Echocardiographic Assessment of Valvular Involvement in Chronic Rheumatic Heart Disease in BSMMU, Bangladesh.

Rheumatic heart disease (RHD) is a disease of poverty, is almost entirely preventable, and is the most common cardiovascular disease worldwide in those under 25 years especially in the developing county like Bangladesh. RHD is caused by acute rheumatic fever (ARF) which typically results in cumulative valvular lesions that may present clinically after a number of years of sub-clinical disease. It has a progressive course and patients usually may require valve repair/replacement in future. Echocardiography is an easily available, non-invasive, widely used, standard tool for diagnosis and evaluation of RHD. But there is scarcity of echocardiographic study of Valvular Involvement in Chronic Rheumatic Heart Disease (CHRD) in Bangladesh. This study was aimed to utilize echocardiography as a tool to evaluate patients of CRHD in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. This observational study was conducted in the Department of Cardiology, BSMMU from September 2018 to August 2019. Echocardiography was done in each patient only once with VividE9®machine. Among 1350 echocardiography, 101 patients (7.5%) were diagnosed as RHD including post valve replacement patients. The mean age of the patients was 40±14 years and 64.34% were female. Mitral stenosis (MS) was the commonest lesion in 84.15% followed by mitral regurgitation (MR) in 66.33%, tricuspid regurgitation (TR) in 57.43%, aortic regurgitation (AR) in 49.51%, aortic stenosis (AS) in 26.74% and pulmonary regurgitation in 10.89%. The frequency of complications like pulmonary hypertension, heart failure, atrial fibrillation (AF), LA thrombus, stroke and infective endocarditis was 67.33%, 61.05%, 18.81%, 6.93%, 3.96% and 0.99% respectively. History of Rheumatic fever was present only in 10.89% patient. Mitral stenosis was the commonest lesion seen mostly in female and most common complication was pulmonary hypertension. Mean age of patients in this study was higher than other contemporary studies and frequency as well as severity of complications was also more in female.

Assessment of Risk Factors of Heart Failure: A Case Control Study.

Heart failure (HF) is becoming an increasingly prevalent healthcare problem. Besides, Ischemic heart disease (IHD) and Hypertension (HTN), there is a number of other factors that continue to evolve as risk factors for heart failure. The aim of the study was to identify the different risk factors of heart failure patients. This case-control study was conducted in the Department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from August 2014 to July 2015. It was included 75 patients of heart failure (cases) and 75 age and sex matched adult individuals (friends and relations of heart failure cases) as controls. The risk factors studied were grouped into demographic, clinical, behavioral and biochemical variables. The age distribution between case and control groups was almost identical with mean ages of either group being 55 years (p=0.922). The sex distribution was also fairly comparable with male being predominant in both the groups (p=0.574). In this study IHD followed by uncontrolled hypertension (p=0.001) are came out to be the predominant risk factors of heart failure followed by smoking and obesity (p<0.001). From the findings of the study, it can be concluded that a number of risk factors are involved in heart failure cases. Of them ischemic heart disease and uncontrolled hypertension are the predominant ones followed by smoking and obesity. The best strategy would, therefore, be to treat and control ischemic heart disease, hypertension, obesity, diabetes and smoking habit in the population. However, as the risk factors in the population continue to change; ongoing surveillance is important to guide right preventive strategy in future.

Detection of Vascular Changes in Systemic Lupus Erythematosus by Carotid Duplex Study in A Tertiary Cardiac Hospital.

Systemic lupus erythematosus (SLE) is a common autoimmune connective tissue disorder and mainly affected female patients. This cross sectional study was performed in the department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2008 to June 2012. A total fifty (50) SLE patients were diagnosed on the basis of ACR criteria, having no cardiovascular symptoms. Another 50 age-matched normal individuals were included to compare with SLE group. Congenital vascular disease, ischaemic heart disease, congenital heart disease, rheumatic heart disease, hypothyroidism and any other inflammatory disease along with SLE were excluded from study. All patients were evaluated by Carotid duplex study. Mean age of SLE was 26.70±7.3 and mean age of normal subject was 25.64±8.01. Most of the SLE patients were female (about 92%) and male (about 8%). And about 94% was female in normal group and 6% was male. In Right common carotid arteries (RCCA), mean Intema medial thickness (IMT) was 0.86±0.10 IN SLE group and 0.73±0.06 in normal group. In LCCA, mean IMT was 0.89±0.14 in SLE group and 0.76±0.10 in normal group. IMT in SLE group was increased than control group. There was a significant difference (p=0.001) in both right and left side. The percentage rate of change in PSV and EDV of Carotid arteries of the SLE group was significantly higher than the control group (Both left and right side p=0.001). In RCCA, the PSV was 91.72±19.46 in SLE group and 62.60±6.66 in normal group (p=0.001). And EDV was 27.02±8.23 in SLE group and 16.48±2.32 in normal group (p=0.001). In LCCA, the PSV was 82.06±22.28 in SLE group and 60.36±7.54 in normal group (p=0.001). And EDV was 27.82±6.61 in SLE group and 18.08±2.69 in normal group (p=0.001). In LICA, mean PSV was 83.46±23.54 in SLE group and 60.36±7.54 in normal group (p=0.001). And EDV was 29.36±8.56 in SLE group and 18.08±2.69 in normal group (p=0.001). In RICA, mean PSV was 61.56±7.66 in SLE group and 62.16±5.35 in normal group (p=0.651) which was not significant. And EDV was 26.36±2.26 in SLE group and 19.00±2.17 in normal group (p=0.001). But majority of the vessels showed significant P value which signifies that vascular changes were more evident in SLE group than normal control group. SLE patients with carotid artery blood flow velocity and structural changes in endothelial function changes more evident than control group. Compared with the normal control group, IMT, PSV and EDV were significantly higher in SLE group, the difference was statistically significant (P<0.05). Vascular changes are common in SLE when clinically asymptomatic. Carotid duplex study is a non invasive tool for early detection of vascular changes to prevent stroke in SLE patients.

