Publications by authors named "Hugh Wolfenden"

24 Publications

  • Page 1 of 1

Should cardiac surgery be delayed in patients with uncorrected hypothyroidism?

Interact Cardiovasc Thorac Surg 2020 11;31(5):618-621

Department of Cardiothoracic Surgery, Prince of Wales Hospital, Randwick, NSW, Australia.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'should cardiac surgery be delayed in patients with uncorrected hypothyroidism?' A total of 1412 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There was limited high-quality evidence with the majority of the studies being retrospective. One propensity-matched analysis and 6 cohort studies provided the evidence that there was no significant difference in the rate of major adverse cardiac events including mortality based on thyroid status. However, hypothyroidism and subclinical hypothyroidism were associated with higher rates of postoperative atrial fibrillation. Based on the available evidence, we conclude that cardiac surgery should not be delayed to allow achievement of euthyroid status.
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http://dx.doi.org/10.1093/icvts/ivaa172DOI Listing
November 2020

'Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?'

Ann Med Surg (Lond) 2020 Sep 11;57:264-267. Epub 2020 Aug 11.

Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, Australia.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?' Altogether more than 118 papers were found using the reported search, of which 4 represented the best evidence to answer the clinical question, which included 2 prospective cohort studies and 2 retrospective observational studies. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. There is a significant variation within the MIDCAB and TECAB techniques amongst the studies-including the experience of the surgeon, use of cardiopulmonary bypass, patient selection, and target vessel grafting strategies-highlighting the complexity of comparing these two minimally invasive procedures. Operative times were comparable across all studies, with TECAB patients having higher transfusions rates and conversion rates to either a median sternotomy or MIDCAB procedure. Overall safety was comparable between the two cohort groups, with similar length of stay and 30-day mortality. However, the TECAB group were more likely to require re-operation for bleeding and reintervention for early revascularisation with greater total hospital costs than the MIDCAB patients. Based on the available evidence, we conclude that TECAB is associated with a higher rate of transfusions, conversion to median sternotomy or MIDCAB, early graft failure and reintervention compared to the MIDCAB approach. We advise caution in adopting a TECAB approach.
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http://dx.doi.org/10.1016/j.amsu.2020.07.060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453057PMC
September 2020

In patients undergoing dialysis who require a valve replacement is a bioprosthetic valve superior to a mechanical prosthesis in terms of long-term survival and morbidity?

Interact Cardiovasc Thorac Surg 2020 08;31(2):174-178

Department of Cardiothoracic Surgery, Prince of Wales Hospital, Randwick, NSW, Australia.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In [dialysis patients undergoing a valve replacement] is [a bioprosthetic valve superior to a mechanical prosthesis] for [long-term survival and morbidity]'. Altogether more than 501 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There was limited high-quality evidence with all studies being retrospective. One meta-analysis and four cohort studies provided the evidence that there was no significant difference in long-term survival based on prosthesis type. However, the majority of studies demonstrated a significantly higher rate of valve-related complications including bleeding and thromboembolism, and readmission to hospital in the mechanical valve prosthesis group, likely related to the requirement for long-term anticoagulation. We conclude that overall long-term survival in dialysis-dependent patients is poor. While prosthesis type does not play a significant contributing role to long-term survival, bioprosthetic valves were associated with significantly fewer valve-related complications. Based on the available evidence, a bioprosthetic valve may be more suitable in this high-risk group of patients as it may avoid the complications associated with long-term anticoagulation without any reduction in long-term survival.
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http://dx.doi.org/10.1093/icvts/ivaa084DOI Listing
August 2020

Operative Results of Mitral Valve Repair and Replacement in Chronic Ischaemic Mitral Valve Regurgitation.

Heart Lung Circ 2020 Nov 9;29(11):1713-1724. Epub 2020 Apr 9.

Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia.

Background: Ischaemic mitral regurgitation (IMR) carries significant morbidity and mortality. Surgical management includes coronary artery bypass surgery alone or concomitant with mitral valve repair or replacement. There is ongoing debate regarding the appropriate approach to the mitral valve in relation to long-term outcomes. This review examines our early and late follow-up, with operative and echocardiographic outcomes for mitral valve repair and mitral replacement for chronic IMR.

Methods: A retrospective review was performed on prospectively collected data of 119 consecutive patients who either underwent mitral repair (n=101) or mitral replacement (n=18) for chronic IMR at Prince Henry and The Prince of Wales hospitals in Sydney between 1999-2016. All patients had pre and postoperative transthoracic echocardiograms. Follow-up echocardiographic data was obtained from the most recent clinical appointment. Follow-up mortality outcomes were obtained with ethics approval from the Australian National Death Index (NDI).

