Platypnea-orthodeoxia syndrome (POS) in a patient who had undergone partial liver resection

A South Asian male in his early 60s presented with acute-onset dyspnoea on postoperative day 4 after undergoing middle hepatic vein sacrificing partial liver resection for epithelioid angiomyolipoma. The patient's SpO2 on presentation was 65% in standing position which improved to 90% in left lateral decubitus. He was suspected of having platypnea-orthodeoxia syndrome (POS) which was confirmed on echocardiogram with microbubble contrast showing a large intracardiac right-to-left shunt. The patient was taken up for transcatheter closure of patent foramen ovale (PFO). A 30 mm Amplatzer PFO Occluder was deployed across the PFO which reduced the intracardiac shunt resulting in an improved arterial saturation as well as immediate relief of patient's symptoms. This case illustrates the importance of suspecting and recognising POS clinically as well as the efficacy of transcatheter closure of PFO in such cases leading to resolution of hypoxaemia in a short span of time.

Endomyocardial fibrosis: a tragic conundrum or a mere negligence?

Often termed as 'vanishing mystery' epidemiologically, endomyocardial fibrosis (EMF) continues to be the the most common cause of restrictive cardiomyopathy in Africa and some parts of the Indian subcontinent, where it is considered a significant public health problem. On the other hand, in developed countries, it is considered a rare phenomenon. This entity is considered incurable due to lack of targeted therapies, even after 75 years since its discovery. The authors describe here a case of an Indian male, in his early 30s who presented with complaints of dyspnoea on minimal daily activities, swelling of both legs and abdominal fullness for 3 months. The clinical features were suggestive of isolated right heart failure. He was diagnosed with EMF on echocardiography and the findings were confirmed on cardiac MRI. The patient has progressed to develop biventricular dysfunction and is being managed symptomatically with diuretics due to unavailability of targeted treatment options at present.

Left ventricular global longitudinal strain imaging in identifying subclinical myocardial dysfunction among covid-19 survivors

BACKGROUND

Covid-19 is multi-system viral infection caused by SARS-CoV-2 virus. Apart from having acute severe respiratory illness causing high mortality, the disease also has a variety of cardiovascular manifestations contributing to morbidity as well as mortality. Cardiac dysfunction and myocarditis are well established complications of Covid-19 as evident in multiple studies after the Covid-19 pandemic. However it is not sufficiently studied in Indian patients either by Echocardiography or by any other imaging modalities like cardiac magnetic resonance imaging (MRI).

METHODOLOGY

In this study, we analysed the severity of Left ventricular(LV) dysfunction in Covid-19 survivors. A total of 100 consecutive patients of Covid-19 after one month of discharge who had no underlying cardiovascular diseases underwent echocardiography and global longitudinal strain (GLS) imaging. This study cohort included patients with mild 42 (42%),moderate 46(46%) and severe 12(12%) Covid-19 disease as defined by computerised tomography (CT) severity score.

RESULT

We observed that total 36(36%) patients had reduced ejection fraction(EF) which included 11 patients having EF <40% and remaining 25(25%) having EF 40-50% (p<0.002). Also 22 (22%) patients had abnormal global longitudinal strain (GLS) values with normal ejection fraction which is suggestive of subclinical myocarditis. We observed LV dysfunction in 7(19.5%) patients who had severe Covid-19 while mild to moderate LV dysfunction observed in 29(80.5%) non critical patients.

CONCLUSION

In conclusion our study demonstrates that myocardial dysfunction is common in covid-19 regardless of disease severity. 2D-echocardiography with GLS is likely to detect early LV dysfunction among these patients.

Parenteral Iron Therapy in Patients with Heart Failure in a Resource Constrained Setting In India - Our Experience

OBJECTIVES

To assess the prevalence of Iron Deficiency and impact of Parenteral Iron therapy in patients with Symptomatic Heart failure, the role of exercise capacity and serial Echocardiography in assessing treatment response.

METHODS

Study was performed in a Government Hospital for 24 months, December 2017 to December 2019.120 participants were recruited. Patients with symptomatic heart failure and Serum Ferritin &lt;100 mg/dl were recruited and those with diagnosed Ischemic Cardiomyopathy or unwilling to give consent were excluded. They underwent a functional assessment and 2D Echo at baseline, after 30 and 90 days of IV Carboxymaltose. The data was analysed represented in appropriate figures. A P value &lt;0.05 was considered significant.

