Frequency of metabolic syndrome in patients with ischaemic heart disease.

OBJECTIVE: To evaluate the frequency of metabolic syndrome in patients with Ischaemic Heart Disease. METHODS: This was a cross sectional observational study. Patients with a first time cardiac event arriving in emergency room during the period October 2009 to April 2010, were included. Five components of Metabolic syndrome were defined according to criteria set by International Diabetes Federation, American Heart Association & National Heart, Lung and Blood Institute which had abdominal obesity (waist circumference) as an integral part of the syndrome. Blood sugar, triglycerides, HDL-C were measured within 24 hrs of cardiac insult. Hypertension was defined as blood pressure > 130/85 mmHg. Variables were integrated for descriptive statistics. RESULTS: A total of 477 patients diagnosed with Ischaemic Heart Disease were inducted in the study. There were 355 (74%) males and 122 (26%) females. Frequency of metabolic syndrome in Ischaemic heart disease was seen in 195 (54.95%) males and 96 (78.7%) females (p < 0.001). According to recent criteria abdominal obesity was observed in 91 (81.1%) females as compared to males 219 (61.7%) (p < 0.001) Similarly, low HDL and Hypertension were high in frequency in females. No significant difference in triglycerides levels was found in either gender. CONCLUSION: Frequency of metabolic syndrome with Ischaemic heart disease was high in females as compared to males. This could be attributed to the increased prevalence of abdominal obesity.

Successful management of dislodged stents during percutaneous coronary intervention.

Stent dislodgement is a very rare but recognized and potentially serious complication of percutaneous coronary intervention (PCI). This case series describe the incidence and etiology of such cases at National Institute of Cardiovascular Diseases, Karachi during the year 2008 and the method of treatment of this complication.

Coronary embolism causing acute myocardial infarction in a patient with mitral valve prosthesis: successful management with angioplasty.

A 24-year-old male patient with anterior myocardial infarction, caused by embolization from mitral valve prosthesis due to inadequate anticoagulation is presented. The patient underwent cardiac catheterization within 90 minutes of arrival. Angiography showed total occlusion of the left anterior descending coronary artery (LAD) after the second diagonal branch. Thrombus was extracted with export catheter from LAD, and coronary artery perfusion was restored. The pain disappeared completely immediately after this intervention. Transoesophageal echocardiography performed 2 days later revealed no thrombus at the prosthetic valve. In conclusion, this case demonstrated that coronary embolism may occur even without prosthetic valve thrombus or dysfunction with suboptimal International Normalized Ratio levels, and can be successfully treated with coronary angiography with clot extraction with aspiration catheter (Export XT 6F Medtronic) only, without stenting.

Clinical, Angiographic Characteristics and In-Hospital Outcomes of Smoker and Nonsmoker Patients After Primary Percutaneous Coronary Intervention.

BACKGROUND: Smoking is a well-established cardiac risk factor there is dearth of Local data regarding clinical and angiographic characteristics of smoker patients. OBJECTIVES: This study was planned to assess the differences in the clinical characteristics, angiographic characteristics, and in-hospital outcomes of smokers and nonsmokers after primary percutaneous coronary intervention at a tertiary care hospital in Karachi, Pakistan. METHODS: We included patients between 40 and 80 years of age diagnosed with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention from July 1, 2017, to March 31, 2018. Clinical and angiographic characteristics and in-hospital outcomes were obtained from the cases submitted to the National Cardiovascular Data Registry's CathPCI (Catheterization-Percutaneous Coronary Intervention) Registry from our site. RESULTS: A total of 3,255 patients were included in this study. Smokers consist of 25.1% (817) of the total sample. A high majority of smokers were male, 98.8% (807), and smokers were relatively younger as compared to nonsmokers with a mean age of 52.89 ± 10.59 versus 55.98 ± 11.24 years; p < 0.001. Smokers had higher post-procedure TIMI (Thrombolysis In Myocardial Infarction) flow grade III: 97.8% (794) versus 95.53% (2,329); p = 0.037, and they had a relatively low mortality rate: 2.69% (22) versus 3.16% (77); p = 0.502. CONCLUSIONS: Smokers were predominantly male and around 3 years younger than nonsmokers. Diabetes mellitus and hypertension were less common among smokers and single-vessel disease was the more common angiographic finding for smokers as compared to 3-vessel disease for nonsmokers. No statistically significant differences in in-hospital outcomes were observed. ST-segment elevation myocardial infarction in smokers despite younger age and the low atherosclerotic risk profile, in our region, emphasize the need for nicotine addiction management and smoking cessation campaigns at large and for pre-discharge counseling.

