Publications by authors named "Lynette Teo"

56 Publications

Age- and Sex-Specific Changes in CMR Feature Tracking-Based Right Atrial and Ventricular Functional Parameters in Healthy Asians.

Front Cardiovasc Med 2021 4;8:664431. Epub 2021 Jun 4.

National Heart Centre Singapore, Singapore, Singapore.

Cardiovascular magnetic resonance (CMR) is the reference standard for non-invasive assessment of right-sided heart function. Recent advances in CMR post-processing facilitate quantification of tricuspid annular (TA) dynamics and longitudinal strains of the right ventricle (RV) and right atrium (RA). We aimed to determine age- and sex-specific changes in CMR-derived TA dynamics, and RV and RA functional parameters in healthy Asian adults. We studied 360 healthy subjects aged 21-79 years, with 30 men and 30 women in each of the six age groups. Functional parameters of RV and RA were measured on standard four-chamber cine CMR using fast feature tracking: (1) TA peak velocities (systolic velocity S', early diastolic velocity E', late diastolic velocity A') and TA plane systolic excursion (TAPSE); (2) RV global longitudinal strain (GLS) and strain rates; and (3) RA phasic longitudinal strains and strain rates. S' and TAPSE exhibited negative correlations with age. RV GLS was significantly higher in females than in males but not associated with age in both sexes. Females had similar E', lower A', and higher E'/A' ratios compared to males. Positive associations of E' and E'/A', and negative association of A' with age were observed in both sexes. Females had higher RA reservoir and conduit strains compared to males. There were significantly negative and positive associations between RA conduit and booster strains, respectively, with age. Age- and sex-specific reference ranges were established, and associations revealed, for fast CMR feature tracking parameters of right heart function in a large normal Asian population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fcvm.2021.664431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213369PMC
June 2021

Impact of age, sex and ethnicity on intra-cardiac flow components and left ventricular kinetic energy derived from 4D flow CMR.

Int J Cardiol 2021 08 25;336:105-112. Epub 2021 May 25.

National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore; Duke-NUS Medical School, National University of Singapore, 8 College Road, 169857, Singapore. Electronic address:

Background: Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) allows quantification of left ventricular (LV) blood flow. We aimed to 1) establish reference ranges for 4D flow CMR-derived LV relative flow components and kinetic energy parameters indexed to end-diastolic volume (KEi) among healthy Asian subjects, 2) assess effects of age and sex on these parameters, and 3) compare these parameters between Asian and Caucasian subjects.

Methods: 74 healthy Asian subjects underwent cine and 4D flow CMR. Relative flow components (direct flow, retained inflow, delayed ejection flow, residual volume) and multiple phasic KEi (LV global, peak systolic, systolic, diastolic, peak E-wave, peak A-wave) were analyzed. Sex- and age-specific reference ranges were reported.

Results: Relative flow components and systolic phase KEi did not vary with age. Women had higher retained inflow and peak E-wave KEi, lower residual volume, peak systolic and systolic KEi than men. Peak A-wave KEi increased significantly (r = 0.474) whereas peak E-wave KEi (r = -0.458) and E-wave/A-wave ratio (r = -0.528) decreased with age. A sub-population (n = 44) was compared with 44 sex- and age-matched Caucasian subjects: no significant group differences were observed for all 4D flow CMR parameters.

Conclusion: Asian sex- and age-specific 4D flow CMR reference ranges were established. Sex differences in retained inflow, residual volume, peak systolic, systolic KEi and peak E-wave KEi were observed. Ageing influenced diastolic KEi but not systolic phase KEi or relative flow components. All studied parameters were similar between sex- and age-matched Asian and Caucasian subjects, implying generalizability of the ranges.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2021.05.035DOI Listing
August 2021

Lung Cancer in Singapore.

J Thorac Oncol 2021 06;16(6):906-911

Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtho.2020.11.020DOI Listing
June 2021

Rescue extracorporeal membrane oxygenation for massive anterior mediastinal masses.

J Artif Organs 2021 Apr 3. Epub 2021 Apr 3.

Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre Singapore, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore.

