The Unique Role of Cutting Balloon Angioplasty in Debulking Multiple Nodular Calcium in Osteoproximal and Mid-left Anterior Descending Coronary Artery.

We report a rare case of multiple nodular calcium in the left anterior descending coronary artery in an octogenarian presenting with unstable angina. Dilatation with the noncompliant and scoring balloon could not yield the nodular calcium and it was only the cutting balloon that could yield the nodular calcium and successful coronary angioplasty could be accomplished with good angiographic results with distal Thrombolysis in Myocardial Infarction (III) flow. This case demonstrates the unique role of cutting balloons in the angioplasty of coronary lesions with multiple nodular calcium.

Unmasking a Rare Case of Long-Standing Minimal Pericardial Effusion in Dermatomyositis.

We report an extremely rare case of long-standing (> six months) minimal pericardial effusion attributed to dermatomyositis. The patient was inadvertently administered antitubercular drug therapy for three months after which the patient developed significant weight loss, extreme anorexia, nausea, and vomiting refractory to conventional management. The key message in the manuscript is that even indolent dermatomyositis can present solely as an unexplained pericardial effusion in an individual.

Unveiling a Rare Side Effect: A Report of a Unique Case of Second-Degree Type 2 Sinoatrial Node Exit Block Induced by Adenosine Infusion.

Adenosine is a widely used pharmacologic agent in the field of cardiology, predominantly for the termination of supraventricular tachycardias and diagnostic purposes. Most of the side effects are short-lasting due to its very short half-life. Fatal complications of adenosine are rare but can include ventricular fibrillation, ventricular tachycardia, and asystole. Proper medical supervision and monitoring are crucial to minimize risks. We report a unique case of a second-degree type 2 sinoatrial node exit block following intravenous adenosine administration in a 25-year-old male presenting with palpitations.

Polymorphic Ventricular Tachycardia in Acute Cervical Spinal Cord Injury: A Rare Occurrence in the Setting of Normal QTc.

Cardiovascular manifestations like bradycardia, hypotension, fluctuation of blood pressure, and supraventricular arrhythmia are common in acute spinal cervical injury above the C6 level and are the major cause of mortality and morbidity in them. Ventricular tachycardia (VT) and fibrillation have only been reported in a few cases, but polymorphic VT (PMVT) has not been reported. We report a very rare case of acute cervical spinal cord injury patient who developed PMVT in the setting of normal QT interval degenerating to ventricular fibrillation, causing cardiac arrest before surgery.

A Case of Bradycardia-Induced Torsades De Pointes in a Patient Presenting to the Emergency Room With Cardiac Arrest.

Torsades de pointes (TdP) is a less common type of ventricular tachycardia (VT) characterized by polymorphic VT of changing amplitude and characteristic twists around the isoelectric baseline. It is almost always associated with QT interval prolongation. Unless immediately intervened, it can lead to ventricular fibrillation followed by cardiac arrest. We report a case of a patient with bradycardia-induced TdP who presented to the emergency room with cardiac arrest.

U-shaped and L-shaped Left Main Coronary Artery: Rare Congenital Anomalies.

Congenital anomalies in the shape of the coronary arteries are extremely uncommon to encounter in routine clinical practice in interventional cardiology. In this study, we describe two uncommon shape anomalies of the left main coronary artery, that is, U-shaped left main coronary artery and L-shaped left main coronary artery. These anomalies were observed in two consecutive patients who presented with atypical chest pain and exertional shortness of breath. These uncommon shape anomalies of the left main coronary artery hold their clinical significance during intervention as those require robust guide catheter support during the difficult passage of the routine coronary hardwires.

Exercise-Induced Ventricular Tachycardia: A Case Report.

Exercise-induced ventricular tachycardia (EIVT) is a very rare condition that can occur in both structurally normal and abnormal hearts. It is important to recognize and understand the triggers, symptoms, and implications of this condition. In this report, we present a case of a young patient who experienced symptoms of palpitation, presyncope, and syncope during exertion. We also review the pathophysiology, clinical presentation, diagnosis, and management of exercise-induced ventricular arrhythmia. This information is particularly important in the context of sports medicine and cardiovascular health.

A Ball Valve Thrombus in a Young Obese Male With Hyperlipidemia.

