Best management of patients with malignant pericardial effusion: A comparative study between imaging-guided pericardiocentesis and surgical pericardial window.

Background: The clinical course of malignancies is frequently complicated by third spacing in body cavities, including pericardial effusion. What remains the optimal management for malignant pericardial effusion is a dilemma. Aim: We aimed to compare 30-day outcomes of imaging-guided pericardiocentesis and surgical pericardial window in patients with malignant pericardial effusion. Methods: A retrospective observational study was done at a tertiary care hospital. We reviewed hospital record files of 91 consecutive patients admitted with malignant pericardial effusion from January 2010 to December 2019 and requiring imaging-guided pericardiocentesis or pericardial window. Results: A total of 71 patients were included in the final analysis. Most patients were male (68%). The mean age was 45 years. Hypertension was the most common comorbid condition. Lymphoma or leukemia (39%) was the most common cause of malignant pericardial effusion followed by lung cancer (28%). About 57.7% of patients underwent pericardiocentesis, and the remainder underwent surgical pericardial window (42.3%). The overall procedural success was 97.2%, and the overall mortality was 5.6%. The success rate was similar when pericardiocentesis was compared with the surgical pericardial window (p = 0.22). The length of hospital stay was higher in patients undergoing pericardial window (p = 0.007), whereas the re-accumulation rate was higher in the pericardiocentesis group (0% versus 34%, p < 0.001). Patients undergoing pericardial window had higher odds of major bleeding requiring transfusions. Conclusion: There is a higher rate of recurrence following isolated pericardiocentesis but a comparable mortality difference between the two procedures. Complication rates can be reduced by improving surgical technique and peri-operative management. Meticulous surgical care, infection precautions, and good glycemic control in this immunocompromised subset can preserve the pericardial window as a better management option. Relevance to Patients: Pericardial window is a promising and effective management option for patients with recurrent malignant pericardial effusion, but it comes at the cost of bleeding and infection. More extensive trials are needed to understand better the long-term outcomes of pericardial window or pericardiocentesis in patients with malignant effusion.

Transseptal Puncture Through an Interatrial Septum With Lipomatous Hypertrophy: A False Perception of Success and Failure.

Transseptal puncture is a standard procedure to access the left atrium during catheter ablation of arrhythmias. It is associated with high success and a meager complication rate in the contemporary era. The potential complications of transseptal puncture include aortic puncture, perforation of the right/left atrial free wall resulting in pericardial effusion/tamponade, and systemic thromboembolism. The dissection of the interatrial septum (IAS) is a rare complication of transseptal puncture, reported in less than 1% of the procedures. We report a case of a dissection of the IAS during an attempted transseptal puncture in a 72-year-old man with lipomatous hypertrophy of the interatrial septum.

Takotsubo Like Cardiomyopathy with Concomitant Pheochromocytoma: A Rare Presentation.

Pheochromocytoma classically presents with headache, diaphoresis, palpitations and, raised blood pressure. Rarely, it manifests as cardiomyopathy. Herein, we present a case of a 42-year woman who presented with heart failure and on work-up was found to have pheochromocytoma leading to Takotsubo-like cardiomyopathy. The biochemical profile revealed raised serum metanephrines and normetanephrines. CT abdomen showed a left adrenal mass. Within two weeks of presentation and before surgical excision of the mass, she recovered from cardiomyopathy. After medical optimisation, the patient underwent elective adrenalectomy, which on histological evaluation revealed pheochromocytoma. Key Words: Cardiomyopathy, Pheochromocytoma, Adrenal mass.

Clinical characteristics and prognostic factors of atrial fibrillation at a tertiary center of Pakistan - From a South-Asian perspective - A cross-sectional study.

