Cardiovascular Journal of Africa: Vol 26, Issue 4, July / August 2015

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CARDIOVASCULAR JOURNAL OF AFRICA: VOLUME 26, ISSUE 4, jULY/AUG 2015

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Title: From the Editor’s Desk
Authors: Commerford, P
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 151
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Abstract: In this issue of the Journal, Seedat (page 193) asks why the control of hypertension in sub-Saharan Africa is as bad as it is. Citing the importance of the disease as a cause of death and disability, he concludes that both the prevalence of hypertension and the failure to control it properly is driven by the poverty of the population of the region, the cost of pharmaceuticals, and a lack of medical resources. He finishes with a rousing call, echoing the late iconic President Mandela, to all of us to find African solutions to African problems.
Title: Hypertension in sub-Saharan Africa: a massive and increasing health disaster awaiting solution
Authors: Campbell, NRC; Lemogoum, D
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 152-154
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Abstract: Increased blood pressure is the leading risk for death globally. While this is also true in sub-Saharan Africa, there are many hypertension issues that are unique to the region. A prime and important example is that in most countries in the region, population blood pressure is increasing, while in most countries in the rest of the globe, population blood pressure is decreasing.
Title: Analysis of clinical outcomes of intra-aortic balloon pump use during coronary artery bypass surgery
Authors: Yumun, G; Aydin, U; Ata, Y; Toktaş, F; Pala, AA; Ozyazicioglu, AF; Turk, T; Yavuz, S
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 155-158
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DOI Number:10.5830/CVJA-2015-010
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-010
Abstract: Aim: The mortality rate of coronary artery bypass surgery increases with advanced patient age. This intra-aortic balloon pump (IABP) study was conducted to compare older patients (above 65 years of age) with younger patients (below 65 years of age) who had undergone coronary artery bypass surgery and had had an IABP inserted, with regard to hospital stay, clinical features, intensive care unit stay, postoperative complications, and mortality and morbidity rates.
Methods: One hundred and ninety patients who had undergone coronary artery bypass surgery and had required IABP support were enrolled in this study. Patients younger than 65 years of age were considered younger, and the others were considered older. Ninety-two patients were in younger group and 98 patients were older group. The mortality rates, pre-operative clinical characteristics, postoperative complications, and duration of intensive care unit and hospital stay of the groups were compared. The risk factors for mortality and complications were analysed
Results: One hundred and thirty-eight of the patients were male, and the mean age was 62.7 ± 9.9 years. The mortality rate was higher in the older patient group than the younger group [34 (37.7%) and 23 (23.4 %), respectively (p = 0.043)]. The crossclamp time, mean ejection fraction, cardiopulmonary bypass time, and length of stay in the intensive care unit were similar between the two groups (p > 0.05). Cardiopulmonary bypass time was the unique independent risk factor for mortality in both groups.
Conclusion: In this study, high mortality rates in the postoperative period were similar to those in prior studies regarding IABP support. The complication rates were higher in the older patient group. Prolonged cardiopulmonary bypass time and advanced age were determined to be significant risk factors for mortality.
Title: Comparison of neutrophil:lymphocyte ratios following coronary artery bypass surgery with or without cardiopulmonary bypass
Authors: Aldemir, M; Bakı, ED; Adalı, F; Çarşanba, G; Tecer, E; Taş, HU
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 159-164
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DOI Number: 10.5830/CVJA-2015-015
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-015
Abstract: Objective: Coronary artery bypass graft (CABG) surgery may induce postoperative systemic changes in leukocyte counts, including leukocytosis, neutrophilia or lymphopenia. This retrospective clinical study investigated whether offpump coronary artery bypass (OPCAB) surgery working on the beating heart without extracorporeal circulation could favourably affect leukocyte counts, including neutrophil-tolymphocyte (N:L) ratio, after CABG.
Methods: In this study, 30 patients who underwent isolated CABG with cardiopulmonary bypass (CPB), and another 30 patients who underwent the same operation without CPB between May 2010 and May 2013, were screened from the computerised database of our hospital. Pre-operative, and first and fifth postoperative day differential counts of leukocytes with the N:L ratio of peripheral blood were obtained.
Results: A significant increase in total leukocyte and neutrophil counts and N:L ratio, and a decrease in lymphocyte counts were observed at all time points after surgery in both groups. N:L ratio was significantly higher in the CPB group compared with the OPCAB group on the first postoperative day (20.73 ± 13.85 vs 10.19 ± 4.55, p < 0.001), but this difference disappeared on the fifth postoperative day.
