King Abdulaziz Cardiac Center Research Articles

Predictors of delayed pre-hospital presentation among patients with ST-segment elevation myocardial infarction.

Background: Early treatment of ST elevation myocardial infarction (STEMI) is essential to improve survival of these patients. However, not all patients present early enough to receive optimal treatment especially in third world countries. Social factors affecting early vs. late treatment have not been studied, particularly in the Middle East. Thus, the aim of this study was to determine the social factors associated with delayed presentation of STEMI patients. Methods: All patients with STEMI presenting to King Abdulaziz Cardiac Center (KACC) between October 2013 and July 2014 were approached. After obtaining consent, patients were interviewed regarding their psychosocial circumstances using a standardized questionnaire. Their medical charts were also reviewed for further clinical data. Patients were divided according to their symptom-to-door time into early ( ≤ 6h) and late (>6h) presentation and group comparisons were conducted. Results: A total of 79 patients were enrolled, of which 24 patients (30%) presented late. Patients with increased symptom-to-door time had higher prevalence of diabetes (40% vs. 79.2%, p = 0.001), hypertension (43.6% vs. 70.8%, p = 0.023), and dyslipidemia (23.6% vs. 54.2%, p = 0.009). Most of the late presenters did not undergo primary coronary intervention (72.7% vs. 47.8%, P = 0.034) and had less prior information about myocardial infarction (43.6% vs. 25%, P = 0.023). Late presenters were more often illiterates and lived most often far away from the hospital. Using multivariate logistic regression; dyslipidemia was the only independent predictor for the late hospital presentation for STEMI patients. Conclusion: One third of patients with STEMI present more than six hours after symptom onset; these patients have a higher prevalence of coronary risk factors and less information about STEMI. Programs should be designed to educate patients and the general public about the symptoms of STEMI and the necessary action to be taken if a heart attack is suspected.

What are the Predictors of Coronary Artery Disease in Young Saudi Arabian Patients

Background: Coronary artery disease (CAD) is defined as obstruction of the lumen of the coronary artery due to formation of atherosclerotic plaque. This eventually leads to reduced blood supply to the heart. It could lead to high morbidity and mortality. Risk factors for CAD are divided into modifiable or nonmodifiable. Modifiable such as diabetes, hypertension, hyperlipidemia, obesity, smoking while non-modifiable risks are family history, age, and gender according to previous studies. Objectives: The aim of this study is to identify the predictors and the prevalence of coronary disease risk factors among young Saudi patients. Methods: This study reviewed 1061 patients referred to the cardiac catheterization lab in King Abdulaziz Cardiac Center in Riyadh between the year 2008 and 2013. Included patients were males and females aged 18-45 years who underwent coronary angiography for various clinical indications. Results: The results were divided into two groups; Group A aged 35years. Male gender in Gp.A 143(16.1%) vs. Gp.B 746(83.9%) p-value= 0.500. Smoking Gp.A 84(15.8%) vs. Gp.B 446(84.2%) p=0.680. Obesity Gp.A 43(14.1%) vs. Gp.B 262(85.9%) p=0.234. Family history Gp.A 24(23.1%) vs. 80(76.9%) p=0.069. Hyperlipidemia Gp.A 40(12.9%) vs. Gp.B 271(87.1%) p=0.045. Hypertension Gp.A 20(8.2%) vs. Gp 233(91.8%) p= 35 years we found that HTN and Diabetes were statistically significant risk factors. Therefore, a modification of lifestyle habits is recommended.

Do We Need More Than a Transthoracic Echocardiography When Evaluating Children with Congenital Heart Disease before Cardiac Surgery?

