ABSTRACTS
Jamal Al Khinji, Ali Kindawi, Abdulaziz Al Khulaifi
Hamad Medical Corporation, Doha, Qatar
Off-pump coronary artery bypass (CABG) surgery has been widely used and is gaining more popularity in the Gulf region. Blood and its products have many unwanted side effects. The aim of this study was to test the hypothesis that off-pump CABG may reduce the perioperative use of blood in CABG surgery.
Study Design:
Retrospective analysis of patients undergoing CABG surgery.
Group 1 (Gp1) consisted of 81 patients who underwent CABG without use of cardiopulmonary bypass (off-pump). In group 2 (Gp2), 80 patients had on-pump CABG. The amount of blood, fresh frozen plasma (FFP) and platelet concentrate that was transfused to each patient was compared between the two groups.
Blood usage was also standardized to the number of grafts performed.
Results:
Both groups had similar demographic profiles. Gp1 had a mean of 2.8 +/-0.22 grafts per patient compared to 3.3+/-0.20 grafts per patient in Gp2.
Blood usage was significantly lower in Gp1 (mean=1+/-0.2 units) compared to Gp2 (mean= 3.5+/-0.9 units) p<0.05; as was platelet transfusion (Gp1=1.1+/-0.1 vs Gp2= 2.9+-0.7) and the use of FFP (Gp1= 0.7+/-0.1 vs Gp2=2.9+/-0.7).
Conclusion:
These preliminary data may show that off-pump surgery has the advantage of reduced need for blood, FFP and platelet transfusion in patients undergoing CABG operations.
This may lead to a significant reduction in blood- related complications as well as desirable economic implications.
Marei Hassan A. Aysha
Sohar Hospital, Sohar, Oman
Background:
With the recent introduction of the acute myocardial infarction register in the Sultanate of Oman, we wished to review our contribution to the management of such patients admitted to the coronary care unit (CCU) of a secondary-care hospital.
Objectives:
To assess the in-hospital morbidity and mortality, the prevalence of risk factors in this highly selected population, and whether patients received optimal medical therapy while hospitalized or at discharge.
Patients and Methods:
Case sheets of all consecutive patients admitted to the CCU between August 1st, 2000 and July 31st, 2001 were retrieved. All data, including personal details, clinical presentations, complications, risk factors, transfer to the tertiary care center, and medical therapy received while in-patient or at discharge, was collected and analyzed.
Results:
Of 1033 patients admitted to the CCU,
567 (54.9%) were treated for acute coronary syndromes.
Of this total, 207 (36.5%) were treated
for acute myocardial infarction (AMI); and of
this number, 192 (92.8%) were discharged home,
3, transferred to the tertiary care, and 12 (5.8%)
died. The presentation was typical chest pain
in 176 (85%) and heart failure of variable severity
in 12 (4.3%). The admission ECG showed STSEMI
pattern in 134 patients (65.7%), NSTSEMI changes
in 67 (31.4%), and LBBB pattern in 6 (2.9%). On
further analysis, STSEMI evolved into QWMI and
NQWMI changes in 62.7% and 34.3%, respectively,
whereas, NSTSEMI evolved into QWMI and NQWMI changes
in 40.6% and 46.9%, respectively. However, LBBB
persisted in 4 patients (66.7%), and evolved into
QWMI pattern in the other two patients. Among
patients who presented with STSEMI, 98 (73.4%)
received thrombolytic therapy (TT) while 27 (75%)
were late arrivals for TT.
Heparin was administered in 60 (93.8%) of the patients admitted with findings of NSTSEMI. Among survivors, the majority received aspirin, beta blockers, ACE inhibitors and statins (98.1%, 89.3%, 77.7% and 77.2% respectively). In contrast, CCB was prescribed in only 25 (12.3%) patients.
Diabetes mellitus and hypertension, the most common risk factors, were found in 32.4% and 27.9% of patients, respectively. Smoking was not a common habit among the Omanis in comparison to the expatriates (8.8% vs 25%). Although a history of hypercholesterolaemia was present in only 11 patients (5.4%), a cholesterol level of 5 mmol or more was found in 145 (78.4%).
Thirty two patients (15.5%) experienced angina prior to admission.
In-hospital complications were frequent but successfully managed. Heart failure developed in 31 patients (15%) and transient CHB, in 3 (1.5%). Apart from reperfusion arrhythmias, significant atrial or ventricular arrhythmias occurred in 11 patients (5.4%). In addition, 4 patients (2%) re-infarcted and two others suffered a cerebral vascular accident. Among nonsurvivors, 6 (50%) were 70 years of age or older and the majority (76%) developed QWMI changes.
Conclusion:
In view of these results and despite inadequate specialist staff running the unit, the regional hospital contributes in the management of patients with AMI.
At the same time, improvements are needed in prescription habits and, through health education, the media and a proper hospital ambulance system, in public awareness to seek medical advice and avoid delay in hospital admission.
Kadhim J. Sulieman, FRCP
Royal Hospital, Muscat, Oman
We analyzed 50 adult patients who were admitted
to the Royal Hospital during the last 10 years
with a definite diagnosis of infective endocarditis
according to Dukes criteria. T
here were 28 males and 22 females, with a mean
age of 36 years.
Forty percent had underlying rheumatic heart disease,
16% had mitral valve prolapse, 16% had congenital
heart disease, 6% had prosthetic valve involvement,
and 22% had normal valve endocarditis.
Fever was present in 96% of patients and
cardiac murmur, in 98%.
Twenty-two percent had splenomegaly, 20%
had embolic manifestations, 34% had congestive
heart failure, and 12% developed acute renal failure.
Streptococcus was isolated from 32% of patients;
staphylococcus, from 20%; and gram negative organisms,
from 6%. Forty-two percent of patients had culture
negative endocarditis. Echocardiography was done
in all patients, but vegetations were found in
only 80%. Five patients (10%) required early surgery,
and 10 patients (20%) died in hospital.
Seventy percent of all in-hospital deaths, 75%
of those with embolic manifestations, and 100%
of those requiring early surgery were patients
with large (10 mm or greater diameter) vegetations.
The pattern of infective endocarditis in the Royal
Hospital in Oman is similar to that reported from
other centers. The high incidence of culture negative
endocarditis is probably due to the use of antibiotics
prior to referral to the Royal Hospital. Among
the various parameters studied, only large vegetation
size was associated with increased mortality,
embolic manifestations, or the need for early
surgery.
Abdullah Amer Al-Riyami, Ph.D, FRCP
Royal Hospital, Muscat, Oman
The Royal Hospital is one of the two tertiary institutions draining an Omani population of 2 million. As a consequence, the cardiology department gets referrals from regional and district hospitals across the country for further cardiac evaluation.
This paper describes the activities of the Cardiac Catheterization Laboratory from the time of its commission in 1988 to the present day.
Seventy eight procedures were performed in 1988, including 66 adult angiograms and 12 permanent pacemaker implantations (see table).
These figures doubled in the subsequent year.
In 1990, the first diagnostic paediatric procedure was performed, coincident with the appointment of a paediatric cardiologist.
In 1991, fifteen paediatric interventional procedures were done, including PDA closure, pulmonary and mitral balloon valvuloplasty, and dilatation of aortic coarctation. Twenty one PTCA procedures were performed for the first time in 1994, all by a visiting interventionist. Our first PTCA procedure performed by local staff took place in April 1997, and since then the numbers of such interventions have increased gradually.
These include single, double and occasionally triple vessel PTCA. Patients presenting with cardiogenic shock and those with contraindications to thrombolytic therapy have been taken for primary PTCA, with intra aortic balloon support, in cases of shock.
PTCA has been performed in totally occluded arteries as well as grafts. Recently, increasing numbers of patients have undergone direct elective stenting. In the year 2000, a total of 1,372 procedures were performed, compared to the initial number of 78 in 1988. Overall, a grand total of 8288 procedures have been carried out in the cardiac catheterization laboratory.
|
|
|
1988
|
1989
|
1990
|
1991
|
1992
|
1993
|
1994
|
1995
|
1996
|
1997
|
1998
|
1999
|
2000
|
Adult angio
|
66 |
116 |
221 |
364 |
403 |
443 |
486 |
512 |
564 |
754 |
712 |
736 |
895 |
PTCA
|
|
|
|
2 |
|
21 |
|
|
97 |
180 |
240 |
297 |
|
PTMC
|
|
|
|
|
|
|
|
|
5 |
19 |
13 |
13 |
|
EP study |
|
|
|
|
|
|
|
2 |
1 |
3 |
3 |
3 |
|
Pacemaker |
12 |
22 |
19 |
15 |
12 |
25 |
23 |
32 |
21 |
23 |
24 |
29 |
37 |
Ped angio |
|
|
1 |
18 |
50 |
55 |
59 |
51 |
66 |
63 |
69 |
83 |
84 |
Ped Intervention |
|
|
15 |
9 |
14 |
10 |
7 |
13 |
14 |
23 |
40 |
44 |
|
I.A.B.P. |
|
|
|
|
|
|
|
|
|
|
8 |
17 |
|
Total |
78 |
138 |
241 |
412 |
476 |
537 |
599 |
602 |
666 |
959 |
1030 |
1144 |
1406 |
AWalid Bsata , MD, FRCPI, FACP
Bugshan Hospital, Jeddah, Saudi Arabia
Blood pressure is a quantifiable
trait which varies continuously throughout the
whole population and whose regulation is controlled
by a variety of mechanisms that involve several
genetic loci and environmental factors. Blood
pressure level is, in part, genetically inherited,
and hypertension can be due to a single gene abnormality
or, much more often, the effect of several predisposition
genes in conjunction with environmental factors.
Less than 5% of patients with hypertension have
a defined genetic cause.
Three rare monogenic autosomal forms of hypertension
are characterized by an extracellular volume expansion
with suppressed plasma rennin, a slight hypokalemia,
and inappropieately high kaliuresis . The glucocoricoid
suppressible hypertension (GSH) is due to an abnormal
production of aldosterone in the adrenal zona
fasciculate by a chimeric 11.B. hydroxylase /
aldosterone synthase gene.
The second syndrome is Liddle’s syndrome, which
is due to overactivity of the epithelial amiloride–sensitive
sodium channel. Lastly, the syndrome of apparent
mineralocoricoid excess (AME) is caused by a deficit
in 11-B hydroxysteriod dehydrogenase , the enzyme
inactivating cortisol in the kidney. Candidate
genes in essential hypertension have been studied
but neither the rennin nor the angiotensin II
receptor (AT1) genes seem to play an important
role in human hypertension.
The angiotensin converting enzyme gene (ACE)
appears not to be a contributor of blood pressure
variance. Angiotensinogen has been linked to hypertension
in several sib-pair studies and in Caucasians
and Afro-Carribean populations, as well as in
pregnancy-induced hypertension. In most of the
studies performed with other candidate genes,
such as the SA gene, the endothelial NO synthase
was negative. The sole exception was the alpha
adducing gene.
Finally, Harrap offers, as a working model,
an interaction between genes and environment in
which the average population blood pressure is
determined by environmental factors, but blood
pressure rank within the distribution is decided
largely by genes.
Siddiq Ibrahim Khalil, MD, FACC
Almana Hospital, Jubail, Saudi Arabia
Atrial myxoma is the commonest benign cardiac tumor.
