Publications by authors named "Alex Pui-Wai Lee"

80 Publications

Association of C-reactive protein and non-steroidal anti-inflammatory drugs with cardiovascular events in patients with psoriatic arthritis: a time-dependent Cox regression analysis.

Ther Adv Musculoskelet Dis 2021 30;13:1759720X211027712. Epub 2021 Jun 30.

Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.

Aims: Psoriatic arthritis (PsA) is associated with accelerated atherosclerosis due to underlying inflammation. Whether inflammatory burden and drugs used to suppress inflammation over time are associated with cardiovascular (CV) events remained unclear. This study aims to examine the time-varying effect of C-reactive protein (CRP) levels and the use of drugs, including non-steroidal anti-inflammatory drugs (NSAIDs) and disease modifying anti-rheumatic drugs, on the risk of CV events independent of traditional CV risk factors in PsA patients.

Methods: A retrospective cohort analysis was performed in patients with PsA who were recruited from 2008 to 2015 and followed until the end of 2019. The outcome was occurrence of a first CV event. Framingham risk score (FRS) was used to quantify the traditional CV risk. Cox proportional hazard models with time-varying CRP levels and drugs used were analysed to identify the risk factors for CV events in PsA patients.

Results: Two hundred patients with PsA [median age: 47.5 (40.0-56.0); male: 119 (59.5%)] were recruited. After a mean follow-up of 8.8 ± 3.8 years, 30 (15%) patients developed a first CV event. The multivariable Cox regression model showed that time-varying CRP level [hazard ratio (HR) 1.02, 95% confidence interval (CI) 1.00-1.04] and NSAIDs exposure (HR 0.38, 95% CI 0.15-0.96) were significantly associated with CV events after adjusting for baseline FRS (HR 5.06, 95% CI 1.84-13.92).

Conclusion: Increased inflammatory burden as reflected by elevated CRP level was associated with increased risk of CV events, while the risk was significantly reduced with NSAIDs use in PsA patients.
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http://dx.doi.org/10.1177/1759720X211027712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252335PMC
June 2021

Deep learning-based automated left ventricular ejection fraction assessment using 2D echocardiography.

Am J Physiol Heart Circ Physiol 2021 Jun 25. Epub 2021 Jun 25.

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Sha Tin, Hong Kong SAR, China.

Background: Deep-learning (DL) has been applied for automatic left ventricle (LV) ejection fraction (EF) measurement, but the diagnostic performance was rarely evaluated for various phenotypes of heart disease. This study aims to evaluate a new DL algorithm for automated LVEF measurement using two-dimensional echocardiography (2DE) images collected from 3 centers. The impact of 3 ultrasound machines and 3 phenotypes of heart diseases on the automatic LVEF measurement was evaluated.

Methods And Results: Using 36890 frames of 2DE from 340 patients, we developed a DL algorithm based on U-Net (DPS-Net) and the biplane Simpson's method was applied for LVEF calculation. Results showed a high performance in LV segmentation and LVEF measurement across phenotypes and echo systems by using DPS-Net. Good performance was obtained for LV segmentation when DPS-Net was tested on the CAMUS dataset (Dice coefficient of 0.932 and 0.928 for ED and ES). Better performance of LV segmentation in study-wise evaluation was observed by comparing the DPS-Net v2 to the EchoNet-dynamic algorithm (p = 0.008). DPS-Net was associated with high correlations and good agreements for the LVEF measurement. High diagnostic performance was obtained that the area under receiver operator characteristic curve was 0.974, 0.948, 0.968 and 0.972 for normal hearts and disease phenotypes including atrial fibrillation, hypertrophic cardiomyopathy, dilated cardiomyopathy, respectively.

Conclusion: High performance was obtained by using DPS-Net in LV detection and LVEF measurement for heart failure with several phenotypes. High performance was observed in a large-scale dataset, suggesting that the DPS-Net was highly adaptive across different echocardiographic systems.
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http://dx.doi.org/10.1152/ajpheart.00416.2020DOI Listing
June 2021

Direct 3D ultrasound fusion for transesophageal echocardiography.

Comput Biol Med 2021 07 21;134:104502. Epub 2021 May 21.

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital and Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Science, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.

Background: Real-time three-dimensional transesophageal echocardiography (3D TEE) has been increasingly used in clinic for fast 3D analysis of cardiac anatomy and function. However, 3D TEE still suffers from the limited field of view (FoV). It is challenging to adopt conventional multi-view fusion methods to 3D TEE images because feature-based registration methods tend to fail in the ultrasound scenario, and conventional intensity-based methods have poor convergence properties and require an iterative coarse-to-fine strategy.

Methods: A novel multi-view registration and fusion method is proposed to enlarge the FoV of 3D TEE images efficiently. A direct method is proposed to solve the registration problem in the Lie algebra space. Fast implementation is realized by searching voxels on three orthogonal planes between two volumes. Besides, a weighted-average 3D fusion method is proposed to fuse the aligned images seamlessly. For a sequence of 3D TEE images, they are fused incrementally.

Results: Qualitative and quantitative results of in-vivo experiments indicate that the proposed registration algorithm outperforms a state-of-the-art PCA-based registration method in terms of accuracy and efficiency. Image registration and fusion performed on 76 in-vivo 3D TEE volumes from nine patients show apparent enlargement of FoV (enlarged around two times) in the obtained fused images.

Conclusions: The proposed methods can fuse 3D TEE images efficiently and accurately so that the whole Region of Interest (ROI) can be seen in a single frame. This research shows good potential to assist clinical diagnosis, preoperative planning, and future intraoperative guidance with 3D TEE.
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http://dx.doi.org/10.1016/j.compbiomed.2021.104502DOI Listing
July 2021

High Prevalence of Late-Onset Fabry Cardiomyopathy in a Cohort of 499 Non-Selective Patients with Left Ventricular Hypertrophy: The Asian Fabry Cardiomyopathy High-Risk Screening Study (ASIAN-FAME).