RESULTS

Of 120 patients recruited, 28 were male and 92 were female. The mean age of presentation was 44 +/- 5.4 years. The Mean baseline Haemoglobin was 11.7 +/- 0.38 gm/dl.The baseline Ferritin levels were 16.69 +/-2.9 ug/L. HFpEF was predominant with 65% cases. The NYHA status and 6min HWT tests showed a statistically significant improvement and Echocardiography findings showed a statistically insignificant improvement after Parenteral Iron.

CONCLUSION

Iron Deficiency is a major risk factor in Heart Failure including HFpEF and prevails in the younger population.Parenteral Iron Carboxymaltose followed by oral iron supplementation is effective in Heart Failure patients, especially in HFpEF. Functional capacity and NYHA status appear to be the time tested markers for Iron repletion.

Validation of "left ventricular early inflow-outflow index": A novel echocardiographic method for quantification of mitral regurgitation in an Indian population with special focus on rheumatic etiology

BACKGROUND

Quantification of mitral regurgitation (MR) has always required an "integrated approach" as there is no single gold-standard method. We investigated a new Doppler-derived parameter "left ventricular early inflow-outflow index (LVEIO)" for the quantification of MR and its likelihood to predict severe MR in correlation with already established parameters in an Indian population including a large subset of patients with rheumatic etiology.

METHODS

A prospective study was performed at a major tertiary care center in western India over a 5-month period. Five hundred patients diagnosed with isolated MR including 260 (52%) patients with rheumatic etiology were included in the study after applying exclusion criteria. We analyzed MR using color flow jet, effective regurgitant orifice area (EROA), and vena contracta (VC) width. LVEIO is a simplification of the regurgitant volume (RV) method, which was calculated as "E velocity divided by LV outflow velocity integrated over the systolic ejection period left ventricular outflow tract velocity time integral" and compared with the established parameters.

RESULTS

LVEIO was 4.65 ± 1.45, 6.56 ± 1.52, and 9.91 ± 3.70 among patients diagnosed with mild, moderate, and severe MR, respectively (p < 0.001). Those with LVEIO ≥8 were the most likely to have severe MR (positive likelihood ratio: 10.42). LVEIO had specificity of 93.25% for diagnosis of severe MR with positive predictive value of 86.36%. There was positive correlation observed between LVEIO and VC width (r = 0.591), RV (r = 0.410), and EROA (r = 0.778) (all p < 0.001) in the Pearson correlation test. The specificity of LVEIO remained consistent in diagnosing severe MR in patients with rheumatic etiology.

CONCLUSION

LVEIO is a simple yet specific Doppler echocardiographic parameter for estimation of severity of MR including that of rheumatic etiology.

Percutaneous balloon valvuloplasty with Inoue balloon catheter technique for pulmonary valve stenosis in adolescents and adults

Background

Percutaneous balloon pulmonary valvuloplasty is the procedure of choice for uncomplicated severe or symptomatic pulmonary stenosis. The present study describes our experience in balloon pulmonary valvuloplasty using the Inoue balloon catheter in adolescent and adult patients.

Aims

To assess the immediate and mid-term outcomes of percutaneous balloon valvuloplasty with Inoue balloon catheter in adolescent and adult patients.

Methods and results

Between June 2010 and July 2015, we performed percutaneous balloon pulmonary valvuloplasty with Inoue balloon catheter in 32 patients (59.37% females) aged 8 to 54 years (mean 23.6 ± 11.5). Following the procedure, the mean right ventricular systolic pressure and the pulmonary valvular peak-to-peak systolic gradient decreased from (121.6 ± 42.4 to 61.19 ± 24.5 mmHg, p = 0.001) and (100.9 ± 43.3 to 36.4 ± 22.5 mmHg, p = 0.001), respectively. Twenty patients (Group A) showed immediate optimal results with post-procedure peak systolic gradient <36 mmHg while 12 patients (Group B) had suboptimal results. An increase in pulmonary regurgitation by one grade was detected in 17 patients (53.2%). Twenty-three patients available for follow-up (mean duration, 2.75 years [range 0.25–5 years]) had a mean residual peak gradient of 23.6 ± 2.51 mmHg on Doppler echocardiography with attenuation of reactive RVOT stenosis in all Group B patients. There was no further increase in grade of pulmonary regurgitation or restenosis on mid-term follow-up.

