Incidental Detection of Ischemic Myocardium on 68 Ga-FAPI PET/CT.

Recent studies using Ga-68-labeled fibroblast activation protein inhibitors (FAPI) PET have shown strong association between focal uptake of FAPI in myocardium and presence of coronary artery disease. We present an interesting case of a 76-year-old female with breast cancer with incidental uptake on FAPI PET in apex and septal wall of left ventricle myocardium correlating with findings of ischemia on dobutamine stress myocardial perfusion imaging and anatomical stenosis on coronary angiography.

Predictors of short-term outcomes in patients undergoing percutaneous coronary intervention in cardiogenic shock complicating STEMI-A tertiary care center experience.

BACKGROUND: Studying the outcomes in patients presenting with cardiogenic shock with ST-segment elevation myocardial infarction (CS-STEMI) and undergoing primary or rescue percutaneous coronary intervention (PCI) may give an insight to the unmet needs in STEMI-care in our region and may help in future recommendations in improving survival. MATERIALS AND METHODOLGY: During the period from January 2001- June 2017, there were 114 patients included in the study. The demographic, clinical and angiographic characteristics were compared between the survivors and non-survivors. All these variables were also compared between two-time frames (Phase 1- January 2001 to June 2007; Phase 2- July 2007 to June 2017). RESULTS: Among patients undergoing PCI for STEMI, 7.5% were in cardiogenic shock. In-hospital mortality for the patients included in the study was 53.5%. Total ischemic time (OR=0.99, 0.99-1; p=0.02), left ventricular ejection fraction (LVEF) (OR=0.90, 0.82-0.98; p=0.02), need for cardio-pulmonary resuscitation (OR=0.12, 0.24-0.66; p=0.01), and post PCI TIMI flows (OR=0.08, 0.02-0.29; p<0.001) were the significant determinants of in-hospital mortality in the regression analysis. There was no significant change in mortality between the two phases of the study, though there was a reduction in total ischemic and door-to-balloon times, transfer admissions, use of thrombolytics, glycoprotein IIb/IIIa inhibitors, intra-aortic balloon pump, and mechanical ventilation in phase 2. CONCLUSION: Patients presenting in CS-STEMI and undergoing PCI continue to experience high mortality rates, despite improvements in total ischemic times. Further improvement in the systems-of-care are required to bring about reduction in mortality in this high-risk subset.

Initial outcome following invasive cardiac electrophysiologic studies and radiofrequency ablation of atrial fibrillation.

BACKGROUND: Cardiac electrophysiologic study and radiofrequency ablation (RFA) have become an established mode of treatment for patients with refractory arrhythmias. These procedures are carried out regularly at the cardiac catheterization laboratory of Madras Medical Mission India. OBJECTIVE: The purpose of this study was to evaluate our experience with cardiac electrophysiologic studies (EPS) and RFA catheter of atrial fibrillation (AF). MATERIALS AND METHODS: This was a retrospective study carried out in the Cardiac Electrophysiology Department of the Institute of Cardiovascular Diseases, Madras Medical Mission, India. All cases diagnosed to have AF following cardiac EPS between January 2010 and April 2014 was selected for the study. The records, which were obtained from the Cardiac Electrophysiology Clinical Research Office of Madras Medical Mission, were reviewed. Forty-nine cases were chosen for analysis, using SPSS statistical software version 15. RESULTS: There were 49 patients, 23 males and 26 females. The mean age was 57.53 years. Commonly associated diseases were diabetes mellitus 8 (16.3%), hypertension 18 (36.7%), and coronary heart disease 14 (28.5%). The ventricular rate was rapid most cases (91.2%). AF was diagnosed as being paroxysmal in 40 (81.6%), persistent in 5 (10.2%), chronic in 3 (6.1%), and lone in 1 (2.0%). Ablation was carried out in 28 (57.1%), the success rate being 90% for pulmonary vein isolation, and 90.9% for atrioventricular node ablation. Complication rate was 2.04%. CONCLUSIONS: Treatment of AF by RFA is highly effective and safe.

Focal Purkinje ventricular tachycardia ablation in structurally normal heart.

