Symmetrical peripheral gangrene and Roth spots in a patient with infective endocarditis.

We present a case of a young man with symmetrical peripheral gangrene (SPG) resulting from Streptococcus viridans-related infective endocarditis, an association which has not previously been reported. SPG is associated with up to 40% mortality and may necessitate amputation; early identification and treatment of the precipitating factors is very important.

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital of Northern India.

OBJECTIVES: To evaluate the prevalence and pattern of congenital coronary artery anomalies (CAAs) in the adult population undergoing catheter coronary angiography. METHODS: The coronary angiograms done between October 2015 and September 2020 were reviewed for the presence of coronary anomalies based upon Angelini's classification. The medical record of patients with anomalies was reviewed for symptomatology and indication of angiography. RESULTS: CAAs were found in 129 (87 males and 42 females) of 6,258 patients giving a prevalence of 2.06%. The mean age was 57.8 ± 11.8 (range 32-81) years. Among these, the anomalous origin and course of the coronaries were the most common anomaly seen in 81 (1.29%) patients, followed by intrinsic anomalies of the coronary arterial system in 44 (0.7%) patients and anomalies of coronary termination and anomalous anastomotic vessels in 2 (0.03%) patients each. Overall, the absence of the left main trunk with a separate origin of the left anterior descending (LAD) and the circumflex artery was the commonest anomaly seen in 46 (0.74%) patients, followed by dual LAD in 35 (0.56%) patients. The anomalous origin of the right coronary artery (RCA) from the left sinus was seen in 14 patients (0.22%) and that of the circumflex artery from the right sinus or right coronary artery was seen in 11 patients (0.17%). The origin of the left main and RCA from ascending aorta was found in eight (0.13%) patients. One (0.02%) patient had a single coronary artery, and another one (0.02%) had all the three coronary arteries arising from the right sinus; however, with separate ostia. The split RCA was seen in nine (0.14%) patients and there were two (0.03%) patients each of coronary artery fistulae, and of anomalous anastomotic vessels. CONCLUSIONS: The prevalence of congenital coronary anomalies in this study was 2.06%. The commonest anomaly was that of origin and courses of the vessels, however, the pattern of anomalies is different from previous studies.

Evaluation of intracoronary blood from obstructive vessel in patients of ST-elevation myocardial infarction undergoing PPCI.

OBJECTIVE: Information available on acid-base imbalance in ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention is limited and no data were present on intracoronary blood analysis, extracted from obstructed artery. METHODS: This was a prospective study conducted over 12 months in which STEMI patients presenting in emergency and undergoing primary percutaneous coronary intervention were included. Blood gas analysis of intracoronary arterial blood from obstructed vessel and peripheral arterial blood was performed. Patients in whom adequate intracoronary sample could not be obtained were excluded. Intracoronary and peripheral arterial blood gas measurements were correlated and relationship of intracoronary parameters were compared with clinical parameters, investigational markers and short-term outcome. RESULTS: The mean age of study population was 54.8 years and average symptom onset to door time was 162 min. On comparing intracoronary blood with peripheral blood arterial obtained, pH (95% confidence interval [CI] -0.01 to 0.02;p = 0.44), lactate (95% CI 0.03-0.1;p = 0.28), bicarbonate (95% CI 0.6-1.5;p = 0.64), pCO2 (95% CI 1.1-2.4;p = 0.79) and pO2 (95% CI 3.2-47.5; p = 0.06) were all found to be statistically insignificant. Intracoronary hyperlactatemia was present in patients presenting with higher symptom onset to door time (p = 0.025). Systolic blood pressure (SBP) (p = 0.03) was also significantly lower in patients who had high intracoronary lactate levels. CONCLUSION: The evaluation of intracoronary blood provides no additional information regarding the prognosis and short-term (30-day) outcome of the patients when compared with peripheral blood. However, there was a significant intracoronary hyperlactatemia in patients presenting late after symptom onset. SBP was also significantly less in patients with high intracoronary lactate, which signifies that predominant cause of hyperlactatemia was systemic hypoperfusion rather than local increase in lactate levels.