The clinical presentation is bizarre and in most cases thromboembolic complications constitute the main clinical presentation.
We report one case that presented as late onset bronchial asthma in a 48 year-old female. The patient, mother of 14 children, during a 3-month period,became incapacitated by episodes of severe bronchospasm, which were resistant to most available remedies for bronchial asthma. TEE features are presented in video, and various aspects of atrial myxoma and treatment are discussed.
Prof. Dr. Al-Kubaisy , A. Waqar, Prof. Dr. Niazi, D. Amjad
Saddam College of Medicine, University of Saddam, Baghdad, Iraq
Aim of the Study :
Hepatitis C virus (HCV) recently was identified as a major cause of post transfusion hepatitis world-wide. This study was undertaken to evaluate the role of blood transfusion in the prevalence of HCV infection, by testing antibody and RAN of HCV, and also to detect if blood transfusion acts as a nonconfounding risk factor for HCV infection .
Material and Methods:
Sera from 3491 pregnant women were investigated for the presence of HCV antibodies (anti-HCV) by using a third generation enzyme immunoassay (EIA-3) as a screening test, followed by immunoblotassay (Lia
Tek-III).
In addition, 94 sera of the study group were subjected to molecular analysis (at laboratories of Sorin BioMedica, Italy) for the detection of viral RAN and genotypes of HCV using RT-PCR and DAN enzyme immunoassay
(DEIA) method.
Results:
Our study revealed, that the seroprevalence rate of HCV specific Ab & RAN were significantly higher ( 16.32% and 80%, respectively ) among women with a history of blood transfusion , compared to women with no such history ( 2.53% and 56.5%, respectively; p=0.0001 and 0.01). There was a significant, direct, linear correlation between amount of blood transfused and the seropositive rate of anti-HCV ( r=0.7, p=0.046) .
Using multivariate analysis, this study demonstrated that, blood transfusion acted significantly as an nonconfounding risk factor for HCV infection (adjusted OR = 1.938;95% C.I.=1.646 – 2.28), and the risk of exposure increased with increasing number of blood units transfused. We found no significant association between HCV genotypic distribution and history of blood transfusion. However, a high proportion of women with a history of blood transfusion were harboring HCV genotype – 4 or lb (50% and 40%, respectively).
Conclusions and Recommendations:
Our study provides evidence that blood transfusion acts as an nonconfounding risk factor for HCV infection and is also a mode of transmission.
Therefore, strict screening of blood donors for HCV antibody and / or RNA is recommended
S. Maatoug*, S. Ayedi*, S. Bardaa*, Z. Khemikhem*, Z. Hammami*, T. Rebai**
Department of Legal Medicine, CHU and ** Laboratory of Histology University of Medicine,
Sfax,Tunisia
Arrythmogenic dysplasia of the right ventricle is a rare congenital malformation characterized by replacement of the right ventricular myocardium by fatty or fibro-fatty tissue. It may produce serious arrythmias, resulting in sudden death, especially if the condition is not diagnosed.
It is usually observed in children, and the ventricular arrythmia is caused by the right ventricular
dysplasia.
This ranges from simple extrasystoles to ventricular tachycardia.
The genetic basis of this pathology has been elucidated by several researchers who discovered a chromosomal defect localized at the level of the chromosome 14 (14q23-q24).
Most authors recognize this pathology as a cause of sudden death in young sportsmen and athletes.
We present the case of a fifteen-year-old-child who died suddenly. His medico-legal autopsy revealed dysplasia of the right ventricular myocardium.
After discovering this case, we studied the macroscopic and histological aspect of the heart and compared our results with those of other researchers.
The collaboration of doctors and researchers belong to various medical fields, including coroners, anatomical pathologists, cardiologists and general practitioners, is necessary to diagnose this malformation.
Their objective is to warn the patient’s family of the risk of this disease and prevent further unexpected sudden deaths within the same family.
S. Mokahal, Abraham Chacko, FRCP, R. Davis, FRCP
Tawam Hospital, Al Ain, United Arab Emirates
Background:
Atrial fibrillation (AF) is a common problem in hospital and carries a significantly increased risk of stroke and death.
Methods: Medical records of 80 patients with atrial fibrillation were retrospectively analysed for age, gender, co-morbid disease, stroke incidence, anticoagulation, type of atrial fibrillation, and medication used.
Findings:
Average age of the study group was 62 years, with the following age-distribution:
20-30 (14%), 30-40 (0.5%), 40-50 (14%), 50 - 60 (18%), 60 - 70 (15%) and remaining 39% over 70.
The male to female ratio was 1:1. Twenty-four percent had coronary heart disease and 29% had hypertension.
Only 2 patients suffered a CVA. The duration of AF varied from 1 - 12 years. Fifty-four percent of patients had paroxysmal atrial fibrillation Only 25% of patients were on anticoagulation and 25% received aspirin alone.
Forty-seven percent of the patients were on digoxin at some time, but only 10% were on other anti-arrhythmic drugs (sotalol, propafenone or amiodarone)
Conclusion:
The incidence of stroke in this cohort of patients was low (2.5%), despite 72% of the patients being over 50 years in age.
The percentage of patients on anticoagulation was low and this reflects physician reluctance to initiate anticoagulation, due to perceived and known lack of compliance by patients.
These findings raise the intriguing possibility that non-Western patients may be at a lower risk of thromboembolism with atrial fibrillation.
A.Robida, V. Bricelj, Ahmed Tohami El Tohami
Hamad Medical Corporation, Doha, Qatar
Introduction :
Arterial tortuosity is a new emerging syndrome with characteristic clinical features of skin hyperextensibility, hypermobile joints, a characteristic face, and arterial abnormalities.
To date, no large study has examined the cardiovascular abnormalities with echocardiography in children with these arterial anomalies .
Objectives :
The objectives of our case –control study was an echocardiographic evaluation of the heart and great arteries in a population of children with a phenotype of arterial tortuosity syndrome .
Methods:
Twenty–one consecutive children belonging
to one extended family, nine girls and twelve
boys, with a median age of 3 years ( range = 1
day to 16 years), with similar clinical features
of velvety, hyperextensible skin, hypermobility
of joints, and characteristic facial features,
were studied prospectively with echocardiography
.
Cross-sectional measurements included the aortic
annulus, sinus of Valsalva, and the ascending
aorta in the parasternal long axis view.
In the short axis parasternal view, the
pulmonary trunk was measured midway between the
pulmonary valve and bifurcation.
The right and left pulmonary arteries were measured
at their bifurcation points. The appearance of
a bifid pulmonary artery, an elongation of the
aortic arch and tortuosity and elongation of the
brachiocephalic arteries, using a high parasternal
short axis view and short long axis suprasternal
views, were assessed qualitatively. The descending
aorta was visualized in its long axis in a sagittal
subcostal view.
The control group consisted of 21 normal age and
weight- matched children who were evaluated with
echocardiography for possible heart disease.
Results:
No statistically significant difference in quantitative data was found in the echocardiographic measurements between the two groups.
However, all children in the study group had a bifid pulmonary artery, elongation of the aortic arch and tortuosity and elongation of the brachiocephalic arteries.
Seven of these children also had tortuosity of the descending aorta, three had dilatation of the aortic annulus, sinus of Valsalva and ascending aorta, and five had multiple peripheral pulmonary arterial stenoses.
Conclusion:
The consistent findings of a bifid pulmonary artery, elongation of the aortic arch, and tortuosity and elongation of the brachiocephalic arteries can be reliably evaluated with echocardiography, thus identifying children with arterial tortuosity, even early in life when characteristic facial features may not yet be present.
Molecular or histologic characteristics were not studied in our children with arterial tortuosity, but molecular and gene mapping investigations are underway elsewhere.
Andrej Robida, Blado Bricelj, Vikas Kohli
Hamad Medical Corporation, Doha, Qatar
Objectives:
To find out how coil occlusion of the arterial duct compares with Amplatzer duct occluder and if implantation of a device is possible in a small pediatric cardiology program.
Methods:
From August 1996 to July 2001, we attempted to close 25 persistently patent arterial ducts in the catheterization laboratory. In the coil group, there were 15 patients with age ranging from 6 months to 34 years (median 3.4 years) and weight, from 7.8 to 65 kg (median 14.1 kg).
Diameter of ductuses at their narrowest point were 1.0 to 3.5 mm (2 +/- 0.6) and both anterograde and retrograde methods were used . Diameter of the coils was at least two times larger than the narrowest side of a ductus. The Amplatzer duct occluder group consisted of 10 patients with ages ranging from 5.5 months to 37 years (median 1.9 years) and weight, from 10.5 to 67 kg ( median 11.5
kg
The size of the narrowest part of the ductus was 1.3 to 5.2mm ( 2.7+/- 0.4). The Amplatzer duct occluder was 2 mm larger than the narrowest diameter of a ductus. An angiogram was done 10 minutes after the procedure and an echocardiogram 1 day, 1 month, 3 months, 6 months and then yearly after implantation of a device .
Echocardiography follow-up time was 1 month to 61 months.
Results:
There were 13 type A ductuses , 1 type B , and 1 type D in the coil group.
One to 2 coils were implanted . One patient had a residual left - to -right shunt after previously implanted Rashkind double umbrella device and another patient had residual patency after previous surgical
ligation.
A small residual left-to- right shunt was observed on the angiogram in only one patient and that disappeared by 6 months on echocardiographic follow up.
Four coils, 2 free and 2 detachable, embolized to the left pulmonary artery at the beginning of our experience.
In three patients, coils embolized immediately upon release and, in one, 5 hours after deployment. One coil was retrieved in the catheterization laboratory, one required surgical retrieval from the right ventricle with concomitant ductal ligation, and 2 were left in place in a small branch of the left pulmonary artery.
Ductuses were closed with implantation of a larger coil at the same session in 2 patients and one day later in another patient. Amplatzer duct occluders of sizes 6-4 to 10-8 mm were deployed in 9 type A ductuses and in 1 type E ductus. One patient crossed over from the coil group. One device was deemed too small and was retrieved and replaced with a larger one. No residual shunt was observed 10 minutes after deployment or upon echocardiographic follow-up from 2 months to 3.5 years.
No complications were encountered. Arterial ducts closed by Amplatzer ocluder device were larger than those closed by coils, but there was no statistically significant difference between the two groups in size of the narrowest part of ductus ( p= 0.09) .
Conclusion:
Closure of the arterial duct with an Amplatzer duct occluder is safer, and the immediate closure rate is higher than closure with coils. Smaller ductuses are suitable for coil occlusion and larger ones for the Amplatzer duct occluder device .
Both methods of non-surgical closure are feasible in a small pediatric cardiac program.
M. Amiri, R. Vakili, A. Jalali, N. Sarraf-Zadegan
Shahrekord University of Medical Sciences & Isfahan
Cardiovascular Research Center Isfahan, Iran
Introduction:
Epidemiologic studies have shown that there is a significant association between cardiovascular disease and hypercholesterolemia. One percent reduction in cholesterol level induces a 2% reduction in the incidence of myocardial infarction. In order to determine the effects of brewer’s yeast on serum lipids in moderate hypercholesterolemia (200>Total cholesterol<339 mg/dl), a randomized, placebo-controlled trial was performed.
