Hala Agha

Device-associated infection rates in adult and pediatric intensive care units of hospitals in Egypt. International Nosocomial Infection Control Consortium (INICC) findings

PURPOSE To determine the rate of device-associated healthcare-associated infections (DA-HAIs) at a respiratory intensive care unit (RICU) and in the pediatric intensive care units (PICUs) of member hospitals of the International Nosocomial Infection Control Consortium (INICC) in Egypt. MATERIALS AND METHODS A prospective cohort DA-HAI surveillance study was conducted from December 2008 to July 2010 by applying the methodology of the INICC and the definitions of the NHSN-CDC. RESULTS In the RICU, 473 patients were hospitalized for 2930d and acquired 155 DA-HAIs, with an overall rate of 32.8%. There were 52.9 DA-HAIs per 1000 ICU-days. In the PICUs, 143 patients were hospitalized for 1535d and acquired 35 DA-HAIs, with an overall rate of 24.5%. There were 22.8 DA-HAIs per 1000 ICU-days. The central line-associated blood stream infection (CLABSI) rate was 22.5 per 1000 line-days in the RICU and 18.8 in the PICUs; the ventilator-associated pneumonia (VAP) rate was 73.4 per 1000 ventilator-days in the RICU and 31.8 in the PICUs; and the catheter-associated urinary tract infection (CAUTI) rate was 34.2 per 1000 catheter-days in the RICU. CONCLUSIONS DA-HAIs in the ICUs in Egypt pose greater threats to patient safety than in industrialized countries, and infection control programs, including surveillance and guidelines, must become a priority.

Stenting the arterial duct in neonates and infants with congenital heart disease and duct-dependent pulmonary blood flow: A multicenter experience of an evolving therapy over 18 years

The primary aim of this multi‐institutional study was to describe our 18‐year experience of ductal stenting (DS) in infants with a duct‐dependent pulmonary circulation. The secondary aim sought to identify a subgroup of patients who may benefit the most using this evolving technique.

Apolipoprotein E gene polymorphism and the risk of left ventricular dysfunction among Egyptian β-thalassemia major

In Egypt, β-thalassemia is the most common hereditary hemolytic anemia. Cardiac dysfunction, secondary to iron overload with formation of oxygen free radicals, is the most common cause of death in β-thalassemia patients. This study was designed to determine whether the allelic genotype of apolipoprotein E (Apo E), which exhibits antioxidant properties, could represent a genetic risk factor for the development of left ventricular (LV) dysfunction in β-thalassemia major. Fifty Egyptian β-thalassemia major patients were subjected to echocardiography to assess LV function. Apo E genotyping by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) was done for all patients in addition to 50 age and sex matched healthy control subjects. Patients were classified into three groups. Group I and II were clinically asymptomatic. Group II subjects had evidence of LV dilatation, while Group III patients had clinical and echocardiographic findings of LV failure. Apo E4 allele was significantly higher among Group II and III than in controls. In conclusion, Apo E4 allele can be considered as a genetic risk factor for LV dysfunctions in β-thalassemic patients. It could be used as predictive indicator for additional risk of LV failure, particularly in asymptomatic patients with LV dilatation, requiring a closer follow-up, to prevent further disease progression.

Regression of a Large Congenital Hepatic Arteriovenous Malformation

Congenital hepatic arteriovenous malformations are rarely seen in association with persistent neonatal pulmonary hypertension. We report the case of a full-term female newborn who presented with heart failure and respiratory distress soon after birth. Echocardiographic investigation revealed severe persistent pulmonary hypertension and patent ductus arteriosus. Here we report spontaneous regression in size of both the feeder vessel and the vascular bed of the congenital hepatic arteriovenous malformation. We postulate that our conservative use of oral heart failure therapy, in the form of diuretic agents and captopril, decreased the congestion and diameter of the affected vessels.

