Journal of the Saudi Heart Association

Editorial Board

2012-01-01

Message from the Editor-in-Chief

Hani K. Najm — 2012-01-01

2011 has been an excellent year for the Journal of the Saudi Heart Association. We have acquired a lot of attention and have experienced an increase in the number of manuscripts submitted to the journal. In addition, our full-text electronic downloads have increased 78% in the past year with the majority of downloads coming from the United States (14%) followed closely by China (12%) and then Saudi Arabia and UK (5% each).

Efficacy of a single dose intravenous heparin in reducing sheath-thrombus formation during diagnostic angiography: A randomized controlled trial

2011-10-24

Abstract: Background: Femoral arterial sheath thrombosis and distal embolization are well-recognized complications of cardiac catheterization but the occlusion is extremely rare. Heparinized saline flushes are used during diagnostic coronary angiography to prevent thrombus formation within the sheath lumen. However, the use of prophylactic intravenous heparin following the femoral arterial sheath insertion is controversial. The aim of this study is to evaluate the effectiveness of 2000 units of intravenous heparin bolus in comparison to a saline placebo on the thrombus formation within the arterial sheath during the diagnostic coronary angiography.Methods: Eligible patients were randomized to receive either a study drug or placebo at the time of femoral sheath insertion. The sheath was aspirated and flushed for any presence of thrombus after each catheter exchange and at the end of the procedure. Five milliliters of blood were extracted and visualized on clean gauze followed by a saline flush. The primary end-point was the effectiveness of the study drug on reducing the incidence of sheath-thrombus formation.Results: Three hundred and twenty patients were randomized into two arms. Three hundred and four patients were analyzed: 147 patients in heparin arm and 157 patients in placebo arm after exclusion of 13 patients in heparin arm and three in placebo arm because of incomplete reports. The baseline characteristics were similar and sheath-thrombi formation was observed in 20% of the total cohort.Of the heparin arm, 12% (19 patients) developed sheath-thrombus formation, whereas 26% (42 patients) in the placebo arm, p-value=0.002. An adjusted logistic regression model showed that the only predictor for the sheath-thrombus formation was the study drug (i.e. heparin). The odds ratio of developing a thrombus in the control arm was 2.5 (95% CI: 1.4–4.5, p=0.003). There were no bleeding events observed.Conclusion: The risk of thrombus formation is significant and intravenous heparin significantly reduced thrombus formation during diagnostic coronary angiography, with no excess bleeding events.

Age and its relationship to acute coronary syndromes in the Saudi Project for Assessment of Coronary Events (SPACE) registry: The SPACE age study

2011-10-19

Abstract: Objective: To characterize risk profile of acute coronary syndrome (ACS) patients in different age groups and compare management provided to in-hospital outcome.Design: Prospective multi-hospital registry.Setting: Seventeen secondary and tertiary care hospitals in Saudi Arabia.Patients: Five thousand and fifty-five patients with ACS. They were divided into four groups: ⩽40years, 41–55years, 56–70years and ⩾70years. Main outcome measures: prevalence, utilization and mortality.Results: Ninety-four percent of patients <40years compared to 68% of patients >70years were men. Diabetes was present in 70% of patients aged 56–70years. Smoking was present in 66% of those <40years compared to 7% of patients >70years. Fifty-three percent of the patients >70years and 25% of those <40years had history of ischemic heart disease. Sixty percent of patients <40years presented with ST elevation myocardial infarction (STEMI) while non-ST elevation myocardial infarction was the presentation in 49% of patients >70years. Thirty-four percent of patients >70years compared to 10% of patients <40years presented >12h from symptom onset with STEMI. Fifty-four percent of patients >70 compared to 64–71% of those <70years had coronary angiography. Twenty-four percent of patients >70 compared to 34–40% of those <70years had percutaneous coronary intervention. Reperfusion shortfall for STEMI was 16–18% in patients >56years compared to 11% in patients <40years. Mortality was 7% in patients >70years compared to 1.6–3% in patients <70years. For all comparisons (p<0.001).Conclusions: Young and old ACS patients have unique risk factors and present differently. Older patients have higher in-hospital mortality as they are treated less aggressively. There is an urgent need for a national prevention program as well as a systematic improvement in the care for patients with ACS including a system of care for STEMI patients. For older patients there is a need to identify medical as well as social factors that influence the therapeutic management plans.

