Yeow Leng Chua’s research while affiliated with National Heart Centre Singapore and other places

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Publications (128)


Immunomodulatory therapy in children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS, MIS-C; RECOVERY): a randomised, controlled, open-label, platform trial
  • Article

January 2024

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2,136 Reads

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12 Citations

The Lancet Child & Adolescent Health

Saul N Faust

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Richard Haynes

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Christine E Jones

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A Zuriaga-Alvaro

Figure 1. Mitral annular disjunction (MAD) on echocardiography. (a) Transthoracic echography (TTE) showed posterior leaflet prolapse with eccentric mitral regurgitation, with MAD seen (double-arrow). (b) Transesophageal echocardiography (TEE) of same patient also demonstrated MAD in systole (double-arrow). (c) MAD was demonstrated on parasternal long axis view on TTE, with the distance between mitral valve leaflet-atrial wall and left ventricle measured at 7 mm (arrow). (d) The hypermobile posterior annulus could be appreciated on the M-mode of TTE (arrow).
Figure 2. Illustrations of mitral annular disjunction (MAD) and surgical principles for mitral valve surgery. (a) Normal mitral valve: mitral annular plane is in its normal position (dashed line). (b) Mitral valve prolapse (MVP) without MAD: mitral annulus plane (dashed line) remains in its normal position despite prolapse of the mitral leaflet. (c) MVP with MAD: the mitral annulus is "dislocated" away from the normal left ventricle-left atrial (LV-LA) myocardium junction resulting in MAD (double-arrow), and the mitral annular plane (dashed line) has shifted towards LA. (d) MAD can be treated by mitral valve surgery, by suturing the prosthetic ring or valve (arrowhead) to the correct level of the LV-LA myocardial junction. The mitral annulus is stabilized, and the MAD can be obliterated after mitral surgery (arrow). Ao: aorta; LV: left ventricle; LA: left atrium; MV: mitral valve; MVP: mitral valve prolapse; MAD: mitral annular disjunction.
Mitral Annular Disjunction: Clinical Implications and Surgical Considerations
  • Literature Review
  • Full-text available

December 2023

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1,388 Reads

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2 Citations

Cardiology Research

Mitral annular disjunction is a cardiac structural abnormality characterized by the distinct separation between the top of the left ventricular myocardium and the mitral annulus supporting the posterior mitral leaflet occurring during systole. It has recently gained wide attention due to the increasing recognition of the link between mitral annular disjunction and arrhythmogenic mitral valve prolapse, particularly, with the increased risks of ventricular arrhythmias resulting in sudden cardiac death. This review has summarized the recent progress in the diagnostic modalities, clinical implications of mitral annular disjunction, and its specific surgical considerations.

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Fig. 2 Delay of event analysis for all-cause death, ABC adherent vs. non-adherent in high-complexity cluster subgroup. Legend: DoE, delay of event. Figures reported are estimates [95% confidence intervals]
Fig. 3 Central Illustration (Created with Biorender.com)
Abbreviations ABC: Atrial fibrillation Better Care; ACE: Angiotensin-converting enzyme; AF: Atrial fibrillation; CAD: Coronary artery disease; CI: Confidence interval; DoE: Delay of event; EHRA: European Heart Rhythm Association; EORP: EURObservational Research Programme; ESC: European Society of Cardiology; FI: Frailty index; HF: Heart failure; HR: Hazard ratio; IQR: Interquartile range; MACE: Major adverse cardiovascular event; NNT: Number needed to treat; NOAC: Non-vitamin K antagonist oral anticoagulant; OAC: Oral anticoagulant; PAD: Peripheral artery disease; SD: Standard deviation; TIA: Transient ischaemic attack; VKA: Vitamin K antagonist.
Delay of event analysis, ABC adherent vs. non adherent (n=6091)
Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

September 2022

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319 Reads

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46 Citations

BMC Medicine

Background Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients.


Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry

May 2022

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44 Reads

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5 Citations

Aims The 4S-AF classification scheme comprises of four domains: stroke risk (St), symptoms (Sy), severity of atrial fibrillation (AF) burden (Sb), and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and compare outcomes in AF patients according to the 4S-AF-led decision-making process. Methods and results Atrial fibrillation patients from 250 centres across 27 European countries were included. A 4S-AF score was calculated as the sum of each domain with a maximum score of 9. Of 6321 patients, 8.4% had low (St), 47.5% EHRA I (Sy), 40.5% newly diagnosed or paroxysmal AF (Sb), and 5.1% no cardiovascular risk factors or left atrial enlargement (Su). Median follow-up was 24 months. Using multivariable Cox regression analysis, independent predictors of all-cause mortality were (St) [adjusted hazard ratio (aHR) 8.21, 95% confidence interval (CI): 2.60–25.9], (Sb) (aHR 1.21, 95% CI: 1.08–1.35), and (Su) (aHR 1.27, 95% CI: 1.14–1.41). For CV mortality and any thromboembolic event, only (Su) (aHR 1.73, 95% CI: 1.45–2.06) and (Sy) (aHR 1.29, 95% CI: 1.00–1.66) were statistically significant, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Higher 4S-AF score was related to a significant increase in all-cause mortality, CV mortality, any thromboembolic event, and ischaemic stroke but not major bleeding. Treatment of all 4S-AF domains was associated with an independent decrease in all-cause mortality (aHR 0.71, 95% CI: 0.55–0.92). For each 4S-AF domain left untreated, the risk of all-cause mortality increased substantially (aHR 1.35, 95% CI: 1.16–1.56). Conclusion Implementation of the novel 4S-AF scheme is feasible, and treatment decisions based on this scheme improve mortality rates in AF.



Figure 1. Preoperative echocardiography. (a, b) Treated endocarditis: (a) Severely dilated tricuspid valve annulus measuring 59 mm (arrows), with non-coapting tricuspid valve leaflets. (b) Dilated tricuspid valve annulus (arrows) measuring 39 mm, with central malcoaptation and severe tricuspid regurgitation. (c, d) Active endocarditis: large, mobile vegetations (arrows) on damaged tricuspid valve leaflets.
Operative and Postoperative Data All, n = 7 (%)
Isolated Tricuspid Valve Replacement for Infective Endocarditis

April 2022

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34 Reads

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2 Citations

Cardiology Research

Background: Existing data regarding isolated tricuspid valve replacement for primary tricuspid valve disease such as infective endocarditis (IE) are limited. The aim of this study was to review our experience of isolated tricuspid valve replacement for IE. Methods: A retrospective review was performed to evaluate the perioperative and long-term outcomes of patients undergoing isolated tricuspid valve replacement for IE at our tertiary referral center between January 2000 and December 2014. Surgical outcomes were reviewed to include survival and postoperative complications. Results: Seven patients underwent isolated tricuspid valve replacement for IE during the study period. Mean age was 41 ± 14 years with six (86%) males. Six patients (86%) were intravenous drug users. Five patients (71%) presented with septic emboli to the lungs. Five patients (71%) had active endocarditis at the time of surgery. The indications for surgery were heart failure in three patients (43%), persistent sepsis in three patients (43%) and both in one patient (14%). Methicillin-sensitive Staphylococcus aureus was the most common infective organism, isolated in five patients (71%). There were no in-hospital mortalities or permanent pacemaker implantations. Follow-up was completed in 86% of the cases. The median follow-up period was 13 months (range 2 to 129 months). Three patients (43%) died during the follow-up period, at 7 months, 8 months and 13 months, respectively. All deaths were associated with prosthetic valve IE and recurrent intravenous drug use. Conclusions: This study supplements the paucity of data pertaining to tricuspid valve replacement for IE in the local population. Survival outcomes can be improved with prompt surgical intervention, optimal medical optimization, and a holistic, psychosocial approach targeting intravenous drug abuse.





Citations (70)


... An intention-to-treat analysis of data from the RECOV-ERY trial, a multicenter RCT in the UK, in which 214 patients with MIS-C were randomized to initial treatment with supportive care, IVIg alone (2 g/kg), or methylprednisolone (10 mg/kg/day for 3 days), demonstrated shorter length-of-stay with corticosteroids compared to supportive care, and no benefit of IVIg on this outcome [92], demonstrating the benefit of corticosteroid monotherapy as initial treatment for MIS-C. Neither corticosteroids nor IVIg reduced the need for critical care, vasopressors, advanced respiratory support, development of CALs, and development of LV systolic dysfunction. ...

Reference:

An Update on Multi-System Inflammatory Syndrome in Children
Immunomodulatory therapy in children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS, MIS-C; RECOVERY): a randomised, controlled, open-label, platform trial
  • Citing Article
  • January 2024

The Lancet Child & Adolescent Health

... The fact that only 9% of unknown-cause patients in our study showed replacement fibrosis is probably due to a compound of these and maybe still unknown pathophysiological mechanisms that result in arrhythmias even before being measurable. Then, if the currently more prevalent idea of a sequence consisting of a hypermobile mitral valve apparatus causing persistent myocardial stretch, which itself leads to myocardial fibrosis, proves right or at least partially truthful, future considerations regarding treatment could involve interventional or surgical remedying of the primarily underlying hypermobility before the development of clinically relevant fibrosis [35]. ...

