Pakistan Journal of Cardiovascular Interventions <p>Pakistan Journal of Cardiovascular Interventions is a biannual, open access, peer-reviewed journal of the Pakistan Society of interventional cardiology. The journal publishes original research, reviews, clinical reports, case studies, legal and policy perspectives articles focusing on interventional procedures and techniques.</p> Pakistan society of interventional cardiology en-US Pakistan Journal of Cardiovascular Interventions 2790-4415 <p></p> The need for Self-Regulation employing Appropriate Use Criteria (AUC) <p>Involvement of our cardiology community in developing indigenous AUC in the light of current evidence shall enhance our understanding of the benefits and risks of different indications of procedures. The appropriate and universal use of AUC has the potential to improve patient care and, at the same time, prevent misuse of procedures. This shall surely result in a reduction of the overall cost. The way to rationally look at AUC is to understand that the mirror of AUC helps us reflect on the value of care we provide to patients. If we work hard towards this goal, we should be able to retain the privilege of self-regulation and, more significantly, the trust of our patients and community. To conclude, if we as cardiologists do not work hard to not only clearly define AUC but actively measure appropriateness, we stand a great chance of losing to self-regulate our clinical practice.</p> Mohammad Hafizullah Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 01 05 Nightmare of Coronary Wire Loop Jail from Side Branch to Main Vessel during Primary Percutaneous Coronary Interventions <p><strong>Background: </strong>Guide wire breakage and entrapment inside the coronary circulation are rare but extremely dangerous complications of coronary intervention that can be life-threatening by resulting in embolization of thrombi, perforation of the coronary vasculature, and thrombus development.</p> <p><strong>Case Presentation: </strong>A male patient who developed a complication of left circumflex artery guide wire looped and trapped under left anterior descending artery (LAD) stent during Primary PCI and went for emergency cardiac surgery for removal.</p> <p><strong>Management &amp; Results: </strong>Guide wire entrapment during the intervention should always consider this as a risk factor, especially when intervening in the tortuous coronary vasculature, and it is important to keep several wires, snare wires, and a surgical team on board as a backup.</p> <p><strong>Conclusion: </strong>Although guide wire entanglement infrequently occurs during interventions, interventionists should always be on the lookout for it, especially in patients with convoluted coronary arteries. Before working on these patient's coronary arteries, it's essential to have a surgical team, lots of wires, and snare wires on hand. These preventative measures may be effective in reducing death and morbidity under adverse conditions.</p> Mukesh Kumar Muhammad Naeem Mengal Taimur Asif Ali Tariq Ashraf Rizwan Qurban Ali Khawaja Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 35 39 Anomalous Coronary Artery Presenting with S-T Elevation Myocardial Infarction: A Case Report <p><strong>Background: </strong>Coronary artery anomalies are very rare congenital conditions. Rarely occurring but potentially fatal abnormalities of the coronary vasculature, abnormalities of the coronary arteries can cause significant cardiac events such as myocardial ischemia (S-T Segment elevation MI) and cardiac arrest.</p> <p><strong>Case Presentation: </strong>We are presenting a case of a 60 years old hypertensive female patient who presented with ST-segment elevation in all precordial leads.</p> <p><strong>Management &amp; Results: </strong>On angiography, a giant right coronary artery was seen, and no Left coronary artery origin was not appreciated. Hence, Multidimensional CT angiography was done that showed dilated and ectatic left main coronary artery circulation originating from the pulmonary artery just above the pulmonary valve. The patient was declared a high-risk surgical candidate, was advised medical therapy, including beta blockers, dual antiplatelet, and antihyperlipidemic medications, and was advised to restrict physical activity.</p> <p><strong>Conclusion: </strong>The rare presentation of an aberrant coronary artery is myocardial infarction with ST-segment elevation, and it might be difficult for doctors and cardiologists to determine the true reason without intervention. To optimize the care of these patients, traditional CAA and MDCT must be integrated with the clinical presentation of the patient.