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Speech induced atrial tachycardia is peculiar and an extremely uncommon clinical situation. Though the exact patho-mechanism for such an association cannot be ascertained. It is postulated to be caused by cardiac autonomic modulation by vagal innervation around the ganglionated plexus (GP) of the heart. We hereby present a unique case of atrial tachycardia which could be induced only by speech and was successfully mapped and ablated on to the floor of left atrium (LA), which is a possible site of posteromedial left atrial ganglionated plexus.
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The surgical treatment options for pediatric aortic valve disease are limited and have debatable long-term durability. In the current situation, the Ross procedure is considered in children for aortic valve disease(s). It is a complex surgical procedure with the risk of neo-aortic dilatation, converting a single valve disease into double valve disease, and associated with future re-interventions. Conversely, the Ozaki procedure has shown promising results in adults. Thus, the present study aimed to provide comparative evidence on the effectiveness and safety of the Ozaki versus Ross procedure for pediatric patients by performing a meta-analytic comparison of reporting outcomes. A total of 15 relevant articles were downloaded and among them, seven articles (one prospective study, five retrospective studies, and one case series) were used in the analysis. Primary outcomes such as physiological laminar flow pattern and hemodynamic parameters, and secondary outcomes such as hospital stays, adverse effects, mortality, and numbers of re-intervention(s) were measured in the meta-analysis. There were no significant differences in the age of patients between children who underwent the Ozaki procedure and those who underwent the Ross procedure at the time of surgeries. The Ozaki procedure is a good solution to an aortic problem(s) similar to the Ross procedure. Unlike the Ross procedure, the Ozaki procedure has restored a physiological laminar flow pattern in the short-term follow-up without the bi-valvular disease. Mean hospital stays (p = 0.048), mean follow-up (p = 0.02), adverse effects (p = 0.02), death, and numbers of re-intervention(s) of children who underwent the Ozaki procedure were fewer than those who underwent the Ross procedure. The time required for re-intervention(s) is higher for children who underwent the Ozaki procedure than those who underwent the Ross procedure. None of the procedures, including the Ozaki procedure for aortic valve disease(s), has significant effects on hemodynamic parameters and the frequent death rate of children after surgeries. Based on our analysis, we may suggest the Ozaki procedure for aortic valve disease surgery in children.
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Ventricular septal defect (VSD) is a catastrophic acute myocardial infarction (MI) complication. Despite a significant reduction in the prevalence of post-MI VSD with the advancement of surgical techniques, it is still considered fatal with a high mortality rate. The trends in the clinical outcomes of patients with post-MI VSD show discretion due to the complexity of the disease. Therefore, the present analysis aimed to evaluate the surgical outcomes and associated risks in the patients of post-MI VSD. A thorough literature survey resulted in 40 studies of our interest. The pooled proportion of differential variables, including the incidence of cardiogenic shock, 30-day survival, and overall mortality, were estimated using Bayesian hierarchical models. The risk difference was estimated for the location of MI and VSD and mortality in patients with coronary artery bypass graft (CABG). In addition, the heterogeneity tests for inconsistency and publication biases using Egger's and Begg's tests were also estimated. The analysis revealed a significant risk difference of 0.23 and 0.27 for the anterior vs. posterior location of MI and VSD, respectively. Further, the pooled proportion of 30-day survival and mortality was found to be 54.43% (95% credible interval (CI): 52.88-55.98%) and 48.22% (95% CI: 4-12.3%), respectively. Moreover, the heterogeneity test revealed significant inconsistencies in all the datasets with an I2 index of >90% (p<0.0001). Lastly, the publication bias results suggested no evidence of asymmetry and small-study effects. Conclusively, the surgical management of post-MI VSD patients is considered beneficial; however, the outcomes signify its fatal behavior.
