Determination of positivity of computed tomographic angiography in poorly visualized left anterior descending artery on conventional angiography

Objective: To determine the positivity of CT angiography in visualization of poorly visualized left anterior descending artery [LAD] on conventional angiography for decision of its surgical revascularization. Study Design: Descriptive study. Place and Duration of Study: Department of Cardiac Surgery, Faisalabad Institute of Cardiology, Faisalabad, from July 2014 to March 2015

Methodology: This study involved 55 patients who had non-graftable LAD on conventional coronary angiography [CCA]. All patients underwent computed tomography angiography [CTA]. Patients having graftable LAD on CTA then underwent coronary artery bypass grafting [CABG]. Peroperatively, the characteristics of LAD such as diameter, calcification and graftability were also recorded

Results: The mean age of the patients was 52.76 +/-8.52 years. There were 45 [81.8%] male and 10 [18.2%] female patients. Out of 55 patients, CTA revealed graftable LAD in 33 [60%] cases while LAD was non-graftable in 22 [40%] cases. Out of 33 patients having graftable LAD, 26 [78.79%] patients underwent CABG; whereas, remaining 7 [21.21%] patients had different reasons like other associated diseases and refusal from surgery. Among those who underwent surgery, LAD was graftable in all the patients [100%] peroperatively. Peroperatively 11 [42.3%] patients had mild calcification followed by severe calcification in 9 [34.6%] and moderate calcification in 6 [23.1%] cases. Fifteen [57.7%] patients had LAD caliber >1.5 mm while 11 [42.3%] patients had LAD caliber between 1.25 - 1.5 mm preoperatively

Conclusion: Positivity of the CT angiography for poorly visualized LAD on conventional angiography was 60% in the present study

Determination of positivity of computed tomographic angiography in poorly visualized left anterior descending artery on conventional angiography

Objective: To determine the positivity of CT angiography in visualization of poorly visualized left anterior descending artery [LAD] on conventional angiography for decision of its surgical revascularization

Study Design: Descriptive study

Place and Duration of Study: Department of Cardiac Surgery, Faisalabad Institute of Cardiology, Faisalabad, from July 2014 to March 2015

Methodology: This study involved 55 patients who had non-graftable LAD on conventional coronary angiography [CCA].All patients underwent computed tomography angiography [CTA]. Patients having graftable LAD on CTA then underwent coronary artery bypass grafting [CABG]. Peroperatively, the characteristics of LAD such as diameter, calcification and graftability were also recorded

Results: The mean age of the patients was 52.76 +/-8.52 years. There were 45 [81.8%] male and 10 [18.2%] female patients. Out of 55 patients, CTA revealed graftable LAD in 33 [60%] cases while LAD was non-graftable in 22 [40%] cases. Out of 33 patients having graftable LAD, 26 [78.79%] patients underwent CABG; whereas, remaining 7 [21.21%] patients had different reasons like other associated diseases and refusal from surgery. Among those who underwent surgery, LAD was graftable in all the patients [100%] peroperatively. Peroperatively 11 [42.3%] patients had mild calcification followed by severe calcification in 9 [34.6%] and moderate calcification in 6 [23.1%] cases. Fifteen [57.7%] patients had LAD caliber >1.5 mm while 11 [42.3%] patients had LAD caliber between 1.25 - 1.5 mm peroperatively

Conclusion: Positivity of the CT angiography for poorly visualized LAD on conventional angiography was 60% in the present study

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

Thyroid disorders; and cardiovascular risks

Thyroid hormones have many effects on cardiovascular function, and deficiency or excess of thyroid hormones can result in cardiac dysfunction. Abnormalities of the cardiovascular system are often identified during examination of hyperthyroid and hypothyroid patients

Objective: The aim of this study was to address the effects of thyroid hormones on the cardiovascular system and the clinical relevance of the cardiovascular response to thyroid dysfunction

Study Design: Cross sectional study

Setting: The study was conducted at Allied Hospital / Punjab Medical College Faisalabad and PINUM Hospital Faisalabad

