First Reported Case of Arrhythmogenic Right Ventricular Cardiomyopathy in Oman

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare genetic disorder characterized by fatty degeneration of the right ventricular myocardium with variable involvement of the left ventricle. The condition is associated with exercise-mediated ventricular tachycardia and is one of the recognized causes of sudden cardiac death in the young and in athletes. Here, we report the first confirmed case of ARVC in Oman and present its electrocardiographic, echocardiographic features, and radiological findings on gated, contrast-enhanced cardiac computed tomography. Our patient was a 22-year-old male who had presented to our hospital for evaluation and investigation of syncope and symptomatic palpitations

Spontaneous Coronary Artery Dissection: An Under-recognized Cause of Acute Coronary Syndromes

Spontaneous coronary artery dissection (SCAD) is a rare condition that is often underdiagnosed given limitations of conventional cineangiography. In addition to the diagnostic challenge, the condition poses a major therapeutic dilemma given paucity of literature to guide management. We report the case of a 55-year-old woman, who presented with acute coronary syndrome. Coronary angiography at the time of the index hospitalization revealed type 2 SCAD. She was managed conservatively. Repeat coronary angiography three months later showed complete resolution of the previously noted dissection. Because of the high association between SCAD and fibromuscular dysplasia (FMD), a cross-sectional imaging was performed in this case, which ruled out underlying FMD. The patient has been followed longitudinally since her index event and has had no reported recurrences

Percutaneous Septal Reduction Therapy in a Patient with Severely Symptomatic Hypertrophic Obstructive Cardiomyopathy: An experience from a tertiary care center

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Angiographic Predictors of Viability During Intervention for a ST Elevation Myocardial Infarction

Objectives: This study aimed to identify angiographic features that would predict myocardial viability after coronary intervention for ST elevation myocardial infarction (STEMI). Methods: This retrospective study included patients who attended Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019 with a STEMI. Results: A total of 72 patients (61 male; mean age = 54.9 ± 12.7 years) were included in the study; 11 patients had evidence of non-viability on echocardiography. There were 13 patients with viable myocardium and 3 with non-viable myocardium who had a myocardial blush grade (MBG) of 2 or lower. Similarly, 10 patients with viability and 1 with non-viable myocardium had thrombolysis in myocardial infarction (TIMI) flow of 2 or lower in the infarct related artery (IRA). However, none of these were statistically significant. The TIMI flow in the IRA at the end of the procedure correlated with the MBG. Conclusion: There were no clear angiographic features during primary angioplasty that could predict myocardial viability. Keywords: Myocardial infarction; Coronary Angiography; Viability; Oman

The Yield of Cardiac Investigations in Patients Presenting with an Acute Ischemic Stroke: A single tertiary centre experience

Objectives: Strokes are a major source of morbidity and mortality. The Aim of this study was to evaluate the effectiveness of routine cardiac investigations in identifying a cardioembolic aetiology for ischemic strokes. Methods: This was a retrospective study of patients who had presented with a stroke to our institution between January and December 2019. Results: A total 183 patients (mean age 66.2+13.5 years, 109 or 59.6% male) were included in the final analysis. The common risk factors were hypertension (74.9%) diabetes (61.7%), and hyperlipidaemia (54.6%). The Middle cerebral artery (MCA) was the commonest artery affected (44 or 24%). On admission, 14(7.6%) patients were in atrial fibrillation with the rest being in sinus rhythm. On 24-hour ECG holter monitoring, no abnormalities were noted in 135 patients. Atrial fibrillation was seen in 15(8.1%) patients (inclusive of the 14 who had AF on resting ECG). 32 (17.4%) patients had evidence of non-sustained atrial arrhythmia and 9(4.9%) had non sustained ventricular tachycardia. Thirty patients(16.3%) were also noted to have frequent supraventricular ectopics (>30/hour) while 5(2.7%) patients had a high ventricular ectopic burden (>10% burden). No significant abnormalities were noted in the echocardiograms of the patients, but 10 out of 132 (7.5%) patients had a positive bubble echo. Twenty-four (13.1%) patients had enlarged left atria. Conclusion: The overall diagnostic yield of abnormalities from routine cardiac testing for patients with stroke appears to be low. Targeted screening of patients with crytogenic stroke as suggested by newer guidelines is recommended. Keywords: Cerebrovascular Accidents; Echocardiography; Atrial Fibrillation; Oman