Conclusion: CPB results in transient but significant changes in leukocyte counts in the peripheral blood stream in terms of N:L ratio compared with the off-pump technique of CABG.
Title: Prediction of mid-term outcome after cryo-balloon ablation of atrial fibrillation using post-procedure high-sensitivity troponin level
Authors: Aksu, T; Golcuk, SE; Guler, TE; Yalin, K; Erden, İ
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 165-170
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DOI Number: 10.5830/CVJA-2015-027
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-027
Abstract: Objective: High-sensitivity troponin I (hsTnI) assays lead to, among other things, improvement in the detection of myocardial injury and improved risk stratification of patients with atrial fibrillation (AF). The aim of this study was to investigate the association between post-procedure cardiac biomarkers and clinical outcome in patients undergoing cryo-balloon ablation (CA) for AF.
Methods: A total of 57 patients (mean age 55.1 ± 12.2 years, 50.9% female) with symptomatic paroxysmal AF underwent the CA procedure. Two hundred and twenty-eight pulmonary veins (PVs) were attempted for pulmonary vein isolation (PVI) with a second-generation cryo-balloon. hsTnI, CK-MB mass and myoglobin samples were prospectively obtained before and 24 hours after ablation.
Results: At a mean follow up of 214.6 ± 24.3 days, the probability of being arrhythmia free after a single procedure was 86%. Post-ablation hsTnI (p = 0.001), left atrial (LA) diameter (p = 0.002), duration of AF (p = 0.002), mean minimal temperature of the left superior pulmonary vein (p = 0.005), and age (p = 0.021) were associated with increased AF recurrence rate. On multivariate analysis, lower hsTnI level was the only independent predictor for AF recurrence (p = 0.012). Post-ablation hsTnI levels lower than 4.40 ng/ml predicted AF recurrence during follow up, with a sensitivity of 86% and a specificity of 96%.
Conclusion: It is well recognised that the PV antrum contributes to initiation and/or perpetuation of AF. A lower postablation hsTnI level may predict an increased AF recurrence rate, suggesting inadequate ablation of the PV antrum. This may be used as a non-invasive marker to predict the outcome of AF.
Title: Efficacy of full-fat milk and diluted lemon juice in reducing infra-cardiac activity of 99mTc sestamibi during myocardial perfusion imaging
Authors: Purbhoo, K; Di Tamba, M; Vangu, W
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 171-176
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DOI Number: 10.5830/CVJA-2015-033
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-033
Abstract: Background: When using 99mTc sestamibi for myocardial perfusion imaging, increased splanchnic activity creates a problem in the visual and quantitative interpretation of the inferior and infero-septal walls of the left ventricle. We sought to determine whether the administration of diluted lemon juice or full-fat milk would be effective in reducing interfering infra-cardiac activity and therefore result in an improvement in image quality. We compared the administration of full-fat milk and diluted lemon juice to a control group that had no intervention.
Methods: The study was carried out prospectively. All patients referred to our institution for myocardial perfusion imaging from November 2009 to May 2012 were invited to be enrolled in the study. A total of 630 patients were randomised into three groups. Group 0 (G0), 246 patients, were given diluted lemon juice, group 1 (G1), 313 patients, were given full-fat milk, and group 2 (G2), 71 patients, had no intervention (control group). A routine two-day protocol was used and the patients were given the same intervention on both days. Raw data of both the stress and rest images were visually assessed for the presence of infra-cardiac activity, and quantitative grading of the relative intensity of myocardial activity to infra-cardiac activity was determined. The physicians were blinded to the intervention received and the data were reviewed simultaneously.
Results: The overall incidence of interfering infra-cardiac activity at stress was 84.1, 84.5 and 96.6% in G0, G1 and G2, respectively (p = 0.005). At rest it was 91.7, 90.1 and 100% in G0, G1 and G2, respectively (p = 0.0063). The visual and quantitative results favoured both milk and lemon juice in reducing the amount of interfering infra-cardiac activity versus no intervention.
Conclusion: The administration of milk or lemon juice resulted in a significant decrease in the intensity of infra-cardiac activity compared to the control group. This reduction in intensity was even more significant in the milk group for patients assessed during rest myocardial perfusion imaging.
