Periprocedural and in-hospital outcomes among percutaneous coronary intervention in saphenous vein graft: A retrospective observational study at a tertiary care hospital in south Asian country

Background: Saphenous vein graft (SVG) may occlude either early or several months to years after coronary artery bypass graft (CABG) surgery. Doing re-do CABG surgery is associated with higher complication and mortality rate as compared to percutaneous coronary intervention (PCI) in SVG. However, PCI of SVG is associated with more periprocedural and in-hospital complications as compared to PCI of native coronary arteries. Due to the scarcity of local data in this regard, this study was designed to estimate the periprocedural and in-hospital outcomes among PCI in SVG.Objectives: We aim to study the periprocedural and in-hospital outcomes among patients who underwent PCI in SVG.Methods: It is a retrospective observational study. We reviewed hospital record files of 167 consecutive patients, admitted to Aga Khan University Hospital, Karachi, from January 2010 to December 2019, who underwent PCI in SVG.Results: Out of 167 patients, 145 (86.8%) were male with a mean age of 72.26 (±8.46) years. Hypertension was the most common comorbid condition. Majority of 141(84.4%) patients presented within 6-10 years since the last CABG done. Seventy-eight (46.7%) patients presented with non-ST elevation myocardial infarction (NSTEMI). Patients who presented with acute coronary syndrome (ACS), 51 (36.9%), and 21 (15.2%) had congestive heart failure and cardiogenic shock on presentation respectively. Coronary angiography was performed in the majority of 155 (92.8%) patients through the femoral artery. The body of the SVG was the most common site affected by the disease. In 88 (52.7%) patients stents were deployed in SVG to obtuse marginal (OM). Drug-eluting stents (DES) were used in 124 (74.3%) patients. 22 (13.2%) of patients developed periprocedural complications, predominantly slow flow and 7 (4.2)% patients had in-hospital complications.Conclusions: PCI of SVG is associated with a high procedural success rate and acceptable risk for periprocedural and in-hospital complications. PCI of SVG may be considered as a safe and efficacious option for the percutaneous intervention of SVG lesions

Severe mixed mitral valve disease due to massive mitral annular calcification: A case report and literature review

We present an unusual case of massive mitral annular calcification (MAC) leading to severe mixed mitral valve disease, viz severe mitral regurgitation and severe mitral stenosis. To our knowledge, severe mixed mitral valve disease secondary to MAC is extremely rare. The patient (a 65-year-old lady) presented with worsening shortness of breath and signs of congestive heart failure. Echocardiographic examination revealed massive mitral annular calcification. Despite the massive annular calcification, she had experienced neither embolism nor endocarditis in the past. Because of severe symptomatic mitral regurgitation and mitral stenosis, surgery was advised; however, the patient declined it

Patterns of left ventricular hypertrophy and late gadolinium enhancement on cardiac MRI in patients with hypertrophic cardiomyopathy and their prognostic significance - An experience from a south Asian country

Objectives: Cardiac magnetic resonance (CMR) imaging is very pertinent in the diagnosis and risk stratification of patients with hypertrophic cardiomyopathy (HCM). We aimed to assess the patterns of left ventricular (LV) hypertrophy, late gadolinium enhancement (LGE), and their prognostic significance in HCM patients in Pakistani population, as no such data are available from Pakistan.Material and methods: This was a retrospective, single center study. All patients who had confirmed diagnosis of HCM on CMR at Aga Khan University Hospital during the period of 2011-2019 were identified and included in the study.Results: A total of 74 patients were included with the mean age of 45.6 ± 15 years and the majority 71.6 % (n = 53) being male. Maximal LV wall thickness was 21.1 ± 5 mm, asymmetrical septal hypertrophy being the most common pattern (62.2%, n = 46). LGE was present in 75.7% (n = 56) with most common site being septum plus LV free wall (24.3%, n =18). Mean ejection fraction% was found to be lower in patients with LGE (P \u3c 0.001). Major adverse cardiac events (MACE) were observed in 40.5% (n = 30). Presence of LGE and right ventricular involvement was found to have a statistically significant association with MACE (P value 0.018 and 0.046, respectively). In multivariable analysis, only LGE was significantly associated with MACE (odd ratio: 4.65; 95% CI: 1.21-17.88).Conclusion: Asymmetrical septal hypertrophy was the most common pattern of hypertrophy. LGE was present in three fourth of the study population and it was significantly associated with MACE

