Early and Long-Term Clinical Outcomes of Ductal Stenting Versus Surgical Aortopulmonary Shunt Among Young Infants with Duct-Dependent Pulmonary Circulation

Surgical aortopulmonary shunting (SAPS) and ductal stenting (DS) are the main palliations in infants with cyanotic congenital heart diseases (CHD). We aimed to study the safety and efficacy of DS and to compare it with SAPS as a palliative procedure in infants with CHD and duct-dependent pulmonary circulation. Retrospective institutional clinical data review of consecutive infants aged < 3 months who underwent DS or SAPS over 5 years. The primary outcome was procedural success which was defined as event-free survival (mortality, need for re-intervention, procedural failure) at 30 days post-procedure. The secondary outcome was defined by a composite of death, major adverse cardiovascular events, or need for re-intervention at 6 months and on long-term follow-up. We included 102 infants (DS, n = 53 and SAPS, n = 49). The median age at DS and SAPS was 4 days (IQR 2.0-8.5) and 8 days (IQR 4.0-39.0), respectively. The median weight at intervention was 3.0 kg (IQR 3.0-3.0) and 3.0 kg (IQR 2.5-3.0) in the two respective arms. Tetralogy of Fallot with pulmonary atresia was the most common indication for DS and SAPS. The 30-day mortality was significantly higher in SAPS group as compared with DS group (p < 0.05). However, 30-day major adverse cardiac events (MACE) rates were similar in both groups (p = 0.29). DS was associated with shorter duration of mechanical ventilation, duration of stay in the intensive care and hospital stay than with SAPS. At 6 months, there was no significant difference in terms of mortality or event-free survival. Long-term MACE-free survival was also comparable (p = 0.13). DS is an effective and safer alternative to SAPS in infants with duct-dependent pulmonary circulation, offering reduced procedure-related mortality and morbidity than SAPS. Careful study of ductal anatomy is crucial to procedural success. However, long-term outcomes are similar in both procedures.

Natural history of coronary stents: 14 year follow-up of drug eluting stents versus bare metal stents

BACKGROUND

Several randomized trials have shown the effectiveness of drug-eluting stents (DES) over bare metal stents (BMS) in terms of repeat revascularization at 1 year; however long term data in this context is conflicting.

AIM

To assess the long term clinical outcomes after coronary artery stenting with drug-eluting stents and bare metal stents.

METHODS

This is a retrospective cohort study, including 100 consecutive patients with Coronary Artery Disease who underwent successful percutaneous intervention (PCI) with implantation of DES and contemporary 100 patients who underwent PCI with implantation of BMS in the years 2005 and 2006 at our center.

RESULTS

Over a median follow-up of 14 years, the primary composite outcome of major adverse cardiovascular and cerebrovascular events (MACCE) was found to be similar in both the groups [DES-37; BMS-36 (p value = 0.88)]. At 1 year of follow-up, the incidence of MACCE was significantly lower with DES group than BMS group [DES-3; BMS-10, P value = 0.04]; but the benefit was not seen at 5 years, 10 years and 14 years follow-up. The incidence of very late stent thrombosis in our study population was similar in either of the groups (p value = 0.13). Obesity and creatinine of >1.4 mg/dl were found to be the predictors of all-cause death.

CONCLUSION

In patients with coronary artery disease, the composite endpoint of MACCE for the first year after stenting was significantly lower in patients receiving DES than those receiving BMS; however, at very long term follow-up, the event rates were similar.

Left cardiac sympathetic denervation in children with Jervell Lange-Nielsen syndrome and drug refractory torsades - A case series

INTRODUCTION

Long QT syndrome is an inherited malignant channelopathy which leads to life-threatening arrhythmia, with multiple genotypes. Jervell and Lange-Nielsen syndrome (JLNS) is an autosomal recessive subtype of this disease, characterized by congenital sensorineural deafness and a high incidence of sudden cardiac death (SCD).

