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Objective: To study the outcome of concomitant treatment of a non-chronic total occlusion lesion at the time of chronic total occlusion intervention at AFIC-NIHD. Study Design: Observational study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi, from Nov 2020 to Apr 2021. Methodology: A total of 171 patients presenting with chronic total coronary occlusion lesions were enrolled in study. Patients were randomized into two groups, group one with chronic total coronary occlusion only group and group two with combined group (chronic total coronary occlusion with non-chronic total coronary occlusion lesion) after coronary angiogram. The primary end-point assessed was angiographic (<30% residual diameter stenosis), clinical and procedural outcomes (TIMI grade flow, major adverse cardiac events (MACE) including death, stent thrombosis (ST), MI, repeated symptoms requiring repeat target vessel revascularization (TVR) either PCI or CABG, pericardial tamponade requiring pericardiocentesis or surgery and stroke) in patients with only chronic total coronary occlusion PCI group and combined group (chronic total coronary occlusion with non-chronic total coronary occlusion). Results: A total of 171 patients with chronic total coronary occlusion lesions were enrolled in the study. The mean age was 60.61 ± 9.68. There was no significant difference in perihospital complications, MACE in the two groups. However, there was increased contrast volume and radiation used in the combined group. Conclusion: Combined chronic total coronary occlusion and non-chronic total coronary occlusion lesion PCI can be done in a single procedural setting with acceptable complications and high success rate. [ABSTRACT FROM AUTHOR]

Objective: To determine whether a planned 2-stent double kissing crush technique is superior to provisional stenting patients presenting with true distal LM bifurcation lesions. Study Design: Cross-sectional comparative study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi Pakistan, from Dec 2020 to May 2021. Methodology: A total of 70 patients enrolled in the study presented with true distal LM bifurcation lesions (Medina 1, 1, 1 or 0, 1, 1). Patients were randomized to PS or DK crush technique. The primary end-point was peri hospital and 1 month composite rate target lesion failure (TLF): target vessel myocardial infarction (TVMI), cardiac death, stent thrombosis (ST), target vessel revascularization (TVR). Routine clinical follow up done at 2 weeks and 4 weeks followed by 3 and 6 months thereafter. Results: A total of 70 patients fulfilling the inclusion criteria were enrolled in the study. The patient population was divided into two groups. Group A participants underwent DK crush technique while group B participants underwent provisional stenting. In group A [DK crush technique] 16 (45.7%) patients presented with Non-ST elevation MI followed by 14 (40%) who presented with chronic coronary syndrome (CCS) while in group B [Provisional stenting] 13 (37.1%) presented with chronic coronary syndrome followed by 9 (25.7%) who presented with non-ST elevation MI. Conclusion: LM-PCI is an acceptable procedure in patients with true distal LM bifurcation lesions who are candidates for PCI. This study also showed that DK-Crush has good periprocedural and angiographic outcomes and superior to PS in complex LMCAD lesions. PS is an acceptable option in simple distal LMCAD. [ABSTRACT FROM AUTHOR]

Objective: To compare profile, clinical characteristics and outcomes of patients admitted with acute heart failure and reduced ejection fraction to those patients with preserved ejection fraction. Study Design: Descriptive cross sectional study. Place and Duration of Study: The study was carried out at Armed Forces Institute of Cardiology & National Institute of Heart Diseases from April to November 2016. Material and Methods: All patients presenting to AFIC ER and diagnosed with acute heart failure were included in this study. Echocardiography was done for all the patients. Baseline characteristics, clinical profile, lab investigations and outcomes were documented. Results: A total of 288 patients were included in this study, 223 (77.4%) patients had reduced ejection fraction (EF) <50% (HFrEF), 65 (22.5%) patients had preserved EF >50% HFpEF. Significantly higher numbers of female patients were seen in HFpEF group (0.04). Patients with preserved EF were significantly more hypertensive than patients with reduced EF (75.5% vs 54.0%, p-value 0.05), similarly systolic blood pressure >161 mmHg and diastolic blood pressure >101 mmHg was observed in patients with preserved EF as compared to patients with reduced EF. Heart failure complications including valvular heart disease (severe MR) and atrial fibrillation were more frequent in patients with preserved EF as compared to patients with reduced EF (10.8% vs 2.6% p 0.05 and 9.0% vs 1.3% p 0.04). Cardiogenic shock was more commonly encountered in patients with reduced EF (30.1% vs 4.6% p 0.03). NSTEMI was diagnosed in 15.6 (35.0%) patients with reduced EF and 3 (4.61%) patients with preserved EF (p-value 0.04). In hospital mortality was similar for both groups. Conclusion: Hypertension, valvular heart disease and a trial fibrillation is more commonly present in acute heart failure patients with preserved EF. However acute heart failure patients with reduced EF more frequently have ischemic heart disease and present with NSTEMI and cardiogenic shock. Whereas, mortality is same for both groups. Therefore patients presenting with acute heart failure and preserved EF should be treated as aggressively as those with reduced EF. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of diabetes mellitus in non ST segment elevation myocardial infarction. Study Design: Cross-sectional. Place and Duration of Study: The study was carried out at the Armed Forces Institute of Cardiology (AFIC) Rawalpindi, from Apr 2010 to Oct 2010. Material and Methods: In this study three hundred fifty two patients with non ST elevation myocardial infarction (NSTEMI) who fulfilled the inclusion criteria were studied while they were admitted to the hospital. They were divided into diabetic and non diabetic groups. Frequency of age, gender, rising levels of cardiac biochemical markers, plasma glucose and HbA1c were seen in both diabetic and non diabetic patients. Results were obtained by using chi-square method and independent t-test. Results: Out of 352 patients of NSTEMI 193 were diabetics. The study population was categorized in three groups according to age as; 30-45, 46-60, and 61-75 years respectively. It was found that 46-60 years group was most frequently affected with frequency of 46.1%, p<0.001 with male predominance as 67.9% and females as 32.1%. Cardiac biochemical markers were raised with mean for CK 528.51 U/L SD ± 275.82 and CK MB 79.39 U/L SD ± 32.5, p<0.001 respectively. Raised fasting plasma glucose was found in 189 patients mean 8.74 mmol/L SD ± 1.52, p<0.001 and elevated HbA1c seen in 187 patients mean 7.94% SD ± 0.83, p<0.001. Conclusion: Despite modern therapies for unstable angina (UA)/NSTEMI diabetes is an independent cardiovascular risk factor, therefore we need aggressive strategies to manage the high risk group of patients. [ABSTRACT FROM AUTHOR]

