Nepalese Heart Journal

Right Bundle Branch Block Morphology After Right Ventricular Endocardial Pacing – When Should a Cardiologist Begin to Worry ?

Vijay Yadav — 2021-04-30

Even though the left bundle branch block (LBBB) morphology in the surface electrocardiogram (ECG) is expected after right ventricular endocardial pacing, the right bundle branch block (RBBB) morphology may be paradoxically seen in around 8 to 10% of patients. The paced RBBB morphology should be given special attention in terms of safe RV pacing or septal and free wall perforation. Simple techniques such as moving the leads V1-2 to one interspace lower than standard (Klein maneuver) and combining frontal QRS axis between -30° to -90°, precordial transition point at or within V3, and absence of S wave in lead I as an algorithmic approach may correctly identify the pacemaker lead in right ventricle with high sensitivity, specificity, and positive predictive value.

Clinical Profile and Outcome of COVID 19 Patients at Tertiary Cardiovascular Center of Nepal.

Kunjang Sherpa — 2021-04-30

Background and Aims: Cardiovascular comorbidities are common in patients with COVID-19 and these patients are at higher risk of morbidity and mortality. It is not known if the presence of cardiovascular co-morbid conditions poses independent risk or whether this is mediated by other factors.

Methods: This is a retrospective follow up study done at Shahid Gangalal National Heart Centre (SGNHC). The main objective of this study was to study the clinical profile, baseline comorbidities, and outcome of cardiac patients and health care worker diagnosed with COVID 19. This study retrospectively evaluated case records of all cardiovascular disease (CVD) patients admitted at SGNHC with COVID 19 cases from 1st case diagnosed on July at SGNHC till September 2020.

Results: During this study period, 90 patients with COVID 19 with cardiovascular disease were admitted. The mean age of the study population was 52.3±19 years with 65.6% being male. Among the study population 52 (57.8%) had past history of cardiovascular disease, hypertension in 18 (20%) cases, diabetes in 8 (8.9%) cases. Among the patients with cardiovascular diagnosis, acute coronary syndrome was most common cardiovascular diagnosis in 23 (25.6% cases) followed by rheumatic heart disease in 21 (23.4%) cases, dilated cardiomyopathy in 7 (7.8% cases), ischemic cardiomyopathy with reduced ejection fraction (EF) in 7 (7.8%) cases, post coronary artery bypass graft (CABG) in 8 (8.9%), post valve replacement in 5 (5.5%), congenital heart disease in 3.3% cases and complete heart block in 3.3% cases. Most of the cases were symptomatic with moderate illness in 46.7% cases, mild illness in 41.4% cases and severe/critical illness in 11.1% cases. Among COVID patients with cardiovascular disease, the mortality was 11.1%.

Conclusion: Patients with cardiovascular disease with COVID 19 have more severe COVID 19 symptoms and has higher COVID 19 related death, so strict vigilance and early intervention is needed to improve its outcome.

The Spectrum of Congenital Heart Diseases Operated at Shahid Gangalal National Heart Center in the last 5 Years.

Navin Chandra Gautam — 2021-04-30

Background and Aims: The spectrum of congenital heart diseases (CHD) presenting for surgery to any cardiac center varies depending upon the geographical location of the center. This study is aimed to reveal the spectrum of CHD operated at a tertiary level cardiac center of Nepal.

Methods: This is a retrospective study conducted at the Department of Cardiovascular Surgery at Shahid Gangalal National Heart Center (SGNHC), Kathmandu, over a period of five years, from April 14, 2015 to April 13, 2020. All patients with a confirmed diagnosis of congenital heart disease who had undergone palliative or definitive cardiac surgery were included.

Results: Out of the total 2698 patients, there were 1374 (50.93%) females. The total number of acyanotic congenital heart disease was 1919 (71.13%), and that of cyanotic was 779 (28.87%). Male to female ratio among acyanotic and cyanotic were 0.85:1 and 1.31:1 respectively. Among all CHDs, atrial septal defect (ASD) (38.13%) followed by ventricular septal defect (VSD) (21.68%) and atrioventricular septal defect (AVSD) (5.04%) respectively were the commonest acyanotic heart lesions. Considering only the pediatric population (age 0-18 years), the commonest was VSD (27.06%) followed by ASD (22.3%) respectively. The commonest cyanotic was tetralogy of Fallot (TOF) (14.15%) followed by double outlet right ventricle (DORV) (4.44%) and total anomalous pulmonary venous connection (TAPVC) (2.89%) respectively.

