A simpler approach to seal severe coronary perforation with bare metal stent

The case of a coronary artery perforation in which overinflation of a balloon at an angulated segment of the left anterior descending (LAD) artery after stent deployment resulted in an Ellis type III coronary artery perforation is presented. A bare metal stent (BMS) was used successfully to seal this high-grade perforation. Here, it is demonstrated that it may not be illogical to consider BMS as the first choice before embarking on use of a covered stent if the clinical/haemodynamic condition of the patient allows it and if a covered stent is not available

Mother and child technique combined with super selective pharmacological intervention for large intracoronary thrombus

Primary percutaneous intervention (PCI) in acute ST elevation myocardial infarction (MI) is a preferred way of treatment nowadays. Sometimes it becomes difficult to get good myocardial blood flow during PCI if clot burden is large. In this case of an elderly lady, the use of Mother and Child Technique combined with super selective pharmacological intervention is demonstrated to achieve good blood flow when conventional means are not working

Outcomes in ST elevation Myocardial Infarction; a comparison of a tertiary care center in Pakistan with European centers

OBJECTIVES: To evaluate the clinical characteristics and in hospital outcome data of patients presenting to the Aga Khan University Hospital with ST elevation Myocardial Infarction (STEMI) and its comparison with data from patients enrolled in the European Heart registry for the same duration.METHODS: Data on 296 patients with STEMI was prospectively collected from 1st January 2010, till 31st December 2010 from the cardiology section at the Aga Khan University Hospital. European data was collected on 7485 patients retrieved from the Eurobservational Research programme Acute Coronary Syndrome Registry 2010 for the same duration.RESULTS: A total of 296 patients were enrolled from AKUH and 7485 from European centers for the year 2010. Majority of patients in both groups were male. Pakistani patients were more likely to be younger and diabetic (

Percutaneous coronary intervention in unprotected left main coronary artery disease

Percutaneous coronary intervention for unprotected left main coronary artery disease is potentially an important intervention in surgically unstable patients. A detailed review of medical record and visual analysis of coronary angiography and PCI procedure was undertaken. The study was conducted at the Aga Khan University Hospital, from January 2003 to December 2007. Patients included in the study had unprotected \u3e 70% left main stenosis with ongoing ischemia, considered unsuitable for surgical revascularization. A total of 9 patients were included with a mean age of 70.1 years. Six patients had cardiogenic shock. Eight patients had bifurcation lesion. Simultaneous kissing stenting technique was used in 4 patients. There were 4 in-hospital deaths while 5 patients were alive at discharge. All 4 patients who expired had cardiogenic shock. Four patients were alive at a mean follow-up of 17 months. PCI turned out to be an alternative therapeutic option for unprotected left main coronary artery disease when surgery is declined

Safety and Efficacy of Drug-Eluting Balloons in the Treatment of Drug-Eluting In-Stent Restenosis: Experience of a Tertiary Care Hospital

Background: The advent of drug-eluting balloons (DEBs) is a promising development for coronary revascularization procedures, especially for in-stent restenosis (ISR). This study aims to highlight our experience with DEBs in the treatment of drug-eluting ISR at a tertiary care hospital in Pakistan. Methods: All Patients presenting to our institution from August 2008 to February 2011 with significant drug-eluting in-stent restenosis (DES-ISR) who were eligible to receive treatment via DEB were included in the analysis. Patient baseline characteristics and angiographic data about the lesion characteristics were obtained. Postprocedural and follow-up endpoints, including cardiac death, myocardial infarction, and repeat revascularization, ie, major adverse cardiovascular events (MACE), were included in the analysis. Results: A total of 26 Patients received treatment with DEB in the study period, with a significant number having major predisposing factors for the development of ischemic heart disease (IHD, 46% diabetics, 92% hypertensives). The culprit lesion was most commonly identified in the left anterior descending (31%), with presence of American College of Cardiology/American Heart Association lesion type C in 68% of Patients. The SeQuent Please paclitaxel-eluting balloon (B. Braun) was used for revascularization. Patients were followed for a median of 16 months. Only 5 Patients (19%) developed MACE during this period. Conclusion: Our experience demonstrates the effectiveness of DEBs in the treatment of drug-eluting ISR, especially in complex lesions with Patients having significant risk factors for development of IHD. However, further studies are needed to define their indications in this role

