Potential application of 68Ga-FAPI PET/CT for diagnosing cardiac sarcoidosis.

Detecting cardiac sarcoidosis; a potentially life-threatening condition is challenging and requires a multimodality imaging approach using echocardiography, PET/CT and CMR. Although 18F-FDG is the recommended PET tracer for evaluating cardiac sarcoidosis, it is limited by physiological cardiac FDG uptake and requires stringent patient preparation/ dietary modifications before imaging. We hereby present a case of cardiac sarcoidosis demonstrating myocardial FAPI uptake on cardiac PET, highlighting the potential role of 68Ga-FAPI PET in the evaluation of cardiac sarcoidosis.

Prominent aortic radiotracer activity on equilibrium radionuclide ventriculography (ERNV) due to anterior transposition of aorta: A clue to diagnosing levo-transposition of great arteries (L-TGA) ?

Levo-transposition of great arteries (L-TGA) is a rare acyanotic congenital heart anomaly characterized by transposition of morphological left and right ventricles along with their corresponding atrio-ventricular valves in addition to transposition of primary arteries. Many cases of L-TGA are asymptomatic and are diagnosed accidently in adulthood during workup of other conditions. We hereby report a patient with incidentally diagnosed L-TGA who was subjected to Equilibrium Radionuclide Ventriculography (ERNV) for assessment of ventricular function. Planar ERNV images in best septal view showed prominent tracer activity in the anteriorly transposed aorta which can be a helpful clue to raise the suspicion of L-TGA in an asymptomatic adult undergoing ERNV.

Scrub Typhus - The Most Common Cause of Febrile Jaundice in a Tertiary Care Hospital of Himalayan State.

BACKGROUND: Most common cause of jaundice in south east Asia is of infective etiology. Combination of fever with jaundice can cause diagnostic problem as this duo is present in many infective diseases. Timely diagnosis by simple laboratory investigations can save a lot of time and prevent morbidity and mortality. Our main aim was to determine the most common etiology of infectious jaundice in a tertiary care hospital of Himalayan state and to study their clinical profile. METHODOLOGY: This was a prospective observational study done in one year. All the patients more than 18 years of age presenting with jaundice with bilirubin >1.5mg/dl were taken. The clinical profile was observed and investigations for etiology were done. RESULTS: Total number of patients studied were 170. Maximum number of patients were 50 (39.4%) in age group less than 30 years and females outnumbered males with 1.8:1 ratio (64.7% v/s 35.3%). Fever was the most common presenting complaint in 127 (74.7%) patients and most common etiology was scrub typhus with 103 patients (60.6%) followed by hepatitis E in 36 patients (21.2%) and leptospirosis in 9 patients (5.3%). CONCLUSIONS: Scrub typhus is the commonest cause of febrile jaundice in Himachal Pradesh. The general physicians should be sensitized for the early diagnosis to reduce mortality.

Cushing's Disease presenting as Suicidal Depression.

A case of Cushing disease, who presented with suicidal depression as the main complaint is reported. Prompt diagnosis and early management of the underlying cause of Cushing's disease, not only relieved features of hypercortisolaemia but also remitted depression fully.

Role of fibrinogen, albumin and fibrinogen to albumin ratio in determining angiographic severity and outcomes in acute coronary syndrome.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic unmasked the huge deficit in healthcare resources worldwide. It highlighted the need for efficient risk stratification in management of cardiovascular emergencies. AIM: To study the applicability of the old, available and affordable nonconventional biomarkers: albumin and fibrinogen in their ability to predict angiographic severity and clinical outcomes in patients with acute coronary syndrome (ACS). METHODS: In this prospective, observational study, 166 consecutive patients with ACS were enrolled. Fibrinogen, albumin and their ratio were determined from serum. Patients with underlying chronic liver disease, active malignancy, autoimmune disease, active COVID-19 infection and undergoing thrombolysis were excluded. RESULTS: Mean age of the population was 60.5 ± 1.5 years, 74.1% being males. ST elevation myocardial infarction (STEMI) was most common presentation of ACS seen in 57% patients. Fibrinogen albumin ratio (FAR) ≥ 19.2, had a sensitivity of 76.9% and specificity of 78.9 % [area under the receiver operating characteristic curves (AUROC) = 0.8, P = 0.001] to predict ≤ thrombolysis in myocardial infarction (TIMI) 1 flow in culprit artery in STEMI patients. Even in non-STEMI patients, FAR ≥ 18.85 predicted the same with 80% sensitivity and 63% specificity (AUROC = 0.715, P = 0.006). CONCLUSION: Novel biomarkers, with their high cost, lack of availability and long turn over time are impractical for real-world use. Identifying ≤ TIMI 1 flow in the culprit artery has significant impact of management and outcome. Our study has shown that readily available biomarkers like fibrinogen and albumin can help identify these high-risk patients with good accuracy. This allows risk-stratification and individualization of treatment in ACS.

