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

Incidence, management and subsequent outcome of transcatheter embolized devices- three years audit at a tertiary cardiac care center

To audit the incidence of misplaced devices during varied interventional procedures carried out in our catheter lab over a period of three years. Descriptive study Armed Forces Institute of Cardiology and National Institute of Heart Diseases. From January 2011 to December 2103 All adult and pediatric cases with structural heart disease both congenital and acquired undergoing interventional procedures were included in the study. Out of a total of 3256 patients, 1174 patients who underwent cardiac catheter device implantation procedures during the study period were included in the study. Nineteen patients out of 1174 patients [1.6%] had device embolization acutely or sub acutely following the procedure. The varied reasons for the device embolizations were analyzed in this study. We concluded that for retrieval to be successful via the transcathter approach, it was important to have a wide selection of retrieval equipment available and to be conversant with its use. Our audit also concludes that device implantation at our center are safe and an effective procedure with minimal complications

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

Surgical closure of ventricular septal defect - experience at Armed Forces Institute of Cardiology

To evaluate the results of surgical closure of ventricular septal defect [VSD] with special focus on immediate complications and mortality. Quasi experimental study. Pediatric cardiac surgical department of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1stJanuary 2011 to 31st Dec 2012. All patients undergoing surgical closure of VSD were included in the study. All patients underwent detailed pre-operative assessment including detailed examination, blood tests, chest x-ray, echocardiography and doppler. The surgery was performed under general anesthesia. VSD was closed using polytetrafluoroethylene [PTFE] patch with prolene interrupted sutures. Good post operative care was ensured. The patients were discharged on 7[th] post-operative day and advised follow up after one week. A total of 230 consecutive patients underwent VSD closure with male to female ratio of 2.2:1and mean age was 5.7 +/- 6.5 years. Mean height was 94.8 +/- 31.4 cms and mean weight was 15.3 +/- 12.6 kgs. Per membranous VSDs were most common accounting for 67.4% of cases. Indications for surgery were moderate to large VSDs [77.8%], associated with other congenital heart diseases [CHDs] [8.3%], coronary cusp prolapse with or without aortic regurgitation [13.5%] and infective endocarditis [0.4%]. In one case aortic valve replacement was also done for severe aortic regurgitation due to gross right coronary cusp prolapse. There were 10 [4.3%] deaths in study population and their mean age was 3.5 +/- 5.5 years. In 02[0.9%] patients, permanent pacemaker was also implanted. Open heart surgery for VSD is safe with low mortality in experienced hands

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

Safety and technical success of percutaneous left main coronary artery stenting

Critical stenosis of left main coronary artery [LMCA] has always remained a challenge for interventional cardiologists. Conventionally Coronary Artery Bypass Grafting [CABG] is done for these patients but recently Percutaneous Coronary Intervention [PCI] is also being tried more frequently, but data of PCI is scarce in this regard. Our objective was to determine the safety and technical success rate of percutaneous left main coronary artery stenting. This was 12 month follow up study conducted at Pakistan Institute of Medical Sciences [PIMS], Islamabad from 11th Jan 2012 to 11th Jan 2013. All symptomatic patients who underwent coronary angiogram at PIMS and were found to have either isolated LMCA disease or coexisting osteal Left Anterior Descending [LAD] artery disease were potentially eligible for the study. Patients who had previous surgical treatment for coronary artery disease and those with renal dysfunction requiring dialysis were excluded. Patients were counselled in detail regarding the pros and cons of PCI versus CABG. Those who opted for PCI were included in the study. All these patients were treated with percutaneous left main coronary artery stenting with or without osteal LAD stenting. Seventy two patients had LMCA disease during angiogram. Fifteen patients opted for CABG. Four patients did not meet the inclusion criteria, whereas 53 patients were finally enrolled. Mean age of patients were 55.45 +/- 10.275 years. Twenty nine patients were with acute coronary syndrome and 22 presented with unstable angina. PCI with stenting was technically successful in all patients. One patient died three months after PCI, there was no other mortality. Our study showed that Percutaneous Coronary Intervention [PCI] to LMS has good technical success rate; the safety of the procedure is also acceptable

