Masood Sadiq

Simultaneous treatment of native coarctation of the aorta combined with patent ductus arteriosus using a covered stent

A 19‐year‐old girl with coarctation of the aorta and patent ductus arteriosus underwent simultaneous treatment of native coarctation and closure of ductus arteriosus using a covered Cheatham‐Platinum stent. This technique may be used as an alternative to other forms of interventional therapy or surgery for this combination of lesions in adolescents and adults. Cathet Cardiovasc Intervent 2003;59:387–390.

Infective endocarditis in children — incidence, pattern, diagnosis and management in a developing country

BACKGROUND In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high. OBJECTIVE Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome. SETTING A tertiary referral center for paediatric and adult cardiology. PATIENTS AND METHODS All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Dukes criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases. RESULTS Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9 +/- 4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients). CONCLUSIONS The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.

Successful occlusion of a coronary arteriovenous fistula using an Amplatzer duct occluder.

In an 11-year old boy with a large coronary arteriovenous fistula between the left coronary artery and the right atrium, we achieved successful closure using a 10-8 Amplatzer Duct Occluder introduced from the right internal jugular vein. Angiography 6 weeks later showed complete occlusion of the fistula, with normal opacification of the left coronary arterial system. This technique may be used as an alternative to coils and surgery in selected patients.

Device closure of atrial septal defect: medium-term outcome with special reference to complications.

BACKGROUND There are concerns over the outcome of device closure of secundum atrial septal defect with special reference to erosions and aortic regurgitation. AIM To assess the medium-term outcome of device closure of atrial septal defects with special reference to complications. METHODS A total of 205 patients with secundum atrial septal defects underwent transcatheter closure from October, 1999 to April, 2009. The median age was 18 (1.4-55) years. Amplatzer Septal Occluder was used in all the patients. Medium-term follow-up was available in 176 of 200 (88%) patients. RESULTS Device closure was successful in 200 out of 205 (98%) patients. The device embolised in four patients and was associated with short inferior caval vein margin (p = 0.003). Balloon sizing in 71 patients (35%) resulted in implantation of a larger device (p = 0.002). Early complications included pericardial effusion, 2:1 heart block, and infective endocarditis (1 patient each). There were eight patients who reported migraine (3.9%). At median follow-up of 5.8 (0.6-10.3) years, complete closure occurred in 197 out of 200 patients. Short superior caval vein margin was associated with a residual shunt (p < 0.001). There were two patients who developed mild aortic regurgitation (1%), which correlated with a device-to-defect ratio of >1.3:1 (p = 0.001). There were no erosions, late embolisation, or thromboembolism. Atrial fibrillation occurred in three adults (1.5%). CONCLUSIONS Device closure of secundum atrial septal defects using Amplatzer Septal Occluder is safe and effective in the medium term. Short inferior caval vein margin correlates with increased risk of embolisation and short superior caval vein margin with a residual shunt. The risk of developing aortic regurgitation is low and correlates with increased device-to-defect ratio.

Covered stents in the management of native coarctation of the Aorta—Intermediate and long‐term follow‐up

Objectives To evaluate the results of covered Cheatham-Platinum stent implantation in the management of native coarctation of the aorta and report intermediate and long-term follow-up. Background Covered stents are being used increasingly in severe and complex coarctation of the aorta mainly to reduce risk of aortic wall complications. There is, however, limited data on the intermediate and long-term outcome. Patients and Methods Fifty-six patients received 59 covered Cheatham-Platinum stents (January 2002–December 2011) at a single center—in 54 patients as primary treatment and in 2 as a rescue. Mean age was 22.25 ± 1.2 (11–56) years and mean weight 58.6 ± 2.1 (32–99) kg. Primary end points were reduction in systolic pressure gradient and an increase in coarctation segment diameter. Changes in antihypertensive medicines and complications were recorded on follow-up. Results Mean coarctation segment diameter increased from 4.69 ± 0.20 to 15.1 ± 3.2 mm (P <  0.0001). The systolic gradient decreased from mean of 51.4 ± 3.4 to 4.6 ± 0.7 mm Hg (P <  0.0001). There was one death 3 days postprocedure due to cerebral anoxia. There was one dissection diagnosed 24-hr postprocedure. At a mean follow-up of 45.9 ± 3.9 (3–120) months, all stents were patent and in good position on computed tomography. Four (7.1%) patients underwent successful redilation. Antihypertensive medication was decreased or stopped in 37 (66%) patients. Conclusions Covered Cheetham-Platinum stents may be used effectively as therapy of choice in selected patients with severe coarctation of the aorta. Aortic wall complications occur even with covered stents. Covered stents provide a safe alternative to conventional stenting in the intermediate and long-term and can be redilated safely to keep pace with somatic growth.© 2013 Wiley Periodicals, Inc.To evaluate the results of covered Cheatham‐Platinum stent implantation in the management of native coarctation of the aorta and report intermediate and long‐term follow‐up.