To determine if a transthoracic echocardiography (TTE) can be used as the sole diagnostic imaging modality to evaluate children with congenital heart disease (CHD) undergoing cardiac surgery. A retrospective study was carried out at the King Abdulaziz Cardiac Center. We reviewed all pediatric patients who underwent cardiac surgery during the period January 2011 to December 2011. Three hundred ninety-two pediatric patients with CHD fulfilled the inclusion criteria. Of these patients, 287 (73%) underwent surgical interventions based on a TTE alone, while 105 (27%) required additional diagnostic imaging modalities, including a cardiac catheterization (68/105; 65%), cardiac computed tomography angiography (36/105; 34%), or cardiac magnetic resonance imaging (1/105; 1%). A TTE was not enough for all the patients who underwent a cardiac catheterization to find out additional anatomical information (22%), either to directly measure pulmonary artery pressures (62%) or to study vascular reactivity in patients with pulmonary hypertension (16%). Of 36 patients who underwent a cardiac computed tomography angiography, five (14%) had additional information to be added to TTE findings. Of all the patients, 81% had enough information using only the TTE compared to 19% in whom the TTE was not enough to provide all needed information. Only (7/392; 1.8%) patients had additional minor intraoperative findings that did not affect the surgical decision. Despite the emergence of other imaging modalities, a TTE can be used as the sole diagnostic imaging modality for a preoperative assessment in the majority of children with CHD. Other imaging modalities can be employed with limited indications.

4. Comparing risk factors profile in patients with Coronary Artery Disease who underwent cardiac catheterization with those revealed to have normal coronary arteries: A case-control study

Coronary Artery Disease (CAD) is one of the major causes of morbidity and a leading public health issue, comprising the death causes of millions of men and women worldwide. Most of prior studies in the region of the modifiable risk factors were cross-sectional studies. Study was conducted to compare those who revealed to have CAD after cardiac catheterization with those who shown to be free from CAD. The comparison planned based on the following variables: age, gender, Body Mass Index (BMI), smoking, hypertension, dyslipidemia, diabetes mellitus, and the presence or absence of family history of CAD, in order to identify significant risk factors of CAD in our population. Second objective was to identify the most important predictors for CAD, in order to help clinicians identifying main characteristics of a cardiac cath candidate in our population. A case-control study was conducted by extracting data of patients who underwent cardiac cath between 10th of June 2008 and 8 July 2013. Patients’ information was taken from King Abdulaziz Cardiac Center in Riyadh (KACC) catheterization lab with the following inclusion and exclusion criteria: Inclusion criteria: Age >18, both genders, suspected to have CAD and had at least one visit prior to catheterization. Exclusion criteria: other cardiac diseases including valvular disease, vacuities, congenital anomalies, and cath done not primarily to rule out CAD Sample size was calculated based on presence of family history with estimated proportion of 0.048 in controls, odd ratio of 3, 95% confidence level and 90% power to be 484 subjects in total (with a case to control ratio of 1:1, 242 for each group). The sample size then was maximized to include all patient who were found not having CAD after heart cath (total of 456 for control group), cases (those found to have CAD) were minimized to 456 subjects through computerized based simple random sampling technique. Data was recorded in data collection sheet based on subjects’ disease status (diseased, or not diseased), and their exposure to single or multiple factors. Total of 912 subjects included in the analysis, 456 for each group. The mean was 58.52 ± 13, and the mean BMI was 29.8 ± 6. Smoker were 25.5%, those with hypertension were 58%. Hyperlipidemia was experienced in 49%, diabetes in 50.7% of subjects. Family history of CAD presented in 4.8% of total subject who went for cardiac cath. All expected risk factors entered in the logistic regression analysis, and showed significantly different prevalence in patients with CAD compared to those without; gender (P < 0.001),diabetes (P < 0.001),age (P < 0.001), BMI (P < 0.001), dyslipidaemia (P < 0.001), smoking (P = 0.017), family history (P = 0.994) and hypertension with P < 0.001. The most important predictors of CAD in our population were age, gender, BMI, dyslipidaemia, diabetes mellitus and smoking. Whereas, family history was not recognized as predictor, this is may be due improper documentation of this variable in patient records.

43. Predictors of delayed presentation among patients with STEMI (ST elevation myocardial infarction) in King Abdul-Aziz Cardiac Center, Riyadh, KSA

