The South African Cardiovascular Magnetic Resonance (SA-CMR) Registry: An Interim Analysis of Clinical Utility, Indications and Baseline Characteristics of Patients Undergoing CMR in a Single Centre in South Africa

Background Cardiovascular magnetic resonance (CMR) is a clinically useful imaging modality that is fast becoming a routine tool in clinical practice. In 2013, the results of the first multi-national registry, EuroCMR, were published. The study highlighted the clinical significance and impact of CMR in Europe. More recently, the global CMR registry (GCMR) has been established to standardise data from international centres in order to support the role of CMR across diverse patient demographics. Despite South Africa joining the GCMR network, the role of CMR in the South African context remains undefined and at present there is limited research pertaining to its use. The South African CMR (SA-CMR) registry was founded in 2016 with a view to gain insight into CMR in the South African setting. This interim analysis of the first 1,142 patients aims to establish the clinical use and indications for CMR, to assess the quality of CMR images and to the assess the baseline demographic and clinical characteristics of the cohort. Secondary objectives aim to ascertain the impact of CMR on patient management. Methods SA-CMR was designed to be a national registry that consists of both retrospective and prospective CMR data. This analysis reports on the single-centre experience at Groote Schuur Hospital, Cape Town. The retrospective arm consists of patients that underwent CMR at Groote Schuur Hospital (GSH) from its introduction in 2005 to April 2017. This interim analysis will assess the first 1,142 patients in this retrospective arm. Results Of the indications for use of CMR in Cape Town, the ascertainment of the presence of cardiomyopathies or their delineation accounted for 54% of scans performed. 15% were utilised to define congenital cardiac anomalies. The average age of patients undergoing CMR was 40 years old and there was a slightly increased percentage of female to male patients (52.65% vs 47.32%). Image quality was diagnostic in 99% of cases and adverse reactions from gadolinium contrast agent use only occurred in 0.18% of patients – of which none were fatal. 34% of scans showed either an alternative diagnosis or additive information which subsequently resulted in an alteration in clinical management of the patient. Conclusion In comparison with the European cohort, where the most important indication for CMR was risk stratification in suspected coronary artery disease, SA-CMR showed that, in the South African setting, CMR was utilised predominantly for investigation of cardiomyopathies. SACMR further supported CMR as a safe imaging technique which has assisted in diagnostics and clinical management of patients with cardiovascular disease in South Africa

Severe reperfusion lung injury after double lung transplantation

AIM: To demonstrate the effects of combined inhaled nitric oxide and surfactant replacement as treatment for acute respiratory distress syndrome. This treatment has not previously been documented for reperfusion injury after double lung transplantation. METHOD: A 24-year-old female with cystic fibrosis underwent double lung transplantation. During implantation of the second lung a marked increase in pulmonary artery pressure associated with systemic hypotension, hypoxemia and low cardiac output were observed. Notwithstanding the patient received support from cardiovascular drugs and pulmonary vasodilators cardiopulmonary by-pass was necessary. In the intensive care unit the patient received the same drug support, inhaled nitric oxide and two bronchoscopic applications of bovine surfactant. RESULTS: A rapid improvement in PaO(2)/FiO(2) within 2–3 hours of administration of surfactant was seen. The patient is well at follow-up 1 year post-transplant. CONCLUSION: There is a potential role for a combined therapy with inhaled nitric oxide and surfactant replacement in reperfusion injury after lung transplantation

Continuous right ventricular end diastolic volume and right ventricular ejection fraction during liver transplantation: A multicenter study

Cardiac preload is traditionally considered to be represented by its filling pressures, but more recently, estimations of end diastolic volume of the left or right ventricle have been shown to better reflect preload. One method of determining volumes is the evaluation of the continuous right ventricular end diastolic volume index (cRVEDVI) on the basis of the cardiac output thermodilution technique. Because preload and myocardial contractility are the main factors determining cardiac output during liver transplantation (LTx), accurate determination of preload is important. Thus, monitoring of cRVEDVI and cRVEF should help with fluid management and with the assessment of the need for inotropic and vasoactive agents. In this multicenter study, we looked for possible relationships between the stroke volume index (SVI) and cRVEDVI, cRVEF, and filling pressures at 4 predefined steps in 244 patients undergoing LTx. Univariate and multivariate autoregression models (across phases of the surgical procedure) were fitted to assess the possible association between SVI and cRVEDVI, pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) after adjustment for cRVEF (categorized as 40%). SVI was strongly associated with both cRVEDVI and cRVEF. The model showing the best fit to the data was that including cRVEDVI. Even after adjustment for cRVEF, there was a statistically significant (P < 0.05) relationship between SVI and cRVEDVI with a regression coefficient (slope of the regression line) of 0.25; this meant that an increase in cRVEDVI of 1 mL m(-2) resulted in an increase in SVI of 0.25 mL m(-2). The correlations between SVI and CVP and PAOP were less strong. We conclude that cRVEDVI reflected preload better than CVP and PAOP

Risk factors for Coronavirus disease 2019 (Covid-19) death in a population cohort study from the Western Cape province, South Africa

Risk factors for coronavirus disease 2019 (COVID-19) death in sub-Saharan Africa and the effects of human immunodeficiency virus (HIV) and tuberculosis on COVID-19 outcomes are unknown. We conducted a population cohort study using linked data from adults attending public-sector health facilities in the Western Cape, South Africa. We used Cox proportional hazards models, adjusted for age, sex, location, and comorbidities, to examine the associations between HIV, tuberculosis, and COVID-19 death from 1 March to 9 June 2020 among (1) public-sector “active patients” (≥1 visit in the 3 years before March 2020); (2) laboratory-diagnosed COVID-19 cases; and (3) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19, comparing adults living with and without HIV using modeled population estimates.Among 3 460 932 patients (16% living with HIV), 22 308 were diagnosed with COVID-19, of whom 625 died. COVID19 death was associated with male sex, increasing age, diabetes, hypertension, and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR], 2.14; 95% confidence interval [CI], 1.70–2.70), with similar risks across strata of viral loads and immunosuppression. Current and previous diagnoses of tuberculosis were associated with COVID-19 death (aHR, 2.70 [95% CI, 1.81–4.04] and 1.51 [95% CI, 1.18–1.93], respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI, 1.96–2.86); population attributable fraction 8.5% (95% CI, 6.1–11.1)

Dyspnoea: Pathophysiology and a clinical approach

Dyspnoea, also known as shortness of breath or breathlessness, is a subjective awareness of the sensation of uncomfortable breathing. It may be of physiological, pathological or social origin. The pathophysiology of dyspnoea is complex, and involves the activation of several pathways that lead to increased work of breathing, stimulation of the receptors of the upper or lower airway, lung parenchyma, or chest wall, and excessive stimulation of the respiratory centre by central and peripheral chemoreceptors. Activation of these pathways is relayed to the central nervous system via respiratory muscle and vagal afferents, which are consequently interpreted by the individual in the context of the affective state, attention, and prior experience, resulting in the awareness of breathing. The clinical evaluation and approach to the management of dyspnoea are directed by the clinical presentation and underlying cause. The causes of dyspnoea are manifold, and include a spectrum of disorders, from benign to serious and life-threatening entities. The pathophysiology, aetiology, clinical presentation and management of dyspnoea are reviewed