Non-invasive investigations in heroin users and non-users - a case control study

Objective: To compare heroin users with their age and gender matched relatives as regards non-invasive investigations like chest x-ray, electrocardiography [ECG] and 2D-echocardiography

Study Design: Case control study

Place and Duration of Study: Armed Forces Institute of Cardiology-National Institute of Heart Diseases, Rawalpindi, from Feb 2010 to Jul 2010

Material and Methods: Sixty one heroin users [cases] and their 100 non-substance abuser age and gender matched relatives [controls] were included through non-probability consecutive sampling. Chest x-ray [CXR], 12-lead electrocardiography [ECG] and two-dimensional echocardiography [2D-ECHO] were done of each one and the result was interpreted by respected consultants. The data were analyzed on SPSS version 15. Descriptive statistics of mean and standard deviation [SD] were described for quantitative variables while frequency and percentages for qualitative variables. Independent samples t-test compared quantitative variables while for qualitative variables chi-square test was used. Ninety five percent confidence intervals were calculated for all variables

Results: Statistically significant differences were noted between cases and controls as regards chest X-ray. A total of 10% cases had findings consistent with tuberculosis [TB] as compared to 3% controls [p=0.045]. There was however no cardiac abnormality in any study subject. Significant 12-lead ECG findings other than normal were noticed in 12 [19.7%] heroin users as compared to 10 [10%] controls [p=0.083]. In 12 lead ECG, the predominant finding was t wave inversion in leads AVF and III. According to 2D-echocardiography [2D-echo] reports, 15 [24.6%] heroin users [cases] and 17 [17%] controls had abnormal findings [p=0.242]. We report no vegetations on any cardiac valve

Conclusion: On radiological and cardiac parameters, heroin users are a different population as compared to the non-heroin users. The knowledge about variations on non-invasive investigations not only helps the healthcare workers to optimize treatment regarding rehabilitation but also facilitate diagnosis and treatment

Percutaneous transcatheter PDA device closure in infancy

To evaluate the results and complications associated with transcatheter closure of patent ductus arteriosus [PDA] in infants. Quasi-experimental study. Paediatric Cardiology Department of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD], Rawalpindi, from December 2010 to June 2012. Infants undergoing transcatheter device closure of PDA were included. All patients were evaluated by experienced Paediatric Cardiologists with 2-D echocardiography and Doppler before the procedure. Success of closure and complications were recorded. The age of patients varied from 05 - 12 months and 31 [56.4%] were females. Out of the 55 infants, 3 [5.4%] were not offered device closure after aortogram [two large tubular type ducts and one tiny duct, considered unsuitable for device closure]; while in 50 [96.1%] patients out of remaining 52, the duct was successfully closed with transcatheter PDA device or coil. In one infant, device deployment resulted in acquired coarctation, necessitating device retrieval by Snare followed by surgical duct interruption and another patient had non-fatal cardiac arrest during device deployment leading to abandonment of procedure and subsequent successful surgical interruption. Local vascular complications occurred in 12 [21.8%] of cases and all were satisfactorily treated. Transcatheter device closure of PDA in infants was an effective procedure in the majority of cases; however, there were considerable number of local access site vascular complications

Comparative study to evaluate the efficacy of transthoracic echocardiography versus cardiac catheterization for pre operative assessment of tetralogy of fallot

To determine the results of transthoracic echocardiography and cardiac catheterization for pre operative assessment of Tetralogy of Fallot and operative outcomes for the patients. Case Series; prospective descriptive study. Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi, Jan 2006 to December 2010. All patients admitted in AFIC/NIHD for surgical repair of Tetralogy of Fallot. A total of 746 patients were included in study, male [33%], female [67%], mean age was 4.7 years. Group I was evaluated for total correction with combined transthoracic two dimensional echocardiography and cardiac catheterization, and group II was subjected to transthoracic two dimensional echocardiography only for pre operative assessment. Overall mortality was 8.4% in group I and 10.8% in group II. In group II, 84% had total correction and 16% had closed heart, while in group II 73% had open heart and 27% had closed heart surgery. Tetralogy of Fallot is the leading cause of cyanotic congenital cardiac heart disease. The pre operative evaluation with help of Transthoracic two dimensional echocardiography requires oral sedation, is cost effective and minimally invasive. Cardiac catheterization being reserved for the patients having inadequate information on Transthoracic echocardiography. Early surgery during childhood has long term benefits in terms of morbidity and lifestyle adjustment

Management of patients with acute myocardial infarction complicated by ventricular septal rupture - AFIC study

