Clinical and neurocognitive outcomes after transcatheter aortic valve implantation (TAVI) with cerebral protection: initial experience with a novel dual-filter device in Southeast Asia.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is increasingly performed in patients with severe aortic stenosis. A novel dual-filter system to reduce cerebral embolism during TAVI recently became available. We aimed to assess the feasibility, safety, and clinical and neurocognitive outcomes of TAVI with cerebral protection in Asian patients. METHODS: 40 consecutive patients undergoing TAVI with cerebral protection were enrolled. All procedures were performed via femoral access using the self-expanding Evolut R/PRO or Portico, or the balloon-expandable SAPIEN 3 bioprostheses. Baseline characteristics, procedural and clinical outcomes were recorded. Cognition was assessed at baseline and 30 days using the abbreviated mental test (AMT). RESULTS: The mean age of the patients (75% male) was 76.4 ± 8.4 years. TAVI was uncomplicated in all patients. The filter device was successfully deployed in 38 (95.0%) patients without safety issues. There was no stroke or death at 30 days, and the survival rate at nine months was 95.0%. There was no overall cognitive change (baseline vs. 30-day AMT: 9.2 ± 1.1 vs. 9.0 ± 1.5, p = 0.12), and only 1 (2.5%) patient developed impaired cognition at 30 days. Patients with a decreased AMT score at 30 days were significantly older than those without (82.1 ± 4.5 vs. 74.4 ± 7.7 years, p = 0.019). All patients with decreased AMT scores were aged ≥ 76 years. CONCLUSION: In this early Asian experience of TAVI under cerebral protection, the filter device was successfully deployed in 95% of patients, with 100% procedural success. There were no filter-related complications and no stroke or mortality at 30 days. Overall cognition was preserved, although increased age was associated with a decline in AMT score.

Assessment and Management of Dry Eye Disease and Meibomian Gland Dysfunction: Providing a Singapore Framework.

ABSTRACT: The purpose of this article is to provide a framework for general ophthalmologists in Singapore to manage dry eye. This framework considers the evidence in the literature as well as recommendations from expert panels such as the Tear Film & Ocular Surface Society Dry Eye Workshop II and the Asia Cornea Society Workgroup.This article covers the assessment of patient medical history and ask triage questions to identify local and systemic causes of dry eye disease (DED), excluding other possible causes, as well as the risk factors for DED and ocular surface inflammation. Evaluation of clinical signs to establish the diagnosis of DED and differentiation from other causes of irritable, red eyes are described. Tests for understanding the underlying disease processes and severity of DED are also presented.Management of dry eye should involve patient education and engagement. Information about the natural history and chronic nature of DED should be provided to improve long-term management of the disease and enhance compliance. Aggravating factors should be removed or lessened.We provide a guide to determine the most appropriate treatment (or combination of treatments) based on the severity and cause(s) of the disease, as well as the patient's needs and preferences. The aim of the management is to relieve ocular discomfort and prevent worsening of symptoms and signs, as well as to optimize visual function and minimize structural ocular damage. We also discuss the systematic follow-up and assessment of treatment response, as well as monitoring side effects of treatment, bearing in mind continuous support and reassurance to patients.

Perioperative considerations for COVID-19 patients: lessons learned from the pandemic -a case series.

Background: As the coronavirus disease 2019 (COVID-19) pandemic spreads globally, hospitals are rushing to adapt their facilities, which were not designed to deal with infections adequately. Here, we present the management of a suspected COVID-19 patient. Case: A 66-year-old man with a recent travel history, infective symptoms, and chest X-ray was presented to our hospital. Considering his septic condition, we decided to perform an emergency surgery. The patient was given supplemental oxygen through a face mask and transported to an operating theatre on a plastic-covered trolley. An experienced anesthetist performed rapid sequence intubation using a video laryngoscope. Due to the initial presentation of respiratory distress, the patient remained intubated after surgery to avoid re-intubation. Precautions against droplet, contact, and airborne infection were instituted. Conclusions: Our objective was to facilitate surgical management of patients with known or suspected COVID-19 while minimizing the risk of nosocomial transmission to healthcare workers and other patients.