Methods:
In this study, brewer’s yeast and placebo groups included 21 and 23 people, respectively. These subjects were selected through simple random sampling among those referred to the Nutrition Unit in Isfahan Cardiovascular Research Center and then divided randomly into two groups. They had not undergone any treatment for controlling serum lipids, blood pressure, or blood sugar, and had no metabolic or cardiovascular disease. The brewer’s yeast group received 320-mg tablets of brewer’s yeast, and the placebo group received placebo tablets for 12 weeks (2 tablets, four times daily). In both groups, serum lipids were measured by autoanalyzer Elan 2000 at intervals of 3-weeks throughout the study period.
Results:
In the brewer’s yeast group, total cholesterol decreased significantly from 262.15 ± 37.75 mg/dl to 257.0 ± 41.52 mg/dl (p=0.004). Also, LDL cholesterol decreased slightly (p=0.007). An undesireable effect was observed on HDL cholesterol and triglycerides which decreased from 46.25 ± 7.15 mg/dl to 43.05 ± 5.84 mg/dl (p=0.05) and increased from 242.85 ± 74.88 mg/dl to 254.85 ± 69.86 mg/dl (p=0.000), respectively.
Conclusion:
We conclude that brewer’s yeast can improve hypercholesterolemia, but more extensive metabolic studies are needed to investigate its usefulness in clinical practice.
Najih M. Alassdy, M. AlKhateeb
Al-Rasheed Cardiac Center, Baghdad, Iraq
Objective:
To study the concept of adequate versus complete revascularization in high-risk patients with coronary heart disease.
Background:
Dealing with older age patients who have multi-vessel disease and bad left ventricular (LV) function is a problem, especially when they are subjected to long ischaemic and bypass times.
Method:
A total of 50 patients with multi-vessel disease and bad LV function (LV EF<30%) had one or two grafts done on a beating heart without cardiopulmonary bypass (Study Group), compared with a group of similar patients revascularized using conventional cardiopulmonary support (Conventional Group).
Results:
There was one death in the study group (SG), compared to 8% mortality in the conventional group (CG).
The relief of symptoms was very impressive in a high percentage of patients, and the rate of postoperative complications was very low.
Conclusion:
It is recommended not to subject high-risk patients to the deleterious effects of cardiopulmonary byass and myocardial ischemia when adequate revascularization is possible on the beating heart.
Amer Chaikhouni, MD, Nawolo Jamil, MD, Kayali Taher, MD, Hylani Mohammed, MD
Cardiac Surgery Unit, Al-Salam Hospital, Aleppo, Syria
The open-heart surgery program in Aleppo, Syria was started in October 1996.
During the first five years, 460 cardiac operations were performed:
CABG 308 ( 67%), valve 79(17%), congenital 60( 13%), and combined procedures 15(3%). The overall mortality was 7%. Study of the 308 CABG operations demonstrated that the average age was 56 years, and the majority of the patients were men (79%). Smoking was the most common risk factor (74%), followed by hypertension in 38%, and diabetes in 35%.
The average preoperative ejection fraction (EF) was 46%, and 20% of the patients had EF< 40%.
Urgent operations were done in 41%.
The average number of grafts was 3.25/patient.
An internal mammary artery was used in 87% of the operations.
The average aortic cross clamp time was 67 minutes, and the average pump time was 127 minutes. The average hospital stay was 6 days.
Morbidity occurred in 25% of the patients, and the overall mortality of CABG operations was 8%. Mortality was associated with advanced age, female sex, low EF, urgent operations, and high risk score.
Amer Chaikhouni, MD, Cardiology & Cardiovascular Surgery Dept.,
Hamad Medical Corporation, Doha, Qatar, and Cardiac Surgery Unit, Al-Salam Hospital, Aleppo, Syria
The first operation for congenital heart disease in Qatar was performed on 11/4/1983. During the next ten years, 296 such operations were performed. The average age of the patients was 14 years (range 1 day to 52 years).
At the time of operation, 40 patients (13.5%) were less than one month old, and 114 patients (38.5%) were less than one year of age. There were 159 male (54%), and 137 female (46%) patients.
Among this group, there were 65 Qatari nationals (22%), 128 Arabs of other nationalities (43%), 79 patients from the Indian subcontinent (27%), and 24 of other nationalities (8%). The most common operations were closure of PDA in 75, closure of ASD in 67, systemic-pulmonary shunt in 51, pulmonary artery banding in 21, and total correction of Fallot’s tetralogy in 21 patients.
Open-heart operations were performed in 140 (47%), and closed cardiac procedures in 156 (53%). Morbidity occurred in 56 (19%) patients.
Heart failure and postoperative bleeding were the most common complications.
The early mortality rate in open-heart operations was 13%, and in closed cardiac procedures, 8%.
Amer Chaikhouni, MD
Cardiology & Cardiovascular Surgery Dept.,
Hamad Medical Corporation, Doha, Qatar, and Cardiac Surgery Unit, Al-Salam Hospital, Aleppo, Syria
The first cardiac valve operation in Qatar was performed on 27/6/1983.
During the first decade thereafter, a total of 1025 cardiac operations were performed. Of these, 202 (20%) were valve operations.
The Average age of the adult valve patients was 36 years, and 141 procedures were done in men (70%), compared with 61 in women (30%).
Nationality of the patients was:
Qatari 24 (12%), other Arabs 94 (47%), Indian Subcontinent 71 (35%), and other nationalities 13 (6%).
The most common valve disease was mitral stenosis, which occured in 104 patients (51%), and the most common valve operation was mitral valve replacement in 91 patients (45%).
The average aortic cross-clamp time was 58 minutes, and the average pump time was 88 minutes.
Morbidity occurred in 16% of patients, and the overall hospital mortality was 6%. Mortality was associated with mitral valve operations, female sex, redo operations, and combined procedures.
Anwer Jamsheer, Amal Mandi, Fatima Ahmed, Maheeba Abdulla
Salmaniya Medical Complex, Manama, Bahrain
Objectives:
This prospective study was designed to evaluate the feasibility, safety and cost effectiveness of early discharge using a Modified Bruce Protocol (MBPR) exercise test (ET) for risk stratification within three days of acute myocardial infarction (AMI).
Methods:
Of 148 consecutive patients with AMI, 36 (24.3%) whose clinical condition was classified as uncomplicated (no rest angina, heart failure, or arrhythmia) underwent MBPR-ET. Within one month, after maximization of anti-anginal therapy, the ET was repeated using the conventional BPR. A scheduled daily telephone interview was used for 4 consecutive days to evaluate the early post discharge course.
Thereafter, evaluation relied upon regular clinic visits at 1,3 and 6 months, at which point an echocardiogram was repeated.
Results: Among the 148 patients, in-hospital death occurred in 9 (6%). Thirty patients (83.5%) underwent MBPR-ET and were discharged within 72 hours, 5 (13.8%) within 96 hours, and one patient within 99 hours. This gave a study group consisting of 36 patients with a mean age of 49± 8.4 years. There were no hospital deaths in the early discharge group.
The MBPR-ET was negative in 15 patients (41.6%), positive in 11(30.5%), and borderline (BL) in 9 (25%). With repeated ET using BPR, there was no crossover between the positive and negative groups [ 20 negative(55%) and 13 positive (36.1%) tests]. Pharmacological stress MIBI was done for 1 patient with positive results. Subsequently, coronary angiography was performed in 15 patients (41.6%),12 had PTCA and stenting (33.3%) , 2 had CABG (5.5%) and 1 patient (2.7%) had failed recanalization. At 6 months, there were no deaths, no AMI, and no left ventricular aneurysm.
Among the early discharge group, there were three unscheduled hospital visits, one (2.7%) within 24 hrs after discharge, with pulmonary edema, 1 (2.7%) with angina pectoris and 1 (2.7%) with palpitation / bradycardia. The average cost of hospitalization for the early discharge group was $1326 compared to $2636 for the regular stay group.
Conclusions:
In uncomplicated AMI, early discharge after MBPR-ET is feasible, safe and cost effective. However, MBPR-ET fell short of being an ideal early triage method, because it was not conclusive in a substantial number of patients. A large- scale, controlled trial is required for confirmation of these results.
Shervin Ziabakhsh
Shariati Hospital, Tehran, Iran
Introduction:
Demonstration of long-term patency of the radial artery graft by Carpentier has lead to its increasing use in CABG surgery.
The early patency rate was 95 % after one year, and now this is the second choice of conduit for CABG. Because of its increased use, the complications of harvesting the radial artery will become more common and this study was done to elucidate these complications.
Materials & Methods:
Between September 2000 and February 2001, 244 patients underwent CABG at the Dr. Shariati Hospital, Tehran, Iran. Their ages ranged from 34 to 79 years ( mean = 56 years). In 111, the radial artery was harvested in the non- dominant hand.
The LIMA was harvested in all but four patients.
The mean number of grafts was 3.38/patient.
Allens test (considered positive if longer than 10 seconds ), was done preoperatively in all patients, and two point discrimination was carried out in the dorsum of first web of the hand both pre and postoperatively.
Results:
Allen test was positive unilaterally in 8.8% and bilaterally in 10.2%. The most common complication encountered after radial artery harvesting was dysesthesia and hypoesthesia of the dorsum of first web and the first and second digits.
This resolved completely after 3 months in 70% of cases.
Complications encountered in one patient each were:
Limited skin necrosis at edges of the wound, hemorrhage from the drain, and wound
hematoma.
There was no ischemia of the hand.
Comment: Radial Artery harvesting after preoperative Allens test is a safe procedure.
The wound heals properly and no hand ischemia was seen .
The most common complication is hypoesthesia & dysesthesia in dorsum of first web of hand and first and second fingers, which generally is temporary.
Because of its possible anatomic anomalies and risk of nerve damage, the artery must be harvested by expert surgeons.
Adnan Al-Asousi, Hasan Ali Khan, Aiad Al-Anzi
Department of Medicine, Al-Jahra Hospital, Jahra, Kuwait
Objective:
To call attention to the fact that right ventricular infarction (RVI) can be misdiagnosed as an anterior myocardial infarction (MI), and to facilitate correct management through detection of
RVI.
Cases:
Two patients presented with typical chest pain and ECG changes of anterior MI, along with significant ST elevation in V4r.
On detailed study of the cases with serial ECGs and echocardiography, “isolated” RVI was confirmed in one case and RVI with inferior MI (rather than anterior MI) in the other. One case had clinical evidence of RVI and in another did not.
Discussion and Conclusions:
RVI occurs in 40 to 50% of patients with acute inferior MI and its presence can have important clinical, hemodynamic, and prognostic implications.
The first ECG diagnosis of RVI was reported by Erhardt and colleagues, who showed that ST elevation in the right precordial leads (V3r and V4r), was a reliable sign of RVI, as verified at autopsy.
In 1985, ST segment elevation in lead V1 was reported in patients with acute inferior wall MI associated with RVI. These changes can be easily mistaken for signs of acute anterior MI, especially when the ST elevation extends as far as leads V5 and V6. Such changes, however, were noted in only a minority of patients (10%), despite the 40 to 50% incidence of RVI associated with inferior MI.
This observation may be explained by the principles of reciprocal changes and the influences of the flowing currents.
