Best management of patients with malignant pericardial effusion: A comparative study between imaging-guided pericardiocentesis and surgical pericardial window.

Background: The clinical course of malignancies is frequently complicated by third spacing in body cavities, including pericardial effusion. What remains the optimal management for malignant pericardial effusion is a dilemma. Aim: We aimed to compare 30-day outcomes of imaging-guided pericardiocentesis and surgical pericardial window in patients with malignant pericardial effusion. Methods: A retrospective observational study was done at a tertiary care hospital. We reviewed hospital record files of 91 consecutive patients admitted with malignant pericardial effusion from January 2010 to December 2019 and requiring imaging-guided pericardiocentesis or pericardial window. Results: A total of 71 patients were included in the final analysis. Most patients were male (68%). The mean age was 45 years. Hypertension was the most common comorbid condition. Lymphoma or leukemia (39%) was the most common cause of malignant pericardial effusion followed by lung cancer (28%). About 57.7% of patients underwent pericardiocentesis, and the remainder underwent surgical pericardial window (42.3%). The overall procedural success was 97.2%, and the overall mortality was 5.6%. The success rate was similar when pericardiocentesis was compared with the surgical pericardial window (p = 0.22). The length of hospital stay was higher in patients undergoing pericardial window (p = 0.007), whereas the re-accumulation rate was higher in the pericardiocentesis group (0% versus 34%, p < 0.001). Patients undergoing pericardial window had higher odds of major bleeding requiring transfusions. Conclusion: There is a higher rate of recurrence following isolated pericardiocentesis but a comparable mortality difference between the two procedures. Complication rates can be reduced by improving surgical technique and peri-operative management. Meticulous surgical care, infection precautions, and good glycemic control in this immunocompromised subset can preserve the pericardial window as a better management option. Relevance to Patients: Pericardial window is a promising and effective management option for patients with recurrent malignant pericardial effusion, but it comes at the cost of bleeding and infection. More extensive trials are needed to understand better the long-term outcomes of pericardial window or pericardiocentesis in patients with malignant effusion.

Transseptal Puncture Through an Interatrial Septum With Lipomatous Hypertrophy: A False Perception of Success and Failure.

Transseptal puncture is a standard procedure to access the left atrium during catheter ablation of arrhythmias. It is associated with high success and a meager complication rate in the contemporary era. The potential complications of transseptal puncture include aortic puncture, perforation of the right/left atrial free wall resulting in pericardial effusion/tamponade, and systemic thromboembolism. The dissection of the interatrial septum (IAS) is a rare complication of transseptal puncture, reported in less than 1% of the procedures. We report a case of a dissection of the IAS during an attempted transseptal puncture in a 72-year-old man with lipomatous hypertrophy of the interatrial septum.

Takotsubo Like Cardiomyopathy with Concomitant Pheochromocytoma: A Rare Presentation.

Pheochromocytoma classically presents with headache, diaphoresis, palpitations and, raised blood pressure. Rarely, it manifests as cardiomyopathy. Herein, we present a case of a 42-year woman who presented with heart failure and on work-up was found to have pheochromocytoma leading to Takotsubo-like cardiomyopathy. The biochemical profile revealed raised serum metanephrines and normetanephrines. CT abdomen showed a left adrenal mass. Within two weeks of presentation and before surgical excision of the mass, she recovered from cardiomyopathy. After medical optimisation, the patient underwent elective adrenalectomy, which on histological evaluation revealed pheochromocytoma. Key Words: Cardiomyopathy, Pheochromocytoma, Adrenal mass.

Pacemaker Failure to Capture Caused by Electrocautery: A Rare Pacemaker Pulse Generator Change Complication.

In the advent of increasing benefits of cardiac devices, more and more implants are being done. Pacing devices reaching the end of service need to be changed. The use of electrocautery (EC) to maintain hemostasis during cardiac device implantation is efficient and safe. Device makers have variable recommendations for the use of EC. Generally, considered safe, EC has been rarely known to cause device failure. We describe a case of a dual-chamber device, pulse generator change, where EC caused a sudden, unexpected loss of pacing function that lasted for 30 seconds. This case report highlights the gaps in the process of undertaking these high-risk changes.