Evaluation of Mandibular Incisive Canal using Cone Beam Computed Tomography in Malaysians.

OBJECTIVES: The risk of damaging the mandibular incisive canal (MIC) during surgery in the anterior mandible should not be overlooked. Hence, preoperative radiographic assessment is essential to avoid complications. This study was aimed to estimate the length of the MIC in the interforaminal safe zone, to analyse its course in relation to the lingual and the buccal cortical plates of the mandible using cone beam computed tomography (CBCT) scans and to relate the above findings to age, gender, dental status and Malaysian races. METHODS: Retrospective analysis of 100 CBCT scans (n = 200) was performed on both sides of the mandible. Cross-sectional and panoramic images were reconstructed. The length of the MIC and the horizontal distances between the MIC and the buccal and the lingual cortical plates were measured at the three different points (starting, mid-, end points). Independent samples t-test and one-way ANOVA test were used to analyse the variation in the length and course of the MIC in gender, age, dental status and Malaysian races. RESULTS: The mean length of the MIC was 11.31 ± 2.65 mm, with the Malays having the longest MIC, followed by the Chinese and the Indians (p < 0.05). The MIC deviated towards the lingual cortical plate, with significance seen in the Indian and the male patients (p < 0.05). No significant difference was noticed with respect to patient age and dental status. CONCLUSIONS: Assessment of the MIC should be performed using CBCT on a case-by-case basis as it provides essential information during preoperative planning of surgery in the anterior mandible.

Continuous spinal anaesthesia: A retrospective analysis of 318 cases.

BACKGROUND AND AIMS: Continuous spinal anaesthesia (CSA) is an underutilised anaesthetic technique. Our objectives were to evaluate the use of CSA in our institution, its efficacy, ease to use and safety. METHODS: This was a retrospective analysis conducted in a tertiary centre. Records of all patients who underwent surgery and received CSA between December 2008 and July 2017 were reviewed. Their demographic profiles, type and duration of surgery were analysed. The outcomes measured were the success of CSA, technical evaluation and difficulties encountered, intraoperative haemodynamics, usage of vasopressors and any reported complications. Statistical analysis was done using Chi-square test. RESULTS: Three hundred and eighteen patients (94%) successfully underwent surgery using CSA. Twenty cases (6%) had failed CSA, of which five of them had CSA insertion failure, while the rest failed to complete the operation under CSA, thus requiring conversion to general anaesthesia. Patients who have had an initial intrathecal local anaesthetic (LA) volume ≥1.5 ml had higher odds (odds ratio (OR) 2.78; 95% confidence interval [CI], 1.70-4.57) of developing hypotension compared to those who had <1.5 ml (P < 0.001). There were no reported post-dural puncture headache, neurological sequelae or infection. CONCLUSION: CSA is a useful anaesthetic technique with low failure rate. The key to achieving haemodynamic stability is by giving a small initial bolus, then titrating the block up to required height using aliquots of 0.5 ml of intrathecal LA through the catheter.

The effect of intravitreal injections on dry eye, and proposed management strategies.

Intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents has become a commonly used treatment method for a number of ophthalmic conditions, including age-related macular degeneration. Although anti-VEGF therapy has shown promising results for many patients, there are several aspects of its application that have not been thoroughly investigated. One of these is the development and/or escalation of concurrent dry eye syndrome. Many patients undergoing treatment are already predisposed to dry eye disease due to their age and overall ocular health. As dry eye can have a substantial impact on quality of life, it has become increasingly apparent that the clinical signs and symptoms should be closely monitored and aggressively managed. This will allow for the optimization of patient comfort and visual potential. Here, we discuss the reasons why dry eye may develop during the course of repeated ocular anti-VEGF therapy, highlighting the key concerns about current practices and proposing possible solutions to improve the outcome for the patients.

Variant screening of the serum amyloid A1 gene and functional study of the p.Gly90Asp variant for its role in atherosclerosis.

