Initial Experience of Dobutamine Stress Echocardiography in Ibn Al-Bitar Hospital for Cardiac Surgery

Background: Dobutamine stress echocardiography (DSE) is a well established non invasive test for the diagnosis and risk stratification of patients with coronary artery disease. Aim of the study was to conduct a pilot study in order to establish the basis for the future routine practice of DSE in our center (Ibn Al- Bitar Hospital for Cardiac Surgery). Patients and Methods: Fifty consecutive patients who were referred from the outpatient of our center, from August 2007 to July 2008, were included. The age range was 39 – 70 years with an average of 57.18 years. Fifty-eight percent were males. Patients were enrolled in the study in accordance with the American Heart Association/ American College of Cardiology guidelines, including mainly those who are unable to exercise due to an orthopedic problem (26%) or limited functional capacity (30%). Some Patients with resting electrocardiographic changes (20%) and non diagnostic exercise test (14%) were also included as well as five patients (10%) for the assessment of myocardial viability. The baseline echocardiogram was normal in 44 % of cases. Others had resting wall motion abnormalities due to previous myocardial infarction (50%) or left bundle branch block (6%). Dobutamine was given by a syringe or an infusion pump at incremental doses (every three minutes) of 5,10,20,30, and finally 40 μg/kg/min. Atropine was needed at peak test in 36% of cases to increase the proportion of patients who reach the target heart rate. Results: The test was positive in 5 patients (10%); negative in 34(68%), non diagnostic in 2(4%), aborted due to intolerable symptoms in 3(6%) and stopped due to arrhythmias in 3(6%) patients. Side effects included chest tightness and irritability in 40%, headache in 12%, nausea and vomiting in 10%, and postural hypotension in 4%. Infrequent ventricular/atrial ectopics occurred in 13%, supraventricular tachycardia in one patient, and complex multiple ventricular ectopics in 3 patients; no incidence of sustained ventricular tachycardia or ventricular fibrillation occurred. There was no incidence of myocardial infarction or death. Conclusions: DSE is a safe and practical test provided it is used according to the recommendedprotocols. A special unit for DSE in our centre is recommended

Percutaneous Transluminal Mitral Commissurotomy using Inoue Balloon in Iraqi population

Background: Mitral stenosis (MS) is the most common valve disease in developing countries and there are many ways to deal with this condition. The aim of this study was to evaluate the immediate results of percutaneous transvenous mitral commissurotomy (PTMC) in patients with severe symptomatic rheumatic mitral stenosis. Patients and Methods: From May 2006 to August 2007, 58 patients (17 male, 41 female) with age range (16-57) years, underwent PTMC in Ibn AL- Bitar Hospital for Cardiac Surgery. All the patients were symptomatic, their MVA 1.5 cm2 with NYHA class II-IV. Clinical evaluation and echocardiographic examination were carried out before and after PTMC, mitral valve structures were assessed using Wilkins score. The procedure was performed under local anesthesia, using the step-wise Inoue balloon technique with the antegrade transvenous approach. Results: The procedure was successful in 51(88%) of the patients and unsuccessful in the remaining 7(12%) patients. Successful result was defined as post procedure mitral valve area ( MVA) 1.5 cm² as assessed by echocardiography and no mitral regurgitation (MR)>2 according to sellers classification. Mitral valve area increased from 0.93 ±0.2 to 1.84±0.2 cm² after the procedure (P<0.001) as measured by echocardiography. Severe MR was observed in 1(1.7%) patients, while new mild - moderate MR have been detected in 9(17.6%) patients. Symptomatic improvement was seen in all patients who underwent successful PTMC .There where no procedure related deaths, temponade or the need for emergent mitral valve replacement. Conclusion: percutaneous transvenous mitral commissurotomy by Inoue balloon technique is safe and effective procedure for patients with severe and symptomatic rheumatic MS. The ideal candidate are those patients with pliable valve ,but still most of patients with relatively high Wilkins echo score can get considerable benefit

