Prosthetic mitral valve thrombosis, malfunction, and paroxysmal mitral regurgitation.

Intermittent dysfunction of mechanical mitral valve prosthesis is an uncommon condition. It carries serious clinical implications if unrecognized. Here, we present a case of a 28-year-old female with a history of rheumatic multivalvular disease, for which she had undergone double valve replacement and tricuspid annuloplasty. Six months later, she presented with heart failure. Clinical examination revealed intermittent loss of closing clicks followed by a pansystolic murmur at the apex, suggestive of mitral prosthetic valve dysfunction. We highlight the echocardiographic findings of paroxysmal mitral valvular regurgitation secondary to prosthetic valve malfunction secondary to prosthetic valve thrombosis.

Spectrum of cyanotic congenital heart disease diagnosed by echocardiographic evaluation in patients attending paediatric cardiology clinic of a tertiary cardiac care centre.

BACKGROUND: Cyanotic CHD comprises up to 25% of cases of all causes of CHD. RATIONALE: There is lack of data about the present spectrum of congenital cyanotic heart disease in the paediatric age group. OBJECTIVE: The present study was undertaken to determine the spectrum of patients with congenital cyanotic heart disease in the paediatric age group in tertiary paediatric cardiac care clinic. DESIGN: Prospective observational study. SETTING: Paediatric cardiac clinic of a tertiary cardiac care centre. METHODS: All children aged 0-18 years with suspected cyanotic CHD were provisionally included in this study. They underwent a thorough echocardiographic evaluation, and those patients who had definitive diagnosis of congenital cyanotic heart disease were included for final analysis. RESULTS: A total of 119 children met the inclusion criteria. Tetralogy of Fallot and its variant were the most common congenital cyanotic heart disease with proportion of about 44%. Other common malformations were double outlet right ventricle (14%), pulmonary atresia with ventricular septal defect (8%), total anomalous pulmonary venous connection (7%), d-transposition of the great arteries (9%), tricuspid valve anomalies--tricuspid atresia and Ebstein's anomaly--hypoplastic left-heart syndrome, truncus arteriosus, and complex CHD such as single ventricle. CONCLUSION: Tetralogy of Fallot and its variants were the most common cyanotic heart disease diagnosed in our patients. As there were a significant proportion of cases with complex cyanotic CHD, paediatric cardiologists should be familiar with the diagnosis and management of all these complex congenital malformations of the heart.

Percutaneous stenting of interrupted aortic arch to treat compressive myelopathy.

Neurological complications of coarctation of aorta include spontaneous SAH, intracerebral hemorrhage, and cerebral abscess. Interrupted aortic arch (IAA) present as compressive myelopathy is not known. We describe an adult male presenting to neurology department with progressive paraparesis and was detected to have IAA with intraspinal collaterals causing compressive myelopathy. He was successfully treated with percutaneous stenting of IAA with dramatic improvement in paraparesis. © 2014 Wiley Periodicals, Inc.

Clinical, echocardiographic and microbiological study, and analysis of outcomes of infective endocarditis in tropical countries: a prospective analysis from India.

BACKGROUND AND AIM OF THE STUDY: The aim of this prospective observational study was to evaluate the clinical, echocardiographic, microbiological profile and outcomes of patients with definitive infective endocarditis (IE) in tropical countries. METHODS: Between September 2010 and March 2013, a total of 109 patients with 111 episodes of definitive IE (as per the modified Duke's criteria) was enrolled in the study. The mean age at presentation was 32.7 ± 17.2 years (range: 2-70 years), and there was a male preponderance (3:1). RESULTS: Native valve disease was identified in 57 cases of IE, followed by congenital heart disease (n = 35), prosthetic valve disease (n = 11), normal valves (n = 5) and pacemaker lead infection (n = 1). Echocardiography was diagnostic in all patients except one. Positive blood cultures were obtained in 68 episodes, with streptococci (n = 34) and staphylococci (n = 11) the most common organisms. At least one major complication was identified in 60 patients. Ultimately, only 15 patients underwent surgery for IE, but 25 died during their hospital stay. On multivariate analysis, prosthetic valve involvement, combined mitral and aortic valve involvement, male gender, and leukocytosis were independent predictors of mortality. CONCLUSION: IE in India is associated with a higher mortality and lower rates of culture positivity compared to the west; rates of surgery for IE in India are unacceptably low. Changing epidemiological trends may pose newer challenges in the near future.

Balloon mitral valvotomy in juvenile rheumatic mitral stenosis: comparison of immediate results with adults.

