Fetomaternal Outcome of Pregnancy in Women with Tetralogy of Fallot.

This prospective study was done to determine fetomaternal outcomes of pregnancy in women with Tetralogy of Fallot (TOF) and carried out in two centres especially in the care of patients with adult congenital heart disease (CHD) from January 2005 to December 2009. Clinical, haemodynamic and obstetric data were reviewed for pregnant women with TOF. Ten (10) pregnant women were identified in the age range 18 to 47 years. Most of the patients were in the age group of 18 to 27 years, 34 to 36 weeks gestational age (in week) and primi gravida (60%). Right-sided aortic arch (20%) and major anomalies of pulmonary collaterals (30%) were common anomalies anatomical association. Normal vaginal delivery was the mode of delivery (70%) in the majority of the patients. Spontaneous abortions were occurred in 3(30%) patients. Primary maternal cardiac events complicating pregnancies were congestive heart failure (20%), arrhythmias and cardiovascular events (10%). Premature labor (40%) was the most common obstetric complication. Premature birth (40%), fetal demise (20%), neonatal death (10%) and cardiac anomaly at birth (10%) were the offspring complications in the study. Women with TOF can go through pregnancy with a low risk to themselves with frequent treatable complications, but there is a high incidence of miscarriage, premature births and low birth weight. An incidence of congenital anomaly in the fetus is higher than that found in the normal population.

Association of Diastolic Dysfunction with N-terminal Pro-B-type Natriuretic Peptide Level in Heart Failure Patients with Preserved Ejection Fraction.

Heart failure is a major public health issue with a current prevalence of over 23 million worldwide. Epidemiologic studies suggest that nearly one-half of patients with heart failure have a normal ejection fraction that is now termed HFpEF. Prevalence of HFpEF is approximately 50% (range 40-71%). Most pathophysiologic abnormalities in patients with HFpEF are related to diastolic function. Doppler echocardiography is the choice of investigation for evaluation of Diastolic function. Tissue Doppler Imaging is a new dimension in this concept. Natriuretitic peptides are widely accepted biomarker in HFrEF patients. Now a days, it is also considered for HFpEF patients for diagnostic & prognostic purpose. Aim of this study was to find out the association of Diastolic dysfunction with N-terminal Pro B-type Natriuretic Peptide level in HFpEF patients. This cross-sectional analytical study was conducted in the department of Cardiology in Mymensingh Medical College Hospital, Mymensingh, Bangladesh from October 2016 to September 2017. Total 120 HFpEF patients were included after considering inclusion and exclusion criteria. Sample population was divided into two groups, Group I: HFpEF patients with normal Diastolic function. Group II: HFpEF patients with diastolic dysfunction in this study mean NT-pro BNP value of Group I and Group II were 104.07±7.2pg/ml and 943.19±112.51pg/ml respectively, which was statistically significant (p value <0.05). Among the echocardiographic parameters LV hypertrophy, Left atrial volume index (LAVI), TDI derived mitral annular velocity, e' septal velocity, E/e' (septal) ratio, Decelaration time were statistically significant. In this study, it was also shown that the levels of NT-proBNP had positive correlation with Doppler parameters. Statistically significant moderate positive correlation was observed between NT-proBNP level and LAVI value, correlation coefficient (r=0.553, p=0.001) suggesting that the higher the level of NT Pro BNP level, the higher value of the LAVI value. Statistically significant moderate positive correlation was also observed between NT-proBNP level and E/e' (septal), correlation coefficient (r=0.526, p=0.001) suggesting that the higher the level of NT Pro BNP level, the Higher value of the E/e' (septal) value in HFpEF patients with diastolic dysfunction. In subgroup analysis of Group II ,mean NT-proBNP level showed affirmative relation with severity of diastolic dysfunction grades ranging from grade I (340.76±24.42) to grade III (3727.83±306.50) Diastolic dysfunction is associated with elevated NT-proBNP level in HFpEF patients & NT-proBNP value rises with gradual deterioration of Diastolic dysfunction among the HFpEF patients.

Clinical Profile and Outcome of Peripartum Cardiomyopathy - A Study in a Tertiary Cardiac Hospital of Bangladesh.

