Pakistan Following Foot Prints of Developed World in Structural Interventions: Experience of Transcatheter Aortic Valve Implantation Reported First Time.

Background The aim of this study was to evaluate the safety and efficacy of transcatheter aortic valve implantation (TAVI) program in a Tertiary care hospital in Karachi, Pakistan. Methodology This study was conducted by interventional cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Karachi from July 2015 to February 2020. All patients of severe aortic stenosis (AS) who underwent TAVI were included. Baseline characteristics, in-hospital course and one-month follow-up data were collected. Results This study included 100 consecutive patients with severe AS undergoing TAVI. Sixty-three (63.0%) patients were males and the mean age was 67.38 ± 10.73 years. Eighty-five (85%) patients were in the New York Heart Association (NYHA) class III-IV. Aortic valve mean gradient was 51.33±10.47 mmHg and 50% of patients had bicuspid aortic valves. Core valve was implanted in 86 (86%) and evolute-R aortic valve was implanted in 14 (14%) patients. TAVI was successfully done in 94% of patients. Post-deployment aortic valve mean gradient was 5.33±4.13 mmHg. Major vascular access site complications were noted in 14% and atrioventricular (AV) blocks were seen in 22% of cases. There was a significant difference in symptoms of patients before and after the procedure. Overall, eight (8%) patients expired during hospital stay. At one-month follow-up, 76% of patients were found to have no limitation of physical activities. Conclusions Results of this study showed that TAVI is a safe procedure in these high-risk patients and is an alternative to surgery for AS patients in the region.

Acute ST-Elevation Myocardial Infarction Before and During the COVID-19 Pandemic: What is the Clinically Significant Difference?

Background In the current coronavirus disease-2019 (COVID-19) pandemic, the pattern of hospital admissions for acute ST-elevation myocardial infarction (STEMI) is changing, and increased mortality and morbidity is being noted in these patients. Cardiac manifestations of COVID-19 are complex and include STEMI, myocarditis, myocardial injury, and cardiomyopathy. The objective of our study was to compare the data of patients with STEMI presenting in COVID-19 versus the non-COVID-19 era.  Methods We analyzed the clinical and angiographic characteristics of STEMI patients undergoing primary percutaneous coronary intervention (PCI) at our center. The primary outcome variables were admission rate for STEMI, mean total ischemic time (TIT), coronary artery disease burden, mean ejection fraction, and in-hospital mortality for three defined groups. Group A consisted of patients who underwent primary PCI from March through April 2020. Group B included patients who underwent primary PCI from January to February 2020. Group C consisted of patients who underwent primary PCI from March to April 2019. We then compared the data among the three groups and calculated any significant p-value (p<.001). Results In Group A, 1139 patients were admitted for primary PCI. The mean admission rate was 18.6 ± 4.36 admissions per day. There were 1535 patients in Group B and an admission rate of 26.01 ± 4.90 (p<.001 compared to Group A). In Group C, there were 1537 patients and an admission rate of 24.8 ± 4.55 (p<.001, compared to Group A). The mean TIT was 429.25±272.16 minutes for Group A, 359.78±148.04 minutes for Group B, and 346.75±207.31 minutes for Group C (p<.001). A higher mortality rate was noted in Group A (COVID-19 era) versus Group C (non-COVID-19 era; p<.001). Conclusions A lower admission rate, higher TIT, and higher mortality rates were noted in patients with acute STEMI during the COVID-19 pandemic compared to the pre-COVID era. During the COVID-19 pandemic, physicians should bear in mind that patients with STEMI have increased mortality and morbidity. Where possible, efforts should be made for timely management of these critical patients to decrease mortality.

Frequency of Thrombolysis in Myocardial Infarction III Flow in Patients With Primary Percutaneous Coronary Intervention: Not All Culprit Vessels Are Completely Occluded in ST Elevation Myocardial Infarction.

Background ST elevation myocardial infarction (STEMI) is classically characterized by total occlusion of the culprit coronary artery. However during primary percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) 0 flow is not observed in all patients' culprit arteries in angiographic views. This study was conducted to find out the frequency of TIMI flow in acute STEMI patients in view of the above concept. The aim of this study was to evaluate the frequency of pre-procedural TIMI III flow in those patients who underwent primary PCI for acute STEMI in a public sector hospital in Karachi, Pakistan. Methodology This study is an audit of already saved data in the catheterization laboratory of the National Institute of Cardiovascular Diseases (NICVD), Karachi, that was collected prospectively from January 2016 to December 2018. These data were collected after taking consent from those patients who presented to hospital within 12 hours of symptoms and underwent primary PCI. Data were entered and analyzed on Statistical Package for the Social Sciences (SPSS) version 19 (IBM Corp., Armonk, NY, USA). Results A total of 8018 patients were included in this study who presented with STEMI and underwent primary PCI. Out of them 80.9% were males. Hypertension was the leading risk factor in 54.1% (4340) of patients. TIMI III flow was present in 11.4% of patients before primary PCI, while TIMI 0, I and II flow were present in 57.1%, 15.1%, and 16.3% of patients respectively (p<0.001). Fourteen percent of patients with TIMI III flow were of age group 51 to 60 years. Among those who had TIMI III flow, 11.2% were those with door to balloon time of <90 minutes. In 11% of cases, left anterior descending (LAD) artery had TIMI III flow as compared to other vessels (p<0.001). The length of the lesion was significantly smaller in patients who had TIMI III flow compared to those who had TIMI 0-II flow. Conclusions This study revealed that not all patients with acute STEMI had totally occluded culprit coronary artery but some of them had angiographic TIMI I-III flow in the infarct-related artery. Further studies are needed to find the reason for re-establishment of flow in the culprit vessel in STEMI patients before PCI.

