Vol. 29 No. 1 (2024)

Early detection of Congenital Hypothyroidism (CH) is crucial to prevent intellectual disability in affected neonates. Neonatal screening for CH typically involves measuring thyroid-stimulating hormone (TSH) and thyroxine (T4) levels, with methods varying between cord blood and venous blood sampling. This study aims to compare the efficacy and reliability of cord blood versus day 3 venous blood sampling in the screening for CH to inform best practices. Methods: This prospective comparative study involved 1,000 term neonates born at Springfield Children’s Hospital over an 18-month period. Cord blood and day 3 venous blood samples were analyzed for T3, T4, and TSH levels using competitive immunoassay techniques. The primary outcomes measured were the mean levels of T3, T4, and TSH, and the secondary outcome was the detection rate of CH based on these hormone levels. Statistical analyses included paired t-tests for continuous variables and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) calculations for screening efficacy. Results: Significant differences were found in TSH levels between cord blood and day 3 venous samples (p<0.001), but not in T3 and T4 levels. CH was initially suspected in 25 neonates (2.5%) based on cord blood screening and confirmed in 15 neonates (1.5%) on day 3 venous blood screening. The sensitivity and specificity were 100% and 97.5% for cord blood screening, and 100% and 98.5% for day 3 venous blood screening, respectively. PPV and NPV were higher for day 3 venous blood screening compared to cord blood screening. Conclusions: Both cord blood and day 3 venous blood sampling are effective for neonatal CH screening, each with distinct advantages. Day 3 venous sampling, however, demonstrated slightly higher specificity and PPV, suggesting a more accurate reflection of persistent CH. These findings support the use of venous blood sampling on day 3 of life as a reliable method for CH screening, potentially reducing the number of false-positive results and enhancing the early detection and treatment of CH.

Objectives: This study aimed to examine whether the projected patient-prosthesis mismatch (PPM) rate calculated using the ideal body weight of patients can theoretically show a significant improvement compared to the actual rate of PPM conventionally calculated with the actual body weight of patients. Methods: We retrospectively analysed 2827 patients who underwent aortic valve replacement over 10 years. The rate of PPM was evaluated by measuring the iEOA using the body weight of the patients at the time of the operation and their ideal body weight. The difference in PPM rate was compared using the chi-square test; additionally, a P value < 0.05 was considered significant. Results: We observed a projected PPM rate of 50.2% with a moderate PPM of 45% and a severe PPM of 5.2% when the real body weight of the patients at the time of their operation was included in the calculus. Simulating a BMI of 22 for all patients, the rates of moderate and severe PPM decreased to 43.8% and 0.5%, respectively (P < 0.001). When simulating a lower BMI at 21, 20, and 19, there was a further significant reduction in moderate PPM at 38.8%, 33.4%, and 26.8%, respectively, and severe PPM at 0.2% and 0.1%, respectively (P < 0.001). Conclusions A significant reduction in post-aortic valve replacement PPM was predicted when the ideal body weight of the patient was used instead of actual body weight, suggesting that pre- and postoperative weight loss programmes should be part of the strategy to reduce PPM.

Background: Acute Aortic Syndrome’s (AAS) is a group of acute emergencies that include aortic dissection, intramural haematoma, penetrating atherosclerotic ulcer, and impending or ruptured aortic aneurysms. Various precipitating factors have been associated with the development of AAS, but it is unclear whether these factors are correlators or predictors of the disease. A clear understanding of these elements could improve the diagnosis, prevention, and treatment of AAS, with an accurate appreciation for risk stratification. Methods: A thorough literature search was conducted through several electronic databases to collate papers within the literature discussing precipitating factors leading to AAS. These results were discussed and analysed, grouping the individual factors into predictors or correlators of AAS. Results: The factors identified as correlators were age, certain chronobiological patterns, polycystic kidney disease and immunology. The factors identified as predictors included genetics, omics, and kidney markers. D-dimer, diabetes mellitus and aortic size were not implicated in the development of AAS, with diabetes mellitus found to be protective against AAS. Conclusion: Recognising the precipitating factors that increase the risk of disease empowers clinicians to be more diligent regarding methods of AAS diagnosis and prevention, as well as enables improved treatment techniques to be implemented. These results are key as they can both potentially help reduce the AAS incidence rate and uncover new potential avenues of research that can be explored in the future.

