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Fulltext A ten-year review of ruptured sinus of valsalva: clinico-pathological and echo-Doppler features

Shah RP, Ding ZP, Ng AS, Quek SS

Singapore Med J, 2001 Oct;42(10):473-6.
PMID: 11874151

Rupture of the sinus of valsalva (RSOV) is an uncommon condition with a variety of manifestations ranging from an asymptomatic murmur to cardiogenic shock. This retrospective 10-year review (1985-1995) of 18 patients from a single institution revealed that 6 (33%) were female and 12 (67%) were male with a mean age of 37.6 +/- 13.4 years and that 72% were Chinese by ethnic descent with the remaining 28% being Malay. Eight patients (44.4%) presented with an asymptomatic murmur, 4 (22.2%) with acute chest pain, 4 (22.2%) with mild heart failure, 2 (11.1%) with severe heart failure, and 2 (11.1%) with cardiogenic shock. Rupture of the right aneurysmal coronary cusp (RCC) made up 15 (83.3%) while those of the non-coronary cusp (NCC) made up the remaining. Most of the RCC ruptures were directed into the right ventricle and all of the NCC ruptures were into the right atrium. Ventricular septal defects (VSDs) were found in 9 (50%) of the patients, (although detected by echocardiography in only one third of those patients), aortic regurgitation in 6 (33.3%) and aortic valve vegetations in 2 (11.1%). Echocardiography was found to be accurate in diagnosing RSOVs with 100% diagnostic accuracy after 1990 with four misdiagnoses before 1990. Of these four patients, two were misdiagnosed as having VSDs, one as having a coronary arteriovenous fistula and one as having a patent ductus arteriosus. The anatomical structure of the "windsock" was seen in 64% of the patients who were correctly diagnosed. The pattern of colour flow and spectral Doppler was seen in all patients and helped to localise the site of rupture and the direction of flow. In summary, echocardiography is a simple and accurate way of diagnosing and defining RSOVs and is the imaging modality of choice.
Fulltext Ethnic variations in female vulnerability after an acute coronary event

Mak KH, Kark JD, Chia KS, Sim LL, Foong BH, Ding ZP, et al.

Heart, 2004 Jun;90(6):621-6.
PMID: 15145860

OBJECTIVE: To determine the ethnic variation of short and long term female vulnerability after an acute coronary event in a population of Chinese, Indians, and Malays.
DESIGN: Population based registry.
PATIENTS: Residents of Singapore between the ages of 20-64 years with coronary events. Case identification and classification procedures were modified from the MONICA (monitoring trends and determinants in cardiovascular disease) project.
MAIN OUTCOME MEASURES: Adjusted 28 day case fatality and long term mortality.
RESULTS: From 1991 to 1999, there were 16 320 acute coronary events, including 3497 women. Age adjusted 28 day case fatality was greater in women (51.5% v 38.6%, p < 0.001), with a larger sex difference evident among younger Malay patients. This inequality between the sexes was observed in both the pre-hospitalisation and post-admission periods. Among hospitalised patients, women were older, were less likely to have suffered from a previous Q wave or anterior wall myocardial infarction, and had lower peak creatine kinase concentrations. Case fatality was higher among women, with adjusted hazard ratios of 1.64 (95% confidence interval (CI) 1.43 to 1.88) and 1.50 (95% CI 1.37 to 1.64) for 28 day and mean four year follow up periods. There were significant interactions of sex and age with ethnic group (p = 0.017). The adjusted hazards for mortality among Chinese, Indian, and Malay women versus men were 1.30, 1.71, and 1.96, respectively. The excess mortality among women diminished with age.
CONCLUSION: In this multiethnic population, both pre-hospitalisation and post-admission case fatality rates were substantially higher among women. The sex discrepancy in long term mortality was greatest among Malays and in the younger age groups.
The MitraClip Asia-Pacific registry: Differences in outcomes between functional and degenerative mitral regurgitation

Tay E, Muda N, Yap J, Muller DW, Santoso T, Walters DL, et al.