Transcatheter Closure of Post Infarction Subacute Ventricular Septal Defect: A Case Report.

Ventricular septal rupture (VSR) is an uncommon but lethal complication of acute myocardial infarction (MI). Although early surgical closure is the treatment of choice, hospital mortality after emergency surgery remains high. Transcatheter closure of post myocardial infarction ventricular septal defect (PIVSD) has emerged as a potential treatment option in selected cases. Herein, we report a case present in AFC Health FORTIS Heart Institute, Khulna, Bangladesh on 10 February 2017 of sub acute post-MI VSR that was successfully closed using an Amplatzerseptal occlude (ASD) device. The patient had undergone primary percutaneous coronary intervention (PCI) 15 days earlier in the setting of acute MI.

Comparison between Glyceryl Trinitrate and Trimetazidine in Ischaemic Cardiomyopathy Patients.

Ischaemic cardiomyopathy (ICM) remains a major health problem, both in developed and developing countries like Bangladesh where it causes a significant number of morbidity and mortality. The treatment and outcome of ICM chiefly depends on the presence and extent of hibernating myocardium. In this regard addressing anginal symptoms is the key to patients' comfort as well to achieving the goal of treatment. Glyceryl trinitrate (GTN) and trimetazidine (TMZ) are two widely used drugs for relieving angina. This pilot study was designed to answer some of the confusions and controversies regarding their use and to bring precision in decision making in the treatment of ICM. Here, comparison of GTN and trimetazidine were done by assessing the symptoms by NYHA and CCS class following their use in ICM patients, admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from 15th October, 2015 to 15th April, 2016, who were randomly placed in two groups in a prospective manner. Most of the patients were in age group 51-60 years and were male in both the groups. It was observed that there was no significant difference in NYHA and CCS class at base line and at discharge between two groups (p>0.05). But statistically significant (p<0.05), improvement noted at 6 weeks and 12 weeks in GTN group in comparison to trimetazidine group. GTN stood out to be a better option than TMZ in the treatment of ICM. Moreover GTN is a cheaper option than TMZ.

Clinical Profile and Outcome of Peripartum Cardiomyopathy - A Study in a Tertiary Cardiac Hospital of Bangladesh.

This study was done to evaluate the clinical profile, management and to analysis of pregnancy outcomes of peripartum cardiomyopathy pregnant women. Follow up was done after treatment and to see the prognosis. All patients admitted with peripartum cardiomyopathy from July 2009 to June 2014 in the department of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh were considered for this observational study. Seventy two (72) women were evaluated. Primi-paras are 28 (39%) of the total study population. Fifty two patients (72%) were clinically improved and in 35 (48% ) the left ventricular functional status returned to normal with the treatment of Diuretics, selective Beta-blocker, Angiotensin converting enzyme inhibitor(ACEI) or Angiotensin receptor blocker (ARB) and vitamin B complex. Eleven cases (15%) developed persistent cardiomyopathy that is persistent left ventricular dysfunction beyond six months of presentation. Ten women (14%) presented with thromboembolic events and anti coagulant were prescribed for life long for secondary prevention. Maternal mortality was 8 (13%). Among all live births four had intra uterine growth retardation and another three had died during the neonatal period. The patients of peripartum cardiomyopathy were improved symptomatically and prognosis was good with the treatment of diuretic, selective beta-blocker, ACEI or ARB and vitamin B complex. Regular clinical follow up with echocardiography and monitoring of INR if the patients are in Anticoagulant are advised to reduce the morbidity and mortality.

