"Mother and child technique" combined with super selective pharmacological intervention for large intracoronary thrombus

Primary percutaneous intervention [PCI] in acute ST elevation myocardial infarction [MI] is a preferred way of treatment nowadays. Sometimes it becomes difficult to get good myocardial blood flow during PCI if clot burden is large. In this case of an elderly lady, the use of "Mother and Child Technique" combined with super selective pharmacological intervention is demonstrated to achieve good blood flow when conventional means are not working

Percutaneous coronary intervention in unprotected left main coronary artery disease

Percutaneous coronary intervention for unprotected left main coronary artery disease is potentially an important intervention in surgically unstable patients. A detailed review of medical record and visual analysis of coronary angiography and PCI procedure was undertaken. The study was conducted at the Aga Khan University Hospital, from January 2003 to December 2007. Patients included in the study had unprotected > 70% left main stenosis with ongoing ischemia, considered unsuitable for surgical revascularization. A total of 9 patients were included with a mean age of 70.1 years. Six patients had cardiogenic shock. Eight patients had bifurcation lesion. Simultaneous kissing stenting technique was used in 4 patients. There were 4 in-hospital deaths while 5 patients were alive at discharge. All 4 patients who expired had cardiogenic shock. Four patients were alive at a mean follow-up of 17 months. PCI turned out to be an alternative therapeutic option for unprotected left main coronary artery disease when surgery is declined

Trends of lipid abnormalities in Pakistani type-2 diabetes mellitus patients: a tertiary care centre data

To ascertain trends of lipid abnormalities in Pakistani Type-2 Diabetes Mellitus patients. Fasting lipid profiles of 328 outpatient adult type 2 diabetes mellitus patients visiting the Aga Khan University Hospital, from January 2005 to January 2006 were prospectively reviewed and abstracted on a pre-specified proforma. Demographic features, different patterns of dyslipidemia in accordance with specified risk categories, and the proportion of patients with none, one, two, or three lipid values outside clinical targets were noted. The influence of sex on dyslipidemia pattern was also assessed. Our patients had higher average HbA1c levels and higher total cholesterol, LDL and lower HDL levels. The triglycerides levels in our female patients were higher. The percentage of our patients with a high-, borderline-, or low-risk LDL cholesterol were 54, 29, and 16%, respectively [P = 0.51]. On a percentage basis, 73% were in the high-risk HDL cholesterol group, 18% were in the borderline-risk group and 9% in the low-risk group, respectively [P< 0.0001]. Regarding triglyceride concentrations, 16% had high-risk triglyceride levels, 34% were in the borderline-risk category, whereas 50% had a low-risk triglyceride levels [P< 0.0001]. Patient proportion with None, One, Two, or Three Values outside clinical targets on percentage basis were 2, 16, 48, and 34%, respectively [P< 0.0001]. Women were found to have greater odds of having LDL cholesterol above the target level i.e. >100mg/dl. Combination of high LDL and a low HDL cholesterol level was the commonest pattern of dyslipidemia found. Second was unfavorable levels of all three lipoproteins combined and the third was an isolated increase in LDL cholesterol. A greater proportion of women were found dyslipidemic

Successful treatment of early postinfarction massive ventricular septal rupture and cardiogenic shock

A 65 years old woman presented to the ER with vomiting and severe retro-sternal chest pain for twelve hours. She was extremely dyspneic with a respiratory rate of 32/min, heart rate of 120/min, blood pressure of 70/50 mmHg and 02 saturations of 91% on 15 liters by face mask. She had bilateral crepitations upto mid lung zones bilaterally and had pan systolic murmur and had cool extremities with no pedal pulses. ECG showed massive anterior ST elevation myocardial infarction. An emergent echocardiography showed dilated right ventricle, and a large ventricular septal rupture anteriorly with severely reduced LV function. Patient was intubated, taken to the cardiac catheterization lab. An IABP was placed and on angiography large ventricular septal rupture was identified along with complete LAD occlusion. Median sternotomy was performed and patient was placed on cardiopulmonary bypass. The anterior infracted portion was excised and large anterior VSD was identified. The edges were debrided and then a large 7.5 cm defect in the anterior interventricular septum was identified. A Dacron patch was sewn along the edges of the VSD with interrupted plegeteted ethibond sutures and then the free wall of the LV and RV were brought together with plegeted prolene sutures; thus sandwitching the patch and closing the ventricular free wall also. LAD was grafted with a vein graft. IABP was removed after 48 hours and the patient was extubated. The rest of the hospital stay was unremarkable and patient was discharged home in 10 days

