Percutaneous heart valve interventions: a South African perspective

Valvular heart disease represents a significant health care challenge in South Africa, mainly due to the prevalence of rheumatic fever. This review discusses the recent advances in percutaneous heart valve treatment, including heart valve replacement, as an alternative to open prosthetic valve replacement and it’s relevance in South Africa. Balloon mitral valvotomy is discussed with emphasis on patient selection, management during pregnancy and management in the presence of left atrial thrombus. Further developments regarding the percutaneous treatment of mitral valve disease include percutaneous treatment of mitral incompetence by annuloplasty via the coronary sinus and edge-to-edge repair with the aid of a mitral clip. Transcatheter aortic valve replacement is the more developed procedure and two valves have the CE mark of approval. Both have good short to medium term data demonstrating efficacy but are technically difficult to insert, very expensive and patient selection remains a major problem. Their use is thus limited to patients turned down for conventional surgery.Percutaneous pulmonary valve replacement has good evidence to show efficacy but its use is largely limited to patients with degenerated pulmonary outflow tract conduits

An interesting cause of syncope

Patient with a history of repeated episodes of syncope over the preceding week

Pericardial effusion with cystic mass

Patient with a 2-month history of exertional dyspnoea and a non-productive cough

Evaluation of the SUNHEART Cardiology Outreach Programme

Introduction: The demand for advanced cardiac care and specialised interventions is on the increase and this results in bottlenecks and increased waiting times for patients who require advanced cardiac care. By decentralising cardiac care, and using a hub-and-spoke model, the SUNHEART Outreach Programme of cardiovascular care aims to improve access to advanced cardiac care in the Western Cape. Tygerberg Hospital is the central hub, with the fi rst spoke being Paarl Hospital. Objective: To determine the value of the SUNHEART Outreach Programme to the public health care system. Methods: An audit of patients accessing the OutreachProgramme was performed for the period May 2013 - May 2014 and consequently compared to a historical cohort of patients accessing the health care system during the preceding 6 months, from October 2012 -April 2013. Access to advanced cardiac care was measured in time to initial evaluation, time to defi nitive diagnosis or intervention and patient compliance with appointments. The value to the health care system was also assessed by performing a cost analysis of transport of patients and health care workers, as well as compliance with appointments. We documented the spectrum of disease requiring advanced cardiac care toguide future interventions. Results: Data of 185 patients were included in the audit. Sixty four patients were referred to tertiary care from October 2012 - April 2013 and 121 patients were referred to the outreach facility from May 2013 - May 2014. There was a signifi cant reduction in waiting times with the median days to appointment of the historical cohort being 85 days compared to 18 days in the Outreach Programme cohort (p<0.01). Patient compliance with appointments was signifi cantly superior in the Outreach Programme cohort (90% vs. 56%: p<0.01). Valvular (36.5%) and ischaemic heart disease (35.5%) were the major pathologies requiring access to cardiac care services. Transport costs per patient treated was signifi cantly reduced in the outreach programme cohort (R118,09 vs. R308,77). Conclusion: Decentralisation of services in the form of an Outreach Programme, with a central hub, improves access to advanced cardiac care by decreasing waiting time, improving compliance with appointments and decreasing travel costs

Managing the asymptomatic diabetic patient with silent myocardial ischaemia

Coronary artery disease is common in diabetic patients and remains the major cause of death in these patients. However myocardial ischaemia resulting from coronary lesions does not always give rise to symptoms. The managing physician must therefore consider the benefit of screening for silent myocardial ischaemia in diabetic patients. Screening all diabetic patients is not recommended. The challenge to the physician is to select the patient subgroups likely to benefit from screening. Patients with more than one cardiac risk factor (dyslipidaemia, hypertension, smoking, family history, microalbuminuria) in addition to diabetes, as well as patients with established macrovascular disease, e.g. peripheral vascular disease, will benefit most from screening. A standard treadmill stress ECG is the recommended screening test. A number of additional tests have been proposed to select high-risk patients for screening. Of these, testing for microalbuminuria and elevated CRP levels are most likely to influence decision-making. Once silent ischaemia has been detected in a diabetic patient, the mainstay of treatment remains the aggressive control of risk factors, improvement of glycaemic control and aspirin therapy. The use of beta-blockers and ACE-inhibitors often need consideration. The attending physician must then consider referring the patient to a cardiologist for angiography and possible intervention. This decision is based on the presence of poor prognostic signs during the stress ECG and the number of risk factors present. Microalbuminuria and elevated CRP levels are helpful in assisting with the risk stratification process.Revie

Prevalence of ST-elevation in right precordial leads in patients presenting with acute coronary syndrome without ST-elevation in standard 12-lead electrocardiography

Objective: The aim of this preliminary study was to determine the prevalence of isolated ST-elevation in the right precordial leads and the potential impact the addition had to risk stratification in patients with acute coronary syndrome. Methods: Right-sided precordial leads (V4R, V5R and V6R) were routinely added to standard 12-lead electrocardiogram (ECG) on all patients presenting with acute coronary syndrome at the Tygerberg cardiac unit for a 7-month period. Patients without ST-elevation on standard 12-lead ECG were selected and evaluated for isolated right-sided ST-elevation. Demographic data, ECG-characteristics and cardiac enzymes were also recorded. Risk scoring using the TIMI-risk score was done and patients with isolated ST-elevation in right-sided leads without ST-changes (i.e. depression) in 12-lead ECG were experimentally awarded another point. Coronary angiography if performed was also noted. Results: Seventy-seven patients were selected, among them 4 patients (5.19%) had isolated ST-elevation in right-sided ECG. Only 1 patient (1.3%) was awarded an additional point for ST-elevation in right-sided leads without ST-depression on 12-lead ECG increasing the TIMI score from 6 to 7. Angiography revealed no patients with isolated right-sided ST-elevation with non-dominant right coronary artery occlusion. Conclusion: The addition of right-sided leads did not alter risk scoring significantly and therefore the results of this study do not support the routine addition of such leads. This study also did not prove that isolated ST-elevation occurs in right-sided leads in patients with occluded non-dominant right coronary arteries.Conference Pape

Cardiac sarcoidosis - The value of magnetic resonance imaging: A case report and brief review of the literature

This report describes the management of a 40-year-old woman presenting with recurrent monomorphic ventricular tachycardias secondary to cardiac sarcoidosis. She was managed with a combination of steroids, azathioprine and mexiletine. Magnetic resonance imaging proved to be of great help in diagnosing this condition as well as in following up the response to therapy. A brief review on the management of this condition is presented.Articl

Mitogen-activated protein kinase (MAPK) in cardiac tissues

Mitogen-activated protein kinase (MAPK) has recently emerged as a prominent role player in intracellular signalling in the ventricular myocyte with attention being focussed on its possible role in the development of ventricular hypertrophy. It is becoming clear that MAPK is also active in other cells of cardiac origin such as cardiac fibroblasts and possible functions of this signalling pathway in the heart have yet to be explored. In this report the mammalian MAPK pathway is briefly outlined, before reviewing current knowledge of the MAPK pathway in cardiac tissue (ventricular myocytes, vascular smooth muscle cells and cardiac fibroblasts). New data is also presented on the presence and activity of MAPK in two additional cardiac celltypes namely atrial myocytes and vascular endothelial cells from the coronary microcirculation.Articl

Restenosis after coronary angioplasty - A review of the pathogenesis and strategies for prevention

[No abstract available]Revie