Search

Background and Aims: To assess the difficulties encountered while performing coronary angiography and percutaneous coronary intervention in anomalous right coronary artery arising from the left sinus of Valsalva. Methods: Between January 2016 and December 2020, a total of 23 patients underwent coronary angiography and eight underwent percutaneous coronary intervention for an angiographic significant lesion in the anomalous right coronary artery arising from the left sinus of Valsalva. The vascular approach, usage of catheters, fluoroscopic time, and the amount of contrast used were also assessed. Results: Among 6000 coronary angiography and 1500 percutaneous coronary intervention performed, 33 patients (0.55%) had right coronary artery arising from the left sinus of Valsalva. Altogether, 14 patients had type-A, seven had Type-B, eight had Type-C, and four had Type-D anomalous right coronary artery arising from the left sinus of Valsalva. Coronary Angiography was accomplished with the Tiger catheter in 13 patients, Judkins left JL in 8 patients, and Extra-backup (XB3) in one patient. In the percutaneous coronary intervention group, cannulation was done with Judkins left (JL), Amplatz left (AL), and XB in five, two, and one patient respectively and among five type-A patients, four were cannulated with JL and one with XB; one Type-B with JL4; and two Type-C with AL2. The mean fluoroscopic time and contrast volume consumption for coronary angiography and percutaneous coronary intervention were 9.9 minutes and 47 minutes respectively and 63ml and 229 ml respectively. Conclusion: Coronary intervention of anomalous right coronary artery arising from the left sinus of Valsalva is difficult due to inappropriate selection of guide catheter and is associated with a higher both mean fluoroscopic time and contrast volume. Radial route is equally effective for successful procedure.

Background and Aims: Coronary artery disease is one of the important causes of deaths in females in many countries. Females with chest pain are more likely to be treated in a different way as compared to males at the time of presentation. Worldwide, there has been a considerable rise in the number of females who are undergoing coronary angiography recently. Methods: This study was a single-centre, prospective, observational study conducted in the department of cardiology, MCVTC, Tribhuvan University, Nepal. The study period was from 5th July 2020 to 4th July 2021.155 female patients with anginal chest pain were enrolled. Data were collected after thorough history taking, physical examination, laboratory investigations, and coronary angiography. They were further divided into three age groups:65 years. Subsequently statistical analysis was done using latest version of SPSS. Results: The mean age of the patients was 59.64 years (SD=11.428). There were 119 (76.77%) postmenopausal patients. The most prevalent risk factor of IHD was HTN (43.87% ). Obesity/overweight was most common (58.62%) in those with age

Background and Aims: The prevalence of chronic kidney disease (CKD) and coronary artery disease (CAD) is increasing in Nepal. Chronic inflammation, metabolic and uremic effect of CKD along with traditional cardiovascular (CV) risk factor makes CV disease common and unique in these patients. Even with advancement in treatment, acute coronary syndrome (ACS), there is tendency towards lower rates of evidence-based therapies. This study was conducted with an aim to know clinical profile and the management strategy of CKD patient presenting with ACS. Methods: Single-centered, cross-sectional study carried out in, Manmohan Cardiothoracic and Vascular Transplant Centre, Kathmandu from July 2021 to December 2021. Of total 68 patient with ACS and CKD, history, physical examination, laboratory investigations along with electrocardiogram, echocardiography and coronary angiogram, were critically assessed. Results: Out of total 68 patients, 47 (69.1%) were male. In CKD patient presenting with ACS, predominant age group involved was 51-60 years (27.9%) with the mean age of 61.4 years. Out of them, 34 (50%) were in stage 5 with 32 (47.1%) already on maintenance hemodialysis. Average serum creatine and creatine clearance was 5.84 mg/dl and 16.29 mL/min/1.73m2 respectively. Smoking, diabetes and hypertension were common occurring in 39 (57.4%), 49 (72.1%) and 57 (83.8%) of all CKD patient respectively. Among them, 61 (89.7%) underwent angiography in which 23 (37.7%) had triple vessel disease. Percutaneous intervention was done for 38 (55.9%) patients and 13 (19.1%) were referred for coronary artery bypass graft (CABG). Conclusion: Traditional risk factor and multivessel involvement were common in CKD patient presenting with ACS and there less tendency to undergo revascularization procedure, especially with advancing age in the studied population.

