Hemopericardium Following Transseptal Puncture During Balloon Mitral Valvotomy: Management Strategies and Outcomes.

BACKGROUND: Hemopericardium is a major complication of balloon mitral valvotomy (BMV). Only a few studies are available to address this issue following transseptal access. In addition, the management strategy regarding completion of BMV is uncertain. OBJECTIVE: We sought to determine the incidence of hemopericardium complicating transseptal puncture during BMV. In addition, the management strategy adopted and outcomes are highlighted. METHODS: This prospective study included 29 consecutive patients who developed hemopericardium following transseptal access during BMV. RESULTS: Out of 1424 patients who underwent BMV, hemopericardium developed in 29 patients following transseptal access (2.0%). The mean age of the study cohort was 36.9 ± 13.7 years and 82.8% were women. A second transseptal puncture was done and BMV was completed in 26 patients (89.6%). An acceptable hemodynamic result was obtained in 22 patients (84.6%). Six patients (20.7%) underwent emergency surgery for hemopericardium. The sites of perforation were inferior vena cava-right atrial junction in 4 cases, left atrial posterior wall in 1 case, and left atrial appendage in 1 case. In addition to repair of the perforation, a total of 2 patients underwent mitral valve replacement and 1 patient underwent open mitral commissurotomy. The in-hospital mortality rate was 6.9%. CONCLUSIONS: The incidence of hemopericardium complicating transseptal access during BMV was 2.0%, and was associated with a mortality rate of 6.9%. BMV can be safely performed in the same sitting with a second transseptal puncture, in patients with a favorable valve morphology. Surgical intervention can be reserved for a subset of patients with persistent pericardial collection.

Prosthetic mitral valve thrombosis, malfunction, and paroxysmal mitral regurgitation.

Intermittent dysfunction of mechanical mitral valve prosthesis is an uncommon condition. It carries serious clinical implications if unrecognized. Here, we present a case of a 28-year-old female with a history of rheumatic multivalvular disease, for which she had undergone double valve replacement and tricuspid annuloplasty. Six months later, she presented with heart failure. Clinical examination revealed intermittent loss of closing clicks followed by a pansystolic murmur at the apex, suggestive of mitral prosthetic valve dysfunction. We highlight the echocardiographic findings of paroxysmal mitral valvular regurgitation secondary to prosthetic valve malfunction secondary to prosthetic valve thrombosis.

Percutaneous Stenting for Unprotected Left Main Chronic Total Occlusion.

PCI of a left main coronary artery chronic total occlusion followed by PCI of the right coronary artery was performed in a patient refusing CABG surgery.

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.

Lipomatous hamartoma of mitral valve.

Primary cardiac tumors are very rare, and tumors arising from cardiac valves are extremely rare. We present a case of lipomatous hamartoma of the mitral valve in a young female. This is the 6th case of lipomatous hamartoma of the mitral valve to be reported. We discuss the operative and histopathological findings.

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.

Hydatid cyst of lung: An uncommon cause of chest pain in young.

Echinococcosis can involve any organ. The liver is the most common organ involved, followed by the lungs. Depending on the location of involvement it can have varied presentation. We describe a young adult presenting with chest pain secondary to a pulmonary giant hydatid cyst. A pulmonary hydatid cyst should be considered in the differential diagnosis of patients presenting with chest pain without conventional risk factors of coronary artery disease, especially in a tropical region.

Xanthoma tuberosum in homozygous familial hypercholesterolemia.

Familial homozygous hypercholesterolemia is one of the high risk factors that can result in premature coronary arterial disease leading to severe morbidity and premature death in children and young adults. We describe a rare example of extensive xanthoma tuberosum in a case of familial homozygous hypercholesterolemia.

Clinical, echocardiographic and microbiological study, and analysis of outcomes of infective endocarditis in tropical countries: a prospective analysis from India.