Conclusion: Female population was slightly more in number amid acyanotic lesion whereas male population was dominant in cyanotic lesion. The commonest acyanotic CHD was ASD and, TOF was the commonest cyanotic lesion.

Study of Clinical, Angiographic Profile and Outcome of Patients Undergoing Coronary Angioplasty of Left main Coronary Artery: MCVTC Experience.

Ratna Mani Gajurel — 2021-04-30

Background and Aims: Coronary artery bypass graft is the treatment of choice for left main disease. However the results from several large multicenter trials have shown that the angioplasty of left main disease is an alternative treatment. The aim of this study was to assess the outcome of patients undergoing angioplasty of left main disease.

Methods: This prospective study was conducted at Manmohan cardiothoracic vascular and transplant center, Maharajgunj, Kathmandu, Nepal. Twenty-Five patients with a diagnosis of left main coronary artery disease who underwent coronary angioplasty were enrolled in the study. The cases were followed up and outcomes on follow up were assessed.

Results: Patients with left main disease enrolled in this study belonged to the age group of 51 to 77 years. The mean age of patients was 64.7±8.12 with 68% (17) male and 32% (8) female. Among 25 patients 3 patients had single vessel disease, double vessel in 10 patients and triple vessel in 12 patients. Three patients (12%) had previous history of percutaneous coronary intervention and 1 (4%) had previous history of coronary artery bypass graft. All patients underwent successful procedure with unprotected left main stenting in 14 cases (56%). There was few major and minor complications and no procedure related mortality and in hospital death.

Conclusion: Left main coronary angioplasty is a safe and alternative procedure to CABG with low incidence of major clinical events.

Efficacy and Safety of Focal Atrial Tachycardia and Typical Atrial Flutter Ablation in Nepal-A Single Center Experience.

Roshan Raut — 2021-04-30

Background and Aims: Atrial tachycardia is classified as focal atrial tachycardia or macro-reentrant atrial tachycardia. Macro-reentrant atrial tachycardia involves large circuit and is also called atrial flutter in which cavotricuspid isthmus dependent flutter, also called typical atrial flutter is the most common. The aim of this study is to report the efficacy and safety of catheter ablations of these arrhythmias, for the first time in Nepal.

Methods: This is a retrospective observational study of the patients who underwent electrophysiological study with ablation for focal atrial tachycardia and typical atrial flutters at Shahid Gangalal National Heart Center (SGNHC) from March, 2015 to February 2020.

Results: Altogether, 49 patients, 27 for focal atrial tachycardia and 22 for typical atrial flutter, underwent electrophysiology study with intent to ablation. In two patients, atrial tachycardia could not be induced, therefore 25 patients underwent ablation for atrial tachycardia. Out of 25 patients, the successful ablation achieved in 24 patients (96%) with recurrence in three patients (12%), with no major complications. Atrial tachycardia more commonly originated from right atrium than the left atrium (68% vs. 32%). Among 22 patients who underwent cavotricuspid isthmus ablation for typical atrial flutter; successful ablation achieved in 21 patients (95%) with recurrence in two patients (9%) and a single case of access site hematoma. Counterclockwise flutter was found to be more common than clockwise flutter (91% vs. 9%).

Conclusion: In SGNHC, the ablations of focal atrial tachycardia and the typical atrial flutter has a high success and low complication rate.

Trends and Profile of Permanent Pacemaker Implantation in Nepal. Experience From Tertiary Cardiac Center (SGNHC) From 2001 to 2020.

Murari Dhungana — 2021-04-30

Background and Aims: The number of pacemaker implantation is increasing at various centres of Nepal with increase in cardiac services. However, there are few data available regarding the pacemaker implantation in Nepal. This study intend to focus and study trends and profile of permanent pacemaker implantation (PPI) of 19 years experience at the referral tertiary cardiac center which will reflect intended objective of this study.