The aim of this study was to report management; peri-procedural and short term results of patients hospitalized with acute myocardial infarction [MI]complicated by ventricular septal rupture [VSR] considered high risk or unfit for surgical repair at AFIC-NIHD. Quasi experimental study Adult and paediatric cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] January 2012 to 31[st] August 2013. We included 12 patients with post myocardial infarction VSR with mean age of 59 years [41-85 years], who underwent elective transcatheter closure. The entry criteria for trans-catheter closure after initial medical stabilization was 1] patients with ventricular septal rupture up to 20 mm size with significant left to right shunting [Qp/Qs >1.5] 2] defect anatomy and location thought to be suitable for device closure or otherwise considered high risk or unfit for surgical closure. The time from the onset of infarction to the index procedure ranged between 4 to 20 days [mean 10.83 days]. There were ten patients in acute phase [2 weeks or less] and two presented in sub-acute phase [> 2 weeks]. Ten patients were in NYHA class III and one each in class II and IV. A successful device implantation occurred in all patients except in one in whom second attempt failed. The defect size ranged 4-18 mm [mean 9.25 mm] and the devices ranging from 8-22 mm [mean 13.3 mm] were implanted. The procedure time ranged from 90-140 min [mean 105 min]. In all patients Qp/Qs was more than 2 and decreased to less than two after the procedure. Six surviving patients are in NYHA class II and doing well. One patient died one hour after the procedure whereas one patient died twelve hour after the closure because of re-infarction. One patient developed another VSR leak 3 days after the procedure and device closure was attempted again but the device could not be deployed. He subsequently died awaiting surgery. Primary trans-catheter closure of post-infarction ventricular septal rupture may be an alternative to surgery in patients with suitable anatomy and high risk or unfit for surgery

Outcome and immediate complications of device occlusion of different types of patent ductus arteriosus with range of devices

The aim of our study was to report the outcome and immediate complications of PDA device closure, comparing ducts according to Krichenko classification. Quasi experimental study. Pediatric Cardiology Department of Armed Forces Institute of Cardiology / National institute of Heart Diseases [AFIC/NIHD] from 1[st] May 2012 to 30[th] Nov 2013. Total 368 consecutive cases, were included with intention of transcatheter closure of patent ductus arteriosus [PDA]. Detailed echocardiography was done before procedure. Aortogram determined duct size, length, narrowest diameter and morphology. Device attempted only after duct was considered suitable. The mean narrowest duct diameter was 4.5 +/- 2.4 mm. Out of 368 cases, five cases were considered unsuitable for device closure after aortogram. In two cases, device embolized after deployment and in one case procedure abandoned due to technical reasons. There was no cardiac perforation, tamponade or death in our study population. The success according to Krichenko duct types was 100% for type A, 100% for type B, 87.5% for type C, 100% for type D and 100% for type E. PDA device closure is a safe and effective therapeutic option in vast majority of cases. Type C tubular type ducts are more difficult to negotiate with high complication rates

Prospective study of percutaneous balloon pulmonary valvuloplasty - immediate results and complications

To assess the results and immediate complications of percutaneous balloon pulmonary valvuloplasty at AFIC/NIHD. Quasi experimental study Paediatric cardiology department of Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC-NIHD] Pakistan from 01[st] October 2010 to 31[st] September 2013. This study comprised 143 patients [74 male and 69 female] with pulmonary valve stenosis undergoing percutaneous balloon valvuloplasty. The procedure was classified as successful when the angiographic derived peak to peak pressure gradient [PG]across right ventricular outflow tract was reduced to less than 50% of pre-procedural value, suboptimal if reduction was 25-50% and unsuccessful if PG reduced by less than 25% of its initial value. The mean age of study population was 8.4 +/- 10.3 years and procedure was successful in 133 [93%] cases. Mean PG was reduced from 85.6 +/- 34.4 mmHg to 24.7 +/- 14.5 mmHg [p< 0.001]. Procedure was considered unsuccessful in one case, where PG across right ventricular outflow tract [RVOT] reduced from 70 to 60 mmHg, due to concomitant infundibular bands. In another nine patients, procedure considered suboptimal, as mean PG reduced from 81 +/- 24.1 to 50 +/- 16 mmHg. Among study population, 31 [21.7%] cases were considered as critical pulmonary stenosis. There were two deaths, two non fatal cardiac arrests, one life threatening arrhythmias and minor rhythm problems in five cases, but no cardiac tamponade or emergency cardiac surgery in our study population. Percutaneous balloon valvuloplasty was effective and safe for the treatment of pulmonary valve stenosis with excellent short term results

spectrum of anatomical variations in patients with tetralogy of fallot undergoing diagnostic cardiac catheterization

To determine the various anatomic associations in patients undergoing diagnostic cardiac catheterization with Tetralogy of Fallot. Descriptive study. Armed forces Institute of Cardiology and National Institute of Heart Diseases, from Jan 2012 to Dec 2012 All patients with tetralogy of fallot [TOF] who underwent cardiac catheterization were included in the study. A standard catheterization with cine-angiograms was performed and different associations were recorded. A total 200 patients underwent catheterization during 12 months. The mean age of patients was 6.3 years including 66% [n=132] male and 34% [n=68] female patients. The most common associated anomaly in our patients was major aortopulmonary collateral arteries [MAPCAS] 28% [17% significant and 11% insignificant]. The other associated anomalies were right sided arch in 10%patients, additional muscular ventricular septal defects in 4% [8] patients, persistence of left superior vena cava in 5%[10] patients, patent ductus arteriosus in 5% [10] patients, absent left pulmonary artery in 1% [2] patients and left anterior descending coronary artery crossing right ventricular outflow tract [RVOT] in 1%patients. There was no cardiac perforation, tamponade, cardiac arrest or death during this period. Major aortopulmonary collateral arteries remained the most common finding which necessitated early diagnosis and management in order to prevent long term complications