: Patients with repaired tetralogy of Fallot often have pulmonary valvar regurgitation with variable degrees of right ventricular dilatation, which may lead to dysfunction of both ventricles. Therefore, some patients may need pulmonary valve replacement. This calls for adequate patient selection, and there are ventricular volumetric guidelines to aid this. However, pulmonary valve replacement has caused a dilemma because: 1- It often does not reverse right ventricular dilatation back to normal nor prevent arrhythmias. 2- It is argued that right ventricular dilatation occurs early after repair of tetralogy of Fallot but remains stable thereafter. 3- The patient’ prognosis is said to be affected mainly by the function of the left ventricle rather than that of the right ventricle. 4- Prosthetic valves on the right side of the heart are more prone to infection as compared to the left side since bacteria can reach them easily. All these concerns are examined in this Opinion Article. Overall, this dilemma is justified but usually not sufficiently elaborated and often gives the incorrect message that this procedure is of no benefit. The reality is, however, that pulmonary valvar regurgitation is a harmful condition and deserves to be remedied on hemodynamic grounds. The dilemma arises because hemodynamic improvement after valve implantation may be partial, and many think that this is not enough to justify an intervention, especially with the added risk of endocarditis. However, if valve replacement is to be offered, this should be done in a timely fashion; waiting too long is associated with a worse outcome.

Multivalvular heart disease represents a less explored domain within cardiovascular surgery. In patients with aortic stenosis (AS) undergoing surgical or transcatheter aortic valve replacement (TAVR), the prevalence of moderate to severe mitral regurgitation (MR) ranges from 8% to 33%. Among the most common presentations are patients with severe AS and clinically significant functional MR. In instances of moderate surgical risk, open-heart surgery is typically performed, sometimes involving combined valve correction procedures. However, for patients deemed to be at high surgical risk or deemed inoperable, an interventional approach may be considered if the anatomy of both the aortic and mitral valves is conducive to such intervention. Careful analysis of each patient is essential in determining the appropriate treatment strategy, whether it involves isolated TAVR or if a staged intervention targeting the aortic and mitral valves is warranted. In the article, we present a review of the literature devoted to the strategy for bivalvular interventions in patients of high surgical risk and also a clinical case of a successful step-by-step interventional approach in an 83-year-old patient of high surgical risk with hemodynamically significant aortic and mitral valve disease, along with an analysis of the chosen approach.

Background: Transcatheter edge-to-edge repair of the mitral valve (M-TEER) improves outcomes in patients with chronic severe symptomatic mitral valve regurgitation who are at high risk for surgical mitral valve repair or replacement. This systematic review and meta-analysis aimed to describe the outcomes of M-TEER in patients with moderate-to-severe (stage III; Group 1) chronic kidney diseases (CKD) and end-stage kidney disease (stages IV-V; Group 2) in comparison with those with normal kidney function or mild CKD (stages I-II; Group 3). Methods: A systematic literature search of PubMed, Scopus, and Embase was conducted from inception to December 10th, 2023. The odds ratio (OR) with a 95% confidence interval (CI) was pooled using the random-effects model. Results: We screened 6,090 articles of which 40 citations were reviewed in full texts. Eight cohort observational studies met the eligibility criteria. Group 1 versus Group 3: short-term and long-term mortality were significantly higher in Group 1 [(OR 1.73, CI: 1.30-2.29) and (OR 1.78, CI: 1.38-2.29), respectively]. The shock was significantly higher (OR 1.95, CI: 1.45-2.63), and vascular complications were significantly lower (OR 0.51, CI: 0.26-0.99) in Group 1. The incidence of stroke, cardiac tamponade, or conversion to open surgery did not differ between groups [OR 0.87, CI: 0.34-2.23), (OR 1.52, CI: 0.62-2.75), or (OR 0.53, 95% CI: 0.12-2.24), respectively]. Group 2 versus Group 3: long-term mortality was significantly higher in Group 2 (OR 3.56, CI: 2.53-5.02) without a difference in short-term mortality (OR 4.92, CI: 0.91-26.72) or conversion to open surgery (OR 0.92, CI: 0.45-1.91) between groups. Conclusion: In patients who are undergoing M-TEER, impaired kidney function may be associated with increased odds of mortality in comparison with absence or mild kidney impairment.

