Single Versus Dual Antiplatelet Therapy After Coronary Artery Bypass Grafting for Unprotected Left-Main Coronary Disease

BACKGROUND

The use of dual antiplatelet therapy (DAPT) after coronary revascularization for left-main disease is still debated. The study aimed to characterize patients who received dual versus single antiplatelet therapy (SAPT) after coronary artery bypass grafting (CABG) for unprotected left-main disease and compare the outcomes of those patients.

RESULTS

This multicenter retrospective cohort study included 551 patients who were grouped into 2 groups: patients who received SAPT (n = 150) and those who received DAPT (n = 401). There were no differences in age ( P = 0.451), gender ( P = 0.063), smoking ( P = 0.941), diabetes mellitus ( P = 0.773), history of myocardial infarction ( P = 0.709), chronic kidney disease ( P = 0.615), atrial fibrillation ( P = 0.306), or cerebrovascular accident ( P = 0.550) between patients who received SAPT versus DAPT. DAPTs were more commonly used in patients with acute coronary syndrome [87 (58%) vs. 273 (68.08%); P = 0.027], after off-pump CABG [12 (8%) vs. 73 (18.2%); P = 0.003] and in patients with radial artery grafts [1 (0.67%) vs. 32 (7.98%); P < 0.001]. While SAPTs were more commonly used in patients with low ejection fraction [55 (36.67%) vs. 61 (15.21%); P < 0.001] and in patients with postoperative acute kidney injury [27 (18%) vs. 37 (9.23%); P = 0.004]. The attributed treatment effect of DAPT for follow-up major adverse cerebrovascular and cardiac events was not significantly different from that of SAPT [β, -2.08 (95% confidence interval (CI), -20.8-16.7); P = 0.828]. The attributed treatment effect of DAPT on follow-up all-cause mortality was not significantly different from that of SAPT [β, 4.12 (CI, -11.1-19.32); P = 0.595]. There was no difference in bleeding between groups ( P = 0.666).

CONCLUSIONS

DAPTs were more commonly used in patients with acute coronary syndrome, after off-pump CABG, and with radial artery grafts. SAPTs were more commonly used in patients with low ejection fraction and acute kidney injury. Patients on DAPT after CABG for left-main disease had comparable major adverse cerebrovascular and cardiac events and survival to patients on SAPT, with no difference in bleeding events.

A Practical Approach to the Management of Residual Cardiovascular Risk: United Arab Emirates Expert Consensus Panel on the Evidence for Icosapent Ethyl and Omega-3 Fatty Acids

PURPOSE

Patients with hyperlipidemia treated with statins remain at a residual cardiovascular (CV) risk. Omega-3 polyunsaturated fatty acids hold the potential to mitigate the residual CV risk in statin-treated patients, with persistently elevated triglyceride (TG) levels.

METHOD

We reviewed the current evidence on the use of icosapent ethyl (IPE), an omega-3 fatty acid yielding a pure form of eicosapentaenoic acid.

RESULTS

REDUCE-IT reported a significant 25% reduction in CV events, including the need for coronary revascularization, the risk of fatal/nonfatal myocardial infarction, stroke, hospitalization for unstable angina, and CV death in patients on IPE, unseen with other omega-3 fatty acids treatments. IPE was effective in all patients regardless of baseline CV risk enhancers (TG levels, type-2 diabetes status, weight status, prior revascularization, or renal function). Adverse events (atrial fibrillation/flutter) related to IPE have occurred mostly in patients with prior atrial fibrillation. Yet, the net clinical benefit largely exceeded potential risks. The combination with other omega-3 polyunsaturated fatty acids, in particular DHA, eliminated the effect of EPA alone, as reported in the STRENGTH and OMEMI trials. Adding IPE to statin treatment seems to be cost-effective, especially in the context of secondary prevention of CVD, decreasing CV event frequency and subsequently the use of healthcare resources.