Diagnostic importance of platelet parameters in patients with acute coronary syndrome admitted to a tertiary care hospital in southwest region, Saudi Arabia

2011-10-24

Abstract: Objective: Identifying risk factors for acute coronary syndrome (ACS) is important for both diagnostic and prognostic purposes. Abnormal platelet parameters, mainly platelet count (PC), mean platelet volume (MPV) and platelet distribution width (PDW) are thought to be among these risk factors. In this study, the associations between PC, MPV and PDW and ACS were investigated in patients admitted to the tertiary care hospital in the south west region of Saudi Arabia.Materials and methods: A retrospective cohort of 212 patients with the diagnosis of ACS admitted to Aseer Central Hospital during the period extending from February 1, 2008 to October 31, 2008 were included. The control group consisted of 49 matched subjects who were admitted for chest pain investigation and subsequently found to be non-cardiac chest pain after performing relevant investigations. Blood samples were taken at the time of admission for platelet parameters. Statistical analysis was made using SPSS software and P-values were considered significant if <0.05.Results: A total of 212 patients with acute coronary syndrome (80 patients with MI and 132 patients with UA) and 49 matched controls were studied. The PC was not statistically different among the three groups (283.3±94.8×109L−1 for MI cases, 262±60.8×109L−1 for UA cases and 275.8±58.9×109L−1 for controls). The MPV was significantly larger in MI cases compared to controls (8.99±1.5fl vs. 8.38±0.51fl, respectively, P<0.009), similarly, the MPV was significantly larger in UA cases compared to controls (9.23±1.19fl vs. 8.38±0.51fl, respectively, P<0.001). The PDW was significantly higher in MI cases compared to controls (15.88±1.5fl vs. 11.96±1.8fl, respectively, P<0.001), similarly, the PDW as also significantly larger in UA cases compared to controls (18.1±18fl vs. 11.96±1.8fl, respectively, P<0.019).Conclusion: Platelet parameters mainly MPV and PDW are readily available and relatively simple and inexpensive laboratory tests which we detected to be significantly raised in patients who have suffered an acute coronary syndrome compared with controls.

Initial experience of using intracardiac echocardiography (ICE) for guiding balloon mitral valvuloplasty (BMV)

2011-10-24

Abstract: Background and aims: BMV is an established treatment for rheumatic mitral valve stenosis. The procedure is historically guided by fluoroscopy, and the role of intracardiac echocardiogram (ICE) guidance is not well defined. We report our initial experience of using ICE to guide BMV procedures.Methods: During BMV procedure, ICE catheter was inserted into the right atrium from the right femoral vein, and the septal puncture was monitored by ICE, as well as positioning of the balloon in the mitral valve. Comparisons were made between ICE, transthoracic echocardiography (TTE), and catheterization derived hemodynamic measurements (cath).Results: Seventeen patients with mitral stenosis underwent the procedure. The mean age was 44.4±21years. The mean MV area increased from 0.9±0.1cm2 to 1.7±0.2cm2, P<0.0001 and the mean gradient decreased from 12.6±5.8mmHg to 4.9±1.8mmHg, P<0.001. Atrial septum puncture and guidance of the balloon into the MV apparatus were obtained in all patients under ICE guidance. Severe MR developed in one patient and was readily detected by ICE. ICE derived gradient measurements were comparable to those obtained by TTE, and cath.Conclusion: ICE guidance of BMV is feasible, and useful in monitoring safe septal puncture, optimizing balloon positioning, and in detecting complications. The hemodynamic measurements obtained were comparable to those obtained by TTE, and cath.

