BACKGROUND:Tygerberg Hospital (TBH) is a tertiary-level hospital in Western Cape Province, South Africa, that provides healthcare to a large low- to middle-income population with services including centralised advanced cardiac care. Acute coronary syndrome (ACS) remains an important cause of death in the region despite a high burden of communicable diseases, including HIV.OBJECTIVES:To describe the incidence of ST-elevation myocardial infarction (STEMI) and high-risk non-ST-elevation ACS (HR-NSTEACS) in the TBH referral network, describe the in-hospital and 30-day mortality of these patients, and identify important high-risk population characteristics.METHODS:The Tygerberg Acute Coronary Syndrome Registry database is an ongoing prospective study that enrols all STEMI and HR-NSTEACS patients in the TBH referral network. All patients aged >18 years presenting with STEMI or HR-NSTEACS were treated in accordance with current European Society of Cardiology guidelines and were included prospectively over a 9-month surveillance period. A waiver of consent was granted to include patients who died before giving informed consent. Data collected included a demographic profile, risk factors for cardiovascular disease, in-hospital therapy and 30-day mortality.RESULTS:A total of 586 patients were enrolled, with a male predominance (64.5%) and incidence rates of STEMI and HR-NSTEACS of 14.7 per 100 000 and 15.6 per 100 000, respectively. The mean patient age was 58 years, and STEMI patients tended to be younger than HR-NSTEACS patients (56 v. 58 years; p=0.01). Cardiovascular risk factors were prevalent overall, but hypertension (79.8% v. 68.3%; p<0.01) and pre-existing IHD (29.1% v. 7.0%; p=0.03) were more prevalent in the HR-NSTEACS group. HIV was present in 12.6% of patients tested, similar to the background population rate. The overall 30-day all-cause mortality rate was 6.1%, with an in-hospital mortality rate of 3.9%. The 30-day mortality rates were similar for STEMI (1.8%) and HR-NSTEACS (2.6%) (p=0.75). HIV did not affect mortality rates.CONCLUSION:Use of a guideline-based approach to treating ACS in a low- to middle-income country setting yields mortality rates comparable to those in high-income countries. However, the lower-than-expected incidence rates of both STEMI and HR-NSTEACS in a relatively young population with a high prevalence of traditional cardiovascular risk factors, and a relatively high proportion of STEMI, suggest potential under-recording of ischaemic heart disease in the region. The rate and outcomes of coronary artery disease (CAD) in people living with HIV were similar to those in people without HIV, suggesting that traditional risk factors still drive CAD outcomes in the region.

BACKGROUND: Preeclampsia complicates approximately 5% of all pregnancies. When pulmonary edema occurs, it accounts for 50% of preeclampsia-related mortality. Currently, there is no consensus on the degree to which left ventricular systolic dysfunction contributes to the development of pulmonary edema. OBJECTIVE: This study aimed to use cardiac magnetic resonance imaging to detect subtle changes in left ventricular systolic function and evidence of acute left ventricular dysfunction (through tissue characterization) in women with preeclampsia complicated by pulmonary edema compared with both preeclamptic and normotensive controls. STUDY DESIGN: Cases were postpartum women aged >= 18 years presenting with preeclampsia complicated by pulmonary edema. Of note, 2 control groups were recruited: women with preeclampsia without pulmonary edema and women with normotensive pregnancies. All women underwent echocardiography and 1.5T cardiac magnetic resonance imaging with native T1 and T2 mapping. Gadolinium contrast was administered to cases only. Because of small sample sizes, a nonparametric test (Kruskal-Wallis) with pairwise posthoc analysis using Bonferroni correction was used to compare the differences between the groups. Cardiac magnetic resonance images were interpreted by 2 independent reporters. The intraclass correlation coefficient was calculated to assess interobserver reliability. RESULTS: Here, 20 women with preeclampsia complicated by pulmonary edema, 13 women with preeclampsia (5 with severe features and 8 without severe features), and 6 normotensive controls were recruited. There was no difference in the baseline characteristics between groups apart from the expected differences in blood pressure. Left atrial sizes were similar across all groups. Women with preeclampsia complicated by pulmonary edema had increased left ventricular mass (P=.01) but had normal systolic function compared with the normotensive controls. Furthermore, they had elevated native T1 values (P=.025) and a trend toward elevated T2 values (P=.07) in the absence of late gadolinium enhancement consistent with myocardial edema. Moreover, myocardial edema was present in all women with eclampsia or hemolysis, elevated liver enzymes, and low platelet count. Women with preeclampsia without severe features had similar findings to the normotensive controls. All cardiac magnetic resonance imaging measurements showed a very high level of interobserver correlation. CONCLUSION: This study focused on cardiac magnetic resonance imaging in women with preeclampsia complicated by pulmonary edema, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count. We have demonstrated normal systolic function with myocardial edema in women with preeclampsia with these severe features. These findings implicate an acute myocardial process as part of this clinical syndrome. The pathogenesis of myocardial edema and its relationship to pulmonary edema require further elucidation. With normal left atrial sizes, any hemodynamic component must be acute.