CONCLUSION

Importantly, IPE has been endorsed by 20 international medical societies as a statin add-on treatment in patients with dyslipidemia and high CV risk. Robust medical evidence supports IPE as a pillar in the management of dyslipidemia.

Red Flags in Acute Myocarditis

Acute myocarditis is an inflammatory disease of the heart that may occur in the setting of infection, immune system activation or exposure to certain drugs. Often, it is caused by viruses, whereby the clinical course is usually benign; however, it may also present with rapidly progressive fulminant myocarditis, which is associated with high morbidity and mortality. This review highlights the critical red flags - from the clinical, biochemical, imaging and histopathological perspectives - that should raise the index of suspicion of acute myocarditis. We also present an illustrative case of a young female patient with rapidly progressive cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation as a bridge to orthotopic heart transplantation. The patient showed no clinical or echocardiographic recovery signs and eventually underwent orthotopic heart transplantation. Furthermore, we elaborate on the classifications of acute myocarditis based on clinical presentation and histopathology classifications, focusing on identifying key red flags that will inform early diagnosis and appropriate management in such challenging cases.

Does Gender Affect the Outcomes of Myocardial Revascularization for Left-Main Coronary Artery Disease?

Currently, gender is not considered in the choice of the revascularization strategy for patients with unprotected left main coronary artery (ULMCA) disease. This study analyzed the effect of gender on the outcomes of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with ULMCA disease. Females who had PCI (n = 328) were compared with females who had CABG (n = 132) and PCI in males (n = 894) was compared with CABG (n = 784). Females with CABG had higher overall hospital mortality and major adverse cardiovascular events (MACE) than females with PCI. Male patients with CABG had higher MACE; however, mortality did not differ between males with CABG vs PCI. In female patients, follow-up mortality was significantly higher in CABG patients, and target lesion revascularization was higher in patients with PCI. Male patients had no difference in mortality and MACE between groups; however, MI was higher with CABG, and congestive heart failure was higher with PCI. In conclusion, women with ULMCA disease treated with PCI could have better survival with lower MACE compared with CABG. These differences were not evident in males treated with either CABG or PCI. PCI could be the preferred revascularization strategy in women with ULMCA disease.

Left Main Coronary Artery Revascularization in Patients with Impaired Renal Function: Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting

INTRODUCTION

The evidence about the optimal revascularization strategy in patients with left main coronary artery (LMCA) disease and impaired renal function is limited. Thus, we aimed to compare the outcomes of LMCA disease revascularization (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG]) in patients with and without impaired renal function.

METHODS

This retrospective cohort study included 2,138 patients recruited from 14 centers between 2015 and 2,019. We compared patients with impaired renal function who had PCI (n= 316) to those who had CABG (n = 121) and compared patients with normal renal function who had PCI (n = 906) to those who had CABG (n = 795). The study outcomes were in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Multivariable logistic regression analysis showed that the risk of in-hospital MACCE was significantly higher in CABG compared to PCI in patients with impaired renal function (odds ratio [OR]: 8.13 [95% CI: 4.19-15.76], p < 0.001) and normal renal function (OR: 2.59 [95% CI: 1.79-3.73]; p < 0.001). There were no differences in follow-up MACCE between CABG and PCI in patients with impaired renal function (HR: 1.14 [95% CI: 0.71-1.81], p = 0.585) and normal renal function (HR: 1.12 [0.90-1.39], p = 0.312).

CONCLUSIONS

PCI could have an advantage over CABG in revascularization of LMCA disease in patients with impaired renal function regarding in-hospital MACCE. The follow-up MACCE was comparable between PCI and CABG in patients with impaired and normal renal function.

Percutaneous coronary intervention vs. coronary artery bypass grafting in emergency and non-emergency unprotected left-main revascularization

BACKGROUND

The optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease.

