Muhammad Munawar

Lipid-lowering treatment in hypercholesterolaemic patients: the CEPHEUS Pan-Asian survey:

Background: Treatment of hypercholesterolaemia in Asia is rarely evaluated on a large scale, and data on treatment outcome are scarce. The Pan-Asian CEPHEUS study aimed to assess low-density lipoprotein cholesterol (LDL-C) goal attainment among patients on lipid-lowering therapy. Methods: This survey was conducted in eight Asian countries. Hypercholesterolaemic patients aged ≥18 years who had been on lipid-lowering treatment for ≥3 months (stable medication for ≥6 weeks) were recruited, and lipid concentrations were measured. Demographic and other clinically relevant information were collected, and the cardiovascular risk of each patient was determined. Definitions and criteria set by the updated 2004 National Cholesterol Education Program guidelines were applied. Results: In this survey, 501 physicians enrolled 8064 patients, of whom 7281 were included in the final analysis. The mean age was 61.0 years, 44.4% were female, and 85.1% were on statin monotherapy. LDL-C goal attainment was reported in 49.1% of patients overall, including 51.2% of primary and 48.7% of secondary prevention patients, and 36.6% of patients with familial hypercholesterolaemia. The LDL-C goal was attained in 75.4% of moderate risk, 55.4% of high risk, and only 34.9% of very high-risk patients. Goal attainment was directly related to age and inversely related to cardiovascular risk and baseline LDL-C. Conclusion: A large proportion of Asian hypercholesterolaemic patients on lipid-lowering drugs are not at recommended LDL-C levels and remain at risk for cardiovascular disease. Given the proven efficacy of lipid-lowering drugs in the reduction of LDL-C, there is room for further optimization of treatments to maximize benefits and improve outcomes.

Amplatzer Septal Occluder Sealed the Complicating Aortic Root Perforation During Transseptal Procedure

An octogenarian man with severe rheumatic mitral stenosis underwent percutaneous transvenous mitral commissurotomy. The procedure was complicated by accidental unrecognized aortic root puncture by Brockenbrough needle followed by the delivery of the 8-F Mullin sheath (Medtronic, Minneapolis,

Transcatheter closure of coronary artery fistula using Guglielmi detachable coil

Background Coronary artery fistula (CAF) is a rare anomaly. Transcatheter CAF closure has been introduced using various materials, but only few data are available on the Guglielmi detachable coil (GDC). The advantage of using GDC for transcatheter CAF closure is more controllable, therefore much safer when compared to other coils. This report is about our experience in transcatheter closure of CAF using fibered GDC in our hospital. Methods & Results From 2002 to 2007, there were 10 patients with CAFs (age range: 28 to 56 year-old, 7 males) who underwent transcatheter CAF closure. There were a total of 19 CAFs which originated from right coronary (n = 5), left circumflex (n = 3), left anterior descending artery (n = 10) and left main trunk (n = 1). Median number of coil deployment for each fistula was 3 (range: 1 to 6). The pulmonary artery was the most common site of the distal communication of CAFs (n = 14), followed by right atrium (n = 3), left atrium (n = 1) and left ventricle (n = 1). Immediate coronary angiography after GDC deployment revealed no residual shunt in 12 (63.2%) CAFs, significant reduction of the flow in 5 (26.3%), while 2 (10.5%) could not be closed due to small size. Nine (90%) patients underwent a repeated angiography within 3 to 8 months. Among 12 CAFs that were occluded immediately post-deployment, there were 2 CAFs with insignificant residual flow. Among 6 CAFs with significantly decreased flow immediately post-deployment, 2 were occluded totally in the follow-up angiography. In total, 12 (70.5%) CAFs were occluded completely and 5 (29.5%) CAFs still had insignificant residual flow, which did not need any additional coil deployment. During a mean follow up of 4.3 ± 0.7 year, all patients remained symptom and complication free. Conclusions The fibered GDC is a safe and effective method for percutaneous closure of the CAFs.

Successful percutaneous coronary intervention for chronic total occlusion of right coronary artery in patient with dextrocardia.

Situs inversus with dextrocardia is rare congenital anomaly. Coronary artery disease in such patients is quite rare. We reported a 52-year-old man with dextrocardia and chronic total occlusion at the proximal right coronary artery just after conus branch and severe stenosis at the proximal left anterior descending artery. He underwent successful percutaneous coronary intervention with stenting of total occluded right coronary artery and simultaneously stenting of the proximal left anterior descending artery.

Left ventricular lead positioning in cardiac resynchronization therapy: an innovative retrograde approach without using snare

AIMS Ideal positioning of left ventricular (LV) pacing lead in cardiac resynchronization therapy (CRT) is technically demanding. This case aims to place LV lead in anterolateral branch of coronary sinus (CS) using collateral route blindly. METHODS AND RESULTS Externalization via the CS ostium using collaterals retrogrogradely, which was not visible in initial balloon occlusion venography, through one delivery sheath with the support of commonly used micro-guide catheter and subsequent successful LV lead placement in anterolateral branch of CS. CONCLUSION This innovative retrograde approach for LV pacing lead implantation in anterolateral branch of CS obviated the need for snare technique to capture the distal end of the wire when antegrade route was not successful.

