Analysis of ST segment depression in Supraventricular Tachycardia and its relationship with underlying mechanism.

BACKGROUND: Electrocardiographic diagnosis of causes of supraventricular tachycardia (SVT) is sometimes difficult and application of routine algorithms can lead to misdiagnosis in as many as 37% of patients. ST segment depression may be useful in diagnosing the nature of SVT. METHODS: We reviewed surface electrocardiogram (ECG) characteristics of 300 patients having SVT with 1:1 AV relationship and correlated findings with electrophysiology study (EPS) findings. Final diagnosis of AVNRT (Atrioventricular nodal reentrant tachycardia), Orthodromic AVRT (atrioventricular reentrant tachycardia) and atrial tachycardia (AT) was correlated with ECG parameters like heart rate, ST segment depressions and QRS morphology. RESULTS: Out of 300 patients, majority patients included in study, were having AVNRT or AVRT. ST depression predicted AVRT if the ST depression was > 2mm (overall sensitivity of 38.3% and specificity of 93.8% to predict AVRT) and was downsloping in morphology (sensitivity of 36.9% and specificity of 94.7% to predict AVRT). At heart rates >214 beats per minute (bpm) as measured by 7 small squares of ECG at 25mm/sec, downsloping ST depression >2mm had a sensitivity 37.9% of and specificity of 89.2% to predict AVRT. At heart rate <214 bpm, downsloping ST depression >2mm had sensitivity of 37.2% and specificity of 96.5% to predict AVRT. Downsloping ST depression of >2 mm helps to differentiate AVNRT from AVRT. CONCLUSION: A downsloping ST segment depression >2mm predicted SVT being an AVRT and can be used as a useful criteria in diagnosing the tachycardia.

An Incidental Finding of a Cecal Lymphangioma Managed Conservatively.

Colonic lymphangiomas are rare and mostly incidental findings found on colonoscopy. It is important to be able to differentiate them from other lesions, such as lipomas. Furthermore, when in close proximity to the appendiceal orifice, such as cecal lesions, they must be differentiated from mucocele and carcinoid tumors. We present a case of a cecal lymphangioma that was managed conservatively. By using endoscopic ultrasound (EUS) and computed tomography to better characterize the cecal mass, it was unnecessary to perform a biopsy or polypectomy. This case highlights that biopsy and/or removal of lymphangiomas are not warranted in all cases of colonic lymphangiomas, especially when lesions are less than 2 cm.

Minimizing Incision in Living Donor Liver Transplantation: Initial Experience and Comparative Analysis of Upper Midline Incision in 115 Recipients.

Living donor liver transplantation (LDLT) needs "Mercedes Benz" or "J-shaped" incision, causing short and long-term complications. An upper midline incision (UMI) is less invasive alternative but technically challenging. Reporting UMI for recipients in LDLT vs. conventional J-shaped incision. Retrospective analysis, July 2021 to December 2022. Peri-operative details and post-transplant outcomes of 115 consecutive adult LDLT recipients transplanted with UMI compared with 140 recipients with J-shaped incision. Cohorts had similar preoperative and intraoperative variables. The UMI group had significant shorter time to ambulation (3 ± 1.6 vs. 3.6 ± 1.3 days, p = 0.001), ICU stay (3.8 ± 1.3 vs. 4.4 ± 1.5 days, p = 0.001), but a similar hospital stay (15.6±7.6 vs. 16.1±10.9 days, p = 0.677), lower incidence of pleural effusion (11.3% vs. 27.1% p = 0.002), and post-operative ileus (1.7% vs. 9.3% p = 0.011). The rates of graft dysfunction (4.3% vs. 8.5% p = 0.412), biliary complications (6.1% vs. 12.1% p = 0.099), 90-day mortality (7.8% vs. 12.1% p = 0.598) were similar. UMI-LDLT afforded benefits such as reduced pleuropulmonary complications, better early post-operative recovery and reduction in scar-related complaints in the medium-term. This is a safe, non-inferior and reproducible technique for LDLT.

Incidence, clinical characteristics, electrophysiological characteristics and outcomes of patients with baseline PR prolongation undergoing radiofrequency ablation for Atrioventricular nodal reentrant tachycardia.

