PURPOSE: The gap in evidence in the management of multivalvular lesions can be addressed by providing more data on clinical and echocardiographic outcomes after percutaneous transmitral commissurotomy (PTMC) in patients with concomitant significant tricuspid regurgitation (TR) at baseline. METHODS This is a single-center cohort study of adult Filipinos 19 years or older, admitted between January 2019 and October 2020 due to severe mitral stenosis with moderate to severe TR subjected to PTMC. The outcome post-PTMC was divided into 2 groups: significant TR, which included the progression of moderate to severe TR or persistence of severe TR, and insignificant TR group, which included those with mild TR, regression of moderate to mild TR, severe to moderate, or persistence of moderate TR. The clinical and echocardiographic parameters of these groups were compared at baseline, at 24 hours, 1 month, and 6 months postprocedure. The numerical data between significant and nonsignificant TR were compared using nonparametric Mann–Whitney U test and categorical data using the x2 test.
Rheumatic Heart Disease ; Mitral Valve Stenosis ; Tricuspid Valve Insufficiency ; tricuspid regurgitation

Introduction: Acute coronary syndrome (ACS) presenting as non-ST-elevation myocardial infarction (NSTEMI) in a very young Filipina female with a maternal history of premature coronary artery disease and no comorbidities is a rare occurrence and seldom suspected. An integral approach using clinical presentation, information derived from ECG, cardiac troponin and risk assessment criteria should be used in order to arrive at the proper diagnosis and management. The other challenges encountered were angioedema secondary to clopidogrel hypersensitivity and financial constraints. These factors should be taken into consideration when deciding the short and long-term treatment especially after percutaneous coronary intervention and stenting. Case presentation: A 27-year-old active, female, Filipino, single, with a normal body mass index, non-smoker nonalcoholic drinker, no use of recreational drugs, no history of previous hospitalization, and comorbidities presented with sudden onset severe angina accompanied by diaphoresis and dyspnea. She was immediately brought to a local hospital, 12LECG showed T wave inversion on the inferior leads, troponin I was positive at 0.51ng/ml (0-.08) She was given aspirin, followed by clopidogrel in which she developed periorbital edema, dyspnea and was treated immediately with intravenous hydrocortisone and maintained on cetirizine and prednisone for five days. The clopidogrel was shifted to cilostazol. A coronary angiogram was done which showed a severe coronary artery disease at proximal right coronary artery. She underwent percutaneous coronary with stenting and was discharged stable and improved. Conclusion A delay in diagnosis and management may happen in a very young Filipino female presenting with acute chest pain and no comorbidities. A family history of premature coronary artery disease is a clinical marker of risk for acute coronary syndrome. A genetic testing may further establish this relationship. The clinical presentation of typical angina, T-wave inversions on inferior leads, highly abnormal cardiac troponin and very-high-risk criteria of recurrent or ongoing chest pain refractory to medical treatment warrants an immediate invasive strategy of coronary angiogram with revascularization. An angioedema secondary to clopidogrel hypersensitivity is a rare complication and can cause reluctance in a patient. The financial capacity to maintain long term treatment of dual antiplatelet should be considered for better compliance. A shared decision making between the physician and patient is a valuable tool in facing these challenges.
Myocardial Infarction ; Young Adult ; Cilostazol

Introduction: Marfan syndrome is an autosomal dominant disorder of connective tissue that results from abnormal fibrillin-1. It is caused by a mutation in the FBN1 gene making it a multisystemic disease. It is the most common but may have overlap with other thoracic aortic syndromes. It is primarily diagnosed using the 2010 revised Ghent nosology criteria that rely on the presence of family history, progressive aortic root dilatation or dissection, ectopia lentis, genetic testing, and systemic features. Unfortunately, a lack of nationwide awareness, family history, and medical access may lead to delayed diagnosis and treatment in our setting.

Case Summary: We report 4 cases of Marfan Syndrome from May to October 2019, which were seen at our institution. They presented with either recently diagnosed aortic aneurysm, dissection, or severe heart failure. We used the Revised Ghent Nosology for diagnosis and treated them with the standard of care. However, outcomes were different across patients.