The direction of precordial ST segments in acute inferior MI with RVI is subjected to two opposing influences.
RVI tends to elevate the ST segments, while inferior and posterolateral MIs tend to produce reciprocal ST depression.
The MI that prevails will give the net effects on the ECG, and thus some RVI will mimic an anterior MI. As the management is different in the two situations, it is important to recognize and treat RVI accordingly.
Q.Shamileh, MD, W. Sawalha, MD, MRCP(UK), H. Abbadi, MD, A.Odeh, MD, MRCP(UK)
Queen Alia Heart Institute, Amman, Jordan
Background:
Direct stenting of renal artery stenosis is a relatively new strategy that potentially offers quick and safe theraputic intervention.
Objectives:
We assessed the safety and efficacy of direct renal artery stenosis stenting in patients with significant renal artery stenosis, aiming to control hypertension, preserve renal function, control recurrent flash pulmonary oedema, and improve management of congestive heart failure and progressive angina.
Methods:
Pre-mounted balloon expandable stents were placed directly in 86 consecutive patients (98 vessels) with significant renal artery stenosis. Eighty-six percent of the patients had unilateral renal artery stenosis and 14% had bilateral
stenosis.
Results:
The procedural angiographic success was 100%. A reduction of the diameter of the stenosis equal or greater than 10% was achieved in all 98 stented arteries.
The mean angiographic renal artery stenosis pre-stenting was 85+ 12% (mean ± SD). This was reduced to 6 + 4% after
stenting.
Conclusion:
Direct renal artery stenosis stenting appears to be feasible, time-saving and achieves a high rate of success in patients with various subsets of renal artery stenosis.
Jawad Al Lawati, Asya Al Riyami, Ali Jaffer Mohammed
Ministry of Health, Muscat, Oman
The Oman Health Survey 2000 has demonstrated a high prevalence of cardiovascular disease risk factors among a sample of 5840 Omanis aged 20 years and older.
More than 10% of the population were diabetic and 6.
1% had impaired fasting glucose (1999 WHO Diagnostic Criteria).
The prevalence of hypertension (systolic blood pressure >= 140 mmHg and/ or diastolic blood pressure >= 90 mmHg) was 23% among males and 20% among females.
Over 40% of subjects had elevated serum cholesterol (total cholesterol >= 5.2 mmol/L) and more than a third were overweight or obese (BMI >= 25 kg/m2). All of the above risk factors were more common in urban areas and increased with the increasing age of the cohort. Several risk factors were inversely related to education and income.
A demonstration project of primary prevention has recently been initiated with a local community as the main strategy to combat the expected surge of cardiovascular and other non-communicable diseases.
Farouk El-Sabban
Department of Physiology, University of Malaya Medical Center Kuala Lumpur, Malaysia
Background :
Blood supply to tissues is very important, as it carries oxygen and nutrients needed for normal biological processes in cells. Exchange between the blood and tissue take place at the microcirculatory level. The brain is very sensitive to low oxygen and glucose, and therefore requires sufficient blood flow to its cells.
Formation of clots (thrombi) in brain vessels reduces flow with serious adverse effects.
Objectives:
The objectives of this work were to:
1) devise a method in which blood clots are formed by free radical injury, 2) apply this method in experiments on brain circulation in live animals and 3) explore other possible applications in different tissues and settings.
Methods:
The free radical is generated by direct exposure of vessels, in which a dye (sodium fluorescein) has been injected and circulates in the blood, to intense mercury light.
This produces a singlet oxygen free radical which causes injury to the lining of the blood vessel in live laboratory animals.
Consequently, platelet aggregates are formed.
The times for both the first observed platelet aggregate and for platelets to grow and block the vessel are recorded by a set of 4 stopwatches.
Observations are also recorded on video tapes, for further viewing and analysis.
Applications:
This method is versatile and can be employed
in many different studies.
However, it was mostly used for assessing
factors that either encourage or inhibit thrombosis
in microvascular fields, such as medications,
natural products, medicinal plants, and environmental
and nutritional factors.
While this method was devised primarily
as an in vivo procedure, it has been employed
successfully also in studies with brain tissue
slices in vitro. Other studies involving blood
flow in the microcirculation, such as microvascular
permeability and vasoactivity, can utilize this
method also.
A. Al-Awadhi, B. Bharagava, K.M. Nair, S. Koshy, M. Arif, H. Hassan-Ali, M. Haida
Cardiology Unit, Salmaniya Medical Centre & Ministry of Health State of Bahrain
Over the past year, 167 cases of
myocardial infraction in the young (<45 years)
were admitted to this tertiary referral hospital.
Of the 167 patients, the 118 males (M) and 49
females (F) had a mean age of 37.4±7.3 and 37.1±6.5
years, respectively. There were 113 Bahraini (B)
patients and 54 non-Bahraini (NB) patients. All
patients were studied for their risk factor profiles,
including hypertension (HT), hyperlipidemia (total
cholesterol >5.2mmol;Tg>1.8mmol), smoking, diabetes
mellitus (DM) (fasting or random blood sugars
>5.8 and 9.0 mmol), obesity (BMI > 30), and sedentary
lifestyle.
The mean length of hospital stay was 7.8
days. Although the mean age between the B and
NB were similar, the B males tended to be younger
than NB males (35.7 vs 39.8 years, respectively).
Hyperlipidemia was found to be higher in
males presenting with MI (p=0.03), however no
difference could be found between B and NB. Smoking
was higher in young males (p<0.001). Obesity was
commoner in females (p=0.03) and was associated
with a more sedentary lifestyle in females (p=0.04).
BM and BF tended to be more hypertensive
and diabetic, respectively; while NBM tended to
be more hyperlipidemic.
In the entire cohort diabetes and obesity
were associated with higher hyperlipidemia (p=0.04;
p<0.05, respectively).
Hyperlipidemia and smoking were more common in
young males presenting with MI. Obesity and sedentary
lifestyle were more frequent in females presenting
with MI.
|
BM (n=72)
|
NBM (n=46)
|
BF (n=41)
|
NBF (n=8)
|
P
|
HT %
|
62.5 |
47.8 |
17.1 |
100.0 |
0.19 |
Lipids %
|
41.7 |
43.5 |
24.4 |
25.0 |
0.03 |
Smoking %
|
37.0 |
45.0 |
12.0 |
0.0 |
<0.001 |
DM % |
23.6 |
39.1 |
39.0 |
25.0 |
0.24 |
Obesity % |
25.0 |
21.7 |
41.5 |
37.5 |
0.03 |
Sedentary % |
49.0 |
50.0 |
76.0 |
75.0 |
0.04 |
A. Al-Awadhi, M. Ali, S. Koshy
Cardiology Unit, Salmaniya Medical Centre & Ministry of Health State of Bahrain
We have analysed the safety of thrombolytic therapy at our unit over a period of seven years, with particular reference to bleeding complications. During this period, 686 patients received thrombolysis with r-TPA (n=281) or streptokinase (SK; n=405). Among the 686 patients, 5 received thrombolysis on more than one occasion. Standard indications, contraindications and dosage schedule were followed.
The incidence of major events with the two agents are given below:
|
Patients(n)
|
Strokes (n)
|
Non Hemorrhagic
|
Hemorrhagic
|
Deaths (n)
|
SK
|
405 |
12 |
3 |
9 |
6 |
r-TPA
|
281 |
5 |
1 |
4 |
2 |
Total
|
686 |
17 |
4 |
13 |
8 |
Minor bleeding episodes were slightly higher with r-TPA;
however there were no statistically significant differences between the two agents in either major or minor complications.
Thrombolytic therapy has revolutionized the management of acute myocardial infraction. Several large multicenter trials have shown the efficacy of thrombolysis in achieving reperfusion, preserving the myocardial function, and improving survival.
Since the untoward effects are negiligible, and considering the significant survival benefit as well as the improved short and log-term morbidity and mortality, thrombolytic therapy should be offered at the earliest possible time in all cases of myocardial infraction (observing proper precautions).
The present paper is part of an ongoing study in the cardiac unit of Salmaniya Medical Center, which is the largest referral hospital in Bahrain under the Ministry of Health. The results of various observations and analysis will be discussed.
M. R. H. A. Al Marri, MD, FRCPC, FCCP, A. R. Al Nabit, MD, A. Salam, MD
Department of Medicine, Hamad Medical Corporation,
Doha, Qatar
Retrospective review of a 9-year period from January 1992 to December 2000, at the Hamad General Hospital in the State of Qatar, revealed 21 cases of tuberculous pericarditis among a total of 97 patients with pericarditis.
Qatari nationals accounted for 23.4% and patients from the Indian subcontinent, for 47.6%. The sex-ratio was 0.64 and the mean age was 36.8 ± 7.1 years.
Hospitalization was justified by dyspnea (2 cases), thoracic pain (6 cases), or lower limb edema (1 case). Electrocardiography showed microvoltage in 18 cases, and thoracic radiography showed cardiomegaly in 8. Although 15 cases had an associated pleural effusion, only 2 patients had pulmonary imaging suggestive of tuberculosis.
Tuberculous pericarditis was proved by the following examinations:|
pericardial puncture (18 cases), pericardial and pleural biopsy (11 and 10 cases, respectively), identification of alcohol-acid-fast bacilli in sputum (2 cases:
1 smear positive, 1 culture positive). Histologic proof was obtained in 4 of 11 pericardial biopsies and 6 of 10 pleural biopsies.
The organism was cultured 9 times from pathological specimens, twice from 20 sputum cultures, 5 times from 11 pericardial biopsies, and twice from 10 pleural biopsies. All patients were treated with antituberculous drugs and
prednisone.
16 patients were declared cured at the end of treatment, 1 left the country and 4 were lost to follow-up.
Tuberculous pericarditis has become rare in developed countries but is still a challenging problem in Qatar. In spite of antituberculous treatment associated with corticosteroids, the prognosis remains poor, due to evolution of pericardial constriction and death.
M. M. Al-Nozha, M. Nouh, S. Al-Harthi, M. Arafah, A. Al-Mobeireek, M. Al-Matouq, N. Kan, O. Attas, Y. Al-Mazrou, M. Al-Shahid, M. Abdullah, A. Al-Khadhra, K. Al-Marzouki
King Saud University, Ministry of Health, King Faisal Specialist Hospital & Research Center, Prince Sultan Cardiac Centre, King Faisal University, King AbdulAziz University, Saudi Arabia
Background:Coronary Artery Disease in Saudis (CADIS) is a six years national study to determine the prevalence of coronary artery disease (CAD) and its traditional risk-factors among Saudis. The project consists of 3 sub-projects.