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BACKGROUND: Extremely large aortic valve anatomy is one of the remaining limitations leading to exclusion of patients for transcatheter aortic valve replacement (TAVR). AIMS: The newly approved Myval 32 mm device is designed for use in aortic annulus areas up to 840 mm2 . Here we want to share the initial worldwide experience with the device. METHODS AND RESULTS: Retrospective data were collected from 10 patients with aortic stenosis and very large annular anatomy (mean area 765.5 mm2 ), who underwent implantation with 32 mm Myval transcatheter heart valve at eight centers. Valve Academic Research Consortium-2 device success was achieved in all cases. Mild paravalvular leak was observed in three patients and two patients required new pacemaker implantation. One patient experienced retroperitoneal hemorrhage caused by the contralateral 6 F sheath and required surgical revision. No device-related complications, stroke, or death from any cause occurred within the 30-day follow-up period. In a studied cohort of 2219 consecutive TAVR-screened patients from a central European site, only 0.27% of patients showed larger anatomy than covered by the 32 mm Myval device by instructions for use without off-label use of overexpansion. This rate was significantly higher for the 34 mm Evolut Pro (1.8%) and 29 mm Sapien 3 (2.1%) devices. CONCLUSIONS: The Myval 32 mm prosthesis showed promising initial results in a cohort of patients who previously had to be excluded from TAVR. It is desirable that all future TAVR systems accommodate larger anatomy to allow optimal treatment of all patients.
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Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Desenho de Prótese , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversosRESUMO
INTRODUCTION: Double-orifice mitral valve or left atrioventricular valve is a rare congenital cardiac anomaly that may be associated with an atrioventricular septal defect. The surgical management of double-orifice mitral valve/double-orifice left atrioventricular valve with atrioventricular septal defect is highly challenging with acceptable clinical outcomes. This meta-analysis is aimed to evaluate the surgical outcomes of double-orifice mitral valve/double-orifice left atrioventricular valve repair in patients with atrioventricular septal defect. METHODS AND RESULTS: A total of eight studies were retrieved from the literature by searching through PubMed, Google Scholar, Embase, and Cochrane databases. Using Bayesian hierarchical models, we estimated the pooled proportion of incidence of double-orifice mitral valve/double-orifice left atrioventricular valve with atrioventricular septal defect as 4.88% in patients who underwent surgical repair (7 studies; 3295 patients; 95% credible interval [CI] 4.2-5.7%). As compared to pre-operative regurgitation, the pooled proportions of post-operative regurgitation were significantly low in patients with moderate status: 5.1 versus 26.39% and severe status: 5.7 versus 29.38% [8 studies; 171 patients]. Moreover, the heterogeneity test revealed consistency in the data (p < 0.05). Lastly, the pooled estimated proportions of early and late mortality following surgical interventions were low, that is, 5 and 7.4%, respectively. CONCLUSION: The surgical management of moderate to severe regurgitation showed corrective benefits post-operatively and was associated with low incidence of early mortality and re-operation.
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Cardiopatias Congênitas , Defeitos dos Septos Cardíacos , Insuficiência da Valva Mitral , Humanos , Lactente , Valva Mitral/cirurgia , Valva Mitral/anormalidades , Teorema de Bayes , Defeitos dos Septos Cardíacos/cirurgia , Cardiopatias Congênitas/cirurgia , Insuficiência da Valva Mitral/cirurgia , Reoperação , Resultado do TratamentoRESUMO
Atrial high rate episodes (AHRE) confers increased morbidity and mortality amongst patients with permanent pacemaker implantation (PPI). The incidence of AHREs and it's clinical predictors in Indian patients without prior history of atrial fibrillation (AF) are not well understood. A total of 100 dual-chamber PPI patients, who had no prior history of AF, underwent pacemaker interrogation starting from a minimum of 1 month after implantation to detect any AHREs. The incidence of AHREs was 17% at a mean follow up 15.2 ± 7.5 months. Only right ventricular apical lead position was found to have an independent association with AHREs (OR: 3.50, 95% CI: 1.02-12.03; p = 0.04).