Prediction of Pulmonary Regurge and Right Ventricular Function in Asymptomatic Repaired Tetralogy of Fallot Patients in Developing Countries: A Comparison to Cardiac Magnetic Resonance Imaging

Objective: To assess the value of conventional echocardiographic measurements for quantification of pulmonary regurge and right ventricular function in comparison to Cardiac Magnetic Resonance Imaging (CMR) after surgical repair of Tetralogy Of Fallot (TOF). Methods: Twenty five asymptomatic children after TOF repair (9.2 ± 4 years) were compared to twenty five age matched healthy children. Echocardiographic quantification of pulmonary regurge was assessed by (1) pulmonary regurge jet width/pulmonary artery diameter, (2) pulmonary pressure half time, (3) pulmonary regurge index; pulmonary regurge duration to diastole duration, (4) no flow time; diastole duration - pulmonary regurge duration and (5) diastole/systole velocity time integral ratio. Measurements derived from conventional echocardiography were compared to pulmonary regurgitant fraction, right ventricular volumes and ejection fraction by CMR. Results: On CMR, the pulmonary regurgitant fraction was 28.64 ± 10.2%. By conventional echocardiography, pulmonary regurge index and no flow time were found to offer the best prediction for severity of pulmonary regurge. Pulmonary regurge index of 64 msec has sensitivity of 81% and specificity of 100% (AUC=0.894) in identifying significant pulmonary regurge. Compared to controls, patients after TOF repair showed significantly lower right ventricle myocardial velocities, higher E/ E‘ ratio and prolonged MPI. Among the TOF patients, right ventricular MPI showed significant negative correlation (r=-0.402; P=0.008) with tricuspid valve annulus peak systolic velocity (S‘) and significant positive correlation (r= 0. 413; P=0.04) with right ventricle stroke volume by CMR. Conclusion: Conventional echocardiography can offer a simple, readily available and accurate tool for quantification of pulmonary regurge and right ventricular function during mid- term follow up after surgical repair of tetralogy of Fallot.

Stenting the arterial duct in neonates and infants with congenital heart disease and duct-dependent pulmonary blood flow

The primary aim of this multi‐institutional study was to describe our 18‐year experience of ductal stenting (DS) in infants with a duct‐dependent pulmonary circulation. The secondary aim sought to identify a subgroup of patients who may benefit the most using this evolving technique.

Can myocardial remodeling be a useful surrogate predictor of myocardial iron load? A 3D echocardiographic multicentric study

The relationship between myocardial iron load and eccentric myocardial remodeling remains an under‐investigated area; it was thought that remodeling is rather linked to fibrosis. This study aims to determine whether or not measures of remodeling can be used as predictors of myocardial iron. For this purpose, 60 patients with thalassemia were studied with 3D echocardiography and myocardial relaxometry (T2*) by Cardiac MRI. 3D derived sphericity index was significantly higher in patients with myocardial iron load. It was correlated with T2* with a 100% sensitivity and specificity (cut‐off value of 0.34) to discriminate between patients with and without myocardial iron overload.

Acute Kawasaki disease with emphasis on the echocardiographic profile: A single center experience

Background: Echocardiographic features of acute Kawasaki disease (KD) have not been well characterized in Egyptian children. This study aimed to provide insight into the pattern of cardiac involvement in Egyptian children with Kawasaki disease, focusing on echocardiographic coronary abnormalities and their associated risk predictors. Methods and Results: Medical records of 64 KD patients from 2012 to 2016 were retrospectively analyzed with recalculation of coronary artery z-scores during the first eight weeks after fever onset. All patients received intravenous immunoglobulin (IVIG) and 57.8% were treated within 10 days of illness onset. Coronary abnormalities were found in 53.1% of all patients, and in 43.2% of those who received IVIG within 10 days. Giant aneurysms (z-score>10) comprised 23.5% of all coronary abnormalities. Coronary thrombosis occurred in two patients (5%), both of whom developed myocardial infarction, and one succumbed to heart failure with eventual in-hospital death. Overall, 7% of patients had mitral regurgitation (n = 5), 1.5% had aortic regurgitation (n = 1), and 7.8% had pericardial effusion (n = 5). Among a number of laboratory and clinical predictors, platelet count had the strongest association with coronary abnormalities (Area under Receiver-operating characteristic (ROC) curve: 0.794; 95% confidence interval 0.678–0.910; P < 0.001). Conclusion: Coronary abnormalities occur in a substantial percentage of KD in Egypt, with associated evidence of severe inflammation. Further efforts are required to increase awareness of the disease and to emphasize the importance of early IVIG administration. Future studies should also be undertaken to characterize the long term progression profile of the disease as well as the possible genetic background of the disease in Egypt.

