Nasser J. Hayat

Left atrial appendage function in mitral stenosis: is a group in sinus rhythm at risk of thromboembolism?

OBJECTIVE To study the left atrial appendage (LAA) function and potential for embolization in severe mitral stenosis (MS). BACKGROUND Patients with MS and atrial fibrillation or in sinus rhythm develop systemic emboli. LAA function has not been well studied in sinus rhythm. METHODS Forty consecutive patients with MS (valve area < or =0.7 cm2/m2) were studied. LAA ejection fraction and peak emptying velocity were measured along with other data. RESULTS Patients were subgrouped according to LAA Doppler flow pattern. Group I (n=13) in sinus rhythm had biphasic high velocity > or =25 cm/s. Group II (n=13) in sinus rhythm had biphasic low velocity <25 cm/s. Group III (n=14) in atrial fibrillation had multiphasic irregular flow <25 cm/s or no definite flow. The LAA ejection fraction and peak emptying velocity were strikingly different in all groups. They were lower in group II when compared to group I. Group II had intermediate risk for thromboembolism compared to Group I and III as judged by systemic embolization, spontaneous echo contrast, thrombus in left atrium and LAA. CONCLUSION A subset of mitral stenosis in sinus rhythm at increased risk of embolization can be suspected by Doppler transesophageal echocardiographic LAA flow profile.

Extent and severity of atherosclerotic vascular disease in patients undergoing coronary angiography--the Kuwait Vascular Study.

Only a few angiographic studies have correlated the presence and severity of coronary artery disease with atherosclerosis in other arteries. The presence of disease in more than 1 area clearly has important implications on management. One hundred and seventy eight patients had angiographic evaluation of their peripheral arteries and abdominal aorta after routine diagnostic coronary angiography. The extent and severity of vascular disease was correlated with those of coronary artery disease. Of the 178 patients, 73.6% were men (mean age ± sd was 52.93 ±10.12 years). Hypercholesterolemia (59%), systemic hypertension (56.7%) and diabetes mellitus (50.6%) were the major risk factors. Triple-vessel coronary artery disease was present in 48.9%, and 13.5% had normal coronaries. A new atherosclerotic vascular disease score, which reflects the presence and severity of atherosclerotic vascular disease elsewhere, was seen to correlate significantly with the extent of coronary artery disease. Of particular interest was the involvement of the first part of the vertebral artery in 41.6% of patients. The combined involvement of the abdominal aorta, renal artery, and iliac artery segments (together referred to as the lower body segment) was seen almost exclusively in those with 2- or 3-vessel coronary artery disease. Also there was a direct correlation between the extent of coronary artery disease and the score in the lower body segment as opposed to the upper body segment (subclavian, vertebral, and internal mammary arteries). The presence of atherosclerotic vascular disease correlated with the severity of coronary artery disease, particularly in respect to disease in the lower body segment. Thus early detection of such disease in the iliac or femoral arteries has a potential for early diagnosis of significant coronary artery disease.

Predictors of coronary disease in patients with end stage renal disease.

Patients with end stage renal disease have a high prevalence of cardiovascular disease and coronary arteriography is often routinely performed prior to kidney transplantation. However, the value of the conventional risk factors and non-invasive markers of coronary artery disease (CAD) in triaging patients for coronary arteriography has not been fully examined. 116 patients with end stage renal disease were evaluated. Coronary arteriography was performed in all patients either for a suspicion of CAD or as part of a routine pre-transplant evaluation. Lesions causing ≥ 50% luminal diameter stenosis in any of the three major coronary artery systems were considered significant. The mean age was 53.3 ± 9.3 years. Significant CAD was present in 69 patients (60%). Increasing age, family history of premature ischemic heart disease, the presence of angina, abnormal Q waves on the ECG or abnormal ST segment depression and the presence of coronary calcification were significant markers of coronary artery disease. However male gender, diabetes mellitus and obesity did not correlate with coronary disease. Even though hypertension, hypercholesterolemia and smoking were also not useful predictors these could have been modified by the renal failure. In conclusion increasing age, a family history of premature ischemic heart disease and some non-invasive markers were useful predictors of coronary disease.

Angioplasty in the stent era: results of a consecutive series of patients undergoing coronary angioplasty without surgical backup

UNLABELLED We prospectively studied the angiographic and clinical outcome in a group of 117 consecutive patients (140 vessels) undergoing coronary angioplasty in the stent ERA without surgical backup. There were no exclusion criteria. Intracoronary stents were deployed in 36 vessels (26%) either as a bailout procedure or for a suboptimal result following balloon angioplasty. Procedural success was achieved in 126 vessels in 108 patients (90%). Two patients developed Q-wave myocardial infarction and another two developed nonQ myocardial infarction. One patient died suddenly 2 days following an initially successful procedure. No patient was referred for emergency coronary artery bypass grafting and there were no vascular complications. Clinical or angiographic follow up was available in 87% of the patients and an angiographic follow up in 50% of the patients. At a median angiographic follow up of 210 days restenosis was seen in 34% of the vessels. Restenosis occurred in three of the 21 (14%) stented vessels and in 18 of the 41 (44%) nonstented vessels (P<0.02). CONCLUSION In the stent era, coronary angioplasty can be safely performed without surgical backup. A satisfactory immediate and long-term result could be achieved by stenting 26% of the vessels.