Reasons for cancellation of elective cardiac surgery at Prince Sultan Cardiac Centre, Saudi Arabia

Nabeel Sultan, Abdul Rashid, Syed M. Abbas — 2011-10-24

Abstract: The cancellation of surgery is a significant drain on health resources. However, a persistent problem in most hospitals is short notice cancellation of scheduled operations, even upto the day of surgery. In some cases, patients have been prepared for surgery, and the staff is assembled and expecting to operate. In UK 8% of scheduled elective operations are cancelled within 24hours of surgery. The reasons include cancellation by the patient, cancellation for poorly optimized medical conditions, or cancellations due to poor organization. Many of these are difficult to quantify. However, one relatively easily measured factor is the possibility that some operating lists were predictably over-booked. An operating list may over-run because of delayed starts, slow turnover, unanticipated surgical/anaesthetic problems or staff shortages. Many of these are difficult to quantify.Background and objective: Prince Sultan Cardiac center is one of the largest referral center in the Middle East and there is no published data on the reasons for cancellation of specifically cardiac procedures. However, an audit was performed to assess the reasons for the cancellation of the cases on the day of surgery in cardiac theatres. According to one of the studies published in an Australian journal the percentage of cancelled cardiothoracic cases was determined to be 15.8%.Results: Total number of cardiac surgical patients including pediatric and adult during a period from June 2008 to May 2009 were 2191. Out of those, 1681 cases were done during the study period, 510 (23.27%) cases were cancelled during the study period. The operation theatre was functional for 331days during the study period. Cancellations done by the surgeons were 34% while the patient’s related cancellations were 32%. The administrative issues contributed to 34% in overall cancellation and anaesthetist-related cancellation were 0%.Conclusion: We estimated 22% of the elective operations which were cancelled on the day of surgery were potentially avoidable. There is still a need to do further research to look for the identifiable reasons and strategic measures to eliminate the reasons for cancellation on the day of surgery.

Electrocardiographic findings in heat stroke and exhaustion: A study on Makkah pilgrims

L. Mimish — 2011-10-19

Abstract: Over two million pilgrims perform annual rituals in Makkah region, which when coincides with summer months, exposes them to outdoor temperatures exceeding 45°C and humidity approaching 80%. Accordingly, heat illnesses are common including explicit heat strokes and heat exhaustion. No previous studies elaborated on electrocardiographic changes among this unique cohort.Objective: To compare electrocardiographic changes in three groups exposed to high outdoor temperatures, namely, patients with heat stroke compared to patients with heat exhaustion and a control group exposed to the same outdoor temperatures without clinical manifestations.Subjects and methods: Through case control design, two case groups of patients were selected. The first group (G1) was 34 patients admitted to the cooling units with clinical picture of heat stroke and the second group (G2) comprised 28 patients admitted with heat exhaustion. The control group (G3) included 31 patients selected from relatives of patients and outdoor workers. The outcome for comparison was 12-lead electrocardiographic changes done for all selected individuals. For (G1), the ECG was done while they were prepared for cooling or immediately when cooling was started.Results: In G1, 18 were females and 16 males with ages of 20–76years (59±11years). Their heart rates ranged from 64 to 160 beats per minute (mean 120±24 per minute). Only 5/34 ECGs were completely normal. Sinus tachycardia was present in 27/34 patients (79%), with ischemic changes in 9/34 ECGs.In G2, 24 were males and four females with ages of 25–80 (mean 47±15years), the heart rate ranged from 64 to 170 per minute (mean 97±16 per minute). Seven out of 28 ECGs were normal (25%) while 21/28 had some abnormalities. None had ischemic changes.Control group (G3), was five females and 26 males ages 18–80years (mean 38±15years), 22/31 had normal ECGs (71%). All had normal sinus rhythm, 56–98 beats per minute (74±11). Nine patients had some electrocardiographic abnormalities but none had ischemic changes.Conclusion: We conclude that electrocardiographic abnormalities occur with a high frequency in patients with heat stroke and heat exhaustion, with sinus tachycardia and ischemic changes occurring more frequently in patients with heat stroke.

The unusual hypertensive patient

Saad Al Bugami, Mansour Al Motairi, Ahmed Al Zahrani, Atif Al Zahrani — 2011-10-26

Abstract: Many young patients with systemic hypertension have secondary causes which if identified early could lessen the cardiovascular complications associated with long standing hypertension. Coarctation of the aorta is one of those rare causes. We describe a 40 year old male with hypertension, coarctation of the aorta, bicuspid aortic valve, PDA and an adrenal mass.