METHODS

This retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n = 264) to patients who underwent CABG (n = 196) and patients with non-emergent LMCA revascularization with PCI (n = 958) to those who underwent CABG (n = 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Emergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P = 0.017) and in-hospital mortality (P = 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P = 0.015) and intermediate (P < 0.001) EuroSCORE. PCI was associated with lower MACCE in patients with low (P = 0.002) and intermediate (P = 0.008) SYNTAX scores. In non-emergent revascularization, PCI was associated with reduced hospital mortality in patients with intermediate (P = 0.001) and high (P = 0.002) EuroSCORE compared to CABG. PCI was associated with lower hospital mortality in patients with low (P = 0.031) and intermediate (P = 0.001) SYNTAX scores. At a median follow-up time of 20 months (IQR: 10-37), emergency PCI had lower MACCE compared to CABG [HR: 0.30 (95% CI 0.14-0.66), P < 0.003], with no significant difference in all-cause mortality between emergency PCI and CABG [HR: 1.18 (95% CI 0.23-6.08), P = 0.845].

CONCLUSIONS

PCI could be advantageous over CABG in revascularizing LMCA disease in emergencies. PCI could be preferred for revascularization of non-emergent LMCA in patients with intermediate EuroSCORE and low and intermediate SYNTAX scores.

Outcomes of Left Main Revascularization in Patients with Anemia: Gulf Left Main Registry

INTRODUCTION

The aim of this study was to evaluate the effects of baseline anemia and anemia following revascularization on outcomes in patients with unprotected left main coronary artery (ULMCA) disease.

METHODS

This was a retrospective, multicenter, observational study conducted between January 2015 and December 2019. The data on patients with ULMCA who underwent revascularization through percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were stratified by the hemoglobin level at baseline into anemic and non-anemic groups to compare in-hospital events. The pre-discharge hemoglobin following revascularization was categorized into very low (<80 g/L for men and women), low (≥80 and ≤119 g/L for women and ≤129 g/L for men), and normal (≥130 g/L for men and ≥120 g/L for women) to assess impact on follow-up outcomes.

RESULTS

A total of 2,138 patients were included, 796 (37.2%) of whom had anemia at baseline. A total of 319 developed anemia after revascularization and moved from being non-anemic at baseline to anemic at discharge. There was no difference in hospital major adverse cardiac and cerebrovascular event (MACCE) and mortality between CABG and PCI in anemic patients. At a median follow-up time of 20 months (interquartile range [IQR]: 27), patients with pre-discharge anemia who underwent PCI had a higher incidence of congestive heart failure (CHF) (p < 0.0001), and those who underwent CABG had significantly higher follow-up mortality (HR: 9.85 (95% CI: 2.53-38.43), p = 0.001).

CONCLUSION

In this Gulf LM study, baseline anemia had no impact upon in-hospital MACCE and total mortality following revascularization (PCI or CABG). However, pre-discharge anemia is associated with worse outcomes after ULMCA disease revascularization, with significantly higher all-cause mortality in patients who had CABG, and a higher incidence of CHF in PCI patients, at a median follow-up time of 20 months (IQR: 27).

Outcomes of Transcatheter Aortic Valve Replacement in the United Arab Emirates: Real-world, Single-centre Experience from an Emerging Programme

Background

Data on outcomes of transcatheter aortic valve replacement (TAVR) in the Middle East, particularly in the United Arab Emirates (UAE), are limited. Whether centres with a low volume of patients requiring the procedure can achieve similar outcomes as those reported in pivotal clinical trials remains unclear. This study evaluates procedural outcomes of patients undergoing TAVR in a newly established programme in the UAE.

Methods

Procedural outcomes of consecutive patients who underwent transfemoral TAVR at a single centre in the UAE between January 2016 and November 2021 were compared with those at centres in the lowest quartile (Q1) of procedural volume in the Transcatheter Valve Therapy Registry, which covers centres in the US.

Results

Among the 183 patients included in the study, the median age was 76 years (interquartile range [IQR] 71-82), and 42.1% of patients were women, with a median Society of Thoracic Surgeons predicted risk of mortality score of 4.6 (IQR 2.9-7.5). Most of the patients (93.3%) received a balloon-expandable valve. All-cause death within 30 days, stroke and major vascular complications occurred in 0.6%, 0.6% and 2.2% of patients, respectively, compared with 3.1%, 2.2% and 4% in patients treated at Q1 hospitals.

