Reverse Takotsubo Cardiomyopathy Following COVISHIELD Vaccination: A Rare Case of an Anaphylactic Reaction.

This case report describes a 47-year-old female healthcare worker who developed reverse takotsubo cardiomyopathy (TTC) following the administration of the COVISHIELD COVID-19 vaccine. Within minutes of receiving the vaccine, she experienced acute shortness of breath, nausea, and restlessness, along with a significant drop in blood pressure. She was diagnosed with an anaphylactic reaction and promptly treated with adrenaline and fluids. In the intensive cardiac care unit, she exhibited hypotension, had vision loss, and developed pulmonary edema. Further evaluation revealed abnormal ECG findings, elevated troponin levels, and reduced left ventricular ejection fraction (LVEF). Coronary angiography ruled out obstructive coronary artery disease. The patient gradually improved over several days and was discharged with a recovered left ventricular function. This case highlights the occurrence of TTC triggered by anaphylaxis to the COVID-19 vaccine and emphasizes the need for preparedness to manage such emergencies in vaccination centers.

A Rare Case of Sleep Terror Disorder in an Adult With Chronic Alcohol Abuse: A Case Report and Literature Review.

Sleep terror disorder and chronic alcohol abuse are severe conditions that can significantly impact an individual's quality of life. Sleep terror disorder is characterized by sudden and intense episodes of fear or terror, while chronic alcohol abuse can lead to physical and psychological problems that can negatively impact sleep quality. This patient had terminal insomnia with episodes of terror, screaming, and no memory of arousal. Treatment of sleep terror disorder in chronic alcohol abuse patients involves addressing any underlying medical or psychological issues, medication, and cognitive-behavioral therapy (CBT). CBT can help identify and dispute harmful thought patterns and teach coping mechanisms. We present a case of an adult male who had terminal insomnia with episodes of terror, screaming, and no memory of arousal.

Comparison of neonatal and maternal outcomes of anti-diabetic drugs in the treatment of gestational diabetes mellitus: Findings from Bayesian network meta-analysis.

The safety and efficacy of different anti-diabetic drugs are not clear because of the lack of sufficiently powered clinical trials. This network meta-analysis was conducted to compare the efficacy and safety of three anti-diabetic drugs (insulin, glyburide, and metformin), and rank them as per their efficiency to control glucose levels, pregnancy, and neonatal outcomes. The study design is a systematic review, meta-analysis, and network meta-analysis. After a systematic search of existing databases, 34 randomized controlled trials were selected for inclusion in the analysis. We did pairwise network meta-analysis to calculate standardized mean difference and odds ratio (OR) as the summary measures for numerical and dichotomous variables, respectively, by using random-effects model. Our key outcomes were incidence of neonatal hypoglycemia, respiratory distress syndrome, macrosomia, C-section, admission to neonatal intensive care unit (NICU) and mean differences in the birth weight of neonates, gestational age at birth, HbA1C levels, fasting blood sugar, large at gestational age, and post-prandial glucose. It was found that metformin significantly lowered the post-prandial levels of glucose as compared with both glyburide and insulin in pairwise analysis (SMD = 14.11 [23-4.8]; SMD = 22.45 [30-14]), respectively. There was a significant reduction in birth weights of babies whose mothers were administered metformin as compared with either glyburide or insulin. The proportion of neonates admission to NICU was significantly lower for metformin when compared with insulin [Log OR = 0.334 (0.0184, 0.6814))]. Large at gestational age was significantly lower for metformin as compared with both glyburide and insulin [log OR = 0.6882 (0.171, 1.329), log OR = 0.393 (0.00179, 0.8218)], respectively. Oral anti-diabetic drugs especially metformin performed better than both glyburide and insulin for all neonatal and maternal outcomes except that it significantly lowered the neonatal birth weight.

A case of "very" very late stent thrombosis: More than 12 years after DES.