Impact of Blood Transfusion on Troponin I Levels and Outcomes after Cardiac Surgery: A Cohort Study

Objectives: Increased cardiac troponin I (TI) has been suggested to be a sensitive indicator of intraoperative myocardial injury. We investigated the association of transfusion on TI levels post-surgery and outcomes in patients undergoing elective cardiac surgeries. Methods: We conducted a retrospective review of 542 patients. Patients were divided into two groups based on TI levels at 24 hours (TI24) (> 6.5 µg/L vs. ≤ 6.5 µg/L). The impact of transfusion on TI levels was estimated using logistic regression and adjusted for using a multivariable model that included aortic cross-clamp time and preoperative ejection fraction. The effect of TI on the clinical outcomes was examined. Results: Red blood cell (RBC) transfusion was found to be associated with high TI levels (odds ratio (OR) = 2.33, p = 0.007, 95% confidence interval (CI): 1.30–4.30). A trend was observed when aortic cross-clamp time and preoperative ejection fraction were adjusted for (OR = 2.06, p = 0.080, 95% CI: 0.90–4.70). An association was found between aortic cross-clamp time and high TI levels in the multivariable model (OR = 1.01, p = 0.028, 95% CI: 1.00–1.02). Elevated TI levels was associated with higher mortality (OR = 4.15, p = 0.017, 95% CI: 1.29–13.08), renal failure (OR = 2.99, p = 0.004, 95% CI: 1.41–6.32), and increased length of stay in-hospital (OR = 4.50, p = 0.020, 95% CI: 0.69–8.30). Conclusions: RBC transfusion is associated with increased TI24 post-cardiac surgery and worse outcomes, albeit a confounding effect cannot be excluded. Larger studies are required to confirm these findings

Epidemiology, Outcomes and Coronary Angiography Findings of Patients Following Out-of-Hospital Cardiac Arrest: A single-centre experience from Oman

Objectives: Out-of-hospital cardiac arrests (OHCAs) are a leading cause of death worldwide. However, data regarding the management and outcomes of affected patients are lacking in the Middle East. The current study aimed to present the angiographic findings and outcomes of patients presenting with OHCA in Muscat, Oman. Methods: This retrospective study took place between January 2012 and December 2016 at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman. All adult patients who presented following an OHCA to the Emergency Department of SQUH during the study period were included. Demographic and clinical data were collected from electronic medical records. Results: A total of 216 patients were included in the study. The majority (63.9%) presented after having collapsed, while 22.3% presented with chest pains. Asystole was the most frequent initial cardiac rhythm (62.5%), with only 10% having ventricular tachycardia/fibrillation. Very few patients (1.4%) had received cardiopulmonary resuscitation (CPR) prior to presentation. In total, 85 patients (39.4%) returned to spontaneous circulation (RSC); of these, post-RSC electrocardiography revealed an ST-segment elevation in 41.2% and normal findings in 23.5%. There were 63 patients who underwent coronary angiography, with 28 requiring stenting. Overall, 13% of patients survived and were discharged, although three survivors suffered permanent hypoxic brain damage. Conclusion: The overall survival rate of patients who had experienced an OHCA was low. Education programmes should focus on the benefits of immediate CPR for individuals experiencing an OHCA, with more opportunities for CPR training to be made available to the general public in Oman. Keywords: Out-of-Hospital Cardiac Arrest; Cardiopulmonary Resuscitation; Patient Outcome Assessment; Survival Rate; Coronary Angiography; Oman

Acute Myocardial Infarction after Switching from Warfarin to Dabigatran

Dabigatran etexilate is a recently approved direct thrombin inhibitor (DTI), which is superior to warfarin in the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF). However, dabigatran use is associated with an increased risk of myocardial infarction (MI) compared to warfarin. The mechanisms for this association effect remain speculative. We present a case of an acute MI and cardiac arrest in a patient with chronic AF who had been recently switched from warfarin to dabigatran. Urgent coronary angiography, at St. Michael’s hospital (Toronto, Canada), revealed evidence of thromboembolism to the distal posterior descending artery. The patient was treated medically and switched back from dabigatran to warfarin. He did well and was discharged after an uneventful stay in the coronary care unit