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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 20 | Issue 4
Page Nos. 133-183

Online since Thursday, November 14, 2019

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ORIGINAL ARTICLES  

A teaching intervention increases the performance of handheld ultrasound devices for assessment of left ventricular ejection fraction Highly accessed article p. 133
Smitha Anilkumar, Sajad Adhiraja, Bassim Albizreh, Rajvir Singh, Naser Elkum, Alessandro Salustri
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_91_19  PMID:31803368
Background: Few studies have demonstrated the utility of a teaching program for evaluation of left ventricular ejection fraction (LVEF) of echocardiographic images acquired with high-end machines. No study to date explored the value of similar programs when a handheld ultrasound device is used. The aim of this study was to determine whether a teaching intervention could improve the accuracy and the reliability of LVEF visual assessment of echocardiographic images acquired with HUD. Materials and Methods: Twenty echocardiograms acquired with a hand-held ultrasound device with a spectrum of LVEF were presented to 26 participants with varying experience in echocardiography (range 2–12 years) for single-point LVEF visual estimates. After this baseline assessment, participants underwent three training sessions which included analysis of the individual baseline results and review and interpretation of additional 60 cases from the same platform. After 2 months, 20 new echocardiograms were presented to the same 26 participants for visual LVEF assessment. For each participant, the visual LVEF for each case was compared with the reference LVEF (quantitative measurements by experts), and a difference of > ±5% was considered a misclassification. Results: The misclassification rate was 61% preintervention and decreased to 41% after intervention (P < 0.0001). The mean absolute differences in LVEF between visual estimates and reference before and after intervention for all readers were −7.9 ± 9.6 and −1.2 ± 7.8, respectively (P < 0.0001). Inter-rater repeatability analysis was performed using the intraclass correlation coefficient. The intraclass correlation coefficient for inter-rater reliability was fair preintervention (0.65, 95% confidence interval [CI] 0.59 0.71) and good after intervention (0.80, 95% CI 0.73 0.87), and there were no differences when categorized according to the level of experience. Conclusions: A teaching intervention can improve the accuracy and the reliability in the visual LVEF assessment of images acquired with handheld ultrasound device.
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Percutaneous device closure of patent ductus arteriosus in adult patients with 10-year follow-up p. 139
Wail Alkashkari, Saad Albugami, Jamilah Alrahimi, Mohammed Althobaiti, Abdulhalim Kinsara, Ahmed Abousa, Ahmed Krimly, Atif Alzahrani, Akram Niazi, Hayam Aburemish
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_21_19  PMID:31803369
Objectives: We report our 10-year experience with transcatheter closure of patent ductus arteriosus (PDA) in adult using different closure devices. Background: Transcatheter closure of PDA in adults can be challenging because of frequently associated comorbidities. Reports on immediate and intermediate-term results of PDA closure are excellent. This study aimed to provide the outcomes of PDA closure using different devices on long and very long term follow-up in adults. Materials and Methods: Between September 2009 and December 2018, data were retrospectively reviewed from 27 patients who underwent transcatheter closure of PDA. Outcome parameters were procedural success, procedure-related complications, evidence of residual shunt, and improvement in the signs/symptoms for which the procedure was performed. The mean follow-up interval was 72 months. Results: A device was successfully implanted in 27 of 27 patients (15 females). Median age and weight were 24 years (range: 18–57 years) and 69 kg (range: 53–102 kg), respectively. The mean PDA diameter was 4.1 ± 2.1 mm. Devices used were Amplatzer Duct Occluder (19/27), Occlutech Duct Occluder (6/27), and PFM Nit-Occlud (2/27). Doppler transthoracic echocardiography (TTE) demonstrated 92.6% of full occlusion at day 1, rising to 96.3% at 1 month. Three procedure-related complications occurred with no death. Among symptomatic 26 patients (96.3%), there was marked improvement in symptoms. Among 22 patients (81.5%) for whom the procedure was performed to address left ventricular (LV) enlargement, there was reduction or stabilization in LV size on serial TTEs. Conclusions: Transcatheter closure of PDA in the adult patient appears to be safe and effective.
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Characteristics of out of hospital cardiac arrest in the United Arab Emirates p. 146
Saad Essa Alqahtani, Ahmed Saleh Alhajeri, Ayman Adel Ahmed, Sahar Yousef Mashal
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_80_19  PMID:31803370
