IntroductioUnderstanding the symptom and health expenditure burden among patients with advanced congestive heart failure (CHF) and their family caregivers is essential to reform policy and practice needed to provide quality care to these patients at affordable prices. The proposed cohort study titled Singapore Cohort of Patients with Advanced Heart Failure aims to describe trajectories of quality of life among patients and their primary informal caregivers, quantify healthcare utilisation and expenditures, assess changes in patient and caregiver awareness of and preferences for knowing diagnostic and prognostic information, awareness and utilisation of palliative care services, preferences for treatments and decision making, perceived quality of care, self-care, caregiver psychological distress and caregiver burden.MethodsThis cohort study will recruit 250 patients with New York Heart Association Classification class III and IV CHF from inpatient wards at two public tertiary healthcare institutions in Singapore. Patients and their primary informal caregiver are being surveyed every 4 months until patients’ death; caregivers are followed until 8 weeks postpatient death. Medical and billing records of patients are obtained and merged with patients’ survey data.Ethics and disseminationThe study has been approved by an ethics board. Results from the study will be disseminated through publications and presentations targeting researchers, policy makers and clinicians interested in understanding and improving care for patients with advanced CHF.Trial registration numberNCT03089034.

Chronic severe mitral regurgitation (MR) confers negative hemodynamic consequences and long-term morbidity and mortality1. The adverse remodeling processes result in the inability of mitral valve leaflets to co-apt optimally in functional MR (FMR)2. Even after optimal medical therapy, or revascularization, FMR may not necessarily be reduced adequately. In such patients who remain persistently symptomatic from residual MR, the next course of management may be the surgical or percutaneous intervention of the mitral valve apparatus. Subsequently, percutaneous repair via transcatheter delivered systems has emerged as the treatment of choice; especially, in patients assessed to be at a high operative risk with a suitable anatomy for minimally invasive approaches to re-appose the mitral leaflets3. This has also revolutionized the approach to the management of primary mitral regurgitation (PMR), such as from mitral valve prolapse. It was treated conventionally by the surgical intervention with mitral valve repair or replacement, allowing an alternative option for the high surgical risk patients 4. In our center, the transcatheter mitral valve repair procedure (MitraClip) has been introduced in the year 2012, providing an option of percutaneous intervention to the patients where MR is unsuitable for the surgical correction. However, persistent symptoms may occur due to the concomitant non-valvular or non-cardiac pathologies, particularly chronic pulmonary diseases. Also, assessment of functional class is subjective and may be confounded by other variables, such as sedentary lifestyle, self-imposed exercise restrictions, or orthopedic conditions. The cardiopulmonary exercise test (CPET) provides an objective assessment of the exercise capacity, obviating the subjective aspects of self-reported symptoms and functional status Besides, CPET is also useful to discern pulmonary and functional status. Besides, CPET is also useful to discern pulmonary and non-cardiac contributory components of the perceived decreased functional capacity, including motivational factors. Multiple CPET parameters, related to hemodynamic surrogates before and after the MitraClip procedure, also enable a more objective evaluation of the cardiovascular impact of the repair, allowing insights into the improvements in cardiac hemodynamics post intervention7-10.

Background  Systemic lupus erythematosus (SLE) valvulopathy can manifest as a spectrum of pathologies and treatment of severe valvular dysfunction thus far has been surgical. However, surgery in patients with SLE is frequently associated with high morbidity and mortality due to the presence of significant co-morbidities. Case summary  We report the case of a 41-year-old woman with SLE and anti-phospholipid syndrome with extensive co-morbidities including lupus nephritis, pancytopaenia, cerebrovascular accident, and severe airway obstruction from ipsilateral lung collapse and bronchiectasis. She had severe mitral regurgitation (MR) from Libman–Sacks endocarditis and in recent months developed heart failure with progressive exertional dyspnoea from New York Heart Association (NYHA) functional Class from New York Heart Association (NYHA) functional class II to III. In addition, there was progressive left ventricular dilatation and reduction in left ventricular ejection fraction. In view of the high surgical risk, she underwent transcatheter edge-to-edge repair (TEER) of the mitral valve with the MitraClip system. At 1-month follow-up, she was back to NYHA functional Class II with mild MR. Discussion Our case demonstrates that in select patient with suitable anatomy, TEER is a potential treatment option for severe MR from SLE valvulopathy.

Background The clinical value and cost-effectiveness of invasive treatments for patients with coronary artery disease is unclear. Invasive treatments such as coronary artery bypass grafting and percutaneous coronary intervention are frequently used as a starting treatment, yet they are much more costly than optimal medical therapy. While patients may transition into other treatments over time, the choices of starting treatments are likely important determinants of costs and health outcomes. The aim is to predict by how much costs and health outcomes will change from a decision to use different starting treatments for patients with coronary artery disease in an Asian setting. Methods A cost-effectiveness study using a Markov model informed by data from Singapore General Hospital was done. All patients with initial presentations of stable coronary disease and no acute coronary syndromes who received medical treatments and interventional therapies were included. We compare existing practice, where the starting treatment can be medical therapy or stent percutaneous coronary interventions or coronary artery bypass grafting, with alternate starting treatment strategies. Results When compared to ‘existing practice’ a policy of starting 14% of patients with coronary artery bypass grafting and 86% with optimal medical therapy showed savings of $1,743 per patient and 0.23 additional quality adjusted life years. A change to policy nationwide would save $10 million and generate 1,380 quality adjusted life years. Conclusions Increasing coronary artery bypass grafting and use of medical therapy in the setting of coronary artery disease is likely to saves costs and improve health outcomes. A definitive study to address the question we investigate would be very difficult to undertake and so using existing data to model the expected outcomes is a useful tool. There are likely to be large and complex barriers to the implementation of any policy change based on the findings of this study.

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