Iron-catalyzed C-H Alkylation/Ring Opening with vinylbenzofurans Enabled by Triazoles.

We report an unprecedented iron-catalyzed C-H annulation using readily available 2-vinylbenzofurans as the reaction pattern. The redox-neutral strategy, based on cheap, non-toxic and earth abundant iron catalysts, exploits triazole assistance to promote a cascade C-H alkylation, benzofuran ring-opening and insertion into a Fe-N bond, to form highly functionalized isoquinolones. Detailed mechanistic studies supported by DFT calculations fully disclosed the manifold of the iron catalysis.

Electrocatalytic Formal C(sp2)-H Alkylations via Nickel-Catalyzed Cross-Electrophile Coupling with Versatile Arylsulfonium Salts.

Producing sp3-hybridized carbon-enriched molecules is of particular interest due to their high success rate in clinical trials. The installation of aliphatic chains onto aromatic scaffolds was accomplished by nickel-catalyzed C(sp2)-C(sp3) cross-electrophile coupling with arylsulfonium salts. Thus, simple non-prefunctionalized arenes could be alkylated through the formation of aryldibenzothiophenium salts. The reaction employs an electrochemical approach to avoid potentially hazardous chemical redox agents, and importantly, the one-pot alkylation proved also viable, highlighting the robustness of our approach.

The role of 12-lead electrocardiogram in the risk stratification of non-ST elevation acute coronary syndrome and the correlation with coronary angiography - The CINCHONa study - A prospective cohort study in Northern India.

Background: Clinical guidelines recommend risk stratification of non-ST elevation acute coronary syndrome (NST-ACS) using the GRACE risk score. However, the GRACE risk score is not followed widely in clinical practice due to various reasons. Our primary objectives of this study were to correlate the presenting electrocardiogram (ECG) of NST-ACS with coronary angiography (CAG) findings and to identify specific ECG changes that are suggestive of severe coronary artery disease (CAD) thus helping to triage all patients with NST-ACS. Materials and Methods: This prospective observational study was undertaken on patients diagnosed with NST-ACS in a medical college hospital, in Northern India over one and a ½ years. The admission ECG of the patients was compared with CAG findings to find out the correlation between the two with respect to severity of CAD. Categorical and quantitative variables were compared using the Chi-square test and independent t-test, respectively. Odds ratio (OR) were calculated using the univariate logistic regression analysis. Results: On comparing the two groups with normal and abnormal ECG, we found that smokers had significantly higher odds of having an abnormal ECG (OR 3.31; 95% confidence interval [CI] [1.29-8.50]). Patients with an abnormal ECG had significantly lower left ventricular ejection fraction compared to those with normal ECG (52.01 ± 10.56 vs. 55.96 ± 6.13%, P = 0.045). The patients with severe CAD on CAG had significantly higher odds of abnormal ECG (OR 3.68, 95% CI [1.2311.04]). Of the specific ECG abnormalities, ST depression and T-wave inversion in same or different leads were significantly associated with severity of CAD (OR 0.13, 95% CI [0.04-0.43], P = 0.001 and OR 0.13, 95% CI [0.03-0.46], P = 0.002, respectively). Conclusion: The identification of ECG changes suggestive of high-risk CAD can dictate to transfer such patients without delay to a percutaneous coronary intervention capable hospital for urgent CAG with intent to revascularization, thus helping in risk stratification of NST-ACS at the community level.

