Transhepatic balloon mitral valvotomy in mitral stenosis with interrupted inferior vena cava.

A 38-year-old female was found to have severe mitral stenosis, severe pulmonary arterial hypertension with moderate tricuspid regurgitation, dilated right atrium, persistent left superior vena cava, and hugely dilated coronary sinus. The scheduled balloon mitral valvotomy via trans-femoral approach was abandoned after the venogram revealed the presence of left-sided inferior vena cava with hemi-azygos continuation draining into coronary sinus via left-sided superior vena cava. Balloon mitral valvotomy was attempted from the right trans-jugular route, but we were unable to puncture the inter-atrial septum due to the hugely dilated coronary sinus and right atrium. A transhepatic approach was used and balloon mitral valvotomy was successfully done with a standard balloon of 24 mm size without any complication. In patients with inferior vena cava anomalies or interruption, a percutaneous transhepatic approach is a feasible alternative for performing balloon mitral valvotomy.

Predictors of left ventricular dysfunction in patients with Takayasu's arteritis: a single centre experience.

OBJECTIVES: To determine the factors (clinical, biochemical, angiographic, and echocardiographic) which predict left ventricular (LV) dysfunction in Takayasu's arteritis (TAK). TAK causes inflammation of the aorta and its large branches. Systemic hypertension, aortic valvular disease, and coronary artery involvement are probable contributors to LV dysfunction in some patients. In other patients, inflammation and resulting myocarditis play an essential role. However, the prevalence and relative contribution of such predictors of LV dysfunction in TAK patients is unknown. METHODS: We enrolled 87 patients with angiographically confirmed TAK in the study after proper informed consent. A complete clinical, biochemical, and echocardiographic evaluation of all the cases was done. We defined LV systolic dysfunction as an ejection fraction below 50% and diastolic dysfunction by ASE 2016 criteria into grades I, II, and III. RESULTS: We evaluated 87 consecutive angiographically proven TAK patients. The incidence of LV systolic and diastolic dysfunction in our study was 19.5% (17/87) and 100% (87/87), respectively. All the patients with LV dysfunction (n=17, 100%) had an ITAS 2010 score of more than two suggestive of active disease. In 15 (88%) out of 17 patients with LV systolic dysfunction, we could identify a significant haemodynamic cause of LV dysfunction (untreated hypertension HTN, descending thoracic or abdominal aorta stenosis, renal artery stenosis, coronary stenosis, significant valvular regurgitation). In the rest 2 cases, no important haemodynamic factor was present, and here LV dysfunction was probably because of myocarditis and its sequalae. CONCLUSIONS: This study represents the largest cohort of TAK patients to estimate LV systolic and diastolic dysfunction. We have found LV systolic and diastolic dysfunction multifactorial, with hemodynamic and inflammatory factors contributing to its pathophysiology.

Role of cardiovascular magnetic resonance imaging in COVID-19 recovered patients: A short-term follow-up study.

OBJECTIVE: Cardiac involvement in recovered COVID-19 patients assessed by cardiac magnetic resonance imaging (MRI). METHODS: Subjects recently recovered from COVID-19 and with an abnormal left ventricular global longitudinal strain were enrolled. Cardiac MRI in all the enrolled subjects was done at baseline (within 30-90 days following recovery from COVID-19) with a follow-up scan at 6 months in individuals with an abnormal baseline scan. Additionally, 20 age-and sex-matched individuals were enrolled as healthy controls (HCs). RESULTS: All the 30 enrolled subjects were symptomatic during active COVID-19 disease and were categorized as mild: 11 (36.7%), moderate: 6 (20%), and severe: 13 (43.3%). Of the 30 patients, 16 (53.3%) had abnormal CMR findings. Myocardial edema was reported in 12 (40%) patients while 10 (33.3%) had late gadolinium enhancement (LGE). No difference was observed in terms of conventional left ventricular (LV) parameters; however, COVID-19-recovered patients had significantly lower right ventricular (RV) ejection fraction, RV stroke volume, and RV cardiac index compared to HCs. Follow-up scan was abnormal in 4/16 (25%) with LGE persisting in three patients (who had severe COVID-19 [3/4;75%]). Subjects with severe COVID-19 had a greater frequency of LGE (53.8%) and myocardial edema (61.5%) as compared to mild and moderate cases. Myocardial T1 (1284 ± 43.8 ms vs. 1147.6 ± 68.4 ms; p < .0001) and T2 values (50.8 ± 16.7 ms vs. 42.6 ± 3.6 ms; p = .04) were significantly higher in post COVID-19 subjects compared to HCs. Similarly, T1 and T2 values of severe COVID-19 patients were significantly higher compared to mild and moderate cases. CONCLUSIONS: An abnormal CMR was seen in half of the recovered patients with persistent abnormality in one-fourth at 6 months. Our study suggests a need for closer follow-up among recovered subjects in order to evaluate for long-term cardiovascular sequelae. COVID-19 causes structural changes in the myocardium in a small segment of patients with partial spontaneous resolution.