Methods: Sub-project A is a community-based study with respondents randomly selected from households in rural and urban areas. Both males and females in the age group of 30 to 70 years are interviewed and examined. ECGs are done, and fasting blood samples are collected for sugar and lipid profiles. Sub-project B is a multi-center hospital-based study, to determine the annual incidence of acute coronary events and the annual rates of coronary angiography, interventional procedures and coronary artery bypass graft surgery. All patients admitted with the diagnosis of CAD are interviewed and examined. Results of investigations, diagnostic and therapeutic procedures, and management, including surgery and outcome, are recorded. Sub-project C examines the more recently-identified risk factors among Saudi patients admitted to King Khalid University Hospital, Riyadh, with the diagnosis of CAD. This includes homeostatic variables, biochemical tests and genetic markers
Results: Sub-project A: The total number of subjects in the selected sample was 18,628. The prevalence of hypertension was 21%. The Prevalence of diabetes (FBS ž 7 mmol) was 23%, and, impaired fasting blood glucose (FBS 6.1 – 6.9 mmol) was 15%. Forty-six percent had a fasting total cholesterol (FTC) of < 5.2 mmol, while 31% had FTC of 5.2 – 6.2 mmol, and 23% had FTC of ž 6.2 mmol. Thirty-five percent were over-weight (BMI 25 - <30), 31% had grade II obesity (BMI 30 – 40) and 4% had gross obesity (BMI >40). Thirteen percent were current smokers, 3% were passive smokers and 9% were ex-smokers. Sub-project B: The total number of patients admitted with provisional diagnosis of CAD was 9607 (7073 Saudis). The prevalence of systolic and diastolic hypertension among Saudi patients was 34% and 22%, respectively. Fifty-one percent had diabetes, and 13% had impaired fasting blood glucose. Fifty-five percent had FTC of < 5.2, 28% had FTC of 5.2 – 6.2, and in 17% the level was ž 6.2. Forty percent of the patients were over-weight, 25% had grade II obesity, and 2% were grossly obese. Twenty-twopercent were current smokers, 1% were passive smokers, and 18% were ex-smokers. Among 2534 non-Saudi patients, 35% were hypertensive, 31% were diabetic and 60% were smokers.
Conclusion: CAD risk factors are common among the Saudi population and among patients with CAD. A national preventive program should be planned and implemented without any further delay.
A. Kakadekar, R. McKay, M. Tyrrell
Royal University Hospital, Saskatoon, Canada
Purpose:
Both
the type and incidence of TAPVC are thought to be different among First
Nation’s people. To see this influenced outcome, we reviewed the
complete experience of an institution serving a significant population of
such patients.
Methods
Between 9/93 and 2/98, 19 patients were
admitted to Royal University Hospital with TAPVC. Diagnosis was made by
echo in 9 and by echo and cardiac catheterization in 10. Median age at
diagnosis and surgery were 5 days and 27 days, respectively. There were 13
males and 6 females: 14 patients were native. The types of TAPVC were
infracardiac (9), Supracardiac (4), intracardiac (3), and mixed (3).
Additional cardiac diagnosis included small VSD’s (2) and congenital
heart block (1). Two patients had syndromes with multiple noncardiac
defects. Follow-up was complete (100%) and ranged from 0.76 yrs to 6.4
years.
Results:
All patients survived operation, but one
received only compassionate care when the extent of multiple anomalies
became clear 32 days postoperatively. Another patient died 18 months after
surgery due to bronchopneumonia with pre-existing high right sided
pressure. Complications included SVT (2) and diagram paralysis (3).
Re-operation was needed in 3 patients, 1 each for an unsuspected
mixed-type connection, an SVC obstruction, and a diaphragm placation. At
follow-up all patients had normal cardiac examination and widely patent
pulmonary venous pathways on echo. Doppler velocities were normal
excepting two unexplained gradients of 10 to 16 mmHg. One patient with
delayed diagnosis had moderate developmental delay and another, borderline
neurological impalement.
Conclusion:
Native patients predominated in this
small series and the incidence of obstructed or mixed venous connections
was considerably higher than generally reported. Early diagnosis and
efficacious surgical repair, however, still achieved excellent survival
among these high-risk patients.
A. Alighanadi,
S. Asgary2, N. Sarrafzadegan2
Pharmacognosy Department, School of Pharmacy1 and Cardiovascular Research
Centre2
Isfahan University of Medical Sciences, Isfahan, Iran
Objective:
Free radical-induced oxidative damages
lead to various pathological events including atherosclerosis. Much
interest exists in the possibility that the antioxidant constituents of
some medicinal plants may reduce the risk of such disease by inhibiting of
this oxidative damage. Achillea millefolium is one of the medicinal plants
that is used for treatment of such disorders in cardiovascular diseases.
Material & Methods:
The polyphenolic and total
extracts of dried flowers and leaves of A. millefolium were prepared by
pharmacological methods. For evaluating of the actions of extracts as
protective agents against oxidative damages mediated by lipid peroxidation
in biomembranes, we used a method based on free radica- induced
deterioration of erythrocyte membranes and hemolysis. In this method,
oxidative hemolysis was induced by 2,2’-Azobis
(2-amidinopropane)-dihydrochloride (AAPH) and, in order to estimate the
antihemolytic potency of herbal extracts, erythrocyte suspensions were
incubated with each extract and AAPH.
Results:
Extracts retarded the occurrence of
hemolysis and suppressed its percentage. The polyphenolic extract of the
plant was much more effective than total extract in suppressing the
hemolysis of erythrocytes in the experiment.
Conclusion:
The polyphenolic extract of A.
millefolium protects against oxidative cell injury in human erythrocytes.
Flavonid compounds of the extract have been partly associated with these
biochemical actions.
H. Al Tarief, N. Kalis, Z. Arekat, M. Worthington
Mohmmad Bin Khalifa Bin Sulman Al Khalifa Cardiac Centre
State of Bahrain
Coarctation of the aorta which requires emergency surgical correction during
infancy remains a surgical challenge with a significant
rate of recoarctation, primarily due to anatomical
variation and size of the vessels. We conducted
a retrospective analysis of a four year period
to assess the presentation, anatomy, associated
defects, surgical repair and course of patients
operated for coarctation during the first year
of life.
|
mean
(range or %)
|
Number of Patients
|
20 |
Age at surgery (weeks)
|
3.9(1-12) |
Sex (male/female)
|
16/4 |
Cases with Associated Congenital
Defects
|
17 |
Patients on Prostaglandins Prior to Repair
|
19 |
Anatomy: Coarctation
Interrupted Arch
|
17
3 |
Repair: End to End Anastomosis
Patch Repair
Subclavian Angioplasty
|
17
2
1 |
Reoperation for Recoarctation
|
5(20%) |
Interval Between Primary Operation and Reoperation (months)
|
16.25(2.75-30) |
Mortality
|
0 |
All patients
required surgical intervention within the first
three months of life, and repair was safely
performed within the first weeks of life. Most
patients were in a critical condition prior to
repair, requiring intravenous prostaglandins to
maintain the patency of the arterial duct and
dopamine for inotropic support. Associated
congenital defects often accompanied coarctation
of the aorta. Sixty six percent (2/3) of
interrupted arch patients required reoperation for
restenosis, as opposed to 17.6% (3/17) of the
coarctation patients. In the patients requiring
reoperation, the mean delay from first to second
operation was 16.25 months, which allowed for
significant growth in this group of high risk
patients.
R. Subramanyan, R. Narayan, S.M.
Khusaiby
Department of Paediatric Cardiology, Royal Hospital
Muscat, Sultanate of Oman
Objective:
This study was performed
to determine the frequency and characteristics of residual
shunts and reopening of persistently patent arterial ducts
(PDA) after initial successful closure by coil or device.
Background:
Transcatheter closure is
now widely accepted as the treatment of choice for PDA. In
occsional patients, however, we found that the shunt
persisted or reappeared after successful closure. Though
this shunt is usually small, it has implications for
infective endocarditis prophylaxis and occurrence of
haemolysis.
All 72 patients who
underwent successful percutaneous transcatheter PDA
closure were studied. Procedural success was defined as
stable coil or device position with total abolition of
flow, or the presence of only a trace of flow into the
pulmonary artery on angiography. PDA persistence or
reopening was diagnosed by Doppler echocardiography (DE)
at follow-up between 3-6 months.
Results:
PDA closure was done by
single coil in 45 patients (63%), two coils in 7 patients
(10%), Rashkind’s double umbrella in 6 patients (8%), or
Amplatzer device in 14 patients (19%). None of the coils
or device embolised.
Immediate successful closure rate was
76% for the entire group and 67% for the single coil and
Rashkind’s Umbrella group.
Residual shunt or reopening
at follow-up was not detected in any patient with
double-coil or Amplatzer device closure. At follow-up 3
patients (50%) with Rashkind’s umbrella and 40 patients
(89%) with single coil showed complete abolition of the
shunt.
Three patients (50%) with Rashkind’s device had
persistence of the shunt, 2 needing further coil
occlusion.
In the single coil group 3 patients (7%)
continued to have a trivial shunt on DE but no murmur was
audible.
In 2 patients (4%) with documented complete
occlusion by a single coil, the PDA reopened.
One of them
had a continuous murmur and underwent a repeat coil
procedure.
Conclusion:
Small residual shunts and reopening can
occur after successful single coil or Rashkind's Umbrella
closure of PDA. We believe that selection of an
appropriate device and use of more than one coil can
eliminate this problem.
T. R. Mycyk, MD, FRCSC, R. McKay,
MD, FRCS, FRCSC, J. Loewy, MD FRCPC
Royal University Hospital, Saskatoon,
Canada
Isolated coronary ostial stenosis is a
rare but lethal variant of coronary artery / aortic
pathology, found most often in younger patients.
Conventional techniques of bypass grafting generally
require one or two higher risk reoperations in such cases.
The quest for optimal surgical management led us to
re-evaluate direct coronary ostial patch angioplasty in
selected patients.
Sixteen patients (7 female and 9 male)
aged 4 to 78 years (average= 57.7 years) underwent direct
coronary patch angioplasty as an isolated or combined
procedure between January 1992 and January 2001. There
were no deaths, strokes or perioperative infractions. All
sixteen patients remain free of angina up to eight years
postoperatively. Postoperative angiograms, CT scans and
MRI scanning confirm very satisfactory surgical results.
Current surgical techniques, myocardial preservation,
monitoring and non-invasive follow-up make coronary ostial
patch angioplasty a safe, physiologic and clinically effective alternative to
multiple bypass grafting in selected patients with fixed, non-calcified and
non-spasmodic ostial stenosis.
F.G.Y. AL-Umran, FICMS Ibn
Al-Nafees Hospital for Cardiothoracic Surgery >Baghdad,
Iraq
The influence of 60 preoperative, intraoperative
and postoperative variables on operative mortality following 380
aortic valve replacements (1993 to 2000), was investigated using
stepwise logistic regression analysis. Overall operative mortality
was 10% with the lowest rate in the last year (7.4%). Strong
independent determinants of operative mortality in the entire group
were high left ventricular mass index, severe aortic regurgitation,
the presence of preoperative renal impairment, low ejection fraction
on ventriculogram, and peripheral oedema. The early results of
aortic valve replacement can thus be related to several specific
variables which describe the functional and physiological status of
the patients. This information should provide for a more rational
approach to aortic valve replacement, at least in terms of early
risk/ benefit deliberations. The cardiac surgeon must identify the
factors that predict postoperative mortality to develop alternative
strategies for high risk patients.
P. Rempel BScPT
Hamad Medical Corporation, Doha, Qatar
Objective:
The purpose of this review was to
educate the pediatric cardiac team regarding benefits of a new
physiotherapy program in the pre and post operative management of
surgical cases.