Knowledge and practice of radiation safety among invasive cardiologists

OBJECTIVE: To assess the availability, practices and knowledge of radiation safety measures among invasive cardiologists in a tertiary care hospital. METHOD: A cross sectional survey of invasive cardiologists working in academic institutions was conducted using a questionnaire. RESULTS: A total of 28 cardiologists completed the questionnaire with a mean working experience of 10.5 + 7.6 years. All were of the opinion that radiation safety is extremely important and 93% always used lead aprons. Less than half of them used other radiation protective measures including thyroid collar, lead eyeglasses and lead shields. Only 7% regularly utilized a radiation dose badge to monitor the exposure. This may be related to the availability, as lead aprons are readily available but other devices i.e. lead glasses, lead shield and radiation dose badge is available to less than a third of them. On evaluating knowledge only one fourth knew more than 60% of the answers to questions testing the basic principles of radiation safety. When working experience of cardiologists was correlated with their knowledge and practice of radiation safety surprisingly a paradoxical relationship was noted. Mean number of correct answers in those with experience of \u3e 10 years vs \u3c 10 years was 45% vs 56%, p \u3c 0.03. All of the above findings are probably because less than 50% have received any formal education in this important field. CONCLUSIONS: There is a lack of standard radiation safety measures and equipments in cardiac catheterization laboratories. Significant lapses exist in practice and lack of knowledge of radiation safety among invasive cardiologists in this part of the world. With rapid growth in the number of cardiac catheterization laboratories in developing countries significant improvement in knowledge, practice and availability of radiation safety measures is needed

Effect of percutaneous mitral vavuloplasty on pregnant mother and foetus--a tertiary care hospital experience from a developing country

This study evaluated the short and long-term consequences of Percutaneous Mitral Valvuloplasty (PMV) in pregnant patients and their offspring, in a tertiary care setting, Karachi, Pakistan. The hospital database was used to retrieve all patients who underwent PMV during pregnancy in the period 1998-2007. The follow up data of the patients and the born children were obtained from the hospital records and also by contacting the patients via phone. Six patients underwent PMV but follow-up was available for 5 patients only. All 5 patients were admitted due to severe mitral stenosis with symptoms of dyspnea and palpitation. Mean age was 27 +/- 5.3 years with a mean gestational age at the time of procedure of 22.20 +/- 1.6 weeks. The mean valve area increased from 0.94 +/- 0.22 cm2 preoperatively to 1.62 +/- 0.50 cm2 post-operatively. The ejection fraction changed from a mean of 50 +/- 11.7% to 56 +/- 2.2%. There were no maternal deaths, abortions or stillbirths. Developmental milestones were achieved at the appropriate ages in all babies. PMV appears to be a safe and effective intervention for patients with severe MS during pregnancy. Keywords: Mitral stenosis, Percutaneous Mitra

Secondary prevention of heart disease - knowledge among cardiologists and Omega-3 (Omega-3) fatty acid prescribing behaviors in Karachi, Pakistan

Background: The use of omega-3 fatty acids is a currently proven strategy for secondary prevention of heart disease. The prescription practices for this important nutraceutical is not currently known. It is imperative to assess the knowledge of cardiologists regarding the benefits of omega-3 fatty acids and to determine the frequency of its prescription. The aim of the study was to determine the practices and associations of dietary fish prescribing among cardiologists of Karachi and to assess their knowledge of fish oil supplementation and attitudes toward dietary practices. Methods: A cross sectional survey was conducted during the period of January to March, 2008. A self report questionnaire was employed. All practicing cardiologists of Karachi were included in the study. Multiple logistic regression analysis was performed to determine the independent factors associated with high fish prescribers. Results: The sample comprised of a total of 163 cardiologists practicing in Karachi, Pakistan. Most (73.6%) of the cardiologists fell in the age range of 28 - 45 years and were male (90.8%). High fish prescribers only comprised 36.2% of the respondents. After adjusting for age and gender, multivariate analysis revealed that only the variable of knowledge about fish oil\u27s role in reducing sudden cardiac death was independently associated with high fish prescribers OR = 6.38 [95% CI 2.58-15.78]. Conclusion: The level of knowledge about the benefits of omega-3 fatty acids is high and the cardiologists harbor a favorable attitude towards dispensing dietary fish advice. However, the prescription practices are less than optimal and not concordant with recommendations of organisations such as the American Heart Association and National Heart Foundation of Australia. The knowledge of prevention of sudden cardiac death in CVD Patients has been identified as an important predictor of high fish prescription. This particular life-saving property of omega-3 fatty acids should be the focus of any implemented educational strategy targeted to improve secondary CVD prevention via omega-3 fatty acid supplementation