We would like to share our ideas on the publication titled “One Vax Two Lives: a social media campaign and research program to address COVID-19 vaccine hesitancy in pregnancy.”1Marcell L. Dokania E. Navia I. et al.One Vax Two Lives: a social media campaign and research program to address COVID-19 vaccine hesitancy in pregnancy.Am J Obstet Gynecol. 2022; 9378 (00476–8)Google Scholar Marcell et al reviewed the lessons learned in the campaign and how the most effective elements might be applied to relevant areas of maternal public health.1Marcell L. Dokania E. Navia I. et al.One Vax Two Lives: a social media campaign and research program to address COVID-19 vaccine hesitancy in pregnancy.Am J Obstet Gynecol. 2022; 9378 (00476–8)Google Scholar We can all agree that vaccine apprehension with regard to COVID-19 vaccine’s detrimental effects is a substantial issue which, if not addressed, may have an impact on other commonly used vaccines and healthcare services. It is critical to stress that a person’s decision to receive the COVID-19 vaccine can be influenced by a number of circumstances, including the location and severity of the outbreak. The level of trust people have in their local public health system impacts their propensity to adopt the vaccine. Their willingness to implement public health measures during the COVID-19 outbreak was influenced by their level of faith in their local public health system.2Mungmunpuntipantip R. Wiwanitkit V. Parental willingness to vaccinate against COVID-19.J Paediatr Child Health. 2022; 58: 741-742Crossref PubMed Scopus (1) Google Scholar Adoption rates may further alter considerably when additional information on the efficacy and safety of various vaccine types becomes available.2Mungmunpuntipantip R. Wiwanitkit V. Parental willingness to vaccinate against COVID-19.J Paediatr Child Health. 2022; 58: 741-742Crossref PubMed Scopus (1) Google Scholar According to a Hong Kong–based study, people’s preferences may alter with time.3Xiao J. Cheung J.K. Wu P. Ni M.Y. Cowling B.J. Liao Q. Temporal changes in factors associated with COVID-19 vaccine hesitancy and uptake among adults in Hong Kong: serial cross-sectional surveys.Lancet Reg Health West Pac. 2022; 23100441PubMed Google Scholar Instead of the traditional cross-sectional or retrospective study on document design, a longitudinal study paradigm should be used to analyze the outbreak’s repercussions and the factors associated with immunization.

Cardiovascular magnetic resonance (CMR) is considered the reference imaging modality in providing a non-invasive diagnosis of acute myocarditis (AM), as it allows for the detection of myocardial injury associated with AM. However, the diagnostic sensitivity and pattern of CMR findings appear to differ according to clinical presentation. This is a retrospective cross-sectional study. Consecutive adult patients presenting to a single tertiary centre in South Africa between August 2017 and January 2022 with AM confirmed on endomyocardial biopsy (EMB) were enrolled. Patients with infarct-like symptoms, defined as those presenting primarily with chest pain syndrome with associated ST-T wave changes on electrocardiogram, or heart failure (HF) symptoms, defined as clinical signs and symptoms of HF without significant chest discomfort, were compared using contrasted CMR and parametric techniques with EMB confirmation of AM as diagnostic gold standard. Forty-one patients were identified including 23 (56

