Primary Percutaneous Coronary Intervention Using BaLloon-Assisted Sliding and Tracking (BLAST) of Diagnostic Catheter to Negotiate Double Hairpin Loop of Radial Artery

During transradial intervention, sharp edge of the guide catheter tip may act like a “razor-blade” and can prevent the catheter navigation especially in situation like double hair pin loop. Here, we report primary percutaneous coronary intervention (PCI) through diagnostic catheter using an innovative technique, balloon-assisted sliding and tracking (BLAST), to overcome this double hairpin loop, thus saving time and contrast volume.

Acute Myocardial Infarction Due to Coronary Artery Embolism in a 22-Year-Old Woman with Mitral Stenosis with Atrial Fibrillation Under Warfarinization: Successful Management with Anticoagulation

Patient: Female, 22

Final Diagnosis: Acute myocardial infarction due to coronary artery embolism in a 22-year-old woman with mitral stenosis with atrial fibrillation under warfarinization: successful management with anticoagulation

Symptoms: Chest pain

Medication: —

Clinical Procedure: Coronary angiography

Specialty: Cardiology

Integration and decentralisation of TB-HIV services increases HIV testing of TB cases in Rajasthan, India

The proportion of tuberculosis (TB) patients tested for the human immunodeficiency virus (HIV) in the state of Ra-jasthan, India, is limited by the availability of HIV testing facilities. Rajasthan implemented a policy of initiating TB-HIV diagnosis at all health institutions in July 2013. The number of TB diagnostic facilities increased from 33 to 63 in Banswara District and from 22 to 68 in Jhunjhunu District, while the number of HIV testing facilities in these districts increased from 1 to 53 and from 10 to 81, respectively, after the policy implementation. The proportion of TB patients tested for HIV increased by respectively 27% and 19%.

Acute myocardial infarction in very young adults: A clinical presentation, risk factors, hospital outcome index, and their angiographic characteristics in North India-AMIYA Study

BACKGROUND

India is currently in the fourth stage of epidemiological transitions where cardiovascular disease is the leading cause of mortality and morbidity. Purpose of the present study was to assess the risk factors, clinical presentation, angiographic profile including severity, and in-hospital outcome of very young adults (aged ≤ 30 years) with first acute myocardial infarction (AMI).

METHODS

Total of 1,116 consecutive patients with ST-segment elevation acute myocardial infarction (STEMI) were studied between March 2013 and February 2015 at LPS Institute of Cardiology, Kanpur, Uttar Pradesh, India.

RESULTS

Mean age of the patients was 26.3 years. Risk factors were smoking (78.5%), family history of premature coronary artery disease (CAD) (46.8%), obesity (39.1%), physical inactivity (38.7%) and stressful life events (29.6%). The most common symptom and presentation was chest pain and anterior wall myocardial infarction (AWMI) in 94.8% and 58.8%, respectively. About 80.6% of patients had obstructive CAD with single vessel disease (57.6%), double-vessel disease (12.9%) and left main involvement (3.2%). Left anterior descending (LAD) was commonest culprit artery (58.1%) followed by right coronary artery in 28.2%. In-hospital mortality was 2.8%. Percutaneous coronary intervention was performed in 71.6% of patients. Median number and length of stent were 1.18 and 28 ± 16 mm, respectively.

CONCLUSION

AMI in very young adult occurred most commonly in male. Smoking was the most common risk factor. AWMI owing to LAD artery involvement was the most common presentation. Mean time of presentation after symptom onset was 16.9 hours. In contrast to western population, it is characterised by earlier onset, delayed presentation, more severity, diffuse disease, and more morbidity but with favourable in-hospital mortality.

Atypical Double Right Coronary Artery Presenting With Acute Coronary Syndrome, Cardiogenic Shock and Complete Heart Block

Double right coronary artery (RCA) is an extremely rare coronary artery anomaly. We here report an atherosclerotic double RCA which appeared after primary percutaneous intervention performed to treat a 34-year-old male presenting with acute inferior myocardial infarction, cardiogenic shock and complete heart block. This is an unusual case as double RCA had been hidden by total atherosclerotic occlusion of the proximal part of the RCA and complete restoration of patency led complete heart block back to normal sinus rhythm.

Efficacy and Safety of Thrombolytic Therapy in Acute Submassive Pulmonary Embolism: Follow-Up Study

BACKGROUND

Thrombolysis in acute submassive pulmonary embolism (PE) remains controversial. So we studied impact of thrombolytic therapy in acute submassive PE in terms of mortality, hemodynamic status, improvement in right ventricular function, and safety in terms of major and minor bleeding.

