How significant is the radiation exposure during electrophysiology study and ablation procedures for supraventricular tachycardia?

Radiation exposure during electrophysiology procedures has been a point of discussion. We measured the ionising radiation dosage during ablation procedures for supraventricular tachycardia. This was compared with coronary angiographies performed via the radial route to put it in perspective. We found that the radiation dosage during the ablation procedure was far lower, less than forty percent of that during coronary angiography (Air Kerma 249.1 mGy ± 266.95 mGy v/s 671.9 mGy ± 328.6 mGy; p < 0.001).

Is the right ventricular function affected by permanent pacemaker?

AIMS: The effect of right ventricular (RV) pacing on left ventricular (LV) function has been extensively evaluated, but the effect on RV function per se has not been evaluated systematically. We aimed to assess the effect of dual chamber pacemaker on RV function. METHODS AND RESULTS: All consecutive patients undergoing dual chamber pacemaker from January 2018 to March 2019 for AV block with a structurally normal heart were included. They underwent pre-procedure detailed echocardiography (including three-dimensional [3D] RV ejection fraction [RVEF]), a screening echocardiogram 2 days after pacemaker implantation and again a detailed echocardiogram at 6-month follow-up. We compared the baseline echocardiographic RV parameters with those 6 months after the pacemaker implantation. A total of 60 patients underwent successful pacemaker implantation. At 6 months, most of the patients were pacemaker dependent with pacing percentage of 98.9% ± 2.4%; there was a significant increase in TR and a mean drop in RVEF by 2.8 ± 5%, with 23 (38.3%) having at least a 5% decrease in RVEF. The drop in RVEF positively correlated with TR vena contracta at 6 months but did not correlate with pulmonary artery systolic pressure at 6 months. CONCLUSION: Our study shows the presence of demonstrable RV dysfunction as early as 6 months in a majority of patients who have undergone pacemaker implantation.

Asymptomatic chronic traumatic aortic valve perforation with severe aortic regurgitation.

Here, we present a young asymptomatic male patient incidentally diagnosed to have aortic regurgitation (AR). The patient had a history of a blunt trauma to the thorax two years back but did never have any symptoms. Transthoracic echocardiography showed a moderately dilated left ventricle with normal systolic function and severe AR with normal nondilated aortic root and tri-leaflet aortic valve. To diagnose the etiology of the AR, a transesophageal echocardiogram (TEE) was done, which revealed a perforation in the nonadjacent leaflet (NAL) and confirmed severe AR with two AR jets being clearly visualized, one through the point of incomplete coaptation and other one through the perforated area in the NAL. The patient was treated with aortic valve replacement and was doing well on follow-up.

Acute hemodynamics of cardiac sympathetic denervation.

INTRODUCTION: We aimed to study the immediate hemodynamic effects of thoracoscopic bilateral cardiac sympathetic denervation (CSD) for recurrent ventricular tachycardia (VT) or VT storm. METHOD: We studied a group of 18 adults who underwent bilateral thoracoscopic CSD; the blood pressure (BP) and Heart Rate (HR) were continuously monitored during the surgery and up to 6 h post-operatively. RESULTS: Immediately on removal of the sympathetic ganglia, the patients had a drop in both the systolic (110 mm Hg to 95.8 mm Hg, p < 0.001) and diastolic BP (69.4 mm Hg to65 mm Hg, p = 0.007) along with a drop in the HR (81.6 bpm to 61.2 bpm, p < 0.001).At 6 h after CSD, the systolic and diastolic BP did not recover significantly, while there was recovery in HR (61.2 bpm to 66 bpm, p = 0.02). There was no significant difference between those with and without left ventricular (LV) systolic dysfunction. CONCLUSION: The acute hemodynamic changes during the perioperative period of CSD are significant but not serious. Awareness of this is useful for peri-operative management.

Complete reversal of constriction physiology with antitubercular treatment without steroid: a case report.