Title: Cardiovascular risk factors among patients with chronic kidney disease attending a tertiary hospital in Uganda
Authors: Babua, C; Kalyesubula, R Okello, E; Kakande, B; Sebatta, E; Mungoma, M; Mondo, CK
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 177-180
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DOI Number: 10.5830/CVJA-2015-045
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-045
Abstract: Introduction: Chronic kidney disease (CKD) is a risk factor for the development of cardiovascular disease, which is the primary cause of morbidity and mortality in patients with CKD. Local data about cardiovascular risk factors among CKD patients is generally scanty.
Objective: To determine the prevalence of the common cardiovascular risk factors among patients with CKD attending the nephrology out-patient clinic in Mulago national referral hospital in Uganda.
Methods: This was a cross-sectional study in which 217 patients with a mean age of 43 years were recruited over a period of nine months. Data on demographic characteristics, risk factors for cardiovascular disease, complete blood count, renal function tests/electrolytes, and lipid profiles were collected using a standardised questionnaire.
Results: One hundred and eleven (51.2%) of the participants were male. Hypertension was reported in 90% of participants while cigarette smoking was present in 11.5%. Twenty-two participants (10.2%) were obese and 16.1% were diabetic. A total of 71.9% had a haemoglobin concentration < 11 g/dl, with the prevalence of anaemia increasing with advancing renal failure (p < 0.001); 44.7% were hypocalcaemic and 39.2% had hyperphosphataemia. The prevalence of abnormal calcium and phosphate levels was found to increase with declining renal function (p = 0.004 for calcium and p < 0.001 for phosphate).
Conclusion: This study demonstrated that both traditional and non-traditional cardiovascular risk factors occurred frequently in patients with CKD attending the nephrology out-patient clinic at Mulago Hospital.
Title: Performance of re-used pacemakers and implantable cardioverter defibrillators compared with new devices at Groote Schuur Hospital in Cape Town, South Africa
Authors: Jama, ZV; Chin, A; Badri, M; Mayosi, BM
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 181-187
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DOI Number: 10.5830/CVJA-2015-048
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-048
Abstract: Objectives: Little is known about the performance of re-used pacemakers and implantable cardioverter defibrillators (ICDs) in Africa. We sought to compare the risk of infection and the rate of malfunction of re-used pacemakers and ICDs with new devices implanted at Groote Schuur Hospital in Cape Town, South Africa.
Methods: This was a retrospective case comparison study of the performance of re-used pacemakers and ICDs in comparison with new devices implanted at Groote Schuur Hospital over a 10-year period. The outcomes were incidence of device infection, device malfunction, early battery depletion, and device removal due to infection, malfunction, or early battery depletion.
Results: Data for 126 devices implanted in 126 patients between 2003 and 2013 were analysed, of which 102 (81%) were pacemakers (51 re-used and 51 new) and 24 (19%) were ICDs (12 re-used and 12 new). There was no device infection, malfunction, early battery depletion or device removal in either the re-used or new pacemaker groups over the median follow up of 15.1 months [interquartile range (IQR), 1.3–36.24 months] for the re-used pacemakers, and 55.8 months (IQR, 20.3–77.8 months) for the new pacemakers. In the ICD group, no device infection occurred over a median follow up of 35.9 months (IQR, 17.0–70.9 months) for the re-used ICDs and 45.7 months (IQR, 37.6–53.7 months) for the new ICDs. One device delivered inappropriate shocks, which resolved without intervention and with no harm to the patient. This re-used ICD subsequently needed generator replacement 14 months later. In both the pacemaker and ICD groups, there were no procedure-non-related infections documented for the respective follow-up periods.
Conclusion: No significant differences were found in performance between re-used and new pacemakers and ICDs with regard to infection rates, device malfunction, battery life and device removal for complications. Pacemaker and ICD re-use is feasible and safe and is a viable option for patients with bradyarrhythmias and tachyarrthythmias.
Title: Glycaemic, blood pressure and cholesterol control in 25 629 diabetics
Authors: Pinchevsky, Y; Butkow, N; Chirwa, T; Raal, FJ
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 188-192
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DOI Number: 10.5830/CVJA-2015-050
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-050
Abstract: Objective: To examine and compare the extent to which people with type 2 diabetes (T2DM) are achieving haemoglobin A_1c (HbA_1c), blood pressure (BP) and LDL cholesterol(LDL-C) treatment targets.
Methods: A review of databases (MEDLINE Ovid, Pubmed and Sabinet) was performed and limited to the following terms: type 2 diabetes mellitus AND guideline AND goal achievement for the years 2009 to 2014 (five years).