Preoperative emobilisation of juvenile nasopharyngeal angiofibroma.

INTRODUCTION: Juvenile nasopharyngeal angiofibroma(JNA) are highly vascular benign tumours originating in the sphenopalatine fossa and may extend to the pterygopalatine fossa, paranasal sinuses, and nasal cavity. The management of JNA has evolved greatly with development of endoscopy. Treatment modality has changed from open approach to endoscopic approach due to various advantages offered by the endoscopic approach. Bleeding during the surgery can compromise the exposure and surgical excision of JNA endoscopically. There have been many techniques to decrease intraoperative bleeding including external carotid ligation, hypotensive anaesthesia and more recently embolization of the feeding vessels. Embolization of the tumour has made the endoscopic excision of JNA easier because of less bleeding. This study was taken to find out the outcomes of surgical excision of JNA after embolization. METHODOLOGY: We retrospectively reviewed 22 histopathological proven JNA cases that underwent preoperative embolization followed by resection during the period of June 2015 to December 2020 in our tertiary care hospital. From the records demographic, clinical, radiological imaging (CECT nose and PNS), angiographic, pre-operative embolization and operative details were evaluated. RESULT: In the present study a total of 22 cases of angiofibroma were taken up for surgical excision after embolization. A complete endonasal endoscopic resection could be done in 21/22 cases with average operative time of 141 minutes (80 minutes-190 minutes range). The mean blood loss during surgery was 1163 ml (Range 500 ml- 1900 ml). In 7/22 (31.81%) subjects required intraoperative blood transfusion. No perioperative surgical complications occurred. CONCLUSION: Endoscopic excision of JNA has now become the primary operative technique and pre operative embolization in such cases can reduce the intraoperative time, blood loss and tumour relapse rate. It is a relatively safe procedure in a hand of an expert and must be done where ever available.

Coordination of Intraoperative Neurophysiologic Monitoring Technologist and Surgery Schedules.

Resource coordination in surgical scheduling remains challenging in health care delivery systems. This is especially the case in highly-specialized settings such as coordinating Intraoperative Neurophysiologic Monitoring (IONM) resources. Inefficient coordination yields higher costs, limited access to care, and creates constraints to surgical quality and outcomes. To maximize utilization of IONM resources, optimization-based algorithms are proposed to effectively schedule IONM surgical cases and technologists and evaluate staffing needs. Data with 10 days of case volumes, their surgery durations, and technologist staffing was used to demonstrate method effectiveness. An iterative optimization-based model that determines both optimal surgery and technologist start time (operational scenario 4) was built in an Excel spreadsheet along with Excel's Solver settings. It was compared with current practice (operational scenario 1) and optimization solution on only surgery start time (operational scenario 2) or technologist start time (operational scenario 3). Comparisons are made with respect to technologist overtime and under-utilization time. The results conclude that scenario 4 significantly reduces overtime by 74% and under-utilization time by 86% as well as technologist needs by 10%. For practices that do not have flexibility to alter surgeon preference on surgery start time or IONM technologist staffing levels, both scenarios 2 and 3 also result in substantial reductions in technologist overtime and under-utilization. Moreover, IONM technologist staffing options are discussed to accommodate technologist preferences and set constraints for surgical case scheduling. All optimization-based approaches presented in this paper are able to improve utilization of IONM resources and ultimately improve the coordination and efficiency of highly-specialized resources.