Background: Tricuspid valve endocarditis (TVE) remains a significant cause of morbidity and mortality worldwide. Given the considerable variation in presentation and severity, as well as ongoing advances in percutaneous and operative interventions, the optimal treatment strategy remains undetermined. This study aims to report the outcomes of medical management (MM), percutaneous mechanical aspiration (PMA), and surgical intervention in isolated TVE patients. Methods: We conducted a single-centre retrospective review of consecutive patients with isolated TVE from June 2020 to January 2023. Diagnosis was based on the modified Duke criteria and confirmed with echocardiographic findings. Patients were categorized based on the intervention received: MM, PMA, or surgical intervention. The type of intervention received was determined by the consensus agreement of a multidisciplinary high-risk heart team. Primary outcomes included 30-day and 1-year survival rates. Secondary outcomes included length of hospital stay, degree of residual tricuspid regurgitation, and complications including septic emboli, pleural effusion, and stroke. Results: Overall, 20 patients were treated for TVE: 7 received MM, 4 underwent PMA, and 9 underwent surgical intervention. The 30-day survival rates were 57.1% for MM, 100% for PMA, and 100% for surgery (p=0.038). One-year survival rates were 57.1% for MM, 100% for PMA, and 88.9% for surgery (p=0.155). PMA patients had the longest median hospital stay (14.5 days), followed by surgical (13.5 days) and MM (5 days) groups. Post-intervention echocardiography showed a significant reduction in tricuspid regurgitation severity in the surgical group but an increase in the PMA group. Complications including septic emboli, reoperation, heart block and pleural effusion were insignificant between groups. Conclusion: This study suggests that intervention, either PMA or surgery, may offer superior short-term survival benefits compared to MM in surgically fit patients presenting with isolated TVE. The findings highlight the need for a multidisciplinary approach in managing TVE and suggest further prospective studies are warranted to establish definitive treatment guidelines,

Despite advances in the field of cardiology, cardiogenic shock (CS) remains a management dilemma with a high mortality rate. While most cases of CS are secondary to acute coronary syndrome (ACS), approximately one-fifth can be attributed to delayed mechanical complications of ACS, such as arrhythmia, cardiac tamponade, or valvular heart diseases. The coexistence of CS and mitral valve diseases (MVDs) further complicates clinical presentation, diagnosis, and management strategies. Surgical interventions are considered the gold standard for managing MVDs in the context of CS. However, these patients are often at extreme surgical risk and may not achieve favorable outcomes. Catheter-based interventions have garnered increasing interest, but despite their promising results, most trials have excluded patients in unstable or critical conditions. Pharmacological and mechanical circulatory support provide a bridge to definitive transcatheter or surgical intervention.

Elderly patients with frailty and multiple comorbidities increasingly require mitral valve surgery. This includes patients who have previously undergone surgery with a tissue valve, which may deteriorate over time and require replacement. These cases are considered high-risk. There is growing interest in performing valve replacements using minimally invasive techniques, including access via the groin. However, such approaches are not always feasible. Here, we report the first case where innovative, "outside-the-box" thinking was employed to replace the valve using a non-conventional approach.