AIMS: The objective of the study was to study and compare the clinical, echocardiographic and haemodynamic profile of juvenile rheumatic mitral stenosis (age ≤20 years) with severe mitral stenosis in adults, both before and immediately after balloon mitral valvotomy and also to evaluate the safety and efficacy of the procedure in juvenile patients. METHODS: Forty juvenile patients aged 20 years or younger were analysed with 40 consecutive adult patients who underwent balloon mitral valvotomy using Accura balloon in our institution. The procedure was successful in all the patients. The clinical, echocardiographic and haemodynamic parameters were compared pre- and post-balloon mitral valvotomy in both the groups. RESULTS: New York Heart Association functional class was comparable in both the groups (II and III, 62.5% and 37.5% vs. 60% and 40%). Atrial fibrillation was not seen in the juvenile group whereas 25% of the adult group had atrial fibrillation (p<0.001). Mitral valve deformity was comparable (Wilkins Score - 8.57±0.67 vs. 8.6±0.67, p=NS). Mitral valve area index by 2D echo was 0.62±0.097 cm2/m2 in the juvenile group and 0.621±0.097 cm2/m2 in the adult group (p=0.72) and was larger in the juvenile group (1.38±0.19 vs 1.29±0.18 cm2/m2) after the procedure (p value <0.03). Mitral valve gradient (19.85±7.31 mm hg vs. 14.63±5.33 mm hg. P value<0.001) and mean PASP (70.15±1+.2 mm hg vs. 60.10±19.32 mm of hg. P value <0.02) was higher in the juvenile group before balloon mitral valvotomy, after balloon mitral valvotomy the values were 7.45±2.57 vs. 5.78±2.24 mm of hg, (P<0.003) and 40.48±10.30 vs. 41±15.62 respectively (p=0.85). The mean value for left atrial pressure was comparable in both the groups both pre- and post-balloon mitral valvotomy (P value 0.076 and 0.54 respectively). There was no significant difference in the procedural success (95% vs 100%, p value <0.15). CONCLUSION: Balloon mitral valvotomy is safe and effective in young with rheumatic mitral stenosis and provides better immediate results compared to adults.

Real-world evidence of BioMime sirolimus-eluting stent in obstructive coronary artery disease: the meriT-2 trial.

Background: The efficacy and safety of the ultrathin BioMime sirolimus-eluting coronary stent (SES) system in treating single or multiple de novo native coronary lesions, in-stent restenosis, and bifurcation lesions have been evidenced at 1 year. Aims: We sought to investigate the long-term safety and efficacy of the BioMime SES in a real-world population with obstructive coronary artery disease (CAD). Methods: The prospective, single-arm, multicentre meriT-2 trial enrolled 250 patients from 11 sites across India. The safety endpoint was the cumulative frequency of major adverse cardiovascular events (MACE) at 5 years, defined as a composite of cardiac death, myocardial infarction (MI), emergent coronary artery bypass grafting or clinically indicated target lesion revascularisation (CI-TLR). Stent thrombosis (ST) was evaluated according to the Academic Research Consortium definitions. Results: A total of 214 (85.6%) subjects completed the 5-year follow-up. The mean age of patients was 57.44±10.75 years, and 82.71% were males. A total of 308 lesions were treated with BioMime SES. Most of the lesions were localised in the left anterior descending artery (45.46%) and were type B2 lesions (44.81%). The cumulative MACE rate at 5 years was 8.9% (n=19), including 0.9% cardiac deaths, 1.9% MI and 6.1% CI-TLR. The rate of ST was only 0.5%. The Kaplan-Meier survivor analysis revealed actuarial survivorship of 95.6% for the intention-to-treat population (n=250) over 5 years. Conclusions: The long-term clinical outcomes of the meriT-2 trial established the safety and efficacy of the ultrathin-strut biodegradable-polymer-based BioMime SES with satisfactory clinical outcomes at 5 years.

Acute severe mitral regurgitation following balloon mitral valvotomy: echocardiographic features, operative findings, and outcome in 50 surgical cases.