Heart rate variability as a marker of cardiovascular dysautonomia in post-COVID-19 syndrome using artificial intelligence.

INTRODUCTION: Cardiovascular dysautonomia comprising postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH) is one of the presentations in COVID-19 recovered subjects. We aim to determine the prevalence of cardiovascular dysautonomia in post COVID-19 patients and to evaluate an Artificial Intelligence (AI) model to identify time domain heart rate variability (HRV) measures most suitable for short term ECG in these subjects. METHODS: This observational study enrolled 92 recently COVID-19 recovered subjects who underwent measurement of heart rate and blood pressure response to standing up from supine position and a 12-lead ECG recording for 60 s period during supine paced breathing. Using feature extraction, ECG features including those of HRV (RMSSD and SDNN) were obtained. An AI model was constructed with ShAP AI interpretability to determine time domain HRV features representing post COVID-19 recovered state. In addition, 120 healthy volunteers were enrolled as controls. RESULTS: Cardiovascular dysautonomia was present in 15.21% (OH:13.04%; POTS:2.17%). Patients with OH had significantly lower HRV and higher inflammatory markers. HRV (RMSSD) was significantly lower in post COVID-19 patients compared to healthy controls (13.9 ± 11.8 ms vs 19.9 ± 19.5 ms; P = 0.01) with inverse correlation between HRV and inflammatory markers. Multiple perceptron was best performing AI model with HRV(RMSSD) being the top time domain HRV feature distinguishing between COVID-19 recovered patients and healthy controls. CONCLUSION: Present study showed that cardiovascular dysautonomia is common in COVID-19 recovered subjects with a significantly lower HRV compared to healthy controls. The AI model was able to distinguish between COVID-19 recovered patients and healthy controls.

Left ventricular global longitudinal strain in COVID-19 recovered patients.

OBJECTIVES: Myocardial injury during active coronavirus disease-2019 (COVID-19) infection is well described; however, its persistence during recovery is unclear. We assessed left ventricle (LV) global longitudinal strain (GLS) using speckle tracking echocardiography (STE) in COVID-19 recovered patients and its correlation with various parameters. METHODS: A total of 134 subjects within 30-45 days post recovery from COVID-19 infection and normal LV ejection fraction were enrolled. Routine blood investigations, inflammatory markers (on admission) and comprehensive echocardiography including STE were done for all. RESULTS: Of the 134 subjects, 121 (90.3%) were symptomatic during COVID-19 illness and were categorized as mild: 61 (45.5%), moderate: 50 (37.3%) and severe: 10 (7.5%) COVID-19 illness. Asymptomatic COVID-19 infection was reported in 13 (9.7%) patients. Subclinical LV and right ventricle (RV) dysfunction were seen in 40 (29.9%) and 14 (10.5%) patients, respectively. Impaired LVGLS was reported in 1 (7.7%), 8 (13.1%), 22 (44%) and 9 (90%) subjects with asymptomatic, mild, moderate and severe disease, respectively. LVGLS was significantly lower in patients recovered from severe illness(mild: -21 ± 3.4%; moderate: -18.1 ± 6.9%; severe: -15.5 ± 3.1%; p < 0.0001). Subjects with reduced LVGLS had significantly higher interleukin-6 (p < 0.0001), C-reactive protein (p = 0.001), lactate dehydrogenase (p = 0.009), serum ferritin (p = 0.03), and troponin (p = 0.01) levels during index admission. CONCLUSIONS: Subclinical LV dysfunction was seen in nearly a third of recovered COVID-19 patients while 10.5% had RV dysfunction. Our study suggests a need for closer follow-up among COVID-19 recovered subjects to elucidate long-term cardiovascular outcomes.

Prevalence and patterns of coronary artery anomalies in 28,800 adult patients undergoing angiography in a large tertiary care centre in India.

