Background: Controversy regarding the definition of the upper limit of normal (ULN) for dilated m... more Background: Controversy regarding the definition of the upper limit of normal (ULN) for dilated mid-ascending aorta (mAA) stems from variation in criteria, based on several small-sized studies with small datasets of normal subjects (DONS). The present study was carried out to demonstrate this variation in the prevalence of mAA dilation and to identify the optimal definition by creating the largest DONS. Methods: Echocardiographic studies of patients ≥ 15 years of age performed at a large tertiary care center over 4 years ( n = 49,330) were retrospectively evaluated. The leading-edge-to-leading-edge technique was used to measure the mAA in diastole. The largest-to-date DONS ( n = 2334) was created, including those who were normal on medical record review, did not have any of the 28 causes of dilated aorta, and had normal echocardiograms. Because age had the strongest correlation with mAA (multivariate adjusted R2 = 0.26), as compared with sex, height, and weight, we created a new ULN...
Objectives The cutoff for dilated mid-ascending aorta (mAA) is controversial and has several defi... more Objectives The cutoff for dilated mid-ascending aorta (mAA) is controversial and has several definitions. The present study was carried out to determine the prevalence of mAA dilation based on published definitions and to identify the optimal cutoff. Methods Echocardiographic studies of patients >15 years of age performed at a large tertiary care center over 4 years, n = 49,330, were retrospectively evaluated. Leading-edge-to-leading-edge technique was used to measure the mAA in diastole. Several cutoff criteria were included. In addition, we defined normals in our database as those who, after 28 causes of dilated aorta were excluded, were normal both clinically and echocardiographically ( n = 2334). Results The mean age was 64.2 ± 17.1 years, and 31.5% were men. The prevalence of dilated mAA based on absolute criteria with sex stratification varied between 17% and 23% and based on relative criteria (to age, body surface area, and sex) varied between 6% and 11%. It further decrea...
Love at First Bite is a stop motion animation that is meant to highlight the benefits of chocolat... more Love at First Bite is a stop motion animation that is meant to highlight the benefits of chocolate and its uses throughout history. The benefits can be seen through the eyes of Dar-C, a dark chocolate shape-shifter, and a typical college student named Amy. The film combined three animation styles: traditional 2D, cutouts, and stop motion. The visual style of this film was influenced by the character design from the French film Ernest & Celestine and the overall feel of the television show Adventure Tim
This article aims to comment on pandemic preparedness strategies, especially for refugees and int... more This article aims to comment on pandemic preparedness strategies, especially for refugees and internally displaced persons (IDPs) in Yemen, and the obstacles that may hinder their success. Yemen is currently undergoing the largest humanitarian crisis worldwide, with 283,000 refugees from the Middle East and Africa, and 3.6 million internally displaced inhabitants. Basic needs including food, water and shelter have been compromised, in the setting of political unrest and financial instability. The effects of healthcare discrimination and inadequate healthcare facilities have intensified in the setting of the COVID-19 pandemic, where healthcare resources are of the utmost significance. This amounts to a wake-up call for concerned international bodies and charitable organizations to intensify their efforts in view of the rising infection rate. Since March 2020, numerous endeavors have been made by the United Nations High Commissioner for Refugees (UNHCR) and partners, such as the Inter...
Background: Dicrotic Notch (DN) is known to dampen with age, with increasing arterial stiffness p... more Background: Dicrotic Notch (DN) is known to dampen with age, with increasing arterial stiffness probably due to arterial calcification. Since arterial calcification has recently been shown to predominantly involve descending thoracic aorta, we hypothesized that calcification in different segments of thoracic aorta will have a different impact on DN. Methods: A sample of 44 patients with invasive thoracic aortic pressure tracings during cardiac catheterization was selected for this study. Non-contrast CT scans were evaluated for presence of calcification in aortic segments (ascending aorta (AA), aortic arch (arch) and descending aorta (DA)) and then quantified. DN was categorized based on aortic pressure tracings into 4 grades. Grade 1 represented normal DN; grades 2, 3 and 4 represented progressively diminishing DN, where grade 4 represented absent DN. Compliance was calculated as a change in stroke volume over aortic pulse pressure with both measurements obtained from echocardiogra...