[Efficacité du tirofiban intracoronaire avant pose d'un stent suivi d'une perfusion dans une charge de thrombus importante prouvée par angiographie : une étude randomisée]. / Efficacy of pre stenting intracoronary tirofiban followed by infusion in angiographically proven large thrombus burden : A randomized controlled study.

BACKGROUND: The presence of angiographic thrombus is associated with poor outcomes in contemporary cardiology practice. Percutaneous coronary intervention (PCI) in such lesions is associated with slow flow and no-reflow phenomenon which translate into poor clinical outcomes. METHODS: This was a single-centre, prospective, open-label, randomized controlled study with 50 patients each in intervention group and control group. Patients with angiographically proven large thrombus burden were recruited. In the intervention group, patients were given loading dose of intracoronary tirofiban (25 mcg/kg infused over 5 minutes) followed by prolonged infusion of tirofiban (0.15 mcg/kg/min for 12-18 hours) followed by PCI after 48-72 hours interval. In control group patients were taken up directly for PCI during the index procedure. Outcomes were assessed angiographically and in terms of clinical endpoints. RESULTS: The primary composite-endpoint of recurrent angina, myocardial infarction, cardiovascular death, target lesion revascularization and unscheduled CABG was significantly lower in the intervention arm compared to control arm (4% vs 16%, p = 0.04). Amongst the secondary endpoints, a statistically significant 30-day increase in ejection fraction from baseline was observed in the intervention group compared to the control group (1.6 ± 1.3 vs 0.2 ± 0.4, p = 0.0001). Overall mortality was similar in the two groups (4% vs 8%, p = 0.39). The primary safety endpoint of major bleeding was also similar in the 2 groups (2% vs 0%, p = 0.31). CONCLUSIONS: Tirofiban use prior to PCI in high thrombus burden was associated with improved clinical and angiographic endpoints with similar adverse events compared to controls.

Novel markers of COVID-19 mortality-A comparative study with patients of acute coronary syndrome.

Background: COVID-19 can cause severe pneumonia that can progress to multiple organ failure. It is believed that dysregulation of inflammation and cytokine storm, contributes to severe COVID-19. As inflammatory mediators play an important role in the pathogenesis of the severe disease, inflammatory markers like fever, leucocytosis, and C-reactive protein are known to predict severe disease. Various other biomarkers have been known to have prognostic value in patients with COVID-19 infection. Inflammation, both local and systemic plays an important role in the pathogenesis of acute coronary syndrome (ACS). Thus in this study, we aimed to compare and describe the various biomarkers, and mortality between patients admitted with COVID-19 infection and ACS patients without COVID-19 infection. Methods: In a retrospective observational case-control study, a total of 108 patients admitted to our hospital during the month of May 2021 with COVID-19 were enrolled. Patients of the acute coronary syndrome (tested negative for COVID-19 infection) admitted during the same month were enrolled (including both the intensive care unit and ward) as controls. Results: The median age of patients with COVID was significantly lower than that of patients with acute coronary syndrome [49 years (IQR, 36-62 years) and 60 years (IQR, 52-66 years)]. Left ventricular ejection fraction was significantly higher among patients with COVID infection (58.5 ± 6.3% versus 36.9 ± 9.3%). The total leukocyte count was significantly higher among patients with COVID-19 compared to those with acute coronary syndrome [13200 per microliter (8625-17500) vs 9800 per microliter (8150-12150), P < 0.001]. The blood urea level was significantly higher among patients with COVID infection [52.5 (IQR, 34.7-81.5) versus 20 (IQR, 16-31)]. Levels of C-reactive protein were significantly higher among patients with COVID [39 (IQR, 7.7-100) versus 2 (1.4-3.5)]. The mortality of patients hospitalized with COVID was 4 times higher than those with acute coronary syndrome [25.9% (28) versus 6.1% (6)]. Survivors of COVID-19 had higher hemoglobin levels than those who did not [12.5 g/dLvs 11.5 g/dL, P = 0.03]. Conclusions: Elevated total leukocyte counts reflect underlying secondary bacterial infection among patients with COVID-19 and help initiate appropriate antibiotics. Depletion of intravascular volume reflected by an increased urea/creatinine ratio increases the risk of mortality and warrants aggressive measures of rehydration and albumin infusion.

COVID-19 presenting as acute pericarditis.

