Milad El-Segaier

Computer-based detection and analysis of heart sound and murmur.

To develop a digital algorithm that detects first and second heart sounds, defines the systole and diastole, and characterises the systolic murmur. Heart sounds were recorded in 300 children with a cardiac murmur, using an electronic stethoscope. A Digital algorithm was developed for detection of first and second heart sounds. R-waves and T-waves in the electrocardiography were used as references for detection. The sound signal analysis was carried out using the short-time Fourier transform. The first heart sound detection rate, with reference to the R-wave, was 100% within 0.05–0.2R-R interval. The second heart sound detection rate between the end of the T-wave and the 0.6R-R interval was 97%. The systolic and diastolic phases of the cardiac cycle could be identified. Because of the overlap between heart sounds and murmur a systolic segment between the first and second heart sounds (20–70%) was selected for murmur analysis. The maximum intensity of the systolic murmur, its average frequency, and the mean spectral power were quantified. The frequency at the point with the highest sound intensity in the spectrum and its time from the first heart sound, the highest frequency, and frequency range were also determined. This method will serve as the foundation for computer-based detection of heart sounds and the characterisation of cardiac murmurs.

Infections as a stimulus for coronary occlusion, obstruction, or acute coronary syndromes

Background: Atherosclerosis is considered to be an inflammatory disease. Infections are a significant cause of inflammation. Acute infections might precipitate acute coronary syndromes (ACS) whereas chronic infections might be stimuli for the development of atherosclerosis. Methods: Coronary angiograms were done on 211 of 335 patients with ACS and the percentage of coronary obstruction was determined. Serum antibody levels to Chlamydia pneumoniae, C. pneumoniae heat shock protein 60 (CpnHSP60), human heat shock protein 60 (hHSP60), enterovirus (EV), herpes simplex virus (HSV), cytomegalovirus (CMV), and two major periodontal pathogens, Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis, were measured in healthy controls (n = 355) and all patients. Results: Serum antibody levels to periodontal pathogens did not correlate with ACS. However, IgA-class antibody levels to Aggregatibacter actinomycetemcomitans (p = 0.021), CpnHSP60 (p = 0.048) an hHSP60 (p = 0.038) were higher in patients with coronary occlusion or obstruction compared to those without any obstruction. Odds ratios for coronary changes in the highest quartile as compared to the lower quartiles were for A. actinomycetemcomitans IgA 7.84 (95% CI 1.02—60.39, p = 0.048), for CpnHSP60 IgA 8.61 (1.12—65.89, p = 0.038), and for human HSP60 IgA 3.51 (0.79—15.69, p = 0.100). Conclusions: We have previously reported that EV and HSV titres correlated significantly to acute coronary events. They do not correlate to the degree of coronary obstruction as shown here. However, infection by A. actinomycetemcomitans or C. pneumoniae or host response against them associated with coronary obstruction. Clinical coronary events may arise by the effect of acute infections and obstructing lesions by a chronic inflammatory stimulus.

Late coronary complications after arterial switch operation and their treatment

Objectives: To report the late coronary complications and their treatment after arterial switch operation (ASO). Background: Asymptomatic patients after ASO may have coronary ostial stenosis or obstruction. Methods: Since 1980, 279 patients were operated with ASO. At the time of preparing this article, selective follow‐up coronary angiograms were done on 81 patients. Results: Coronary stenosis was found in six patients. A 6‐year‐old patient with left coronary artery (LCA) ostial stenosis and a 9‐year‐old patient with conus branch occlusion had good collaterals without a need for further treatment. One patient with LCA obstruction, myocardial infarction, and left ventricular failure was operated with osteoplasty at age of 16 years. In three essentially asymptomatic patients, stenting of LCA ostium stenosis was done: in two of them with drug‐eluting stents at 9 and 10 years of age and in one with bare‐metal stent at 18 years of age. One of these patients was earlier treated with balloon dilatation at 5 years of age which caused intimal dissection. Conclusions: Asymptomatic patients with an uneventful course after ASO may have coronary obstruction. This necessitates follow‐up coronary evaluation in all patients. Stenting of the coronary arteries is an option for treatment.

