Publications

Abstract

Abstract

Background

Methods

Results

Conclusions

Introduction: The data on comparison of costs and benefits for aortic valve replacement from an Australian healthcare perspective are scarce. The study quantifies hospital-associated resource use and costs of trans-catheter valve insertion (TAVI) and surgical aortic valve replacement (SAVR) procedures including length of stay, ICU hours; subsequent hospital admissions related to aortic stenosis, over 12 months.

Methods: A retrospective cohort analysis of patients who underwent TAVI or SAVR undertaken at Royal Prince Alfred Hospital (2012–2017). Patients were identified using the hospital patient database and electronic medical records. Resource use was valued using the Independent Hospital Pricing Authority’s net efficient price and national weighted activity units (NWAUs). Results are presented as mean values with standard deviations, and costs are presented in 2017 Australian dollars.

Results: Of 482 patients, mean age 77 years (SD 13), 64% males.

Introduction: Trans-catheter aortic valve implantations have been performed in Australia since 2008 and numbers have been steadily increasing. Royal Prince Alfred Hospital was one of the first Australian centres to run a TAVI program. This study analyses the evolving numbers and demographics of patients undergoing TAVI and SAVR following introduction of the TAVI program in 2009.

Methods: Retrospective cohort analysis of patients undergoing TAVI and SAVR at RPAH between 2009 and 2018. Patients classified from a database of cardiothoracic and transcatheter procedures with additional information from hospital medical records.

Results: Between 2009 and 2018, 737 patients underwent isolated AVR at RPAH.

Introduction: Definitive management of severe aortic stenosis has evolved rapidly. Indications for trans-catheter procedures have progressed from patients deemed inoperable to high risk and now to patients representing intermediate surgical risk. Health resource availability also are determinants on treatment received. Advanced age and high surgical risk impact resource use through higher costs and length of stay.

This study examines and compares the demographics and surgical risk scores of patients undergoing isolated surgical and trans-catheter aortic valve replacements at Royal Prince Alfred Hospital in Sydney.

Method: This retrospective cohort analysis examined 124 consecutive patients undergoing isolated aortic valve replacements at Royal Prince Alfred Hospital between October 2016 and January 2018. Patients were identified from a database of cardiothoracic and transcatheter procedures with additional demographics recorded from hospital medical records. Surgical risk scores were calculated using the Society of Thoracic Surgeons risk calculator.

Results: 124 consecutive patients between October 2016 and Jan 2018.

Introduction: Patients with BAV are heterogeneous and risk prediction for the complications of valvulopathy and/or aortopathy remains challenging.

Methods: Adult patients who had undergone aortic or aortic valve surgery for BAV were identified from our Adult Congenital Heart and Cardiothoracic Surgery databases. BAV morphology was classified according to the number of raphes present according to the Sievers classification [1].

Results: 571 patients were included (73.4% males, median age at surgery 62 years). The commonest indication for surgery was aortic valve dysfunction (69.5%) followed by aortic disease (15.2%). The commonest haemodynamic abnormality was aortic stenosis (74.4%), then aortic regurgitation (13.1%). 36.6% required aortic surgery in addition to valve replacement. 24.7% of patients had concomitant CABG. 30-day mortality was 1.4%, in patients with and without aortic replacement surgery.

Data on BAV morphotype was available in 346 patients (60.6%); one raphe (type 1) in 82.1%, no raphes (type 0) in 7.2% and two raphes (type 2) in 2.3%. Patients with type 2 valves were significantly younger at time of surgery than patients with type 1 valves (36 vs 63 years, p = 0.008). Patients with type 0 valves were much more likely to require aortic surgery than patients with type 1 valves (68% vs 37.3%, p = 0.005) and were more likely to require both proximal and distal aortic replacement (p = 0.014).

Conclusion: A significant number of patients undergoing surgery for BAV had associated aortopathy requiring aortic surgery. BAV morphology influenced age at valve surgery, and the need for aortic surgery.

Aims: Retrospective studies have suggested improved survival outcomes with the use of Extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest (ECPR). We sought to prospectively assess outcomes in refractory cardiac arrest treated with ECPR.

Methods: The 2CHEER trial (mechanical CPR, Hypothermia, ECMO and Early Reperfusion) is a multi-centre, prospective cohort study conducted at Royal Prince Alfred and St Vincent’s Hospitals, Sydney, NSW with the NSW Ambulance service. Patients aged 12–70 years with refractory cardiac arrest were enrolled into the 2CHEER treatment bundle.

Results: From 2016 to 2018, 25 patients were eligible for the 2CHEER protocol (13 (52%) OHCA, 12 (48%) IHCA; 17 (68%) males. Median age was 57 (IQR 39–65) years and all patients received bystander CPR. VT/VF was initial rhythm in 17 (68%) of patients. ECMO flow was established in all patients; median time from collapse until initiation of ECMO 57 (IQR 38–73) min. Percutaneous coronary intervention was performed in 18 (72%) patients. Median duration of ECMO support was 52 (IQR 24 –108) hours. Survival to hospital discharge was 64% (7) for IHCA and (36% (4) for OHCA. Survival with favourable neurological outcome (CPC 1 or 2) occurred in all survivors; (11/25) (44%) of total patients. Time to ECMO flow was significantly associated with survival p < 0.001. Initial rhythm and percutaneous intervention were not.

Conclusion: Treatment of refractory cardiac arrest with ECMO is feasible and associated with very good neurologically intact survival.

Out-of-hospital cardiac arrest (OOHCA) is a significant cause of mortality, with regionally pooled survival until discharge ranging from 3.0–9.7%. Early and effective cardiopulmonary resuscitation (CPR) remains crucial to improving overall survival, and mechanical CPR has been proposed as a method with which to improve its quality and consistency. Outcomes of mechanical CPR are mixed, and several case reports have highlighted potentially harmful complications, including solid and hollow organ injury and subsequent mortality.

Purpose: A high volume of thoracic surgery is performed in Australia and New Zealand each year, although no national database exists for the routine capture of clinical outcomes. A thoracic surgery database would allow clinical research, internal hospital auditing, hospital benchmarking, development of risk prediction models, and assessment of healthcare resource utilisation.