Material and Methods:
The physiotherapy
program began in March 2001 with a focus of management on
pre-operative instruction on the surgical ward and post operative
follow-up in PICU. Once patients were transferred back to the ward
for the convalescent stage, physiotherapy continued to follow
respiratory and neurological progress. Out-patient physiotherapy was
arranged if needed to follow the respiratory and neurological status
in the Physiotherapy Centre. Continuing education lectures were
provided to the nursing staff to inform them of the role of
physiotherapy and to highlight specific treatment techniques in the
post-operative period. Use of the face mask to provide chest
physiotherapy was common medical practice prior to March 2001 and
alternative treatments needed to be taught.
Results:
A total of 40 patients were referred
for physiotherapy in the pre-operative period. Families and patients
were instructed in the physiotherapy management pre-operatively.
Follow-up of all 40 patients has occurred in PICU. Incentive Spiro
meters were used in all patients over 5 years of age. Three patients
required treatment and management for feeding difficulties post
operatively. Two patients were referred for continuing out-patient
physiotherapy treatment, 1 for right upper lobe collapse and one for
left hemiparesis. A total of 32 nurses were instructed in a lecture
setting regarding the role of physiotherapy. Clinical bedside
teaching for nursing occured regularly on the ward and PICU to
assist with physiotherapy management and discharge planning for each
patient. The use of face masks to deliver chest physiotherapy
treatments is no longer being used in the clinical setting. Various
manual forms of chest treatment are now widely used on the ward and
in PICU to promote independence with respiratory control and
breathing, and to improve independence with functional mobility.
Conclusions:
The success of the physiotherapy program in the
management of cardiac surgery cases is team oriented and clinically
sound. The nursing staff has been shown alternative physiotherapy
treatment measures to facilitate post operative recovery. Family and
patient teaching pre-operatively assists with post operative
expectations of physiotherapy treatment. Functional mobility and
deep breathing exercises as part of the physiotherapy management
strategy are in keeping with the clinical practice in other major
cardiac surgery centers. Alternative physiotherapy respiratory
techniques are currently being explored as additional treatment
options for the pediatric cardiac patient.
M. Balghith, V. Menon, D. P. Humen, B. I. Jugdut
University of Alberta and King Fahd National Guard
Hospital
Edmonton, Canada and Riyadh, Saudi Arabia
Background:
Limitation of remodeling
by angiotensin-converting enzyme (ACE) inhibitors
has already been shown to improve systolic function.
We studied the effects of captopril (CL), an ACE
inhibitor, and nitroglycerin( NTG) on diastolic
dysfunction after transmural acute myocardial
infraction (TAM).
Methods:
One hundred and sixty patients
were randomized (double-blind factorial design,
n=20/cell) 48 hours after a first anterior (ATAMI)
or inferior ( ITAMI) myocardial infarction, to
receive a placebo, CL( 6.25- 25mg TID) , NTG (
buccal 1-3mg TID;5 hourly with an 8-hour washout
) or NTG + CL for 6 weeks. Quantitative two-dimensional
echocardiograms and Doppler of were analyzed for
peak early (E) and late (A) flow velocity, E/A
ratio and deceleration time (DT) as well as other
remodeling parameters at 4 times (2 days , 6 weeks,
6 months, and 1 year).
Results:
The percent changes
over 1 year, as mean ± sem, are summarized in
the table.
Placebo
CL
NTG NTG+CL
|
ATAMI
E/A ratio
-10+9 20+6*
22+17 28+16
DT
68+13 20+9*
39+17 36+14
ITAMI
E/A ratio
-6+15 6+16
30+17 22+16
DT
1+13 13+7
18+15 3+8
|
*P< 0.009 versus placebo
(ANOVA)
|
Conclusion:
Persistent improvement in diastolic
function was significant only in the ATAMI subgroup
receiving captopril therapy.
Howaida Al-Qethamy, Khawar Aizaz,
Saber Aboelnazar, Samina Hijab, Yahya Al-Faraidi
Department of Cardiac Surgery,
Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
Objective:
The arterial switch
operation (ASO) is the procedure of choice for
transposed great arteries in the neonate, but
pulmonary artery (PA) banding with or without
a Blalock-Taussig (BT) shunt, and secondary ASO,
is recommended for patients beyond the neonatal
period. An interval of one week to about 8 months
has been reported between the two stages. This
study reviews our experience and mid-term results
with two-stage ASO.
Methods:
A retrospective study reviewed
49 patients with simple TGA (n=28) or TGA with
VSD (n=21), who underwent two-stage ASO between
January 1995 and September 2000. The mean interval
between procedures was 21.89 ± 9.86 months following
preliminary PA banding ± BT shunt. The mean age
was 36 ± 21.31 months, and the mean weight was
10.86 ± 2.97 Kg.
Results:
The mean ICU stay was 5.12 ± 4.22 days and mean
hospital stay was 10.67±5.69 days. Hospital mortality
was 8% (n=4). All patients were followed up for
a mean period of 18.12 ± 14.38 months. There was
onelate death. Actuarial survival was 92% at 3
years and 90% at 5 years. Reoperation was required
in one patient for a false aneurysm of the ascending
aorta, giving a freedom from reoperation at 3
and 5 years of 100% and 98%, respectively.
Conclusion:
Late anatomic correction
of TGA, six months or longer after PA banding
± BT shunt, can be performed with an acceptable
mortality and low morbidity. But the question
remains «Is Late Ever Too Late?». Although the
ASO can be done even years after initial palliation,
undue delay may lead to left ventricular dysfunction,
arrhythmias, neo-aortic valve regurgitation and
obstruction below the systemic arterial valve.
Dr. Adel Lawati
Oman
Introduction:
Emergency coronary artery bypass
grafting (CABG) carries a higher risk of mortality
than elective operation. This paper reviews our
experience with emergency CABG during a 5 years
period from 1995 to 2000.
Methods:
A total of 980 patients
underwent CABG during this period, 27 as emergencies.
Seventeen patients underwent CABG for medically
refractory unstable angina and 10 patients for
post infarction unstable angina, 12 hours to 20
days after myocardial infarction.
Results:
Six of the 27 patients
needed insertion of an intra aortic balloon pump
(IABP), 2 pre-operatively and 4, post bypass.
There was only one death, giving a mortality rate
of 3.7%. No patient was re-explored for bleeding.
One patient had a cerebral complication necessitating
prolonged ventilation.
Conclusion:
Our data suggests that emergency
CABG can be done with low mortality, but there
is a greater need for mechanical support in this
group of patients.
J. M. T. Al-Hayali
Department of Medicine, College of Medicine
Mosul, Iraq
Diabetes mellitus is an independent
risk factor in the development of coronary heart
disease. Acute myocardial infarction (AMI) is
associated with higher mortality in the diabetic
than non-diabetic patients, and the metabolic
derangement that accompanies AMI may be a responsible
cofactor. Hyperglycemia may also develop in some
AMI patients as part of the metabolic response
to stress. It is, therefore, important to be able
to establish the origin of the hyperglycemia by
measuring, in addition to blood glucose, another
index of the glycemic state such as glycated haemoglobin
or glycated serum proteins. Recently, serum fructosamine
assay, a novel colorimetic assay of glycated serum
protein, has been described as an intermediate
term index of glycemic control that could be used
for this purpose.
The aim of the present study
was to evaluate the changes in plasma glucose
and their effect on the progress in non-diabetic
and diabetic patients who developed complications
following AMI.
Assessment of the glycemic state
was performed by measuring plasma glucose and
serum fructosamine concentrations in 62 patients
with confirmed acute myocardial infarction. Twenty
six percent of the non-diabetic patients showed
hyperglycemia on admission. Marked increase in
serum cortisol level was observed which was significantly
(P<0.01) higher in the hyperglycemic patients
(both diabetic and non-diabetic) than non-diabetic
patients with normoglycemia. A significant correlation
was found between admission serum cortisol and
plasma glucose (r=0.52, P <0.001) in the diabetic
group. There was no significant difference in
infract size as assessed by peak serum aspartate
transminase activity between non-diabetic and
diabetic patients. No significant correlation
was found between peak aspartate transaminase
activity and admission cortisol level in non-diabetics
and diabetics. A stepwise increase in the frequency
of arrhythmias was demonstrated in hyperglycaemic
patients (diabetic and non-diabetic), as well
as pump failure and heart block in diabetic patients.
F. Al-Kandari, A. Al-Syayegh
Chest Disease Hospital, Kuwait
Study Design:
Twenty six patients in Kuwait who received
an implantable cardiac defibrillator ( ICD) for life threatening ventricular
arrhythmias between July 2000 and October 2001 were reviewed
retrospectively. Eleven patients had their device implanted locally in
Kuwait after October 2000. Evaluation included clinical characteristics of
the patients, as well as indications and type of ICD implanted,
antitachycardia pacing (ATP), shocks, and the number of shocks per episode
of ventricular tachycardia (VT) or ventricular fibrillation (VF).
Results:
Twenty three men and 3 women had a mean age
of 52 ± 14 years. . The mean left ventricular ejection fraction (LVEF) was
32.6%. The underlying heart disease was ischemic cardiomyopathy in 19
patients, idiopathic dilated cardiomyopathy in 3, idiopathic VT/VF in 3, and
hypertrophic obstructive cardiomyopathy in 1. Clinical congestive heart
failure (CHF) was present in 34.6% and preexisting atrial fibrillation (AF)
in 27%. The indication for ICD was syncopal VT in 12 patients, VT arrest in
3, VF arrest in 4, inducible VT at electrophysiology study ( EPS) in
patients with CAD, or low LVEF and nonsustained VT on Holter monitor. One
patient with HOCM received a prophylactic ICD. Half of the devices implanted
were dual chamber and half were single chamber. Ten patients received a
total of 177 ICD therapies including ATP and shocks. Thirty eight shocks
occurred in 9 patients, all of whom received one shock per episode, except
for 2 patients who had 3 shocks per episode. Six patients had inappropriate
shocks due to AF.
Conclusion:
ICD was used as initial therapy for all patients with
high risk ventricular tachyarrhythmias, including aborted cardiac arrest or
symptomatic VT. The new strategy of risk stratification in patients with
previous CAD, low LVEF (< 40%) and non-sustained VT on Holter
monitor or EPS has broadened the indications for proplylactic use of ICD,
and these comprised a number of our patients.
Ibrahim R. al -Rashdan, MD, Christus Thomas, MD
Chest Disease Hospital, Kuwait
Background:
Identification of patients with renal artery
stenosis by clinical suspicion, followed by noninvasive investigations and
finally renal arteriogram lacks sensitivity in the first two steps of the
diagnostic process. In this study we used angiography to evaluate the prevalence
of renal artery stenosis in 101 consecutive hypertensive patients who underwent
cardiac catheterization.
Study Design:
As part of the Kuwait Vascular Study protocol, 178
consecutive patients undergoing cardiac catheterization had mandatory peripheral
angiograms, including subclavian, iliac, and renal arteries. This sub-study
reviewed renal arteriograms in 97 of the 101 hypertensive patients.
Results:
Only 70 patients had normal renal arteries. Ten patients had
< 50% stenosis and 16 patients had > 50% stenosis of one or both renal
arteries. One patient had ectasia of the renal arteries. In this subset of
patients, 14 had normal coronaries; 17, single vessel disease; 22, two vessel
disease; and 48, 3 vessel disease, In the single vessel disease patients, one
had >50% stenosis in one or both of the renal arteries. Patients with two
vessel coronary disease did not differ from those with single vessel disease.