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Fibrilação Atrial , Marca-Passo Artificial , Humanos , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/terapia , Fibrilação Atrial/diagnóstico , Incidência , Marca-Passo Artificial/efeitos adversos , Estimulação Cardíaca Artificial/efeitos adversosRESUMO
Anomalous ascending aortic origin of left pulmonary artery in association with aortopulmonary window has not been reported so far in literature and is the main highlight of the present case.
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Defeito do Septo Aortopulmonar , Artéria Pulmonar , Aorta/anormalidades , Aorta/diagnóstico por imagem , Aorta/cirurgia , Defeito do Septo Aortopulmonar/diagnóstico por imagem , Defeito do Septo Aortopulmonar/cirurgia , Humanos , Artéria Pulmonar/anormalidades , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/cirurgiaRESUMO
Internal thoracic artery aneurysms (ITAAs) are rare with wide variation in clinical presentation and a high risk of rupture. Endovascular techniques are increasingly being used for treatment of such aneurysms over surgical repair in recent times. A 34-year-old male presented with progressive swelling of the right anterior chest wall for 2 weeks and was diagnosed with right internal thoracic artery aneurysm with contained rupture. He underwent successful endovascular repair with coil embolization of ruptured right ITAA. Post intervention computed tomography (CT) angiography confirmed sealing of the ruptured aneurysm with no residual filling of the sac. At six months follow-up he is doing well with complete resolution of hematoma. This case demonstrates that an endovascular approach with coil embolization is a feasible and safe option for treating the rare ruptured ITAAs.
Os aneurismas da artéria torácica interna (ITAAs) são raros, com ampla variação na apresentação clínica e alto risco de ruptura. As técnicas endovasculares têm sido cada vez mais utilizadas para o tratamento desses aneurismas em relação ao reparo cirúrgico. Um homem de 34 anos de idade apresentou edema progressivo da parede torácica anterior direita por 2 semanas e foi diagnosticado com aneurisma da artéria mamária interna direita com ruptura contida. Ele foi submetido a reparo endovascular bem-sucedido, com embolização de ITAA direito roto. A angiotomografia computadorizada (angioTC) pós-intervenção confirmou o selamento do aneurisma rompido, sem enchimento residual do saco. No seguimento de 6 meses, ele estava bem, com resolução completa do hematoma. Este caso demonstra que a abordagem endovascular com embolização com molas é uma opção viável e segura no tratamento dos raros ITAAs rotos.
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A 74-year-old man presented with failure of a bioprosthetic aortic valve implanted 7 years earlier, with a mean gradient of 44 mm Hg across the aortic valve. During valve-in-valve transcatheter aortic valve replacement, we came across an unusual complication of strut inversion at the lower end of the valve. (Level of Difficulty: Advanced.).
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Ortner's syndrome is hoarseness of the voice caused by enlarged cardiac structures compressing the left recurrent laryngeal nerve (LRLN). The LRLN is vulnerable for impingement by cardiac structures due to its anatomical course. LRLN is longer and it hooks below the arch of the aorta, posterior to the ligamentum arteriosum before ascending toward the tracheo- esophageal groove. Ortner's syndrome has been commonly described with left atrial enlargement due to mitral stenosis; however, other causes like aortic aneurysm, pulmonary artery aneurysm, and aortic dissection have been described. Although rare, hoarseness of the voice could be the only presenting complaint in aortic aneurysms as in the case described herein.
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Aneurisma da Aorta Torácica , Aneurisma Aórtico , Dissecção Aórtica , Paralisia das Pregas Vocais , Dissecção Aórtica/complicações , Aneurisma Aórtico/complicações , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico , Rouquidão/complicações , Rouquidão/etiologia , Humanos , Paralisia das Pregas Vocais/diagnóstico , Paralisia das Pregas Vocais/etiologiaRESUMO
A cross-sectional study was conducted to predict time in therapeutic range (TTR) using clinical history, examination, and socioeconomic data. Study included warfarin-receiving patients from outpatient-clinic. In 203 patients studied, mean warfarin start-dose was 2.55 mg/day and maintenance-dose/week was 30.79 mg. Body mass index (BMI) (p = 0.03), warfarin maintenance dose/day (p = 0.02), and comorbidity presence (p = 0.04) were significantly associated with TTR. Occupation (p = 0.53), income (p = 0.83), education (p = 0.55), and socioeconomic score (p = 0.73) showed non-significant association with TTR. A TTR predicting nomogram was built from clinical history and examination findings.
