Trans-radial Angioplasty of Anomalous Origin of Right Coronary Artery: A Single-Centre Experience.

Successful percutaneous coronary intervention (PCI) to anomalous coronary arteries is technically challenging, particularly through transradial route. The application of appropriate techniques and devices may help overcome these challenges. The objective of this study is to explore the technical and procedural challenges in percutaneous coronary intervention (PCI) of anomalous origin of right coronary artery (AORCA) through the trans-radial route. This prospective study consisted of 25 consecutive patients who underwent PCI for an angiographically significant stenosis in AORCA from November 2017 to May 2019 at Ibrahim Cardiac Hospital & Research Institute (ICHRI). Demographic details and procedural data including numbers of catheters used, access, hardware, techniques, duration of procedure, volume of contrast and complications were recorded and statistically analyzed. The origin of AORCA was 48.0% each from the right and left coronary sinus, with 4.0% arising from the ascending aorta. Among those of right coronary sinus origin, superior take off was 83.3% and inferior take-off was 8.3%, with a further 8.3% originating from the left main, with a common origin with the left anterior descending (LAD) artery, from right coronary sinus. The mean age was 55.8±7.5 years. Diabetics were 84.0%, hypertensive 88.0%, dyslipidemic 68.0% and 20.0% had a history of smoking. Percutaneous coronary intervention (PCI) was performed successfully in 100.0% cases. Transradial access was the default route for coronary angiography in all cases. Angioplasty was performed trans-radially in 92.0% and trans-femoral in 8.0%, for two cases requiring switch over from radial to femoral route. The average number of guide catheters used was (2.0±1.0), (range: 1-4). The guide catheter hooked the coronary ostium selectively in 32.0%, off ostium in 56.0% and deep intubation was done in 12.0% cases. Anchoring wire to enhance guide support was used in 12.0%. 6 Fr guide extension catheter Guidezilla was used in 8.0% cases. The average duration of the procedure was 39.4 (range; 15-90) minutes, the average volume of contrast used was 67.0 (range: 30-150) ml. Average stent length was 28.6 (range; 12-43) mm. For PCI, Judkin's left (JL) and Judkin's Right (JR) were most commonly used guides (36.0% and 28.0% respectively), followed by multipurpose angled (MPA) guide (12.0%). The majority of the lesions stented were of ACC/AHA classification of type B (48.0%) followed by type A (36.0%) and type C (16.0%). Thrombus extraction was performed in a single case. One case was complicated by coronary artery dissection. PCI of AORCA through transradial route is technically challenging but feasible with a reasonable amount of contrast and radiation, and appropriate use of guides and techniques. Proper localization of ostium and selection of suitable guide is the key to success, aided by additional devices in the armamentarium of interventional cardiology such as guide extension catheter and anchoring wires.

Predictors of In-hospital Mortality in Patients Presenting with Acute Coronary Syndromes in a Tertiary Cardiac Center in Dhaka, Bangladesh.