Results: There was no statistical difference between cardiopulmonary bypass (CPB) time, cross-clamp time, time spent in intensive care unit (ICU) and time to discharge between cohorts. The replacement cohort was noted to have higher preoperative pulmonary artery (PA) pressures and a higher severity of IMR. Seven (7) deaths were in the mitral valve (MV) repair group within 30 days (6.9%) and three deaths in the MV replacement group within 30 days (16.7%). Echocardiographic follow-up was complete in 78% of the MV repair cohort at an average of 4.06±2.66 years, and 73% complete in the MV replacement cohort at an average of 6.09±4.3 years. Three (3) patients had prior MV repair before MV replacement early at days zero and 17, and late at 8 years respectively. Follow-up echocardiography showed mitral regurgitation (MR) in the mitral valve repair cohort as ≤ mild in 83.5% and ≤ trivial in 35.6%. In the MV replacement cohort MR ≤ mild in 100% and ≤ trivial in 82% with no moderate or severe MR. Preoperative tricuspid regurgitation (TR) and a flexible annuloplasty were predictive of an MR grade > mild in the repair cohort at discharge. Five-year (5-year) survival for the repair cohort was 85% with a mean follow-up time of 7.1±3.83 years. For the replacement cohort, five-year survival was 77.8% with a mean follow-up time of 5.35±1.54 years.

Conclusions: Mitral valve repair and replacement for chronic IMR has acceptable mortality, reintervention rates and excellent postoperative echocardiographic degrees of IMR in this cohort. Further evaluation is required into quality of life post intervention for IMR and of preoperative predictive factors of significant MR postoperatively to help guide the appropriate choice of treatment. The presence of preoperative tricuspid regurgitation of moderate grade or higher, and the use of a flexible annuloplasty may indicate patients more likely to have a higher grade of MR at follow-up following mitral valve repair in patients with IMR.
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http://dx.doi.org/10.1016/j.hlc.2020.03.007DOI Listing
November 2020

Mitral valve surgery and coronary artery bypass grafting for moderate-to-severe ischemic mitral regurgitation: Meta-analysis of clinical and echocardiographic outcomes.

J Thorac Cardiovasc Surg 2017 07 22;154(1):127-136. Epub 2017 Mar 22.

The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia. Electronic address:

Objective: This meta-analysis was conducted to compare clinical and echocardiographic outcomes following isolated coronary artery bypass grafting (CABG) versus CABG and mitral valve (MV) surgery in patients with moderate-to-severe ischemic mitral regurgitation (IMR).

Methods: Seven databases were systematically searched to identify relevant studies. For eligibility, studies were required to report on the primary endpoint of perioperative or late mortality. Data were analyzed according to predefined clinical endpoints.

Results: Four randomized controlled trials (RCTs) (n = 505) and 15 observational studies (OS) (n = 3785) met the criteria for inclusion. Compared with isolated CABG, concomitant CABG and MV surgery was not associated with increased perioperative mortality (RCTs: relative risk [RR] 0.89, 95% confidence interval [CI], 0.26-3.02; OS: RR 1.40, 95% CI, 0.88-2.23). CABG and MV surgery was associated with significantly lower incidence of moderate-to-severe MR at follow-up (RCTs: RR 0.16, 95% CI, 0.04-0.75; OS: RR 0.20, 95% CI, 0.09-0.48). Late mortality was similar between the surgical approaches in RCTs (hazard ratio [HR] 1.20, 95% CI, 0.57-2.53) and OS (HR 0.99, 95% CI, 0.81-1.21). There were no significant differences in echocardiographic outcomes. These results remained consistent in subgroup analyses restricted to patients with strictly moderate IMR.

Conclusions: In patients with moderate-to-severe IMR, the addition of MV surgery to CABG was not associated with increased perioperative mortality. Although concomitant MV surgery reduced recurrence of moderate-to-severe MR at follow-up, this was not associated with a reduction in late mortality. Larger trials with longer follow-up duration are required to further assess long-term survival and freedom from reintervention.
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http://dx.doi.org/10.1016/j.jtcvs.2017.03.039DOI Listing
July 2017

Functional mitral valve regurgitation: repair or replacement?