OBJECTIVES: Serum amyloid A1 (SAA1) is a major acute-phase protein that is increasingly used as a reliable predictor of coronary artery disease (CAD). In this study we aim to screen the SAAI promoter and exons for genetic variants and to determine their association with CAD. In addition, we also carried out functional study on a variant of p.Gly90Asp encoded by the SAA1 gene. METHODS: Variant screening of SAA1 was performed using high resolution melting (HRM) analysis. Genetic association of p.Gly90Asp with CAD was determined in 800 CAD patients and 773 Chinese control subjects. Functional study of p.Gly90Asp was carried out using THP-1-derived macrophages and HL-60 promyelocytic leukemia cells. RESULTS: A total of 6 SNPs were identified, of which 2 were found to be novel (c.-913G > A and c.92-5T > G). The rare allele of p.Gly90Asp has a lower frequency of 0.013 in the CAD patients although this is not statistically significant. Functional studies of p.Gly90Asp revealed that the variant has decreased upregulation of key cytokines such as IL-8, MCP-1 and TNF-α as well as SERPINB2. CONCLUSIONS: We found the variant p.Gly90Asp SAA1 protein eliciting significantly reduced inflammatory responses in macrophages through a reduction in the secretion of inflammatory cytokines. Despite strong functional effects, the minor allele frequency is too low in the population to attain statistical significance difference between cases and controls.

Biolimus-eluting biodegradable polymer-coated stent versus bare metal stent in acute ST-elevation and non-ST elevation myocardial infarction: Justification for biodegradable polymer-coated stent in acute coronary syndrome (JANICE) registry.

AIMS: We evaluated the efficacy and safety of a biolimus- eluting biodegradable polymer-coated stent (BES) in patients with ST-segment elevation and non ST-segment elevation acute myocardial infarction (AMI). METHODS AND RESULTS: This was an observational study involving a single centre patient registry. We compared the rates of cardiac death, myocardial infarction, target vessel revascularization (TVR) and composite end point of cardiac death and myocardial infarction at 24 months in 106 patients who received BES versus 94 patients who received an otherwise similar bare metal stent (BMS) during percutaneous coronary intervention for AMI. There was no significant difference in the rate of cardiac death (0.9% versus 7.4%; P = 0.09), myocardial infarction (4.7% versus 3.2%; P = 0.69), stent thrombosis (0.9% versus 3.2%; P = 0.30) or cardiac death and myocardial infarction (5.7% versus 10.6%; P = 0.30) between the two groups. The rate of TVR was significantly higher in the BMS group (1.9% versus 8.5%; P = 0.04), with patients receiving BMS being four times more likely to require TVR. CONCLUSION: The use of BES in selected patients with AMI appears to be safe and is associated with significantly reduced rate of TVR, when compared with an otherwise similar BMS.

Endothelial progenitor cell capture stent implantation in patients with ST-segment elevation acute myocardial infarction: one year follow-up.

AIMS: The Genous endothelial progenitor cell (EPC) capture stent is a bioengineered R stent coated with immobilised antibodies on its stent struts to allow for the capture of circulating EPCs to promote rapid endothelisation. We assessed the impact of this stent in the primary percutaneous coronary intervention (PCI) of patients with acute ST-elevation myocardial infarction (STEMI) and examined its long term clinical outcomes. METHODS AND RESULTS: All patients with acute STEMI without cardiogenic shock who underwent primary PCI between January 2005 and April 2007 and received the stent were enrolled in the study. The study endpoints were major adverse cardiac events (MACE) defined as death, MI and target vessel revascularisation (TVR) at 30 days, six months and one year. A total of 321 enrolled patients received 357 EPC capture stents during the study period. The cohort comprises 81.0% males with mean age of 54.6+/-11.6 years. The mean stent length used was 20.98+/-5.50 mm and mean stent size was 2.99+/-0.32 mm. Ninety-four percent of patients achieved Thrombolysis in Myocardial Infarction (TIMI) 3 flow post-procedurally. The cumulative MACE rate was 8.1% at 30 days, 10.0% at six months and 12.2% at one year. There was one patient who developed acute stent thrombosis and another two with subacute stent thromboses. No late thrombosis or late cardiac mortality was observed in our cohort. The need for TVR was 4.4% at one year. CONCLUSIONS: The use of EPC capture stents in patients who underwent primary PCI for STEMI is safe and showed good clinical outcomes, with low rates of TVR and no late stent thrombosis.