Catheter Cardiovasc Interv, 2016 Jun;87(7):E275-81.
PMID: 26508564 DOI: 10.1002/ccd.26289

OBJECTIVES: The objective of this study is to describe and compare the use of the MitraClip therapy in mitral regurgitation (MR) patients with degenerative MR (DMR) and functional MR (FMR).
INTRODUCTION: Percutaneous edge-to-edge repair of severe MR using the MitraClip device is approved for use in the USA for high risk DMR while European guidelines include its use in FMR patients as well.
METHODS: The MitraClip in the Asia-Pacific Registry (MARS) is a multicenter retrospective registry, involving eight sites in five Asia-Pacific countries. Clinical and echocardiographic characteristics, procedural outcomes and 1-month outcomes [death and major adverse events (MAE)] were compared between FMR and DMR patients treated with the MitraClip.
RESULTS: A total of 163 patients were included from 2011 to 2014. The acute procedural success rates for FMR (95.5%, n = 84) and DMR (92%, n = 69) were similar (P = 0.515). 45% of FMR had ≥2 clips inserted compared to 60% of those with DMR (P = 0.064).The 30-day mortality rate for FMR and DMR was similar at 4.5% and 6.7% respectively (P = 0.555). The 30-day MAE rate was 9.2% for FMR and 14.7% for DMR (P = 0.281). Both FMR and DMR patients had significant improvements in the severity of MR and NYHA class after 30 days. There was a significantly greater reduction in left ventricular end-diastolic diameter (P = 0.002) and end systolic diameter (P = 0.017) in DMR than in FMR.
CONCLUSIONS: The MitraClip therapy is a safe and efficacious treatment option for both FMR and DMR. Although, there is a significantly greater reduction in LV volumes in DMR, patients in both groups report clinical benefit with improvement in functional class. © 2015 Wiley Periodicals, Inc.
Prognostic Value of Left Atrial Strain in Aortic Stenosis: A Competing Risk Analysis

Tan ESJ, Jin X, Oon YY, Chan SP, Gong L, Lunaria JB, et al.

J Am Soc Echocardiogr, 2023 Jan;36(1):29-37.e5.
PMID: 36441088 DOI: 10.1016/j.echo.2022.10.011

BACKGROUND: The role of left atrial (LA) strain as an imaging biomarker in aortic stenosis is not well established. The aim of this study was to investigate the prognostic performance of phasic LA strain in relation to clinical and echocardiographic variables and N-terminal pro-B-type natriuretic peptide in asymptomatic and minimally symptomatic patients with moderate to severe aortic stenosis and left ventricular ejection fraction > 50%.
METHODS: LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured using speckle-tracking echocardiography. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, progression to New York Heart Association functional class III or IV, acute coronary syndrome, or syncope. Secondary outcomes 1 and 2 comprised the same end points but excluded acute coronary syndrome and additionally syncope, respectively. The prognostic performance of phasic LA strain cutoffs was evaluated in competing risk analyses, aortic valve replacement being the competing risk.
RESULTS: Among 173 patients (mean age, 69 ± 11 years; mean peak transaortic velocity, 4.0 ± 0.8 m/sec), median LASr, LAScd, and LASct were 27% (interquartile range [IQR], 22%-32%), 12% (IQR, 8%-15%), and 16% (IQR, 13%-18%), respectively. Over a median of 2.7 years (IQR, 1.4-4.6 years), the primary outcome and secondary outcomes 1 and 2 occurred in 66 (38%), 62 (36%), and 59 (34%) patients, respectively. LASr < 20%, LAScd < 6%, and LASct < 12% were identified as optimal cutoffs of the primary outcome. In competing risk analyses, progressing from echocardiographic to echocardiographic-clinical and combined models incorporating N-terminal pro-B-type natriuretic peptide, LA strain parameters outperformed other key echocardiographic variables and significantly predicted clinical outcomes. LASr < 20% was associated with the primary outcome and secondary outcome 1, LAScd < 6% with all clinical outcomes, and LASct < 12% with secondary outcome 2. LAScd < 6% had the highest specificity (95%) and positive predictive value (82%) for the primary outcome, and competing risk models incorporating LAScd < 6% had the best discriminative value.
CONCLUSIONS: In well-compensated patients with moderate to severe aortic stenosis and preserved left ventricular ejection fractions, LA strain was superior to other echocardiographic indices and incremental to N-terminal pro-B-type natriuretic peptide for risk stratification. LAScd < 6%, LASr < 20%, and LASct < 12% identified patients at higher risk for adverse outcomes.