A journey from CABG to drug-eluting balloon.

A middle aged male underwent series of percutaneous coronary intervention (PCI) of left main stenosis for Canadian cardiovascular society (CCS) IV angina. He developed recurrent severe proliferative in-stent restenosis which was treated with different available options including drug-eluting stents and finally with drug-eluting balloons. During his treatment, challenges of PCI including left main chronic total occlusion PCI, complications like coronary perforation were encountered and treated successfully.

Complications of intracoronary abciximab bolus-only versus standard protocol during percutaneous coronary intervention in acute coronary syndrome.

BACKGROUND: Abciximab reduces major adverse cardiac events in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI). Standard protocol is intravenous abciximab bolus during PCI plus abciximab infusion for 12-18 h post pPCI. Intracoronary (IC) abciximab bolus administration results in high local drug concentrations and hence it should have higher antiplatelet effect. In this study, we assess the short-term efficacy and safety of IC compared to IV bolus of abciximab in ACS patients during pPCI. METHODS: We compared the clinical outcomes between the IC (n = 56) and standard protocol (n = 170) group of patients. Primary endpoints included bleeding/vascular/ischemic complications and MACE. RESULTS: The two groups were similar with respect to baseline characteristics. IC abciximab bolus only reduced bleeding complications, with no moderate bleed versus 7.2% in standard protocol group (p value 0.04). Ischemic/vascular complications had statistically insignificant difference between the two groups. CONCLUSION: We found no significant difference between IC abciximab bolus only and standard abciximab therapy in terms of ischemic/vascular complications and MACE. But there was higher risk of moderate bleed in standard therapy group. The IC bolus route of abciximab may be superior to the intravenous route. Prospective randomized trials are warranted to validate these findings.

Safety and efficacy of drug-eluting balloons in the treatment of drug-eluting in-stent restenosis: experience of a tertiary care hospital.

BACKGROUND: The advent of drug-eluting balloons (DEBs) is a promising development for coronary revascularization procedures, especially for in-stent restenosis (ISR). This study aims to highlight our experience with DEBs in the treatment of drug-eluting ISR at a tertiary care hospital in Pakistan. METHODS: All patients presenting to our institution from August 2008 to February 2011 with significant drug-eluting in-stent restenosis (DES-ISR) who were eligible to receive treatment via DEB were included in the analysis. Patient baseline characteristics and angiographic data about the lesion characteristics were obtained. Postprocedural and follow-up endpoints, including cardiac death, myocardial infarction, and repeat revascularization, ie, major adverse cardiovascular events (MACE), were included in the analysis. RESULTS: A total of 26 patients received treatment with DEB in the study period, with a significant number having major predisposing factors for the development of ischemic heart disease (IHD; 46% diabetics; 92% hypertensives). The culprit lesion was most commonly identified in the left anterior descending (31%), with presence of American College of Cardiology/American Heart Association lesion type C in 68% of patients. The SeQuent Please paclitaxel-eluting balloon (B. Braun) was used for revascularization. Patients were followed for a median of 16 months. Only 5 patients (19%) developed MACE during this period. CONCLUSION: Our experience demonstrates the effectiveness of DEBs in the treatment of drug-eluting ISR, especially in complex lesions with patients having significant risk factors for development of IHD. However, further studies are needed to define their indications in this role.

Effect of percutaneous mitral vavuloplasty on pregnant mother and foetus--a tertiary care hospital experience from a developing country.