Results: A total of 14 studies (25 629 patients) were selected across 19 different countries. An HbA_1c level of 7.0% (or less) was achieved by 44.5% of subjects (range 19.2–70.5%), while 35.2% (range 7.4–66.3%) achieved BP of 130/80 mmHg (or less), and 51.4% (range 20.0–82.9%) had an LDL-C level of either 2.5 or 2.6 mmol/l (100 mg/dl or less).
Conclusion: Despite guideline recommendations that lowering ofHbA_1c, BP and lipids to target levels in T2DM will lead to a reduction in morbidity and mortality rates, we found that control of these risk factors remains suboptimal, even across different settings.
Title: Why is control of hypertension in sub-Saharan Africa poor?
Authors: Seedat, YK
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 193-195
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DOI Number: 10.5830/CVJA-2015-065
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-065
Abstract: In sub-Saharan Africa (SSA) in 2010, hypertension (defined as systolic blood pressure ≥ 115 mmHg) was the leading cause of death, increasing 67% since 1990. It was also the sixth leading cause of disability, contributing more than 11 million adjusted life years. In SSA, stroke was the main outcome of uncontrolled hypertension. Poverty is the major underlying factor for hypertension and cardiovascular disease. This article analyses the causes of poor compliance in the treatment of hypertension in SSA and provides suggestions on the treatment of hypertension in a poverty-stricken continent.
Title: First Melody® valve implantations in Africa
Authors: Buys, DG; Greig, C; Brown SC
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 196-199
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DOI Number: 10.5830/CVJA-2015-007
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-007
Abstract: Congenital heart lesions involving the right ventricular outflow tract (RVOT) are a common problem in paediatric cardiology. These patients need multiple surgical interventions in the form of valved conduits over a lifetime. Surgical re-valvulation was the standard treatment option until the introduction of percutaneous pulmonary valves over a decade ago. These valves can be used to prolong the lifespan of conduits and reduce the number of re-operations. The Melody® valve (Medtronic, Minneapolis, MN, USA) was introduced as the first dedicated percutaneous pulmonary valve. Percutaneous pulmonary valves can be implanted successfully and have the advantage of short hospitalisations. We describe the first three Melody® valve implantations in Africa.
Title: Cardio News
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: 200
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Title: The prevalence of symptomatic infantile heart disease at Louga Regional Hospital, Senegal
Authors: Ba Ngouala, GAB; Affangla, DA; Leye, M; Kane, A
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: e1-e5
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DOI Number: 10.5830/CVJA-2015-031
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-031
Abstract: The management of congenital or acquired infantile heart diseases in sub-Saharan African countries still presents problems, particularly with diagnosis and access to surgical treatment. Our objectives were to describe the heart diseases observed in the paediatric setting of the Louga Regional Hospital (LRH) and report their short-term evolution.
In the study period from 1 July 2009 to 31 December 2012, 82 children out of 18 815 presented with heart disease, which was a prevalence of 4.3/1 000. There was a female predominance, with a ratio of 1.2. The most frequent presenting conditions were dyspnoea at 47.5%, followed by heart murmurs at 35.3%, and congestive heart failure at 13.4%. Congenital heart diseases were the most frequent, representing 69.5% of the cases, followed by acquired heart diseases at 29.3%, and mixed-type cases at 1.2%. The most frequently encountered congenital heart diseases were ventricular septal defect (24.4%), followed by atrioventricular septal defect (12.2%), tetralogy of Fallot (9.8%) and patent ductus arteriosus (7.3%). Acquired heart disease was represented by rheumatic heart disease, found in 25.6% of the cases, and tuberculous pericarditis in 3.7%. The mortality rate was high, with 20 children dying (24.4%) during the study period. Only 13 out of 82 patients (15.9%) were operable and surgery was carried out in France, courtesy of the association Humanitarian Mécénat Chirurgie Cardiaque.
Infantile heart diseases were therefore not very frequent in the paediatric unit of Louga Regional Hospital. However, congenital heart disease was more frequent than acquired heart disease, with a high mortality rate. Access to surgery remains limited.
Title: Unrepaired persistent truncus arteriosus in a 38-year-old woman with an uneventful pregnancy
Authors: Abid, D; Daoud, E; Kahla, SB; Mallek, S; Abid, L; Fourati, H; Mnif, Z; Kammoun, S
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: e6-e8
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DOI Number: 10.5830/CVJA-2015-005
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-005
Abstract: Persistent truncus arteriosus (PTA) is a rare conotruncal defect, defined as a single arterial vessel arising from the heart, which gives origin to the systemic, pulmonary and coronary circulations. It has an extremely poor prognosis and carries a high mortality rate during the early years of life unless surgically repaired. A few known cases have been reported of patients reaching maturity, and exceptionally, patients suffering from this disease having lived into the fourth decade.