CORONARY ARTERY DISEASE AMONG DIABETIC AND NON-DIABETIC PATIENTS WITH END STAGE RENAL DISEASE

Cardiovascular disease is the major cause of death among patients with end stage renal disease and accounts for about half the deaths among the dialysis population. Several researchers have reported a high prevalence of coronary artery disease among diabetic patients with renal failure and coronary arteriography is often considered an integral part of the pretransplant evaluation of diabetic patients with end stage renal disease. However, very few reports have addressed the question of coronary disease in non-diabetic patients, and the pattern and prevalence of coronary artery disease in non-diabetic patients with end stage renal disease are not well defined. We evaluated the clinical and coronary angiographic findings in 158 consecutive patients (84 diabetic and 74 non-diabetic) with end stage renal disease. The coronary arteries were divided into 16 segments and each segment was analyzed for the presence of coronary disease, which was defined as the presence of ≥ 50% luminal diameter stenosis. Diabetic patients had more adverse risk factors for coronary artery disease, yet there was no significant difference in the prevalence of coronary artery disease between the diabetic and non-diabetic patients (67% vs. 55%, p = 0.15), or in the number of affected coronary artery segments (2.0 vs. 1.4, p = 0.05). Triple vessel coronary artery disease was however, significantly more common among the diabetic subjects (27% vs. 12%, p = 0.005). Non-diabetic patients with end stage renal disease also have a high prevalence of coronary artery disease and may merit as careful investigation of their coronary status as their diabetic counterparts.

Angiographic Comparison of Coronary Artery Disease in Arab Women with and without Type II Diabetes mellitus

Objective: To compare angiographic features in women with and without type II diabetes mellitus. Subjects and Methods: One hundred and six consecutive women who underwent diagnostic coronary angiography in the Chest Diseases Hospital, Kuwait, were chosen for the study. Quantitative coronary angiography was performed and the angiographic features were assessed. Results: Eighty-two patients had coronary artery disease. Of these, 59 (72%) had type II diabetes mellitus and 23 (28%) were non-diabetics. Segmental disease involving the mid and distal left anterior descending artery was more common in diabetics than non-diabetics. Diabetics had a greater number of long lesions and more distal coronary artery disease. However, the caliber and suitability of the distal vessels for grafting was similar. Conclusion: Angiographic severity of coronary artery disease in this selective group of mostly Arab women was more in those with type II diabetes mellitus than non-diabetics. However, the distal luminal diameter was similar in both groups.

Clinical and angiographic features in patients under 35 years with a first Q wave acute myocardial infarction

Sixty patients less than 35 years with a first Q wave acute myocardial infarction were prospectively studied to evaluate their features, risk factors and evidence of any viral infection. Typical chest pain was present in 98.3% with Q waves and ST segment elevation in all. None had hypotension or cardiogenic shock. Smoking was the most common risk factor (81.7%). Mean total cholesterol was 5.74 (+/-1.42) mmol/l. History of a viral illness was present in 28.3%, severe emotional stress in 21.7% and exhausting physical activity in 18.3%. Mean left ventricular diastolic and end systolic volumes were increased (90.11+/-22.5 ml/m2) and (46.62+/-20.46 ml/m2), respectively. The ejection fraction was depressed (49.71+/-1.6%). Triple vessel disease was seen only in 6.8 and 26.7% had insignificant or no coronary artery disease. Left anterior descending artery was most frequently involved (66%). None had left main involvement. Coronary ectasia was present in 11.7%, intracoronary thrombus in 28.3% and 40% had collaterals. Patients with no significant disease had no diabetes, a smaller number had a raised total cholesterol or smoked and had a lower ejection fraction. Patients from the Indian subcontinent who had fewer conventional risk factors, had more severe disease than those from the Arab world suggesting that other etiological factors need investigation.

Disease of Proximal Part of Vertebral Artery in Patients with Coronary Artery Disease

Recognition of coincidence of cerebral vascular disease is of importance in patients with coronary artery disease. One hundred and seventy-three patients who underwent coronary angiography were also studied by angiography of subclavian arteries and abdominal aorta. The majority of the patients (128/173; 74%) were men. Risk factors of hypertension, diabetes, and hypercholesterolemia were present in a high percentage of patients. Disease of the proximal part of the vertebral artery was seen in 41.6% (72/173). Presence of vertebral artery disease was significantly correlated with diabetes (p = 0.02), renal artery stenosis (p = 0.003), coronary artery disease (p = 0.05), and iliac artery disease (p = 0.05). The proximal part of the vertebral artery was found to be affected in a high percentage (41.6%) of patients under going coronary angiography.

Cardiac Involvement in Idiopathic Hypereosinophilic Syndrome: A Comprehensive Echo Doppler Study

A 38-year-old male with hypereosinophilic syndrome presented with severe respiratory and cardiac failure. The two-dimensional echocardiography showed a thrombus that extended from the apex to posterob

Cardiac Myxoma – Manifestations and Management: Kuwait Experience and Review of the Literature

Over the past 14 years, 12 patients were diagnosed as having cardiac myxoma. All cases were sporadic, single, large, left atrial myxomas. These patients presented with nonspecific cardiac and noncardi