Burabha Pussadhamma

Asymptomatic cardiac involvement in Thai systemic sclerosis: prevalence and clinical correlations with non-cardiac manifestations (preliminary report)

OBJECTIVE To determine the prevalence of asymptomatic cardiac involvement and its correlation with non-cardiac manifestation in Thai SSc patients. METHODS A cross-sectional study was carried out between January 2012 and June 2013 at Srinagarind Hospital, Khon Kaen University, Thailand, on adult SSc patients without signs or symptoms suggestive of cardiac involvement. We excluded those with overlap syndrome, having serum creatinine >123.8 µmol/l, history of cardiac diseases, any atherosclerosis risk factors and receiving angiotensin-converting enzyme inhibitors. Non-invasive tests related to cardiac involvement were performed, including: echocardiography, ECG, chest X-ray, inflammatory biomarkers, cardiac enzymes and N-terminal prohormone of brain natriuretic peptide. RESULTS A total of 103 SSc patients were enrolled, 61.2% of whom were in the subset. Of these, 63 patients had at least one test abnormality (prevalence 61.2%; 95% CI 51.6, 70.7). The two leading cardiac abnormalities were diastolic dysfunction (44.7%) and elevation of cardiac enzymes (36.9%). The only predictor for cardiac involvement per multivariate analysis was the dcSSc subtype with a higher modified Rodnan skin score, and shorter disease duration (odds ratio = 3.37; 95% CI 1.07, 10.65). Compared with the limited subtype, dcSSc was also significantly associated with elevated cardiac enzyme and prolonged distance between a Q wave and T wave in an ECG (QT interval). CONCLUSION Asymptomatic cardiac involvement in Thai SSc was not uncommon, and the most common finding was diastolic dysfunction. Elevated cardiac enzymes were found in one-third of the patients, which correlated with the dcSSc subtype with a higher modified Rodnan skin score and shorter disease duration, suggestive of early myocardial microcirculation disruption. Long-term follow-up was performed to elucidate the clinical implication of these abnormalities.

Effect of genotype on pulmonary hypertension risk in patients with thalassemia

Pulmonary hypertension is one of the major complications in patients with non‐transfusion‐dependent thalassemia (NTDT). Patients with NTDT have distinct genetic subgroups. Therefore, the effects of different genotype groups on pulmonary hypertension risk in patients with NTDT were assessed.

Prognostic factors of in-hospital mortality in all comers with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background The prognostic factors of in-hospital mortality in all comers and unselected patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have not been well established. Objective To identify the predictive factors of in-hospital mortality in patients with STEMI undergoing primary PCI in a tertiary heart centre. Methods Between January 2008 and December 2011, all patients with STEMI undergoing primary PCI were retrospectively included in this study. Baseline characteristics and angiographic data were reviewed and recorded. The study endpoint was all-cause in-hospital mortality. Results Of the 541 patients included in the study, 63 (11.6%) died during hospitalisation. Cardiogenic shock at admission was recorded in 301 patients (55.6%) and 424 patients (78%) had multivessel disease. Median door-to-device time was 65 min. After adjustment for baseline variables, the factors associated with in-hospital mortality included age >60 years (OR 2.98, 95% CI 1.17 to 7.05; p=0.01), left ventricular ejection fraction <40% (OR 2.53, 95% CI 1.20 to 5.36; p=0.02), and final TIMI flow grade 0/1 (OR 20.55, 95% CI 3.49 to 120.94; p=0.001). Conclusions Age, left ventricular function and final TIMI flow are significant predictors of adverse outcomes in unselected patients with STEMI undergoing primary PCI.

First Case of Tricuspid Valve Endocarditis Caused by Gemella bergeri.

Gemella bergeri is a Gram-positive cocci species arranged in pairs and composes the normal flora of oral cavity, digestive and urinary tract. Several species of Gemella are known to cause endocarditis. Here, we report the first case in Thailand of G. bergeri endocarditis whose blood culture was negative using routine methods but was positive by PCR identification of bacteria in the affected valve. A 37-year-old male presented with prolonged fever, weight loss, and dyspnea on exertion. By transthoracic echocardiography, he was suspected of having infective endocarditis of the tricuspid valve. The patient underwent tricuspid valve repair and vegetectomy. Routine hospital blood cultures were negative but G. bergeri was identified by PCR/sequencing of the heart valve tissue.

