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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.

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.

Background and objectives: Cardiovascular disease is a major health problem reaching epidemic proportions. Although Acute Coronary Syndrome (ACS) is an uncommon entity in the young, it constitutes a rising burden in the socioeconomic status of the country because of its impact on the economically productive age group. Early identification and control of the cardiovascular risk factors helps to prevent cases of Myocardial Infarction (MI) in young resulting in reduced health burden. Therefore, we aimed to assess clinical pattern and the prevalence of cardiovascular risk factors in the young and economically productive population of an underdeveloped country to lower the socioeconomic burden. Methods: A total of 60 patients presenting at the cardiology department of Manmohan Cardiothoracic Vascular and Transplant Center were included in our study after fulfilling the inclusion criteria. ACS was diagnosed by cardiac enzymes, electrocardiography, and echocardiography and coronary intervention was done in the cardiac catheterization room. Patients were followed up at 1 and 3-months and reassessed clinically and by echocardiography. Results: Mean age of presentation was 38.55 + 4.98 (SD) years. Over three-fourth of the patients were male (80%) and nearly three-quarter experienced ST-elevated MI (73%). Smoking was the most prevalent risk factor (67%), followed by dyslipidemia (40%), diabetes (32%), hypertension (30%), and obesity (13%). Most of the patients presented with single-vessel disease (65%), followed by double-vessel disease (18%), triple-vessel disease (12%), left main disease (3%), and minor coronary artery disease (2%). Conclusions: ACS in underdeveloped country is more common in male and single-vessel disease is the most common clinical pattern of ACS and smoking the most prevalent risk factor.

IntroductionCoronary artery disease is the major cause of death all over the world. There are studies suggesting association between blood group and coronary artery disease. We attempted to study the frequency of ABO blood group and its association with acute coronary syndrome (ACS) in our hospital.MethodsThis is a retrospective, cross sectional study carried out in Manmohan Cardiothoracic Vascular and Transplant Centre from March 2018 to February 2019. Patients who were admitted with diagnosis of ACS were enrolled in the study. Data were recorded and analyzed using SPSS 20. Association between blood group and ACS was analyzed using chi square test and logistic regression.ResultsTotal 430 patients were admitted with diagnosis of ACS during the study period, of which 307 (71.4 %) were male and Mean age was 61.22 years (±10.75). Blood group O was the most common type of blood group observed in 207 (48%) patients. ACS was significantly higher in blood group O compared to other groups after adjusting for normal ABO blood group prevalence in general population: blood group O vs. A (OR: 3.45, 95% CI: 2.48- 4.79, p

Background Atrial myxoma remains a rare clinical entity with an incidence of surgically resected cases of 0.5–0.7 per million population and prevalence of Case presentation A 55-year-old Brahmin man with no history of diabetes mellitus and hypertension, presented with complaints of dizziness, headache, vomiting, double vision, and unsteadiness of gait for 2 weeks. His headache was sudden in onset, of a pulsating type and localized on left temporal side. Vomiting was projectile and bilious. Double vision was present in all directions of gaze and he had uncoordinated movement of his body and tilting to the left side. On examination, his cerebellar functions were impaired. He was thoroughly investigated for the cause of stroke after abnormal magnetic resonance imaging results with normal computed tomography angiography of his brain. Echocardiography and computed tomography of his chest showed a mass attached to intra-atrial septum and prolapsing through mitral valve, which was suggestive of left atrial myxoma. Five days following admission, he developed abdominal pain due to thromboembolism causing splenic and renal infarct. Conclusion Although rare, atrial myxoma has to be considered a cause of stroke and other embolic phenomenon causing multiorgan infarctions. Early and timely diagnosis of the condition can prevent further recurrence and inappropriate anticoagulant therapy. It would be pertinent to have echocardiography done in patients who present with a stroke, arrhythmias, and other constitutional symptoms. The tumor once detected must be removed surgically as early as possible, which not only reduces serious thromboembolic complications but can be potentially curative.