J Clin Med 2021 May 17;10(10). Epub 2021 May 17.

Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China.

Left ventricular hypertrophy (LVH) caused by cardiac variant Fabry disease (FD) is typically late-onset and may mimic LVH caused by abnormal loading conditions. We aimed to determine the prevalence of FD in a non-selective patient population of everyday practice presenting with LVH, including those with hypertension and valve disease. We measured plasma alpha-galactosidase A activity using dried blood spot tests in 499 (age = 66 ± 13 years; 336 men) Hong Kong Chinese patients with LVH defined as maximal LV septal/posterior wall thickness ≥13 mm on echocardiography. Patients with low enzyme activity underwent mutation analysis of the GLA gene. Eight (age = 53-74 years; all men) unrelated patients (1.6%) had low plasma alpha-galactosidase A activity (0.57 ± 0.27 μmol/L wb/hr) and all were confirmed to have the GLA IVS4 + 919G > A mutation. FD patients presented with heart failure ( = 5), heart block ( = 2), ventricular tachycardia ( = 1), chest pain ( = 3), and/or murmur ( = 1). Uncontrolled hypertension ( = 4) and/or severe mitral/aortic valve pathology ( = 2) were frequent. Ethnic subgroups included Teochew ( = 5), Canton ( = 2), and Wenzhou ( = 1). Endomyocardial biopsy ( = 6) revealed hypertrophic myocytes with vacuolization and dense lamellar bodies. Late-onset IVS4 + 919G > A FD is prevalent among Chinese LVH patients, and should be considered as a cause of LVH in adult patients even when hypertension and/or valve pathology are present.
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http://dx.doi.org/10.3390/jcm10102160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157141PMC
May 2021

Valvular Disease and Heart Failure with Preserved Ejection Fraction.

Heart Fail Clin 2021 Jul;17(3):387-395

Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong SAR, China; Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China. Electronic address:

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome of shortness of breath and/or exercise intolerance secondary to elevated left ventricular filling pressures at rest or with exertion either as a result of primary diastolic dysfunction (primary HFpEF) or secondary to specific underlying causes (secondary HFpEF). In secondary HFpEF, early intervention of underlying valvular heart disease generally improves symptoms and prolongs survival. In primary HFpEF, there is increasing awareness of the existence and prognostic implications of secondary atrioventricular valve regurgitation. Further studies will clarify their mechanisms and the effectiveness of valvular intervention in this intriguing HFpEF subgroup.
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http://dx.doi.org/10.1016/j.hfc.2021.02.005DOI Listing
July 2021

Pocket-Size Mobile Echocardiographic Screening of Thoracic Aortic Aneurysms in Hypertensive Patients.

Ann Thorac Surg 2021 05 19;111(5):1554-1559. Epub 2020 Sep 19.

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong. Electronic address:

Background: Patients with hypertension may develop a thoracic aortic aneurysm (TAA) that can be asymptomatic but potentially life-threatening. We sought to assess the prevalence of asymptomatic TAA among hypertensive patients with a point-of-care screening program using pocket-size mobile echocardiographic (PME) devices.

Methods: We prospectively performed transthoracic aortic ultrasound using a PME device on patients attending our hypertension clinics between June 2016 and July 2018. The echo examinations were performed by a research fellow to obtain aortic diameter measurements including the aortic sinus, sinotubular junction, ascending aorta, aortic arch, and descending thoracic aorta through various standard echo views. Images were stored on the PME and transferred to a desktop computer for measurements and further statistical analysis.

Results: During the study period 1529 hypertensive patients (mean age, 62 years [range, 30-85]; 824 men) were recruited. The prevalence of TAA (defined as maximum aortic diameter ≥ 4.5 cm and/or >50% larger than the diameter of the adjacent normal aorta) in our study population was 7.5% (115/1529). Multiple logistic regression analysis identified male gender (odds ratio, 2.120; P < .001) and older age (odds ratio, 1.031; P < .001) as independent factors associated with TAA.

Conclusions: Silent TAA is common among hypertensive patients in Hong Kong. We found the PME device to be effective in detecting TAA in a clinic setting. Such an approach may be useful for early detection of TAA among at-risk patients, allowing aggressive blood pressure control and early surgical intervention to prevent catastrophic complications.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.018DOI Listing
May 2021

DAPSA, carotid plaque and cardiovascular events in psoriatic arthritis: a longitudinal study.

Ann Rheum Dis 2020 10 31;79(10):1320-1326. Epub 2020 Jul 31.

Department of Medicine & Therapeutics, The Chinese University of Hong Kong, New Territories, Hong Kong.

Objective: To examine whether Disease Activity in Psoriatic Arthritis (DAPSA) reflecting the inflammatory component of psoriatic arthritis (PsA) can predict cardiovascular (CV) events independent of traditional CV risk factors and subclinical carotid atherosclerosis.

Methods: A cohort analysis was performed in patients with PsA who had been followed since 2006. The outcome of interest was first CV event. Four different CV disease (CVD) risk scores and DAPSA were computed at baseline. The presence of carotid plaque (CP) and carotid intima-media thickness (CIMT) was also determined in a subgroup of patients using high-resolution ultrasound. The association between DAPSA, CVD risk scores, CP, CIMT and the occurrence of CV events was assessed using Cox proportional hazard models.

Results: 189 patients with PsA (mean age: 48.9 years; male: 104 (55.0%)) were recruited. After a median follow-up of 9.9 years, 27 (14.3%) patients developed a CV event. Higher DAPSA was significantly associated with an increased risk of developing CV events (HR: 1.04, 95% CI (1.01 to 1.08), p=0.009). The association remained significant after adjusting for all CV risk scores in the multivariable models. In the subgroup analysis, 154 patients underwent carotid ultrasound assessment and 23 (14.9%) of them experienced a CV event. CP was associated with increased risk of developing CV events after adjusting for three CV risk scores and DAPSA, with HR ranging from 2.35 to 3.42.