Acute Myocardial Infarction After Coronavirus Vaccine: A Rare Adverse Effect.

A 61-year-old male presented to the emergency department with left arm and jaw pain for three hours which started 90 minutes after receiving the first dose of Moderna vaccine for coronavirus disease 2019 (COVID-19). He had a prior history of ischemic heart disease. Initial investigations confirmed the diagnosis of acute coronary syndrome. The patient was managed for non-ST-elevation myocardial infarction and percutaneous coronary intervention to the right posterior descending artery was done, and he was discharged after two days of hospital stay. As the patient was doing well for many years and was compliant with medications, this event was likely triggered by the coronavirus vaccine. Healthcare providers should be aware of the side effects of the vaccine and further investigations should be carried out in high-risk patients before vaccination. However, worldwide coronavirus vaccination programs play a significant role to halt this pandemic and these rare adverse side effects of the vaccine should never discourage people from the vaccination but monitoring of evolving data by the concerned authorities is very important so that these events can be prevented in future.

Clinical characteristics and prognostic factors of atrial fibrillation at a tertiary center of Pakistan - From a South-Asian perspective - A cross-sectional study.

BACKGROUND: There is lack of large data from South-Asian region on atrial fibrillation and it is imperative that clinical presentation, prognostic factors, management pursued, and outcomes are known for this part of the world. Once collective evidence for the region is known, region-specific guidelines can be laid forward. OBJECTIVES: To evaluate clinical characteristics and prognostic factors of atrial fibrillation at a tertiary care center of Pakistan. METHODS: This was a retrospective study conducted at a tertiary care center of Pakistan. Period of study ranged from July-December 2018. All hospitalized patients who were admitted with atrial fibrillation as a primary or associated diagnosis were enrolled. RESULTS: A total of 636 patients were enrolled. The mean age was 68.5 ± 12 years and 49.5% (315) were male. 90.6% of the patients were admitted via emergency room. Majority (59.9%) had previously known AF and 40% developed new-onset AF during the hospital stay. Hypertension was the most common co-morbid condition (85.4%) followed by Diabetes Mellitus (40.1%). At least 9% had rheumatic heart disease. The median CHA2DS2VASc and HASBLED scores were 4 and 2 respectively. More than one-third of patients had sepsis as a primary diagnosis (36.8%). The in-hospital mortality of patients with atrial fibrillation was 6.7%. Patients with new-onset AF had higher mortality. Sepsis and stroke were independently associated with a higher mortality. There was no significant difference in median CHA2DS2VASc and HASBLED scores for patients with new-onset and previously known AF. On discharge, 83% of the eligible patients received oral anticoagulation. CONCLUSION: There was higher prevalence of chronic co-morbid conditions in the studied population leading to a higher CHA2DS2VASC Score. Sepsis and stroke were independently associated with higher in-hospital mortality.

Comparing sensitivity and specificity of pacemaker ID application and cardiac rhythm management device-finder application in identifying cardiac implantable electronic device manufacturer using chest radiograph - An observational study.

BACKGROUND: Smartphone-based applications to identify cardiac implantable electronic devices (CIED) are extremely useful in circumstances, where urgent device interrogation is needed, and a device identification card is not available. Few studies have provided insights regarding the utility of these applications. We have studied two widely available applications i.e., Pacemaker ID app (PMIDa) or Cardiac Rhythm Management Device-Finder (CRMD-f) to identify device manufacturers in CIEDs. METHODS: 547 patients who underwent CIED implantation from the year 2016-2020 in our institute were enrolled. There were 438 Medtronic and 109 St. Jude's devices. All chest radiographs were de-identified and resized into 225*225 pixels focusing on the CIED. PMIDa and CRMD-f applications were used to identify the CIED. Accuracy, sensitivity, specificity, negative predictive value, and positive predictive value for both applications were calculated and compared. RESULTS: Overall, CRMD-f application has higher specificity (93.58 vs. 82.5%) but lower sensitivity (53.6 vs. 55%) than PMIDa. The accuracy of both applications was comparable (61.6% vs. 60.5%). Accuracy varied with CIED model and type tested, and radiograph projection used. Accuracy is greatest with Cardiac-Resynchronization-Therapy (CRT) devices for both applications, followed by a single lead pacemaker. CONCLUSION: CRMD-f has higher accuracy and specificity for CIED manufacturer identification. Both PMIDa and CRMD-f are specific tools to identify CIED but have low sensitivity.