A 21-year-old man presented with recurrent palpitations and giddiness. Clinical examination, echocardiography, and magnetic resonance imaging revealed a structurally normal heart. Electrocardiography showed broad-complex tachycardia with 250 beats per minute, which required cardioversion. An electrophysiological study could not induce tachycardia by programmed electrical stimulation. On isoprenaline infusion, frequent ventricular ectopics, bigeminy, nonsustained ventricular tachycardia, and broad-complex tachycardia similar to clinical tachycardia were readily inducible. This was considered to be ventricular tachycardia due to enhanced automaticity. Using 3-dimensional electroanatomical mapping, successful ablation was undertaken. The patient was asymptomatic on follow-up after 12 and 18 months.

Catheter ablation of atrial arrhythmias in a patient with surgically corrected congenital heart disease and inferior vena cava interruption.

A 15 year old girl who underwent surgical correction of ventricular septal defect and patent ductus arteriosus ligation in childhood presented with atrial tachycardia of crista terminalis origin and counterclockwise atrial flutter. She also had associated interruption of inferior vena cava which continued as azygous vein and left superior vena cava which drained via coronary sinus into the right atrium. She underwent radiofrequency ablation of both the tachycardias via internal jugular vein and azygous vein approach using 3D electroanatomical mapping system.

Characteristics, treatment and one-year outcomes of patients with acute coronary syndrome in a tertiary hospital in India.

BACKGROUND: Coronary artery disease (CAD) is a major cause of death in India. Data on outcome of CAD is scarce in the Indian population. This study determined the characteristics, treatment and one-year outcomes of acute coronary syndrome (ACS) in an Indian Cardiac Centre. METHODS: We carried out a cross sectional retrospective analysis of 1468 ACS patients hospitalized between January 2008 and December 2010 and followed up for 1 year in the Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai. Mortality at 1 year, its determinants and 1 year major adverse cardiac events (MACE) were determined. RESULTS: The patients were aged 62.2 ± 11.2 years; males (75.2%) and had ST segment elevation myocardial infarction (STEMI) (33.9%), non ST segment elevation myocardial infarction (44.2%) and unstable angina (21.9%). Key pharmacotherapy included aspirin (98.2%), clopidogrel (95.1%), statins (95.6%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (50.6%) and beta blocker (83.1%). Angiography rate was 80.6%. In the STEMI group, 53.3% had primary angioplasty, 20.3% were thrombolysed and 16.1% received sole medical therapy. Overall coronary artery bypass graft rate was 12.4%. At one year, all-cause mortality and composite MACE were 2.5% and 9.7%, respectively. MACE included death (2.5%), reinfarction (4.0%), resuscitated cardiac arrest (1.8%), stroke (1.1%) and bleeding (0.4%). Main factors associated with mortality were combined left ventricular systolic and diastolic dysfunction (OR = 20.0, 95% CI = 6.63-69.4) and positive troponin I (OR = 12.56, 95% CI = 1.78-25.23). Troponin I independently predicted mortality. CONCLUSIONS: ACS population was older than previously described in India. Evidence-based pharmacotherapy and interventions, and outcomes were comparable to the developed nations.

Coronary intervention in anomalous origin of the right coronary artery (ARCA) from the left sinus of valsalva (LSOV): a single center experience.

OBJECTIVE: To assess the technical challenges in percutaneous coronary intervention of Anomalous right coronary artery arising from the left sinus of valsalva. METHODS: Between year 2008 and 2012, a total of 17 patients underwent PCI for an angiographically significant lesion in the right coronary artery of an anomalous origin in the LSOV. Their procedure details such as usage of catheters, radiation time, amount of contrast used were assessed. RESULTS: A total of 17 patients with anomalous right coronary artery underwent PCI during the above mentioned period. 8 patients had type A origin, 3 had type B origin and the remaining 6 had type C origin. Type A origin RCA were successfully cannulated in 6 patients with Judkins left 5.0 and in 2 patients using Judkins left 4.0. Extra back up (EBU) 3.5 were doing well in 2 patients of Type B origin and the remaining one patient was successfully cannulated using Judkins left 4.0. In type C origin 4 patients had successful cannulation with Amplatz Left 1.0, 1 patient with Amplatz Left 2.0 and 1 patient with Judkins left 4.0. The mean fluoroscopic time was 20.7 min and amount of contrast used was 210 ml. CONCLUSION: PCI of anomalous RCA origin from LSOV requires appropriate guide catheter selection according to the anatomy of origin for successful cannulation and to reduce the contrast usage and radiation exposure.

A prospective, randomized study to evaluate the efficacy of various diuretic strategies in acute decompensated heart failure.