Period: October 2014 to August 2015

Materials and Methods: Total 100 patients with thyroid disease [Hypo/hyperthyroidism] were enrolled in the study. Any patient age >/=20 years, that had documented history of thyroid disease [Hypothyroidism or hyperthyroidism] or on medications for thyroid disorder was recruited in this study

Results: Total 100 consecutive patients with abnormal thyroid function tests who fulfill the inclusion and exclusion criteria were enrolled in the study. Mean age was 47.9 +/- 23.20 years. 16% were male and 84% were female. Majority of the patients 37[37%] were in age group 51 - 60 years. 53% were suffering from overt hyperthyroidism and 31% were suffering from hypothyroidism. Subclinical hyperthyroidism and hypothyroidism was present in 7% and 9% patients respectively. Goiter was present in 24% patients. Atrial fibrillation was observed in 34% hyperthyroid patients. Overall 23% were diabetics and 25% had H/O hypertension. Dyslipidemia was present in 20% hyperthyroid and 25% hypothyroid patients. Echocardiography was performed in 19% patients. 7% patients undergone thyroid surgery. Overall 11% patients were suffering from CCF. Pulmonary hypertension was observed in 17% hyperthyroid and 35.48% hypothyroid patients. MeanFT4 in hypothyroid patients was 1.16 +/- 022 ng/dl. Mean TSH was 10.92 +/- 21.09 [microIU/ml] in hypothyroid and 0.19 +/- 0.14 [microIU/ml] in hyperthyroid patients

Conclusions: The outcome of this study suggests that patients with untreated overt / subclinical thyroid dysfunction are at increased risk of cardiovascular complications

Acute febrile illness; during the course of oral anticoagulation warrants immediate INR check

Oral anticoagulation is needed in many patients like after prosthetic valves insertion, in atrial fibrillation, clots in LA, clots in LV and DVT etc. It is mainly achieved by warfarin sodium which has many interactions with multiple other drugs and its action varies in different other chronic diseased states. to see the response of acute febrile illness on the chronic stable state of INR on a fixed dose of oral warfarin sodium. All the patients with acutely deranged INR who had a stable and controlled INR previously and a fixed dose of warfarin sodium were admitted in the cardiac surgical ward at FIC and their history was explored and recorded. A total of 966 patients were admitted in [CSW] during the period of April, 2012 to April, 2014 with deranged INR. INR was checked twice or sometimes thrice to rule out the laboratory error. 504 patients were female and 462 patients were male, 56 patients had repeated admission for their INR control, most of them were callous regarding taking dose of warfarin so they were excluded from the study. A total of 631 patients had low INR due to missed dose of warfarin sodium. Out of them 13 patients got stuck valve for which emergency redo prosthetic valve replacement was done. 06 patients died in emergency due to late presentation after the prosthetic valve got stuck. Only 279 patients had high INR on the previous dose of warfarin sodium, out of them 216 patients had out of range INR. They were treated by FFP transfusion and holding the Warfarin sodium dose for certain period of time.76% of the patients give H/o acute febrile states 101-103 with rigor and chills [Malaria, enteric fever, pharangitis, cellulitis, boils and UTI etc. etc.] since last 3-4 days for which they had got treatment from some local Gen. practitioners and gave the H/o bleeding gums, general body malaise, bruising, joint aches and pains. 24% of patients denied any acute febrile illness before their INR got out of range 2 patients died in emergency due to intra cerebral bleed after INR got uncontrolled. Any acute febrile illness even of short duration may cause sudden derangement of previously controlled INR on certain fixed dose of warfarin sodium which can create a life threatening situation like intra-cerebral bleed, haem-arthrosis, excessive menstrual blood loss leading to severe anemia. Other less dangerous situation are gum bleed, bruising, joint aches and pains and general malaise. So, it is always advisable and logical to get INR check when ever any acute febrile illness even of short duration is encountered to avoid grave situations