Predictors of transient left ventricular dysfunction following transcatheter patent ductus arteriosus closure in pediatric age

Objectives To evaluate the left ventricular function before and after transcatheter percutaneous patent ductus arteriosus (PDA) closure, and to identify the predictors of myocardial dysfunction post-PDA closure if present. Interventions Transcatheter PDA closure; conventional, Doppler, and tissue Doppler imaging; and speckle tracking echocardiography. Outcome measures To determine the feasibility and reliability of tissue Doppler and myocardial deformation imaging for evaluating myocardial function in children undergoing transcatheter PDA closure. Patients and methods Forty-two children diagnosed with hemodynamically significant PDA underwent percutaneous PDA closure. Conventional, Doppler, and tissue Doppler imaging, and speckle-derived strain rate echocardiography were performed at preclosure and at 48 hours, 1 month, and 6 months postclosure. Tissue Doppler velocities of the lateral and septal mitral valve annuli were obtained. Global and regional longitudinal peak systolic strain values were determined using two-dimensional speckle tracking echocardiography. Results The median age of the patients was 2 years and body weight was 15 kg, with the mean PDA diameter of 3.11 ± 0.99 mm. M-mode measurements (left ventricular end diastolic diameter, left atrium diameter to aortic annulus ratio, ejection fraction, and shortening fraction) reduced significantly early after PDA closure (p < 0.001). After 1 month, left ventricular end diastolic diameter and left atrium diameter to aortic annulus ratio continued to decrease, while ejection fraction and fractional shortening improved significantly. All tissue Doppler velocities showed a significant decrease at 48 hours with significant prolongation of global myocardial function (p < 0.001) and then were normalized within 1 month postclosure. Similarly, global longitudinal strain significantly decreased at 48 hours postclosure (p < 0.001), which also recovered at 1 month follow-up. Preclosure global longitudinal strain showed a good correlation with the postclosure prolongation of the myocardial performance index. Conclusion Transcatheter PDA closure causes a significant decrease in left ventricular performance early after PDA closure, which recovers completely within 1 month. Preclosure global longitudinal strain can be a predictor of postclosure myocardial dysfunction.

ASD device closure in pediatrics: 3-Dimensional transthoracic echocardiography perspective

Objective Real-time three-dimensional echocardiography, using both reconstruction methods and RT3D, has been used as an extra helping tool in several forms of congenital heart diseases. Our aim was to understand the relation of the ASD device to all surrounding structures by 3-dimensional echocardiography (3D). Methods This prospective study included 37 patients diagnosed as ASD secundum by transthoracic (TTE) and transesophageal echocardiography (TEE) referred for transcatheter closure from October 2013 to July 2016. Follow-up for 1 year using 2D and 3D-echocardiography was performed to assess the relations of the device to the surrounding structures. Results Transcatheter ASD closure and echocardiographic examinations were successfully performed for all patients. By 3D echocardiography, 16 patients (43.24%) had their ASD device close to the aortico-mitral continuity plane without apparent regurgitation, while the rest of our patients (56.75%) the devices were away from this plane. The following variables were significantly different between the two groups; body surface area, atrioventricular rim (AV), device size, left disc size and ratio of left disc to interatrial septum. A cut-off AV rim length not less than 8 mm was found optimal to avoid device encroachment on the sensitive surrounding structures. New Formula was constructed to aid in device choice. Conclusion Use of 3D before and after ASD closure is of value to determine the device relation to the surrounding structures. AV rim by TEE is an important rim to avoid eventual encroachment on the mitral valve and aorta.