Accuracy of 64-slice CT coronary angiography: our initial experience.

OBJECTIVE: The objective of our study was to evaluate the diagnostic accuracy of 64-slice computed tomography coronary angiography to detect haemodynamically significant stenosis (>50% luminal narrowing) in comparison to invasive coronary angiography and further analyze the result accounting for heart rate, coronary calcification and location of lesion in the coronary tree. METHODS AND RESULTS: Forty patients (39 male, 1 female; mean age 50.9 years) underwent both CT coronary angiography and invasive coronary angiography with in a gap of one day. All vessels were included in the study and no patient was excluded due to high heart rate. On per-segment based analysis with invasive coronary angiography as the gold standard, CT coronary angiography correctly identified 62 out of 78 significant stenoses with an overall sensitivity of 79.5% (62 of 78), specificity of 98.5% (532 of 540), positive predictive value of 88.6% (62 of 70) and negative predictive value of 97.1% (532 of 548). CONCLUSION: Our result suggests that 64-slice CT coronary angiography has high diagnostic accuracy to detect haemodynamically significant stenosis.

Novel non-surgical method of managing cardiac perforation during percutaneous transvenous mitral commissurotomy.

We describe a new technique of sealing cardiac perforation resulting in cardiac tamponade during transvenous mitral commissurotomy by percutaneous instillation of cyanoacrylate glue at the perforation site, thus avoiding surgery.

Difficult percutaneous transvenous mitral commissurotomy: a new technique for left atrium to left ventricular entry.

Percutaneous transvenous mitral commissurotomy using Inoue balloon is an effective procedure for the management of patients with juvenile mitral stenosis. Inability to cross the mitral valve by the Inoue balloon catheter is one of the important reasons for failure of the procedure. We describe a new technique, facilitating left atrium to left ventricular entry using double loop of Inoue balloon catheter in a child with small left atrium.

Isolated thrombus producing tricuspid stenosis: an unusual presentation in primary antiphospholipid syndrome.

We report the case of a female patient who presented with signs and symptoms of tricuspid stenosis. Echocardiography revealed a sessile mass on the tricuspid valve. A diagnosis of primary cardiac tumor was made but histopathologic examination revealed the mass to be an organized thrombus. Subsequent serological tests showed elevated titers of anticardiolipin antibodies in the absence of any associated disease. This case highlights an unusual presentation of the primary antiphospholipid syndrome.

A constricting band: an unusual cause of incomplete expansion of Amplatzer septal occluder device.

Various problems and complications have been reported during transcatheter closure of ostium secundum atrial septal defect with Amplatzer septal occluder. We report an unusual problem that was responsible for incomplete expansion of the waist of the device, not yet reported in world literature. A polyester band in continuation with the polyester mesh was found constricting the waist of the device, which after being cut led to successful redeployment of the device.

Stenting of a septal perforator for post-myocardial infarction angina.

Occlusion of a septal perforator branch alone, without the involvement of the left anterior descending coronary artery, leading to acute myocardial infarction is unusual. We report a case in which an isolated severely stenotic thrombus-containing first septal artery causing intractable post-myocardial infarction angina was successfully dilated and stented.

Post-stenotic dilatation: challenge in renal ostial stenting--a simple solution.

Stenting is the treatment of choice for treating stenotic renal ostial lesions. During the stenting of an ostial lesion in a renal artery with post-stenotic dilatation, we were faced with the problems of unavailability of a balloon of appropriate length and diameter, and determining the real reference vessel diameter. The problem was solved by a simple technique.

Unusual ST-t changes in Ebstein's anomaly with occlusion of a nondominant coronary artery.

We present a case report of a patient of Ebstein's anomaly presenting with unusual ECG changes during acute coronary syndrome. The patient had undergone radiofrequency ablation of right posteroseptal accessory pathway. Two years later, he presented with acute chest pain. His ECG revealed ST elevation of 6-7 mm in leads III, aVF. V3R and V1-V4 with atrioventricular dissociation. He was thrombolysed for the same. He subsequently underwent an angiogram for continuing angina. His angiogram showed a nondominant right coronary artery with a 95% stenosis. The left circumflex artery was dominant but without any stenosis. The left anterior descending artery was also normal. Angiogplasty and stenting were done for the right coronary artery lesion and the patient did well on follow-up. The ST segment elevation in the anterior precordial leads resulting from occlusion of a nondominant right coronary artery is unusual. The possible reason for this is the isolated right ventricular infarction in the absence of any left ventricular infarction. Thus the electrical current of injury resulting from the right ventricular infarction was unopposed by any counterbalancing current of injury from the inferior surface of the left ventricle.