Valvular patients; post operative course, size of the left atrium can predict the cost effectiveness

Cost effectiveness in any surgical procedure is a major contributory factor in the continuation of medical services in developing countries. Limited data is available in assessing the factors related with the duration of ICU stay and treatment after valvular replacement surgeries. Our aim was to see the correlation of pre operative Left Atrial size of the patient and duration of post operative stay in ICU. Observational Study. March 2010 to April 2014. Faisalabad Institute of Cardialogoy, Faisalabad. A total of 550 consecutive patients with valvular lesions were included in the study. Their Left Atrial size was measured echocardiographically pre-operatively and their stay /course in the ICU was monitored. Three categories were identified in regard with the Left Atrial size and the ICU stay. If LA size is below 60 cm2, the post operative course and stay in ICU is normal and lasts for about 1-2 days. If LA size is between 60-65 mm2, the post operative course may be complicated and prolonged by the atrial fibrillation / flutter for which pharmacological cardio version may be needed and the stay in ICU is prolonged and may last for about 2-3 days. And if pre-operative LA size is more the 65 mm2 the patient may behave in entirely different way. His atrial fibrillation persists in spite of electro cardiovertion or pharmacological cardiovertion and his stay in ICU may last up to 4-5 days and thus the cost of treatment is raised. LA size can predict the post operative behavior of the patient in ICU and duration of stay and expected cost of the treatment. Smaller is the size of LA, shorter is the stay in ICU and thus lesser is the post operative cost and vice versa

Early postoperative valvular patient; modified devaga's repair for moderate to sever TR is a cost-effective maneuver

Rheumatic Heart Disease is affecting the tricuspid valve almost as equally as it affects the other valves of the heart and the fact is that the single valvular disease of the heart is rare in our population. Objectives: To determine the cost effectiveness of modified devagia repair in relief of post operative valvular patient. Period: 2009-2014. Setting: Faisalabad Institute of cardiology Faisalabad, Method: All the patients with mitral valve disease having concomitant tricuspid valve regurgitation operated upon. Average age of 14 years to 45 years without gender discrimination. Result: A total of 380 patients were studied having concomitant mitral and tricuspid disease. Out of which 276 patients had moderate to severe tricuspid regurgitation on per-operative digital assessment for which modified DeVaga's repair was essential and done. Only 104 patients had moderate tricuspid regurgitation on per-operative digital assessment which was the main population of address in our study. Out of these, 76 patients were decided for modified DeVaga's repair due to their moderate tricuspid regurgitation and 28 patients were left alone without modified DeVaga's repair due to their mild to moderate tricuspid regurgitation. Then their early post operative course was monitored in terms of ICU stay and their functional recovery after operation. Patients with modified DeVaga's repair for moderate tricuspid regurgitation showed 30-42 hours early weaning of inotropes and mobilization from ICU than the patients without modified DeVaga's repair for mild to moderate tricuspid regurgitation. It is thus evident that modified DeVaga's repair for moderate tricuspid regurgitation saved hours of ICU stay, cost of ICU treatment, man hours of doctors, nurses and paramedical staff showing good post surgical functional recovery as well. Conclusions: Modified DeVaga's repair for moderate tricuspid regurgitation has a cost effective impact in the treatment of valvular patients causing early and good functional recovery after valvular replacement procedures, saving man hours of Cardiac surgeons, Nurses, Paramedical staff, patients and thus their cost of treatment.