Introduction: Atrial fibrillation is the most common cardiac arrhythmia encountered in clinical practice that affects morbidity and mortality to a large extent. This study was intended to determine various clinical profile and etiological factors in valvular and non-valvular atrial fibrillation and evaluate the usage of anticoagulants in them in the settings of developing nation like ours. Methods: A hospital based cross-sectional observational prospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Nepal for a period of sixteen months. All the patients with atrial fibrillation who were admitted in the cardiology department were included. The demographic profile, etiology, clinical features and the usage of anticoagulants were recorded. Results: A total of 175 patients with atrial fibrillation were enrolled in the study with 62% nonvalvular and 38% valvular cases. The overall mean age was 60 ± 16.79 years but among valvular atrial fibrillation, it was 47.9 ± 14.013 and among nonvalvular atrial fibrillation, it was 67.85 ± 13.507 years. Majority of patients were female (56%). Sixty percent were from outside Kathmandu valley. Rheumatic heart disease was the most common cause (38.9%) followed by dilated cardiomyopathy, systemic hypertension, degenerative valvular heart disease, coronary artery disease, etc. The most common presentation was dyspnea. About 79% of valvular and 17% of nonvalvular atrial fibrillation patients were using anticoagulants. Conclusion: Atrial fibrillation was common in young females and rheumatic heart disease was the leading cause. There was inadequate use of anticoagulants in both valvular and nonvalvular atrial fibrillation probably due to the economic constraints and geographical hurdles.

Background and Aims: Percutaneous Coronary Intervention (PCI) is the preferred method of revascularization in Acute ST Elevation Myocardial Infarction (STEMI). Our aim was to study the clinical profile and outcomes of patients who underwent PCI for STEMI at tertiary cardiac centre of Nepal. Methods: It is a retrospective, single centre study, performed at Tribhuvan University, Manmohan Cardiothoracic Vascular and Transplant Centre, Kathmandu, Nepal. All patients who underwent PCI for STEMI from November 2015 to July 2018 were enrolled in this study. All the data were collected from hospital registry and cath lab records. Results: The Study showed that out of 232 patients who presented with STEMI, 74.5% were male with average age of 57.39 years. The mean time of presentation after onset of symptom/s was 17.5 hours. About 66% patients presented in less than 12 hours of symptoms onset, 21% presented at 12-24 hours of symptoms onset and 13% patients presented late. Primary PCI was done in 87% of patients. Almost all patients (98.2%) underwent coronary artery stenting with drug eluting stents. Multivessel PCI during index procedure was done in 7 patients. TIMI III flow following PCI was achieved in 97% cases. Average LVEF at discharge was 44.73%. There were 8 deaths, all after Primary PCI. In-hospital mortality rates for patients presenting with and without cardiogenic shock were 38.46% and 1.59% respectively. The overall mortality rate was 3.98%. Conclusion: This study has reemphasized that PCI is effective in the management of STEMI cases in Nepal with improving mortality rates and decreasing complications. Minimizing the delayed presentation after the onset of symptoms should be one of the prime focuses for effective management of STEMI.

DOI: https://doi.org/10.3126/njh.v16i1.23895 Background and Aims: Acute coronary syndrome (ACS) refers to a group of clinical symptoms consistent with new onset or worsening ischemic symptoms. ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) are the three types of ACS. The objectives were to study the risk factors prevalence, angiographic distribution and severity of coronary artery stenosis in ACS among patients admitted in Cardiology Department of Manmohan Cardiothoracic Vascular and Transplant Center (MCVTC). Methods: This is a restrospective study of 419 ACS patients admitted and treated in MCVTC from November 2017 to October 2018. Patients were divided into STEMI, NSTEMI and UA then analyzed for various risk factors, angiographic patterns and severity of coronary artery disease. Results: Mean age of presentation was 59.3A}12.8 years. Majority were male 317(75.7%). Most patients had STEMI 252 (60.1%) followed by NSTEMI 98 (23.4%) and UA 69 (16.5 %). Risk factors: smoking was present in 241 (57.5%), hypertension in 212 (50.6%), diabetes in 144 (34.4%), dyslipidemia in 58 (13.8%). Single-vessel disease was present in 34.6 % patients, double- vessel disease was present in 27.44 % patients and triple vessel disease was present in 26.3 % patients, left main disease in 1.4 % patients. Normal coronaries were present in 6.4% patients and minor coronary artery disease in 3.8 % patients. Conclusions: STEMI was the most common presentation. Three quarters of ACS were male patients. Smoking was most prevalent risk factor. Single vessel involvement was the most common CAG finding in all spectrum of ACS. Diabetic patients had more multivessel disease. Keywords: Acute Coronary Syndrome, Angiogram, Nepal.

Left ventricular pseudoaneurysm is a rare mechanical complication of acute myocardial infarction. The study aims at early detection of a rare complication of myocardial infarction which carries a grave prognosis and whose mainstay of management is surgical. We describe a 60 year old male who presented with typical ischemic type of chest pain with low blood pressure and heart rate. A 12 lead electrocardiogram showed atrioventricular (AV) dissocation with ST segment elevation in the inferior leads. The initial echocardiography depicted moderate pericardial effusion without tamponade. The possibilities of both, acute mechanical complications of myocardial infarction, and acute aortic dissection were sought of. The echocardiography on the following day revealed a free wall rupture of the infero-posterior wall of left ventricle with formation of a pseudoaneurysm. This was further proved by the computed tomography (CT) of chest with contrast, which in addition, ruled out acute aortic dissection. The patient was planned for an early surgery. Pre-operative coronary angiogram revealed complete occlusion of distal left circumflex artery and 70-80% discrete stenosis of mid left anterior descending artery.

