July - December - nuhcs

in this issue02 New Director of CVRI– Prof Mark Richards03 NUHCS/CVRI nuhcscvri Centre centre Grant grant04 EVAR & TEAVR Sizing andPlanning Workshopvisiting HMDP– prof Prof Claudio claudio Cina cina06 Vascular Medicine and Therapy– HMDP Visit08 Mending Broken Hearts– The the Minimally minimally Invasive invasive Wayway10 The 4 th Asian CardiothoracicSurgery Specialty Update Course11 Cardiac Electrophysiology andAblation – Implantable CardiacDefibrillator12 Lion City: My Second Home13 Asian Hospital Award– For Our RIE Project14 A UK Perspective15 My Year in Montreal, QueBecbec16 Watchman Device: No MoreWarfarin for Patients withAtrial Fibrillation17 3 rd Asia Pacific VenousThromboembolism ASTC18 A Survival Seminar onCardiovascular Health & Care19 The World Is Going“Minimally Invasive”20 Echo Singapore 200921 Visit byProf Shinichi Takamoto, M.D.EditorA/Prof Poh Kian Keongfractional Flow Reserve (FFR)Guided Angioplasty – A NewParadigm in Treating CoronaryHeart Disease22 Cardiac Department Family Day23 Highlight on the Best PosterAward at TCT24 Happenings26 Abstracts & Publications28 Directory, Award & CongratsAdvisorA/Prof Tan Huay CheemContents are not to be reproducedwithout the permission of NUHCSPro ProNew Director ofCardiovascularResearch Institute(CVRI)MarkRichardsWe welcome Professor MarkRichards, who joined us inNovember 2009 as the Director ofCardiovascular Research Institute(CVRI) and Professor in theDepartment of Medicine, NationalUniversity of Singapore (NUS).Prior to joining us, ProfRichards was a Cardiologist atthe Canterbury District HealthBoard and Professor in Medicineat t h e U n i ve r s i t y o f O t a g o,Christchurch. He will retain co-directorship of the ChristchurchCardioendocrine Research group and remain as Professorof Cardiovascular Studies for the National Heart Foundationof New Zealand.Prof Richards has been actively involved in research andreceived numerous local and national research grants from variousinstitutions in New Zealand. He is the author of more than 300peer‐reviewed articles published in various cardiovascular, generalmedicine, hypertension, clinical chemistry and endocrinology journalssince 1983. In addition, he is a member of the editorial boards fornumerous peer-reviewed journals which include European Journalof Internal Medicine, Cardiovascular Drugs Review, New ZealandMedical Journal etc.As a new director on board, Prof Mark Richards hopes toincrease the interaction between basic scientists and clinicians,develop research programs, provide infrastructure support,improvement on existing tests, diagnosis and treatment etc. Withintwo months of joining, Prof Richards has also lined-up a seriesof action plans for CVRI including rolling out a clinical studiesprogramme, setting up animal laboratory facilities and developinga biomarker assay laboratory.THI PULSE |

NUHCS/CVRICentre GrantProf Mark RichardsTheme Principal Investigators From Left A/Prof Ling Lieng Hsi, A/Prof Shirley Ooi, Dr Theodore Kofidis, Dr Carolyn Lam.The NUHCS/CVRI has been successful in securing a CentreGrant to pursue “bench to bedside” translational cardiovascularresearch. Led by Prof Mark Richards, Director, CardiovascularResearch Institute (CVRI) of NUHS, and four theme PrincipalInvestigators, Assoc Prof Ling Lieng Hsi, Assoc Prof Shirley Ooi,Dr Theodore Kofidis and Dr Carolyn Lam, the Grant of some$6 million over an initial 2 years (with the potential for furthersupport for up to 5 years overall) will underpin a programmeof research involving up to 100 investigators and collaboratorsaimed at improving the ability to detect and to manage a range ofheart disease.A major project within the programme will focus onpatients admitted to the major Singapore hospitals with heart failure.The primary questions to be addressed will include the relativeprevalence and outcome for heart failure with and without preservedventricular contractile function. Patients will be characterised withcardiac imaging, biomarker immunoassays and gene typing withthe intent to better understand the mechanisms underlying thespectrum of heart failure from those with low ejection fractionthrough to those with preserved contractile function. The eventualaim is to establishing specific improved therapies for subtypes ofheart failure.The biomarker theme will be further pursued in theEmergency Department, with exploration of novel candidate peptidebiomarker tests for detection of cardiac ischaemia or heart failurein patients presenting with new onset symptoms of possible acutecoronary syndromes or acute heart failure. These studies carry onthe Centre Grant Director’s long-term interest and expertise in thecardiac natriuretic peptides (including the cardiac B type cardiacpeptides BNP which are now established markers for the diagnosisof heart failure).Cardiac valve disease underlies heart failure in a proportionof cases and methods for assessment of the severity and rate ofprogression of major forms of valve disease (mitral regurgitationand aortic stenosis) are often unsatisfactory. The Centre Grant’svalve projects aim to assess the added value of plasma biomarkermeasurements in predicting progression of valve diseaseand in optimising timing of interventions such as valve replacementor repair.Finally, the “blue skies” element of the programme will consistof pre-clinical studies devoted to the development of bioengineeredtissue constructs seeded with progenitor cells to be used in therepair of post-infarction left ventricular scar.The overall programme incorporates the activity andpartnership of about 100 principal investigators, co-investigatorsand collaborators. Its translational nature is designed to link clinicto laboratory and it will act as a foundation for ongoing integratedcardiovascular research in Singapore.THI PULSE |

EVAR & TEAVRSizing and Planning WorkshopDr Jackie HoMedtronic, one of the leading aortic stent-graft producingcompanies, had partnered with the National University HeartCentre to organize an EVAR & TEAVR Sizing and PlanningWorkshop on 21 st –22 nd August, 2009. A/Prof Peter Roblessand Dr Jackie Ho were invited as speakers for the workshop.This workshop targeted clinicians who had just started or wereplanning to start their endovascular service for aortic diseases. Itfocused on the knowledge of planning and sizing of aortic stent-graftfor treatment of both abdominal and thoracic aortic aneurysm aswell as commonly encountered pitfalls and how to prevent them.Besides didactic lecture, participants were given aneurysm patients’CT scan for planning practice. The participants of this workshopconsisted of Cardiothoracic surgeons, Cardiologists, VascularSurgeons and Intervention Radiologists. They came from varioushospitals in Singapore, South Korea and Taiwan.Visiting HMDPProf Claudio CinaDr Jackie HoWe are honored and delighted to have Prof ClaudioCina to be the visiting expert to NHG from 20 th –26 th November.Prof Cina is the Professor of Surgery and Division Chief ofVascular Surgery in St Michael’s Hospital, University of Toronto. Hehas vast experience in open and endovascular surgery for the aortaparticularly thoracic aorta. He developed the Thoraco-abdominalaortic aneurysm surgery programme and the programme for Support,Investigation, and Technology evolution of Endovascular therapy inMcMaster University. He is the principle investigator of manyclinical trials, author to numerous journal articles and reviewer forrenounced journal including Cochrane library, Journal of VascularSurgery, Evidence Based Cardiovascular Surgery etc. As a dedicatededucator, he built a course to teach surgeons with basic endovascularskill to master the technique of endovascular stent graft treatmentfor aortic diseases. He received the PAIRO travel award for clinicaleducators, and “Mentor of the Year Award” by The Royal Collegeof Physicians and Surgeons of Canada in year 2004.On the first day of his visit, he provided a very comprehensiveyet interesting, easy-to-understand grand round on “Medicalepidemiology and Biostatistics for Clinicians”. He first illustratedwhy clinicians need to understand statistics and the common pitfallspeople get fooled by statistical data. He then vividly explainedthe process of how to formulate a clinical study and apply theappropriate statistical method. Among the audience, there weredoctors from different specialties, trainees, nurses and researchstaffs. They asked numerous questions and a thorough discussionTHI PULSE |