Early treatment of ST elevation myocardial infarction (STEMI) is essential for the survival of these patients. Not all Saudi patients present early enough to receive optimal treatment. Thus, the aim of this study is to determine the social factors that are associated with delayed presentation of STEMI patients. All patients with STEMI presenting to King Abdul-Aziz Cardiac Center (KACC) from 10/2013 to 7/2014 were enrolled. After obtaining consent, patients were interviewed regarding their psychosocial circumstances using a questionnaire. Their medical charts were also reviewed for further clinical data. Patients were divided according to their symptom to door time into early (⩽6 h) and late (>6 h). Data comparison was done between them. A total of 79 patients were enrolled, of which 24 patients (30%) presented late. Patients with increased symptom to door time had higher prevalence of diabetes (40% vs. 79.2%, p = 0.001), hypertension (43.6% vs. 70.8%, p = 0.023), and dyslipidemia (23.6% vs. 54.2%, p = 0.009). Most of the late presenters did not undergo PCI (primary coronary intervention) (72.7% vs. 47.8%, p = 0.034) and had less background information about myocardial infarction (43.6% vs. 25%, p = 0.023). There was no significant difference between the two groups in other clinical and social variables. Almost 30% of our patients with STEMI presented more than six hours after symptom onset, these patients have high prevalence of coronary risk factors. Programs should be designed to educate these patients at risk about the symptoms of STEMI and the necessary action to be taken if a heart attack is suspected.

64. Evaluation of cardiovascular anomalies in conjoined twins: A single-centre experience from King Abdulaziz Cardiac Center

A Stanford Type A aortic dissection is a life-threatening surgical emergency that requires emergent surgery. The mortality after repair is high especially if the aortic dissection is complicated by visceral or peripheral malperfusion. We describe a case of a male patient who presented with an aortic dissection involving the ascending aorta, aortic arch, descending thoracic and the abdominal aorta up to the iliac bifurcation. The dissection also involved the visceral and renal arteries with evidence of superior mesenteric artery (SMA) occlusion. Successful outcome was achieved by endovascular stenting of his SMA, followed by Bental procedure. To the best of our knowledge this is the first case report in English literature of SMA stenting followed by Bental procedure to treat acute type A aortic dissection complicated by SMA occlusion.

Characteristics, treatment, and outcome of patients with acute coronary syndrome presenting at King Abdulaziz Cardiac Center compared with the European patients

The aim of this study was to examine the management of acute coronary syndrome (ACS) at King Abdul Aziz Cardiac Center (KACC) and to compare our practice with that of the European population of Euro Heart Survey—2009 (EHS 2009). This is a study of 3233 consecutive ACS patients who presented to KACC from January 2010 to December 2013. The data describing baseline characteristics, treatment, and outcome were collected and compared with that of EHS-2009 population. The diagnosis of ST elevation myocardial infarction (STEMI) and non-STEMI at KACC compared with EHS 2009 was 30 vs. 70% and 60.5 vs. 39.5%, respectively. Our population was younger with more male patients. Smoking, obesity, hypertension, hyperlipidaemia, diabetes, and renal failure were more common in the KACC population. More echocardiograms were performed at KACC, while the diagnostic angiograms performed were comparable in the two populations. More PCI procedures were performed for non-STEMI at KACC, while similar number of primary PCI was performed in two populations of STEMI. The adherence to the recommended medical therapy was more frequent in KACC population. Despite high burden of risk factors, the in-hospital mortality trend was lower at KACC compared with EHS-2009 population. KACC population was younger, with more risk factors for coronary artery disease and better adherence to guidelines recommended medical treatment. More PCI were performed at KACC for non-STEMI patients. The in-hospital mortality was lower at KACC compared with EHS-2009 population.

Adult cardiac critical care at the King Abdulaziz Cardiac Center.

Adult Cardiac Critical Cardiac Care division at the King Abdulaziz Cardiac Center – Riyadh, Saudi Arabia, was created in 2011 to address the critical care needs of cardiac surgery and adult cardiology patients that were beyond the scope of their specialties. The division offers its services in two semi-closed intensive care units consisting of 17 beds of Level 3 care. The concept and rationale behind this relatively new subspecialty and its organization in our center are presented in this brief report.