BACKGROUND: Constrictive pericarditis is a chronic inflammation of the pericardium leading to the thickening of the pericardium that restricts cardiac filling. Globally tuberculosis is the commonest aetiology of constrictive pericarditis. Though normally considered to be an irreversible pathology; which requires surgical pericardiectomy, in early stage of the disease antitubercular therapy (ATT) along with steroids and other anti-inflammatory therapy can reverse the pathology. But, complete reversal of constrictive physiology with ATT without any anti-inflammatory drugs is not documented. CASE SUMMARY: Here, we describe a case where a 54-year-old lady presented with progressive dyspnoea and pedal oedema for 2 years along with anorexia and weight loss for two months. Two-dimensional echocardiography and computed tomography scan was suggestive of constrictive pericarditis. In view of systemic features and high acute phase reactants, patient was started on oral ATT without any steroids. After 4 months, constriction physiology was completely reversed. DISCUSSION: Constriction physiology if treated timely can be largely reversed only with ATT without adjuvant anti-inflammatory therapy. Further studies are required to find out the specific indications of anti-inflammatory therapy in tubercular constrictive pericarditis.

Diagnostic dilemma: Kikuchi's disease or tuberculosis?

Any patient from a tuberculosis (TB) endemic area such as India with classical clinical features of fever, weight loss and lymphadenopathy, making a diagnosis of Kikuchi's disease (KD) prior to waiting for the 6-week culture is not appropriate. KD or histiocytic necrotising lymphadenitis is a rare self-limiting cervical lymphadenitis, often a diagnosis of exclusion. One needs to exclude TB, sarcodosis, lymphoma and autoimmune diseases to make such a diagnosis. The patient here with classical clinical presentation of TB with lymph node biopsy mimicking KD (biopsy and immunohistochemistry) posed a big diagnostic dilemma. However, culture of the biopsied lymphatic tissue was confirmed to be mycobacterium TB after the 6th week of incubation. The patient was treated with antitubercular drugs initially, and later, steroid was added in view of his persistent symptoms and he responded. One should wait for the tissue culture report to confirm or exclude the diagnosis of TB. Exclusion should not be based only on laboratory criteria. Histopathogically, TB can mimic any other granulomatous disorder.

Waldenstrom macroglobulinemia presenting with pancreatic mass: a case report and review of literature.

CONTEXT: Waldenstrom macroglobulinemia is a rare lymphoplasmacytic lymphoma characterized by a wide range of clinical presentations related to direct tumor infiltration and the production of IgM. Most commonly it presents with cytopenia, hepatosplenomegaly, lymphadenopathy, constitutional symptoms, and hyperviscosity syndrome. CASE REPORT: We report a case of Waldenstrom macroglobulinemia in an 60-year-old female who initially presented with intermittent abdominal pain. The patient had no peripheral lymphadenopathy. On extensive investigation she was found to have pancreatic mass. The diagnosis of Waldenstrom macroglobulinemia was established after cytomorphology and immunohistochemical analysis of the patient's bone marrow revealed the presence of a lymphoid/lymphoplasmacytoid-like bone marrow infiltrate along with an elevated serum IgM level. The patient responded both clinically and serologically to chemotherapy. This case is unusual because the patient lacked all common clinical features of Waldenstrom macroglobulinemia with exception of anemia. CONCLUSION: To our knowledge this is the first report of a patient with Waldenstrom macroglobulinemia presenting with a pancreatic mass adding to the spectrum of clinical presentations seen in this disease. This adds to the wide variety of gastrointestinal related clinical presentations of Waldenstrom macroglobulinemia and points to the need for considering Waldenstrom macroglobulinemia along with other lymphoid neoplasms in the differential diagnosis of pancreatic lesions.

Periampullary mass--a rare presentation of poorly differentiated neuroendocrine cancer of duodenum in a young adult: a case report and review of literature.

Poorly differentiated neuroendocrine tumour in the periampullary region of the duodenum is a rare entity. This entity usually present in old men. Here we report a periampullary poorly differentiated neuroendocrine cancer (PDEC) of duodenum presenting in a young man with subacute history of jaundice, abdominal pain, pancreatitis and constitutional symptoms. MRI localised the tumour and endoscopy-guided biopsy of the lesion proved the diagnosis. Although palliative surgery and chemotherapy were planned, the patient opted to leave against medical advice.

Hepatic myelopathy in a patient with decompensated alcoholic cirrhosis and portal colopathy.

Cirrhotic or hepatic myelopathy is a rare neurological complication of chronic liver disease usually seen in adults and presents as a progressive pure motor spastic paraparesis which is usually associated with overt liver failure and a surgical or spontaneous systemic portocaval shunt. We describe the development of progressive spastic paraparesis, in a patient with alcoholic cirrhosis with portal hypertension and portal colopathy who presented with the first episode of hepatic encephalopathy. The patient had not undergone any shunt procedure.