OBJECTIVE: To analyze the echocardiographic and operative findings with respect to mitral valve anatomy in individuals undergoing emergency surgery for acute severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV). In addition, the clinical profile and outcomes are highlighted. BACKGROUND: Acute severe MR is a major complication of BMV. There are only a few reports which have studied the echocardiographic and operative findings in this setting. In addition, optimal timing of surgery is uncertain. METHODS: Prospective study of 50 consecutive patients undergoing emergency mitral valve replacement (MVR) for acute severe MR following BMV. RESULTS: In 3855 patients who underwent BMV, acute severe MR developed in 50 cases (1.3%) and was referred for emergency MVR. Hypotension (72%), hypoxia (64%), orthopnea (14%), and pulmonary edema (12%) were the clinical manifestations. Severe MR was secondary to anterior mitral leaflet tear in 36 cases (72%), paracommisural tear with annular involvement in seven cases (14%), posterior mitral leaflet tear in five cases (10%) and chordal tear in two cases (4%). The correlation between two-dimensional transthoracic echocardiography (2D-TTE) and operative finding for mitral valve calcification was found to be strong (r = 0.862), in contrast to submitral fusion, where it was found to be moderate (r = 0.536). In-hospital mortality was 12%. Mortality was higher in patients whose time to surgery was ≥24 hr when compared to those who underwent MVR within 24 hr (P < 0.001). CONCLUSIONS: Hypotension and hypoxia are the predominant manifestations of acute severe MR following BMV. Anterior mitral leaflet tear is the most common etiology for severe MR. 2D-TTE underestimated the severity of submitral disease. Early MVR (<24 hr) is recommended for optimal outcome.

An adult patient of double-chambered right ventricle with ventricular septal defect incidentally diagnosed after presentation with acute myocardial infarction.

The double-chambered right ventricle (DCRV) is a rare congenital heart disease caused by hypertrophic anomalous muscle bands that divide the ventricular cavity, resulting in the formation of a high-pressure proximal chamber and other low-pressure distal one. Because of its evolving nature, its diagnosis is usually made during childhood/adolescence and very rarely during adulthood. It accounts for approximately 0.5-1% of patients with congenital heart disease. We report a case of a 50-year-old man who presented to us with acute inferior wall myocardial infarction (MI). Echocardiography revealed the features of DCRV and ventricular septal defect. Coronary angiogram revealed significant stenosis in right coronary artery. This is the first case where an adult patient with DCRV incidentally diagnosed after presentation with acute MI and had undergone successful coronary angioplasty.

Left ventricular hydatid cyst: an uncommon cause of chest pain in young adults.

Isolated cardiac involvement in hydatid disease is very rare. We report the case of a young adult male who presented to the emergency department with acute onset of chest pain and was surprisingly detected to have a hydatid cyst in the left ventricular myocardium. The transthoracic echocardiography and cardiac magnetic resonance imaging confirmed the diagnosis. Cardiac hydatid disease should be considered in the differential diagnosis of chest pain in young individuals in the absence of conventional risk factors of atherosclerosis.

Tombstone-like electrocardiographic changes during exercise stress test.

A 45-year-old man showed tombstone-like electrocardiographic change during stage 1 of stress testing, using Bruce protocol. The raw rhythm strip did not show any ST-T changes. These pseudochanges were probably the result of computer-synthesized averaging algorithm errors.

Isolated left ventricular noncompaction mimicking ventricular mass.

Isolated left ventricular noncompaction is an inherited cardiomyopathy characterized by multiple prominent trabeculations with deep intertrabecular recesses. The diagnosis is often missed because echocardiography poses inherent problems of poor echo window in assessment of the LV apex, which is most commonly involved in noncompaction. We report a case in which conventional 2D echocardiography failed to demonstrate multiple prominent trabeculations. Contrast echocardiography confirmed the presence of multiple trabeculations with deep intertrabecular recesses. This report emphasizes the importance of contrast echocardiography in the diagnosis of ventricular noncompaction.

The prevalence of enteroviral RNA and protein in mitral valves of chronic rheumatic heart disease.

INTRODUCTION: Acute Rheumatic Fever/ Rheumatic Heart Disease (ARF/RHD), a sequel of group A streptococcal (GAS) infection, even today constitutes a public health issue in developing countries including India. Differences in the prevalence of ARF/RHD in countries with a similar prevalence of GAS infections indicate the role of other cofactors in pathogenesis of RHD. METHODOLOGY: We investigated the prevalence of enterovirus (EV) in RHD by probing for both EV RNA and VP1 protein using Nonisotopic In Situ Hybridization (NISH) and Immunohistochemistry (IHC) respectively in 75 valvectomy specimens obtained from RHD cases. RESULTS: Twenty-eight (37%) of the valves showed tissue inflammation with lymphocytic infiltration in a majority of the cases. Twenty-six and 27 (38% and 40%) of the 68 valves showed the presence of EV by IHC and NISH respectively, indicating a very good association between the two tests; however, only about 46 to 48% of them exhibited tissue inflammation. In eight cases (12%) the EV genome was detectable in absence of VP1 protein perhaps indicating a latent viral infection. CONCLUSIONS: Due to a high degree of endemicity of EV in India, we are tempted to speculate that EV may be responsible for the severity and rapid progression of RHD. The virus could either be working synergistically with GAS or could be an opportunist infecting damaged valves.

