Background: Rheumatic heart disease is the most common cardiac disease in Yemen. It is associated with high morbidity and mortality. Valve replacement is the most common open heart surgery procedure in our cardiac center. The use of mechanical valves remains burdened with serious complications such as thrombosis. Valve thrombosis is still associated with high mortality ^] The reported mortality rate of the redo operation ranges from 8 to 20% and up to 37-54% in critically ill patients. Objective: The aim of the present study was to investigate mechanical valve obstruction among Yemeni patients. Patients and Methods: Between January 2003 and April 2007, 2794 patients underwent prosthetic valve replacement in our center, Al-Thawra Hospital. Of those patients, 129 (4.6%) underwent reoperation for te obstructive mechanical valve. Patients with clinical suspicion of prosthetic valve obstruction (PVO) were admitted emergently to the CCU and the diagnosis was confirmed with echocardiography. All patients had heart failure; 95% of them were in NYHA class IV. All were transferred directly from the CCU to the operating room. The mean age was 34.8 ± 13.4 years. Two patients received preoperative thrombolytic therapy that was not successful. Obstruction involved the mitral valve prosthesis in 47 (36.4%); the aortic prosthesis in 16 (12.4%) patients; both valves in 21 (16.3%) patients; mitral valve replacement with tricuspid valve repair in 22(17%); double valve replacement with tricuspid valve repair in 1 (0.8%); redo mitral valve replacement with aortic valve cleaning in 7 (5.4%) cases; aortic valve cleaning in 5 (3.9%) patients; mitral valve cleaning in 5 (3.9%); and 5 (3.9%) patients had redo mitral with aortic replacement. Results: The operations were performed urgently. The etiology of the obstruction was thrombus in 111 (86%), pannus formation in 4 (3%), pannus and thrombus in 6 (4.8%), vegetation in 7 (5.4%) patients, and interposition of suturing materials in 1 (0.8%) patient. The in- hospital mortality was 23/129 (17.8%). Conclusion: The incidence of prosthetic valve obstruction remains high in Yemen. The vast majority of the patients who are referred to our hospital come from remote provinces in the country where regular INR measurement is not readily available. For those who are living in areas without good medical care, certain measures are necessary to avoid this disastrous complication: (1) good patient education, (2) free INR testing and free anticoagulant drugs such as warfarin; and (3) use of tissue rather than mechanical valves.

Aims: Phase-1 Cardiac Rehabilitation (CR) is an important part in the treatment of patients with ST-Elevation Myocardial Infarction (STEMI). Lack of literature in the rural Indian setting led to the design of this study. Setting and Design: Secondary care rural hospital, non-randomized experimental study. Materials and Methods: Fifteen historical controls and 15 prospectively enrolled patients between January 2007 and December 2007. The prospectively enrolled patients received the phase-1, exercise-based, protocol-guided CR. At discharge, the six-minute walk test (6MWT) distance, Borg's Rating of Perceived Exertion (RPE) after the 6MWT, time to return to baseline parameters after the 6MWT, and complications were assessed. Statistical Analysis used: Independent t-test and the Mann Whitney test. Results: Statistically significant (P < 0.01) differences in ratings of perceived exertion (RPE) and time to return to baseline parameters post the 6MWT were seen in the experimental group ((2 vs. 4 and 5.47 vs. 7.93 minutes, respectively). No significant changes in the 6MWT distance between the groups were noticed (470+151.76 m and 379+170.70 m, respectively). No adverse events during the 6MWT and the phase-1 CR were observed. Conclusion: Protocol-guided, phase-1 CR produces a much faster return of heart rate and blood pressure to baseline following the 6MWT, without producing a great rise in the RPE during the 6MWT, which suggests a training benefit among these patients. The 6MWT can be safely administered in this rural population. However, larger studies will be required to validate these results.

Post operative atrial fibrillation (POAF) is more common than before due to increased numbers of cardiac surgeries. This in turn is associated with increased incidence of post operative complication, length of hospital stay and subsequent increase the cost of hospitalization. Therefore preventing and/or minimizing atrial fibrillation by pharmacological or nonpharmacological means is a reasonable goal. POAF has also been associated with postoperative delirium and neurocognitive decline. The precise pathophysiology of POAF is unknown, however most of the evidence suggests it is multifactorial. Different risk factors have been reported, and many studies have evaluated the prophylactic effects of different interventions. This review article highlights the incidence, risk factors, and pathogenesis, prevention, and treatment strategies of POAF.

Type IV dual left anterior descending (LAD) coronary artery is a rare anomaly and was detected incidentally during a routine coronary angiogram. The article discusses the types of dual LAD and their clinical implications.

A 60-year-old female presented with anterolateral non-ST elevation myocardial infarction and her coronary angiogram revealed severe left system coronary artery disease with a normal right coronary artery. Following coronary angiogram, she developed acute inferior wall and right ventricular ST elevation myocardial infarction with complete atrioventricular block and cardiogenic shock. Repeat coronary angiogram showed large proximal right coronary thrombus causing subtotal occlusion that was successfully aspirated using a guide catheter. The possible causes for intracoronary thrombosis following coronary angiography are discussed here.

Mural endocardial lesions can be seen as MacCallum plaques in rheumatic heart disease. These plaques appear as map-like areas of thickened, roughened, and wrinkled part of the endocardium in the left atrium. Perhaps they are caused by regurgitant jets of blood flow, due to incompetence of the mitral valve. Although MacCallum plaques are one of the characteristic features in rheumatic heart disease, they are very uncommon in recent times. We hereby report a case of an adolescent female with RHD, who was working as a housemaid in a doctor's house for a few months, and suddenly developed respiratory tract infection and cardiac failure. She died on the fourth day of admission. A medicolegal autopsy was conducted, as her relatives accused her master of sexual assault. On autopsy it was seen that the mitral valves were narrowed, showing multiple vegetations. MacCallum plaque was seen in the dilated left atrium. Hence, it is presented here for educative purposes.