Journal of the Saudi Heart Association

Editorial Board

2012-04-01

Message from the Editor-in-Chief

Hani K. Najm — 2012-04-01

We bring you the second issue of 2012 shortly after the highly successful 23rd scientific session of the Saudi Heart Association (SHA23), held under the patronage of Prince Sultan bin Mohamed bin Saud al Kabir. There were more than 350 talks and six parallel sessions preceded by four pre-conference courses.

JSHA and publication ethics

Hani K. Najm — 2012-04-01

Beginning in the late 2011 the editors of the Journal of the Saudi Heart Association began using the plagiarism detection software, iThenticate (http://www.ithenticate.com/). Every paper which we consider for publication in JSHA will be checked through this software for plagiarism and/or duplicate submission. In addition to this, JSHA is a registered journal with the Committee on Publication Ethics (COPE) (http://publicationethics.org/) and actively follows the COPE Code of Conduct and Best Practice for Journal Editors.

Gender differences in cardiovascular risk factors among adolescents in Aseer Region, southwestern Saudi Arabia

2011-10-19

Abstract: Objective: The objective of this study was to explore gender differences in the prevalence of silent and clinical apparent cardiovascular risk factors among adolescents in Aseer Region, southwestern Saudi Arabia.Materials and methods: A cross-sectional study on a stratified sample of 1869 adolescents was carried out. They were interviewed and examined for weight and height, systolic and diastolic blood pressure using standardized techniques.Results: The study revealed high prevalence of some potential behavioral and biological cardiovascular diseases (CVD) risk factors among adolescent males and females in the study area. Behavioral risk factors included inadequate low consumption of fruits and vegetables, physical inactivity, and smoking. Physical inactivity was significantly more prevalent among females than males (42.9% and 25.7%, respectively). Smoking was significantly more among females than males (11.8% and 1.3%, respectively). Biological risk factors found were family history of CVD, obesity and high blood pressure. Obesity was significantly prevalent among females (29.4%) compared to males (20.6%). Males had significantly more high blood pressure than females. In logistic regression analysis, being male (aOR=2.992, 95% CI=1.933–4.742) and obesity (aOR=2.995, 95% CI=2.342–3.991) were found to be significant risk factors in developing high blood pressure among adolescents in the region.Conclusions: Presence of cardiovascular risk factors among adolescents is a public health problem in the region. There is a need for a national program in the country to prevent and control cardiovascular risk factors among adolescents.

Risk modeling for ventricular assist device support in post-cardiotomy shock

Bahaaldin Alsoufi, Vivek Rao, Augustine Tang, Manjula Maganti, Robert Cusimano — 2012-02-15

Abstract: Background: Post-cardiotomy shock (PCS) has a complex etiology. Although treatment with inotrops and intra-aortic balloon pump (IABP) support improves cardiac performance, end-organ injuries are common and lead to prolonged ICU stay, extended hospitalization and increased mortality. Early consideration of mechanical circulatory support may prevent such complications and improve outcome.Methods: Between January 1997 and January 2002, 321 patients required IABP and inotropic support for PCS following coronary artery bypass grafting (CABG) at our institution. Perioperative variables including age, mixed venous saturation (MVO2), inotropic requirements and LV function were analyzed using multivariate statistical methods. All explanatory variables with a univariate p value <0.10 were entered into a stepwise logistic regression model to predict hospital mortality. Odds ratios from significant variables (p<0.05) in the regression model were used to compose a risk score.Results: Overall hospital mortality was 16%. The independent risk factors for mortality in this population were: MVO2<60% (OR=3.2), milrinone>0.5μg/kg/min (OR=3.2), age>75 (OR=2.7), adrenaline>0.1μg/kg/min (OR=1.5). A 15-point risk score was developed based on the regression model. Hospital mortality in patients with a score >6 was 46% (n=13/28), 3–6 was 31% (n=9/29) and <3 was 11% (n=29/264).Conclusions: A significant proportion of patients with PCS continue to face high mortality despite IABP and inotropic support. Advanced age, heavy inotropic dependency and poor oxygen delivery all predicted increased risk for death. Further investigation is needed to assess whether early institution of VAD support could improve outcome in this high-risk group of patients.

