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Multiple Traumatic Milia Following Implanted Cardiac Device
Abstracts
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late surgery set at 7 days were 13.5% vs 10.8%, 1.40 (0.61-3.02); 14 days were 20.7% vs 13.0%, 1.95 (0.95-4.01); and all “early or late surgery” 14.5% vs 10.2%, 1.58 (1.01-2.47). Pooled odds ratio of early versus late surgery for long-term mortality was 2.95 (0.35-25.0), and for neurological events during follow-up, pooled odds ratio for embolic events was 1.22 (0.33-4.56) and for intracranial bleeding 1.55 (0.16-15.32). Conclusion: Early surgery within 1-2 weeks of diagnosis of infective endocarditis with cerebral embolism can be safely performed, and is not associated with statistically higher long-term mortality or neurological events. Data is however limited and larger and randomised studies would help to determine the optimal timing. http://dx.doi.org/10.1016/j.hlc.2016.06.686 685 Meta-Analysis of Effects of Epicardial Fat and Anterior Fat Pad Dissection on Postoperative Atrial Fibrillation T. Agbaedeng 1,∗ , R. Mahajan 1 , D. Munawar 1 , A. Elliott 1 , D. Twomey 1 , S. Kurmar 1 , J. Varzaly 2 , D. Lau 1 , P. Sanders 1 1 Centre
for Heart Rhythm Disorders, South Australian Health and Medical Research, Australia 2 Centre for Heart Rhythm Disorders and Cardiothoracic Surgery Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia Introduction: Epicardial fat is considered a mechanistic link between obesity and AF. However, its association with postoperative AF is not well described. There is also suggestion that surgical technique removing the anterior fat pad (AFP) during cardiac bypass may dissect the parasympathetic fibres and therefore impact on the incidence of postoperative AF. Thus, we performed a systematic review and metaanalysis to evaluate the strength of the evidence for the relationships. Methodology: MEDLINE, Embase and Web of Science were searched with key words “epicardial’, “pericardial“, “adipose“, “fat” and “atrial fibrillation” up to July 2015. After exclusions, nine studies reporting these associations were included in a random effects meta-analysis, with the effects sizes reported as standardised mean difference (SMD) for studies reporting different units of EAT (volume (10ml/1SD)/thickness) and risk ratio (RR) of events. Results: Total EAT was significantly increased in patients with incident postoperative AF (SMD = 1.02; 95% confidence interval (CI) = 0.58-1.46; p=0.00001) as compared to those maintaining sinus rhythm. AFP removal did not significantly increase the risk of postoperative AF (RR = 1.54; 95% CI = 0.93-2.55; p=0.09). Additionally, the procedural manipulation did not impact on the risk of postoperative complications, with no significant impact on rehospitalisation, risk of stroke or risk of mortality in the postoperative period (p>0.05). Conclusion: Increased quantity of epicardial fat is significantly associated with the incidence of new-onset
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postoperative AF. AFP removal does not significantly impact on the risk of post-op AF nor on postoperative complications.