Conclusion: Higher DAPSA and the presence of CP could independently predict CVD events in addition to traditional CV risk scores in patients with PsA.
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http://dx.doi.org/10.1136/annrheumdis-2020-217595DOI Listing
October 2020

Three-dimensional transesophageal echocardiography measurement of mitral valve area in patients with rheumatic mitral stenosis: multiplanar reconstruction or 3D direct planimetry?

Int J Cardiovasc Imaging 2021 Jan 27;37(1):99-107. Epub 2020 Jul 27.

Echo Lab, Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430060, China.

3D direct planimetry is increasingly used in clinical practice as a rapid way to measure the mitral valve area (MVA) in patients with rheumatic mitral stenosis (MS) who underwent three-dimensional transesophageal echocardiography (3D-TEE). However, data on its accuracy and reliability are scarce. This study aimed to compare the MVA measurements obtained by 3D direct planimetry to the conventional technique multiplanar reconstruction (MPR) in MS patients using 3D-TEE. We retrospectively included 49 patients with rheumatic MS undergoing clinically-indicated 3D-TEE in the study. We determined the 3D direct planimetry measurements of MVA from the left atria aspect (MVA) and the left ventricle aspect (MVA), and compared those with the MPR method (MVA). We also assessed the major and minor diameters of the mitral valve orifice using MPR and 3D direct planimetry. We found an excellent agreement between the MVA measurements obtained by the MPR method and 3D direct planimetry (MVA and MVA) [intraclass correlation coefficients (ICC) = 0.951 and 0.950, respectively]. However, the MVA measurements were significantly larger than the MVA and MVA (p < 0.001; mean difference: 0.12 ± 0.15 cm and 0.11 ± 0.16 cm, respectively).The inter-observer and intra-observer variability ICC were 0.875 and 0.856 for MVA, 0.982 and 0.984 for MVA, and 0.988 and 0.986 for MVA, respectively. The major diameter measured by MPR (1.90 ± 0.42 cm) was significantly larger than that obtained by 3D direct planimetry (1.72 ± 0.35 cm for the LA aspect, p < 0.001; 1.73 ± 0.36 cm for the LV aspect, p < 0.001). The minor diameter measured by MPR (0.96 ± 0.25 cm) did not differ from that derived by 3D direct planimetry (0.94 ± 0.25 cm for the LA aspect, p = 0.07; 0.95 ± 0.27 cm for the LV aspect, p = 0.32). 3D direct planimetry provides highly reproducible measurements of MVA and yields data in excellent agreement with those obtained by the MPR method. The discrepancy between the two techniques may be due to differences in major diameter measurements of the mitral valve orifice.
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http://dx.doi.org/10.1007/s10554-020-01950-1DOI Listing
January 2021

Atrial functional mitral regurgitation: mechanisms and surgical implications.

Asian Cardiovasc Thorac Ann 2020 Sep 1;28(7):421-426. Epub 2020 Jul 1.

Division of Cardiology, Department of Medicine and Therapeutics, Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong.

The term atrial functional mitral regurgitation refers to a newly recognized disease entity in which mitral regurgitation occurs secondary to left atrial disease, without left ventricular dilatation and intrinsic mitral valve disease, typically in the setting of long-standing atrial fibrillation. Recent evidence suggests that atrial functional mitral regurgitation is associated with increased risk of death and heart failure re-hospitalization. The etiology, pathophysiology, and mechanism of atrial functional mitral regurgitation is not completely understood but they should not be regarded as the same as for the conventional type of functional mitral regurgitation secondary to left ventricular dilatation and dysfunction. Mitral annular dilatation, atriogenic leaflet distortion, insufficient leaflet remodeling, and subtle left ventricular dysfunction may play a role in the pathogenesis of atrial functional mitral regurgitation. The therapeutic and surgical considerations of atrial functional mitral regurgitation are different from those of ventricular functional mitral regurgitation. In this review, we assess current evidence regarding this new disease entity and propose a new surgical approach based on up-to-date understanding and experience of this condition.
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http://dx.doi.org/10.1177/0218492320941388DOI Listing
September 2020

Procedural and short-term outcomes of occluding large left atrial appendages with the LAmbre device.

EuroIntervention 2021 May;17(1):90-92

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China.

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http://dx.doi.org/10.4244/EIJ-D-19-00821DOI Listing
May 2021

Three-dimensional printing in structural heart disease and intervention.

Ann Transl Med 2019 Oct;7(20):579

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.

Three-dimensional (3D) printing refers to the process by which physical objects are built by depositing materials in layers based on a specific digital design. It was initially used in manufacture industry. Inspired by the technology, clinicians have recently attempted to integrate 3D printing into medical applications. One of the medical specialties that has recently made such attempt is cardiology, especially in the field of structural heart disease (SHD). SHD refers to a group of non-coronary cardiovascular disorders and related interventions. Obvious examples are aortic stenosis, mitral regurgitation, atrial septal defect, and known or potential left atrial appendage (LAA) clots. In the last decade, cardiologists have witnessed a dramatic increase in the types and complexity of catheter-based interventions for SHD. Current imaging modalities have important limitations in accurate delineation of cardiac anatomies necessary for SHD interventions. Application of 3D printing in SHD interventional planning enables tangible appreciation of cardiac anatomy and allows interventional device testing. 3D printing is used in diagnostic workup, guidance of treatment strategies, and procedural simulation, facilitating hemodynamic research, enhancing interventional training, and promoting patient-clinician communication. In this review, we attempt to define the concept, technique, and work flow of 3D printing in SHD and its interventions, highlighting the reported clinical benefits and unsolved issues, as well as exploring future developments in this field.
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http://dx.doi.org/10.21037/atm.2019.09.73DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861816PMC
October 2019

Anticipating coronary obstruction with three-dimensional printing in transcatheter aortic valve implantation.