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

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

Congenital malformations

To determine frequency, pattern of distribution of congenital malformations in newborn. Cross-sectional observational study. Study was carried out in the Department of neonatology, Military Hospital Rawalpindi during the period of January 2008 to Dec 2008. All the newborns were examined and mothers were interviewed. Baby's antenatal record was also noted and recorded in a Performa. Antenatal ultrasonography record was also recorded. Any internal malformation was also noted. Babies who were found to have any malformations were screened for the congenital malformations. Screening was done with latest laboratory tests, radiological evidences and chromosomal studies for suspected trisomies. Congenital anomalies were noted in a Performa. Neural tube defect [NTD] was found to be the commonest type of anomaly. Among the most frequent NTD were hydrocephalus and menigomyelocele. Following that were the cardiac anomalies and genitourinary tract anomalies. Trisomy 21 was detected in two of the babies while one newborn had trisomy 13. NTD were the most prevalent anomaly detected and early prenatal diagnosis is helpful in decreasing the indirect prevalence of perinatal mortality by offering early termination. Folic acid supplementation should be advocated before conception

Iron deficiency anemia; single verses three times daily doses of ferrous sulphate

The adherence to treatment of iron deficiency anemia often is poor in both developed and developing countries. The current standard therapy is oral ferrous sulfate administered 3 times daily. It is possible that adherence would improve with a single-dose daily treatment regimen. To compare single versus thrice daily ferrous sulfate for treatment of iron deficiency anemia in young children. Quasi experimental study Setting: Children Department Military Hospital Rawalpindi. From [01 Jan to 31 Mar 05 and 03 Jul to 02 Oct 05]. Total 250 patients of iron deficiency anemia [hemoglobin values: 7.0 to 9.9 gm/dl and serum ferritin values: 10 ng/ml or less] were identified. Children divided into two groups and matched on the basis of age; and gender. One group [n=125] received ferrous sulfate once daily and the control group [n=125] received ferrous sulfate thrice daily at a total dose of 6 mg/kg/day of elemental iron for 2 months. Hemoglobin and serum ferritin values were measured as baseline and at the end of the study. Successful treatment of anemia [target hemoglobin > 10 gm/dl] occurred in 81.42 of the single dose nd in 79.83% of thrice daily dose groups and the side effects were minimal between the two groups. A single versus a 3 times daily dose of ferrous sulfate resulted in a similar rate of successful treatment of iron deficiency anemia, without significant side effects

Etiology of short stature in children

To determine the causes of short stature in children with special emphasis on growth hormone deficiency. Case series. Department of Paediatrics, Military Hospital, Rawalpindi and Combined Military Hospital, Multan from September 2004 to January 2007. Two hundred and fourteen children [140 boys and 74 girls], ranging from 02 to 15 years presenting with short stature were studied. Height and weight were plotted on appropriate growth charts and centiles determined. Relevant hematological and biochemical investigations including thyroid profile were done. Bone age was determined in all cases. Growth hormone axis was investigated after excluding other causes. Karyotyping was done in selected cases. Data was analyzed by SPSS 10.0 by descriptive statistics. Mean values were compared using t-test. In this study, the five most common etiological factors in order of frequency were Constitutional Growth Delay [CGD], Familial Short Stature [FSS], malnutrition, coeliac disease and Growth Hormone Deficiency [GHD]. In 37.4% of patients, the study revealed normal variants of growth - CGD, FSS or combination of both, 46.7% cases had non-endocrinological and 15.9% had endocrinological etiology. CGD [22.1%] in males and FSS [27%] in females were the most common etiology. GHD was found in 6.1% children and it comprised 38.2% of all endocrinological causes. Children with height falling below 0.4[th] centile were more likely to have a pathological short stature [79.2%] compared to 39.3% whose height was below 3rd centile but above 0.4[th] centile [p<0.05]. CGD and FSS are most common causes of short stature in boys and girls respectively, whereas, GHD is a relatively uncommon etiology