Comprehensive noninvasive evaluation of bypass grafts and native coronary arteries in patients after coronary bypass surgery: accuracy of 64-slice multidetector computed tomography compared to invasive coronary angiography.

AIMS: We assessed the accuracy of 64-slice multidetector computed tomography (MDCT) compared with that of invasive coronary angiography (ICA) in the evaluation of symptomatic postcoronary artery bypass graft (post-CABG) patients. METHODS: MDCT and ICA were performed in 44 consecutive post-CABG patients with chest pain (mean age 66 +/- 10 years, mean duration post-CABG 9 +/- 5 years). MDCT findings were compared with the corresponding ICA, which was read by an interventional cardiologist blinded to the MDCT findings. Significant stenosis was defined as at least 50% luminal stenosis. RESULTS: One hundred and thirty-seven grafts (31 arterial and 106 venous), all evaluable by MDCT, were assessed. In a 'per graft' analysis, MDCT could detect significant disease in bypass grafts (graft occlusion or stenosis) with a sensitivity of 98% and specificity of 98%. In a 'per segment' analysis, MDCT could detect significant disease in all native coronary arteries with a sensitivity of 91% and specificity of 79% and in clinically relevant native coronary arteries with a sensitivity of 92% and specificity of 84%. In a 'per vessel' analysis, MDCT could differentiate native arterial occlusion from nonocclusive stenosis with a sensitivity of 68% and specificity of 70%. In a 'per patient' analysis, MDCT could detect significant disease in bypass grafts or clinically relevant native coronary arteries with a sensitivity of 100%, specificity of 40% and accuracy of 93%. CONCLUSION: Sixty-four-slice MDCT allows evaluation of bypass grafts and native coronary arteries in post-CABG patients. Although accurate for detecting bypass graft disease, 64-slice MDCT has significant limitations when evaluating native arteries in post-CABG patients.

Clinical predictors of stent thrombosis in the "real world" drug-eluting stent era.

BACKGROUND: Drug-eluting stents (DESs) are effective in reducing restenosis and the need for repeat revascularization procedures in patients who undergo percutaneous coronary intervention (PCI). There is however an increased concern with the safety of DES with regard to stent thrombosis (ST). We examined the incidence of ST among patients who received DES and determined the clinical predictors. METHODS: All patients who underwent PCI in our centre were prospectively enrolled in a cardiovascular database. All cases of ST, as defined by 2006 Academic Research Consortium (ARC) hierarchical classification as definite and probable, from August 2002 to August 2006 were reviewed and analyzed. The clinical, angiographic and procedural characteristics of patients who developed ST were compared with those who did not. RESULTS: The study population comprised 1580 patients who received DES implantation. The cumulative incidence of ST was 1.5%: acute ST 0.2%, subacute ST 0.9%, late ST 0.2% and very late ST 0.2%. Mortality and myocardial infarction occurred in 16% and 84% of patients, respectively, as a consequence of ST. Multivariate analysis showed that patients presenting with cardiogenic shock, acute coronary syndrome, presence of multivessel disease, impaired baseline TIMI flow and higher number of stents implanted per lesion were predictive of ST. CONCLUSION: The incidence of DES ST in our 'real world' registry was low. There were clinical and angiographic characteristics identified as independent predictors of ST.

Association between falls and high-risk medication use in hospitalized Asian elderly patients.