Methods: This was a retrospective cross sectional study done at Shahid Gangalal National Heart Centre (SGNHC). The data of the patient who underwent PPI from 2001 November to 2020 August were reviewed. Patients data including age, sex, indication for pacing, mode of pacing, type of pacemaker implanted, implantation parameters such as lead impedence and threshold were recorded and analyzed.

Results: A total of 3631 pacemaker implantation were performed at SGNHC from 2001 November to 2020 August. Among the total patients, 59.4% were male with mean age of 65.2±15.2 years. The most common indication was degenerative complete heart block (74.8%). Sick sinus syndrome (8.2%) was the second most common indication of pacing. The single chamber were implanted in 93.3% cases and dual chamber in 6.7% cases. VVIR was the most common mode of implantation in 93.1% cases, followed by DDDR (6.7%). AAIR (0.1%) and VDD in 0.1% cases. The total number of pacemaker implanted yearly in SGNHC has increased since the early year of implantation. During the early years most of the pacemakers were Single chamber (VVI) pacemaker and the implantation of dual chamber pacemaker increased gradually from year 2010 onwards. After the year 2010 the implantation of dual chamber pacemaker has increased significantly compared to prior to 2010 (p= 0.001). There were no gender differences in use of single chamber and dual chamber implantation during this period. (p value = 0.489). The dual chamber were implanted mostly in age group less than 65 year compared to more than 65 years (P value = 0.001).

Conclusion: There is gradual increase in the number of pacemaker implantation yearly at SGNHC and since 2010 there is also increase in number of dual chamber pacemaker implantation though the single chamber pacemaker outnumbered the dual chamber implantation.

A Study of Clinical Profile and Complications In Patients with ST-Elevation Myocardial Infarction Attending In College of Medical Sciences Teaching Hospital, Bharatpur (Chitwan), Nepal.

Pradeep Thapa — 2021-04-30

Background and Aims: ST-Elevation Myocardial Infarction (STEMI) is a leading cause of morbidity and mortality. This study aims to summarize the clinical profile and complications of patients with STEMI in a teaching hospital.

Methods: This was a prospective hospital based descriptive and observational study conducted at College of Medical Sciences Teaching Hospital (CoMSTH), Bharatpur from January 2017 to July 2018 in 110 patients with a diagnosis of acute STEMI.

Results: Out of 110 patients the mean age of presentation was 59.31 years and 64.5% were male. Typical chest pain (90%) was the most common presenting symptom and 45.5% patients presented within six hours of chest pain. Most common traditional risk factors were hypertension and smoking which were present in 44 (40%) cases, followed by diabetes in 33 (30%), dyslipidemia in 22 (20%). Majority of patients (49.1%) were in killips class I, and only 9 (8.2%) patients were in cardiogenic shock (killips class IV). Inferior wall was the most common in 30% patients followed by anteroseptal wall MI (23.6%), anterior wall MI (11.8%) and combined (anterior and inferior) in 10%. Revascularization with primary Percutaneous Coronary Intervention (PCI) was done in 46 (41.8%) patients, thrombolysis was done in 41 (37.3%) patients. Arrhythmias (39.1%) followed by heart failure (24.5%) were the common complications. The overall in-hospital mortality was 16 (14.5%).

Conclusions: Patients with acute STEMI at College of Medical Sciences Teaching Hospital (CoMSTH) were predominantly male with hypertension and smoking as the commonest risk factors. Arrhythmias were the most common complications and in-hospital mortality rate was 14.5%.

An Echocardiographic Study of Right Ventricular Morphology and Function in Systemic Hypertension.

Murari Prasad Barakoti — 2021-04-30

Background and Aims: Hypertension is a common medical condition that leads to increased risk of cardiovascular conditions including coronary artery disease, heart failure, stroke, renal diseases, blindness and cardiovascular death. Long term hypertension will affect left ventricle by hypertrophy and several functional derangements. Since heart works as a unit, right heart changes are expected. Right ventricular dysfunction has a strong prognostic significance and we aim to study right ventricular parameters in hypertensive patients.

Methods: We studied 71 hypertensive subjects and 66 matched control without hypertension in echocardiography laboratory for chamber dimensions and right ventricular systolic and diastolic parameters.