A rare but possibly catastrophic consequence of drug-eluting stents (DES) is very late stent thrombosis. We report a case of 74-year-old male who sustained a ST elevation myocardial infarction (STEMI) 12 years after initial Paclitaxel eluting stent implantation (PES). This is the longest time between stent placement and the development of an acute coronary event due to very late stent thrombosis that we are aware of (VLST). The implications for prognosis and therapy are significant because they highlight the uncertainty around the recommended duration of antiplatelet medication in patients with DES. Clinicians face challenges in treating those patients particularly when competing medical conditions demand the discontinuation of antiplatelet therapy. VLST is concerning since the underlying pathophysiology is unknown, and the best preventive treatments and duration of antiplatelet medication after stent implantation are unknown.

Reducing the Wire Crossing Time in Primary Percutaneous Coronary Angioplasty: A Study From a Tier II City in India.

Acute coronary syndrome is a major cause of morbidity and mortality all over the world. Timely intervention in ST-elevation myocardial infarction (STEMI) in the form of primary angioplasty is the gold standard of treatment to reduce mortality and morbidity. "Time is muscle" is the phrase to impress upon the importance of time in treating patients with STEMI. Traditional treatment target included "door to balloon time" of 90 min or less. This "door to balloon time" is now rephrased as the "wire crossing time" (WCT). The European Society of Cardiology (ESC) updated its guidelines further, reducing the target of wire crossing time to 60 min. The present study is a brief report on the door to wire crossing time status in one of the tertiary care centers of a nonmetro city. Retrospective analysis of case records was done for 79 patients admitted with acute MI who underwent primary angioplasty between November 2018 and June 2019 (pre-corrective action group). Various reasons for the delay, right from the time of the patient reaching the emergency room (ER) to the time of wire crossing, were analysed and measures were taken to reduce the delay. The post-corrective action group comprised 77 patients. The major causes of a prolonged WCT in our setup were delayed diagnosis of STEMI in ER, delay in giving consent by the patient's relatives, financial issues, and availability of cath lab technicians during the off-duty hour. The delay in WCT in our center was 121 min. Remedial actions were taken to mitigate the problems at each step, which resulted in a reduction of delay by 20 min, i.e., to 101 min leading to a significant difference in the outcome in view of morbidity and mortality.

Endodontic Emergencies Encountered in a Tertiary Dental Hospital during the Periods of Prelockdown, Lockdown, and Sequential Unlock Phases of the First Wave of COVID-19 in Ahmedabad City, India.

INTRODUCTION: With the worldwide spread of SARS-CoV-2 infection, temporary suspension of all the elective dental procedures and an urgent shift to nonaerosol producing dental treatments were observed. This study provides a detailed description of emergency treatments provided in the Department of Endodontics at a tertiary healthcare centre during the period of prelockdown, lockdown, and sequential unlocking from March 1, 2020, to October 31, 2020. METHODS: Access to General and Departmental OPD data along with treatment records was obtained and was segregated based on age, sex, and treatments performed. Treatments were divided into aerosol generating procedures (AGPs) and non-AGPs and further subdivided into palliative treatment (PT), pulp capping (PC), incision and drainage (ID), temporary filling (TF), pulpectomy (PU), and pulpotomy (PO). Data was analysed and subjected to chi-square test. RESULTS: A total of 15052 patients approached general OPD during the period of 8 months of which 5698 (37.86%) were endodontic in origin and treatments offered were PT 858 (15.05%), PO 1560 (27.37%), PU 2018 (35.42%), TF 500 (8.78%), ID 164 (2.88%), and PC 598 (10.94%). Also, more females (57.28% (3264/5698)) visited the department as compared to males (42.72% (2434/5698)). CONCLUSION: The pandemic had turned the tables on over the people around the world, and it has become extremely necessary to rule out the emergencies needed to treat the patients accordingly shifting more towards non-AGPs compared to AGPs among the various age groups of the society.

Mapping the Conduction System in Patients Undergoing Transcatheter Device Closure of Perimembranous Ventricular Septal Defect: A Proof-of-Concept Study.