Résumé Contexte: Les directives cliniques recommandent la stratification du risque de syndrome coronarien aigu sans élévation du segment ST (SCA-NST) à l'aide du GRACE cote de risque. Cependant, le score de risque GRACE n'est pas largement suivi dans la pratique clinique pour diverses raisons. Nos objectifs premiers de cette étude étaient de corréler l'électrocardiogramme (ECG) de présentation du NST-ACS avec les résultats de l'angiographie coronarienne (CAG) et de identifier les modifications spécifiques de l'ECG qui suggèrent une maladie coronarienne (CAD) sévère, aidant ainsi au triage de tous les patients atteints de NST-ACS. Matériels et Méthodes: Cette étude observationnelle prospective a été entreprise sur des patients diagnostiqués avec un NST-ACS dans une faculté de médecine. hôpital, dans le nord de l'Inde pendant un an et demi. L'ECG d'admission des patients a été comparé aux résultats du CAG pour déterminer la corrélation entre les deux par rapport à la sévérité de la coronaropathie. Les variables catégorielles et quantitatives ont été comparées à l'aide du test du Chi-carré et test t indépendant, respectivement. Les rapports de cotes (OR) ont été calculés à l'aide de l'analyse de régression logistique univariée. Résultats: En comparant les deux groupes avec un ECG normal et anormal, nous avons constaté que les fumeurs avaient une probabilité significativement plus élevée d'avoir un ECG anormal (OR 3,31 ; Intervalle de confiance à 95 % [IC] [1,29­8,50]). Les patients avec un ECG anormal avaient une fraction d'éjection ventriculaire gauche significativement inférieure à à ceux ayant un ECG normal (52,01 ± 10,56 vs 55,96 ± 6,13 %, P = 0,045). Les patients atteints de coronaropathie sévère sur CAG avaient des taux significativement plus élevés risque d'ECG anormal (OR 3,68, IC à 95 % [1,2311,04]). Parmi les anomalies spécifiques de l'ECG, le sous-décalage du segment ST et l'inversion de l'onde T dans le même ou différentes dérivations étaient significativement associées à la sévérité de la coronaropathie (OR 0,13, IC 95 % [0,04­0,43], P = 0,001 et OR 0,13, IC 95 % [0,03­0,46], P = 0,002, respectivement). Conclusion: L'identification des modifications de l'ECG suggérant une coronaropathie à haut risque peut dicter le transfert de ces patients sans délai vers un hôpital capable d'intervention coronarienne percutanée pour CAG urgent avec intention de revascularisation, contribuant ainsi au risque stratification du NST-ACS au niveau communautaire. Mots-clés: Syndrome coronarien aigu, coronarographie, électrocardiogramme, score de risque GRACE, coronarien aigu sans sus-décalage du segment ST syndrome.

Rational Designing of Bimetallic/Trimetallic Hydrogen Evolution Reaction Catalysts Using Supervised Machine Learning.

Cost-efficient electrocatalysts to replace precious platinum group metals- (PGMs-) based catalysts for the hydrogen evolution reaction (HER) carry significant potential for sustainable energy solutions. Machine learning (ML) methods have provided new avenues for intelligent screening and predicting efficient heterogeneous catalysts in recent years. We coalesce density functional theory (DFT) and supervised ML methods to discover earth-abundant active heterogeneous NiCoCu-based HER catalysts. An intuitive generalized microstructure model was designed to study the adsorbate's surface coverage and generate input features for the ML process. The study utilizes optimized eXtreme Gradient Boost Regression (XGBR) models to screen NiCoCu alloy-based catalysts for HER. We show that the most active HER catalysts can be screened from an extensive set of catalysts with this approach. Therefore, our approach can provide an efficient way to discover novel heterogeneous catalysts for various electrochemical reactions.

Target Vessel Versus Complete Revascularization in Non-ST Elevation Myocardial Infarction Without Cardiogenic Shock.

Introduction The role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR. Methods It was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes. Results The mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively. Conclusion CR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.

Outcomes With Intermediate Left Main Disease: Analysis From the ISCHEMIA Trial.