We thank Jha and Jha1Jha N. Jha A.K. Pathophysiology of pulmonary and myocardial edema in preeclampsia.Am J Obstet Gynecol. 2022; 228: 118Abstract Full Text Full Text PDF Scopus (1) Google Scholar for their comments on our work. The determinants of myocardial and pulmonary edema, are likely multifactorial. The goal of this study, however, was to address the conflicting results in the echocardiography literature suggesting a degree of reduced left ventricular ejection fraction (LVEF) detected using various methods of LVEF quantification. We selected cardiac magnetic resonance imaging (MRI) to assess the LVEF for its superior volumetric assessment and high degree of interobserver correlation. Currently, MRI-based strain imaging is investigational without a clinical indication for use. Therefore, the finding of a normal LVEF on cardiac MRI in all groups, confirms that overtly reduced LVEF is not the cause of pulmonary edema. We expected to find a stark difference between women with preeclampsia complicated by pulmonary edema and those without pulmonary edema. Instead, the MRI findings in all women with preeclampsia with severe features were similar, and they differed significantly from women with preeclampsia without severe features and normotensive controls. Jha and Jha1Jha N. Jha A.K. Pathophysiology of pulmonary and myocardial edema in preeclampsia.Am J Obstet Gynecol. 2022; 228: 118Abstract Full Text Full Text PDF Scopus (1) Google Scholar note that the left atrial volumes indexed to body surface area (LAVI) were above the echocardiographically derived cutoff of 34 mL/m2, which could suggest diastolic dysfunction in the women with pulmonary edema.2Harkness A. Ring L. Augustine D.X. et al.Normal reference intervals for cardiac dimensions and function for use in echocardiographic practice: a guideline from the British Society of Echocardiography.Echo Res Pract. 2020; 7: G1-G18Crossref PubMed Scopus (60) Google Scholar The left atrial volumes reported were cardiac MRI-derived volumes, however, and the LAVI in all groups fell below 39 mL/m2, which is the normal mean LAVI for women on MRI.3Kawel-Boehm N. Hetzel S.J. Ambale-Venkatesh B. et al.Reference ranges (“normal values”) for cardiovascular magnetic resonance (CMR) in adults and children: 2020 update.J Cardiovasc Magn Reson. 2020; 22: 87Crossref PubMed Scopus (182) Google Scholar The suggestion that pulmonary edema occurs on the basis of the severity of hypertension is not supported by our findings. Women with pulmonary edema had the highest mean systolic pressures, and women with severe features of HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome and eclampsia had the highest diastolic pressures; however, there was no statistically significant difference between these 2 groups. The difference in blood pressures was driven by the relatively lower blood pressures in the group having preeclampsia without severe features and normotensive controls. As a condition characterized primarily by endothelial dysfunction, a degree of increased capillary permeability is expected in preeclampsia.4Erez O. Romero R. Jung E. et al.Preeclampsia and eclampsia: the conceptual evolution of a syndrome.Am J Obstet Gynecol. 2022; 226: S786-803Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Although women having preeclampsia with severe features are thought to have more severe endothelial dysfunction, it is not clear whether endothelial dysfunction and capillary permeability are more abnormal in one manifestation of preeclampsia with severe features than another. We feel that this neither satisfactorily differentiates the groups nor conclusively describes the mechanism underlying pulmonary edema. Indeed, the question may not be why some women with preeclampsia develop pulmonary edema but rather why all women with preeclampsia with severe features do not. Pathophysiology of pulmonary and myocardial edema in preeclampsiaAmerican Journal of Obstetrics & GynecologyVol. 228Issue 1PreviewJoubert et al have made a commendable effort to elucidate the pathophysiology of pulmonary and myocardial edema in various preeclampsia phenotypes.1 Nevertheless, we do have a few alternative explanations. The authors ruled out overt left ventricular systolic dysfunction (LVSD) as a cause of pulmonary edema in preeclampsia. Therefore, the absence of LVSD despite the presence of myocardial edema is indeed noteworthy. Nevertheless, a normal LV systolic function was demonstrated in several previous studies that reported myocardial edema. Full-Text PDF

Retinoic acid isomers have been used with some success as chemotherapeutic agents, most recently with 13-cis retinoic acid showing impressive clinical efficacy in the paediatric malignancy neuroblastoma. The aim of this commentary is to review the evidence that 13-cis retinoic acid is a pro-drug, and consider the implications of retinoid metabolism and isomerisation for the further development of retinoic acid for cancer therapy. The low binding affinity of 13-cis retinoic acid for retinoic acid receptors, low activity in gene expression assays and the accumulation of the all-trans isomer in cells treated with 13-cis retinoic acid, coupled with the more-favourable pharmacokinetic profile of 13-cis retinoic acid compared to other isomers, suggest that intracellular isomerisation to all-trans retinoic acid is the key process underlying the biological activity of 13-cis retinoic acid. Intracellular metabolism of all-trans retinoic acid by a positive auto-regulatory loop may result in clinical resistance to retinoic acid. Agents that block or reduce the metabolism of all-trans retinoic acid are therefore attractive targets for drug development. Devising strategies to deliver 13-cis retinoic acid to tumour cells and facilitate the intracellular isomerisation of 13-cis retinoic acid, while limiting metabolism of all-trans retinoic acid, may have a major impact on the efficacy of 13-cis retinoic acid in paediatric oncology.