Med J Aust 2016 Nov;205(10):438-440

Prince of Wales Hospital, Sydney, NSW.

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http://dx.doi.org/10.5694/mja16.00553DOI Listing
November 2016

Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: Meta-Analysis of Clinical Outcomes and Cost-Effectiveness.

Curr Pharm Des 2016 ;22(13):1965-77

The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.

Objective: Transcatheter aortic valve implantation (TAVI) has emerged as a feasible alternative treatment to conventional surgical aortic valve replacement (AVR) for high-risk patients with aortic stenosis. The present systematic review aimed to assess the comparative clinical and cost-effectiveness outcomes of TAVI versus AVR, and meta-analyse standardized clinical endpoints.

Methods: An electronic search was conducted on 9 online databases to identify all relevant studies. Eligible studies had to report on either periprocedural mortality or incremental cost-effectiveness ratio (ICER) to be included for analysis.

Results: The systematic review identified 24 studies that reported on comparative clinical outcomes, including three randomized controlled trials and ten matched observational studies involving 7906 patients. Meta-analysis demonstrated no significant differences in regards to mortality, stroke, myocardial infarction or acute renal failure. Patients who underwent TAVI were more likely to experience major vascular complications or arrhythmias requiring permanent pacemaker insertion. Patients who underwent AVR were more likely to experience major bleeding. Eleven analyses from 7 economic studies reported on ICER. Six analyses defined TAVI to be low value, 2 analyses defined TAVI to be intermediate value, and three analyses defined TAVI to be high value.

Conclusion: The present study demonstrated no significant differences in regards to mortality or stroke between the two therapeutic procedures. However, the cost-effectiveness and long-term efficacy of TAVI may require further investigation. Technological improvement and increased experience may broaden the clinical indication for TAVI for low-intermediate risk patients in the future.
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http://dx.doi.org/10.2174/1381612822666160219120713DOI Listing
December 2016

Is a Robotic Operation Safe for Mitral Valve Repair?

Ann Thorac Surg 2015 Dec;100(6):2416

The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.

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http://dx.doi.org/10.1016/j.athoracsur.2015.05.114DOI Listing
December 2015

A meta-analysis of mitral valve repair versus replacement for ischemic mitral regurgitation.

Ann Cardiothorac Surg 2015 Sep;4(5):400-10

1 The Systematic Review Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Department of Cardiology, 3 Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, Australia.

Background: The development of ischemic mitral regurgitation (IMR) portends a poor prognosis and is associated with adverse long-term outcomes. Although both mitral valve repair (MVr) and mitral valve replacement (MVR) have been performed in the surgical management of IMR, there remains uncertainty regarding the optimal approach. The aim of the present study was to meta-analyze these two procedures, with mortality as the primary endpoint.

Methods: Seven databases were systematically searched for studies reporting peri-operative or late mortality following MVr and MVR for IMR. Data were independently extracted by two reviewers and meta-analyzed according to pre-defined study selection criteria and clinical endpoints.

Results: Overall, 22 observational studies (n=3,815 patients) and one randomized controlled trial (n=251) were included. Meta-analysis demonstrated significantly reduced peri-operative mortality [relative risk (RR) 0.61; 95% confidence intervals (CI), 0.47-0.77; I(2)=0%; P<0.001] and late mortality (RR, 0.78; 95% CI, 0.67-0.92; I(2)=0%; P=0.002) following MVr. This finding was more pronounced in studies with longer follow-up beyond 3 years. At latest follow-up, recurrence of at least moderate mitral regurgitation (MR) was higher following MVr (RR, 5.21; 95% CI, 2.66-10.22; I(2)=46%; P<0.001) but the incidence of mitral valve re-operations were similar.

Conclusions: In the present meta-analysis, MVr was associated with reduced peri-operative and late mortality compared to MVR, despite an increased recurrence of at least moderate MR at follow-up. However, these findings must be considered within the context of the differing patient characteristics that may affect allocation to MVr or MVR. Larger prospective studies are warranted to further compare long-term survival and freedom from re-intervention.
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http://dx.doi.org/10.3978/j.issn.2225-319X.2015.09.06DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598464PMC
September 2015

Meta-Analysis of Different Procedures: The Importance of Recognizing the Spectrum of Pleurectomy/Decortication Techniques.

Ann Thorac Surg 2015 Sep;100(3):1133

Collaborative Research Group, Macquarie University, Macquarie Park, Australia.