Results: The right ventricular free wall thickness (5.46±1.97mm vs 4.77±0.81mm; P=0.01) and interventricular septal thickness (11.62±2.64mm vs 9.10±1.16mm; P<0.01) were significantly higher among hypertensive patients. Right ventricular dimensions namely basal diameter (26.41±4.97mm vs 29.16±5.22mm; P<0.01), mid-ventricular diameter (25.83±4.40mmvs 27.44±5.05mm; P=0.05) and right ventricular long-axis length (69.54±7.08 mm vs 73.28±7.08mm; P<0.01) were significantly low among hypertensive patients. Tricuspid Annular Plane Systolic Excursion (TAPSE) was significantly lower among hypertensive patients (18.84±1.85mm vs control 20.54±2.65mm; P<0.01). A significant statistical correlation was found between mitral E/A ratio and tricuspid E/A ratio (R2 linear=0.78, P=0.01).

Conclusion: The effect of hypertension in right ventricular structure and function are found to be subtle but definite as seen in diastolic wave velocities, right ventricular wall thickness, internal chamber dimensions and TAPSE. Assessment of hypertensive effect on heart will help to control hypertension in stringent way.

Lipid Profile in Postmenopausal Diabetic Female.

Rabindra Simkhada — 2021-04-30

Background and Aims: Postmenopausal diabetic female are at increased risk of cardiovascular disease. The objective of this study was to study their lipid profile and prevalence of dyslipidemia and assess relation of control of lipid components with various risk factors.

Methods: A cross sectional prospective study conducted at Shahid Gangalal National Heart Centre from 15th July 2020 to 14th October 2020 including 109 postmenopausal diabetic female. Detailed history along with clinical examination were conducted. Fasting lipid profile and other relevant investigations were obtained.

Results: Mean age of participants was 63.48±9.26 years. Mean age of menopause was 48.59±1.88 years. A total of 37 (33.9%) were hypertensive, 17 (15.6%) were smoker, 67 (61.5%) were physically inactive. A total of 91 (83.5%) were non-vegetarian. Thirty eight (34.9%) had their blood sugar controlled with hemoglobin A1c of <7%. The mean total cholesterol and high density lipoprotein were 5.21±0.97 mmol/l and 1.02±0.13 mmol/l. Similarly mean triglyceride and low density lipoprotein were 2.24±0.75 mmol/l and 3.04±0.12 mmol/l. Dyslipidemia was present in 82.6%. Significant correlation of control of blood sugar with total cholesterol control status (R=0.28, P=0.01), low density lipoprotein control status (R=0.38, P=0.01), high density lipoprotein control status (R=0.36, P=0.04) and triglyceride control status (R=0.30, P=0.04) were seen.

Conclusion: Dyslipidemia was common in post menopausal diabetic female. Blood sugar control status showed significant correlation with lipid profile parameters. A good sugar control and evaluation for lipid abnormalities is recommended in postmenopausal diabetic female.

The Effect of Transesophageal Echocardiography Probe Insertion in Endotracheal Tube Cuff Pressure in Adult Cardiac Surgical Patients.

Santosh Sharma Parajuli — 2021-04-30

Background and Aims: Insertion of transesophageal echocardiography probe in cardiac surgical patient is a routine practice for surgical planning and decision making. However it may increase the endotracheal tube cuff pressure as it lies adjacent to the posterior wall of trachea. The aim of this study is to evaluate the changes in cuff pressure after insertion of the transesophageal echocardiography probe and after completion of initial manipulation of the transesophageal echocardiography probe during various examinations in adult cardiac surgical patients.

Methods: Thirty six patients undergoing elective cardiac surgery requiring Transesophageal Echocardiography (TEE) monitoring were enrolled in the study. After induction of general anesthesia and endotracheal intubation cuff pressure were measured at 3 points of time; just after intubation (T1), after transesophageal probe insertion (T2) and after initial completion of TEE study (T3). The mean increase in cuff pressure at various point of time were compared.