Background and Aims: Coronary bifurcation lesions are associated with high atherosclerotic plaque burden due to turbulent blood flow and high shear stress. There are various strategies for bifurcation stenting however, they are often prone to major cardiac events during percutaneous coronary intervention. The aim of this study was to assess the clinical profile and procedural outcome of patients with coronary bifurcation lesions. Methods: This retrospective study was carried out at Manmohan Cardiothoracic Vascular and Transplant center, Kathmandu, Nepal. Two hundred and eight patients were enrolled in this study who had coronary bifurcation lesions seen on invasive coronary angiography from August 2017 to October 2021. The procedural complications were assessed. Results: The mean age of patients with coronary bifurcation lesions was 61.48±11.19 years. Out of total 208 patients, 77% were males. True bifurcation lesion was seen in 65.4% of patients. Left anterior descending artery with diagonal was the most common bifurcation lesion (67.3%). The provisional stenting was done in 80.8% of patients and rest underwent 2-stent strategy. The complications mainly observed during the provisional stenting were plaque shift and side branch dissection. Conclusion: The provisional stenting is the most preferred and suitable technique for most bifurcation lesions if technically feasible.

Background and Aims:Transcatheter closure of the secundum atrial septal defect (ASD) has become an accepted alternative to surgical repair. We aimed to analyze and compare the changes in cardiac hemodynamics with transthoracic echocardiography (TTE) before, within 48 hours, and after 3 months of ASD closure. Methods: This was a prospective, single-centered study of 43 patients who underwent ASD device closure in the Manmohan Cardiothoracic Vascular and Transplant Center during June 2020 to June 2021 with Amplatzer Septal Occluder under transesophageal and fluoroscopic guidance. The patients were evaluated with TTE before, at 48 hours, and 3 months after the procedure. Results: At 48 hours and 3 months of device closure, the right atrial major dimension, the maximum blood flow velocity at the pulmonary valve orifice, mean flow velocity, velocity time integral, and E peak and A peak blood flow velocity at the tricuspid valve orifice were significantly reduced (P < 0.001). At 3 months, the dimensions and ejection fraction of the left ventricle showed significant increment (P < 0.001). Likewise, the right atrial minor dimension and area, right ventricular basal, mid, and longitudinal dimensions, tricuspid annular plane systolic excursion, right ventricular Tei Index, and fractional area change were significantly reduced (P < 0.001). The main pulmonary artery diameter, pulmonary artery systolic and mean pressure, and the pulmonary vascular resistance and index were significantly reduced (p

Rheumatic heart disease (RHD), is a common cause of mitral stenosis (MS) in developing nations. As per current recommendation, Percutaneous Transvenous Mitral Commissurotomy (PTMC) is advised as a Class IA (I-Class Of Recommendation, COR; A-Level Of Evidence, LOE) indication in patients with symptomatic severe mitral stenosis. We aim to examine the clinical profile and in-hospital results of PTMC for mitral stenosis.A cross-sectional retrospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center from April 2020 to May 2022. A structured questionnaire was used to collect the data and ethical approval for conducting the study was taken from the Institutional Review Committee (IRC) of Institute of Medicine (IOM). The data was collected in Microsoft Excel (Ver. 2013). For statistical analysis, SPSS 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) Association was measured using a parametric and non-parametric test (depending upon the distribution of data) and p value 0.05 was considered significant.A total of 104 patients who met the inclusion criteria underwent PTMC during the study period. The mean age group of the patient was 41.7 ± 12.5 years, of which 23 (22.1%) were males and 81 (78.9%) were females. Mean mitral valve area prior to PTMC was 0.98 ± 0.19 mmSuccessful PTMC is highly influenced by the patients' increasing age, valve morphology (calcification, thickness, mobility), Left atrial dimensions, Pre PTMC mitral valve area, Degree of Baseline mitral regurgitation. Post procedure development of MR is usually well tolerated but rarely be severe enough requiring surgical valve replacement.

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.

Introduction Acute ST Elevation Myocardial infarction (STEMI) is a cardiovascular emergency and is associated with significant adverse short and long-term outcome. The objective of this study was to determine the short-term outcome in terms of heart failure, myocardial reinfarction, stroke, hospital readmission and mortality in patients admitted with STEMI MethodsIt was a prospective observational study conducted at Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu from May 2014 to April 2015. All patients admitted with diagnosis of STEMI during study period were enrolled. Patients were treated on the basis of existing guidelines. Mode of management, adverse outcomes and mortality of patients during the study period were evaluated. The discharged patients were followed up for 30 days. Statistical analysis was performed with SPSS version 20. Ethical approval was taken from the Institutional Review Committee of Institute of Medicine. ResultsThe median duration of presentation was 20 hours, and only 40% of the patients presented within 12 hours of symptom onset. Primary PCI was performed in 50 (33%), thrombolysis was performed in 29(19%) and conservative medical management was done in 72 (48%) patients. Overall outcome occurred in 52 (37.7%) patients. In hospital and 30 day mortality was 14 (9.2%) and 17 (11%) respectively. Heart failure was present in 28(18.5%), myocardial reinfarction 8 (5%), stroke 4 (2.6%), and hospital readmission was 18 (12%). Conservatively treated patients had significantly more adverse outcomes (p=0.02). More patients in conservatively managed group had hospital readmission. (p=0.04) ConclusionThere were more overall adverse outcomes in conservatitley managed group which is mainly due to more hospital readmission.