UNLABELLED: This study evaluated the short and long-term consequences of Percutaneous Mitral Valvuloplasty (PMV) in pregnant patients and their offspring, in a tertiary care setting, Karachi, Pakistan. The hospital database was used to retrieve all patients who underwent PMV during pregnancy in the period 1998-2007. The follow up data of the patients and the born children were obtained from the hospital records and also by contacting the patients via phone. Six patients underwent PMV but follow-up was available for 5 patients only. All 5 patients were admitted due to severe mitral stenosis with symptoms of dyspnea and palpitation. Mean age was 27 +/- 5.3 years with a mean gestational age at the time of procedure of 22.20 +/- 1.6 weeks. The mean valve area increased from 0.94 +/- 0.22 cm2 preoperatively to 1.62 +/- 0.50 cm2 post-operatively. The ejection fraction changed from a mean of 50 +/- 11.7% to 56 +/- 2.2%. There were no maternal deaths, abortions or stillbirths. Developmental milestones were achieved at the appropriate ages in all babies. PMV appears to be a safe and effective intervention for patients with severe MS during pregnancy. KEYWORDS: Mitral stenosis, Percutaneous Mitral

Adherence to the European Society of Cardiology (ESC) guidelines for chronic heart failure--a national survey of the cardiologists in Pakistan.

BACKGROUND: The aims of this study were to evaluate the awareness of and attitudes towards the 2005 European Society of Cardiology (ESC) guidelines for Heart Failure (HF) of the cardiologists in Pakistan and assess barriers to adherence to guidelines. METHODS: A cross-sectional survey was conducted in person from March to July 2009 to all cardiologists practicing in 4 major cities in Pakistan (Karachi, Lahore, Quetta and Peshawar). A validated, semi-structured questionnaire assessing ESC 2005 Guidelines for HF was used to obtain information from cardiologists. It included questions about awareness and relevance of HF guidelines (See Additional File 1). Respondents' management choices were compared with those of an expert panel based on the guidelines for three fictitious patient cases. Cardiologists were also asked about major barriers to adherence to guidelines. RESULTS: A total of 372 cardiologists were approached; 305 consented to participate (overall response rate, 82.0%). The survey showed a very high awareness of CHF guidelines; 97.4% aware of any guideline. About 13.8% considered ESC guidelines as relevant or very relevant for guiding treatment decisions while 92.8% chose AHA guidelines in relevance. 87.2% of respondents perceived that they adhered to the HF guidelines. For the patient cases, the proportions of respondents who made recommendations that completely matched those of the guidelines were 7% (Scenario 1), 0% (Scenario 2) and 20% (Scenario 3). Respondents considered patient compliance (59%) and cost/health economics (50%) as major barriers to guideline implementation. CONCLUSION: We found important self reported departures from recommended HF management guidelines among cardiologists of Pakistan.

"Mother and child technique" combined with super selective pharmacological intervention for large intracoronary thrombus.

Primary percutaneous intervention (PCI) in acute ST elevation myocardial infarction (MI) is a preferred way of treatment nowadays. Sometimes it becomes difficult to get good myocardial blood flow during PCI if clot burden is large. In this case of an elderly lady, the use of "Mother and Child Technique" combined with super selective pharmacological intervention is demonstrated to achieve good blood flow when conventional means are not working.

Percutaneous coronary intervention of left main pseudoaneurysm with customized covered stents.

Left main pseuodaneurysm is a rare entity and is one of the potentially lethal consequences of coronary artery dissection. We describe a case of a young woman who almost a week after her delivery developed spontaneous left main dissection, manifested as acute anterior myocardial infarction. Left on medical treatment alone over a month, spontaneous dissection progressed to symptomatic large left main pseuodaneurysm, which was treated percutaneously with covered stents. © 2011 Wiley-Liss, Inc.

Myocardial infarction in a youngster due to giant coronary aneurysm.

A 22-year old male presented with acute inferior wall myocardial infarction. Coronary angiogram revealed normal left coronary arteries and a giant coronary aneurysm in right coronary artery (RCA). Primary angioplasty of RCA was performed. Large thrombus burden was retrieved with aspiration device and coronary flow restored. However, despite best efforts some thrombus remained and decision to stent was deferred to a later date. Dimensions of aneurysm on quantitative coronary angiogram were 15 mm in width and 46 mm in length. Two weeks later coronary angiogram revealed normal flow in RCA without any angiographically visible thrombus. PCI was performed with two 3.0 × 28 mm Covered stents, Graft Master (JoStent) deployed across the aneurysm, overlapping each other. This completely sealed the aneurysm and intravascular ultrasound confirmed no leakage through the covered stents. Patient remains asymptomatic 2 months post procedure on triple antiplatelet therapy.

