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Background: Left ventricular mass (LVM) is an independent risk factor for cardiovascular outcome. We aimed to define normal reference values of LVM/body surface area (BSA) in a multiethnic Southeast Asian population across ages, and define demographic parameters that predict LVM/BSA. Methods: 198 subjects (44% men, mean age 40 ± 14 years, 82% Chinese, 13% Malay and 5% Indian) with no cardiovascular comorbidity and had normal echo images for age were included in the analysis. Echo LVM was calculated as: 1.04 ×[(left ventricular internal diameter at end-diastole {LVIDd}+ interventricular septal thickness at end-diastole {IVSd}+ left ventricular posterior wall thickness at end-diastole {LVPWd})3− LVIDd3× 0.8]+ 0.61, indexed by BSA (LVM/BSA)* and expressed as g/m2. Results: BSA and blood pressure (BP) were comparable between dichotomous age groups < or ≥ 50 years within the same gender. Women aged ≥ 50 years had larger IVSD, LVPWd, LVM and LVM/BSA compared to younger cohort. (p < 0.01 for all variables). The 95th percentile of LVM in men and women were 189 g and 148 g respectively; corresponding values for LVM/BSA were 106 and 96 g/m2. These values are consistently smaller than published values from the West. Age (r = 0.27, P < 0.001), gender (r =−0.30, P < 0.001), and systolic BP (r = 0.25, P = 0.003) were significant univariate predictors of LVM/BSA. Conclusion: We therefore propose a different cutoff value for the diagnosis of LV hypertrophy among Southeast Asians. [ABSTRACT FROM AUTHOR]

Tricuspid regurgitation (TR) is the most common valvular abnormality after orthotopic heart transplantation (OHT), with a reported incidence of up to 84%, depending on the definition of significant regurgitation and surgical methods of OHT employed. While multiple etiologies are implicated in the development of TR after OHT, endomyocardial biopsy (EMB), performed to detect allograft rejection, is the single most important contributor to significant TR by causing anatomic disruption of the tricuspid valvular structure. Although the clinical course of TR is heterogeneous, hemodynamically significant regurgitation generally leads to progressive right-heart dysfunction and symptoms. In cases refractory to diuretic-based medical therapy, surgical correction of TR has been shown to effectively alleviate the condition and provide symptomatic and organ function improvement. Tricuspid valve repair and replacement are viable surgical options, the application of which often depends on the institution’s experience and underlying valve pathology. A non-invasive surveillance technique to detect allograft rejection is on the horizon, and may reduce the number of EMBs performed as well as the procedure-related tissue damage that leads to TR. [Copyright &y& Elsevier]

Background: Stroke-work loss (SWL) represents the amount of energy the left ventricle dissipates as heat because of outflow obstruction. Recent studies suggest that SWL > 25% was the most clinically efficient Doppler measure for predicting hemodynamic significance, symptomatic status, and outcome in patients with aortic stenosis (AS). However, SWL may be affected by systolic blood pressure (SBP). Objective: To determine if SWL reliably predicts hemodynamic significance of AS in patients with hypertension. Methods: We studied 42 consecutive patients with hemodynamically significant AS requiring aortic valve replacement (AVR). Data on demographics, preoperative hemodynamics, and echocardiographic parameters were obtained. SWL was measured using the formula SWL = 100 × mean PG/ (mean PG + SBP), where PG is transaortic pressure gradient. Patients were considered hypertensive if their BP > 140/90 mmHg or if they are on antihypertensive medications. Results: There were 27 males (64%) and mean age was 68 ± 11 years. Twenty-four patients (57%) were hypertensive. Mean SBP was 134 ± 24 mmHg, mean transaortic PG 47 ± 20 mmHg, effective valve orifice area (EOA) by Doppler estimation 0.74 ± 0.23 cm2, and SWL 26 ± 9%. Patients with hypertension had smaller SWL than normotensives ( table I ). SWL was >25% in 20 (49%) patients, and fewer patients with hypertension have SWL >25% (33% vs 71%, P = 0.019). Of note, patients with SWL ≤25% had significantly higher SBP (145 ± 21 mmHg vs 122 ± 22 mmHg, P = 0.02). Conclusion: SWL underestimates the hemodynamic significance of aortic stenosis in the majority of patients with hypertension. [ABSTRACT FROM AUTHOR]