BACKGROUND: There is lack of large data from South-Asian region on atrial fibrillation and it is imperative that clinical presentation, prognostic factors, management pursued, and outcomes are known for this part of the world. Once collective evidence for the region is known, region-specific guidelines can be laid forward. OBJECTIVES: To evaluate clinical characteristics and prognostic factors of atrial fibrillation at a tertiary care center of Pakistan. METHODS: This was a retrospective study conducted at a tertiary care center of Pakistan. Period of study ranged from July-December 2018. All hospitalized patients who were admitted with atrial fibrillation as a primary or associated diagnosis were enrolled. RESULTS: A total of 636 patients were enrolled. The mean age was 68.5 ± 12 years and 49.5% (315) were male. 90.6% of the patients were admitted via emergency room. Majority (59.9%) had previously known AF and 40% developed new-onset AF during the hospital stay. Hypertension was the most common co-morbid condition (85.4%) followed by Diabetes Mellitus (40.1%). At least 9% had rheumatic heart disease. The median CHA2DS2VASc and HASBLED scores were 4 and 2 respectively. More than one-third of patients had sepsis as a primary diagnosis (36.8%). The in-hospital mortality of patients with atrial fibrillation was 6.7%. Patients with new-onset AF had higher mortality. Sepsis and stroke were independently associated with a higher mortality. There was no significant difference in median CHA2DS2VASc and HASBLED scores for patients with new-onset and previously known AF. On discharge, 83% of the eligible patients received oral anticoagulation. CONCLUSION: There was higher prevalence of chronic co-morbid conditions in the studied population leading to a higher CHA2DS2VASC Score. Sepsis and stroke were independently associated with higher in-hospital mortality.

Comparing sensitivity and specificity of pacemaker ID application and cardiac rhythm management device-finder application in identifying cardiac implantable electronic device manufacturer using chest radiograph - An observational study.

BACKGROUND: Smartphone-based applications to identify cardiac implantable electronic devices (CIED) are extremely useful in circumstances, where urgent device interrogation is needed, and a device identification card is not available. Few studies have provided insights regarding the utility of these applications. We have studied two widely available applications i.e., Pacemaker ID app (PMIDa) or Cardiac Rhythm Management Device-Finder (CRMD-f) to identify device manufacturers in CIEDs. METHODS: 547 patients who underwent CIED implantation from the year 2016-2020 in our institute were enrolled. There were 438 Medtronic and 109 St. Jude's devices. All chest radiographs were de-identified and resized into 225*225 pixels focusing on the CIED. PMIDa and CRMD-f applications were used to identify the CIED. Accuracy, sensitivity, specificity, negative predictive value, and positive predictive value for both applications were calculated and compared. RESULTS: Overall, CRMD-f application has higher specificity (93.58 vs. 82.5%) but lower sensitivity (53.6 vs. 55%) than PMIDa. The accuracy of both applications was comparable (61.6% vs. 60.5%). Accuracy varied with CIED model and type tested, and radiograph projection used. Accuracy is greatest with Cardiac-Resynchronization-Therapy (CRT) devices for both applications, followed by a single lead pacemaker. CONCLUSION: CRMD-f has higher accuracy and specificity for CIED manufacturer identification. Both PMIDa and CRMD-f are specific tools to identify CIED but have low sensitivity.

Cardiovascular fellow-in-training feedback on virtual and simulator-based learning experience during Covid-19 pandemic in a low to middle income country - A cross-sectional study.

