Closure of right pulmonary artery to left atrium fistula by duct occluder device.

We report the successful transcatheter closure of the right pulmonary artery fistula to the left atrium in a 4-year-old boy, who had presented with cyanosis and easy fatigability, identified after two-dimensional echocardiogram with bubble contrast study, computed tomography (CT) angiography, and cardiac catheterization. The fistula was successfully closed by a transcatheter approach using an 18/16 duct occluder device. There was marked improvement clinically and no complication on 2-months follow-up.

Association Of Hypertensive Retinopathy With Angiographic Severity Of Coronary Artery Disease Determined By Syntax Score.

BACKGROUND: Hypertension is a leading cause of morbidity among developing and developed countries. Hypertensive Retinopathy is a micro vascular complication of long standing hypertension while CAD is a macro vascular complication. The main objective of the study was to determine the association between worsening grade of hypertensive retinopathy with angiographic severity of coronary artery disease (CAD) measured by Syntax Score. METHODS: This was a cross sectional study which was conducted after approval from IRB. All patients with history of hypertension, who underwent coronary angiography, were included in the study. After a detailed history and physical exam, all included patients were subjected to fundoscopy. Patients were categorized into 4 groups according to Keith et al classification of hypertensive retinopathy: No HR, Mild HR, Moderate HR and Severe HR. Patients were also categorized into three groups on the basis of angiographic severity of CAD by syntax score (SS): Mild CAD (SS<22), Moderate CAD (SS: 22-32) and Severe CAD (SS>32). Data was analysed in SPSS Version 20.0. Categorical and continuous variables were described as frequencies/percentages and Mean±SD respectively. RESULTS: A total of 370 patients were included in the study out of which 205 were males with a mean age of 55.3±10.07 years. Mean duration of hypertension was 8.1±2.7 years with a mean SBP of 130.1±37.2 mmHg and mean DBP of 90.3±17.3 mmHg. Patients with no HR, mild HR, moderate HR and severe HR had a mean SS of 11.7±4.5, 17.1±3.9, 26.3±5.1 and 37.9±5.1 respectively. Significant association was found between HR and severity of CAD with a chi square value of 285.53 (p<0.001). PORs for worsening grade of HR with severity of CAD increased from 0.341 (p<0.001) for mild HR to 2.33 (p<0.001) times for severe HR. CONCLUSIONS: A higher grade of hypertensive retinopathy is significantly associated to a higher angiographic severity of CAD by syntax score.

ELECTIVE PERCUTANEOUS CORONARY INTERVENTIONS--A COMPARISION OF EFFICACY OF CLOPIDOGREL AND PRASUGREL.

BACKGROUND: Percutaneous coronary interventions are almost always preceded by the loading dose of platelets inhibiter drugs such as clopidogrel or prasugrel and followed by maintenance therapy to decrease the mortality and morbidity due to stent thrombosis. This study was conducted to compare the efficacy of clopidogrel and prasugrel for inhibiting platelet aggregation among patients undergoing elective percutaneous coronary intervention. METHODS: This randomized controlled trial study was done in Department of Cardiology, Postgraduate Medical Institute Govt. Lady Reading Hospital Peshawar. A total of 148 patients were randomly allocated to either group-A containing 74 patients using clopidogrel or group-B containing 74 patients using prasugrel RESULTS: Group-A had 55 (74.3%) male and 19 (25.7%) females while group-B had 56(75.7%) males and 18 (24.3%) females (p=0.85). Mean age was 54.9 +/- 11.2 years in group-A and was 57.7 +/- 8.7 years in group-B (p=0.09). Mean body weight was 71.8?6.4 Kg in group-A and 70.8 +/- 6.3 Kg in group-B (p=0.35). Mean Baseline platelet aggregation before drug administration was 10.43 +/- 1.9 ohm in group-A while 10.12 +/- 2.2 ohm in group-B (p=0.36). Mean Follow up platelet aggregation 6 hours after drug administration was 5.88 +/- 2.9 in group-A while it was 3.47 +/- 1.8 ohm in group-B (p=0.001). Mean Difference between basal and follow up platelet aggregation +/-SD was 52.9649 +/- 24.77 in group-A while it was 82.25 +/- 14.34 in group-B (p=0.001). 63(85.15%) of group-A had inhibition of platelets aggregation >10% as compare to 72(97.3%) of group-B had inhibition of platelets aggregation >10% (p=0.009). CONCLUSION: Prasugrel is more efficacious than clopidogrel in term of inhibition of platelets aggregation.

Radiation exposure in different cardiac catheterization procedures in cath lab.