Vascular Medicine and TherapyHMDP visitA/Prof Peter RoblessVascular Medicine and Therapy, one of the core clinicalprograms at the National University Heart Centre, will focuson limb preservation and improved outcomes in patients withperipheral vascular disease. Cardiovascular disease is on the rise inSingapore and the Asia Pacific region. In 2007, the NUHCS vascularteam saw a 60% increase in the number of patients warded and a79% increase in patients seeking outpatient treatment. Patients withatherosclerosis (hardening of the arteries) often have multi-levelailments involving the heart, brain, kidney and lower leg arteries.Often due to the lack of awareness, patients with vascular diseaseare late in seeking treatment, resulting in a higher incidence oflower limb amputation, diseases of the heart and blood vessels aswell as death.The recently published Reduction of Atherothrombosis forContinued Health (REACH) Registry, an international prospectiveregistry of patients with cardiovascular disease, included 881patients recruited from Singapore. The findings were recentlypublished by A/Prof Yeo Tiong Cheng on behalf of the Singaporecollaborators in the Annals of the Academy of Medicine. Ouraverage patient age was 65 years with 80% of patients havingsymptoms from either heart disease, vascular stroke or lower legcirculation problems. One in five patients with lower limb vasculardisease suffered a cardiovascular event or was admitted to hospitalover the 12-month study period. It was found that known vascularrisk factors are common in Singapore patients within the REACHRegistry and that there was room for improvement in vascularrisk factor control.The World Health Organisation estimates that one-third ofthe world’s diabetic patients will come from Asia by the year 2025.Complications from diabetes pose a large healthcare burden to theindividual and the community. Foot problems are the most commoncause of admission to hospital for people with diabetes and mayaccount for up to 40% of healthcare resources in developing countries.Fortunately up to 85% of amputations can be avoided and prevention isthe first step towards solving diabetic foot problems. Strategies aimedat preventing foot ulcers are cost-effective and can be cost-saving.Once diabetic foot problems develop, a multi-disciplinary approachis required to manage these complications effectively.To this end, an NHG Human Manpower Development PlanGrant was awarded to a team from NUHCS to visit two centres ofexcellence in the USA to observe their vascular medicine and limbpreservation programs. The team comprised a Vascular Surgeon(PAR), Vascular Technologist (CC), Podiatrist (AE), VascularNurse (FA) and a CTVS OT Nurse (HK). We visited the Beth IsraelDeaconess Medical Centre (BIDMC) in Boston, which is home tothe world famous Joslin Diabetes Centre and a teaching hospitalof Harvard Medical School. The team also visited the ClevelandClinic Heart and Vascular Centre, Cleveland, Ohio as well as theYale New Haven Hospital in Connecticut, New England.We were generously hosted by Dr David Campbell and teamat BIDMC to observe first hand a world renowned multidisciplinaryteam comprising vascular surgeons, podiatric surgeons andendocrinologists specializing in lower limb salvage. The teambenefited from direct observation of inpatient and outpatient care,THI PULSE |

operative and interventional proceduresand multidisciplinary case discussion atBIDMC.At the Cleveland Clinic we werehosted by Dr Roy Greenberg from theDept of Vascular Surgery. The teamwas able to observe vascular medicineward rounds, multi-discipline meetingsand visit the non-invasive vascular lab.SN Hamidah visited the hybrid OR suiteto observe the workflow and practice ina hybrid operating room. Several casesincluding hybrid CABG/PCI, fenestratedand branched endografts, hybrid arch and ascending aorta surgerywere observed.At the end of the HMDP visit, two members of the team(PR and AE) were invited to visit the Yale New Haven Hospitaland Medical School’s section of vascular surgery. We were hostedby Prof Bauer Sumpio, a leading figure in lower extremity limbsalvage. It was an education to visit Yale and to observe the lowerlimb clinics and vascular programme in action.Having visited three centres of excellence, we observedthat excellent results were achieved by having several disciplinesincluding allied health working together to care for patients withlower extremity vascular disease.The newly formed vascular medicine programme at NUHCSaims to prevent amputation and to save lives and limbs potentiallylost to vascular disease. One of the goals of the vascular medicineteam HMDP is to start a one-stop clinic and inpatient ward round forpatients with vascular disease based on the programs we observed fromour visit. This more coordinated and holistic approach encouragescollaboration, innovation and improved patient experience.Members of the HMDP TeamA/Prof Peter Robless Senior Consultant vascular surgeonCarole Canlas Vascular technologistAdriaan Erasmus Principal PodiatristHamidah Karim Theatre nurse (CTVS)Florence Ang Vascular care nurseTHI PULSE |

mending broken heartsThe Minimally Invasive WayDr Cindy Hia, Dr Terence Lim, A/Prof Quek Swee Chye,A/Prof William Yip & Dr James YipDr Zahid Amin with the Paediatric and Adult Cardiology team.Left to right: Dr Cindy Hia, Dr James Yip, Prof Zahid Amin, A/Prof Quek Swee Chye,A/Prof William Yip. Absent with apologies: Dr Terence Lim.Transcatheter intervention in congenital heart disease hasalways been an exciting and challenging field, perfect for thepaediatric or adult congenital heart disease cardiologist who thriveson adrenaline surges. Cases are often varied and the success ofeach intervention is not only dependent on the technical skill ofthe operator but also on strategizing the safest route to achieve anacceptable physiological state for a given complex lesion.This year, we had the privilege of having Professor ZahidAmin to perform some challenging transcatheter interventions withus. He was invited under the auspices of the National University ofSingapore. Professor Amin has a remarkable background. He firstobtained did his fellowship in cardiovascular surgery in Texas HeartInstitute, Children’s Hospital of Philadelphia and Miami Children’sHospital before pursuing a carrier in paediatric cardiology. He isnow the Director of the Cardiac Catheterization & Hybrid Suite atRush Center for Congenital and Structural Heart Disease, Chicago.Once over dinner, he remarked that he has always been enthralledwith the heart as an organ. As he went through his rotations insurgery, he found that “the heart was the most beautiful in the body.”He went on to describe how one could stop the heart during surgeryand restart it again thereafter and it would continue to beat. “Trydoing that to the brain,” he said.His visit started with detailed discussion of the cases that wehad proposed to do with him. Over the next few days, we performedseveral diagnostic and interventional cardiac catheterizations withhim. The first two patients were 4-year-old girls who had moderatelylarge secundum atrial septal defects. These were successfully closedusing the Amplatzer ASD occluder.ASD device closure is now commonly done and has becomethe mainstay for treatment of patients with favorable anatomy.However, this procedure is as much an art as it is a science. Thereare so many different ASD devices available on the market at presentand even experts may have difficulty agreeing with each other ontype and size of device for a given defect. Fortunately, we had themaster to give us his thoughts on ASD closure using the Amplatzerdevice – Professor Amin not only happens to be the proctor forAGA but also monitors all complications arising from the use ofthe Amplatzer ASD occluder device.There were three particularly memorable cases. One wasan elective balloon dilatation of a previously implanted stent ofrecoarctation of the aorta following subclavian flap repair for ayoung man. This patient was the first patient to undergo stentingof coarctation of the aorta in Singapore. This was performed at ourvery own hospital together with Dr Michael Rigby (Royal BromptonHospital, London, UK) in 2007 during his visit as a HMDP visitingexpert. Occasionally, when the coarctation is very narrow, repeatdilatation of the stent is required after one to two years. This usuallyinvolves the use of a high pressure balloon 16 –20mm in diameter.The procedure in this patient was successfully accomplished.The second case involved stenting of coarctation forrecoarctation after repair of double aortic arch for a teenager.Again, this was a very tight recoarctation. Stenting for coarctationof the aorta is usually done for adolescents and adults who havebeen diagnosed late with native coarctation of the aorta or haverecoarctation of the aorta. It is an acceptable alternative to surgery.Several varieties of stents and balloons are now available to theinterventionist such as bare stents, covered stents, pre-mountedstents, ordinary high pressure balloons, BIB (balloon-in-balloon)balloons to name a few. Biodegradable stents are also beingdeveloped for young infants.Stenting of coarctation is not for the faint-hearted.Angiography is first performed in the ascending aorta to visualizethe site of coarctation. From the femoral artery, a large long sheath(usually 10 –14 Fr) is advanced into the descending thoracic aortaover a stiff long-exchange wire parked (preferably in the rightsubclavian artery) to till it is beyond the site of coarctation. Theballoon-mounted stent is then advanced into its proper positionacross the coarctation site. The sheath is then withdrawn distallyprior to inflation and deployment of the stent. Understandably,THI PULSE |

