Fathima Aaysha Cader

Pulmonary embolism as a complication of an electrophysiological study: a case report

BackgroundElectrophysiological studies have become an established practice in the evaluation and treatment of arrhythmias. Symptomatic pulmonary embolism as a result of deep vein thrombosis arising from multiple venous sheath femoral vein catheterization is an uncommon complication associated with it. We report the case of a 33-year-old woman who developed pulmonary embolism after an electrophysiological study, which was successfully treated at a cardiac hospital in Bangladesh.Case presentationA 33-year-old Bangladeshi woman with hypertension and diabetes had initially presented with recurrent episodes of paroxysmal atrial fibrillation that manifested as palpitations for 2 years. Her atrial fibrillation was drug-refractory and could not be attributed to a treatable etiology. She had undergone an electrophysiological study at a different hospital, where right femoral venous catheterization was performed followed by the insertion of three venous sheaths. However, tachyarrhythmia could not be induced and a procedure to isolate the pulmonary vein was postponed because all the veins could not be isolated. Forty-eight hours later, she presented to our hospital with shortness of breath, chest heaviness, palpitations, and recurrent episodes of syncope.She had normal coronary arteries and no other risk factors for venous thromboembolism. She was hemodynamically stable on examination. There was echocardiographic evidence of pulmonary hypertension and right ventricular dilatation and dysfunction. A computed tomography pulmonary angiogram confirmed pulmonary embolus in the descending branch of her left pulmonary artery, extending up to the segmental arteries.Subsequently, a duplex ultrasound confirmed acute deep vein thrombosis affecting her right ilio-femoral segment. She was successfully managed with subcutaneous enoxaparin and oral warfarin (target international normalized ratio 2.5–3).ConclusionsPulmonary embolism is a rare but serious complication that may occur in patients who undergo electrophysiological studies. Multiple venous sheaths inserted into the femoral vein and catheter-induced endothelial injury, further compounded by prolonged procedural time, may be responsible for the increased thrombogenicity leading to deep vein thrombosis and subsequent pulmonary embolism. An adequate observation time after the procedure and clinical alertness are necessary for rapid diagnosis and treatment.

TCTAP A-034 Angiographic Analysis of Trans-radial Percutaneous Coronary Intervention (PCI) Cases by the Backup Support of Guide Extension Catheter

The guide extension catheter – Guidezilla (Boston Scientific, United States of America) is a useful tool in the armamentarium of the interventional cardiologist. As an adaptation of the “mother and child” system, it provides an extension to the guide catheter with better coaxial alignment and

Gender Differences in Clinical, Angiographic and Procedural Profiles between Young Patients with Acute Coronary Syndrome undergoing Percutaneous Coronary Intervention

Background: Acute coronary syndrome (ACS) is increasingly prevalent among young patients, particularly in South Asia, where young patients are known to present with multiple risk factors and gender-based differences in angiographic profiles. This study aimed to compare gender differences in clinical, angiographic and procedural profiles between young patients with ACS undergoing percutaneous coronary intervention (PCI). Methods: This prospective observational study was done at the National Institute of Cardiovascular Diseases (NICVD) from April 2016 to March 2017. 190 young patients with ACS undergoing PCI were included. Clinical, angiographic and procedural variables were compared and statistically analyzed. Results: The mean age of young females and males was 43.8±6.9 years and 40.1±4.3 years respectively (p<<0.001). Young women had significantly more risk factors of hypertension (62.1% vs 33.7%, p<0.001) and diabetes (57.9% vs 31.6%, p<0.001) in comparison to young men. Smoking was significantly greater among young males (70.5% vs 0%, p<0.001). Young females had significantly better mean ejection fraction (EF) (48.4±9.3% vs 45.1±10.4%, p=0. 02). Left main coronary artery (3.2% vs. 1.1%, p=0.61) and left anterior descending artery (51.6% vs. 45.3%, p=0.38) were more frequently involved among young females. Young males showed angiographically more severe CAD and greater frequency of multivessel CAD with higher DVD (22.1%vs 18.9%, p=0.58) and TVD (18.9%vs 11.6%, p=0.15). Conclusion: Significantly more young women with ACS presented with hypertension and diabetes than young males. However, they had better ejection fraction and less severe angiographic profiles. Cardiovasc. j. 2018; 10(2): 113-120

Angiographic Analysis of Trans-Radial Percutaneous Coronary Intervention Cases by the Backup Support of Guide Extension Catheter