BACKGROUND: Interventional procedures render cardiologolists and their team members to high doses of radiations. This study was conducted to assess the radiation exposure in various cardiac catheterization procedures. METHODS: This descriptive cross sectional study was conducted at the catheterization laboratory of Lady Reading Hospital Peshawar from November 2008 to December 2009. Patients were categorized into four groups for procedures a. coronary angiography, b. percutaneous coronary intervention (PCI), c. permanent pacemakers (PPM) and d. percutaneous transvenous mitral commisurotomy (PTMC), two groups for operators (consultants and trainees), and three groups for various accesses (femoral, radial and sub-clavian). RESULTS: A total of 99 patients undergoing cardiac catheterization were studied. Coronary angiography was performed in 52 (52.5%) patients, PCI in 32 (32.3%)), pacemakers in 6 (6.1%), and PTMC in 9 (9.1%) patients. Consultants did 72 (72.7%) procedures and trainees did 27 (27.3%) procedures. Through radial access, 22 (22.2%) procedures were performed, 71 (71.7%) through femoral, and 6 (6.1%) through sub-clavian. The mean radiation dose for coronary angiography was (4907.862 +/- 15231.6358 microGym2), PCI (10375.16 +/- 16083.4385 microGym2), pacemakers (1406.823 +/- 785.489 microGym2), and PTMC (1157.91 +/- 760.437 microGym2). The mean radiation dose for radial (6147.33 +/- 8480.37 microGym2), femoral (6512.58 +/- 16566.73 microGym2), and sub-clavian was (1406.82 +/- 785.48 microGym2). While for various operators consultants (7489.5 +/- 16925.55 microGym2), and trainees (2475.25 +/- 1178.86 microGym2). The mean time for radial (8.59 +/- 7.28 min), femoral (6.95 +/- 6.43 min) and sub-clavian was (8.24 +/- 4.81 min). The mean time for coronary angiography (4.56 +/- 5.32 min), PCI (11.44 +/- 6.92 min), PPM (8.24 +/- 4.81 min), and PTMC (8.28 +/- 5.01 min). CONCLUSIONS: Radiation dose varies substantially across different groups by different operators and different routes.

Frequency of anxiety and psychosocial stressful events in patients with acute myocardial infraction.

BACKGROUND: The impact of psychological factors in acute coronary events is only now emerging. A growing body of evidence attests to the influence of emotional and stress-related psychosocial factors in the aetiology of Coronary Artery Disease (CAD) and morbidity and mortality among individuals with coronary heart disease. The objectives were to look for the frequency of anxiety and psychosocial stressful events in patients with acute myocardial infarction. METHODS: Two hundred consecutive patients of Acute Myocardial Infarction (AMI) without complications who presented to the Coronary Care Unit of Cardiology Department, Lady Reading Hospital Peshawar, and 200 healthy controls among relatives of patients were assessed on Holmes Rahe Social scale (HRS) and Hospital Anxiety and Depression Scale (HADS) scale for the presence of anxiety and stressful life events in period preceding AMI. RESULTS: Sixty-three percent of the patients were male in both groups. Mean age of patients was 59 years while that of controls was 52 years. For scores of anxiety on HADS, 34% of the controls had normal score compared to of the 19% AMI group (p<0.001), while 57% of the AMI patients had abnormal score compared to 39% of the control group (p<0.001). The number events reported on HRS scale in patients with AMI were significantly more (4.2 +/- 2) compared to the number of events (2.7 +/- 1.6) in the control group with (p<0.001). Scores for the number of events on HRS scale were significantly less (98 +/- 64) in controls compared to (158 +/- 5.8) in group with AMI (p<0.001). Anxiety was diagnosed in 70% of the female patients compared to 50% of the male patients. CONCLUSION: Significant number of patients with acute myocardial infarction when assessed on standard scales had anxiety and stressful life events in the weeks preceding the event. These were more common in female than male patients.

Outcome of balloon pulmonic valvuloplasty with 18 months follow up.

OBJECTIVE: To determine the immediate and intermediate term outcome of balloon pulmonic valvuloplasty by echocardiography. METHODS: This study was conducted in the Department of Cardiology Postgraduate Medical Institute Lady Reading Hospital (LRH), Peshawar from July 1999 to January 2003. Patients with severe pulmonic valve stenosis who underwent balloon pulmonic valvuloplasty during this period were included in the study. Forty Patients fulfilling the study inclusion criteria were followed up to 18 months by two dimensional and Doppler echocardiographic examinations at 6 months interval. Patients with dysplastic valve leaflets or for whom 18 months follow up data was not available were excluded from the study. Echocardiographic data was collected prospectively. Echocardiographic hemodynamic data was analysed initially and at all three follow up visits, using descriptive statistics and paired t-test. RESULTS: Total 64 balloon pulmonic valvuloplasty procedures were performed during this period. Forty patients fulfilled the study inclusion criteria and the remaining 24 patients were excluded from the study. Mean age of the patients was 13.05 +/- 8.22 years, ranging from 1-33 years. Pre-peak pulmonic valve gradient reduced from 100.9 +/- 29.20 mmHg to 31.38 +/- 15.99 mmHg (p < 0.0001) immediately after balloon pulmonic valvuloplasty. Pulmonic valve gradient at day 1 (31.38 +/- 15.99) reduced significantly at 18 months (18.88 +/- 10.24) (p < 0.0001). Complication encountered during the procedure was transient ventricular tachycardia or multiple premature ventricular contractions. CONCLUSION: Balloon pulmonic valvuloplasty is safe and effective in reducing pulmonic valve gradient acutely and the benefit persists till 18 months. Further fall in pulmonic valve gradient is seen in intermediate term follow up.