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http://dx.doi.org/10.1016/j.athoracsur.2015.02.050DOI Listing
September 2015

Asymptomatic mitral regurgitation-wait or operate?

Ann Cardiothorac Surg 2015 Jul;4(4):397-8

1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.3978/j.issn.2225-319X.2015.03.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526503PMC
July 2015

A meta-analysis of robotic vs. conventional mitral valve surgery.

Ann Cardiothorac Surg 2015 Jul;4(4):305-14

1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Department of Cardiothoracic Surgery, 3 Department of Cardiology, Prince of Wales Hospital, Sydney, Australia ; 4 The Royal Prince Alfred Hospital, Sydney University, Sydney, Australia.

Objectives: The present study is the first meta-analysis to compare the surgical outcomes of robotic vs. conventional mitral valve surgery in patients with degenerative mitral valve disease.

Methods: A systematic review of the literature was conducted to identify all relevant studies with comparative data on robotic vs. conventional mitral valve surgery. Predefined primary endpoints included mortality, stroke and reoperation for bleeding. Secondary endpoints included cross-clamp time, cardiopulmonary bypass time, length of hospitalization and duration of intensive care unit (ICU) stay. Echocardiographic outcomes were assessed when possible.

Results: Six relevant retrospective studies with comparative data for robotic vs. conventional mitral valve surgery were identified from the existing literature. Meta-analysis demonstrated a superior perioperative survival outcome for patients who underwent robotic surgery. Incidences of stroke and reoperation were not statistically different between the two treatment arms. Patients who underwent robotic surgery required a significantly longer period of cardiopulmonary bypass time and cross-clamp time. However, the lengths of hospitalization and ICU stay were not significantly different. Both surgical techniques appeared to achieve satisfactory echocardiographic outcomes in the majority of patients.

Conclusions: Current evidence on comparative outcomes of robotic vs. conventional mitral surgery is limited, and results of the present meta-analysis should be interpreted with caution due to differing patient characteristics. However, it has been demonstrated that robotic mitral valve surgery can be safely performed by expert surgeons for selected patients. A successful robotic program is dependent on a specially trained team and a sufficient volume of referrals to attain and maintain safety.
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http://dx.doi.org/10.3978/j.issn.2225-319X.2014.10.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526493PMC
July 2015

Systematic review of percutaneous interventions for malignant pericardial effusion.

Heart 2015 Oct 15;101(20):1619-26. Epub 2015 Jul 15.

The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia.

The present systematic review assessed the safety and efficacy of percutaneous interventions for malignant pericardial effusion (MPE), with primary endpoint of recurrence of pericardial effusion. Electronic searches of six databases identified thirty-one studies, reporting outcomes following isolated pericardiocentesis (n=305), pericardiocentesis followed by extended catheter drainage (n=486), pericardial instillation of sclerosing agents (n=392) or percutaneous balloon pericardiotomy (PBP) (n=157). Isolated pericardiocentesis demonstrated a pooled recurrence rate of 38.3%. Pooled recurrence rates for extended catheter drainage, pericardial sclerosis and PBP were 12.1%, 10.8% and 10.3%, respectively. Procedure-related mortality ranged from 0.5-1.0% across the percutaneous interventions. Although isolated pericardiocentesis can safely deliver immediate symptomatic relief, subsequent catheter drainage or sclerotherapy are required to minimize recurrence. PBP has been shown to be highly effective and may be particularly useful in managing recurrent effusions. Ultimately, the choice of intervention must be based on the clinical status of patients, their underlying malignancy and the expertise available.
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http://dx.doi.org/10.1136/heartjnl-2015-307907DOI Listing
October 2015

Reduced efficacy of transcatheter and surgical revascularization in Takayasu arteritis.

Int J Rheum Dis 2019 Jan 26;22(1):152-157. Epub 2014 Dec 26.

Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.

A 55-year-old woman with newly diagnosed Takayasu arteritis was followed for 7 years, during which time she underwent bare metal stenting, drug eluting stenting and coronary bypass grafting for critical coronary and renal artery stenoses. Interventions were initially successful but restenosis occurred within 24 months for all modalities. In contrast, native vessel disease was largely stable after the introduction of immunosuppressive therapy. We advocate a conservative revascularization approach in Takayasu arteritis in the absence of critical end organ ischemia and early optimization of medical therapy.
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http://dx.doi.org/10.1111/1756-185X.12549DOI Listing
January 2019

Transcatheter aortic valve replacement: does it work and can we afford it?

