Wire entanglement to retrieve a dislodged stent from the proximal right coronary artery

A 70-year-old woman who was a known diabetic and had hypertension presented with non-ST-elevation myocardial infarction. A coronary angiogram showed a significant lesion in the mid-portion of right coronary artery (RCA) followed by distal cut-off.

Quadricuspid aortic valve

A 56-year-old man presented with typical angina for 1 day and a prior history of exertional dyspnea of 6 months duration. Clinically, he was diagnosed with severe aortic regurgitation (AR). Electrocardiogram showed left ventricular hypertrophy with volume overload.

Quadricuspid aortic valve

A 56-year-old man presented with typical angina for 1 day and a prior history of exertional dyspnea of 6 months duration. Clinically, he was diagnosed with severe aortic regurgitation (AR). Electrocardiogram showed left ventricular hypertrophy with volume overload.

Major Aortopulmonary Collaterals From Coronary Arteries and Dual Left Anterior Descending Artery in an Adult With Tetralogy of Fallot

Major aortopulmonary collaterals (APCs) are more common with tetralogy of Fallot (TOF) with pulmonary atresia. Collateral arteries, when present, arise most commonly from the descending thoracic aorta, less commonly from the subclavian arteries, and rarely from the abdominal aorta or its branches or from the coronary arteries. Collaterals arising from the coronary arteries can cause myocardial ischemia due to coronary steal phenomenon. They can be addressed either by endovascular interventions like coiling or surgical ligation during the intracardiac repair. Coronary anomalies are seen in 5%-7% of TOF patients. In approximately 4% of TOF patients, the left anterior descending artery (LAD) or an accessory LAD takes origin from the right coronary artery or right coronary sinus and crosses the right ventricular outflow tract in its course toward the left ventricle. Presence of such anomalous coronary anatomy poses certain challenges during intracardiac repair of TOF.

Vieussens' Arterial Ring

The Vieussens' artery is an anastomotic communication between the conus branch of the right coronary artery and the left anterior descending (LAD). Vieussens' ring is so named because it circles around the great vessels in the form of a partial ring. The course of the artery can be best understood in 2 orthogonal views. In the left oblique view, the artery appears coursing upward to the left. In the right oblique view, it courses anteriorly across the right ventricular outflow tract. The clinical significance of Vieussens' arterial ring lies in it being a major source of collateral blood flow to an occluded LAD. The presence of this large collateral may explain preserved ventricular function in our patient, despite severe triple-vessel disease.

Ortner's Syndrome Due to Giant Thoracic Aortic Aneurysm

Ortner's syndrome is hoarseness of the voice caused by enlarged cardiac structures compressing the left recurrent laryngeal nerve (LRLN). The LRLN is vulnerable for impingement by cardiac structures due to its anatomical course. LRLN is longer and it hooks below the arch of the aorta, posterior to the ligamentum arteriosum before ascending toward the tracheo- esophageal groove. Ortner's syndrome has been commonly described with left atrial enlargement due to mitral stenosis; however, other causes like aortic aneurysm, pulmonary artery aneurysm, and aortic dissection have been described. Although rare, hoarseness of the voice could be the only presenting complaint in aortic aneurysms as in the case described herein.

Abnormal blood supply to a normal lung: left circumflex artery branch supplying the right lung

A middle-aged woman with hypertension presented with atypical chest pain of 1 month duration and had a positive exercise stress test. She underwent diagnostic coronary angiography which demonstrated an anomalous branch arising from the proximal part of the left circumflex artery supplying the right lung. She had atherosclerotic plaques in the right coronary artery and left anterior descending artery. Stress myocardial perfusion imaging did not reveal any inducible ischaemia in the left circumflex artery territory. She was started on medical therapy for coronary artery disease and is doing well on follow-up.

Successful endovascular repair with coil embolization of ruptured right internal thoracic artery aneurysm

Internal thoracic artery aneurysms (ITAAs) are rare with wide variation in clinical presentation and a high risk of rupture. Endovascular techniques are increasingly being used for treatment of such aneurysms over surgical repair in recent times. A 34-year-old male presented with progressive swelling of the right anterior chest wall for 2 weeks and was diagnosed with right internal thoracic artery aneurysm with contained rupture. He underwent successful endovascular repair with coil embolization of ruptured right ITAA. Post intervention computed tomography (CT) angiography confirmed sealing of the ruptured aneurysm with no residual filling of the sac. At six months follow-up he is doing well with complete resolution of hematoma. This case demonstrates that an endovascular approach with coil embolization is a feasible and safe option for treating the rare ruptured ITAAs.

Kounis syndrome secondary to nimesulide ingestion: a case report

Background

Kounis syndrome, also known as "allergic myocardial infarction," is a rare co-occurrence of acute coronary syndrome (ACS) in the setting of hypersensitivity reaction to any agent. Non-steroidal anti-inflammatory drugs (NSAIDs) like are often implicated in causing allergic reactions. Here, we present a case of anterior wall myocardial infarction (AWMI) occurred following angioedema secondary to intake of Nimesulide, not described earlier in literature.