METHODOLOGY

We prospectively followed up six children who underwent left cardiac sympathetic denervation (LCSD) for JLNS in view of high-risk features despite being on maximally tolerated doses of oral propranolol.

RESULTS

Mean age at diagnosis was 2.75 ± 0.39 years, with a significant delay between onset of symptoms and diagnosis (mean 7.2 ± 3.5 months). All had sensorineural hearing loss, conforming to the JLNS phenotype. Mean QTc interval was 603 ± 93 ms, with T wave alternans (TWA) seen in all cases. All were started on propranolol and subsequently subjected to LCSD, and 3 underwent AAI permanent pacemaker implantation. Over a mean follow-up of 20 months, there was a significant reduction in QTc (603 ± 93 ms to 501 ± 33 ms, p = .04), which was persistent on follow-up (525 ± 41 ms) and only two out of six had persistent T wave alternans on ECG (p < .01). None of these children had presyncope, syncope, seizures, torsades de pointes, cardiac arrest or death on follow up following LCSD.

CONCLUSION

Jervell Lange-Nielsen syndrome is a subtype of LQTS with high-risk features. LCSD, an effective therapeutic option for those having symptoms despite being on propranolol, results in significant reduction of QTc interval and amelioration of symptoms.

Cardiac magnetic resonance imaging in right ventricular outflow tract arrhythmia: a retrospective analysis from a tertiary care centre in South India

INTRODUCTION

Arrhythmia arising from right ventricular outflow tract (RVOT) is the most common cause of idiopathic ventricular arrhythmia. Previous studies involving cardiac magnetic resonance imaging (MRI) in these patients are known to show abnormalities in up to 60% of patients.

METHODOLOGY

This was a retrospective descriptive analysis of patients having idiopathic RVOT arrhythmia who underwent cardiac MRI between January 2010 and December 2020. Clinical and demographic details were recorded from the electronic medical records and cardiac MRI of all patients were reviewed.

RESULTS

Among 214 patients with RVOT arrhythmia, 64 underwent cardiac MRI. A total of 41 patients, who did not have any abnormality on baseline echocardiogram were included in the study. There was male preponderance (56.1%), with median age of 43 years. About 43.9% had syncope. Twenty-four-hour Holter study revealed a premature ventricular complex (PVC) burden of 26.3 ± 11.7%. MRI showed structural abnormalities in 51.2% of patients, which commonly included RV sacculations and aneurysms. Late gadolinium enhancement (LGE) was seen in six patients, which was mostly seen in RV free wall. Right ventricular (RV) systolic dysfunction was evident in 29.3%. About 9.8% fulfilled the criteria for arrhythmogenic RV cardiomyopathy (ARVC). Out of 23 patients with baseline abnormalities on ECHO, 87% had structural abnormalities on MRI, and 43.5% fulfilled the criteria for ARVC.

CONCLUSIONS

Additional imaging by cardiac MRI helps to identify structural abnormalities in 51.2% of patients with RVOT arrhythmias, even with normal baseline echocardiogram and electrocardiogram (ECG). It is useful tool to rule out ARVC in this subset of patients, and can help in increasing the diagnostic yield in the early stages.

Management of a complicated 'pacemaker pocket' site infection

Pocket site infection after implantation of a pacemaker is a dreaded complication which requires removing the device and reimplanting it at a contralateral site. Difficulties arise when the patient is dependent on pacing and when there are issues with venous access at the contralateral site. We report a patient with pacemaker pocket site infection with congenital complete heart block managed with explantation of the device, semi-permanent pacing during antibiotic treatment, reimplantation of the device at the contralateral site and management of subtotal subclavian vein stenosis noted during reimplantation.