Survival of patients treated with intra-aortic balloon counterpulsation at a tertiary care center in Pakistan – patient characteristics and predictors of in-hospital mortality

BACKGROUND: Intra-aortic balloon counterpulsation (IABC) has an established role in the treatment of patients presenting with critical cardiac illnesses, including cardiogenic shock, refractory ischemia and for prophylaxis and treatment of complications of percutaneous coronary interventions (PCI). Patients requiring IABC represent a high-risk subset with an expected high mortality. There are virtually no data on usage patterns as well as outcomes of patients in the Indo-Pakistan subcontinent who require IABC. This is the first report on a sizeable experience with IABC from Pakistan. METHODS: Hospital charts of 95 patients (mean age 58.8 (± 10.4) years; 78.9% male) undergoing IABC between 2000–2002 were reviewed. Logistic regression was used to determine univariate and multivariate predictors of in-hospital mortality. RESULTS: The most frequent indications for IABC were cardiogenic shock (48.4%) and refractory ischemia (24.2%). Revascularization (surgical or PCI) was performed in 74 patients (77.9%). The overall in-hospital mortality rate was 34.7%. Univariate predictors of in-hospital mortality included (odds ratio [95% CI]) age (OR 1.06 [1.01–1.11] for every year increase in age); diabetes (OR 3.68 [1.51–8.92]) and cardiogenic shock at presentation (OR 4.85 [1.92–12.2]). Furthermore, prior CABG (OR 0.12 [0.04–0.34]), and in-hospital revascularization (OR 0.05 [0.01–0.189]) was protective against mortality. In the multivariate analysis, independent predictors of in-hospital mortality were age (OR 1.13 [1.05–1.22] for every year increase in age); diabetes (OR 6.35 [1.61–24.97]) and cardiogenic shock at presentation (OR 10.0 [2.33–42.95]). Again, revascularization during hospitalization (OR 0.02 [0.003–0.12]) conferred a protective effect. The overall complication rate was low (8.5%). CONCLUSIONS: Patients requiring IABC represent a high-risk group with substantial in-hospital mortality. Despite this high mortality, over two-thirds of patients do leave the hospital alive, suggesting that IABC is a feasible therapeutic device, even in a developing country

Adherence to the European Society of Cardiology (ESC) guidelines for chronic heart failure - A national survey of the cardiologists in Pakistan

<p>Abstract</p> <p>Background</p> <p>The aims of this study were to evaluate the awareness of and attitudes towards the 2005 European Society of Cardiology (ESC) guidelines for Heart Failure (HF) of the cardiologists in Pakistan and assess barriers to adherence to guidelines.</p> <p>Methods</p> <p>A cross-sectional survey was conducted in person from March to July 2009 to all cardiologists practicing in 4 major cities in Pakistan (Karachi, Lahore, Quetta and Peshawar). A validated, semi-structured questionnaire assessing ESC 2005 Guidelines for HF was used to obtain information from cardiologists. It included questions about awareness and relevance of HF guidelines (See Additional File <supplr sid="S1">1</supplr>). Respondents' management choices were compared with those of an expert panel based on the guidelines for three fictitious patient cases. Cardiologists were also asked about major barriers to adherence to guidelines.</p> <suppl id="S1"> <title> <p>Additional file 1</p> </title> <text> <p><b>Questionnaire</b>. Description: Questionnaire that was administered to participants.</p> </text> <file name="1471-2261-11-68-S1.DOC"> <p>Click here for file</p> </file> </suppl> <p>Results</p> <p>A total of 372 cardiologists were approached; 305 consented to participate (overall response rate, 82.0%). The survey showed a very high awareness of CHF guidelines; 97.4% aware of any guideline. About 13.8% considered ESC guidelines as relevant or very relevant for guiding treatment decisions while 92.8% chose AHA guidelines in relevance. 87.2% of respondents perceived that they adhered to the HF guidelines. For the patient cases, the proportions of respondents who made recommendations that completely matched those of the guidelines were 7% (Scenario 1), 0% (Scenario 2) and 20% (Scenario 3). Respondents considered patient compliance (59%) and cost/health economics (50%) as major barriers to guideline implementation.</p> <p>Conclusion</p> <p>We found important self reported departures from recommended HF management guidelines among cardiologists of Pakistan.</p