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Fibrilação Atrial , Varfarina , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Análise Custo-Benefício , Estudos Transversais , Humanos , Coeficiente Internacional Normatizado , Nomogramas , Varfarina/uso terapêuticoRESUMO
BACKGROUND: The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients. METHODS: The study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded. RESULTS: A total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (<50% stenosis) CAD in 17 (24%) patients and normal coronaries in 21 (30%) patients. Overall 49 (70%) patients had evidence of CAD. Amongst patients without obstructive CAD, slow flow was seen in 16 (42%) patients. Lower baseline ejection fraction, lower haemoglobin & albumin levels and higher creatinine levels was associated with increased mortality. In patients without obstructive CAD, hospitalizations for fast ventricular rate were significantly increased in those having slow flow on CAG (p = 0.005). CONCLUSIONS: Majority (70%) of our patients had evidence of atherosclerotic CAD on CAG. A large proportion of patients without obstructive CAD had slow flow on CAG.
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Fibrilação Atrial , Doença da Artéria Coronariana , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Angiografia Coronária/métodos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Centros de Atenção TerciáriaRESUMO
Inadvertent deployment of stent grafts into the false lumen during thoracic endovascular aortic repair (TEVAR) is rare and is associated with catastrophic consequences. We present a case of accidental stent-graft deployment from the true lumen into the false lumen during TEVAR, resulting in hemodynamic collapse and visceral malperfusion. We successfully performed a bailout using the Brockenbrough needle to create new access from the true lumen to the false lumen and implanted another overlapping stent graft.
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Abstract Internal thoracic artery aneurysms (ITAAs) are rare with wide variation in clinical presentation and a high risk of rupture. Endovascular techniques are increasingly being used for treatment of such aneurysms over surgical repair in recent times. A 34-year-old male presented with progressive swelling of the right anterior chest wall for 2 weeks and was diagnosed with right internal thoracic artery aneurysm with contained rupture. He underwent successful endovascular repair with coil embolization of ruptured right ITAA. Post intervention computed tomography (CT) angiography confirmed sealing of the ruptured aneurysm with no residual filling of the sac. At six months follow-up he is doing well with complete resolution of hematoma. This case demonstrates that an endovascular approach with coil embolization is a feasible and safe option for treating the rare ruptured ITAAs.
Resumo Os aneurismas da artéria torácica interna (ITAAs) são raros, com ampla variação na apresentação clínica e alto risco de ruptura. As técnicas endovasculares têm sido cada vez mais utilizadas para o tratamento desses aneurismas em relação ao reparo cirúrgico. Um homem de 34 anos de idade apresentou edema progressivo da parede torácica anterior direita por 2 semanas e foi diagnosticado com aneurisma da artéria mamária interna direita com ruptura contida. Ele foi submetido a reparo endovascular bem-sucedido, com embolização de ITAA direito roto. A angiotomografia computadorizada (angioTC) pós-intervenção confirmou o selamento do aneurisma rompido, sem enchimento residual do saco. No seguimento de 6 meses, ele estava bem, com resolução completa do hematoma. Este caso demonstra que a abordagem endovascular com embolização com molas é uma opção viável e segura no tratamento dos raros ITAAs rotos.
