Percutaneous transmitral commissurotomy [PTMC]; procedural success and immediate results, a tertiary care hospital experience from developing country

Background: Mitral stenosis is one of the grave consequences of rheumatic heart disease. Balloon valvuloplasty for stenosed mitral and pulmonary valves has been practiced with good results in the world. Since Inoue et al. introduced balloon valvuloplasty in 1982, percutaneous transmitral commissurotomy [PTMC] has become the treatment of choice for mitral stenosis replacing surgical commissurotomy and mitral valve replacement in many cases

Objective: The aim of this study was to audit the procedural success, in hospital outcome in patients undergoing percutaneous trans-mitral balloon commissurotomy [PTMC] in our set up. Study Design: Observational cross sectional study. Place and Duration: The study was conducted at Faisalabad Institute of Cardiology Faisalabad from March 2011 to December 2013

Materials and Methods: Total one hundred and twenty four patients underwent percutaneous transmitral commissurotomy from March 2011 to December 2013. Any patient of age >/= 10 years with mitral stenosis who fulfills the inclusion and exclusion criteria for PTMC was enrolled in this study. A full history particularly, age, sex, occupation, address, symptoms regarding their referral for medical checkup was noted. Detailed clinical examination especially relevant cardiovascular examination of all the patients was done. ECG of every patient was done. Baseline routine investigations including blood complete with ESR, electrolytes, CRP, LFT, RFT was done in each case. A baseline echocardiography was performed in all patients. Mitral valve area was calculated by planimetry and by pressure half time method. Severity of mitral stenosis was graded as: very sever stenosis [valve area <1cm[2]], severe [valve area 1- 1.5 cm [2]] moderate [valve area 1.5- 2 cm[2]] and mild [valve area > 2.0 cm[2]]. To exclude any clot in LA and LA appendage Transesophageal echocardiography [TEE] was performed. In Cath Lab pre and post PTMC invasive hemodynamics including LA, RA, RV, left ventricular end-diastolic pressure [LVEDP], and transmitral pressure gradient [PG] was calculated. Those patients who have echo contrast on echocardiography were given 5000 IU heparin IV after septal puncture. Antibiotic prophylaxis was initiated in all patients thereafter. The procedure was performed under local anesthesia, if needed moderate sedation was given with midazolam. The procedure was ended when either at least one commissure was splitted, adequate increase in mitral valve area or increase in degree of MR or decrease in mean LA pressure to ½ of pre PTMC value or decrease in mitral valve gradient was observed. After 24-48 hours patient was discharged and before discharge transthorasic echo was done to measure all the parameters as pre PTMC along with any echo finding of pericardial effusion

Results: Total 124 patients were studied, 92[74.2%] were female and 32[25.8%] were male showing a female predominance. The mean age was 27.29 +/- 9.3. Most of the patients 58[46.8%] were in age group 21-30 years. 87[70.16%] patients were in atrial fibrillation and 37[29.83%] had sinus rhythm. The procedure was successful in 118[95.16%] patients. 2[1.6%] patients need urgent MVR due to severe MR and 1 [0.8%] died during procedure. Most of the patients 85[68.55%] were in NYHA class III. After PTMC, ASD was present in 13[10.5%] patients. After PTMC moderate MR was seen in 2[1.6%] and severe MR was observed in 4[2.173%] patients. Most of the patients 115[92.7%] before PTMC were in severe pulmonary hypertension and after PTMC most of the patients 91[73.4%] were in mild pulmonary hypertension. Pre PTMC mean MVA [cm[2]] was 0.684 +/- 0.1226 and post PTMC it was 1.533 +/- 0.281 cm[2]. Mean MVPG pre PTMC was 26.178 +/- 5.94 mmHg and post PTMC it was 7.62 +/- 5.007 mmHg with significant p value 0.0001. Mean LA pressure before procedure was 29.68 +/- 8.137 mmHg and post PTMC it was 12.28 +/- 6.99 and p value was 0.0001. 10 patients had special problems, 3 had previous H/O PTMC, 3 were pregnant lady, one has kyphoscoliosis, one had large IAS aneurysm, one had H/O CVA and one patient was suffering from renal cell carcinoma

Conclusions: The outcome of this study suggests that PTMC is a safe procedure in experienced hand with good success rate and optimal results even in patients with special problems like pregnancy, previous CVA and redo cases

Clinical presentation, risk factors and outcome of stroke at a district level teaching hospital

Stroke is a fatal clinical syndrome with mortality rate ranging up to 25%. Hypertension, smoking and diabetes mellitus are common preventable risk factors which are associated with serious outcome. Objective of this study was to determine the clinical presentation, risk factors and outcome of stroke. A cross-sectional study was conducted in the Medical Wards of DHQ Teaching Hospital, Mirpur Azad Kashmir from March 2010 to January 2011. A questionnaire was prepared in accordance with the objectives of the study. Frequency of risk factors in patients with stroke were studied. Different clinical features were also noted and response to the given treatment was checked in the form of mortality and recovery. Frequencies and percentages were calculated using SPSS-12. Two hundred patients with stroke were selected. Of the total, 136 [68%] had hypertension, 55 [27.5%] were smokers, 53 [26.5%] had diabetes and 25 [12.5%] patients had ischemic heart disease. One hundred and two [51%] patients presented with headache, 99 [49.5%] developed hemiplegia and 94 [47%] had loss of consciousness. CT brain showed infarction in 144 [72%] patients while 56 [28%] had haemorrhage. Observed mortality in this study was 18 [9%] while 182 [91%] patients were discharged after treatment. Hypertension, smoking and diabetes mellitus are major modifiable risk factors for stroke. Headache, hemiplegia and loss of consciousness are major clinical features. Ischemic stroke is much common compared to hemorrhagic stroke. With proper care stroke is manageable satisfactorily

Presentation of congestive cardiac failure in children with ventricular septal defect

While there is much data on cardiac problems of adults, there is a limited statistical data available to evaluate the magnitude of the cardiac problems in children in Pakistan. Many of these children present with recurrent chest infections and congestive cardiac failure [CCF], and are managed by general practitioners. A careful search for underlying cardiac problems and awareness about the presentation of CCF and its magnitude will definitely decrease the morbidity and mortality of these children. The objective of this study was to see the frequency and clinical presentation of CCF in children with Ventricular Septal Defect [VSD]. Forty-nine patients met the preset criteria during the study period of 6 months. A detailed history and physical examination with special emphasis on symptoms and signs was sought and the findings were noted in a questionnaire. Data was analysed using SPSS-11. Frequencies and percentages were calculated for all categorical variables. CCF in VSD was found more in males, with a male to female ratio of 1.45:1. Majority [63.1%] of the patients presented in infancy. The common symptoms at presentation were dyspnoea [98%], cough [83.7%], and feeding difficulty [9.6%]. Other important symptoms were fever, fatigue, failure to thrive, sweating and wheezing. The common physical signs in order of frequency were murmur 98%, tachypnoea 91.8%, tachycardia 89.8%, hepatomegally 89.9% and crackles in chest 85.7%. Other presenting signs were displaced apex beat 57%, oedema 28.6% and chest deformity 20.4%. Regarding the type of VSD, perimembranous was the commonest 61.2% as confirmed by echocardiography. This study was done on a smaller scale in hospitalised children. The exact studies regarding CCF in paediatric patients are scarce. There is a need to design more studies in children with CCF. Early recognition of signs and symptoms of CCF on paediatric patients with VSD and awareness at primary health care level can prevent the delay in the diagnosis and early referrals by GPs to hospital setup will definitely reduce the morbidity and mortality