BACKGROUND: Patients with significant (≥50%) left main disease (LMD) have a high risk of cardiovascular events, and guidelines recommend revascularization to improve survival. However, the impact of intermediate LMD (stenosis, 25%-49%) on outcomes is unclear. METHODS: Randomized ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) participants who underwent coronary computed tomography angiography at baseline were categorized into those with (25%-49%) and without (<25%) intermediate LMD. The primary outcome was a composite of cardiovascular mortality, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. The primary quality of life outcome was the Seattle Angina Questionnaire summary score. RESULTS: Among the 3699 participants who satisfied the inclusion criteria, 962 (26%) had intermediate LMD. Among invasive strategy participants with intermediate LMD on coronary computed tomography angiography, 49 (7.0%) had significant (≥50% stenosis) left main stenosis on invasive angiography. Patients with intermediate LMD had a higher risk of cardiovascular events in the unadjusted but not in the fully adjusted model compared with those without intermediate LMD. An invasive strategy increased procedural MI and decreased nonprocedural MI with no significant difference for other outcomes including the primary end point. There was no meaningful heterogeneity of treatment effect based on intermediate LMD status except for nonprocedural MI for which there was a greater absolute reduction with invasive management in the intermediate LMD group (-6.4% versus -2.0%; Pinteraction=0.049). The invasive strategy improved angina-related quality of life and the benefit was durable throughout follow-up without significant heterogeneity based on intermediate LMD status. CONCLUSIONS: In the ISCHEMIA trial, there was no meaningful heterogeneity of treatment benefit from an invasive strategy regardless of intermediate LMD status except for a greater absolute risk reduction in nonprocedural MI with invasive management in those with intermediate LMD. An invasive strategy increased procedural MI, reduced nonprocedural MI, and improved angina-related quality of life. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01471522.

Comparing the Modified Frailty Index with conventional scores for prediction of cardiac resynchronization therapy response in patients with heart failure.

OBJECTIVE: The aim of the study was to compare, Modified Frailty Index (mFI), EAARN (LVEF <22%, Atrial Fibrillation, Age ≥70 years, Renal function (eGFR <60 mL/min/1.73m2), NYHA class IV), and ScREEN (female Sex, Renal function (eGFR ≥60 mL/min/1.73m2), LVEF ≥25%, ECG (QRS duration ≥150 ms) and NYHA class ≤III) score for predicting cardiac resynchronization therapy (CRT) response and all-cause mortality. METHODS: In this prospective, non-randomized, single-center, observational study we enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant scores were calculated, and patients were followed for six months. Performance of each score for prediction of CRT response (defined as ≥15% reduction in left ventricular end-systolic volume [LVESV]) and all-cause mortality was compared. RESULTS: Optimal CRT response was seen in seventy patients with nine deaths. All the three scores exhibited modest performance for prediction of CRT response and all-cause mortality with AUC ranging from 0.608 to 0.701. mFI has an additional benefit for prediction of prolonged post-procedure stay and 30-day rehospitalization events. CONCLUSION: mFI, ScREEN and EAARN score can be used reliably for predicting all-cause mortality and response to CRT.

Six months clinical outcome comparison between quadripolar and bipolar left ventricular leads in cardiac resynchronization therapy: A prospective, non-randomized, single-centre observational study.

BACKGROUND AND OBJECTIVES: Quadripolar left ventricular (LV) leads in cardiac resynchronization therapy (CRT) offer multi-vector pacing with different pacing configurations and hence enabling LV pacing at most suitable site with better lead stability. We aim to compare the outcomes between quadripolar and bipolar LV lead in patients receiving CRT. METHODS: In this prospective, non-randomized, single-center observational study, we enrolled 93 patients receiving CRT with bipolar (BiP) (n = 31) and quadripolar (Quad) (n = 62) LV lead between August 2016 to August 2019. Patients were followed for six months, and outcomes were compared with respect to CRT response (defined as ≥5% absolute increase in left ventricle ejection fraction), electrocardiographic, echocardiographic parameters, NYHA functional class improvement, and incidence of LV lead-related complication. RESULTS: At the end of six months follow up, CRT with quadripolar lead was associated with better response rate as compared to bipolar pacing (85.48% vs 64.51%; p = 0.03), lesser heart failure (HF) hospitalization events (1.5 vs 2; p = 0.04) and better improvement in HF symptoms (patients with ≥1 NYHA improvement 87.09% vs 67.74%; p = 0.04). There were fewer deaths per 100 patient-year (6.45 vs 9.37; p = 0.04) and more narrowing of QRS duration (Δ12.56 ± 3.11 ms vs Δ7.29 ± 1.87 ms; p = 0.04) with quadripolar lead use. Lead related complications were significantly more with the use of bipolar lead (74.19% vs 41.94%; p = 0.02). CONCLUSIONS: Our prospective, non-randomized, single-center observational study reveals that patients receiving CRT with quadripolar leads have a better response to therapy, lesser heart failure hospitalizations, lower all-cause mortality, and fewer lead-related complications, proving its superiority over the bipolar lead.