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Humanos , Masculino , Adulto , Aneurisma Roto/terapia , Embolização Terapêutica , Procedimentos Endovasculares , Artéria Torácica Interna/diagnóstico por imagem , Angiografia por Tomografia ComputadorizadaRESUMO
OBJECTIVE: Several studies have demonstrated a shift in the spectrum of infective endocarditis (IE) in the developed world. We aimed to investigate whether demographic and microbiologic characteristics of IE have changed in India. DESIGN: A retrospective analysis of patients with in north India between 2010 and 2020. METHODS: The clinical and laboratory profiles of 199 IE admitted to an academic hospital patients who met the modified Duke criteria for definite IE were analysed. RESULTS: The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005). CONCLUSION: IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU.
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Endocardite Bacteriana , Endocardite , Adulto , Endocardite/diagnóstico , Endocardite/epidemiologia , Endocardite/etiologia , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/epidemiologia , Hospitais , Humanos , Masculino , Estudos Retrospectivos , Staphylococcus aureusRESUMO
BACKGROUND: Coronary artery perforation (CAP), although rare, can often be a life-threatening complication of percutaneous coronary intervention. Looped wire tip or buckling of wire is conventionally considered safer due to reduced risk of migration into smaller branches and false lumen. Occasionally, buckling can indicate the entry of tip into dissection plane, or the advancement of looped wire can cause small vessel injury leading to perforation. Distal coronary perforation can be life threatening and coil, foam, and thrombin injection are some of the material widely used for sealing it. CASE SUMMARY: We hereby report three different cases illustrating the vessel injury that the looped wire can cause in the distal vasculature related to various mechanisms like high elastic recoil tension, dissection by the non-leading wire tip, or hard wire lacerating the fragile small branches. All these mechanisms lead to distal coronary perforation leading to cardiac tamponade. Each case also illustrate the novel technique of autologous fat globule embolization for the management of distal CAP. DISCUSSION: Distal coronary perforation is often due to guidewire-related vessel injury and is more common with hydrophilic wires. Looped wire tip can sometime indicate vessel injury and its advancement further down the coronary artery may result in serious vessel injury and perforation. Management of distal coronary perforation is challenging, and here we demonstrate the steps of using the readily available autologous fat globules by selectively injecting them into the small coronary artery to control the leak.
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BACKGROUND: At our tertiary care cardiology center, we are receiving soldiers who sustained acute ST-Elevation Myocardial Infarction (STEMI) during the strenuous Battle Field Efficiency Test (BPET) and other such activities. METHODS: This was a single-center observational study to assimilate and analyze the precipitating causes, risk factors, symptoms, and the efficacy of the management protocols in soldiers sustaining STEMI during the BPET or other forms of strenuous military training. RESULTS: All 25 soldiers with documented STEMI following strenuous military training presented with chest pain as the primary symptom. 88% had symptoms either during or within 1st hour of the strenuous activity. 76% underwent thrombolysis with an angiographic success rate of 95%. Primary PCI was possible in only 3/25 (12%) of the cases, of which 2 (66%) did not require stenting after thrombus aspiration; 88% of soldiers reported "training for the event" for less than four times/week. CONCLUSION: STEMI precipitated by strenuous unaccustomed military training have exclusively single vessel affection with an excellent response to thrombolysis and thrombus aspiration. Thus, the timely institution of pharmacological or mechanical revascularization therapy has dramatic results in the preservation of ventricular function. The lack of training for the strenuous event provides strong evidence for comprehensive, graded, physical training prior to strenuous military activities to prevent acute coronary syndromes.
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Interrupted inferior vena cava (IVC) with azygous continuation provides technical challenge in many percutaneous cardiac interventions. They are performed via the femoral venous access route. We describe four such cases in whom, patent ductus arteriosus (PDA) device closure was done in interrupted IVC. All the four cases were done using the femoral route. Two cases were done via retrograde approach through femoral artery access, in which one was closed with a muscular VSD device and the other with a Gianturco coil. The introduction of newer closure devices helps in the retrograde approach. Two cases were done via anterograde approach through the femoral venous route, with a loop through the azygous vein. One child had transient bradycardia due to cardiac stretch which normalized after the device deployment and introducer system removal. Thus, we describe different femoral approaches in interrupted IVC patients for PDA closure, with the difficulties faced and the complications managed.