Cardiovascular Journal of Africa - Volume 25, Issue 1, 2014
Volumes & issues
Volume 25, Issue 1, 2014
Chronic dissecting aneurysm of the ascending aorta developed in a patient who had rejected surgical treatment for type II acute ascending aortic dissection three years earlier : online article - case reportSource: Cardiovascular Journal of Africa 25, pp 1 –4 (2014) http://dx.doi.org/10.5830/CVJA-2013-079More Less
A 66-year-old male patient was admitted to our clinic because of shortness of breath and chest pain. A grade 4/6 diastolic murmur was heard on auscultation. Physical examination revealed signs of congestive heart failure and poor peripheral perfusion. There was a diagnosis of type II ascending aortic dissection in the history of the patient. He had refused emergency surgical intervention three years earlier. Computed tomography revealed that the ascending aorta was dilated to about 10 cm in diameter, and there was a chronic aortic type II dissection. The patient had second- to third-degree aortic insufficiency and he had a calcified bicuspid aortic valve on echocardiography. Two-vessel disease and a 90-mmHg aortic gradient were detected on angiography. Graft replacement of the ascending aorta, serape aortic valve replacement with a mechanical valve, and coronary arterial bypass grafting were performed successfully under cardiopulmonary bypass with an open aortic technique. The patient was discharged on the 10th postoperative day with no problems.
From the economics of TAVI and the pathophysiology of heart and vessel disease to metabolic disease in Africa and the developing world : editorialAuthor Paul A. BrinkSource: Cardiovascular Journal of Africa 25 (2014)More Less
Vascular calcification is not associated with increased ambulatory central aortic systolic pressure in prevalent dialysis patients : cardiovascular topicSource: Cardiovascular Journal of Africa 25, pp 4 –8 (2014) http://dx.doi.org/10.5830/CVJA-2013-081More Less
Introduction : Central aortic systolic pressure (CASP) strongly predicts cardiovascular outcomes. We undertook to measure ambulatory CASP in 74 prevalent dialysis patients using the BPro (HealthStats, Singapore) device. We also determined whether coronary or abdominal aortic calcification was associated with changes in CASP and whether interdialytic CASP predicted ambulatory measurement.
Methods : All patients underwent computed tomography for coronary calcium score, lateral abdominal radiography for aortic calcium score, echocardiography for left ventricular mass index and ambulatory blood pressure measurement using BPro calibrated to brachial blood pressure. HealthStats was able to convert standard BPro SOFT® data into ambulatory CASP.
Results : Ambulatory CASP was not different in those without and with coronary (137.6 vs 141.8 mmHg, respectively, p = 0.6) or aortic (136.6 vs 145.6 mmHg, respectively, p = 0.2) calcification. Furthermore, when expressed as a percentage of brachial systolic blood pressure to control for peripheral blood pressure, any difference in CASP was abolished: CASP: brachial systolic blood pressure ratio = 0.9 across all categories regardless of the presence of coronary or aortic calcification (p = 0.2 and 0.4, respectively). Supporting this finding, left ventricular mass index was also not different in those with or without vascular calcification (p = 0.7 and 0.8 for coronary and aortic calcification). Inter-dialytic office blood pressure and CASP correlated excellently with ambulatory measurements (r = 0.9 for both).
Conclusion : Vascular calcification was not associated with changes in ambulatory central aortic systolic pressure in this cohort of prevalent dialysis patients. Inter-dialytic blood pressure and CASP correlated very well with ambulatory measurement.
Tachycardia-induced cardiomyopathy due to repetitive monomorphic ventricular ectopy in association with isolated left ventricular non-compaction : online article - case reportSource: Cardiovascular Journal of Africa 25, pp 5 –7 (2014) http://dx.doi.org/10.5830/CVJA-2013-080More Less
Isolated left ventricular non-compaction is a rare genetic disorder manifesting mainly with heart failure, ventricular arrhythmias and systemic embolism. Isolated ventricular tachycardia originating from the right ventricular outflow tract is an arrhythmia that can be treated medically and/or by radiofrequency catheter ablation. Here, we report a case of an asymptomatic 16-year-old boy with a new diagnosis of dilated cardiomyopathy, left ventricular non-compaction and right ventricular outflow tract tachycardia. Electrophysiological studies and radiofrequency ablation of the right ventricular outflow tract tachycardia resulted in normalisation of left ventricular systolic function. This is the first case reporting left ventricular non-compaction in association with tachycardia-induced cardiomyopathy secondary to repetitive monomorphic right ventricular outflow tract tachycardia.