Among the 48 patients with three vessel disease, 45 of whom underwent renal
studies, 17(38%) had renal artery stenosis. This was greater than 50% in13
(29%). Out of 14 patients with normal coronaries, only 1 had > 50% stenosis
of a renal artery.
Conclusion:
The prevalence of renal artery stenosis is
significant among hypertensive patients undergoing cardiac catheterization for
evaluation of CAD, especially those with three vessel disease.
M. Zubaid, S. Hani, C. Thomas, I. Al-Rashdan, N. Hayet, A.
Habashi, Departments of Medicine and Cardiology, Kuwait University and Chest
Disease Hospital, Kuwait
Objectives:
To investigate the immediate and 30 day safety and
efficacy of reused balloons (RB), compared with new balloons (NB) during
coronary angioplasty
Material and Methods:
During a one-year period, all patients, with the exception of
those in cardiogenic shock or with total occlusion of a vessel for longer than 3
months, were prospectively randomized in a double blind study comparing RB to
NB. The strategy in each arm was to initially use the assigned balloon type and,
if this failed to cross, then use a smaller caliber balloon of the same type. If
the second balloon also failed, cross over to the other arm was allowed.
Results:
A total of 309 patients were entered into the study and clinical characteristics
were similar in both arms. The following were
the procedural results:
|
RB (N=178)
|
NB(n=99)
|
P-value
|
Left anterior descending artery
|
44% |
39% |
NS |
Initial strategy successful
|
96% |
99% |
NS |
Crossover rate
|
4% |
1% |
0.028 |
Angiographic success |
99% |
99% |
NS |
Number balloons/lesion |
1.3±0.5 |
1.2±0.5 |
NS |
Total procedure time (minutes) |
27±12 |
29±14 |
NS |
Fluroscopy time after lesion
crossed with wire (minutes)
|
4.8±3.6 |
4.7±3.4 |
NS |
30-day MACE
|
51 |
6.5 |
NS |
MACE = Major Adverse Cardiac Events NS = not significant
MACE break down was as follows: RB arm: Death 1.3%, MI 3.8%,
emergency PTCA 0.6%, emergency CABG 1.3%. The corresponding figures for the NB
arm were: 1.2%, 3.9%, 1.3%, and 0.7%.
Conclusion:
RB are as safe and effective as NB in coronary angioplasty. Despite a higher
cross over rate, RB are not associated with longer procedure times or more
complications.
Xubail Mohammad, Rashed Wafa
Kuwait University, Kuwait
Objectives:
To document the rate of use of thrombolytic therapy (TT) and
to identify the reasons for any shortfall at a major university hospital in
Kuwait
Material and Methods:
A retrospective analysis of 983 consecutive patients
with acute myocardial infarction between June 1994 and May 1997 was performed.
Shortfall was defined as the number of patients who were eligible for TT but did
not receive it .
Results:
The patient population was young, with 59% less
than 55 years of age. Thirty nine percent had diabetes. Of the total study
group, 669 patients (68%) were eligible for TT. Of the eligible group, 625
patients (93.4%) received TT while 44 did not, giving a shortfall of 6.6%. The
reasons for the shortfall were unknown in 23 cases, retinopathy in 13, temporary
pacemaker insertion in 2, and mildly elevated blood pressure in 2.
Conclusion:
Our thrombolysis rate is high and the shortfall is
low compared with those reported in the literature. However, changes should
still be implemented to avoid any unnecessary shortfall.
Jasim M. T. Al-Hayali
College of Medicine, Mosul, Iraq
From January 2000 to June 2001,
we studied 17 male and 5 female patients who presented
to the emergency department with either complaints
suggestive of acute aortic dissection (severe
abdominal and chest pain) or features of an acute
vascular event (8 cerbrovascular; 4 peripheral
) and the heart a possible source of emboli. All
patients had undergone basic investigations, including
surface ECG and transthoracic echocardigram, without
reaching a conclusive diagnosis and were thus
submitted to transesophageal echocardiography
(TEE) under local anesthesia. In two of those
who presented with chest pain, TEE established
the correct diagnosis of dissecting aneurysm of
the aorta. Three patients from the second group
showed evidence of left atrial thrombi, and 4
patients were found to have a patent foramen ovale.
Thus, the etiology of symptoms was found in 9
of 21 patients (43.8%), and we conclude that transesophageal
echocardiography should be regarded as a useful
diagnostic test in the emergency department.
Ibrahim Tarik Hashem, Khella
Akila, Radwan Mahmoud, El Awady Mohamed
Primary Health Care, Ministry of Health, Abu Dhabi,
UAE
This study was carried out in
1998-1999, to estimate the prevalence of some
selected coronary heart disease (CHD) risk factors
among Egyptians residing in Abu Dhabi city, and
to study the relation of these risk factors with
duration of stay in Abu Dhabi, family deprivation
and family income. It was designed as a cross-sectional
study and included 377 males in the age range
from 19 to 61 years.
Subjects were collected during
the pre-employment medical examination and the
follow-up examination which is required for renewal
of residency visas. They were investigated for
abnormal cholesterol levels, high blood pressure,
cigarettes smoking, diabetes mellitus, obesity
and physical inactivity. Plasma total cholesterol
level was 200 mg/dl in 33.9%, 51.5% had
HDL-cholesterol level <35mg/dl and 44.8% had
LDL-cholesterol level 130 mg/dl. The overall
prevalence of diabetes mellitus (random blood
sugar 200 mg/dl) was 2.7%, hypertension
(BP 140/90 mm Hg or reported antihypertensive
medications) 61.3%, overweight (BMI 25)
63.9%, high waist to hip ratio (0.95) 18.6%,
physical inactivity 21.2% and cigarette smoking
40.8%. Duration of stay in UAE and family income
had unfavorable effects on some of the investigated
risk factors, while family deprivation had a beneficial
effect on some.
With exclusion of diabetes mellitus and increased
waist to hip ratio, Egyptians residing in Abu
Dhabi city showed a high incidence of risk factors.
Further studies are needed to assess the risk
of CHD among Egyptians living outside their own
country.
J. Al-Hayali
College of Medicine, Mosul, Iraq
An 11 year old boy suddenly presented
with shortness of breath, and palpitation. ECG
revealed supraventricular tachycardia at 170 beats/min,
and, following resuscitation, chest x-ray showed
cardiomegaly. Surface echocardiography demonstrated
a well- defined, cystic lesion attached to the
upper part of the left atrium, which was confirmed
at cardiac catheterization. During surgery, a
huge cystic lesion was found, into which the heart
was sinking. The lesion was removed, and later
was proven by histopathology to be true aneurysm.
Post-operatively the patient did well. Review
of the literature disclosed no similar cases.
Hasan Ali Khan, Adnan Al-Asousi,
Aiad Al-Anzi
Department of Medicine, Noninvasive Cardiac Laboratory,
Al-Jahra Hospital, Kuwait
Objective:
To present various
types of interesting space occupying lesions encountered
in and around the heart during routine echocardiography
in a general hospital.
Materials:
Echocardiography pictures
were selected from the large number examinations
done in our department over a period of nine years.
Discussion and Conclusion:
A large number of conditions
may produce space-occupying lesions which look
like masses, and it is the experience of the echo
cardiographer that determines the clinical significance
of these findings. In some cases, normal anatomical
structures cause artifacts, (e.g. a thickened
calcified moderator band) or may be of questionable
significance (e.g. false tendons in the left ventricle).
These require clinical correlation to confirm
the diagnosis. Truly pathological conditions which
cause hemodynamic disturbances may be infective,
(vegetations) hematogenous (thrombi) or neoplastic
(tumours). One must also recognize iatrogenic
shadows resembling masses, especially in postoperative
cases. These include prosthetic valves, pacemakers,
and coronary stents. We have particularly explored
the possibility of imaging stents with a view
to detecting coronary blood flow as evidence of
stent patency in the future.
Hasan Ali Khan, Aiad Al-Anzi,
Adnan Al-Asousi
Department of Medicine, Coronary Care Unit, Al-Jahra
Hospital, Kuwait.
Objective:
RMVT is a rare form of tachycardia, suspicion
of which makes the diagnosis easier. This presentation
is intended to facilitate understanding of the
types of ventricular tachycardia (VT) presenting
in a structurally normal heart and their management
A patient presented with palpitation and syncope
induced by minimal exertion and demonstrated changes
of RMVT on ECG. Radio-frequency catheter ablation
results will be presented.
Discussion and Conclusions:
Primary electrophysiological
abnormalities of the heart can be the cause of
VT with no suggestion of heart disease or dysfunction
on the echocardiogram or the electrocardiogram
during sinus rhythm. These VTs are sometimes referred
to as «normal heart» VT. It is important to recognize
the source of these tachyarrhythmias, as some
of them respond to calcium channel blockers and
therefore may mistakenly be called supraventricular
tachycardia. Two distinct types of normal-heart
monomorphic VTs are described. One originates
from the right ventricular outflow tract region
and shows a left bundle-branch block QRS morphology
with a right inferior axis. The other form originates
in the left ventricle near the apex with a typical
right bundle-branch block QRS morphology and a
superior axis. The diagnosis of these VTs and
the exact focus of origin are determined by electrophysiological
studies, using pace mapping technique. The curative
treatment of both is a radio-frequency (RF) catheter
ablation. These VTs may respond to a number of
anti-arrhythmic agents but more typically respond
to calcium channel blockers such as verapamil.
Some are particularly sensitive to adenosine,
especially those originating from the right side.
The degree of response and long-term effects of
RF treatment are also much better in VTs originating
from the right side of the heart.
P. Prashanth, MBBS, MD, A. M.
RIYAMI, FRCP
Department of Cardiology, Royal Hospital, Muscat,
Oman
Objective:
To assess prevalence of C-reactive
protein (CRP) elevation in patients with unstable
angina and to determine its in-hospital prognostic
significance and correlation with severity of
coronary artery disease (CAD)
Methods:
50 patients with Braunwald
IIIB unstable angina and ECG changes without biochemical
evidence of necrosis (negative first Troponin
T), had serum samples taken at presentation (before
initiation of thrombolytic treatment) and were
followed until discharge. The 34 men and 16 women
had a mean age of 61±11 years, and the mean time
from last anginal episode was 5±5 hours. The outcome
events were recurrent angina, non-Q and Q-wave
myocardial infarction, cardiac death and urgent
revascularization. Coronary angiography was done
in all patients to assess the severity of CAD.
CRP was measured by rate nephelometry (>10mg/L
abnormal), and Troponin T, by enzyme immunoassay(>0.1
ng/ml abnormal).
Results:
Twenty-one patients (42%)
had CRP elevation >10mg/L (Group I), and 29
patients (58%) had levels <10mg/L (Group II).
There were no differences between Group I and
II with respect to baseline clinical characteristics.
