Diagnostic accuracy of cardiac computed tomographic angiography and transesophageal echocardiography in evaluation of patients with prosthetic paravalvular leakage.

PURPOSE: Computed Tomography (CT) scan has been well addressed to provide diagnostic information for patients with prosthetic heart valve (PHV) dysfunction. However, its role in the assessment of patients with prosthetic paravalvular leakage (PVL) has not been studied thoroughly. So, this study was conducted to assess the feasibility, reproducibility, and accuracy of CT for diagnosis of prosthetic PVL using surgical findings as the reference standard. MATERIALS AND METHODS: This was a prospective cohort study that was conducted on 26 consecutive patients with suspected prosthetic PVL who underwent both transesophageal echocardiography (TEE) and 64-slice ECG-gated CT. The gold standard was the intraoperative findings. Surgery was performed on 26 patients. RESULTS: There was an excellent degree of agreement between CT and intraoperative findings for diagnosis, localization of prosthetic PVL. The perimeter of prosthetic PVL measured by CT was strongly correlated with echocardiographic severity of PVL by TEE (Spearman's Correlation Coefficient, r = .83, p = .0014). CONCLUSION: This study demonstrates that cardiac CT showed comparable diagnostic accuracy to TEE and intraoperative findings for the detection, localization, and assessment of severity of prosthetic PVL. Moreover, CT was shown to be useful in detection of other findings related to prosthetic cardiac valves.

Impact of Cardiac Computed Tomographic Angiography on Diagnostic and Therapeutic Decisions in Patients with Suspected Prosthetic Heart Valve Dysfunction.

INTRODUCTION: Computed Tomography (CT) scan is a helpful tool to assess the coronary arteries and the great vessels. However, its routine use in the assessment of patients with suspected prosthetic valve dysfunction (PVD) has not been studied thoroughly. OBJECTIVE: To determine the impact of routine cardiac computed tomography angiography (CCTA) on diagnostic and therapeutic decisions in patients with suspected PVD. METHODS AND RESULTS: This was a prospective cohort study that was conducted on 50 consecutive patients with suspected PVD who underwent both 64-slice ECG-gated CT and transesophageal echocardiography (TEE). The gold standard was the intraoperative findings. Surgery was performed in forty-six patients. ECG-gated CT showed findings that were not detected by TEE in sixteen patients (32%) namely aortic root abscess, aortic pseudoaneurysm, paravalvular leakage (PVL), sclero-calcific disruption of sutures as cause of PVL, mechanical prosthesis occluder malfunction, an underlying thrombus as cause of malfunction and finally presence of aortic dissection. Furthermore, CTA findings dictated treatment changes in fourteen patients (28%). CONCLUSION: This study demonstrates that ECG-gated CTA has a complementary role to TEE in patients with suspected PVD. CCTA is more accurate in diagnosis of periannular complications (Aortic root abscess and Pseudo-aneurysm) and in delineating their anatomical relation to surrounding cardiac structures. Therefore CCTA can have important role in deciding and planning the method of correction whether surgical or percutaneous and has to be considered after TEE in patients with a high suspicion on PVD.

Clinical features and outcomes of infective endocarditis in Egypt: an 11-year experience at a tertiary care facility.

