Three-dimensional electroanatomical mapping guided right bundle branch pacing in congenitally corrected transposition of great arteries.

AIMS: The ideal pacing strategy has been the Achilles' heel for patients with congenitally corrected transposition of great arteries (ccTGA) with bradycardia. Various pacing modalities were documented in the literature. This article describes a novel pacing strategy and its feasibility in ccTGA with an intact ventricular septum. METHODS AND RESULTS: We prospectively recruited three patients with ccTGA who presented with symptomatic complete heart block to our institute and were evaluated. All patients were planned for conduction system pacing. Those who had more than moderate or severe systemic atrioventricular regurgitation and systemic ventricular dysfunction were planned for conduction system pacing with an additional lead in the coronary sinus (CS) tributary, i.e. bundle branch pacing optimized cardiac resynchronization therapy with the intention to achieve incremental benefit. Since right bundle pacing is not described previously and in view of anatomical complexity in location, three-dimensional (3D) anatomical mapping was done with the EnSite system and later right bundle capture is identified conventionally as that of a left bundle in a normal heart. All three patients have stable lead positions and adequate thresholds at short-term follow-up. CONCLUSION: In this report, we demonstrated the feasibility of permanent physiological pacing of the systemic ventricle by capturing the right bundle with 3D anatomical mapping guidance, which results in physiological activation of the systemic ventricle.

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.

Response to spontaneous and induced His refractory ventricular premature beats during long RP tachycardia: What is the mechanism?

This electrophysiology tracing demonstrates a graded postexcitation response of the retrograde limb of an orthodromic reentrant tachycardia circuit with varying His refractory VPB coupling intervals, which reiterates the decrementally conducting retrograde limb of the tachycardia circuit.

A case report of left circumflex stent infection and mycotic aneurysm: a rare but life-threatening complication of percutaneous coronary intervention.

BACKGROUND: Coronary stent infections are an uncommon but deadly complication of percutaneous coronary intervention. Mortality remains as high as 40-60% even with adequate treatment. We report such an interesting case of left circumflex stent (LCX) infection and mycotic aneurysm that was successfully managed with antibiotics and surgery. CASE PRESENTATION: A middle-aged man who underwent percutaneous coronary intervention (PCI) to the left circumflex artery four weeks prior was referred as a case of pyrexia of unknown origin, not responding to antibiotics, and colchicine started for suspected Dressler syndrome. Although the inflammatory markers were elevated, the results of the blood culture did not show any growth. Echocardiography showed a doubtful echogenic structure in the left atrioventricular groove and mild pericardial effusion, and a stent infection was suspected. PET scan showed focal metabolic activity in the region of the LCX stent, with metabolically active supraclavicular and paratracheal lymph nodes, and a coronary angiogram revealed an aneurysm arising distal to the stented LCX. A diagnosis of stent infection and associated mycotic aneurysm was made, and the patient underwent surgery which included aneurysm repair, stent retrieval, and coronary artery bypass graft (CABG) to the major and terminal OM. The postoperative course was uneventful, and the patient was discharged without complications. CONCLUSIONS: It is important to investigate the possibility of coronary stent infection in individuals experiencing prolonged fever following PCI. PET scans and coronary angiograms can aid in diagnosis when echocardiograms are inconclusive. Adequate antibiotic therapy and timely surgery are crucial for successfully managing coronary stent infections.

Long term safety and efficacy of the Yukon Choice Flex sirolimus-eluting coronary stent-a real-world data from India.

In-stent restenosis and stent thrombosis are the major concerns while choosing a coronary stent. This single-centre, retrospective study evaluated the one and three-year clinical outcomes following implantation of Yukon Choice Flex (YCF) sirolimus-eluting stent. A total of 168 consecutive patients with 217 lesions underwent stenting with YCF stent. The presentation was with acute coronary syndrome in 158 (94%) patients. At 3 years, 9 (5.3%) patients died due to cardiac cause. Myocardial infarction, and definite stent thrombosis occurred in 10 (6%) and 4 (2.4%) patients respectively. Redo stenting and coronary artery bypass surgery was performed in 3 (1.8%) and 1 (0.6%) patient respectively. The use of YCF sirolimus eluting stent was associated with a favourable safety and efficacy profile at one and three-years of follow-up in a high-risk population.