COVID-19 BBIBP-CorV vaccine and transient heart block - A phenomenon by chance or a possible correlation - A case report

Importance: Bradyarrhythmia during COVID19 illness carries prognostic significance. Electrophysiological side effects of COVID19 vaccine remain largely unknown. It is imperative to report nature of cardiovascular side effects of the vaccine.Case presentation: An 80 years-old-man presented with complains of dizziness, trepidation and shortness of breath following his first shot of COVID-19 BBIBP-CorV (Sino-pharm). ECG on arrival showed 2:1 atrioventricular block with an underlying old left bundle branch block. The AV block changed into Mobitz type-I over the course of next 2 days and into a sinus 1:1 conduction on fourth day of presentation. However, our patient underwent permanent pacemaker implantation due to the underlying conduction tissue disease and intermittent 2:1 AV block during the hospital stay.Clinical discussion: It is likely that patients with an already diseased conduction system are at an increased risk of worsening of AV block following inoculation of the vaccine. Vaccine associated AV blocks are likely to be reversible. Presence of prior coronary artery disease and electrical abnormalities are important considerations.Conclusion: COVID-19 vaccine may have added side effects in subjects with known heart disease. Humoral response towards the vaccine might interfere with the conduction system of the heart and more so in patients with diseased and scarred myocardium

Comparing sensitivity and specificity of pacemaker ID application and cardiac rhythm management device-finder application in identifying cardiac implantable electronic device manufacturer using chest radiograph - An observational study

Background: Smartphone-based applications to identify cardiac implantable electronic devices (CIED) are extremely useful in circumstances, where urgent device interrogation is needed, and a device identification card is not available. Few studies have provided insights regarding the utility of these applications. We have studied two widely available applications i.e., Pacemaker ID app (PMIDa) or Cardiac Rhythm Management Device-Finder (CRMD-f) to identify device manufacturers in CIEDs.Methods: 547 patients who underwent CIED implantation from the year 2016-2020 in our institute were enrolled. There were 438 Medtronic and 109 St. Jude\u27s devices. All chest radiographs were de-identified and resized into 225*225 pixels focusing on the CIED. PMIDa and CRMD-f applications were used to identify the CIED. Accuracy, sensitivity, specificity, negative predictive value, and positive predictive value for both applications were calculated and compared.Results: Overall, CRMD-f application has higher specificity (93.58 vs. 82.5%) but lower sensitivity (53.6 vs. 55%) than PMIDa. The accuracy of both applications was comparable (61.6% vs. 60.5%). Accuracy varied with CIED model and type tested, and radiograph projection used. Accuracy is greatest with Cardiac-Resynchronization-Therapy (CRT) devices for both applications, followed by a single lead pacemaker.Conclusion: CRMD-f has higher accuracy and specificity for CIED manufacturer identification. Both PMIDa and CRMD-f are specific tools to identify CIED but have low sensitivity

Double-chambered left ventricle: Diagnosis by CMR and review of the literature

Background: A double-chambered left ventricle (DCLV) is an extremely rare congenital malformation. The exact prevalence of DCLV is not known, although studies have reported prevalence of 0.04-0.42%. This abnormality is characterized by the sub-division of left ventricle into two chambers, the main left ventricular chamber (MLVC) and the accessory chamber (AC) by a septum or muscle band. Case presentation: We are reporting two cases of DCLV, one in an adult male and an infant, who were referred for undergoing cardiac magnetic resonance (CMR) imaging. The adult patient was asymptomatic, whereas the infant had the diagnosis of left ventricular aneurysm on fetal echocardiography. On CMR, we confirmed the diagnosis of DCLV in both patients, as well as moderate aortic insufficiency in the adult patient. Both patients were lost to follow-up. Conclusions: The double-chambered left ventricle (DCLV) is commonly detected in infancy or childhood. Although echocardiography can help detect double-chambered ventricles, MRI provides a better knowledge of this problem and can also be used to diagnose other related heart disorder