Introduction: Atrial fibrillation is the most prevalent supraventricular arrhythmia responsible forthe large morbidity and mortality burden worldwide. There are various causes of atrial fibrillationthat may affect the prognosis of patients. This study was intended to determine different echocardiographic findings in patients with atrial fibrillation in a tertiary care center. Methods: A descriptive cross-sectional study was conducted at Manmohan Cardiothoracic Vascularand Transplant Center, Institute of Medicine, among 175 patients with atrial fibrillation admittedin the cardiology department from June 2017 to October 2018. It was approved by the InstitutionalReview Board of the Institute of Medicine (Ref.:411(6-11-E)2/073/074). Convenience sampling wasused. Statistical analysis was done using Statistical Package for Social Sciences version 21.0. Results: A total of 175 patients with atrial fibrillation were enrolled where Rheumatic heart disease 68 (38.9%) was the leading cause in which 54 (79.4%) had mitral valve lesion, 1 (1.5%) hadaortic valve lesion and rest had a combination of both. The mixed lesion of mitral stenosis and mitral regurgitation was the commonest. The left atrium size was larger in valvular atrial fibrillation(47.29±6.651mm). The left ventricular systolic dysfunction was seen more in non-valvular atrialfibrillation. The commonest site of thrombus formation was left atrium 7 (63.6%). Conclusions: Atrial fibrillation was common in rheumatic heart disease, especially mixed lesions ofmitral stenosis and regurgitation. Valvular atrial fibrillation had a larger left atrium. The thrombuswas seen in mitral stenosis and left ventricular systolic dysfunction. The left atrium size and left ventricular ejection fraction were associated with the occurrence of atrial fibrillation.

Complete heart block is a rare presentation in a patient with COVID-19 infection that may result when the virus enters the myocardial cell by the angiotensin-converting enzyme-2 receptor. Here, we report a case of forty-nine-year male with COVID-19 with complete heart block (CHB).

The incidence of acute coronary syndrome (ACS) is rising globally. Electrocardiography is still one of the best diagnostic modalities for it. Although some of the ECG changes of ACS are well known among medical practitioners, there are a handful of ECG changes that do not get the recognition they deserve. Among these are localized ST-segment depressions in a vascular territory and altered precordial T-wave balance. The urgency of management varies among the various subtypes of ACS, especially in low resource settings. ST-segment depression localized to a vascular territory is a sign of ST-elevation myocardial infarction (MI) in the reciprocal lead which may not always be evident and hence, requires emergent reperfusion therapy. On the other hand, altered precordial T-wave balance (T1 > T6, T-wave in V1 > 1.5 mm and upright T-wave in V1) may be predictive of significant coronary artery disease (CAD).

Background and Aims: Coronary artery disease (CAD) constitute a major cause of cardiovascular morbidity and mortality worldwide with an enormous burden on healthcare resources. Prevalence and pattern of CAD in patients of rheumatic and non-rhemuatic valvular heart diseases varies widely with limited data on optimal strategies for diagnosis and treatment.Methods: This study includes 97 patients with rheumatic and non-rheumatic valvular heart disease who underwent coronary angiogram (CAG) before cardiac surgery. Patients were divided into two groups based on rheumatic heart disease (RHD) & non-rheumatic disease (Non-RHD) and correlate the patterns of CAD.Results: Out of 97 patients, 22 (22.6%) patients were found to have significant CAD. In patients with non-rheumatic origin CAD was common (15 patients, 68.1%) as compared to rheumatic origin (7 patients, 31. 8%). In rheumatic origin, the prevalence was 7(12.2%) out of 57 patients while in non-rheumatic origin, was 15(37.5%) out of 40 patients. In RHD group, all patients with CAD were found to have single vessel diease (SVD) while, in non-RHD group, 11 patients (73.3%) had SVD, 3 patients (16.7%) had double vessel disease (DVD) and one patient (5.6%) had triple vessel disease (TVD).Conclusions: Prevalence of CAD is higher in patients with non-RHD in comparison to those with RHD. We also found SVD to be the most common pattern of CAD in both rheumatic and non-rheumatic valvular heart disease.