A ball valve thrombus is a common entity in rheumatic mitral stenosis where a large clot forms in the left atrial appendage, the clot detaches from the left atrial appendage, swirls in the left atrium in a clockwise manner, obstructs the mitral inflow producing cyclic acute pulmonary edema, and likely causes left ventricular outflow tract obstruction producing transient syncope or embolism to the brain producing dense hemiplegia. Besides rheumatic mitral stenosis, ball valve thrombus has been described in post-mitral valve replacement patients and restrictive cardiomyopathy. Left atrial myxoma sometimes rocks across the mitral valve producing the effect of a ball valve thrombus. Right atrial ball valve thrombus has been described after prolonged parenteral nutrition through a central line in intensive care units and in carcinoma patients with cardiac metastasis. We report an extremely rare case of a ball valve thrombus in an obese individual where dyslipidemia was the sole triggering factor for the formation of a ball valve thrombus in the left atrium.

Cracking the Left Main Coronary Artery Nodular Calcium With a Scoring Balloon.

Nodular calcium in the coronary artery poses a great challenge during coronary intervention. Although rotational atherectomy is the preferred modality of treatment of nodular calcium, we treated the left main coronary artery (LMCA) nodular calcium with a scoring balloon during primary angioplasty of an octogenarian with anterior wall myocardial infarction and EKG suggestive of LMCA occlusion. During primary coronary angioplasty, the scoring balloon alone also sometimes suffices in achieving good angiographic results and thrombolysis in myocardial infarction grade III (TIMI III) flow.

A novel PID controller for pressure control of artificial ventilator using optimal rule based fuzzy inference system with RCTO algorithm.

In order to improve the pressure tracking response of an artificial ventilator system, a novel proportional integral derivative (PID) controller is designed in the present work by utilizing an optimal rule-based fuzzy inference system (FIS) with a reshaped class-topper optimization algorithm (RCTO), which is named as (Fuzzy-PID). Firstly, a patient-hose blower-driven artificial ventilator model is considered, and the transfer function model is established. The ventilator is assumed to operate in pressure control mode. Then, a fuzzy-PID control structure is formulated such that the error and change in error between the desired airway pressure and actual airway pressure of the ventilator are set as inputs to the FIS. The gains of the PID controller (proportional gain, derivative gain, and integral gain) are set as outputs of the FIS. A reshaped class topper optimization algorithm (RCTO) is developed to optimize rules of the FIS to establish optimal coordination among the input and output variables of the FIS. Finally, the optimized Fuzzy-PID controller is examined for the ventilator under different scenarios such as parametric uncertainties, external disturbances, sensor noise, and a time-varying breathing pattern. In addition, the stability analysis of the system is carried out using the Nyquist stability method, and the sensitivity of the optimal Fuzzy-PID is examined for different blower parameters. The simulation results showed satisfactory results in terms of peak time, overshoot, and settling time for all cases, which were also compared with existing results. It is observed in the simulation results that the overshoot in the pressure profile is improved by 16% with the proposed optimal rule based fuzzy-PID as compared with randomly selected rules for the system. Settling time and peak time are also improved 60-80% compared to the existing method. The control signal generated by the proposed controller is also improved in magnitude by 80-90% compared to the existing method. With a lower magnitude, the control signal can also avoid actuator saturation problems.

An optimal internal model proportional integral controller to improve pressure tracking profile of artificial ventilator.

Mechanical ventilator (MV) is a breathing support medical equipment used during medical surgery or in an intensive care unit (ICU) for critical patients to reduce the breathing work of the patient under ventilation. In this work, a piston-driven mechanical ventilator is studied. Such types of ventilators are generally used as anaesthesia ventilators with volume-controlled modes. A modern ventilator can operate in different modes, such as volume control, pressure control, or both. Pressure-controlled mode may be better suited for some cases, such as patients undergoing laparoscopic surgery, as compared to volume-controlled mode because it may increase compliance during pneumoperitoneum, enhance oxygenation, and lower the stress response postoperatively. The pressure profile of a PCV must exactly track the pressure profile of a patient under ventilation to avoid ventilator-induced diaphragmatic dysfunction. Therefore, an optimal internal model control base proportional integral (IMC-PI) controller is proposed. The optimum parameter of the filter component of the IMC-PI controller is found by an enhanced class topper optimization (ECTO) algorithm. The performance of the proposed controller is analyzed in different scenarios and compared with existing results. Graphical Abstract Optimal internal model proportional integral controller for human respiratory ventilator.