The prognostic role of serum uric acid level in patients with acute ST elevation myocardial infarction

Bita Omidvar, Fazlolah Ayatollahi, Mohammad Alasti — 2012-02-02

Abstract: Objectives: The role of uric acid as a prognostic factor in patients with acute ST elevation myocardial infarction is controversial. The purpose of this study was to demonstrate the relationship between serum uric acid level and mortality during admission period and 30-day period after admission.Methods: We assessed the relation between serum uric acid level and in-hospital and short-term mortality rates in 184 patients admitted with acute ST elevation myocardial infarction. We divided the patients according to their gender and uric acid level measured on admission into four groups: group A1: men with uric acid ⩽7mg/dl versus group B1: men with uric acid >7mg/dl and group A2: women with uric acid ⩽5.6mg/dl versus group B2: women with uric acid >5.6mg/dl. The patients were followed for 30days after admission.Results: In-hospital mortality rate in group B1 was higher than group A1 [P value: 0.011, Relative risk: 13.33 (95% confidence interval: 1.55–114.7)]. Short-term all-cause mortality was significantly higher in group B1 patients [P value: 0.037, Relative risk: 3.3 (95% confidence interval: 1.02–10.64)]. Multivariate logistic regression analysis of data showed an odds ratio of 15.23 for in-hospital mortality and odds ratio of 3.76 for short-term mortality in male hyperuricemic patients.Conclusions: Our data suggest that in the acute phase of ST elevation myocardial infarction, uric acid has a prognostic role for in-hospital and short-term (30-day) mortality in men.

Waiting time for transfer of patients with prostaglandin dependant congenital heart defects to tertiary cardiac centers

Abdul Rahman Al Mesned, Ali A. Al Akhfash, Maha Sayed — 2011-10-24

Abstract: Worldwide congenital heart defects (CHD) are the leading cause of infant deaths owing to congenital anomalies. Delay in diagnosing and operating in neonates with prostaglandin dependant CHD may lead to significant morbidity and mortality.Objectives: To assess the time interval needed for acceptance and transfer of patients with critical CHD to a tertiary cardiac center and the impact on the patient’s survival.Study design: Retrospective database reviews of all cases diagnosed to have prostaglandin dependant (PG) CHD at Prince Sultan Cardiac Center-Qassim during a 43months period (from May 2007 to December 2010).Results: During the study period 104 patients were diagnosed to have PG dependant CHD. Patients with PG dependant systemic circulation constitute 60% of patients. Patients with ventricular septal defect (VSD) associated with coarctation of the aorta constituted 16% of patients. The mean waiting time for transfer to a tertiary cardiac center was 10±10days. Twenty-two (21%) patients died while waiting for acceptance and transfer. Eleven patients were diagnosed with hypoplastic left heart syndrome (HLHS). There was no significant difference in the waiting time for those with or without HLHS, with a mean of 9days for both. Six of our patients had infections with positive blood cultures. The mean waiting period for those with proved infection was 25days compared with 8days for those with no proved infection (p value<0.005).Conclusion: There are a significant number of patients with severe CHD who die while waiting for acceptance and transfer to a tertiary cardiac center. The causes for delay could be the presence of infection, prematurity and low birth weight. The limited numbers of tertiary cardiac centers in Saudi Arabia as well as cardiac ICU beds are among the factors delaying the acceptance of patients requiring cardiac surgery.

Relationship between HLA molecules and late restenosis after coronary stent placement

2011-10-17

Abstract: Objective: The objective of this study is to confirm whether there is relation between the human leucocyte antigen (HLA) locus and restenosis after percutaneous coronary intervention (PCI) holds in our patient population and whether it can be useful as a prognostic factor.Methods: We examined the HLA phenotypes in 46 consecutive patients (39 men, 7 women, mean age of 57±9years) who had successful stent implantation in the coronary artery. Selective coronary arteriography was performed 6months after coronary stenting to assess the presence of restenosis. The HLA phenotyping was performed for HLA-A,-B,-C antigens by Terasaki microlymphocytotoxicity technique and for HLA-DR alleles with PCR-SSP technique.Results: Restenosis(R+) was present in 12 (26.1%) patients (11 men, 1 woman, mean age of 57±10years). For HLA Class I antigens frequency of HLA-B62 and HLA-CW2 antigen was slightly higher in restenotic patients but did not reach statistical significance. For HLA-DR alleles restenotic patients had higher frequencies for HLA-DRB1∗01(R+ %25, R− %14.7), and HLA-DR11(R+ %41.7, R− %20.6), without reaching statistical significance and lower frequencies for DR7(R+ %0, R− %17.6) and D13(R+%8.3, R− %32.4) and HLA-DR53 (R+ %25, R− %35.3) without reaching statistical significance.Conclusion: In conclusion, results show that there was no relationship between the development of restenosis and HLA-subtypes.

