Bilateral Page kidney in a postpartum female: a case report.

Page kidney results from external compression of the kidney by a subcapsular hematoma and is one of the rare but treatable causes of secondary hypertension. The majority are traumatic or iatrogenic and often unilateral. Spontaneous bilateral Page kidney is rare. Case Presentation: A 35-year P1 with gestational hypertension presented with a persistent postpartum elevation of blood pressure (BP). Imaging studies revealed bilateral renal subcapsular hematoma (left>right). She was managed with an angiotensin receptor blocker initially and ultrasound-guided percutaneous drainage of the collection for the optimal control of elevated BP. Clinical Discussion: Ultrasonography and computed tomography of the kidneys are the most frequently used for diagnosing a Page kidney. Medical management with antihypertensive and regular follow-ups form the first line of treatment in Page kidneys. Percutaneous drainage, surgical decortication, laparoscopic intervention, and nephrectomy are necessary in cases of organized late hematomas. Conclusion: Spontaneous bilateral Page kidney is a rare but potentially treatable and curable form of hypertension. Percutaneous drainage is an effective method to drain the hematoma and control elevated BP.

Atrial Septal Defect Size and Rims on Transesophageal Echocardiogram.

Background and aims:Rims and size of atrial septal defect (ASD) are crucial for the success of transcatheter ASD closure. The maximal diameter and dimensions of various rims of the ASD are essential for sizing and optimal placement of the device. We aimed to study the size and rims of ASD in our patients. Methods:This was a prospective study that was done at Shahid Gangalal National Heart Centre. All patients aged over 18 and referred to a unit IV in the Department of Cardiology for ASD device closure were included in the study. The study duration was six months, from April to September 2018. The size and rims of ASD were evaluated by transesophageal echocardiogram. Results:During the study, 173 patients underwent transesophageal echocardiogram. Most of them [122 (70.1%)] were women. Age ranged from 18 to 68 (mean, 35 years). The most common symptom was shortness of breath. Twenty-one (12.1%) patients were incidentally detected with ASDs. Sinus rhythm with right bundle branch block was present in 148 (85.5%) subjects. Right atrium and right ventricle were dilated in 162 (93.6%) patients. One patient had dextrocardia with situs inversus. More than half of all patients (54.9%) had mild tricuspid regurgitation. Mean tricuspid regurgitation pressure gradient was 39.5±16.8 mm Hg. More than one ASD was present in 11 (6.3%) patients. ASD size ranged from 2 mm to 43 mm in 4-chamber view, 2 mm to 44 mm in short axis view, and 2 mm to 47 mm in bicaval view. The mean ASD size was 18.6±7.7 mm in 4-chamber view, 19.6±8.5 mm in short axis view, and 18.7±8.0 mm in bicaval view. In only 11 (6.4%) patients, all rims were present and not floppy, while in other 11 (6.4%) subjects all rims were present, but floppy. With the exception of aortic rim, all other rims were present and good in 55 (33.9%) patients, while in 45 (27.7%) patients, other rims were present but floppy. Conclusion:Many ASD have absent, inadequate and floppy rims.

Submitral Aneurysm: An Unusual Aneurysm of the Left Ventricle.

We report a case of a 42-year-old man with a submitral aneurysm who presented to the emergency room in circulatory collapse, with left ventricular obstruction and severe mitral valve stenosis and regurgitation secondary to the aneurysm. Resection of the aneurysm and mitral valve replacement were performed through a median sternotomy without any complication and with good results.

Prehospital Events in ST- Elevation Myocardial Infarction Undergoing Primary Angioplasty.