Angiotensin converting enzyme inhibitor as an additive treatment after successful balloon dilation of a critical pulmonary valve stenosis

M.O. Galal, A.M. Alzahrani, M.E. Elhoury — 2011-10-24

Abstract: A 2days old, 2.7kg heavy baby boy with critical pulmonary stenosis, underwent successful balloon dilation. After the uneventful procedure, he remained oxygen dependent. The baby was given oral angiotensin converting enzyme inhibitor (ACE inhibitor), instead of an infusion of alpha blocker.Within few hours, in the afternoon of the same day after administration of ACE Inhibitor, the baby could be weaned off oxygen, maintaining on room air, oxygen saturation between 87% and 92%. At follow-up, two months later, his saturation was 99% on room air.We believe that some neonates with critical pulmonary valve stenosis who remain oxygen dependent despite successful balloon dilation, could benefit from such management.

Reconstruction of cavopulmonary pathway for the patient with persistent arteriovenous malformations due to offset flow from hepatic vein

Narutoshi Hibino, Pranava Sinha, Mary Donofrio, Richard A. Jonas — 2011-10-24

Abstract: The hypoxemia caused by arteriovenous malformations after cavopulmonary shunt in patients with heterotaxy, an interrupted inferior vena cava and single ventricle physiology have been treated by incorporation of hepatic vein flow into the pulmonary circulation. However, some patients have persistent arteriovenous malformations because of offset hepatic venous flow to one pulmonary artery. Various approaches have been used to change offset flow to achieve balanced hepatic flow to the lungs in this patient population. This case report highlights the challenges that may be associated with anastomosis of the azygos vein to the inferior vena cava at the level of the diaphragm and illustrates an alternative technique to direct hepatic venous blood into an affected lung with arteriovenous malformations. The redirection of hepatic venous flow to the affected pulmonary artery resulted in resolution of symptoms within months of surgery.

Suture-less aortic valve replacement

Hani K. Najm, Munir Ahmad — 2012-01-01

Aortic valve replacement remains challenging in patients with small and calcified aortic root, left ventricular dysfunction, advanced age and multiple co-morbidities. Conventional stented bio-prostheses avoid need for prolonged anti-coagulation but leave unacceptably high residual aortic root gradients because of their structure and profile. Development of stent-less bio-prostheses was successful in reducing residual gradients across the aortic root but their use is limited because of complicated implantation techniques and need for prolonged cardiopulmonary bypass. Percutaneous and trans-apical techniques of aortic valve replacement are promising but current incidence of complications is high. These techniques are also not useful if patients need other concomitant cardiac surgical procedures. Surgical implantation of suture-less aortic prosthesis is a new technique that offers quick and easy implantation of newly designed prosthesis with short bypass time, reduced need for annular debridement and gradients comparable with stent-less bio-prostheses. The technique is thus suitable for elderly patients and for those with small aortic annulus, extensive annular calcification and impaired left ventricular function. Quick implantation also makes this technique suitable for patients who require concomitant cardiac procedures or who have renal or pulmonary insufficiency. We have recently performed this procedure at King Abdulaziz Cardiac Center, Riyadh, on three patients with excellent clinical and echocardiographic results. The illustration and operative pictures show details of this new technique of aortic valve replacement.

Journal of the Saudi Heart Association

Editorial Board

Table of Contents

Message from the Editor-in-Chief

Efficacy of a single dose intravenous heparin in reducing sheath-thrombus formation during diagnostic angiography: A randomized controlled trial

Age and its relationship to acute coronary syndromes in the Saudi Project for Assessment of Coronary Events (SPACE) registry: The SPACE age study

Diagnostic importance of platelet parameters in patients with acute coronary syndrome admitted to a tertiary care hospital in southwest region, Saudi Arabia

Initial experience of using intracardiac echocardiography (ICE) for guiding balloon mitral valvuloplasty (BMV)

Reasons for cancellation of elective cardiac surgery at Prince Sultan Cardiac Centre, Saudi Arabia

Electrocardiographic findings in heat stroke and exhaustion: A study on Makkah pilgrims

The unusual hypertensive patient

Angiotensin converting enzyme inhibitor as an additive treatment after successful balloon dilation of a critical pulmonary valve stenosis

Reconstruction of cavopulmonary pathway for the patient with persistent arteriovenous malformations due to offset flow from hepatic vein

Suture-less aortic valve replacement