Elective versus urgent in-hospital transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is maturing as a treatment option and is now often undertaken during an unscheduled index hospital admission. The aim of this study was to look at procedural and mid-term outcomes of patients undergoing elective versus urgent in-hospital transcatheter aortic valve implantation. METHODS: We identified a total of 1,157 patients who underwent TAVI between November 2007 and November 2019 at the Sussex Cardiac Centre in the UK. We compared the demographics, procedural outcomes, 30-day and 1-year mortality between elective and urgent patients. Emergency and salvage TAVI cases were excluded. RESULTS: Of the 1,157 patients who underwent the procedure, 975 (84.3%) had elective while 182 (15.7%) had urgent TAVI. Predominant aortic stenosis was more frequent in elective patients (91.7% vs. 77.4%); p < .01), while predominant aortic regurgitation was seen more commonly in the urgent group (11.5% vs. 4.2%; p < .01). Implantation success was similar between the elective (99.1%) and urgent group (99.4%). In-hospital (1.65% vs. 1.3%: p .11), 30 day (3.5% vs. 3.3%: p .81) and 1 year (10.9% vs. 11%; p .81) mortality rates were similar in the elective and urgent groups, respectively. CONCLUSIONS: In contemporary practice, urgent TAVI undertaken on the index admission can be performed at similar risk to elective outpatient TAVI.

Bioprosthetic mitral valve thrombosis and subsequent obstruction from non-Hodgkins lymphoma despite anticoagulation.

Malignancy can cause a hypercoagulable state, it rarely causes prosthetic valve thrombosis, with only limited cases reports due to lymphoma. Although no standardised approach for treatment exists, the combination of early diagnosis, surgical intervention and adjuvant chemotherapy are likely to provide the best chances of survival. We describe an interesting case of a bioprosthetic mitral valve thrombosis leading to valve obstruction in a patient with non-Hodgkin's lymphoma despite being on anticoagulation.

Persistent left superior vena cava with absent right superior vena cava: review of the literature and clinical implications.

Persistent left superior vena cava (PLSVC) is the most common venous anomaly of the thorax affecting 0.5-2% of the general population. PLSVC with absent right SVC, which is also referred to as isolated PLSVC, occurs in 0.09-0.13% of patients. PLSVC should be suspected whenever a dilated coronary sinus is discovered on transthoracic echocardiography. Transthoracic echocardiography serves as an excellent modality to diagnose PLSVC. The presence of PLSVC can be confirmed by performing a bilateral "bubble study" with injection of agitated saline from both the left and the right peripheral arm veins. Although PLSVC is a benign condition, it may have important clinical implications in certain situations. We describe a case of PLSVC with an absent right SVC followed by a review of the literature and the clinical implications associated with this condition.

The effectiveness of prophylactic proton pump inhibitors for prevention of non-steroidal anti inflammatory drugs associated gastric and duodenal ulcers in elderly.

UNLABELLED: Aims was undertaken to ensure concomitant usage of proton pump inhibitors (PPIs) with Non-Steroidal Anti-inflammatory Drugs (NSAIDs) in Elderly, in order to avoid upper gastrointestinal (GI) symptoms and ulcers. METHODS: Reviewing of 386 patients' prescription on the EMIS (Egton Medical Information Systems) Web, on April 2014. Checking who have not been prescribed PPIs with NSAIDs, offering them appointment for prescription and discussion about risks and benefits of PPIs. Re-audit of 390 patients' prescription on the EMIS Web, on July 2014. Exclusion criteria in the audit and re-audit were; NSAIDs usage for more than 3 years, contra-indications for PPIs, and patients who declined inclusion in the audit. RESULTS: In the first audit cycle, a total of 386 patients' prescription reviewed, 23 (6%) patients were not prescribed PPIs with NSAIDs and were eligible for PPIs prescription. Those patients were contacted by post, an appointment arranged for them and prescribed the PPIs. 12 weeks later a re-audit was done, showed that all patients (100%) who are prescribed NSAIDs are prescribed prophylactic PPIs. None of the patients who are prescribed NSAIDs and PPIs concomitantly developed upper GI symptoms or ulcers. CONCLUSIONS: The audit increased the awareness of the junior doctors of the importance of concomitant prescription of PPIs with NSAIDs, in accordance with the electronic Medical Compendium (eMC) guidelines, to prevent upper GI symptoms and ulcers. That was reflected in the re-audit having 100% of the patients prescribed NSAIDs and PPIs concomitantly.

