Peripheral Artery Stent Dehiscence: Percutaneous Management.

An elderly male presented with left abdominal swelling of 1-week duration and inability to move the left lower limb. He had undergone bilateral common iliac and left external iliac artery stenting with self-expandable stents for aortoiliac occlusive disease 1 month back. Clinical examination revealed tender abdominal nonpulsatile mass with systolic bruit. Ultrasonography suggested retroperitoneal hematoma. His hemoglobin was 7 g%. Echocardiogram showed ejection fraction of 40%. Computed tomography angiogram revealed large 10 × 10 retroperitoneal hematoma with possibility of continued bleeding from the left external iliac artery. He was taken up for urgent catheterization after consultation with the vascular surgeons who deemed him high risk for surgery in view of left ventricular dysfunction. Abdominal aortogram showed diffuse extravasation of contrast from the junction of left common iliac artery and external iliac artery into the retroperitoneal space. Sustained balloon occlusion of the vessel across the extravasated portion was done, still the leak persisted. Two covered stents were deployed in the external iliac artery overlapping each other, percutaneously resulting in complete closure of leak with good distal runoff. His symptoms improved considerably the next day with a decrease in abdominal swelling and he was able to move his left lower limb. Ultrasound of the abdomen showed regression of the retroperitoneal hematoma and no suspicion of leak. Computed tomography angiogram done 10 days and 2 months later showed regression of retroperitoneal hematoma and no extravasation with good peripheral runoff.

Spectrum of cyanotic congenital heart disease diagnosed by echocardiographic evaluation in patients attending paediatric cardiology clinic of a tertiary cardiac care centre.

BACKGROUND: Cyanotic CHD comprises up to 25% of cases of all causes of CHD. RATIONALE: There is lack of data about the present spectrum of congenital cyanotic heart disease in the paediatric age group. OBJECTIVE: The present study was undertaken to determine the spectrum of patients with congenital cyanotic heart disease in the paediatric age group in tertiary paediatric cardiac care clinic. DESIGN: Prospective observational study. SETTING: Paediatric cardiac clinic of a tertiary cardiac care centre. METHODS: All children aged 0-18 years with suspected cyanotic CHD were provisionally included in this study. They underwent a thorough echocardiographic evaluation, and those patients who had definitive diagnosis of congenital cyanotic heart disease were included for final analysis. RESULTS: A total of 119 children met the inclusion criteria. Tetralogy of Fallot and its variant were the most common congenital cyanotic heart disease with proportion of about 44%. Other common malformations were double outlet right ventricle (14%), pulmonary atresia with ventricular septal defect (8%), total anomalous pulmonary venous connection (7%), d-transposition of the great arteries (9%), tricuspid valve anomalies--tricuspid atresia and Ebstein's anomaly--hypoplastic left-heart syndrome, truncus arteriosus, and complex CHD such as single ventricle. CONCLUSION: Tetralogy of Fallot and its variants were the most common cyanotic heart disease diagnosed in our patients. As there were a significant proportion of cases with complex cyanotic CHD, paediatric cardiologists should be familiar with the diagnosis and management of all these complex congenital malformations of the heart.

Dilated cardiomyopathy being the presenting manifestation of Takayasu arteritis and treated with renal angioplasty.

Dilated cardiomyopathy (DCM) is an uncommon complication of Takayasu arteritis (TA) with a prevalence of about 6%. We report a case of 14-year-old girl who presented with dyspnea, bipedal edema, loss of weight, and easy fatigability for three months. She was being treated for DCM for the same duration. Clinical examination revealed absence of both upper limb pulses. Echocardiography revealed features of DCM with severe biventricular dysfunction (ejection fraction 30%). Computed tomography angiogram confirmed the diagnosis of TA and revealed the presence of bilateral renal artery stenosis. Bilateral renal angioplasty was done, and immunosuppressant therapy with oral prednisolone and weekly oral methotrexate was started.

An adult patient of double-chambered right ventricle with ventricular septal defect incidentally diagnosed after presentation with acute myocardial infarction.