Aortoarteritis presenting with hypoparathyroidism.

Clinical manifestations of aortoarteritis (Takayasu's arteritis) are varied, depending on the involved segment of the aorta and its branches. A case of a young Indian woman with aortoarteritis presenting primarily with hypoparathyroidism is reported. Aortogram showed total occlusion of the arch arteries. To the best of our knowledge, the occurrence of hypoparathyroidism in aortoarteritis has not been reported. Possible mechanisms of such an involvement are discussed.

False-positive exercise stress electrocardiogram due to accessory pathway in the absence of manifest preexcitation.

False-positive exercise testing in patients with an accessory pathway has been described only in patients with manifest preexcitation during exercise. We describe a patient in whom marked ST-segment changes were seen during an exercise test in the absence of any preexcitation of the QRS complexes. The role of the accessory pathway in producing the ST changes was reaffirmed by absence of this abnormality following catheter ablation of the accessory pathway.

Mitral regurgitation following percutaneous transvenous mitral commissurotomy: a single-center experience.

BACKGROUND AND AIM OF THE STUDY: Percutaneous transvenous mitral commissurotomy (PTMC) has revolutionized the treatment of patients with symptomatic mitral stenosis and is now established as the procedure of choice. Despite high technical expertise in PTMC using the Inoue balloon, mitral regurgitation (MR) remains a major procedure-related complication. We retrospectively analyzed our data of PTMC using the Inoue balloon with regard to the incidence of MR, its likely causative mechanism, and follow up of these patients. METHODS: During the past ten years, PTMC was performed in 3,650 patients (median age 26 years; range: 8-76 years), of whom 910 (24.9%) were juveniles. Preprocedure mitral valve area (MVA) was 0.9 +/- 0.4 cm2 (range: 0.3-1.3 cm2); MR was mild in 1,396 cases (38.2%), moderate in 394 (10.8%) and severe in 22 (0.6%). None of the patients was rejected on the basis of echocardiographic score. RESULTS: The procedure was successful in 3,276 (89.8%), with post-procedure MVA of 1.7 +/- 0.6 cm2 (range: 1.4-2.6 cm2), and without development of any major complication. Severe MR was seen in 120 patients (3.3%), of whom 66 (1.8%) required urgent mitral valve replacement (MVR). Echocardiography in these latter patients showed leaflet rupture in 48 (72.7%), chordal rupture in 12 (18.2%) and excessive commissural tear in six (9.1%). Fifty-four patients (1.5%) with severe MR post PTMC were followed with medical treatment; echocardiography in these patients revealed chordal rupture in 40 (74.1%) and excessive commissural tear in 14 (25.9%). Follow up data were available in 49 patients (1.3%); 30 (0.8%) required MVR and 19 (0.5%) were in NYHA class II at a median follow up of 24 months. Moderate MR was seen in 188 cases (5.1%), with predominant causative mechanisms of excessive commissural tear in 120 (63.8%) and chordal rupture in 68 (36.2%). Severity of MR worsened in 30 cases (0.8%), of which 20 (0.6%) required elective MVR on follow up. MR decreased in 58 patients (1.6%), in whom excessive commissural tear was the causative mechanism. CONCLUSION: Significant MR (moderate or severe) after PTMC was seen in 308 patients (8.4%), of whom 116 (3.2%) required MVR urgently or on follow up. All patients with leaflet rupture during PTMC developed severe MR and required urgent MVR. There was a tendency for the severity of MR to decrease with time in cases where excessive commissural tear was the causative mechanism.

Long-term follow-up results after plain balloon coronary angioplasty.