Outcomes in ST elevation Myocardial Infarction; a comparison of a tertiary care center in Pakistan with European centers.

OBJECTIVES: To evaluate the clinical characteristics and in hospital outcome data of patients presenting to the Aga Khan University Hospital with ST elevation Myocardial Infarction (STEMI) and its comparison with data from patients enrolled in the European Heart registry for the same duration. METHODS: Data on 296 patients with STEMI was prospectively collected from 1st January 2010, till 31st December 2010 from the cardiology section at the Aga Khan University Hospital. European data was collected on 7485 patients retrieved from the Eurobservational Research programme Acute Coronary Syndrome Registry 2010 for the same duration. RESULTS: A total of 296 patients were enrolled from AKUH and 7485 from European centers for the year 2010. Majority of patients in both groups were male. Pakistani patients were more likely to be younger and diabetic (p<0.05) with higher frequency of prior myocardial infarction and angina (p<0.05). They were less likely to be smokers and previously diagnosed as dyslipidemic. Most patients presented to hospital with chest pain, median time between symptom onset and hospital arrival was 3.8 (2.0-8.5) hours. One third of European patients received a thrombolytic agent compared with less than 5% of AKU/Pakistani patients. Almost 90% of AKU/Pakistani patients underwent primary percutaneous intervention. Approximately 5.8% of our patients were not candidates for any reperfusion therapy vs. 4.8% of European patients. On coronary angiogram, the majority of patients had single or two vessel Coronary Artery Disease. We had a higher frequency of high risk lesions, 97.86 vs. 84.14 %( p=0.002).Our patients had more drug eluting stents 42.5% vs. 25.9 % (p=0.01) implanted, due to more diabetics and smaller vessel size. We also had a similar proportion of patients undergoing coronary artery bypass graft. Frequency of complications was similar for both cohorts. Median hospital stay in our patients was shorter, survival at hospital discharge being similar between both groups (P=0.42) CONCLUSIONS: The patients presenting to Aga Khan University Hospital with STEMI were younger and more likely to be diabetic. They had a higher frequency of prior Myocardial Infarction and angina. They underwent revascularization with primary percutaneous intervention more often and usually for more complex lesions requiring greater use of drug eluting stents. Survival at discharge was similar compared to European Centers.

Contrast-induced nephropathy in patients undergoing percutaneous coronary intervention.

Contrast Induced Nephropathy (CIN) is a feared complication of numerous radiological procedures that expose patients to contrast media. The most notorious of these procedures is percutaneous coronary intervention (PCI). Not only is this a leading cause of morbidity and mortality, but it also adds to increased costs in high risk patients undergoing PCI. It is thought to result from direct cytotoxicity and hemodynamic challenge to renal tissue. CIN is defined as an increase in serum creatinine by either ≥0.5 mg/dL or by ≥25% from baseline within the first 2-3 days after contrast administration, after other causes of renal impairment have been excluded. The incidence is considerably higher in diabetics, elderly and patients with pre-existing renal disease when compared to the general population. The nephrotoxic potential of various contrast agents must be evaluated completely, with prevention as the mainstay of focus as no effective treatment exists. The purpose of this article is to examine the pathophysiology, risk factors, and clinical course of CIN, as well as the most recent studies dealing with its prevention and potential therapeutic interventions, especially during PCI. The role of gadolinium as an alternative to iodinated contrast is also discussed.

Percutaneous coronary intervention in unprotected left main coronary artery disease.