Conclusion

Patients undergoing transfemoral TAVR at an emerging centre in the Middle East had favourable outcomes compared with those performed at Q1 hospitals in the US. These findings suggest that careful patient selection for TAVR is critical and may help optimise patient outcomes, especially when procedural volumes are low.

Outcomes of Myocardial Revascularization in Diabetic Patients With Left Main Coronary Artery Disease: A Multicenter Observational Study From Three Gulf Countries

BACKGROUND

Real-world data for managing patients with diabetes and left main coronary artery (LMCA) disease are scarce. We compared percutaneous coronary intervention (PCI) outcomes versus coronary artery bypass grafting (CABG) in diabetes and LMCA disease patients.

METHODS

We retrospectively studied patients with LMCA presented to 14 centers from 2015 to 2019. The study included 2138 patients with unprotected LMCA disease; 1468 (68.7 %) had diabetes. Patients were grouped into; diabetes with PCI (n = 804) or CABG (n = 664) and non-diabetes with PCI (n = 418) or CABG (n = 252).

RESULTS

In diabetes, cardiac (34 (5.1 %) vs. 22 (2.7 %); P = 0.016), non-cardiac (13 (2 %) vs. 6 (0.7 %); P = 0.027) and total hospital mortality (47 (7.1 %) vs. 28 (3.5 %); P = 0.0019), myocardial infarction (45 (6.8 %) vs. 11 (1.4 %); P = 0.001), cerebrovascular events (25 (3.8 %) vs. 12 (1.5 %); P = 0.005) and minor bleeding (65 (9.8 %) vs. 50 (6.2 %); P = 0.006) were significantly higher in CABG patients compared to PCI; respectively. The median follow-up time was 20 (10-37) months. In diabetes, total mortality was higher in CABG (P = 0.001) while congestive heart failure was higher in PCI (P = 0.001). There were no differences in major adverse cerebrovascular events and target lesion revascularization between PCI and CABG. Predictors of mortality in diabetes were high anatomical SYNTAX, peripheral arterial disease, chronic kidney disease, and cardiogenic shock.

CONCLUSIONS

In this multicenter retrospective study, we found no significant difference in clinical outcomes during the short-term follow-up between PCI with second-generation DES and CABG except for lower total mortality and a higher rate of congestive heart failure in PCI group of patients. Randomized trials to characterize patients who could benefit from each treatment option are needed.

Impact of left ventricular ejection fraction on outcomes after left main revascularization: g-LM Registry

AIMS

The impact of left ventricular dysfunction on clinical outcomes following revascularization is not well established in patients with unprotected left main coronary artery disease (ULMCA). In this study, we evaluated the impact of left ventricular ejection fraction (LVEF) on clinical outcomes of patients with ULMCA requiring revascularization with percutaneous coronary intervention (PCI) compared with coronary artery bypass graft (CABG).

METHODS

The details of the design, methods, end points, and relevant definitions are outlined in the Gulf Left Main Registry: a retrospective, observational study conducted between January 2015 and December 2019 across 14 centres in 3 Gulf countries. In this study, the data on patients with ULMCA who underwent revascularization through PCI or CABG were stratified by LVEF into three main subgroups; low (l-LVEF <40%), mid-range (m-LVEF 40-49%), and preserved (p-LVEF ≥50%). Primary outcomes were hospital major adverse cardiovascular and cerebrovascular events (MACCE) and mortality and follow-up MACCE and mortality.