Angiography to detect diversion of superior vena cava flow secondary to surgical repair of sinus venosus atrial septal defect

Redirecting superior vena cava [SVC] flow to left atrium [LA] is an iatrogenic complication following surgical repair of sinus venosus atrial septal defect. This case report describes a patient who continued to have hypoxia following the surgical repair of sinus venosus atrial septal defect. Transesophageal echocardiogram and right heart catheterization did not reveal any abnormality. Contrastangiography was performed from right internal jugular vein which confirmed flow from SVC to LA. Emergent corrective surgery then resulted in an uneventful hospital course

Cardiac myxomas clinical spectrum and outcome

To describe the characteristics and outcome of patients with cardiac myxomas. A case series. The Aga Khan University Hospital [AKUH], from 1999 to 2004. All patients diagnosed and managed as having cardiac myxomas at AKUH, during a period of six years [1999- 2004] were included. Data was collected by reviewing clinical records. Follow-up data was collected from the clinical records and by a telephone interview where required. Out of 15 patients who were diagnosed to have cardiac myxomas, complete information was available in 14 patients. There was a female predominance [64%] with a mean age of 47 years. About two-thirds [71%] had symptom of dyspnoea. Half of the patients [50%] had neurological symptoms at presentation. Constitutional symptoms were present in 36% of patients. About two-third of patients [71%] had positive findings on cardiac auscultation. None of the patients had any rhythm abnormalities on the ECG. Diagnosis was made by transthoracic echocardiography in all patients. All of the tumors were located in the left atrium, and majority [64%] were attached to the interatrial septum. All patients were advised surgical treatment, however, only 8 [57%] were operated upon. Outcome was good in those who were operated upon, with no peri and postoperative mortality. Cardiac myxomas are a rare, but potentially curable form of heart disease. They occur in a wide range of age groups with a female predominance. Dyspnea is the most common clinical feature followed by embolic complications. Left atrium is the most common site of location. Surgical excision is a safe and effective procedure

Late in-stent restenosis in a patient with drug-eluting stent

Drug coated stents have reduced the incidence of in-stent restenosis with coronary intervention. whether this effect is long lasting or just delaying the process is not clear. We report here a case of late in-stent restenosis with Raoamycin drug eluting stent.

Chronic total occlusion of left main coronary artery

A 64 years old diabetic male underwent diagnostic coronary angiography for stable angina [Canadian Class II] of 6 months duration. He had only one episode of prolonged rest angina two months prior to presentation. Electrocardiogram was abnormal for complete right bundle branch block with left anterior fascicular block and Q-wave anteroseptal myocardial infarction. Coronary angiography revealed total occlusion of the distal LMCA with minimal antegrade flow in the left coronary system beyond the occlusion. The right coronary artery [RCA] had 90% stenosis in the posterolateral branch and supplied collateral circulation to the left coronary arteries with retrograde filling of left anterior descending [LAD] and left circumflex [LCX]. The patient underwent urgent CABG. Revascularization was performed with left internal mammary artery anastomosed to LAD and vein grafts to LCX and RCA. The postoperative course remained uneventful with early discharge and the patient is currently asymptomatic undergoing cardiac rehabilitation

Transesophageal echocardiogram: retrospective review and current clinical applications

Since the introduction of transesophageal echocardiogram in early eighties, clinical application of this diagnostic procedure has increased tremendously. A retrospective study to evaluate the indications of performing this test was done at The Aga Khan University Hospital. Also reviewed in detail are its current clinical applications. A total of 236 procedures were performed during the period of March 1995 to April 2000. Only 2 patients [0.91] had complications. TEE is a safe and effective disfunction tool