Introduction Temporary transvenous pacemaker insertion is an emergency lifesaving procedure for patients with hemodynamically unstable and life-threatening bradyarrythmias. The aim of this study was to analyze demographics, indications, route of insertion and complications in patients undergoing temporary transvenous pacemaker implantation. MethodsThis was a retrospective observational study conducted at a tertiary-care center in Nepal. The hospital records of patients who had undergone temporary transvenous pacemaker implantation between July 2015 and June 2019 were reviewed. ResultsA total of 343 patients with mean age of 65.52±16.09 years received temporary transvenous pacing. Out of these 205 (59.8%) were males. Greater proportion of patients were between the age group of 70-80 years (n=76, 22.2%). Hypertension (n=97, 28.3%) was the most common comorbidity noted. The most common indication for temporary pacing was symptomatic complete heart block 165 (59.6%). Total of 288 (84%) patients received permanent pacemakers while 55(16%) had reversible cause so TPI was removed. Right Femoral vein was the most common (99%) venous access site. Among the 343 patients, complications were observed in 29 (8.4%) of cases during and after the temporary transvenous pacemaker insertion. The overall mortality stood low at 2% (n=7). ConclusionTemporary transvenous pacemaker insertion is required in elderly population presenting with bradyarrythmias and occasionally in acute myocardial infarction presenting with bradyarrythmias as complication. Temporary pacemaker insertion was overall a safe procedure with infrequent serious complications; however, strategies to avoid and alleviate such complications (RV perforation) should be sought and implemented.

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.

Background and Aims: Heart failure is one of the debilitating conditions in patients with various forms of heart disease. It can have impacts on various aspects of the life of a patient. There have been few studies on the etiological aspects and precipitants of heart failure in the Nepalese population. The aim of our study is to find out the major factors that lead to decompensation of heart failure in patients who already have established heart failure. Methods: This study was a single-centre, prospective, observational study conducted in the emergency department of Manmohan Cardiothoracic Vascular and Transplant Centre (MCVTC) from 1st June 2019 to 30th November 2019. Hundred and one patients with established heart failure in the past, who presented again with decompensated heart failure were enrolled. Results: The mean age of the patients was 62.81 years (SD=15.92). Factors responsible for acute decompensation of heart failure were identified in 95.0 % of patients included in the study. The most common factor identified was poor compliance with medications and diet and fluid intake (38.6%). Next to it was arrhythmia identified in about 35.6% of cases.Other important factors responsible for decompensation in our study were infection (12.8%), anemia (4.9%) and ischemia (2.9%). Conclusion: Preventable and identifiable factors are responsible for the decompensation of heart failure. Most of these factors can be modified with the use of proper patient counseling/patient education, thereby reducing recurrent hospital admissions and economic burden to the patient and the government as well.

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

De Winter’s pattern is a rare anterior wall ST segment elevation myocardial infarction (STEMI) equivalent electrocardiogram (ECG) pattern that signifies 2% of proximal left anterior descending (LAD) coronary artery occlusion. We present a case of 48 years old male who presented in emergency room with a typical ischemic type of chest pain for 2 hours duration whose 12 lead ECG showed the typical De Winter’s pattern. The patient underwent immediate coronary angiography (CAG) which revealed 95-99% thrombotic occlusion of the proximal to mid left anterior descending artery. He underwent primary percutaneous coronary intervention (PPCI) with an Everolimus eluting stent that eventually resulted in a favorable outcome. Through this case report, we aim to highlight the importance of timely recognition of the rare ECG pattern and the role of PPCI as an optimal therapeutic option for such patients.