BACKGROUND: Few data are available on the characteristics of infective endocarditis (IE) cases in Egypt. The aim of this work is to describe the characteristics and outcomes of IE patients and evaluate the temporal changes in IE diagnostic and therapeutic aspects over 11 years. RESULTS: The IE registry included 398 patients referred to the Endocarditis Unit of a tertiary care facility with the diagnosis of possible or definite IE. Patients were recruited over two periods; period 1 (n = 237, 59.5%) from February 2005 to December 2011 and period 2 (n = 161, 40.5%) from January 2012 to September 2016. An electronic database was constructed to include information on patients' clinical and microbiological characteristics as well as complications and mortality. The median age was 30 years and rheumatic valvular heart disease was the commonest underlying cardiac disease (34.7%). Healthcare-associated IE affected 185 patients (46.5%) and 275 patients (69.1%) had negative blood cultures. The most common complications were heart failure (n = 148, 37.2%), peripheral embolization (n = 133, 33.4%), and severe sepsis (n = 100, 25.1%). In-hospital mortality occurred in 108 patients (27.1%). Period 2 was characterized by a higher prevalence of injection drug use-associated IE (15.5% vs. 7.2%, p = 0.008), a higher staphylococcal IE (50.0% vs. 35.7%, p = 0.038), lower complications (31.1% vs. 45.1%, p = 0.005), and a lower in-hospital mortality (19.9% vs. 32.1%, p = 0.007). CONCLUSION: This Egyptian registry showed high rates of culture-negative IE, complications, and in-hospital mortality in a largely young population of patients. Improvements were noted in the rates of complications and mortality in the second half of the reporting period.

Comparison of Safety and Effectiveness Between Right Versus Left Radial Arterial Access in Primary Percutaneous Coronary Intervention for Acute ST Segment Elevation Myocardial Infarction.

BACKGROUND: Transradial approach (TRA) is now considered the standard of care in many centres for elective and primary percutaneous intervention (PCI). The use of the radial approach in ST segment elevation myocardial infarction (STEMI) patients has been associated with a significant reduction in major adverse cardiac events. However, it is still unclear if the side of radial access (right vs. left) has impact on safety and effectiveness of TRA in primary PCI. So this study was conducted to compare the safety, feasibility, and outcomes of right radial access (RRA) vs. left radial access (LRA) in the setting of primary PCI. METHODS: We retrospectively analysed the data of 400 consecutive patients presenting to our institution with STEMI for whom primary PCIs were performed via RRA and LRA. RESULTS: Mean age of the whole studied population was 57±12.8 years, with male predominance (77.2%). There were 202 cases in the RRA group and 198 in the LRA group, with no significant difference in demographics and clinical characteristics for patients included in both groups. There was no significant difference in procedure success rate (97.5% for RRA vs. 98.4% for LRA; P=0.77). In addition, no significant difference between both approaches was observed in the contrast volume, number of catheters, fluoroscopy time (FT), needle-to-balloon time, post-procedure vascular complications, in hospital reinfarction, stroke/transient ischaemic attack (TIA) or death. CONCLUSION: Right radial access and LRA are equally safe and effective in the setting of primary PCI. Both approaches have a high success rate and comparable needle-to-balloon time.

The effect of ivabradine on functional capacity in patients with chronic obstructive pulmonary disease.

Increased sympathetic tone and use of bronchodilators increase heart rate and this may worsen functional capacity in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to look at the short-term effect of the heart rate lowering drug ivabradine on clinical status in COPD patients.We randomised 80 COPD patients with sinus heart rate ≥90 bpm into either taking ivabradine 7.5 mg twice per day or placebo for two weeks. We assessed all patients using the modified Borg scale and 6-minute walk test at baseline and then again 2 weeks after randomisation.There were no significant differences in age, sex, severity of airway obstruction (measured using forceful exhalation), severity of diastolic dysfunction or pulmonary artery systolic pressure between the two groups. The ivabradine group showed significant improvement in 6-minute walk distance (from 192.6±108.8 m at baseline to 285.1±88.9 m at the end of the study) compared with the control group (230.6±68.4 at baseline and 250.4±65.8 m at the end of study) (p<0.001). This improvement in the drug group was associated with significant improvement of dyspnea on modified Borg scale (p=0.007).Lowering heart rate with ivabradine can improve exercise capacity and functional class in COPD patients with resting heart rate >90 bpm.

Prevalence of intracranial atherosclerosis among patients with coronary artery disease: a 1-year hospital-based study.