AIM: Most studies looking at the relation between medication use and fall among the hospitalized elderly patients, were done in Western countries. So, a study was planned to investigate the role of medications in causing falls in hospitalized Asian elderly patients. METHODS: Case note review was done for all patients age 65 years and above, who fell at least once during their hospital stay over a 12-month period. Information obtained from the case notes included: (i) demographic information; (ii) Modified Morse Fall scale; (iii) circumstances and time of fall; and (iv) medication use. From the hospital admission database, an age- and sex-matched control group was selected for comparison. RESULTS: Over the 12-month study period, 298 patients met the study criteria. Average age of the patients was 75.8 years, 60.4% were male and 84.9% were Chinese. Multivariate analysis showed that fallers had longer lengths of stay and were more likely to have a history of falls. Fallers were also more likely to be taking hypnotics, cough preparations and anti-platelets, but less likely to be taking paracetamol. Fallers were on fewer medications. CONCLUSION: Elderly hospitalized patients on hypnotic drugs, cough preparations and anti-platelets were more likely to fall. Appropriate usage of analgesics, especially paracetamol, to relieve pain may reduce falls.

Acanthamoeba keratitis associated with contact lens wear in Singapore.

PURPOSE: To describe an outbreak of Acanthamoeba keratitis (AK) cases among contact lens wearers. DESIGN: Retrospective cohort study. METHODS: Patients with AK were included. Relevant demographic and clinical data were obtained from case records, and patients were interviewed using a standardized questionnaire. Contact lens practices, including type of contact lens and solution used, were noted. In addition, clinical features at presentation, management, and clinical outcomes were recorded. RESULTS: Forty-two patients (affecting 43 eyes) treated between 2000 and 2007 were included. Diagnosis was made by microbiologic culture in 35 cases and by microbiologic and histologic analysis in 2 cases, whereas the remainder were diagnosed based on clinical features and response to treatment. There was a gradual increase in cases since 2005, with a sharp increase in 2007, when 8 local patients were treated. Of 30 patients where contact lens solution data were available, 18 reported using a Complete brand Multipurpose solution (Advanced Medical Optics, Santa Ana, California, USA) before the infection. Among resident cases treated since February 2006, 7 (63%) of 11 patients used a Complete brand solution. Suboptimal hygiene practices were found in all patients interviewed. Fifteen patients required corneal grafting, with 11 undergoing therapeutic deep lamellar keratoplasty (DLK), 2 undergoing optical penetrating keratoplasty (PK), 1 undergoing optical DLK, and 1 undergoing therapeutic PK. The remainder were treated successfully medically with combination antiamebic therapy. The average duration of therapy was 116.2 days (range, 15 to 283 days). Of patients with radial keratoneuritis with or without epithelial disease, 83.3% achieved final vision of 20/40 or better, whereas this was achieved in 41.7% of those with ring infiltrate. Twenty-five percent of patients with ring infiltrate had final visual acuity of counting fingers or worse, whereas no patient with keratoneuritis and epithelial disease had final vision worse than counting fingers. CONCLUSIONS: There was an increase in the number of contact lens users with AK seen in the major eye departments of Singapore. Most of our patients also reported using a Complete brand Multipurpose solution before infection, and this parallels a similar outbreak in the United States. Increasing severity of infection was associated with worse visual outcome.

Primary percutaneous coronary intervention for acute myocardial infarction secondary to acute left main coronary occlusion in an institution without on-site cardiothoracic surgical support.

AIMS: There is no consensus on the optimal management of acute myocardial infarction due to acute left main coronary occlusion (LMCO). We evaluated the feasibility of primary percutaneous coronary intervention (PCI) for acute LMCO in an institution without on-site cardiothoracic surgical (CTS) support. METHODS AND RESULTS: We retrospectively identified 20 patients, median age 67 years (range 38 to 81). Sixteen patients presented with cardiogenic shock. All patients required intra-aortic balloon pump counterpulsation and inotropic support. Sixteen patients underwent stenting and four had balloon angioplasty only. Thrombolysis In Myocardial Infarction 3 flow was restored in 13 patients. Post-PCI, six patients were transferred to a tertiary institution for further care: three underwent extracorporeal membrane oxygenation (ECMO), one underwent both ECMO and coronary artery bypass grafting (CABG), one died before ECMO initiation and one stabilised without further intervention. Thirteen patients died in-hospital. There was one subsequent death out of the seven hospital survivors, with median follow-up 390 days (range 60 to 660 days). There was a trend towards survival with a shorter door-to-balloon time (p = 0.07). CONCLUSIONS: Primary PCI may be a feasible initial revascularisation strategy for acute LMCO in centres without on-site CTS support.