RESULTS

A total of 2137 patients were included; 1221 underwent PCI and 916 had CABG. During hospitalization, MACCE was significantly higher in patients with l-LVEF [(10.10%), P = 0.005] and m-LVEF [(10.80%), P = 0.009], whereas total mortality was higher in patients with m-LVEF [(7.40%), P = 0.009] and p-LVEF [(7.10%), P = 0.045] who underwent CABG. There was no mortality difference between groups in patients with l-LVEF. At a median follow-up of 15 months, there was no difference in MACCE and total mortality between patients who underwent CABG or PCI with p-LVEF and m-LVEF.

CONCLUSION

CABG was associated with higher in-hospital events. Hospital mortality in patients with l-LVEF was comparable between CABG and PCI. At 15 months' follow-up, PCI could have an advantage in decreasing MACCE in patients with l-LVEF.

Unprotected Left Main Revascularization in the Setting of Non-Coronary Atherosclerosis: Gulf Left Main Registry

BACKGROUND

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in revascularization of left main coronary artery (LMCA) disease has been evaluated in previous studies. However, there has been minimal study of the relationship between co-existing non-coronary atherosclerosis (NCA) and LMCA disease revascularization. We aim to examine this relationship.

METHODS

The Gulf-LM study is a retrospective analysis of unprotected LMCA revascularization cases undergoing PCI with second generation drug-eluting stent versus CABG across 14 centers within 3 Gulf countries between January 2015 and December 2019. A total of 2138 patients were included, 381 with coexisting NCA and 1757 without. Outcomes examined included major adverse cardiovascular and cerebrovascular events (MACCE), cardiac and non-cardiac death, and all bleeding.

RESULTS

In patients with NCA, preexisting myocardial infarction and congestive heart failure were more common, with PCI being the most common revascularization strategy. A statistically significant reduction in in-hospital MACCE and all bleeding was noted in patients with NCA undergoing PCI as compared to CABG. At a median follow-up of 15 months, MACCE and major bleeding outcomes continued to favor the PCI group, though no such difference was identified between revascularization strategies in patients without NCA.

CONCLUSIONS

In this multicenter retrospective study of patients with and without NCA who require revascularization (PCI and CABG) for unprotected LMCA disease, PCI demonstrated a better clinical outcome in MACCE both in-hospital and during the short-term follow-up in patients with NCA. However, no such difference was observed in patients without NCA.

Polyvascular Disease in the Gulf Region: Concealed Marker of Poor Outcomes in Acute Coronary Syndrome

BACKGROUND

Polyvascular disease (PolyVD) is the presence of atherosclerosis in multiple vascular territories and is associated with an increased risk of major adverse cardiac and cerebrovascular events (MACCE).

OBJECTIVES

Our study aims to draw attention to the prevalence and outcomes of PolyVD in patients presenting with acute coronary syndrome (ACS) in the Gulf region. Highlighting the disease burden of PolyVD in our population will lead to more vigilant surveillance, better clinical outcomes, and improved quality of life.

METHODS

Data from 685 adults who presented with ACS from January 2015 to June 2020 was reviewed retrospectively. We evaluated lower extremity artery disease (LEAD) and cerebrovascular disease (CVD) using ABI and carotid duplex.

RESULTS

35% (n = 238) of patients had PolyVD. 70% patients with LEAD and 65% patients with CVD were asymptomatic. PolyVD was associated with an increased likelihood (aOR,1.69 (1.02-2.81); p = 0.03) of MACCE at 1-year.

CONCLUSIONS

Since the progression of atherosclerosis is an insidious process, most patients remain asymptomatic before presenting with fatal vascular events.

One Versus Two Stents Strategies for Unprotected Left Main Intervention: Gulf Left Main Registry

The optimal stenting strategy for unprotected left main coronary artery (ULMCA) disease remains debated. This retrospective observational study (Gulf Left Main Registry) analyzed the outcomes of 1 vs 2 stents in patients with unprotected left main percutaneous coronary intervention (PCI). Overall, 1222 patients were evaluated; 173 had 1 stent and 1049 had 2 stents. The 2-stent group was older with more comorbidities, higher mean SYNTAX scores, and more distal bifurcation lesions. In the 1-stent group, in-hospital events were significant for major bleeding, and better mean creatinine clearance. At median follow-up of 20 months, the 1-stent group was more likely to have target lesion revascularization (TLR). Total mortality was numerically lower in the 1-stent group (.00% vs 2.10%); however, this was not statistically significant (P=.068). Our analysis demonstrates the benefits of a 2-stent approach for ULMCA patients with high SYNTAX scores and lesions in both major side branches, while the potential benefit of a 1-stent approach for less complex ULMCA was also observed. Further studies with longer follow-up are needed to definitively demonstrate the optimal approach.