Coronary artery anomalies (CAAs) are a diverse group of disorders with varied clinical presentation and pathophysiological mechanisms. A majority of these anomalies are asymptomatic and often an incidental finding on coronary angiogram or autopsy. This retrospective study included 28,800 patients who underwent coronary angiography from 2016 to 2020. The coronary angiograms were reviewed by two independent reviewers and CAAs were documented. CAAs were classified into i) anomalies of coronary artery connection, ii) anomalies of intrinsic coronary arterial anatomy and iii) anomalies of myocardial/coronary artery interaction as proposed by the European Society of Cardiology. Of the 28,800 coronary angiograms, CAAs were present in 4.12% with anomalies in the left coronary artery (LCA) being most common. Anomalies of coronary artery connection were most common (48.48%) followed by anomalies of myocardial/coronary artery interaction (34.49%) and anomalies of intrinsic coronary artery anatomy (17.03%). Among anomalies of coronary artery connection, absent left main trunk or split LCA with separate origins of left anterior descending coronary artery and left circumflex coronary artery from the left coronary sinus of Valsalva (22.59%) was most common. An intramural course or "myocardial bridge" had an incidence of 1.16%  while incidence of coronary artery fistulae (CAF) was 0.115%.

An Algorithm for Pairing Interventionalists and Surgeons for the TAVR Procedure.

The Transcatheter Aortic Valve Replacement (TAVR) procedure requires an initial consultation and a subsequent procedure by an interventionalist (IC) and surgeon. The IC-surgeon pair coordination is extremely challenging, especially at Mayo Clinic due to provider time commitments distributed across practice, research, and education activities. Current practice aims to establish the coordination manually, resulting in a scheduling process that is cumbersome and time consuming for the schedulers. We develop an algorithm for pairing ICs and surgeons that minimizes the lead time (days elapsed between the clinic consult and procedure). As compared to current practice, this algorithm is able to reduce average lead time by 59% and increase possible IC-surgeon pairs by 7%. The proposed algorithm is shown to be flexible enough to incorporate practice variations such as lead time upper bound and two procedure days for a single consult day. Algorithm alternatives are also presented for practices who may find the proposed algorithm infeasible for their practice.

Racial Disparities are Present in the Timing of Radiographic Assessment and Surgical Treatment of Hip Fractures.

BACKGROUND: Hip fractures are associated with 1-year mortality rates as high as 19% to 33%. Nonwhite patients have higher mortality and lower mobility rates at 6 months postoperatively than white patients. Studies have extensively documented racial disparities in hip fracture outcomes, but few have directly assessed racial disparities in the timing of hip fracture care. QUESTIONS/PURPOSES: Our purpose was to assess racial disparities in the care provided to patients with hip fractures. We asked, (1) do racial disparities exist in radiographic timing, surgical timing, length of hospital stay, and 30-day hospital readmission rates? (2) Does the hospital type modify the association between race and the outcomes of interest? METHODS: We retrospectively reviewed the records of 1535 patients aged 60 years or older who were admitted to the emergency department and treated surgically for a hip fracture at one of five hospitals (three community hospitals and two tertiary hospitals) in our health system from 2015 to 2017. Multivariable generalized linear models were used to assess associations between race and the outcomes of interest. RESULTS: After adjusting for patient characteristics, we found that black patients had a longer mean time to radiographic evaluation (4.2 hours; 95% confidence interval, -0.6 to 9.0 versus 1.2 hours; 95% CI, 0.1-2.3; p = 0.01) and surgical fixation (41 hours; 95% CI, 34-48 versus 34 hours 95% CI, 32-35; p < 0.05) than white patients did. Hospital type only modified the association between race and surgical timing. In community hospitals, black patients experienced a 51% (95% CI, 17%-95%; p < 0.01) longer time to surgery than white patients did; however, there were no differences in surgical timing between black and white patients in tertiary hospitals. No race-based differences were observed in the length of hospital stay and 30-day hospital readmission rates. CONCLUSIONS: After adjusting for patient characteristics, we found that black patients experienced longer wait times to radiographic evaluation and surgical fixation than white patients. Hospitals should consider evaluating racial disparities in the timing of hip fracture care in their health systems. Raising awareness of these disparities and implementing unconscious bias training for healthcare providers may help mitigate these disparities and improve the timing of care for patients who are at a greater risk of delay. LEVEL OF EVIDENCE: Level III, therapeutic study.

Arthroscopic Rotator Cuff Repair: A General Instructional Course Lecture.