Postoperative Aortic Regurgitation in Outflow Ventricular Septal Defect: Determinants of Outcome

Aortic cusp prolapse is an acquired complication and usually precedes the development of aortic regurgitation (AR) in unoperated outflow ventricular septal defect (VSD). However, its impact on postoperative AR-progression is unknown. 161 patients with outflow-VSD and AR who underwent surgery between 2006 and 2012 were studied retrospectively. 31 patients without prolapse (group-I), 87 with only right coronary cusp (RCC) (group-II), 43 with noncoronary cusp (NCC) prolapse (group-III: 23 only NCC (IIIa), 20 both NCC-RCC (IIIb)) were followed postoperatively for a mean 6.05 ± 2.4 years (range 3-12 years). Moderate or severe-AR was present in 4.2%, 36.8%, 52.2% and 80% preoperatively; in 3.2%, 10.3%, 39.1% and 30% patients at follow-up in group-I, II, IIIa, and IIIb, respectively. Although freedom from significant-AR (moderate or severe AR) or aortic valve replacement (AVR) at 10 years was lesser in subaortic-VSD than subpulmonic-VSD (64.3 ± 7.5% vs 87.9 ± 3.6%; P = 0.02), the difference was not significant when compared within prolapse groups (80 ± 8% vs 88.7 ± 4.0%, P = 0.28 in group-II; 40.7 ± 11.8 vs 70 ± 14.5%, P = 0.48 in group-III). The significant-AR or AVR free survival in patients with trivial or mild preoperative-AR was not significantly different between prolapse groups (98.2 ± 1.8% vs 75 ± 21.7% in group-II and III respectively; P = 0.85). However, in those with moderate or severe preoperative-AR it was significantly lesser in group-III than II (30.1 ± 9.8% vs 65.6 ± 8.4%, respectively; P = 0.04). Group-III, compare to group-II, had 3.28 and 5.24-time risk of development of significant-AR or requirement of AVR, respectively. Prolapse of NCC alone or in addition to RCC prolapse has unfavourable impact on the postoperative outcomes, especially in subaortic-VSD after development of more than mild AR preoperatively.

Narrow QRS Tachycardia: What Is the Mechanism?

A 45-year-old man was referred for radiofrequency catheter ablation of narrow QRS tachycardia that terminated with intravenous adenosine. A 12-lead electrocardiogram showed no baseline pre-excitation. The echocardiogram was essentially normal. The electrophysiological study showed a normal atrial-His interval of 110 ms and a His-ventricular interval of 44 ms during sinus rhythm. An anterograde study demonstrated no dual atrioventricular nodal physiology. Atrial pacing protocols easily and reproducibly induced a narrow QRS tachycardia. What is the mechanism of the tachycardia?

Interesting Response with the Delivery of Right Ventricular Extrastimulus of Increasing Prematurity

A 45-year-old man with no structural heart disease underwent an electrophysiology study for recurrent episodes of palpitation. There was no evidence of pre-excitation on the baseline electrocardiogram. Baseline intervals, including the A-H and H-V intervals, were within the normal limits and remained so during the electrophysiology study. An interesting response was observed with the delivery of ventricular extrastimuli with increasing prematurity from the right ventricular apex, triggering consideration of the possible mechanism.

Tricuspid annular PVCS: Radiofrequency ablation by subtricuspid retrograde catheter approach

Tricuspid annular PVCs constitute 8% of idiopathic PVCs and 5% of RV PVCs. Although a rare entity to encounter in routine clinical practice, it can be a prime culprit behind major arrhythmic burden in few individuals. Electroanatomic approach with sub tricuspid retrograde catheter technique can target those annular PVCs and decrease the arrhythmia burden to normal or near normal range. Although procedural approach for parahisian PVCs requires a close look to avoid injury to native conduction system, TA PVCs are a real challenge due to inherent catheter instability and contact issue in sub tricuspid retrograde approach.

Tachycardiomyopathy managed by successful ablation of right ventricular outflow tract premature ventricular complexes

Tachycardiomyopathy is a common reversible cause of left ventricular dysfunction. Prompt diagnosis and treatment of this condition is essential to ensure a good prognosis for the patient. We report a case of tachycardiomyopathy due to frequent premature ventricular complexes arising from the right ventricular outflow tract midseptum managed with successful ablation.