The management of massive anterior mediastinal masses (AMM) is challenging. With the burgeoning role of extracorporeal membrane oxygenation support (ECMO) beyond the confines of salvage therapy, more trained clinicians are adopting it as a bridge for high-risk procedures or situations where temporary respiratory or cardiac support is required. We report our experience with using ECMO in the management of massive AMM in this case series of three patients sharing their clinical details and the lessons learned from them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10047-021-01264-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019298PMC
April 2021

Cardiovascular magnetic resonance-assessed fast global longitudinal strain parameters add diagnostic and prognostic insights in right ventricular volume and pressure loading disease conditions.

J Cardiovasc Magn Reson 2021 04 1;23(1):38. Epub 2021 Apr 1.

National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore, Singapore.

Background: Parameters of myocardial deformation may provide improved insights into right ventricular (RV) dysfunction. We quantified RV longitudinal myocardial function using a fast, semi-automated method and investigated its diagnostic and prognostic values in patients with repaired tetralogy of Fallot (rTOF) and pulmonary arterial hypertension (PAH), who respectively exemplify patients with RV volume and pressure overload conditions.

Methods: The study enrolled 150 patients (rTOF, n = 75; PAH, n = 75) and 75 healthy controls. RV parameters of interest were fast global longitudinal strain (GLS) and strain rates during systole (GLSR), early diastole (GLSR) and late diastole (GLSR), obtained by tracking the distance from the medial and lateral tricuspid valve insertions to the RV epicardial apex on cine cardiovascular magnetic resonance (CMR).

Results: The RV fast GLS exhibited good agreement with strain values obtained by conventional feature tracking approach (bias - 4.9%, error limits (± 2·standard deviation) ± 4.3%) with fast GLS achieving greater reproducibility and requiring reduced analysis time. Mean RV fast GLS was reduced in PAH and rTOF groups compared to healthy controls (PAH < rTOF < healthy controls: 15.1 ± 4.9 < 19.3 ± 2.4 < 24.4 ± 3.0%, all P < 0.001 in pairwise comparisons). In rTOF patients, RV fast GLS was significantly associated with metabolic equivalents, peak oxygen consumption (PVO) and percentage of predicted PVO achieved during cardiopulmonary exercise testing. Lower RV fast GLS was associated with subnormal exercise capacity in rTOF (area under the curve (AUC) = 0.822, sensitivity = 72%, specificity = 91%, cut-off = 19.3%). In PAH patients, reduced RV fast GLS was associated with RV decompensated hemodynamics (AUC = 0.717, sensitivity = 75%, specificity = 58%, cut-off = 14.6%) and higher risk of clinical worsening (AUC = 0.808, sensitivity = 79%, specificity = 70 %, cut-off = 16.0%).

Conclusions: Quantitative RV fast strain and strain rate parameters assessed from CMR identify abnormalities of RV function in rTOF and PAH and are predictive of exercise capacity, RV decompensation and clinical risks in these patients. Trial registry Clinicaltrials.gov: NCT03217240.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12968-021-00724-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015087PMC
April 2021

Three coronary arteries arising from one coronary cusp.

Cardiol J 2020 ;27(5):644-645

National University Heart Centre, 1E Kent Ridge Road, 119228 Singapore, Singapore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5603/CJ.2020.0156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078969PMC
August 2021

Treatment to reduce vascular calcification in hemodialysis patients using vitamin K (Trevasc-HDK): A study protocol for a randomized controlled trial.

Medicine (Baltimore) 2020 Sep;99(36):e21906

Division of Nephrology, National University Hospital Singapore.

Introduction: End stage renal failure patients on hemodialysis have significant vascular calcification This is postulated to be related to sub-clinical vitamin K deficiency, which is prevalent in hemodialysis patients. Vitamin K deficiency result in the failure of the matrix GLA protein (MGP) to undergo carboxylation. MGP is a natural local inhibitor of vascular calcification and the lack of functional carboxylated MGP may contribute to increase vascular calcification. Vitamin K supplement should therefore correct this anomaly and decrease the rate or severity of vascular calcification in this population of patients on long-term maintenance hemodialysis. Our study seeks to evaluate the prevalence and the progression of vascular calcification in a cohort of maintenance hemodialysis patients. It will also evaluate the efficacy of vitamin K supplementation in reducing the progression of vascular calcification in this group of patients.