http://dx.doi.org/10.1016/j.hlc.2016.06.687 686 Mitral Valve Repair Versus Replacement: Contemporary 2005-2012 Study T. Wang ∗ , S. Harmos, T. Ramanathan Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: Mitral valve disease is becoming more prevalent with the ageing population and mitral valve repair is preferred over replacement for severe symptomatic disease when feasible due to superior outcomes. The recent introduction of percutaneous mitral valve interventions add dimension to the management of this condition in high risk patients. We compared the characteristics and outcomes of mitral valve repair and replacement in the current era. Methods: All patients undergoing isolated mitral valve repair or replacement at Auckland City Hospital during 2005-2012 were studied and compared using univariate and multivariate analyses of surgery and outcomes. Results: Amongst 407 patients having mitral valve surgery, 196 had repair and 211 had replacement. Mitral valve replacement rather than repair was independently associated with female sex, previous cardiac surgery, diabetes and mitral stenosis, and these patients had significantly higher EuroSCOREs and STS Score (P<0.001). There were no significant differences in operative mortality 1.5%(3) vs 3.5% (7), P=0.541 or mortality during follow-up P=0.222. Age, critical preoperative state, and previous valve surgery independently predicted operative mortality. Postoperative composite morbidity occurred more frequently for replacement 22.7% (48) vs 14.8% (28) P=0.043, mainly due to higher rates of renal failure P=0.006, ventilation>24 hours P=0.009 and prolonged hospital stay>14 days P<0.001. Conclusion: Mitral valve replacement patients had higher prevalence of cardiac surgery risk factors at baseline, and had higher postoperative complication rates but similar operative or long-term mortality. http://dx.doi.org/10.1016/j.hlc.2016.06.688 687 Multiple Traumatic Milia Following Implanted Cardiac Device L. Abdel-Malek 1,∗ , P. Peters 1,2 1 Dermatology
Department, Gold Coast University Hospital, Southport, Australia 2 School of Medicine, Griffith University, Gold Coast, Australia
Abstracts
A 79 year-old male underwent AICD (Quadra Assura MP St Jude Medical) implantation for dilated cardiomyopathy. The patient had been on the oral anticoagulant rivaroxaban, which was ceased five days prior to implantation. The implantation itself was uneventful however skin tears occurred upon removal of the adhesive drapes. These were treated with steri-strips and a course of oral antibiotics (clindamycin 300mg BD). The patient was admitted for postoperative recovery overnight. The site continued to ooze gently, which settled with firm dressing support. Dressing changes continued over the next month with gradual healing of the site with numerous small white papules over the device location on the external skin. One month following discharge, the patient was reviewed in cardiothoracic outpatients and was noted to have what was felt to be prominent follicles of the skin and was referred to the dermatology outpatients department. The patient presented with a well-circumscribed region of numerous small keratin filled papules and hypertrophic scarring (Fig. 1). This was consistent with traumatic milia due to the skin tears and healing that occurred post device insertion. Milia are small keratin filled cysts occurring in the sub epidermal/superficial dermis that arise from damage to the pilosebaceous unit. As the lesions are benign in nature and were located directly over the device site, nil further treatment was undertaken to address cosmetic concerns. Of note, the same patient also had widespread blue/grey pigmentation over the arms and dorsal hands in a photo-exposed distribution secondary to use of amiodarone (Fig. 2).
Figure 1. Multiple milia occurring following postoperative skin tear whilst inserting cardiac device. Hypertrophic scarring can also be seen.
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Figure 2. Blue-grey pigmentation over the photo exposed regions on the patient’s forearms and dorsal hands secondary to long-term amiodarone use.
http://dx.doi.org/10.1016/j.hlc.2016.06.689 688 Outcomes After Rheumatic Mitral Valve Surgery: Repair or Replace E. Russell 1,2,∗ , W. Walsh 3 , L. Tran 1 , C. Reid 1,4 , G. Maguire 1,2 1 Monash
University, Melbourne, Australia Melbourne, Australia 3 Prince of Wales Hospital, Sydney, Australia 4 Curtin University, Perth, Australia 2 BakerIDI,
Background: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. Despite its impact there is limited understanding of the factors influencing outcome following mitral valve surgery for RHD. Methods: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to assess outcomes following mitral valve repair or replacement for RHD valvular disease. Results: Outcome of 119 RHD mitral valve repair and 1078 RHD mitral valve replacement surgeries was analysed. RHD-related mitral valve repair surgery was significantly more common for younger, male, Indigenous patients with moderate or severe mitral valve regurgitation but fewer comorbidities. Patients having RHD mitral valve repair surgery, compared with replacement, had a slightly shorter mean length of hospital stay (11.7 days compared to 12.2 days, p=0.045) a higher rate of 30-day re-operation for valve dysfunction (1.7% compared to 0.3%, p=0.024) but no difference in 30-day survival. Survival out to five years following RHDrelated mitral valve surgery was 84.0% (95% CI 80.2 – 87.3), with mitral valve repair 82.4% (95% CI 69.1 – 91.6) and replacement 84.2% (95% CI 80.2 – 87.7). There was no significant difference in survival out to five years. Survival in Indigenous Australians was comparable for mitral valve repair and replacement surgery out to five years. Conclusion: In a large prospective cohort study we have demonstrated survival following RHD mitral valve repair surgery in Australia is equivalent to replacement surgery.
