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AIM: To evaluate the effects of radial incision of the tricuspid valve in patients who had undergone ventricular septal defect (VSD) closure. METHODS: Overall 173 patients were included in this study between 2012 and 2019. In 44 individuals, a tricuspid valve radial incision (TVRI) was included in the surgical process. RESULTS: There were no mortalities. The demographic data did not differ between the groups. The mean ages of the TVRI and non-TVRI groups were 2.92 ± 3.88 and 2.69 ± 2.80 years, respectively. There were no significant differences between the groups in terms of mean duration of cardiopulmonary bypass aortic cross-clamp, postoperative intubation time and intensive care unit stay. Mild tricuspid valve regurgitation was detected in only two patients in the TVRI and six patients in the non-TVRI groups. There was no tricuspid valve stenosis and all patients were in New York Heart Association functional class 1. CONCLUSION: This technique, which can facilitate exposure and closure of VSDs, did not compromise the tricuspid valve function at mid-term, therefore proving to be safe.

Background Previous trials remain inconsistent regarding the advantages and hazards related to intracoronary (IC) compared with intravenous (IV) administration of thrombolytics. We aimed to evaluate the safety and effectiveness of IC versus IV tirofiban administration in diabetic patients (DM) with acute ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PCI). Methods This trial included 95 patients who were randomised to high-dose bolus plus a maintenance dose of tirofiban administered either IV or IC. The groups were compared for the incidence of composite major adverse cardiac events (MACE) at 30 days. Levels of cardiac markers were recorded pre- and post-intervention for myocardial perfusion. Results The MACE were not different between the groups, but post-procedure myocardial blush grade (MBG) 3 and thrombolysis in myocardial infarction (TIMI) 3 flow were significant in the IC group (p = 0.45, 0.21, respectively), favouring the IC strategy. Peak values of both creatine kinase-muscle/brain (CK-MB) and high-sensitivity troponin T (hs-TnT) were significantly lower in the IC group (155.68 ± 121, 4291 ± 334 ng/dl) versus the IV group (192.4 ± 86, 5342 ± 286 ng/dl) (p = 0.021, p = 0.035, respectively). The peak value was significantly lower in the IC group than the IV group in terms of ST-segment resolution and 30-day left ventricular ejection fraction (LVEF) (p = 0.016 and 0.023, respectively). Conclusion Thirty days post PCI, IC tirofiban was more efficient in ameliorating blood flow in the coronary arteries and myocardial tissue perfusion in DM patients after STEMI despite bleeding events, and MACE rates showed no significant difference between the groups. The IC group showed better improvement in LVEF.

Background Alirocumab reduces low-density lipoprotein cholesterol (LDL-C) levels by up to 61%. The ODYSSEY Open-Label Extension study investigated the effect of alirocumab in patients with heterozygous familial hypercholesterolaemia (HeFH) over 144 weeks. Methods Eligible patients with HeFH had completed an earlier double-blind, randomised, placebo-controlled parent study. Patients were initiated on 75 mg alirocumab Q2W subcutaneous (SC) unless baseline LDL-C was > 8.9 mmol/l, in which case they received 150 mg alirocumab Q2W. Dose titration to 150 mg Q2W was at the investigator's discretion. Results The study enrolled 167 patients and the parent study mean (± SD) baseline LDL-C level was 3.65 ± 1.9 mmol/l. Mean LDL-C level was reduced by 48.7% at week 144; mean on-treatment LDL-C was 2.30 ± 1.24 mmol/l. Eight patients reported injection-site reactions, with one treatment discontinuation. Treatment emergent anti-drug antibodies were identified in five patients but these did not affect the efficacy. Conclusions Alirocumab effectively and safely reduced LDL-C in these patients.

BACKGROUND: Patients with coronary artery disease (CAD) are prone to depression, and its presence is associated with poor adverse cardiac outcomes. Although lifestyle modification (LSM) has been shown to be beneficial in managing depression in patients with CAD, it is not known whether the mode of cardiac intervention [(coronary artery bypass graft surgery (CABG) versus percutaneous coronary intervention (PCI)] influences the outcome. OBJECTIVES: We examined the prevalence of depression among myocardial infarction (MI) patients after revascularisation and compared the effect of LSM on incidence of depression in patients who underwent CABG versus PCI. METHODS: We evaluated the risk-factor profile, depression characteristics and lifestyle changes of 100 consecutive participants undergoing coronary revascularisation over a 15-month period (January 2017 to May 2018). The Beck depression inventory II (BDI-II) was used to assess depression and the Goldin leisure-time exercise (GLTE) questionnaire to assess physical activity (PA). RESULTS: One hundred patients were recruited (mean age: males 60.73 ± 4.52 years, females 60.29 ± 3.64 years) but five dropped out, leaving 95 patients for complete analysis. Most of the patients were low-income earners [53 (53.0%)], and 21 (21.0%) had tertiary-level education. The majority had multiple CAD risk factors and co-morbidities (79.0%). Prior to the LSM programme, 51 patients (51.0%) had depression and depressive traits [CABG 34 (66.7%) vs PCI 17 (33.3%), p = 0.047]. After LSM the overall prevalence of depression and depressive traits fell to 33 patients (34.7%) [PCI eight (23.0%) vs CABG 25 patients (72.0%), p = 0.001]. The mean depression scores also fell from 21.11 ± 7.75 to 14.98 ± 9.61 (p = 0.002). At baseline, PCI patients were more physically active compared to CABG patients [three (60.0%) vs two patients (40.0%), respectively, p = 0.715]. After LSM, more PCI patients undertook PA compared to CABG subjects [24 (60.0%) vs 14 patients (35.0%), respectively, p = 0.012]. The PA score was also higher among the PCI group compared to the CABG group [14.16 ± 9.73 vs 9.40 ± 10.94, respectively, p = 0.024]. In fully compliant subjects, the benefit derived was similar regardless of the mode of intervention [OR 1.10, 95% CI: 0.78–4.23, p = 0.191]. Using multivariate analysis, the main predictors of depression and depressive traits were female gender (OR 3.29, 95% CI: 1.51–11.03, p = 0.008), CABG (OR 1.86, 95% CI: 1.68–5.77, p = 0.003), heart failure (OR 2.65, 95% CI: 5.87–13.62, p = 0.000), kidney failure (OR 1.41, 95% CI: 1.30–5.23, p = 0.041), atrial fibrillation (OR 1.60, 95% CI: 1.40–4.77, p = 0.023), low PA (OR 1.97, 95%, CI: 11.23–33.20, p = 0.000), previous history of depression (OR 8.99, 95% CI: 1.90–7.89, p = 0.002) and low income (OR 2.21, 95% CI: 1.40–2.85, p = 0.000). CONCLUSIONS: Depression and depressive traits are common among subjects undergoing coronary revascularisation, more so among CABG than PCI participants. LSM reduced the prevalence of depression and depressive traits, with fully compliant CABG versus PCI groups deriving nearly the same benefits from the LSM regime. No significant reduction in incidence of depression was recorded among LSM partly compliant patients. This study suggests that failure to implement lifestyle changes and engage in PA are major barriers to managing depression after coronary revascularisation.