Percutaneous Coronary Intervention Vs Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Disease: G-LM Registry

Coronary artery bypass surgery (CABG) has been the standard of care for revascularization for patients with obstructive unprotected left main coronary disease (ULMCA). There have been multiple randomized and registry data demonstrating the technical and clinical efficacy of PCI in certain patients with ULMCA. The purpose of this study is to evaluate clinical outcomes of ULMCA PCI as compared to CABG in patients requiring revascularization in three Gulf countries. All ULMCA cases treated by PCI with DES versus CABG were retrospectively identified from 14 centers in 3 Arab Gulf countries (KSA, UAE, and Bahrain) from January 2015 to December 2019. In total, 2138 patients were included: 1222 were treated with PCI versus 916 with CABG. Patients undergoing PCI were older, and had higher comorbidities and mean European System for Cardiac Operative Risk Evaluation (EuroSCORE). Aborted cardiac arrest and cardiogenic shock were reported more in the PCI group at hospital presentation. In addition, lower ejection fractions were reported in the PCI group. In hospital mortality and major adverse cardiovascular and cerebrovascular events (MACCE) occurred more in patients undergoing CABG than PCI. At median follow-up of 15 months (interquartile range, 30), no difference was observed in freedom from revascularization, MACCE, or total mortality between those treated with PCI and CABG. While findings are similar to Western data registries, continued follow-up will be needed to ascertain whether this pattern continues into latter years.

Review Article--Clinical Overview of Myocardial Infarction Without Obstructive Coronary Artey Disease (MINOCA)

The term myocardial infarction with non-obstructive coronary arteries (MINOCA) applies to patients who have clinical evidence of AMI but coronary angiography reveals no coronary obstructions and an alternative diagnosis is not possible. It is a heterogenous group of disease. Its prognosis, predictors of mortality and optimum management is unclear. In this review, we present a disease overview for MINOCA including the clinical features, adopted definitions, prevalence, diagnosis, treatment, and prognosis.

Successful Bail-Out Stenting for Iatrogenic Right Coronary Artery Dissection in a Young Male

Catheter-induced coronary artery dissection is a serious complication of coronary angiography. Percutaneous intervention is usually indicated in case of large spiral dissections, however, wiring into the true lumen can be challenging. This case reports the novel use of intravascular ultrasound-guided rescue percutaneous coronary intervention for stenting an iatrogenic spiral dissection of the right coronary artery. (Level of Difficulty: Intermediate.)

Hyperdominant left anterior descending artery presenting as anterior wall ST segment elevation myocardial infarction: A rare coronary anomaly

We report on a 75 year-old man who presented with severe chest pain for four hours. Physical examination was unremarkable and he was haemodynamically stable. ECG done in the ED showed ST segment elevations along with Q waves in the anterior and inferior leads with T wave inversions. He was rushed to the catheterization lab where the left anterior descending (LAD) artery was 99%occluded in the proximal segment while distal left circumflex showed 50-60% lesion. He underwent primary percutaneous coronary intervention to LAD with drug eluting stent and made an uneventful recovery. The LADwas found to be wrapping around the apex and continuing as the posterior descending artery (PDA). To the best of our knowledge, there are few case reports on the continuation of LAD across the left ventricular apex as PDA in the presence of a normally arising but small right coronary artery.