Frequency of metastasis detection with diffusion-weighted whole-body imaging with background body signal suppression

Objective: To determine the frequency of metastasis detection with diffusion-weighted whole-body imaging with background body signal suppression

Study Design: A Cross sectional study

Place and Duration of Study: The study was conducted at Punjab Medical College and Allied hospital Radiology and Oncology departments, Faisalabad from January 14, 2010 to May 28, 2012

Patients and Methods: A total number of 86 patients of all ages and both sexes with histopathological diagnosis of carcinoma presenting to the outdoor department and admitted in oncology department of Punjab Medical college and Affiliated hospital were selected. Whole-body MRI was performed using a 1.5-Tesla system [Intera Release 9; Philips, Best, The Netherlands] with a Mobi-Trak moving tabletop and b value of 1000. Both the T1 weighted and the STIR images at each station were reconstructed. On MRI, a lesion of high signal intensity on DWIBS, a lesion of high signal intensity on STIR images and low signal intensity on T1 weighted images was considered to be a suspected metastasis

Results: Out of 86 patients, 70 [81.4%] had metastasis. Osseous metastasis was detected in 13 [18.6%] patients however in 57 [81.4%] patients, both osseous and extra osseous metastasis were detected. Liver metastasis was detected in 47 [82.5%] patients out of 57 patients with extra osseous metastasis. Adrenal metastasis was found in 12 [21.1%] patients, brain in 13 [22.8%] patients, lung in 19 [33.3%] patients, renal in 6[10.5%] patients and peritoneal dissemination was seen in 5 [8.8%] patients. Nodal metastasis was detected in 57 patients and maximum number of 19 lymph nodes were detected

Conclusion: DWIBS MRI is helpful in the early diagnosis of metastasis

Severe hypocalcaemia following coronary artery bypass grafting due to hypoparathyroidism

A 55 years old man was extubated on first postoperative day following coronary artery bypass grafting at 7:30 am. The same day at 5 pm, he became drowsy but arousable only on painful stimuli with severe generalized hypertonia and bilateral upgoing plantars. He was reventilated and a provisional diagnosis of cerebrovascular accident was made. CT scan of brain was normal except for bilateral basal ganglia calcification. On further investigations, he was found to be severely hypocalcaemic due to hypoparathyroidism. All symptoms resolved on the treatment of his hypocalcaemia. There was no history of neck surgery in this patient and the case additionally highlights important interaction between parathyroid hormone [PTH] in calcium metabolism

Triggering of acute coronary syndromes by physical exertion and anger

Objectives: To assess the role of vigorous physical exertion and anger as triggers of acute coronary syndromes [ACS]

Materials And Methods: This prospective observational study was conducted at the Punjab Institute of Cardiology, Lahore from April to September 2010. Two hundred patients admitted through emergency and out patient department were studied. Patients were questioned in detail about the circumstances surrounding the onset of acute symptoms. Anger was assessed according to the anger scale comprising of 7 points and physical activity was assessed according to activity scale also comprising of 7 points

Results: The mean age of the study population was 54.2 +/- 10.8 years. There were 149[74.5%] males and 51[25.5%] females. Diabetes mellitus occurred in 69[34.5%], hypertension 86[43%], smoking 71[35.5%] and dyslipidemia in 51[25.5%] patients. Majority of patients had low education status with primary education in 75[37.5%] and illiteracy in 74[37%] patients. Premonitory symptoms occurred in 92[46%] patients. Most patients 65[32.5%] presented to the hospital in 6-12 hours duration of onset of symptoms followed by 54[27%] patients presenting in 0-6 hours. Typical chest pain occurred in 166[83%] patients. Mostly patients 123[61.5%] had ST segment elevation myocardial infarction, followed by Non ST segment elevation myocardial infarction in 45[22.5%] and unstable angina in 31[15.5%] patients. The onset anger scale identified 25[12.5%] patients having associated anger at the time of onset of symptoms. According to anger scale, level 1 anger was observed in 5[2.5%], level 3 in 3[1.5%], level 4 in 4[2%], level 5 in 5[2.5%], level 6 in 6[3%] and level 7 in 2[1%] patients. The history of exertion at the time of onset of symptoms revealed that 95[47.5%] patients had level 1 exertion followed by level 2 exertion in 61[30.5%] and level 4 exertion in 14[7%] patients

Conclusion: This study confirms previous results and shows a graded exposure- response relationship between physical exertion intensity and triggering of AMI onset. The specific clinical and sociodemographic factors associated with physical exertion and anger suggest that different pathophysiological processes may be involved