COVID 19, caused by SARS-CoV-2, is a highly infectious disease, mainly affects the respiratory system. In this article, we have presented a case of COVID-19, who presented solely with pericarditis without myocarditis, without any respiratory symptoms. The diagnosis was made based on clinical, electrocardiographic, radiological and biological findings. He was treated successfully with aspirin and colchicine. Our case highlights an atypical presentation of COVID-19, which should be kept in mind in the present pandemic and to diagnose and isolate early to limit the spread of infection.

A rare cause of myocardial infarction and ventricular tachycardia in a young male with HIV/AIDS - spontaneous coronary artery dissection: A case report.

HIV/AIDS is a multisystemic disorder and occurrence of cardiovascular disease is higher compared to non-HIV individuals. Spontaneous coronary artery dissection (SCAD) remains a rare and underdiagnosed cause of acute coronary syndrome (ACS), even in modern day era. SCAD is predominantly seen in young to middle aged females and present as a non-atherosclerotic cause of myocardial ischaemia, infarction or sudden cardiac death (SCD); with or without ventricular arrythmias. Ventricular tachycardia (VT) can sometimes be the initial presentation of SCAD. HIV associated arteriopathy can predispose to occurrence of SCAD. We report a case of a 38-year-old male suffering from HIV/AIDS, with no conventional risk factors presenting as VT. Coronary angiogram showed SCAD in right coronary artery without any flow limitation.

Vieussens' Arterial Ring.

The Vieussens' artery is an anastomotic communication between the conus branch of the right coronary artery and the left anterior descending (LAD). Vieussens' ring is so named because it circles around the great vessels in the form of a partial ring. The course of the artery can be best understood in 2 orthogonal views. In the left oblique view, the artery appears coursing upward to the left. In the right oblique view, it courses anteriorly across the right ventricular outflow tract. The clinical significance of Vieussens' arterial ring lies in it being a major source of collateral blood flow to an occluded LAD. The presence of this large collateral may explain preserved ventricular function in our patient, despite severe triple-vessel disease.

Intraoperative evaluation of renal resistive index with transesophageal echocardiography for the assessment of acute renal injury in patients undergoing coronary artery bypass grafting surgery: A prospective observational study.

Background: Acute kidney injury (AKI) is a common complication after on pump coronary artery bypass grafting (CABG) surgery and is associated with a poor prognosis. Postoperative AKI is associated with morbidity, mortality, and increase in length of intensive care unit (ICU) stay and increases the financial burden. Identifying individuals at risk for developing AKI in postoperative period is extremely important to optimize outcomes. The aim of the study is to evaluate the association between the intraoperative transesophageal echocardiography (TEE) derived renal resistive index (RRI) and AKI in patients undergoing on-pump CABG surgery. Methods: This prospective observational study was conducted in patients more than 18 years of age undergoing elective on pump CABG surgery between July 1, 2018, and December 31, 2019, at a tertiary care center. All preoperative, intraoperative, and postoperative parameters were recorded. TEE measurement was performed in hemodynamically stable patients before the sternum was opened. Postoperative AKI was diagnosed based on the serial measurement of serum creatinine and the monitoring of urine output. Results: A total of 115 patients were included in our study. Thirty-nine (33.91%) patients had RRI >0.7 while remaining seventy-six (66.08%) patients had RRI <0.7. AKI was diagnosed in 26% (30/115) patients. AKI rates were significantly higher in patients with RRI values exceeding 0.7 with 46.15% (18/39) compared to 15.75% (12/76) in RRI values of less than 0.7. Multivariate analysis revealed that AKI was associated with an increase in RRI and diabetes mellitus. The RRI assessed by receiver operating characteristic (ROC) curve and the area under the curve (AUC) to distinguish between non-AKI and AKI groups were 0.705 (95% CI: 0.588-0.826) for preoperative RRI. The most accurate cut-off value to distinguish non-AKI and AKI groups was a preoperative RRI of 0.68 with a sensitivity of 70% and specificity of 67%. Conclusions: An increased intraoperative RRI is an independent predictor of AKI in the postoperative period in patients undergoing CABG surgery. The cutoff value of TEE-derived RRI in the intraoperative period should be >0.68 to predict AKI in the postoperative period.

Predictors of dementia amongst newly diagnosed non-valvular atrial fibrillation patients.

Atrial fibrillation (AF) confers a 2-to-3-fold increased risk of developing cognitive dysfunction and dementia, independent of age and past stroke. The purpose of study was to identify risk factors for developing dementia amongst AF patients in India. This was a single-centre, prospective, observational study wherein recently diagnosed, treatment naïve, persistent non-valvular AF patients were enrolled. All patients were screened for dementia using the Mini-Mental state exam. Amongst a total of 108 patients enrolled, 40 (37%) had dementia. The most common cognitive deficits were in attention and calculation followed by memory deficits. Factors independently contributing to dementia were advanced age, female sex, presence of diabetes, elevated pulmonary artery pressures and a lower serum albumin.