Patterns of cardiovascular diseases in COVID-19 patients admitted to tertiary cardiac care centre.

OBJECTIVES: To analyse the pattern of cardiovascular diseases (CVDs) in COVID-19 patients admitted to tertiary cardiac care centre. METHODS: We retrospectively analysed 511 adult patients admitted between July 1, 2020, and November 30, 2020, with COVID-19 infection and having either new onset or pre-existing CVDs. Clinical features, electrocardiogram (ECG), echocardiography, chest X-ray, biomarkers, haematological and biochemical parameters were analysed. RESULTS: The mean age of the patients was 56.62 ± 14.74 years. Male: Female ratio was 2.78:1. Pre-existing CVDs were present in 258 patients (50.5%). The most common cardiovascular manifestation was acute coronary syndrome (ACS), seen in 259 patients (50.7%). ST-segment elevation myocardial infarction (STEMI) was more common than non-ST-segment elevation ACS (NSTE-ACS). Possible myocarditis was seen in 52 patients (10.1%). Rhythm and conduction abnormalities were noted in 144 patients (28.2%), the most common being QT prolongation, seen in 51 patients (10%). In-hospital mortality occurred in 97 patients (18.9%). Age, serum Ferritin level, D-dimer, NT-pro-BNP and total leukocyte count were significantly higher among patients with in-hospital mortality compared to survival group. Blood lymphocyte count and Haemoglobin level were significantly lower in mortality-group, compared to survival-group. Incidence of pre-existing CVDs, cardiogenic shock, heart failure, atrial fibrillation (AF), and renal failure were significantly higher in mortality-group compared to survival-group. CONCLUSION: The most common CVD in COVID-19 patients in our study was ACS. STEMI was more common than NSTE-ACS. Advanced age, elevated serum ferritin, D-dimer, NT pro-BNP, leucocytosis, lymphopenia, lower haemoglobin, pre-existing CVDs heart failure, cardiogenic shock, AF and renal failure were associated with increased mortality in these patients.

Cerebrovascular Events Complicating Cardiac Catheterization - A Tertiary Care Cardiac Centre Experience.

Background: Cerebrovascular events (CVEs) are one of the rare complications of cardiac catheterization. This prospective single-center study was conducted to assess the incidence, presentations, and outcomes of CVEs in patients undergoing cardiac catheterization. Methods: Patients undergoing cardiac catheterization who developed CVEs within 48 h of procedure were analyzed prospectively with clinical assessment and neuroimaging. Results: Out of 55,664 patients, 35 had periprocedural CVEs (0.063%). The incidence of periprocedural CVEs with balloon mitral valvotomy, percutaneous coronary intervention, and coronary angiography was 0.127%, 0.112%, and 0.043%, respectively. A larger proportion of periprocedural CVEs occurred in patients with acute coronary syndrome (ACS, 77.1%) than in patients with stable coronary artery disease (CAD). The majority of CVEs were ischemic type (33 patients, 94.3%). It was most commonly seen in the left middle cerebral artery (MCA) territory. Hemorrhagic CVEs were very rare (2 patients, 5.7%). The majority of the CVEs manifested during or within 24 h of the procedure (31 patients, 88.6%). Neurodeficits persisted during the hospital stay in 20 patients (57.2%), who had longer duration of procedure compared to those with recovered deficits (P = 0.0125). In-hospital mortality occurred in three patients (8.5%) and post-discharge mortality in another 3 (8.5%). Conclusions: Periprocedural CVEs are rare and have decreased over time. They occur in a greater proportion in patients with ACS than in patients with stable CAD, more with interventional than diagnostic procedures. Ischemic event in the left MCA territory is the most common manifestation, commonly seen within 24 h of the procedure. Longer duration of procedure was a risk factor for larger infarcts and hence persistent neurodeficit at discharge. Although a substantial number of patients recover the neurodeficits, periprocedural CVEs are associated with adverse outcomes.

Role of Angiotensin-Converting Enzyme (ACE) gene polymorphism and ACE activity in predicting outcome after acute myocardial infarction.