The double-chambered right ventricle (DCRV) is a rare congenital heart disease caused by hypertrophic anomalous muscle bands that divide the ventricular cavity, resulting in the formation of a high-pressure proximal chamber and other low-pressure distal one. Because of its evolving nature, its diagnosis is usually made during childhood/adolescence and very rarely during adulthood. It accounts for approximately 0.5-1% of patients with congenital heart disease. We report a case of a 50-year-old man who presented to us with acute inferior wall myocardial infarction (MI). Echocardiography revealed the features of DCRV and ventricular septal defect. Coronary angiogram revealed significant stenosis in right coronary artery. This is the first case where an adult patient with DCRV incidentally diagnosed after presentation with acute MI and had undergone successful coronary angioplasty.

Acute severe mitral regurgitation following balloon mitral valvotomy: echocardiographic features, operative findings, and outcome in 50 surgical cases.

OBJECTIVE: To analyze the echocardiographic and operative findings with respect to mitral valve anatomy in individuals undergoing emergency surgery for acute severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV). In addition, the clinical profile and outcomes are highlighted. BACKGROUND: Acute severe MR is a major complication of BMV. There are only a few reports which have studied the echocardiographic and operative findings in this setting. In addition, optimal timing of surgery is uncertain. METHODS: Prospective study of 50 consecutive patients undergoing emergency mitral valve replacement (MVR) for acute severe MR following BMV. RESULTS: In 3855 patients who underwent BMV, acute severe MR developed in 50 cases (1.3%) and was referred for emergency MVR. Hypotension (72%), hypoxia (64%), orthopnea (14%), and pulmonary edema (12%) were the clinical manifestations. Severe MR was secondary to anterior mitral leaflet tear in 36 cases (72%), paracommisural tear with annular involvement in seven cases (14%), posterior mitral leaflet tear in five cases (10%) and chordal tear in two cases (4%). The correlation between two-dimensional transthoracic echocardiography (2D-TTE) and operative finding for mitral valve calcification was found to be strong (r = 0.862), in contrast to submitral fusion, where it was found to be moderate (r = 0.536). In-hospital mortality was 12%. Mortality was higher in patients whose time to surgery was ≥24 hr when compared to those who underwent MVR within 24 hr (P < 0.001). CONCLUSIONS: Hypotension and hypoxia are the predominant manifestations of acute severe MR following BMV. Anterior mitral leaflet tear is the most common etiology for severe MR. 2D-TTE underestimated the severity of submitral disease. Early MVR (<24 hr) is recommended for optimal outcome.

Successful management of Ellis type III left anterior descending artery perforation following percutaneous coronary intervention by a covered stent: Successfully resolved the dramatic complication.

Coronary artery perforation is a rare but catastrophic complication of percutaneous coronary intervention (PCI). Grade III coronary perforation and rupture invariably results in pericardial effusion and tamponade requiring urgent pericardiocentesis. Advances in coronary intervention have increased the opportunity to treat coronary artery perforation. We are reporting a case of 55 years old hypertensive female who presented with effort angina. Coronary angiogram revealed significant stenosis in the left anterior descending coronary artery. Post PCI, she had Ellis type III coronary perforation and pericardial tamponade and cardiogenic shock. The patient was resuscitated, pericardiocentesis done, autologous blood transfusion given and covered stent deployed.

An unusual percutaneous transmitral commissurotomy: A collection of four rare occurrences!

We are presenting an interesting case of a 30-year-old patient taken for percutaneous transvenous mitral commissurotomy (PTMC) for severe rheumatic mitral stenosis in which there was a collection of four unusual occurrences during the course of a procedure. She had recurrent generalized tonic-clonic seizures immediately after femoral sheath insertion requiring the patient to be mechanically ventilated. Subsequently, the pressure tracings recorded with catheters in the aorta and the pulmonary artery showed transient unusually high supra-systemic pulmonary artery pressure. During inflation the Accura PTMC balloon which was used to dilate the mitral valve ruptured and the procedure subsequently had to be completed using another balloon catheter. During the procedure the presence of a distended stomach due to insufflations of air during positive pressure ventilation which subsided subsequently was another unusual documentation on fluoroscopy. The final outcome of the procedure was successful. This case presents an interesting collection of unusual occurrences during a PTMC procedure which started on an unusual note but ended on a successful one. Careful assessment and appropriate management of complications can lead to successful outcome of procedures as in our case.