Results: The cuff pressure (mean±SD) at T1, T2 and T3 were 24.61±2.72, 30.22±5.61 and 32.25±4.45 cm of H₂O respectively.The cuff pressure increased significantly from T1 to T2 (p<0.001) and from T1 to T3 (p<0.001). The cuff pressure was > 30 cm of H₂O in 18 (50%) of patients at T3 which was readjusted back to 25-30 cm of H₂O by with drawing air from the cuff.

Conclusion: Endotracheal tube cuff pressure should be routinely monitored either intermittently or continuously after transesophageal echocardiography probe insertion till it is in situ and pressure should be readjusted to avoid unwanted complications.

Spectrum of Quality of Life after Valve Surgery in Patients with Rheumatic Heart Disease.

Dikshya Joshi — 2021-04-30

Background and Aims: Improvement in quality of life is one of the principal goals of valve surgery. The purpose of this study was to assess the quality of life in patients living with mechanical heart valves.

Methods: We conducted a cross-sectional descriptive study among 131 (42 Males, and 89 Female) patients, who had undergone valve procedures at different times in clinic visit of department of cardiac surgery, unit I of Shahid Gangalal National Heart Centre from August 1 till August 29, 2019. Quality of life index was measured using Ferrans and Power quality of life index, cardiac version IV via written questionnaire or verbal interview.

Results: Mean age was 40.57±1.4 (16-75) years. Mean duration of follow up was 4.68±4.03 years (3 months to 18 years). Subjects reported the lowest quality of life scores in the health and functioning domain prior to surgery (15.61±1.30), which improved 47.15% after surgery (22.95±0.45), psychological/spiritual domain improved 16.68%, social and economic domain 26.24%, family domain 11.49%, with overall improvement 28.62%. Women had significantly lower mean overall quality of life index (22.99±03.58) (95% confidence interval 22.24-23.75) compared to male counterparts (24.21±4.11) (95% confidence interval 22.92-25.49) (p<0.05). Family domain had the highest score at the latest follow up (28.84±1.63). There was a statistically significant correlation between the duration of operation and overall quality of life index (Pearson's rho 0.217, p<0.01). There was no significant difference with the patients’ age.

Conclusion: This study confers significant improvement of quality of life after valve surgery with time. Age does not appear to limit the quality of life. Family support seems to be the biggest strength in our population.

Left Ventricular Non-Compaction Cardiomyopathy, Ventricular Septal Defect and Pre-excitation: A Rare Coexistence of Three Abnormities in an Adult Patient.

Tufan Çınar — 2021-04-30

A congenital cardiac condition characterized by ventricular trabeculations and intertrabecular recesses is described as a non-compaction cardiomyopathy. In clinical practice, since it can be associated with severe mortality and morbidity due to progressive heart failure, thromboembolic events, and fatal arrhythmias, it is important to consider non-compaction cardiomyopathy. In this case, we have an adult patient who underwent surgery due to a ventricular septal defect (VSD) and who was later diagnosed with left ventricular non-compaction cardiomyopathy (LVNC) and pre-excitation. To our knowledge, this is the first case of VSD, LVNC, and pre-excitation simultaneously present in an adult patient.

Transcatheter Closure of Atrial Septal Defect and Balloon Pulmonary Valvuloplasty with Inoue Balloon in Adult Patients.

Chandra Mani Adhikari — 2021-04-30

Secundum type atrial septal defect combined with pulmonic stenosis is a relatively uncommon condition in adult patients. When occurred separately they can be treated with transcatheter intervention. When they occur together ideal treatment option is not clear. We report a case of combined percutaneous pulmonary valvuloplasty done with the Inoue balloon and transcatheter atrial septal defect closure in an adult patient.

Asymptomatic Presentation in Arrhythmogenic Right Ventricular Cardiomyopathy: a Case Report.

Anish Hirachan — 2021-04-30

Arrythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiac condition leading to one of the common cause for sudden cardiac death in young individuals. It is characterized by fibrofatty replacement of the cardiac myocytes predominantly the right ventricle. As the presentation can be varied and very nonspecific, it often leads to delay in diagnosis and specific treatment. Here, we present a 30 year male who was asymptomatic and detected to have electrocardiograph (ECG) and echocardiographic abnormalities suggestive of ARVC. Further, a cardiac imaging with cardiac MRI confirmed the diagnosis of ARVC highlighting the importance of multimodality imaging.