Earlier studies that investigated the relation of atrioventricular (AV) conduction system to perimembranous ventricular septal defect (pmVSD) were based on cardiopathological specimens. To study the relationship of conduction system to pmVSD using 3-dimensional electroanatomic mapping system (EAMS) in patients undergoing device closure. Fifteen consecutive cases of pmVSD from January 2014 to July 2017 (age > 2 years and weight > 8 kg) were included in the study. The course of conduction system and its relationship with the pmVSD was mapped before and after device closure, with the use of EAMS. Median age and weight of the cohort was 10 years (range 4-21 years) and 25 kg (range 13-55) respectively. Device implantation was successful in all patients except 1. The course and relation of the conduction system were posteroinferior to the pmVSD in all cases (100%), and away from the defect in 67% (10/15). In patient with baseline RBBB, the right-sided conduction system was in close proximity to the pmVSD. Two patients had part of left-sided conduction system in close proximity to pmVSD or device edges. Two patients developed RBBB following device deployment, which reverted to normal on follow up. No patient developed high grade AV block during the median follow-up of 34 months (range 24-62). This experimental study has shown the feasibility of 3D EAM of conduction system during device closure of pmVSD. This novel concept can be utilized to understand the anatomy of conduction system in other congenital heart diseases.

Radial Artery Pseudoaneurysm Following Cardiac Catheterization: A Case Report.

The transradial approach is the most preferred method for cardiac catheterization. The radial route approach has many advantages, including fewer puncture site-related complications and early mobility and discharge. The vascular complications include radial artery spasms, occlusions, dissections, perforations, and compartment syndrome. Although pseudoaneurysms are a well-known complication of femoral access (0.2%-3%), pseudoaneurysms are very infrequent (0.05%) after radial artery access. Very few cases of radial pseudoaneurysms have been reported to date. We present a rare case of an 82-year-old man on dual antiplatelet and anticoagulant therapy who underwent coronary angiography via the radial route. The patient developed a pseudoaneurysm requiring surgical intervention.

Impact of the inflammation on the outcomes of catheter ablation of drug-refractory ventricular tachycardia in cardiac sarcoidosis.

INTRODUCTION: Catheter ablation (CA) of ventricular tachycardia (VT) in cardiac sarcoidosis (CS) has been reported with varying success. However, there is a scarcity of data on the outcomes of CA based on ongoing inflammation. OBJECTIVE: We hypothesized that the response to VT ablation depends upon the stage of the disease. METHODS: Between July 2004 and December 2018, 24 patients of CS presented with drug-refractory VT at CARE Hospital (Hyderabad) and the University of Minnesota (Minneapolis, MN). Patients were classified into two groups based on cardiac magnetic resonance imaging and positron emission tomography: (a) inflammatory phase, (b) scar phase. All patients underwent 3D electro-anatomic mapping guided CA. RESULTS: The clinical VT was ablated in all but one patient. In 16 patients (66.6%), both the clinical and nonclinical VTs were ablated (complete success), while in seven patients (29.1%) nonclinical VTs was still inducible. In patients with inflammation (group A), complete success for VT ablation was achieved in 10 out of 17 (58.8%). In patients without inflammation (group B), complete success was achieved in six out of seven patients (85.7%). Eleven patients (45.8%) had a recurrence of VT. Among patients in the inflammatory phase (group A): 10 out of 17 patients had a recurrence of VT, while only one out of seven patients in the scar phase (group B) had VT recurrence over a mean follow-up of 5.7 ± 3.9 years. Epicardial ablation was performed in 10 (41.6%) patients. CONCLUSION: CA of drug-refractory VT in CS is effective, often requiring the epicardial approach. Incomplete success and recurrence of VT were higher in the inflammatory phase of the disease.

Demographic & angiographic profile of young patients aged 40 year & less undergoing coronary angiography in a tier II city of Eastern India.