Endovascular stenting in transverse aortic arch hypoplasia

Describe outcomes from stenting transverse aortic arch hypoplasia.

Optimal dose of adenosine effective for supraventricular tachycardia in children.

OBJECTIVE To determine the optimal adenosine dose effective in supraventricular tachycardia (SVT) and underlying conditions affecting the effective dose in children. STUDY DESIGN Experimental study. PLACE AND DURATION OF STUDY Department of Cardiology, The Childrens Hospital and Institute of Child Health, Lahore, from July 2008 to June 2011. METHODOLOGY All children presenting with SVT were administered adenosine in rapid boluses according to PALS guidelines using incremental doses of 100, 200 and 300 μg/kg. The response was recorded on 12 lead ECG. Preexcitation was documented and echocardiography performed on all children after attaining sinus rhythm. Mann Whitney test and Kruskal-Wallis test were used as a test of significance to determine any difference in effective adenosine dose between normal heart and various underlying conditions, taking p < 0.05 as significant. RESULTS Eighty five patients were treated for 110 episodes of SVT with adenosine. M:F ratio was 2.2:1. Their age ranged from 6 days to 14 years with mean age of 27.9 months. Adenosine was effective in reverting 97 episodes of SVT to sinus rhythm (88.2%). A dose of upto 100 μg/kg was only effective in 36.4% episodes of SVT. Two hundred μg/kg was effective in 44.3% of those not responding to 100 μg/kg dose (n = 31/70, cumulative 64.5%). A dose of 300 μg/kg was effective in further 25 patients not responding to lower doses (n = 25/38, 65.8%; cumulative 88.2%). Mean effective dose of adenosine was 185.3 + 81.0 μg/kg with median effective dose of 200 μg/kg. Significantly higher dose of adenosine was required in children with underlying pre-excitation, n = 18/97 (220.8 + 67.6 μg/kg vs. 177.2 + 81.9 μg/kg, p = 0.039). CONCLUSION Adenosine is an effective medicine in treating SVT in children. A higher dose of 200 μg/kg may be used as first bolus particularly in children with pre-excitation.

Device Closure of Patent Ductus Arteriosus in Marfan Patients: Safety and Effect on the Aortic Root Diameter

OBJECTIVES There is little evidence in the medical literature about safety of PDA device closure and its effects on aortic root diameter in Marfan patients. We reported on nine Marfan patients whose ducts were occluded by coil or Amplatzer Duct Occluder. PATIENTS AND INTERVENTIONS Two patients had aneurismal type E ducts which were closed by a single coil, respectively. The others had conical ducts for which even Amplatzer occluder, stiff, or double coils were used. RESULTS No untoward consequence was found during a median follow up period of 18.5 months (range 3 months to 6.33 years). Two patients had small residual shunts. The observed change in the mean ratio of aortic root diameter to its estimated value was statistically insignificant in seven patients who had complete data on their aortic root diameter before PDA closure and during the follow up. CONCLUSIONS We concluded that PDA device closure in Marfan patients is safe. Risk of residual shunt is higher even after closure of small ducts.

Pattern of congenital heart disease in a developing country tertiary care center: Factors associated with delayed diagnosis

Objective: To determine the delay in diagnosis of various types of congenital heart defects in children and factors associated with such delay. Patients and Methods: For this observational study, 354 patients having congenital heart disease (CHD) presenting for the first time to the Department of Cardiology, Childrens Hospital, Lahore, Pakistan, between January 1, 2015 and June 30, 2015, were enrolled after obtaining informed verbal consent from the guardian of each child. Demographical profile and various factors under observation were recorded. Results: Among the 354 enrolled children (M: F 1.7:1) with age ranging from 1 to 176 months (median 24 months), 301 (85.1%) had delayed diagnosis of CHD (mainly acyanotic 65.3%), with median delay (8 months). Main factors for delay were delayed first consultation to a doctor (37.2%) and delayed diagnosis by a health professional (22.5%). Other factors included delayed referral to a tertiary care hospital (13.3%), social taboos (13.0%), and financial constraints (12.3%). Most children were delivered outside hospital settings (88.7%). Children with siblings less than two (40%) were less delayed than those having two or more siblings (60%, P < 0.001). Conclusion: Diagnosis of congenital heart defect was delayed in majority of patients. Multiple factors such as lack of adequately trained health system and socioeconomic constraints were responsible for the delay. There is a need to develop an efficient referral system and improve public awareness in developing countries for early diagnosis and management of such children.

Coronary artery spasm after ingestion of Imodium (loperamide) in a 14-year-old boy

We report a 14-year-old boy who presented with acute chest pain, following the ingestion of loperamide for acute diarrhea. Twelve lead electrocardiogram (ECG) showed evidence of acute ischemia indicating acute coronary artery spasm. The changes reverted with treatment within a few hours with no permanent effect on myocardial function. This report highlights a rare side effect of loperamide, often debated in adults and never reported in adolescents.