Radiotherapy Alone or With Chemotherapy in the Management of Carcinoma of the Supraglottic Larynx: A 25-Year Community Hospital Experience.

OBJECTIVES: The purpose of this study was to retrospectively review outcomes for patients treated with definitive radiotherapy for carcinoma of the supraglottic larynx at a community hospital and to compare our results with the literature. MATERIALS AND METHODS: Treatment records of 46 patients with localized carcinoma of the supraglottic larynx treated from January 1987 through January 2012 were reviewed. Overall, 18 (39%) presented with stage I or II disease, whereas 28 (61%) presented with stage III to IV. In total, 30 patients (65%) were treated using hyperfractionation, whereas 16 (35%) received once-daily fractionation. Twelve patients (26%) received concurrent chemotherapy with weekly cisplatin. The Kaplan-Meier method was used to assess outcomes. RESULTS: The median follow-up for the living patients was 6.7 years (range, 1.7 to 23.1 y). At 5 years, the local-regional control (LRC), ultimate LRC, laryngeal preservation, and overall survival (OS) rates were 70%, 82%, 65%, and 53%, respectively. At 5 years, disease-free survival and cause-specific survival rates were 75% and 76%, respectively. The 5-year OS rates by American Joint Committee on Cancer stage were as follows: I to II, 61%; III, 51%; and IV, 44%. For those receiving concurrent chemotherapy, there was no improvement in 5-year LRC (83% vs. 66%; P=0.4081) or OS (55% vs. 50%; P=0.7697). For those receiving hyperfractionation, there was no improvement in 5-year LRC (75% vs. 63%; P=0.3369) or OS (55% vs. 50%; P=0.4161). CONCLUSIONS: Our outcomes are similar to those reported in the literature. Neither hyperfractionation nor chemotherapy appeared to confer a benefit for disease control or OS possibly owing to small sample size and the inherent bias of a retrospective review.

Assessment of Femoral Artery Bifurcation Level with Conventional Angiography.

Introduction The common femoral artery (CFA) is the optimal access point for femoral arterial puncture. A higher or lower puncture can result in various vascular complications and by the proper definition of the femoral arterial bifurcation level and the optimal puncture point such complications can potentially be avoided. In the literature, little data is available about the frequency of femoral artery bifurcation and the relationship between the bifurcation level of one artery and its contralateral counterpart in our part of the world. Methods We performed a prospective study from April 2016 to September 2016 to define the frequency of bifurcation of the CFA in relation to the femoral head and the relationship between bilateral CFA bifurcations, with bilateral femoral angiography on 579 patients undergoing routine coronary angiography. Results The frequency of normal/low, high, and very high femoral bifurcations was 66%, 26%, and 8%, respectively. There was no significant difference in the bifurcation of CFA between the two sides (p = 0.51). A specific bifurcation level on one side significantly increased the likelihood of the same bifurcation level on the contralateral side (odds ratio (OR) = 151.86 (51.39-448.77)). A multivariable logistic regression analysis revealed age, race, gender, height and weight, body surface area (BSA), and body mass index (BMI) were not predictive of any specific bifurcation level on either side. Conclusions The majority (two-thirds) of the individuals in the study population were with normal/low femoral bifurcation with no significant difference in bifurcation level on either side.

Risk Factors of Atrial Fibrillation in Patients with Heart Failure.

Introduction Coexistence of atrial fibrillation (AF) in patients with heart failure (HF) is a common phenomenon associated with poor prognosis. Therefore, this study was designed with an aim to estimate the different risk factors of atrial fibrillation (AF) in patients with HF. Methods In this study, patients of either gender, 18 to 80 years of age, and with echocardiographic confirmation of HF presenting at the adult cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan were consecutively included. Patients diagnosed with chronic obstructive airway diseases, pneumonia, or pericarditis, and patients diagnosed with existing AF were excluded from the study. Data regarding demographic and clinical risk factors of AF were obtained using a structural proforma. Results Out of 150 patients, 59.3% (89) were females, and the mean age was 50 ± 16 years. A majority of the patients, 55.3% (83), had a history of rheumatic heart diseases (RHD) and 22.7 (34) percent had a history of transient ischemic attack (TIA) or cerebrovascular accident (CVA). On echocardiography, 28.0% (42) of the patients had right ventricular (RV) dysfunction, and the clot was seen in 28.0% (42) of the patients. Mitral stenosis (MS) and mitral regurgitation (MR) were observed in 34.5% (61) and 29.3% (52) of the patients, respectively. Conclusion We observed that the adult population with HF tends to have multiple risk factors of AF. More coordinated efforts are needed by the healthcare professionals to understand and manage these coupled conditions.