Progressive coronary artery aneurysm presenting as acute myocardial infarction.

Coronary artery aneurysms (CAA) are commonly of atherosclerotic origin and asymptomatic. The natural history is uncertain given its uncommon occurrence and lack of longitudinal data. We report a case of CAA, presenting with myocardial infarction. Follow-up coronary angiography revealed enlargement of the CAA, suggesting a progressive nature.

A novel drug-eluting stent using bioabsorbable polymer technology: two-year follow-up of the CURAMI registry.

BACKGROUND: There are safety concerns on drug-eluting stents (DESs) using durable polymer. The long-term outcome of next generation DESs using bioabsorbable polymer technology remains unknown. METHODS: From March to June, 2005, a novel sirolimus-eluting (170 microg/cm2), bioabsorbable polymer (PLA and PLGA, eroded over 45 days) coated stent was implanted for treatment of acute myocardial infarction (AMI) in 49 patients (male 86%, age 55+10 years, diabetes 31%). All culprits were de novo lesions in the native coronary artery. On discharge, aspirin and clopidogrel for 3 months followed by life-long aspirin were prescribed. Angiographic follow-up was performed at 8 months. Clinical follow-up was performed at 4, 9 and 24 months. RESULTS: Angiographic success rate was 100%. In-hospital adverse events consisted of 1 death (2%). All except one patient (due to aspirin allergy) were compliant to the 3 months dual antiplatelet therapy, and there was no adverse event during this period. One patient developed re-infarction in another coronary territory at 6 months. Twenty-seven patients (56%) underwent 8-month angiographic follow-up (Table 3). At 24 months, 6 patients had 7 major adverse cardiac events (12.2%, 1 death, 2 re-infarctions and 4 target lesion revascularizations). There were no incidences of subacute or late stent thrombosis. CONCLUSIONS: The Cura stent, using bioabsorbable polymer technology, appears to be safe at 2 years follow-up. Although the angiographic follow-up parameters were unfavorable, this report paves the way for further studies on DES using bioabsorbable polymer technology.

Use of endothelial progenitor cell capture stent (Genous Bio-Engineered R Stent) during primary percutaneous coronary intervention in acute myocardial infarction: intermediate- to long-term clinical follow-up.

AIMS: We assessed the use of the endothelial progenitor cell (EPC) capture stent in primary percutaneous intervention in ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: One hundred and twenty patients with acute STEMI without cardiogenic shock received 129 EPC capture stents. Procedural success was achieved in 95% of patients. Dual antiplatelet therapy was given for a month and statin therapy started immediately after the procedure. The study end points are major adverse cardiac events inhospital and at 30 days, 6 months, and 1 year. Hypertension was present in 47.5% and diabetes mellitus in 30% of the patients. The left anterior descending artery was the treated artery in 54% of the patients. Mean lesion length was 17.4 +/- 7.15 mm with mean reference vessel diameter of 3.18 +/- 0.6 mm. Platelet glycoprotein IIb/IIIa inhibitor was used in 14% of patients and 58% had thrombosuction before stent implantation. Ninety-five percent of patients achieved Thrombolysis in Myocardial Infarction 3 flow with cumulative major adverse cardiac event rate at 1.6% inhospital, 4.2% at 30 days, 5.8% at 6 months, and 9.2% at 1 year. There was 1 patient each with acute and subacute stent thrombosis but no incidence of late stent thrombosis. CONCLUSION: Using EPC capture stent during primary percutaneous coronary intervention for STEMI is feasible and safe.