INTRODUCTION: Pre-hospital delay includes time from onset of symptoms of myocardial infarction till arrival to emergency room of the hospital. This defines time from symptom onset to first medical contact and first medical contact to emergency room. This study aims to study the prehospital events and determining factors in patients undergoing primary angioplasty. METHODS: This was a cross sectional study in Shahid Gangalal National Heart Centre for three months. Timings of chest pain, first medical contact time, transfer time to hospital and overall pre-hospital time for PCI and risk factors were analysed. RESULTS: There were 79 cases with 66 (83.5%) males and 13 (16.5%) females with mean age 56±11.2 years. Risk factors were 60 (75.9%), smoking, 47 (59.5%) hypertension, 25 (31.6%) diabetes, 22 (27.8%) dyslipidaemia and 16 (20.3%) heart failure. Chest pain was maximum in 5 to 9 AM. The median prehospital delay was 300 minutes (5.0 hours) of which symptom to first medical contact was 165 minutes and first medical contact to hospital was 80 minutes. The longer median prehospital delay for hypertension, diabetes, female and age ≥50 years and the shorter for male, age less than 50 years, dyslipidemia and heart failure, though not statistically significant. Private transport was the preferred from symptom to first medical contact and ambulance for first medical contact to emergency room. Patients received in ER had aspirin 72 (91.1%), atorvastatin 54 (68.4%) and double anti-platelets 45 (57%). CONCLUSIONS: Chest pain was common in morning and the prehospital delay can be minimized by improving time from symptom to first medical contact and first medical contact to Emergency room.

First-episode versus recurrent acute rheumatic fever: is it different?

BACKGROUND: Recurrent episodes of acute rheumatic fever (RF) can lead to rheumatic heart disease with considerable disability and mortality in children. RF can recur in the absence of secondary prophylaxis. The differences in clinical manifestations and outcome between first-episode and recurrent RF have been less studied. METHODS: A cross-section of patients under 14 years was studied for 2 years (2003-2005) in order to compare the clinical, laboratory, echocardiographic profile and outcome of first-episode RF with recurrent attacks, and risk factors for recurrence and mortality. Patients without a previous history of RF and/or mitral stenosis (MS) and/or aortic stenosis (AS) were defined as first-episode patients, and patients with previous history of RF and/or MS and/or AS, were defined as recurrent RF patients based on the Jones criteria. RESULTS: Of 51 patients in total, 26 had first-episode RF and 25 had recurrent RF. Arthritis occurred in a significantly higher number of first-episode patients (P = 0.047) whereas shortness of breath (SOB; P = 0.003), palpitation (P = 0.034), and aortic regurgitation (AR; P = 0.001) occurred in a significantly higher number of recurrent RF patients. Audible murmur of corresponding echocardiographic regurgitation was present in all recurrent RF patients whereas audible murmur was present in 61.5% and echocardiographic regurgitation in 81% in first-episode patients (P = 0.007). Palpitation, SOB, audible murmur, thrill, age and AR on admission were independent predictors of recurrence. Palpitation, age and AS on admission were independent predictors of mortality. CONCLUSIONS: Subclinical carditis occurred only in the first-episode patients, which requires further evaluation for clinical significance. Because all deaths occurred in recurrent RF group (P = 0.02), secondary prophylaxis and management of sore throat need re-emphasis.

Primary Percutaneous Coronary Intervention (PPCI) in acute myocardial infarction complicated with cardiogenic shock in a newly emerging cardiac center in Nepal.

BACKGROUND: Acute myocardial infarction (AMI) is complicated by cardiogenic shock in 7~10% of patients. Mortality rate is exceedingly high and reaches 70-80% in those treated conservatively. Large thrombolytic trials demonstrate 60% mortality with most effective thrombolytic agent. METHODS: In between September 2005 to August 2008 total PCI in Shahid Gangalal National Heart Center (SGNHC) in Nepal was 452. Among them primary PCI (PPCI) in AMI with cardiogenic shock was done in only 16 patients (3.5%). RESULTS: This study showed in-hospital mortality of 50% (n = 8). Of 50% (n = 8) alive patients with cardiogenic shock who underwent PPCI, 6 patients are in routine follow-up over 12 months and 2 were doing well in subsequent 6 months but not in follow up after that. CONCLUSION: Primary PCI in AMI complicated by cardiogenic shock has lower mortality and improved outcome. High cost, high in-hospital mortality and lack of trained personnel are major limitations.