Successful primary percutaneous coronary intervention in a centenarian patient with acute myocardial infarction : online article - case reportSource: Cardiovascular Journal of Africa 25, pp 8 –10 (2014) http://dx.doi.org/10.5830/CVJA-2014-001More Less
A 104-year-old male patient was admitted to the emergency department with chest pain. An electrocardiogram showed ST-segment elevation in the anterior leads. He was immediately taken to the catheterisation laboratory for emergency angiography, which showed thrombotic stenosis at the proximal portion of the left anterior descending (LAD) artery. After intervention on the LAD lesion, successful balloon angioplasty with stenting was performed. Here, we report a case of successful primary percutaneous coronary intervention (PCI) in a centenarian patient with acute myocardial infarction. There are few clinical data on centenarian patients with acute myocardial infarction undergoing primary PCI. To the best of best our knowledge, this case is the first reported in the literature where primary PCI was performed on a centenarian patient.
Source: Cardiovascular Journal of Africa 25, pp 8 –20 (2014)More Less
We read with interest the article by Osmonov et al. about an asymptomatic 16-year-old boy with left ventricular hypertrabeculation/non-compaction (LVHT) who was incidentally investigated cardiologically for repetitive monomorphic couplets/triplets of premature ventricular ectopic beats with left bundle branch block morphology and inferior QRS axis. We have the following comments and concerns.
Endothelial function and germ-line ACE I/D, eNOS and PAI-1 gene profiles in patients with coronary slow flow in the Canakkale population : multiple thrombophilic gene profiles in coronary slow flow : cardiovascular topicSource: Cardiovascular Journal of Africa 25, pp 9 –14 (2014) http://dx.doi.org/10.5830/CVJA-2013-083More Less
Background : We examined the effects of ACE, PAI-1 and eNOS gene polymorphisms on endothelial function. The genes are related to atherosclerosis and endothelial dysfunction in coronary slow flow (CSF).
Methods : Thirty-three patients with angiographically proven CSF and 48 subjects with normal coronary flow were enrolled in this study. Coronary flow patterns were determined by the thrombolysis in myocardial infarction (TIMI) frame count method. Endothelial function was assessed in the brachial artery by endothelium-dependent flow-mediated dilatation (FMD). PAI-1 4G/5G, eNOS T-786C and ACE I/D polymorphisms were determined by polymerase chain reaction (PCR) amplification.
Results : No difference was found between the groups regarding age, heart rate and blood pressure. Males were more prevalent among patients with CSF than control subjects (58.8 vs 29.8%, p = 0.009). Mean TIMI frame counts were significantly higher in CSF patients (24.2 ± 4.0 vs 13.1 ± 2.5 fpm, p = 0.001). FMD was significantly lower in CSF patients than in the controls (4.9 ± 6.6 vs 7.9 ± 5.6%, p = 0.029). TIMI frame count and FMD were found to be negatively correlated in a correlation analysis (r = -0.269, p = 0.015). PAI-1 4G/5G, eNOS T-786C and ACE I/D polymorphisms were similar in the two groups.
Conclusions : This study showed that endothelial function was impaired in patients with CSF. PAI-1, ACE and eNOS polymorphisms were not related to CSF in our study population.
Source: Cardiovascular Journal of Africa 25, pp 15 –20 (2014) http://dx.doi.org/10.5830/CVJA-2013-085More Less
Objective : The aim of this study was to evaluate atrial conduction abnormalities obtained by tissue Doppler imaging (TDI) and electrocardiogram analysis in pregnant subjects.
