AFRICA CARDIOVASCULAR JOURNAL OF AFRICA • Kenya Cardiac Society July 2023 26 Methods We present a case of a 32-year-old female who had mitral valve replacement after her first pregnancy at age 28; who now sought care 10 weeks into her second pregnancy. She was on warfarin 5mg daily (except Wednesdays 7.5 mg), enalapril 5 mg OD, digoxin 0.125mg OD and furosemide 40 mg OD. A multidisciplinary team involving an adult and pediatric cardiologist seasoned in fetal echocardiography, obstetrician and anesthesiologist was formed. Serial obstetrical and fetal echocardiograms were done to assess fetal malformations and cardiac anomalies, as well as serial INRs maintaining a therapeutic INR. Warfarin dosage was maintained at 5mg OD, digoxin and enalapril stopped, furosemide taken as required. Folic acid and junior aspirin were introduced. She was booked for elective cesarean at thirty-eight weeks. Warfarin was bridged with enoxaparin 5 days to surgery and was stopped 24 hours prior. She proceded to have a successful delivery. Image: Fetal Echocardiogram during routine checkup. Conclusions Cardiac disease in pregnancy is common in Kenya with a high mortality. Pre-pregnancy evaluation is ideal and tertiary referral hospitals should set up high risk cardiac obstetric clinics which can guarantee multidisciplinary care with good outcomes. References 1. Lumsden, R., Barasa, F., Park, L. P., Ochieng, C. B., Alera, J. M., Millar, H. C., Bloomfield, G. S., & Christoffersen-Deb, A. (2020). High Burden of Cardiac Disease in Pregnancy at a National Referral Hospital in Western Kenya. Global heart, 15(1), 10. https://doi.org/10.5334/gh.404 2. Richardson A, Shah S, Harris C, McCulloch G, Antoun P. Anticoagulation for the Pregnant Patient with a Mechanical Heart Valve, No Perfect Therapy: Review of Guidelines for Anticoagulation in the Pregnant Patient. Case Rep Cardiol. 2017;2017:3090273. doi: 10.1155/2017/3090273. Epub 2017 Nov 22. PMID: 29359052; PMCID: PMC5735605. 3. Christiana C. Burt, MA MB BChir FRCA , Jacqueline Durbridge, FRCA, Management of cardiac disease in pregnancy, Continuing Education in Anaesthesia Critical Care & Pain, Volume 9, Issue 2, April 2009, Pages 44–47, https://doi.org/10.1093/bjaceaccp/ mkp005 Submission ID: 40 UTILITY OF MULTIMODALITY IMAGING IN PROSTHETIC VALVE ASSESSMENT K MWAZO, B NDUATI, UMMEKULSUM A VARVANI Background Multimodality imaging that includes Chest X-ray (CXR), Cinefluoroscopy, Transthoracic and transoesophageal echocardiography, CT scan and MRI are the standard of care when assessing prosthetic heart valve (PHV) malfunction. We present a case study to demonstrate the role of multimodality imaging in PHV. Methods We reviewed a 25-year-old female with a history of rheumatic heart disease who underwent mitral valve repair in 2012 and aortic valve replacement in 2016 and was discharged on warfarin with no regular follow-up. In 2023, she was admitted with progressive exertional dysnoea and syncopal episodes and was found to have a sub therapeutic INR of 1.2. Auscultatory findings included pansystolic and diastolic murmurs. A 2D echocardiogram prior to admission revealed a well seated aortic valve prosthesis with reduced occluder motion and elevated transaortic gradients (AVmaxVel 5.6m/s AVmean PG 89mmHg,) with moderate AR and moderate MR. A bedside echo showed apical aneurysmal dilatation with poor contractility (LVEF 30-35%). Aortic valve malfunction was suspected. CXR showed valve prostheses in the mitral and aortic positions. Fluoroscopy revealed abnormal aortic valve prosthesis occluder motion which were stuck in the closed position. TOE further confirmed these findings. In the absence of onsite open heart surgery we elected to infuse a thrombolytic streptokinase but unfortunately the patient demised Results Doppler echocardiography is themethodof choice, with TOEpreferred over TTE in presence of technical difficulties. Cinefluoroscopy has a complementary role in evaluating disc mobility of mechanical PHVs and valve ring structure, Cardiac CT permits visualization of occluder motion in mechanical valves. CMR may be useful especially when TTE is non-diagnostic and TOE is undesirable. Nuclear imaging currently has very limited application in the evaluation of PHV other than in the setting of suspected infective endocarditis. Conclusion Multimodality imaging in assessing PHVs especially in technical difficulties/complications can provide incremental information vital for proper management. Submission ID: 41 UNUSUAL PRESENTATION OF AN ANOMALOUS RIGHT CORONARY ARTERY CHEBET CHEPKWONY Background The incidence of abnormal aorti c origin of the coronary arteries is low with reported values of approximately 0.64 percent of births and 0.17 percent inasymptomati c children and adolescents. In the anomalous aorti c origin of the right coronary artery (AAORCA), the anomalous right coronary artery (RCA) can eitheroriginate from the pulmonary artery, the ascending aorta, left ventricle, the left anterior descending artery, the left circumfl ex artery, the posterior sinus of Valsalva, orfrom the left sinus of Valsalva. The RCA arising from the left sinus of Valsalva is one of the most common subtypes. AAORCA can then undergo 3 diff erent courses: a high inter-arterial course between theaorta and pulmonary artery, a hypoplasti c anomalous orifi ce with shorter inter-arterial course or a low inter-arterial course between the aorta and right ventricular outf lowtract. Sudden Cardiac Death [SCD] and major adverse cardiac events like arrythmias that could lead to SCD were found to be signifi cantly higher in pati ents with a high inter-arterial course and on rare occasions angina and ischemia. Case presentation A 38 year old male pati ent presented to us with worsening anginal pain with diffi culty in breathing for two weeks. His chest pain score was at 7/10 atrest. The chest pain was relieved with nitroglycerin spray but he was having breakthrough conti nuous chest pain. He had no signifi cant past medical history. Initi al troponinlevel and subsequent values were normal. Electrocardiogram [ECG] showed normal sinus rhythm on admission. His 2D Echocardiogram was unremarkable. ECG gatedComputerized Tomographic Coronary Angiogram showed an anomalous origin of his right coronary artery fromthe left coronarysinuswithproximal inter-arterial coursebetween the aorta and pulmonary trunk. The RCA was dominant and ha a slit like appearance at origin. Left heart catheterizati on showed acute take off of RCA withdiffi culty to deliver equipment for stenti ng. He underwent successful ex-plantati on and re-implantati on of the right coronary artery with uneventf ul recovery andsubsequent discharge home. Conclusion Anomalous coronary artery with a malignant inter-arterial course is a very rare. It also rarely presents with angina and ischemia. The usual presentati on issudden cardiac death (SCD). Treatment opti ons include open heart surgery with ex-plantati on and re-implantati on of the anomalous coronary artery.
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