Abstract: Left atrial (LA) volume reflects left ventricular (LV) diastolic properties. The latter is an important determinant of exercise capacity in patients with normal LV systolic function. We hypothesized that LA volume predicts exercise capacity in patients with isolated LV diastolic dysfunction. Echocardiography and treadmill exercise testing were performed in 256 patients with normal LV systolic function (ejection fraction≥50%). Diastolic dysfunction was defined using standard Doppler criteria. LA volume was measured using the ellipsoid method and indexed to the body surface area. 119 patients had LV diastolic dysfunction. They had higher indexed maximum LA volume (LA Volmax, p =0.004) and lower exercise capacity (p <0.001). Univariate predictors of exercise capacity were age, mitral E / A, E wave deceleration time, ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E /Ea), and indexed LA Volmax. On multivariate analysis, only age, mitral E / A and indexed LA Volmax were independent predictors of exercise capacity. Notably, the combination of LV diastolic dysfunction and enlarged LA Volmax predicted worse exercise intolerance. In conclusion, indexed LA volume is an independent and reliable predictor of exercise capacity in patients with isolated LV diastolic dysfunction. [ABSTRACT FROM AUTHOR]

Abstract: Sildenafil, a selective inhibitor of cyclic guanosine monophosphate (cGMP) specific phosphodiesterase-5 inhibitor, has shown promising results as a novel oral monotherapy in the treatment of pulmonary arterial hypertension (PAH). We conducted a cross-sectional survey of 19 consecutive PAH patients, aged 16–75 years, with WHO functional class II or worse over 3 months of oral sildenafil. Improvement in exercise capacity was achieved in 15/19 (79%) patients. 6-minute walk test distance increased from 299±118 m to 360±127 m, p =0.016, and WHO functional class decreased significantly. Both PASP and CI showed a non-significant trend toward improvement. Patients also reported significant improvement in physical (p =0.002) and social (p <0.001) functioning, and general health (p =0.01) of Rand SF-36 questionnaire. There was improvement in domains of role limitation due to physical health (p =0.16), emotion (p =0.14), and energy level (p =0.4). Our study suggests that oral sildenafil monotherapy is effective in improving exercise capacity and health-related quality of life amongst PAH patients. [Copyright &y& Elsevier]

Introduction: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) mortality remains high despite revascularization and the use of the intra-aortic balloon pump (IABP). Advanced mechanical circulatory support (MCS) devices, such as catheter-based ventricular assist devices (cVAD), may impact mortality. We aim to identify predictors of mortality in AMI-CS implanted with IABP and the proportion eligible for advanced MCS in an Asian population. Methods: We retrospectively analyzed a cohort of Society for Cardiovascular Angiography and Intervention (SCAI) stage C and above AMI-CS patients with IABP implanted from 2017–2019. We excluded patients who had IABP implanted for indications other than AMI-CS. Primary outcome was 30-day mortality. Binary logistic regression was used to calculate adjusted odds ratios (aOR) for patient characteristics. Results: Over the 3-year period, 242 patients (mean age 64.1 ± 12.4 years, 88% males) with AMI-CS had IABP implanted. 30-day mortality was 55%. On univariate analysis, cardiac arrest (p < 0.001), inotrope/vasopressor use prior to IABP (p = 0.004) was more common in non-survivors. Non-survivors were less likely to be smokers (p = 0.001), had lower ejection fraction, higher creatinine/ lactate and lower pH (all p < 0.001). On multi-variate analysis, predictors of mortality were cardiac arrest prior to IABP (aOR 4.00, CI 2.28–7.03), inotrope/vasopressor prior to IABP (aOR 2.41, CI 1.18–4.96), lower arterial pH (aOR 0.02, CI 0.00–0.31), higher lactate (aOR 2.42, CI 1.00–1.19), and lower hemoglobin (aOR 0.83, CI 0.71–0.98). Using institutional MCS criteria, 106 patients (44%) would have qualified for advanced MCS. Conclusions: Early mortality in AMI-CS remains high despite IABP. Many patients would have qualified for higher degrees of MCS. [ABSTRACT FROM AUTHOR]