ABSTRACT Holt Oram Syndrome (HOS) falls in rare prevalence category with probability of 0.7 in 100,000 live births. It is a rare autosomal dominant multiple malformation syndrome characterized by abnormalities affecting hands, wrists, arms, congenital heart defects and/or conduction problems. Genetic mutations observed in TBX5 gene is attributed as the main cause of HOS. Our patient in his late 40s was diagnosed with Holt Oram Syndrome. He presented with typical conditions of congenital heart abnormalities (ASD) and upper limb malformations. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship of serum LDL-C and HDL-C levels with Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) Scores to predict all-cause 30 days mortality following first onset Acute Coronary Syndrome (ACS). Study Design: Descriptive cross-sectional study. Place and Duration of Study: Inpatient departments of Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi, from Jan 2019 to Jun 2019. Methodology: Ethical approval was taken from Institutional Ethical Review Board (IERB), AFIC/NIHD. Patients of any age and both genders who presented with chest pain and satisfied criteria for type 1 Myocardial Infarction (MI), as stated in 4th Universal Definition of MI, were included in study by non-probability consecutive sampling technique. Patients with a previous history of ischemic heart disease, Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Graft (CABG) surgery and patients taking lipids lowering medications over at least 3 months prior to admission were excluded. Both TIMI and GRACE scores for ST Elevation MI (STEMI) and Non-ST Elevation MI (NSTEMI) were calculated at time of admission. One non fasting blood sample was drawn for serum lipid levels from each patient within 24 hours of hospital admission and was analyzed using ROCHE cobas 6000 c501 analyzer. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Results: Out of 236 patients, 210 were male and 26 were female. Minimum recorded age was 25 years and maximum 90 years. Subjects presented with NSTEMI seem older (65.5 ± 7.3 years) than the ones presented with STEMI (59.7 ± 12.5 years). Anterior wall MI was the most common presentation (35%). Hypertension was the most common (57.6%) risk factor noted for Coronary Artery Disease (CAD). Serum lipids had a higher trend among STEMI subjects than NSTEMI and a lower trend among deceased subjects, as compared to survivors, in both STEMI and NSTEMI groups. Negative correlations were recorded between LDL-C and GRACE score in STEMI group (-0.277) and between HDL-C and both GRACE and TIMI scores (-0.349 and -0.299, respectively) in NSTEMI group. Conclusion: A significant paradoxical lower levels of serum lipids were found in deceased subjects who presented with ACS. [ABSTRACT FROM AUTHOR]