COVID-19 encephalopathy: an unusual presentation with new-onset seizure causing convulsive status epilepticus

Although neurological manifestations such as headache and myalgias have been observed with COVID-19, presentation with more serious neurological illness is uncommon and rare. We report a case of a middle-aged woman who presented to the emergency department of a tertiary care hospital. Her clinical presentation was primarily neurological rather than the more common presentation with respiratory manifestations. She presented with generalised tonic-clonic seizures, along with history of undocumented low-grade fever and generalised body aches. The positive SARS-CoV-2 RT-PCR nasal swab, the cerebrospinal fluid analysis (lymphocytic pleocytosis) and electroencephalogram were consistent with viral encephalitis; brain imaging was unremarkable. This case highlights the variable presenting features of COVID-19 infection as patients can primarily present with neurological manifestations in the absence of significant respiratory symptoms. We believe it is important to recognise neurological disease associated with SARS-CoV-2 in patients with asymptomatic respiratory infectio

Case report: Aorto-left atrial fistula-A rare complication of native aortic valve endocarditis

Background: Aorto-cavitary fistula is a rare complication of infective endocarditis. Multimodal imaging is commonly required to assess the severity and extent of infection because of the complex pathology of the valvular and paravalvular apparatus in endocarditis. Case presentation: We present an unusual case of a middle-aged man with recent history of meningoencephalitis who developed infective endocarditis complicated by ruptured abscess in inter-valvular fibrosa between aortic and mitral valve resulting in free communication or fistula formation between aorta and left atrium. Patient underwent double valve replacement (aortic and mitral) along with repair of the aorta. Conclusions: Our case highlights recognition of this rare clinical presentation of aorto-left atrial fistula in infective endocarditis and the diagnostic role of transesophageal echocardiography in good clinical outcome with aggressive and timely managemen

Clinico-radiological and bronchoscopic predictors of microbiological yield in sputum negative tuberculosis in Pakistan

To determine association of clinico-radiological factors and radiological activity with diagnostic yield in sputum-smear negative tuberculosis (TB). Prospective observational study in Military Hospital Rawalpindi from July to December 2018. Adult patients having no contraindications to bronchoscopy were included. HIV positive patients and those on anti-tuberculosis therapy for more than one week were excluded. High-Resolution Computed tomography (HRCT) findings were classified based on active and inactive tuberculosis features. Washings were sent for Acid-Fast Bacillus (AFB) smear, GeneXpert assay and cultures. Out of 215 patients, 42.3% (91) were diagnosed with microbiological or histological evidence of TB. On univariate analysis, cavitation (p-value \u3c0.001), soft-tissue nodules (p-value 0.04), and endobronchial mucosal changes (p-value 0.02) were associated with culture positivity. Presence of cavitation (OR= 4.10; CI= 2.18,7.73; p-value\u3c0.001) was the only independent predictor of microbiological yield. Diagnostic yield was 70%, 50%, 12.5% and 8.6% in patients with definitely active, probably active, indeterminate and inactive tuberculosis HRCT features respectively. Sensitivity, specificity, positive predictive value and negative predictive value of HRCT active TB were 95.38% (95% CI 87.10 -99.04), 48.00 % (95% CI 39.78 -56.30), 44.29% (95% CI 40.31 -48.33), 96.00 % (95%CI 88.70 -98.66) respectively. There was no significant association between age groups, smoking status and gender with diagnosis of tuberculosis in our study. Radiological activity and certain visualized bronchoscopic changes were associated with good diagnostic performance and can be used as predictive factors in diagnosis of active smear negative tuberculosis

A Meta-Analysis on Incidence of Barotrauma in Patients with COVID-19 ARDS Undergoing Invasive Mechanical Ventilation

Barotrauma is a common complication in patients with Acute Respiratory Distress Syndrome (ARDS) undergoing Invasive Mechanical Ventilation (IMV) [...