Turner's syndrome with Severe Coarctation of the Aorta: A Case Report.

Cardiovascular abnormalities are frequently encountered in patients with Turner's syndrome. A 12-year-old girl with Turner's syndrome (TS) was referred from the endocrinology department for management of hypertension. After Echocardiography and CT angiography, we confirmed that she had severe coarctation of the aorta, just distal to the left subclavian artery. Due to high-pressure gradient in the coarct segment, in presence of hypertension, we made the decision for percutaneous intervention of coarctation of aorta.

Immediate & Short Term Outcome of Using Single Bolus Eptifibatide in Percutaneous Coronary Intervention: A Randomized Control Study.

The purpose of this study was to assess the immediate and short term outcome of single bolus dose of eptifibatide in elective percutaneous coronary intervention (PCI). We enrolled 146 patients who underwent elective PCI from May 2013 to May 2014 in University Cardiac Centre, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Among 146 patients, seventy four patients received single bolus dose of eptifibatide (10 mg intra coronary single bolus dose) just after crossing the lesion were selected as case. The other 72 patients, who did not receive eptifibatide, were selected as control. All patients of both the groups were treated with aspirin, clopidogrel before and after the procedure and all received a single bolus dose of Clopidogrel (300mg) before the procedure. All patient received weight adjusted doses of heparin during and after the procedure. The outcome measures were 24-hours and 30-day morbidity (complications or adverse events) and mortality. The patients of eptifibatide group experienced significantly lower incidence of QMI lesions and complete absence of NQMI lesion in 24 hours of PCI as compared to 5.6% and 6.9% of the lesions respectively in their control counterparts (p=0.027 and p=0.025 respectively). However, the incidence of bleeding and target vessel revascularization (TVR) were no different between the groups (p=0.255 and p=0.117). There was no incidence of TVR at all in the eptifibatide group as opposed to 5.6% in the control group in 30 days following stenting (p=0.017). Single bolus dose of eptifibatite reduces the Major adverse cardiac events as immediate and short term outcome in elective percutaneous coronary intervention.

A Case Report on Percutaneous Coronary Intervention in Chronic Total Occlusion by Retrograde Visualization.

As bilateral approach is paramount in chronic total occlusions with retrograde flow, the use of two radial arteries, two femoral arteries or combination technique using one radial and one femoral artery will probably be increasingly reported in the near future. After puncture of opposite groin, a diagnostic 6 Fr catheter is used to intubate the ostium of the contralateral artery. By visualizing the distal vessel in multiple projections, contralateral injections help to direct the progression of the wire in the occluded segment towards the distal true lumen and confirm the intraluminal position of the wire after the occluded segment. We are reporting a case with chronic total occlusion where we used bilateral femoral access and simultaneous contrast injection to visualize retrograde flow in LAD while opening CTO through ante-grade pathway.

Haemorrhagic stroke after thrombolysis with streptokinase.

A 54 years old male presented with central chest pain for five hours in a local hospital, Comilla. He was diagnosed as a case of acute STEMI (Extensive Anterior) and was thrombolized with Streptokinase 1.5 million IU. His pain was relieved, ST segment was depressed by >50% after thrombolysis. While in hospital, he developed weakness of his left limbs with gradually deteriorating level of consciousness. A CT scan of brain showed haemorrhage in the right frontoparietal region. This is a rare case of haemorrhagic stroke after thrombolysis with streptokinase.

Cardiovascular complications in patients with end stage renal disease on maintenance haemodialysis.

This cross-sectional study was carried out at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Medical College Hospital (DMCH), National Institute of Kidney Diseases & Urology (NIKDU) and Kidney Foundation from July 2005 to June 2007 to find the cardiovascular complications in end stage renal disease (ESRD) patients on maintenance haemodialysis. Patients of both sexes with age ranging from 18-59 years and getting at least 8 hours of haemodialysis per week for the last 3 months were enrolled in the study. A total of 126 such patients were included in the study. Among 126 patients 77(61.1%) developed some types of cardiovascular complications. In terms of type of complications 63.6% of the patients had LVH, 23.4% had ischemic heart disease (IHD) and 10.4% had congestive heart failure (CCF) and 2.6% cardiomyopathy. Over 96% patients were hypertensive, followed by 46.8% diabetics and 42.1% smokers. Presence of hypertension, diabetes, family history of diabetes and hypertension were observed to be significantly higher in patients who developed cardiovascular complications (p<0.05). It is deserved that cardiovascular complications (CVC) are very common in ESRD patients on maintenance haemodialysis (MHD). Poor control of blood pressure, low Haemoglobin level and poor glycaemic control are higher in ESRD patients on MHD and are possibly related to the development of cardiovascular complications.