Lead one ratio: A new electrocardiogram marker for cardiac resynchronization therapy response.

BACKGROUND: Wider QRS duration and presence of left bundle branch block (LBBB) predict better cardiac resynchronization therapy (CRT) response. Despite strict patient selection, one-third of patients have a sub-optimal response. We aim to evaluate the impact of lead one ratio (LOR) on CRT response. METHODS: We enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant 12-lead electrocardiogram (ECG) was recorded, and LOR was derived by dividing the maximum positive deflection of QRS complex in ECG lead I by the maximum negative deflection in lead I; cut-off value of 12 was used to divide the cohort into two groups. Patients were followed for 6 months, and outcomes were compared for CRT response, New York Heart Association (NYHA) class improvement, all-cause mortality, and heart failure (HF) hospitalization events. RESULTS: At the end of 6-month follow-up, LOR ≥ 12 was associated with significantly better CRT response (75.76% vs. 51.85% in LOR < 12, P = 0.02), lower mortality per 100 patient-years (9.09 vs. 14.81 in LOR < 12, P = 0.012), and more improvement in HF symptoms (NYHA improvement) (78.79% vs. 55.56% in LOR < 12, P = 0.02). Patients with LOR < 12 had more HF hospitalization events (2.04 vs. 1.81 episodes in LOR ≥ 12, P = 0.029) and less QRS narrowing (∆5.74 ± 2.09 vs. ∆7.10 ± 3.97 ms in LOR ≥ 12, P = 0.01). QRS duration and LBBB morphology were predictors of response in both groups of patients. CONCLUSION: LOR ≥ 12 was associated with better response to CRT, less HF hospitalization, and more relief in HF symptoms. This ratio helps to identify possible sub-optimal response among patients with an indication for CRT.

Transpedal Approach in Failed Antegrade Attempt of Lower Limb Peripheral Arterial Disease-A Review with Different Treatment Strategies.

Transpedal access is an evolving technique primarily used in patients after failed femoral antegrade approach to revascularize complex tibiopedal lesions. In patients who are at high risk for surgery the transpedal access may be the only option in failed antegrade femoral access to avoid amputation of the limbs. In recent years transpedal access is used routinely to revascularize supra-popliteal lesions due to more success and less complications over femoral artery approach. Retrograde approach parse will not give success in all cases and importantly success depends on techniques used. There are different techniques that need to be used depending on lesion characteristics, comorbidities, and hardware available to improve success with less complications. This review provides different strategies for successful treatment of iliac and femoral artery lesions by transpedal approach after failed antegrade femoral attempt.

Rate of Rehospitalization in 60 Days of Discharge and It's Determinants in Patients with Heart Failure with Reduced Ejection Fraction in a Tertiary Care Centre in India.