EuroIntervention 2020 Mar;15(16):1424-1425

Laboratory for Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong, China.

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http://dx.doi.org/10.4244/EIJ-D-19-00609DOI Listing
March 2020

Novel Mechanisms in Heart Failure With Preserved, Midrange, and Reduced Ejection Fraction.

Front Physiol 2019 5;10:874. Epub 2019 Jul 5.

Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.

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http://dx.doi.org/10.3389/fphys.2019.00874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625157PMC
July 2019

Electrocardiographic evidence of abnormal atrial phenotype in Brugada syndrome.

J Electrocardiol 2019 Jul - Aug;55:102-106. Epub 2019 May 13.

Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, PR China; Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR, PR China; Division of Cardiology, Kingston Health Science Center, Queen's University, Kingston, Ontario, Canada. Electronic address:

Background: Brugada syndrome (BrS) is an inherited ion channelopathy that may predispose affected individuals to atrial cardiomyopathy. We tested the hypothesis that BrS patients have higher degrees of atrial electrophysiological abnormalities compared to controls, and these can be reflected by changes in P-wave parameters determined on the electrocardiogram (ECG).

Methods: This was a single-center retrospective study comparing BrS patients to age- and gender-matched control subjects. Mean P-wave duration (PWD), maximum PWD (PWD) and minimum PWD (PWD), P-wave dispersion (PWD - PWD), and P-wave terminal force in V1 (PTFV1) were measured. PWD ≥ 120 ms, in the presence and absence of biphasic P-waves in the inferior leads, were termed advanced and partial inter-atrial block (IAB), respectively.

Results: The proportion of IAB was significantly higher in BrS patients (28/51; 55%) than in control subjects (14/51; 27%; Fisher's Exact test; P < 0.01). Advanced IAB was observed in two BrS patients but none of the control subjects (P = 0.50). Compared to controls, BrS patients showed higher PWD (107 [98-113] vs. 97 [90-108] ms; KWANOVA, P < 0.01), PWD (123 [110-132] vs. 113 [107-121] ms; P < 0.001) but statistically indistinguishable PWD (82 [72-92] vs. 77 [69-85]; P = 0.09), and P-wave dispersion (38 [26-52] vs. 37 [23-45] ms; P = 0.14). PTFV1 was significantly higher in BrS patients than in control subjects (24 [0-40] vs. 0 [0-27] mm.ms; P < 0.05).

Conclusion: Atrial conduction abnormalities are frequently observed in BrS. These patients may require monitoring for future development of atrial fibrillation and stroke.
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http://dx.doi.org/10.1016/j.jelectrocard.2019.05.005DOI Listing
June 2021

Device Sizing Guided by Echocardiography-Based Three-Dimensional Printing Is Associated with Superior Outcome after Percutaneous Left Atrial Appendage Occlusion.

J Am Soc Echocardiogr 2019 06 2;32(6):708-719.e1. Epub 2019 Apr 2.

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China. Electronic address:

Background: Left atrial appendage (LAA) occlusion is an alternative to anticoagulation for stroke prevention in patients with atrial fibrillation. Accurate device sizing is crucial for optimal outcome. Patient-specific LAA models can be created using three-dimensional (3D) printing from 3D transesophageal echocardiographic (TEE) images, allowing in vitro model testing for device selection. The aims of this study were to assess the association of model-based device selection with procedural safety and efficacy and to determine if preprocedural model testing leads to superior outcomes.

Methods: In 72 patients who underwent imaging-guided LAA occlusion, 3D models of the LAA were created from 3D TEE data sets retrospectively (retrospective cohort). The optimal device determined by in vitro model testing was compared with the actual device used. Associations of model-match and model-mismatch device sizing with outcomes were analyzed. In another 32 patients, device selection was prospectively guided by 3D models in adjunct to imaging (prospective cohort). The impact of model-based sizing on outcomes was assessed by comparing the two cohorts.

Results: Patients in the retrospective cohort with model-mismatch sizing had longer procedure times, more implantation failures, more devices used per procedure, more procedural complications, more peridevice leak, more device thrombus, and higher cumulative incidence rates of ischemic stroke and cardiovascular or unexplained death (P < .05 for all) over 3.0 ± 2.3 years after LAA occlusion. Compared with the retrospective imaging-guided cohort, the prospective model-guided patients achieved higher implantation success and shorter procedural times (P < .05) without complications. Clinical device compression (r = 0.92) and protrusion (r = 0.95) agreed highly with model testing (P < .0001). Predictors for sizing mismatch were nonwindsock morphology (odds ratio, 4.7) and prominent LAA trabeculations (odds ratio, 7.1).

Conclusions: In patients undergoing LAA occlusion, device size selection in agreement with 3D-printed model-based sizing is associated with improved safety and efficacy. Preprocedural device sizing with 3D models in adjunct to imaging guidance may lead to superior outcomes.
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http://dx.doi.org/10.1016/j.echo.2019.02.003DOI Listing
June 2019

Occlusion of a Multilobed Shallow Left Atrial Appendage Using a Special LAmbre Device After Failed Watchman Implantation.

J Invasive Cardiol 2019 02;31(2):E41-E42

Division of Cardiology, Department of Medicine and Therapeutics, 9/F Clinical Sciences Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR, China.

Although reported failure rates of the Watchman device are low, the ballshaped device is not suitable for shallow and multilobed left atrial appendages (LAAs). The LAmbre device is available in two configurations - standard (cover 4-6 mm larger in diameter than the umbrella) and special (cover 12- 14 mm larger than the umbrella) - which allows the closure of a wide range of LAA anatomies. This case illustrates that the LAmbre device can be used for complex LAA anatomies that are not suitable for the Watchman device.
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February 2019

Mitral Annular and Left Ventricular Dynamics in Atrial Functional Mitral Regurgitation: A Three-Dimensional and Speckle-Tracking Echocardiographic Study.