The outcomes of acute coronary syndromes (ACS) vary internationally, given regional differences in patient co-morbidities, access to health care, interventional procedures and adherence to guideline-based management practices. This study aimed to identify the predictors of mortality from a large ACS registry of patients admitted to a tertiary care cardiac centre in Dhaka, Bangladesh. This was a hospital record based retrospective cross sectional observational study that included all patients presenting with ACS to Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh from January 2013 to December 2013. Data were collected from cardiac catheterization laboratory database and hospital discharge records. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 16.0. A p value <0.05 was considered statistically significant. Ethical approval was obtained by Institutional Review Board of the hospital. A total of 1914 ACS patients were studied: 39.8% presented with ST-elevation myocardial infarction (STEMI), 39.7% with non-ST-elevation myocardial infarction (NSTEMI) and 20.5% with unstable angina (UA). There were 146 in-hospital deaths (7.6%). Mortality was highest among STEMI patients (10.5%), followed by NSTEMI (8.1%) and UA (1.03%). The mean age of expired patients was significantly higher than that of those who survived (64.82±12.14 years vs. 57.32±11.99 years; p<0.001). Male patients were 71.4%, with no significant gender differences observed between expired and surviving groups. Age >50 years {odds ratio (OR) 2.56, p=0.005}, chronic kidney disease (CKD) (OR 2.1, p<0.001), shock (OR 16.82, p<0.001), left ventricular failure (LVF) (OR 2.43, p<0.001) and STEMI (OR 1.92, p=0.002) were independent predictors of mortality among ACS patients. Although diabetes per se was not associated with mortality (OR 1.3; 95% CI=0.89-1.91; p=0.169), uncontrolled diabetes defined as HbA1c levels ≥7.5% had significant risk of mortality (OR 51.4, p<0.001). ACS patients who did not undergo angiography (OR 16.4; p<0.001) or PCI (OR 18.9; p<0.001) had greater risk of mortality. ACS patients complicated with shock, LVF, uncontrolled diabetes and CKD had increased risk of in-hospital mortality. Improved outcomes may be likely with prompt angiography and PCI during index admission. This study is a preliminary initiative, and prospective multi-centre registries with nation-wide involvement are warranted.

Impact of Myocardial Blush Grade on In-Hospital Outcome after Primary Percutaneous Coronary Intervention.

Primary percutaneous coronary intervention (PPCI) is the optimal reperfusion strategy in patients with ST elevation Myocardial Infarction (STEMI). However, despite achieving TIMI 3 flow after PPCI, some patients have less optimal perfusion at the myocardial tissue level, as assessed by Myocardial Blush Grade (MBG) and consequently show adverse outcome. This prospective observational study was performed in the National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh from March 2016 to February 2017. Total 74 patients with STEMI who underwent primary PCI and achieved TIMI 3 flow were included among them 37 patients were taken with low MBG (grade 0 or 1) in Group I and other 37 patients with high MBG (grade II or III) were taken in Group II. Mean age of Group I and Group II were 53.70±9.17 and 51.49±9.41 years respectively (p=0.536). Male to female ratio was 5.7:1. Smoking (59.5% versus 35.1%, p=0.036) and diabetes mellitus (43.2% versus 18.9%, p=0.024) were significantly higher in low MBG group than high MBG group. Multi vessel involvement (24.3% versus 5.4%, p=0.022) and anterior MI (72.9% versus 51.4%, p=0.047) were significantly higher in low MBG group. LVEF was significantly lower in low MBG group than high MBG group (49.92?6.60% versus 58.84?4.55%, p=0.003). Among the complications acute heart failure was found significantly higher in low MBG group than high MBG group (8.1% versus 0.0%, p=0.048) along with total adverse in hospital outcome (24.3% versus 5.4%, p=0.041). In study population total mortality was 2.7% and all were in low MBG group (5.4%). Multivariate logistic regression analysis showed MBG was an independent predictor of adverse in hospital outcome after PPCI (OR 6.553, 95% CI 1.984-21.643, p=0.002). Low MBG is associated with more adverse in hospital outcome after PPCI. So, along with TIMI 3 flow following PPCI we have to assess MBG for evaluation of complete reperfusion and further outcome.

National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI).

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Gitelman's Syndrome Presenting with Hypocalcaemia - A Case Report.

Gitelman's syndrome is an autosomal recessive renal tubular disorder characterized by severe hypomagnesaemia, hypokalaemia, metabolic alkalosis and hypocalcaemia. It is caused by defective NaCl transport in the Distal Convoluted Tubule and presents in adolescence or adulthood, with a distinctly more benign course than Bartter's Syndrome. The dominant clinical features are muscle weakness, fatigue, carpopedal spasm, cramps and tetany. We report the case of a 26 year old male who presented with flaccid quadriparesis and carpopedal spasms, hypokalaemia, hypomagnesaemia, hypocalcaemia and severe urinary magnesium wasting. He was treated with potassium and magnesium supplementation and regained full function of all limbs.