Background and Objectives: Identifying the patients with acute heart failure (HF) at high risk for rehospitalization after hospital discharge will enable proper optimization of treatment. This study is aimed to evaluate the rehospitalization rate at 60 days of discharge and their predictors in patients of chronic heart failure with reduced ejection fraction (HFrEF). Methods: This prospective observational study enrolled patients with left ventricle ejection fraction (LVEF) <40%, who were admitted because of acute decompensation. Patients were followed for 60 days to analyze rehospitalization rate and its predictors. Results: Of 103 HFrEF patients (74% male; mean age 55.8 years) enrolled, 7 patients died during index admission and 3 patients lost to follow up. The 60-day rehospitalization rate was 37% (34/93). We studied 23 clinical and 9 biochemical predictors of rehospitalization. Out of 34 events of rehospitalization, 79.41% (n=28) was due to cardiac cause followed by respiratory 5.8% (n=2), renal 5.8% (n=2) and others 5.8% (n=2). Among all the parameters, on logistic regression analysis having longer length of index hospital stay (>7 days) (52.8% vs. 28.8%; odds ratio [OR], 1.79; confidence interval [CI], 1.2-7.25; p=0.040) and chronic kidney disease (CKD) (26.5% vs. 8.5%; OR, 3.06; CI, 1.1-57.04; p=0.050) independently increased the risk of rehospitalization at 60 days of discharge. Further higher haemoglobin level (11.3 vs. 9.9 gm/dL; OR, 0.71; CI, 0.48-0.97; p=0.050) and higher LVEF at index admission (30.4% vs. 26.5%; OR, 0.87; CI, 0.75-0.99; p=0.049) were associated with decreased the risk of rehospitalization. Conclusions: Our study reveals that patients with HFrEF have significantly higher rehospitalization rate (37%) and in-hospital mortality rates (6.78%) of any chronic cardiac disease conditions. Correction of low hemoglobin and special care in those who are having very low LVEF, CKD and longer length of stay, including tailored therapy and frequent visits may play an important role in preventing future rehospitalization in these patients.

Role of strain imaging for assessment of myocardial viability in symptomatic myocardial infarction with single vessel disease: An observational study.

PURPOSE: To study and evaluate the predictive value of strain imaging parameters in patients undergoing viability assessment postmyocardial infarction (MI) in comparison with Dobutamine stress echocardiography (DSE) alone. METHODS: This was a prospective observational study (October, 2016-March, 2018), which recruited 100 symptomatic patients with MI, and angiographically proven single vessel disease, LV dysfunction with severe hypokinesia/akinesia on 2D echocardiography and viability proven by baseline DSE. Patients undergoing primary PCI were excluded. Patients were recruited in two groups: DSE alone (first group) and strain imaging with DSE (second group). Revascularization was done in all patients. Patients were assessed at 3 months for functional recovery by 2D echocardiography. RESULTS: On 3 month follow-up after revascularization, 37 patients (74%) in first group and 33 patients (66.67%) in second group had functional recovery. Dobutamine-stimulated strain parameters such as circumferential strain (CS; P = .005), radial velocity (RV; P < .001), longitudinal strain (LS; P < .001), and longitudinal strain rate (LSR; P < .001) were found to be a significant predictor of viability. The greatest area under the curve (AUC) for the ROC curves was obtained for low dose dobutamine RV (AUC = 0.92), low dose dobutamine LS (AUC = 0.94), and low dose dobutamine LSR (AUC = 0.88). Positive predictive value of the combination of low dose DSE with strain parameters (RV-97.2%, LS-97.4%, and LSR-87.5%) for myocardial viability was significantly higher than low dose DSE positive/low dose strain parameters negative patients as well as low dose DSE group alone. CONCLUSION: Evaluation of strain parameters with low dose DSE is clinically feasible for the detection of myocardial viability and adds incremental value to the subjective and semiquantitative wall-motion scoring. LS at low dose DSE with WMSI was found to have the highest positive predictive value.

Baseline Predictors of Low-Density Lipoprotein Cholesterol and Systolic Blood Pressure Goal Attainment After 1 Year in the ISCHEMIA Trial.