Figure 1Figure 2the major complications of this procedure include aortic rupture(and death), dislodgement of the stent and femoral arterialthrombosis. As such, a vascular and/or congenital cardiothoracicsurgeon should be on standby during this procedure. We are happyto report that our patient had a successful deployment of the stentwithout any complications (see Figure 1).The third patient had complex cyanotic heart disease withuniventricular physiology. He had undergone successful completionof Fontan procedure but had developed cyanosis over time. Adecision was made to close his Fontan fenestration to improve hisoxygen saturation. This was done using an Amplatzer ASD occluder(see Figure 2).Apart from learning tips and tricks at the cath lab, we hadthe opportunity to glean some pearls of wisdom from his lecturesand through insightful case discussions. We hope that ProfessorAmin found his visit to Singapore as memorable and enjoyable aswe found it.There is one thing which we will always remember fromhis visit – indeed, “the heart is a beautiful organ”.Answer to ECG QuizSilent Myocardial IschaemiaThe ECG in panel A is normal. The ECG in panel B showsthe following: (1) the sinus rate is 150/min (ii) markedhorizontal ST segment depression (approximately 2 mm) isseen in multiple leads — V3 to V6, II, III and aVF. Subsequentcoronary angiography showed severe triple vessel disease. TheST segment depression during the stress test was regarded asbeing due to myocardial ischaemia. In the absence of any chestpain, the patient was diagnosed as having silent ischaemic heartdisease. After coronary artery bypass grafting was performed,a treadmill exercise stress test was repeated and the ECG wascompletely normal.Silent myocardial ischaemia is a challenging clinicalentity, where the patient has significant myocardial ischaemia,but no chest pain. It is seen most commonly in patients withdiabetes mellitus.Acknowledgements:Dr Vivien Yip, for inspiring Prof Zahid Amin’s rendition of “the heart is a beautiful organ”.THI PULSE |

The 4 th AsianCardiothoracic SurgerySpecialty Update CourseDr Ooi Oon CheongThe Department of Cardiac, Thoracic & Vascular Surgeryof the National University Heart Centre Singapore (NUHCS)was proud to host the 4 th Asian Cardiothoracic Surgery SpecialtyUpdate Course (ACSSUC) recently. Back by popular demand, itwas attended by a significantly greater number of delegates thanduring its inaugural meeting in 2006. Held over a three-day periodbetween November 19 th and 21 st , a total of 132 cardiac, thoracic,and vascular surgeons from Asia, Europe and the Middle Eastparticipated in the course at the Clinical Research Centre, NationalUniversity of Singapore, making this the most successful course yetin the series. A record‐breaking number of nurses and allied heathpersonnel, 159 and 48 respectively, descended upon the satellitevenue at the Khoo Teck Puat Advanced Surgery Training Centre(KTP – ASTC), National University Hospital, for seminars on thenursing and perfusion aspects of cardiac and thoracic surgery.Organised jointly by the NUHCS, the Chinese Universityof Hong Kong, and the Royal College of Surgeons of Edinburgh,this Update Course is held annually between Singapore and HongKong on alternate years. The course was moderated by both localand international experts in the field and generated a lot of livelydiscussions between the delegates and faculty members. “Thiscourse was designed to provide a platform to discuss contentioussubjects close to the heart and management of complex cases, andto feature clinically relevant information on present and futuredirections in these areas. It is our aim for this course to be botheducationally enlightening and socially entertaining,” Prof LeeChuen Neng, Head of the Department of Cardiac, Thoracic &Vascular Surgery, NUHCS, who is also the Organising Chairmanthis year, explained.Lt. Colonel Dr Ali Gohar Zamir, a consultant cardiac surgeonfrom the National Institute of Heart Disease in Rawalpindi, Pakistan,found the interactive sessions on Applied Physiology and Critical Careparticularly useful in updating his basic science knowledge on thecardiovascular system. He also said, “Prof Lee’s lecture on Trainingthe Cardiothoracic Surgeon of the Future has given me a clearer visionof the specialty’s cutting-edge training armamentarium.”A new highlight that was added to the course for the veryfirst time in the series is the Pre-Course Skills Laboratory sessionson advanced cardiac surgical techniques in which 30 delegatesparticipated. The Mitral Valve Repair session was instructed byDrs Nguyen Van Phan and Taweesak Chotivatanapong, renownedcardiac surgeons with a special interest in the mitral valve fromVietnam and Thailand respectively. The Bentall’s Operation sessionwas taught by Dr Chua Yeow Leng from the National HeartCentre Singapore and Dr Malakh Shrestha from Germany. Boththe instructors and participants were impressed by the trainingfacilities at the KTP – ASTC Surgery and Minimal Access Research &Training (SMART) Laboratory in which these workshops were held.Professor Patrick Magee, Course Convenor from the Royal Collegeof Surgeons of Edinburgh said, “I also thought the wet lab was agreat success. This was helped of course by the wonderful facilitiesin the postgrad centre.”Building on the success of this course, the tripartiteconvenors have decided to host the 5 th Update Course again nextyear around October. Three workshops are planned: SurgicalPrinciples of Thoracic Trauma, Mitral/Aortic Surgery Techniquesand Simple/Complex Video Assisted Thoracic Procedures.Here’s wishing another round of groundbreaking seminars in 2010.Merry Christmas and a Happy New Year to all!THI PULSE | 10

Cardiac Electrophysiology and AblationImplantableCardiac DefibrillatorLive coursesDr Seow Swee ChongHeart rhythm disorders (arrhythmias) are common ineveryday medical practice. Over the past decade, major advancesin technological capability have led to great leaps in understandingthe mechanisms of arrhythmias. This has led to a rapid expansionof the subspecialty field of cardiac electrophysiology particularlyin developed countries.Today, electrophysiology is the “gold standard” for thediagnosis of cardiac arrhythmias and the advent of radiofrequencyablation (RFA) together with sophisticated three-dimensionalelectroanatomical mapping systems have made a “cure” possible formost arrhythmias. Yet, the adoption of such technology has been slowerin Asia primarily because of the infrastructure required to supportsuch complex procedures and the cost of sophisticated equipment.Sudden cardiac death has been prominent in the newsrecently. Its burden is expected to increase as the population agesand more people are afflicted by heart disease contributed to inpart by diet and lifestyle. For persons at very high risk of suddendeath, the implantable cardiac defibrillator (ICD) has been shownin numerous trials to reduce this risk by as much as a third. Unlikea pacemaker, the ICD implant process involves more complexprogramming and diagnostics. With the recent revision of theAmerican and European Cardiology guidelines advocating the useof ICDs in advanced heart failure, there has been an upsurge in thenumber of such procedures worldwide. Asia has only just started tocatch on this trend, with many physicians keen on performing theprocedure but with limited access and exposure to training.As a leading tertiary cardiology centre in the region, theCardiac Department at the National University Hospital organizedan Electrophysiology and ablation course in August and a live ICDimplant course in July 2009 to meet these needs.With participants comprising Cardiologists and TechnicalSpecialists from regional countries (Korea, Thailand, Vietnam,Philippines), these courses, which were organized by Dr SeowSwee Chong and Dr Abdul Razakjr Bin Omar (both ConsultantElectrophysiologists at NUH), were well-received and a resoundingsuccess. It was also an excellent opportunity for our doctors to networkwith regional physicians and exchange ideas; as well as to establishworking relationships with medical institutions internationally.THI PULSE | 11