A catastrophic cause of chest pain.

Chest pain can be a manifestation of aortic pathology and must be considered in any patient with a history of chest trauma, hypertension, atherosclerosis, connective tissue disorder and/or radiographically abnormal aortic contours. Acute intramural haematoma can resemble acute myocardial infarction and can be life-threatening if not correctly diagnosed. Electrocardiogram (ECG) must be carried out in all patients as it helps distinguish acute myocardial infarction (for which antiplatelets and anticoagulants may be life-saving) from intramural haematoma (for which these drugs may be detrimental). Other imaging modalities may be considered depending upon the clinical situation.

Intravascular lithotripsy for severe coronary calcification: a systematic review.

INTRODUCTION: Coronary artery calcification remains a challenge in percutaneous coronary interventions, due to the higher risk of suboptimal result with subsequent poor clinical outcomes. Intravascular lithotripsy is a novel way of treating severe coronary calcification as it has the ability to modify calcium both circumferentially as well as transmurally, facilitating stent expansion and apposition. We conducted a systematic overview of the published literature on intravascular lithotripsy (IVL) assessing the efficacy and feasibility of IVL in treating severe coronary calcification. EVIDENCE ACQUISITION: Of the retrieved publications, 62 met our inclusion criteria and were included. A total of 1389 patients (1414 lesions) with significant coronary calcification or under-expanded stents underwent IVL. EVIDENCE SYNTHESIS: The mean age was 72.03 years (74.7% male). There was a significant improvement in acute and sustained vessel patency, with mean minimal lumen diameter of 2.78±0.46 mm, resulting in acute gain of 1.72±0.51 mm. The acute procedural success rate was 78.2 to 100% with in-hospital complication rate of 5.6 to 7.0%. The majority of the studies reported 30-day MACE, which was between 2.2 to 7.8%. CONCLUSIONS: The recent studies have highlighted that the use of IVL with adjuvant intracoronary imaging has revolutionized the way of treating heavily calcified, non-dilatable coronary lesions and is likely to succeed the conventional ways of treating these complex lesions. We need further studies to gauge the long-term efficacy and safety of IVL against techniques currently available for calcium modification including conventional balloons, cutting or scoring balloons, rotational atherectomy and laser atherectomy.

Coronary Artery Aneurysm: Evaluation, Prognosis, and Proposed Treatment Strategies.

Coronary artery aneurysm is a rare disorder, which occurs in 0.3%-4.9% of patients undergoing coronary angiography. Atherosclerosis accounts for >90% of coronary artery aneurysms in adults, whereas Kawasaki disease is responsible for most cases in children. Recently, with the advent of implantation of drug-eluting stents, there are increasing reports suggesting stents causing coronary aneurysms, months or years after the procedure. The pathophysiology of coronary artery aneurysm is not completely understood but is thought to be similar to that for aneurysms of larger vessels, with the destruction of arterial media, thinning of the arterial wall, increased wall stress, and progressive dilatation of the coronary artery segment. Coronary angiography remains the gold standard tool, providing information about the size, shape, and location and is also useful for planning the strategy of surgical resection. The natural history and prognosis remain unclear. Despite the important anatomical abnormality of the coronary artery, the treatment options of coronary artery aneuryms are still poorly defined and present a therapeutic challenge. We describe four cases, which were managed differently followed by a review of the current literature and propose some treatment strategies.

Lesson of the month 1: Case reports of arrhythmogenic cardiomyopathies in military personnel.

In military recruits, sudden cardiac death rates have been reported as varying from 2 to 13 per 100,000 per year which are mostly related to exercise. However, the development of structural heart changes that may be associated with ventricular arrhythmias have not been reported among this cohort, despite them undergoing endurance training similar to athletes. Here, we report two cases where military personnel were found to have life-threatening cardiac arrhythmias associated with structural heart disease, highlighting the importance of early recognition and treatment of these arrhythmias.

High frequency of false positive results in HIV screening in blood banks.