BACKGROUND: COVID-19 pandemic has introduced us to a greater need of virtual learning platforms and has resulted in less clinical exposure for fellows-in-training. Virtual and simulator-based learning is not widely available in LMIC. It is imperative to analyze feedback of CV fellow-in-training regarding this mode of learning before large scale implementation. METHODOLOGY: This was an observational study conducted between July-August 2020. A multicentered survey was conducted. Survey questionnaire was disseminated to FIT (fellow-in-training) via Google Forms. The questionnaire contained a total of 24 questions about virtual and simulator-based learning during the pandemic. RESULTS: A total of 68 FIT responded to the survey. The mean age was 29.9 years. There were 37% females and 63% males. Majority (75%) agreed that it was easier for them to reach for online sessions than physical sessions. 60% FIT were confident in asking questions or giving comments during the online sessions. 57.4% FIT felt it easier to go through cardiovascular imaging/illustrations via online platforms. 50% (34) were confident that if online sessions had to continue, they would have enough academic learning before they graduated from the program and 54.4% (37) wanted online sessions to continue even beyond the pandemic days. 37.5% (18 out of 48) agreed that the simulator-based teaching was helping them practice skills in times of less clinical exposure. CONCLUSION: COVID-19 pandemic has significantly impacted cardiovascular FIT learning curve because of less hands-on and lack of physical teaching sessions. LMIC have lack of robust e-learning platforms. Virtual learning is convenient for academic learning with growing acceptance amongst fellows. FIT from LMIC are less acquaint to simulator-based teaching and there is a need to invest in simulator-based cardiovascular teaching in LMIC.

Clinically isolated aortitis presenting as inferior ST-elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm: a rare and forgotten cause of acute coronary syndrome in a young patient with no evidence of systemic vasculitis.

A 21-year-old man presented with chest pain, diaphoresis and dyspnoea. Electrocardiogram (ECG) showed inferior ST-elevation myocardial infarction. Troponin I was positive. Patient underwent left heart catheterisation, which revealed normal epicardial coronary arteries except for right coronary artery which could not be engaged. CT coronary angiogram was done, which revealed large right sinus of Valsalva aneurysm giving rise to a pinched out right coronary artery. Patient underwent composite graft replacement of aortic valve, aortic root and ascending aorta along with a saphenous vein graft to right coronary artery. He was discharged in stable condition on fifth postoperative day. Biopsy of the aneurysmal tissue was suggestive of vasculitic aetiology. There was no evidence of systemic vasculitis and Magnetic Resonance Angiography (MRA) screen was negative for Takayasu's arteritis. Our patient was, hence, diagnosed with clinically isolated aortitis leading to ST elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm.

Pericardiocentesis Indications and Complications: A Retrospective Observational Study in a Tertiary Care Hospital in Karachi, Pakistan.

INTRODUCTION: Pericardiocentesis is crucial for the diagnosis and management of diseases responsible for significant pericardial effusions. Pericardiocentesis was performed the first time by Riolanus for cardiac tamponade. He described the process of trephination of the sternum to remove the abnormally accumulated fluid from the pericardial space. However, with the advancement of expertise in echocardiography assisted procedures, echocardiography-guided diagnostic and therapeutic pericardiocentesis is now considered standard clinical practice in the treatment of pericardial effusions. OBJECTIVES: We aim to study different causes of pericardial effusion and indications of pericardiocentesis as well as complications associated with it in our population. METHODS: This is a retrospective observational study done at Aga Khan University Hospital, Karachi. We reviewed hospital record files of 66 patients admitted to Aga Khan University Hospital from January 2010 to December 2019 who underwent pericardiocentesis. RESULTS: Out of 66 patients, 43 (65.2%) were male. The mean age of the study population was 48.59±18.9 years and 41 (62.1%) of them had underlying active malignancy with hematological malignancies being most common followed by lung carcinoma. In the majority of patients (71.2%), pericardiocentesis was performed at the bedside, and the rest of them (28.8%) underwent pericardiocentesis in the cardiac catheterization laboratory. Of all the patients, 46 (69.7%) underwent pericardiocentesis under echocardiography guidance and 18 (27.3%) required fluoroscopy. Successful pericardiocentesis was performed in 65 (98.5%) of the patients, two (3%) patients developed access site infection and only one (1.5%) patient became hemodynamically unstable while undergoing pericardiocentesis Conclusion: Malignancy, predominantly lymphoma, is the most common cause of pericardial effusion requiring pericardiocentesis. Dyspnea is the most common symptom of presentation with cardiac tamponade. Echocardiography is the commonly used imaging modality for pericardiocentesis. Bedside setting is the most common setting used for pericardiocentesis. Imaging guided pericardiocentesis has a very high success and low complication rate.