Infective endarteritis of coronaries following percutaneous coronary intervention (stentocarditis) leading to pseudoaneurysm - a retrospective study of eleven cases.

Background: Coronary endarteritis and stent abscess following percutaneous coronary intervention (PCI) are rare and challenging conditions with no clear treatment guidelines available. Aims: This retrospective study aims to present the clinical features, patient and procedural factors, management strategies, and outcomes in 11 consecutive cases referred between 2018 and 2022. Methods: We retrospectively analysed 11 cases of coronary endarteritis and stent abscess post-PCI that were referred from various centres. We recorded clinical features, patient demographics, procedural factors, and management approaches, and evaluated treatment outcomes. Results: Among the 11 patients, 7 (63.6%) were male. PCIs had been performed in the right coronary artery (6, 54.5%), left anterior descending artery (3, 27.3%), and circumflex artery (2, 18.2%). The presenting symptoms included fever, pericarditis with effusion, tamponade, and postinterventional angina due to stent occlusion. Fever occurred in 10 (90.9%) patients, and the majority (70%) of patients experienced fever within one week of PCI. Staphylococcus aureus was the predominant organism (54.5%), followed by Pseudomonas aeruginosa. Transthoracic echocardiography revealed abscess cavities in 10 patients. All patients received vancomycin and piperacillin-tazobactam. Surgery was considered in 7 cases with abscesses >2 cm; one patient refused and responded to antibiotics for 4 weeks. Possible risk factors included repeated use of local sites, reuse of hardware, multiple guidewire manipulations, prolonged catheterisation, inadequate sterility, and diabetes. Conclusions: This study provides insights into coronary endarteritis and stent abscess following PCI. The lack of clear treatment guidelines highlights the challenges in managing this condition. Identifying risk factors may aid in preventive strategies. Further research is needed to develop standardised approaches for effective management.

Is Electrocardiogram Helpful in Predicting a Rise in Troponin I as a Marker of Anthracycline Cardiotoxicity?

Objective: Screening patients on anthracycline-based chemotherapy regimens for the development of cardiotoxicity can be resource intensive. We therefore studied various traditional electrocardiogram (ECG) parameters to correlate and possibly predict the development of elevated Troponin I as a surrogate marker of anthracycline-induced cardiotoxicity. Materials and Methods: This was a single-centre prospective cohort study done between January 2014 to January 2016. Baseline ECG was compared with ECG performed after chemotherapy and different parameters were compared. Patients were divided into Troponin I positive and negative groups based on the test performed at the end of chemotherapy, using a cut-off of 0.06 ng/dL. Results: Of the 160 patients studied, 131 (81.9%) were Troponin I negative (TnI-) and 29 (18.1%) were positive (TnI+). Breast cancer accounted for 79% of all cancers in this study. Many ECG parameters were compared between the TnI- and TnI+ groups. Of them, TP segment and TP/QT showed a significant decrease in the TnI+ group. The mean (95% confidence interval) TP in the TnI- group was 162.9 ms (145.4, 180.4) and in TnI+ groups was 117.9 ms (89, 146.8) (p = 0.03). Corresponding values for TP/QT were 0.47 (0.42, 0.51) and 0.35 (0.27, 0.42) (p = 0.02). These changes were not significant in multivariate analysis and likely reflected the different mean heart rates (HR) in both the groups, as suggested by partial correlation which was run with HR as a confounder. Conclusion: ECG parameters, such as QTcH, TP and TP/QT do not helpful predicting Troponin I elevations in patients on anthracycline-based chemotherapy. Further studies based on hard endpoints, for example, clinical systolic dysfunction occurring at one year, would give better information on their utility.

Kawasaki disease with giant aneurysm of left coronary artery and complete occlusion of right coronary artery.

Kawasaki disease is an acute febrile medium-vessel vasculitis affecting children. Though coronary artery aneurysm is a common complication, stenosis and occlusion are rare. Here, we report a case of Kawasaki disease with concomitant aneurysm and complete occlusion of different coronary arteries in the same patient.

Angiotensin-converting enzyme inhibitors and receptor blockers in heart failure and chronic kidney disease - Demystifying controversies.

In clinical setting, congestive heart failure (CHF) and chronic kidney disease (CKD) often co-exist in patients due to common underlying predisposing factors. An intricate equilibrium between the cardiovascular and renal system is maintained through rennin angiotensin-aldosterone axis and autonomic nervous system. Consequent to favorable hemodynamic modification, angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blocking (ARB) therapy have proven to be an indispensable aspect of heart failure management with morbidity and mortality benefit. Additionally, progression to end stage renal failure may be halted by renin angiotensin aldosterone system (RAAS) blockade in patients with preexisting renal dysfunction. However, concern over the safety of RAAS blockade in presence of renal impairment has led to profound underutilization of these drugs in CHF patients with renal insufficiency. This review aims to provide a simplified guide to pathophysiology and management options of this perplexing situation.

