Objectives: This study evaluated the immediate procedural outcomes, complications, and predictors of adverse events following balloon pulmonary valvuloplasty (BPV) in infants and young children with impaired right ventricular (RV) function. Methodology: This prospective observational study included consecutive children weighing less than 10 kg who underwent BPV for isolated moderate-to-severe valvular pulmonary stenosis at a tertiary pediatric cardiac center between July 2006 and June 2024. Patients were categorized according to baseline RV systolic function using predefined echocardiographic criteria. Demographic characteristics, procedural variables, hemodynamic measurements, procedural success, and peri-procedural complications were prospectively recorded and compared between children with normal and impaired RV function. Binary logistic regression analysis was performed to identify factors independently associated with procedural complications. Results: A total of 368 children underwent BPV during the study period, including 93 (25.3%) with impaired RV function. Overall procedural success was achieved in 342 patients (92.9%). Children with impaired RV function had significantly lower procedural success than those with preserved RV function (88.2% vs. 94.5%; p=0.038) and experienced significantly longer procedure and fluoroscopy times. Procedural complications occurred in 52 children (14%), whereas serious complications occurred in eight patients (2%). Arrhythmias and cardiopulmonary resuscitation were significantly more frequent in children with impaired RV function. Binary logistic regression demonstrated that impaired RV function independently increased the likelihood of procedural complications (OR=2.5, 95% CI 1.34–4.70; p=0.004). Despite the increased procedural risk, 99% of children with impaired RV function demonstrated early improvement in RV systolic function within 24–48 hours after intervention. Conclusion: Balloon pulmonary valvuloplasty provides excellent immediate hemodynamic and clinical outcomes in infants and young children with significant valvular pulmonary stenosis, including those with impaired RV systolic function. Although impaired RV function is associated with a higher risk of peri-procedural complications, successful intervention can be achieved in the majority of patients when meticulous procedural planning, careful catheter manipulation, comprehensive hemodynamic monitoring, and appropriate balloon sizing are employed.
Objectives: This study aimed to evaluate the natural course, spontaneous closure rate, and occurrence of structural complications among children with isolated small perimembranous ventricular septal defects (PM-VSDs managed at a tertiary cardiac center in Karachi. Methodology: This prospective observational cohort study was conducted at the Department of Pediatric Cardiology, National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan, between November 2025 and May 2026. A small PM-VSD was defined echocardiographically as a ventricular septal defect measuring less than 50% of the aortic annulus diameter, demonstrating a peak Doppler pressure gradient ≥50 mmHg, with no evidence of pulmonary hypertension or left heart chamber enlargement. A total of 550 consecutive pediatric patients aged 2–15 years with isolated small PM-VSDs were enrolled and followed prospectively through serial clinical assessments and transthoracic echocardiography. The mean follow-up duration was 3.33 months (IQR: 1.8–5.2 months). Primary outcomes included spontaneous defect closure, persistence of the defect, development of structural complications, and requirement for intervention. Results: A total of 550 patients were included in the final analysis. Male patients constituted 64% of the study population, and the mean age at diagnosis was 5.69 ± 4.4 years. Incidental cardiac murmur was the most frequent presenting finding. Spontaneous closure occurred in 12.54% (n=69) of patients, whereas persistent PM-VSD was observed in 57.2% (n=315). Progressive complications requiring intervention developed in 22.54% (n=124), while 7.63% (n=42) were lost to follow-up. Structural complications included aortic valve prolapse with aortic regurgitation (48.72%), right ventricular outflow tract obstruction (13.63%), infective endocarditis (6.0%), and rhythm disturbances (1.63%). Although spontaneous closure was numerically more frequent among children diagnosed before five years of age than in older children (14.0% vs. 10.7%), the difference was not statistically significant (χ²=1.43, p=0.49). Conclusion: Small PM-VSDs demonstrated a heterogeneous clinical course characterized by relatively low spontaneous closure rates and a substantial burden of structural complications in this cohort. These findings emphasize the importance of regular long-term clinical and echocardiographic surveillance for early recognition of disease progression and timely intervention to prevent irreversible cardiac complications.