Ischaemic heart disease in pregnancy

Nabeel S. Bondagji — 2012-01-24

Abstract: Ischaemic heart disease (IHD) in pregnancy, particularly myocardial infarction (MI), is a rare yet potentially fatal condition for the mother and the foetus. With delays in the age of conception, the changes in some social habits among females including cigarette and shisha smoking in addition to an increased prevalence of diabetes mellitus, IHD may represent a real hazard among pregnant women in the near future. The difficulty in the diagnosis emerges from the similarity of the signs and symptoms of ischaemia and infarct to some of the physiological adaptations that occur in a normal pregnancy. The physiological changes that are normal in pregnancy may aggravate pre-existing disease and may unmask some underlying unrecognized coronary vascular changes; therefore, the diagnosis requires a high index of suspicion and careful assessment of the underlying risk factors. The management of IHD always requires a multidisciplinary team approach. The management of each patient should be individualized according to the clinical condition, the risk factors, and the availability of the necessary support. Pregnancy after MI may be an acceptable and reasonably safe option provided the cited criteria are met. A systematic PubMed search was performed to identify all published data including cases reports, small series and systematic reviews in the existing literature. These publications were comprised of both retrospective and cross sectional population studies to maximize the number of cases considered in order to reach conclusions and make recommendations based on the best available evidence considering the rare occurrence of this event. The epidemiology, diagnosis, medical and surgical treatment, and prognosis of IHD in pregnancy are the subjects of the present review.

Diastolic dysfunction and heart failure with a preserved ejection fraction: Relevance in critical illness and anaesthesia

R. Maharaj — 2012-02-03

Abstract: Epidemiological and clinical studies suggest that HF with a preserved ejection fraction will become the more common form of HF which clinicians will encounter. The spectrum of diastolic disease extends from the asymptomatic phase to fulminant cardiac failure. These patients are commonly encountered in operating rooms and critical care units. A clearer understanding of the underlying pathophysiology and clinical implications of HF with a preserved ejection fraction is fundamental to directing further research and to evaluate interventions. This review highlights the impact of diastolic dysfunction and HF with a preserved ejection fraction during the perioperative period and during critical illness.

Cardiovascular disease in Hajj pilgrims

Abdullah Al Shimemeri — 2012-02-20

Abstract: The changing pattern of hospital admissions during Hajj, the Muslims yearly pilgrimage attracting millions of pilgrims from all around the globe, has gradually seen infectious causes of hospital admission replaced by cardiovascular diseases as a leading cause of both intensive care unit admission and death. While this trend is partly associated with the high quality of medical services and awareness programs targeted at reducing the spread of infections, at the same time it underscores an urgent need to establish a pragmatic system to manage the challenge of cardiovascular morbidities and mortality during Hajj.Search strategy and inclusion criteria: A PubMed Central (PMC) literature search without date restrictions was performed for articles reporting on the medical experience during Hajj. There were 109 articles were returned using “Hajj” and “mortality” as search terms. After determining relevance to the current theme based on both direct and indirect reference to the pattern hospital admission during Hajj, 20 articles reporting on conducted studies were obtained. Data from these studies reporting on the pattern and outcome of hospitalization during Hajj were examined and helped in arriving at the conclusions presented in this review.

Use of microvena snare catheter in non-ST elevation myocardial infarction due to saphenous vein graft occlusive thrombi

Mohammed Balghith — 2011-12-15

Abstract: A 75-year-old man presented with acute coronary syndrome; he had a saphenous vein graft thrombosis. Percutaneous coronary intervention of bypass graft vessels is more challenging due to a higher incidence of periprocedural distal micro-emobilization and myocardial infarction. Current guidelines for percutaneous coronary intervention advocate the use of distal embolic protection devices, especially in patients with large thrombus burden, undergoing percutaneous intervention for vein graft disease. This patient was treated by manual aspiration of graft thrombus using a microvena catheter and successful clot removal was achieved. There are yet no best available therapeutic options for patients undergoing percutaneous coronary intervention of saphenous vein graft lesions.