Organization and metrics of the Division of Advanced Cardiac Imaging, King Abdulaziz Cardiac Center

Non-invasive cardiac imaging (including nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance imaging) developed rapidly over the past few years. The leadership of King Abdulaziz Cardiac Center (KACC) adopted the concept of multimodality imaging cardiologist and developed in the year 2000 a strategic plan to invest in this new branch of cardiology. A new cardiac imaging center is currently under construction with the aim to be the hub for large enterprise of clinical, research, and educational activities. Awaiting the completion of the new imaging center, the division has been active in supporting a busy clinical service in temporary locations that allow access to all imaging modalities. Of note, the first 82-Rubidium cardiac PET MPI in the Middle East was performed at KACC in 2011. In addition, the imaging division plays an important role in the teaching and training of medical and paramedical students as well as community cardiologists and radiologist instructing them on the best practices in advanced cardiac imaging. Moreover, research is going to be an integral part of the division mission with >10 research protocols currently being active in the division. Thus, the advanced cardiac imaging division at KACC performs high-quality clinical work, educates and teaches local and regional physicians, and performs research. In short, it is a Saudi cardiac imaging service that operates on high-quality academic standards.

Predicted and observed mortality in adult cardiac surgery in the King Abdulaziz Cardiac Center: application of EuroSCORE I and EuroSCORE II

This paper was designed to review the risk for and the actual mortality rate of patients subjected to cardiac surgery at the King Abdulaziz Cardiac Center (KACC). The European System for Cardiac Operative Risk Evaluation (EuroSCORE I and EuroSCORE II) was used to assess the expected and observed operative risk of all (1176) patients undergoing cardiac surgery at the KACC from 2010 to 2012. The overall predicted mortality was 4.48% (SD 5.29) while the observed mortality was 1.27% (>30 days 0.42% and <30 days 0.85%). For all coronary artery bypass grafting (CABG), the EuroSCORE I over estimated mortality (3.8% predicted vs. 0.97% observed). The same was found to be true for isolated CABG (3.8% predicted vs. 0.38% observed) and for CABG plus valve cases (predicted 8.34% vs. 3.4% observed) or isolated valvular surgery (5% predicted vs. 2.9% observed). EuroSCORE II also showed the same trend as EuroSCORE I in a smaller group of patients of 411 (3.08% predicted vs. 0.731% observed mortality). EuroSCORE I and EuroSCORE II overestimated the predicted mortality in our cardiac surgery patients.

Modern organization of an echocardiographic laboratory: the experience of the King Abdulaziz Cardiac Center (KACC) in Riyadh

Today, echocardiography is a key diagnostic procedure in clinical and interventional cardiology with expanding indications and applications. It is based on a number of established and rapidly evolving techniques, which make cardiac ultrasound a complex and very specialized activity. High-volume and high-level echocardiographic laboratories are performing standard and advanced transthoracic, transoesophageal and stress-echo procedures as well as intraoperative and emergency examinations. These modalities require a high level of organization in order to guarantee adequate standards in terms of appropriateness, accuracy, reproducibility, timing and safety of all procedures, as well as in terms of education and research activity. We describe the organization of the Adult Echocardiography Laboratory at the King Abdulaziz Cardiac Center (KACC) in Riyadh, one of the greatest centers in Saudi Arabia.

Pediatric cardiology division, metrics, and organization

The pediatric cardiology division at the King Abdulaziz Cardiac center is a unit that provides a tertiary level of care for children with complex congenital and acquired heart diseases from all around Saudi Arabia. Further, we are also involved in training and research programs, both at national and international levels. This paper describes the organization and metrics of our section as well as our teaching and research activities. Besides our Pediatric Cardiology Fellowship Program, the following additional topics are outlined in detail: outpatient services, echocardiography, advanced cardiac imaging, cardiac catheterization, pediatric electrophysiology, pulmonary hypertension program, data collection, and academic activities.

Cardiac catheterization laboratory, organization, and metrics

The cardiac catheterization laboratory (cathlab) at King Abdulaziz Cardiac Center is a tertiary facility with the staff and technology to support advanced coronary, valvular, and structural heart disease therapies. The latest interventional devices and supporting diagnostic tools are in routine use. The facility has three biplane laboratories, which serve more than 2000 patients each year. Interventions are well supported by high-quality biplane flat panel imaging, intravascular ultrasound, fractional flow reserve, …

Evaluation of cardiovascular anomalies in conjoined twins: a single-center experience from King Abdulaziz Cardiac Center