Methods: This will be a single-center randomized, prospective and open-label interventional clinical trial of end stage renal failure patients on hemodialysis. We aim to recruit 200 patients. Eligible patients will be randomized to either the standard care arm or active treatment arm. Active treatment arm patients will receive standard care plus supplementation with oral vitamin K2 isoform 360 mcg 3 times weekly for a total duration of 18 months. Primary outcome measured will be absolute difference in coronary artery calcification score at 18-month between control and intervention arms. Secondary outcomes will be to compare absolute difference in aortic valve calcification, percentage of patients with regression of coronary artery calcification of at least 10%, absolute difference in aortic and systemic arterial stiffness, mortality from any cause and major adverse cardiovascular over the same period.

Discussion: Evidence of successful regression or retardation of vascular calcification will support the conduct of larger and longer-term trials aimed at reducing cardiovascular disease mortality and major adverse cardiovascular events in this high-risk population using a safe and inexpensive strategy TRIAL REGISTRATION:: ClinicalTrials.gov NCT02870829. Registered on 17 August 2016 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02870829National University Hospital's Institutional Review Board (2015/01000).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MD.0000000000021906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478798PMC
September 2020

Quantification of effects of mean blood pressure and left ventricular mass on noninvasive fast fractional flow reserve.

Am J Physiol Heart Circ Physiol 2020 08 17;319(2):H360-H369. Epub 2020 Jul 17.

National Heart Centre Singapore, Singapore.

Proper inlet boundary conditions are essential for accurate computational fluid dynamics (CFD) modeling. We developed methodology to derive noninvasive FFR using CFD and computed tomography coronary angiography (CTCA) images. This study aims to assess the influence of brachial mean blood pressure (MBP) and total coronary inflow on FFR computation. Twenty-two patients underwent both CTCA and FFR measurements. Total coronary flow was computed from left ventricular mass (LVM) measured from CTCA. A total of 286 CFD simulations were run by varying MBP and LVM at 70, 80, 90, 100, 110, 120, and 130% of the measured values. FFR increased with incrementally higher input values of MBP: 0.78 ± 0.12, 0.80 ± 0.11, 0.82 ± 0.10, 0.84 ± 0.09, 0.85 ± 0.08, 0.86 ± 0.08, and 0.87 ± 0.07, respectively. Conversely, FFR decreased with incrementally higher inputs value of LVM: 0.86 ± 0.08, 0.85 ± 0.08, 0.84 ± 0.09, 0.84 ± 0.09, 0.83 ± 0.10, 0.83 ± 0.10, and 0.82 ± 0.10, respectively. Noninvasive FFR calculated using measured MBP and LVM on a total of 30 vessels was 0.84 ± 0.09 and correlated well with invasive FFR (0.83 ± 0.09) ( = 0.92, < 0.001). Positive association was observed between FFR and MBP input values (mmHg) and negative association between FFR and LVM values (g). Respective slopes were 0.0016 and -0.005, respectively, suggesting potential application of FFR in a clinical setting. Inaccurate MBP and LVM inputs differing from patient-specific values could result in misclassification of borderline ischemic lesions. While brachial mean blood pressure (MBP) and left ventricular mass (LVM) measured from CTCA are the two CFD simulation input parameters, their effects on noninvasive fractional flow reserve (FFR) have not been systematically investigated. We demonstrate that inaccurate MBP and LVM inputs differing from patient-specific values could result in misclassification of borderline ischemic lesions. This is important in the clinical application of noninvasive FFR in coronary artery disease diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1152/ajpheart.00135.2020DOI Listing
August 2020

Computed tomography coronary angiography - past, present and future.

Singapore Med J 2020 Mar;61(3):109-115

Department of Diagnostic Imaging, National University Hospital, Singapore.

Computed tomography coronary angiography (CTCA) is a robust and reliable non-invasive alternative imaging modality to invasive coronary angiography, which is the reference standard in evaluating the degree of coronary artery stenosis. CTCA has high negative predictive value and can confidently exclude significant coronary artery disease (CAD) in low to intermediate risk patients. Over the years, substantial effort has been made to reduce the radiation dose and increase the cost efficiency of CTCA. In this review, we present the evolution of computed tomography scanners in the context of coronary artery imaging as well as its clinical applications and limitations. We also highlight the future directions of CTCA as a one-stop non-invasive imaging modality for anatomic and functional assessment of CAD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.11622/smedj.2020028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905109PMC
March 2020

Single Coronary Artery in a Young Male with Chest Pain.

