Anoop Ninan Koshy

Tricuspid regurgitation and pulmonary artery systolic pressure may contribute to post-operative morbidity and mortality in liver transplantation. Previous studies suggest that a high Model for End-Stage Liver Disease score may influence the relationship between tricuspid regurgitation and post-operative mortality. Adult patients undergoing liver transplantation workup between 2010 and 2023 were included in this retrospective observational cohort study. Patients with significant portopulmonary hypertension were excluded. Transthoracic echocardiograms were completed pre-transplant and patients were followed up for one year post-operatively. 1031 patients (median MELD score 17, IQR 12-23) underwent transthoracic echocardiography for liver transplantation workup, of whom 708 underwent successful transplantation. Mild or greater tricuspid regurgitation did not predict 1-year mortality in the overall population (HR 1.79 (95% CI 0.78-4.11), p=0.19). Among patients with MELD scores ≥20, mild or greater tricuspid regurgitation was a significant predictor of 1-year mortality (7 (12.7%) vs 9 (3.8%), p=0.01) (HR 3.46 (1.30-10.32), p=0.02). Tricuspid regurgitation in patients with high MELD scores was associated with a trend towards an increased risk of 30-day major adverse cardiovascular events (9 (16.4)% vs 46 (8.1%), p=0.06), driven predominantly by rates of post-operative heart failure (12.7% vs 3.8%, HR 3.66 (95%CI 1.30-10.32), p=0.01). Elevated pulmonary artery systolic pressure was associated with prolonged hospital stay (30 days (14-46) vs 15 days (11-29), p=0.01). Our study confirms that mild or greater tricuspid regurgitation is a significant predictor of 1-year mortality in patients with high MELD scores undergoing liver transplantation. Tricuspid regurgitation severity should be considered during pre-liver transplantation risk stratification.

Background: In Australia, chronic liver disease is now the third leading cause of premature death in people aged 50–59 years, and the fourth leading cause in all other 5-year age groups from 35 to 70 years in Australia. A consensus statement on the diagnosis and management of portal hypertension in patients with cirrhosis was developed by the Gastroenterological Society of Australia (GESA), the peak national organization for health care professionals and researchers working in gastroenterology and hepatology, to provide contemporary, evidence-based clinical guidelines. A summary of its recommendations is presented here. Methods: The consensus statement was developed in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument and the 2016 National Health and Medical Research Council Standards for Guidelines. A panel of 46 health care professionals with expertise in managing portal hypertension participated in the development of the consensus statement. The consensus development conference method was used to determine consensus for each recommendation, with a hybrid face-to-face and online meeting held in Noosa, Australia, on 3 August 2024, followed by 2 online meetings. Results: A total of 52 recommendations were approved by the consensus development group without dissent across the following domains: (1) diagnosis, risk stratification, and prevention of decompensation; (2) portal hypertension–related bleeding; (3) ascites and renal impairment; (4) hepatic encephalopathy; (5) sarcopenia, nutrition, and frailty; (6) thrombosis in cirrhosis; (7) cardiopulmonary complications; (8) surgery and portal hypertension; and (9) pregnancy and portal hypertension. Discussion: This is the first Australian consensus statement on the diagnosis and management of portal hypertension in patients with cirrhosis. The recommendations in this summary document provide standardized clinical guidance with the goal of improving outcomes for patients with cirrhosis and portal hypertension in Australia.

Background: Platypnoea-orthodeoxia syndrome (POS) is a rare but underdiagnosed cause of positional dyspnoea and hypoxaemia. It results from right-to-left interatrial shunting through a patent foramen ovale (PFO) or atrial septal defect (ASD), often precipitated by anatomical or functional distortions. Objectives: We systematically characterised the clinical spectrum, anatomical correlates and procedural outcomes associated with percutaneous closure in patients diagnosed with intracardiac POS. Methods: A systematic search of PubMed, Embase and MEDLINE databases was conducted. Case reports, case series and observational studies were included if they involved patients with POS with percutaneous closure of PFO/ASD. Results: A total of 469 patients from 196 studies (183 case reports/series, 13 observational studies) were identified (mean age 68.3±14.1 years; 51% female). Common symptoms included orthodeoxia (95%), exertional dyspnoea (42%) and platypnoea (35%) with a median time from symptoms to diagnosis of 13 (IQR 4–26) weeks. Anatomical contributors included aortic dilation (33%), thoracic structural abnormalities/surgery (33%) and right heart disorders (15%). A mean PFO/ASD diameter of 11.5±5.2 mm and a pulmonary blood flow/systemic blood flow ratio of 0.89±0.34 was noted. Amplatzer occluders were the most used device (60% of closures). Postclosure oxygen saturation improved significantly (pre: 79.5±8.7% vs post: 94.5±5.0%). Symptomatic improvement was reported in 82% of cases, with a low procedural complication rate of 5%. Conclusions: POS remains an underdiagnosed clinical entity, where systematic evaluation for POS should be considered in patients with positional desaturation and unexplained hypoxaemia. Percutaneous closure of the interatrial shunt offers significant symptomatic and physiological benefit with a favourable safety profile. PROSPERO registration number: CRD420250652717.