Circ Cardiovasc Interv 2014 Dec;7(6):741-3

From The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, New South Wales, Australia (C.C., T.D.Y.); and Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia (H.W.).

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.114.002081DOI Listing
December 2014

Outcomes of cardiac surgery in chronic kidney disease.

J Thorac Cardiovasc Surg 2014 Nov 15;148(5):2167-73. Epub 2014 Jan 15.

University of New South Wales, Sydney, Australia; Department of Nephrology, Westmead Hospital, Sydney, Australia.

Objective: To identify predictors of early and late outcomes of cardiac surgery in patients with chronic kidney disease.

Methods: Patients (n=545) with serum creatinine≥200 μmol/L or renal dialysis were identified from databases maintained by the largest Sydney cardiothoracic surgical units with data consistent with the Australian and New Zealand Society of Cardiothoracic Surgeons data definitions. The patient data were matched against the National Dialysis Database and the New South Wales Register of Births, Deaths, and Marriages. Statistical analysis was used to identify predictors of early and late outcomes.

Results: The Kaplan-Meier estimate of 1-, 5-, and 10-year survival for all patients was 78%, 56%, and 36%, respectively. The outcomes were similar after coronary bypass surgery and valve replacement and were also similar for dialysis and nondialysis patients. The odds ratios for the significant independent predictors of outcomes were, for perioperative death, age (1.4 per decade), emergency surgery (7.0), redo surgery (3.8), left ventricular impairment (moderate, 2.7; severe, 4.4); for new early postoperative dialysis, estimated glomerular filtration rate<20 mL/min (3.8), emergency surgery (2.7), tricuspid valve surgery (4.4); for new permanent dialysis within 6 months of surgery, serum estimated glomerular filtration rate<20 mL/min (odds ratio, 4.6). The hazard ratio for the independent predictors of late death in those alive 6 months after surgery was 1.4 per decade for age and 1.4 for moderate or severe left ventricular impairment.

Conclusions: Left ventricular impairment is a risk factor for perioperative and late death in patients with kidney disease. After cardiac surgery, preoperative dialysis-dependent and dialysis-free patients had similar long-term outcomes.
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http://dx.doi.org/10.1016/j.jtcvs.2013.12.064DOI Listing
November 2014

Recurrent ischaemic mitral regurgitation post mitral annuloplasty due to suture dehiscence evaluated using real time three dimensional transoesophageal echocardiography.

Heart Lung Circ 2012 Dec 21;21(12):844-6. Epub 2012 Jun 21.

Department of Cardiology, Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia.

Ischaemic mitral regurgitation after myocardial infarction results from geometric changes in left ventricular shape and displacement of papillary muscles with resultant tethering and incomplete leaflet coaptation of mitral leaflets. Post mitral valve repair, both valve apparatus related factors such as persistent leaflet tethering and progressive left ventricular adverse remodelling and procedure related factors such as ring dehiscence are important causes of recurrent mitral regurgitation after initial undersized mitral ring annuloplasty. Three-dimensional echocardiography is a novel clinical tool that has the potential to provide additional anatomical and functional information regarding the mechanism of recurrent mitral regurgitation post mitral valve repair that is complementary to standard two dimensional transoesophageal echocardiography thus helping guide the most appropriate subsequent therapeutic intervention.
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http://dx.doi.org/10.1016/j.hlc.2012.05.003DOI Listing
December 2012

Giant right atrium in an adult: case report of a rare condition.

Heart Lung Circ 2012 Jan 17;21(1):50-2. Epub 2011 Oct 17.

Eastern Heart Clinic, The Prince of Wales Hospital, Barker St., Randwick, NSW, Australia.

We report one of the largest descriptions of the right atrium (RA) in an adult, in absence of Ebstein's anomaly, tricuspid stenosis and other common adult associations of RA enlargement, such as pulmonary hypertension secondary to chronic pulmonary disease or severe mitral valvular pathology and pulmonary embolism. The RA volume was estimated to be over 1400 ml and was notably disproportionate to that of the left atrium and either ventricle.
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http://dx.doi.org/10.1016/j.hlc.2011.06.007DOI Listing
January 2012

Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study).

Anesthesiology 2009 Nov;111(5):1075-84

University of New South Wales Clinical School, Sydney, Australia.

Background: Commonly used sedatives/analgesics can increase the risk of postoperative complications, including delirium. This double-blinded study assessed the neurobehavioral, hemodynamic, and sedative characteristics of dexmedetomidine compared with morphine-based regimen after cardiac surgery at equivalent levels of sedation and analgesia.