Clinical and procedural predictors and short-term survival of the patients with no reflow phenomenon after primary percutaneous coronary intervention.

OBJECTIVES: In the present study, we analysed the incidence of no-reflow phenomenon, its clinical and procedural predictors, and associated in-hospital outcomes for the patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: No-reflow phenomenon after primary PCI is a procedural complication associated with adverse post-procedure outcomes. METHODS: Data for this study were extracted from global registry, NCDR®, the site of National Institute of Cardiovascular Disease (NICVD), Karachi from July 2017 to March 2018. The demographic, clinical, and procedural characteristics, and in-hospital outcomes were analysed for the patients with and without no-reflow after primary PCI. RESULTS: Of total of 3255 patients, no-reflow phenomenon was found in 132 (4.1%) patients and it was associated with significantly higher in-hospitality mortality (6.8% vs. 2.9%; p = 0.01), cerebrovascular accident (1.5% vs. 0%; p < 0.001), post procedure bleeding (2.3% vs. 0.5%; p = 0.009), and cardiogenic shock (3.8% vs. 1.2%; p = 0.011). The multivariate analysis showed advanced age [odds ratio = 1.63, 95% confidence interval 1.09-2.44, p = 0.018], diabetes [1.66, 1.14-2.42, p = 0.009], prior history of CABG [8.70, 1.45-52.04, p = 0.018], low pre-procedure TIMI flow grade [2.04, 1.3-3.21, p = 0.002], longer length of target lesion [1.51, 1.06-2.16, p = 0.023], and 10 fold raised troponin I [1.55, 1.08-2.23, p = 0.018] were the independent predictors of no-reflow. CONCLUSIONS: In this selected group of patients, the no-reflow phenomenon after primary percutaneous coronary intervention is not that uncommon. It is associated with an increased risk of adverse post-procedure hospital course including mortality. Pathophysiology of the no-reflow phenomenon is complex and opaque, however, it can be predicted based on certain clinical and procedural characteristics.

Left main coronary artery dissection during percutaneous coronary intervention in patient with chronic total occlusion.

Catheter induced left main coronary artery dissection is a rare but well recognized life threatening complication of coronary angiography and angioplasty. We present a case of left main coronary artery dissection induced with a guide catheter while dealing with chronic total occlusion (CTO) and bailout stenting of left main and Left anterior descending (LAD) artery.

Multivessel Disease As A Prognostic Marker In Patients Presenting For Primary Percutaneous Coronary Intervention.

BACKGROUND: Multi-vessel disease is associated with higher mortality rates in ST-Elevation Myocardial Infarction (STEMI) patients, which may further alter clinical course and decision making. Hence, the purpose of this study is to determine prevalence, in hospital and early after discharge (up to 30 days) outcome of patients with multi-vessel disease as compared to single vessel disease presenting with acute STEMI undergoing Primary PCI. METHODS: This study includes 282 consecutive selected patients, presented in emergency department with acute STEMI; undergo primary percutaneous coronary intervention (PCI) at Catheterization Laboratory of National Institute of Cardiovascular Diseases (NICVD), Karachi Pakistan during the study period of 17th December 2016 to 16th June 2017. Demographic characteristics, clinical history, post procedural complications, and short term adverse clinical events in patients with SVD and MVD were assessed and compared using z-test, t-test, and Fisher's Exact test.. RESULTS: Comparing the patients with single vessel disease, multi-vessel disease patients have worse post procedural outcomes, increased overall complications, length of hospital stay, higher referral for CABG, and in-hospital mortality. On follow up relatively higher, but not statistically significant, patient with MVD developed recurrence of symptoms and got re-admission. CONCLUSIONS: Multi-vessel disease in patients presenting for primary PCI is the direct indicative of significantly higher post procedure complications, mortality, morbidity, and prolonged hospitalization. Also, risk of recurrence of symptoms and re-admission remains high in patients with multi-vessel disease..