BACKGROUND: The Ace polymorphism had shown association with ACE activity, premature atherosclerosis, myocardial infarction, LV dysfunction, LV remodelling, severity and extent of CAD and mortality after MI. Though ACE I/D polymorphism has been reported to be associated with various cardiovascular diseases it remained a controversial risk factor and studies have presented conflicting results. This study was designed to determine the association between ACE) gene insertion/deletion (I/D) polymorphism, ACE activity and acute STEMI in Indian population and to determine its influence on outcome after acute MI. MATERIALS AND METHODS: We investigated 934 patients diagnosed with acute STEMI who underwent thrombolysis. ACE I/D polymorphism was detected by polymerase chain reaction and ACE activity was measured in 615 patients. RESULTS: The prevalence of DD, ID, and II genotypes in our study group were 41.97%, 34.36%, and 23.66% respectively. The ACE polymorphism was not significantly associated with the type of myocardial infarction, the LV ejection fraction, the number of vessels diseased and patency of the vessel after thrombolysis. The polymorphism had no influence on in hospital mortality (P = 0.453). The ACE activity also showed no influence on in hospital mortality (P = 0.482). The age > 60 years, Male gender, occluded artery and severe LV dysfunction (LVEF < 35%) were predictors of in-hospital mortality on multivariate regression analysis. CONCLUSION: There was no differences among ACE (I/D) polymorphism observed in STEMI population. Neither ACE I/D polymorphism nor ACE activity predicted in-hospital mortality inpatients admitted with acute STEMI.

Hemopericardium Following Transseptal Puncture During Balloon Mitral Valvotomy: Management Strategies and Outcomes.

BACKGROUND: Hemopericardium is a major complication of balloon mitral valvotomy (BMV). Only a few studies are available to address this issue following transseptal access. In addition, the management strategy regarding completion of BMV is uncertain. OBJECTIVE: We sought to determine the incidence of hemopericardium complicating transseptal puncture during BMV. In addition, the management strategy adopted and outcomes are highlighted. METHODS: This prospective study included 29 consecutive patients who developed hemopericardium following transseptal access during BMV. RESULTS: Out of 1424 patients who underwent BMV, hemopericardium developed in 29 patients following transseptal access (2.0%). The mean age of the study cohort was 36.9 ± 13.7 years and 82.8% were women. A second transseptal puncture was done and BMV was completed in 26 patients (89.6%). An acceptable hemodynamic result was obtained in 22 patients (84.6%). Six patients (20.7%) underwent emergency surgery for hemopericardium. The sites of perforation were inferior vena cava-right atrial junction in 4 cases, left atrial posterior wall in 1 case, and left atrial appendage in 1 case. In addition to repair of the perforation, a total of 2 patients underwent mitral valve replacement and 1 patient underwent open mitral commissurotomy. The in-hospital mortality rate was 6.9%. CONCLUSIONS: The incidence of hemopericardium complicating transseptal access during BMV was 2.0%, and was associated with a mortality rate of 6.9%. BMV can be safely performed in the same sitting with a second transseptal puncture, in patients with a favorable valve morphology. Surgical intervention can be reserved for a subset of patients with persistent pericardial collection.

The challenge produced by familial homozygous hypercholesterolemia when treating premature coronary arterial disease in the young.

BACKGROUND: Familial hypercholesterolemia is a monogenic, autosomal dominant disorder caused by mutations in the LDL receptor gene. Familial homozygous hypercholesterolemia results when both the alleles have the defective mutation. It is characterized by cutaneous and tendinous xanthomas, premature corneal arcing, and is associated with an increased risk of coronary arterial disease. It is also seriously underdiagnosed, resulting in delayed treatment. METHODS: We present a cross-sectional study of 5 patients with familial homozygous hypercholesterolemia who presented to the department of cardiology at Sri Jayadeva Institute of Cardiology, Bangalore, India. All of them underwent coronary angiography as part of the investigation of their angina. RESULTS: All 5 patients were in 2nd or 3rd decade of life, 4 being male, and 4 presenting with effort angina, the other having unstable angina. All had multiple tendinous xanthomas. The majority had significant high grade coronary arterial stenosis. Coronary arterial bypass grafting was necessary in 3, with the others undergoing percutaneous insertion of coronary arterial stents. CONCLUSION: Familial homozygous hypercholesterolemia is a potentially dangerous risk factor that can result in premature coronary arterial disease in children and young adults. This can result in severe morbidity and premature death in young individuals. We also emphasise the need to screen first-degree relatives and extended family members, this playing an important role in early detection and treatment. Despite recent advances in treatment using lipid lowering agents, the disease remains a significant challenge.