The ECG role in identifying the etiology of tachycardia-induced cardiomyopathy (TIC)

M. Al Mehairi, S.A. Al Ghamdi, K. Dagriri, A. Al Fagih — 2011-12-12

Abstract: Tachycardia-induced cardiomyopathy (TIC) is a well recognized entity of heart failure (HF) and various mechanisms due to tachyarrhythmias have been postulated to be responsible for impaired cardiac contractility. Previously reported cases showed reversibility of such disorders whenever stable cardiac rhythm is maintained adequately and we report on a 16-year-old boy who has been diagnosed to have TIC, which was misinterpreted initially as sinus tachycardia secondary to dilated cardiomyopathy and heart failure. A complete recovery of his left ventricular function was achieved by radiofrequency catheter ablation and highlights the importance of a 12-lead electrocardiogram (ECG) assessment in such patients.

Hypoplastic left heart syndrome, cor triatriatum and partial anomalous pulmonary venous connection: Imaging of a very rare association

2011-10-24

Abstract: A newborn is presented with an association of hypoplastic left heart syndrome, cor triatriatum and partial anomalous pulmonary venous connection. The diagnosis was established with echocardiography and further confirmed with computed tomography. To our knowledge the images of such an association have never been reported before.

Simultaneous endovascular stent and renal stent placement for acute type B aortic dissection with malperfusion of kidney

Sinan Dagdelen, Ebuzer Aydın, Hasan Karabulut — 2012-02-15

Abstract: Acute aortic dissection frequently causes life-threatening organ ischemia. The optimal therapy for acute type-B aortic dissection is still controversial. Surgery for acute dissection with organ malperfusion is known to carry a high morbidity and mortality; however endovascular treatment is becoming an alternative form of treatment. We report a clinical case of emergency percutaneous thoracal aorta endovascular stenting and renal artery stenting in a patient who had renal malperfusion and acute renal failure due to acute type-B dissection. The present case is a fundamental examples of collaboration between the cardiologist and cardiovascular surgeon in a hybrid procedure.

Letter in response to the original article: “Evaluation of femoral approach to coronary sinus catheterisation in electrophysiological and ablation procedures: Single centre experience” authored by Osama Abdel Atty, Mohamed Morsy and Mark M. Gallagher (Journal of the Saudi Heart Association, Volume 23, Issue 4, October 2011, pp. 213–216)

David Chase — 2012-01-11

The authors present data from their centre regarding cannulating the coronary sinus by the femoral venous approach. As the author correctly points out, this approach has become increasingly feasible with the use of long sheaths such as the Swartz SL3 sheath (Daig Corp., Minnetonka, MN, USA) as has been previously demonstrated .

Response to Letter by: Chase, doi: 10.1016/j.jsha.2012.01.001

Mark M. Gallagher — 2012-01-19

In reply to the letter by Dr. Chase, we agree that differences between individuals in the anatomy of the right atrium can make cannulation of the coronary sinus difficult in some cases. We routinely use a medium curve deflectable catheter. In difficult cases we perform imaging of the coronary sinus by contrast injection using an Amplaz Left II coronary catheter from a femoral approach. Long sheaths such as the SL0 are very rarely required (<1% of cases) in our institution. The experience of the operator is more important than these technical details. In our institution, an experienced operator (>1000 cases as first operator) is available for all procedures to avoid having to revert to subclavian access for coronary sinus cannulation.

Transcatheter Aortic Valve Implantation (core valve) prosthesis complicated by mitral stenosis

Mohammed Balghith, Ahmad Omran, Ahmad Saileek, Ali Alghamdi, Hani Najm — 2012-03-09

Abstract: A 90year-old male patient, known to have severe aortic stenosis (AS), was admitted with chest pain, shortness of breath and swelling of both lower limbs. He had history of ischemic heart disease and percutaneous coronary intervention (PCI) of left anterior descending artery (LAD) in 2002. He also had long standing hypertension, primary hypothyroidism and hypercalcemia. He had a permanent pacemaker, chronic gastritis, gastrointestinal bleeding and bilateral knee osteoarthritis in 2007. Patient was treated medically for his heart failure symptoms. Transthoracic echocardiogram (TTE) showed normal ejection fraction >55% and severe aortic stenosis, aortic valve area 0.58cm2, mean G 64mmHg and peak gradient of 118mm Hg. In November 2010 the patient was evaluated for the transcatheter aortic valve implantation (TAVI) program after a multidisciplinary evaluation. His predicted Euro Score was 28% and both risk and benefits were explained to the family. A 29mm core valve prosthesis was deployed. The TTE 4days later showed mitral valve (MV) area=2.04cm2 and MG across MV=6mm Hg. Impingement of anterior mitral valve leaflet (AMVL) by the inflow portion of core valve prosthesis led to mild mitral stenosis (MS). TEE is a helpful tool to diagnose this phenomenon.