Background: Out of hospital cardiac arrest is one of the leading causes of death globally. This study aimed to identify the characteristics of out of hospital cardiac arrest patients who were attended and treated by the National Ambulance crew. A lot of studies reported the importance of implementing chain of survival to increase survival rates from cardiac arrest. To be implemented in United Arab Emirates (UAE), it required a detailed study of the community engagement. The study aimed to explore the demography of the incidences, location, age, gender epidemiology of the patients who had their cardiac arrest witnessed along with their Bystander cardiopulmonary resuscitation (CPR) performed prior to the arrival of National Ambulance and public access to an automated external defibrillator. The return of spontaneous circulation was also explored prior to their arrival to the emergency department. Methods: The research is a prospective descriptive cohort study of out of hospital cardiac arrest patients attended by National Ambulance between July 2017 and June 2018. The National Ambulance provides emergency medical services for public and private hospitals in the Emirates of Sharjah, Ajman, Ras-al-Khaimah, Fujairah, and Umm Al-Quwain and its clients in Abu Dhabi in UAE. Data for the study were collected by the National Ambulance crew attending the OHCA patients, using a structured questionnaire. Results: In this 1-year period, a total of 715 out of hospital cardiac arrest cases were attended by the National Ambulance with higher percentage (77%) of male patients. Resuscitation and transportation were attempted for 95% whereas 5% were pronounced dead on the spot. In this study, the median age of the patients was 50 years. Majority of the patients were Asians 55% (n = 395) followed by Arabs non-UAE citizens 19.4% (n = 139) and UAE citizens 16% (n = 113). Patients facing sudden cardiac arrest in their homes or residences represented 69.9% (n = 500), street and public places 22.5% (n = 161), and workplace 6.8% (n = 49). The percentage of patients who had witnessed cardiac arrest was 51.7% (n = 370) only 197 had CPR performed on them prior to the arrival of National Ambulance. Low public access to AED was found in this population that is 1.8% (n = 13). A majority of the participants in this study had nonshockable rhythms 84.3% (n = 603) whereas shockable rhythms presented on 11% (n = 80). The percentage of patients who had ROSC at the scene or en route to the hospitals was found 9.2% (n = 66). Conclusion: In this 1-year study, the result showed that cardiac arrest was recognized and witnessed in about half of the cases, but low bystander CPR was performed. Low public access and use of AED were found. Data on hospitalized and discharged OHCA patients were not available and required further linkage and corporation between ambulance services and hospitals to ensure data continuity of OHCA cases. This study is essential for the implementation of proper chain of survival and reduction in mortality rates in UAE.
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Transulnar versus transradial access as a default strategy for percutaneous coronary intervention p. 152
Bhanwar L Ranwa, Kumari Priti
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_96_18  PMID:31803371
Background: Percutaneous coronary interventions (PCI) are undergoing a paradigm shift from femoral to forearm approach due to obvious advantages in terms of patient safety, comfort, and faster ambulation. Transradial access (TRA) has been established as a primary forearm access site. Use of transulnar access (TUA) as an alternative to radial route can serve as novel forearm access to the interventionalists. Aim: The aim of this study is to evaluate TUA versus TRA access as a default strategy for PCI. Materials and Methods: This was a prospective, single-center randomized controlled trial involving 2700 patients, of whom 220 underwent PCI in 1:1 randomization to TUA (n = 110) or TRA (n = 110). The primary endpoint was composite of major adverse cardiac events during hospital stay, cross-over to another arterial site, major vascular events of the arm during hospital stay (large hematoma with hemoglobin drop of ≥5 g%) and occlusion rate. Secondary endpoints were individual components of primary endpoint and spasm of the vessel. Results: Two groups did not differ in baseline characteristics. On intention to treat (ITT) analysis, primary end point occurred in 10.91% of TUA and 12.73% of TRA arm (odds ratio [OR]: 0.84; 95% confidence interval [CI], 0.37–1.91; P = 0.68 at α = 0.05). Further on per protocol (PP) analysis, primary end point occurred in 9.21% of TUA and 11.11% of TRA arm (OR: 0.81; 95% CI, 0.29–2.30; P = 0.68 at α = 0.05). Secondary endpoints also did not differ significantly between the two groups in ITT and PP analysis. Conclusions: TUA is an excellent alternative to TRA, while performing PCI when performed by an experienced operator. When utilized as an option, TUA increases the chance of success with forearm access and reduces the need for cross over to femoral route.
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REVIEW ARTICLE Top