Objective: To determine the frequency of multivessel coronary artery disease (MVD) in patients with premature coronary artery disease (PCAD) presenting with ST-elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI). Methodology: This prospective descriptive cross-sectional study was conducted at the Department of Cardiology, Chaudhary Pervaiz Elahi Institute of Cardiology, Multan, from 01-02-2024 to 31-01-2025. A total of 171 patients with premature CAD (males <45 years; females <55 years) presenting with STEMI and treated with primary PCI were enrolled. Multivessel disease was defined as ≥70% stenosis in at least two major epicardial coronary arteries or ≥50% stenosis of the left main trunk on coronary angiography confirmed by quantitative coronary angiography (QCA). Associations were assessed using chi-square testing, and multivariable logistic regression was performed to identify independent predictors. Results: The mean age was 41.06 ± 5.67 years, and 86.5% of patients were male. Multivessel disease was identified in 79 (46.2%) patients. Stratified analysis showed no statistically significant association between MVD and demographic or conventional cardiovascular risk factors (all p > 0.05). On multivariable analysis, diabetes (OR = 1.953; 95% CI: 0.913–4.178) and obesity (OR = 2.068; 95% CI: 0.829–5.160) were associated with higher odds of MVD, although these did not reach statistical significance. Conclusion: Nearly half of patients with premature CAD undergoing primary PCI had multivessel disease. Although traditional risk factors did not show statistically significant independent associations, the high burden of MVD in this young population underscores the need for aggressive risk assessment and preventive strategies.
Scientific publishing is undergoing a profound transformation, driven by increasing demands for rapid dissemination, transparency, and accessibility of research. Among the most influential developments is the widespread adoption of preprints—complete scientific manuscripts that are made publicly available online before undergoing formal peer review. By enabling immediate access to research findings, preprints accelerate scientific communication, invite constructive community feedback, and facilitate collaboration while reducing delays inherent to traditional publishing. One of the principal advantages of preprints is that they establish a publicly accessible, time-stamped record of scientific work, allowing authors to demonstrate the originality and precedence of their findings before journal publication [1]. Most preprint servers assign a Digital Object Identifier (DOI), providing a permanent and citable record that safeguards intellectual ownership and helps establish priority of discovery. This timestamp can reduce the risk of "scooping" while ensuring that early scientific contributions receive appropriate recognition. Importantly, once posted, preprints generally remain permanently accessible and cannot be withdrawn except under exceptional circumstances, thereby becoming part of the enduring scientific record [2]. Unlike articles published in peer-reviewed journals, preprints are disseminated before formal scientific evaluation. Nevertheless, reputable preprint servers conduct preliminary screening for plagiarism, ethical compliance, inappropriate content, and basic submission quality before making manuscripts publicly available. Furthermore, preprint platforms encourage post-publication scholarly discussion by allowing readers to provide comments and enabling authors to revise and update subsequent versions of their work [3]. Following this process, a preprint may ultimately be accepted for publication in a peer-reviewed journal, remain unpublished, or be rejected during editorial or peer-review assessment [4]. The COVID-19 pandemic dramatically accelerated the adoption of preprints, highlighting both their tremendous value and their inherent limitations. Rapid sharing of emerging evidence contributed substantially to global scientific collaboration and informed public health responses. At the same time, the widespread circulation of findings that had not undergone peer review underscored the potential risks of premature interpretation, media misrepresentation, and inappropriate clinical application. These experiences emphasized the need for clear editorial policies that balance the speed of scientific communication with scientific rigor, transparency, and public responsibility. Recognizing this evolving landscape, the Pakistan Heart Journal (PHJ) supports the responsible use of preprints in cardiovascular and clinical research. PHJ welcomes submissions that have previously been deposited on recognized preprint servers, reflecting its commitment to promoting openness while maintaining the highest standards of scientific integrity. During manuscript submission, authors must clearly disclose any prior preprint posting, including the name of the preprint server and the corresponding DOI. All manuscripts previously posted as preprints undergo PHJ's standard double-blind peer-review process, and editorial decisions are based solely on scientific merit rather than prior public availability. Authors remain fully responsible for ensuring compliance with ethical and reporting standards, including protection of patient confidentiality, data privacy, institutional ethical approvals, conflict-of-interest disclosures, funding transparency, authorship accountability, and appropriate disclosure of artificial intelligence (AI)-assisted writing or analytical tools where applicable. The Pakistan Heart Journal aligns