AIM: The purpose of this article was to report the low rates of intensive care unit admission and mortality in intermediate- and high-risk COVID-19 patients, and to share our clinical approach with other colleagues. In addition, we sought to reveal the relationship between myocardial injury and clinical outcomes such as death, intensive care unit uptake and hospital stay, and the relationship between inflammatory parameters and cardiac biomarkers in a cardiovascular perspective. METHODS: Patients admitted to the emergency department in the Department of Internal Medicine, Faculty of Medicine, Istanbul University, with laboratory or clinically and radiologically confirmed COVID-19 were included in this retrospective cross-sectional study, which was conducted from 11 March to 10 April 2020. The demographic (age and gender) and clinical (symptoms, co-morbidities, treatments, complications and outcomes) characteristics, laboratory findings, and results of cardiac examinations (cardiac biomarkers and electrocardiography) of patients during hospitalisation were collected from their medical records by two investigators. Data were analysed using SPSS version 25.0 (IBM). A two-sided p < 0.05 was considered statistically significant. Analysis began on 11 April 2020. RESULTS: Mortality and intensive care unit admission rates were statistically significantly higher in patients with cardiac injury than in those without. There was a positive correlation between levels of high-sensitivity TNT and fibrinogen, D-dimer, ferritin, procalcitonin and C-reactive protein (r = 0.24, p < 0.01; r = 0.37, p < 0.01; r = 0.25, p < 0.01, r = 0.34, p < 0.01; r = 0.31, p < 0.01). CONCLUSIONS: The first general data of our 309 patients regarding low mortality and intensive care admission rates, and particular treatment algorithms specific to our centre should be helpful in determining better treatment strategies in the future. Our study emphasises the importance and frequency of cardiovascular outcomes, and the significance of some cardiac biomarkers in predicting COVID-19 prognosis.

BACKGROUND: The rate of cardiac implantable electronic device (CIED) implantation in low- and middle-income countries is increasing. Patients recieving these devices are frequently older and with multiple co-morbidities, which may later lead to complications requiring CIED removal. CIED removals are associated with life-threatening complications. However, high sucesss rates are reported in high-income countries. The purpose of this study was to report on the experience of CIED removal in a resource-constrained setting. METHODS: In this retrospective study, we included consecutive adult patients admitted to Groote Schuur Hospital and the University of Cape Town Private Academic Hospital for CIED removal from 1 January 2008 to 31 December 2019. RESULTS: During the study period, 53 patients underwent CIED removal (26 extractions and 27 explants). The patients had a mean (standard deviation) age of 59.1 (16.0) years. A history of systemic hypertension was present in 50.9% of patients, diabetes mellitus in 30.2% and dilated cardiomyopathy in 47.2%. Complete heart block was the leading indication for CIED implantation (37.7%), and device infection was the leading indication for removal (69.2%). CIEDs were removed after a median (interquantile range) of 243 (53–831) days. There were 40 leads extracted and 35 explants. Lead extractions were perfomed in the cardiac catheterisation laboratory under general anaesthesia via a percutaneous transvenous superior approach. There was one major and one minor complication related to lead extraction. CONCLUSION: CIED infections were the primary indication for CIED removal in a tertiary referral centre in South Africa. Despite being a low-volume centre, we report a high percutaneous transvenous extraction success rate with low complication rate; results which are comparable to high-volume centres.

INTRODUCTION: In South Africa, cardiac disease continues to be the most important non-obstetric cause of maternal death. Methods: A record review of 74 pregnant women with cardiac disease was performed to determine the prevalence and outcomes of cardiac disease at Charlotte Maxeke Johannesburg Academic Hospital between January and December 2017. METHODS: A record review of 74 pregnant women with cardiac disease was performed to determine the prevalence and outcomes of cardiac disease at Charlotte Maxeke Johannesburg Academic Hospital between January and December 2017. RESULTS: Rheumatic heart disease was the most common cardiac diagnosis (n = 21, 28.4%), followed by pulmonary hypertension (n = 13, 17.6%) and congenital heart disease (n = 12, 16.2%). There were one (1.4%) maternal and two (2.7%) perinatal deaths. Neonatal complications included pre-term delivery (n = 20, 32.3%) and small-for-gestational-age infants (n = 10, 16.1%). Cardiac complications (n = 30, 40.5%) included heart failure (n = 15, 20.3%), pulmonary hypertension (n = 11, 14.9%) and blood transfusions (n = 8, 10.8%). CONCLUSION: Cardiac disease in pregnancy was associated with a high risk of maternal and neonatal complications. Pre-conceptual counselling and managing pregnant women at a dedicated centre by a multidisciplinary team could, however, improve outcomes.

