Case report: Aorto-left atrial fistula-A rare complication of native aortic valve endocarditis.

BACKGROUND: Aorto-cavitary fistula is a rare complication of infective endocarditis. Multimodal imaging is commonly required to assess the severity and extent of infection because of the complex pathology of the valvular and paravalvular apparatus in endocarditis. CASE PRESENTATION: We present an unusual case of a middle-aged man with recent history of meningoencephalitis who developed infective endocarditis complicated by ruptured abscess in inter-valvular fibrosa between aortic and mitral valve resulting in free communication or fistula formation between aorta and left atrium. Patient underwent double valve replacement (aortic and mitral) along with repair of the aorta. CONCLUSIONS: Our case highlights recognition of this rare clinical presentation of aorto-left atrial fistula in infective endocarditis and the diagnostic role of transesophageal echocardiography in good clinical outcome with aggressive and timely management.

Double-chambered left ventricle: diagnosis by CMR and review of the literature.

BACKGROUND: A double-chambered left ventricle (DCLV) is an extremely rare congenital malformation. The exact prevalence of DCLV is not known, although studies have reported prevalence of 0.04-0.42%. This abnormality is characterized by the sub-division of left ventricle into two chambers, the main left ventricular chamber (MLVC) and the accessory chamber (AC) by a septum or muscle band. CASE PRESENTATION: We are reporting two cases of DCLV, one in an adult male and an infant, who were referred for undergoing cardiac magnetic resonance (CMR) imaging. The adult patient was asymptomatic, whereas the infant had the diagnosis of left ventricular aneurysm on fetal echocardiography. On CMR, we confirmed the diagnosis of DCLV in both patients, as well as moderate aortic insufficiency in the adult patient. Both patients were lost to follow-up. CONCLUSIONS: The double-chambered left ventricle (DCLV) is commonly detected in infancy or childhood. Although echocardiography can help detect double-chambered ventricles, MRI provides a better knowledge of this problem and can also be used to diagnose other related heart disorders.

Clinical Features and Outcomes of Acute Chlorine Gas Inhalation; a Brief Report.

Introduction: On March 6th,2020, chlorine gas leak was reported at Engro Polymer & Chemicals Plant in Karachi City, Pakistan. This study aimed to evaluate the clinical features and outcomes of patients who presented to emergency department (ED) following this event. Methods: This retrospective cross-sectional study, evaluated the clinical features and outcomes (length of hospital stay, complications, and mechanical ventilation requirement) of patients presenting to ED of Aga Khan University Hospital, Karachi, Pakistan, with history of chlorine gas exposure at the Engro Plant from 6th March to 14th March 2020. Results: 38 patients with mean age of 33.1 ± 8.1 years presented to ED with history of chlorine gas exposure (100% male). 4 (10.5%) cases had comorbid diseases. Most common presenting symptom was dyspnea, observed in 33 (86.8%) cases, followed by cough, seen in 27 (71.1%) subjects. 13.2% (5/38) patients had infiltration on chest x-ray and 33 (86.8 %) required hospitalization. 6 (15.8%) patients had repeat presentation requiring hospitalization or ED visit. 18 (47.4%) were managed with high flow oxygen therapy, 9 (23.7%) required non-invasive ventilation and one patient was intubated due to development of pneumo-mediastinum. Mean length of stay was 1.55 ± 1.58 days and no patients died. Presence of tachycardia was the only finding significantly associated with need for oxygen (p = 0.033) and non-invasive ventilation (p = 0.012). Conclusion: The majority of patients presenting with acute chlorine gas exposure showed good clinical outcomes and rapid recovery, however, a high index of suspicion and vigilance should be maintained for complications such as pneumomediastinum and acute respiratory distress syndrome in these patients.

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country.

Background: COVID-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources. Methods: A single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23. Results: Among 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5). Conclusion: There was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.

COVID-19 encephalopathy: an unusual presentation with new-onset seizure causing convulsive status epilepticus.