This study was done to evaluate the clinical profile, management and to analysis of pregnancy outcomes of peripartum cardiomyopathy pregnant women. Follow up was done after treatment and to see the prognosis. All patients admitted with peripartum cardiomyopathy from July 2009 to June 2014 in the department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh were considered for this observational study. Seventy two (72) women were evaluated. Primi-paras are 28 (39%) of the total study population. Fifty two patients (72%) were clinically improved and in 35 (48% ) the left ventricular functional status returned to normal with the treatment of Diuretics, selective Beta-blocker, Angiotensin converting enzyme inhibitor(ACEI) or Angiotensin receptor blocker (ARB) and vitamin B complex. Eleven cases (15%) developed persistent cardiomyopathy that is persistent left ventricular dysfunction beyond six months of presentation. Ten women (14%) presented with thromboembolic events and anti coagulant were prescribed for life long for secondary prevention. Maternal mortality was 8 (13%). Among all live births four had intra uterine growth retardation and another three had died during the neonatal period. The patients of peripartum cardiomyopathy were improved symptomatically and prognosis was good with the treatment of diuretic, selective beta-blocker, ACEI or ARB and vitamin B complex. Regular clinical follow up with echocardiography and monitoring of INR if the patients are in Anticoagulant are advised to reduce the morbidity and mortality.

Risk of Acute Coronary Syndrome is Better Predicted by Apolipoprotein B in Young People than Dyslipidemic Parameter of Conventional Lipid Profile.

The traditional lipidic parameters when present and clusters within reference range, often fails to predict the risk of acute coronary syndrome in young population in this region. Measurement of Apolipoprotein B (Apo B), a parameter of the lipoprotein-lipid profile, provides a method of quantifying the concentration of lipoproteins, rather than their cholesterol content. Present study aimed to quantify the risk of acute coronary syndrome (ACS) in young people with having none to less number of traditional lipidic parameters for dyslipidemia. This is a case control study among 50 cases of first attack of ACS among 18-45 years of age of both sexes, admitted in coronary care unit of Mymensingh Medical College Hospital, Mymensingh, Bangladesh from June 2009 to May 2010. Data was recently reanalyzed. Out of five sub-sets of lipid profile, namely TC, TG, HDL-C, LDL-C and non-HDL-C, 16(32%) cases were dyslipidemic by 0 (none) parameter, 13(26%) cases by one parameter, 7(14%) cases by two parameters, 4(8%) cases by three cases, 7(14%) cases by four parameters and 3(6%) cases by all five parameters. It was found that none to lesser the number of dyslipidemic parameters, greater the percentage of ACS cases and they are having hyper ApoB with statistically significant association (p<0.05).

Iron Polymaltose Complex in the Treatment of Iron Deficiency Anemia in Pregnancy.

Iron deficiency anaemia is a major public health problem in pregnancy. About 58% of pregnant women in developed countries are anaemic mainly due to iron deficiency resulting a serious negative consequences on children, mothers and eventually on the nation. This quasi-experimental multi centered study (Before after study) was done to evaluate the efficacy and tolerability of Iron Polymaltose Complex (IPC) in the treatment of iron deficiency anaemia and it was performed at the OPD of Bangladesh Medical College and two other clinics of Dhaka city from August 2011 to September 2013. A total of 80 (eighty) subjects were selected by purposive sampling as per inclusion and exclusion criteria. They were treated by Iron Polymaltose-IPC [47mg elemental iron + Folic Acid 0.5mg + Zinc 22.5mg - Once daily orally for 12 weeks]. At the beginning and after 12 weeks of intervention by Iron Polymaltose Complex (IPC) Hb%, Packed Cell Volume (PCV), Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH), Serum iron, and Serum ferritin were measured. Data were analyzed by SPSS version 13.0. Paired and unpaired 't' test was used to analyze differences within groups and between groups. Chi-square test was done to analyze primary efficacy parameters and adverse drug reactions (ADR). Most of the respondents were within the age group of 18-23 and 30-35 years (32.6% each). Significant differences were found by treatment with IPC for 12 weeks in Hb%, PCV, MCV, MCH, Serum iron, and Serum ferritin level. In iron deficiency anaemia during pregnancy IPC may be used as a safe and cost-effective therapeutic management.

Correlation between Troponin-I and B-Type Natriuretic Peptide Level in Acute Myocardial Infarction Patients with Heart Failure.