AIM: In this study, we aimed to investigate the effect of the single aortic cross-clamp technique (SCT) (aortic cross-clamp only) versus the multiple-clamp technique (MCT) (aortic cross-clamp + side-biting clamp) on postoperative stroke in octogenarians undergoing coronary artery bypass grafting (CABG). METHODS: A total of 171 patients aged 80 years and older who underwent isolated CABG were retrospectively analysed. The patients were divided into two groups according to the technique used during surgery: group 1 (n = 88) received the SCT, and group 2 (n = 83) received the MCT. Postoperative stroke was evaluated. RESULTS: Of the patients, 127 were men and 44 were women. The mean age was 83.05 ± 8.81 years in group 1 and 82.14 ± 8.92 years in group 2. There was no statistically significant difference in the rate of postoperative stroke between the two techniques (p > 0.05). CONCLUSION: Postoperative stroke in octogenarians may result from not only the cross-clamp technique used but also several other factors. We found that both techniques yielded similar outcomes.

Background Reliable vascular access is key to sustainable haemodialysis treatment. Guidelines recommend an arteriovenous fistula (AVF) as the preferred modality in preference to arteriovenous grafts (AVGs) or central venous catheters (CVCs). There are limited data on vascular access in sub-Saharan Africa. This study aimed to evaluate the vascular access used in a South African tertiary hospital and identify problems with achieving the recommended access goals. Methods A cross-sectional analysis was performed of the haemodialysis programme at Livingstone Tertiary Hospital. Current and initial vascular access used, timing until the creation of permanent access, and any complications experienced were recorded. Results CVCs were used in 56% of subjects, 38% were using an AVF and 5% were using an AVG. Only 12% of the group had no AVF attempt. The overwhelming majority (95%) had dialysis initiated with a CVC. The rate of pre-emptive AVF creation was low and a delay in AVF creation was seen in 63% of patients. Central venous stenosis or occlusion was present in 26% of patients and likely due to prior or current CVC use. Conclusions The prevalence of CVC use was high and there were significant delays to AVF creation. High rates of central venous stenosis compromise future AVF use and are likely due to prolonged CVC use. Changes needed to improve the vascular access service include a multidisciplinary access clinic, dedicated theatre list, vascular access co-ordinator and further data collection to continually evaluate the vascular access service.

Background Congenital heart disease (CHD) is an important cause of childhood morbidity. The birth prevalence and distribution of CHD among neonates in a tertiary hospital in Nigeria was determined. Methods This descriptive, cross-sectional study involved consecutive neonates in the neonatal and postnatal wards of the hospital. Bedside echocardiography was conducted on all neonates. Data entry and analysis was done with IBM-SPSS version 20.0. Results A total of 2 849 neonates were recruited, consisting of 1 482 (52.0%) males. Forty-one neonates had CHD, giving a birth prevalence of 14.4/1 000 live births. Of the 41 with CHD, 21 (51.2%) were male. Thirty-six (87.8%) neonates had acyanotic CHD, of which the commonest was isolated ventricular septal defect [11 (26.8%)]. Transposition of the great arteries [3 (7.3%)] was the commonest cyanotic CHD. Conclusions The birth prevalence of 14.4/1 000 live births in this study is high and buttresses the need for strengthening existing cardiac services in Nigeria.

BACKGROUND: Blood pressure (BP) is known to increase inevitably with age. Understanding the different ages at which great gains could be achieved for intervention to prevent and control BP would be of public health importance. METHODS: Data collected between 2003 and 2014 from 1 969 women aged 22 to 89 years were used in this study. Growth curve models were fitted to describe intra- and inter-individual trajectories. For BP tracking, the intra-class correlation coefficient (ICC) was used to measure dependency of observations from the same individual. RESULTS: Four patterns were identified: a slow decrease in BP with age before 30 years; a period of gradual increase in midlife up to 60 years; a flattening and slightly declining trend; and another increase in BP in advanced age. These phases persisted but at slightly lower levels after adjustment for body mass index. Three groups of increasing trajectories were identified. The respective number (%) in the low, medium and highly elevated BP groups were 1 386 (70.4%), 482 (24.5%) and 101 (5.1%) for systolic BP; and 1 167 (59.3%), 709 (36.0%) and 93 (4.7%) for diastolic BP. The ICC was strong at 0.71 and 0.79 for systolic and diastolic BP, respectively. CONCLUSION: These results show that BP preventative and control measures early in life would be beneficial for control later in life, and since increase in body mass index may worsen hypertension, it should be prevented early and independently.

BACKGROUND: Human immunodeficiency virus (HIV) infection and highly active antiretroviral therapy (HAART) are implicated in cardiovascular diseases. The objective of this study was to evaluate the clinical and echocardiographic findings in HIV-infected adults. METHODS: One hundred HIV subjects on HAART, 100 HAART-naïve patients and 100 controls were recruited in this cross-sectional study. RESULTS: Mean CD4 cell count was significantly higher in the HAART-exposed (408.43 ± 221.62) than the HAART-naïve groups (250.06 ± 154.26) (p < 0.001). Weight loss (49%), skin lesions (14%), body weakness (24%), oral thrush (10%) and lymphadenopathy (10%) were more prevalent in HAARTnaïve patients (p < 0.05). Dimensions of aortic root (2.71 cm), left atrium (3.27 cm) and left ventricular mass index (79.95) were significantly higher in HIV-positive subjects on HAART (p < 0.05). CONCLUSION: Clinical features of HIV and the CD4 nadir were more prevalent in the HIV-positive, HAART-naïve subjects. Dimensions of the aortic root, left atrium and left ventricle were relatively larger in the HAART-exposed patients while wall thickness and ejection fraction were higher in the HAART-naïve subjects.

OBJECTIVE: Chronic diabetes mellitus is associated with detrimental cardiovascular complications and electrolyte imbalances such as hypomagnesaemia. We investigated the effect of magnesium (Mg(2+)) on cardiac function and the possible role of histological and electrical alterations in chronic, streptozotocin-induced diabetic rats. METHODS: Wistar rats were treated once intraperitoneally with streptozotocin or citrate, and then daily with MgSO(4) or saline for four weeks. Cardiac contractile and electrocardiographic parameters were measured on Langendorff-perfused hearts. Other hearts were histologically stained or immunoblotted for the mitochondrial ATP synthase (ATP5A). RESULTS: In diabetic hearts, Mg(2+) prevented a diabetes-induced decrease in left ventricular developed pressure and improved contractility indices, as well as attenuated the reduction in heart rate and prolongation of QT interval, but not the QT interval corrected for heart rate (QTc). Histologically, there were neither differences in cardiomyocyte width nor interstitial collagen. The expression of ATP5A was not different among the treatment groups. CONCLUSION: Mg(2+) supplementation improved cardiac contractile activity in chronic diabetic hearts via mechanisms unrelated to electrocardiographic or histologically detectable myocardial alterations.

