Graeme Maguire is Executive Director of Baker IDI Heart and Diabetes Institute’s Clinical Research Domain and a specialist physician in general internal and respiratory medicine with experience in health service provision, health-related research and health policy and protocol development. He is a Professor of Medicine at Monash University, an NHMRC Practitioner Fellow and a physician at Monash Medical Centre, Melbourne. Graeme’s interests include regional health service evaluation and practice, chronic disease diagnosis and care, and tropical and Aboriginal and Torres Strait Islander respiratory and cardiovascular health with a particular interest in the prevention of ARF/RHD across the health continuum. ABSTRACT Rheumatic heart disease (RHD) remains an important preventable cause of heart disease. In Australia it particularly affects younger Indigenous and older non-Indigenous Australians. Evidence regarding the best time, type and site for surgery is largely anecdotal. Whether Australia should support larger centres of excellence for valve surgery and particularly RHD-related disease remains debatable.
Factors influencing treatment choice and outcome following surgery will be outlined with particular reference to the local Australian experience based on findings from the Australian cardiac surgery registry. Patient and outcome data relating to 20116 valve procedures (1560 RHD and 18556 non-RHD-related) at 25 surgical sites, preformed by 93 surgeons will be presented and discussed. Prior to operation RHD patients are younger, more likely to be female and Indigenous Australian, to have AF and previous percutaneous balloon valvuloplasty.
Following surgery RHD patients have longer ventilation, fewer strokes and more readmissions and anticoagulant complications. Factors independently associated with poorer longer-term survival following RHD surgery include older age, diabetes and chronic kidney disease, longer invasive ventilation time and prolonged stay in hospital. Survival in Indigenous Australians is nonetheless comparable to that seen in non-Indigenous Australians.
The influence of surgeon and surgical site caseload is not simple. Adjusted thirty day, but not longer term survival, is superior in higher volume centres. In contrast average annual surgeon caseload is not related to 30-day mortality but superior longer-term survival is seen for surgeons with individual caseloads in the middle strata of those analysed.
Australia is providing surgical care for patients with RHD and non-RHD related valve disease that is equivalent to that seen elsewhere with no difference in outcome seen for Indigenous Australians. Advocating for concentrating valve surgery and particularly RHD surgery in a defined group of surgeons operating in higher volume ‘centres of excellence’ is not supported by available local Australian data.
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