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late surgery set at 7 days were 13.5% vs 10.8%, 1.40 (0.61-3.02); 14 days were 20.7% vs 13.0%, 1.95 (0.95-4.01); and all “early or late surgery” 14.5% vs 10.2%, 1.58 (1.01-2.47). Pooled odds ratio of early versus late surgery for long-term mortality was 2.95 (0.35-25.0), and for neurological events during follow-up, pooled odds ratio for embolic events was 1.22 (0.33-4.56) and for intracranial bleeding 1.55 (0.16-15.32). Conclusion: Early surgery within 1-2 weeks of diagnosis of infective endocarditis with cerebral embolism can be safely performed, and is not associated with statistically higher long-term mortality or neurological events. Data is however limited and larger and randomised studies would help to determine the optimal timing. http://dx.doi.org/10.1016/j.hlc.2016.06.686 685 Meta-Analysis of Effects of Epicardial Fat and Anterior Fat Pad Dissection on Postoperative Atrial Fibrillation T. Agbaedeng 1,∗ , R. Mahajan 1 , D. Munawar 1 , A. Elliott 1 , D. Twomey 1 , S. Kurmar 1 , J. Varzaly 2 , D. Lau 1 , P. Sanders 1 1 Centre
for Heart Rhythm Disorders, South Australian Health and Medical Research, Australia 2 Centre for Heart Rhythm Disorders and Cardiothoracic Surgery Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia Introduction: Epicardial fat is considered a mechanistic link between obesity and AF. However, its association with postoperative AF is not well described. There is also suggestion that surgical technique removing the anterior fat pad (AFP) during cardiac bypass may dissect the parasympathetic fibres and therefore impact on the incidence of postoperative AF. Thus, we performed a systematic review and metaanalysis to evaluate the strength of the evidence for the relationships. Methodology: MEDLINE, Embase and Web of Science were searched with key words “epicardial’, “pericardial“, “adipose“, “fat” and “atrial fibrillation” up to July 2015. After exclusions, nine studies reporting these associations were included in a random effects meta-analysis, with the effects sizes reported as standardised mean difference (SMD) for studies reporting different units of EAT (volume (10ml/1SD)/thickness) and risk ratio (RR) of events. Results: Total EAT was significantly increased in patients with incident postoperative AF (SMD = 1.02; 95% confidence interval (CI) = 0.58-1.46; p=0.00001) as compared to those maintaining sinus rhythm. AFP removal did not significantly increase the risk of postoperative AF (RR = 1.54; 95% CI = 0.93-2.55; p=0.09). Additionally, the procedural manipulation did not impact on the risk of postoperative complications, with no significant impact on rehospitalisation, risk of stroke or risk of mortality in the postoperative period (p>0.05). Conclusion: Increased quantity of epicardial fat is significantly associated with the incidence of new-onset
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postoperative AF. AFP removal does not significantly impact on the risk of post-op AF nor on postoperative complications.
