Chandra Mani Adhikari

Carotid intima-media thickness (CIMT) and carotid plaques in young Nepalese patients with angiographically documented coronary artery disease

BACKGROUND Carotid intima-media thickness (CIMT) and carotid plaques are non-invasive surrogate markers of early evaluation of coronary artery disease (CAD) and sub clinical atherosclerosis. The objective of the study was to evaluate CIMT and carotid plaques in less than 45 years old Nepalese patients with angiographically proven CAD. METHODS A total of 54 patients with angiographically documented CAD at less than 45 years of age were enrolled. CAD was confirmed by coronary angiography. Demographic profile was obtained. High resolution B-mode ultrasound was used to detect the CIMT and carotid plaques. RESULTS The study population included 44 males and 10 females, with a mean ± SD age of 38.4±4.3 years (range, 25-44 years). Cardiovascular risks factors included smoking in 81%, Hypertension in 52%, diabetes in 19% and alcohol consumption in 78% of patients. Lipid profile (mean ± SD) was normal except for elevated triglyceride (TG) levels of 204±130.8 mg/dL. By angiography, 64.8% had single vessel disease, 26% had double vessel disease and 9.2% had triple vessel disease. Ultrasound detected either thickened CIMT or presence of plaques in 46 (85.2%) cases (group-A) and 8 (14.8%) had negative (normal) carotid study (group-B). Among the 46 patients with positive findings 63% had carotid plaques and 37% had thickened CIMT only. The majority (69%) of the carotid plaques were detected at the carotid bulbs. In total population, carotid plaque was detected in 53.7% of cases. There was no statistical significant difference of age, body mass index (BMI) and lipid level between group-A and group-B. CONCLUSIONS Increased CIMT and carotid plaques are detected in majority of the young Nepalese patients with angiographically documented CAD. The majority of carotid plaques are detected at the carotid bulbs. Routine carotid ultrasound study in young individuals with CAD risk factors appears worthwhile.

Percutaneous transvenous mitral commissurotomy in juvenile mitral stenosis

BACKGROUND Percutaneous transvenous mitral commissurotomy (PTMC) is a valid alternative to surgical therapy in selected patients with mitral stenosis. Juvenile mitral stenosis (JMS) varies uniquely from adult rheumatic heart disease (RHD). We aimed to evaluate the efficacy of PTMC in JMS patients. METHODS It was a single centre, retrospective study conducted between July 2013 to June 2015 in Shahid Gangalal National Heart Centre, Kathmandu, Nepal. Medical records of all consecutive patients aged less than 21 years who underwent PTMC were included. Mitral valve area (MVA), left atrial pressure and mitral regurgitation (MR) were compared pre and post procedure. RESULTS During the study period 131 JMS patients underwent PTMC. Seventy (53.4%) were female and 61 (46.6%) were male. Among the 131 patients, 40 (30.5%) patients were below the age of 15 years. Patient age ranged between 9 to 20 years with the mean of 16.3±2.9 years. Electrocardiography (ECG) findings were normal sinus rhythm in 115 (87.7%) patients and atrial fibrillation in 16 (12.3%) patients. Left atrial size ranged from 2.9 to 6.1 cm with the mean of 4.5±0.6 cm. The mean MVA increased from 0.8±0.1 cm(2) to 1.6±0.2 following PTMC. Mean left atrial pressure decreased from their pre-PTMC state of 27.5±8.6 to 14.1±5.8 mmHg. Successful results were observed in 115 (87.7%) patients. Suboptimal MVA <1.5 cm(2) in 11 (8.4%) patients and post-procedure MR of more than moderate MR in 5 (3.8%) patients was the reason for unsuccessful PTMC. CONCLUSIONS PTMC in JMS is safe and effective.

Percutaneous transluminal mitral valvuloplasty in post Mitral valve repair and Aortic valve replacement patient

MV repair in the rheumatic population is feasible with acceptable long-term results. Incidence of mitral stenosis (MS) following mitral valve (MV) repair for severe rheumatic mitral regurgitation (MR) and usefulness of percutaneous transluminal mitral valvuloplasty in these patients is not described in literature. We report a case of successful PTMC in severe MS following MV repair for severe rheumatic MR.

Clinical profile, management and outcome of pulmonary embolism in Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Background and aims Pulmonary embolism (PE) is associated with a significant mortality and morbidity. We aim to study clinical profile, management and outcome of PE at Shahid Gangalal National heart Centre, Kathmandu, Nepal. Methods It was a retrprospective, single centre study, conducted from January 2015 to December 2016. Haemodynamics was used for risk Simplified, PESI score, predisposing factors, symptoms, clinical features at the time of admission, ECG features, echocardiogram, treatment received and the outcome were reviewed. Results During the study period 23 cases of PE were admitted. Nine were males and 14 were females. Eleven patients were diagnosed as provoked PE. High risk PE was diagnosed in four patients, Non-high risk in 19 patients. The most common clinical presentation was shortness of breath. The most common finding in ECG is sinus tachycardia followed by ST-T changes in V1-V3. Eight patient had SPO2 less than 90%. Most of the patients had a normal chest radiograph. Echocardiography revealed dilated RA and RV in 20 patients. All high risk PE patients were thrombolyzed with streptokinase. All patients who were diagnosed as Non-high risk PE were treated with LMWH. All the patients were treated with oral anticoagulants. Mean hospital stay was 9.7 ± 4.9 days. Two patients died during hospital stay. S-PESI score was 1.4 ± 0.9 respectively. Mean warfarin dose at the time of discharge was 5.9 ± 1.6 mg. Conclusion PE is an under diagnosed clinical problem world over. Suspicion is the most important part to come to the diagnosis of PE.

Fibromuscular dysplasia in an adult male as a cause of renal artery stenosis and secondary hypertension treated with renal artery stenting

Background Renovascular hypertension due to fibromuscular dysplasia is an uncommon cause of secondary hypertension and is more common in females. This entity is an important treatable cause of secondary hypertension. Case presentation We report the case of a 21-year-old asymptomatic male found to have high blood pressure on routine checkup. Renal angiogram revealed fibromuscular dysplasia involving the right renal artery. He underwent percutaneous angioplasty with complete recovery. The single antihypertensive which he was on was stopped next month. Conclusion Fibromuscular dysplasia causing stenosis of renal artery is uncommon. High degree of suspicion is required for the timely diagnosis and treatment of this potentially treatable cause of secondary hypertension.

β-blockers in Post ST Elevation Myocardial Infarction Patient with Low Left Ventricular Systolic Function: A Retrospective Study at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Aims: Despite well developed guidelines in the management of ST elevation myocardial infarction with low left ventricular ejection fraction, β-blockers remain an underutilized therapy. We aim to assess the adherence of β-blocker use during the discharge in Shahid Gangalal National Heart Centre, Kathmandu, Nepal. Study Design: Retrospective, Observational study.