Between September 1987 and June 1992, 571 patients of coronary artery disease underwent percutaneous transluminal coronary angioplasty in our institute. Their ages ranged from 31-82 years (mean 51 +/- 9) and majority (88.3%) were males. At baseline, 318 (55.7%) patients had chronic stable angina, 184 (32.2%) unstable angina, and 57 (10%) underwent PTCA for recurrence of angina in the post-infarction period. Single vessel angioplasty was performed in 406 (71.1%), two-vessel angioplasty in 121 (21.2%) and three or more vessels were dilated in 44 (7.7%). The procedure was successful in 524 (91.8%) patients. Follow-up was available in 438 (83.6%) patients, and ranged from 78 to 135 months (mean 89 +/- 29) with all the patients completing at least 60 months of follow-up. Using Kaplan-Meier statistical analysis, event-free survival (freedom from repeat percutaneous transluminal coronary angioplasty, myocardial infarction, coronary artery bypass surgery, or death) was 72.5 percent at three, 68.0 percent at five, 61.8 percent at seven and 55.6 percent at 10 years of follow-up. Freedom from major adverse cardiac events (myocardial infarction, coronary artery bypass surgery or death) was 88.3, 85.8, 82.0 and 75.4 percent at 3, 5, 7 and 10 years, respectively. Overall survival was 97.4 and 95.2 percent, respectively at 5 and 10 years. Subgroup analysis for all major events was done between males and females, diabetics and non-diabetics, previous history or absence of myocardial infarction, stable versus unstable angina and single versus multivessel disease. Event-free survival rates were compared between the groups using log rank test. On follow-up, the need for surgical revascularisation was more in males compared to females although statistically insignificant, and in patients with unstable angina compared to stable angina (p < 0.02). Similarly, freedom from major adverse cardiac events was significantly better in females compared to males (p < 0.05) and in stable versus unstable angina (p < 0.01). Event-free survival (repeat percutaneous transluminal coronary angioplasty, myocardial infarction, coronary artery bypass surgery, death) was also significantly better in patients with stable angina (p < 0.02). The other outcomes were comparable in all the subgroups. In conclusion, plain balloon angioplasty provides excellent long-term results in patients with coronary artery disease in terms of reduction in major adverse cardiovascular events and need for subsequent revascularisation.

Percutaneous transluminal angioplasty for stenosis of the aorta due to aortic arteritis in children.

Percutaneous transluminal balloon angioplasty for stenosis of the aorta due to aortic arteritis was attempted on 45 lesions in 41 children (age range, 4-14 years; mean, 9.9+/-4.2 years) presenting with symptoms of hypertension, severe congestive heart failure, and lower limb claudication. Balloon dilatation was technically successful in 38 (92.7%) patients for 41 stenotic lesions (91.1%). The mean peak systolic pressure gradient (PSG) decreased from 71.7 +/- 23.9 mmHg to 23.2 +/- 17.5 mmHg (p < 0.001) and the diameter of the stenosed segment increased from 3.3 +/- 1.1 mm to 7.5 +/- 2.2 mm (p < 0.001) immediately after angioplasty. Patients with short-segment (<3 cm) stenosis had a lower residual gradient (17.9 +/- 11.1 mmHg vs 30.5 +/- 22.6 mmHg; p < 0.05) and a wider diameter of the aorta (8.8 +/- 1.1 mm vs 7.5 +/- 2.2 mm; p < 0.02) compared to patients with long-segment (>/=3 cm) stenosis. Four patients required stent implantation; 2 for flow-limiting dissection, 1 for failure to reduce PSG by >50%, and 1 for recurrent restenosis. There was marked hemodynamic and angiographic improvement in these 4 patients. Hemodynamic and angiographic restudy in 21 of the 41 patients at mean follow-up period of 6.2 +/- 4.2 months (range, 3-24 months) showed restenosis in 4 (19%) patients. Restenosis was more common in patients with long-segment stenosis than those with short-segment stenosis (30% vs 9.1%). Late restudy in 8 patients, done at 3-7 years after first restudy, showed no recurrence of aortic narrowing. On clinical follow-up of 38 patients for a mean of 58.8 +/- 36.0 months (range, 8-146 months) there was marked improvement in symptoms. Hypertension was cured in 11 (29%), improved in 24 (63%), and persisted in 3 (8%). Six patients with associated severe renal artery stenosis showed further improvement in hypertension after successful renal angioplasty. Severe congestive heart failure improved in 21 (95.4%) of 22 patients. Mean left ventricular ejection fraction improved from 0.32 +/- 0.08 to 0. 48 +/- 0.10 (p < 0.001) at a mean follow-up of 28.7 +/- 8.4 months in these patients. Hemodynamic restudy in 10 of these patients showed improvements in left ventricular end-diastolic pressure from a mean 37 +/- 9 mmHg (range, 25-55 mmHg) to 16.4 +/- 6.2 mmHg (range, 6-25 mmHg) (p < 0.001). Lower limb claudication improved in all 4 patients. Our results suggest that percutaneous transluminal balloon angioplasty in children is safe and highly effective in relieving stenosis of the aorta due to aortic arteritis, with marked clinical improvement, and should be the treatment of choice particularly for discrete stenosis.