Objectives The aim of the study was to compare the clinical outcomes [atrial fibrillation (AF), atrio-ventricular (AV) block, device sepsis and lead revision] of patients with sinus node dysfunction (SND) between atrial-pacing atrial-sensing inhibited-response rate-adaptive (AAIR) versus dual-chamber rate-adaptive (DDDR) pacing. The choice of AAIR pacing versus DDDR pacing was determined by AV nodal functional testing at implant. Methods We conducted a retrospective review of consecutive patients who underwent AAIR and DDDR pacing over a 10-year period. Results One hundred and sixteen patients required pacing for symptomatic SND. Fifty-four (46.6%) patients received AAIR pacemakers and 62 (53.4%) received DDDR pacemakers based on AV nodal functional testing at implant. Patients who had AV Wenkebach with atrial pacing at 120 beats per minute received DDDR pacing. Overall the mean age of patients with SND was 65 years and 66.4% were females, 30% were diabetics and 71% were hypertensives. Pre-syncope/syncope (84%) and dizziness (69%) were the most common symptoms. Sinus pauses and sinus bradycardia were the most common ECG manifestations. Over a median follow up of five (IQR: 2-11) years, four patients (7.4%) developed AF in the AAIR group compared to three (4.8%) in the DDDR group (p = 0.70). AV block occurred in one patient in the AAIR group, who required an upgrade to a DDDR pacemaker. There was no difference in device sepsis or need for lead revision between the two groups. Conclusions We found that AV nodal functional testing with atrial pacing at the time of pacemaker implantation was a useful tool to help guide the implanter between AAIR or DDDR pacing. Patients who underwent AAIR pacing had a low risk of AF, AV block or lead revision. In resource-limited settings, AAIR pacing guided by AV nodal functional testing should be considered as an alternative to DDDR pacing.

Background: Carotid endarterectomy (CEA) is a prophylactic operation that is used to mitigate the risk of stroke caused by embolism of atherosclerotic plaques in the carotid bifurcation. Previously, the large, multicentre, randomised, controlled GALA study found no significant differences in clinical outcomes between patients treated using general or local anaesthesia. While this study provided important insights into disease outcomes based on treatment modalities, it did not answer questions regarding the safety of CEA under local anaesthesia in patients at high risk for cardiovascular complications. Here, we examined the use of two different management plans in patients requiring both carotid endarterectomy and coronary artery bypass grafting (CABG), in terms of their effects on hospital mortality. Methods: Thirty-four patients consecutively operated on in our cardiovascular department were included in this analysis. The patients were divided into two groups based on the anaesthetic management plan. The first group consisted of patients who underwent CEA and CABG under general anaesthesia in the same session (GA group); the second group consisted of patients who initially underwent CEA under cervical block anaesthesia followed by CABG under general anaesthesia in a separate session (CB-GA group). These two groups were compared in terms of postoperative complications and hospital mortality. Results: The incidence of postoperative myocardial infarction was higher in the CB-GA group, with four patients experiencing postoperative myocardial infarction, compared to no patients in the GA group. Conclusion: For patients requiring CEA and CABG, performing both operations under general anaesthesia in the same session was safer than initially performing CEA under cervical block anaesthesia followed by CABG under general anaesthesia. WOS:000672606600004 2-s2.0-85112482410 PubMed: 33729273

BACKGROUND: Cardiac surgery with cardiopulmonary bypass (CPB) is known to contribute towards the incidence of acute kidney injury (AKI) and peri-operative morbidity and mortality. There are several patient, anaesthetic and surgical factors that contribute to its occurrence. It is imperative to know the profile of a patient who is likely to develop this complication to mitigate for modifiable risks. This study aimed at describing a profile of AKI in an adult patient (over the age of 18 years) following cardiac surgery on CPB. Factors associated with the development of cardiac surgery-associated acute kidney injury (CSA-AKI) are described, as well as the relationship between CSA-AKI and in-hospital mortality. METHODS: This was a contextual, descriptive and retrospective single-centre study with data of 476 adult patients admitted post cardiac surgery between January 2016 and December 2017. Data were collected from Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa. All adult patients who presented for elective cardiac surgery (coronary artery bypass graft), valvular, aortic and other cardiac surgery on CPB were included. Peri-operative factors such as patient demographics, baseline renal function, co-morbid factors, length of CPB and aortic cross-clamp time, degree of hypothermia, use of assist devices, and post-operative serum creatinine (SCr) levels were collected. Incomplete essential peri-operative data and data for patients who presented on renal replacement therapy (RRT) already were excluded. AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: One hundred and thirty-five (28%) patients developed CSA-AKI and 20, 5 and 3% were in KDIGO 1, 2 and 3, respectively. Older age (p = 0.024), female gender (p = 0.015), higher serum creatinine level (p = 0.025), and lower estimated glomerular filtration rate (eGFR) (p = 0.025) were associated with the development of CSA-AKI, while a history of hypertension was predictive. Forty-six of the 476 patients died. Mortality rates were significantly higher in those with AKI compared to those without [28 (21%) vs 18 (5%), respectively (p = 0.001)]. The incidence was significantly worse in those with severe kidney injury, as evidenced by mortality rates of 44 versus 5% between KDIGO 3 and KDIGO 1 (p < 0.001). Pre-operative eGFR and CSA-AKI requiring RRT were significantly associated with mortality, while pre-operative eGFR was an independent predictor of mortality (hazard ratio 0.99, 95% confidence interval: 0.97–0.99, p = 0.019). CONCLUSION: A history of hypertension was predictive of the development of CSA-AKI, and pre-operative eGFR was an independent predictor of mortality in this cohort. Both factors are modifiable.