Impact of Oral Thrombolysis After Catheter-based Thrombectomy in Acute and Subacute Submassive Pulmonary Thromboembolism

Pulmonary thromboembolism (PTE) is a relatively common cardiovascular emergency and massive PTE has always been a major source of morbidity and mortality.[1] The traditional window period for thrombolysis in patients presenting with acute PTE is two weeks.[2] We present a series of three patients with sub-massive PTE, out of which two patients had acute and one patient subacute presentation. They had initially undergone catheter-based pulmonary embolectomy and intrapulmonary thrombolysis, but there was incomplete resolution of the thrombus in all three patients 48 hours after the procedures. Subsequently, they were treated with oral thrombolytic therapy (Lumbrokinase) for 12 weeks and all the patients had complete resolution of thrombus at three months follow-up and made a full recovery. To the best of our knowledge, the above-mentioned novel approach combined with adjunctive oral thrombolytic therapy is being reported for the first time. Case 1 A 49-year-old Indonesian man, hypertensive and diabetic, presented with a three-week history of progressive dyspnea and chest pain, especially during breathing and one week history of hemoptysis prior to admission. On presentation, he was hemodynamically stable with oxygen saturation >95% on room air. The electrocardiogram (ECG) showed normal sinus rhythm. Laboratory analysis revealed a fibrin degradation test (D-Dimer) result of 4.08 μg/ml, Troponin I 0.19 ng/ml, and NT-ProBNP 2094 pg/ml. Computed tomography of pulmonary angiogram (CTPA) showed a large filling defect in the right pulmonary artery (PA) and a minimal filling defect in the left PA [Figure 1, pre-procedure, case 1]. The right ventricle (RV) was dilated. Catheter-based pulmonary thrombectomy was performed followed by intrapulmonary thrombolysis with Streptokinase for the next 10 hours. Repeat CTPA 48 hours post-procedure (pre-discharge) showed resolution of the thrombus in the left PA, but there was still a small thrombus in the right PA [Figure 1, pre-discharge, case 1]. Figure 1 Pre procedure. Case 1: CTPA showing a large filling defect in the RPA (big arrow) and a minimal filling defect in the LPA (small arrow). Case 2: CTPA showing a large thrombus in the RPA (big arrow) and LPA (small arrow). Case 3: CTPA showing a large filling ... The patient was discharged with dual antiplatelet and oral thrombolytic. Two capsules of Thromboles® (The Institute of Biophysics, Chinese Academy of Sciences, Beijing, China) each containing 250 mg of Lumbrokinase extract equivalent to 300,000 units of Lumbrokinase derived from an artificially cultured Lumbricus strain, were administered three times daily for 12 weeks. Follow-up CTPA at three months showed complete resolution of the thrombus in the right PA [Figure 1, follow up three months, case 1]. Case 2 A 37-year-old man, non-hypertensive and non-diabetic, presented with chest pain and dyspnea at rest for the previous one week prior to admission. He was hemodynamically stable. ECG showed sinus rhythm with T-wave inversion in V1-4. Laboratory results showed D-Dimer 5 μg/ml, Troponin I 0.35 ng/ml, and NT-ProBNP 5965 pg/ml. CTPA showed extensive thrombi in both left and right PAs [Figure 1, pre-procedure, case 2] and dilatation of the RV. Catheter-based pulmonary thrombectomy was performed, followed by intrapulmonary thrombolysis with Streptokinase for the next 10 hours. Repeat CTPA was performed 48 hours after the procedure (pre-discharge) and still showed thrombus in both PAs [Figure 1, pre-discharge, case 2]. He was discharged with dual anti-platelet and oral thrombolytic (two capsules of Thromboles were administered three times daily for 12 weeks). Follow-up CTPA at three months showed complete resolution of thrombus in both PAs [Figure 1, follow up three months, case 2]. There was also T-wave resolution in the precordial leads of an ECG at three months. Case 3 A 70-year-old man presented with sudden onset of shortness of breath for the previous 24 hours prior to admission. ECG showed sinus rhythm with T wave inversion in V1–3. Laboratory results showed D-Dimer 0.62 μg/ml, Troponin I 0.22 ng/ml, and NT-Pro BNP 934 pg/ml. CTPA showed extensive thrombus in the right PA and a small thrombus in the left PA [Figure 1, pre-procedure, case 3] along with RV dilatation. Catheter-based pulmonary thrombectomy was performed, followed by intrapulmonary thrombolysis with Streptokinase for the next 10 hours. Repeat CTPA 48 hours after the procedure still showed some thrombus in the right PA [Figure 1, pre-discharge, case 3, although showed no thrombus at both RPA and LPA but in Figure 2, case 3, pre-discharge still showed a thrombus at the branch of RPA] and the ECG showed T-wave resolution in the precordial leads. Figure 2 Case 3: RPA and LPA did not show the filling defect (see figure 1), but the thrombus was clearly seen in the right superior anterior branch of the RPA during pre-discharge which was completely resolved at 3 months follow up. RPA denotes right pulmonary ... He was discharged with dual antiplatelet and oral thrombolytic (two capsules of Thromboles were administered three times daily for 12 weeks). Follow-up CTPA at three months showed complete resolution of thrombus in right PA [Figure 1, follow up three months, case 3 and Figure 2, case 3, follow up three months].