Introduction: Routine hypercoagulability testing is not currently indicated in patients undergoin... more Introduction: Routine hypercoagulability testing is not currently indicated in patients undergoing plasma donation. We present two cases in young males without significant risk factors or other identifiable causes of stroke who unexpectedly developed ischemic strokes within 24 hours of donating plasma. Case Presentation: A 24-year-old man with a family history of factor V leiden deficiency presented with right sided weakness one hour after donating plasma. MRI brain revealed an acute infarct involving the left basal ganglia and adjacent periventricular region. Investigations including a glycohemoglobin level, lipid panel, echocardiogram, MRV brain, and cerebral angiogram were unremarkable. A hypercoagulable work-up revealed borderline elevations in factor II (129[percnt], reference range 65-120[percnt]). Testing for prothrombin 20210A mutation was negative. The patient was also found to be heterozygous for the MTHFR gene, with normal homocysteine levels. (6.1; reference range 4-12) ...
Objective: To find out the prevalence of CAS in patients undergoing CABGsurgery at KIHD. Methodol... more Objective: To find out the prevalence of CAS in patients undergoing CABGsurgery at KIHD. Methodology: This cross sectional study was conducted at the cardiology andcardiac surgery units of Karachi Institute of Heart Diseases, Karachi, Pakistanfrom September, 2013 to November, 2014. Consecutive patients undergoingCABG surgery at KIHD were included in the study. Doppler ultrasound study ofboth carotid arteries was done. Patients with previous CABG surgery, congestivecardiac failure and history of stroke or TIA were excluded. Results: A total of 56 patients were included. Of them 46 were males. The meanage was 56.77± 8.72 years. Significant CAS was found in 28(50%) patients.Bilateral CAS was found in 18(32.14%) patients. Unilateral CAS was found in5(8.93%) on each side. Conclusion: Significant CAS was found in majority of the patients undergoingCABG at our institution, signifying risk of CVA. Key Words: Coronary Artery Bypass Grafting , Carotid Artery Stenosis, CoronaryArtery Disease, ...
Catheterization and Cardiovascular Interventions, 2016
Background: A single small study (n=97) has suggested that absence of dicrotic notch (DN) in the ... more Background: A single small study (n=97) has suggested that absence of dicrotic notch (DN) in the coronary artery, distal to an intermediate stenosis, may indicate a significant stenosis, proven by an abnormal fractional flow reserve (FFR). This finding has neither been evaluated by other studies nor compared against other, more established, non hyperemic indices like Pd/Pa. It is unclear if DN is representative of coronary stenosis or coronary stiffness. Methods: Of the 926 FFR measurements performed in a large tertiary care center over last 4 years, we included 405 measurements after excluding tracings with inadequate baseline data and absent aortic DN. Tracings with pre-adenosine measurement with 8 cardiac cycles were printed and distal dicrotic notch (DDN) was characterized visually into four types, i.e., full notch, partial notch, definite change in angle of descending limb at the end of systole, and absent DN, by two different observers. Operating test characteristics of DDN were measured against the criterion standard of FFR ≤0.8 to detect significant ischemia. Coronary calcium score (CaSc), as a marker for coronary stiffness of the vessels, was evaluated by CT. Results: Out of 405 patients, 52 had absent DDN. The mean FFR in those with absent DDN was significantly lower (0.79 versus 0.86; p= \u3c0.0001) compared to those with a DDN. The receiver operating area under the curve (AUC) for predicting FFR \u3c0.80 was 0.59 (p\u3c0.0001) for DDN, as compared to 0.89 (p= \u3c0.0001) for baseline Pd/Pa. The sensitivity, specificity, PPV and NPV of DDN were 26%, 92%, 56%, 76%, respectively as compared to 79%, 82%, 63% and 91% for Pd/Pa \u3c 0.93. Those with absent DDN (n=5) had a much higher CaSc (897 vs. 463; p=0.11) than those with DDN (n=32). The AUC to predict absence of DDN by CaSc was 0.62. A CaSc of 82 or lower successfully ruled out an absent DDN. Conclusion: While DDN is associated with an abnormal FFR, our data suggest meaningfully lower performance in prediction of an abnormal FFR as compared to Pd/Pa, indicating that Pd/Pa should be preferred over DDN in clinical practice. DDN appears to be partially explained by coronary stiffness. Further studies to define the relative role of stenosis vs stiffness in regression of DDN are underway
Journal of the American College of Cardiology, 2016
A few prior studies have demonstrated the increased prevalence of dilated ascending aorta in pati... more A few prior studies have demonstrated the increased prevalence of dilated ascending aorta in patients with hypertrophic cardiomyopathy (HCM). There are no studies evaluating the relative association of HCM with sinus of Valsalva (SV) versus mid ascending aorta (MAA). In addition, the mechanism
Background: Controversy regarding the definition of the upper limit of normal (ULN) for dilated m... more Background: Controversy regarding the definition of the upper limit of normal (ULN) for dilated mid-ascending aorta (mAA) stems from variation in criteria, based on several small-sized studies with small datasets of normal subjects (DONS). The present study was carried out to demonstrate this variation in the prevalence of mAA dilation and to identify the optimal definition by creating the largest DONS. Methods: Echocardiographic studies of patients ≥ 15 years of age performed at a large tertiary care center over 4 years ( n = 49,330) were retrospectively evaluated. The leading-edge-to-leading-edge technique was used to measure the mAA in diastole. The largest-to-date DONS ( n = 2334) was created, including those who were normal on medical record review, did not have any of the 28 causes of dilated aorta, and had normal echocardiograms. Because age had the strongest correlation with mAA (multivariate adjusted R2 = 0.26), as compared with sex, height, and weight, we created a new ULN...