LionCity my secondhomeA/Prof Ronald LeeIn 2002, I was pursuing my overseas training in Rotterdam, theNetherlands. The winter in Europe is always freezing cold, at leastcompared with that in Hong Kong. One day, I read the news thatSingapore is committed to developing herself into a research hubin Asia. At the same time, I was contemplating if I should move tothe Lion City.The migration to Singapore was not a smooth process at thebeginning. Referred by a previous colleague, I met Professor LimYean Leng at the National Heart Centre in the Outram campus.However, during the interview, Professor Lim told me that he wasabout to return to Australia. He suggested that I met his brother atthe National University Hospital. Although I was puzzled, I decidedto give it a try. It turned out that this could be the most importantmeeting in my life. The interview with Associate Professor LimYean Teng was surprisingly smooth, and I was offered the post ofassociate consultant on the spot. With joy and ambition, I returnedto the Netherlands to continue my training the next day.Needless to say, I had to spend an enormous amount ofeffort to convince my wife and my parents about the changes thatwere going to happen. Furthermore, selling my apartment in HongKong actually incurred a loss of S$400,000. After overcomingall the hardship, my wife and I eventually came to Singapore tolook for accommodation in the summer of 2003. This was inthe immediate aftermath of SARS, the dreadful infection thataffected both Hong Kong and Singapore badly. The most directand immediate impact on us was that nobody here was willing tolet me view their apartment when they knew we came from HongKong. With much difficulty and negotiation, we managed to settledown at Tiong Bahru.July 11, 2003 was the first day I started working at theNational University Hospital. The medical system and hospitalworking environment in Singaporeand Hong Kong are similar, butnot identical. It is fair to say thatthere are pros and cons for thetwo systems. In Singapore, theremuneration for doctors isrelatively low (I startedby making half of myprevious salary in HongKong), the cardiac wardsare not air-conditionedand the public transportto National UniversityHospital is inconvenient.On the other hand, thereare certain key features thatmade my adaptation easyand without much pain. Thecolleagues here are veryfriendly and supportive.Helping hands are alwaysaround whenever needed.My knowledge, skills andexperience in interventionalc a r d i o l o g y a r e b e t t e rInterventional cardiology team at the NationalUniversity Hospital, during the 1st AsianInterventional Cardiovascular Therapeutics(AICT) in 2006.recognized and respected here. Chief and leaders at the departmentare young, energetic and open-minded. There is a strong culture offree exchange of views and opinions on various issues pertainingto our work. Nobody will get penalized by expressing a differentopinion.In this stable and harmonious working environ-ment, Imanaged to start and cultivate my research projects. Importantly,I am given all the trust, support and independence a youngresearcher needed. Under the leadership of Associate ProfessorTan Huay Cheem, my research output has steadily increased, andpublication in reputable medical journals has begun over the pastfew years. Needless to say, these achievements would not have beenpossible without the contribution and support of my colleagues.Joining the Yong Loo Lin School of Medicine as an academic staffin 2007 and being awarded the degree of Doctor of Medicine in2009 represent two important milestones in my academic career.Yet, what I treasure most is still the friendship I have cultivatedwith my like-minded comrades over these years.Is there any difficulty in adapting to living in Singapore?The answer is ‘Yes’, in two areas. I miss the winter in Hong Kong.This is especially true during Christmas and New Year, whencold weather is a prerequisite for festival atmosphere. Besides,even though there are many delicious cuisines in Singapore, I stillmiss the roasted goose and preserved eggs at ‘Yung Kee’ restaurant,French toast and pantyhose milk tea in the neighbourhood cafes, aswell as dim sum I used to enjoy every weekend. I have yet to findan authentic Hong Kong cafe in Singapore.After living in Singapore for close to seven years, my wifeand I finally decided to start our family here. With God’s blessing,our twins would have been born by the time the next issue of‘Pulse’ is in print. Hopefully, they will be healthy and adorable.As a parent-to-be, my wish for them is that they would inherit thepleasant characters of Singaporeans, including being energetic,optimistic and hard working.THI PULSE | 12

New Consultanta UKperspectiveDr Kristine TeohReturning to Singapore tojoin the team at NUHS, I haveencountered the same issues as Ipreviously faced in the UK and feltthat this was an opportune momentto share my thoughts.A week into my post I acceptedthe challenge of working with the CTVSdatabase team to produce an AdultCardiac Surgical Database Report,and was introduced to the conceptof ACGME. The first challenge reminded me of James Wisheart’ssuspension during the Bristol Inquiry, and the ramifications of theinvestigation and its conclusions on the National Health Service.In the case of the second challenge, memories and misgivings ofthe UK Department of Health’s “Modernising Medical Careers”(MMC) programme came flooding back.Initially aimed at streamlining the “lost years” of the SeniorHouse Officer (SHO) grade, MMC evolved into a completerestructuring of postgraduate medical training. The goal was totrain a specialist within eight years of leaving medical school, withan optional two more years for subspecialty training. It was laterrevealed (by the DH) that one purpose of MMC was to water downpostgraduate training so that all doctors would be trained sufficientlyfor service provision as a “sub-consultant specialist” grade, but onlya few would progress to full consultant status. This agenda hasapparently been shelved, but not without some uproar – not helpedby the Deputy Chief Medical Officer advising medical students to“scale down their career expectations in future.”Ten thousand doctors marched in protest. The FinancialTimes described the implementation of MMC as “inefficient,inflexible and inhumane”, observing that “these highly trainedprofessionals … are being treated with contempt”. An all-partyCommons Health Committee described its implementation as“defective”, “unsafe”, “disastrous” and “inept”, and was critical ofmedical leadership as “ineffective” and “unable to speak with acoherent voice”. In May 2007 the BMA Chairman, Jim Johnson,resigned over his support of the government’s reforms.Five years down the line, the UK is slowly ironingout the problems that arose out of MMC and its recruitmentprocess, MTAS. As we take our first steps to implement our ownMinistry of Health’s agenda for change in postgraduatemedical training in Singapore, and work with ACGME to developa structure for a five-year training programme and for recruitmentinto this training, we must take care to learn from the UK’s examplerather than making the same mistakes. It is crucial that a wholegeneration of doctors and their patients do not suffer.On a more positive note, cardiac surgery in particularhas responded well to the challenge of Bristol, leading theway in benchmarking and reporting in the UK. The drive toimprove the quality of healthcare here at NUHS is on thesame wavelength as my own philosophy. Interrogating ourDendrite database to produce our own ‘Blue Book’ will bejust the first step towards expanding and improving our clinicalservices. The pursuit of quality also includes the opportunity toexplore and develop my research interests and ideas, and to beinvolved with teaching and training tomorrow’s consultants. I lookforward to it!THI PULSE | 14

My Year InMontréal, QuébecTo be exact, it was actually a year and four months. I confess tohaving been extremely ill-prepared for my time in la belle province.First, my crash course in French was barely sufficient for ordering ameal at a restaurant, let alone holding a conversation with a patient.Needless to say, when I found out that I was going to be workingand living in the most hard-nosed francophone part of the city, Ipicked up the language very quickly. My second mistake was todelegate my search for an apartment to someone else, with thesimple typically Singaporean instructions to “find some place good,convenient and cheap.” Upon arrival at my new home in Montréal,I was perhaps not surprised to find that only the last criterion hadbeen fulfilled.As previously discussed with my mentor at the MontréalHeart Institute (MHI), Dr Jean-François Tanguay, I was to spend fourdays a week in the cardiac catheterization laboratory and one day aweek in Dr Pierre Théroux’s platelet laboratory. My first day in thecatheterization was truly an intimidating one. Not having toucheda catheter for two years during my research fellowship at Duke, myanxiety heightened when I was told by Jean-François that he wouldbe checking emails on his Blackberry in the control room after hislong summer vacation, and that he would only enter the angiographysuite if I encountered any difficulty. That was the French-Canadianway of building independence in their fellows, and it certainlyserved that purpose well! The attendings would patiently observe,and occasionally give verbal cues, while fellows struggled throughcases during the early part of their training, and they would only takeover when there were safety concerns. In order to facilitate training,four catheterization suites would function for an operating list thatwould normally require only two suites, as fellows were expected totake longer than experienced attendings. No concerns about waitingtimes, maximization of catheterization laboratory facilities or othersuch mundane affairs – vive la système de santé Canadienne!Starting out in the platelet laboratory was not any easier,and the first few sessions were spent relearning the most basictechniques such as pipetting platelet rich plasma without disruptingthe buffy coat. My supervisor in the platelet laboratory, Dr ArnaudBennefoy, jokingly asked if it was more difficult than performingpercutaneous coronary intervention, but fortunately, he did notwait long enough for my response! I found the offline analysis offlow cytometric data to be the most challenging exercise in theDr Mark Chanplatelet laboratory, and it took me many weeks to just to grasp thebasic concepts and to be proficient in using the various softwaremodules. I was working on a novel fluorescent labeling techniqueto determine the order of platelet membrane lipid rafts, but thewide emission spectra of the fluorochrome used meant that we hadto work on an eight-colour flow cytometer to get the co-labelingexperiments right. Many of the ex vivo shear-induced aggregationmodels I worked on were also home-brewed contraptions, sotroubleshooting of technical issues was required on a regularbasis. On an intellectual level, I would certainly agree that thiswas a lot harder than interventional cardiology, but at a practicallevel, I realised that there were many parallels in the plateletlaboratory and catheterization laboratory – that attention to detail,a well‐prepared protocol or strategy, and the ability to improvisewere all key to success in either domain. In fact, I found my timein the platelet laboratory to be such an enriching experience thatI spent an additional three months of unpaid leave to complete myseries of experiments.But the most enjoyable time was when my buddy from theDuke Clinical Research Institute, Dr Marc Jolicoeur, came back towork as an attending physician at the Montréal Heart Institute. There,together with a friend from São Paulo, Brazil, and another colleagueoriginally from Taiwan, we performed a series of myocardial infarctionexperiments in animal models to detect metabolomic markers ofmyocardial injury. So for five straight days, we spent mornings in theanimal laboratory, afternoons in the metabolomic laboratory, andevenings at some of the best restaurants and wine bars in Montréal.Another memorable occasion was when A/Prof Tan Huay Cheem andDr Adrian Low attended the interventional symposium organised bythe Montréal Heart Institute last summer. Then it was good friends,good food and good wine all over again. Who said science and fundo not go hand-in-hand?I will not have space to write about the long-harsh winter,the voluminous amounts of transmission-wrecking snow and thevery cold but very enjoyable winter vacation I had in Charlevoix,Québec because that will have to be a full-length article by itself. I’mtruly grateful for the time spent in this great city, which has exposedme to some very unique opportunities that I would otherwise nothave experienced had I remained in the United States for my clinicaltraining. Au revoir et merci beaucoup, mes amis de Montréal!THI PULSE | 15