J Am Soc Echocardiogr 2019 04 21;32(4):503-513. Epub 2019 Jan 21.

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China. Electronic address:

Background: Patients with atrial fibrillation (AF) and left atrial (LA) enlargement may develop functional, normal leaflet motion mitral regurgitation (MR) without left ventricular (LV) remodeling. Mitral annular dynamics and LV mechanics are important for preserving normal mitral valve function. The aim of this study was to assess the annular and LV dynamics in patients with AF and functional MR.

Methods: Twenty-one patients with AF with moderate or more MR (AFMR+ group), 46 matched patients with AF with no or mild MR (AFMR- group), and 19 normal patients were retrospectively studied. Mitral annular dynamics were quantitatively assessed using three-dimensional echocardiography. Systolic LV global longitudinal strain (GLS), global circumferential strain, and LA strain were measured using two-dimensional speckle-tracking echocardiography.

Results: The normal annulus displayed presystolic followed by systolic contraction and increase in saddle shape (P < .01 for all). Presystolic annular dynamics were abolished in both groups of patients with AF (P > .05 vs normal). In contrast, systolic and total annular dynamics during the cardiac cycle were preserved in AFMR- patients (P > .10 vs normal) but impaired in AFMR+ patients (P < .05 vs normal and AFMR-). LV GLS (P < .0001) and LA strain (P = .02), but not LV global circumferential strain (P = .97), were impaired in AFMR+ compared with AFMR- patients despite comparable LA and LV volumes. MR severity correlated with systolic annular contraction (r = 0.64, P < .0001), saddle deepening (r = 0.53, P = .003), and LV GLS (r = 0.46, P < .0001). Multivariate analysis identified that impaired systolic contraction (odds ratio, 2.18; P = .001) and saddle deepening (odds ratio, 2.68; P = .04) were independently associated with MR. Excluding annular dynamics from the model, less negative LV GLS, but not LA strain, became associated with MR (odds ratio, 1.93; P < .0001).

Conclusions: In patients with AF and absent LA contraction, the normal predominantly "atriogenic" annular dynamics become "ventriculogenic." Isolated LA enlargement is insufficient to cause important MR without coexisting abnormal LV mechanics and annular dynamics during systole. "Atrial" functional MR may not be purely an atrial disorder.
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http://dx.doi.org/10.1016/j.echo.2018.11.009DOI Listing
April 2019

Spondyloarthritis-Related Autoimmune Aortitis Complicated by Severe Aortic Regurgitation.

Circ Cardiovasc Imaging 2019 12;12(1):e008341

Department of Medicine and Therapeutics (W.K.C., G.T., K.K.H.K., L.T., A.P.W.L., L.S.T.), Faculty of Medicine, Chinese University of Hong Kong, SAR.

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http://dx.doi.org/10.1161/CIRCIMAGING.118.008341DOI Listing
December 2019

Cancer antigen-125 and outcomes in acute heart failure: a systematic review and meta-analysis.

Heart Asia 2018 26;10(2):e011044. Epub 2018 Oct 26.

Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Valencia, Spain.

Background: Carbohydrate antigen-125 (CA125) is an ovarian cancer marker, but recent work has examined its role in risk stratification in heart failure. A recent meta-analysis examined its prognostic value in heart failure generally. However, there has been no systematic evaluation of its role specifically in acute heart failure (AHF).

Methods: PubMed and EMBASE databases were searched until 11 May 2018 for studies that evaluated the prognostic value of CA125 in AHF.

Results: A total of 129 and 179 entries were retrieved from PubMed and EMBASE. Sixteen studies (15 cohort studies, 1 randomised trial) including 8401 subjects with AHF (mean age 71 years old, 52% male, mean follow-up 13 months, range of patients 525.1±598.2) were included. High CA125 levels were associated with a 68% increase in all-cause mortality (8 studies, HRs: 1.68, 95% CI 1.36 to 2.07; p<0.0001; I: 74%) and 77% increase in heart failure-related readmissions (5 studies, HRs: 1.77, 95% CI 1.22 to 2.59; p<0.01; I: 73%). CA125 levels were higher in patients with fluid overload symptoms and signs compared with those without them, with a mean difference of 54.8 U/mL (5 studies, SE: 13.2 U/mL; p<0.0001; I: 78%).

Conclusion: Our meta-analysis found that high CA125 levels are associated with AHF symptoms, heart failure-related hospital readmissions and all-cause mortality. Therefore, CA125 emerges as a useful risk stratification tool for identifying high-risk patients with more severe fluid overload, as well as for monitoring following an AHF episode.
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http://dx.doi.org/10.1136/heartasia-2018-011044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204439PMC
October 2018

Single Leaflet Device Attachment Complicating Percutaneous Edge-to-Edge Repair of the Tricuspid Valve Using the MitraClip.

J Invasive Cardiol 2018 09;30(9):E93-E94

9/F Department of Medicine and Therapeutics, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong SAR.

A 72-year-old woman with severe mitral and tricuspid regurgitation secondary to chronic atrial fibrillation presented with refractory heart failure despite optimal medical treatment. She was considered inoperable, and thus underwent transcatheter edge-to-edge repair of both valves using the MitraClip system as a compassionate use.
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September 2018

Quantitative analysis of mitral valve morphology in atrial functional mitral regurgitation using real-time 3-dimensional echocardiography atrial functional mitral regurgitation.

Cardiovasc Ultrasound 2018 Aug 21;16(1):13. Epub 2018 Aug 21.

Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China.

Background: Atrial fibrillation (AF) can result in atrial functional mitral regurgitation (MR), but the mechanism remains controversial. Few data about the relationship between the 3-dimensional morphology of the MV and the degree of MR in AF exist.