Endovascular stenting for unsuccessful angioplasty of the aorta in aortoarteritis.

PURPOSE: The efficacy and safety of endovascular stent implantation to correct dissection or a suboptimal result after percutaneous transluminal angioplasty (PTA) was evaluated in patients suffering from aortic stenosis due to aortoarteritis. METHODS: Twelve children and young adults [aged (mean +/- SD) 18.2 +/- 8.7 years] underwent stent implantation after PTA of the aorta, seven for obstructive dissection, four for ineffective balloon dilatation, and one for recurrent restenosis. Nine patients underwent implantation of self-expandable stents and three received balloon-expandable Palmaz stents. RESULTS: Stent implantation could be successfully performed in all 12 patients. After stent implantation, the peak systolic pressure gradient decreased from 91 +/- 33.5 mmHg to 12.4 +/- 12.5 mmHg (p < 0.001). The diameter of the stenosed segment increased from 4.6 +/- 0.8 mm to 11.1 +/- 1.9 mm (p < 0.001). The dissection was completely covered in all seven patients with dissection. Except for epigastric pain with vomiting in one patient, there was no complication. On follow-up, over 12-57 months (mean 26.8 +/- 10.8 months), 11 patients (91.6%) had marked improvement in their blood pressure. Patients with congestive heart failure and claudication also showed improvement. Repeat catheterization in five patients, between 6-30 months (mean 16.8 +/- 9.1 months) after stent implantation, showed sustained improvement in four and a fusiform, long segment, intrastent restenosis after 30 months in one child. The stenosis was safely redilated. CONCLUSION: Endovascular aortic stent implantation is safe and provides good immediate relief in patients with unsatisfactory results after balloon angioplasty. Improvement is sustained in most patients on intermediate-term follow-up.

High speed rotational atherectomy for diffuse in-stent restenosis: short- and mid-term follow-up results.

Between January 1997 to May 1998, 37 consecutive patients underwent high speed rotational atherectomy with adjunctive balloon angioplasty for the management of first-time diffuse variety of in-stent restenosis in the native coronary arteries. Their age ranged from 38 to 71 years (mean 54.3 +/- 9.7 years). All the patients underwent initial stent implantation at moderate to high pressure. Patients were either symptomatic or demonstrated significant ischaemia by non-invasive testing. The median time from the index procedure to in-stent restenosis was 20 weeks (range 9-40 weeks). Majority (78.1%) of lesions were in the territory of left anterior descending coronary artery. The mean lesion length was 24.3 +/- 8.3 mm (range 12-42 mm). Five lesions each (12.2%) were total occlusion and ostial in location. High speed rotational atherectomy was performed using stepped burr technique in majority (90.2%) with the largest burr corresponding to approximately 70 percent of the reference vessel diameter. The initial burr size ranged from 1.5-2.0 mm, final burr was 1.75-2.25 mm and the average number of burrs used per target vessel was 2.2 +/- 0.3 (range 1-3). Adjunctive balloon angioplasty was performed in all (100%) cases using a semi-compliant oversized balloon (balloon-to-artery ratio 1.1:1) inflated at a pressure of 6.5 +/- 2.1 atmospheres (range 4-10). The procedure was successful in all cases without any major complications (death, Q-MI, CABG or repeat PTCA). Over a median follow-up of 10 months, 27 (73%) patients were asymptomatic. Recurrence of clinical events occurred in 10 (27%) patients at median interval of 16 weeks after rotational atherectomy. Angina was controlled on drug therapy in six (16.2%) and target vessel revascularisation was required in three (8.1%) cases. By the Kaplan-Meier estimate, an event-free survival (absence of death, Q-MI, recurrence of angina, target vessel revascularisation) was 97.3, 94.6, 75.7 and 72.6 percent at 1, 3, 6 and 12 months, respectively. Thus, rotational atherectomy using a stepped burr approach for adequate debulking, followed by adjunctive balloon angioplasty is safe with excellent in-hospital results for the treatment of diffuse in-stent restenosis. Although recurrence of symptoms develops in approximately one-fourth of patients on follow-up, it is much less than reported with balloon angioplasty in this subgroup of patients.