A novel Human Conception Optimizer for solving optimization problems.

Computational techniques are widely used to solve complex optimization problems in different fields such as engineering, finance, biology, and so on. In this paper, the Human Conception Optimizer (HCO) is proposed as a novel metaheuristic algorithm to solve any optimization problems. The idea of this algorithm is based on some biological principles of the human conception process, such as the selective nature of cervical gel in the female reproductive system to allow only healthy sperm cells into the cervix, the guidance nature of mucus gel to help sperm track a genital tracking path towards the egg in the Fallopian tube, the asymmetric nature of flagellar movement which allows sperm cells to move in the reproductive system, the sperm hyperactivation process to make them able to fertilize an egg. Thus, the strategies pursued by the sperm in searching for the egg in the Fallopian tube are modeled mathematically. The best sperm which will meet the position of the egg will be the solution of the algorithm. The performance of the proposed HCO algorithm is examined with a set of basic benchmark test functions called IEEE CEC-2005 and IEEE CEC-2020. A comparative study is also performed between the HCO algorithm and other available algorithms. The significance of the results is verified with statistical test methods. To validate the proposed HCO algorithm, two real-world engineering optimization problems are examined. For this purpose, a complex 14 over-current relay based IEEE 8 bus distribution system is considered. With the proposed algorithm, an improvement of 50% to 60% in total relay operating times is observed comparing with some existing results for the same system. Another engineering problem of designing an optimal proportional integral derivative (PID) controller for a blower driven patient hose mechanical ventilator (MV) is examined. A significant improvement in terms of response time, settling time is observed in the MV system by comparing with existing results.

Extended Kalman filter state estimation-based nonlinear explicit model predictive control design for blood glucose regulation of type 1 diabetic patient.

The computational burden of iterative online optimization-based model predictive control (MPC) process is solved by adapting off-line optimization-based nonlinear explicit model predictive control (NEMPC). In this paper, the application of NEMPC is verified to regulate blood glucose level in type 1 diabetes mellitus (T1DM) patients. The objective of glucose regulation is to avoid hyperglycemia (> 180 mg/dl) and hypoglycemia (< 50 mg/dl) by maintaining glucose level in the range of 70 to 180 mg/dl. It helps to avoid time complexity of iterative process during solution of optimization stage in MPC. In the nonlinear T1DM model, only the state dynamic of sugar is measurable with low complexity and high cost among other states of the model. Therefore, an extended Kalman filter (EKF) is used developed to estimate unavailable states. The information of the estimated states are used to develop the proposed control approach for the T1DM patients. The simulation results of the NEMPC along with EKF-based state estimator for T1DM model shows the regulation of blood glucose-level (BGL) within 70 to 180 mg/dl within 120 min. The robustness of the proposed scheme is also verified under the change in parameters and food disturbance. The control variability grid analysis (CVGA) of NEMPC for 50 numbers of virtual T1DM patients under random parametric changes and meal disturbances shows the avoidance of hypoglycemia and hyperglycemia in type 1 diabetic patients. The proposed control method is simple, robust and efficient to regulate glucose level in T1DM patients. Extended Kalman filter state estimator based nonlinear explicit model predictive control for blood glucose regulation in Type 1 diabetic patients.

Dual atrio ventricular node in heterotaxy syndrome.

Our interesting electrocardiogram has two qRS morphology without features of preexcitation suggesting two atrio ventricular node conduction system. All cardiologists should be aware of this feature in heterotaxy syndrome as reentrant supraventricular tachycardia may develop in these patients.

Device closure of fistula from left lower pulmonary artery to left atrium using a vascular plug: A case report.