A case of recent myocardial infarction with cardiac failure.

CLINICAL INTRODUCTION: A 50-year-old hypertensive smoker presented with a typical angina of 2 days duration. An urgent ECG revealed extensive anterior wall myocardial infarction. In view of the delayed presentation, the patient was conservatively managed with heparin. In-hospital echocardiogram showed akinesia of entire left anterior descending artery (LAD) territory with severe left ventricular (LV) dysfunction. He was discharged with a plan for early coronary intervention. However, he presented a fortnight later with acute pulmonary oedema. General appraisal revealed a restless individual who was dyspnoeic and diaphoretic at rest. On clinical examination, the patient was in hypotension with features of biventricular failure. A 12-lead ECG showed QS pattern with persistent ST segment elevation in precordial leads. The chest radiograph demonstrated features of pulmonary oedema, cardiomegaly and bilateral pleural effusion. Creatine Phosphokinase-MB (CPK-MB) was negative. A preliminary transthoracic echocardiography was done (figure 1 and see online supplementary video 1). QUESTION: What is the most likely diagnosis based on the echocardiogram? LV pseudo-aneurysm with contained ruptureDissecting intramural haematoma of LV apexVentricular apical aneurysm with thrombusLV non-compaction with prominent ventricular trabaculations.

A comparative study of ivabradine and atenolol in patients with moderate mitral stenosis in sinus rhythm.

BACKGROUND: Beta-blockers are frequently used in patients with mitral stenosis to control the heart rate and alleviate exercise-related symptoms. The objective of our study was to examine whether ivabradine was superior to atenolol for achieving higher exercise capacity in patients with moderate mitral stenosis in sinus rhythm. We also evaluated their effects on left ventricular myocardial performance index (MPI). METHODS AND RESULTS: Eighty-two patients with moderate mitral stenosis in sinus rhythm were randomized to receive ivabradine (n=42) 5mg twice daily or atenolol (n=40) 50mg daily for 6 weeks. Transthoracic echocardiography and treadmill test were performed at baseline and after completion of 6 weeks of treatment. Mean total exercise duration in seconds markedly improved in both study groups at 6 weeks (298.57±99.05s vs. 349.12±103.53s; p=0.0001 in ivabradine group, 290.90±92.42s vs. 339.90±99.84s; p=0.0001 in atenolol group). On head-to-head comparison, there was no significant change in improvement of exercise time between ivabradine and atenolol group (p=0.847). Left ventricular MPI did not show any significant change from baseline and at 6 weeks in both drug groups (49.8%±8% vs. 48.3%±7% in ivabradine group, 52.9%±10% vs. 50.9%±10% in atenolol groups; p=0.602). CONCLUSION: Ivabradine or atenolol can be used for heart rate control in patients with moderate mitral stenosis in sinus rhythm. Ivabradine is not superior to atenolol for controlling heart rate or exercise capacity. Left ventricular MPI was unaffected by either of the drugs.

An unusual cause of acute cor pulmonale--significance of the 'continuous diaphragm sign'.

A patient presented with chest pain and clinical features of acute right heart failure. Initial work up revealed the presence of severe PAH. Acute pulmonary embolism is the commonest and most life-threatening cause for acute cor pulmonale. Even though the clinical picture suggested pulmonary embolism, a subtle sign was missed from the first chest X-ray taken in the emergency department. However on reanalysis the 'continuous diaphragm sign' later guided us towards the diagnosis. Our case represents one of the first reports of a rare etiology for acute cor pulmonale--hypersensitivity pneumonitis. Right ventricular dysfunction was caused by an acute rise in pulmonary artery pressures as well as by the compressive effects of pneumomediastinum. We emphasize the role played by a good quality chest X-ray early in the management of acute chest pain syndromes. However pulmonary embolism should be ruled out conclusively before redirecting attention to less malignant conditions.

Malignant arrhythmia with benign tumour: fibrolipoma of the left ventricle.