Watchman Deviceno more warfarinfor patientswithAtrial FibrillationDr James YipThe Watchman Left Atrial Appendage Occluder.On 20 th October 2009, NUHCS implanted its first patient with theWatchman Device. This is a left atrial appendage (LAA) occlusiondevice which is designed to prevent the embolization of thrombithat may form in the LAA in patient with atrial fibrillation (AF). Itmay protect patients from ischemic stroke or systemic embolismand eliminate the need for long-term anticoagulation (warfarin)therapy. Patients with AF are at significantly higher risk for ischemicstroke or systemic embolism than patients who do not have AF.About 91% of all thrombi in patients with non-valvular AF isfound in the LAA. Chronic anticoagulation in the elderly carriesthe risk of significant bleeding in about 1% per year along with theneed frequent blood testing for INR and warfarin titration. Thisprocedure is suitable for patients with a non valvular cause of atrialfibrillation and significant risk factors for embolism which requireanticoagulation therapy.Our patient had atrial fibrillation and a history of priorstroke with hemorrhagic conversion. After initial transesophagealechocardiography (TEE) which confirmed a favourable LAAFluroscopic image of the Watchmandevice deployed.Transesophageal Echocardiogram of the Watchmandevice being deployed in the left atrial appendage.anatomy, we performed a trans-septal puncture under generalanesthesia in the cardiac catheterization lab with initial vascularaccess through the femoral vein. The Watchman device wasdeployed in the left atrial appendage under TEE and fluoroscopicguidance. The patient was able to ambulate the same day after theprocedure and was discharged on both warfarin and anti platlettherapy. About seven weeks after the procedure, another TEE wasperformed to check the seal of the Watchman device. Warfarin wasthen withdrawn and the patient continued on long term antiplatlettherapy.In the recent PROTECT AF Trial (Lancet 2009; 374:534 – 42) the primary efficacy event rate was 3·0 per 100 patient inthe intervention group and 4·9 per 100 patient-years in the controlgroup. This showed that treatment with the Watchman device wasnot inferior to warfarin therapy and may be an alternative strategyto chronic warfarin therapy for stroke prophylaxis in patients withnon-valvular AF.THI PULSE | 16

3 rd Asia PacificVenousThromboembolismTraining ProgrammeASTC 27 th – 28 th Aug 2009A/Prof Peter Robless and Dr Teo Swee GuanThe 3 rd Asia Pacific VTE Training Programme was held onthe 27 th – 28 th August 2009 at the Tan Sri Khoo Teck Puat AdvancedSurgery Training Centre at NUH. The aim of the programme wasto highlight the current practice in prevention, diagnosis andtreatment of venous thromboembolism (VTE) in the Asia Pacificregion. This was the third regional workshop of its kind and theprogramme was kindly supported by an educational grant fromSanofi Aventis. The core topics discussed were the current evidencebase for VTE prevention and management, novel anticoagulants,regional incidence of VTE, computer aided anticoagulation,pharamcogenetics, imaging, mechanical thrombolysis, lowmolecular-weight heparins, VTE in the ICU and stroke, IVC filtersand endovenous interventions.Following the success of the previous workshops thehighly‐rated vascular ultrasound workshop held at the Non-InvasiveVascular Lab, NUHCS, was in high demand. The participants weregiven a hands-on session on non-invasive imaging in venous andarterial disease by Carole Canlas and Cathy Serrano. Our principalpodiatrist Adriaan Erasmus and the team was also on hand todemonstrate current best practice in the venous ulcer workshopusing live patient case demonstrations.Guest teaching faculty included A/Prof Liew Ngoh Chin(Putra University, Malaysia), Dr Huyen Tran (Australian Centrefor Blood Diseases, Monash University), Dr Rajiv Parakh (Headof Vascular and Endovascular Surgery, Sir Ganga Ram Hospital,New Delhi) and Dr Manish Taneja (Dept of Radiology, SingaporeGeneral Hospital). Our multi-disciplinary local faculty fromNUHS included Drs Teo Swee Guan, Sudhakar Venkatesh,Jackie Ho, Hee Hwan Tak, Benjamin Chuah, Suresh Nathan,Graeme MacLaren, James Yip, Bernard Chan, Adriaan Erasmus,Carole Canlas, Cathy Serrano, Florence Ang, Raj Siddhu andPecky De Silva. There were 27 attending delegates from Australia,Indonesia, Taiwan, Pakistan, Malaysia and Singapore.It is an exciting time to be involved with the care of venousdisorders as there have been several key advances in the lastdecade. Dr Huyen Tran opened the workshop with an update onVirchow’s triad explained with advances in molecular biology. Thelatest ACCP Guidelines (2008) were summarised by Dr Jackie Ho.The state of VTE in Asia and India was summarised by Drs NCLiew and Rajiv Parakh respectively. In addition, the most up-todatework from the region and the international collaborative effortleading to improved understanding of these topics was presentedand discussed. Venous and lymphatic diseases are both common anddistressing for sufferers. From the active regional participation inthese workshops, it is clear there is an unmet need in education andawareness in managing venous thromboembolism in the region.Venous disease also imposes a large financial burden on the healthservices of most industrialised countries. This workshop broughttogether a genuinely multi-disciplinary approach on all aspectsof venous thromboembolic disease, diagnosis, pathophysiologyand treatment. This workshop aimed to provide those attendingwith knowledge of the current thinking in the effective clinicalmanagement of venous disease, current practice in tertiary regionalcentres and exchange of ideas from the Asia Pacific region.THI PULSE | 17

A Survival Seminar OnCardiovascular Health & Careof heartsand healthSharon ChanOn the 3 rd of October, National University Heart Centre,Singapore (NUHCS), with the aid of our Corporate Planning andDevelopment colleagues, collaborated with Channel NewsAsiato organize a public seminar. The seminar, held at Suntec CityConvention Centre, focused on two main concerns – heart failureand heart attack.Five of our heart specialists – A/Prof Tan Huay Cheem,A/Prof Michael Caleb, Dr Chai Ping, Dr Abdul Razakjr andDr Raymond Wong – shared and discussed with the participantson how one can outsmart heart diseases, what one can do whenan attack occurs and why there is now better hope for heart failuresurvivors.“Of Hearts and Health” garnered much interest and thetickets were sold out two weeks prior to the event. We even had toturn down some interested members of the public who had comeby on the actual day in an attempt to purchase the tickets onsite.For participants who managed to get the tickets, they were not tobe disappointed.Not only were the talks engaging and educational butthey also gave an insight which cannot be otherwise obtained.Several of the videos shown during the talks were exclusive andnever‐seen‐before footages. During the break, our participants werealso treated to “live demonstrations” where we had volunteers on thetreadmill showcasing an exercise stress ECG test and the workingsof an echocardiography machine. Last but not least, the seminarended with an interactive and intense Q&A session between theparticipants and our panel of speakers.All in all, it was a huge success!THI PULSE | 18