Outflow Ventricular Septal Defect with Aortic Regurgitation: Optimal timing of Surgery?

BACKGROUND

Ideal time of surgery still remains controversial in outflow ventricular septal defect (VSD) with aortic regurgitation (AR). We aimed to identify the prevalence and predictors of postoperative AR progression.

METHODS

154 patients with outflow-VSD and AR who underwent VSD surgery between 2006 and 2012 were studied retrospectively.

RESULTS

Total 80 patients with subpulmonic-VSD and 74 with subaortic-VSD were followed-up for mean 6.32+/-2.27 years (range 3-12 years). Of them, 100 had trivial to mild (group-A) and 54 had moderate to severe preoperative-AR (group-B). At follow-up, There was no significant worsening of mean residual AR in group-A (p=0.16) and subpulmonic-VSD of group-B (p=0.083). However, it worsened significantly in subaortic-VSD (1.85+/-0.87 vs 2.21+/-1.08, p=0.005) of group-B. Only 2 (both had subaortic-VSD) patients of group-A developed moderate AR and none required aortic valve replacement (AVR), while 23 (42.60%) of group-B patients developed moderate or severe AR and 7 (30.4%) of them required AVR. Moreover, all who needed AVR had subaortic-VSD and had undergone valvuloplasty during VSD-closure. The 10 years freedom from moderate or severe-AR was significantly lower in group-B than group-A in both VSDs (subaortic-VSD 42.5+/-10.7% vs 89.3+/-8.1%, p<0.01; subpulmonic-VSD 66.7+/-10.3% vs 100%, p<0.01). On multiple regression analysis, postoperative residual-AR was the only predictor of AR-progression (standardized coefficients =0.48; p<0.001) at follow-up.

CONCLUSIONS

Mild preoperative-AR rarely progressed after VSD-repair. However, worsening of AR could not be prevented effectively, even with valvuloplasty, after the development of moderate or severe AR. Mild or more postoperative residual-AR need close follow-up, especially in subaortic-VSD.

Discordant responses to his refractory premature ventricular beats (PVBs) during a regular narrow QRS tachycardia. What is the mechanism

A 32-year-old lady was evaluated for recurrent episodes of palpitation. During one of the palpitation episodes a regular narrow QRS tachycardia was documented, and it got terminated with the administration of IV adenosine. The baseline 12 lead electrocardiogram (ECG) did not show any manifest preexcitation. There was no evidence of structural heart disease by echocardiogram. Patient underwent an electrophysiology (EP) study after informed consent. Quadripolar catheters were placed at the His region and right ventricular (RV) apex. A decapolar catheter was placed in the coronary sinus (CS) with CS 9, 10 dipoles at CS OS region and CS 1, 2 dipoles at CS distal region. A mapping & ablation catheter was positioned at right atrial (RA) appendage. Baseline atrial and ventricular pacing protocols could not be performed as both atrial and ventricular pacing were easily inducing a regular narrow QRS tachycardia. His refractory premature ventricular beats [PVBs] were delivered from RVRV apex and left ventricular [LV] free wall. Discordant responses were obtained. What is the mechanism?

Transition during radiofrequency ablation of manifest preexcitation. What is the mechanism?

A 45-year-old lady was evaluated for recurrent episodes of palpitation. Her 12‑lead electrocardiogram (ECG) showed manifest but incomplete pre-excitation consistent with left sided accessory pathway. There was no structural heart disease by echocardiogram. She underwent an electrophysiology (EP) study after informed consent. A narrow QRS tachycardia consistent with orthodromic AV re-entry got induced. The accessory pathway was mapped to 2 'O clock of the mitral annulus (MA). While radio frequency ablation (RFA) was being performed at that site, an interesting phenomenon was observed (Figs. 1 & 2). What is the mechanism?