The median CRP level on admission in Group I was
18.5mg/L (range = 10.0-162.0) compared with 4.0mg/L
(range = 0.1-7.5) in Group II. Group I patients
had more symptomatic ischemic episodes in hospital
than Group II patients (mean = 4.6±2.5 episodes/patient
vs 1.6±2.4; p=0.004). Twelve patients subsequently
had non-Q MI, 2 died, and 4 required immediate
coronary revascularization in Group I, compared
with no deaths, 5 small non-Q MI and 2 cases of
urgent revascularization in Group II. The total
number of events in group I was 18 (91% of patients)
vs 7 (23% of patients) in group II (p=< 0.001).
At angiography, 15 patients (71%) in Group I had
severe triple vessel disease as compared to 7
patients (23%) in group II ( p=<0.05). Ninety-one
percent of patients with elevated CRP were referred
for revascularization, compared to 45% of those
without CRP elevation (p<0.02). The sensitivity
of admission CRP level >10mg/L as a marker
of subsequent cardiac events was 72 percent, the
specificity was 88 percent, and the positive predictive
valve was 86 percent.
Conclusions:
Raised CRP level is predictive
of increased risk for major, in-hospital cardiovascular
events in patients with unstable angina, and it
has a good correlation with increased severity
of coronary artery disease on angiography and
the need for revascularisation procedures. Patients
with abnormal CRP should undergo angiography ±
revascularisation during the same hospital admission,
whereas those with normal CRP can be managed with
optimization of antianginal therapy, followed
by elective investigation, depending upon spontaneous
or stress-induced ischemia.
J. Al-Suwaidi, TC Gerber, A Schmermund
, R Lennon, ST Higano, J. Rumberger,
DR Holmes Jr., PF Sheedy, A Lerman
Department of Cardiology and Cardiovascular Surgery,
Hamad Medical Corporation, and the Mayo Foundation
Doha, Qatar, and Rochester, MN, USA
Objective:
Coronary endothelial dysfunction
and coronary calcification detected by electron
beam computed tomography (EBCT) are both considered
markers for early coronary atherosclerosis, but
the association between those two processes has
never been examined
Methods:
Thirty-eight consecutive
patients (19 men, age 48.2+12.7 years)
with no or mild coronary artery disease (diameter
stenosis <20% by angiography) underwent graded
administration of intracoronary acelylcholine
( Ach,10-6 to 10-4 M) into the left anterior descending
coronary artery (LAD). The resulting percent change
of coronary blood flow ( %ذCBFAch) and coronary
artery diameter ( %ذCADAch) were measured.
Quantification of coronary calcium using EBCT
was performed immediately after coronary catheterization
from 3-mm high-resolution tomograms. The calcification
areas and Agatston scores for the LAD and the
entire coronary tree were determined.
Results:
Eight patients
(29%) had an abnormal coronary blood flow response
to Ach ( < 50%ذCBFAch), and 28
(93%) had abnormal epicardial coronary artery
response to Ach ( < 20%ذCADAch).
Twenty-three patients had coronary calcium (average
Agatston scores: total, 175 + 256; LAD
only, 104+ 156). Overall, there was no
correlation between coronary endothelial function
and any measure of coronary calcification (R <
0.1, P=ns) (See table).
Total Calcium Score
|
P
|
|
>
80 (n=9) |
<80(n=29) |
|
% ÐCBF Ach
|
144.2+
69.9 |
94.7
+ 119.3 |
0.36
% |
ÐCAD Ach
|
-2.4+
7.9 |
-12.7+
31.8 |
0.96 |
Conclusions:
In early coronary atherosclerosis, coronary
endothelial dysfunction and coronary calcification
as measured by EBCT appear to be independent processes.
A.Gehani, A. Al-Mulla, J. Al-Suwaidi,
O.Tamimi, A. Chaikhouni, F. Mahrous, A. Ashraf,
H. A. Hajar
Cardiology and Cardiovascular Surgery Department,
Hamad Medical Corporation, Doha, Qatar
Background:
Why do some patients
suffer acute myocardial infarction (AMI) despite
angiographically normal coronary arteries (NL+MI),
while others enjoy an AMI-free life, despite extensive
three vessel disease (3VD-MI)? This is the largest
study of patient with AMI and normal coronary
angiography, and the first to compare this group
with those having extensive CAD, but no AMI.
Methods:
Of 10,000 patients
admitted to the cardiology service, first myocardial
infarction (MI) was confirmed in 2356 patients,
of whom 1609 had coronary angiography. In 77 patients
(4.1%) with MI, coronary angiography was found
to be entirely normal. This subset was compared
to 123 patients with severe three vessel coronary
disease, but no MI.
Results:
Patients with NL+MI
were on average 13 years younger (42±8.3 vs 55±10.5,
p<0.05), and a higher percentage were less
than 40 years of age (33 vs 9; 43% vs 7.3%) than
those in the 3VD-MI group. Patients with NC+MI
were more often current smokers (80.5% vs 29%,
p<0.01), while patients with 3VD-MI were more
often diabetic (54% vs 9%, p<0.01), had higher
cholesterol (5.6±1.1 vs 4.9±1.0 Mmol/l, p<0.01),
and had a higher incidence of chronic stable angina
(52% vs 22%, p<0.01) and heart failure (6%
compared to none in the NL+MI group). 61 of 77
NL+MI patients (79%) had a single risk factor
and, in 87%, this was smoking alone. Diabetes
as a sole risk factor was rare in this group.
Conclusion:
In patients who suffer MI despite normal coronary
angiography, smoking is a major risk factor. In
contrast, for patients with extensive angiographic
CAD but no MI, diabetes, rather than smoking,
is the dominant risk factor. These findings, as
indicated by comparison of groups in the extremes
of the spectrum, support the view that the risk
factors for stable and unstable CAD are different.
Smoking appears to be a major risk factor for
AMI (even with normal coronary angiography) while
diabetes is a major risk factor for more severe
but stable CAD.
A. A. Gehani, J. Al-Suwaidi ,
O. Tamimi, H. A. Hajar
Department of Cardiology and Cardiac Surgery,
Hamad Medical Corporation, Doha, Qatar
The responses of smokers (SM)
and diabetics (DM) to thrombolytic therapy (Tx)
are often reported separately. In the present
study, the clinical and angiographic profile of
1340 consecutive patients with AMI who were either
smokers (N=930) or diabetics (N=410) are compared.
I.V Streptokinase (1.5x106 IU) was given to 503
of SM (62.6%) and 103 of DM (25.2%). Overall,
in-hospital mortality was higher in DM (17.6%
vs 3.9%, p<0.05). Tx had a greater impact on
mortality in SM (1.8% with vs 6.3% without Tx,
a 71% reduction) compared to DM (11.6% with vs
17.7% without Tx, a 38% reduction). Angiography
was performed on 753 SM (84%) and 220 DM (65%).
In the Tx group, SM was associated with a higher
rate of patent coronary vessels than DM (86.3%
vs 80.5% respectively, p<0.01). The reverse
was true in those who did not receive Tx (78%
patency in SM vs 84% in DM, p<0.05). DM had
a lower ejection fraction (EF) than SM (51±14.8
vs 54±12.4, respectively, p<0.05). More importantly,
severe LV dysfunction (EF<40%) was commoner
in DM (21% vs 11.3% in SM, p<0.001). These
finding were consistent even when correcting for
difference in age (58±11 yrs in DM vs 46±9 in
SM), gender (70% males in DM vs 98% in SM) and
peak CPK (1500±1776 in DM vs 2327±2620 in SM)
using multiple linear regression analysis.
Conclusions:
Smokers appear to derive a greater
benefit from thrombolytic therapy than diabetics,
but, as compared to smoking, diabetes has a stronger
negative effect on survival and LV function, even
in patients receiving thrombolysis.
Z. Arekat, H. Al Tarief, M. Worthington
Mohmmad Bin Khalifa Bin Sulman Al Khalifa Cardiac
Centre, State of Bahrain
We conducted a retrospective analysis to evaluate
our conversion from performing primarily ONCAB
(standard CABG on bypass) to OPCAB (off pump CABG)
procedures. From October 2000, we elected to attempt
OPCAB in all patients undergoing coronary artery
bypass surgery. An ONCAB procedure was, however,
primarily performed on patients with haemodynamic
instability or diffuse coronary artery disease
and small vessels.
The OPCAB procedures were perfomed using
the Medtronic Octopus stabilizer and intraluminal
shunts. The ONCAB procedures were performed with
cardiopulmonary bypass in a cardioplegia-arrested
heart, using intermittent antegrade and retrograde
cardioplegia.
Results:
|
OPCAB(mean±sem)
|
ONCAB (mean±sem)
|
Cases 1999-2000
2000-2001
|
22(8.56%)
149(71.3%) |
235
60 |
Conversion to ONCAB
|
|
5.84% |
Left Main Stem Disease#
|
9.94% |
23.4% |
Grafts per patient*
|
3.31±
0.08 |
4.25
± 0.04 |
At least one IMA graft
|
99.5% |
100% |
Bilateral IMA grafts#*
|
26% |
42% |
Inotropic Support#
|
25.7% |
61.2% |
ICU Stay* (days)
|
1.09 ±0.03 |
1.35 ± 0.06 |
Hospital Stay* (days)
|
6.53
± 0.2 |
7.77 ± 0.2 |
ICU Blood Loss(ml)
|
1066
± 82 |
1121
± 41 |
Atrial Fibrillation
|
7.0% |
9.8% |
Major Neurological Event#
|
0 |
3.7% |
Mortality#
|
0 |
3.39% |
#* p < 0.001 Chi-Squared
# p <0.05 Chi-Squared
* p < 0.001 Unpaired T- test
Conclusion:
OPCAB procedures were safely performed in 71.3%
of patients with reduced requirements for inotropic
support, shorter ICU and ward stay, fewer major
neurological events and no increase in mortality.
Only 5.8% of patients required conversion to ONCAB.
The mean number of grafts was reduced as was the
number of bilateral internal mammary artery grafts
in the OPCAB group. There was, however, no difference
in post-operative bleeding or the incidence of
perioperative atrial fibrillation.
A.Zargarzadeh, M. A. Tamaddon
Isfahan University of Medical Sciences, Isfahan,
Iran
Objective:
The objective of this study was
to evaluate the prescribing habits and monitoring
parameters for warfarin used as an anticoagulant
in in-patient settings.
Material & Methods:
Three hundred medical records
of patients who had been hospitalized in three
different teaching hospitals within the span of
one year were selected randomly and reviewed retrospectively.
Twenty two parameters, such as initial dose, dosage
adjustment, PT/INR, adverse effects, indications
for anticoagulation, and drug interactions, were
measured and compared to predefined thresholds
using American College of Chest Physicians (ACCP)
guidelines. ANOVA one-way and Chi-square statistics
were the major tests used to analyse the data.
Results:
The initial dose indicator
met acceptable criteria only 66.3% of the time,
compared to our threshold of 90% (p<0.001).
Only 67.9% of dosage adjustments met the criteria,
compared to our threshold of 95% (p<0.001).
PT/INR during the final two days of hospitalization
(which should be within therapeutic range) met
the criteria only in 16.3%, compared to a threshold
of 70% (p<0.001). Heparin-warfarin overlap
met criteria only half of the time, compared with
our 70% threshold (p<0.001).
Conclusion:
Some aspects of warfarin
prescription in our in-patient settings do not
meet the criteria recommended by ACCP. Educational
programs are needed to improve warfarin use in
these facilities.
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