OBJECTIVES To compare the long-term performance of the Nunn and 2-patch techniques for the repair of complete atrioventricular septal defects. METHODS Between January 1995 and December 2015, a total of 188 patients (Nunn n = 41; 2-patch n = 147) were identified from hospital databases. Univariable Cox regression was performed to calculate the risk of reintervention in each group. Propensity score matching was used to balance the Nunn group and the 2-patch group. RESULTS Baseline characteristics including age at surgery, weight, trisomy 21, other cardiac anomalies, previous operations and preoperative atrioventricular valve regurgitation did not differ between the 2 groups. Overall, there was no difference in mortality between the 2 groups (P = 0.43). Duration of cardiopulmonary bypass (CPB) and myocardial ischaemia time were 29 min (P < 0.001) and 28 min (P < 0.001) longer, respectively, in the 2-patch group. Median follow-up was 10.8 years (2–21 years). Unadjusted Cox regression did not reveal a significant difference in the risk of reoperation for either group 9 years after initial surgery [hazard ratio (HR) (Nunn) 0.512, 95% confidence interval 0.176–1.49; Nunn 89%; 2-patch 82%]. This finding was reiterated from Cox regression performed on the propensity-matched sample (31 pairs). The probability of freedom from moderate or worse left atrioventricular valve regurgitation or left ventricular outflow obstruction was similar in the 2 groups. CONCLUSIONS The Nunn and 2-patch techniques are comparable in terms of the long-term mortality and probability of freedom from reoperation, moderate or severe left atrioventricular valve regurgitation and left ventricular outflow obstruction. However, the duration of CPB and myocardial ischaemia is longer in the 2-patch group.

Hamman’s sign refers to an unusual click that occurs in synchrony with heart sounds, and is pathognomonic for left-sided pneumothorax and spontaneous mediastinum. In this case, a 17-year-old man living in a rural area used his smartphone to record an audible clicking sound emanating from his thorax. This occurred following coughing episodes secondary to an upper respiratory tract infection. Initially, this prompted a request for an echocardiogram to exclude structural cardiac anomalies; however, Hamman’s sign was also considered. This facilitated the timely diagnosis of pneumothorax to be made via a simple chest radiograph, one of the only imaging modalities available at the patient’s rural health service. To promote awareness of this rare clinical phenomenon, this report also presents the patient’s own sound recording of Hamman’s sign and corresponding chest radiographs.

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significant reduction in left atrial (LA) (p=0.001) and LV enddiastolic M-mode dimensions (p=0.001) and volumes (p=0.006), with no change in LV end-systolic volumes, yielding a significant reduction in LV functional measures (fractional shortening (34.5 vs 31.5%, p=0.006), fourchamber ejection fraction (62.6 vs 51.7%, p=0.002) and LV longitudinal strain (-24.3 vs-18.2%, p,0.001). Compared to controls, LA and LV dimensions remained increased with a reduction in all functional parameters after repair. There was a moderate negative correlation between preoperative enddiastolic volumes and postoperative longitudinal strain (r 2 =0.35). Discussion: Persistent LV and LA remodelling with decreased LV function is observed after repair of RHD-MR. While these results reflect changes to volume loading, the unmasking of decreased LV function and persistent remodelling; and linear relation to preoperative LV size, may suggest that early intervention to alleviate MR could benefit selected patients and warrants further study.

Background Anticoagulation to prevent stroke is a mainstay of atrial fibrillation (AF) management. Patients with established cardiovascular disease (CVD) may have conditions that fulfil Virchow's triad for thrombogenesis even in sinus rhythm. Previous investigation into the benefit of warfarin compared to placebo or antiplatelet drug in sinus rhythm found a reduction in stroke rates, but with an increase in bleeding. The efficacy and safety of non-vitamin K oral anticoagulant (NOAC) agents has not been studied. Purpose To assess the safety and efficacy of NOAC agents in patients without AF. Methods An electronic database search for randomized controlled trials that evaluated a NOAC and control drug (placebo or antiplatelet) in non-AF patients with CVD was conducted up until 1 September 2019. The primary efficacy and safety outcomes were ischemic stroke and major bleeding, respectively. The net clinical benefit (NCB) was calculated as a weighted sum of rate differences of ischemic stroke and major bleeding. Groups were stratified according to intensity of anticoagulation (full vs. low dose NOAC). Results Twelve randomized controlled trials were identified with a total of 83,008 patients (50,617 on NOAC, 32391 on control drug; mean age 66±2.7 years). CVD included coronary artery disease (78.3%), hypertension (73.7%), diabetes mellitus (34.7%), peripheral arterial disease (30.3%), previous stroke (21.7%), renal disease (22.9%) and heart failure (18.4%). Over a mean follow-up of 17.3 months, 1347 (1.6%) ischemic strokes occurred. Use of NOAC was associated with 28% reduction in ischemic stroke (odds-ratio [OR] 0.72, 95% confidence-interval [CI] 0.60 to 0.87; 1.1 vs. 1.8 events per 100-person years), with numbers needed to treat of 145 patients to prevent one stroke. Major bleeding was increased nearly 2-fold (OR 1.83, 95% CI 1.46 to 2.29; 2.1 vs. 1.0 events per 100-person years). The NCB demonstrated overall harm with the use of NOAC agents in this patient population (NCB = −0.28, 95% CI: −0.79 to 0.23). Use of full dose NOAC was widely unsafe (NCB = −0.35, 95% CI: −1.25 to 0.54) and low dose NOAC approached null therapeutic safety advantage (NCB = −0.06, 95% CI: −0.47 to 0.35). Conclusion Patients with CVD are at increased of ischemic stroke in the absence of AF. The use of NOAC agents in this non-AF population reduces rate of ischemic stroke however overall risk of bleeding exceeds antithrombotic benefit. Low-dose NOACs demonstrate a neutral NCB suggesting a point of clinical equipoise and deserve further scrutiny. Ischemic stroke vs major bleeding Funding Acknowledgement Type of funding source: None