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   Table of Contents - Current issue
April-June 2022
Volume 23 | Issue 2
Page Nos. 67-126

Online since Saturday, July 23, 2022

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Gender association with incidence, clinical profile, and outcome of out-of-hospital cardiac arrest: A middle east perspective p. 67
Fadi Khazaal, Abdulrahman Arabi, Ashfaq Patel, Rajvir Singh, Jassim Mohd Al Suwaidi, Awad Al-Qahtani, Salaheddin Omran Arafa, Nidal Asaad, Hajar A Hajar
Background: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide. However, there is limited information on the outcome of the OHCA in the Middle East population, and limited studies have been carried out in the Arab Gulf countries. Hence, we aim to study the incidence and rate of survival in the OHCA setting and to assess the impact of gender on the clinical outcome following OHCA. Methods: Retrospective analysis of a prospective registry of all eligible, consecutive, and nontraumatic adult patients who successfully resuscitated (return of spontaneous circulation) from “Cardiac Arrest” occurring outside the hospital, Hospitalized in Doha, Qatar from January 1991 to June 2010. Results: A total of 41,453 consecutive patients were admitted during the study, of whom 987 (2.4%) had a diagnosis of OHCA. Among them, 269 (27.3%) were women and 718 (72.7%) were men. Although the mortality rate was higher in females than in males (65.4% vs. 57.7%, P = 0.03), the logistic regression analysis did not show gender as an independent predictor of death in this clinical setting. Conclusion: In this sample of the state population, women who have OHCAs had a lower rate of survival, but gender was not an independent predictor of mortality following OHCA.
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Surviving a decade or more after coronary revascularization in a middle Eastern population: The impact of diabetes mellitus p. 73
Imad A Alhaddad, Ramzi Tabbalat, Yousef Khader, Zaid Elkarmi, Zaid Dahabreh, Ayman Hammoudeh
Introduction: Studies that evaluate Middle Eastern patients who have long-term survival after coronary artery revascularization are scarce. The prevalence of diabetes mellitus (DM) is high and rapidly increasing in our region. Methods: The study enrolled consecutive ambulatory or in-patients who had percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery at least 10 years earlier. Collected data included cardiovascular risk factors at the time of the index revascularization and evolution of risk factors since then, the occurrence of cardiovascular events, and the need for coronary revascularization after the index procedure. Events were compared between patients with DM and no DM at baseline. Results: The study population consisted of 891 consecutive patients with 351 patients (39.4%) had DM and 540 patients (60.6%) had no DM. The mean age at baseline was 53.9 ± 8.8 years for DM patients and 53.0 ± 9.8 years for no DM patients (P = 0.16). At baseline, the DM group had more hypertension (70.9% vs. 27.6%, P < 0.0001), more dyslipidemias (12% vs. 5.2%, P = 0.001) but less smokers compared to no DM group (44.4% vs. 58.3%, P < 0.001). DM and no DM groups had similar proportion of PCI (65.5% vs. 68.3%, P = 0.42) and CABG (34.5% vs. 31.7%, P = 0.43) at baseline. Following the index revascularization procedure, acute coronary events, heart failure, and stroke developed in similar proportions in the two groups. Repeat revascularization after the index procedure showed that the DM group had more PCI compared to no DM group (52.7% vs. 45.4%, P = 0.04) but similar proportions of CABG (7.1% vs. 9.8%, P = 0.20). Conclusions: In this retrospective observation of Middle Eastern patients who survived at least a decade after coronary revascularization, the DM group had more hypertension and dyslipidemias but fewer smokers compared to no DM at baseline. During follow-up, the DM group required more PCI revascularization compared with no DM group.