Mitral Annular Disjunction: Clinical Implications and Surgical Considerations

Cardiology Research

... 10 Various studies have shown that appropriate characterisations of AF patients according to the 4S-AF scheme followed by corresponding managements were associated with improved clinical outcomes (Fig. 2). [19][20][21][22] Patients with all 4S-AF domains treated were associated with a 29% lower risk of mortality in EORP-AF registry, and a 62% lower risk of composite outcome of ischaemic stroke/systemic embolic events (SEEs), heart failure, acute coronary syndrome, significant coronary artery disease requiring coronary intervention and mortality in APHRS registry. 19,20 For Sb domain, the AF burden should ideally be assessed via ...

Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry
  • Citing Article
  • May 2022

... We included patients with AF from two large, prospective observational registries from Europe and Asia. Details on the studies' design, baseline characteristics and primary results have been previously published [11,12]. Briefly, both registries enrolled consecutive adult patients (> 18 years old) with an ECG-documented episode of AF in the 12 months before inclusion. ...

Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: the EORP-AF General Long-Term Registry
  • Citing Article
  • July 2019

... Polypharmacy has been linked to detrimental effects on the prognosis of patients with AF, including all-cause mortality, thromboembolism and major bleeding [4,5]. Indeed, concomitant pharmacological treatment contributes to increased complexity of management of patients with AF [6]. ...

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

BMC Medicine

... Current guidelines suggest that switching warfarin to a NOAC and maintaining an adequate TTR cannot be sustained [2][3][4][5]. Therefore, the quality of anticoagulation control (AC) prediction model with TTR is needed, and the SAMe-TT 2 R 2 scoring system (Sex, female; Age, < 60 yr; Medical history, more than two comorbidities; Treatment, interacting drug, e.g., Amiodarone; Tobacco use (doubled); and Race (doubled) is available for this purpose [6][7][8][9][10][11][12][13][14][15][16][17]. The patients with SAMe-TT 2 R 2 score more than 1 point are less likely to achieve a good TTR and alternative strategies may be required [8]. ...

The SAMe-TT2R2 score and quality of anticoagulation in atrial fibrillation: a simple aid to decision-making on who is suitable (or not) for vitamin K antagonists
  • Citing Article
  • April 2015

... The APHRS AF registry also examined the clinical utility and prognostic implications of the 4S-AF scheme [7]. As expected, increasing adverse features by the 4S-AF scheme is associated with worse outcomes, consistent with prior analyses from Europe [8,9] and China [10]. Nonetheless, if the 4S-AF domains are appropriately treated, for example, for stroke risk, anticoagulation therapy reduces the composite clinical outcome, as does appropriate rate or rhythm control and risk factor management [7]. ...

Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry
  • Citing Article
  • May 2022

... The study enrolled consecutive AF inpatients and outpatients in 250 cardiology practices, across 27 countries. Details on study design, baseline characteristics, outcomes adjudication and follow-up are reported elsewhere [18,19]. ...

Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: the EORP-AF General Long-Term Registry
  • Citing Article
  • July 2019

... The studied patients had paroxysmal or persistent AF with high CHA 2 DS 2 -VASc scores and multiple cardiovascular and non-cardiovascular comorbidities. They were considered high-risk phenotypes of AF according to the cluster analysis of the clinical characteristics of patients with AF. 32,33 Vigneshwar et al. 34 analysed 789 patients on VA-ECMO and reported that pre-ECMO sinus rhythm was associated with a survival benefit. Wang et al. 35 conducted a small retrospective study of 87 patients on PC-ECMO and reported that the frequency of AF was 13% and 38% (P < 0.001) in survivors and non-survivors, respectively; however, it was not included in the logistic regression model. ...

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry
  • Citing Article
  • December 2021

... They used the ESC-EHRA EORP-AF General Long-Term Registry. 17 They reported that compared with beta-blockers, digoxin therapy was associated with increased all-cause mortality. However, in multivariable analysis, there were no differences in any of the outcomes between both groups after accounting for potential confounders. ...

Contemporary stroke prevention strategies in 11 096 European patients with atrial fibrillation: a report from the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) Long-Term General Registry
  • Citing Article
  • May 2018