METHOD

A single-center, prospective, randomized study of 86 patients was conducted at LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, India. Patients received thrombolysis (single bolus of tenecteplase) with unfractionated heparin (UFH, group I) or placebo with UFH (group II).

RESULT

Mean age of patients was 54.35 ± 12.8 years with male dominance (M:F = 70%:30%). Smoking was the most common risk factor seen in 29% of all patients, followed by recent history of immobilization (25%), history of surgery or major trauma within past 1 month (15%), dyslipidemia (10%) and diabetes mellitus (10%). Dyspnea was the most common symptom in 80% of all patients, followed by chest pain in 55% and syncope in 6%. Primary efficacy outcome occurred significantly better in group I vs. group II (4.5% vs. 20%; P = 0.04), and significant difference was also found in hemodynamic decompensation (4.5% vs. 20%; P = 0.04), the fall in mean pulmonary artery systolic pressure (PASP) (28.8% vs. 22.5%; P = 0.03), improvement in right ventricular (RV) function (70% vs. 40%; P = 0.001) and mean hospital stay (8.1 ± 2.5 vs. 11.1 ± 2.14 days; P = 0.001). There was no difference in mortality and major bleeding as safety outcome but increased minor bleeding occurred in group I patients (16% vs. 12%; P = 0.04).

CONCLUSION

Patients with acute submassive PE do not derive overall mortality benefit, recurrent PE and rehospitalization with thrombolytic therapy but had improved clinical outcome in form of decrease in hemodynamic decompensation, mean hospital stay, PASP and improvement of RV function with similar risk of major bleed but at cost of increased minor bleeding.

Bi-Luminal Mitral Valve: Incidence, Clinical Features, Associated Anomaly and Echocardiographic Evaluation

Objective

The aim of the study was to know the incidence, clinical features, associated anomaly and echocardiographic evaluation of bi-luminal mitral valve (also known as double orifice mitral valve or DOMV) in patients with suspected mitral valve disease, continous murmur or left-to-right shunt.

Methods

Twenty-eight patients with DOMV were diagnosed by transthoracic echocardiography (TTE) in a retrospective review of 52,256 echocardiographic studies in 45,898 patients performed between 2000 and 2015.

Results

The mean age was 20.1 years (15 - 34 years) with female preponderance (M/F: 1:1.8). Dyspnea and diastolic murmur were the most common symptoms found in 19 (67.8%) and 19 (67.8%) of patients, respectively. Normal sinus rhythm was the most common electrocardiographic finding. Twenty-five (89%) patients had complete bridge, while three (11%) had incomplete bridge type of DOMV. Twenty-one (75%) had severe mitral stenosis (MS) including severe tricuspid regurgitation (n = 13, 61%), ventricular septal defect (VSD, n = 3, 14%), complete endocardial cushion defect (ECD, n = 3, 14%), and mild to moderate mitral regurgitation (MR) (n = 2, 11%), moderate MS and moderate MR were found in four (16%) patients among complete bridge type of DOMV, while all patients with incomplete bridge type had severe MS and patent ductus arteriosus (PDA) as associated lesions. Overall, 24 (85%) had severe and four (15%) had moderate MS.

Conclusions

DOMV as a cause of symptomatic mitral valve disease was seen in young and middle-aged patients with estimated incidence of 0.06%. Dyspnea and diastolic murmur were the most common symptoms. Mostly, it was an isolated anomaly but in majority, associated with VSD, complete ECD and PDA. TTE examination is a reliable and sufficient means of diagnosing DOMV and determining its type.

Prognostic Importance of Exercise Brain Natriuretic Peptide in Asymptomatic Chronic Organic Severe Mitral Regurgitation: An Observational Study

BACKGROUND

The optimal timing of surgery in patients with chronic organic severe mitral regurgitation (MR) continues to be debated, especially for those who are asymptomatic. The aim of the study was to determine independent and additive prognostic value of exercise brain natriuretic peptide (eBNP) in patients with severe asymptomatic MR and normal left ventricular ejection fraction (LVEF).

METHODS

Two hundred twenty-three consecutive patients with severe MR defined by effective regurgitant orifice (ERO) area ≥ 40 mm² and/or residual volume ≥ 60 mL, LVEF > 60%, and normal LV end-systolic diameter < 40 mm underwent symptom limited exercise treadmill test (TMT). Echocardiography was done immediately after exercise. Data were obtained within 3 minutes of peak exercise. BNP levels were assessed before echo (after 30 minutes of supine rest) and at exercise (i.e., within the 3 minutes of the end of effort). Patients were followed up every 3 months up to 15 months for major adverse cardiac events (MACEs) (cardiovascular death, need for mitral valve surgery and hospitalization for acute pulmonary edema or heart failure).