Evaluation of Asymptomatic Carotid Artery Stenosis Prior to Coronary Artery Bypass Grafting - A Prospective Observational Study in North Indian Population.

Background: Carotid artery stenosis (CAS) is an established risk factor for peri-operative neurological complications in patients following coronary artery bypass grafting (CABG). However, routine pre-surgical screening for CAS is still a matter of debate. This study was conducted to study the prevalence of asymptomatic carotid artery disease in patients undergoing CABG and to determine the predictors of significant carotid stenosis in them. Methods: In this prospective observational study, 112 patients, who were planned for CABG, were enrolled, and their demographic details, risk factor profile, and coronary angiogram parameters were analyzed. Results: Carotid stenosis was observed in 75.0% of the study population with 11.6% having unilateral and 63.4% having bilateral carotid stenosis. A total of 56.2% of the patients had mild, 14.3% had moderate, and 4.5% had severe carotid stenosis. The presence of significant carotid stenosis showed a correlation with chronic stable angina (P = 0.009), significant left main (LM) disease (P = 0.001), chronic total occlusion (P = 0.043), and coronary vessel calcification (P = 0.004). Multivariate analysis of all the predictor variables in a regression model showed that significant LM disease (Odds ratio (OR):6.5, P = 0.002) and coronary artery calcification (OR: 4.3, P = 0.024) were the only independent predictors of significant CAS in the study population. Conclusion: The presence of significant carotid vessel stenosis in patients undergoing CABG in the Indian population has a stronger association with the chronicity of the coronary artery disease rather than the coronary atheroma load (as determined by the modified Gensini score). The presence of significant LM disease and coronary artery calcification may be useful in detecting high-risk patients for significant CAS during the pre-surgical workup.

Accuracy of Global Longitudinal and Territorial Longitudinal Strain in Determining Myocardial Viability in Comparison to Single-Photon Emission Computed Tomography in Out of Window Period Anterior Wall Myocardial Infarction Patients.

BACKGROUND: To determine the accuracy of global longitudinal strain and territorial longitudinal strain in determining myocardial viability in comparison to single-photon emission computed tomography in out of window period anterior wall myocardial infarction patients. METHODS: This was a single-center, prospective study carried out in a tertiary care center in northern India. All patients presenting with anterior wall myocardial infarction-out of window period without ongoing chest pain and akinetic left-anterior descending territory on echocardiography were recruited. All patients underwent strain echocardiography and the determination of both global longitudinal strain and territorial longitudinal strain within 12-48 hours of anterior wall myocardial infarction. In addition, all underwent single-photon emission computed tomography to determine the viability status of the anterior myocardium. RESULTS: Fifty-one patients of anterior wall myocardial infarction-out of window period were enrolled and underwent strain imaging with speckle tracking and single-photon emission computed tomography for viability determination. Gobal longitudinal strain and territorial longitudinal strain were significantly reduced in patients with nonviable myocardium (P < .001). On receiver-operating curves, a gobal longitudinal strain of <10.45% had a sensitivity of 77.8% and specificity of 93.9% (AUC=0.889) in predicting nonviability on single-photon emission computed tomography. Similarly, a territorial longitudinal strain of <7.60% had a sensitivity of 77.8% and specificity of 84.8% (AUC=0.825) in predicting nonviability. CONCLUSIONS: Treatment strategies in patients presenting with anterior wall myocardial infarction, outside the window period is largely guided by the hemodynamic status and influenced by the viability status of the myocardium. Strain echocardiography using speckle tracking provides gobal longitudinal strain and territorial longitudinal strain, both of which have good sensitivity and specificity in predicting viability and can be performed safely and quickly in high-risk group of patients.

Left main revascularization with optical coherence tomography in a young male with newly diagnosed homozygous familial hypercholesterolemia.

Familial hypercholesterolemia is the most common primary lipid disorder responsible for coronary artery disease. A 22-year-old male presented with history of accelerating angina and extensive xanthomatous lesions all over the body. Coronary angiography showed significant left main and left anterior descending artery disease. Optical coherence tomography (OCT) imaging revealed areas of lipid rich plaque with thin capped fibrous atheroma, and inflammatory cell infiltration. Area of maximum stenosis showed fibrous plaque with dense lipid pool. OCT in this patient clarified plaque characteristics and achieved optimal procedural results. There were only few case reports which described OCT findings in patients with familial hypercholesterolemia. .