Effect of hydration with or without n-acetylcysteine on contrast induced nephropathy in patients undergoing coronary angiography and percutaneous coronary intervention.

Contrast induced nephropathy (CIN), an acute decline in renal function after the administration of intravenous contrast in the absence of other causes, is the third leading cause of acute renal failure in hospitalized patients. Antioxidant N-acetylcysteine prevents acute contrast nephrotoxicity in patients with impaired renal function who underwent coronary angiography (CAG) and percutaneous coronary intervention (PCI). Hydration is the cornerstone in preventing CIN. N-acetylcysteine has additive preventive affect. We compared N-acetylcysteine plus hydration with hydration alone in preventing CIN. Patients were assigned to receive either premedication with hydration with normal saline (1ml/kg/hour-12 hour before and 12 hour after CAG and intravenous PCI) alone or to receive both hydration and oral N acetylcysteine (600mg bid for 2 days, starting day before CAG and PCI). Main out come was occurrence of ≥25% or ≥0.5mg/dl increase in serum creatinine level within 24 to 48 hours after contrast administration; change in creatinine clearance and serum creatinine level. Six patients (12%) of hydration group i.e. Group A and none of the patients of N-acetylcysteine All group i.e. Group B develop CIN (p=0.012). Baseline serum creatinine level was slightly higher in N-acetylcysteine group than hydration group (1.52±0.32 and 1.44±0.22). After 24 hours of CAG and PCI serum creatinine level lower than base line in N-acetylcysteine group but slightly higher than base line in hydration group (1.42±0.39 and 1.51±0.38). Difference in serum creatinine in both the groups were statistically significant (p=0.006 in N-acetylcysteine group and p=0.029 in hydration group). Creatinine clearance rate significantly improved in N-acetylcysteine group after coronary intervention. In conclusion, N-acetylcysteine and hydration prevent CIN better than hydration alone in high risk patients.

Contrast induced nephropathy in patients with pre-existing renal impairment undergoing coronary angiogram and percutaneous transluminal coronary angioplasty.

Contrast induced nephropathy is the third leading cause of acute renal failure in hospitalized patients. However, its incidence and risk factors in Bangladeshi population undergoing coronary angiogram and percutaneous coronary intervention is not clear. This study was to assess the incidence of contrast induced nephropathy in patients, with or without pre existing renal impairment, undergoing coronary angiogram and percutaneous transluminal coronary angioplasty in Bangladeshi population. Two hundred patients undergoing coronary angiogram and percutaneous were included in the study .Patients having history of contrast allergy and patients on renal dialysis were excluded from the study. Serum creatinine level was estimated before the undergoing procedure. Creatinine clearance rate was calculated by applying Cockcroft Gault formula to the preprocedure serum creatinine level. Patients were assigned to one of the two groups, that is with or without chronic renal insufficiency. Serum creatinine levels were again estimated at the end of 24 hours of contrast exposure. The rise of serum creatinine by ≥0.5mg/dl or ≥25% occurring within 24 hours of contrast administration was defined as contrast induced nephropathy. The incidences of Contrast induced nephropathy (CIN) in these groups were compared. We tried to analyze whether there is relation between the incidence of CIN with contrast volume, chronic renal insufficiency, diabetes mellitus, and coronary procedures undergone. We enrolled 120 pre existing chronic renal insufficiency patients and 80 patients without pre existing chronic renal insufficiency. In this study 21.7% of pre existing chronic renal insufficiency group and 6.3% of no pre existing chronic renal insufficiency group developed contrast induced nephropathy (p=0.003). Contrast induced nephropathy is an iatrogenic disorder and pre existing renal impairment is one of the risk factors for developing contrast induced nephropathy.

Association of cardiac ischemic score and coronary collateral circulation.

Coronary collateral circulation maintains myocardial perfusion in coronary atherosclerotic disease. The indicators of cardiac ischemia, (Angina pectoris on exertion, during emotion, previous myocardial infarction and prior coronary intervention) are associated with presence of coronary collateral circulation. In this prospective observational cross sectional study, 128 patients with history of angina pectoris on exertion and or during emotion and or myocardial infarction and or previous coronary intervention were enrolled. The cardiac ischemic score (range 1-4) was calculated by adding 1 point for each of the above four clinical factors, which can be easily assessed. Presence of coronary collaterals in coronary angiogram was defined as Rentrop grade ≥1. Patients were divided into two groups. Group A patients having Rentrop grade 0 and Group B patients are with collateral circulation, having Rentrop grade 1-3. Patients having cardiac ischemic score (range 1-4) are compared in these groups. Maximum (83.3%) patients of Group B with coronary collateral circulation had cardiac ischemic score 2-4, but majority (86.4%) of Group A patients without collaterals showed the score only 1. Thus the cardiac ischemic score is strongly associated with the presence of coronary collaterals.