Rotator cuff pathology is one of the most common reasons for patients to seek orthopaedic consultation. Although in many cases these issues can be resolved with proper conservative management, many of these patients benefit from surgical treatment. The goal of this instructional course lecture is to identify factors that can potentially lead to worse outcomes following repair, describe the history and techniques behind transosseous anchorless repairs, discuss subscapularis tears and their management, and to analyze the most current data regarding double-row rotator cuff repairs. Rotator cuff tears managed surgically have been proven to provide significant pain relief and improved function; however, surgical intervention in patients with significant risk factors for failure can lead to substantial disability for the patient.

Minimal clinically important differences after subpectoral biceps tenodesis: definition and retrospective assessment of predictive factors.

BACKGROUND: Minimal clinically important differences (MCIDs) at 1 year after subpectoral biceps tenodesis are unknown for the American Shoulder and Elbow Surgeons (ASES) scale, Subjective Shoulder Value (SSV), and visual analog scale (VAS) for pain. Our objectives were to determine MCIDs for these measures at 1 year after biceps tenodesis and to identify preoperative factors that predict attainment of MCIDs. METHODS: We included 52 patients who underwent arthroscopic débridement, decompression, and mini-open biceps tenodesis from 2016-2018. We analyzed age, sex, body mass index value, arm dominance, diagnosis, range of shoulder motion, and preoperative and 1-year postoperative ASES, SSV, and VAS scores. MCIDs were calculated using a distribution-based method of one-half the standard deviation. Preoperative thresholds predictive of MCIDs were calculated with univariate logistic regression. Multiple logistic regression was used to determine factors that predict MCIDs. Significance was set at a 2-tailed P value of <.05. RESULTS: MCIDs for the ASES, SSV, and VAS were 13, 12, and 1.6 points, respectively. Preoperative ASES score <59 predicted MCID on the ASES (P = .03); VAS score >3 predicted MCID on the VAS (P < .01); external shoulder rotation >40° predicted MCID on the SSV (P = .02); and age >41 years predicted MCID on the VAS (P = .02). CONCLUSION: At 1 year after débridement, decompression, and biceps tenodesis, MCIDs were 13, 12, and 1.6 points for the ASES, SSV, and VAS, respectively. Patients most likely to attain MCIDs were those aged >41 years, those with the most preoperative pain, and those with the poorest preoperative shoulder function.

Bradyarrhythmias in patients with COVID-19: A case series.

Novel coronavirus disease (COVID-19) can have variety of cardiac manifestations; however, less is known about the prevalence, clinical characteristics and outcomes of bradyarrhythmias in patients with COVID-19. In the present case series of bradyarrhythmia in patients with COVID-19, we report complete heart block requiring intervention in 5 patients and sinus node dysfunction in 2 patients.

Comparison of transport of chemotherapeutic drugs in voxelized heterogeneous model of human brain tumor.

Systemic administration of chemotherapeutic drugs is widely used in the treatment of cancer. However, a good understanding of drug transport barriers that influence the treatment efficacy is still lacking. In this study, a voxelized numerical model based on dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) and computational fluid dynamics (CFD) is employed to study the transport and efficacy of three different chemotherapeutic drugs, namely methotrexate, doxorubicin and cisplatin in human brain tumors. DCE-MRI data provides realistic heterogeneous vasculature of the tumor, the permeability of tissue to contrast agent, interstitial volume fraction (porosity) of the tissue and patient-specific arterial input function (AIF). The permeability of tissue to aforementioned drugs is determined by correlating it with the permeability of tissue to the contrast agent. The model is employed to simulate drug concentration in the tissue and compare the effect of heterogeneous vasculature on the distribution of the drugs in the tumor. The drug accumulation is observed to be higher in high permeability areas initially, and in higher porosity areas at later times. Furthermore, it is observed that methotrexate remains in the interstitial space of the tumor in higher concentration for a longer duration as compared to other two drugs, facilitating more tumor cell killing.

Does Anteromedial Portal Drilling Improve Footprint Placement in Anterior Cruciate Ligament Reconstruction?