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Long-term outcomes of tetralogy of fallot in the Kingdom of Bahrain p. 78
Abhinav Agarwal, Suad R Al Amer, Habib Al Tarif, Aieshah Ahmed Ismael, Abdulla Faisal Alshaiji, Vimalarani Arulselvam, Neale Nicola Kalis
Introduction: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Surgical correction has improved survival but re-intervention is often required. Objectives: The objective is to assess outcomes after surgical repair of TOF, long-term follow-up, and factors that influence these results. Materials and Methods: This is a retrospective study conducted in a tertiary care center. Records of patients diagnosed with TOF from 1992 to 2019 (37 years) were retrieved from a detailed database. Patients who underwent complete correction were grouped according to diagnosis, the technique utilized in surgical repair, need for staged repair, and syndromic association. Univariate actuarial and event-free survival analysis was performed. The endpoint for an event was death or re-intervention. Results: A total of 230 patients were diagnosed with TOF and 174 patients underwent complete surgical repair. At 40 years postoperatively, survival was 96%. Actuarial survival was independent of syndromic associations, anatomical diagnosis, type of surgery, or previous shunt. Event-free survival (EFS) survival was 8.12%. EFS was significantly worse for patients with pulmonary atresia (PA) (Hazard ratio, 4.1125; 95% confidence interval [CI], 1.2654–13.3657; P < 0.0001) and for those that required homograft/conduit. The median duration for EFS was 22.73 years, 19.58 years, and 9.12 years for transannular patch (TAP), pulmonary valve-sparing (PVS), and homograft group, respectively. The survival curve for the PVS group merged with that of TAP 20 years postoperatively. Similarly, it merged at 22 years for staged versus primary repair and at 22.73 years for syndromic versus nonsyndromic patients. A weak correlation was found between age at surgery and event-free duration (cc, 0.309; P < 0.0001). The need for TAP was not influenced by the previous palliation, χ2 (1, n = 154) = 3.36, P = 0.0667, or with interval to complete correction after the shunt procedure (P = 0.9672). Conclusions: Total correction of TOF has low perioperative mortality and good long-term survival, but the need for re-interventions is high. This study demonstrated that patients requiring homograft/conduit and those with a diagnosis of PA had worse outcomes. Comparison between different surgical groups showed merging of survival curves in follow-up that signifies gradual loss of survival advantage over time.
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Impact of COVID-19 on workload and workflow in echocardiography unit in a tertiary care university hospital: A monocentric observational study p. 86
Mikhael Kossaify, Hazar Kanj, Christina Tarabay, Antoine Kossaify
Background: The COVID-19 pandemic is a new unexpected worldwide condition with a heavy burden on health-care institutions and health-care workers. Objective: We sought to examine the impact of COVID-19 on workload and workflow in the echocardiography unit in a tertiary care university hospital. Methods: We conducted a monocentric observational study, evaluating workload and workflow during the COVID-19 year relative to the previous year. Results: The findings show a substantial reduction in workload (55.20%) along with significant changes in workflow in the echocardiography unit during the pandemic. Changes in workflow involved measures implemented for protection, changes in echo indications which became more selective, changes in echo pattern, reduction in human flow in echocardiography laboratory, delays in reporting and archiving, and changes in training and teaching. Conclusion: COVID-19 pandemic had a substantial impact on the echocardiography unit, with a significant reduction in workload and considerable changes in workflow. In the future, it is essential to be better prepared as individuals, health-care workers, health-care institutions, and the general community, to deal better with any potential “invisible enemy.”
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Long-term consequences of ventricular septal defect closure using Nit-Occlud Le VSD coil device: A systematic review and meta-analysis p. 93
Mehdi Ghaderian, Farzad Shahsanaei, Samin Behdad, Safura Mozafari
Background: The successful management of ventricular septal defect (VSD) has been possible through the development of advanced techniques. In this regard, percutaneous VSD closure by employing different types of occluders as an alternative for surgery can help to achieve the most desirable postprocedural consequences. However, the studies reported contradictory results on the use of different brands of VSD occluders. Herein, we performed a systematic review and meta-analysis of published studies to assess pooled long-term success rate and potential complications of using the Nit-Occlud Lê VSD coil for VSD closure. Materials and Methods: Two reviewers began to deeply search the various databases for all eligible studies in accordance with the considered keywords. The inclusion criterion for retrieving the studies was to describe the mid-term or long-term consequences of VSD closing by the Nit-Occlud Lê VSD coil device. In the final, eight articles were eligible for the analysis. The follow-up time of the studies ranged from 6 months to 5 years. Results: The success rate of the procedure ranged from 87.0% to 100% considering the weight of each study, the pooled success rate of VSDs closure by Nit-Occlud Lê VSD coil device was 93.1% (95% confidence interval [CI]: 89.9% to 95.5%). The pooled prevalence of postprocedural residual shunt was estimated to be 9.6% (95%CI: 6.8% to 13.4%). The corrected pooled prevalence of trivial mild aortic regurgitation (AR) was 2.9% (95%CI: 1.5% to 5.4%); however, moderate-to-severe AR and complete heart block or right bundle branch block were shown to be rare. Conclusion: VSD closure using a Nit-Occlud Lê VSD coil device can lead to a high success rate with low rates of residual shunt, cardiac conductive or vascular disturbances.