Regular narrow QRS tachycardia. What is the mechanism?

A 45-years-old lady with no structural heart disease on echocardiogram presented with recurrent episodes of palpitation. There was no baseline preexcitation. Twelve lead surface electrocardiograms (ECG) recorded during one of the episodes are provided. What is the likely mechanism of the tachycardia? [Figure: see text].

Re-entrant ventricular tachycardia in a postoperative case of tetralogy of Fallot - Ablated successfully under the three-dimensional mapping system

A 47-year-old female underwent cardiac repair for tetralogy of Fallot at the age of 12 years. Subsequently, she was asymptomatic on follow-up. Recently, she presented elsewhere with palpitations and presyncope with documented ventricular tachycardia (VT) having left bundle branch block morphology with inferior QRS axis and late precordial transition. She was reported to have cardioverted and referred to our center for electrophysiology study (EP). She underwent EP study which induced clinical VT which was hemodynamically stable and the mechanism of VT was confirmed as re-entry. With the help of three-dimensional mapping system, VT circuit was identified in the posterior right ventricular outflow tract region between the pulmonary valve and upper end of ventricular septal defect patch. Delivery of radiofrequency energy during VT terminated the tachycardia with no further inducible VT despite aggressive pacing protocols.

Clinical profile & long-term natural history of symptomatic coronary artery disease in young patients (<30 yr)

Background & objectives:

Several studies have shown a high prevalence of cardiovascular risk factors in patients in the age group of 30-74 yr, but there is a paucity of data in young patients below 30 yr. We analyzed the clinical and coronary angiographic profile of patients <30 yr of age with symptomatic coronary artery disease (CAD) and also assessed their intermediate and long-term outcomes.

Methods:

All patients less than 30 yr of age who presented with symptomatic CAD from 1978 to 2017 in the department of Cardiology of a tertiary care hospital in south India, were studied for coronary risk factors and angiographic and treatment patterns, and the follow up data were collected.

Results:

The mean age of the 159 patients <30 yr of age was 26.7±3.29 yr. Male preponderance was observed (91.8%), 63.5 per cent patients were smokers and 88.3 per cent were dyslipidaemic. Acute myocardial infarction was the most common mode of presentation. Forty one per cent patients were non-adherent to medications. Risk factor control was inadequate with respect to smoking cessation, alcoholism, physical activity and dietary regulation. The predictors of long-term mortality were multivessel CAD [hazard ratio (HR): 1.927, 95% confidence interval (CI): 1.003-3.701] and reduction in ejection fraction (EF) (10% decrease in EF; HR: 1.349, 95% CI: 1.096-1.662). Overall mortality was 30 per cent at 10 yr and 48 per cent at 20 yr.

Interpretation & conclusions:

Decreasing EF and multivessel involvement were found to be the strong correlates for long-term mortality in young patients below 30 yr of age with CAD. High long-term mortality rates and poor risk factor control suggest the vast scope for the improvement of outcomes in these patients with aggressive risk factor control.

Mitral valve leaflet diverticulum with vegetation-a rare complication in rheumatic heart disease

Diverticulum of mitral leaflet is a rare complication, which is recognized by its central clearing with characteristic diastolic collapse and systolic expansion on echocardiogram. It is found to be commonly associated with infective endocarditis while various other mechanisms of its formation have been suggested. The present case with an underlying history of rheumatic heart disease complicated by infective endocarditis well demonstrates the formation of mitral leaflet diverticulum and its possible complications. Surgical findings revealed diverticulum of the anterior mitral leaflet, and the patient underwent double valve replacement.

Wide and narrow QRS tachycardias: What is the mechanism?