Twiddlers syndrome presenting as life threatening electrical storm

A 75-year-old man underwent implantation of a single chamber implantable cardioverter defibrillator (ICD) for primary prevention of his underlying severe non-ischaemic cardiomyopathy. Thirteen months later, he presented to the emergency room(ER) with inappropriate ICD shocks as a result of over sensing of the right ventricular lead and double counting of the right atrial signals. The chest X-ray (CXR) revealed a right ventricular ICD lead displaced into the right atrium with coiling in the pocket. The right ventricular shocking coil was noted at the tricuspid annulus. The lead was removed from the pocket and was replaced with a new lead. This case represents the classical Twiddler's syndrome in an ICD with potential lethal consequences.

Massive pulmonary embolism presenting as seizures

Pulmonary embolism can present in various ways, though seizure activity has been rarely reported. We report a 38 years old male who had met a road traffic accident, underwent surgery, presented a month later with seizures, chest pain, shortness of breath and low blood pressure. Massive pulmonary embolism was diagnosed on CTPA, with classical features on ECG and echocardiogram and the patient was successfully managed with thrombolysis. Massive pulmonary embolism (MPE) should be kept in mind in patients who present with seizures, chest pain and haemodynamic instability.

Unusual presentation of a young man with disseminated tuberculosis and right ventricular mass

We report a 22-year-old man who presented to the emergency department with worsening shortness of breath and chronic fever for 2 months. Physical examination was unremarkable except for raised jugular venous pressure and palpable liver. Echocardiogram showed a large right ventricular mass causing obstruction at tricuspid valve. A subsequent chest CT scan confirmed the presence of a large mass in the right ventricle. There were multiple enlarged lymph nodes and consolidation in the right upper lobe. Diagnosis of disseminated tuberculosis (TB) was made and later confirmed by histopathology of lymph node biopsy along with positive sputum culture for acid-fast bacilli. Remarkable recovery was observed on antituberculous therapy, with complete disappearance of the cardiac mass on echocardiogram, at 1-year follow-up. Although unusual and rare, myocardial involvement as a large mass should be kept in mind while treating patients with disseminated TB.

Transradial primary percutaneous coronary intervention - experience from a tertiary care cardiac centre

OBJECTIVE

To determine the outcomes of primary percutaneous coronary intervention via transradial approach in a tertiary care cardiac centre.

METHODS

The study retrospectively reviewed the medical records of 160 consecutive patients who presented to Tabba Heart Institute, a private-sector facility in Karachi, between January 2009 and January 2011 with acute ST-elevation myocardial infarction and treated with primary percutaneous coronary intervention via transradial approach. The primary end-points were in-hospital mortality and procedural success. Secondary end-points were access site bleeding complication and 30-day outcomes (mortality, myocardial infarction and congestive cardiac failure).

RESULTS

The mean age of the patients was 55.9+/-11.7 years and 126 (79%) were males. The procedural success was 98% (n=157). Three (1.8%) patients died during hospitalisation. Forearm haematoma (>5cm) was observed in three (1.8%) patients. No mortality was observed in 30-day follow-up after discharge, while myocardial infarction and congestive cardiac failure were 1.25% (n=2) and 4% (n=6) respectively.

CONCLUSIONS

High procedural success and favourable clinical outcomes matching the international data can be achieved in our patients undergoing primary percutaneous coronary intervention via transradial approach.

Primary percutaneous coronary intervention for ST elevation myocardial infarction complicated by cardiogenic shock

OBJECTIVE

To determine the outcomes of primary percutaneous coronary intervention for ST elevation myocardial infarction complicated by cardiogenic shock.

METHODS

The retrospective study was conducted at the Tabba Heart Institute, a private-sector facility in Karachi. It reviewed the medical records of 56 consecutive patients between January 2009 and June 2011 with acute ST elevation myocardial infarction complicated by cardiogenic shock and subjected to primary percutaneous coronary intervention. The primary end point was in-hospital mortality and its predictors. SPSS 14 was used for statistical analysis.

