Consensus and development of document for management of stabilized acute decompensated heart failure with reduced ejection fraction in India.

AIM: Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required. METHODOLOGY: A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings. RESULTS: Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse. CONCLUSION: This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

Use of 'Guideliner' catheter to overcome failure of delivery of Absorb™ Bioresorbable Vascular Scaffold in calcified tortuous coronary lesions: technical considerations in 'Real World Patients'.

In our series of 177 real world patients (223 lesions) who underwent Absorb Bioresorbable Vascular Scaffold (BVS) implantation, 78 lesions were calcified and tortuous lesions. In four of these, despite adequate lesion bed preparation, appropriate guiding catheter support and use of buddy wires, the BVS failed to track through the proximal calcified and tortuous coronary anatomy (CTCA). "Guide Liner" catheter (GLC) had to be finally used to resuccessfully deliver and implant BVS to the lesion site. We report for the first time four cases of use of guideliner catheter to successfully overcome failed delivery of BVS to the lesion site through proximal CTCA, calcified and tortuous coronary artery (CTCA) lesions treated with Absorb™ BVS. Because the BVS is a large profile device, certain difficulties were encountered in delivering it through the GLC, which were finally overcome. We have therefore discussed the 'lessons and learnt' and "salient practice points" to enable successful delivery of BVS through the GLC.

Adenosine induced coronary spasm - a rare presentation.

Adenosine is commonly used as a pharmacological agent in myocardial perfusion imaging, as an antiarrhythmic agent, and in Cath Lab. during PCI for treating no reflow phenomenon. Coronary spasm has been reported following adenosine injection during stress imaging. We report a rare complication with ST segment elevation, following adenosine injection, given for treatment of supraventricular tachycardia.

Evolving coronary stent designs. Journey from substance to sublime.

Coronary artery disease continues to remain a global health care burden. Paradoxical changes in global economies have redefined future development and consumption markets. Within the next decade the need for high quality, low cost coronary stents may reach up to 10 million units. Parallel changes in technological trends further necessitate ingenuity in coronary stent development. Developing nations, armed with novel technologies, supported with low development costs and access to high end manufacturing are poised to serve the global demands of future coronary stent requirements. New concepts in DES engineering employing novel stent designs, drug delivery technologies and affordable DES systems will effectively bridge the need gap between metal backed DES and its ultimate nemesis the bioresorbable scaffold.

Type IV Dual Left Anterior Descending Coronary Artery:A Rare Anomaly.

Type IV dual left anterior descending (LAD) coronary artery is a rare anomaly and was detected incidentally during a routine coronary angiogram. The article discusses the types of dual LAD and their clinical implications.

Measurement and modeling of bentazone in the river Main (Germany) originating from point and non-point sources.

A Water Framework Directive pilot project combines measured data and model approaches to calculate fluxes and mass balance of the pesticide bentazone in an 81 km section of the river Main (Germany). During the study period (six weeks in spring 2004) the observed bentazone inflow and outflow in the river section amounted to 52.8 and 53.1 kg, respectively; the maximum concentrations reached 220 and 290 ng l(-1). Based on sampling of seven sewage treatment plants a specific loss of 0.87 g bentazone per farm was calculated. Extrapolation to the entire sub-basin results in 2.6 kg bentazone in total as point source contribution from farms. Diffuse input into the surface water network occurred after an intensive rainfall event on May 7th. Total bentazone load was simulated with the pesticide emission model DRIPS to be 23.2 kg. One third of this load was estimated to be degraded by photolysis before reaching the main waterway, the river Main. The ATV water quality model was applied to predict the concentration profile of bentazone in river Main between Schweinfurt and Würzburg with reasonable results. The difference between total measured and modeled fluxes amounted to 1.5 kg corresponding to 2% of the overall input. The combined approach of monitoring and modeling appears to be a valuable strategy to quantify the relevance of point and non-point sources and to focus effective mitigation measures to the most relevant origins within a river basin.

Choice of DES: is there a difference?

Restenosis after percutaneous coronary interventions has been a major limitation of this otherwise very well-accepted method of coronary revascularisation. Coronary stents work by scaffolding the intimal flaps and preventing elastic recoil, which was a major problem after balloon angioplasty. The neointimal growth response to stenting contributes significantly to the restenotic process. Randomised studies comparing coronary artery bypass surgery with coronary stenting especially in multivessel disease clearly highlighted this problem. The problem has been greater in magnitude in special subgroups: diabetics, patients with small vessels (≤2.5 mm in diameter), long segments of disease (≥20 mm in length), etc. These limitations of Bare metal stents have been addressed by drug-eluting stents (DESs). Third-generation stents with bioabsorbable polymers like the Biolimus releasing Biomatrix stent have already become available in Europe and parts of Asia. A longer follow-up will prove their long-term safety vis-à-vis first-generation DES. The polymer-free stent with capability of using more than one drug, though very attractive, needs larger multicentric studies before gaining wider acceptance. The fully bioabsorbable stent is yet another promising concept. The feasibility has already been demonstrated, and finer refinements are under way. The future of newer DES thus is very promising, and most of the issues related to first-generation DES are at the threshold of being solved.

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.

Very late stent thrombosis after implantation of drug eluting stent.

A case of late stent occlusion of a Sirolimus eluting Cypher stent (Cordis, Johnson and Johnson) presenting as acute ST elevation myocardial infarction 22 months after deployment is reported. The possible mechanisms are discussed.

Delayed occurrence of restenosis in drug eluting stents: an evidence of delayed healing.

Drug eluting stents have made a significant impact on restenosis. However, there are concerns regarding delayed "catch-up" of restenosis. In this case report we present two such patients with delayed occurrence of restenosis after drug eluting stent implantation.

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.

Management of acute myocardial infarction--primary angioplasty the treatment of choice!

The management goal of acute myocardial infarction is prompt revascularization. Recent years have seen improvements in both pharmacological and mechanical methods of revascularization of the infarct related arteries. This brief review summarises these developments and ongoing efforts.