AIMS AND OBJECTIVES: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common supraventricular tachycardia (SVT). Prolonged PR interval(>200 ms) on baseline electrocardiogram (ECG) is uncommon in such patients. The aim of the current study was to evaluate the incidence, clinical, electrophysiological characteristics, and outcomes of patients with baseline prolongation of PR interval undergoing radio-frequency ablation (RFA) for AVNRT. METHODS: Over 10 years, out of the total number of 1435 patients with diagnosed AVNRT, 16 patients had prolonged PR intervals at baseline. All underwent elective RFA. A retrospective analysis of clinical, and electrophysiological characteristics and outcomes was done. The PR interval and atria-ventricular block cycle length values were compared with those patients with a normal interval at baseline and had undergone a successful slow pathway modification for AVNRT. RESULTS: Out of 1435 patients with AVNRT, 16 (0.9 %) patients had baseline PR prolongation on ECG. The mean(+SD) age of the study population was 62.9 + 15.9 years. 10 (62.5 %) were males. The average PR interval was 264.2 + 24.1 ms. Slow fast AVNRT was seen in all. The anatomical site of success for ablation was the lower part of Koch's triangle in all patients. During ablation, a good sustained junctional rhythm was noted in all, with no AV (Atrioventricular) block or PR prolongation noted during ablation in any of the patients. PR interval decreased by more than 20 ms in 10 (62.5 %) patients. AVBCL (AV node block cycle length) increased on an average of 58.7 ms post-ablation. Only one patient developed AV block on follow-up. CONCLUSION: A prolonged PR interval on baseline ECG is uncommon in patients with AVNRT. In these patients, slow pathway modification can be done safely and effectively. AVBCL (AV node block cycle length) increases immediately post-ablation. The risk of AV block though low persists on follow-up.

A unique location of the accessory pathway in a child with permanent junctional reciprocating tachycardia.

Permanent junctional reciprocating tachycardia (PJRT) is a rare supra ventricular tachycardia (SVT) due to an accessory pathway (AP), characterized by slow and decremental retrograde conduction, which is predominantly seen in infants and children. Although the typical site of AP in PJRT is a right posteroseptal region around or just within the coronary sinus (CS), atypical sites of AP have been described. We report a rare case of PJRT in a 7-year-old girl with an AP located in the superio-paraseptal (Para-Hsian) region that was successfully ablated through a non-coronary sinus.

Cystic Artery Pseudoaneurysm Secondary to Cholecystitis: A Rare Cause of Hemobilia.

Cystic artery pseudoaneurysm (CAP) is usually seen as a complication of cholecystectomy. Infrequently, CAP can develop in the setting of cholecystitis and can present as hemobilia when the aneurysm ruptures. Here, we present the case of an 88-year-old male with hemobilia secondary to CAP which was successfully managed by embolization after an initial biliary stent placement.

Split right coronary artery with split posterior descending artery.

We report a case of an 87-year-old man where coronary CT angiography incidentally demonstrated a "split" right coronary artery (RCA) featuring a "split" posterior descending artery. This case focusses on the morphological description of this variant as well as its differentiation from a "dual" or "duplicated" RCA.

A Unique Presentation of Jaundice.

Obstructive jaundice has many common etiologies, which might cause us to overlook diagnoses that are far worse. This is a case of a Hispanic male who presented with jaundice and worsening liver function. During his hospitalization, he was erroneously diagnosed before being diagnosed with gastric cancer. Even though biliary obstruction has many common etiologies, there are cases that can't be explained, which warrants further investigation such as malignant etiologies.

Carotid Artery Stenting for a Nonagenarian Presenting as Stuttering Stroke.

Carotid artery stenting (CAS) is performed in patients with minor strokes and transient ischemic attacks (TIAs) to prevent further strokes. However, most operators do not intervene in older adults. We had a 92-year patient with recurrent minor strokes with two possible proximate causes - cardioembolism and significant symptomatic left carotid stenosis. This patient continued to have recurrent ischemic events in the left carotid territory despite optimum management of the cardioembolic source with dual antiplatelets and anticoagulation and was successfully treated with left CAS. The role of carotid revascularization in older patients with high-grade symptomatic carotid stenosis and cardiac comorbidities is discussed.

Anal polyp.

Our case accurately describes a not infrequent finding that is not well understood by endoscopists. Fibroepithelial polyps are benign and should be considered in the differential diagnosis of anorectal polyp.

Atresia of the coronary sinus ostium with persistent left superior caval vein.

We describe a case of a 33-year-old woman with congenitally corrected transposition where computed tomography angiography incidentally detected ostial atresia of the coronary sinus with dilatation of the terminal parts of the middle cardiac vein and great cardiac vein and retrograde drainage of the coronary sinus into the persistent left superior caval vein, the intercommunicating vein, then to the right superior caval vein, and ultimately into the right atrium.

1029 genomes of self-declared healthy individuals from India reveal prevalent and clinically relevant cardiac ion channelopathy variants.

