Cardiac Resynchronization Therapy in Heart Failure in Sub-Saharan Africa Environment: Experience of the Principal Hospital of Dakar (Senegal)

Background: Heart failure is a major public health challenge in sub-Saharan Africa. In patients with chronic Heart Failure and cardiac desynchrony, studies have suggested that cardiac resynchronization, can improve cardiac function and the quality of life of patients. However, in Sub-Saharan Africa, very few studies have been done on cardiac resynchronization which is in its infancy. The aim of this study is to report the local data from our hospital. Method: It was a transversal, descriptive and analytical study conducted from November 2019 to September 2022 at the Cardiology Department of the Principal Hospital of Dakar. Results: Twelve patients were implanted for Cardiac Resynchronization Therapy (CRT). The sex ratio was 8 males/4 females. The average age was 67 ± 11 years. Ten patients had non-ischemic heart disease and the two others had ischemic one. All of them had NYHA III or IV scores before CRT. The Quality of Life (QOL) was judged as poor by all of the patients. The average duration of QRS was 156 ± 9 ms. 27.9% ± 5% was the mean Left Ventricular ejection fraction (LVEF). Complications occur in 3/12 patients (25%). It was one CS vein dissection, one micro LV lead dislodgement and one phrenic nerve stimulation. Nine patients, who were considered as responders, had an improvement of QOL and NYHA, the LVEF increased and the end-diastolic dimension, and the duration of the QRS interval all decreased. Two patients do not respond and one (1) who had permanent atrial fibrillation, was a secondary responder after an atrioventricular junction ablation. Conclusion: Cardiac resynchronization is a therapy that improves the QOL of patients, the LVEF and reduces the duration of the QRS interval. However, this procedure is not without risk of complications. In sub-Saharan Africa, the major challenge is to improve the financial accessibility of this therapy for the population.

Late Diagnosis of Takayasu Disease in a 50-Year-Old African Black Woman with Repeated Episodes of Heart Failure: Seeing the Forest through the Trees—A Case Report

Background: First described in 1908, TAK has now been recognized as a non-specific inflammatory disease of unknown etiology, predominantly affecting young females. Sometimes, it progresses into relatively rare and potentially fatal scenarios such heart failure. Case Presentation: Here, we present the case of a 50-year sub-saharan female suffering from acute heart failure related to TAK. Despite constitutional symptoms (fever, malaise, weight loss) and more characteristic features such claudication of lower extremities, carotydinia, and pulseless syndrome, diagnosis of TAK was delayed since main presentation was heart failure. Immunosuppressive and anticoagulant therapies have induced improvement in cardiac manifestations. Conclusion: Early diagnosis and proper treatment can protect the patient from dangerous complications such heart failure.

Low Cost Equipment and Short Duration Program Are Not Barriers to Good Outcomes of Cardiac Rehabilitation in Senegalese Patients with Coronary Artery Disease

Cardiac rehabilitation is still underused in Africa, despite its cost effectiveness widely demonstrated around the world. Aim: To evaluate the results of a cardiac rehabilitation program in the first Senegalese outpatient center in low resource context. Patients and Method: We carried out a prospective and interventional study. It compared on one hand a group of coronary patients at baseline and after 6 months of our rehabilitation program and on the other hand a control group of patients not enrolled in rehabilitation. Results: We included 70 patients (30 in the rehabilitation group and 40 in the control group). After rehabilitation, the functional capacity improved: 6.99 ± 2.9 Mets at M0 vs 8.8 ± 2.23 Mets at M6, p = 0.0001. Patients of intervention group significantly increased motivation to lifestyle changes and knowledge about their disease. We found better control at 6 months of hypertension (84.50% vs 33.70%, p = 0.003), diabetes (70.00% vs 26.70%, p = 0.0042), LDL cholesterol (33.00% vs 5.00%, p = 0.002) in the group “Rehabilitation”. Prevalence of psychosocial issues like anxiety and depression decreased in intervention group: 50.00% at M0 to 23.33% at M3 (p = 0.021), then 30.00% at M6 (p = 0.18). Return to work and resuming sexual activity were not significantly different. Conclusion: Comprehensive cardiac rehabilitation program, with low cost equipment in a short duration, could have real benefits in the management of coronary artery disease by reducing anxiety and depression, improving treatment compliance, control of cardiovascular risk factors, lifestyle changes and disease knowledge.

