Percutaneous Coronary Intervention in Anomalously arising Coronary Arteries.

OBJECTIVE: Anomalous origin of coronary arteries (ACA) is rare. The objective of this communication is to describe the difficulties in angiographic recognition and challenges in percutaneous management. METHODS: The material for this retrospective study was provided by contributing interventional cardiologists practicing in tertiary care centers. RESULTS: From 2010 to 2019, 27 patients underwent percutaneous coronary intervention (PCI) for ACA. Four groups were encountered including anomalous origin from opposite sinus [left anomalous coronary artery from opposite sinus (L-ACAOS, n = 5), right anomalous coronary artery from opposite sinus (R-ACAOS n = 4)], origin of left circumflex from right sinus (n = 12), and origin of right coronary artery from posterior sinus (n = 6). The selection of a guiding catheter is the crucial step and a wide range of accessories was required to achieve an excellent outcome. Radial access may have an advantage in R-ACAOS, although the majority had a successful procedure from the femoral approach. CONCLUSION: Percutaneous management of patients with anomalous coronary arteries is challenging but can be accomplished with an excellent immediate outcome.

Cardiac Amyloidosis: A Case Series from India.

OBJECTIVE: Cardiac amyloidosis (CA) is not well recognized in Indian literature. The aim of this communication is to highlight the difficulties in diagnosis. METHODS: A retrospective analysis of data of six patients of CA diagnosed during 2008 to 2015 was done. Clinical, investigative, management and follow-up data is analyzed. RESULTS: The mean age was 51 years with male preponderance. Heart failure was the commonest manifestation. Atrial arrhythmias were seen in 33%. Syncope, peripheral neuropathy and macroglossia were striking features. A speckled inter-ventricular septum (66%) or thickened inter-atrial septum (16%) on echocardiography strongly favoured CA. Other echocardiography features include thickened ventricular wall, enlarged atria and pericardial effusion (PE). Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) was characteristic of CA. Plasma cell dyscrasia confirmed light chain amyloidosis. Abdominal fat pad and rectal biopsy confirmed the diagnosis. Chemotherapy for plasma cell dyscrasia was administered in 50% of patients. CONCLUSION: Echocardiography and CMR imaging enable the diagnosis of CA in background of strong clinical suspicion. Abdominal fat pad biopsy is a simple and reliable method for confirming the diagnosis. IMPLICATIONS AND PRACTICE: The awareness of this entity can enable an early diagnosis and improve the survival with timely novel chemotherapy.

Impact of COVID-19 on heart failure hospitalization and outcome in India - A cardiological society of India study (CSI-HF in COVID 19 times study - "The COVID C-HF study").

OBJECTIVES: The presentation and outcomes of acute decompensated heart failure (ADHF) during COVID times (June 2020 to Dec 2020) were compared with the historical control during the same period in 2019. METHODS: Data of 4806 consecutive patients of acute HF admitted in 22 centres in the country were collected during this period. The admission patterns, aetiology, outcomes, prescription of guideline-directed medical therapy (GDMT) and interventions were analysed in this retrospective study. RESULTS: Admissions for acute heart failure during the pandemic period in 2020 decreased by 20% compared to the corresponding six-month period in 2019, with numbers dropping from 2675 to 2131. However, no difference in the epidemiology was seen. The mean age of presentation in 2019 was 61.75 (±13.7) years, and 59.97 (±14.6) years in 2020. There was a significant decrease in the mean age of presentation (p = 0.001). Also. the proportion of male patients decreased significantly from 68.67% to 65.84% (p = 0.037). The in-hospital mortality for acute heart failure did not differ significantly between 2019 and 2020 (4.19% and 4.,97%) respectively (p = 0.19). The proportion of patients with HFrEF did not change in 2020 compared to 2019 (76.82% vs 75.74%, respectively). The average duration of hospital stay was 6.5 days. CONCLUSION: The outcomes of ADHF patients admitted during the Covid pandemic did not differ significantly. The length of hospital stay remained the same. The study highlighted the sub-optimal use of GDMT, though slightly improving over the last few years.

Percutaneous transluminal renal stenting for transplant renal artery stenosis.