BACKGROUND: The first clinical manifestation of the Wolff– Parkinson–White syndrome in previously asymptomatic individuals may be sudden cardiac death. The options for non-invasive risk stratification are limited in the current era beyond ambulatory rhythm monitoring and an exercise stress test. In our study, we sought to investigate whether there was a relationship between the shortest measured P- to delta-wave time interval (PDI) on the conduction properties of surface electrocardiogram and accessory pathways expressed as antegrade effective refractory period (APERP). METHODS: Demographic data, symptom status, electrocardiograms (ECG) and intra-cardiac recordings of invasive electrophysiology testing of 103 patients who underwent accessory pathway ablation procedures were collected. Exclusion criteria were: (1) intermittently occurring pre-excitation, which was detected in previous ECGs, (2) delta-wave resolution on treadmill test, (3) presence of multiple accessory pathways, and (4) accessory pathway locations other than the septum. The PDI was measured as the time interval from the beginning of the P wave to the earliest upstroke or downstroke of the delta wave on V1 and V2 derivations of the surface ECG, and the shortest measurement was recorded. RESULTS: Patients were grouped into two groups: group I, if APERP was < 240 ms and group II if APERP was ≥ 240 ms. PDI was significantly shorter in group II. By correlation analysis, a positive and moderate correlation between PDI and APERP (r = 0.598, p < 0.001) and PDI and age (r = 0.800, p < 0.001) was found, and a negative and moderate correlation between PDI and inducible AF (r = –492, p < 0.001). The best cut-off value for PDI to predict APERP ≥ 240 was 90.5 ms with a sensitivity of 80% and a specificity of 83%. CONCLUSION: Our results demonstrate that there was a strong correlation between the P- to delta-wave interval and universally accepted risk factors, such as low age, low APERP and atrial fibrillation inducibility. Further studies with larger patient groups and follow-up data are needed to appraise its predictive value.

Introduction The aim of this study was to characterise the recent features of patients with infective endocarditis (IE) at one referral centre in southern Turkey, in order to be able to identify the high-risk subgroup and revise preventative measures and management strategies. Methods Medical records of patients 18 years and older, who had been diagnosed with IE according to the Duke criteria between January 2009 and October 2019, were retrospectively evaluated in a referral general hospital. Results The total of 139 IE cases comprised 59.7% males and 40.3% females, with a mean age of 55 ± 16 years. The most encountered symptom was fever (55.4%) and the mitral valve (54%) was the most frequently involved. The most common causative micro-organisms were coagulase-negative staphylococci (30.2%). The in-hospital mortality rate was 30.2%, with congestive heart failure, chronic renal disease and chronic dialysis found to be significantly associated with in-hospital mortality. Conclusions The study results demonstrate the recent epidemiological features of IE in southern Turkey that are important for clinicians to manage diagnostic and therapeutic processes successfully. Older age, the predominance of staphylococci and higher surgery rates are consistent with the changing trends of IE in some parts the world.

INTRODUCTION: This study describes the effects of mitral valve replacement (MVR) on left ventricular (LV) function in patients with severe rheumatic mitral regurgitation (MR). METHODS: This was a retrospective analysis over a nine-year period (2005–2013). Clinical and echocardiographic parameters were recorded pre-operatively and at two weeks, six weeks to three months and six months following MVR. RESULTS: Of the 132 patients included in the study, 66% were in New York Heart Association (NYHA) class III–IV and 38% presented with clinical features of heart failure. Pre-operatively, 28% of subjects had impaired LV function [ejection fraction (EF) < 60%] and the majority had advanced chamber dilatation [left ventricular end-diastolic diameter (LVEDD) 60.7 ± 7.9 mm (n = 132), left ventricular end-systolic diameter (LVESD) 39.9 ± 7.2 mm (n = 118) and left atrial size 61.2 ± 12.6 mm (n = 128)]. Paired analysis of 83 patients revealed that the EF was > 55% in 87% (n = 72) pre-operatively, decreasing to 20% (n = 17) of patients at two weeks postoperatively (p < 0.001); thereafter an EF > 55% was recorded in 60% (n = 50) at the six-month follow-up visit (p < 0.001). On multivariate analysis, only LVESD emerged as a significant predictor of postoperative LV dysfunction. CONCLUSION: In this study, most patients with severe MR presented late with significant impairment of LV function and chamber dilatation that often did not recover fully after surgery. This study emphasises early comprehensive evaluation of severe MR followed by timeous surgery in order to preserve LV function.

BACKGROUND: Recent evidence suggests that there is a change in the profile of rheumatic mitral regurgitation (MR) in South Africa to a pattern of chronic fibrotic valvular disease. OBJECTIVE: This study describes the clinical profile of patients with rheumatic MR in the province of KwaZulu-Natal (KZN). METHODS: A retrospective chart review was performed on patients seven years and older with moderate to severe rheumatic MR referred to Inkosi Albert Luthuli Central Hospital from 2006 to 2015. RESULTS: There were 320 patients meeting the study criteria (mean age 22.2 ± 15.8 years, male:female 1:2). Severe dyspnoea was present in 45.9% of patients, heart failure in 117 (36.6%) and atrial fibrillation in 13.8%. Three patients were diagnosed with active carditis at initial presentation and a further 31 had evidence of carditis during follow up. Of the 216 patients who underwent surgery, over one-third (37%) had prolapse of the anterior mitral leaflet, which was due to chordal elongation (n = 63, 29.2%) and/or ruptured chordae (n = 41, 19%). There were 32 deaths (10%) and of these, 27 (8.4%) patients died prior to surgery. CONCLUSION: Rheumatic MR in KZN predominantly affects the young, with concomitant carditis resulting in high morbidity and mortality rates.