BACKGROUND: This study was carried out to determine the frequency of false-positive results during serological screening for the presence of antibodies against HIV-I/2 in blood banks. METHODS: A cross-sectional study was conducted from January-December 1999 as screening of voluntary non-renumerated blood donor pool for HIV in the public sector blood banks, in all the six divisions of Balochistan. 5000 subjects were screened for the presence of antibodies against HIV-I/ 2. The subjects were all males between the age group 18-50 years, attending the public sector blood banks as non-renumerated blood donors. Strategy 1 was adopted for initial screening. Strategy II and III were observed in retesting on ELISA, as recommended by UNAIDS/WHO for blood banks. RESULTS: Out of 5000 subjects, 48 (0.96%) were positive for HIV-I/2 on Strategy I, 37 (77% of 48) met the criteria of false positive, while only 11 (0.22% of 5000) were found to be true positive. CONCLUSION: In blood banks, screening for HIV antibodies is performed for intervention of the positive donations. UNAIDS / WHO Strategy-I is observed on a smaller workload blood banks where donations are less than 20 per day. A high rate of false positive results in serological HIV screening on Strategy-I depicts that the test is highly sensitive but not highly specific. Labeling someone with HIV positive, when actually he is not, forces the health authorities to find other ways of HIV screening in blood banks, which should be much more specific and therefore reliable.

Bi-annual surge of Crimean-Congo haemorrhagic fever (CCHF): a five-year experience.

OBJECTIVE: To determine the peak time of outbreak of Crimean-Congo haemorrhagic fever (CCHF) and to highlight the disease-specific areas in the Balochistan province of Pakistan. DESIGN: A hospital-based case-series study. PLACE AND DURATION: A five-year study was conducted by the Department of Pathology in collaboration with the Department of Medicine, Sandeman Provincial Teaching Hospital, Quetta, Balochistan, Pakistan, from 1 March 1997 to 28 February 2002. PATIENTS AND METHODS: A total of 135 cases were included in the study based on a high index of suspicion of CCHF. The mean age was 33.5+/-18.7 years. Two sets of blood samples were drawn on admission; one set was sent for urgent routine investigations while the other was sent to CDC, Atlanta, USA, for confirmation. RESULTS: The study showed that CCHF was more common between March and May and again, between August and October, depicting a bi-annual surge. Out of 135 suspected cases, 83 (61.4%) were confirmed to have CCHF and were given platelet concentrate and ribavirin. It ws observed that CCHF was more common in specific areas of the province. CONCLUSIONS: It is essential to raise the level of knowledge regarding CCHF, especially in disease-specific areas, focussing on the peak outbreak periods.

Early repolarization syndrome: A cause of sudden cardiac death.

Early repolarization syndrome (ERS), demonstrated as J-point elevation on an electrocardiograph, was formerly thought to be a benign entity, but the recent studies have demonstrated that it can be linked to a considerable risk of life - threatening arrhythmias and sudden cardiac death (SCD). Early repolarization characteristics associated with SCD include high - amplitude J-point elevation, horizontal and/or downslopping ST segments, and inferior and/or lateral leads location. The prevalence of ERS varies between 3% and 24%, depending on age, sex and J-point elevation (0.05 mV vs 0.1 mV) being the main determinants. ERS patients are sporadic and they are at a higher risk of having recurrent cardiac events. Implantable cardioverter-defibrillator implantation and isoproterenol are the suggested therapies in this set of patients. On the other hand, asymptomatic patients with ERS are common and have a better prognosis. The risk stratification in asymptomatic patients with ERS still remains a grey area. This review provides an outline of the up-to-date evidence associated with ERS and the risk of life - threatening arrhythmias. Further prospective studies are required to elucidate the mechanisms of ventricular arrhythmogenesis in patients with ERS.

Awareness of HIV and AIDS among fishermen in coastal areas of Balochistan.

OBJECTIVE: The aim of this study is to determine the knowledge, attitude, behaviour and practices regarding HIV/AIDS among the fishermen community in the coastal areas of Balochistan. DESIGN: A cross-sectional survey. PLACE AND DURATION OF STUDY: This study was conducted between September-October 2000 at Gidani, a coastal area of Balochistan. PATIENTS AND METHODS: About 1000 fishermen were interviewed to assess the knowledge, attitude, behaviour and practices regarding HIV/AIDS. It was a community based survey involving the key informants, interviews and focused group discussions. RESULTS: There was little awareness regarding causes and prevention of HIV/AIDS in the community. While healthcare providers believe that the prevalence of HIV/AIDS is high, the community did not consider themselves at risk. Adolescents with any sexual health problems visit hakims and quacks. The community was aware of the etiology and some of the risk factors associated with AIDS, most probably due to the recent public health campaigns against the disease. CONCLUSION: Considering the suspected high prevalence of HIV/AIDS and the relative lack of knowledge, it is imperative that a public health intervention program be initiated in these areas. This must include educating not only the community but also the health workers. The Government's initiative to train community workers in reproductive health is a step in the right direction.