AIM: To evaluate the safety and efficacy of various initial strategies of loop diuretic administration in patients with acute decompensated heart failure (ADHF) on diuresis, renal function, electrolyte balance and clinical outcomes. METHODS: Consecutive patients admitted with ADHF were randomized into three groups - intravenous furosemide infusion + intravenous dopamine, intravenous furosemide bolus in two divided doses and intravenous furosemide continuous infusion alone. At 48 h, the treating physician could adjust the diuretic strategy. Primary endpoint was negative fluid balance at 24 h after admission. Secondary end points were duration of hospital stay, negative fluid balance at 48, 72, 96 h, the trend of serum electrolytes, and renal function and 30 day clinical outcome (death and emergency department visits). RESULTS: Overall ninety patients (thirty in each group) were included in the study. There was a greater diuresis in first 24 h (p = 0.002) and a shorter hospital stay (p = 0.023) with the bolus group. There was no significant difference in renal function and serum sodium and serum potassium levels. There was no difference in the number of emergency department visits among the three groups. CONCLUSION: All three modes of diuretic therapies can be practiced with no difference in worsening of renal function and electrolyte levels. Bolus dose administration with its rapid volume loss and shorter hospital stay might be a more effective diuretic strategy.

Outcome of primary PCI - an Indian tertiary care center experience.

OBJECTIVE: To assess the feasibility and outcomes of primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) in Indian Scenario. METHODS: Between January 2005 and December 2012, consecutive STEMI patients who underwent PPCI within 12 h of onset of chest pain were prospectively enrolled in a PPCI registry. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital and 30 day major adverse cardiovascular events (MACE) [death, reinfarction, bleeding, urgent coronary artery bypass surgery (CABG) and stroke] were assessed. RESULTS: A total of 672 patients underwent PPCI during this period. The mean age was 52 ± 13.4 years and 583 (86.7%) were males, 275 (40.9%) were hypertensives and 336 (50%) were diabetics. Thirty one (4.6%) patients had cardiogenic shock (CS). Anterior myocardial infarction was diagnosed in 398 (59.2%) patients. The median chest pain onset to hospital arrival time, door-to-balloon time and total ischemic times were 200 (10-720), 65 (20-300), and 275 (55-785) minutes respectively. In-hospital adverse events occurred in 54 (8.0%) patients [death 28 (4.2%), reinfarction 8 (1.2%), major bleeding 9 (1.3%), urgent CABG 4 (0.6%) and stroke 1 (0.14%)]. Nineteen patients with CS died (mortality rate - (61.3%)). At the end of 30 days, 64 (9.5%) patients had MACE [death 35 (5.2%), reinfarction 10 (2.1%), major bleeding 10 (1.5%), urgent CABG 4 (0.6%) and stroke 1 (0.1%)]. CONCLUSION: Our study has shown that PPCI is feasible with good outcomes in Indian scenario. Even though the recommended door-to-balloon time can be achieved, the total ischemic time remained long. CS in the setting of STEMI was associated with poor outcomes.

Surgical considerations in chronic pseudoaneurysms involving the celiac axis.

Aneurysms involving the celiac axis are rare. We present a case of thoracoabdominal aortic aneurysm involving the celiac artery origin. A 46-year-old man was diagnosed to have an aortic aneurysm, when he presented with a one year history of abdominal pain. He underwent a laparotomy for aneurysm repair at another institution and was deemed to be inoperable. He underwent surgical repair thoracophrenolaparotomy using a 'clamp and sew method'. Approach to the aneurysm, preservation of critical structures and collaterals, resulted in an excellent patient recovery.

Takayasu's arteritis mimicking acute aortic dissection.

A 17-year-old girl presented with a history of dyspnea on exertion and fever of 1-week duration. She was evaluated elsewhere with transesophageal echocardiography and helical computed tomographic scan, and she had been diagnosed with an acute type I dissection of the aorta. She had also been diagnosed with severe aortic regurgitation and a suspected aortic root abscess. On the operating table, we found no evidence of dissection, but we did find that her aorta was severely thickened and inflamed. The patient's aortic valve was replaced. In view of the left main stem ostial stenosis, we harvested and grafted the left internal thoracic artery to the left anterior descending artery. During the operation it is of paramount importance to rule out dissections involving the arch and coronary ostial narrowing.