To combat the coronavirus disease 2019 (COVID‐19) pandemic, many countries have started population vaccination programs using messenger ribonucleic acid (mRNA) vaccines. With the widespread use of such vaccines, reports are emerging worldwide, of the vaccine's association with the development of myocarditis. Younger men are more likely to develop postvaccine myocarditis, which usually presents as self‐limiting chest pain within a week after the second dose. We present a case of myocarditis following vaccination with tozinameran (BNT162b2, Pfizer‐BioNTech), which presented late, with ventricular tachycardia (VT) reduced left ventricular ejection fraction (LVEF). [ABSTRACT FROM AUTHOR]

Cor triatriatum dexter ( CTD) is an extremely rare congenital condition arising from the persistence of the right valve of the sinus venosus. It divides the right atrium (RA) into 2 separate chambers. We report a case of a 50-year-old man who had an incidental finding of CTD on transesophageal echocardiogram. An incomplete membrane of the RA was seen, and three-dimensional echocardiogram delineated the structure clearly as a triangular sail-like structure with multiple orifices and a fenestration. [ABSTRACT FROM AUTHOR]

Purpose:Validation studies of the PAM-13 have found differences in scale performance, suggesting that health beliefs embedded in different cultures and/or self-management needs of different client groups influence how people respond to the items. The purpose of this study was to examine how adults with cardiac conditions in Singapore interpreted and responded to the PAM-13, to investigate possible reasons for differences in responses and to propose solutions to overcome them. Methods:We conducted retrospective cognitive interviews with 13 participants in an out-patient heart center. Interviews were transcribed and analyzed based on the framework approach to qualitative analysis. The four stages from Tourangeau’s cognitive model were used as a framework to index the data from each item. Results:There was variation in comprehension of questions leading to variation in responses. Comprehension issues were due to terms perceived by participants to be vague and the use of English terms uncommon in Singapore. Cultural influences impacted decision processes and problems with response processes of the self-rating Likert scale surfaced. Conclusions:This study reinforces the need to culturally adapt the tool, even when language translation is not necessary. Providing Likert scales with a larger number of may widen the relevance of PAM-13 in Singapore.Implications for rehabilitationNeed to culturally adapt assessment tool, even when language translation is not necessary.Consider using Likert scales with a larger number of categories when using in Asian countries such as Singapore.Caution must be taken when using PAM-13 levels to decide interventions for each individual. [ABSTRACT FROM AUTHOR]

Purpose: The Patient Activation Measure (PAM-13) measures patients' knowledge, skill, and confidence in chronic condition self-management. The purpose of this study was to assess the validity of PAM-13 (English version) among English-speaking adults with cardiac conditions in Singapore.Methods: A cross-sectional study was conducted in a convenient sample of 270 heart clinic patients. Using the unitary concept of validity, evidence of (1) internal structure via data quality, unidimensionality, differential item functioning, and internal consistency, (2) response process through item difficulty and item fit using Rasch modeling, and (3) relationship to other variables via correlations with depression and self-efficacy were examined.Results: The item response was high with only one missing answer. All items had a small floor effect, but nine out of 13 items had a ceiling effect larger than 15 %. Cronbach's α was 0.86, and average inter-item correlations was 0.324. Results suggested unidimensionality; however, differences in item difficulty ranking were found. A low, negative correlation was found with depression, while a moderate, positive correlation was found with self-efficacy.Conclusion: Evidence in all three areas of validity were mixed. Caution should be exercised when using categorical activation "level" to inform clinical decisions. [ABSTRACT FROM AUTHOR]