RESULTS

The mean age of the study patients was 63 +/- 11.7 years; 38 (68%) were male; 32 (57%) were hypertensive; and 39 (69%) were diabetic. Most infarcts were anterior in location (n = 36; 64%). Besides, 33 (59%) required ventilatory support. Intra-aortic balloon pump was placed in 30 (54%), and 33 (59%) patients had multivessel coronary artery disease. In-hospital mortality occurred in 26 (46%). Multivariate logistic regression analysis showed that age > 60 years (p < 0.05), diabetes (p < 0.01) and left ventricular ejection fraction < 40% (p < 0.01) were independent predictors of in-hospital mortality.

CONCLUSIONS

Results emphasise the need of aggressive management of patients with cardiogenic shock utilising primary percutaneous coronary intervention as a reperfusion strategy to improve clinical outcomes.

Coronary artery disease in patients undergoing valve replacement at a tertiary care cardiac centre

OBJECTIVE

To determine the prevalence of coronary artery disease in patients undergoing valve surgery at a tertiary care cardiac centre.

METHODS

The medical records of 144 consecutive patients who underwent mitral, aortic or dual (mitral and aortic) valve replacement surgery at the Tabba Heart Institue between January 2006 to December 2008 were retrospectively reviewed. All patients underwent coronary angiogram. Significant coronary artery disease (CAD) is defined as coronary stenosis of > or = 50%.

RESULTS

There were 74 (51.4%) males and 70 (48.6%) females in the study. The mean age was 51.64 +/- 11 years. Of all, 73 (50.7%) underwent mitral valve replacement, 47 (32.6%) had aortic and 24 (16.7%) had dual valve replacement. Out of 144 patients, 99 (68.8%) had < 50% coronary stenosis and remaining 45 (31.3%) had > or = 50% stenosis. In patients who had undergone mitral valve replacement (MVR), significant coronary disease was found in 32.9%, whereas in patients who had undergone aortic valve replacement (AVR) and dual valve replacement (DVR) the prevalence of coronary disease was 31.9% and 25% respectively.

CONCLUSIONS

Our results suggest that the overall prevalence of coronary artery disease in patients undergoing valve surgery in our population is comparable with prevalence reported in international data.

Pleuro pericardial cyst

A 68-year-old male, presented with exertional dyspnoea and chest pain in his anterior chest wall for 3 months. He had no previous history of cardiac disease. Clinical examination failed to show anything significant. Chest X-ray showed a mass superimposed over the upper cardiac silhouette. He was further evaluated by chest CT, which showed a cystic mass in the anterior mediastinum measuring 9 x 7 cm in its maximum diameter. On surgical excision and histopathological examination, findings were consistent with benign pleuropericardial cyst, confirming the earlier diagnosis.

Doppler derived gradient of St. Jude mechanical prosthesis, early postoperative assessment

OBJECTIVE

To determine the doppler derived mean gradients of St Jude mechanical prosthesis in early postoperative period in patients undergoing valve replacement at a tertiary care cardiac centre.

METHODS

Medical records of 190 consecutive patients who underwent 233 mitral, aortic or dual (mitral and aortic) valve replacement by St Jude bileaflet mechanical prosthesis at Tabba Heart Institute, between March 2006 to December 2008 were reviewed. Doppler derived mean gradients were assessed predischarge and recorded.

RESULTS

There were 98 (51.5%) males and 92 (48.5%) females in the study cohort. The mean age was 40 +/- 14 years. Of the total, 101 (53%) had mitral, 46 (24.2%) had aortic and 43 (22.6%) patients had dual valve replacement. Doppler derived mean gradient was assessed across 144 mitral and 89 aortic St Jude mechanical prosthesis. Doppler derived mean gradient for St Jude mitral prosthesis was 3.5 mm Hg and for St Jude aortic prosthesis was 10.2 mm Hg.

CONCLUSIONS

The study determines baseline gradients across mitral and aortic St Jude mechanical prosthesis in our population. These can be used as reference gradients to assess St Jude prosthetic valve function in patients who did not have early postoperative doppler assessment.