Atrial Fibrillation in Wolff Parkinson White Syndrome: About a Case in Senegal

WOLFF PARKINSON and WHITE (WPW) syndrome is the most common form of pre-excitation. It is associated in some cases with atrial fibrillation with a high risk of sudden death. We report the case of a 64-year-old hypertensive woman with a history of ischemic stroke. She presented with hyperkinetic palpitations without hemodynamics instability on admission. The electrocardiogram recorded a complete tachyarrhythmia by pre-excitation atrial fibrillation, with a mean rate of 300 beats per minute. Electrophysiological investigation revealed an accessory pathway located at the ostium of the coronary sinus, which was successfully ablated by radiofrequency. A drug treatment based on flecaine 100 mg was introduced. The patient was asymptomatic after one month of outpatient follow-up.

Inadvertent Lead Malposition in the Left Ventricle during Permanent Ventricular Pacing about One Case

Inadvertent Lead Malposition in Left Ventricle is a rare and underdiagnosed incident, which may occur during implantation of cardiac electronic devices and may remain asymptomatic. We reported the case of a 71-year-old man who was implanted with a ventricular single-chamber pacemaker for a slow atrial fibrillation with syncope and whose routine transthoracic echocardiography 23 months after implantation displayed a malposition of the pacemaker lead into the Left Ventricle through a patent foramen oval. The patient was asymptomatic. The electrocardiogram showed right bundle branch block QRS-paced morphology with a positive QRS pattern in V1, a median paced QRS axis on the frontal plane at -120°, a Precordial transition on V5. At the lateral Chest X-ray the lead curved backwards to the spine. Given the age of this old patient who already received oral anticoagulant for Atrial Fibrillation and the Lead malposition discovered 23 months after pacemaker’s implantation, we decided to maintain the lead in LV and continue anticoagulation.

Myocardial Infarction Complicating Vasospastic Angina in a Female Patient—Case Report

Coronary artery vasospasm is an infrequent cause of acute coronary syndrome (ACS). A 50-year-old female developed persistent chest discomfort related to anterior STEMI. After an unsuccessful thrombolysis attempt, due to delay concern, the patient was then sent to the catheterization laboratory for rescue PCI. The coronary angiogram revealed a TIMI 3 flow proximal LAD significant stenosis with spastic appearance of the coronary arteries which has improved after intracoronary nitrates administration. Optical Coherence Tomography (OCT) excluded coronary artery dissection and haematoma also revealed thrombus on moderate atherosclerotic plaque. The patient was then pain-free;she was managed medically and discharged after few days of monitoring. Three weeks later, she developed transient chest pain with ST segment elevation while cycling during rehabilitation program. Provocation test by Ergonovine was positive with complete occlusion of proximal RCA (right coronary artery) complicated by transient complete heart block and shock. She was stabilized with 7 mg of intracoronary nitrates injection. She was discharged after close monitoring with calcium channel blocker and tobacco cessation. ACS may complicate prolonged coronary artery vasospasm making the diagnosis challenging. OCT may help understand ACS mechanism and exclude spontaneous coronary artery dissection. Provocation test is crucial for confirmation.

Cardiovascular and Cerebrovascular Prognosis at 5 Years of Patients Who Presented with an Ischemic Stroke at Principal Hospital of Dakar

Aims: To determine the cardiovascular and cerebrovascular prognosis at 5 years of patients who underwent an ischemic stroke in Senegal. Methods: We performed a descriptive, retrospective and exhaustive study conducted at Principal Hospital of Dakar. We included all patients hospitalized at Principal Hospital of Dakar from 2013 to 2019 for an ischemic stroke confirmed by a cerebral CT-Scanner or by magnetic resonance imaging, and who survived the acute phase. Results: Overall, one hundred and seventy-one (171) patients were gathered. Ninety-six (96) male patients account for 56.14% and seventy-five (75) female patients account for 43.86%, with a sex ratio of 1.28. Patients’mean age was 66.33 ±13.99 years. Twenty-one (21) young patients (12.35%), aged less than 50 years, presented with an ischemic stroke. Myocardial infarction was found in a female patient (0.6%) 3 months after she experienced an ischemic stroke, nine (9) patients (5.29%) underwent a recurrence of the ischemic stroke with a mean recurrence period of 8 months and extremes ranging from 1 to 24 months. Five (5) patients (2.92%) developed dementia with a score less than 28. A 30 years old patient presented with epilepsy 12 months after the ischemic stroke accounting for 0.58%. We registered ninety (90) deaths that occurred in a mean period of 24 months ± 9.8 after they presented their ischemic stroke, standing for 52.63% amongst which thirty-five (35) accounting for 39% were female patients and fifty-five patients (55) representing 61% were male patients. Mortality-related factors included: advanced age, past medical history of heart surgery, known as dyslipidemia, physical inactivity, obesity and recurrent ischemic stroke. Conclusion: Long-term prognosis of ischemic stroke remains unclear in Senegal. Therefore, a strategy for primary prevention is highly crucial and it requires the control of risk factors in general and that of high blood pressure in particular.