Aim: Growth differentiation factor 15 (GDF15) is a cytokine highly expressed in states of inflammatory stress. We aimed to study the clinical correlates and prognostic significance of plasma GDF15 in heart failure with preserved ejection fraction (HFpEF) vs. reduced ejection fraction(HFrEF), compared with N-terminal pro-brain natriuretic peptide (NT-proBNP), an indicator of haemodynamic wall stress.Methods: Plasma GDF15 and NT-proBNP were prospectively measured in 916 consecutive patients with HFrEF (EF <50%; n = 730) and HFpEF (EF ≥50%; n = 186), and measured again at 6 months in 488 patients. Patients were followed up for a composite outcome of death or first HF rehospitalization.Results: Median GDF15baseline values were similarly elevated in HFpEF [2862 (1812 represent the 25th percentile and 4176 represent the 75th percentile) ng/L] and HFrEF [2517 (1555, 4030) ng/L] (P = 0.184), whereas NT-proBNP was significantly lower in HFpEF than HFrEF (1119 ng/L vs. 2335 ng/L, P < 0.001). Independent correlates of GDF15baseline were age, systolic blood pressure, New York Heart Association (NYHA) class, diabetes, atrial fibrillation, sodium, haemoglobin, creatinine, diuretic therapy, high sensitivity troponin T (hsTnT) and NT-proBNP (all P < 0.05). During a median follow-up of 23 months, there were 379 events (307 HFrEF, 72 HFpEF). GDF15 remained a significant independent predictor for composite outcome even after adjusting for important clinical predictors including hsTnT and NT-proBNP (adjusted hazard ratio 1.76 per 1 Ln U, 95% confidence interval 1.39-2.21; P < 0.001), regardless of HF group (Pinteraction  = 0.275). GDF15baseline provided incremental prognostic value when added to clinical predictors, hsTnT and NT-proBNP (area under receiver operating characteristic curve increased from 0.720 to 0.740, P < 0.019), with a net reclassification improvement of 0.183 (P = 0.004). Patients with ≥20% GDF156months increase had higher risk for composite outcome (adjusted hazard ratio 1.68, 95% confidence interval 1.15-2.45; P = 0.007) compared with those with GDF156months within ± 20% of baseline.Conclusions: The similarly elevated levels and independent prognostic utility of GDF15 in HFrEF and HFpEF suggest that beyond haemodynamic stress (NT-proBNP), inflammatory injury (GDF15) may play an important role in both HF syndromes. [ABSTRACT FROM AUTHOR]

Background: Severe functional tricuspid regurgitation (TR) is associated with poor outcomes. We sought to examine the predictors of early mortality and if severe TR with heart failure (HF) is a stage too late for intervention. Methods: Our study retrospectively identified 635 consecutive patients who had severe functional TR diagnosed on trans-thoracic echocardiography in an academic medical centre from 2000- 2016. We assessed their underlying comorbidities and analyzed their impact on survival. Results: Mean follow-up was 1084 days. There were 371 (58.4%) females, and the mean age at diagnosis was 68.6 years. The mean Body Mass Index, left ventricular ejection fraction (LVEF) and pulmonary artery systolic pressure (PASP) were 23.8 kg/m2, 48.6% and 53.8 mmHg, respectively. Pre-existing or incident atrial fibrillation (AF) and ischemic heart disease were 420 (66.1%) and 312 (49.1%) respectively. A total of 307 (48.4%) patients had HF prior and 123 (19.4%) had incident HF. The mechanisms for severe TR were left heart disease ± pulmonary hypertension (72 %), AF with annular modeling (20.4 %), and isolated right ventricular dilatation (7.6 %). There were 286 (45.0%) deaths during follow up, with 154 (24.3%) dying within a year. The median survival was about 690 days. Multivariate analysis revealed that age at diagnosis (HR 1.03, p: 0.001), prior HF admission (HR: 1.31, p: 0.048), PASP of more than 50 mmHg (HR: 1.48, p: 0.004) and LVEF less than 50% (HR: 1.35, p: 0.041) were significantly associated with time to death. Conclusion: In patients with severe functional TR, advanced age, prior HF admission, LVEF <50%, PASP >50 mm Hg are malignant features, representing an advanced stage of the disease and associated with early mortality. Ability to interpret effectiveness of trans-catheter therapies in this group of patients may be limited, which future clinical intervention trials should take into account. [ABSTRACT FROM AUTHOR]