BACKGROUND: Risk factor control is the cornerstone of managing stable ischemic heart disease but is often not achieved. Predictors of risk factor control in a randomized clinical trial have not been described. METHODS AND RESULTS: The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) randomized individuals with at least moderate inducible ischemia and obstructive coronary artery disease to an initial invasive or conservative strategy in addition to optimal medical therapy. The primary aim of this analysis was to determine predictors of meeting trial goals for LDL-C (low-density lipoprotein cholesterol, goal <70 mg/dL) or systolic blood pressure (SBP, goal <140 mm Hg) at 1 year post-randomization. We included all randomized participants in the ISCHEMIA trial with baseline and 1-year LDL-C and SBP values by January 28, 2019. Among the 3984 ISCHEMIA participants (78% of 5179 randomized) with available data, 35% were at goal for LDL-C, and 65% were at goal for SBP at baseline. At 1 year, the percent at goal increased to 52% for LDL-C and 75% for SBP. Adjusted odds of 1-year LDL-C goal attainment were greater with older age (odds ratio [OR], 1.11 [95% CI, 1.03-1.20] per 10 years), lower baseline LDL-C (OR, 1.19 [95% CI, 1.17-1.22] per 10 mg/dL), high-intensity statin use (OR, 1.30 [95% CI, 1.12-1.51]), nonwhite race (OR, 1.32 [95% CI, 1.07-1.63]), and North American enrollment compared with other regions (OR, 1.32 [95% CI, 1.06-1.66]). Women were less likely than men to achieve 1-year LDL-C goal (OR, 0.68 [95% CI, 0.58-0.80]). Adjusted odds of 1-year SBP goal attainment were greater with lower baseline SBP (OR, 1.27 [95% CI, 1.22-1.33] per 10 mm Hg) and with North American enrollment (OR, 1.35 [95% CI, 1.04-1.76]). CONCLUSIONS: In ISCHEMIA, older age, male sex, high-intensity statin use, lower baseline LDL-C, and North American location predicted 1-year LDL-C goal attainment, whereas lower baseline SBP and North American location predicted 1-year SBP goal attainment. Future studies should examine the effects of sex disparities, international practice patterns, and provider behavior on risk factor control.

Acute effect of primary PCI on diastolic dysfunction recovery in anterior wall STEMI - A non-invasive evaluation by echocardiography.

BACKGROUND: It is well established fact that acute coronary occlusion leads to diastolic dysfunction, followed by systolic dysfunction when myonecrosis occur. It is also proven that primary percutaneous coronary intervention (PPCI) is an excellent therapy for ST elevation myocardial infarction (STEMI) to improve outcomes. However there is a paucity of information on efficacy of PPCI in improving diastolic function. Evaluation of the role of PPCI in improving diastolic dysfunction is required. METHODS: 61 patients with first anterior wall STEMI who underwent PPCI to left anterior descending artery were included. Echocardiographic evaluation was performed within 24 h of PPCI and then on day 15, 3 months and 6 months after PPCI. We evaluated the prevalence of diastolic dysfunction after PPCI and its recovery during 6 months along with effect of duration of chest pain on diastolic function. RESULTS: 54.1% of patients had diastolic dysfunction after PPCI whereas it was only 21.3% after 6 months (p value < 0.001). Diastolic function indices like deceleration time, isovolumic relaxation time, E wave, A wave, E/A ratio, left atrial volume and index improved statistically from baseline to 6 months except mitral E/e' ratio. As time required to achieve reperfusion increases (chest pain duration and D to B time) the incidence of residual diastolic dysfunction also increases (p value < 0.001). Patients with TIMI flow < III had more diastolic dysfunction (p value < 0.001). CONCLUSIONS: Primary PCI improves diastolic dysfunction in patients with anterior wall STEMI over a period of 6 months. Time to achieve reperfusion and effectiveness of reperfusion have significant effect on diastolic dysfunction.

Embolized Guidewire into Central Aorta: A Nightmare in the Pediatric Intensive Care Unit.

A 4-month-old preterm, critically ill infant weighing 3.8 kg was admitted to our pediatric intensive care unit with congestive cardiac failure due to a large ventricular septal defect and its sequelae. During an attempt to insert a central line into the right subclavian vein at bedside, the guidewire inadvertently entered the subclavian artery and embolized distally. After multiple failed retrieval attempts, including surgical femoral cut-down to retrieve the wire, it was removed finally by fluoroscopic-guided percutaneous catheterization with the help of a cardiac bioptome and a gooseneck snare utilizing a novel maneuver.

Large pectoral haematoma post-transradial catheterisation: an unusual but avoidable complication.