NUHCS Venturing Forward...the world is going“minimally invasive”Dr Theo Kofidis & Prof Lee Chuen NengAs cardiac surgery evolves to include less invasivetechniques, we, at the CTVS of the NUHCS are following pace withthe world’s leading centres. We have recently introduced minimallyinvasive programme for heart valve surgery, to provide up-to-datepatient care at the lowest possible trauma for the patient.One of the primary principles of surgery is to operate bycausing the least possible burden, complications and immobility tothe patient. As technology evolves, so do the various approachesto treat heart disease: new instruments and techniques in theoperations theatre, as well as newly acquired surgical skills come toaccomplish the spectrum of procedures offered to our patients.We have recently started the minimally invasive mitralvalve surgery programme, using high-end equipment and the mostadvanced surgical standards. With mitral valve disease dominatingheart valve nosology in the region, the new methodology, whichdoes not require a median sternotomy, seems to be very welcomedby our patients, and attracts them from all corners of the globe. Aswe use to say in our surgical jargon “all that the patients takes homefrom the hospital is his scar,” and the one associated with mediansternotomy may be deterrent for many of them. Indeed, many ofour mitral valve patients lately, have opted for the new procedure,due to the less invasiveness, better cosmesis, better and immediatemobilization, less bleeding and infection complications and shorterhospital stay the new procedure offers.Briefly, a median sternotomy is omitted, and instead,a mini-lateral thoracotomy of 5cm is fashioned. Tiny incisions(3 – 5mm) are made to introduce the necessary retractor and thecross-clamp or camera. The procedure is done on the arrestedheart using shafted, endoscopic instruments. The exposure of themitral valve (and tricuspid if necessary) is excellent and superiorto that achieved through a median sternotomy. The valve can beboth repaired or replaced through this access, and internationalexperience is cumulating fast. In fact, the minimally invasive heartvalve surgery is already considered the golden standard in many ofthe leading cardiac centers of the western world.“We make our mark by continuouslytrying to overcome it” –turning minimally invasive heartvalve surgery even less invasive.Is it enough for NUHCS toestablish new services started in otherdeveloped countries, to make its markas a world leader in cardiac care? Ofcourse, staying current with the latestdevelopments is one part of the evolutionand survival process in the upcoming harshcompetition in Asia. But we want to look further, and bringabout novelty to take the lead and deserve our reputation asthe leading centre in Asia. Backed by a very robust and innovativeCardiology team, an ever-growing research apparatus, newteaching modalities, an innovative Advanced Surgical TrainingCentre, we shape the procedures of the future. We develop thenew procedures further and share our experience with ourcolleagues at a local and international level: we have alreadyperformed combined procedures through the mini-lateralthoracotomy, treated atrial fibrillation in mega-atria (7 – 10cm)with excellent results. We design new atrial retractorsto omit even the otherwise most essential working ports on the chestwall. The last procedure for instance was carried out through a singleaccess mini-thoracotomy, without any ports for CO 2 insufflation,camera, venting, or otherwise. The size of the atrium or the heart orconcomitant pulmonary hypertension are not deterrent for the choiceof this procedure.Patient satisfaction is high and gratification for the surgeonand referring cardiologist similarly so. We have seen patients wakingup in joy following the procedure in the ICU and looking for the scar,which they cannot find. This is a primary source ofreconfirmation for our NUHCS team, that possessesmore gravity than any published statistics and numbers.We have included some photographs of our patients, onedecompensated before surgery, the other one an athlete withnew-onset atrial fibrillation, restored and satisfied three resp.eight days after the operation, both in sinus rhythm, the second one(a US citizen) back to full sports activity.With the remodeled NUHCS coming up, enriched bya hybrid theatre, a young and aspired team for trans‐cathetervalve therapy, flanked by a whole array of minimallyinvasive and robotic procedures, we look forward to a brightfuture of prosperity of knowledge, patient care and academic spirit.Singapore and NUHCS are ready to make their mark in healthcare – and pass it!THI PULSE | 19

Echo Singapore 2009A/Prof Ling Lieng Hsi, Programme Director,Echo SingaporeInternational and regional experts in cardiovascularimaging convened for the 5 th Echo Singapore 2009 meeting heldat the Clinical Research Centre, Yong Loo Lin School of Medicine,NUS, from 14 th – 16 th October 2009. The conference was jointlyorganized by the National University Heart Centre, Singapore,and National Heart Centre, Singapore, and co-sponsored by theSingapore Cardiac Society. Programme Directors were Drs LingLieng Hsi and Bijoy Khandheria and Associate Directors, Drs DingZee Pin and Yong Quek Wei. For 2009, the overseas faculty includedDrs. Dominic Leung, Jagdish Mohan, Mark Richards, GregoryScalia, Lissa Sugeng and Gabriel Yip, all luminaries in their fieldsof expertise. They were expertly supported by our distinguishedlocal faculty from all cardiac care hospitals in Singapore.Consonant with the theme “Cardiovascular Ultrasoundin Practice”, Echo Singapore 2009 highlighted the use ofechocardiography and complementary imaging modalities inclinical practice, particularly in the universe of Heart Failure,a major cardiovascular problem in this region and worldwide.The programme also emphasized the growing role of 3-DimensionalEchocardiography in the assessment of cardiac remodeling andmyocardial and valvular function. This important role took centre stageduring the Singapore Cardiac Society Echo Singapore Lecture whenDr. Sugeng expertly delivered a panoramic overview of the advent ofthis exciting technology. The various symposia generated considerableinterest and exchange between the faculty and a packed audience.Live case demonstrations, case-based scenarios and use of an audienceresponse system further enhanced interaction. As customary, severalbooks on cardiovascular imaging were awarded during daily luckydraws, courtesy of PG Books and Siemens Singapore.Echo Singapore 2009 also scored several “firsts”. Debateson controversial areas in cardiovascular medicine were held forthe first time. The quality of scientific exchange as well as thehilarious banter between proponents and opponents of the motionwere thoroughly enjoyed by the audience. Inaugural pre- andpost-conference hands‐on training sessions on Philips QLAB andGeneral Electric EchoPac image analysis software were organized.These sessions were over-subscribed and based on immediateaudience feeback, highly educational. Another first was the scientificabstract competition, won by Dr. Scalia for his intriguing workon a novel index of mitral prosthesis dysfunction, with Dr. ZhongLiang garnering the first runner-up spot for his research into leftventricular torsion using speckle tracking echocardiography.Despite challenges arising from the financial downturn,Echo Singapore 2009 had a successful conclusion, thanks tothe support of all involved – the sterling guest and local faculty,members of the Organizing Committee, our generous sponsors(including platinum sponsors, Philips Medical Systems and GeneralElectric Healthcare/Scanmed Technology), the indefatigableevent organizers from National Healthcare Group ConferenceManagement Unit, technical staff who worked tirelessly behind thescenes, and not least members of the audience, many of whom havefaithfully attended Echo Singapore through the years. Indeed, for2009, the registered number of participants was 221, a milestone.To all involved in making Echo Singapore 2009 a success, theOrganizing Committee owes a debt of gratitude. We look forwardto your collaboration again in 2011!THI PULSE | 20

visit byProf Shinichi Takamoto, M.D.A/Prof Peter RoblessProf Shinichi Takamoto, an internationally renownedcardiothoracic surgeon visited the Dept of CTVS on the 18 th August2009. Dr Takamoto is CEO of Mitsui Memorial Hospital, Tokyo,former Chairman of Dept. of Cardiothoracic Surgery, GraduateSchool of Medicine, University of Tokyo and the Secretary-Generalof the Asian Society for Cardiovascular Thoracic Surgery (ASCVTS).He was hosted by Prof CN Lee who is the President of the ASCVTSand was given a tour of the hospital including the CT ICU and theAdvanced Surgery Training Centre. Dr Takamoto then gave an experttalk on “New modification of David V Procedure” at the Khoo TeckPuat ASTC. The talk was well attended by CTS surgeons from NUHand SGH and was followed by a lively discussion over breakfast.Dr Takamoto also had the opportunity to meet our hospitaladministration represented by Mr Noel Cheah and Michael Leow toshare his experience of building a cardiovascular surgery programmein Tokyo. Several issues including postgraduate training, clinicaldatabases and hybrid angiographic operating suites for Cardiovascularsurgery were discussed. Dr Takamoto was then given a tour of thecardiovascular research programs by Dr Theo Kofidis.The day ended with dinner hosted by Prof CN Lee wherecommon areas for future collaboration were discussed.Fractional Flow Reserve (FFR) Guided Angioplastya new paradigm in treating coronaryheart diseaseIn patients with a narrowing of the heart arteries, it may bedifficult to ascertain if the narrowing is sufficient to account for thepatient’s symptoms, especially where an intermediate (50 % – 65%)narrowing is present. Indiscriminate fixing of these narrowingswith balloon angioplasty or stenting without clear documentationof their hemodynamic significance results in increased costand subjects the patient to an unnecessary procedure. The idealsituation is an objection evaluation of the narrowing beforeproceeding with the angioplasty procedure. This may howeverentail taking the patient out of the catheterization laboratory andrescheduling a stress test at another day. This of course results inpatient inconvenience, increases cost, and results in yet anotherpuncture of the patient’s vessel to gain access to the heart arteries ifthe procedure confirms significant narrowing.A better situation, therefore, may be the evaluation ofthe narrowing while the patient is still on-table in the cardiaccatheterization laboratory. This can be performed using a specialwire that enables one to calculate the fractional flow reserve (FFR),a physiologic measure on the hemodynamic significance of a vesselnarrowing.FFR is essentially the ratio of the blood pressure as measuredby the special wire distal to the narrowing to the patient’s centralDr Adrian Lowblood pressure. This mathematical index was conceptualized morethan 10 years ago and is supported by a large body of evidence.Numerous studies have documented the safety and utilityof FFR and performing angioplasty to narrowings that are notsignificant by FFR measurement has been shown to not result inbenefit to the patient. In fact, a recent study called FAME documentbetter outcomes and lower cost for patients undergoing multiplevessel interventions using this method. Hence, it is not surprisingthat physicians, health care providers and payers such as insurancecompanies have taken a keen interest in the use of FFR in guidingangioplasty for patients.Our institution has substantial experience in the use ofFFR-guided angioplasty and is recognized to be a major leader inthe region. To promote its use, we have organized several courses inSingapore and overseas educating physicians and other health careproviders on the perils of wanton angioplasty and guiding them onthe need for a physiology guided approach.In the new year we have several more courses lined up inSingapore and the region and it is our hope that physicians will adopta physiology guided approach to treating narrowings of the heartarteries. This will reduce the number of unnecessary proceduresand medical cost without compromising patient outcome.THI PULSE | 21