Background: Historically, infective endocarditis(IE) in South Africa was associated with the viridans group of streptococci affecting patients with underlying rheumatic heart disease(RHD). A changing IE bacteriological profile raises the question of whether the profile of underlying valvular abnormality has changed. Methods: The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and April 2021. Patients underwent detailed transthoracic-and transoesophageal echocardiography to assess their underlying cardiac and valvular structure. Results: Seventy one patients were included. A predisposing endocardial abnormality was detected in 49.3% of patients, with RHD the most common single identifiable aetiology(16.9%). In-hospital mortality rate was similar in patients with and without a predisposing endocardial abnormality(20% vs 16.7%; p=0.72), as was the rate of embolic events(20% vs. 27.2%;p=0.58). Significantly more patients with a predisposing endocardial abnormality had an indication for surgery(94.3% vs 69.4%;p<0.01). The viridans group of streptococci were more prevalent in patients with a predisposing endocardial abnormality(25.7% vs 2.7%;p<0.01). Left-sided linear vegetation size more than 10mm was associated with an increased risk of in-hospital mortality(24vs.5%; p=0.05). Conclusion: We have observed a marked decrease in the prevalence of RHD in this cohort of patients with IE. The viridans group of streptococci was an uncommon cause of IE in patients where no predisposing endocardial abnormality was detected. The presence of a predisposing endocardial abnormality was not associated with an increased risk of in-hospital mortality or embolic events. Linear vegetation length more than 10mm was associated with an increased risk of in-hospital mortality in patients with left-sided IE.

We describe the first case of successful management of left ventricular outflow tract obstruction developing late after transcatheter aortic valve replacement with right ventricular apical pacing. The possible mechanisms of obstruction resolution are described. (Level of Difficulty: Advanced.)

Pre-eclampsia is a leading cause of maternal and perinatal morbidity and mortality. The burden of disease lies mainly in low-middle income countries. The aim of this project is to establish a pre-eclampsia biobank in South Africa to facilitate research in the field of pre-eclampsia with a focus on phenotyping severe disease.The approach of our biobank is to collect biological specimens, detailed clinical data, tests, and biophysical examinations, including magnetic resonance imaging (MRI) of the brain, MRI of the heart, transcranial Doppler, echocardiography, and cognitive function tests.Women diagnosed with pre-eclampsia and normotensive controls are enrolled in the biobank at admission to Tygerberg University Hospital (Cape Town, South Africa). Biological samples and clinical data are collected at inclusion/delivery and during the hospital stay. Special investigations as per above are performed in a subset of women. After two months, women are followed up by telephonic interviews. This project aims to establish a biobank and database for severe organ complications of pre-eclampsia in a low-middle income country where the incidence of pre-eclampsia with organ complications is high. The study integrates different methods to investigate pre-eclampsia, focusing on improved understanding of pathophysiology, prediction of organ complications, and potentially future drug evaluation and discovery.

Background Blood culture negative infective endocarditis (BCNIE) poses both a diagnostic and therapeutic challenge. High rates of BCNIE reported in South Africa have been attributed to antibiotic use prior to blood culture sampling.Objectives To assess the impact of a systematic approach to organism detection and identify the causes of infective endocarditis (IE), in particular causes of BCNIE.Design Prospective cohort study.Methods The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and February 2021. A set protocol for organism detection with management of patients by an endocarditis team was employed. This prospective cohort was compared with a retrospective cohort of patients with IE admitted between January 2017 and December 2018.Results One hundred and forty patients with IE were included, with 75 and 65 patients in the retrospective and prospective cohorts, respectively. Baseline demographic characteristics were similar with a mean age of 39.6 years and male predominance (male sex=67.1%). The rate of BCNIE was lower in the prospective group (28/65 or 43.1%) compared with the retrospective group (47/75 or 62.7%; p=0.039). The BCNIE in-hospital mortality rate in the retrospective cohort was 23.4% compared with 14.2% in the prospective cohort (p=0.35). A cause was identified (including non-culture techniques) in 86.2% of patients in the prospective cohort, with Staphylococcus aureus (26.2%), Bartonella species (20%) and the viridans streptococci (15.3%) being most common.Conclusion The introduction of a set protocol for organism detection, managed by an endocarditis team, has identified Staphylococcusaureus as the most common cause of IE and identified non-culturable organisms, in particular Bartonella quintana, as an important cause of BCNIE. A reduction in in-hospital mortality in patients with BCNIE was observed, but did not reach statistical significance.

