Heavily thickened pericardium with constrictive pericarditis.

A middle-aged male presented with symptoms of exertional shortness of breath and leg swelling for the past six months. Examination revealed raised jugular venous pressure (JVP), pitting pedal oedema, muffled heart sounds, bilateral pleural effusion and hepatomegaly. Echocardiogram showed features of constrictive pericarditis with heavily thickened pericardium, which was confirmed by cardiac computed tomography (CT). The patient underwent pericardiectomy following which echocardiographic features of constriction were reversed and the patient became asymptomatic

Non-compaction of the left ventricle and associated ventricular septal defect.

A case report of a 28-year-old patient, who presented with symptoms and signs of congestive heart failure and had clinical signs of ventricular septal defect as well. On further work-up echocardiogram showed non-compaction of the left ventricle with severe left ventricular systolic dysfunction and a ventricular septal defect. He was treated with standard treatment of heart failure and is doing well

Quadricuspid aortic valve with aortic regurgitation: a rare echocardiographic finding.

We report on a middle-aged woman treated for chronic hepatitis C virus infection with pegylated interferon. Auscultation revealed a diastolic murmur and the peripheral signs of aortic regurgitation. She had shortness of breath on moderate exertion for the past 4 months, which she attributed to her liver disease. Echocardiogram showed a quadricuspid aortic valve with severe aortic regurgitation. She was referred to a cardiothoracic surgeon for aortic valve replacement (AVR). However, she decided against AVR despite detailed counselling, and opted for medical treatment

Coronary artery dissection after blunt chest trauma.

Blunt thoracic trauma may result in cardiac injuries ranging from simple arrhythmias to fatal cardiac rupture. Coronary artery dissection culminating in acute myocardial infarction (AMI) is rare after blunt chest trauma. Here we report a case of a 37-year-old man who had an AMI secondary to coronary dissection resulting from blunt chest trauma after involvement in a physical fight

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

Acute myocardial infarction from a lower-middle income country-A comprehensive report on performance measures and quality metrics using National Cardiovascular Data Registry

Introduction: Epidemic of cardiovascular disease (CVD) is widely projected in South Asian population and estimated to get double in two decades. Ischemic heart disease (IHD) is one of the spectrums of CVD and acute myocardial infarction (AMI) being the common manifestations of IHD. National Cardiovascular Data Registry (NCDR) is a registry data that measure their practices and improve quality of care. In this project we aim to see our performance trends in the care of IHD including AMI patients over two year\u27s period.Material & methods: A cross sectional study conducted at the Aga Khan University Hospital, Karachi, Pakistan. All patients aged 18 years and above admitted to adult Cardiology units with chest pain and acute coronary syndrome are eligible to be included in NCDR data set. Data on demographics and initial characteristics of patients were extracted from NCDR institutional dataset. The data was then compared between 2019 and 2020 on performance, quality, and efficiency metrics.Result: In 2019 to 2020, 1542 patients with acute coronary syndrome and stable ischemic heart disease were admitted. Out of these, 1042 patients (67.8%) were males. According to our data, the 2020 mortality rate was about 5.25%. In 2019 and 2020, bleeding rates were 1.1% and 1.6%, respectively. Our data showed 100% PCI in 90 minutes in 2019 while 87% in 2020. According to the appropriateness criteria for PCI, 80% were appropriate, while 20% were possibly appropriate in both years. The median length of stay following a procedure was 2 days in 2019 and 1 day in 2020.Conclusion: This study described the common and unique characteristics of patients with myocardial infarction representing population from South Asian region. Overall, the procedural performance measure and outcome metrics are up to the international benchmarks. Cultural, financial, and pandemic effects identified certain challenges

Interrupted aortic arch complicated with takotsubo cardiomyopathy mimicking aortic dissection

A 50-year-old man presented to the emergency department with interscapular pain, diaphoresis and restlessness. Initial examination raised the possibility of aortic dissection; however, the CT scan did not concur with the diagnosis. An ECG showed ST segment elevation in leads V1-V6 and echocardiography showed severe left ventricular systolic dysfunction. Coronary angiography through the right femoral artery was attempted but the diagnostic catheter could not be advanced to the ascending aorta. Radiocontrast injection showed complete obstruction of the descending aorta. Coronary angiography through right radial approach showed mild left anterior descending disease. The aortogram showed complete interruption of the ascending aorta with extensive collateral network. Left ventricle gram was consistent with stress-induced cardiomyopathy. We noticed intermittent confusion and agitation. MRI of the brain showed areas of deep white matter ischaemia as well as microhaemorrhages, suggesting posterior reversible leucoencephalopathy syndrome. He unfortunately went into cardiac arrest and could not be revived

QRS duration and echocardiographic evidence of left ventricular dyssynchrony in patients with left ventricular systolic dysfunction

