Crazy accessory pathway- going round the bend!

A 15-year-old boy with manifest preexcitation and recurrent palpitations had undergone an unsuccessful ablation procedure elsewhere and was subsequently referred to us. The ECG suggested a left free wall pathway but there was a pattern break in lead V2. This helped localise the accessory pathway to the summit region and achieve success.

A Study of Prehospital Delay Patterns in Acute Myocardial Infarction in an Urban Tertiary Care Institute in Mumbai.

OBJECTIVE: There is now increasing awareness about the need for early diagnosis in patients presenting with chest pain. Pre-hospital delay remains a major hurdle in the institution of early reperfusion therapy, which is crucial in salvaging 'at-risk' myocardium and reducing adverse cardiovascular events following ST elevation myocardial infarction (STEMI). This study aims to determine the incidence and the determinants of delayed presentation STEMI and the potential impact of such delay on adverse cardiovascular outcomes. METHODS: We prospectively evaluated all patients who were admitted in the emergency department of our hospital with STEMI from March 2014 to February 2016. Data was collected sequentially at the time of admission, discharge and during follow-up. Patients were evaluated with serial ECGs, continuous ECG monitoring and echocardiography. RESULTS: Out of 1386 patients with STEMI, delayed presentation was seen in 1148 (> 2 hrs) and 805 (> 4 hrs) patients. The duration from onset of symptoms to the presentation in the emergency room (pre-hospital delay) was 228 ± 341minutes.The door to needle time was 34 ± 24 minutes. The major factors for pre-hospital delay were misinterpretation of symptoms (45%) and transportation problems (27%). CONCLUSIONS: The problem of pre-hospital delay continues to remain a major hurdle in initiating timely reperfusion therapy in patients with acute STEMI. Lack of awareness and poor transportation facilities are the major contributors. It should be the goal of STEMI care programmes of the future to make a concerted effort to addressing these factors, in order to optimize the benefit of reperfusion therapy for this high risk group of patients.

Is accelerated idioventricular rhythm a good marker for reperfusion after streptokinase?

BACKGROUND: Accelerated idioventricular rhythm (AIVR) is a common arrhythmia observed in patients with ST segment elevation myocardial infarction (MI). It is not clear how much value AIVR has in predicting successful reperfusion, since there have been conflicting data regarding this in the past. Streptokinase (STK) even today is the commonest thrombolytic agent used in the public health care set-up in India.(1) Most data for the use of STK are from the 1990s, which had showed that at best it is effective in only 50% of patients in restoring adequate flow.(2) It is probable that with the current dual-antiplatelet loading dose regimen and other newer medications, this figure could be higher. Also, rescue angioplasty for failed thrombolysis is the standard of care now, unlike before. Hence, we need reliable non-invasive markers to judge successful reperfusion in the present era. While ST segment resolution is the standard marker for reperfusion used in thrombolytic trials, in several instances it is not definitive. An additional marker would thus be very useful, especially in such cases. METHODS: This was a prospective observational study carried out at a public teaching hospital. 200 consecutive patients with a diagnosis of acute MI who were given STK within 12h of index pain were included. The STK dose was 1.5 million units, infused over 30min; the ECG was again recorded after 90min of completion of the infusion. Continuous ECG monitoring for the first 24h of ICCU stay was performed and AIVRs during this period were documented. Early AIVR was defined as that occurring within 2h of completing the STK infusion. Echocardiography was performed 24h after presentation. The time course of AIVR was studied vis-a-vis the outcome of thrombolysis. RESULTS: AIVR was seen in 41% of the patients. Though AIVR was found to have low sensitivity (45%) and specificity (64%) as a predictor of successful thrombolysis, early AIVR was a reliable sign of successful thrombolysis (p<0.05). The sensitivity (45%) of early AIVR was low; however, the specificity (94%) and positive predictive value (94%) were very good. CONCLUSION: AIVR is a common arrhythmia in the setting of STEMI receiving thrombolytic therapy. Early AIVR is more common with successful thrombolysis, with an excellent positive predictive value. Thus, early AIVR can be used as an additive criterion to ST segment resolution as a non-invasive marker of successful thrombolysis with STK.

Incessant fascicular VT presenting as cardiogenic shock with multi-organ dysfunction syndrome.

We report a rare clinical presentation of incessant idiopathic fascicular ventricular tachycardia (FVT), presenting as multi-organ dysfunction (MOD) syndrome with cardiogenic shock. Our patient was a 19-year-old male who presented with slowly progressive dyspnea from New York Heart Association (NYHA) II to NYHA IV at the time of presentation, palpitations, and dilated cardiomyopathy due to drug-refractory FVT. The patient was in cardiogenic shock with raised central venous pressures and required inotropic support for maintaining systolic blood pressure above 90 mmHg. The MOD was seen in the form of deranged liver and kidney parameters. Echocardiography showed a dilated left ventricle (LV, 58 mm at end-diastole, 52 mm at end-systole) and decreased ejection fraction (20%). Electrocardiography showed a wide-QRS tachycardia (QRS 140 ms, cycle length 440 ms), with RsR' in lead V1 and a QRS axis of -60°. After stabilization with ventilation, inotropic support, and cautious use of diuretics, an electrophysiologic study was performed. A Purkinje potential with early local ventricular activation was recorded from the LV inferoseptal region. The tachycardia was ablated at this site with radiofrequency (RF) energy (40 W for 35 sec). Over a 3-month follow-up, the patient remained asymptomatic and the LV size and function returned to normal. .

Comparative randomized study on efficacy of losartan versus propranolol in lowering portal pressure in decompensated chronic liver disease.

OBJECTIVE: This study aimed to compare the efficacy of losartan, an angiotensin II receptor antagonist, with propranolol on portal hypertension in patients with decompensated chronic liver disease. METHODS: In all, 30 patients with Child-Pugh B cirrhosis and large varices without any prior therapy for portal hypertension were randomized to either losartan (n = 15) or propranolol (n = 15). Clinical, biochemical and hemodynamic parameters including hepatic venous pressure gradient (HVPG), wedged hepatic venous pressure (WHVP), mean arterial blood pressure (MABP) and free hepatic venous pressure (FHVP) were measured at baseline and after 4-week therapy. Patients with HVPG < 12 mmHg were regarded as responders. RESULTS: An equal number of responders were seen in both groups (6/15, 40.0%). The reduction of WHVP and HVPG was greater in the losartan group than in the propranolol group, although no significant differences between them were found. Heart rate decreased more in the propranolol arm than in the losartan arm (P < 0.01); however, no correlation between the decrease of heart rate and the reduction of HVPG was observed. One patient in the losartan group, although a responder, had gastrointestinal bleeding 2 months after the drug administration, but the varices were small under endoscopy and did not require definitive therapy. The fall of MABP was greater with losartan, with no statistical difference between the two groups. CONCLUSION: The effect of losartan was comparable to propranolol in reducing portal pressure in decompensated Child-Pugh B chronic liver disease.

Tetralogy of Fallot with restrictive ventricular septal defect by accessory tricuspid leaflet tissue.

In tetralogy of Fallot septal defect is usually large because of malalignment of outlet septum, restrictive defect has been reported rarely. We present a case of tetralogy of Fallot with accessory tricuspid leaflet tissue restricting ventricular septal defect. The report includes echocardiographic and catheter images of this rare presentation of tetralogy of Fallot.

Failure of deflation of an Inoue balloon during percutaneous balloon mitral valvuloplasty.

We describe an unusual complication of the Inoue balloon technique, which has been treated successfully by application of a different technique. This technique has not been described elsewhere to the best of our knowledge.