Cardiac DepartmentFamily DayDr Joshua Loh, Chairman, Organizing CommitteeIt’s the time of the year again when Cardiac Departmentgets together for a day of fun, fun and more fun during the annualFamily Day!Being in the organizing committee this year, our task was toscour the entire Singapore (from east to west, north to south) fora venue befitting of an expanding department demanding a day ofgood clean fun, and in the end we landed in a little island south ofSingapore’s mainland – Sentosa!Surprisingly, on 22 nd November, Singapore was bathed inwarm sunshine after a damp and gloomy week preceding it. Thecrowd slowly trickled into the Rasa Sentosa Pavilion Ballroom from6 p.m. Some families spent the entire day visiting the attractionsaround Sentosa, others went swimming earlier at the Rasa Sentosaswimming pool, most were ravenous and thirsty on arrival.The theme for the night was “Movie Magic”, and eachsub-department under Cardiac was given a movie to dress by.The night started with cocktails, chit chats, lots of much missedcatching-ups and instant glamour shots which most broughthome as a souvenir. The children put in effort in the sand-artand acrylic key-chain decoration contest, and theirefforts paid off later on when the winners received their prizesfrom the judges.The action started around 7 p.m. after opening speechesby Chief and Director of Cardiac Department, this was when theMC of the night worked up our appetites with some mass games.In the end, the Winners were released first to enjoy the sumptuousinternational buffet spread as their reward, while the Championshad to wait it out with rumbling stomachs for their turn.With stomachs satisfied, we were treated to a delightfulopening dance item by the Ward 63 and 56 nurses when theymerged the movie themes Saturday Night Fever with 881. Theline “... and nobody and nobody but you …” were still resonating inour heads until the team from CCU exploded on stage with theirhighly energized version of High School Musical, and this won theteam the best performance award!This was followed by the Registrars’, Medical Officers’and Fellows’ item of Hairy Potter (Dr Devinder Singh), whereour own Professor Balloontodoor (Dr Yeo Wee Tiong) brought theaudience through a magical journey through “Heartwarts”. Wemanaged to capture the best-dressed team award!There were games, games and more games! Fromballoon‐blowing to a soulful rendition of a timeless classic Hokkiensong by one of the Consultants, from scrambling to pluck a whitehair off a poor audience’s head to getting dizzy running clockwiseand anti-clockwise around the dinner tables and many moregames, everyone had a great time together! Both the Championsand Winners chalked up points for their efforts, and everyonewas rewarded with much fun and laughter. Some among uswere even lucky to bag one of 40 lucky draw prizes given out(all thanks to the sponsors in Cardiac Department: Consultants,OPS, Chief, Director)!We owe our sincere thanks to members of the Organizingcommittee, Ms Christina Ng, Ms Nanmullai Ramasamy, Ms LaiShuet Ming, Ms Tan Sze Hwee, Ms Margaret Choong, Ms SusanLam, Ms Suzana Aziz and Dr Yeo Wee Tiong for putting in muchtime and effort to help make this event a great success!As you can see from the “family portrait”, our departmenthas really grown throughout the years (we were barely able to fiteveryone in to the picture, even with the use of wide-angle functionon the DSLR)! What was really encouraging was the fact that theCardiac Department, despite its expanding size and busy schedule,found time to get together and have fun as a family. I hope thistradition continues on and I look forward to the next CardiacDepartment Family Day 2010!THI PULSE | 22

hihlighthihlighton theBest PosterAwardat TCTDr Joshua LohI had the opportunity to embark on a project with A/ProfTan Huay Cheem titled: “Selective Use of Drug-Eluting Stent InHigh Risk Versus Bare Metal Stent in Low Risk Patients Accordingto Predefined Clinical Score Confers Similar 4-Year Long-TermClinical Outcomes.”In our study of 1,250 patients undergoing elective PercutaneousCoronary Intervention (PCI), our findings showed that that by applyingpredefined clinical criteria to identify patients at high risk of developingin-stent restenosis, similar favorable long term (at four years) clinicaloutcomes of death, myocardial infarction, stent thrombosis, and targetvessel revascularization can be achieved with selective drug-elutingstent (DES) usage versus bare metal stent (BMS).The implication is that the operators’ judgement remainsan important determinant in patients’ outcomes. Also, by keepingthe usage of DES low by reserving it for high-risk patients, thisapproach significantly reduces the cost of PCI treatment and needfor prolonged dual antiplatelet therapy.This abstract was submitted to Transcatheter CardiovascularTherapeutics (TCT) 2009 at San Francisco and was accepted forposter presentation. In addition, it was also chosen as the “Top 25posters” at TCT. The study findings and discussion points were alsohighlighted in the TCT Daily on 23 rd September, 2009, as a featuredarticle. As part of the award presentation, the scientific committeewas at the poster for a mini discussion.A/Prof Tan Huay Cheem and Dr Joshua Loh, with their winning poster abstract.As this is my first trip to a major conference, it was trulyan eye opener. I was fortunate to attend a comprehensive BoardReview Course for Interventional Fellows during the first twopre-conference days. The “Live” cases in the theatre sessions wereinteresting as it showcased not only expertise from all over theglobe, but also detailed discussion with the moderator panel onstrategies to solve the problem added extra intellectual depth. TheLate Breaking Trials session was also inspirational.A/Prof Tan Huay Cheem was on the moderator panel forone of the “Live” case session, and was among an expert panel in aspecial case discussion on Contrast Nephropathy. He also presentedan interesting case on an unusual cause of Left main disease. An oralabstract on “Safety and Efficacy of Intracoronary bolus Abciximabonly vs bolus and infusion in Primary PCI” was presented in a sessionby our interventional fellow, Dr Ngo Minh Hung.This conference gave me a chance to meet up and interactwith cardiology colleagues, trainees and ex-fellows from Singaporeand abroad. It has been a truly enriching experience and I stronglyencourage all trainees and fellows to participate in a major conferenceduring their training.THI PULSE | 23

happeningsCardiac Clinics Team Building12 December 2009MO Farewell Dinner27 October 2009THI PULSE | 24