JACC Case Rep 2020 May 20;2(5):721-722. Epub 2020 May 20.

National University Heart Centre, Singapore National University Health System, Singapore.

A young male presented to the hospital with chest pain. A coronary angiogram and a subsequent computed tomography coronary angiogram revealed a single coronary artery arising from the right coronary sinus which bifurcated into the right coronary artery and a large branch which supplies the left coronary artery territory. ().
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccas.2020.03.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302055PMC
May 2020

Treatment Guidance for Patients With Lung Cancer During the Coronavirus 2019 Pandemic.

J Thorac Oncol 2020 07 15;15(7):1119-1136. Epub 2020 May 15.

Department of Medicine, Penn State Cancer Institute, Hershey, Pennsylvania. Electronic address:

The global coronavirus disease 2019 pandemic continues to escalate at a rapid pace inundating medical facilities and creating substantial challenges globally. The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with cancer seems to be higher, especially as they are more likely to present with an immunocompromised condition, either from cancer itself or from the treatments they receive. A major consideration in the delivery of cancer care during the pandemic is to balance the risk of patient exposure and infection with the need to provide effective cancer treatment. Many aspects of the SARS-CoV-2 infection currently remain poorly characterized and even less is known about the course of infection in the context of a patient with cancer. As SARS-CoV-2 is highly contagious, the risk of infection directly affects the cancer patient being treated, other cancer patients in close proximity, and health care providers. Infection at any level for patients or providers can cause considerable disruption to even the most effective treatment plans. Lung cancer patients, especially those with reduced lung function and cardiopulmonary comorbidities are more likely to have increased risk and mortality from coronavirus disease 2019 as one of its common manifestations is as an acute respiratory illness. The purpose of this manuscript is to present a practical multidisciplinary and international overview to assist in treatment for lung cancer patients during this pandemic, with the caveat that evidence is lacking in many areas. It is expected that firmer recommendations can be developed as more evidence becomes available.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtho.2020.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227539PMC
July 2020

Asymptomatic phaeochromocytoma in a patient with Holt-Oram syndrome: a case report.

Eur Heart J Case Rep 2019 Dec 9;3(4):1-5. Epub 2019 Nov 9.

National University Health System, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.

Background: Holt-Oram syndrome (HOS) is a rare congenital disease that affects the heart and upper limbs. Phaeochromocytoma, a catecholamine-secreting tumour, is a rare neuroendocrine disorder. We present an interesting case presentation of these two rare disorders in a patient who was asymptomatic for phaeochromocytoma.

Case Summary: A 28-year-old woman who was diagnosed at birth with HOS, presented to the hospital with heart failure. She has a past medical history of corrected cyanotic congenital heart disease. She presented with dyspnoea but she did not have headaches, tremors, or diaphoresis. Cardiac magnetic resonance scan was done to investigate the cause of her heart failure and revealed right ventricular systolic dysfunction and a suspicious adrenal lesion. Magnetic resonance imaging adrenal confirmed the presence of the adrenal lesion and concerns were raised for a possible phaeochromocytoma. Biochemical tests showed raised plasma free metanephrine levels. Gallium-68 DOTA positron emission tomography scan showed intense right adrenal gland uptake in keeping with diagnosis of phaeochromocytoma.

Discussion: Phaeochromocytoma appears to be more prevalent in patients who are in a chronic hypoxic state. This hypoxic state has been postulated to cause the proliferation of adrenal tissue and therefore the formation of phaeochromocytomas. The hypoxia-inducing factor, which is increased in patients with phaeochromocytoma, has been identified as one of the key factors driving this process as it modulates genes that regulate angiogenesis and proliferation. Congenital heart defects seen in HOS can progress to cyanotic heart disease if left uncorrected and may have been the driver for the development of phaeochromocytoma in our patient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ehjcr/ytz206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026609PMC
December 2019

Elevated Right Atrial Pressure Associated with Alteration of Left Ventricular Contractility and Ventricular-Arterial Coupling in Pulmonary Artery Hypertension.