Discussion: The life expectancy is comparable to the general population If early diagnosis is achieved. A myriad of known cardiovascular complications can manifest from severe valvular heart disease secondary to mitral valve prolapse, aortic root dilatation, and, most commonly, aortic dissection.

Conclusion: A late diagnosis presenting as aortic dissection or severe valvular heart disease may have a poor quality of life and prognosis. A thoracic aortic syndrome, most commonly Marfan, should still be considered in patients with aortic criterion and premature aortic syndrome even if a systemic score of 7 is not fulfilled. The screening of first-degree relatives of affected patients is an effective strategy to diagnose them at an early stage where they are still asymptomatic.

PURPOSE

The combined mitral stenosis (MS) and aortic regurgitation (AR) impose opposite loading conditions on the left ventricle. Physiologically, the relief of MS may increase the severity of AR.

Participants were Filipinos 19 years or older, admitted because of severe MS with mild to moderate AR. The outcome of percutaneous transmitral commissurotomy (PTMC) was divided into two groups: (1) significant AR that included the increase in severity of AR: mild to moderate/severe or moderate to severe AR, and (2) the insignificant AR group, which included any decrease in the severity of AR: moderate to mild or persistence of mild or moderate AR. These groups were compared from baseline, 24 hours, 1 month, and 6 months using the same echocardiographic parameters. The numerical data between significant and insignificant tricuspid regurgitation were compared using nonparametric Mann-Whitney U test and categorical data using the χ2 test.

A total of 43 participants were analyzed. At 24 hours post-PTMC, the significant AR group had significantly lower left ventricular end-diastolic dimension (3.83 vs 4.5, P = 0.008), left ventricular end-systolic dimension (2.33 vs 2.97, P = 0.017), right ventricular fraction area change (38.6 vs 48.7, P = 0.025), and left ventricular outflow tract (1.66 vs 2.02, P = 0.020) and higher systolic pulmonary arterial pressure (57 vs 32.4, P = 0.008). At 1 and 6 months, there were no significant differences in echocardiographic parameters between the significant and insignificant AR groups' left ventricular end-diastolic dimension (4.58 vs 4.5, 4.64 vs 4.57), left ventricular end-systolic dimension (3.1 vs 2.9, 2.9 vs 2.91), and systolic pulmonary arterial pressure (28 vs 34.7, 33.8 vs 32.4). Those with significant AR had a higher mean Wilkin score (mean, 10; P = 0.007) and subvalvular thickening (mean, 2.6; P = 0.005).

On short-term follow-up, the presence of mild to moderate AR before PTMC does not lead to severe AR. The outcomes regardless of the group showed a good functional class and no significant echocardiographic differences when compared.

Introduction: Ruptured mycotic aortic aneurysm is a rare and life-threatening condition. An early and proper initiation of antibiotics aside from aneurysmal repair is of paramount importance. The typhidot IgG and IgM may help with this dilemma, especially when the blood culture is negative and during the waiting period for the the aortic sample result. Case: A 47-year-old male Filipino with type 2 diabetes mellitus presented with severe back pain for one month and intermittent fever for three weeks. Complete blood count showed anemia and leukocytosis with predominance of neutrophils. On computed tomography of the aorta, a segmental calcification and wall discontinuity in the right posterolateral wall of the infrarenal abdominal aorta with heterogenous collection of blood in the retroperitoneal region was seen and aortic rupture secondary to mycotic aneurysm was considered. He underwent emergency abdominal aortic aneurysm repair with debridement, antibiotic lavage, aortoiliac grafting, anastomosis and omental packing. The typhidot IgG and IgM test was positive and was given ceftriaxone 2gm/IV every 24 hours for six weeks. Blood cultures did not reveal significant growth of any pathogen. The aortic wall culture showed heavy growth for salmonella species sensitive to ceftriaxone, confirming and guiding the management. He was then discharged improved. Conclusion A mycotic aneurysm secondary to salmonella should be one of the considerations in an adult male diabetic presenting with prolonged fever, abdominal and back pain with or without a tender pulsatile mass. The Typhidot test is an easy and affordable test that allows rapid detection of salmonella infection. Early surgical intervention and antibiotics are the treatment of choice
Aneurysm, Infected ; Salmonella