OBJECTIVES: Renal transplantation is a well-accepted therapeutic option for patients with end stage renal disease. Renal artery stenosis occurring in a transplanted kidney is a potentially serious condition and adversely affects graft survival and prognosis. The objective of this study is to document the immediate and intermediate term clinical results of renal stenting in this rare subset of renal artery stenosis. BACKGROUND: There is limited data about the effectiveness of renal stenting in transplant renal artery stenosis. METHODS: Eight patients, aged between 22 and 51 (42.5 ± 9.25) years, were referred to our tertiary care interventional cardiology services for renal intervention. The diagnosis of transplant renal artery stenosis was based on clinical presentation (uncontrolled hypertension (n = 4, 50%), worsening renal function (n = 3, 37.5%) or flash pulmonary oedema (n = 1, 12.5%)] and Doppler ultrasound. RESULTS: All patients had live donor renal transplant using end to end anastomosis 2 to 11 (6.25 ± 3.24) months prior to intervention. Angiography revealed discrete stenosis at the anastomotic site. Intrarenal stenting performed from femoral access using 6 F accessories produced excellent angiographic results. There were no access site or procedure related complications. The intervention produced excellent immediate and intermediate term clinical results. In three patients, there was stabilization of renal function during 62 ± 9.16 months of follow-up with decrease in serum creatinine by 38.86 ± 6.62 %; P = 0.0476. In four patients with refractory hypertension, excellent blood pressure control was achieved with a reduction in mean blood pressure by 25.95 ± 5.48 mm Hg (from 122.4 ± 5.7 to 96.45 ± 2.45 mm Hg; P = 0.0002) during 65.25 ± 23.79 months follow-up. There was decrease in antihypertensive drug requirement from 3.75 ± 0.5 to 1.75 ± 0.5. During follow-up, Doppler ultrasound documented a high peak systolic velocity in one asymptomatic patient with well controlled blood pressure and preserved renal function. Sustained benefits of percutaneous revascularization were supported by normal Doppler parameters in the remaining patients. CONCLUSIONS: Percutaneous renal stenting provides excellent angiographic and clinical results sustained at intermediate term follow-up in patients with symptomatic transplant renal artery stenosis.

Pulmonary valve infective endocarditis: A case series.

Background and Objectives: Infective endocarditis (IE) involving the native pulmonary valve (PV) is extremely rare, with no data in Indian literature. The objective of this communication is to describe the clinical and diagnostic characteristics, underlying risk factors, microbiological features, and management of PVIE. Methods: This is a retrospective analysis of 8 cases of PVIE managed in a tertiary care center from 1992 to 2020. Results: PVIE was observed in 8 patients with underlying congenital cardiac malformation (Group A, 6 Patients) and in patients with central venous catheter (Group B, 2 patients). All the patients had prolonged febrile illness accompanied by right heart failure 4 (50%), septic pulmonary emboli 2 (25%), and pulmonary regurgitation 3 (37.5%). Trans-thoracic echocardiography demonstrated the vegetations, whereas computed tomography of chest diagnosed pulmonary emboli in 2 (25%), and pulmonary artery aneurysm in 1 (12.5%) patient. The early mortality was extremely high (5, 62.5%). Delayed diagnosis, fulminant septicemia, and multi-organ failure resulted in unfavorable outcomes. Conclusions: IE of the native PV is a rare and potentially lethal illness. Diagnosis should be considered in any febrile patient with an underlying congenital defect, central venous line, bacteremia, and comorbidities. Multi-modality imaging should be utilized to enhance the diagnostic yield and detect complications promptly.

Renal denervation therapy for hypertension: truths and half-truths: Renal denervation therapy for hypertension.

Systemic hypertension is a major contributing factor for excessive morbidity and mortality globally. Experimental studies and early clinical trials showed excellent therapeutic responses to renal denervation (RDN) in patients with hypertension. However meta-analyses and objective assessments have failed to show that RDN therapy has any significant effect on blood pressure.  The aim of this review is to introduce the different methods that can be used in RDN, along with the benefits and disadvantages of these methods. Radiofrequency (RF) ablation (of renal nerves) is the most com-mon method of RDN, and we discuss the clinical evaluation of this method in the SYMPLICITY RDN trials. Finally, the development of second-generation RF devices and more comprehensive RDN procedures lead us to consider the current status and future path for RDN.

Tricuspid valve endocarditis in non-drug abusers: A case series from India.