Conclusion

Percutaneous Inoue balloon technique is an attractive alternative with excellent mid-term results for adolescents and adults with isolated pulmonary stenosis.

Is the Sac Waiting to Rupture? Sinus of Valsalva Aneurysm

Completely asymptomatic sinus of Valsalva aneurysms are rare entities, and there is no consensus regarding their management. We present the case of a patient who underwent atrial septal defect device closure at 5 years of age and was lost to follow-up, then presented 6 years later with unruptured sinus of Valsalva aneurysm and was closely followed. The aneurysm eventually ruptured and was successfully operated on with good outcomes.

Subvalvular apparatus and adverse outcome of balloon valvotomy in rheumatic mitral stenosis

BACKGROUND

Balloon mitral valvotomy (BMV) is a well-established therapeutic modality for rheumatic mitral stenosis (RMS). However, there are chances of procedural failure and the more ominous post-procedural severe mitral regurgitation. There are only a few prospective studies, which have evaluated the pathogenic mechanisms for these major complications of BMV, especially in relation to the subvalvular apparatus (SVA) pathology.

METHODS

All symptomatic patients of RMS suitable for BMV by echocardiographic criteria in a span of 1 year were selected. In addition to the standard echocardiographic assessment of RMS (Wilkins score and score by Padial et al.), a separate grading and scoring system was assigned to evaluate the severity of the SVA pathology. The SVA score was 'I', when none of the two SVAs had severe disease, 'II' when one of the two SVAs has severe disease, and 'III' when both SVAs had severe disease. With these scoring systems, the outcomes of BMV (successful procedure, failure, and post-procedural mitral regurgitation) were analyzed. Emergency valve replacement was performed depending on clinical situation, and in cases of replacement, the pathology of the excised mitral valves were compared with echocardiographic findings.

RESULTS

Of the 356 BMVs performed in a year, 43 patients had adverse outcomes in the form of failed procedure (14 patients) and mitral regurgitation (29 patients). Forty-one among these had a SVA score of III. The sensitivity and specificity of the MR score was lesser than the SVA score (sensitivity 0.34 vs. 1.00, specificity 0.92 vs. 0.99, respectively). The mitral valvular morphology in 39 patients who underwent post-procedural valve replacements correlated well with echocardiography findings.

CONCLUSION

It is important to assess the degree of SVA pathology in the conventional echocardiographic assessment for RMS, as BMV would have adverse events when both SVAs were severely diseased.

Aneurysmally dilated major aorto-pulmonary collateral in tetralogy of Fallot

Haemodynamically significant systemic-to-pulmonary artery collaterals may present as a cause of cardiorespiratory compromise in tetralogy of Fallot (TOF) with pulmonary atresia. We present here a case of TOF with pulmonary atresia with aneurysmally dilated aorto-pulmonary collateral causing compression over trachea, presenting as dry irritating cough who died suddenly with haemoptysis probably due to rupture of hypertrophied bronchial collaterals or direct erosion of large major aorto-pulmonary collateral arteries (MAPCA) into the respiratory tract.

Planimetry of mitral valve stenosis in rheumatic heart disease by magnetic resonance imaging

BACKGROUND AND AIM OF THE STUDY

To date, no investigations have been made on the role of magnetic resonance imaging (MRI) in evaluating mitral stenosis (MS) in Asian countries such as India, where rheumatic MS is more common. An accurate assessment of the mitral valve area (MVA) is particularly important when managing patients with valvular stenosis. Current standard techniques to assess the severity of MS include echocardiography and cardiac catheterization, the former of which represents the most practical approach. The study aim was to evaluate the accuracy and clinical utility of planimetry of the MVA and peak gradient, assessed by MRI in comparison with echocardiography, in rheumatic heart disease (RHD) patients with MS.