Clinical, laboratory and echocardiographic profile of acute rheumatic fever in Nepali children.

BACKGROUND: Acute rheumatic fever (RF) is a common, preventable health problem in developing countries. Sporadic outbreaks and the prevalence in some indigenous populations have renewed interest in RF in developed countries also. AIMS: To describe the clinical, laboratory and echocardiographic features, outcome and value of echocardiography in detecting valvular disease in RF. METHODS: A prospective, cross-sectional study was conducted over 2 years. Patients under 14 years admitted to the cardiology unit of Kanti Children's Hospital, Kathmandu with RF using the Jones criteria were recruited consecutively. RESULTS: The median age (range) of the 51 patients was 11 (5-14) years, the male:female ratio was 1.6:1 and 39% had a history of a sore throat. Clinical and laboratory features detected were as follows: carditis 92%, arthritis 33%, chorea 8%, subcutaneous nodules 4%, fever 51%, arthralgia 37%, elevated antistreptolysin O titre 94%, elevated CRP 78%, prolonged PR interval 45%, pericardial effusion 22% and cardiac failure 28%. In total, 36 patients (71%) complained of joint pains. A murmur on auscultation was significantly associated with underlying diseased valves confirmed by echocardiography (p=0.001). A murmur was audible in 78.4% and diseased valves were confirmed by echocardiography in 88.2%. The mitral valve was the most commonly involved valve (82%) and mitral regurgitation the commonest lesion (24%). A thickened mitral valve predicted carditis (p=0.007). Five (10%) patients died. CONCLUSION: Inclusion of echocardiographic evidence of carditis and possibly arthralgia as major criteria would improve case detection.

Percutaneous transvenous mitral commissurotomy.

Two hundred patients underwent Percutaneous transvenous mitral commissurotomy (PTMC) from January 2003 to July 2004. Seventy four percent of the patients were female. Age ranged from 10 years old to 61 years and mean age was 29 years. Twenty three percent of the patients were under 21 years of age. Atrial fibrillation was present in 32.0% of the cases. Mean mitral valve area increased from 0.90cm2 (+/- 0.14) to 1.82cm2 (+/- 0.21) (p = 0.018). Left atrial mean pressure decreased from 21 mmHg mean to 7 mmHg. Subjective improvement was reported in 98.0% of the patients immediately after the procedure. There was no mortality during the hospital stay or within the first month of the procedure. Significant mitral regurgitation of grade 3 was noted in 5 patients. Two developed severe mitral regurgitation. The complications were negligible. One had systemic embolisation during the procedure which recovered over a period of time. One developed deep vein thrombosis which recovered after treatment.

Study of Prevalence, Awareness,and control of Hypertension in a Suburban Area of Kathmandu, Nepal.

BACKGROUND, In the context of rapidly raising occurrence of cardiovascular diseases in the developing countries, it becomes imperative to study the scenario in its various aspects. The present study in Nepal deals with the hypertension as it is one of the major risk factors of cardiovascular diseases. METHODS AND RESULTS, A house-to-house survey was conducted in a suburban area of Kathmandu valley from February to June 2005 in adult population (age >/=18 years) to estimate the prevalence, awareness, treatment, and control rates of hypertension. Blood pressure was measured twice using standardized mercury sphygmomanometer, and an average of the two readings was taken. Total number of subjects were 1114 (men:541; women: 573; mean age: 37.8 -/+ 16.3 years). Overall prevalence of hypertension was 19.7% (22.2% in men and 17.3% in women, p < 0.05).Prevalence of hypertension in age group of >/=40 years was 36%.Awareness, treatment, and control rates were 41.1%, 26%, and 6%, respectively. CONCLUSION, Our study indicates that prevalence of hypertension is significant in Nepal and is comparable with other developing countries of this region. Awareness, treatment, and control rates are poor.