BACKGROUND: Cardiovascular diseases (CVD) and its complications are on an increasing trend in the younger age group. In this study, we aimed to identify the different risk factor profile and coronary angiographic characteristics of young adults presenting with coronary artery disease. METHODS: We conducted this retrospective observational study at Tata Main Hospital, Jamshedpur, Jharkhand, for 5 years between April 2015 and March 2020. Inclusion criteria being patients admitted for acute coronary syndrome or chronic stable angina, aged ≤40 years, who underwent coronary angiography. Those below 40 years of age who underwent angiography in non-CAD (coronary artery disease) setting were excluded. RESULTS: Among the 117 cases included in this study, 81.1% were males and 18.8% were females. Majority of cases, i.e., 52.2% were in the age group of 36-40 years. Risk factor evaluation showed hypertension as the major risk factor, present in 30.76% of patients, followed by diabetes mellitus in 21.36%, Dyslipidaemia was noted in 7.6%. History of smoking was present in 8.54%, history of smokeless tobacco use was in 7.69%, family history of CAD was noted in 9.4% of patients. Among 117 cases, SVD (single-vessel disease) was most prevalent, seen in 55.5% cases. 21.3% had normal or recanalized coronaries. Among SVD, LAD (Left anterior descending artery) was the most commonly involved vessel (80%). CONCLUSIONS: Young patients with CAD are mainly males, and SVD in the form of LAD is more commonly involved. In this vulnerable age group, more emphasis should be given on diagnosis and management of risk factors.

Spontaneous coronary artery dissection involving all major arteries LAD, LCX and RCA -A case report.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and sudden cardiac death. Amongst various etiologies thought to be responsible for this condition, atherosclerosis seems to be the most common. There are various case reports on (SCAD) of single coronary artery but the presence of SCAD of all three arteries is not known. We describe a case of a 45-year-old gentleman without any conventional coronary risk factors, who was referred to us at Tata Main hospital, Jamshedpur, for cardiac evaluation prior to his urethral surgery. Although asymptomatic cardiac-wise, his ECG incidentally revealed healed inferior wall myocardial infarction. Echocardiogram confirmed hypokinetic inferior wall with left ventricular ejection fraction of 50%. His coronary angiography showed spontaneous dissection of LAD, LCX and RCA which was managed conservatively.

Comparative assessment of conventional and light-curable fluoride varnish in the prevention of enamel demineralization during fixed appliance therapy: a split-mouth randomized controlled trial.

Objective: To evaluate the effects of single application of a conventional versus light-curable fluoride varnish (LCFV) on prevention of enamel demineralization during fixed orthodontic treatment over a 4 month period. Design: The research was designed as a split-mouth, randomized control trial (RCT). Methods: Twenty-two patients requiring fixed orthodontic treatment with premolar extractions were included in the RCT. In each patient, two diagonal quadrants (i.e. upper right and lower left, or vice versa) were randomly assigned to receive conventional fluoride varnish or LCFV. After allocation of one intervention, the other diagonal quadrants received the second intervention. At specific time intervals, premolars were extracted and sectioned, and the demineralized lesion was assessed in each group. Main outcome measures: The primary outcome was demineralized enamel lesion depth (DELD) at the end of 45, 90, and 120 days. Randomization: A simple complete randomization list using random allocation rule (restricted randomization) was computer generated to ensure homogeneity of application of conventional or LCFV to each contralateral quadrant in a split-mouth design. Allocation concealment was not employed. Blinding: Blinding was done only for outcome assessor because of clinical limitations. Results: Twenty-two patients with 88 teeth were enrolled in the trial. After excluding the drop-outs, primary analysis was performed on 66 teeth distributed among two interventional groups. Mean difference between DELD among two groups was 36.6 µm [95 per cent confidence interval (CI) 34.61-38.55] and 58.5 µm [95 per cent confidence interval (CI) 55.65-61.43] at 90 and 120 days, respectively. Cluster level analysis performed by Paired t-test showed that DELD was significantly higher (P < 0.001) in the conventional fluoride varnish group at the end of 90 and 120 days as compared to LCFV group. No adverse effect was observed in any patient. Limitations: Being a histologic study, the role of fluoride varnish could be assessed only for 4 months. Conclusion: The result of this study indicate that single application of LCFV (Clinpro™ XT) can prevent enamel demineralization for longer duration (for up to 4 months) of time as compared to conventional fluoride varnish (Duraphat™, 45 days) during fixed appliance therapy. Registration: The trial was registered retrospectively in the Clinical Trial Registry-India, number CTRI/2016/09/007232.

fQRS as a marker of granulomatous disease in patients presenting with ventricular tachycardia and normal left ventricular ejection fraction.