Case presentation

A 45-year-old female developed generalized pruritic, erythematous maculopapular rash, facial puffiness, oral ulcers and hoarseness of voice within few hours following consumption of Nimesulide for fever and body-ache. Due to development of hypotension, electrocardiogram (ECG) was done, which revealed ST elevation in V2–V6, with marked elevation of troponin (TnI) and creatine kinase (CK-MB). He had no chest pain or shortness of breath. Echocardiography showed regional wall motion (RWMA) abnormality in left anterior descending artery (LAD) territory with an ejection fraction of 25%. Coronary angiography showed a complete thrombotic cutoff of LAD, for which Tirofiban infusion was started to decrease thrombus burden. Repeat angiography on next day showed 80% lesion in proximal LAD for which she underwent revascularization with a drug-eluting stent. The patient later showed improvement in cardiac function at 8 months of follow-up.

Conclusions

The occurrence of ACS requiring percutaneous coronary intervention (PCI) in the setting of allergic reactions is rarely reported in the literature. One should be aware of the rare possibility of Kounis syndrome in the setting of hypersensitivity reaction when accompanying features of symptoms suggestive of coronary artery disease co-exists. When indicated, ECG monitoring and cardiac biomarkers in patients with allergic responses help to identify this rare and treatable condition.

Fetal cardiac intervention and fetal cardiac surgery: where are we in 21st century?

Fetal cardiac intervention is an in-utero cardiac procedure done in fetuses with heart diseases like severe aortic stenosis with evolving hypoplastic left heart syndrome, hypoplastic left heart syndrome with an intact or restricted atrial septum, pulmonary atresia with an intact ventricular septum, fetal heart block obstructed total anomalous pulmonary venous return, pericardial collection. The successful biventricular repair can be done in postnatal life after aortic or pulmonary valvuloplasty. Fetal bypass is very challenging because of different physiology. Low prime volume with the high flow can be used to prevent an inflammatory response.

Implementing a three-hourly feeding schedule in stable preterm infants to decrease maternal fatigue

BACKGROUND

A three-hourly feeding schedule has been shown to be as safe as a two-hourly schedule in preterm neonates. It saves nursing time and may be less tiring for the mothers. However, tradition and apprehensions have prevented its wider acceptance. We used a quality improvement approach to implement a three-hourly feeding schedule in stable preterm infants >32 weeks postmenstrual age (PMA) in our unit through a series of plan-do-study-act (PDSA) cycles.

METHODS

All preterm neonates >32 weeks PMA, who were on full enteral feeds and without any respiratory support were eligible. The key quantitative outcome was maternal fatigue score. Safety was assessed in terms of episodes of hypoglycaemia and feed intolerance. Qualitative experiences from nursing staff were captured. The volume of expressed breastmilk and requirement of formula feeds were also recorded. After recording baseline data on a two-hourly feeding schedule, four PDSA cycles were sequentially completed over 21 weeks. The results of each PDSA cycle informed the change strategy for the next cycle.

RESULTS

In the baseline phase, five neonates on a two-hourly schedule were studied. In PDSA cycles I, II, III and IV, a cumulative of 122 neonates were studied on a three-hourly schedule. There was a significant decrease in median maternal fatigue score (13 (IQR 8-23) to 3 (IQR 1-6); p=0.01)). Only one neonate had feed intolerance, while two had mild asymptomatic transient hypoglycaemia. Six (5%) neonates were shifted to two-hourly feeds temporarily due to transient reasons. Nursing staff felt mothers could devote more time to Kangaroo mother care. The volume of expressed breastmilk and requirement of formula feeds were not different from the three-hourly schedule.

CONCLUSIONS

It was possible to change the traditional two-hourly feeding schedule to three-hourly in stable preterm infants using a quality improvement approach, while objectively documenting its safety and benefits.

Spontaneous pulmonary artery thrombus in a neonate

Background

Pulmonary artery thrombosis is rare in neonates and mimics as persistent pulmonary hypertension or congenital heart disease. Risk factors include septicemia, dehydration, polycythemia, maternal diabetes, asphyxia, and inherited thrombophilias. They present with cyanosis and respiratory distress. Careful echocardiogram assessment helps in identifying the thrombus in the pulmonary artery and its branches. Computed tomography pulmonary angiography confirms the diagnosis.

Case presentation

We present a case of term neonate who presented with respiratory distress and cyanosis and a detailed echocardiogram revealed thrombus in the origin of left pulmonary artery. The neonate was managed initially with unfractionated heparin and later with low molecular weight heparin with which there was significant resolution of the thrombus

Conclusion

Spontaneous pulmonary artery thrombosis though rare should be suspected in any cyanotic neonate with respiratory distress. Management in these cases depends on the haemodynamic instability and lung ischemia.