BackgroundThe pacemaker-twiddler’s syndrome is an uncommon cause of pacemaker malfunction. It occurs due to unintentional or deliberate manipulation of the pacemaker pulse generator within its skin pocket by the patient. This causes coiling of the lead and its dislodgement, resulting in failure of ventricular pacing. More commonly reported among elderly females with impaired cognition, the phenomenon usually occurs in the first year following pacemaker implantation. Treatment involves repositioning of the dislodged leads and suture fixation of the lead and pulse generator within its pocket.Case presentationAn 87 year old Bangladeshi lady who underwent a single chamber ventricular pacemaker (VVI mode: i.e. ventricle paced, ventricle sensed, inhibitory mode) implantation with the indication of complete heart block, and presented to us again 7 weeks later, with syncopal attacks. She admitted to repeatedly manipulating the pacemaker generator in her left pectoral region. Physical examination revealed a heart rate of 42 beats/minute, blood pressure 140/80 mmHg and bilateral crackles on lung auscultation. She had no cognitive deficit.An immediate electrocardiogram showed complete heart block with pacemaker spikes and failure to capture. Chest X-ray showed coiled and retracted right ventricular lead and rotated pulse generator. An emergent temporary pace maker was set at a rate of 60 beats per minute. Subsequently, she underwent successful lead repositioning with strong counselling to avoid further twiddling.ConclusionTwiddler’s syndrome should be considered as a cause of pacemaker failure in elderly patients presenting with bradyarrythmias following pacemaker implantation. Chest X-ray and electrocardiograms are simple and easily-available first line investigations for its diagnosis. Lead repositioning is required, however proper patient education and counselling against further manipulation is paramount to long-term management.

Aims: Radial approach is gaining the momentum as a default technique for coronary procedures. Limited trails are available for post coronary artery bypass graft (CABG) patients to compare the merits of femoral & radial access. Methods: It is a single-center study conducted in between January, 2013 to December, 2015. During this study period, post CABG patients were blindly assigned to its five high volume operators. Coronary angiography & intervention procedures were performed by left radial or femoral approach as per assigned operator's choice. Contrast volume was the primary endpoint whereas the procedure & fluoroscopy time, procedural success, access site major bleeding, pre discharge major adverse cardiac event (MACE) were the secondary endpoint both for coronary angiogram (CAG) & percutaneous coronary intervention (PCI). Results: Total 380 post CABG patients were included in this study period. Radial access (n=155) was lower than femoral access (n=225). Compared with femoral access, diagnostic CAG required relatively lower contrast volume though statistically not significant via radial access (70±34 vs. 72±40 ml, p=0.267). Procedure time (25.2±10.7 vs. 26.9±6.8 min, p=0.735), fluoroscopy time (10.7±5.5 vs. 9.5±4.7 min, p=0.424) were almost similar in both access for CAG. Other secondary clinical endpoints were similar among both groups. Interestingly, adhoc PCI was more frequent in radial group (n=54 out of 155, 34.8%) than in femoral group (n=44 out of 225, 19.6%) with p=0.01. Contrast volume in between two groups was pretty similar with p=0.226. The incidence of other secondary endpoints was also not statistically significant. Conclusion: Coronary angiography for post CABG patients through left radial approach seems to be effective, non-inferior in terms of contrast volume, procedure & fluoroscopy time & other clinical end points comparing to femoral access. Anwer Khan Modern Medical College Journal Vol. 10, No. 1: Jan 2019, P 11-16

Background Early revascularization and treatment is key to improving clinical outcomes and reducing mortality in acute myocardial infarction (AMI). In low- and middle-income countries such as Bangladesh, timely management of AMI is challenging, with pre-hospital delays playing a significant role. This study was designed to investigate pre-hospital delay and its associated factors among patients presenting with AMI in the capital city of Dhaka. Methods This retrospective cohort study was conducted on 333 patients presenting with AMI over a 3-month period at two of the largest primary reperfusion-capable tertiary cardiac care centres in Dhaka. Of the total patients, 239(71.8%) were admitted in the National Institute of Cardiovascular Diseases, Dhaka and 94(28.2%) at Ibrahim Cardiac Hospital & Research Institute, Dhaka Data were collected from patients by semi-structured interview and hospital medical records. Pre-hospital delay (median and inter-quartile range) was calculated. Statistical significance was determined by Chi-square test. Multivariate logistic regression analysis was done to determine the independent predictors of pre-hospital delay. Results The mean age of the respondents was 53.8±11.2 years. Two-thirds (67.6%) of the respondents were males. Median total pre-hospital delay was 11.5 (IQR-18.3) hours with median decision time from symptom onset to seeking medical care being 3.0 (IQR: 11.0) hours. Nearly half (48.9%) of patients presented to the hospital more than 12 hours after symptom onset. On multivariate logistic regression analysis, AMI patients with absence of typical chest pain [OR 5.21; (95% CI: 2.5–9.9)], diabetes [OR: 1.7 (95% CI: 1.0–2.9)], residing/staying > 30 km away from nearest hospital at the time of onset [OR: 4.3(95% CI = 2.3–7.2)] and belonged to lower and middle class [OR: 1.9(95% CI = 1.0–3.5)] were significantly associated with pre-hospital delays. Conclusion Acute myocardial infarction (AMI) patients with atypical chest pain, diabetes, staying far away from nearest hospital and belonged to lower and middle socioeconomic strata were significantly associated with pre-hospital delays. The findings could have immense implications for improvements about timely reaching of AMI patients to the hospital within the context of their sociodemographic status and geographic barriers of the city.

Background & objective: Left main coronary artery (LMCA) stenosis (defined as 50 or > 50 percent narrowing of luminal diameter) usually has a bad prognosis unless revascularization done. Isolated left main coronary artery (ILMCA) disease is a rare clinical entity. Although it carries a grave prognosis, its etiology is not well-understood. Determining risk factors for ILMCA disease might be promising in the preventive strategy of ischemic heart diseases. The aim of this study was to determine the demographic and traditional risk factors for left main coronary artery disease.

Background: Transradial cardiac catheterization (TCC) is now preferred method over trans-femoral approach globally including Bangladesh. But the incidence of radial artery occlusion (RAO) after TCC is not infrequent and it ranges from 1-18% in different studies. The aim of our study was to see the incidence of RAO after TCC in a population coming for coronary angiogram and/or coronary intervention and also to evaluate the factors responsible for RAO. Methods: The observational prospective study was performed in all consecutive patients coming for TCC. Pre and three month post-procedural modified Allen’s test, reverse Barbeau test & Duplex ultrasonography for radial artery diameter (RAD), peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistance index (RI) were measured. Results: 69 patients underwent TCC. Mean age was 54 years, 67% were male, 80% hypertensive, 65% diabetic. Follow-up at third month showed one total RAO (1.45%) and mean RAD of the remaining patients was significantly reduced from 2.2+0.03 mm to 2.1+0.03 mm (p=0.001) but none had any symptom or sign of ischemic hand. PSV, EDV & RI were not significantly altered. Reduction of RAD (to <2.0 mm) were significantly higher in female (p=0.032), but no association was found in presence of diabetes or its duration, hypertension, dyslipidaemia, smoking, peripheral vascular disease. The size & number of catheters used or duration of vascular access sheath kept in the artery did not affect the reduction of RAD.Conclusion: The mean RAD of the study was smaller than other study population, but incidence of RAO is very low. RAD was significantly reduced after procedure without any clinical evidence of ischemia or alteration of flow velocity. Female sex was the only factor found to be associated with reduction of RAD in this study.University Heart Journal Vol. 10, No. 2, July 2014; 66-72