Antiplatelet for Coronary Artery Disease in Specific Condition “No Size Fits All”

Antiplatelet is the cornerstone therapy for patient with coronary artery disease. Several comorbidities can influence the efficacy and safety of antiplatelet agent. Diabetes mellitus is characterized by increased platelet reactivity and reduced response to antiplatelet. Elderly patients have both reduced response to antiplatelet and increased risk of bleeding. Patients with renal dysfunction also had decreased efficacy of antiplatelet accompanied with increased risk of bleeding. In patients with atrial fibrillation, the concomitant use of anticoagulant with antiplatelet poses an increased risk of bleeding. In patients with these comorbidities, caution should be stressed in selecting the best regimen of antiplatelet which translates the most optimal efficacy while minimizing the risk of adverse events. In this review, we will discuss the platelet changes in these comorbidities, current evidence of antiplatelet usage in these group of patients and current recommendation.

Management of Heart Failure After CABG

Heart failure (HF) after coronary artery bypass graft (CABG) could be attributed to preoperative HF or postoperative HF. Preoperative HF accounted for about 45 % of patients referred for a condition of HF symptoms with systolic left ventricular (LV) ejection fraction (EF) less than 50 % before the surgery. The goal of treatment in patients with established HF is to relieve symptoms, prevent hospital admission, and improve survival before the surgery. Even though standard medications for HF including beta-blockers, angiotensin-converting enzyme (ACE) inhibitor, and mineralocorticoid have been shown beneficial, the early post surgery introduction of beta-blockers and ACE inhibitors should be cautious in patients with severe low LVEF, low blood pressure, and with pulmonary diseases.

Cardiac Resynchronization Therapy in Graft Failure

Although coronary artery bypass graft (CABG) surgery has had major advances in surgical techniques and will minimize patients’ clinical symptoms and improve survival, vein grafts continue to have high failure rates. If graft failure occurs, it will lead to worsening outcomes such as recurrent myocardial infarction (MI) and heart failure (HF). It has been shown that in select HF patients, cardiac resynchronization therapy (CRT) would lead left ventricular reverse remodeling and improve patients’ symptoms, quality of life, exercise tolerance, and finally improve survival. Most heart failures in patients following CABG are due to graft failures, which are related to occurring ischemia burden or scar tissue due to myocardial infarction. Therefore, in select patients, CRT may also have a beneficial effect, such as in non-CABG heart failure patients. Wider QRS complex with left bundle branch block morphology, low ejection fraction and New York Heart Association (NYHA) functional class II or higher are the only criteria for patient selection as recommended by many guidelines. If the ischemia burden is significant, then its management should be discussed with the local Heart Team (including intervention cardiologist and cardiac surgeon) whether additional percutaneous coronary intervention (PCI) or redo CABG should be performed despite CRT or CRT defibrillator (CRT-D) implantation. The complications related with CRT implantation are left ventricle (LV) lead dislodgement, phrenic nerve stimulation (PNS), and coronary sinus dissection. Although the complication rate is quite low, the implanter should take into consideration these potential complications. New techniques and devices for CRT implantation are now widely used and new advanced LV lead technology is commencing; hence the implantation technique will become easier and safer. The proper follow-up, especially for atrio-ventricular (AV) and ventriculo-ventricular (VV) optimization, is also important and needed besides successful CRT or CRT-D implantation.

Device sizing for transcatheter closure of ruptured sinus of Valsalva as per echocardiography color Doppler turbulent flow jet diameter

Rupture of sinus of Valsalva (SV) is a rare occurrence with a wide spectrum of presentation, ranging from an asymptomatic murmur to cardiogenic shock or even sudden cardiac death. We hereby report a case which was successfully closed by transcatheter technique. In this case, ruptured SV was entered from the aorta, an arteriovenous loop was created and device was implanted using a venous approach. The procedure was safe, effective and uncomplicated, obviating the need for surgery. In this case, the authors report for the first time the use of echo color Doppler turbulent flow jet diameter as a reference value for sizing the device.