BACKGROUND: The prevalence and genetic spectrum of cardiac channelopathies exhibit population-specific differences. We aimed to understand the spectrum of cardiac channelopathy-associated variations in India, which is characterised by a genetically diverse population and is largely understudied in the context of these disorders. RESULTS: We utilised the IndiGenomes dataset comprising 1029 whole genomes from self-declared healthy individuals as a template to filter variants in 36 genes known to cause cardiac channelopathies. Our analysis revealed 186,782 variants, of which we filtered 470 variants that were identified as possibly pathogenic (440 nonsynonymous, 30 high-confidence predicted loss of function ). About 26% (124 out of 470) of these variants were unique to the Indian population as they were not reported in the global population datasets and published literature. Classification of 470 variants by ACMG/AMP guidelines unveiled 13 pathogenic/likely pathogenic (P/LP) variants mapping to 19 out of the 1029 individuals. Further query of 53 probands in an independent cohort of cardiac channelopathy, using exome sequencing, revealed the presence of 3 out of the 13 P/LP variants. The identification of p.G179Sfs*62, p.R823W and c.420 + 2 T > C variants in KCNQ1, KCNH2 and CASQ2 genes, respectively, validate the significance of the P/LP variants in the context of clinical applicability as well as for large-scale population analysis. CONCLUSION: A compendium of ACMG/AMP classified cardiac channelopathy variants in 1029 self-declared healthy Indian population was created. A conservative genotypic prevalence was estimated to be 0.9-1.8% which poses a huge public health burden for a country with large population size like India. In the majority of cases, these disorders are manageable and the risk of sudden cardiac death can be alleviated by appropriate lifestyle modifications as well as treatment regimens/clinical interventions. Clinical utility of the obtained variants was demonstrated using a cardiac channelopathy patient cohort. Our study emphasises the need for large-scale population screening to identify at-risk individuals and take preventive measures. However, we suggest cautious clinical interpretation to be exercised by taking other cardiac channelopathy risk factors into account.

Early repolarization syndrome, epilepsy, and atrial fibrillation in a young girl with novel KCND3 mutation managed with quinidine.

A 6-year-old girl presented with a difficult to control epilepsy syndrome. On evaluation, additional presyncope episodes associated with polymorphic ventricular tachycardia were also noted. A diagnosis of early repolarization syndrome (ERS) was made with an early repolarization pattern on electrocardiogram, documented VT episodes, and clinical presyncope (proposed Shanghai score 7). Paroxysmal atrial fibrillation (AF) was also noted on 24-h Holter recordings. The child was stabilized with isoprenaline infusion and was later discharged with arrhythmia control on quinidine and cilostazol. The genetic evaluation revealed a potassium channel KCND3 gene missense mutation. The case highlights the association of epilepsy syndrome and AF with ERS; the possible association of KCND3 gene mutation with a malignant phenotype; and management issues in a small child.

Effect of Yoga on Clinical Outcomes and Quality of Life in Patients With Vasovagal Syncope (LIVE-Yoga).

OBJECTIVES: This study aims to determine the impact of yoga as an adjunct to standard therapy versus standard therapy alone on the symptomatic burden in patients with recurrent vasovagal syncope (VVS). BACKGROUND: There is a significant reduction in the quality of life (QoL) of patients with recurrent VVS. Existing management therapies have been largely ineffective. Recent trials have demonstrated the efficacy of yoga in diseases with autonomic imbalance, suggesting its possible utility in VVS. METHODS: Patients with recurrent VVS were randomized to receive either a specialized yoga training program in addition to current guideline-based therapy (intervention arm, group 1) or current guideline-based therapy alone (control arm, group 2). The primary outcome was a composite of the number of episodes of syncope and presyncope at 12 months. Secondary outcomes included QoL assessment by World Health Organization Quality of Life Brief Field questionnaire (WHOQoL-BREF) scores and Syncope Functional Status Questionnaire scores at 12 months, head up tilt test, and heart rate variability at 6 weeks. RESULTS: A total of 55 patients underwent randomization. The mean number of syncopal or presyncopal events at 12 months was 0.7 ± 0.7 in the intervention arm compared to 2.52 ± 1.93 in the control arm (P < 0.01). In the intervention arm, 13 (43.3%) patients remained free of events versus 4 (16.0%) patients in the control arm (P = 0.02). QoL at 12 months showed significant improvement of all Syncope Functional Status Questionnaire scores and 2 domains of WHOQoL-BREF scores (P < 0.05). CONCLUSIONS: Yoga as adjunctive therapy is superior to standard therapy alone in reducing the symptomatic burden and improving QoL in patients with recurrent VVS.

Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study.

BACKGROUND: Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association. METHODS: We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors. RESULTS: Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01). CONCLUSION: We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.