Left arm-left leg lead reversal in a case of inferior wall myocardial infarction mimics as high lateral wall infarction.

A 56-year-old male patient was admitted with an evolved inferior wall myocardial infarction (IWMI). Electrocardiogram (ECG) showed presence of ST elevation and T wave inversion in the inferior leads. ECG taken on the next day surprisingly showed features suggestive of acute high lateral wall myocardial infarction (LWMI), without features suggestive of re-infarction which was finally diagnosed to be an artefact due to lead reversal. Lead reversal between left arm and left leg can mimic as high LWMI in a case with IWMI and we should aware of this situation before misdiagnosing it as re-infarction.

Percutaneous coronary intervention in patients with anomalous origin of coronary artery presenting with acute coronary syndrome: A case series.

Coronary artery anomalies are found in 0.6%-1.5% of patients undergoing diagnostic coronary angiogram. Intervention in these patients poses a particular technical challenge secondary to the aberrancies in the vessel origin and course. From March 2011 to February 2013, 13 cases with complex coronary artery anomalies were observed among 2482 patients undergoing CAG (0.52%) at our cath lab. Only three patients had severe stenosis in the anomalous artery sufficient to require an intervention and had presented with myocardial infarction. PCI was performed successfully in these 3 patients two of which had anomalous left circumflex artery and the other having an anomalous right coronary artery.

Left ventricular hydatid cyst: an uncommon cause of chest pain in young adults.

Isolated cardiac involvement in hydatid disease is very rare. We report the case of a young adult male who presented to the emergency department with acute onset of chest pain and was surprisingly detected to have a hydatid cyst in the left ventricular myocardium. The transthoracic echocardiography and cardiac magnetic resonance imaging confirmed the diagnosis. Cardiac hydatid disease should be considered in the differential diagnosis of chest pain in young individuals in the absence of conventional risk factors of atherosclerosis.

Transjugular percutaneous transvenous mitral commissurotomy (PTMC) using conventional PTMC equipment in rheumatic mitral stenosis with interruption of inferior vena cava.

BACKGROUND: Isolated interruption of the inferior vena cava (IVC) is a rare anomaly. We report a series of 4 cases of isolated interruption of the IVC that coexisted with rheumatic mitral stenosis. Interrupted IVC precludes the use of the femoral approach to percutaneous transseptal mitral commissurotomy (PTMC). We describe the jugular approach to PTMC in such cases using conventional PTMC equipment. METHODS AND RESULTS: The mean pre-PTMC mitral valve area was 0.85 cm². Septal puncture was done through the right internal jugular vein with a pediatric Brokenborough needle (Medtronic) using the levophase of pulmonary artery angiogram and the pigtail as guide. The mitral valve was crossed successfully in all cases and appropriately sized Accura balloons (Vascular Concepts) were used for incremental dilatations. Successful balloon dilatation was achieved in all 4 cases (mean post-PTMC mitral valve area of 1.85 cm²) with no complications. CONCLUSION: The jugular approach appears to be a safe and effective alternative in cases of rheumatic mitral stenosis with IVC anomalies, thereby preventing an otherwise necessary surgery.

Infective endocarditis: a rare organism in an uncommon setting.

Facklamia hominis is a rare causative organism of infective endocarditis (IE). Only few cases of infection due to F. hominis have been reported in the literature. We describe a case of IE due to Gram-positive, alpha-haemolytic, catalase-negative coccus F. hominis in an adult patient with rheumatic mitral stenosis. Isolated mitral stenosis is an uncommon valve lesion predisposing to IE. The following paper is being presented to emphasize the possibility of IE due to F. hominis, and laboratories need to be alert of the potential significance in appropriate clinical setting.