Troponins are regarded as markers of choice for the diagnosis of acute myocardial infarction (AMI). But B-type natriuretic peptide (BNP) level is also elevated in AMI and is a quantitative biochemical marker related to the extent of infarction and the left ventricle systolic dysfunction. Thus, BNP has prognostic value. In this study, we investigate the correlation of Troponin-I with BNP levels in patients presenting with AMI with or without Acute Heart Failure. Rationale of this study is to see, whether quantitative Troponin alone can serve for both diagnosis and prognosis of AMI Patients with heart failure or not. This cross-sectional analytical study was conducted in the Department of Cardiology in Mymensingh Medical College Hospital from January 2014 to December 2014. Total 100 patients were studied and divided into two groups - 50 patients in each group. Group I: Patients with first attack of acute myocardial infarction (without heart failure) & Group II: Patients with first attack of acute myocardial infarction with acute heart failure. Mean Troponin-I of Group I and Group II were 3.10±2.68 and 62.93±32.75ng/ml respectively & mean BNP value of Group I and Group II were 20.96±14.18 and 615.65±249.27pg/ml respectively. In this study, it was shown that the levels of BNP had positive correlation with Troponin-I levels, with medium strength of association (r=0.734, p<0.05). Echocardiography shows that patients with high BNP level has low ejection fraction (LVEF) and patients with low BNP level has preserved ejection fraction (LVEF). Thus, the present study shows that the higher the Troponin-I levels, the higher the BNP levels in first attack of AMI patients and the more severe the heart failure (more severe left ventricle dysfunction). There is positive correlation between Troponin-I and BNP levels in first attack of AMI patients with acute heart failure.

Pericardial Tumor Presenting As Recurrent Pericardial Effusion--A Case Report.

Pericardial tumors are unusual and may be difficult to characterise with imaging. They manifest as large, non-contractile, solid masses within the pericardium. Presenting symptoms include heart failure, arrhythmias, sudden death, cyanosis and chest pain. But it can also present as recurrent pericardial effusion misdiagnosed as tuberculosis and other infectious causes. Accordingly a patient with pericardial mass (tumor) presented with recurrent pericardial effusion as a rare case.

Association of heart rate response with scan and left ventricular function on adenosine stress myocardial perfusion imaging.

To evaluate the association of heart rate (HR) response with abnormal scan and/or left ventricular (LV) function in patients undergoing adenosine myocardial perfusion imaging, we prospectively studied 164 consecutive patients who underwent a standard adenosine stress test (without exercise) and myocardial perfusion imaging (MPI) using technetium-99m sestamibi radioisotope. Change in HR was calculated by subtracting HR at rest from peak HR. The percentage change in HR was calculated. All patients underwent stress and resting single photon emission computed tomography (SPECT) imaging. Left ventricular ejection fraction (EF) was calculated using gated SPECT. Mean age was 54 ± 11.7 years and 126 of the patients (72%) were men. We divided the patients into 2 groups: group 1(42 patients, 25%) had normal scans and group 2(122 patients, 74.3%) had abnormal scans; abnormal scans were defined as presence of either fixed defects, reversible defects, or both. Average HR increased by 35 beats/min in the normal scan group compared with 23 beats/min in the abnormal scan group (p=0.002). Sixty four (64) patients (39%) had reduced EF (<45%). This group had an average HR and percentage HR increase of 23 beats/min (27%) compared with an increase of 35 beats/min (38%) in patients with normal EF (p=0.002 and p=0.02, respectively). Thus, a diminished HR response had a significant association with both an abnormal scan and reduced EF on adenosine MPI.

Long-term survival in an un-operated single ventricle.

Single ventricle is a rare and complex congenital heart disease. Neonates with single ventricle have a high mortality. Survival into adulthood is rare without surgical intervention. A case of single ventricle with double inlet and double outlet combined with severe valvular pulmonary stenosis and mitral regurgitation (Grade II) is being reported here. A 36 years old man was admitted for bluish discoloration of lips, tongue and fingers; shortness of breath and recurrent palpitation. His ECG showed atrial fibrillation with fast ventricular rate. Chest X-Ray depicted an enlarged cardiac shadow and right sided pleural effusion. Final diagnosis was made by echocardiogram which demonstrated single ventricle with double inlet and double outlet, severe valvular pulmonary stenosis and mitral regurgitation (Grade II) with good ventricular systolic function.