Methods: Real-time 3-dimensional transesophageal echocardiography (3D-TEE) of the MV was acquired in 168 patients with AF (57.7% persistent AF), including 25 (14.9%) patients with moderate to severe MR (the MR+ group) and 25 patients without AF as controls. The 3-dimensional geometry of the MV apparatus was acquired using dedicated quantification software.

Results: Compared with the group of patients with no or mild MR (the MR- group) and the controls, the MR+ group had a larger left atrium (LA), a more dilated mitral annulus (MA), a reduced annular height to commissural width ratio (AHCWR), indicating flattening of the annular saddle shape, and greater leaflet surfaces and tethering. MR severity was correlated with the MA area (r = 0.43, P < 0.01) and the annulus circumference (r = 0.38, P < 0.01). A logistic regression analysis indicated that the MA area (OR: 1.02, 95% CI: 1.01-1.03, P < 0.01), AHCWR (OR: 0.24, 95% CI: 0.14-0.35, P = 0.04) and MV tenting volume (OR: 3.24, 95% CI: 1.16-9.08, P = 0.03) were independent predictors of MR severity in AF patients.

Conclusions: The mechanisms of "atrial functional MR" are complex and include dilation of the MA, flattening of the annular saddle shape and greater leaflet tethering.
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http://dx.doi.org/10.1186/s12947-018-0131-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6102822PMC
August 2018

Telemonitoring and hemodynamic monitoring to reduce hospitalization rates in heart failure: a systematic review and meta-analysis of randomized controlled trials and real-world studies.

J Geriatr Cardiol 2018 Apr;15(4):298-309

Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, the Second Hospital of Tianjin Medical University, Tianjin, China.

Background: Heart failure is a significant problem leading to repeated hospitalizations. Telemonitoring and hemodynamic monitoring have demonstrated success in reducing hospitalization rates, but not all studies reported significant effects. The aim of this systematic review and meta-analysis is to examine the effectiveness of telemonitoring and wireless hemodynamic monitoring devices in reducing hospitalizations in heart failure.

Methods & Results: PubMed and Cochrane Library were searched up to 1 May 2017 for articles that investigated the effects of telemonitoring or hemodynamic monitoring on hospitalization rates in heart failure. In 31,501 patients (mean age: 68 ± 12 years; 61% male; follow-up 11 ± 8 months), telemonitoring reduced hospitalization rates with a HR of 0.73 (95% CI: 0.65-0.83; < 0.0001) with significant heterogeneity ( = 94%). These effects were observed in the short-term (≤ 6 months: HR = 0.77, 95% CI: 0.65-0.89; < 0.01) and long-term (≥ 12 months: HR = 0.73, 95% CI: 0.62-0.87; < 0.0001). In 4831 patients (mean age 66 ± 18 years; 66% male; follow-up 13 ± 4 months), wireless hemodynamic monitoring also reduced hospitalization rates with a HR of 0.60 (95% CI: 0.53-0.69; < 0.001) with significant heterogeneity ( = 64%).This reduction was observed both in the short-term (HR = 0.55, 95% CI: 0.45-0.68; < 0.001; = 72%) and long-term (HR = 0.64, 95% CI: 0.57-0.72; < 0.001; = 55%).

Conclusions: Telemonitoring and hemodynamic monitoring reduce hospitalization in both short- and long-term in heart failure patients.
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http://dx.doi.org/10.11909/j.issn.1671-5411.2018.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5997618PMC
April 2018

Effect of Treat-to-target Strategies Aiming at Remission of Arterial Stiffness in Early Rheumatoid Arthritis: A Randomized Controlled Study.

J Rheumatol 2018 08 15;45(9):1229-1239. Epub 2018 May 15.

From the Department of Medicine and Therapeutics, and Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong; Department of Medicine, Queen Elizabeth Hospital; Department of Medicine, Tai Po Hospital; Department of Medicine, Tseung Kwan O Hospital; Department of Medicine, Pamela Youde Nethersole Eastern Hospital; Department of Medicine, Kwong Wah Hospital, Hong Kong.

Objective: To determine the efficacy of 2 tight control treatment strategies aiming at Simplified Disease Activity Score (SDAI) remission (SDAI ≤ 3.3) compared to 28-joint count Disease Activity Score (DAS28) remission (DAS28 < 2.6) in the prevention of arterial stiffness in patients with early rheumatoid arthritis (RA).

Methods: This was an open-label study in which 120 patients with early RA were randomized to receive 1 year of tight control treatment. Group 1 (n = 60) aimed to achieve SDAI ≤ 3.3 and Group 2 (n = 60), DAS28 < 2.6. Pulse wave velocity (PWV) and augmentation index (AIx) were measured at baseline and 12 months. A posthoc analysis was also performed to ascertain whether achieving sustained remission could prevent progression in arterial stiffness.

Results: The proportions of patients receiving methotrexate monotherapy were significantly lower in Group 1 throughout the study period. At 12 months, the proportions of patients achieving DAS28 and SDAI remission, and the change in PWV and AIx, were comparable between the 2 groups. In view of the lack of differences between the 2 groups, a posthoc analysis was performed at Month 12, including all 110 patients with PWV, to elucidate the independent predictors associated with the change in PWV. Multivariate analysis revealed that achieving sustained DAS28 remission at months 6, 9, and 12 and a shorter disease duration were independent explanatory variables associated with less progression of PWV.

Conclusion: With limited access to biologic disease-modifying antirheumatic drugs, treatment efforts toward DAS28 and SDAI remission had similar effects in preventing the progression of arterial stiffness at 1 year. However, achieving sustained DAS28 remission was associated with a significantly greater improvement in PWV. [Clinical Trial registration: Clinicaltrial.gov NCT01768923.].
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http://dx.doi.org/10.3899/jrheum.171128DOI Listing
August 2018

Genotype-guided warfarin dosing vs. conventional dosing strategies: a systematic review and meta-analysis of randomized controlled trials.

