The Missing Coronary: A Case Series of Inferior Wall Myocardial Infarction Due to Coronary Anomalies.

Coronary artery anomalies, while often asymptomatic, can sometimes present acutely in the context of myocardial infarction (MI). This case series highlights three unique instances of inferior wall MI precipitated by rare coronary anomalies. The first case involved a 40-year-old male with a congenital absence of the left circumflex artery, presenting with a "shark fin" ECG pattern in inferior leads. Urgent coronary angiography confirmed the anomaly and primary percutaneous coronary intervention (PCI) was performed on a superdominant right coronary artery (RCA). The second case details a 52-year-old male with a split RCA, initially undiagnosed due to apparently normal angiographic findings, later revealed to have a thrombotic occlusion of the posterior division. Careful re-evaluation and imaging from alternative angles facilitated successful PCI. The third case describes a 45-year-old male with an anomalous origin of the RCA from the left sinus of Valsalva, presenting difficulties during arterial engagement in PCI. A modified Judkins left catheter technique was employed to achieve selective cannulation and stent deployment. These cases underscore the importance of early recognition, accurate diagnosis, and innovative interventional strategies in managing acute MI due to congenital coronary anomalies.

Feud, Flower, and Fatal Electrocardiograms.

Oleander is a prevalent tropical plant used in many parts of India for deliberate self-harm. The active ingredients act in a mechanism similar to cardiac glycosides; hence, the toxicological profile is similar to digoxin toxicity. Cardiac toxicity occurs in the form of a heart block with concomitant ventricular arrhythmia. Identifying the distinct electrocardiographic pattern for early diagnosis and initiating emergency management is imperative. Here, we present two such interesting cases of oleander intoxication, one with Nerium oleander and the other with Thevetia peruviana.

Clinical profile and electrophysiological characteristics of atypical atrioventricular nodal reentrant tachycardia: A decade's experience.

OBJECTIVE: To assess the clinical features and inducibility characteristics of atypical atrioventricular nodal reentrant tachycardia (AVNRT) and compare it with typical AVNRT. BACKGROUND: AVNRT is the commonest form of paroxysmal supraventricular tachycardia. The mechanism of AVNRT is very varied. Several classification systems evolved with better understanding but a simplified approach of classification into typical and atypical AVNRT is justifiable and clinically more relevant. In our study, we have assessed the epidemiological profile of atypical AVNRT in a single institute over 10 years and analysed pertinent electrophysiological characteristics. METHOD: In this retrospective observational single center study we analysed data of all AVNRT cases from January 2011 to June 2021. In our study we classified atypical AVNRT and typical AVNRT based on the HA interval; HA≤70 ms in the His bundle region during tachycardia was considered as typical AVNRT. Other parameters were also analysed during tachycardia, such as: induction by atrial or ventricular pacing, AH/HA ratio, tachycardia cycle length and site of the earliest atrial activation. The demographic profile of the patients were also compared between 2 groups. RESULTS: Atypical AVNRT was found in 75/1431 patients (5.2%) of all cases of AVNRT. The age of patients with atypical AVNRT was 52.4 ± 15.2 years (range 9-82 years) while that for typical AVNRT it was 48.2 ± 15.7 years (2-89 years), p = 0.023. There was no gender difference. Atypical AVNRT was induced by only ventricular extrastimuli (VES) in 17/75 (22.6%) while in typical AVNRT this was seen in only 12/1356 patients (0.9%, p < 0.001). Induction of atypical AVNRT was seen by both atrial extrastimuli (AES) and VES in 17/75 patients (22.6%) while in typical AVNRT this was seen in 64/1356 patients (4.8%, p < 0.001). Atypical AVNRT was induced by only AES in 40/75 patients (53.3%) while in typical AVNRT this was seen in 1280/1356 patients (94.3%, p < 0.001). An AH >200 ms during tachycardia was seen in all patients with typical AVNRT and in only 31/75 patients (41.3%) of atypical AVNRT (p < 0.00001). An interesting finding in atypical AVNRT was the earliest atrial activation at the His bundle region in 10/75 (13.3%) patients. CONCLUSION: Atypical AVNRT prevalence depends on the way it is classified; this was 5.2% of all AVNRT cases in our study. Typical AVNRT was seen more frequently in comparatively younger age group and was more often induced by AES. Atypical AVNRT was much more commonly induced by only VES compared to typical AVNRT. It was not so unusual in atypical AVNRT to find the earliest atrial activation in the His bundle region.