BACKGROUND AND AIM OF THE STUDY: The aim of this prospective observational study was to evaluate the clinical, echocardiographic, microbiological profile and outcomes of patients with definitive infective endocarditis (IE) in tropical countries. METHODS: Between September 2010 and March 2013, a total of 109 patients with 111 episodes of definitive IE (as per the modified Duke's criteria) was enrolled in the study. The mean age at presentation was 32.7 ± 17.2 years (range: 2-70 years), and there was a male preponderance (3:1). RESULTS: Native valve disease was identified in 57 cases of IE, followed by congenital heart disease (n = 35), prosthetic valve disease (n = 11), normal valves (n = 5) and pacemaker lead infection (n = 1). Echocardiography was diagnostic in all patients except one. Positive blood cultures were obtained in 68 episodes, with streptococci (n = 34) and staphylococci (n = 11) the most common organisms. At least one major complication was identified in 60 patients. Ultimately, only 15 patients underwent surgery for IE, but 25 died during their hospital stay. On multivariate analysis, prosthetic valve involvement, combined mitral and aortic valve involvement, male gender, and leukocytosis were independent predictors of mortality. CONCLUSION: IE in India is associated with a higher mortality and lower rates of culture positivity compared to the west; rates of surgery for IE in India are unacceptably low. Changing epidemiological trends may pose newer challenges in the near future.

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.

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.

Superior vena caval stenting for idiopathic mediastinal fibrosis.

Relief of superior vena caval (SVC) syndrome due to non-neoplastic mediastinal disease is a challenge. Surgically created bypass grafts have poor long term patency with significant procedural morbidity. We report a case of SVC syndrome, caused by Idiopathic mediastinal fibrosis, treated percutaneously by balloon angioplasty with nitinol self expanding stent.

Cardiac tumour in a patient with rheumatic heart disease.

A 45-year-old female known to suffer from rheumatic heart disease (RHD), presented with breathlessness of 1 year duration. Two-dimensional echocardiography revealed significant mitral and aortic valve disease mandating double valve replacement. In addition, an unusual finding in the form of a well-defined, densely calcified intramyocardial left ventricular mass was noted on echocardiography. The nature and extent of the mass was assessed by additional imaging modalities. Patient underwent excision of the mass followed by double valve replacement. Histopathology was consistent with cardiac calcific amorphous tumour (CAT). An unusual occurrence of CAT in a patient with RHD is presented herein. This rare tumour has not been previously described in patients with RHD.

The challenge produced by familial homozygous hypercholesterolemia when treating premature coronary arterial disease in the young.

BACKGROUND: Familial hypercholesterolemia is a monogenic, autosomal dominant disorder caused by mutations in the LDL receptor gene. Familial homozygous hypercholesterolemia results when both the alleles have the defective mutation. It is characterized by cutaneous and tendinous xanthomas, premature corneal arcing, and is associated with an increased risk of coronary arterial disease. It is also seriously underdiagnosed, resulting in delayed treatment. METHODS: We present a cross-sectional study of 5 patients with familial homozygous hypercholesterolemia who presented to the department of cardiology at Sri Jayadeva Institute of Cardiology, Bangalore, India. All of them underwent coronary angiography as part of the investigation of their angina. RESULTS: All 5 patients were in 2nd or 3rd decade of life, 4 being male, and 4 presenting with effort angina, the other having unstable angina. All had multiple tendinous xanthomas. The majority had significant high grade coronary arterial stenosis. Coronary arterial bypass grafting was necessary in 3, with the others undergoing percutaneous insertion of coronary arterial stents. CONCLUSION: Familial homozygous hypercholesterolemia is a potentially dangerous risk factor that can result in premature coronary arterial disease in children and young adults. This can result in severe morbidity and premature death in young individuals. We also emphasise the need to screen first-degree relatives and extended family members, this playing an important role in early detection and treatment. Despite recent advances in treatment using lipid lowering agents, the disease remains a significant challenge.