Objective: To share our experience of percutaneous trans-catheter aortic valve implantation in patients with severe symptomatic aortic stenosis. Study Design: A retrospective cross sectional study. Place and Duration of Study: The study was conducted at Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD) Rawalpindi, from Mar 2015 to Feb 2020. Methodology: Retrospective analysis of all consecutive patients who underwent percutaneous trans-catheter aortic valve implantation was done to assess its immediate, short and long term outcome and safety. Twenty patients have undergone trans-catheter aortic valve implantation since 2015 in the institute. Base line blood chemistry including creatinine clearance, ultra-sonography abdomen, carotid Doppler, chest X-ray, High-Resolution Computed Tomography chest was done in all cases as part of the protocol. Mean age of the patients was 73 ± 7.91. There were sixteen males (80.0%) and four females (20.0%). All patients under went procedure through transfemoral route. Valve structure and peripheral vasculature for suitability of the procedure was assessed by computerized coronary tomographic angiography with TAVI protocol. In eleven patients aortic valve was trileaflet (55.0%) and in remaining nine it was bicuspid (45.0%). Mean gradient across the valve pre-procedure was 56.37 ± 9.14. Thirteen patients (65.0%) presented with angina/dysnoea NYHA III, 6 patients with syncope (30.0%) and one (5.0%) had heart failure. Two patients had undergone previous coronary artery bypass surgery. Procedure was carried out under general anesthesia in all patients except one. Balloon expandable Edwards Sapienvalve was implanted in two patients and self-expandable Core Valve/Evolut R in eighteen patients. Results: Seventeen patients underwent the procedure successfully with reduction of the mean gradients immediately after valve implantation to less than 15 mmHg recorded in the cath labangiographically subsequently complemented by transthoracic echocardiography. There were 3 deaths during the index hospitalization. Two occurred in the catheterization laboratory, one death was due to development of severe acute aortic regurgitation and second was due to acute coronary obstruction. Third death occurred due to acute kidney injury after seven days. Five patients died in next three months during follow up. One patient required permanent pacemaker because of development of left bundle branch block and second degree atrio-ventricular block post procedure. Conclusion: Transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis is a very effective and procedurally safe option and reasonable alternative to surgical valve replacement in high operative risk individuals. [ABSTRACT FROM AUTHOR]

Objective: To determine the correlation of Global Registry for Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores with Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score (SS) to predict the extent and severity of coronary artery disease (CAD) in patients presented with first onset STE levation Myocardial Infarction (STEMI) undergoing Primary Percutaneous Coronary Intervention (PPCI). Study Design: Descriptive cross-sectional study. Place and Duration of Study: Inpatient departments of Armed Forces Institute of Cardiology/ National Institute of Heart Diseases (AFIC/NIHD), Rawalpindi, from Jan 2019 to Jun 2019. Methodology: Ethical approval was taken from Institutional Ethical Review Board (IERB), AFIC/NIHD. Patients of any age and both genders who presented with chest pain and satisfied criteria for Type 1 Myocardial Infarction (MI), as stated in 4th Universal Definition of MI, were included in study by non-probability consecutive sampling technique. Patients with a previous history of ischemic heart disease, Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Graft (CABG) surgery were excluded. Both TIMI and GRACE scores for STEMI were calculated at time of admission. The extent and severity of CAD were assessed by the SS-I. Each coronary lesion with a diameter stenosis of at least 50%, in vessels of at least 1.5 mm, were scored. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Results: Out of 376 patients, 327 (86.9%) were male and 49 (13.1%) were female. Anterior wall MI was the most common presentation 164 (43.6%). Among risk factors for CAD, hypertension was the most common one 215 (57.2%). A positive correlation was found between SS and GRACE low, intermediate and high-risk groups (0.145). Conclusion: Patients having high GRACE and TIMI scores were more likely to have severe CAD. In comparison with TIMI score, GRACE score was found to have better correlation with SS, but degree of that association was not strong enough to make it a reliable and sole predictor of CAD severity. [ABSTRACT FROM AUTHOR]

Objective: To share our experience of percutaneous trans-catheter aortic valve implantation TAVI in patients with severe symptomatic aortic stenosis. Study Design: A retrospective cross sectional study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases (AFIC/NIHD) Rawalpindi, from Mar 2015 to Aug 2019. Methodology: Sixteen patients have undergone transcatheter aortic valve implantation since 2015 in the institute. Base line blood chemistry including creatinine clearance, ultrasonography abdomen, carotid Doppler, CXR, HRCT chest was done in all cases as part of the protocol. All patients under went procedure through transfemoral route. Valve structure and peripheral vasculature for suitability of the procedure was assessed by computerized coronary tomographic angiography (CCTA) with TAVI protocol. Procedure was carried out under general anesthesia in all patients except one. Results: Sixteen patients underwent the procedure successfully with reduction of the mean gradients immediately after valve implantation to less than 15mmHg recorded in the cath lab angiographically subsequently complemented by echocardiography. There were 2 deaths during the index hospitalization. Both occurred in the cath lab, one death was due to development of severe acute aortic regurgitation and second was due to acute coronary obstruction. Four patients died in next three months during follow up. One patient required permanent pacemaker because of development of left bundle branch block and second degree atrioventricular (AV) block post procedure. Conclusion: Transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis is a very effective and safe procedure and reasonable alternative to surgical valve replacement in high operative risk individuals. [ABSTRACT FROM AUTHOR]