Utility of thick smears of bone marrow aspirate in pyrexia of unknown origin.

OBJECTIVE: To determine the diagnostic efficacy of Giemsa stained thick smear of bone marrow aspirate for evidence of malaria in febrile individuals in whom the diagnosis was otherwise unknown. DESIGN: Descriptive case-series study. PLACE AND DURATION OF STUDY: This study was conducted at the Department of Medicine, Sandeman Provincial Hospital, Quetta, in the Balochistan province of Pakistan, between January 1994 and December 1998. SUBJECTS AND METHODS: A total of 80 patients were included in the study, who presented with history of fever for more than 3 weeks with splenomegaly and pancytopenia. The bone marrow specimens of all these patients were examined. The bone marrow was aspirated from the posterior superior iliac spine. Three sets of smears were made. One set of thin smears was stained by Leishman's stain after air-drying and the second set of thin smears was air-dried, fixed with 97% methanol and later stained with 5% Giemsa stain. The third set of smears was a thick smear stained unfixed with 5% Giemsa stain. A temperature of 37 degrees C and a pH of 7.2 was maintained during the staining process. The presence of malarial parasite in the bone marrow was determined. Besides, the degree of megaloblastic change in erythroid series and the bone marrow cellularity were evaluated. The results obtained were recorded and statistically analyzed. RESULTS: Of the 80 bone marrows examined, 32(40%) showed the presence of malarial parasites, 19(23.75%) showed haematological malignancies, 16(20%) showed bone marrow suppression while 12(15%) showed megaloblastic changes. One (1.25%) case showed Leishman-Donovan bodies. Out of 32 cases showing the presence of malarial parasite in bone marrow, only 5(15.6%) revealed parasites, i.e. Plasmodium falciparum gametocytes on thin smear while 32(100%) cases showed Plasmodium falciparum trophozoites and gametocytes on thick smear. The ratio was 1:6.4. These 32 patients were divided into two groups, one group having mild anaemia (>8 g/dL) and the other severe anaemia (Hb<8 g/dL). In this study 20 patients had mild and 12 had severe anaemia. Megaloblastic changes were seen in 15 cases. Hypocellularity was seen in 3 patients with falciparum malaria while 28 showed normocellularity. The marrow was hypercellular in one patient. CONCLUSION: In patients presenting with prolonged fever, splenomegaly and pancytopenia, the Giemsa stained thick smear of bone marrow aspirates for evidence of malarial parasites was far superior to thin smear in diagnosing Plasmodium falciparum malaria.

Knowledge, attitude and practices regarding Crimean-Congo haemorrhagic fever among healthcare workers in Balochistan.

BACKGROUND: The objective of this study was to determine the knowledge, attitude and practices regarding Crimean-Congo Haemorrhagic Fever (CCHF) among healthcare workers at a tertiary care referral hospital in Balochistan. METHODS: A cross-sectional survey was conducted in April-May 2000 among the doctors, nurses and laboratory technicians of Sandeman Provincial Teaching Hospital, Quetta, Balochistan. A questionnaire was formulated which included the demographic data of the respondents and their knowledge, attitude and practices towards CCHF. RESULTS: A total of 235 healthcare personnel including 150 (63.8%) doctors, 50 (21.2%) nurses and 35 (15%) laboratory technicians were interviewed during the survey. Seventy percent (164) of the subjects were males while 30% (71) were females. One fifty-five (66%) of the total respondents claimed to know what CCHF was. By designation 120 (80%) of doctors, 30 (60%) of nurses and 5 (14%) of laboratory technicians had a prior knowledge about CCHF. One twenty (80%) of the doctors knew the most common presentations of CCHF. All categories of the respondents had a poor knowledge regarding the burial procedure of dead patients. CONCLUSION: This study was an indicator of the poor level of knowledge of healthcare workers regarding the clinical presentations and the modes of spread of CCHF. It is the dire need of the time to educate the healthcare workers about the common preventive measures of this disease, which has resulted in the loss of several important lives in the past in this region.