A unique location of the accessory pathway in a child with permanent junctional reciprocating tachycardia.

Permanent junctional reciprocating tachycardia (PJRT) is a rare supra ventricular tachycardia (SVT) due to an accessory pathway (AP), characterized by slow and decremental retrograde conduction, which is predominantly seen in infants and children. Although the typical site of AP in PJRT is a right posteroseptal region around or just within the coronary sinus (CS), atypical sites of AP have been described. We report a rare case of PJRT in a 7-year-old girl with an AP located in the superio-paraseptal (Para-Hsian) region that was successfully ablated through a non-coronary sinus.

Adenosine-sensitive perinodal atrial tachycardia. What is the mechanism?

Termination of focal atrial tachycardia with adenosine is considered a defining feature for triggered activity. Recent evidence, however, suggests that the perinodal adenosine-sensitive AT has reentry as the mechanism of tachycardia. In this report, we were able to confirm the mechanism of AT as reentry by observing the response to programmed electrical stimulation and demonstrating the fallacy of traditional teaching that the adenosine responsiveness of AT is a criterion for labeling the mechanism as triggered activity.

Wandering ST-Segment in Acute Coronary Syndrome: The Einthoven's Twist.

Interpretation of the ST-segment axis in ST-elevation myocardial infarction (STEMI) plays a crucial role in identifying the culprit artery and optimizing revascularization strategies. In certain conditions, the ST-segment axis may abruptly change during management, creating diagnostic confusion, provoking unnecessary workups, and causing treatment delays. Some reported causes of wandering ST-segment include lead misplacement, progressive injury, coronary vasospasm, migration of the thrombus, and aortic dissection. Here we describe two exciting cases of wandering ST-segment axis in acute coronary syndrome and its management.

Painful LBBB syndrome: a rare cause of angina.

Painful left bundle branch block (LBBB) syndrome is an uncommon condition that is largely underdiagnosed. In this report, we describe a man in his 40s who had typical rate-dependent LBBB associated with angina without evidence of obstructive coronary artery disease.

Utility of urinary biomarkers as a diagnostic tool for early diabetic nephropathy in patients with type 2 diabetes mellitus.

INTRODUCTION: Renal tubulo-interstitial damage has an important role in the pathogenesis of early diabetic nephropathy. Urinary biomarkers can help in the detection of early nephropathy in type 2 diabetic patients. The aim of this study was to estimate the levels of urinary neutrophil gelatinase associated lipocalin (NGAL) and cystatin-C in type 2 diabetic patients with early diabetic nephropathy & to compare them with diabetic patients without nephropathy and to correlate urinary NGAL and cystatin-C levels with microalbuminuria in them. STUDY DESIGN: Cross-sectional comparative study. MATERIAL AND METHODS: The study was conducted on 126 patients with type 2 diabetes along with 30 control subjects attending the outpatient care department of a tertiary care teaching hospital. There were 3 study groups-diabetic patients with microalbuminuria, diabetic patients without albuminuria and control subjects who were non-diabetic without any renal disease. Details on duration of diabetes and glycemic status were obtained from the patients. Urine examination was done for subjects in all the groups to look for microalbuminuria along with estimation of NGAL and cystatin-C levels. Samples were stored at -20 °C in the deep freezer. RESULTS: Urinary NGAL and cystatin-C levels were significantly elevated in patients with microalbuminuria (228.18 & 3.23 ng/ml) as compared to those without albuminuria (146.12 & 2.61 ng/ml) and in control subjects (26.56 & 0.30 ng/ml). Urinary NGAL and cystatin-C levels showed a linear correlation with microalbuminuria in diabetic patients. CONCLUSION: Urinary NGAL and cystatin-C levels were increased in type 2 diabetic patients with early diabetic nephropathy as compared to patients without nephropathy. Urine NGAL and cystatin-C levels also showed a positive correlation with microalbuminuria (urine albumin-creatinine ratio) in patients with type 2 diabetes mellitus.