Coronary artery disease is among the leading cause of morbidity and mortality worldwide. There are limited scientific evidence on the risk factors for coronary artery disease specific to the Nepalese context. This study aimed to determine the association of various modifiable cardiovascular risk factors with coronary artery disease in Nepal.It is a hospital-based case-control study conducted among 300 participants. Case group comprised of 150 newly diagnosed coronary artery disease patients attending Manmohan Cardiothoracic Vascular and Transplant Centre while the Age and sex matched non-cardiac patients (n=150) from the outpatient department of the Department of General Practice and Emergency Medicine of Tribhuvan University Teaching Hospital were recruited as controls. Adjusted odds ratios (AOR) were calculated using multivariable logistic regression.Of the 300 participants, 208 (69.3%) were males and 92 (30.7%) were females. The mean age was 59.8 years ± 11 years (standard deviation). In multivariable analysis, current smoking (AOR=3.05, 95% CI: 1.61-5.78), hypertension (AOR=1.82, 95% CI: 1.08-3.09), diabetes (AOR=3.78, 95% CI: 1.91-7.47), family history of coronary artery disease (AOR=2.92, 95% CI: 1.27-6.71), and low high density lipoprotein (AOR= 2.0, 95% CI: 1.17-3.42) were significantly associated with coronary artery disease. Current alcohol use (AOR=0.51, 95% CI: 0.29-0.89) was identified as a protective factor for coronary artery disease.Among the modifiable cardiovascular risk factors, smoking, hypertension, diabetes, and low level of high density lipoprotein were significantly associated with coronary artery disease, which should be considered while developing public health interventions for cardiovascular disease prevention in Nepal in future.

A young woman at 8 months postpartum presented with dyspnoea, orthopnoea and swelling of lower limbs in which physical examination, chest radiography and echocardiogram were suggestive of acute congestive heart failure with left ventricle dilatation and dysfunction. A suspicion of peripartum cardiomyopathy was made and treated with conventional drug therapy but the patient continued to develop multiple episodes of heart failure. Over time she developed fever and polyarthritis following which autoantibodies, complement level and 24-hour urinary protein were done which helped us to make the diagnosis of Systemic Lupus Erythematosus (SLE) nephritis. The patient was started on high dose corticosteroids. However, after a week, patient developed cardiogenic shock following which intravenous pulse Cyclophosphamide was started and the patient improved clinically and biochemically.

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.

Background and Aims: Although pacemaker implantation has been done regularly in Nepal for the last 20 years, there is no large scale published data of pacemaker implantations. Manmohan Cardiothoracic Vascular and Transplant Centre (MCVTC) have been providing uninterrupted permanent pacemaker implantation services since its inception. This led us an opportunity to report the data regarding permanent pacemaker implantations in MCVTC. Methods: Hospital records of all patients who had undergone PPI at MCVTC between Shrawan 2070 – Ashad 2075/ July 2013- June 2018 (5 years) were searched for and all available data were retrospectively analyzed. Results: A total of 277 cases underwent PPI at MCVTC in 5 years. Out of these 165 (59.5%) were male with male to female ratio of 1.47. The mean age was 65.82±16.10 years with 3 (1.1%) cases of 60 years. Dual chamber units were implanted in 49 (17.7%) cases. Only 13 women (11.6%) received dual chamber pacemaker compared with 36 men (21.8%) (P = 0.029). The most common indication for PPI was complete atrioventricular block 165 (59.6%) followed by sick sinus syndrome 65 (23.5%). Hypertension 84 (30.3%) was the most common co morbidity present. Complication occurred in 5.4% of cases with wound infection as commonest complication and single mortality due to postoperative complications post-RV repair. Conclusion: Single chamber pacemaker was the most commonly used pacemaker. Dual chamber pacemaker was more common in younger patients. Complete heart block was the most common indication. Permanent pacemaker insertion was effective and relatively safe procedure in MCVTC with few complications.

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.

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).

Introduction: Pericardial effusion is one of the common cardiac problems in our part of the world and adds burden to the health and economy of the country, as it is associated with high risk of morbidity and mortality. Our objective of the study was to determine the etiological spectrum of pericardial effusion, their clinical presentations and complications and assessing the usefulness of echocardiographic features of effusion in helping to determine the etiology. Methods: A cross-sectional observational prospective study of 63 patients with diagnosis of pericardial effusion was enrolled in the study. Pericardial effusion was diagnosed by echocardiography and pericardiocentesis was done in the cardiac catheterization room. Patients were followed up 3 monthly for 1 year and reassessed clinically and by echocardiography. Results: Patients presenting with pericardial effusion belonged to the age group of 8 to 88 years. The most common etiology was tuberculosis (36.5%) followed by malignancy (19%) and idiopathic/Viral (12.6%). Among malignancies, carcinoma lung was the most common cause followed by lymphoma. Pericardiocentesis was done in 46 patients (73%) and the approach was subxiphoid. The procedure-related complications were in 4 patients (6.3%) and there was no death as a consequence of the procedure. The total mortality was 12 (19%) with in-hospital death of 6 patients (9.5%). Conclusions: The study showed tuberculosis as the most common cause of pericardial effusion in developing countries like Nepal and as a cause of cardiac tamponade in contrast to the studies from the developed world where malignancy remains the leading cause.

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.

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