Screening of congenital heart disease patients using multiplex ligation‐dependent probe amplification: Early diagnosis of syndromic patients

Recurrent copy number variants (CNVs) are found in a significant proportion of patients with congenital heart disease (CHD) and some of these CNVs are associated with other developmental defects. In some syndromic patients, CHD may be the first presenting symptom, thus screening of patients with CHD for CNVs in specific genomic regions may lead to early diagnosis and awareness of extracardiac symptoms. We designed a multiplex ligation‐dependent probe amplification (MLPA) assay specifically for screening of CHD patients. The MLPA assay allows for simultaneous analysis of CNVs in 25 genomic regions previously associated with CHD. We screened blood samples from 402 CHD patients and identified 14 rare CNVs in 13 (3.2%) patients. Five CNVs were de novo and six where inherited from a healthy parent. The MLPA screen led to early syndrome diagnosis in two of these patients. We conclude that the MLPA assay detects clinically relevant CNVs and suggest that it could be used within pediatric cardiology as a first tier screen to detect clinically relevant CNVs and identify syndromic patients at an early stage.

Nitric oxide in neonatal transposition of the great arteries

Three newborn infants with transposition of the great arteries (TGA) and intact ventricular septum (IVS) developed postnatal persistent pulmonary hypertension of the newborn (PPHN) and were successfully treated with inhaled nitric oxide (iNO). Intervention with balloon atrial septostomy (BAS) was performed in two of the infants before the iNO treatment, but they continued to be severely hypoxic with metabolic acidosis. However, the iNO immediately improved oxygenation and the clinical condition. The third neonate had a moderately large atrial communication and echocardiographic signs of PPHN. He received iNO before BAS with dramatic clinical improvement, which therefore postponed BAS.

Detection of cardiac pathology: time intervals and spectral analysis.

Aim: To develop an objective diagnostic method that facilitates detection of noncyanotic congenital heart diseases.

Blind source separation of cardiac murmurs from heart recordings

A significant percentage of young children present cardiac murmurs. However, only one percent of them are caused by a congenital heart defect; others are physiological. Auscultation of the heart is still the primary diagnostic tool for judging the type of cardiac murmur. An automated system for an initial recording and analysis of the cardiac sounds could enable the primary care physicians to make the initial diagnosis and thus decrease the workload of the specialised health care system. The first step in any automated murmur classifier is the identification of different components of cardiac cycle and separation of the murmurs. Here we propose a new methodological framework to address this issue from a machine learning perspective, combining Independent Component Analysis and Denoising Source Separation. We show that such a method is rather efficient in the separation of cardiac murmurs. The framework is equally capable of separating heart sounds S1 and S2 and artifacts such as voices recorded during the measurements.

High prevalence rate of left superior vena cava determined by echocardiography in patients with congenital heart disease in Saudi Arabia

Background Persistent left superior vena cava (LSVC) is one of the common anomalies of the systemic veins. Its prevalence is 0.1-0.3% in the general population and is more common with congenital heart disease (CHD). The importance of detecting persistent LSVC prior to cardiac surgery is paramount for systemic veins cannulations. Aim The aim was to evaluate the prevalence of persistent LSVC in patients with CHD in Saudi Arabia. Methods All patients referred to our institution had echocardiography. All complete studies were reviewed for the presence of persistent LSVC. A computerized database was created including the demographic data, CHD diagnoses, and the presence of persistent LSVC. Results A total of 2,042 were examined with an age range of 1 day to 16 years. The complete echocardiographic studies were 1,832 (90%) of whom 738 (40%) patients had CHD. The prevalence of persistent LSVC in patients with CHD was 7.8% (OR 9.26, 95% CI 4.7-18.2, p<0.001). The most common cardiac defect associated with persistent LSVC was complete atrioventricular septal defect (AVSD); all patients with AVSD had Down syndrome. The total number of patients with AVSD was 41, and persistent LSVC was found in 11 (26%) of them (odds ratio 5.1, 95% CI 2.4-10.8, p<0.001). Conclusions The prevalence of persistent LSVC in the current population is almost double the reported prevalence obtained using the same echocardiographic screening tool.Background Persistent left superior vena cava (LSVC) is one of the common anomalies of the systemic veins. Its prevalence is 0.1–0.3% in the general population and is more common with congenital heart disease (CHD). The importance of detecting persistent LSVC prior to cardiac surgery is paramount for systemic veins cannulations. Aim The aim was to evaluate the prevalence of persistent LSVC in patients with CHD in Saudi Arabia. Methods All patients referred to our institution had echocardiography. All complete studies were reviewed for the presence of persistent LSVC. A computerized database was created including the demographic data, CHD diagnoses, and the presence of persistent LSVC. Results A total of 2,042 were examined with an age range of 1 day to 16 years. The complete echocardiographic studies were 1,832 (90%) of whom 738 (40%) patients had CHD. The prevalence of persistent LSVC in patients with CHD was 7.8% (OR 9.26, 95% CI 4.7–18.2, p<0.001). The most common cardiac defect associated with persistent LSVC was complete atrioventricular septal defect (AVSD); all patients with AVSD had Down syndrome. The total number of patients with AVSD was 41, and persistent LSVC was found in 11 (26%) of them (odds ratio 5.1, 95% CI 2.4–10.8, p<0.001). Conclusions The prevalence of persistent LSVC in the current population is almost double the reported prevalence obtained using the same echocardiographic screening tool.