Conservative Approach Might Be the Strategy by Default in Stable Angina Patients: A Case Report

Management of stable angina is still a matter of debate. Whether a conservative or invasive approach is better remains unclear. Even though recent large-scale randomized trials depict the conservative strategy as safe and efficient. In this report, we present a case of a 53-year-old male patient with cardiovascular risk factors of hypertension and hypercholesterolemia. He complained about typical chest pain at exertion. The coronary angiogram (CA) revealed severe stenosis of the proximal left anterior descending artery (LAD) ostium. After heart team discussion, coronary artery bypass graft (CABG) was advocated. However, due to a lack of means, the CABG was postponed. Meanwhile, he was managed with guideline-based medical therapy. In addition, he exercised regularly and adopted a healthy diet. Evolution was favorable with excellent symptoms control. A regular follow-up was organized with his cardiologist. A new CA before an eventual CABG six years later showed a significant plaque volume regression of the proximal LAD. We decided to continue conservative management. The stress echocardiogram to assess symptoms and exercise tolerance was normal. Our patient was sent to surgery on top of optimal medical therapy even though angioplasty was a good indication and was feasible. However, while he was struggling to afford the CABG procedure, he adopted a very healthy lifestyle along with medical therapy. Six years later, the result of that approach was without appeal, suggesting and reinforcing the conservative management of stable heart disease over invasive strategy. The recent ISCHEMIA trial is a major argument supporting that approach.

Sex Differences in Clinical and Angiographic Characteristics in Acute Coronary Syndrome Patients in Dakar, Senegal

Background: Coronary artery disease (CAD) is in relentless progression, along with the adoption of western lifestyle in sub-Saharan Africa. In Senegal, the incidence of acute coronary syndrome (ACS) rose from 5% to 12% in Dakar during the last 20 years. That increase was observed in both women and men, and according to current data, the former paid the heaviest price in terms of mortality compared to men. In this study, we aim to retrospectively assess the clinical characteristics and angiographic profile of ACS in women compared to men in two tertiary care centers in Dakar. Methods: In this study, we retrospectively analyzed and compared data between men and women among 133 patients who underwent coronary angiogram for ACS in 2 tertiary centers from February 2019 to January 2020. Results: A total of 133 patients were included in our study of whom 97 (72.9%) were men. The mean age was 58 ± 13.6 years. Women were older than men (61.4 ± 14.3 years vs 56.6 ± 13.5 years (p = 0.07). Hypertension, sedentary lifestyle and obesity were significantly more frequent in women (69.4%, 52.7% and 19.4%) when compared to men (38.8%, 25.7% and 6.19%) respectively, (p = 0.001;0.002 and 0.03). Smoking was less frequent in women (2.8%) than in men (44.3%), (p Conclusion: In our study, women with ACS were older, had more cardiovascular risk factors but less angiographic extent of disease than men.

MINOCA Resulting from Coronary Spasm Confirmed Angiographically without Ergonovine Stimulation: A Case Report

Introduction: Myocardial infarction with nonobstructive coronary arteries disease (MINOCA) encompasses a heterogeneous group of disorders. Multimodality imaging is crucial to figure out the underlying mechanism. Coronary artery spasm is a common cause of MINOCA and might be difficult to identify. Case Presentation: A 43-year-old male with no cardiovascular risk factor presented with prolonged acute chest pain at 5 am that resolved spontaneously. On admission, he was asymptomatic and clinical findings were unremarkable. The electrocardiogram showed an anterolateral negative T wave. The troponin was positive. Coronary angiography (CA) revealed a moderate lesion of the proximal left anterior descending (LAD) coronary artery. He was treated with dual antiplatelet therapy, statin, and beta-blocker with a favourable hospital course. One week later, he presented chest pain recurrences with anterior ST-segment elevation. CA, without intra-radial nitrate, owing to a vasospasm suspicion, showed a sub-occlusion of the proximal LAD which resolved after intracoronary nitrates. Chest pain and ST-segment elevation then disappeared. He remained asymptomatic and was discharged on CCB (calcium channel blocker), long-acting nitrates dual antiplatelet and statin. Cardiac magnetic resonance (CMR) demonstrated an ejection fraction (EF) of 45% with anterior ischemia. Conclusion: Our case is about a common cause of MINOCA, namely coronary spasm, diagnosed by coronary angiogram without provocative test.