Hypertension is the most prevalent cardiovascular disorder in the world. It is associated with target-organ damage in various organs and ECG changes. P-wave dispersion (PWD), which represents inhomogeneous atrial conduction and discontinuation of impulses, has been observed, when prolonged, to predict atrial fibrillation, particularly in the setting of hypertension. This study of PWD in 150 hypertensive patients and controls sought to determine the prevalence of PWD in Nigerian hypertensives and its relationship to left ventricular mass index and left ventricular function. Mean PWD in normal subjects was 32.14 ± 4.72 ms and was significantly shorter than that in hypertensive patients at 38.29 ± 8.02 ms. In the total population, 51.3% had prolonged PWD ( > 33.46 ms); 70% in the hypertensives and 32.7% of controls. The only significant difference in hypertensives with prolonged and normal PWD was the waist circumference. There was a negative correlation between PWD and ejection fraction (r = -0.17, p = 0.03), but not with diastolic function.

Background Implementation of primary percutaneous coronary intervention (PCI) in sub-Saharan Africa remains a challenging issue. The aim of this study was to report the results of primary PCI and outcomes in the catheterisation laboratory of the Abidjan Heart Institute. Methods Between April 2010 and March 2019, all patients aged 18 years presenting to the Abidjan Heart Institute for ST-segment elevation myocardial infarction (STEMI) over the study period and who underwent primary PCI were included. We considered primary PCI when it was performed within 48 hours of the onset of symptoms. Baseline data, PCI characteristics and outcomes were analysed. Results Among a total of 780 patients hospitalised for STEMI, 471 were admitted within 48 hours of the onset of symptoms. One-hundred and sixty six patients underwent primary PCI, with a ratio of primary PCI/STEMI of up to 21.3%. One hundred and six patients (63.9%) were admitted within 12 hours of the onset of symptoms. The femoral approach was the most commonly used (78.3%). Primary PCI was performed with stent implantation in 84.3% of patients. Drug-eluting stents (DES) were used in 42.1% of patients. In most cases, angiographic success was observed (157/166, 94.6%). Non-fatal complications were mainly haematomas (3.6%). Peri-procedural mortality rate was 1.2%. Conclusions Primary PCI can be performed safely in some small-volume centres in sub-Saharan Africa. Healthcare policies and regional networks must be encouraged in order to improve management of STEMI patients.

Background There are few reports of the prevalence of CHD in the neonatal period in sub-Saharan Africa. The only available study in Nigeria was carried out before the widespread availability of echocardiography in the country. We sought to determine the prevalence and spectrum of congenital heart defects (CHD) among neonates in Jos, Nigeria. Methods This cross-sectional study enrolled neonates less than one week of age from the two largest hospitals and their immunisation centres. Relevant information was obtained and an echocardiogram was performed on each neonate. Results There were 3 857 neonates recruited over a two-year period; male-to-female ratio was 1.1:1. A total of 111 babies had CHD, with a prevalence of 28.8 per 1 000. Sixty-four neonates had mild CHD, with a prevalence of 16.6 per 1 000, while moderate and severe CHD were found in 27 (7.0 per 1 000) and 20 (5.2 per 1 000), respectively. Conclusions CHD is prevalent in Nigerian neonates and there is therefore a need for advocacy to improve access to its diagnosis at birth for appropriate management.

INTRODUCTION: Black populations may be more likely to have primary aldosteronism (PA) due to adrenal hyperplasia or other forms of adrenal hyperactivity, with suppressed renin levels and high levels of aldosterone, which may contribute to the development of hypertension. METHODS: This sub-study involved 35 black men matched for age, gender and race, and aged 20–65 years, living in the North West Province of South Africa. RAAS triple-A analysis was carried out with LC-MS/MS quantification. Blood pressure, electrocardiography and other variables were determined with known methods. RESULTS: Hypertensive subjects with higher aldosterone levels showed an increased aldosterone–angiotensin II ratio (AA2 ratio) compared to the hypertensive subjects with low aldosterone levels (10.2 vs 3.0 pmol/l; p = 0.003). The serum potassium concentration was significantly lower in the high-aldosterone group and the serum sodium–potassium ratio was significantly higher compared to the low-aldosterone group (3.9 vs 4.5, p = 0.016, 34.8 vs 31.8, p = 0.032, respectively). Furthermore, aldosterone was positively associated with both left ventricular hypertrophy (Cornell product) (Spearman R = 0.560; p = 0.037) and kidney function [albumin-to-creatinine ratio (ACR)] (Spearman R = 0.589, p = 0.021) in the hypertensive high-serum aldosterone group. CONCLUSIONS: The AA2 ratio, a novel screening test that is currently being validated for PA case detection, was used to identify a PA-like phenotype in black men. Excess aldosterone was associated with endothelial dysfunction and left ventricular hypertrophy, independent of blood pressure.

Objective The aim of this study was to compare the cardiac effects and aortic arterial indices following intravitreal aflibercept treatment or diode laser photocoagulation for the treatment of retinopathy of prematurity (ROP) in infants. Methods This single-centre, retrospective study was conducted in infants who were administered laser photocoagulation (LPC) or intravitreal aflibercept (IVA) treatment as initial treatment and had completed at least one year of corrected age. The patients were evaluated in terms of aortic elastic parameters, right and left ventricular systolic and diastolic function using conventional, pulsed Doppler and tissue Doppler imaging (TDI) echocardiographic parameters. Results Fifteen infants were in the LPC group, 16 in the IVA group, and 20 in the control group. Although there were some statistically significant differences in terms of pulsed and TDI echocardiographic parameters between the treatment and control groups, these values could not clearly be adopted as a diastolic dysfunction and myocardial performance indices were not influenced. The aortic elastic parameters were impaired in both LPC and IVA groups compared to the control group. Consequently, we observed only minor differences between the treatment groups, which may suggest subtle changes due to the anti-angiogenic treatment. Conclusions Although favourable and promising outcomes were obtained with intravitreal injection of anti-vascular endothelial growth factor agents for the treatment of ROP, concerns have been raised about potential systemic side effects, including potential cardiovascular side effects caused by these agents. The small reduction in right ventricular Doppler velocities could probably be explained by the use of anti-angiogenic or laser treatment in infants.