Intracoronary thrombus in an infant with Kawasaki disease and giant coronary aneurysm.

A previously healthy 5-month-old girl presented to ouremergency department with history of fever for 2 weeks,skin rash, red and cracked lips and bilateral redness of theeyes appeared 4 days after fever started. On physicalexamination, the general condition was stable includinggood peripheral perfusion. There was no lymphadenopathy.Chest and abdominal examinations were unremarkable.Electrocardiography, apart from mild sinus tachycardia(HR 110 bpm), was normal with no sign of myocardialischaemia or hypertrophy. Chest X-ray showed cardiomeg-aly. Her blood investigation results were as follows: WBC16.2 9 100/lL (neutrophils 36.7%), normal haemoglobinand platelets 1356 9 100/lL. The kidney function and liverfunction tests were normal. Troponin-T 27 lg/L (lab nor-mal value 14 lg/L) and CKMB 42 lg/L (lab normal value25 lg/L). The diagnosis of Kawasaki disease (KD) wasestablished according to the combination of the clinicalpicture and blood investigations. Echocardiogram wasperformed and showed severe dilatation of left anteriordescending coronary artery with giant fusiform aneurysm(Fig. 1) and intracoronary thrombus (Fig. 2). Additionally,normal myocardial function and moderate pericardialeffusion with no sign of cardiac tamponade. Despite thelate presentation, immunoglobulin infusion was startedcombined with heparin, warfarin and low-dose aspirin. Itwas planned after two days to discontinue heparin. Anelective cardiac computerized tomography (CT) with con-trast injection was performed and shows giant aneurysmaldilatation of right coronary artery (RCA; Fig. 3). A repeatedechocardiography, directed on the RCA, confirms the CTfinding (Fig. 4). The critical evaluation of the initial echo-cardiography examination revealed that the RCA aneurysmwas there from the start but was missed as it is very adjacentto and almost as large as right atrium.Kawasaki disease is also known as mucocutaneouslymph node syndrome. Its diagnosis is usually done throughcombination of certain clinical criteria. One of the mostserious complications of KD is dilatation and fatal aneu-rysms or rupture of coronary arteries in untreated patients.The initial echocardiographic study always evaluates theexistence of coronary artery aneurysms. In the presence of aproximal aneurysm, further coronary artery evaluation isusually performed through CT or magnetic resonancetomography combined with contrast injection and/or car-diac catheterization and angiography.Myocardial ischaemia due to thromboembolism is also awell-reported complication. The guidelines for treatment of

Quantification of left-to-right shunt through patent ductus arteriosus by colour Doppler in children admitted for a device closure

PURPOSE Our animal model suggests that quantification of ductal flow from colour Doppler pixels is possible. We aimed to clarify whether this method can be used to determine a clinically significant ductal shunt in children. METHODS We retrospectively quantified ductal flow from saved images from 20 children who had been admitted for device occlusion of patent ductus arteriosus. Colour Doppler images over the main stem of the pulmonary artery were obtained in longitudinal cross-sections. The colour pixel percentages during diastole, representing ductal flow, were correlated with the documented shunt, measured invasively according to Ficks principle. RESULTS The ratio of pulmonary to systemic flow correlated best with the sum of the percentages of green colour pixels (r = 0.73, r2 = 0.54, p < 0.001). When the shunt was 1.5:1 or more, 12 out of 13 infants had 50% or more of the region of interest covered with green pixels--sensitivity 92%, specificity 71%. The correlation between ductal diameter and pulmonary-to-systemic flow ratio was less significant (r = 0.6, r2 = 0.37, p < 0.03). CONCLUSIONS We conclude that clinically significant shunts with pulmonary-to-systemic flow ratio over 1.5 can be diagnosed with this method where neither the size of the patient nor echocardiographic settings seem to be critical. The method could be used to provide an objective indication for ductal closure, but further prospective studies in children are needed to verify the power of the method.