BACKGROUND: Granulomatous myocarditis may present with sustained monomorphic ventricular tachycardia (SMVT) in the presence of normal left ventricular ejection fraction (LVEF), and could be mistaken for idiopathic ventricular tachycardia (IVT). The use of cardiac imaging for diagnosis can be limited by availability and high cost. ECG is readily available and inexpensive. Fragmented QRS (fQRS) on ECG has been found to be associated with myocardial scar. We hypothesized that fQRS could be useful in the diagnosis of granulomatous VT (GVT). METHODS: We compared the 12-lead ECG of 16 patients with GVT and 42 patients with IVT who presented with SMVT. RESULTS: The presence of fQRS was significantly higher in the GVT group compared to the IVT group (75% versus 19.1%, p < 0.001). The location of fQRS correlated with delayed enhancement cardiac magnetic resonance imaging (DE-CMR) in the same segment in 4/16 patients in the GVT group. It correlated with an affected segment on either DE-CMR or 18FDG positron emission computed tomography in 4/11 patients in the GVT group who had both imaging modality. Whenever fQRS was present in contiguous leads other than the inferior leads, it always corresponded to an affected segment on imaging. CONCLUSIONS: In patients presenting with SMVT and no structural heart disease, the presence of fQRS is strongly associated with granulomatous myocarditis. fQRS on the surface ECG is a helpful tool the presence of which should prompt a CMR for a definitive diagnosis.

Catheter ablation in patients with electrical storm in early post infarction period (6 weeks): a single centre experience.

BACKGROUND: Electrical storm (ES) due to drug refractory ventricular tachycardia (VT) occurring within first few weeks of acute myocardial infarction (MI) has poor prognosis. Catheter ablation has been proposed for treating VT occurring late after MI, but there is limited data on catheter ablation in VT within first few weeks of MI. METHODS AND RESULTS: Five patients (4 males, mean age 54.2±12.11 years) between June 2008 to July 2012, referred for VT presenting as ES refractory to antiarrhythmic drugs in the early post infarction period (six weeks following MI) despite revascularization. Three patients had anterior wall MI and two inferior wall MI with left ventricular ejection fraction ranging from 26 to 35%.All underwent catheter ablation within 48 hours of being in VT except one who presented late. Clinical VT was induced in all five patients. Total number of VTs induced were 11 (2.2±1.09 per patient). Two patients needed epicardial ablation via pericardial puncture. Though acute success was 100%, one patient had recurrence of clinical VT the next day of procedure.One patient succumbed to sepsis with multiple organ failure. The remaining four patients are doing well without further clinical recurrence of VT over a period of 3.7 years of follow-up. CONCLUSION: Catheter ablation can be a useful adjunctive therapy for patients with recurrent VT in the early post infarction period. This procedure appears to be safe with acceptable success rate.

Epicardial ablation of focal atrial tachycardia arising from left atrial appendage in children.

Focal left atrial tachycardia (FLAT) although a common cause of supraventricular tachycardia(SVT) among children, the one's arising from left atrial appendage (LAA) present a unique challenge for successful ablation because of anatomical location. We present two children with FLAT arising from the epicardial LAA, successfully mapped and ablated through percutaneuous epicardial approach.