The purpose of this report was to present a new case of PTA type 1, diagnosed by echocardiography and MRI, in a 41-year-old woman, with the peculiarity of long survival into adult life. She had also experienced a full-term pregnancy and delivery of a normal infant three years prior to her diagnosis. Pulmonary vascular disease made her condition inoperable but she was doing well with medical management after a follow up of 15 months. Based on this work, we concluded that pulmonary arterial hypertension is deleterious for life in some cardiovascular diseases, but in others, allows survival, as occurred in these patients with PTA. The patient’s clinical course and anatomical findings are reported, along with factors that may have contributed to her longevity.
Title: Exudative pericarditis in the evolution of a diffuse large B-cell lymphoma
Authors: Bagacean, C; Tempescul, A; Ianotto, J-C; Marion, V; Pop, D; Zdrenghea, M
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: e9-e11
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DOI Number: 10.5830/CVJA-2015-024
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-024
Abstract: Cardiac involvement in non-Hodgkin’s lymphoma is a rare occurrence with a dismal prognosis, which may evolve with different clinical presentations, the most frequent being heart failure. Diagnosis of cardiac involvement is generally made by cardiac ultrasound. We report a case of lymphomatous pericarditis in the evolution of a non-Hodgkin’s lymphoma, diagnosed by PET-CT scan, and occurring concomitantly with complete isotopic remission of enlarged mediastinal lymph nodes following chemotherapy.
Title: Intermittent symptomatic functional mitral regurgitation illustrated by two cases
Authors: Aydin, A; Gurol, T; Soylu, O; Dagdeviren, B
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: e12-e14
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DOI Number: 10.5830/CVJA-2015-026
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-026
Abstract: Functional mitral regurgitation may have different haemodynamic consequences, clinical implications and treatment options, such as surgical or percutaneous interventions or implanting a pacemaker. Here we present two cases with haemodynamically significant intermittent functional mitral regurgitation as the underlying mechanism of heart failure. The cases underline the importance of a high index of suspicion in patients with intermittent heart failure, and a careful analysis of echocardiographic images with simultaneous ECG, in order to delineate systolic and diastolic mitral regurgitation.
Title: Unusual complication of aortic dissections: intimo–intimal intussusception
Authors: Vural, U; Balci, AY; Aglar, AA; Kizilay, M; Yekeler, İ; Tuygun, AK
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: e15-e18
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DOI Number: 10.5830/CVJA-2015-029
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-029
Abstract: Angiography with a pre-diagnosis of acute coronary syndrome was performed in a 76-year-old female patient presenting to another hospital with symptoms of chest pain and syncope. Upon determination of type III aortic dissection, the patient was referred to our clinic. On CT angiography, the ascending aortic diameter was 57 mm and no dissection flap was observed. There was a filling defect suggestive of intimo–intimal intussusception at the level of the aortic arch, occlusion of the left arteria carotid communis, and a double-channel aorta extending from the left subclavian artery to the iliac artery. On transoesophageal echocardiography, the ascending aorta was seen to be larger than normal and no dissection flap was observed. There were findings suggestive of haematoma and intimo–intimal intussusception at the proximal part of the aortic arch. The dissection flap causing occlusion in the vascular structures was resected. Supracoronary graft replacement of the ascending aorta was performed. Transoesophageal echocardiography is an invasive investigative method with high sensitivity and specificity for the diagnosis of intimo–intimal intussusception.
Title: Bare-metal stent thrombosis two decades after stenting
Authors: Acibuca, A; Gerede, DM; Vurgun, VK
From: Cardiovascular Journal of Africa, Vol 26, Issue 4, July/August
Published: 2015
Pages: e19-e21
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DOI Number: 10.5830/CVJA-2015-034
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-034
Abstract: Very late bare-metal stent (BMS) thrombosis is unusual in clinical practice. To the best of our knowledge, the latest that the thrombosis of a BMS has been reported is 14 years after implantation. Here, we describe a case of BMS thrombosis that occurred two decades after stenting. A 68-year-old male patient was admitted with acute anterior myocardial infarction. This patient had a history of BMS implantation in the left anterior descending coronary artery (LAD) 20 years previously. Immediate coronary angiography demonstrated acute thrombotic occlusion of the stent in the LAD. With this case, we are recording the latest reported incidence of BMS thrombosis after implantation.