A 50-year-old lady was referred for radiofrequency catheter ablation of narrow QRS tachycardia that was terminated with intravenous adenosine. Twelve-lead Electrocardiogram (ECG) was normal during sinus rhythm. The electrophysiological study showed an Atrio-Hisian (AH) interval of 104 ms and Hisio-Ventricular (HV) interval of 45 ms during sinus rhythm. Atrial pacing reproducibly induced regular broad (left bundle branch block morphology) and narrow QRS tachycardias. A spontaneous premature ventricular ectopic from right ventricular apex has resulted in transition of the tachycardia from wide to narrow. What are the likely mechanisms?

Implication of d-dimer in rheumatic severe mitral stenosis – A tertiary centre study

Background

In rheumatic mitral stenosis (MS), left atrial (LA) thrombus and LA spontaneous echo contrast (LA SEC) reflect hypercoagulability. The study focuses on whether D-dimer levels predict the existence of LA thrombus and SEC in patients with severe MS.

Methods

95 consecutive patients with severe MS referred for transesophageal echocardiogram (TEE) between July 2011 and March 2012 to evaluate LA thrombus prior to balloon mitral valvotomy (BMV) were included in the study. D-Dimer levels in these patients were observed.

Results

Out of the 95 patients, 15 (15.8%) had LA thrombus and 52 patients had LA SEC (54.7%). Any correlation between D-Dimer levels and existence (or non-existence) of LA thrombus was not noticed from the receiver operating characteristics (ROC) curve with an area of .535. For patients with LA SEC, the D-Dimer levels were found to be considerably higher (776 ± 866 μg/L vs. 294 ± 331 μg/L, p = .001). An ideal cut-off level of 393 μg/L for diagnosing LA SEC was illustrated by the ROC curve with a sensitivity of 63.4%, specificity of 83.72%, positive predictive value of 82.5% and a negative predictive value of 65.45%.

Conclusions

D-dimer levels were not representative of the presence or absence of LA thrombus in patients with severe MS. Nonetheless, this study demonstrated the substantial link between D-Dimer level and LA SEC. If a D-Dimer level of 400 μg/L or higher is taken as positive, it has high specificity and positive predictive value for diagnosing LA SEC.

Interesting response to ventricular overdrive pacing during regular narrow QRS tachycardia. What is the mechanism?

33 year old gentleman has undergone an electrophysiology study for recurrent paroxysmal palpitation. During one of the episodes of palpitation a regular narrow QRS tachycardia was documented which has terminated with intravenous adenosine. Baseline electrocardiogram did not show any pre-excitation. Atrial-His (AH) and His-Ventricular (HV) intervals were normal at baseline. There was no evidence of dual atrioventricular (AV) nodal physiology. Earliest atrial electrogram during ventricular pacing was recorded at coronary sinus (CS) 9,10 dipoles placed at CS OS region. Narrow QRS tachycardia with cycle length (TCL) of 400 ms and earliest retrograde atrial activation at CS 9,10 dipoles was induced with programmed ventricular stimulation. Ventricular overdrive (VOD) pacing was performed at 30 ms shorter than TCL during the tachycardia (Fig: 1). What is the mechanism of tachycardia?

Incidentally detected right aortic arch with mirror image branching in a patient with rheumatic calcific mitral valve disease

An isolated right-sided aortic arch with no congenital heart disease is extremely rare. We report an adult woman with longstanding rheumatic heart disease causing severe calcific mitral stenosis, moderate mitral regurgitation and moderate pulmonary hypertension, for which she underwent mitral valve replacement and tricuspid annuloplasty. On preoperative work-up, she was detected to have a right-sided aortic arch with mirror image branching along with a ductal dimple. However, there were no associated congenital cardiac defects.

Response of narrow QRS tachycardia in a patient with surgical closure of atrial septal defect to atrial overdrive pacing: What is the mechanism?

A 57-year old woman who had pericardial patch closure of ostium secundum atrial septal defect (ASD) at the age of 23 years presented with shortness of breath. Her echocardiogram showed no residual ASD, good biventricular function and normal pulmonary artery pressures.