Background : The guide extension catheter – Guidezilla (Boston Scientific, United States of America) is a useful adjunctive tool in percutaneous revascularization of complex coronary lesions, and provides an extension to the guide catheter with better coaxial alignment, support and stability. Objective : The objective of this study was to describe the usefulness and easy deliverability of stent by Guidezilla in the trans-radial treatment of complex coronary lesions as our initial experience. Methods : This prospective observational study was conducted at the Department of Cardiology, Ibrahim Cardiac Hospital & Research Institute (ICHRI), Dhaka from July 2016 to September 2017. The transradial approach was used in all cases. Clinical, angiographic and procedural data of percutaneous coronary interventions performed using Guidezilla , including indications for use of Guidezilla were collected and analyzed. Results : A total of 19 procedures (in 18 patients) were evaluated. 57.89% of cases were related to left circumflex coronary artery or obtuse marginal branch. The commonest challenge for use of Guidezilla was proximal angulation (63.15%) and calcification (47.4%). Commonest type of lesion was ACC/ AHA Type C lesion (63.2%). Successful stent deployment was achieved in 16 of the 19 procedures (84.2%). Among the unsuccessful cases, there was stent damage in one case and distal dissection after deployment of a stent in other. Stent deployment was not possible in two cases, due to diffuse lesion and heavy calcification. Conclusions : Guide extension catheter is a good trans-radial back-up support for calcified, complex and tortuous coronary anatomy, which otherwise may have been considered unsuitable for PCI. The use of such support can reduce the necessity for the more expensive alternative of deploying multiple small stents in order to traverse the lesions. Bangladesh Heart Journal 2018; 33(1) : 54-60

Type IV dual left anterior descending coronary artery: a case report

BackgroundDual left anterior descending (LAD) artery or duplication of LAD is a rarely reported coronary anomaly, consisting of two branches supplying the usual distribution of the LAD. Type IV dual LAD, in which a short LAD arises from the left main coronary artery and a long LAD arises from the right coronary artery is remarkably rare, and has not been reported in a Bangladeshi subject.Case presentationWe describe the case of a 70-year old Bangladeshi male who presented with breathlessness in the background of a prior inferior myocardial infarction. Coronary angiography revealed an anomalous dual LAD. The short LAD which arose from the left main coronary artery gave off the first septal branch and terminated after giving off a large diagonal branch which continued further down towards the apex. The long LAD arose from the proximal right coronary artery and after traversing a distance, arrived at the interventricular septum, terminating at the apex after giving off diagonal branches. The right coronary artery was totally occluded from its early mid part and well-collateralized with retrograde flow from the left system.ConclusionWe describe a case with unique variation of dual LAD type IV, which has previously not been described in a Bangladeshi subject thus far. Coronary angiography is vital to determine this coronary anomaly, which is usually detected incidentally on routine angiography for chest pain, sometimes with involvement of significant lesion of other coronary arteries, as in this case.

Graves’ disease presenting as bi - ventricular heart failure with severe pulmonary hypertension and pre-eclampsia in pregnancy – a case report and review of the literature

BackgroundGraves’ disease, a well-known cause of hyperthyroidism, is an autoimmune disease with multi-system involvement. More prevalent among young women, it appears as an uncommon cardiovascular complication during pregnancy, posing a diagnostic challenge, largely owing to difficulty in detecting the complication, as a result of a low index of suspicion of Graves’ disease presenting during pregnancy. Globally, cardiovascular disease is an important factor for pregnancy-related morbidity and mortality. Here, we report a case of Graves’ disease detected for the first time in pregnancy, in a patient presenting with bi- ventricular heart failure, severe pulmonary hypertension and pre- eclampsia. Emphasis is placed on the spectrum of clinical presentations of Graves’ disease, and the importance of considering this thyroid disorder as a possible aetiological factor for such a presentation in pregnancy.Case presentationA 30-year-old Bangladeshi-Bengali woman, in her 28th week of pregnancy presented with severe systemic hypertension, bi-ventricular heart failure and severe pulmonary hypertension with a moderately enlarged thyroid gland. She improved following the administration of high dose intravenous diuretics, and delivered a premature female baby of low birth weight per vaginally, twenty four hours later. Pre-eclampsia was diagnosed on the basis of hypertension first detected in the third trimester, 3+ oedema and mild proteinuria. Electrocardiography revealed sinus tachycardia with incomplete right bundle branch block and echocardiography showed severe pulmonary hypertension with an estimated pulmonary arterial systolic pressure of 73 mm Hg, septal and anterior wall hypokinesia with an ejection fraction of 51%, grade I mitral and tricuspid regurgitation. Thyroid function tests revealed a biochemically hyperthyroid state and positive anti- thyroid peroxidase antibodies was found. 99mTechnetium pertechnetate thyroid scans demonstrated diffuse toxic goiter as evidenced by an enlarged thyroid gland with intense radiotracer concentration all over the gland. The clinical and biochemical findings confirmed the diagnosis of Graves’ disease.ConclusionsGraves’ disease is an uncommon cause of bi-ventricular heart failure and severe pulmonary hypertension in pregnancy, and a high index of clinical suspicion is paramount to its effective diagnosis and treatment.