Left Atrial Enlargement as a Predictor of Atrial Fibrillation in Rheumatic Mitral Valve Disease: An Echocardiography-based Retrospective Cross-sectional Study.

BACKGROUND: Rheumatic heart disease is a major cause of cardiovascular morbidity and mortality in developing nations and is a leading cause of hospital admission due to cardiac problems in our country. This study will evaluate the association between left atrial size and the occurrence of atrial fibrillation and describe the clinical characteristics along with complications related to Rheumatic Mitral valve disease. METHODS: A retrospective cross-sectional study was conducted at a tertiary care center from January 2018 to December 2019. Reports of 207 patients admitted to medical and/or surgical wards with echocardiographic diagnosis of rheumatic mitral valve disease with or without atrial fibrillation were reviewed. Data were collected, entered, and analyzed using the Statistical Package for the Social Science version 25.0. RESULTS: Among 207 patients, atrial fibrillation was present in 90 (43.5%) patients. Atrial fibrillation was higher in patients with mixed mitral valvular lesions compared to isolated mitral stenosis or mitral regurgitation. Univariate and multivariate analysis revealed left atrial size [aOR=1.067, 95% CI: 1.023 - 1.113, P= 0.002] and age [aOR = 1.073, 95% CI: 1.042 - 1.105, P<0.001] as an independent predictor of atrial fibrillation. CONCLUSIONS: Larger left atrium was an independent predictor of atrial fibrillation. Besides this, atrial fibrillation was associated with increasing age, mixed mitral valvular lesion, and moderately reduced left ventricular ejection fraction, but not associated with gender and mitral stenosis severity. Left atrial clot was significantly higher in patients with atrial fibrillation than in sinus rhythm.

Percutaneous transluminal coronary angioplasty in a 52-year-old patient with porcelain aorta and calcified coronaries: A case report.

Porcelain aorta, characterized by extensive calcification of the aortic wall is often associated with coronary calcification. It can pose an increased risk of thromboembolic complications during interventional and surgical procedures. We present a case of a 52-year-old female, a chronic smoker with dyslipidemia with complaints of exertional chest pain for past 6 months. She was diagnosed as a case of non-ST elevation myocardial infarction (NSTEMI) with multivessel CAD, with porcelain aorta and calcified coronaries based on abnormal ECG, elevated troponin and coronary angiography findings. Percutaneous transluminal coronary angioplasty (PTCA) was the treatment modality chosen considering the risk of thromboembolism with aortic manipulation during coronary artery bypass grafting (CABG). Repeat ECG after the procedure showed resolution of ST segment depression. Her hospital stay was uneventful. She was discharged on dual antiplatelet therapy, statin and metoprolol. One-week follow-up revealed normal ECG and blood reports, with further outpatient department visits scheduled every 3 months. Porcelain aorta and coronary calcification is a challenging case for cardiologists. PTCA if done meticulously could be preferable to coronary-artery by-pass grafting (CABG) in such patients. Despite the risks like aortic rupture and thromboembolic complications, PTCA in a case of multivessel CAD with porcelain aorta and calcified coronaries could be a life-saving procedure.

Myocardial infarction with nonobstructive coronaries (MINOCA) following rabies postexposure prophylaxis: A case report.

Key Clinical Message: This case underscores the importance of considering myocardial infarction with nonobstructive coronary arteries (MINOCA) in patients experiencing acute chest pain following rabies vaccination, emphasizing the need for heightened awareness and further research into the association between MINOCA and Rabies vaccination. Abstract: Rabies is a vaccine-preventable deadly viral disease prevalent in Asia and Africa that causes thousands of deaths annually. Rabies pre (PrEP) and postexposure prophylaxis (PEP) is highly effective in annulling rabies-associated deaths. The adverse reactions following rabies vaccination are typically mild. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a rare condition, and its association with rabies vaccination is unprecedented. We present a case of a 43-year-old male with MINOCA following Rabies PEP. A 43-year-old male, nonsmoker and nonalcoholic, presented to the ER with complaints of acute onset left sided chest pain following the completion of the third dose of intradermal rabies vaccine, whose clinical features, ECG changes and lab reports were suggestive of acute presentation of inferior wall MI. Coronary angiography was performed, which however revealed normal coronaries with only slow flow being noted in the left anterior descending (LAD) artery. Echocardiography later showed a normal study with no other relevant diagnosis unveiled on further investigations. Hence a diagnosis of vaccine-induced MINOCA was made. Treatment included antiplatelet therapy, statins, and beta-blockers. MINOCA following rabies vaccination is an unprecedented finding. The clear etiology behind this couldn't be ascertained. The patient's treatment was conventional, emphasizing the need for further research and clinical trials in MINOCA diagnosis and management. This case highlights the need for clinicians to consider MINOCA in patients with acute chest pain post-rabies vaccination. Further research is essential to unravel the association between MINOCA and rabies vaccination, paving the way for optimal management strategies.