Percutaneous coronary intervention for unprotected left main coronary artery disease is potentially an important intervention in surgically unstable patients. A detailed review of medical record and visual analysis of coronary angiography and PCI procedure was undertaken. The study was conducted at the Aga Khan University Hospital, from January 2003 to December 2007. Patients included in the study had unprotected > 70% left main stenosis with ongoing ischemia, considered unsuitable for surgical revascularization. A total of 9 patients were included with a mean age of 70.1 years. Six patients had cardiogenic shock. Eight patients had bifurcation lesion. Simultaneous kissing stenting technique was used in 4 patients. There were 4 in-hospital deaths while 5 patients were alive at discharge. All 4 patients who expired had cardiogenic shock. Four patients were alive at a mean follow-up of 17 months. PCI turned out to be an alternative therapeutic option for unprotected left main coronary artery disease when surgery is declined.

A simpler approach to seal severe coronary perforation with bare metal stent.

The case of a coronary artery perforation in which overinflation of a balloon at an angulated segment of the left anterior descending (LAD) artery after stent deployment resulted in an Ellis type III coronary artery perforation is presented. A bare metal stent (BMS) was used successfully to seal this high-grade perforation. Here, it is demonstrated that it may not be illogical to consider BMS as the first choice before embarking on use of a covered stent if the clinical/haemodynamic condition of the patient allows it and if a covered stent is not available.

Secondary prevention of heart disease--knowledge among cardiologists and omega-3 (omega-3) fatty acid prescribing behaviors in Karachi, Pakistan.

BACKGROUND: The use of omega-3 fatty acids is a currently proven strategy for secondary prevention of heart disease. The prescription practices for this important nutraceutical is not currently known. It is imperative to assess the knowledge of cardiologists regarding the benefits of omega-3 fatty acids and to determine the frequency of its prescription. The aim of the study was to determine the practices and associations of dietary fish prescribing among cardiologists of Karachi and to assess their knowledge of fish oil supplementation and attitudes toward dietary practices. METHODS: A cross sectional survey was conducted during the period of January to March, 2008. A self report questionnaire was employed. All practicing cardiologists of Karachi were included in the study. Multiple logistic regression analysis was performed to determine the independent factors associated with high fish prescribers. RESULTS: The sample comprised of a total of 163 cardiologists practicing in Karachi, Pakistan. Most (73.6%) of the cardiologists fell in the age range of 28-45 years and were male (90.8%). High fish prescribers only comprised 36.2% of the respondents. After adjusting for age and gender, multivariate analysis revealed that only the variable of knowledge about fish oil's role in reducing sudden cardiac death was independently associated with high fish prescribers OR = 6.38 [95% CI 2.58-15.78]. CONCLUSION: The level of knowledge about the benefits of omega-3 fatty acids is high and the cardiologists harbor a favorable attitude towards dispensing dietary fish advice. However, the prescription practices are less than optimal and not concordant with recommendations of organisations such as the American Heart Association and National Heart Foundation of Australia. The knowledge of prevention of sudden cardiac death in CVD patients has been identified as an important predictor of high fish prescription. This particular life-saving property of omega-3 fatty acids should be the focus of any implemented educational strategy targeted to improve secondary CVD prevention via omega-3 fatty acid supplementation.

Early and long term outcome of rescue percutaneous coronary intervention (R-PCI): experience from a tertiary care center in Pakistan: outcome of rescue angioplasty in Pakistan.

