Congenitally Corrected Transposition of the Great Arteries in a Septuagenarian from the Developing Country of Pakistan

Congenitally corrected transposition of the great arteries (CCTGA) is a rare congenital cardiac defect with atrioventricular and ventriculoarterial discordance which leads to heart failure and limits patients\u27 lifespan. We report the case of a 70-year-old lady, from a poor province in Pakistan, who presented for the first time with palpitations and was diagnosed to have CCTGA. She had moderate pulmonic valve stenosis which was protective against heart failure. She had six children all born via spontaneous vertex delivery in her local village. This case exemplifies the fact that pulmonic stenosis is favourable for patients with CCTGA. In a country where the average life expectancy of females is only 68 years, the survival of our patient with CCTGA beyond the average lifespan is indeed interesting

Two Congenital Left-to-Right Shunt Anomalies in a Septuagenarian: ARare Occurrence

Atrial septal defect (ASD) and patent ductus arteriosus (PDA) are common congenital anomalies presenting in childhood. Life expectancy of an uncorrected PDAis shortened to half; and ASD of a significant size has increased morbidity and mortality. Their co-existence in an elderly patient with first presentation at 70 years of age is a rarity. We present the case of a 70-year woman with one-week history of dyspnea with high blood pressure and signs of heart failure. She was found to have a PDA and an ASD with left-to-right shunt. She was managed conservatively. She was offered cardiac catheterization, but she refused. This is the first documented case in local literature with two such congenital heart defects presenting in a septuagenarian. In a country where average life expectancy is in the 60\u27s, the survival of the patient with two heart defects, beyond-average survival age, is interesting

A Curious Case of Intermittent Left Bundle Branch Block Associated with Cough

A handful of cases of voluntary control of left bundle branch block (LBBB) have been described in the literature. We report the case of a middle-aged man who was found to have LBBB on baseline electrocardiogram (ECG) which disappeared on coughing and then reappeared with the same maneuver. Subsequent myocardial perfusion scan showed reduced count in the anteroseptal region likely attributed to LBBB. It is possible that the intermittent conduction changes may be due to the alteration in the vagal tone associated with cough as reflected in the change in the PR interval on the ECG

Sleep Fainting: A Neurocardiogenic Entity

Fainting is a common clinical presentation, with vagally mediated (neurocardiogenic) causes being the most common for syncope presentation to the emergency room, and for hospital admissions. Classic teaching is that upright posture is a prerequisite for vagally mediated syncope (VMS) and that syncope in the supine position has more sinister causes. We present five patients, three males and two females, with a mean age of 44.4 (range 29-67) years, who presented with VMS in the supine position (sleep fainting). Four patients also had a history of classic upright syncope. Based on their clinical features and thorough investigations, we excluded other causes of loss of consciousness and diagnosed these patients to be having VMS in the supine position (sleep fainting). We further describe the management and follow-up of these patients. Sleep fainting/syncope is a new entity and has to be recognized for appropriate management. A diagnosis can be established if there is clinical suspicion, preserved left ventricular function without evidence of coronary artery disease, no high-risk electrocardiographic evidence of pre-excitation, long or short QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia, and normal neurological work-up

Antidromic Atrioventricular Reentrant Tachycardia Dependent on a Unidirectional Left Anterior Accessory Pathway Mimicking Peri-mitral Ventricular Tachycardia: Successful Ablation via a Transseptal Approach

Antidromic atrioventricular reentrant tachycardia (aAVRT) is rare compared to orthodromic atrioventricular reentrant tachycardia (oAVRT). An aAVRT that is dependent on a unidirectional, decremental accessory pathway (AP) is even rarer. Idiopathic ventricular tachycardias (iVT) that have benign prognoses and respond well to medical therapy can be confused with aAVRTs dependent on APs having ventricular insertion sites close to the iVT focus and have a real risk of sudden death. The preferred approach of ablation for such tachycardias with anterograde conduction only is a retrograde aortic approach, which facilitates the mapping of the earliest ventricular activation during atrial pacing or tachycardia from the ventricular side. This, however, necessitates access to the arterial system with accompanying complications. We describe herein the case of a wide complex tachycardia, which was treated initially as VT with intravenous lidocaine. The baseline electrocardiogram (ECG) did not show preexcitation. An electrophysiology study (EPS) revealed a left anterior AP that conducted anterograde only. AVRT was easily inducible at a cycle length of 290 ms. Successful ablation was undertaken via the transseptal approach without recurrence

COVID-19 presenting with spontaneous pneumothorax

The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease mainly affects respiratory system. Its common clinical findings include fever, cough and shortness of breath. Characteristic radiological features of the disease include peripherally distributed, bilateral ground-glass opacities, predominantly involving the lower lung zones. In this report, we present a case of COVID-19 disease presenting with spontaneous pneumothorax. A 26-year male patient was admitted to the Emergency Department with fever, dry cough, shortness of breath and right-sided chest pain. Radiographic imaging of the patient revealed pneumothorax on the right and peripherally distributed non-homogenous opacification. The patient underwent right lateral tube thoracostomy. COVID-19 was diagnosed on testing of nasopharyngeal swab. In conclusion, spontaneous pneumothorax is one of the rare presentations of COVID-19 pneumonia and should be kept in mind in patients presenting with shortness of breath and chest pain