Br J Clin Pharmacol 2018 09 21;84(9):1868-1882. Epub 2018 Jun 21.

Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China.

Aims: Previous trials on the effectiveness of genotype-guided warfarin dosing vs. conventional dosing have been inconclusive. We conducted a systematic review and meta-analysis of randomized trials comparing genotype-guided to conventional dosing strategies.

Methods: PubMed and the Cochrane Library were searched up to 23 October 2017.

Results: A total of 76 and 94 entries were retrieved were retrieved from PubMed and the Cochrane Library, respectively. A total of 2626 subjects in the genotype-guided dosing (mean age 63.3 ± 5.8 years; 46% male) and 2604 subjects in the conventional dosing (mean age 64.7 ± 6.1 years; 46% male) groups (mean follow-up duration 64 days) from 18 trials were included. Compared with conventional dosing, genotype-guided dosing significantly shortened the time to first therapeutic international normalized ratio (INR) (mean difference 2.6 days, standard error 0.3 days; P < 0.0001; I 0%) and time to first stable INR (mean difference 5.9 days, standard error 2.0 days; P < 0.01; I 94%). Genotype-guided dosing also increased the time in therapeutic range (mean difference 3.1%, standard error 1.2%; P < 0.01; I 80%) and reduced the risks of both excessive anticoagulation, defined as INR ≥4 [risk ratio (RR) 0.87; 95% confidence interval (CI) 0.78, 0.98; P < 0.05; I : 0%), and bleeding (RR 0.82; 95% CI 0.69, 0.98; P < 0.05; I 31%). No difference in thromboembolism (RR 0.84; 95% CI 0.56, 1.26; P = 0.40; I 0%) or mortality (RR 1.16; 95% CI 0.46, 2.91; P = 0.76; I 0%) was observed between the two groups.

Conclusions: Genotype-guided warfarin dosing offers better safety with less bleeding compared with conventional dosing strategies. No significant benefit on thromboembolism or mortality was evident.
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http://dx.doi.org/10.1111/bcp.13621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089819PMC
September 2018

Underestimation of Risk of Carotid Subclinical Atherosclerosis by Cardiovascular Risk Scores in Patients with Psoriatic Arthritis.

J Rheumatol 2018 02 15;45(2):218-226. Epub 2017 Nov 15.

From the Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.

Objective: To test the performances of established cardiovascular (CV) risk scores in discriminating subclinical atherosclerosis (SCA) in patients with psoriatic arthritis.

Methods: These scores were calculated: Framingham risk score (FRS), QRISK2, Systematic COronary Risk Evaluation (SCORE), 10-year atherosclerotic cardiovascular disease risk algorithm (ASCVD) from the American College of Cardiology and the American Heart Association, and the European League Against Rheumatism (EULAR)-recommended modified versions (by 1.5 multiplication factor, m-). Carotid intima-media thickness > 0.9 mm and/or the presence of plaque determined by ultrasound were classified as SCA+.

Results: We recruited 146 patients [49.4 ± 10.2 yrs, male: 90 (61.6%)], of whom 142/137/128/118 patients were eligible to calculate FRS/QRISK2/SCORE/ASCVD. Further, 62 (42.5%) patients were SCA+ and were significantly older, with higher systolic blood pressure and higher low-density lipoprotein cholesterol (all p < 0.05). All CV risk scores were significantly higher in patients with SCA+ [FRS: 7.8 (3.9-16.5) vs 2.7 (1.1-7.8), p < 0.001; QRISK2: 5.5 (3.1-10.2) vs 2.9 (1.2-6.3), p < 0.001; SCORE: 1 (0-2) vs 0 (0-1), p < 0.001; ASCVD: 5.6 (2.6-12.4) vs 3.4 (1.4-6.1), p = 0.001]. The Hosmer-Lemeshow test revealed moderate goodness of fit for the 4 CV scores (p ranged from 0.087 to 0.686). However, of the patients with SCA+, those identified as high risk were only 44.1% (by FRS > 10%), 1.8% (QRISK2 > 20%), 10.9% (SCORE > 5%), and 43.6% (ASCVD > 7.5%). By applying the EULAR multiplication factor, 50.8%/14.3%/14.5%/54.5% of the patients with SCA+ were identified as high risk by m-FRS/m-QRISK2/m-SCORE/m-ASCVD, respectively. EULAR modification increased the sensitivity of FRS and ASCVD in discriminating SCA+ from 44% to 51%, and 44% to 55%, respectively.

Conclusion: All CV risk scores underestimated the SCA+ risk. EULAR-recommended modification improved the sensitivity of FRS and ASCVD only to a moderate level.
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http://dx.doi.org/10.3899/jrheum.170025DOI Listing
February 2018

Automated left heart chamber volumetric assessment using three-dimensional echocardiography in Chinese adolescents.

Echo Res Pract 2017 Dec 1;4(4):53-61. Epub 2017 Sep 1.

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, People's Republic of China

Background: Several studies have reported the accuracy and reproducibility of HeartModel for automated determination of three-dimensional echocardiography (3DE)-derived left heart volumes and left ventricular (LV) ejection fraction (LVEF) in adult patients. However, it remains unclear whether this automated adaptive analytics algorithm, derived from a 'training' population, can encompass adequate echo images in Chinese adolescents.

Objectives: The aim of our study was to explore the accuracy of HeartModel in adolescents compared with expert manual three-dimensional (3D) echocardiography.

Methods: Fifty-three Chinese adolescent subjects with or without heart disease underwent 3D echocardiographic imaging with an EPIQ system (Philips). 3D cardiac volumes and LVEF obtained with the automated HeartModel program were compared with manual 3D echocardiographic measurements by an experienced echocardiographer.