Aims: The aim of this study was to explore the use of prolonged occlusion flow-mediated dilatation (PO-FMD) to dilate the radial artery prior to cannulation to increase cannulation success, reduce puncture attempts and reduce access-site complications in transradial coronary angiography. Methods and results: A total of 1,156 patients undergoing transradial coronary angiography were randomised into PO-FMD and sham PO-FMD groups. PO-FMD was achieved by a 10-minute inflation of a blood pressure cuff on the arm to above systolic pressure, followed by deflation with resultant radial artery dilation. In the sham PO-FMD group the cuff was not inflated. Operators were blinded to the intervention. Five hundred and eighty (580) patients were randomised to the sham PO-FMD group and 576 to the PO-FMD group. Cannulation failure was reduced with PO-FMD, with cannulation failure rates of 2.7% in the PO-FMD group and 5.8% in the sham PO-FMD group (p=0.01).The number of puncture attempts was reduced with the use of PO-FMD, with a median of one attempt in the PO-FMD group and two in the sham PO-FMD group (p<0.001). Radial artery pulsation loss (RAPL) was reduced with PO-FMD, with 1.4% in the PO-FMD group and 3.8% in the sham PO-FMD group (p=0.02). Conclusions: PO-FMD reduces cannulation failure rates, decreases puncture attempts, and decreases RAPL during transradial coronary angiography.

Objectives To determine the prevalence of myocardial injury (MInj) in systemic lupus erythematosus (SLE) according to cardiac magnetic resonance (CMR) criteria. To compare clinical and echocardiographic features of patients with and without MInj and identify predictors of myocardial tissue characteristics according to CMR. Methods SLE inpatients underwent CMR screening for MInj based on the Lake Louise Criteria (LLC). Tissue characteristics included inflammation (increased T2-weighted signal or early gadolinium enhancement ratio (EGEr)) and necrosis or fibrosis (late gadolinium enhancement (LGE)). Echocardiographic parameters included left (left ventricular ejection fraction (LVEF)) and right ventricular function (tricuspid annular plane systolic excursion (TAPSE)), global longitudinal strain (GLS), wall motion score (WMSi) and left ventricular internal diameter index (LVIDi). Variables were compared with regards to the presence/absence of CMR criteria. Logistic regression identified variables predictive of CMR tissue characteristics. Results A hundred and six SLE patients were screened of whom 49 patients were included. Fifty-seven patients were excluded due to intolerance of or contraindication to CMR (27/57 due to renal impairment). Twenty-three patients had CMR evidence of MInj, of which 60.9% was subclinical. Inflammation occurred in 16/23 and necrosis/fibrosis in 12/23 patients. Patients with any evidence of MInj were more frequently anti-dsDNA positive ( p = 0.026) and patients fulfilling LLC for myocarditis had higher SLE disease activity ( p = 0.022). The LVIDi ( p = 0.005), LVEF ( p = 0.005) and TAPSE ( p = 0.011) were more abnormal in patients with an increased EGEr, whereas WMSi ( p = 0.002) and GLS (0.020) were more impaired in patients with LGE. On multivariable logistic regression analyses, TAPSE predicted inflammation (OR: 0.045, p = 0.006, CI: 0.005–0.415) and GLS predicted necrosis/fibrosis (OR: 1.329, p = 0.031, CI: 1.026–1.722). A model including lymphocyte count, TAPSE and LVIDi predicted an increased EGEr on CMR (receiver operating characteristic-curve analyses: area under the curve: 0.901, p < 0.001, sensitivity: 88.9%, specificity: 76.3%). Conclusions CMR evidence of MInj frequently occurs in SLE and is often subclinical. The utility of CMR in SLE is limited by a high exclusion rate, mainly due to renal involvement. Models including echocardiographic parameters (TAPSE, LVIDi and GLS) are predictive of CMR myocardial injury. Echocardiography can be used as a cost-effective screening tool with a high negative predictive value, in particular when CMR is contraindicated or unavailable.