An Extensively Calcified Right Atrial Myxoma

FE A 52-year-old woman presented with dyspnea on T U R E A R T IC L E S Aexertion, chest discomfort, and two episodes of orthostatic syncope within 1 month. Cardiac auscultation revealed splitting of S1 sound without murmur. A huge, oval-shaped, calcified mass was found in the cardiac silhouette (Fig 1). Transthoracic echocardiography revealed right atrial (RA) dilatation, with a sessile mass occupying almost the entire RA chamber and causing diastolic obliteration of the tricuspid valve. Computed tomography showed an extensively calcified, interatrial septum-abutted the RA mass of 6 cm diameter (Fig 2). She subsequently underwent removal of the tumor. A mass with a yellowish, smooth surface and a stone-like consistency was adhered to the interatrial septum and was excised (Fig 3). The histopathologic examinations of the mass revealed hyalinized fibrotic thrombus with extensive calcification. The final diagnosis was a degenerative calcified RA myxoma.

A risk score for predicting pulmonary hypertension in patients with non- transfusion-dependent thalassemia in northeastern Thailand: The E-SAAN score

Abstract Introduction Pulmonary hypertension (PH) is a major complication in patients with non-transfusion-dependent thalassemia (NTDT). The risk score was developed to be a screening test for PH risk in these patients. Methods A multi-center study was conducted in patients with NTDT aged ≥10 years old. PH risk was defined as tricuspid regurgitation velocity >2.9 m/s by echocardiography. The clinical parameters significantly associated with PH were entered into the logistic regression model. Results The E-SAAN score included (1) age >35 years (2.5 points), (2) time after splenectomy >5 years (2.5 points), and (3) β-thalassemia/hemoglobin E (2 points). Using the cut-off point of 4.5 points, the score showed a good discrimination in the validating group with an area under receiver-operating characteristics curve of 0.88 (95% CI 0.8–0.95). Conclusion The E-SAAN score is a simple and practical score which can be used as a screening test for PH risk in patients with NTDT.

Incidence of Pulmonary Hypertension in Patients With Systemic Sclerosis and No Pulmonary Symptoms: Is Annual Echocardiographic Screening Necessary?

BackgroundAnnual echocardiographic screening has been recommended for early detection of pulmonary hypertension (PHT) in systemic sclerosis (SSc) patient; however, the cost benefit for cases with no pulmonary symptoms is not well established. ObjectivesThe objective of this study was to determine the incidence and clinical predictors of echocardiographic diagnosis of PHT in “asymptomatic” SSc patients. MethodsA historical cohort of adult SSc patients who underwent echocardiographic screening for PHT at least twice in Khon Kaen University, Thailand, during January 1, 2005, to December 31, 2011, was included. Pulmonary hypertension was defined by an estimate of right ventricular systolic pressure of greater than 40 mm Hg. ResultsA total of 143 medical records were reviewed (female-to-male ratio = 1.7:1). The majority had the diffuse subset (94 cases; 69.6%). Seventy-five (52.4%) were without pulmonary symptoms throughout the follow-up period. Of the 403.1 person-years under observation in the asymptomatic group, only 1 had pulmonary arterial hypertension confirmed by right-sided heart catheterization. The incidence of PHT among such SSc patients was 0.2 per 100 person-years (95% confidence interval [CI], 0.006–0.01 per 100 person-years). The disease duration at the time of PHT detection by echocardiography was 5.1 years. The declining functional class (FC) led to the higher incidence of PHT, with incidence of PHT in those who had declining FC I to FC II and FC I to FC III of 2.1 (95% CI, 0.4–6.0) and 4.2 (95% CI, 0.1–23.3), respectively. ConclusionsThe incidence of echocardiography-diagnosed PHT among Thai with SSc, and no pulmonary symptoms was low. Annual echocardiography is less beneficial among such patients; repeated echocardiography should instead be performed on those with a declining FC.

Kussmaul's sign and rapid X-Y descents in constrictive pericarditis

Right‐sided heart failure is not uncommon. A careful jugular venous examination looking for the distinct Kussmauls sign and rapid X‐Y descents, which are highly indicative of constrictive pericarditis, is markedly helpful in guiding the correct diagnosis and proper management.

Non-BMPR2 mutation heritable pulmonary arterial hypertension in Southeast Asia

A 29-year-old Thai man presented with progressive dyspnea and evidence of pulmonary hypertension. Computed tomography was negative for pulmonary embolism. Cardiac catheterization confirmed the diagnosis of pulmonary arterial hypertension (mean pulmonary artery pressure 54 mm Hg, left ventricular end-diastolic pressure 4 mm Hg, and pulmonary vascular resistance 25 Wood units) without an intracardiac shunt. Two family members had been previously diagnosed with pulmonary hypertension. There was no evidence of left heart disease or respiratory disorders. Based on the definite diagnosis of pulmonary hypertension in 3 family members, heritable pulmonary arterial hypertension was confirmed. Genetic testing indicated no BMPR2 mutation.