Results: There was strong correlation between HeartModel and expert manual 3DE measurements ( = 0.875-0.965, all  < 0.001). Automated LV and left atrial (LA) volumes were slightly overestimated when compared to expert manual measurements, while LVEF showed no significant differences from the manual method. Importantly, the intra- and inter-observer variability of automated 3D echocardiographic model was relatively low (<1%), surpassing the manual approach (3.5-17.4%), yet requiring significantly less analyzing time (20 ± 7 vs 177 ± 30 s,  < 0.001).

Conclusion: Simultaneous quantification of left heart volumes and LVEF with the automated HeartModel program is rapid, accurate and reproducible in Chinese adolescent cohort. Therefore, it has a potential to bring 3D echocardiographic assessment of left heart chamber volumes and function into busy pediatric practice.
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http://dx.doi.org/10.1530/ERP-17-0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633056PMC
December 2017

Functional Implication of Mitral Annular Disjunction in Mitral Valve Prolapse: A Quantitative Dynamic 3D Echocardiographic Study.

JACC Cardiovasc Imaging 2017 12 17;10(12):1424-1433. Epub 2017 May 17.

Cardiology Department, Renji Hospital, Medical College of Shanghai Jiao Tong University, Shanghai, China.

Objectives: This study aimed to assess the hypothesis that mitral annular disjunction (MAD) is associated with abnormal annular dynamics due to decoupling of annular-ventricular function.

Background: MAD, defined as a separation between the atrial wall-mitral valve (MV) junction and left ventricular (LV) attachment, is a structural abnormality occurring in MV prolapse (MVP). Few data exist on the 3-dimensional (3D) geometry of MAD and its functional implication.

Methods: A total of 156 subjects including 101 MVP patients (58 ± 11 years), 30 subjects with normal MV (57 ± 15 years), and 25 heart failure patients with functional mitral regurgitation (66 ± 10 years) were studied using real-time 3D transesophageal echocardiography. The spatial relation between atrial wall, MV, and LV attachment was examined for MAD. The 3D extent of MAD and annular dynamics were quantitatively assessed. The LV global longitudinal strain and basal circumferential strains were measured by speckle tracking echocardiography.

Results: MAD was evident in 42 MVP patients (42%), measuring 8.9 mm (6.3 to 10.7 mm), circumferentially spanning 87 ± 41°. Dynamically, normal and nondisjunctive annulus contracted and increased in a saddle shape during systole. In heart failure patients with functional mitral regurgitation, mitral annulus was dilated and relatively adynamic, probably related to poor LV function. In contrast, disjunctive annulus displayed paradoxical systolic expansion and flattening (p < 0.0001), despite preserved and comparable LV strains with normal patients. The 3D extent of MAD correlated significantly with abnormal annular dynamics and larger regurgitant orifice (p < 0.0001). In MVP patients without MAD, the LV global longitudinal strain correlated inversely with change in height (r = -0.61; p < 0.0001), whereas LV basal circumferential strain correlated with change in area (r = 0.61; p < 0.0001), but not in patients with MAD (p > 0.05).

Conclusions: MAD is a common anatomic abnormality in MVP. The disjunctive annulus is decoupled functionally from the ventricle, leading to paradoxical annular dynamics with systolic expansion and flattening, and may thus require specific intervention.
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http://dx.doi.org/10.1016/j.jcmg.2016.11.022DOI Listing
December 2017

Using Multimaterial 3-Dimensional Printing for Personalized Planning of Complex Structural Heart Disease Intervention.

JACC Cardiovasc Interv 2017 06 17;10(11):e97-e98. Epub 2017 May 17.

Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2017.02.045DOI Listing
June 2017

Increased prevalence of coronary plaque in patients with psoriatic arthritis without prior diagnosis of coronary artery disease.

Ann Rheum Dis 2017 Jul 4;76(7):1237-1244. Epub 2017 Jan 4.

Department of Medicine & Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong.

Objectives: To evaluate coronary atherosclerosis in patients with psoriatic arthritis (PsA) and control subjects using coronary CT angiography (CCTA).

Methods: Ninety consecutive patients with PsA (male: 56(62.2%); 50.3±11.1 years) were recruited. 240 controls (male: 137(57.1%); 49.6±10.7 years) without known cardiovascular (CV) diseases who underwent CCTA due to chest pain and/or multiple CV risk factors were recruited for comparison.

Results: Patients with PsA and controls were matched in age, gender and traditional CV risk factors (all p>0.2). The prevalence of overall plaque (54(60%)/84(35%), p<0.001), calcified plaque (CP) (29(32%)/40(17%), p=0.002), mixed plaque (MP) (20(22%)/18(8%), p<0.001), non-calcified plaque (NCP) (39(43%)/53(22%), p<0.001) and combined MP/NCP (46(51%)/62(26%), p<0.001) were all significantly higher in patients with PsA. Three-vessel disease was diagnosed in 12(13%) patients with PsA and 7(3%) controls (p<0.001), while obstructive plaques (>50% stenosis) were observed in 8(9%) patients with PsA and 7(3%) controls (p=0.033). After adjusting for traditional CV risk factors, PsA remained an independent explanatory variable for all types of coronary plaques (OR: 2.730 to 4.064, all p<0.001). PsA was also an independent explanatory variable for three-vessel disease (OR: 10.798, p<0.001) and obstructive plaque (3.939, p=0.024). In patients with PsA, disease duration was the only disease-specific characteristic associated with more vulnerable plaques (MP/NCP) in multivariate analysis (1.063, p=0.031). The other independent explanatory variables were age ≥55 years (5.636, p=0.005) and male gender (8.197, p=0.001).

Conclusions: Patients with PsA have increased prevalence, burden and severity of coronary atherosclerosis as documented by CCTA. Longer disease duration was independently associated with the presence of vulnerable MP/NCP plaques in patients with PsA.

Trial Registration Number: NCT02232321.
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http://dx.doi.org/10.1136/annrheumdis-2016-210390DOI Listing
July 2017
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