Cardiovascular fellow-in-training feedback on virtual and simulator-based learning experience during Covid-19 pandemic in a low to middle income country - A cross-sectional study.

BACKGROUND: COVID-19 pandemic has introduced us to a greater need of virtual learning platforms and has resulted in less clinical exposure for fellows-in-training. Virtual and simulator-based learning is not widely available in LMIC. It is imperative to analyze feedback of CV fellow-in-training regarding this mode of learning before large scale implementation. METHODOLOGY: This was an observational study conducted between July-August 2020. A multicentered survey was conducted. Survey questionnaire was disseminated to FIT (fellow-in-training) via Google Forms. The questionnaire contained a total of 24 questions about virtual and simulator-based learning during the pandemic. RESULTS: A total of 68 FIT responded to the survey. The mean age was 29.9 years. There were 37% females and 63% males. Majority (75%) agreed that it was easier for them to reach for online sessions than physical sessions. 60% FIT were confident in asking questions or giving comments during the online sessions. 57.4% FIT felt it easier to go through cardiovascular imaging/illustrations via online platforms. 50% (34) were confident that if online sessions had to continue, they would have enough academic learning before they graduated from the program and 54.4% (37) wanted online sessions to continue even beyond the pandemic days. 37.5% (18 out of 48) agreed that the simulator-based teaching was helping them practice skills in times of less clinical exposure. CONCLUSION: COVID-19 pandemic has significantly impacted cardiovascular FIT learning curve because of less hands-on and lack of physical teaching sessions. LMIC have lack of robust e-learning platforms. Virtual learning is convenient for academic learning with growing acceptance amongst fellows. FIT from LMIC are less acquaint to simulator-based teaching and there is a need to invest in simulator-based cardiovascular teaching in LMIC.

COVID-19 Presenting with Spontaneous Pneumothorax.

The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease mainly affects respiratory system. Its common clinical findings include fever, cough and shortness of breath. Characteristic radiological features of the disease include peripherally distributed, bilateral ground-glass opacities, predominantly involving the lower lung zones. In this report, we present a case of COVID-19 disease presenting with spontaneous pneumothorax. A 26-year male patient was admitted to the Emergency Department with fever, dry cough, shortness of breath and right-sided chest pain. Radiographic imaging of the patient revealed pneumothorax on the right and peripherally distributed non-homogenous opacification. The patient underwent right lateral tube thoracostomy. COVID-19 was diagnosed on testing of nasopharyngeal swab. In conclusion, spontaneous pneumothorax is one of the rare presentations of COVID-19 pneumonia and should be kept in mind in patients presenting with shortness of breath and chest pain. Key Words: Spontaneous pneumothorax, Corona, pneumonia.

Brain Abscess Caused by Lactococcus Lactis in a Young Male.

Lactococcus lactis cremoris is one of the gram positive cocci, not known to be pathogenic in humans. We report a case of brain abscess due to lactococcus lactis in an adolescent. An 18-year male with congenitally corrected transposition of great arteries and dextrocardia was admitted with fever, headache and right-sided numbness. Magnetic resonance imaging revealed a well circumscribed irregular heterogeneous abnormal signal intensity lesion in left temporo-parietal lobe having central area of diffusion restriction and peripheral wall enhancement on post-contrast images. He underwent mini-craniotomy for abscess drainage. Pus culture revealed growth of lactococcus lactis. He was treated with ceftriaxone and remained disability-free on six month follow-up. To our knowledge, this is one of the few reports of brain abscess caused by lactococcus lactis. Key Words: Brain abscess, Lactococcus lactis, Adolescent.

Clinically isolated aortitis presenting as inferior ST-elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm: a rare and forgotten cause of acute coronary syndrome in a young patient with no evidence of systemic vasculitis.