Although neurological manifestations such as headache and myalgias have been observed with COVID-19, presentation with more serious neurological illness is uncommon and rare. We report a case of a middle-aged woman who presented to the emergency department of a tertiary care hospital. Her clinical presentation was primarily neurological rather than the more common presentation with respiratory manifestations. She presented with generalised tonic-clonic seizures, along with history of undocumented low-grade fever and generalised body aches. The positive SARS-CoV-2 RT-PCR nasal swab, the cerebrospinal fluid analysis (lymphocytic pleocytosis) and electroencephalogram were consistent with viral encephalitis; brain imaging was unremarkable. This case highlights the variable presenting features of COVID-19 infection as patients can primarily present with neurological manifestations in the absence of significant respiratory symptoms. We believe it is important to recognise neurological disease associated with SARS-CoV-2 in patients with asymptomatic respiratory infection.

Severe mixed mitral valve disease due to massive mitral annular calcification: A case report and literature review.

We present an unusual case of massive mitral annular calcification (MAC) leading to severe mixed mitral valve disease, viz severe mitral regurgitation and severe mitral stenosis. To our knowledge, severe mixed mitral valve disease secondary to MAC is extremely rare. The patient (a 65-year-old lady) presented with worsening shortness of breath and signs of congestive heart failure. Echocardiographic examination revealed massive mitral annular calcification. Despite the massive annular calcification, she had experienced neither embolism nor endocarditis in the past. Because of severe symptomatic mitral regurgitation and mitral stenosis, surgery was advised; however, the patient declined it.

Clinico-radiological and bronchoscopic predictors of microbiological yield in sputum negative tuberculosis in Pakistan.

To determine association of clinico-radiological factors and radiological activity with diagnostic yield in sputum-smear negative tuberculosis (TB). Prospective observational study in the Military Hospital Rawalpindi (Pakistan) from July to December 2018. Adult patients having no contraindications to bronchoscopy were included. HIV positive patients and those on anti-tuberculosis therapy for more than one week were excluded. High-resolution computed tomography (HRCT) findings were classified based on active and inactive tuberculosis features. Washings were sent for acid-fast bacillus (AFB) smear, GeneXpert assay and cultures. Out of 215 patients, 42.3% (91) were diagnosed with microbiological or histological evidence of TB. On univariate analysis, cavitation (p-value <0.001), soft-tissue nodules (p-value 0.04), and endobronchial mucosal changes (p-value 0.02) were associated with culture positivity. Presence of cavitation (OR= 4.10; CI= 2.18,7.73; p-value<0.001) was the only independent predictor of microbiological yield. Diagnostic yield was 70%, 50%, 12.5% and 8.6% in patients with definitely active, probably active, indeterminate and inactive tuberculosis HRCT features respectively. Sensitivity, specificity, positive predictive value and negative predictive value of HRCT active TB were 95.38% (95% CI 87.10-99.04), 48.00 % (95% CI 39.78-56.30), 44.29% (95% CI 40.31-48.33), 96.00 % (95%CI 88.70-98.66) respectively. There was no significant association between age groups, smoking status and gender with diagnosis of tuberculosis in our study. Radiological activity and certain visualized bronchoscopic changes were associated with good diagnostic performance and can be used as predictive factors in diagnosis of active smear negative tuberculosis.

COVID-19 BBIBP-CorV vaccine and transient heart block - A phenomenon by chance or a possible correlation - A case report.

IMPORTANCE: Bradyarrhythmia during COVID19 illness carries prognostic significance. Electrophysiological side effects of COVID19 vaccine remain largely unknown. It is imperative to report nature of cardiovascular side effects of the vaccine. CASE PRESENTATION: An 80 years-old-man presented with complains of dizziness, trepidation and shortness of breath following his first shot of COVID-19 BBIBP-CorV (Sino-pharm). ECG on arrival showed 2:1 atrioventricular block with an underlying old left bundle branch block. The AV block changed into Mobitz type-I over the course of next 2 days and into a sinus 1:1 conduction on fourth day of presentation. However, our patient underwent permanent pacemaker implantation due to the underlying conduction tissue disease and intermittent 2:1 AV block during the hospital stay. CLINICAL DISCUSSION: It is likely that patients with an already diseased conduction system are at an increased risk of worsening of AV block following inoculation of the vaccine. Vaccine associated AV blocks are likely to be reversible. Presence of prior coronary artery disease and electrical abnormalities are important considerations. CONCLUSION: COVID-19 vaccine may have added side effects in subjects with known heart disease. Humoral response towards the vaccine might interfere with the conduction system of the heart and more so in patients with diseased and scarred myocardium.

