwent radiotherapy; 13 adjuvant, three neoadjuvant and two with palliative intent. After median follow-up of 46.4 months, two patients had recurrence (7.4%); both had inadequate deep margins at first excision. There were three all-cause deaths in the cohort. There was one disease-specific mortality with metastatic PDS disease at the time of initial presentation. PDS is a rare cutaneous malignancy most commonly found in the head and neck region in elderly men, which is best managed with adequate surgical excision. The role of radiotherapy is undefined and an area for future investigation.

Impact of interhospital transfer on patients undergoing endovascular thrombectomy for acute ischaemic stroke in an Australian setting

ObjectiveTo assess the impact of interhospital transfer on the interplay between functional outcome, mortality, reperfusion rates and workflow time metrics in patients undergoing endovascular thrombectomy (EVT) for acute ischaemic stroke...

The association between human leukocyte antigen eplet mismatches, de novo donor-specific antibodies, and the risk of acute rejection in pediatric kidney transplant recipients.

The longitudinal relationship between HLA class I and II eplet mismatches, de novo donor-specific antibodies (dnDSA) development, and acute rejection after transplantation in childhood is unknown. Eplet mismatches at HLA class I and II loci were calculated retrospectively for each donor/recipient pair transplanted between 2005 and 2015 at a single Australian center. Logistic regression analyses were conducted to determine the association between the number of eplet mismatches, dnDSA, and acute rejection. The cohort comprised 59 children (aged 0-18years) who received their first kidney allograft and were followed for median (interquartile range) 4.5 (± 2.6) years. Overall, 32% (19/59) developed dnDSA (class I 3% (2/59), class II 14% (8/59), 15% class I and II (9/59)), and 24% (14/59) developed biopsy-proven acute rejection. Every unit increase in class I and II eplet mismatches corresponded to an increase in risk of class I (odds ratio (OR) 1.22, 95% CI 1.07-1.39, p < 0.01) and class II (OR 1.06, 95% CI 1.01-1.11, p = 0.02) dnDSA development. Compared with recipients without dnDSA, class I and II dnDSA were associated with direction of effect towards increased risk of acute cellular rejection (class I: OR 5.87, 95% CI 0.99-34.94, p = 0.05; class II: OR 12.00, 95% CI 1.25-115.36, p = 0.03) and acute antibody-mediated rejection (class I: OR 25.67, 95% CI 3.54-186.10, p < 0.01; class II: OR 9.71, 95% CI 1.64-57.72, p = 0.01). Increasing numbers of HLA class I or II eplet mismatches were associated with the development of dnDSA. Children who developed dnDSA were also more likely to develop acute rejection compared with children without dnDSA.

Early Outcomes of Primary SADI-S: an Australian Experience.

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) surgery is a modification of the traditional duodenal switch (DS) surgery. SADI-S is relatively a new bariatric surgical procedure and has gone by many names depending on the length of the common channel. In this study, we report our initial experience with this novel technique in the Australian population. The medical records of 91 patients who underwent laparoscopic primary SADI-S surgery by one surgeon at a single Australian center from January 2017 through May 2019 were retrospectively studied. Ninety-one patients were identified for analysis. The mean age and preoperative body mass index (BMI) was 46.2 ± 9years and 43.2 ± 5.7kg/m2, respectively. The mean operative time and length of stay were 121.8+/- 25 minutes and 1.4 ± 0.8days, respectively. At 12 and 24months, the patients lost an average BMI of 15.2 ± 5.2kg/m2 and 17.2 ± 5.9kg/m2, respectively. The short-term and long-term complication rates were 4.3% and 0%, respectively. The mortality rate was 0%. Postoperatively, the obstructive sleep apnea, type 2 diabetes, hyperlipidemia, hypertension, and gastroesophageal reflux disease resolution rates were 94, 94, 75, 68, and 13%, respectively. There was no statistically significant difference between most of the preoperative and postoperative nutritional data. SADI-S appears to be a safe bariatric surgical procedure with favorable outcomes at 2years in the Australian population.

Neuromyelitis Optica Spectrum Disorder and Anti-Aquaporin 4 Channel Immunoglobulin in an Australian Pediatric Demyelination Cohort.