Abstract Background The de Winter’s electrocardiogram (ECG) pattern signifying proximal left anterior descending (LAD) artery occlusion was first described in 2008. The ECG changes were thought to be static and mechanisms for this were suggested. In addition, the optimal management of these patients was reported to be via a primary percutaneous coronary intervention (PCI) strategy. Case summary Case 1: A 48-year-old gentleman presented with a 2-h history of ischaemic chest pain with initial de Winter’s pattern on ECG. This progressed to anterior ST-elevation myocardial infarction (STEMI) complicated by ventricular fibrillation. Emergency angiography revealed a mid-vessel LAD occlusion which was successfully reperfused. Case 2: A 34-year-old female presented with a 2-h history of ischaemic chest pain with initial ECG showing a de Winter’s pattern. Due to concerns of performing PCI timeously, a pharmacoinvasive strategy of reperfusion was adopted with resolution of the de Winter’s pattern. Urgent angiography revealed a proximal LAD lesion which was successfully stented. Discussion The two cases highlight that the de Winter’s pattern may in fact not be static, but rather lie along the continuum of ischaemia and may evolve into STEMI. In addition, we provide further evidence that if primary PCI cannot be offered in a timeous manner, thrombolytic therapy may be considered in such patients. The de Winter’s pattern remains a high-risk ECG pattern that requires early recognition and intervention.

Abstract Background Transradial catheterization has become the preferred access site for coronary angiography. The transradial approach is however not without challenges and complications. Cannulation is technically challenging and may require multiple cannulation attempts or access may fail. Local access site complications may occur postprocedurally. Purpose To explore the use of prolonged occlusion flow mediated dilatation (PO-FMD) to dilate the radial artery prior to cannulation to reduce puncture attempts, increase cannulation success and reduce access site complications in transradial coronary angiography. Methods 1156 patients undergoing transradial coronary angiography were randomized into PO-FMD and sham PO-FMD groups. PO-FMD was achieved by a 10 minute inflation of a blood pressure cuff on the arm to above systolic pressure, followed by deflation with resultant radial artery dilation. In the sham PO-FMD group the cuff was not inflated. The operators were blinded to the intervention. Results 580 patients were randomized to the sham PO-FMD group and 576 to the PO-FMD group. The number of puncture attempts were reduced with the use of PO-FMD, with a median number of attempts of 1 in the PO-FMD group and 2 in the sham PO-FMD group (p<0.001). Cannulation failure was reduced with PO-FMD FMD with cannulation failure rates of 2.7% in the PO-FMD group and 5.8% in the sham PO-FMD group (p=0.01). Radial artery pulsation loss (RAPL) was reduced with PO-FMD with 1.4% in the PO-FMD group and 3.8% in the sham PO-FMD group (p=0.02). Conclusion PO-FMD decreases puncture attempts, reduces cannulation failure rates and decreases RAPL during transradial coronary angiography.

Coronary interventions: vascular accessPurpose: To evaluate efficacy and safety of trans ulnar access for coronary angiography and interventions.Methods: A prospective cohort study was conducted in 73 patients who underwent coronary angiography and/or percutaneous coronary intervention at thammasat university hospital from May 2016 to July 2017.Transulnar access was done in patient with normal Allen's test.Procedure was performed by single operator.Primary endpoint was a success rate of vascular access.Secondary endpoints was fluoroscopy time, vascular access time, procedure time for diagnostic coronary angiography, contrast volume during diagnostic coronary angiography ulnar spasm, hematoma of access site, ulnar artery occlusion after procedure Results: Of 73 patients (age 63±14 year, 42.5% Female), 79% (58 patients) was successful transulnar access.The mean vascular access time was 4.8± 5.7 minutes and mean procedural time was 67.17± 57.08 minutes which 54.8% (40 patients) underwent percutaneous coronary intervention.Nine patients (12%) developed ulnar artery spasm during procedure and five patients (6.8%) had significant access site hematoma.No ulnar artery occlusion was demonstrated by Doppler colour ultrasound within one week.Conclusion: Transulnar access was safe and efficacy for patients undergo coronary intervention.This supports the safety and efficacy of transulnar access as an alternative access to transradial approach in patients who had radial access site limitation.