RESULTS

Mean age was 31.2 ± 9 years (range: 18 - 40) with majority being male (n = 153; 68%). Etiologies were rheumatic (n = 201; 90%), mitral valve prolapse (n = 17; 7.6%) and hypertrophic cardiomyopathy (n = 5; 2.4%). BNP level significantly increased from rest (65.24 ± 43.92 pg/mL; median: 43.5 pg/mL) to exercise (100.24 ± 98.24 pg/mL; median: 66.5 pg/mL; P < 0.001). Patients were divided into three tertiles according to eBNP levels (T₁ = 15 - 44; T₂ = 45 - 104; T₃ = 105 - 400). There was trend for significantly lower exercise time in T₃. During TMT, 66 (29.5%) stopped exercise due to dyspnea. They had similar resting BNP level compared with others but had significantly higher eBNP level (136 ± 109.7 pg/mL vs. 84.88 ± 90.2 pg/mL; P < 0.001). During follow-up (15 months), MACE occurred in 83 patients (37.2%): mitral valve replacement (MVR) in 59 patients (symptomatic: 43; LV dilatation or dysfunction: 9; both symptoms and dilatation/dysfunction: 7), 17 hospitalizations for congestive heart failure, five patients developing acute pulmonary edema and atrial fibrillation in remaining two patients. This was 7.6%, 35% and 69% in T₁, T₂ and T₃, respectively and had significantly higher eBNP level than without any event (165 ± 119 pg/mL vs. 57 ± 48 pg/mL; P < 0.001). Using receiver operating characteristic curve analysis, the best cut-off value of eBNP level to predict cardiac events was 90 pg/mL (sensitivity: 75%; specificity: 88.6%; positive predictive value: 79%; negative predictive value: 83.9%).

CONCLUSION

In asymptomatic patients, eBNP level provides incremental prognostic value beyond echocardiographic data and those with elevated eBNP should be considered at high risk for reduced event-free survival and might be considered for early MVR.

Unusual Survival of Anomalous Left Coronary Artery From the Pulmonary Artery With Severe Rheumatic Mitral Stenosis in Septuagenarian Women: Foes Becoming Friends?

ALCAPA syndrome (anomalous origin of the left coronary artery from the pulmonary artery) is a rare disease but lethal with clinical expression from myocardial infarction, congestive heart failure to death during early infancy and unusual survival to adulthood. We report a 73-year-old woman with ALCAPA who presented with exertional dyspnea (NYHA functional class II) over past 2 years. Physical examination revealed soft S, long mid diastolic rumbling murmur and apical pan-systolic murmur. Electrocardiography displayed biatrial enlargement and poor R progression and normal sinus rhythm. Echocardiography established calcified severe mitral stenosis (MS), presence of continuous flow entering the pulmonary trunk, turbulent continuous flow in inter-ventricular septum with left to right shunt in contrast echocardiography and normal systolic function. Coronary angiogram showed absence of left coronary artery (LCA) originating from aorta, dilated and tortuous right coronary artery (RCA) and abundant Rentrop grade 3 intercoronary collateral communicating with LCA originating from pulmonary trunk which was also confirmed on coronary CT angiogram thus establishing diagnosis of ALCAPA. It is exceedingly rare to be associated with severe MS. However, such a long survival in our patient can be explained by the severe pulmonary arterial hypertension which may be contributing to lesser coronary steal.

Thrombocytosis and Raised CRP Levels Predicts Advanced Stage in Esophageal Carcinoma

PURPOSE

The significance of thrombocytosis and raised C-reactive protein (CRP) as prognostic markers in esophageal cancer is unclear.

METHODS

We prospectively studied 50 consecutive patients with esophageal cancer and analyzed the relation of preoperative platelet count and CRP levels with the clinico-pathological characteristics and stage of the disease. The platelet count of 319 × 10(9)/L for thrombocytosis and CRP level >6 mg/dl were taken as cut-off values.

RESULTS

The incidence of thrombocytosis as well as raised CRP level was 50 %. Eighty percent of patients with thrombocytosis had raised CRP levels. None of patients with early disease (stage I) had thrombocytosis while patients with advanced stage were associated with thrombocytosis, 81.81 % in stage III and 100 % in stage IV (p < 0.001). The incidence of elevated CRP levels has shown progressive linear co-relation with the stage of carcinoma, i.e., 0 % in pathological stage I, 16.67 % in stage II, 45.45 % in stage III, and 100 % in stage IV disease (p = 0.011). Patients with thrombocytosis and patients with raised CRP were associated with pathological nodal metastases in 84.61 % cases (p 0.005) and 61.53 % (p 0.030), respectively.

CONCLUSION

Thrombocytosis alone or in combination with raised CRP had progressive linear relation with the stage of esophageal carcinoma.