High frequency of false positive results in HIV screening in blood banks.

BACKGROUND: This study was carried out to determine the frequency of false--positive results during serological screening for the presence of antibodies against HIV-1/2 in blood banks. METHODS: A cross-sectional study was conducted from January--December 1999 as screening of voluntary non-remunerated blood donor pool for HIV in the public sector blood banks, in all the six divisions of Balochistan. 5000 subjects were screened for the presence of antibodies against HIV-1/2. The subjects were all males between the age group 18-50 years, attending the public sector blood banks as non-remunerated blood donors. Strategy I was adopted for initial screening, Strategy II and III were observed in retesting on ELISA, as recommended by UNAIDS/WHO for blood banks. RESULTS: Out of 5000 subjects, 48 (0.96%) were positive for HIV-1/2 on Strategy I, 37 (77% of 48) met the criteria of false positive, while only 11 (0.22% of 5000) were found to be true positive. CONCLUSION: In blood banks, screening for HIV antibodies is performed for intervention of the positive donations. UNAIDS/WHO Strategy-I is observed on a smaller workload blood banks where donations are less than 20 per day. A high rate of false positive results in serological HIV screening on Strategy-I depicts that the test is highly sensitive but not highly specific. Labeling someone with HIV positive, when actually he is not, forces the health authorities to find other ways of HIV screening in blood banks, which should be much more specific and therefore reliable.

Brugada syndrome: a review of the literature.

Brugada syndrome is an example of a channelopathy caused by an alteration in the transmembrane ion currents that together constitute the cardiac action potential. Approximately 20% of the cases of Brugada syndrome have been shown to be associated with mutations in the gene coding for the sodium ion channel in the cell membranes of the muscle cells of the heart. Patients with Brugada syndrome are prone to develop ventricular tachyarrhythmias that may lead to syncope, cardiac arrest or sudden cardiac death. Many clinical situations have been reported to unmask or exacerbate the electrocardiography (ECG) pattern of Brugada syndrome. Genetic testing for Brugada syndrome is clinically available. Here we report two cases of Brugada syndrome followed by a comprehensive review of the literature.

Pregnancy-related Spontaneous Coronary Artery Dissection: Two Case Reports and a Comprehensive Review of Literature.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome, particularly seen in women during pregnancy or in the puerperium. It has a high acute phase mortality. The etiology is uncertain. Hormonal changes during pregnancy, hemodynamic stress and changes in the autoimmune status have been considered as possible etiological factors. A timely diagnosis and institution of appropriate treatment is important for a successful outcome. There is no consensus of opinion for optimal treatment. Conservative management, coronary artery bypass graft surgery, and percutaneous coronary intervention, all have been described in the literature as possible therapeutic options. Spontaneous coronary artery dissection should be considered as a differential in any young woman presenting with chest pain associated with pregnancy. We report two cases of pregnancy-associated spontaneous coronary artery dissection, both successfully managed, along with a comprehensive review of the previously published literature.

Sero-prevalence of hepatitis B virus infection in Balochistan Province of Pakistan.

BACKGROUND/AIM: The objective was to evaluate the sero-prevalence of hepatitis B surface antigen (HBsAg) and IgM antibodies to hepatitis core antigen in Balochistan Province of Pakistan. DESIGN OF THE STUDY: A cross-sectional, population-based study. Place and time of the study: The study was conducted in Balochistan from 1 st January 2004 to 31 st December, 2008. The screening areas included Barkhan, Eashani, Khuzdar, Kodi Zikriani, Kohlu, Rakhni and Turbat. MATERIALS AND METHODS: A total of 15,260 subjects were enrolled; 11,900 (78%) agreed to undergo screening. Fresh serum samples were tested for the presence of hepatitis B surface antigen and IgM antibodies to hepatitis B core antigen. RESULTS: HBsAg was detected in 1166 (9.8%) while anti-HBc IgM was found in 117 (10.0%). HBsAg positivity was seen in 875 (12.7%) males and 291 (5.8%) females. The prevalence of hepatitis B in Balochistan varies from 3.3% in Khuzdar to 17.0% in Kodi Zikriani. CONCLUSIONS: It is utmost important to educate the public, to take proper measures to control the spread of infection and vaccination in order to interrupt transmission of this threatening public health problem in Balochistan province of Pakistan.