http://dx.doi.org/10.1016/j.hlc.2016.06.687 686 Mitral Valve Repair Versus Replacement: Contemporary 2005-2012 Study T. Wang ∗ , S. Harmos, T. Ramanathan Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: Mitral valve disease is becoming more prevalent with the ageing population and mitral valve repair is preferred over replacement for severe symptomatic disease when feasible due to superior outcomes. The recent introduction of percutaneous mitral valve interventions add dimension to the management of this condition in high risk patients. We compared the characteristics and outcomes of mitral valve repair and replacement in the current era. Methods: All patients undergoing isolated mitral valve repair or replacement at Auckland City Hospital during 2005-2012 were studied and compared using univariate and multivariate analyses of surgery and outcomes. Results: Amongst 407 patients having mitral valve surgery, 196 had repair and 211 had replacement. Mitral valve replacement rather than repair was independently associated with female sex, previous cardiac surgery, diabetes and mitral stenosis, and these patients had significantly higher EuroSCOREs and STS Score (P<0.001). There were no significant differences in operative mortality 1.5%(3) vs 3.5% (7), P=0.541 or mortality during follow-up P=0.222. Age, critical preoperative state, and previous valve surgery independently predicted operative mortality. Postoperative composite morbidity occurred more frequently for replacement 22.7% (48) vs 14.8% (28) P=0.043, mainly due to higher rates of renal failure P=0.006, ventilation>24 hours P=0.009 and prolonged hospital stay>14 days P<0.001. Conclusion: Mitral valve replacement patients had higher prevalence of cardiac surgery risk factors at baseline, and had higher postoperative complication rates but similar operative or long-term mortality. http://dx.doi.org/10.1016/j.hlc.2016.06.688 687 Multiple Traumatic Milia Following Implanted Cardiac Device L. Abdel-Malek 1,∗ , P. Peters 1,2 1 Dermatology
Department, Gold Coast University Hospital, Southport, Australia 2 School of Medicine, Griffith University, Gold Coast, Australia
Abstracts
A 79 year-old male underwent AICD (Quadra Assura MP St Jude Medical) implantation for dilated cardiomyopathy. The patient had been on the oral anticoagulant rivaroxaban, which was ceased five days prior to implantation. The implantation itself was uneventful however skin tears occurred upon removal of the adhesive drapes. These were treated with steri-strips and a course of oral antibiotics (clindamycin 300mg BD). The patient was admitted for postoperative recovery overnight. The site continued to ooze gently, which settled with firm dressing support. Dressing changes continued over the next month with gradual healing of the site with numerous small white papules over the device location on the external skin. One month following discharge, the patient was reviewed in cardiothoracic outpatients and was noted to have what was felt to be prominent follicles of the skin and was referred to the dermatology outpatients department. The patient presented with a well-circumscribed region of numerous small keratin filled papules and hypertrophic scarring (Fig. 1). This was consistent with traumatic milia due to the skin tears and healing that occurred post device insertion. Milia are small keratin filled cysts occurring in the sub epidermal/superficial dermis that arise from damage to the pilosebaceous unit. As the lesions are benign in nature and were located directly over the device site, nil further treatment was undertaken to address cosmetic concerns. Of note, the same patient also had widespread blue/grey pigmentation over the arms and dorsal hands in a photo-exposed distribution secondary to use of amiodarone (Fig. 2).
Figure 1. Multiple milia occurring following postoperative skin tear whilst inserting cardiac device. Hypertrophic scarring can also be seen.
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Figure 2. Blue-grey pigmentation over the photo exposed regions on the patient’s forearms and dorsal hands secondary to long-term amiodarone use.
http://dx.doi.org/10.1016/j.hlc.2016.06.689 688 Outcomes After Rheumatic Mitral Valve Surgery: Repair or Replace E. Russell 1,2,∗ , W. Walsh 3 , L. Tran 1 , C. Reid 1,4 , G. Maguire 1,2 1 Monash
University, Melbourne, Australia Melbourne, Australia 3 Prince of Wales Hospital, Sydney, Australia 4 Curtin University, Perth, Australia 2 BakerIDI,
Background: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. Despite its impact there is limited understanding of the factors influencing outcome following mitral valve surgery for RHD. Methods: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to assess outcomes following mitral valve repair or replacement for RHD valvular disease. Results: Outcome of 119 RHD mitral valve repair and 1078 RHD mitral valve replacement surgeries was analysed. RHD-related mitral valve repair surgery was significantly more common for younger, male, Indigenous patients with moderate or severe mitral valve regurgitation but fewer comorbidities. Patients having RHD mitral valve repair surgery, compared with replacement, had a slightly shorter mean length of hospital stay (11.7 days compared to 12.2 days, p=0.045) a higher rate of 30-day re-operation for valve dysfunction (1.7% compared to 0.3%, p=0.024) but no difference in 30-day survival. Survival out to five years following RHDrelated mitral valve surgery was 84.0% (95% CI 80.2 – 87.3), with mitral valve repair 82.4% (95% CI 69.1 – 91.6) and replacement 84.2% (95% CI 80.2 – 87.7). There was no significant difference in survival out to five years. Survival in Indigenous Australians was comparable for mitral valve repair and replacement surgery out to five years. Conclusion: In a large prospective cohort study we have demonstrated survival following RHD mitral valve repair surgery in Australia is equivalent to replacement surgery.