METHODS

Among a group of 30 patients with suspected or known MS, planimetry of the MVA and mitral valve gradient (MVG) was performed with a 1.5 Tesla MRI scanner, using a breath-hold balanced gradient echo sequence (true FISP) and velocity-encoded MRI, respectively. The data obtained were compared with the echocardiographically determined MVA (ECHO-MVA).

RESULTS

The correlation between the MRI-MVA and ECHO-MVA was 0.81 (p < 0.0001), and between the MRI-MVG and ECHO-MVG was 0.81 (p < 0.0001). The MRI-MVA slightly overestimated the ECHO-MVA by 8.1% (1.61 +/- 0.42 cm2 versus 1.48 +/- 0.42 cm2; p < 0.05).

CONCLUSION

To the present authors' knowledge, this study is the first in which MRI has been used to evaluate MVA by planimetry, particularly in RHD. MRI is capable of adequately evaluating patients with rheumatic MS with respect to the peak gradient and MVA by planimetry. Thus, MRI planimetry of the mitral valve orifice in MS offers a reliable and safe method for the quantification of MS. Further studies are required to standardize the procedure in those patients with atrial fibrillation, or who are more symptomatic.

Effects of aspiration thrombectomy on mortality in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: a meta-analysis of the randomized trials

BACKGROUND

Thrombus removal using aspiration-thrombectomy (AT) may improve outcomes in Acute Myocardial Infarction (AMI). We performed a meta-analysis of randomized trials evaluating AT during primary Percutaneous Coronary Intervention (PCI) to determine its impact on mortality and morbidity.

METHODS

Studies were included if they were randomized trials evaluating AT versus control in patients with AMI undergoing primary-PCI. Databases were searched for eligible studies (1990-February 2008). Efficacy outcomes including death as a primary and composite of death, re-MI, stroke and repeat revascularization as a secondary outcome were evaluated at follow-up. Trials were combined using a fixed effects model and heterogeneity was evaluated.

RESULTS

18 trials involving 3871 patients were included. At average follow up of 8.9 months, mortality was significantly reduced in favour of AT (2.9% vs. 4.2%, OR 0.70, CI 0.49-0.99, P=0.04). The secondary outcome of composite of death, MI or stroke at average follow up of 8.9 months was not significantly reduced (5.6% vs. 7.1%, P=0.08) while the secondary outcome of death, MI, stroke, TVR & bleeding was significantly reduced (11% vs. 13.6% OR 0.77, CI 0.63-0.99, P 0.01) in the AT group. Thrombectomy devices were associated with a higher rate of thrombolysis in myocardial infarction 3 flow (OR 1.42; CI 1.17-1.72), Myocardial Blush Grade 3 flow (2.01; 1.74-2.31) and ST resolution (2.40; 2.08-2.78). There was no significant heterogeneity in any of the outcomes.

CONCLUSIONS

In primary PCI, the addition of AT reduces both mortality and recurrent ischemic events at follow up. These benefits are associated with improved early infarct-related artery patency.

Rhabdomyoma of the right atrium: report of a case

Rhabdomyomas are the most common primary cardiac tumors in childhood, and are considered to be congenital lesions. They are uncommon in adolescents and adults due to their tendency for spontaneous regression. Majority of them are located in the ventricular chambers, and are also associated with tuberous sclerosis. The indications for surgery include hemodynamic compromise and intractable arrhythmias. We describe a right atrial rhabdomyoma in a previously healthy 16-year-old girl who presented with palpitation and dizziness of recent onset. Postoperative evaluation had not revealed stigmata of tuberous sclerosis.

Submitral left ventricular pseudoaneurysm after mitral valve replacement: early diagnosis and successful repair

Late left ventricle (LV) rupture with pseudoaneurysm after mitral valve replacement is rare. We report its early diagnosis by advanced technologies, e.g. MRI and successful repair of a type I AV rupture through left atrial approach.

Isolated bilateral coronary ostial stenosis—An uncommon presentation of aortoarteritis

Aortoarteritis presenting with isolated bilateral coronary artery ostial stenosis is a serious but rare condition. This letter emphasizes on a very atypical presentation of aortoarteritis and also distinct but unusual form of angiographic findings involving total occlusion of left main coronary artery from the ostium and tight ostial right coronary artery stenosis that had a fulminant disease course.