BACKGROUND: The availability and use of highly active antiretroviral treatment (HAART) has turned human immunodeficiency virus (HIV) into a chronic disease, allowing patients to live much longer. OBJECTIVES: To report asymptomatic cardiac abnormalities in children and adolescents based on both conventional and tissue Doppler imaging (TDI) echocardiography. METHODS: One hundred and fifty-one patients on HAART were recruited. Demographic and clinical variables were collected through patient interviews and medical record reviews. Conventional echocardiography and TDI were performed on each patient. RESULTS: Mean age was 13.0 ± 3.2 (4.0–19.0) years. Eightythree patients (55%) were female. Age at diagnosis of HIV infection was 5.7 ± 3.3 years. Age at initiation of HAART was 7.34 ± 3.54 years, while duration of HAART was 59 ± 39.1 months. On conventional echocardiography, three cases of left ventricular (LV) systolic dysfunction, two of pulmonary hypertension and one of minimal pericardial effusion were identified. Calculation of myocardial mass index (MMI) revealed that 16 patients had abnormal values. Twenty-seven (17.9%) patients had evidence of LV diastolic dysfunction and 18 (11.9%) had right ventricular (RV) diastolic dysfunction. Nineteen (12.6%) patients had tricuspid annular systolic velocity of < 9.5 cm/s, indicating asymptomatic RV systolic dysfunction. CONCLUSION: While few patients had abnormalities such as reduced LV ejection fraction, pulmonary hypertension and minimal pericardial effusion detectable on conventional echocardiography, a larger proportion of patients had subtle abnormalities such as increased MMI, LV diastolic dysfunction on TDI, RV dysfunction and abnormal myocardial performance index. Such patients may need routine screening and cardiac follow up.

BACKGROUND: Diabetes mellitus (DM) is a risk factor for left ventricular (LV) dysfunction, and microalbuminuria is frequently associated with DM. This study aimed to compare LV function among normotensive type 2 diabetes (T2DM) patients with normoalbuminuria, those with microalbuminuria, and healthy controls. METHODS: This was a cross-sectional study conducted at the diabetes and cardiology clinics of the University of Uyo Teaching Hospital, Uyo, Akwa-Ibom State, Nigeria, from January 2013 to March 2014. Microalbuminuria was tested for using Micral test strips, and echocardiography-derived indices of LV function were compared among the three groups. RESULTS: Sixty-three normoalbuminuric, 71 microalbuminuric T2DM patients and 59 healthy controls were recruited. Mean age of participants was 50 ± 8 years and the three groups were age and gender matched (p = 0.23, p = 0.36, respectively). LV diastolic dysfunction (LVDD) showed a stepwise increase from the healthy controls to the normoalbuminuric to the microalbuminuric T2DM patients (16.9 vs 61.9 vs 78.9%, respectively) (p < 0.001), while E/A ratio and fractional shortening showed a significant stepwise decrease (both p < 0.001). LV systolic dysfunction was rare among the three groups. Microalbuminuria showed a strong direct association with LVDD (OR 3.58, 95% CI: 1.99–6.82, p < 0.001). Age remained independently associated with LVDD (OR 1.10, 95% CI: 1.03–1.17, p = 0.003). CONCLUSIONS: LV diastolic function was altered in Nigerian normotensive T2DM patients, and the presence of microalbuminuria with DM had additional effects on this abnormality. Early screening for DM and microalbuminuria could identify individuals with high cardiovascular risk and possibly abnormal LV function.

BACKGROUND: Although tremendous advances have been made in preventative and therapeutic approaches in heart failure (HF), the hospitalisation and mortality rates for patients with HF is high. The aim of this study was to investigate the association between cystatin C and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and in- and out-of-hospital mortality rates in acute decompensated HF (ADHF). METHODS: Between February 2008 and November 2011, 57 consecutive patients who were admitted with ADHF were included in this prospective study. These patients were clinically followed up every three months by means of visits or telephone interviews. The primary clinical endpoint of this study was any death from heart failure rehospitalisation and/or other causes. RESULTS: The subjects who died during the in-hospital follow up were younger than the survivors (47.4 ± 17.5 vs 60.8 ± 15.8, p = 0.043). There was a notable correlation between plasma cystatin C and NT-proBNP levels (r = 0.324, p = 0.014) and glomerular filtration rate (GFR) (r = –0.638, p < 0.001). Multivariate logistic regression analysis revealed that only cystatin C level [odds ratio (OR): 12.311, 95% confidence interval (CI): 1.616–93.764, p = 0.015] and age [OR: 0.925, 95% CI: 0.866–0.990, p = 0.023] were linked to in-hospital mortality rate. In the multivariate Cox proportional hazard model, only admission sodium level appeared as a significant independent predictor of death during the 36-month follow up [hazard ratio: 0.937, 95% CI: 0.880–0.996, p = 0.037]. CONCLUSION: Evaluation of admission cystatin C levels may provide a reliable prediction of in-hospital mortality, compared to estimated GFR or NT-proBNP levels among patients with ADHF. However, in this trial, during long-term follow up, only admission sodium level significantly predicted death.

OBJECTIVE: To document maternal and foetal morbidity and mortality in anticoagulated, pregnant patients with mechanical heart valves until 42 days post-partum. METHODS: In a tertiary single-centre, prospective cohort, 178 consecutive patients at the cardiac-obstetric clinic were screened for warfarin use between 1 July 2010 and 31 December 2015. Of 33 pregnancies identified, 29 were included. Patients received intravenous unfractionated heparin from six to 12 weeks’ gestation and peripartum, and warfarin from 12 to 36 weeks. Maternal outcomes including death, major haemorrhage and thrombosis, and foetal outcomes were documented. RESULTS: There were two maternal deaths, five returns to theatre post-delivery, eight patients transfused, six major haemorrhages, one case of infective endocarditis and three ischaemic strokes. Ten pregnancies had poor foetal outcomes (six miscarriages, three terminations, one early neonatal death). Twenty patients required more than 30 days’ hospitalisation, and 15 required three or more admissions. HIV positivity was associated with surgical delivery (p = 0.0017). CONCLUSIONS: Complication rates were high despite centralised care.