BACKGROUND: There are limited data on the prevalence of intracranial atherosclerotic disease (ICAD) in patients with coronary artery disease (CAD) worldwide and especially among Egyptians. The purpose of the present study was to determine the prevalence and correlates of ICAD in patients with CAD. METHODS: From January 1, 2012 to January 1, 2013, we recruited 118 consecutive patients who had ischemic heart disease. All patients were assessed for vascular risk factors and the existence of stroke or transient ischemic attack (TIA) and were evaluated by extracranial and transcranial color-coded sonography. All patients underwent coronary angiography. Clinical, echocardiographic and angiographic variables were tested by univariate and multivariate analysis. RESULTS: Out of 118 consecutive patients with CAD, intracranial disease was detected in 14 patients (11.9%). Eight patients (6.8%) had stenosis >50%, while 6 patients (5.1%) had stenosis <50%. The univariate analysis showed that the strongest variables associated with ICAD were the presence of recent or old stroke or TIA, followed by moderate or severe extracranial stenosis, and multivessel or left main CAD. CONCLUSION: We observed low prevalence (6.8%) of high-grade ICAD among Egyptian patients with CAD. Multivessel or left main CAD and moderate-to-severe extracranial carotid stenosis were the strongest predictors for the existence of ICAD among CAD patients.

Comparison between ultrasound-guided compression and para-aneurysmal saline injection in the treatment of postcatheterization femoral artery pseudoaneurysms.

Management of postcatheterization femoral artery pseudoaneurysm (FAP) is problematic. Ultrasound-guided compression (UGC) is painful and cumbersome. Thrombin injection is costly and may cause thromboembolism. Ultrasound-guided para-aneurysmal saline injection (PASI) has been described but was never compared against other treatment methods of FAP. We aimed at comparing the success rate and complications of PASI versus UGC. We randomly assigned 80 patients with postcatheterization FAPs to either UGC (40 patients) or PASI (40 patients). We compared the 2 procedures regarding successful obliteration of the FAP, incidence of vasovagal attacks, procedure time, discontinuation of antiplatelet and/or anticoagulants, and the Doppler waveform in the ipsilateral pedal arteries at the end of the procedure. There was no significant difference between patients in both groups regarding clinical and vascular duplex data. The mean durations of UGC and PASI procedures were 58.14 ± 28.45 and 30.33 ± 8.56 minutes, respectively (p = 0.045). Vasovagal attacks were reported in 10 (25%) and 2 patients (5%) treated with UGC and PASI, respectively (p = 0.05). All patients in both groups had triphasic Doppler waveform in the infrapopliteal arteries before and after the procedure. The primary and final success rates were 75%, 92.5%, 87.5%, and 95% for UGC and PASI, respectively (p = 0.43). In successfully treated patients, there was no reperfusion of the FAP in the follow-up studies (days 1 and 7) in both groups. In conclusion, ultrasound-guided PASI is an effective method for the treatment of FAP. Compared with UGC, PASI is faster, less likely to cause vasovagal reactions, and can be more convenient to patients and physicians.

Delayed diagnosis of familial hypercholesterolemia: a case report of two patients from Egypt.

Two young Egyptian women with homozygous familial hypercholesterolemia (HoFH) were diagnosed after the appearance of vascular complications despite the presence of family history and suggestive clinical features. The first patient was treated by repeated surgical excisions of disfiguring tendon xanthomas diagnosed as "lipomas". The second patient, presenting with embolic ischemia, had an amputation of the forearm and repeated reconstructive surgical procedures. Each patient was diagnosed as HoFH after presenting with typical angina to a cardiologist. The first patient had severe aortic stenosis, left main and multi-vessel coronary artery disease, and died at age 21 years. The second patient had multivessel coronary artery disease that was treated by Percutaneous Coronary Intervention (PCI) with drug-eluting stents. These cases demonstrate that the delayed diagnosis of xanthomas and familial inheritance characteristic of HoFH leads to atherosclerosis and aortic stenosis early in life.