OBJECTIVE: The etiology of tricuspid valve endocarditis (TVE) seems to be different in our country as intravenous (IV) drug abuse is not known to be a major health hazard. The objective of this communication is to study the risk factors, clinical profile, follow-up data of TVE patients and focus on the difficulties in diagnosis and variations encountered. METHODS: A retrospective analysis of data of 10 patients of TVE managed in a tertiary care center during January 1992 to June 2015 was done. RESULTS: TVE was encountered in a diverse subset of patients with cardiac implantable electronic device (CIED) (group I; 3 patients), immunocompromised state with indwelling central venous catheter (CVC) (group II; 2 patients), congenital heart disease (CHD) (group III; 3 patients) and in apparently healthy individuals (group IV; 2 patients). Blood cultures were negative in half the patients. In group I early surgical extraction of leads, device and vegetation provided excellent results. Prognosis was poor with 100% mortality in immunocompromised patients. Patients in group III did well on medical management. The overall mortality was high (30% in hospital and additional 20% within one year). CONCLUSIONS: TVE is rare and can occur in different clinical scenarios. Indiscriminate use of antibiotics modifies the clinical picture causing delay in diagnosis and referral to speciality care. Echocardiography remains the main modality and should be used serially to facilitate early diagnosis. The prognosis is guarded. Early surgery is recommended in pacemaker lead, fungal endocarditis, persistent sepsis or hemodynamic instability for favorable prognosis.

Spontaneous coronary artery dissection: Case series and review of literature.

AIM: Spontaneous coronary artery dissection (SCAD) is a less recognized cause of ST elevation myocardial infarction (STEMI) in clinical practice. The aim of this communication is to describe a case series in South Asian population and highlight on the long-term clinical outcomes on conservative management. METHODS: A retrospective analysis of data of five patients (6 instances) of SCAD managed in a tertiary care center during January 1994 to June 2015 was done. Clinical, angiographic, therapeutic, and follow-up data till end of June 2015 are analyzed. RESULTS: All patients were young (mean - 33 years) and predominantly male. Etiology of SCAD was diverse and included peripartum state, vigorous activity and atherosclerosis. Left anterior descending (LAD) coronary artery was predominantly involved and the majority had angiographic type 1 SCAD. Medical treatment provides excellent long-term benefits. Coronary stenting provided symptomatic benefit in a patient with favorable anatomy. CONCLUSIONS: Clinical recognition of SCAD is difficult. It should be suspected in peripartum state, young females and in presence of other precipitating factors. Coronary angiography is essential for establishing the diagnosis. Medical treatment provides favorable long-term survival. IMPLICATIONS AND PRACTICE: The awareness of SCAD is important for all clinicians involved in STEMI care. A prompt suspicion can avoid administration of thrombolytic therapy. Early coronary angiography will provide an accurate diagnosis and help in deciding appropriate therapy. Percutaneous intervention can be challenging.

Aorto - Left atrial fistula after mitral valve replacement.

Acquired aorto-left atrial fistula is uncommon. A rare case of aorto-left atrial fistula following mitral valve replacement is reported with echocardiographic, computed tomograpic and angiographic images.

Triple vessel percutaneous coronary intervention in a patient with situs inversus dextrocardia using a transradial approach.

Situs inversus dextrocardia is a challenging situation for an interventional cardiologist. This report presents a rare case where multivessel percutaneous coronary intervention was performed in a single sitting using transradial approach. The challenges encountered in the procedure and clues to successful outcome are discussed.

The 'MAP strategy' (Maximum aspiration of atherothrombus and adjunctive glycoprotein IIb/IIIa inhibitor utilization combined with prolonged inflation of balloon/stent) for preventing no-reflow in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: A retrospective analysis of seventy-one cases.

'No-reflow' phenomenon is a common occurrence in percutaneous coronary intervention (PCI). A three-component 'MAP strategy' was designed to prevent no-reflow by addressing both intralesional and intraluminal thrombus in patients with ST-segment elevation myocardial infarction (STEMI). In this analysis, we observed Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 or 2 in all patients, with no incidence of no-reflow. Myocardial blush grade (MBG) 3 or 2 was observed in most (87.32%) patients. Left ventricular ejection fraction (LVEF) was improved, without any incidence of death up to 9-month follow-up. All patients safely tolerated the strategy-driven prolonged, 35-s inflation of the balloon/stent.

Dabigatran for left ventricular thrombus.

Male patient in dilated phase of hypertrophic cardiomyopathy had multiple hospitalizations during the past 2 years either due to congestive heart failure, stroke, scar epilepsy, or atrial fibrillation and ventricular tachycardia. Medication included evidence based therapy for heart failure, cordarone and warfarin. Anticoagulation had to be discontinued due to marked fluctuations in INR. Transthoracic Echocardiography (TTE) revealed a mobile mass in the left ventricle. He was treated with Dabigatran 110mg twice a day for 4 months without any bleeding or embolic episode and complete resolution of thrombus. Dabigatran is a reversible direct thrombin inhibitor and currently approved for the prevention of thromboembolic episodes in non-valvar atrial fibrillation. This case demonstrates possible thrombolytic properties of dabigatran in resolution of left ventricular thrombus.