Methods : A total of 30 pregnant subjects (28 ± 4 years) and 30 controls (28 ± 3 years) were included. Systolic and diastolic left ventricular (LV) function was measured using conventional echocardiography and TDI. Inter-atrial, intra-atrial and intra-left atrial electromechanical coupling (PA) intervals were measured with TDI. P-wave dispersion (PD) was calculated from a 12-lead electrocardiogram.
Results : Atrial electromechanical coupling at the septal and left lateral mitral annulus (PA septal, PA lateral) was significantly prolonged in pregnant subjects (62.1 ± 2.7 vs 55.3 ± 3.2 ms, p < 0.001; 45.7 ± 2.5 vs 43.1 ± 2.7 ms, p < 0.001, respectively). Inter-atrial (PA lateral - PA tricuspid), intra-atrial (PA septum - PA tricuspid) and intra-left atrial (PA lateral - PA septum) electromechanical coupling intervals, maximum P-wave (Pmax) duration and PD were significantly longer in the pregnant subjects (26.4 ± 4.0 vs 20.2 ± 3.6 ms, p < 0.001; 10.0 ± 2.0 vs 8.0 ± 2.6 ms, p = 0.002; 16.4 ± 3.3 vs 12.2 ± 3.0 ms, p < 0.001; 103.1 ± 5.4 vs 96.8 ± 7.4 ms, p < 0.001; 50.7 ± 6.8 vs 41.6 ± 5.5 ms, p < 0.001, respectively). We found a significant positive correlation between inter-atrial and intra-left atrial electromechanical coupling intervals and Pmax (r = 0.282, p = 0.029, r = 0.378, p = 0.003, respectively).
Conclusion : This study showed that atrial electromechanical coupling intervals and PD, which are predictors of AF, were longer in pregnant subjects and this may cause an increased risk of AF in pregnancy.
Source: Cardiovascular Journal of Africa 25, pp 21 –26 (2014) http://dx.doi.org/10.5830/CVJA-2013-090More Less
Objectives : Transcatheter aortic valve implantation (TAVI) has become the standard of care for inoperable patients with severe aortic stenosis and is an alternative to conventional surgery for high-risk aortic valve replacement (AVR) patients. There is a positive correlation between severity of pre-operative patients and hospital costs. The aim of this study was to compare empirically derived costs of the two therapies in South Africa.
Methods : The cost-comparison analysis was performed with a MediClinic database including 239 conventional isolated AVR (cAVR) and 75 TAVI cases. All costs are given in 2011 ZAR. The subset of cAVR patients were derived from the relevant and available information in the database and their costs were compared with TAVI costs.
Results : From the 75 available subjects, mean TAVI costs were ZAR 335.5k ± 47.9k, (median ZAR 326.5k) with a mean (median) ICU and hospital length of stay (LoS) of 2.7 (2.0) and 7.6 (6.5) days, respectively. The mean cAVR cost was lower at ZAR 213.9 ± 87.5k (median ZAR 193.6k) but this included the entire population costs (i.e. low to high surgical risk). When estimating cAVR costs, defined by LoS of more than six and 13 days in the ICU and hospital, respectively, and being over 75 years of age, the estimate increased to ZAR 337.9k, which was above the TAVI mean costs. In-hospital mortality was 5.3 and 7.9% for TAVI and the entire cAVR group, respectively. When considering the subset of cAVR patients most likely to be high risk, it increased to 21.4%.
Conclusions : Within the context of limited clinical data we performed the first attempt at cost-effective analysis of TAVI vs cAVR in South Africa. Treatment of aortic stenosis with cAVR in a post hoc defined high-risk patient segment was more expensive than TAVI in South African centres. Despite common perceptions on costs, adoption of TAVI as an alternative, less-invasive therapy that has been clinically proven and recommended by an FDA advisory panel (Partner A) to be at least as effective as cAVR, has a viable economic argument in appropriate patients.