Immediate and intermediate term results of cheatham platinum stenting for native coarctation of aorta in adults

Background: aortic coarctation is an important cause of hypertension. Surgical repair was considered the conventional treatment for native aortic coarctation while stenting emerged recently as an alternative to surgical repair. Objective: To evaluate the immediate and intermediate results of Cheatham Platinum (CP) stenting for native coarctation of aorta. Methods: This is a prospective study done in Ibn Al-Bitar cardiac Centre, included 32 consecutive adult patients with native coarctation of aorta. Clinical, hemodynamic and procedural data were collected and analyzed for each patient. Covered CP stent was used and mounted on the Balloon-in-Balloon catheter (BIB) in most of the cases. The technique was considered effective if the invasive grade was decrease to &lt;20 mmHg and increased the angiographic diameter &gt;50%. Results: A total of 32 patients had the procedure done with a success rate of 93.4%.&nbsp; Peak gradient across the coarctation fell from 60.0±21.960 to 10.0± 19.821 mmHg post procedure (P, 0.0001). There was no major complications, with no deaths. Systolic blood pressures fell from 164.6±25.889 mmHg to 138.1±17.006 mmHg immediately after stenting and 134.3±12 mmHg at 6 months. No significant complications were seen during procedure and at 6 months follow up. Conclusion: aortic coarctation stent of adults have better fast clinical and angiographic consequences and continued hemodynamic advantages at 6-12 months.&nbsp

Clinical study of patients with hypertrophic cardiomyopathy

Background: Hypertrophic cardiomyopathy (HCM) is a common genetic cardiovascular disease. Its morphologically divided into asymmetrical septal hypertrophy, symmetrical concentric hypertrophy and apical hypertrophy,and physiologically divided into obstructive HCM and non obstructive HCM according to the left ventricular outflow tract (LVOT) gradient at rest or with provocation. Several factors that increase risk of sudden cardiac death (SCD), the more risk factors a patient has, the greater the chance that the patient is exposed to sudden death and sufficient to warrant consideration for interventional therapy. Objective: The aims of the study are to evaluate the clinical presentations, risk stratification and family screening of patients with HCM. Patients and methods: This cross sectional study was performed in Ibn-Albitar hospital for cardiac surgery. We studied the prevalence of certain variables among seventy three patients with  HCM from “June 2010 to April 2012" including the clinical triggers ,electrocardiographic (ECG) changes, ventricular and supraventricular arrhythmia by holter monitoring, morphological and physiological types of HCM by echocardiography, family screening and finally we assessed the risk factors for SCD and candidacy for interventional procedures. Results: A total of seventy three patients, males to females ratio were 1.5:1 with a mean age of 34±26 (years). HCM was higher in patients younger than 45 years of age, 43(58.9%). Eighty seven percent were symptomatic  and (12.3%) were asymptomatic diagnosed by family screening of first degree relatives with HCM. Family history of HCM was identified in (38.3%).Three quarter of patients had asymmetrical septal hypertrophy and (6.8%) had pure apical HCM. Abnormal ECG was found in(87.6%) mainly in the form of left ventricular hypertrophy( LVH )while 9 patients(12.3%) had normal ECG. Nonsustained ventricular tachycardia(NSVT) was found in(30.1%). Echocardiographically, systolic anterior motion(SAM) of the anterior mitral leaflet was seen in about half of patients and three patients (7.6%) had SAM without LVOT obstruction. About half of patients (49.4%) had resting and provocable LVOT obstruction and about half of obstructive type (47.2%) had LVOT gradient ≥50mmhg and are candidate for surgical or percutaneous intervention. Conclusions: Most of our patients were symptomatic and significant number of patients had family history of HCM. Asymmetrical septal hypertrophy was the commonest morphological type of HCM. Relatively equal prevalence of obstructive and nonobstructive HCM and significant number of patients with the obstructive type had LVOT gradient ≥ 50mmhg who are candidate for surgical or trascatheter interventions