Objectives The cutoff for dilated mid-ascending aorta (mAA) is controversial and has several defi... more Objectives The cutoff for dilated mid-ascending aorta (mAA) is controversial and has several definitions. The present study was carried out to determine the prevalence of mAA dilation based on published definitions and to identify the optimal cutoff. Methods Echocardiographic studies of patients >15 years of age performed at a large tertiary care center over 4 years, n = 49,330, were retrospectively evaluated. Leading-edge-to-leading-edge technique was used to measure the mAA in diastole. Several cutoff criteria were included. In addition, we defined normals in our database as those who, after 28 causes of dilated aorta were excluded, were normal both clinically and echocardiographically ( n = 2334). Results The mean age was 64.2 ± 17.1 years, and 31.5% were men. The prevalence of dilated mAA based on absolute criteria with sex stratification varied between 17% and 23% and based on relative criteria (to age, body surface area, and sex) varied between 6% and 11%. It further decrea...
Love at First Bite is a stop motion animation that is meant to highlight the benefits of chocolat... more Love at First Bite is a stop motion animation that is meant to highlight the benefits of chocolate and its uses throughout history. The benefits can be seen through the eyes of Dar-C, a dark chocolate shape-shifter, and a typical college student named Amy. The film combined three animation styles: traditional 2D, cutouts, and stop motion. The visual style of this film was influenced by the character design from the French film Ernest & Celestine and the overall feel of the television show Adventure Tim
This article aims to comment on pandemic preparedness strategies, especially for refugees and int... more This article aims to comment on pandemic preparedness strategies, especially for refugees and internally displaced persons (IDPs) in Yemen, and the obstacles that may hinder their success. Yemen is currently undergoing the largest humanitarian crisis worldwide, with 283,000 refugees from the Middle East and Africa, and 3.6 million internally displaced inhabitants. Basic needs including food, water and shelter have been compromised, in the setting of political unrest and financial instability. The effects of healthcare discrimination and inadequate healthcare facilities have intensified in the setting of the COVID-19 pandemic, where healthcare resources are of the utmost significance. This amounts to a wake-up call for concerned international bodies and charitable organizations to intensify their efforts in view of the rising infection rate. Since March 2020, numerous endeavors have been made by the United Nations High Commissioner for Refugees (UNHCR) and partners, such as the Inter...
Background: Dicrotic Notch (DN) is known to dampen with age, with increasing arterial stiffness p... more Background: Dicrotic Notch (DN) is known to dampen with age, with increasing arterial stiffness probably due to arterial calcification. Since arterial calcification has recently been shown to predominantly involve descending thoracic aorta, we hypothesized that calcification in different segments of thoracic aorta will have a different impact on DN. Methods: A sample of 44 patients with invasive thoracic aortic pressure tracings during cardiac catheterization was selected for this study. Non-contrast CT scans were evaluated for presence of calcification in aortic segments (ascending aorta (AA), aortic arch (arch) and descending aorta (DA)) and then quantified. DN was categorized based on aortic pressure tracings into 4 grades. Grade 1 represented normal DN; grades 2, 3 and 4 represented progressively diminishing DN, where grade 4 represented absent DN. Compliance was calculated as a change in stroke volume over aortic pulse pressure with both measurements obtained from echocardiogra...