Introduction: This review was aimed at understanding the scope of evidence regarding outcomes and complications in nonagenarians (90–99 years of age) undergoing open cardiac surgery. Methods: The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Review Protocol guidelines. A search of three databases, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials, identified articles pertaining to nonagenarians undergoing various open cardiac surgical procedures. No restrictions were applied to study design or publication date. Results: From the initial 1826 articles identified, we included 28 studies from eight countries in a total of 6411 nonagenarians. The median 30-day mortality rate was 10.5% (IQR 7.2–14.6). Postoperative complication rates were reported in 20 studies (71%), and the median major complication rate was 71.4%. Respiratory, cardiac, renal, neurologic, gastrointestinal, and/or infectious complications were reported in 19%, 20%, 14%, 18%, 5%, and 9% of cases, respectively. The median length of hospital stay was 12.5 days (IQR 10.4–18.0). No studies reported unplanned readmissions to the intensive care unit or detailed patient-centered outcome measures. Conclusions: Although age alone should not preclude nonagenarians from undergoing cardiac surgery, the procedure is associated with a significantly elevated risk of morbidity and a relatively high mortality rate. The review findings emphasize the need for international registry data to identify risk factors associated with adverse outcomes, explore strategies to decrease the risk of major complications, and improve postoperative quality of life. Moreover, creating and implementing uniform preoperative frailty assessments, and correlating them with surgical outcomes, will be crucial. Developing standardized patient-reported experience and outcome measures will also be imperative. Scoping review registered on OSF registries (https://osf.io/4mg7n).

Background: Platypnoea-orthodeoxia syndrome (POS) is a rare disorder characterized by dyspnoea and hypoxaemia occurring while upright and improving while recumbent, most often caused by inter-atrial shunting. Diagnosis is challenging, and the syndrome carries considerable morbidity if left untreated. In patients with inter-atrial communications such as a patent foramen ovale (PFO), haemodynamic and structural changes occurring after transcatheter aortic valve implantation (TAVI) can lead to platypnoea-orthodeoxia. Case summary: A 77-year-old patient with severe aortic stenosis was referred for TAVI at our institution. On transthoracic echocardiography, dilatation of the ascending aorta (40 mm) and a mobile atrial septal aneurysm (ASA) were noted. Transcatheter aortic valve implantation was complicated by annular rupture and aortic intramural haematoma (IMH), managed conservatively. Three weeks after discharge, the patient re-presented with cholecystitis and underwent cholecystectomy. Post-operatively, marked hypoxaemia was noted during orthostasis. Transthoracic echocardiography showed the ASA bulging into the left atrium, with a strongly positive saline contrast study while upright. A PFO was identified on transoesophageal echocardiography and successfully percutaneously closed, with hypoxaemia resolving. Discussion: Platypnoea-orthodeoxia syndrome is a rare complication of TAVI, not previously reported after annular rupture. Aortic dilatation is often implicated in platypnoea-orthodeoxia, likely by compressing the interatrial septum and potentiating right-to-left shunting. In our patient, with a mildly dilated aorta prior to intervention, annular rupture and IMH may have further distorted atrial anatomy. Furthermore, rapid improvements in left ventricular compliance and left-sided filling pressures after TAVI may have facilitated the new onset of right-to-left shunting. Platypnoea-orthodeoxia syndrome should be considered in patients with unexplained hypoxaemia after TAVI.

The use of social media continues to introduce novel means for the communication of scientific knowledge. We assessed the change in social media use between pandemics regarding total shares, rates of dissemination and rates of global uptake of articles communicating the spread of diseases between epicentres. We found a substantial temporal increase in the use of social media for this purpose, as well as large global discrepancies in circulation, highlighting the role social media has in the communication of scientific knowledge globally and the importance of journals adopting social media policies.