A 21-year-old man presented with chest pain, diaphoresis and dyspnoea. Electrocardiogram (ECG) showed inferior ST-elevation myocardial infarction. Troponin I was positive. Patient underwent left heart catheterisation, which revealed normal epicardial coronary arteries except for right coronary artery which could not be engaged. CT coronary angiogram was done, which revealed large right sinus of Valsalva aneurysm giving rise to a pinched out right coronary artery. Patient underwent composite graft replacement of aortic valve, aortic root and ascending aorta along with a saphenous vein graft to right coronary artery. He was discharged in stable condition on fifth postoperative day. Biopsy of the aneurysmal tissue was suggestive of vasculitic aetiology. There was no evidence of systemic vasculitis and Magnetic Resonance Angiography (MRA) screen was negative for Takayasu's arteritis. Our patient was, hence, diagnosed with clinically isolated aortitis leading to ST elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm.

COVID-19 Presenting with Spontaneous Pneumothorax.

The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease mainly affects respiratory system. Its common clinical findings include fever, cough and shortness of breath. Characteristic radiological features of the disease include peripherally distributed, bilateral ground-glass opacities, predominantly involving the lower lung zones. In this report, we present a case of COVID-19 disease presenting with spontaneous pneumothorax. A 26-year male patient was admitted to the Emergency Department with fever, dry cough, shortness of breath and right-sided chest pain. Radiographic imaging of the patient revealed pneumothorax on the right and peripherally distributed non-homogenous opacification. The patient underwent right lateral tube thoracostomy. COVID-19 was diagnosed on testing of nasopharyngeal swab. In conclusion, spontaneous pneumothorax is one of the rare presentations of COVID-19 pneumonia and should be kept in mind in patients presenting with shortness of breath and chest pain. Key Words: Spontaneous pneumothorax, Corona, pneumonia.

Reverse Takotsubo Cardiomyopathy Following A Case Of Suspected Meningoencephalitis And Literature Review.

Reverse Takotsubo cardiomyopathy is a rare variant of stress cardiomyopathy. A 22-year-old male presented with altered mentation and fever. He was intubated due to low Glasgow Coma Scale. CT head plain showed diffuse cerebral oedema. Patient had raised troponin-I and echocardiogram revealed reduced ejection fraction with hyperdynamic apical segments and akinetic basal to mid segments suggestive of reverse Takotsubo cardiomyopathy (rTCM). Association of rTCM with neuropsychiatric disorders such as intracranial/epidural haemorrhages and anorexia nervosa has been defined. However, it is rare to have rTCM with meningoencephalitis.

Multi Vessel Coronary Artery Disease Presenting as a False Negative Myocardial Perfusion Imaging and True Positive Exercise Tolerance Test: A Case of Balanced Ischemia.

Non-invasive investigations play an important role in the early diagnosis of coronary artery disease. Although the stress test is an easily available investigation for the diagnosis of obstructive coronary artery disease, its results are affected by the pretest probability. Myocardial perfusion imaging (MPI) is one of the commonly performed non-invasive cardiac imaging. The common reasons for false-negative exercise MPI are reported to be inadequate exercise, a lower dose of radio-tracer, small area of perfusion defect, and ischemia caused by left circumflex or its branches. Balanced ischemia is one of the rare causes of false-negative MPI. In this case report, we present a 73-year-old gentleman who presented with chest pain and shortness of breath. An exercise electrocardiogram (ECG) at five metabolic equivalents was positive for symptoms and electrocardiographic evidence of ischemia, but the myocardial perfusion image did not show ischemia. An invasive coronary angiogram was done due to high-risk exercise ECG, which revealed severe three-vessel coronary artery disease. Although the false-negative myocardial perfusion scan in the presence of a positive exercise electrocardiogram is unusual, it should not be ignored. Positive exercise ECG with the reproduction of symptoms indicates a high probability of critical coronary artery disease, irrespective of perfusion defects.

Long-Term Clinical Outcomes of Percutaneous Coronary Intervention in Saphenous Vein Grafts in a Low to Middle-Income Country.