Treatment of a Rare Vascular Complication of Coronary Stenting in an Octagenarian

The ability of drug-eluting stent (DES) to inhibit intimal proliferation has resulted in a massive increase in their usage over the years. However, it is known that the application of DES can alter the normal cascade of vascular healing, resulting in delayed endothelialisation with risk of vascular complications. Coronary artery aneurysms (CAN) are defined as more than 50% dilatation of the coronary artery compared to the reference vessel diameter with the reported incidence after percutaneous intervention (PCI) being only around 0.35 to 6.0%. Previously, CAN had been reported with the use of bare metal stent secondary to stretch, stent fracture and dissection. However, recently, increasing number of cases have been reported describing CAN after DES implantation. To the best of the authors\u27 knowledge, they present the first case from Pakistan of a left anterior descending coronary artery aneurysm after DES implantation treated successfully with stenting under intravascular ultrasound guidance

Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit.

Objective: To determine the difference in Blood Pressure (BP) readings taken before, during and after the clinic encounter. Study Design: Descriptive study. Place and Duration of Study: Cardiology Clinic, The Aga Khan University Hospital, Karachi, from January to August 2013. Methodology: Hypertensive and normotensive participants aged ≥ 18 years were recruited. Pre-clinic BP was measured by a nurse and in-clinic BP by a physician. After 15 minutes, two post-clinic BP readings were taken at 1 minute interval. All readings were taken using Omron HEM7221-E. Results: Out of 180 participants, males were 57% and 130 (71%) were hypertensive. Mean SBP (Systolic BP) taken preclinic, in-clinic, post-clinic 1 and post-clinic 2 were: 126 ± 20 mmHg, 131 ± 23 mmHg, 126 ± 20 mmHg and 121 ± 21 mmHg respectively (p \u3c 0.001). Mean DBP (Diastolic BP) taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were 77 ± 12 mmHg, 81 ± 13 mmHg, 79 ± 12 mmHg and 79 ± 11 mmHg respectively (p \u3c 0.001). Conclusion: BP taken in the post-clinic setting may significantly be the lowest reading in a clinic encounter, making in-clinic BP unreliable to diagnose or manage hypertension

It’s not always occam\u27s razor – the case of a young man with subaortic membrane with superimposed pulmonary thromboembolism and left main coronary artery disease

Subaortic membrane (SAM) is a discrete fibromuscular structure which causes left ventricular outflow tract obstruction and leads to the symptomatology of valvular aortic stenosis. It is known to be associated with other congenital cardiac defects in around 30% of cases. However, it has not been associated with chronic pulmonary thromboembolism in the past. We present a case of a middle-aged Pakistani man who presented with dyspnea and hemoptysis. He was found to have a SAM and severe pulmonary hypertension on transthoracic echocardiogram. A coronary angiogram revealed non-obstructive left main coronary artery disease. A computed tomography (CT) scan chest was done to evaluate the cause of severe pulmonary hypertension unexplained by SAM which revealed chronic pulmonary thromboembolism. Surgical resection was deferred due to high risk. Hence, he was kept on anticoagulation for pulmonary thromboembolism, and aspirin and a statin for non-obstructive coronary artery disease. Over the course of two months, his symptoms improved. This case highlights the importance of evaluating different causes of pulmonary hypertension in patients with SAM

The Post Clinic Ambulatory Blood Pressure (PC-ABP) study correlates Post Clinic Blood Pressure (PCBP) with the gold standard Ambulatory Blood Pressure

Objectives: Our previous study showed that post-clinic blood pressure (BP) taken 15 min after a physician-patient encounter was the lowest reading in a routine clinic. We aimed to validate this reading with 24 h Ambulatory Blood Pressure Monitoring (ABPM) readings. A cross-sectional study was conducted in the cardiology clinics at the Aga Khan University, Pakistan. Hypertensive patients aged ≥ 18 years, or those referred for the diagnosis of hypertension were included.Results: Of 150 participants, 49% were males. 76% of all participants were hypertensive. Pre-clinic BP reading was measured by a nurse, in-clinic by a physician and 15 min post-clinic by a research assistant using a validated, automated BP device (Omron-HEM7221-E). All patients were referred for 24 h ABPM. Among the three readings taken during a clinic visit, mean (± SD) systolic BP (SBP) pre-clinic, in-clinic, and 15 min post-clinic were 153.2 ± 23, 152.3 ± 21, and 140.0 ± 18 mmHg, respectively. Mean (± SD) diastolic BP (DBP) taken pre-clinic, in-clinic and 15 min post-clinic were 83.5 ± 12, 90.9 ± 12, and 86.4 ± 11 mmHg respectively. Mean (± SD) daytime ambulatory SBP, DBP and pulse readings were 134.7 ± 15, 78.7 ± 15 mmHg, and 72.6 ± 12/min, respectively. Pearson correlation coefficients of pre-clinic, in-clinic and post-clinic SBP with daytime ambulatory-SBP were 0.4 (p value: \u3c 0.001), 0.5 (p value: \u3c 0.001) and 0.6 (p value: \u3c 0.001), respectively. Post-clinic BP has a good correlation with ambulatory BP and may be considered a more reliable reading in the clinic setting