BACKGROUND: Pulmonary artery-to-left atrial fistula is a variant of pulmonary arteriovenous fistula and is a developmental anomaly. Delayed presentation, cyanosis and effort intolerance are some of the important features. The diagnosis is confirmed by computed tomography or pulmonary artery angiography. Catheter-based closure is preferred to surgery. CASE SUMMARY: Left pulmonary artery-to-left atrial fistula is rare. A 40-year-old male presented with effort intolerance, central cyanosis, and recurrent seizures. He had a large and highly tortuous left pulmonary artery-to-left atrial fistula associated with a large aneurysmal sac in the course. Catheter-based closure was performed using a vascular plug. CONCLUSION: Left pulmonary artery-to-left atrial fistula is relatively uncommon compared to right pulmonary artery-to-left atrial fistula. Percutaneous closure by either a transeptal technique or guide wire insertion into the pulmonary vein through the pulmonary artery is preferred. The need for an arteriovenous loop depends on the tortuosity of the course of the fistula and the size of the device to be implanted because a larger device needs a larger sheath, necessitating firm guide wire support to facilitate negotiation of the stiff combination of the delivery sheath and dilator.

Swarm optimization approach to design PID controller for artificially ventilated human respiratory system.

BACKGROUND AND OBJECTIVE: An artificially ventilated human respiratory system is used to help breathing of a patient with respiratory problem. The level of oxygen is maintained stable by controlling the airway pressure in the lungs mechanism with the help of medical ventilator. For pressure control in a ventilator, the airway pressure in lungs mechanism is controlled by a motor driven piston mechanism. The optimal setting of controller parameters of a respiratory ventilator system depends on many factors of a patient such as physical condition of patient, need of oxygen, age of a patient etc. Therefore, computer operated algorithm based artificial ventilation system becomes most popular for its better performance, efficiency, and easy control mechanism. In this paper, a simple swarm optimization based controller design approach is systematically verified to design suitable controller for pressure controlled artificially ventilated human respiratory system. A modified constricted class topper optimization (C-CTO) algorithm is proposed for tuning the controller in an artificial ventilator system. METHODS: A pressure controlled ventilation (PCV) model has been considered. A proportional-integral-derivative (PID) controller structure is considered for the PCV. Three different optimization approach (Particle swarm optimization (PSO), class topper optimization (CTO) and a modified constricted class topper optimization (C-CTO)) are verified one by one for the purpose of tuning PID controller for PVC system. RESULTS: The performances of swarm based controller in PCV system for three different cases are examined in terms of settling times and maximum overshoot of the system. CONCLUSIONS: The swarm based optimization approach is improving the dynamic response of pressure control artificially ventilated human respiratory system. In this paper, a simple piston-motor driven lung mechanism is applied to verify the swarm based approach, but this approach can further be checked in the future for more complex human lungs artificially ventilated system.

Incidence, clinical, electrophysiological characteristics and outcomes of patients with Wolff-Parkinson-White syndrome and atrial fibrillation.

AIMS AND OBJECTIVES: Atrial fibrillation (AF) with preexcitation can be life threatening. Our study evaluated the incidence, clinical features, electrophysiologic characteristics and outcomes of patients presenting with AF and fast ventricular rates associated with an antegrade conducting accessory pathway. METHODS: Hospital data of patients who had undergone electrophysiology study and radiofrequency ablation for AF and Wolff-Parkinson-White (WPW) syndrome was retrospectively evaluated over 10 years and prospective data was further collected over 1 year. Out of 2876 patients undergoing electrophysiology study, 320 patients had manifest preexcitation on ECG. Forty one patients who had presented with AF and fast ventricular rates were included in the study. RESULTS: Forty one (12.8%) patients out of 320 patients of WPW syndrome patients presented with AF and fast ventricular rates. Mean age of presentation was 38.5 ± 12.3 yrs. Twenty nine (72.5%) were male. Most common presenting features were palpitations, presyncope and syncope. Twenty eight (71.1%) patients were electrically cardioverted on presentation, of which two patients having narrow complex tachycardia, when given adenosine, developed AF and fast ventricular rates and had to be electrically cardioverted. Intravenous amiodarone converted AF to sinus rhythm in 11 (28.9%) patients. Right postero-septal pathway (33.3%) followed by coronary sinus epicardial pathway (22.9%) were the most commonly located pathways associated with AF. Five (12.2%) patients had multiple pathways. CS diverticulum was seen in 6 (14.7%) patients. Ablation was done during AF in 6 (14.7%) patients. All except one had immediate successful ablation. One patient had a recurrence of preexcitation on follow up and successfully ablated during redo procedure. CONCLUSION: AF with WPW syndrome is not uncommon. AF is commonly associated with posteriorly located accessory pathways, CS diverticulum and multiple pathways. Radiofrequency ablation has good outcomes.