Large pectoral haematoma is an extremely rare complication of transradial catheterisation. Branch or main vessel injury due to luminal passage of guidewires and catheters may lead to bleeding and haematoma formation at adjacent sites along the vessel track. We present a 53-year-old post-transradial catheterisation patient, who complained of chest pain due to right axillary artery branch perforation causing haematoma, which was emergently managed by embolisation with autologous coagulated blood.

An unconventional valvuloplasty: severe pulmonary stenosis with 'candy cane' inferior vena cava.

Femoral vein is the usual approach to balloon pulmonary valvuloplasty (BPV). However, alternative access may be mandated in some peculiar situations. We hereby report a 10-year-old patient with symptomatic severe valvular pulmonary stenosis with interrupted inferior vena cava which was successfully treated with transjugular BPV. Technical considerations for this approach as well as other possible options for such patients are discussed.

Asymptomatic late embolization of Amplatzer septal occluder device.

Atrial septal defects of Ostium Secundum type with suitable anatomy and margins are commonly closed with septal occluder devices. With the increasing number of catheterization laboratories and increasing availability of different devices, the device closure procedure is very commonly performed in different institutes. Embolization of the septal occluder is one of the most dreaded complications of this procedure, which usually occurs in the early hours or days after the procedure. We report a case of silent embolization of the Amplatzer septal occluder, detected seven months after its use to close an Ostium Secundum atrial septal defect, which was detected during pre-anaesthetic evaluation and echocardiography for non-cardiac surgery. The patient denied having any symptom in-between. The device was retrieved and the defect was closed surgically.

Correlation of corrected QT interval with quantitative cardiac troponin-I levels and its prognostic role in Non-ST-elevation myocardial infarction.

BACKGROUND: Non-ST-elevation Myocardial Infarction (NSTEMI) subgroup of ACS has wide variability in patient prognosis. Risk stratification in NSTE-ACS is essential for deciding about early management. Corrected QT interval estimation is one tool which has utility in bedside risk stratification. Whether it differentiates NSTEMI patients into different risk groups is the contention of this study. OBJECTIVE: To assess (1) correlation between maximum corrected QT interval (QTc) and cardiac Troponin I (cTnI) levels; (2) if prolonged corrected QT interval is an independent predictor of higher MACE in NSTEMI patients. METHODS: We prospectively studied 301 NSTEMI patients. cTnI level and QTc were measured at 0, 12, 24 and 48h post-admission. Patients were followed for 30days post-discharge for incidence of major adverse cardiac events (MACE) defined as composite of cardiac death, non-fatal MI and urgent revascularization. We assessed correlation between cTnI level and maximum QTc value. Regression analysis was performed to identify independent predictors of MACE. RESULTS: We found a strong positive linear correlation between maximum QTc interval and cTnI level with a correlation coefficient of 0.637 (p<0.001). Cut-off value of QTc>468ms predicted poor prognosis in form of MACE with 72% sensitivity and 61% specificity. Multivariate analysis revealed that after adjusting for different prognostic variables, TIMI score>2 and QTc>468ms, were the only independent predictors of MACE. CONCLUSION: QTc-max interval has a strong positive linear correlation with cTnI level. Prolonged QTc has utility as an independent high risk predictor in NSTEMI population.

"Double Ball Valve Mechanism Obstructing Both Right Ventricular Inflow and Outflow": Atypical Presentation of Right Atrial Myxoma Presenting as Right Ventricular Mass.

Large intracavitary masses such as those occupying most of a cardiac chamber and obstructing blood flow are not routinely encountered in clinical practice. The differential diagnosis includes neoplastic as well as nonneoplastic causes. Primary cardiac tumors by themselves are uncommon. We hereby report a rare case of a middle-aged female presenting with New York Heart Association Class III symptoms, whose transthoracic echocardiogram revealed a huge mass in right-sided chambers with a novel double ball valve type movement. She successfully underwent urgent surgical resection of the mass with histopathological confirmation of diagnosis.