Arun Maskey

Door-to-balloon time and the determining factors in a tertiary cardiac center in Nepal

Background Door-to-balloon (DTB) time of 90 min during primary angioplasty is considered as the benchmark duration. Shorter DTB time is preferable, and longer duration can have poor clinical outcomes. Methods A cross-sectional observational study of three months in Shahid Gangalal National Heart Center was conducted in which all patients undergoing primary angioplasty were included. The DTB time was calculated, and the different determining factors were studied. Results Seventy-nine patients undergoing primary percutaneous intervention were studied. The median DTB time was 79 minutes (Interquartile range [IQR] 59–115 min). Forty-six (58.2%) patients had a DTB time of less than 90 min. DTB time varied significantly with direct visit vs transfer (p = 0.029) and office time visit (9 am–5 pm) vs off time (5 pm–9 am) (p = 0.012). DTB time did not differ between any infarct-related vessels (p = 0.471), number of vessels involved (p = 0.638), and the added procedures (defibrillation, thrombosuction, and temporary pacemaker insertion) (p = 0.682) during angioplasty. No significant differences were recorded according to age (p = 0.330), gender (p = 0.254), hypertension (p = 0.073), diabetes (p = 0.487), heart failure (p = 0.316), and baseline left ventricular ejection fraction (LVEF) (p = 0.819). Conclusion The median DTB time in primary angioplasty was less than 90 minutes. The significant determining factors were timing of hospital visit (office vs off time) and type of visit (direct vs transfer). There can be improvement in factors determining DTB time to lower it further.

Acute myocardial infarction following electroconvulsive therapy in a Schizophrenic patient

Deaths due to acute coronary insufficiency have been reported during or following electroconvulsive therapy (ECT). Various mechanisms related to ECT related deaths also include cerebral, and respiratory complications; however, cardiovascular complication remains the most common. Here, we describe a 55 year old male with a longstanding psychiatric illness with multiple antipsychotics under regular follow-up and required repeated ECT therapy to have the disease symptoms under remission. This time he developed acute onset chest pain immediately post ECT shock and diagnosed as Acute anterior wall myocardial infarction and was taken up for successful primary coronary revascularization to left anterior descending (LAD) artery 2 h after the chest pain onset. He was later discharged in a stable state and advised for continuous psychiatric follow-up.

Anomalous origin of left main coronary artery from the right sinus of Valsalva presenting as non ST elevation acute coronary syndrome: A case report

Congenital anomalies of the coronary arteries are a cause of sudden cardiac death. Of the known anatomic variants, anomalous origination of a coronary artery from an opposite sinus of Valsalva (ACAOS) remains a major clinical issue and a challenging condition to treat. Congenital coronary anomalies are likely to be under-recognized, as completing an anatomic assessment in a very large portion of the population would seem unfeasible. However, we present a case report with image of a 49 year old male presented with acute non-ST elevation ACS for which he underwent diagnostic angiography of the coronary system which revealed a common origin of both right and left main coronary artery from right sinus of Valsalva with significant obstructive lesion in the mid segment of right coronary artery. However, due to financial constraints CT angiography could not be done in this patient to identify the detail anatomy and the course of the anomalous left coronary artery origin (L-ACAOS). He was managed medically with dual antiplatelets, beta blockers, nitrates and ACE inhibitors.

Percutaneous transvenous mitral commissurotomy in mitral stenosis and left atrial appendage clot patients in special conditions: Hospital-based study

Background The percutaneous transvenous mitral commissurotomy is an important procedure for the treatment of mitral stenosis. A lot of mitral stenosis cases have left atrial appendage clot which precludes the patient from the benefit of this procedure. The aim of the study was to study the feasibility and safety of the procedure in a patient with appendage clot in the setup of certain urgent conditions. Method All cases of mitral stenosis with significant dyspnea and mitral valve area <1.5 cm2 with left atrial appendage clot and a condition which would preclude the patient from continuing on anticoagulation and needed urgent intervention were included in the study. From January 2011 to December 2013, twenty patients coming to Shahid Gangalal National Heart Centre, Kathmandu were selected for the procedure with conventional sampling technique. Informed written consent was obtained from the patients explaining all possible complications. The approval of the study was taken from the ethical committee of the hospital. Result Mean mitral valve area increased from 0.90 cm2 (SD ± 0.14) to 1.5 cm2 (SD ± 0.21) (p = 0.02). Left atrial mean pressure decreased from mean of 20 to 10 mmHg. Subjective improvement was reported in all. All of the patients had fulfilled criteria for successful PTMC. There was no mortality during hospital stay or in one-week follow-up period. There were no neurological complications or any need for emergency surgery. Conclusion The immediate result of percutaneous transvenous mitral commissurotomy in selected cases of mitral stenosis with left atrial appendage clot is safe and acceptable in certain urgent situations in experienced hands.

Percutaneous Coronary Intervention in Nepal

Introduction : Percutaneous coronary intervention (PCI) is an important aspect of management of ischemic heart disease. The use of PCI has expanded with importance on minimizing post-procedural vascular and bleeding complications while maintaining procedural success. The radial artery has emerged as an alternative to the femoral artery for the access sitefor the procedure. Objectives : The main objective of the study was to assess the trend of PCI, procedural outcome and complications. Methods : This is a retrospective study which included four thousand two hundred and eighty eight patients who had underwent percutaneous coronary intervention during the study period of ten years from 2002 to 2012. The data on demographic profile, angiographic characteristics, outcome and complications of the procedure were analyzed. Results : The mean age of the patients was50 ± 10.5 years ranging from 21 to 91 years. The79.5% (3409) were male and 20.5% (879) were female. The 75.3 % (3228) of the PCI were elective procedure. The 94.38% (4047) of the patient had single vessel PCI and 241(5.62%) had multivessels PCI. The PCI to LAD was the most common in 2153 (47.43%) followed by RCA 1401(30.87%) and then LCX 957 (21.08%). Overall success rate of the procedure was 95.03%. The mortality was observed in 1.07% (46) of the patients. The use of radial artery access for the PCI has a rising trend over years. The 43.5% of the procedure were performed from the radial access in 2012. Conclusion : Percutaneous coronary intervention in Nepal is increasing every year with accepted success rate and complication. With experience more complex cases are being done. Radial PCI has increasing trend.