BACKGROUND: Thrombolysis is the standard of care for STEMI in Pakistan. Failed thrombolysis has a very high morbidity and mortality. Rescue PCI then remains the only option to salvage the myocardium. We sought to analyze the angiographic, immediate and long term clinical outcome of patients undergoing Rescue PCI at our institution in Karachi, Pakistan. METHODS: 58 consecutive patients who underwent rescue PCI for failed thrombolysis between 2002 and 2005 were reviewed. Clinical characteristics, angiographic and procedural details with clinical outcomes including total mortality, recurrent angina, and repeat revascularization were studied. Sources included cardiac catheterization lab database, medical records and follow up at outpatient clinics. RESULTS: Rescue PCI was performed in 58 patients with a mean age 55 +/- 12 years with 47 (79%) male and 11 (21%) females. CAD risk factors were hypertension (53%), dyslipidemia (48%), smoking (34%) and diabetes (34%). 53% had anterior MI, 39% inferior and 8% had a lateral wall MI. The median time frames were: onset of chest pain to ER = 99 min, door to needle time = 35 min, ER to procedure start time = 250 min. The culprit vessels were: Left Anterior Descending (LAD) (53%), Right Coronary Artery (RCA) (32%) and Circumflex (CX) (15%). TIMI flow grades pre-procedural were 0/I = 52%, II = 34%, III = 14% and post procedure 0/I = 8%, II = 6%, III = 86%. The mean follow-up duration was 16.15 months at which 50 (86%) were alive and 43 (74.13%) had event free survival. CONCLUSION: Procedural success, event free survival and mortality in our series of Rescue PCI from Pakistan are comparable to recent international trials and registries. It should be considered as a reasonable option for patients with failed thrombolysis.

Political riots in Pakistan and stress-induced cardiomyopathy: a case report.

A previously healthy middle-aged lady with no prior risk factors for coronary artery disease presented with chest discomfort and ECG changes suggestive of anterolateral ST elevation myocardial infarction. She had had a stressful event prior to the onset of symptoms in that she had been caught up in a riot and had been exposed to intense mental and physical stress. She was found to have severe global left ventricular dysfunction but coronary artery disease was not discovered on coronary angiography. She was treated with antiplatelets, statins, diuretics and aldosterone antagonists. Her left ventricular function was revealed to have improved to normal as shown on echocardiography done on her follow-up 2 months after initial presentation.

Congenital absence of left circumflex artery with a dominant right coronary artery.

Case 1: a 40-year-old man was admitted to our hospital with progressively worsening post myocardial infarction angina. Cardiac catheterisation was performed, which showed total occlusion of the left anterior descending artery (LAD) and the left circumflex artery (LCX) was not visualised. The right coronary artery (RCA) was a large artery supplying the left ventricular inferior and posterolateral walls and filling the LAD artery in retrograde. The patient was referred for coronary artery bypass grafting. Peroperative findings confirmed the angiographic evidence of congenitally absent LCX artery.Case 2: a 39-year-old man with a family history of premature coronary artery disease underwent coronary angiography for the work-up of chest pain. A coronary angiogram showed normal LAD artery and absence of left circumflex system. The RCA was superdominant. An aortogram confirmed no anomalous origin and true absence of LCX artery.

Very late sirolimus-eluting stent displaced fracture in the mid-left anterior descending artery.

Coronary stent fractures are very rare. The predisposing factors for stent fractures are excessive postdilatation, overlapping stents and a hinge site in a tortuous coronary artery. We report a case of very late (after 699 days), displaced, sirolimus-eluting stent fracture deployed at nominal pressures without postdilatation and at a non-hinge portion of the left anterior descending artery.

Knowledge and practice of radiation safety among invasive cardiologists.

OBJECTIVE: To assess the availability, practices and knowledge of radiation safety measures among invasive cardiologists in a tertiary care hospital. METHOD: A cross sectional survey of invasive cardiologists working in academic institutions was conducted using a questionnaire. RESULTS: A total of 28 cardiologists completed the questionnaire with a mean working experience of 10.5 + 7.6 years. All were of the opinion that radiation safety is extremely important and 93% always used lead aprons. Less than half of them used other radiation protective measures including thyroid collar, lead eyeglasses and lead shields. Only 7% regularly utilized a radiation dose badge to monitor the exposure. This may be related to the availability, as lead aprons are readily available but other devices i.e. lead glasses, lead shield and radiation dose badge is available to less than a third of them. On evaluating knowledge only one fourth knew more than 60% of the answers to questions testing the basic principles of radiation safety. When working experience of cardiologists was correlated with their knowledge and practice of radiation safety surprisingly a paradoxical relationship was noted. Mean number of correct answers in those with experience of > 10 years vs < 10 years was 45% vs 56%, p < 0.03. All of the above findings are probably because less than 50% have received any formal education in this important field. CONCLUSIONS: There is a lack of standard radiation safety measures and equipments in cardiac catheterization laboratories. Significant lapses exist in practice and lack of knowledge of radiation safety among invasive cardiologists in this part of the world. With rapid growth in the number of cardiac catheterization laboratories in developing countries significant improvement in knowledge, practice and availability of radiation safety measures is needed.