Background Revascularization of saphenous vein grafts (SVGs) is challenging and debated for the last few decades. The percutaneous revascularization of SVGs was reported to have poorer long-term outcomes than native coronary artery revascularization. Purpose We aim to study the peri-procedural complications and long-term outcomes of the percutaneous revascularization of SVGs in a low-middle-income country. Methods In this retrospective study, we included 110 patients who underwent percutaneous revascularization from January 2011 to March 2020 and followed them retrospectively for long-term outcomes and major adverse cardiovascular events. Results The mean age was 71 ±9, and 81% were male. The most common reason for the presentation was non-ST segment elevation myocardial infarction (NSTEMI) (46%). The mean follow-up period of the study was 48±27 months. The most common comorbidity was hypertension (86%). A drug-eluting stent (80%) was placed in most of the patients, followed by a bare-metal stent (BMS) (14%) and percutaneous balloon angioplasty (POBA) (6%). We did not find any significant difference in major adverse cardiac events (MACE) (P=0.48), target vessel revascularization (TVR) (p=0.69), and target lesion revascularization (TLR) (p=0.54) with drug-eluting stent (DES) as compared to either BMS or POBA. The mean period from coronary artery bypass grafting (CABG) to SVG percutaneous coronary intervention (PCI) was 15± 5.5 years. Multivariate Cox regression analysis showed that an acute coronary syndrome (ACS) event, stroke, and female sex were independently associated with MACE. Conclusion The long-term outcomes of SVG PCI are not affected by the types of stents. Female gender, ACS, and stroke are the independent predictors of MACE after SVG PCI, and statin therapy has a positive impact on the long-term outcomes of SVG PCI.

Atrial Tachycardia Associated With a Tachycardia-Induced Cardiomyopathy in a Patient With Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is an autoimmune disease that involves multiple organ systems. Cardiovascular involvement in SLE is well described in the literature. Cardiac arrhythmias associated with SLE include sinus tachycardia, atrial fibrillation, and atrial ectopy or atrial tachycardia. In this report, we present the case of a patient with SLE who was found to have focal atrial tachycardia that mimicked sinus tachycardia on a 12-lead electrocardiogram (ECG). She was inappropriately treated as a case of sinus tachycardia initially. But she did not respond to the treatment and developed tachycardia-induced cardiomyopathy despite being on antiarrhythmic medications. She subsequently underwent successful radiofrequency catheter ablation and her left ventricular ejection fraction (LVEF) recovered within three months after the ablation.

Pericardiocentesis Indications and Complications: A Retrospective Observational Study in a Tertiary Care Hospital in Karachi, Pakistan.

INTRODUCTION: Pericardiocentesis is crucial for the diagnosis and management of diseases responsible for significant pericardial effusions. Pericardiocentesis was performed the first time by Riolanus for cardiac tamponade. He described the process of trephination of the sternum to remove the abnormally accumulated fluid from the pericardial space. However, with the advancement of expertise in echocardiography assisted procedures, echocardiography-guided diagnostic and therapeutic pericardiocentesis is now considered standard clinical practice in the treatment of pericardial effusions. OBJECTIVES: We aim to study different causes of pericardial effusion and indications of pericardiocentesis as well as complications associated with it in our population. METHODS: This is a retrospective observational study done at Aga Khan University Hospital, Karachi. We reviewed hospital record files of 66 patients admitted to Aga Khan University Hospital from January 2010 to December 2019 who underwent pericardiocentesis. RESULTS: Out of 66 patients, 43 (65.2%) were male. The mean age of the study population was 48.59±18.9 years and 41 (62.1%) of them had underlying active malignancy with hematological malignancies being most common followed by lung carcinoma. In the majority of patients (71.2%), pericardiocentesis was performed at the bedside, and the rest of them (28.8%) underwent pericardiocentesis in the cardiac catheterization laboratory. Of all the patients, 46 (69.7%) underwent pericardiocentesis under echocardiography guidance and 18 (27.3%) required fluoroscopy. Successful pericardiocentesis was performed in 65 (98.5%) of the patients, two (3%) patients developed access site infection and only one (1.5%) patient became hemodynamically unstable while undergoing pericardiocentesis Conclusion: Malignancy, predominantly lymphoma, is the most common cause of pericardial effusion requiring pericardiocentesis. Dyspnea is the most common symptom of presentation with cardiac tamponade. Echocardiography is the commonly used imaging modality for pericardiocentesis. Bedside setting is the most common setting used for pericardiocentesis. Imaging guided pericardiocentesis has a very high success and low complication rate.