BACKGROUND: Considerable debate remains over which anterior cruciate ligament (ACL) reconstruction technique can best restore knee stability. Traditionally, femoral tunnel drilling has been done through a previously drilled tibial tunnel; however, potential nonanatomic tunnel placement can produce a vertical graft, which although it would restore sagittal stability, it would not control rotational stability. To address this, some suggest that the femoral tunnel be created independently of the tibial tunnel through the use of an anteromedial (AM) portal, but whether this results in a more anatomic footprint or in stability comparable to that of the intact contralateral knee still remains controversial. QUESTIONS/PURPOSES: (1) Does the AM technique achieve footprints closer to anatomic than the transtibial (TT) technique? (2) Does the AM technique result in stability equivalent to that of the intact contralateral knee? (3) Are there differences in patient-reported outcomes between the two techniques? METHODS: Twenty male patients who underwent a bone-patellar tendon-bone autograft were recruited for this study, 10 in the TT group and 10 in the AM group. Patients in each group were randomly selected from four surgeons at our institution with both groups demonstrating similar demographics. The type of procedure chosen for each patient was based on the preferred technique of the surgeon. Some surgeons exclusively used the TT technique, whereas other surgeons specifically used the AM technique. Surgeons had no input on which patients were chosen to participate in this study. Mean postoperative time was 13 ± 2.8 and 15 ± 3.2 months for the TT and AM groups, respectively. Patients were identified retrospectively as having either the TT or AM Technique from our institutional database. At followup, clinical outcome scores were gathered as well as the footprint placement and knee stability assessed. To assess the footprint placement and knee stability, three-dimensional surface models of the femur, tibia, and ACL were created from MRI scans. The femoral and tibial footprints of the ACL reconstruction as compared with the intact contralateral ACL were determined. In addition, the AP displacement and rotational displacement of the femur were determined. Lastly, as a secondary measurement of stability, KT-1000 measurements were obtained at the followup visit. An a priori sample size calculation indicated that with 2n = 20 patients, we could detect a difference of 1 mm with 80% power at p < 0.05. A Welch two-sample t-test (p < 0.05) was performed to determine differences in the footprint measurements, AP displacement, rotational displacement, and KT-1000 measurements between the TT and AM groups. We further used the confidence interval approach with 90% confidence intervals on the pairwise mean group differences using a Games-Howell post hoc test to assess equivalence between the TT and AM groups for the previously mentioned measures. RESULTS: The AM and TT techniques were the same in terms of footprint except in the distal-proximal location of the femur. The TT for the femoral footprint (DP%D) was 9% ± 6%, whereas the AM was -1% ± 13% (p = 0.04). The TT technique resulted in a more proximal footprint and therefore a more vertical graft compared with intact ACL. The AP displacement and rotation between groups were the same and clinical outcomes did not demonstrate a difference. CONCLUSIONS: Although the AM portal drilling may place the femoral footprint in a more anatomic position, clinical stability and outcomes may be similar as long as attempts are made at creating an anatomic position of the graft. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparing the Incidence and Clinical Data for Simultaneous Bilateral Versus Unilateral Total Hip Arthroplasty in New York State Between 1990 and 2010.

A New York State database reported information on all total hip arthroplasty cases between 1990 and 2010 comparing unilateral (242,588 cases) to simultaneous bilateral (4538 cases) procedures. Our data showed that the population incidence of this surgery increased 120.2% over twenty years, yet the proportionate number of simultaneous cases has decreased. Simultaneous procedures were found to occur more commonly in younger patients with private insurance. In addition, bilateral procedures showed an increase in PE, DVT, length of stay, and discharge to rehab facilities; whereas mortality and blood transfusions compared to unilateral procedures showed no difference.

Revision total joint arthroplasty: the epidemiology of 63,140 cases in New York State.

Recent evidence suggests a substantial rise in the number of revision total joint arthroplasty (TJA) procedures performed. The New York State SPARCS inpatient database was utilized to identify revision total shoulder, knee, and hip arthroplasty procedures between 1993 and 2010. Yearly incidence and related epidemiology were analyzed. A total of 1,806 revision TSA, 26,080 revision TKA, and 35,254 revision THA cases were identified. The population-based incidence of these procedures increased 288%, 246%, and 44% respectively (P<0.001). Revision burden for hip arthroplasty decreased from 16.1% in 2001 to 11.5% in 2010 (P<0.001). The rates of revision TSAs and TKAs increased at a substantially faster rate than that of revision THAs. Revision burden for hip arthroplasty steadily has decreased since 2001.