Annu Int Conf IEEE Eng Med Biol Soc 2019 Jul;2019:820-823

Pulmonary artery hypertension (PAH) is a progressive disorder which leads to heart failure and death. Development of dilated right ventricle (RV), progressive RV dysfunction and increased right atrial (RA) pressure make the RV transition from a compensated to a decompensated phase and eventually leads to heart failure. However, the relationship between elevated RA pressure and left ventricular contractility and ventricular arterial coupling (VAC) has not been well studied. 36 patients were recruited and underwent both right heart catheterization (RHC) and cardiac magnetic resonance (CMR). Left ventricular (LV) pressure-volume loops were reconstructed from RHC and CMR. LV contractility was assessed by end-systolic elastance (E) using single-beat method and arterial elastance (E) was estimated as the ratio of end-systolic pressure and stroke volume (SV). The VAC was calculated as the ratio of E and E (i.e. E/E). The results demonstrated a nonlinear relationship between RA pressure and E, RA pressure and VAC. E increased when RA pressure increased to 7 mmHg and then decreased when RA pressure exceeded 7 mmHg. E were 2.79 ± 1.61 mmHg/ml, 4.27 ±1 33 mmHg/ml, 2.69 ± 0.89 mmHg/ml and 2.36± 1.10 mmHg/ml at ascending quartiles of RA pressure, respectively (quartile 1: RAP≤5 mmHg; quartile 2: 5<; RAP≤7 mmHg; quartile 3: 7<; RAP 10 mmHg and quartile 4: RAP>10 mmHg). Similarly, VAC were 1.36 ± 0.61, 1.93±0.86, 1.16 ± 0.55 and 0.95± 0.27 the four quartiles (both ANOVA P <; 0.05). We found that there was a nonlinear relationship between RA pressure and LV contractility, and between RA pressure and ventricular-arterial coupling. A cut-off value of 7 mmHg of RAP may indicate a decompensated LV hemodynamics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1109/EMBC.2019.8856814DOI Listing
July 2019

Magnetic resonance imaging of dilated cardiomyopathy: prognostic benefit of identifying late gadolinium enhancement in Asian patients.

Singapore Med J 2021 Jul 10;62(7):347-352. Epub 2019 Dec 10.

Department of Cardiology, National University Heart Centre Singapore, Singapore.

Introduction: Risk stratification in dilated cardiomyopathy (DCM) is imprecise, relying largely on echocardiographic left ventricular ejection fraction (LVEF) and severity of heart failure symptoms. Adverse cardiovascular events are increased by the presence of myocardial scarring. Late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is the gold standard for identifying myocardial scars. We examined the association between LGE on CMR imaging and adverse clinical outcomes during long-term follow-up of Asian patients with DCM.

Methods: Consecutive patients with DCM undergoing CMR imaging at a single Asian academic medical centre between 2005 and 2015 were recruited. Clinical outcomes were tracked using comprehensive electronic medical records and mortality was determined by cross-linkages with national registries. Presence and distribution of LGE on CMR imaging were determined by investigators blinded to patient outcomes. Primary endpoint was a composite of heart failure hospitalisations, appropriate implantable cardioverter-defibrillator shocks and cardiovascular mortality.

Results: Of 86 patients, 64.0% had LGE (80.2% male; mean LVEF 30.1% ± 12.7%). Mid-wall fibrosis (71.7%) was the most common pattern of LGE distribution. Over a mean follow-up period of 4.9 ± 3.2 years, 19 (34.5%) patients with LGE reached the composite endpoint compared to 4 (12.9%) patients without LGE (p = 0.01). Presence of LGE, but not echocardiographic LVEF, independently predicted the primary endpoint (hazard ratio 4.15 [95% confidence interval 1.28-13.50]; p = 0.02).

Conclusion: LGE presence independently predicted adverse clinical events in Asian patients with DCM. Routine use of CMR imaging to characterise the myocardial substrate is recommended for enhanced risk stratification and should strongly influence clinical management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.11622/smedj.2019166DOI Listing
July 2021

A practical and adaptive approach to lung cancer screening: a review of international evidence and position on CT lung cancer screening in the Singaporean population by the College of Radiologists Singapore.

Singapore Med J 2019 Nov;60(11):554-559

Department of Diagnostic Radiology, Changi General Hospital, Singapore.