CCU Christmas CelebrationDecember 2009Cardiac Department Family Day22 November 2009THI PULSE | 25

happeningsA/Prof Tan Huay Cheem performed a live demonstration of complex percutaneouscoronary interventional procedure.John Paul II Hospital, Krakow, Poland5 December 2009Israeli InterventionalCardiology meeting in Tel Aviv7 December 2009...continuedabstractsAnticoagulation Forum’s –10 th NationalConference on Anticoagulant Therapy,7–9 May 2009, Manchester Grand Hyatt inSan Diego, California1. Remote monitoring of warfarin therapy using informationtechnology – a novel and safe approach to conventionalcare – Choong PH, Li GY, Yong N, Yeo TC, Yip WLTranscatheter Cardiovascular Therapeutics,San Francisco, California, The MosconeCentre, September 21–25 20091. Prevalence and predictors of premature discontinuation ofdual antiplatelet therapy after drug-eluting stent implantation:importance of social factors in Asian patients. – Lee CH,Poh CL, Chan YY, Lau C, Teo SC, Low AF2. Selective use of dr ug-eluting stent in highrisk versus bare mental stent in low risk patientsaccording to predefined clinical score conferssimilar 4-year long term clinical outcomes – Loh PY,D Addatu, Shen L, Low AF, Lee CH, Teo SG, Tan HCComparison of Safety and Efficacy ofIntra‐coronary Bolus Abciximab Only vsStandard Intravenous Bolus and InfusionAbciximab in Patients with MyocardialInfarction Undergoing PercutaneousCoronary Intervention– Hung NM, Lee JY, Teo SG, Low AF, Lee CH, Tan HCAmerican Heart Association Scientific Session2009, Orlando, Florida, November 14 –18 20091. The relation of the index of microcirculatory resistanceto indices of microvascular perfusion and cardiac injuryfollowing primary angioplasty for ST-segment elevationmyocardial infarction – Loh PY, Addatu D Jr, Lee CH,Teo SG, Chai P,Poh KK, Tan HC, Low AF2. Nanoparticle based delivery of Hypoxia regulated VEGFtransgene system combined with SkMs engraftment: a saferapproach to treat ischemic cardiomyopathy – Ye L, Su PS,Zhang W, Haider HK, Poh KK, Joyce M, Songco G, Tan HC,Sim KWTHI PULSE | 26

publications1. Interact Cardiovasc Thorac Surg. 2009 Dec;9(6):990‐4.Long-term follow-up after minimal invasive directcoronary artery bypass grafting procedure: a multi‐factorialretrospective analysis at 1000 patient-years. Kofidis T, EmmertMY, Paeschke HG, Emmert LS, Zhang R, Haverich A.2. Tissue Eng Part A. 2009 Nov 12. Ascorbic Acid ImprovesEmbryonic Cardiomyoblast Cell Survival & PromotesVascularization In Potential Myocardial Grafts In Vivo.Martinez EC, Wang J, Gan SU, Singh R, Lee CN, Kofidis T.3. Asian Cardiovasc Thorac Ann. 2009 Oct;17(5):458-61.Endovascular management of traumatic thoracic aortictransection. Asmat A, Tan L, Caleb MG, Lee CN, Robless PA.4. Nucleic Acids Res. 2009 Oct 22. Mesenchymal stemcell secretes microparticles enriched in pre-microRNAs.Chen TS, Lai RC, Lee MM, Choo AB, Lee CN, Lim SK.5. Anaesth Intensive Care. 2009 Sep;37(5):830-2. Continuousvenovenous haemodiafiltration for metformin-inducedlactic acidosis. Pan LT, MacLaren G.6. Expert Rev Cardiovasc Ther. 2009 Aug;7(8):921-8.Myocardial tissue engineering: the quest for the idealmyocardial substitute. Martinez EC, Kofidis T.7. Ann Acad Med Singapore. 2009 Jul;38(7):649-2. Firstpaediatric left ventricular assist device implantation asbridge-to-recovery in Singapore. Kofidis T, Woitek F,Quek SC, Ang BL, Martinez EC, Klima U, Lee CN.8. J Biomed Mater Res A. 2009 Jul;90(1):205-16. Tubularnanofiber scaffolds for tissue engineered small-diametervascular grafts. He W, Ma Z, Teo WE, Dong YX,Robless PA, Lim TC, Ramakrishna S.9. Crit Care Med. 2009 Jun;37(6):2143-4; author reply2144‐5. Pediatric septic shock guidelines and extracorporealmembrane oxygenation management. MacLaren G,Butt W, Best D.10. Intensive Care Med. 2009 Apr;35(4):596-602.Controversies in paediatric continuous renal replacementtherapy. Maclaren G, Butt W.11. J Thorac Cardiovasc Surg. 2009 Mar 24. Intra-atrialembolus trapped in patent foramen ovale before systemicembolization. Ooi OC, Woitek F, Chiew Wong RC,Lee CN, Klima U, Kofidis T.12. Interact Cardiovasc Thorac Surg. 2009 Jan;8(1):49-53.Factors affecting post minimally invasive direct coronaryartery bypass grafting incidence of myocardial infarction,percutaneous transluminal coronary angioplasty, coronaryartery bypass grafting and mortality of cardiac origin.Kofidis T, Gerd Paeschke H, Lichtenberg A, Emmert M,Woitek F, Didilis V, Haverich A, Klima U.13. J Thorac Oncol. 2009 Jan;4(1):12-21. Using wholegenome amplification (WGA) of low-volume biopsiesto assess the prognostic role of EGFR, KRAS, p53, andCMET mutations in advanced-stage non-small cell lungcancer (NSCLC). Lim EH, Zhang SL, Li JL, Yap WS, HoweTC, Tan BP, Lee YS, Wong D, Khoo KL, Seto KY, Tan L,Agasthian T, Koong HN, Tam J, Tan C, Caleb M, Chang A,Ng A, Tan P.14. J Heart Lung Transplant. 2009 Dec 18. Cardiac CalcitoninGene-Related Peptide and Left Ventricular Hypertrophyin the Cardiac Allograft. Huang MH, Lui CY, Abusaid GH,Poh KK, Barbagelata AN, Uretsky BF, Fujise K.15. Singapore Med J. 2009 Oct;50(10):929-30. Managingacute myocardial infarction: are we ready for new advances?Poh KK.16. Singapore Med J. 2009 Oct;50(10):e342-5. Contrastingfatty involvement of the right ventricle: lipoma versuslipomatous hypertrophy. Zhang J, Chong E, Chai P,Poh KK.17. Circulation. 2009 Sep 29;120(13):1213-21. Regulationof vascular contractility and blood pressure by the E2F2transcription factor. Zhou J, Zhu Y, Cheng M, Dinesh D,Thorne T, Poh KK, Liu D, Botros C, Tang YL, Reisdorph N,Kishore R, Losordo DW, Qin G.18. Intern Med J. 2009 Oct 22. Prevalence and predictorsof premature discontinuation of dual antiplatelet therapyafter drug-eluting stent implantation: importance of socialfactors in Asian patients (Discontinuation of antiplatelettherapy in Asian patients). Poh CL, Chan MY, Lau C,Teo SG, Low AF, Tan HC, Lee CH.19. J Interv Cardiol. 2009 Oct;22(5):437-43. Relationbetween door-to-balloon time and microvascular perfusionas evaluated by myocardial blush grade, corrected TIMIframe count, and ST-segment resolution in treatmentof acute myocardial infarction. Lee CH, Tai BC, Lau C,Chen Z, Low AF, Teo SG, Tan HC.20. Am Heart J. 2009 Sep;158(3):327-334.e4. The ThrombinReceptor Antagonist for Clinical Event Reductionin Acute Coronary Syndrome (TRA*CER) trial:study design and rationale. TRA*CER Executive andSteering Committees.21. Ann Acad Med Singapore. 2009 Aug;38(8):663-6. Diastolicheart failure: what, so what and now what? Lam CS.THI PULSE | 27

awarddirectoryNational University HeartCentre, Singapore5 Lower Kent Ridge RoadSingapore 119074Tel 6779 5555Fax 6779 5678Cardiac Clinic HClinic Appointment 6772 5730Fax 6775 1617Cardiac CentreClinic Appointment 6772 5277/6772 5278Fax 6772 5279SVS International Scholars Programme 2010Congratulations to Dr Jackie Ho for being one ofthe four International Scholars selected for thisprogramme for the year 2010.The SVS (Society for Vascular Surgery) InternationalScholars Programme 2010 provides only four scholarships toqualified young vascular surgeons from countries other than theUnited States or Canada. Each scholar is given the opportunityto attend the SVS Annual Meeting 2010 in Boston, where theywill meet vascular surgeons from US as well as various othercountries and following that, visit several leading universitymedical centres and clinics in the States.FeedbackPlease direct your feedback toThe Editor, PULSEc/o NUHCSNational University HospitalCardiac DepartmentLevel 3, Main BuildingSingapore 119074Tel 6772 5565Fax 6778 6057Emailelaine_mc_lee@nuhs.edu.sgcongratsEditorA/Prof Poh Kian KeongAdvisorA/Prof Tan Huay CheemA/Prof Ronald Lee has been conferredDoctor of Medicine (MD) in December 2009by University of Hong Kong.Dr Chai Ping and Dr Adrian Low have beenpromoted from Consultant toSenior Consultant.