We report a case of young male referred for evaluation of recent onset recurrent syncope. Inhospital electrocardiogram revealed an episode of ventricular flutter which reverted spontaneously to sinus rhythm. Transthoracic echocardiogram showed hyperechoic mass in the left ventricle. For further tissue characterization a cardiac magnetic resonance imaging was done which revealed a left ventricular mass with predominant fat content. The tumor was surgically resected. Histopathological examination confirmed the diagnosis of cardiac fibrolipoma. The patient recovered and is currently asymptomatic.

Cystic lymphangioma of pericardium presenting as isolated chylopericardium - a case report.

Isolated chylopericardium due to cystic lymphangioma of pericardium is a rare entity. We report a case of asymptomatic chylopericardium in a young male who presented with cardiomegaly. Echocardiography revealed massive pericardial effusion without tamponade. Pericardiocentesis yielded 1.25 L of tea-colored fluid which showed triglyceride level of 1723 mg/dL and cholesterol of 1021 mg/dL with a cholesterol to triglyceride ratio of <1, characteristic of chylous fluid. Lymphoscintigraphy using 99Tc demonstrated lymphatic leak around the heart region. Fusion of MRI images with lymphoscintigraphy was taken with a view of localizing the leak site; it demonstrated enhancement in the pericardial space. Surgery was done via right lateral thoracotomy. Thoracic duct was ligated above diaphragm and pericardial window created by anterior pericardiectomy. The patient had an uneventful recovery and was well after 6 months of follow up. Pericardial biopsy showed cystic lymphangioma of pericardium.

Echocardiographic assessment of right ventricular function in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis.

BACKGROUND: Presence of right ventricular (RV) infarction imposes a higher risk of adverse events in inferior wall myocardial infarction (IWMI). In this study, we attempted to correlate various indices of RV function assessed by echocardiography with presence of a proximal right coronary artery (RCA) stenosis in patients with first episode of acute IWMI. METHODS: In a prospective study, patients with first episode of acute IWMI underwent echocardiographic assessment within 24 h of symptom onset and indices of RV function viz. RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI) and tissue Doppler velocities from RV free wall were measured. Patients who underwent coronary angiogram (CAG) within one month and they were classified into group 1 and group 2 based on the presence or absence, respectively, of a significant proximal RCA stenosis. RESULTS: There were 90 patients with first episode of IWMI of which 67 patients underwent CAG. There was significant difference between group 1 (n = 26) and group 2 (n = 41) in TAPSE (13.5 ± 1.3 vs 21.3 ± 1.7, p < 0.001), MPI by tissue Doppler (0.87 ± 0.1 vs 0.55 ± 0.2, p < 0.001) and in tissue Doppler systolic velocity from RV free wall (S' 9.8 ± 1.1 vs 15.0 ± 1.5, p < 0.001). There was a good interobserver correlation for TAPSE, MPI by TDI, and S' velocity. TAPSE ≤ 16 (sensitivity 93%, specificity 100%), MPI-TDI ≥ 0.69 (sensitivity 94.7%, specificity 93.5%), S ≤ 12.3 (sensitivity 90.3%, specificity 94.3%) were useful in predicting presence of proximal RCA stenosis. CONCLUSION: RV function indices like TAPSE, MPI-TDI and S' velocity are useful in predicting proximal RCA stenosis in first episode of acute IWMI.

Coronary sinus filling time: a novel method to assess microcirculatory function in patients with angina and normal coronaries.

OBJECTIVE: Dysfunction of the coronary microcirculation is considered as one of the factors responsible for symptoms and abnormal stress tests in patients with angina and normal coronaries (syndrome X). We sought to evaluate the usefulness of coronary sinus filling time (CSFT) to assess coronary microcirculation in this group of patients. METHODS: We compared the CSFT of patients having definite angina or atypical angina with positive treadmill electrocardiography test (angina group), with that of patients undergoing coronary angiogram (CAG) prior to balloon mitral valvuloplasty (control group). During CAG, coronary sinus was visualized in appropriate views and CSFT in seconds was derived from frame count. Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI (cTIMI) frame count, TIMI Myocardial Perfusion grade (TMP) were assessed. RESULTS: There were 41 patients in angina group and 16 in control group. Among the angina group 68.8% were females as against 81.8% in the control group. 87.8% (n = 36) had typical angina. Mean CSFT was 4.25 ± 0.72 s and 3.46 ± 0.99 s in the angina group and control group respectively (p = 0.001). No significant differences were found between the groups with respect to TMP (p = 0.68) & cTIMI frame count (p = 0.22). CONCLUSION: CSFT is a simple method to assess the transit time through coronary microcirculation. CSFT was significantly delayed in patients with angina and normal coronaries. TMP and cTIMI frame count were not significantly different between groups.