</p> Mukesh Kumar Rizwan Qurban Ali Khawaja Fawad Farooq Abdul Hakeem Atif Sher Muhammad Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 40 44 Percutaneous transluminal mitral valve commissurotomy Via Veno-Arterial loop method <p><strong>Background: </strong>Since its inception in 1984 by Inoue and colleagues, percutaneous trans venous mitral commissurotomy (PTMC) is the first line treatment option for severe mitral stenosis with favorable valve morphology. Critical mitral stenosis can however pose a challenge for balloon crossing to the left ventricle. Various techniques have been demonstrated to overcome this difficulty. We use a novel technique to cross mitral valve.</p> <p><strong>Case Presentation: </strong>We describe a case where critical stenosis of rheumatic mitral valve in a young lady which was not amenable to conventional PTMC procedure, was successfully performed via veno-arterial rail method.</p> <p><strong>Management &amp; Results: </strong>After crossing the interatrial septum, mitral valve was tried to cross with the standard technique using Inoue balloon, but failed because the stenosis was very tight. So we have crossed mitral valve through exchanged length terumo wire which was snared in descending aorta and externalized through right femoral artery and then we were able to pass the balloon through the tight mitral valve and the procedure was completed without any complication. Post procedure the pressure gradient dropped to 4mmHg and the mitral valve area was recorded as 1.8cm with 2D echo planimetry.</p> <p><strong>Conclusion: </strong>In difficult to cross MV during PTMC, the veno-arterial rail method can be used easily for a successful procedure.</p> Shah Zeb Muhammad Ishaq Khan Ijaz Hussain Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 45 49 The Impact of Early Successful Primary Percutaneous Coronary Intervention on Left Ventricular Systolic Function in ST Elevation Myocardial Infarction Patients <p><strong>Background: </strong>Treatment delay is considered to be one of the important predictors of survival in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We investigated the impact of early successful PPCI for STEMI patients on left ventricular ejection fraction.</p> <p><strong>Methodology: </strong>This prospective study was carried out on 50 patients having STEMI undergoing PPCI in NICVD Karachi. Patients were divided into two groups, Group A, early presenter, patients received treatment with PPCI within six hours of the onset of symptoms, and group B, late presenter, patients received treatment after six hours up to twenty-four hours of the onset of symptoms.</p> <p><strong>Results: </strong>Group A patients showed promising results, having achieved TIMI grade III flow in 100%, whereas 85% of patients achieved TIMI grade III flow in group B (P = 0.02). There was a statistical difference between the two groups. Using Independent sample T-Test Group A patients showed improved LVEF as compared to Group B (at presentation 45.49±3.99% vs. 35.25±3.85%; P = 0.001 and at 3 months follow up 55.66±0.92% vs. 45.75±1.44%; P = 0.001).</p> <p><strong>Conclusion: </strong>Early PPCI treatment of STEMI patients can lead to improved TIMI grade flow and LVEF. Efforts must be made to shorten the delay in reperfusion therapy.</p> Muhammad Rehanul Haq Mujeebullah Tareen Mukesh Kumar Abdul Hakeem Rajesh Kumar Jawaid Akbar Sial Tahir Saghir Syed Nadeem Hassan Rizvi Tariq Ashraf Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 06 10 Heparin Low Doses and Standard doses Effect on Transradial Catheterization <p><strong>Background: </strong>Transradial artery is being utilized by an expanding number of interventional cardiologists to perform percutaneous interventions. Nevertheless, occlusion of radial artery (RAO) is prominent after transradial (TR) catheterization. The use of anticoagulant drugs is one way to prevent RAO. The use of high-dose heparin and standard-dose heparin is still debatable. The present study will analyze the non-randomized controlled trials of standard and high doses of heparin for the prevention of radial artery occlusion after transradial catheterization.</p> <p><strong>Methodology: </strong>A prospective double-blinded non-randomized controlled trial was carried out. Demographic data on socio-economic statuses, such as age, occupation, gender, and smoking habits, were collected. Grouping was done so that patients may either be placed in group 1, which will receive 2500UI or into group 2, which will get 5000UI of unfractionated heparin. RAO was the critical endpoint of our study. Major bleeding, hematomas, and radial artery spasms were secondary outcome measures.</p> <p><strong>Results: </strong>471 patients were made part of this study. 235 patients were placed in group A which received 2500IU, and 236 were placed in group B, which received 5000IU. RAO was noted to be significantly higher in the group that received the standard dose of UFH as compared to the group that received a high dose of UFH (8 % vs. 3.3 %, p = 0.005). Female gender (OR: 2.951, 95% CI: 1.57-5.46, p = 0.002), hypertension (OR: 0.02, 95% CI: p = 0.005 and standard dose UFH (OR: 2.822, 95% CI: 1.343 – 5.911, p =. 