Pulmonary Embolism in Young Patients: About 24 Cases at the Cardiology Department of Dakar Principal Hospital in Senegal

Introduction: Pulmonary embolism is a relatively common life-threatening cardiovascular emergency. It remains a diagnostic problem because of its nonspecific clinical signs. Objective: The general objective was to study pulmonary embolism in young patients admitted to the cardiology department of Dakar Principal Hospital in Senegal. Methodology: This was a retrospective, descriptive and analytical study in the cardiology department of the Dakar Principal Hospital over a period of two (02) years from January 1, 2015 to December 31, 2016 in young patients admitted for pulmonary embolism. Results: We collected 24 patients with a hospital prevalence of 2.18%. The average age was 42.29 years ± 8.41 years with a male predominance (sex ratio of 1.6). The Wells probability score was low in 54.16% of patients and medium in 45.83%. Functional signs were dominated by chest pain (83.33% of cases) followed by dyspnea (79.16% of cases). The thromboembolic risk factors found were gynecological-obstetrical in 16.6% of cases followed by prolonged bed rest. One case of thrombophilia was present with a deficiency of protein C and antithrombin III. The electrocardiogram recorded sinus tachycardia in 29.16% of patients;the Mac Ginn White sign (S1Q3T3) was found in 25% of cases. Echocardiography showed pulmonary arterial hypertension in 12.48% of cases, dilation of the right ventricle and a paradoxical septal motion in 14.28% of cases. CT pulmonary angiography showed 63.63% of cases with bilateral pulmonary embolism;it was unilateral in 22.72% of cases. Long-term anticoagulation was based on acenocoumarol 4 mg (66.7%) and Rivaroxaban (33.3%). 62.5% of the patients were seen at the 3rd month, when a checking was made to evaluate the tolerance of the treatment, and the evolution of the patient. Conclusion: Pulmonary embolism is not a rare condition in young subjects but is often underdiagnosed. Gyneco-obstetrical factors are predominant in this age group. Direct oral anticoagulants are more and more prescribed in our countries.

Double Compression of Left Atrium and Pulmonary Artery by a Huge Descending Aortic Aneurysm with Intramural Hematoma Mimicking Pulmonary Embolism: A Case Report

Hemodynamic instability secondary to left atrial (LA) compression by an aortic aneurysm is a rare entity. We report?the case of a 43-year old woman with no previous diagnosis of congestive heart failure who was admitted for an initial diagnosis of pulmonary embolism (PE) based on shortness of breath, hypotension and D-Dimers?elevation. The electrocardiogram and blood counts were within normal limits. The chest X-ray revealed widening of the mediastinum. Transthoracic echocardiography demonstrated LA compression by a large descending thoracic aortic aneurysm. Left and right ventricle systolic functions were preserved. Chest angiography showed LA and left pulmonary artery (LPA) compression by a descending aortic aneurysm and an intramural hematoma with no evidence of PE evidence. Emergency surgery could not be done because of her financial status. She was treated medically and was discharged 1?week later with significant improvement. However she remained hypotensive.

Coronary Angioplasty in a Low Income Sub-Saharan Country: Situational Analysis

Introduction: Coronary angioplasty is not widely conducted in sub-Saharan Africa in general and Senegal in particular. The objective of this work was to describe the indications, techniques, results and difficulties of coronary angioplasty in Senegal. Patients and Methods: We prospectively included all patients who underwent coronary angioplasty between July 2012 and November 2014. We evaluated the clinical characteristics, techniques used, and the peri-procedural complications. Results: 110 coronary angioplasties were performed at the cardiac catheterisation unit of the Clinique du Golf in Dakar. The average age of patients was 60.41 ± 10.93 years. A male predominance was noted with a sex ratio of 6.3. Hypertension was found in 57% of patients. The principal indications for coronary angioplasty were for the management of acute coronary syndromes with or without ST elevation, in 29 and 39 patients respectively. The femoral artery was the puncture site in 104 patients. The lesions treated were type A/B1 or B2/C in 53 and 57 cases respectively. The success rates of coronary angioplasties and 30-day mortality were 91% and 0.9% respectively. Conclusion: In sub-Saharan Africa, Senegal in particular, the practice of coronary angioplasty is low. Indeed, many factors linked to socioeconomic status limit the development of coronary angioplasty in Senegal.