its preprint policy with the recommendations of the International Committee of Medical Journal Editors (ICMJE). In accordance with these recommendations, preprints should be clearly identified as non-peer-reviewed manuscripts, include disclosures regarding funding sources and potential conflicts of interest, provide opportunities for public commentary, preserve metadata for withdrawn versions when applicable, and facilitate linkage between the preprint and the final peer-reviewed publication once available. PHJ permits the citation of preprints within submitted manuscripts provided they are explicitly identified as preprints in the reference list and are cited appropriately. However, authors should exercise caution when interpreting or citing findings that have not undergone peer review and should avoid drawing definitive clinical, therapeutic, or policy-changing conclusions based solely on non-peer-reviewed evidence. Following publication, authors are encouraged to update the corresponding preprint record by linking it to the final published version. Posting the journal-edited, accepted, or final published version of an article on a preprint server is not permitted unless specifically allowed by the journal's copyright policy. Acceptance of manuscripts previously available as preprints remains contingent upon fulfillment of PHJ's established editorial standards. Manuscripts must demonstrate originality, methodological rigor, ethical compliance, scientific validity, and relevance to cardiovascular medicine. As with all submissions, manuscripts may be rejected if concerns arise regarding plagiarism, duplicate publication, authorship integrity, research misconduct, or failure to meet the journal's scientific standards. By formalizing its preprint policy, the Pakistan Heart Journal seeks to embrace the advantages of rapid scientific communication while preserving the credibility and reliability of the published cardiovascular literature. This balanced approach reflects the journal's commitment to transparency, responsible innovation, and scientific excellence, ensuring that advances in scholarly publishing strengthen—rather than compromise—the integrity of cardiovascular research. Contribution: KH, AH, and AA contributed equally to the conception and preparation of this editorial and accept full responsibility for its content. Funding: This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing Interests/Conflict of Interest: The authors declare no competing interests. Ethical/IRB Approval: Not applicable. References [1] Alfonso F, Crea F. Preprints: a game changer in scientific publications? Eur Heart J. 2023 Jan 14;44(3):171–173. https://doi.org/10.1093/eurheartj/ehac665 [2] Flanagin A. Public access and open access in scientific publication. In: Christiansen SL, Iverson C, Flanagin A, et al., editors. AMA Manual of Style: A Guide for Authors and Editors. 11th ed. Oxford: Oxford University Press; 2020 [cited 2020 Sep 27]. Available from: https://www.amamanualofstyle.com/ [3] Penfold NC, Polka JK. Technical and social issues influencing the adoption of preprints in the life sciences. PLoS Genet. 2020 Apr 20;16(4):e1008565. https://doi.org/10.1371/journal.pgen.1008565 [4] Flanagin A, Fontanarosa PB, Bauchner H. Preprints involving medical research—do the benefits outweigh the challenges? JAMA. 2020;324(18):1840–1843. https://doi.org/10.1001/jama.2020.20674
Objectives: This study aimed to compare the effectiveness and safety of the standard manufacturer-recommended TR Band deflation protocol with an earlier stepwise (Light) deflation protocol in preventing radial artery occlusion (RAO) following transradial diagnostic coronary angiography. Methodology: A prospective two-center randomized comparative trial was conducted between August 2024 and January 2025 at two tertiary cardiac centers in Sindh, Pakistan. Adult patients undergoing diagnostic coronary angiography through transradial access were randomly assigned in a 1:1 ratio to either the standard TR Band deflation protocol or the Light protocol. The primary outcome was radial artery occlusion assessed 24 hours after the procedure using clinical examination, reverse Barbeau testing, and Doppler ultrasonography. Secondary outcomes included immediate RAO, bleeding complications, hematoma formation, hemostasis time, TR Band reinflation, patient discomfort, and 30-day follow-up outcomes. Results: A total of 270 patients were randomized, including 129 allocated to the standard protocol and 141 to the Light protocol. Overall, 24-hour RAO occurred in 15 patients (5.6%). The incidence of RAO was significantly lower in the Light protocol group compared with the standard protocol group (1.4% vs. 10.1%; p<0.001), corresponding to an absolute risk reduction of 8.7% and a relative risk of 0.14 (95% CI: 0.03–0.56). Minor bleeding occurred more frequently in the Light protocol group (31.9% vs. 19.4%; p=0.024), whereas no major bleeding events were observed in either group. Hematoma formation was less frequent in the Light protocol group, and median time to hemostasis was significantly shorter (2.25 vs. 3.08 hours; p<0.001). No rehospitalizations due to bleeding or RAO occurred during the 30-day follow-up period. Conclusion: The early stepwise (Light) TR Band deflation protocol significantly reduced the incidence of radial artery occlusion while shortening hemostasis time compared with the conventional manufacturer-recommended protocol. Although minor bleeding occurred more frequently, all events were clinically manageable without major bleeding, vascular intervention, or rehospitalization.