Trimetazidine in the prevention of contrast induced nephropathy after coronary angiogram.

This prospective randomized, controlled trial was done to evaluate the efficacy of trimetazidine in the prevention of contrast induced nephropathy in patients with raised serum creatinine levels undergoing coronary angiogram. This study was performed in the Department of Cardiology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from April 2009 to March 2010. Contrast-induced nephropathy (CIN) is a serious complication of coronary angiography that is associated with considerably increased mortality and morbidity, including the need for short-term haemodialysis, extended hospitalisation and permanent impairment of renal function. Trimetazidine (TMZ) has been described as a cellular anti-ischaemic agent. This study was trial with 400 patients. Among them 200 patients treated with trimetazidine plus hydration with normal saline and 200 patients (control) given hydration by normal saline only. It was found that the incidence of CIN was significantly (p<0.05) reduced by trimetazidine administration with saline in comparison with saline alone in patients undergoing coronary angiogram (4% vs. 14%).

Response of vincristine, melphalan, cyclophosphamide and prednisolone in refractory multiple myeloma.

In refractory and relapsing multiple, myeloma good complete response rates may be achieved by Vincristine, Melphalan, Cyclophosphamide and Prednisolone (VMCP) like regimen which is effective alternative and less expensive in developing country like Bangladesh. The study was conducted to see the response of VMCP as an alternative in relapsing or refractory multiple myeloma. The study has been carried out in the department of Haematology, Bangabandhu Sheikh Mujib Medical University from July 2004 to June, 2005. This study was conducted on refractory case of multiple myeloma, having aged between 45 to 70 years. A total of ten patients had been taken for this study group. Newly diagnosed multiple myeloma is not included in this study. All of the 10 patients were treated according to the following VMCP protocol, Vincristine 1mg IV, d1, Melphalan 6mg/m2/d p.o. d1-d7, Cyclophosphamide 120mg/m2/d p.o. d1-d7 Prednisolone 60mg/m2/d p.o. d1-d7. Cycles were repeated every 28 days for 6 cycle. Six out of ten patients with refractory multiple myeloma displayed minimal response (60%) after treatment with 6 cycle of VMCP protocol, three patients entered partial remission (30%), and one (10%) showed complete response.

Role of ETT to diagnose coronary artery disease.

The purpose of the study to predict the coronary arterial disease by exercise treadmill scoring system and to see the correlation of angiographic extent of coronary artery disease by high treadmill score in our country. The present prospective study carried out in the department of cardiology, Bangabandhu Sheikh Mujib Medical University, University Cardiac Centre during the period of January 2006 to July 2006. Based on inclusion and exclusion criteria a total of 80 patient of chronic stable angina or chest pain evaluation having positive ETT who were admitted in university cardiac centre in Bangabandhu Sheikh Mujib Medical University and underwent coronary angiogram within one month were the study population. Among 80 subjects 60(75%) were male and 20(25%) were female and male: female ratio 3:1 Mean age of male subject 51.37±9.08 years and mean age of female subjects were 43.75±7.67 years. Three quarter of the subject had the history of typical anginal pain followed by 21.3% atypical and 3.8% pain of non-anginal origin. All the risk factors like, dyslipidemia (90%), HTN (68.8%) past smoker (45%), current smoker (32.5%), diabetes (36.3%), family history of coronary artery disease (25%) and sudden death of first degree relatives (8.8%); dyslipidemia was the highest percentage. Among 80 subjects more than one third 35% (28) of the subjects were observed to be normal by angiogram, 28.8% (23) had SVD, 16.3% (13) DVD and 20% (16) TVD. Approximately 70% of the significant stenosis was predicted as having high probability of 30.8% as intermediate probability and none as low probability with exercise test scores. Multi-vessel coronary artery disease were predicted by high probability exercise test score 82.8%. Thus high probability score needs urgent coronary angiogram.

Disseminated tuberculosis presenting as acute coronary syndrome.