Transcatheter device closure of patent ductus arteriosus

To determine the efficacy, safety and immediate complications encountered during percutaneous device closure of patent ductus arteriosus [PDA]. Case series. Department of Paediatric Cardiology, AFIC/NIHD, Rawalpindi, from January 2005 to December 2010. Consecutive 500 patients who underwent attempted transcatheter PDA device closure were included in the study. Device type position, success of closure and complications were described as frequency percentage. In 491 cases [98.2%], PDA was successfully occluded including 4 cases [0.8%] where devices were dislodged but retrieved and redeployed in Cath laboratory. PDA occluder devices used in 448 cases [91%] while coils [single or multiple] were used in 42 cases [8.5%] and in one case [0.2%] ASD occluder device was used to occlude the PDA. There were 09 [1.8%] unsuccessful cases, 06 [1.2%] were abandoned as ducts were considered unsuitable for device closure, 02 [0.4%] devices dislodged and needed surgical retrieval and one case [0.2%] was abandoned due to faulty equipment. The narrowest PDA diameter ranged from 0.5 - 14 mm with mean of 4.5 +/- 2.4 mm. There was a single [0.2%] mortality. Transcatheter occlusion of PDA by coil or occluder device is an effective therapeutic option with high success rate. Complication rate is low in the hands of skilled operators yet paediatric cardiac surgical back-up cover is mandatory

Transcatheter device closure of secundum atrial septal defect [ASD] in young children

To analyze the safety and efficacy of device closure of secundum atrial septal defect in children < 5 years of age. Quasi-experimental study. The study was conducted at Armed Forces Institute of Cardiology / National Institute of Heart Diseases Rawalpindi, Pakistan from Dec 2010 - Dec 2012. Forty eight patients < 5 years of age underwent transcatheter closure of secundum ASD during two years. All patients were evaluated with 2-D echocardiography before the procedure. The sizing balloon was used in 6% and general anaesthesia was given in 83% [n=40] of patients. Ninety seven point nine percent [47/48] had successful closure of ASD. The mean age was 4.1 +/- .68 years [range 2.5-5 years] and 58.4% [28/48] were females. The defect size and occluders used were between 5-20 mm [mean 12 +/- 3.5] and 8-22 mm [mean 15 +/- 3.9] respectively, three patients had simultaneous procedures including pulmonary valvuloplasty in two and percutaneous transmitral commissurotomy [PTMC] in one. The major complications remained 2% [1/48] which included device embolization just after release of device while minor complication rate was 12.5%. The median procedure time was 30 min [15-100 min] and median fluoroscopic time was 6 min [1.50-45 min]. There was no emergency surgical exploration or death during this period. Transcatheter device closure of suitable secundum atrial septal defect is effective and safe in young children in skilled and professional hands

Case report: a 14 days old neonate with intracardiac mass

Amjad was a 14 days old neonate, presented with progressive bluish coloration. He initially started on breast feeding but later on was noticed by mother to stop frequently during feeds, cry excessively and developed bluish disceleration of mucosa and lips. On examination, the baby was blue, cold and dehydrated. He had pulse of 150/min, respiratory rate of 60/ min, blood pressure of 80/50 mm of Hg, oxygen saturation of 78% and afebrile. The neonate had a severe perianal rash extending into groins. On cardiovascular examination, apex beat was in left 4th intercostal space lateral to midclavicular line. He had a 3/6 pansystolic murmur at lower left sternal edge with normal heart sound. An S3 gallop was noticed as well as prominent neck veins were seen and liver was tender on palpation. The relevant investigations were carried out revealing Hb of 21g/dl. The 12 lead ECG revealed heart rate of 140/min, PR interval of 80 msec, RSR` in V1 QT interval of 0.2 sec. On chest X-ray cardiomegaly was noticed along with plethoric lung fields. Two dimensional echocardiogram revealed situ solitus, levocardia, AV and VA concordance, systemic venous return to LA, pulmonary venous return to RA, and huge mass was noticed in right atrium extending to right ventricle causing obstruction to pulmonary venous return. On the basis of history, examination and investigations a diagnosis of cardiac tumor was made and diagnostic procedure was preformed. The child was put on intravenous antibiotics, cefitraxone and vitamin K. A big growth from right ventricle was removed adherent to RV cavity and tricuspid valve. It was extending to right atrium. Mass excision was done resulting in a small RV cavity and small pulmonary arteries were seen. The tricuspid valve was dilated. After the tumor resection, RVOT reconstruction was done and RA was closed. Multiple attempts to wean off from bypass were not successful as the right ventricle cavity was not able to cope with systemic venous return and the child expired. The specimen was sent for histopathology which revealed a right sided rhabdomyoma