Neuromyelitis optica spectrum disorder is uncommon in children, and often seronegative for aquaporin-4 immunoglobulin G (AQP4-IgG). We conducted a retrospective study of 67 children presenting to a single Australian center with acquired demyelinating syndromes over a 7-year period. All patients were tested for AQP4-IgG. Five children (7.5%) had neuromyelitis optica spectrum disorder. One child was seropositive for AQP4-IgG (1.5%) and had a relapsing disease course with mild residual deficits. She also had a concomitant motor axonal neuropathy that improved with immunosuppressive therapy. Of the remaining 4 children, 3 had a monophasic course and 1 a relapsing course. Two were tested for anti-myelin oligodendrocyte glycoprotein (anti-MOG) antibody and both were seropositive. This study confirms that neuromyelitis optica spectrum disorder is uncommon in children, and that AQP4-IgG seropositivity is rare. Anti-MOG antibodies should be tested in children with neuromyelitis optica spectrum disorder.

Polyp Detection Rate as a Surrogate for Adenoma and Sessile Serrated Adenoma/Polyp Detection Rates

Introduction: Quality measures for colonoscopy such as adenoma detection rate (ADR) have been proposed to be surveilled for ensuring minimum standards. However, its direct measurement is time consuming and often neglected. Extrapolating ADR and other quality measures from polyp detection rate (PDR) can be a pragmatic alternative. Objective: To determine quotients for estimating ADR and sessile serrated adenoma/polyp detection rate (SSA/P-DR) from PDR in an Australian cohort. Methods: Consecutive adult patient colonoscopies during a 1-year period were retrospectively assessed in a single Australian tertiary endoscopy center. Adenoma detection quotient (ADQ) and SSA/P detection quotient (SSA/P-DQ) were defined as the division of ADR and SSA/P-DR by PDR, respectively. The primary outcome was the number of procedures to achieve a stable cumulative ADQ and SSA/P-DQ. Secondary outcomes included evaluation of ADQ and SSA/P-DQ in different subsets. Results: In total, 2,657 colonoscopies were performed by 15 endoscopists in 2016. The ADR, SSA/P-DR, and PDR found were 32.2, 6.7, and 47.3%, respectively. The ADQ and SSA/P-DQ values found were 0.68 and 0.14, respectively. After approximately 500 procedures, both ADQ and SSA/P-DQ became stable. Interclass correlation coefficient (ICC) for the prediction of ADR from ADQ was excellent for all endoscopists that performed >177 procedures in that year (ICC 0.84). Conclusions: ADQ and SSA/P-DQ values were consistent when over 500 procedures were analyzed. ADQ had an excellent correlation with ADR when >177 procedures per endoscopist were evaluated.

271 Zero Fluoroscopy Electrophysiology Studies and Catheter Ablation, an Initial Australian Single Centre Experience

Radiation use in electrophysiology procedures may have detrimental health impacts to patients as well as being a key occupational hazard for catheter laboratory staff, both from direct effects as well as orthopaedic injuries from heavy lead aprons. Use should be kept as low as reasonably possible (ALARA principle). Advances in 3D electroanatomical mapping systems have greatly reduced the reliance on fluoroscopy for complex electrophysiology procedures. After ultrasound guided femoral venous access a decapolar catheter and electroanatomical mapping system was used to create an anatomic shell from femoral vein to right atrium and superior vena cava. Using this map catheters were then placed in the coronary sinus, HIS and right ventricular apex positions. Where transseptal puncture was required alligator clip electrodes were used to visualise the wire/needle along with intracardiac echo guidance. 5 consecutive patients (aged 15-60) referred to a single operator at our centre for supraventricular tachycardia ablation underwent planned zero fluoroscopy procedures (1 no inducible tachycardia diagnostic study only, 1 AV-nodal reentrant tachycardia, 2 left-sided accessory pathways, 1 coronary sinus os atrial tachycardia). The ablation procedures were successful with no procedural complications. No cases required fluoroscopic screening (Mean X-ray time: 0 minutes, Mean DAP: 0μGym2). Mean procedure time was 160.2 minutes (range: 101 - 211 minutes). Following the second case staff other than the primary operator did not wear lead aprons. Our early experience demonstrates the feasibility of performing right and left sided ablations without fluoroscopy in an Australian setting.