Tuberculosis is a major public health problem in Bangladesh. Though tuberculosis is common but acute myopericarditis can rarely be caused by tuberculosis infection. A case of disseminated tuberculosis presenting with features of acute coronary syndrome is presenting here. A 26 years old man was admitted for severe central chest pain for 2 days and fever for 2 months. His ECG showed ST segment elevation in chest leads, V1 to V4 with elevated Troponin I and high ESR. Chest X-Ray depicted an enlarged cardiac shadow. Echocardiography demonstrated multiple dynamic cavitary lesions involving interventricular septum as well as anterior wall of the left ventricle within myocardium with moderate pericardial effusion with trivial mitral regurgitation. A CT scan of chest with contrast revealed multiple calcific communicating cavities within endocardium and myocardium involving interventricular septum and anterior wall of the left ventricle of heart and multiple cavitary lesions in the mid zone of left lung with bilateral mild pleural effusion. The patient made an excellent recovery on management of acute coronary syndrome and on antitubercular therapy.

In-hospital outcome of patients with acute STEMI with impaired renal function.

Effective risk stratification is integral to the management of patients with acute coronary syndromes. This prospective study was done to evaluate the association between on-admission renal function and in-hospital outcome of patients with acute ST segment elevation myocardial infarction (STEMI). This study was carried out in the department of cardiology, NICVD, Dhaka, Bangladesh during the period from January 2004 to December 2004. Total 90 patients with first episode of acute STEMI were grouped according to renal function. Group I patients had normal renal function and Group II patients had renal impairment. Among group I patients, only 3.7% had Killip class IV heart failure, whereas among group II patients, 19% had Killip class II and 6.3% had Killip class IV heart failure (p<0.001). Mean percent of LVEF was significantly higher in Group I patients (52.0±5.2 vs. 47.9±6.3, p<0.01). Ventricular tachycardia occurred in significantly higher proportion in group II patients (7.4% vs. 63.5%, p<0.001). It was concluded that some in-hospital complications of acute STEMI were significantly higher and others were more prevalent in patients who had associated renal impairment compared to those who had normal renal function. This study can develop a clinical prognostic tool, which is simple, cheap and easily be applied at bedside. Concentrating on aggressive management of such patients may reduce their morbidity and mortality.

Congenital aneurysm of the left atrium.

Isolated left atrial (LA) aneurysm is a rare condition, whereas LA aneurysm secondary to other causes is a fairly common condition. A case of large left atrial aneurysm presented with features of heart failure with cardiac arrhythmia and an abnormal cardiac silhouette on chest X-ray. A 14 years old girl presented with palpitation at rest, shortness of breath, productive cough and bilateral leg swelling for last 8 months. There was no history of chest pain, hemoptysis, syncope, prolonged fever, and rheumatic fever. She was mildly anemic, had raised JVP and mild bilateral pedal edema. There was left parasternal heave, soft S1, loud P2 and a pansystolic murmur of grade 3/6 over mitral area radiating to the left axilla. ECG showed multifocal atrial tachycardia (MAT), chest X-ray showed cardiomegaly with bulging of the left heart border with upper lobe diversion. Echo-Doppler study showed hugely dilated LA (115 mm in diameter), dilated left ventricle, Grade-2+ mitral regurgitation (MR), mild tricuspid regurgitation (TR) and mild pulmonary hypertension with normal appearing mitral, aortic and tricuspid and pulmonary valves. The patient was diagnosed as a case of congenital aneurysm of LA.

Evaluation of left ventricular global function, using Doppler myocardial performance index in patients with systemic hypertension.

The study was designed to compare the Doppler myocardial performance index (Tei index) between those patients with systemic hypertension with normal populations. 50 patients with hypertension (16 with left ventricular hypertrophy and 34 without hypertrophy) were taken as cases and 52 age & sex matched healthy individuals were taken as controls. Left ventricular global function was calculated using the echocardiographic Doppler index as described by Tei et al. (Tei index). Left ventricular global function differs significantly between the groups. It does not differ significantly between those with left ventricular hypertrophy and without hypertrophy. Pulmonary venous flow parameters revealed significant increase in atrial reversal velocity and also significant lengthening of atrial reversal duration. All of these parameters signify worsening diastolic properties. The Tei index is not affected by increasing age and therefore, is appropriate for evaluating left ventricular global function in hypertensive patients, most of whom are middle aged or older. This index may be useful for determining treatment strategy and evaluating treatment effects.