0.007) were found to be the independent predictors of RAO.</p> <p><strong>Conclusion: </strong>Weight-adjusted higher dosage of UFH in TRA for diagnosis yielded remarkable results in reducing the rates of early RAO against the standard administered dosage.</p> Gul Shan Ahmad Tariq Ashraf Muhammad Zafarullah Safoora Anjum Samar Arfeen Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 11 19 The outcome of Intracoronary Tirofiban administration at Primary Percutaneous Coronary Intervention in St-Elevation Myocardial Infarction Patients <p><strong>Background: </strong>ST-elevation myocardial infarction results from obstruction of coronary flow due to intracoronary thrombus formation. Primary PCI is the gold standard and class-I indication for revascularization following STEMI. Investigators in this study aimed to evaluate the TIMI flow and myocardial blush grade after intracoronary Tirofiban administration in patients with STEMI during the primary percutaneous coronary intervention (PPCI) and its outcome.</p> <p><strong>Methodology: </strong>This Cohort study was conducted at Cardiology Department, Niazi Medical &amp; Dental College, Sargodha, after getting informed consent from patients with STEMI. Primary PCI was done in these patients, and two groups were formed. Tirofiban and Non-tirofiban group on basis of Tirofiban administration. Variables included TIMI Grade flow, myocardial blush, major bleeding, minor bleeding, hematoma, MACE, and mortality. P&lt;0.05 was considered statistically significant.</p> <p><strong>Results: </strong>The mean age of the study groups was 41.64 ± 12.30 years, with 74% (N=250) males. It was seen that 39 (31.2%) vs 41 (32.8%) with p-value of 0.786 were hypertensive, 28 (22.4%) vs 34 (27.2%) diabetic were having p-value of 0.380 whereas 34 (27.2%) vs 37 (29.6%) with p-value of 0.674 were smokers. TIMI flow grades in both groups were not similar and showed significant differences, indicating that both groups were independent, with a p-value &lt;0.05. The myocardial blush grade was compared in the two groups and the results showed that the score in both the groups was not similar, having significant differences as the p-value was 0.001; major bleeding compared with minor showed statistical insignificance, which indicated that there is a relationship between the two groups. (p-value=0.625 &amp; 0.705 respectively).</p> <p><strong>Conclusion </strong>Administration of intracoronary Tirofiban was associated with superior clinical prognosis in terms of TIMI flow and myocardial blush grades compared with the other group at primary PCI.</p> Muhammad Asim Saddique Muhammad Munawar Jamshaid Shahid Abbas Komal Jabeen Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 20 27 Frequency of new onset right bundle branch block in acute myocardial infarction and its coronary angiographic findings in patients presenting at Tertiary Care Hospital, Peshawar <p><strong>Background: </strong>Right bundle branch block has prognostic significance in the setting of acute myocardial infarction; this research is intended to determine the incidence of new-onset right bundle branch block in acute myocardial infarction and its angiographic findings.</p> <p><strong>Methodology: </strong>This descriptive cross-sectional study was conducted in a tertiary care hospital, i.e., the Cardiology Department, Lady Reading Hospital, Peshawar, from 13/5/2016 to 13/11/2016. A total of 91 patients were included in the study. Baseline investigation, including ECG (Nihan Koden), Coronary angiography (Siemens Healthineers), on patients who qualify for early invasive therapy and angiographic findings. All the information, like age and gender, was recorded. 91 patients with acute myocardial infarction who presented within 24 hours were observed, in which male to female ratio was 1.17:1. The study enrolled the age group from 30 up to 75 years.</p> <p><strong>Results: </strong>Average age was52.6±7.71 years. New onset right bundle branch block (RBBB) was found in 13(14.29%) patients in acute myocardial infarction.</p> <p><strong>Conclusion: </strong>In conclusion, RBBB was observed in 13% of patients where angiographic findings showed triple vessel disease 38.5%, double vessel coronary artery disease 30.8%, single vessel disease 15.4%, and left main stem disease15.4% respectively, there is a high rate of severe CAD in patients presenting with RBBB in the setting of the acute coronary syndrome, so early reperfusion is recommended.</p> Sami-ur- Rehman Abdur Rahim Jabbar Ali Wasim Sajjad Adil Bilal Rahid Ullah Daud Ahmad Jan Copyright (c) 2022 The Author 2022-06-01 2022-06-01 2 1 28 34