Prevalence of the metabolic syndrome and determination of optimal cut-off values of waist circumference in university employees from Angola : cardiovascular topicSource: Cardiovascular Journal of Africa 25, pp 27 –33 (2014) http://dx.doi.org/10.5830/CVJA-2013-086More Less
Background : Estimates of the prevalence of the metabolic syndrome in Africans may be inconsistent due to lack of African-specific cut-off values of waist circumference (WC). This study determined the prevalence of the metabolic syndrome and defined optimal values of WC in Africans.
Methods : This cross-sectional study collected demographic, anthropometric and clinical data of 615 Universitary employees, in Luanda, Angola. The metabolic syndrome was defined using the third report of the National Cholesterol Education Program Adult Treatment Panel (ATPIII) and the Joint Interim Statement (JIS) criteria. Receiver operating characteristics curves were constructed to assess cut-off values of WC.
Results : The crude prevalence of the metabolic syndrome was higher with the JIS definition (27.8%, age-standardised 14.1%) than with the ATP III definition (17.6%, age-standardised 8.7%). Optimal cut-off values of WC were 87.5 and 80.5 cm in men and women, respectively.
Conclusions : There was a high prevalence of the metabolic syndrome among our African subjects. Our data suggest different WC cut-off values for Africans in relation to other populations.
B-type natriuretic peptide for the prediction of left ventricular remodelling : letter to the editorSource: Cardiovascular Journal of Africa 25, pp 33 –39 (2014)More Less
We read with great interest the recent article by Choi et al. on the optimal time of B-type natriuretic peptide (BNP) sampling for the prediction of left ventricular (LV) remodelling after myocardial infarction (MI). Indeed, as underscored by Choi et al., LV remodelling remains a significant clinical problem in the modern era of MI management. In addition, BNP is currently the sole biomarker that has been convincingly associated with LV remodelling in multiple studies (reviewed in Fertin et al.). It is therefore important to determine the best window of time for its determination in clinical practice.
Echocardiographic estimation of left ventricular filling pressures in patients with mitral valve stenosis : cardiovascular topicSource: Cardiovascular Journal of Africa 25, pp 34 –39 (2014) http://dx.doi.org/10.5830/CVJA-2013-088More Less
Background : Estimation of left ventricular end-diastolic pressure (LVEDP) among patients with mitral valve disease may help to explain their symptoms. However, conventional Doppler measurements have limitations in predicting LVEDP in this group of patients. The aim of this study was to construct a Doppler-derived LVEDP prediction model based on the combined analysis of transmitral and pulmonary venous flow velocity curves.
Methods : Thirty-three patients with moderate to severe mitral stenosis (MS) who had indications for left heart catheterisation enrolled. Two-dimensional, M-mode, colour Doppler and tissue Doppler imaging indices, such as annular early diastolic velocity (Ea), isovolumic relaxation time (IVRT), pulmonary vein systolic and diastolic flow velocities, velocity propagation, left atrium area (LAA), interval between the onset of mitral E and annular Ea (TE-Ea), and Tei index were obtained. LVEDP was measured in all patients during left cardiac catheterisation. Linear correlation and multiple linear regressions were used for analysis.
Results : The mean of LVEDP was 9.9 ± 5.3 mmHg. In univariate analysis, the only significant relationship was noted with LAA (p = 0.05, R2 = 0.11). However, in multivariate regression, LAA, Tei index and Ea remained in the model to predict LVEDP (p = 0.02, R2 = 0.26). For prediction of LVEDP ≥ 15 mmHg, the best model consisted of LAA, IVRT and Ea, and had a sensitivity of 85% and specificity of 85%.
Conclusion : Our results provided evidence that, in patients with moderate to severe MS, LVEDP can be estimated by combining Doppler echocardiographic variables of mitral flow. However, more studies are required to confirm these results.
Source: Cardiovascular Journal of Africa 25 (2014)More Less
Critically aware of the need for funding that will develop research capacity and contribute to academic advancement in South Africa, ethical pharmaceutical company, AstraZeneca Pharmaceuticals, has set up a not-for-profit trust for the disbursement of medical research funding. The company will award R1.5 million a year for three years for academic research; high-level, non-interventional studies including doctoral and postdoctoral work that will generate significant data currently not available.