Methods: A total of 306 patients at least 60 yr old were randomized to receive dexmedetomidine (0.1-0.7 microg x kg(-1) x h(-1)) or morphine (10-70 microg x kg(-1) x h(-1)) with open-label propofol titrated to a target Motor Activity Assessment Scale of 2-4. Primary outcome was the prevalence of delirium measured daily via Confusion Assessment Method for intensive care. Secondary outcomes included ventilation time, additional sedation/analgesia, and hemodynamic and adverse effects.

Results: Of all sedation assessments, 75.2% of dexmedetomidine and 79.6% (P = 0.516) of morphine treatment were in the target range. Delirium incidence was comparable between dexmedetomidine 13 (8.6%) and morphine 22 (15.0%) (relative risk 0.571, 95% confidence interval [CI] 0.256-1.099, P = 0.088), however, dexmedetomidine-managed patients spent 3 fewer days (2 [1-7] versus 5 [2-12]) in delirium (95% CI 1.09-6.67, P = 0.0317). The incidence of delirium was significantly less in a small subgroup requiring intraaortic balloon pump and treated with dexmedetomidine (3 of 20 [15%] versus 9 of 25 [36%]) (relative risk 0.416, 95% CI 0.152-0.637, P = 0.001). Dexmedetomidine-treated patients were more likely to be extubated earlier (relative risk 1.27, 95% CI 1.01-1.60, P = 0.040, log-rank P = 0.036), experienced less systolic hypotension (23% versus 38.1%, P = 0.006), required less norepinephrine (P < 0.001), but had more bradycardia (16.45% versus 6.12%, P = 0.006) than morphine treatment.

Conclusion: Dexmedetomidine reduced the duration but not the incidence of delirium after cardiac surgery with effective analgesia/sedation, less hypotension, less vasopressor requirement, and more bradycardia versus morphine regimen.
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http://dx.doi.org/10.1097/ALN.0b013e3181b6a783DOI Listing
November 2009

Levosimendan for patients with impaired left ventricular function undergoing cardiac surgery.

Interact Cardiovasc Thorac Surg 2006 Jun 23;5(3):322-6. Epub 2006 Mar 23.

Department of Cardiothoracic Surgery, Prince of Wales Hospital, Barker Street, Randwick, New South Wales, 2031, Australia.

The efficacy of levosimendan treatment for a low cardiac output status following cardiac surgery has not been established. Here, we review our initial experiences of the perioperative use of levosimendan. This study is a retrospective uncontrolled trial. Nine patients who underwent cardiac surgery, and developed a low cardiac output status resistant to conventional inotropic support, were given levosimendan. The mean preoperative ejection fraction was 35.2+/-3.4%. All patients were on concomitant inotropic agents and had previously undergone intra-aortic balloon pumping. Cardiac index increased immediately from 2.14+/-0.33 l/min/m(2) at baseline to 2.41+/-0.31 (P=0.02) at 1 h, rising to 2.67+/-0.43 (P<0.001) at 4 h after the loading dose was started. Similarly, the systemic vascular resistance index decreased from 2350+/-525 dynes/s/cm(-5)/m(2) at baseline to 1774+/-360 (P=0.002) at 4 h. In the case of all but one of the patients, either the dose of the concomitant inotropic support or the balloon pumping could be weaned down within 24 h after completion of the levosimendan infusion. No withdrawal of levosimendan was required. Levosimendan could constitute a new therapeutic option for postoperative low cardiac output.
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http://dx.doi.org/10.1510/icvts.2005.122390DOI Listing
June 2006

Five year clinical follow up of patients who have off-pump coronary artery bypass grafting.

Authors:
Hugh Wolfenden

Heart Lung Circ 2003 ;12(3):162-3

Prince of Wales Hospital, Randwick, New South Wales, Australia.

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http://dx.doi.org/10.1046/j.1444-2892.2003.00219.xDOI Listing
August 2008

A simple system to deliver blood cardioplegia.

Ann Thorac Surg 2005 Nov;80(5):1946-7

Department of Cardiothoracic Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia.

We describe a simple and inexpensive system designed to deliver blood cardioplegia either diluted or at the patient's hematocrit, with controlled temperature and additive concentration. This system can be applied to any pump set, and suits any strategy for clinical myocardial preservation.
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http://dx.doi.org/10.1016/j.athoracsur.2004.05.005DOI Listing
November 2005