Introduction: Permanent pacemakers' (PPM) implantation is an integral part of electrophysiology and general cardiology. The implantation technique has evolved a lot since the first implantation. Several innovations have been undertaken to improve the effectiveness, life of the transplant, and patient outcomes. In this study, we introduced a new implantation technique to improve the procedure and possibly reduce the rate of complication. Methods: This study was conducted from January 2016 to February 2017 in Hayatabad Medical Complex, Peshawar. Patients destined for implantation of PPM based on a clinical treatment plan, after proper explanation of the procedure, were brought to the catheterization laboratory. Venogram of the upper limb performed. Patients were scrubbed and draped. The axillary vein was approached via the Seldinger technique. About 2 to 3 cm superolateral to the puncture site, a skin incision was made and subcutaneous pocket constructed, and a guidewire external end was pulled in from inside the pocket keeping the venous end at the place. Subsequently, in a routine way, lead was placed, secured and the wound was closed in layers.Results: A total of 690 PPM were implanted under the study. About 290 devices were implanted in the conventional way and 380 devices via the trans-axillary approach. The mean implantation time was less than 30 minutes via the trans-axillary approach. Immediate and delayed complications of the procedure were minimal. Conclusion:Trans-axillary approach holds some significant advantages over the conventional technique. The subcutaneous pocket and venous puncture successfully reduce the burden of foreign material, minimize the tension on the wound, shorten implantation time and reduce the chances of erosion of the device.

Objective: To analyze various factors contributing to delayed diagnosis of congenital heart disease (CHD) in pediatric population. Study Design: Cross-sectional study. Place and Duration of the Study: Department of Pediatrics and Department of Cardiology, Sheikh Khalifa Bin Zayed Al Nahyan Hospital, Rawalakot from January to December 2020. Material and Methods: A total of 265 children of both genders aged up to 15 years and presenting for the 1st time with the echocardiography confirmed diagnosis of CHD were enrolled. A special proforma was designed and questions were asked from parents/guardians of all study participants. Socio-demographic profile along with improper referral status and inadequate health facilities were noted. SPSS version 26.0 was used for statistical analysis. Qualitative variables like gender, area of residence, literacy status, socio-economic status, types of CHDs, delayed diagnosis (yes/no) and reasons for delayed diagnosis were represented as frequency and percentages. Results: In a total of 265 children included in the study, there were 156 (58.9%) male. Majority of the children, 184 (69.4%) were less than 2 years of age. Body weight below 3rd centile was noted in 164 (61.9%) children. Maternal fetal echocardiography was done in 13 (4.9%). Acyanotic CHD was noted in 180 (67.9%) children while remaining had cyanotic CHD 85 (32.1%). Delayed diagnosis of CHD was noticed in 211 (79.6%) children. Most common factor contributing to delayed diagnosis of CHD was found to be delayed 1st consultation in 85 (40.3%). Delayed or missed diagnosis by the doctor was the 2nd most frequent factor contributing to delayed diagnosis of CHD noted in 52 (24.6%) children. Delayed referrals were observed in 42 (19.9%) children. Conclusion: Delayed diagnosis of CHD was noted among 79.6% cases. Acyanotic CHD was the commonest type of CHD in the present study. Most common factors contributing to delayed diagnosis of CHD were delayed 1st consultation, delayed diagnosis by the doctor and delayed referrals. Keywords: Congenital heart disease, fetal echocardiography, delayed referrals

Objective: To find out the pattern of CHD and associated risk factors among children presenting at a tertiary care hospital. Study Design: A case-control study. Place and Duration of the Study: The Department of Pediatrics and Department of Cardiology, Sheikh Khalifa Bin Zayed Al Nahyan Hospital, Rawlakot from July 2020 to June 2021. Material and Methods: A total of 207 children of both genders, screened by ECG along with chest x-ray and further confirmed with the diagnosis of CHD through echocardiography were enrolled as cases. Same number of healthy controls (n=207) were recruited from immunization center of the study institution. Among cases, types of CHD were noted. For cases and controls, demographic, antenatal and maternal risk factors including maternal age, gender of the child, history of consanguinity, history of febrile illness in pregnancy, use or multi-vitamin or folic acid in pregnancy, bad obstetrical history and maternal diabetes mellitus were noted. Results: In a total of 414 children (207 cases and 207 controls), there were 219 (53.8%) male. In terms of CHD types among cases, VSD was the most noted in 62 (30.0%), ASD 35 (16.9%), TOF 33 (15.9%) and PDA in 30 (14.5%). Cases were found to have significant association with younger age (78.3% cases below 1 year of age vs. 64.7% in controls, p=0.0085), bad obstetrical history (p=0.0002), history of febrile illness in 1st trimester of pregnancy (p=0.0229) and lack of multivitamins and folic acid in the 1st trimester of pregnancy (p=0.0147). Conclusion: Majority of the children with CHDs were male and aged below 1 year. VSD, ASD, TOF and PDA were the most frequent types of CHD. Younger age, bad obstetrical history, history of febrile illness in 1st trimester of pregnancy and lack of multivitamins and folic acid in the 1st trimester of pregnancy were found to have significant association with CHDs among children. Keywords: Congenital heart disease, echocardiography, ventricular septal defect.

IntroductionImplantation of cardiac implantable electronic devices (CIEDs) is an art of science. As the volume of implantation has increased worldwide, so has the rate of complications. Infection, fibrosis, lead and device erosion, lead displacement, right ventricle perforation, lead fracture, and insulation break are the common complications in the implantation process. This exposes the patient for reopening and threatens the implantation for further complication due to infection, fibrosis of veins, failure to retrieve the implanted wire, and failure to re-implant the device on the same site. We slightly changed our implantation technique to preserve the implantation site for future implantation and reduce the rate of complication in the index implantation. MethodsThis randomized control trial was conducted from January 2016 to September 2019 at Hayatabad Medical Complex Peshawar, Pakistan. A consecutive sampling technique was used to obtain a sample size of 602 patients keeping a 95% confidence interval and a 5% margin error. We adopted a strategy to take prick, for implantation of devices, inside the pocket, which reduces the number of sutures, hastens the procedure, prevents erosion, and minimizes the chance of subclavian crush syndrome and insulation break. We also selected the minimum possible length of leads. This will possibly decrease the chances of cumbersome fibrosis around the lead and device and will make future implantation convenient. ResultsThere was a total of 602 procedures in the study period. About 253 (42%) procedures were done in the newly adopted strategy and 349 (58%) were performed in the conventional way. Our complication rate grossly reduces in the novel way of implantation in which we took our prick inside the pocket. ConclusionA slight modification in the implantation of CIEDs not only prevents the rate of complication in the index implantation but will also possibly preserve the site for future implantation.