The aim of the study is to describe varieties of congenital heart disease (CHD) in different types of conjoined twins (ConTw). This is a retrospective (from 1997 to 2014) analysis of 42 sets of ConTw with different levels of body and/or organ fusion, referred to our center for cardiac evaluation prior to separation. Conjoined twins were classified into Classes 1, 2, and 3 according to heart abnormalities and further subclasses of a, b, and c according to minor or major heart disease. Of the 42 sets, there were 35 sets of twins (83.3%) who were symmetrical including 3 craniopagus, 3 pygopagus, 14 thoracopagus, 11 omphalopagus, 3 ischiopagus, and 1 parapagus. Seven sets of twins (16.7%) were asymmetrical with a variable degree of thoraco-omphalo-ischiopagus fusion. Twenty-six of 40 sets (65%) were female. Overall incidence rate of cardiac abnormalities was 76.2%. Major cardiac abnormalities were common in thoracopagus twins (14 sets). Two sets (14%) shared the pericardium, whereas three sets (21.5%) were fused at atrial level, two sets (14%) at ventricle level, and seven sets (50%) had a severely malformed single heart with fusion at both the atrial and ventricular level. Conjoined twins have a high incidence of CHD. All symmetrical thoracopagus tetrapus twins had major cardiac abnormalities precluding their separation and all of them did not survive. Incidence of major cardiac malformations was less in the other types of ConTw.

Pediatric cardiac intensive care at the King Abdulaziz Cardiac Center

Pediatric cardiac intensive care is a subspecialty area that has evolved to address the special need for expert in post-operative care of children requiring heart surgery and interventions. Many hospitals have dedicated units to manage these patients. The ideal model for this care is a subject of debate. This brief paper describes evolution of this program at King AbdulAziz Medical City over the last 12 years.

Noncompaction cardiomyopathy: A new mechanism for mitral regurgitation with distinct clinical, echocardiographic features and pathological correlations

Noncompaction cardiomyopathy (NCCM) is a primary, genetic cardiomyopathy with variable clinical manifestations that include mitral regurgitation (MR). MethodsThis study comprised patients diagnosed with NCCM and MR in two cardiac centers (King Abdul-Aziz Cardiac Center, Riyadh, Kingdom of Saudi Arabia and Sudan Heart Institute, Khartoum, Sudan), and seen in the period between 2002 and 2013. The study describes follow up, clinical, echocardiographic, and histopathological findings. ResultsNineteen cases (85% females) were identified. Ten percent of the cases had relapses and remissions of heart failure. Echocardiographic features included leaflet retraction in all patients, characteristic malcoaptation, and a zigzag deformity of anterior leaflet in 57% of patients. Ruptured chordae were found in 15% of the patients. One patient had pathological examination of the mitral valve which showed myxomatous degeneration, and sclerotic and calcific changes. ConclusionWe describe and discuss a new mechanism for MR caused by NCCM with identifiable clinical and echocardiographic features, and pathological correlations.

Outcome of low body weight (

IntroductionInfants with low body weight (LBW) following cardiac surgery are a major challenge for the post cardiac surgery care unit. It has been observed that post surgery outcome for LBW infants is worse compared to the outcome of normal body weight infants. A study was conducted to compare post operative course and outcome of infants with body weight of 2.2kg or less against infants with normal body weight who underwent similar cardiac surgeries. MethodsA retrospective review was performed for all infants below 2.2kg who underwent cardiac operations at King Abdulaziz Cardiac Center from January 2001 to October 2011. Cases with LBW (Group A) were compared with matching group (Group B) of normal body weight infants who had similar cardiac surgeries and matching surgical risk category. The demographic, ICU parameters, complications, and short-term outcome of both groups were analyzed. ResultsTwo groups were formed, with 37 patients in Group A, and 39 patients in Group B. Except for weight (2.13±0.08kg in Group A vs 3.17±0.2kg in Group B), there was no statistical difference in demographic data between both groups. Cardiac procedures included coarctation repair, arterial switch, ventricular septal defect (VSD) repair, tetralogy of Fallot repair, systemic to pulmonary shunt and Norwood procedures. Patients in Group A had statistically significant difference from Group B in terms of bypass time (p=0.01), duration of inotropes (p=0.01), duration of mechanical ventilation (p=0.004), number of re-intubations (p=0.015), PCICU length of stay (p=0.007), and hospital mortality: 13.5% in Group A vs 0% in Group B (p value 0.02). ConclusionPatients with LBW (<2.2kg) underwent cardiac surgery with overall satisfactory results, but with increased risk of ICU morbidity and mortality.

Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery

Background and aimChylothorax is the accumulation of chyle in the pleural cavity, which usually develops after disruption of the thoracic duct along its intra-thoracic route. In the majority of cases, this rupture is secondary to trauma (including cardio thoracic surgeries). Chylothorax is a potentially serious complication after cardiovascular surgeries that require early diagnosis and adequate management. This study aims to determine the risk factors and the impact of chylothorax on the early postoperative course after pediatric cardiac surgery. MethodsA retrospective study of all cases complicated with chylothorax after pediatric cardiac surgery was conducted at King Abdulaziz Cardiac Center between January 2007 and December 2009. ResultsThere were 1135 cases operated on during the study period. Of these, 57 cases (5%) were complicated by chylothorax in the postoperative period. Thirty patients (54%) were males, while 27 (47%) were females. Ages ranged from 4 to 2759days. The most common surgeries complicated by chylothorax were the single ventricle repair surgeries (15 cases, 27%); arch repairs (10 cases, 18%); ventricular septal defect repairs (10 cases, 18%); atrioventricular septal defect repairs (7 cases, 12%); arterial switch repair (6 cases, 11%), and others (8 cases, 14%). The intensive care unit (ICU) and the length of hospital stays were significantly longer in the chylothorax group. Additionally, some early postoperative parameters such as incidence of sepsis, ventilation time, and inotropes duration and number were higher in the chylothorax group. ConclusionChylothorax after pediatric cardiac surgery is not a rare complication. It occurs more commonly with single ventricle repair and aortic arch repair surgeries, and has a significant impact on the postoperative course and post operative morbidity.

Do we need more than echocardiography before cardiac surgery for children with congenital heart defects

Detailed echocardiographic evaluation for children with congenital heart defects (CHD) can give a lot of information about the pathology. In this study, we aimed to verify whether echocardiography can be used as the main diagnostic modalityto evaluate children undergoing surgery to repair congenital heart defects (CHD). A retrospective review of all patients underwent cardiac surgery for CHD between January 2011 and December 2011 at King Abdulaziz Cardiac Center. The cardiac and hospital data base was reviewed for the diagnostic modalities used before cardiac surgery. The indications and additional value for tests other than echocardiography were evaluated. During the study period 392 patients fulfill the inclusion criteria. 269 (69%) patients underwent cardiac surgery based on echocardiography as the only diagnostic tool. 123 patients (31%) required diagnostic modalities other than echocardiography with one patient underwent cardiac MRI before pulmonary valve replacement, 36/123 patients (30%) underwent computerized tomography (CT) for vascular angiography. and 86 patients (70%) required cardiac catheterization of those 50/86 patients (58%) for hemodynamic assessment. Among all patients Echocardiography provided accurate diagnosis in 317 patients (81%) with confirmatory finding provided by the other diagnostic modality, while 75 patients (19%) were found to have additional diagnostic finding in the other diagnostic modality used. Only 7 patients (0.02%) were found to have additional diagnostic findings intra-operatively. Echocardiography can be used as the main diagnostic modality in majority of children requiring cardiac surgery. Other modalities can be used with limited indications.

Improvement in door-to-balloon time at King Abdulaziz Cardiac Center: Are we achieving the goal?

Background Early reperfusion in acute ST-segment elevation myocardial infarction (STEMI) is very important to improve patients clinical outcome. Implementing institutional plan to decrease door-to-balloon time is crucial to achieve this goal. Our goal is to met the ACC/AHA recommendations of door-to-balloon time Methods A chart review of all cases of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) performed. All door-to-balloon times were recorded. The average door-to-balloon time was calculated. Results 536 patients underwent primary PCI for STEMI from September 3, 2008–Sept 30, 2012. For each patient, the initial presenting time, the first ECG time, the time ER physician saw the patient and activate the cath lab, the time patient arrived to cath lab, and puncture time to balloon inflation were recorded. 52 patients were excluded from the study for not having clear door-to-balloon time. 64.2% of the patients met the ACC/AHA recommendation of Conclusion Sixty-four percent of patients underwent primary PCI in King Abdulaziz Cardiac Center met the recommended guidelines. In 2012, 86% met the recommended guidelines. Our future goal is to achieve the recommended guidelines in all patients.