Cardiac amyloidosis: a report of two cases.

Cardiac amyloidosis is a manifestation of multisystem disorder. The condition is rare, difficult to diagnose and invariably fatal. We report 2 cases of amyloidosis associated with plasma cell dyscrasia. A high index of clinical suspicion, echocardiographic clues (ventricular thickening, diastolic dysfunction, biatrial enlargement) and elevated cardiac biomarkers led to the diagnosis. Early institution of amyloid specific treatment should be the aim. Cardiac treatment is supportive and results are often disappointing.

An unusual case of rupture of left sinus of valsalva aneurysm into main pulmonary artery.

We report a case of left sinus of Valsalva aneurysm rupture into main pulmonary artery who underwent successful surgical correction. The preoperative diagnosis was facilitated by echocardiography, cardiac catheterization, and computed tomography. The benefits of surgery are sustained at 8 months on clinical and angiographic follow-up.

Association between gender, process of care measures, and outcomes in ACS in India: results from the detection and management of coronary heart disease (DEMAT) registry.

BACKGROUND: Studies from high-income countries have shown that women receive less aggressive diagnostics and treatment than men in acute coronary syndromes (ACS), though their short-term mortality does not appear to differ from men. Data on gender differences in ACS presentation, management, and outcomes are sparse in India. METHODS AND RESULTS: The Detection and Management of Coronary Heart Disease (DEMAT) Registry collected data from 1,565 suspected ACS patients (334 women; 1,231 men) from ten tertiary care centers throughout India between 2007-2008. We evaluated gender differences in presentation, in-hospital and discharge management, and 30-day death and major adverse cardiovascular event (MACE; death, re-hospitalization, and cardiac arrest) rates. Women were less likely to present with STEMI than men (38% vs. 55%, p<0.001). Overall inpatient diagnostics and treatment patterns were similar between men and women after adjustment for potential confounders. Optimal discharge management with aspirin, clopidogrel, beta-blockers, and statin therapy was lower for women than men, (58% vs. 65%, p = 0.03), but these differences were attenuated after adjustment (OR = 0.86 (0.62, 1.19)). Neither the outcome of 30-day mortality (OR = 1.40 (0.62, 3.16)) nor MACE (OR = 1.00 (0.67, 1.48)) differed significantly between men and women after adjustment. CONCLUSIONS: ACS in-hospital management, discharge management, and 30-day outcomes did not significantly differ between genders in the DEMAT registry, though consistently higher treatment rates and lower event rates in men compared to women were seen. These findings underscore the importance of further investigation of gender differences in cardiovascular care in India.

Severe pulmonary hypertension in a young patient with end-stage renal disease on chronic hemodialysis.

Severe pulmonary hypertension in a teenager with end-stage renal disease on chronic hemodialysis via arteriovenous access is reported. Clinical presentation included persistent volume overload and pericardial effusion. Serial hemodynamic data obtained at cardiac catheterization confirmed the diagnosis. In addition, detailed biochemical and imaging data (echo- Doppler, computed tomography of chest, computed tomographic pulmonary angiography, VQ lung scan, etc.) were obtained to find out the mechanism. The exact cause of pulmonary hypertension remains unclear, and a multi- factorial mechanism is postulated. This rare case is presented to highlight the role of aggressive dialysis, pericardiocentesis, and use of sildenafil and bosentan in the management.

Hypertension and cardiovascular disease in South Asia: No end in sight.

South Asia is undergoing remarkable economic development, industrialization, and globalization with rapidly changing lifestyles resulting in increasing prevalence of obesity, hypertension, and coronary artery disease. It is estimated that in the year 2000, India had 41.5 million people with hypertension and the burden is projected to increase by another 5 million by the year 2025. Recent studies indicate that there is lack of awareness, underdiagnosis, and suboptimal control of elevated blood pressure. Asia is also emerging as an epicenter of diabetes. In India alone, there were approximately 23 million diabetics in the year 2000, and this burden is expected to rise to 57 million by 2025. Diabetes occurs at an early age in Indians with a lower body mass index and abdominal obesity as a striking feature. It is well documented that coronary artery disease occurs prematurely and pursues a malignant course in patients with South Asian background. Extensive information is now available about the epidemiology and risk factors of coronary disease in Asians. There is an enormous task ahead and herculean efforts are needed to prevent the epidemic.