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Preoperative coronary angiogram in patients with aortic valve endocarditis technical considerations p. 100
Abdulrahman Arabi, Salah Arafa, Awad Al-Qahtani, Omnia Tajelsir Osman, Jassim Alsuwaidi
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Khat chewing and cardiovascular disease p. 103
Ahmed Al-Motarreb, Jassim AL-Suwaidi
Khat chewing is a deeply rooted habit in Yemen. It has social, economic, and medical problems. Chronic use of khat chewing increases the risk of many medical complications. Cathinone, the main khat leaf constituent, has an indirect sympathomimetic action. The effect of khat chewing and cathinone on the cardiovascular system have been identified, including increased risk of hypertension and acute cardiovascular events, as well as increased risk of cardiovascular complications among patients presenting with Acute Coronary Syndrome who are khat chewers.
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Giant coronary aneurysm in an infant with multisystem inflammatory syndrome p. 108
Syed Ahmed Zaki, Anas Abu Hazeem, Asrar Rashid
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV2), also known as COVID-19, has rapidly spread resulting in a worldwide pandemic. Although COVID-19 infections in children are generally mild and nonfatal, there is increasing recognition of its association with the multisystem inflammatory syndrome in children (MIS-C), leading to serious illness and possible long-term complications. This report describes a 6-month-old Indian infant who presented with a 4-day history of fever with nonspecific signs of viral illness and erythematous rash. Although the initial echocardiogram was normal, subsequent scans showed progressive dilatation of bilateral coronary arteries. Despite the timely intervention, he developed left coronary artery thrombosis, leading to myocardial infarction. His SARS-CoV-2 antibody titers were strongly positive. Through this case, we discuss the management of MIS-C with coronary artery involvement. The long-term outcome of coronary artery aneurysm due to MIS-C remains unknown and close follow-up is important. Further research is pivotal for a better understanding of MIS-C.
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An ectopic primary pacemaker in association with isolated persistent left superior vena cava p. 113
Bassim Albizreh, Ahmed Elmagraby, Nidal Asaad, Shahul Hamid, Nora Al Jefairi
We are reporting a case of a young Nepalese man, who was not known to have any past medical history, and who presented with palpitations. An electrocardiogram showed negative P-waves atrial rhythm in II, III, arteriovenous fistula, and V3-V6 with a variable block at 90–130 bpm. No positive “normal” P-waves were demonstrated in any tracing. He was found to have a congenital absence of the right superior vena cava (RSVC) along with persistent left superior vena cava (PLSVC) a condition also called isolated PLSVC (IPLSC). He underwent a treadmill stress test for further evaluation which showed a normal chronotropic response and the same persistent negative P-waves morphology. An invasive electroanatomical and activation mapping showed an absence of RSVC, the earliest atrial activation site in the anterior side of the inferior vena cava (IVC), and the absence of normal (positive) P-waves/normal sinus node (SN) activation. Considering all the available clinical data together, we believe that the patient was living with an ectopic pacemaker node that acts as a primary node and originated in the IVC/right atrium instead of the normal expected SN position. Given the high risk of complete sinoatrial nodal block in case of radiofrequency ablation, the patient was kept on medical treatment with a beta-blocker which was effective in controlling his symptoms and atrial arrhythmia.
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Delivery of acute rehabilitation to a postcoronary artery bypass graft COVID-19 patient in a pandemic environment p. 118
Praveen Jayaprabha Surendran, Prasobh Jacob, Cornelia Sonia Carr, Amr Salah Omar, Suraj Sudarsanan, Shiny Shiju, Yazan Hasan Othman Albadwan, Syed Abdul Ansari Matharsa, Gigi Mathew, Dinesh Kumar Selvamani
During the first wave of the coronavirus disease (COVID-19) pandemic, a 57-year-old COVID-19 male patient was diagnosed with non-ST-elevation myocardial infarction and required urgent coronary artery bypass graft. In-patient cardiac rehabilitation following cardiac surgery was inevitable to limit or prevent various postoperative complications. A routine rehabilitation program was not feasible because of the strict COVID-19 isolation procedures, the high risk of cross infections, and the lack of various resources. Moreover, the detrimental effects of COVID-19 infection on multiple body systems reduced his exercise tolerance, limiting his engagement in physical activity. This case report highlights the various challenges encountered during the rehabilitation of these patients and strategies adopted to overcome them, illustrating the feasibility of a modified rehabilitation program to ensure early functional recovery.
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Cardiac metastasis of malignant melanoma p. 123
Abdelhaleem Shawky Hamada, Samah Farouk Abdulla Mohamed, Smitha Anilkumar
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Is empathy the best medicine? p. 126
Rachel Hajar
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