Aspiration of thrombus in ST segment elevation myocardial infarction.

OBJECTIVE: To evaluate the impact of Export Aspiration Catheter with restoration of ECG changes, arterial flow and myocardial perfusion in patients with ST segment elevation Myocardial Infarction undergoing Percutaneous Coronary Intervention (PCI). METHODS: A total of 40 consecutive patients with ST Segment Elevation Myocardial Infarction (STEMI) were selected. They underwent treatment according to the surgeon's discretion to either standard PCI or PCI with thrombus aspiration Catheter. Primary end points of the study were ST Segment resolution (STR) > 70% and myocardial blush grade (MBG) > 2. RESULTS: The base line clinical and procedural characteristics were same for both the groups. In the post intervention comparison the thrombus aspiration group was found to have significantly better outcomes as compared to the standard PCI group with regards to TIMI flow grade (p = 0.009) and myocardial blush grade (p = 0.001). Considering the criteria for MBG and STR together, the thrombus aspiration was found to have significantly better outcome than the standard PCI group (p = 0.017). CONCLUSION: This non-randomized study shows that Export Aspiration Catheter group with STEMI undergoing primary PCI is feasible and results in better angiographic ECG and myocardial perfusion rates compared with standard PCI. Role of export catheter in rescue PCI and thrombus Sapheneous Venous Graft (SVG) as primary PCI is questionable and needs larger randomized studies to prove its efficacy.

Predictors of successful percutaneous transvenous mitral commissurotomy using the Bonhoeffer Multi-Track system in patients with moderate to severe mitral stenosis: Can we see beyond the Wilkins score?

OBJECTIVE: To know the predictors of a successful outcome of percutaneous transvenous mitral commissurotomy (PTMC) other than described in the Wilkins scoring system. METHODS: Two hundred fifty-eight consecutive patients were enrolled for this observational study in a tertiary care heart center of Pakistan who had a Wilkins score of ≤ 8. Patients with more than mild mitral regurgitation (MR) or having a clot in the left atrium were excluded. The Bonhoeffer multi-track system was used as a default technique. Successful PTMC was defined as achieving a mitral valve area (MVA) of ≥ 1.5 cm(2) with no more than mild MR. RESULTS: Out of 258 PTMC procedures, 197 were successful. The Bonhoeffer multi-track system was used in ~94% cases. Among unsuccessful procedures, 41 patients did not achieve the required valve area, and 21 patients developed more than mild MR, including those 8 patients who did not achieve the required valve area and had more than mild MR. Bigger mean annulus size (33.5 ± 2.6 versus 32.8 ± 2.1 mm; p=0.02) and preprocedure MVA (0.93 ± 0.1 versus 0.87 ± 0.1 cm(2); p=0.002) had a significant effect on successful PTMC. Lower mean preprocedure systolic right ventricular pressure on echo (65.4 ± 19.4 versus 75.3 ± 18 mm Hg; p=0.000) and on cath (74 ± 21.5 versus 81.5 ± 24.6 mm Hg; p=0.002), lower grade of left ventricular dysfunction (p=0.04), and tricuspid regurgitation on echo (p=0.003) also had positive effects on the outcome. CONCLUSION: Bigger preprocedure mitral valve annulus size and mitral valve area, and better left and right ventricular hemodynamics are correlated with successful PTMC.