OBJECTIVE: To determine the association between left ventricular (LV) dyssynchrony assessed by tissue Doppler imaging (TDI) in patients with left ventricular ejection fraction (LVEF) \u3c 35% and prolonged ventricular depolarization on electrocardiography. STUDY DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: The Aga Khan University, Karachi, from June to September 2007. METHODOLOGY: All patients with LVEF \u3c 35% were included. Apical 2-D images were obtained in 4 chamber and 2 chamber views. TDI pulse wave Doppler parameters were measured from these 2 color-coded images. Time interval between the onset of QRS complex and the peak systolic velocity per region was derived. Patients with valvular heart disease, mitral annular calcification, atrial fibrillation and paced rhythm were excluded. Fischer\u27s exact test was used to determine the association between QRS duration and left ventricular dyssynchrony. RESULTS: A total of 60 patients were included. Twenty one patients had QRS duration of \u3e 120 msec. Out of those 21 patients, a total of 6 patients (28.6%) had evidence of dyssynchrony on TDI. Five patients (23.8%) had dyssynchrony on the basis of basal septal and basal lateral velocity difference (p=0.045) and 6 patients (28.6%) had evidence of dyssynchrony based on basal anterior and basal inferior velocity difference (p=0.018). Out of the remaining 39 patients with narrow QRS complex, only 2 patients (5.1%) had dyssynchrony on TDI. CONCLUSION: The study demonstrates a significant association between prolonged QRS duration and left ventricular dyssynchrony on TDI. Therefore, such patients should be screened for prolonged QRS duration on ECG before cardiac resynchronization therapy (CRT)

Long-term clinical outcomes of percutaneous coronary intervention in saphenous vein grafts in a low to middle-income country

Background: Revascularization of saphenous vein grafts (SVGs) is challenging and debated for the last few decades. The percutaneous revascularization of SVGs was reported to have poorer long-term outcomes than native coronary artery revascularization.Purpose: We aim to study the peri-procedural complications and long-term outcomes of the percutaneous revascularization of SVGs in a low-middle-income country.Methods: In this retrospective study, we included 110 patients who underwent percutaneous revascularization from January 2011 to March 2020 and followed them retrospectively for long-term outcomes and major adverse cardiovascular events.Results: The mean age was 71 ±9, and 81% were male. The most common reason for the presentation was non-ST segment elevation myocardial infarction (NSTEMI) (46%). The mean follow-up period of the study was 48±27 months. The most common comorbidity was hypertension (86%). A drug-eluting stent (80%) was placed in most of the patients, followed by a bare-metal stent (BMS) (14%) and percutaneous balloon angioplasty (POBA) (6%). We did not find any significant difference in major adverse cardiac events (MACE) (P=0.48), target vessel revascularization (TVR) (p=0.69), and target lesion revascularization (TLR) (p=0.54) with drug-eluting stent (DES) as compared to either BMS or POBA. The mean period from coronary artery bypass grafting (CABG) to SVG percutaneous coronary intervention (PCI) was 15± 5.5 years. Multivariate Cox regression analysis showed that an acute coronary syndrome (ACS) event, stroke, and female sex were independently associated with MACE.Conclusion: The long-term outcomes of SVG PCI are not affected by the types of stents. Female gender, ACS, and stroke are the independent predictors of MACE after SVG PCI, and statin therapy has a positive impact on the long-term outcomes of SVG PCI

B-type natriuretic peptide versus amino terminal pro-B type natriuretic peptide: selecting the optimal heart failure marker in patients with impaired kidney function

Background: The effect of impaired kidney function on B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) is vague. This study was performed to examine the effect of kidney dysfunction on the afore-mentioned markers and determine appropriate cutoffs for systolic heart failure (SHF). Methods: In this cross sectional study adults with estimated glomerular filtration rate (eGFR)/min for ≥3 months were identified in consulting clinics from June 2009 to March 2010. SHF was defined as documented by a cardiologist with ejection fraction of \u3c 40% and assessed by New York Heart Association classification (NYHA). Plasma was assayed for creatinine (Cr), BNP and NT-proBNP. Results: A total of 190 subjects were enrolled in the study, 95 with and 95 without SHF. The mean age of patients was 58 (±15) years, 67.4% being males. Mean BNP levels showed a 2.5 fold and 1.5 fold increase from chronic kidney disease (CKD) stage 3 to stage 5 in patients with and without SHF respectively. NT-proBNP levels in non-heart failure group were 3 fold higher in CKD stage 5 compared to stage 3. Mean NT-proBNP levels were 4 fold higher in CKD stage 5 compared to stage 3 in patients with SHF. Optimal BNP and NT-proBNP cutoffs of SHF diagnosis for the entire CKD group were 300 pg/ml and 4502 pg/ml respectively. Conclusion: BNP and NT-proBNP were elevated in kidney dysfunction even in the absence of SHF; however the magnitude of increase in NT-proBNP was greater than that of BNP. BNP and NT-proBNP can be useful in diagnosing SHF, nonetheless, by using higher cutoffs stratified according to kidney dysfunction. NT-proBNP appears to predict heart failure better than BNP