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.

Periprocedural and In-Hospital Outcomes Among Percutaneous Coronary Intervention in Saphenous Vein Graft: A Retrospective Observational Study at a Tertiary Care Hospital in South Asian Country.

Background Saphenous vein graft (SVG) may occlude either early or several months to years after coronary artery bypass graft (CABG) surgery. Doing re-do CABG surgery is associated with higher complication and mortality rate as compared to percutaneous coronary intervention (PCI) in SVG. However, PCI of SVG is associated with more periprocedural and in-hospital complications as compared to PCI of native coronary arteries. Due to the scarcity of local data in this regard, this study was designed to estimate the periprocedural and in-hospital outcomes among PCI in SVG. Objectives We aim to study the periprocedural and in-hospital outcomes among patients who underwent PCI in SVG. Methods It is a retrospective observational study. We reviewed hospital record files of 167 consecutive patients, admitted to Aga Khan University Hospital, Karachi, from January 2010 to December 2019, who underwent PCI in SVG. Results Out of 167 patients, 145 (86.8%) were male with a mean age of 72.26 (±8.46) years. Hypertension was the most common comorbid condition. Majority of 141(84.4%) patients presented within 6-10 years since the last CABG done. Seventy-eight (46.7%) patients presented with non-ST elevation myocardial infarction (NSTEMI). Patients who presented with acute coronary syndrome (ACS), 51 (36.9%), and 21 (15.2%) had congestive heart failure and cardiogenic shock on presentation respectively. Coronary angiography was performed in the majority of 155 (92.8%) patients through the femoral artery. The body of the SVG was the most common site affected by the disease. In 88 (52.7%) patients stents were deployed in SVG to obtuse marginal (OM). Drug-eluting stents (DES) were used in 124 (74.3%) patients. 22 (13.2%) of patients developed periprocedural complications, predominantly slow flow and 7 (4.2)% patients had in-hospital complications. Conclusions PCI of SVG is associated with a high procedural success rate and acceptable risk for periprocedural and in-hospital complications. PCI of SVG may be considered as a safe and efficacious option for the percutaneous intervention of SVG lesions.

Patterns of Left Ventricular Hypertrophy and Late Gadolinium Enhancement on Cardiac MRI in Patients with Hypertrophic Cardiomyopathy and their Prognostic Significance - An Experience from a South Asian Country.

OBJECTIVES: Cardiac magnetic resonance (CMR) imaging is very pertinent in the diagnosis and risk stratification of patients with hypertrophic cardiomyopathy (HCM). We aimed to assess the patterns of left ventricular (LV) hypertrophy, late gadolinium enhancement (LGE), and their prognostic significance in HCM patients in Pakistani population, as no such data are available from Pakistan. MATERIAL AND METHODS: This was a retrospective, single center study. All patients who had confirmed diagnosis of HCM on CMR at Aga Khan University Hospital during the period of 2011-2019 were identified and included in the study. RESULTS: A total of 74 patients were included with the mean age of 45.6 ± 15 years and the majority 71.6 % (n = 53) being male. Maximal LV wall thickness was 21.1 ± 5 mm, asymmetrical septal hypertrophy being the most common pattern (62.2%, n = 46). LGE was present in 75.7% (n = 56) with most common site being septum plus LV free wall (24.3%, n =18). Mean ejection fraction% was found to be lower in patients with LGE (P < 0.001). Major adverse cardiac events (MACE) were observed in 40.5% (n = 30). Presence of LGE and right ventricular involvement was found to have a statistically significant association with MACE (P value 0.018 and 0.046, respectively). In multivariable analysis, only LGE was significantly associated with MACE (odd ratio: 4.65; 95% CI: 1.21-17.88). CONCLUSION: Asymmetrical septal hypertrophy was the most common pattern of hypertrophy. LGE was present in three fourth of the study population and it was significantly associated with MACE.