Aim To determine whether a single elevated myocardial performance index (MPI) value in the third trimester of pregnancy is a marker for later adverse obstetric outcomes in stable placental-mediated disease, defined as well-controlled pre-eclampsia (PE) on a single agent and/or uncompensated intra-uterine growth restriction (IUGR). Methods Fifty-five foetuses whose mothers had stable placental-mediated disease, either mild pre-eclampsia controlled on a single agent, and/or uncompensated IUGR in the third trimester, attending the Foetal Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa were prospectively recruited with 55 matched controls. Recorded data for the subjects included demographic data of maternal age and parity, sonographic data of estimated foetal weight (EFW) and amniotic fluid index (AFI), myocardial performance index (MPI), and foetal Doppler data of the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV). Results The mean gestational age in the controls, the IUGR and any PE cases was 31.4, 31.8 and 31.0 weeks, respectively. The distribution of MPI values was significantly lower in the controls compared to all other groups. The highest standardised MPI values were observed in the PE-IUGR group, where a median of 5.62 was observed. The only significant differences observed between the PE and IUGR groups was the UA resistance index (p = 0.01), where the IUGR cases tended to have higher UA values compared to the combined PE group. Borderline statistical significance was observed for the MCA resistance index values ( p = 0.05) between these groups. The overall adverse event rate in the cases was 49%. The highest rate was observed in the PE + IUGR group, where eight out of 12 (67%) experienced adverse events. MPI z-scores served as a good marker of adverse events, as evidenced by the total area under the curve (AUC) of 0.90 on the ROC curve. A cut-off value of 4.5 on the MPI z-score conferred a sensitivity of 89% and specificity of 68% for an adverse event later in pregnancy. In univariate logistic regression, MPI z-score, AFI, EFW, UA Doppler, CPR category, DV Doppler and MCA Doppler were assessed separately as potential predictors of adverse outcome. The only significant predictor of adverse outcome was MPI z-score. Conclusions A single elevated value of the MPI ( z-score > 4.5) in the third trimester in stable placental-mediated disease was a strong indicator of adverse obstetric outcomes later in pregnancy. This has the potential to be incorporated in conjunction with standard monitoring models in stable placental-mediated disease to predict an adverse event later in pregnancy and thus to reduce perinatal morbidity and mortality.

Summary Background The prevalence of hypertension in patients with diabetes is approximately two-fold higher than in age-matched subjects without the disease and, conversely, individuals with hypertension are at increased risk of developing diabetes compared with normotensive persons. Up to 75% of cases of cardiovascular disease (CVD) in patients with diabetes are attributed to hypertension. Diabetics who have hypertension are more likely to develop complications and die, and appropriate blood pressure control in these individuals reduces the risk. This study sought to determine the prevalence and factors associated with hypertension among newly diagnosed adult diabetic patients in a national referral hospital in Uganda. Methods In this cross-sectional study, conducted between June 2014 and January 2015, we recruited 201 newly diagnosed adult diabetic patients. Information on patients’ socio-demographics was obtained using a pre-tested questionnaire, while biophysical profile, blood pressure measurement, biochemical testing and echocardiographic findings were obtained by the research team for all the participants. Bivariate and multivariate logistic regression analyses were used to investigate the association of several factors with hypertension. Results Of the 201 patients recruited, 102 were male (50.8%) and the mean age was 46 ± 15 years. The majority of patients (159) had type 2 diabetes mellitus (DM) (79.1%) with a mean HbA1c level of 13.9 ± 5.3%. The prevalence of hypertension was 61.9% (95% CI: 54.8–68.6%). Knowledge of hypertension status was at 56 (27.7%) patients, 24 (44.4%) hypertensives were on treatment, and 19 (33.9%) were using ACE inhibitors/ angiotensin receptor blockers. The independent factors associated with hypertension were being employed (OR 0.37, 95% CI: 0.16–0.90, p = 0.029) and being overweight or obese (OR 11.6, 95% CI: 4.29–31.2, p < 0.0001). Conclusion The prevalence of hypertension was high in this population of newly diagnosed diabetics, few patients had knowledge of their hypertension status and few were on appropriate treatment. Both modifiable and non-modifiable risk factors were associated with hypertension in this group. Therefore routine assessment, treatment and control of hypertension among diabetics is necessary to prevent cardiovascular complications and death. There is also a need to address the modifiable risk factors.

Background Acute coronary syndrome (ACS) is understudied in sub-Saharan Africa despite its increasing disease burden. We sought to create an ACS registry at Kenyatta National Hospital to evaluate the presentation, management and outcomes of ACS patients. Methods From November 2016 to April 2017, we conducted a retrospective review of ACS cases managed at Kenyatta National Hospital between 2013 and 2016, with a primary discharge diagnosis of ACS, based on International Classification of Diseases (ICD) 10 coding (I20-I24). We compared the presentation, management and outcomes by ACS subtype using analysis of variance testing. We created multivariable logistic regression models using the Global Registry of Acute Coronary Events (GRACE) risk score to evaluate the association between clinical variables, including guideline-directed medical therapy and in-hospital outcomes. Results Among 196 ACS admissions, the majority (65%) was male, and the median age was 58 years. Most (57%) ACS admissions were for ST-segment-elevation myocardial infarction (STEMI). In-hospital dual antiplatelet (> 85%), beta-blockade (72%) and anticoagulant (72%) therapy was common. A minority (33%) of patients with STEMI was eligible for reperfusion therapy but only 5% received reperfusion. In-hospital mortality rate was 17%, and highest among individuals presenting with STEMI (21%). After multivariable adjustment, higher serum creatinine level was associated with higher odds of in-hospital death (OR = 1.84, 95% CI: 1.21 - 2.78), and STEMI and Killip class > 1 were associated with in-hospital composite of death, re-infarction, stroke, major bleeding or cardiac arrest (STEMI: OR = 8.70, 95% CI: 2.52 - 29.93; Killip > 1: OR = 10.7, 95% CI: 3.34-34.6). Conclusions We describe the largest ACS registry at Kenyatta National Hospital to date and identify potential areas for improved ACS care related to diagnostics and management to optimise in-hospital outcomes.