Introduction: Routine hypercoagulability testing is not currently indicated in patients undergoin... more Introduction: Routine hypercoagulability testing is not currently indicated in patients undergoing plasma donation. We present two cases in young males without significant risk factors or other identifiable causes of stroke who unexpectedly developed ischemic strokes within 24 hours of donating plasma. Case Presentation: A 24-year-old man with a family history of factor V leiden deficiency presented with right sided weakness one hour after donating plasma. MRI brain revealed an acute infarct involving the left basal ganglia and adjacent periventricular region. Investigations including a glycohemoglobin level, lipid panel, echocardiogram, MRV brain, and cerebral angiogram were unremarkable. A hypercoagulable work-up revealed borderline elevations in factor II (129[percnt], reference range 65-120[percnt]). Testing for prothrombin 20210A mutation was negative. The patient was also found to be heterozygous for the MTHFR gene, with normal homocysteine levels. (6.1; reference range 4-12) ...
Objective: To find out the prevalence of CAS in patients undergoing CABGsurgery at KIHD. Methodol... more Objective: To find out the prevalence of CAS in patients undergoing CABGsurgery at KIHD. Methodology: This cross sectional study was conducted at the cardiology andcardiac surgery units of Karachi Institute of Heart Diseases, Karachi, Pakistanfrom September, 2013 to November, 2014. Consecutive patients undergoingCABG surgery at KIHD were included in the study. Doppler ultrasound study ofboth carotid arteries was done. Patients with previous CABG surgery, congestivecardiac failure and history of stroke or TIA were excluded. Results: A total of 56 patients were included. Of them 46 were males. The meanage was 56.77± 8.72 years. Significant CAS was found in 28(50%) patients.Bilateral CAS was found in 18(32.14%) patients. Unilateral CAS was found in5(8.93%) on each side. Conclusion: Significant CAS was found in majority of the patients undergoingCABG at our institution, signifying risk of CVA. Key Words: Coronary Artery Bypass Grafting , Carotid Artery Stenosis, CoronaryArtery Disease, ...
Catheterization and Cardiovascular Interventions, 2016
Background: A single small study (n=97) has suggested that absence of dicrotic notch (DN) in the ... more Background: A single small study (n=97) has suggested that absence of dicrotic notch (DN) in the coronary artery, distal to an intermediate stenosis, may indicate a significant stenosis, proven by an abnormal fractional flow reserve (FFR). This finding has neither been evaluated by other studies nor compared against other, more established, non hyperemic indices like Pd/Pa. It is unclear if DN is representative of coronary stenosis or coronary stiffness. Methods: Of the 926 FFR measurements performed in a large tertiary care center over last 4 years, we included 405 measurements after excluding tracings with inadequate baseline data and absent aortic DN. Tracings with pre-adenosine measurement with 8 cardiac cycles were printed and distal dicrotic notch (DDN) was characterized visually into four types, i.e., full notch, partial notch, definite change in angle of descending limb at the end of systole, and absent DN, by two different observers. Operating test characteristics of DDN were measured against the criterion standard of FFR ≤0.8 to detect significant ischemia. Coronary calcium score (CaSc), as a marker for coronary stiffness of the vessels, was evaluated by CT. Results: Out of 405 patients, 52 had absent DDN. The mean FFR in those with absent DDN was significantly lower (0.79 versus 0.86; p= \u3c0.0001) compared to those with a DDN. The receiver operating area under the curve (AUC) for predicting FFR \u3c0.80 was 0.59 (p\u3c0.0001) for DDN, as compared to 0.89 (p= \u3c0.0001) for baseline Pd/Pa. The sensitivity, specificity, PPV and NPV of DDN were 26%, 92%, 56%, 76%, respectively as compared to 79%, 82%, 63% and 91% for Pd/Pa \u3c 0.93. Those with absent DDN (n=5) had a much higher CaSc (897 vs. 463; p=0.11) than those with DDN (n=32). The AUC to predict absence of DDN by CaSc was 0.62. A CaSc of 82 or lower successfully ruled out an absent DDN. Conclusion: While DDN is associated with an abnormal FFR, our data suggest meaningfully lower performance in prediction of an abnormal FFR as compared to Pd/Pa, indicating that Pd/Pa should be preferred over DDN in clinical practice. DDN appears to be partially explained by coronary stiffness. Further studies to define the relative role of stenosis vs stiffness in regression of DDN are underway
Journal of the American College of Cardiology, 2016
A few prior studies have demonstrated the increased prevalence of dilated ascending aorta in pati... more A few prior studies have demonstrated the increased prevalence of dilated ascending aorta in patients with hypertrophic cardiomyopathy (HCM). There are no studies evaluating the relative association of HCM with sinus of Valsalva (SV) versus mid ascending aorta (MAA). In addition, the mechanism
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