Clinical Presentation, Cardiac Magnetic Resonance Findings, and Prognosis of Patients with Arrhythmogenic Right Ventricular Cardiomyopathy - An Experience from Pakistan.

OBJECTIVES: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart-muscle disease, characterized by fibro-fatty replacement and ventricular arrhythmias, that primarily affects the right ventricle (RV). We aimed to look at the clinical presentation, cardiac magnetic resonance (CMR) imaging findings and prognosis of patients with ARVC in Pakistan. MATERIAL AND METHODS: It is a retrospective observational study, 17 consecutive patients with CMR and other findings consistent with ARVC, were enrolled from 2010 to 2019 at a single center. RESULTS: Out of 17 patients, 12 (70.6%) were male with a mean age of 33.5 ± 17.5 years. Family history of sudden cardiac death was present in 3 (17.7%) patients while one (5.9%) patient had family history of ARVC. Syncope was the first presenting symptom in eight (47.1%) patients. On 12 leads ECG, T wave inversion in precordial leads was found in 6 (35.4%) patients, and epsilon wave was present in only 3 (17.7%) patients. On echocardiogram, 13 (76.5%) patients had dilated RV with reduced systolic function. On CMR, majority of patients (n = 14, 82.4%) were found to have RV dilatation with regional dyskinesia and fatty infiltration, 9 (52.9%) of them had left ventricular involvement also. Follow-up was available for 14 patients (82.4%) with a mean follow-up period of 35.5 ± 19.7 months. Three (21.4%) of them died and 10 (71.4%) got admissions for heart failure during follow-up period. CONCLUSION: Arrhythmia related events are the main presenting symptoms of ARVC in this region, and left ventricular involvement in ARVC is not rare in this population. The mortality is relatively high, probably due to advanced disease at the time of presentation and less medical facilities available.

Growth centile charts (anthropometric measurement) of Pakistani pediatric population.

OBJECTIVE: To measure Anthropometric data (Height and Weight) of Pakistani school children (of different socioeconomic and cultural background) 3-16 year, to develop growth centile charts, based on the above measurement and to document obesity and stunting in Pakistani Paediatric population, based on the above measurement. METHODS: A Cross-sectional study with multistage stratified sampling was done in a Nationwide project of Higher Education Commission (HEC, Ref no: 20-441/R&D/2008) to develop growth centile charts of Pakistani paediatric population. Study was conducted from 2006-2009. Children studying in private and government schools of the four provinces of Pakistan were included. Prior to starting the study permission from the principal of the respective school and parents was taken. A total of 12837 children with normal birth weight, complete immunization, no history of chronic infection from 36-192 months (3-16 year) were included. Heights (cms), weight (kg), for Body Mass Index (BMI) (kg/m2), 24 hour diet recall was obtained. All socioeconomic groups were included. Food records of the children were subjected to USDA food exchange list. RESULTS: The average height (cms) of children was 139.11 +/- 18.44, average weight (kg) was 33.21 +/- 11.25 and average BMI was 16.76 +/- 3.22 kg/m2 (range from 11.3-41.98). The 95th centile according to CDC charts for the age groups 3-16 years were calculated. A total of 664 (5.1%) children were found to be obese. In the age group 3-5 years, > 5-10 year and > 10-16 year; 29 (8.1%), 272 (5.1%) and 363 (5.1%) were found to be obese, respectively. CDC height and weight in the three groups of Pakistani children > 3-5 year, > 5-10 year, > 10-16 year were at the 10-25 centile. CONCLUSION: Overall, the prevalence of stunting was 14%. Height and weight was 10-25 centile of the CDC charts. Obesity was 5%. Pakistani centile charts of healthy children from Pakistan have been made.