Safety and utility of oesophago-gastro-duodenoscopy in acute myocardial infarction.

AIM: To study the safety and utility of performing an oesophago-gastro-duodenoscopy (EGD) in the setting of an acute myocardial infarction (AMI). METHODS: Case records of all patients who underwent an EGD for various indications within 4 weeks of an AMI between January 2001 and April 2006 were analyzed. Demographic data, indications for endoscopy, outcomes and complications were noted. Main outcome measures included safety and utility of endoscopy in AMI. RESULTS: A total of 87 EGDs were performed on 85 patients with AMI. Seventy (83%) patients had a non-ST elevation MI, whereas 15 (17%) had ST elevation MI. Mean time between EGD and AMI was 6+/-1.8 days. Indications for EGD were hematemesis and/or melena on presentation in 38 (44.7%), hematemesis and/or melena post anticoagulation in 27 (31.8%). EGD findings were gastric ulcer/erosions in 30 (34%), oesophago-gastric varices in 20 (22%), erosive oesophagitis in 17 (20%) and duodenal ulcer in 11 (13%). Diagnostic yield of EGD was 88%. Endoscopic interventions were performed in 26 (30%) patients with high risk of bleeding lesion. There were no EGD-related mortality, whereas 14 patients re-bled. A total of 21 patients died, including 7/14 (50%) who re-bled, compared with 14/71 (19%) without rebleed (P=0.008). There were no EGD-related deaths. Fourteen patients were on mechanical ventilation and 6/14 (43%) of these died as compared with 15/88 (17%) who were not ventilated (P=0.027). CONCLUSION: EGD is safe and useful in diagnosis and management of gastrointestinal hemorrhage in patients with AMI, and allows decisions about anticoagulation. Re-bleed and need for mechanical ventilation predicts poor outcome in these patients.

Cardiac myxomas--clinical spectrum and outcome.

OBJECTIVE: To describe the characteristics and outcome of patients with cardiac myxomas. DESIGN: A case series. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital (AKUH), from 1999 to 2004. PATIENTS AND METHODS: All patients diagnosed and managed as having cardiac myxomas at AKUH, during a period of six years (1999-2004) were included. Data was collected by reviewing clinical records. Follow-up data was collected from the clinical records and by a telephone interview where required. RESULTS: Out of 15 patients who were diagnosed to have cardiac myxomas, complete information was available in 14 patients. There was a female predominance (64%) with a mean age of 47 years. About two-thirds (71%) had symptom of dyspnoea. Half of the patients (50%) had neurological symptoms at presentation. Constitutional symptoms were present in 36% of patients. About two-third of patients (71%) had positive findings on cardiac auscultation. None of the patients had any rhythm abnormalities on the ECG. Diagnosis was made by transthoracic echocardiography in all patients. All of the tumors were located in the left atrium, and majority (64%) were attached to the interatrial septum. All patients were advised surgical treatment, however, only 8 (57%) were operated upon. Outcome was good in those who were operated upon, with no peri and postoperative mortality. CONCLUSIONS: Cardiac myxomas are a rare, but potentially curable form of heart disease. They occur in a wide range of age groups with a female predominance. Dyspnea is the most common clinical feature followed by embolic complications. Left atrium is the most common site of location. Surgical excision is a safe and effective procedure.