Lung cancer is the leading cause of cancer-related death around the world, being the top cause of cancer-related deaths among men and the second most common cause of cancer-related deaths among women in Singapore. Currently, no screening programme for lung cancer exists in Singapore. Since there is mounting evidence indicating a different epidemiology of lung cancer in Asian countries, including Singapore, compared to the rest of the world, a unique and adaptive approach must be taken for a screening programme to be successful at reducing mortality while maintaining cost-effectiveness and a favourable risk-benefit ratio. This review article promotes the use of low-dose computed tomography of the chest and explores the radiological challenges and future directions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.11622/smedj.2019145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6875803PMC
November 2019

Takotsubo and Takayasu-A Reason to Rhyme?

Arthritis Rheumatol 2019 10 19;71(10):1726. Epub 2019 Aug 19.

National University Health System, Singapore, Singapore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/art.41033DOI Listing
October 2019

Assessing the Impact of a Pulmonary Embolism Response Team and Treatment Protocol on Patients Presenting With Acute Pulmonary Embolism.

Heart Lung Circ 2020 Mar 12;29(3):345-353. Epub 2019 Mar 12.

Department of Cardiology, National University Heart Centre, Singapore. Electronic address:

Background: Pulmonary embolism (PE) care has traditionally been fragmented. The newly introduced Pulmonary Embolism Response Team (PERT) model provides streamlined care based on expedient, multi-disciplinary decision-making. This study aimed to quantify the impact of PERT, as part of a hospital-wide PE treatment protocol, on clinical outcomes.

Methods: Consecutive adult patients with acute PE diagnosed via computed tomography pulmonary angiogram (CTPA) were included. The PERT and treatment protocol were introduced in January 2015. Patient characteristics, therapies, quality measures of CTPA reporting, and clinical outcomes of PE patients treated for 2 years before and after implementation of these changes were evaluated. Primary endpoints were median length of stay in intensive care (ICU) and survival to discharge.

Results: A total of 321 consecutive PE patients were enrolled, of which 154 (treated in 2013-2014) and 167 (2015-2016) patients formed the historical control and study groups, respectively. Implementation of the algorithm was associated with less variance in anticoagulation and improved reporting of right heart strain parameters on CTPA. The ICU stay was reduced from a median of 5 to 2 days (p < 0.01). Eligible massive PE patients receiving reperfusion increased from 30% to 92% (p = 0.01), with mean delay from diagnosis to reperfusion decreasing from 763 to 181 minutes (p < 0.01). Bleeding complications were not increased, but overall survival to discharge remained unchanged.

Conclusions: Introducing a PERT and treatment protocol reduced ICU stay, enhanced quality measures, and improved access of massive PE patients to reperfusion therapies, without increasing bleeding complications or health care costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hlc.2019.02.190DOI Listing
March 2020

Platelet inhibition to target reperfusion injury trial: Rationale and study design.

Clin Cardiol 2019 Jan 17;42(1):5-12. Epub 2018 Dec 17.

The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, UK.

Background: In ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI), current oral P2Y12 platelet inhibitors do not provide maximal platelet inhibition at the time of reperfusion. Furthermore, administration of cangrelor prior to reperfusion has been shown in pre-clinical studies to reduce myocardial infarct (MI) size. Therefore, we hypothesize that cangrelor administered prior to reperfusion in STEMI patients will reduce the incidence of microvascular obstruction (MVO) and limit MI size in STEMI patients treated with PPCI.

Methods: The platelet inhibition to target reperfusion injury (PITRI) trial, is a phase 2A, multi-center, double-blinded, randomized controlled trial, in which 210 STEMI patients will be randomized to receive either an intravenous (IV) bolus of cangrelor (30 μg/kg) followed by a 120-minute infusion (4 μg/kg/min) or matching saline placebo, initiated prior to reperfusion (NCT03102723).

Results: The study started in October 2017 and the anticipated end date would be July 2020. The primary end-point will be MI size quantified by cardiovascular magnetic resonance (CMR) on day 3 post-PPCI. Secondary endpoints will include markers of reperfusion, incidence of MVO, MI size, and adverse left ventricular remodeling at 6 months, and major adverse cardiac and cerebrovascular events.

Summary: The aim of the PITRI trial is to assess whether cangrelor administered prior to reperfusion would reduce acute MI size and MVO, as assessed by CMR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/clc.23110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436500PMC
January 2019

A 67-Year-Old Man With Psoriatic Arthritis and New-Onset Dyspnea.