Unilateral Autosomal Recessive Anophthalmia in a Patient with Cystic Craniopharyngioma.

Anophthalmia is a rare ocular malformation. It is a genetically determined disorder and is typically associated with syndromes. However, sporadic nonsyndromic familial as well as non-familial cases of anophthalmia have also been reported. Non-syndromic familial cases are usually bilateral and have been attributed to autosomal recessive, autosomal dominant, and X-linked inheritance patterns. The authors hereby report a rare case of autosomal recessive unilateral anophthalmia in a patient with no other associated congenital anomaly. Patient was operated for craniopharyngioma. The clinical, radiological and intraoperative findings are discussed.

Primary percutaneous intervention in an unusual vessel using an unusual technique: a case report.

Background: Primary percutaneous intervention (PPCI) of the saphenous vein graft (SVG) is associated with a high risk of distal embolization and no reflow, since SVG lesions are often very friable and have a large thrombotic burden. We report a case of successful PPCI of the SVG using guide catheter thrombectomy with novel double wire technique. Case summary: A 60-year-old male with a past history of coronary artery bypass grafting presented with acute thrombotic occlusion of the SVG to the obtuse marginal graft. Despite appropriate pharmacotherapy (GPIIb/IIIa inhibitors) and thrombosuction, there was a large residual thrombus burden with poor distal flow. In the present case, we decided to perform guide catheter thrombosuction. An exchange length floppy 0.014' wire was passed alongside the pre-existing wire and the 6 Fr JR guide catheter was exchanged for a less traumatic 5 Fr JR guide catheter over the exchange wire. The first wire was kept distally in the vessel along the guiding catheter to maintain the access to the graft vessel. The 5 Fr JR guide catheter was slowly advanced over the wire to the distal portion of the graft, keeping the other wire in the distal portion of the graft to maintain access. A large amount of thrombus was aspirated and the patient improved dramatically. Discussion: This double wire technique is an effortless and novel way to maintain access to the distal vasculature of the occluded artery, while the guide can be safely intubated deep into the coronary artery that helps in removing a very large amount of thrombus because of their larger internal lumen.

Endothelial nitric oxide synthase (eNOS) gene polymorphism (Glu298asp) and nitric oxide (NO) levels in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND: Genetic polymorphism in endothelial Nitric Oxide Synthase (eNOS) are associated with occurrence of multiple cardiovascular diseases (CVDs). METHODS: This study included 300 young ST-segment elevation myocardial infarction (STEMI) patients and 300 healthy controls. STEMI patients were divided into two groups: premature coronary artery disease [CAD] (STEMI<40 years of age) and older STEMI (>40 years of age). Genetic polymorphisms in the eNOS gene (894G/T) was evaluated in both subjects and controls. Plasma levels of nitric oxide (NO) were estimated for both patients as well as controls. RESULTS: Mean age of the study population was 49.7 ± 9.2 years with premature CAD being present in 58 (19.3 %) patients. No significant difference at genotypic (P = 0.589, odds ratio (OR) = 0.9, 95 % CI = 0.6-1.6) and allelic level (P = 0.173, OR = 1.2, 95 % CI = 0.9-1.4) was observed between STEMI patients and healthy controls. Genotype 894 TT had significantly higher frequency in STEMI patients >40 years (P = 0.047, OR: 2.5; 95 % CI = 1.0-6.0). No significant difference at genotypic (P = 0.279) and allelic level (P = 0.493) was observed between premature CAD (STEMI age <40 years) and healthy controls. NO levels (131 ± 59.6 µM vs 118.11 ± 49.96 µM; P = 0.001) was significantly higher in healthy controls as compared to STEMI patients >40 years of age (P= 0.001). CONCLUSION: There was significant association of eNOS gene polymorphism Glu298Asp with STEMI patients > 40 years. However, this association was not observed in premature CAD patients. Lower levels of NO in STEMI patients >40 years suggests its potential role as a marker of CVD.