Atrial fibrillation in Middle Eastern Arabs and South Asians: Summary of published articles in the Arabian Gulf p. 158
Amar M Salam
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_116_19  PMID:31803372
Seven studies are summarized herein focusing on different aspects of Atrial fibrillation (AF) in two unique ethnicities for which there is very limited literature published before; Middle Eastern Arabs and South Asians, using data from a national registry of cardiovascular diseases in Qatar over a 20-years period (1991-2010). These studies shed light upon important aspects of AF presentations and outcomes in these two ethnicities, thereby enriching the world literature on AF. In the process, several novel observations were reported and new questions were raised that warrant further investigations.
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CASE REPORTS Top

Degenerated suturless perceval with (paravalvular leak and AS) treated by valve in valve using S3 Edward valve p. 166
Mohammed Ali Balghith
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_60_19  PMID:31803373
A 70-year-old female patient, known to be diabetic and hypertensive, was diagnosed with coronary artery disease and severe aortic stenosis aortic valve area 0.5 cm, peak gradient of 110 mmHg, mean gradient 55 mmHg). This patient underwent coronary artery bypass graft with two grafts and artery bypass grafting in 2012. She received a sutureless Perceval aortic valve with good postoperative results except for a small jet of paravalvular leak. She did well for 5 years until she began experiencing dyspnea on exertion. The patient was found to have moderate to severe aortic regurgitation and moderate aortic stenosis which progressed over the years with multiple admissions for heart failure and pulmonary edema. The patient was considered high risk for operative treatment. Therefore, she was treated by percutaneous valve-in-valve technique using S3 Edward valve with excellent results.
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Implantation of leadless pacemaker for the development of new left bundle branch block and symptomatic pause following transcatheter aortic valve replacement p. 170
Sneha Nandy, Siu-Hin Wan, Kyle Klarich
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_91_18  PMID:31803374
Cardiac conduction disturbances such as left bundle branch block (LBBB) and atrioventricular blocks (AVB) occur frequently following transcatheter aortic valve replacement (TAVR) and may be associated with adverse clinical events. There is a lack of consensus regarding permanent pacemaker implantation in the case of occurrence of TAVR-related bundle branch blocks or combination of AVB and bundle blocks. Furthermore, there are no guidelines regarding the use of the leadless pacemaker in this setting. We present a patient who underwent successful implantation of a leadless pacemaker for a new LBBB post-TAVR.
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Konno-rastan combined with manougiaun root enlargement for small aortic root with coronary anomaly in a young woman p. 172
Fazal Wahab Khan, Sameh M Said
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_108_18  PMID:31803375
Aortic root enlargement (ARE) is an established procedure to deal with small aortic annulus. It becomes very important to place adequate size prosthesis to prevent patient–prosthesis mismatch (PPM). Aortic root enlargement procedures procedures are technically demanding operations, particularly in obese patients. The presence of coronary artery anomalies adds more complexity to the procedure. We present an interesting case of a 22-year-old obese female with symptomatic severe aortic valve stenosis and anomalous coronary arteries. We successfully performed aortic valve replacement using the combined Konno aortoventriculoplasty and Manouguian posterior aortic root enlargement. Combined aortic root enlargement techniques techniques should be considered in the presence of major coronary anomalies.
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A very late and persistent thrombosis after left atrial appendage occlusion p. 175
Theodoros Sinanis
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_57_19  PMID:31803376
Atrial fibrillation (AF) is the most common cardiac arrhythmia and ischemic stroke represents the most important complication. When the oral anticoagulation cannot be taken due to bleeding problems and considerations, the percutaneous occlusion of the left atrial appendage (LAA) is a possible solution. We present a case of a very late thrombosis of the LAA-Occluder device. The thrombus was diagnosed only after the patient suffered a stroke and a regression could not be achieved, neither with apixaban nor with warfarin alone. A successful result could be observed with the combination of high dose warfarin with aspirin 100mg/day. The possible etiology of this rare complication is an incomplete endothelialization of the device.
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A PICTURE IS WORTH A THOUSAND WORDS Top

Three-dimensional reconstruction of mitral valve by transesophageal echocardiography p. 178
Ahmed Mohamed Elmaghraby, Alessandro Salustri
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_103_19  PMID:31803377
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ART AND MEDICINE Top

The Apothecary p. 180
Smitha Anilkumar
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_104_19  PMID:31803378
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HISTORY OF MEDICINE Top

The invention of electrocardiography machine p. 181
Amar M Salam
DOI:10.4103/HEARTVIEWS.HEARTVIEWS_102_19  PMID:31803379
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