Chest 2018 11;154(5):e127-e134

Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore; University Medicine Cluster, Division of Respiratory and Critical Care Medicine, National University Hospital, National University Health System, Singapore. Electronic address:

A 67-year-old retired air force officer presented with a 6-month history of nonproductive cough, progressive exertional dyspnea, and weight loss. He was unable to walk beyond 100 m compared with his baseline of unlimited walking distance. He denied fever, hemoptysis, myalgia, or chest pain. He had a 30-year history of chronic plaque psoriasis with arthritis, which was managed by his dermatologist with emollients and vitamin D analogues. Joint involvement had previously been controlled with methotrexate, which was discontinued 15 years ago after resolution of his symptoms. He developed a polyarthritis flare a year ago, and adalimumab was initiated with good response.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.chest.2018.07.026DOI Listing
November 2018

A New Model for Risk Stratification of Patients With Acute Pulmonary Embolism.

Clin Appl Thromb Hemost 2018 Dec 28;24(9_suppl):277S-284S. Epub 2018 Oct 28.

Department of Haematology-Oncology, National University Cancer Institute, Singapore.

Pulmonary embolism (PE) is associated with mortality. There are many clinical prediction tools to predict early mortality in acute PE but little consensus on which is best. Our study aims to validate existing prediction tools and derive a predictive model that can be applied to all patients with acute PE in both inpatient and outpatient settings. This is a retrospective cohort study of patients with acute PE. For each patient, the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), European Society of Cardiology (ESC), and Angriman scores were calculated. Scores were assessed by the area under the receive-operating curve (AUC) for 30-day, all-cause mortality. To develop a new prognostic model, elastic logistic regression was used on the derivation cohort to estimate β-coefficients of 8 different variables; these were normalized to weigh them. A total of 321 patients (mean age 60±17 years) were included. Overall 30-day mortality was 10.3%. None of the scores performed well; the AUCs for the PESI, sPESI, ESC, and Angriman scores were 0.67 (95% confidence interval [CI], 0.57-0.77), 0.58 (0.48-0.69), 0.65 (0.55-0.75), and 0.67 (0.57-0.76), respectively. Our new prediction model outperformed PESI, with an AUC of 0.82 (95% CI, 0.76-0.88). At a cutoff score of 100, 195 (60.1%) patients were classified as low risk. Thirty-day mortality was 2.1% (95% CI, 0.8%-5.2%) and 23.0% (16.5%-31.1%) for low- and high-risk groups, respectively ( < .001). In conclusion, we have developed a new model that outperforms existing prediction tools in all comers with PE. However, further validation on external cohorts is required before application.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1076029618808922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714854PMC
December 2018

Takotsubo hypertrophic obstructive cardiomyopathy and bicuspid valvulopathy: implication of multiple imaging modalities.

Eur Heart J 2019 07;40(26):2172

Department of Cardiology, National University Heart Centre, National University Health System, 5 Lower Kent Ridge Rd, Singapore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/eurheartj/ehy673DOI Listing
July 2019

An Unexpected Cause of Trauma-related Myocardial Infarction: Multimodality Assessment of Right Coronary Artery Dissection.

Ann Acad Med Singap 2018 07;47(7):269-271

Department of Diagnostic Imaging, National University Hospital, Singapore.

View Article and Find Full Text PDF

Download full-text PDF

Source
July 2018

Non ST-Elevation Myocardial Infarction in a Patient with Supravalvular Aortic Stenosis. Role of Multi-Modality Imaging.

Ann Acad Med Singap 2017 07;46(7):298-300

Department of Cardiology, National University Heart Centre Singapore, Singapore.

View Article and Find Full Text PDF

Download full-text PDF

Source
July 2017

Prospective comparison between magnetic resonance imaging and computed tomography in colorectal cancer staging.

ANZ J Surg 2018 Jun 13;88(6):E498-E502. Epub 2017 Aug 13.

Department of Diagnostic Imaging, National University Hospital, National University Health System, Singapore.

Background: Diffusion-weighted (DW) imaging is a functional magnetic resonance imaging (MRI) technique that detects lesions with high cellularity, such as malignant tumours. This prospective study was performed to compare the accuracy of DW-MRI with multidetector computed tomography (MDCT) in staging of colorectal cancer.