Induction of Brugada electrocardiogram pattern with aluminum phosphide poisoning: a case report.

Introduction and importance: Aluminum phosphide (ALP) is a commonly used suicidal agent in an agrarian country like Nepal. The unmasking of the Brugada pattern in the electrocardiogram (ECG) associated with ALP poisoning is a rare phenomenon, and studies pertaining to it are scarce in the medical literature. Case presentation: An 18-year-old female presented to the emergency department with multiple episodes of vomiting, headache, blurring of vision, and abdominal pain after 4 h of consumption of ALP with suicidal intent. A 12-lead ECG revealed a coved ST-segment elevation and T-wave inversion in leads V1-V3 with right bundle branch block suggestive of a type 1 Brugada pattern. Her past medical and family history was not significant. The patient made an uneventful recovery with the required supportive treatments. Clinical discussion: Cardiac arrhythmias are the major cause of death in ALP poisoning. Unmasking of the Brugada ECG pattern is a rare but potentially fatal complication implicated in various pharmacological toxicities, including tricyclic antidepressants, cocaine, procainamide, disopyramide, flecainide, and rarely with ALP. Conclusions: ALP poisoning can unmask the Brugada ECG pattern, which can lead to ventricular fibrillation and/or sudden cardiac death.

Prevalence of Myocardial Bridging in Angiography Study.

BACKGROUND: Myocardial bridging is a congenital anomaly in which a segment of epicardial coronary artery takes an intramyocardial course, the systolic compression of which could be asymptomatic or may lead to major hemodynamic changes such as myocardial ischemia, arrhythmias or sudden cardiac death. The prevalence is highly variable depending upon different investigational modalities to diagnose it. Here we have aimed to study the prevalence through invasive coronary angiography. METHODS: This retrospective study was carried out at Manmohan Cardiothoracic Vascular and Transplant center, Kathmandu, Nepal. The invasive coronary angiography of 5096 patients were studied from March 2018 to April 2021 done for various indications. RESULTS: Among all the patients, the myocardial bridging was identified in 257 (5.04%) patients. About 177 (68.9%) were males and 80 (31.1%) were females. The mean age of the patients having myocardial bridging was 54.52 ± 10.31years. Diabetes mellitus was found in 33(12.8%) and hypertension was found in 77(29.9%) patients with myocardial bridging. Stable angina (29.2%) was the most common clinical presentation. Treadmill test was positive in about 70 (27.2%) patients. Majority of patients had myocardial bridge in left anterior descending artery alone (89.9%) and located mostly in mid-part (74.9%). CONCLUSIONS: The myocardial bridging is not an uncommon finding on invasive coronary angiography in middle aged people who present with typical angina.

Echocardiographic Findings in Patients with Atrial Fibrillation in a Tertiary Care Center of Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Atrial fibrillation is the most prevalent supraventricular arrhythmia responsible for the large morbidity and mortality burden worldwide. There are various causes of atrial fibrillation that may affect the prognosis of patients. This study was intended to determine different echocardiographic findings in patients with atrial fibrillation in a tertiary care center. METHODS: A descriptive cross-sectional study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, among 175 patients with atrial fibrillation admitted in the cardiology department from June 2017 to October 2018. It was approved by the Institutional Review Board of the Institute of Medicine (Ref.:411(6-11-E)2/073/074). Convenience sampling was used. Statistical analysis was done using Statistical Package for Social Sciences version 21.0. RESULTS: A total of 175 patients with atrial fibrillation were enrolled where Rheumatic heart disease 68 (38.9%) was the leading cause in which 54 (79.4%) had mitral valve lesion, 1 (1.5%) had aortic valve lesion and rest had a combination of both. The mixed lesion of mitral stenosis and mitral regurgitation was the commonest. The left atrium size was larger in valvular atrial fibrillation (47.296±651mm). The left ventricular systolic dysfunction was seen more in non-valvular atrial fibrillation. The commonest site of thrombus formation was left atrium 7 (63.6%). CONCLUSIONS: Atrial fibrillation was common in rheumatic heart disease, especially mixed lesions of mitral stenosis and regurgitation. Valvular atrial fibrillation had a larger left atrium. The thrombus was seen in mitral stenosis and left ventricular systolic dysfunction. The left atrium size and left ventricular ejection fraction were associated with the occurrence of atrial fibrillation.