Kounis syndrome secondary to nimesulide ingestion: a case report.

BACKGROUND: Kounis syndrome, also known as "allergic myocardial infarction," is a rare co-occurrence of acute coronary syndrome (ACS) in the setting of hypersensitivity reaction to any agent. Non-steroidal anti-inflammatory drugs (NSAIDs) like are often implicated in causing allergic reactions. Here, we present a case of anterior wall myocardial infarction (AWMI) occurred following angioedema secondary to intake of Nimesulide, not described earlier in literature. CASE PRESENTATION: A 45-year-old female developed generalized pruritic, erythematous maculopapular rash, facial puffiness, oral ulcers and hoarseness of voice within few hours following consumption of Nimesulide for fever and body-ache. Due to development of hypotension, electrocardiogram (ECG) was done, which revealed ST elevation in V2-V6, with marked elevation of troponin (TnI) and creatine kinase (CK-MB). He had no chest pain or shortness of breath. Echocardiography showed regional wall motion (RWMA) abnormality in left anterior descending artery (LAD) territory with an ejection fraction of 25%. Coronary angiography showed a complete thrombotic cutoff of LAD, for which Tirofiban infusion was started to decrease thrombus burden. Repeat angiography on next day showed 80% lesion in proximal LAD for which she underwent revascularization with a drug-eluting stent. The patient later showed improvement in cardiac function at 8 months of follow-up. CONCLUSIONS: The occurrence of ACS requiring percutaneous coronary intervention (PCI) in the setting of allergic reactions is rarely reported in the literature. One should be aware of the rare possibility of Kounis syndrome in the setting of hypersensitivity reaction when accompanying features of symptoms suggestive of coronary artery disease co-exists. When indicated, ECG monitoring and cardiac biomarkers in patients with allergic responses help to identify this rare and treatable condition.

Cardiovocal Syndrome Secondary to Thoracic Aortic Aneurysm: An Old Sign Revisited.

A 56-year-old male, chronic smoker, presented with persistent dry cough, hoarseness of voice and difficulty in swallowing. Indirect laryngoscopy revealed left vocal cord paralysis. Further evaluation revealed eccentric saccular aneurysms arising from the aortic arch and descending thoracic aorta, compressing the trachea, esophagus, left atrium and left recurrent laryngeal nerve. The patient was diagnosed with Ortner's syndrome which is an uncommon presentation of aortic aneurysm. He awaits an endovascular aorta aneurysm repair.

Is there a transcatheter solution for a sick neonate with hypoplastic right heart syndrome?: Pulmonary valve perforation in a neonate with hypoplastic right ventricle with pulmonary atresia, restrictive VSD-a case report.

BACKGROUND: Hypoplastic right heart syndrome with pulmonary atresia is a rare cyanotic heart disease with poor prognosis requiring urgent intervention to establish the pulmonary blood flow. Pulmonary blood flow is achieved by BT shunt or percutaneous techniques like PDA stenting or pulmonary valve perforation. Various series have shown that early surgical intervention causes high mortality in these patients. Pulmonary valve perforation is a suitable, physiological alternative to surgical techniques in selected patients. CASE PRESENTATION: We report a case of hypoplastic right heart syndrome with pulmonary atresia and restrictive VSD presenting with cyanosis from birth and underwent pulmonary valve perforation successfully. CONCLUSION: Duct-dependent pulmonary circulation is a pediatric emergency, palliative procedure for establishing adequate pulmonary blood flow is essential early in the life. In the management of duct-dependent pulmonary circulation, RVOT perforation is an effective and safe option in suitable high-risk subgroups. The induced pulmonary regurgitation along with established physiological antegrade flow would be beneficial in the remodeling of tripartite/hypertrophied small RV.