Methods: Thirty patients with histologically proven colorectal cancer were prospectively recruited. Each patient underwent both MDCT and DW-MRI of the abdomen-pelvis for primary staging. Images were evaluated for nodal and distant metastases. The reference standard was histopathological findings for nodal involvement and surveillance imaging for suspected hepatic metastases.

Results: The primary cancers were located in the rectum (n = 16, 53.3%), sigmoid colon (n = 9, 30%) and right colon (n = 5, 16.6%). For nodal metastases, the sensitivity and specificity of DW-MRI were 84.6% (95% confidence interval (CI): 54.6-98.1%) and 20.0% (95% CI: 2.5-55.6%) compared with 84.6% (95% CI: 54.6-98.1%) and 40.0% (95% CI: 12.2-73.8%) for MDCT. For liver metastases, the sensitivity and specificity for DW-MRI were 100.0% (95% CI: 63.1-100.0%) and 100% (95% CI: 84.6-100%) compared with 87.5% (95% CI: 47.4-99.7%) and 95.5% (95% CI: 77.2-99.9%) for MDCT. DW imaging altered the clinical management in three (10.0%) patients by detecting missed hepatic metastases in two patients and accurately diagnosing another patient with a hepatic cyst, mistaken for metastasis on MDCT.

Conclusion: DW-MRI is more accurate for detecting hepatic metastases in colorectal cancer compared with MDCT.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.14138DOI Listing
June 2018

Aortic coarctation progresses to become interrupted aortic arch.

Eur Heart J Cardiovasc Imaging 2017 Sep;18(9):1072

Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, NUHS Tower Block, Level 9, 119228 Singapore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ehjci/jex096DOI Listing
September 2017

Successful Stem Cell Transplantation in a Patient with Pretransplant Hepatic Inflammatory Pseudotumour.

Case Rep Transplant 2016 28;2016:6801916. Epub 2016 Nov 28.

Departments of Laboratory Medicine and Haematology-Oncology, National University Cancer Institute, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore 119228.

Inflammatory pseudotumours (IPT) are rare benign neoplasms of unknown aetiology. We present a case of hepatic IPT which was incidentally discovered in a patient with relapsed B-acute lymphoblastic leukaemia (B-ALL) undergoing pretransplant workup. After investigation to exclude an infective cause she underwent a reduced intensity conditioning stem cell transplant (SCT) successfully and currently remains well and in remission. On repeat liver MRI after SCT, the IPT was seen to be resolving. To the best of our knowledge this is the first report of an adult patient with hepatic IPT successfully undergoing SCT. The reduction in size of the IPT after SCT also suggests an inflammatory rather than an infective aetiology for IPT.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2016/6801916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5149620PMC
November 2016

Magnetic Resonance Elastography and Diffusion Weighted Imaging in the Evaluation of Hepatic Fibrosis in Chronic Hepatitis B.

Gut Liver 2017 May;11(3):401-408

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

Background/aims: Comparison of the accuracy of magnetic resonance elastography (MRE) and diffusion weighted imaging (DWI) for the diagnosis of liver fibrosis in patients with chronic hepatitis B (CHB).

Methods: In this retrospective analysis, we investigated 63 patients with CHB and liver fibrosis. DWI was performed with both breath-hold (DWI-BH) and free-breathing (DWI-FB) sequences (b=0, 500). The mean liver stiffness and apparent diffusion coefficient (ADC) were calculated by drawing regions of interest maps. Fibrosis staging according to the METAVIR system was independently performed by an experienced pathologist. A receiver operating curve (ROC) analysis was conducted to determine the accuracy of MRE, DWI-BH and DWI-FB in the detection and stratification of liver fibrosis. The performance of the detection of significant fibrosis (≥F2), advanced fibrosis (≥F3), and cirrhosis (F4) was also evaluated by comparing areas under the ROC.

Results: There was a moderate and significantly negative correlation between the ADC values and liver stiffness. The accuracies for the detection of ≥F2/≥F3/F4 stage fibrosis with DWI-FB, DWI-BH and MRE were 0.84/0.76/0.72, 0.72/0.83/0.79 and 0.99/0.99/0.98, respectively. The performance of MRE was significantly better than DWI-FB and DWI-BH. There were no significant differences between the performance of DWI-FB and DWI-BH.

Conclusions: MRE is more accurate than DWI for the detection and stratification of liver fibrosis in CHB.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5009/gnl16079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5417783PMC
May 2017
-->