Reuse of explanted, resterilized implantable cardioverter-defibrillators: a cohort study.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) often have clinically useful battery life remaining when explanted because of upgrades, infection, or patient death. OBJECTIVE: To show that explanted ICDs can be resterilized and reused. DESIGN: Retrospective cohort study. SETTING: Multicenter ICD acquisition and single-center ICD reimplantation. PATIENTS: Indigent persons in India who had class I indications for cardiac resynchronization therapy with an ICD and were unable to afford such a device. MEASUREMENTS: Device longevity after reimplantation, device-related complications, number of appropriate therapies, patient clinical characteristics, and deaths. RESULTS: Eighty-one consecutive consenting patients (mean age, 52.6 years; 66 male patients) received 106 explanted devices. Twenty-two patients received a second device and 3 patients received a third device after the prior one reached replacement voltage. Mean time to ICD replacement was 1287.4 days. Follow-up data were available for 75 of 81 (92.6%) patients. Mean follow-up duration for all devices was 824.9 days. No infectious complications occurred; 1 lead dislodgement and 1 lead fracture required repeated surgery. Appropriate therapy (shocks or antitachycardia pacing) was delivered by 64 of 106 (60.4%) devices in 44 of 81 (54.3%) patients. Nine of 81 (11.1%) patients died; mean time from implantation to death was 771.3 days. LIMITATIONS: This is a retrospective report of a single-center experience with a modest number of patients and devices. Follow-up data were missing for 6 patients. No records were kept of the number of devices obtained through postmortem versus antemortem explantation or whether explantation was due to infection or upgrade. Complete data were not available on exact battery voltage at the time of reimplantation, left ventricular ejection fraction, or number of inappropriate shocks. A control group was not possible. CONCLUSION: Explanted ICDs with 3 or more years of estimated remaining battery life can be reused after they are cleaned and resterilized. These devices functioned normally and delivered life-saving therapies, without an increased risk for complications. These preliminary data deserve further validation and, if confirmed, could have important societal and economic implications. PRIMARY FUNDING SOURCE: None.

Neuraxial modulation for refractory ventricular arrhythmias: value of thoracic epidural anesthesia and surgical left cardiac sympathetic denervation.

BACKGROUND: Reducing sympathetic output to the heart from the neuraxis can protect against ventricular arrhythmias. The purpose of this study was to assess the value of thoracic epidural anesthesia (TEA) and left cardiac sympathetic denervation (LCSD) in the management of ventricular arrhythmias in patients with structural heart disease. METHODS AND RESULTS: Clinical data of 14 patients (25 to 75 years old, mean+/-SD of 54.2+/-16.6 years; 13 men) who underwent TEA, LCSD, or both to control ventricular tachycardia (VT) refractory to medical therapy and catheter ablation were reviewed. Twelve patients were in VT storm, and 2 experienced recurrent VT despite maximal medical therapy and catheter ablation procedures. The total number of therapies per patient before either procedure ranged from 5 to 202 (median of 24; 25th and 75th percentile, 5 and 56). Eight patients underwent TEA, and 9 underwent LCSD (3 patients had both procedures). No major procedural complications occurred. After initiation of TEA, 6 patients had a large (> or =80%) decrease in VT burden. After LCSD, 3 patients had no further VT, 2 had recurrent VT that either resolved within 24 hours or responded to catheter ablation, and 4 continued to have recurrent VT. Nine of 14 patients survived to hospital discharge (2 TEA alone, 3 TEA/LCSD combined, and 4 LCSD alone), 1 of the TEA alone patients underwent an urgent cardiac transplantation. CONCLUSIONS: Initiation of TEA and LCSD in patients with refractory VT was associated with a subsequent decrease in arrhythmia burden in 6 (75%) of 8 patients (68% confidence interval 51% to 91%) and 5 (56%) of 9 patients (68% confidence interval 34% to 75%), respectively. These data suggest that TEA and LCSD may be effective additions to the management of refractory ventricular arrhythmias in structural heart disease when other treatment modalities have failed or may serve as a bridge to more definitive therapy.

Left-sided biventricular pacemaker implantation in the presence of persistent left superior vena cava.

Persistent Left Superior Vena Cava (PLSVC) is the most common thoracic venous anomaly encountered during device implantation. The most common problems related to the unusual anatomic access to the heart are reaching a convenient pacing site and ensuring stable lead placement. This report describes left sided implantation of RA, RV and LV leads in a patient with a PLSVC who was referred for cardiac resynchronizaiton therapy. The literature regarding the interventional approach for device implantation in patients with PLSVC is reviewed.

Tilting at windmills.

A 69-year-old man had numerous episodes of syncope over three years. A head-up tilt test had shown a mixed response and he was labeled as having neurocardiogenic syncope. Lifestyle, dietary and pharmacologic measures were ineffective. At electrophysiology study, an easily inducible, self-terminated AV nodal re-entrant tachycardia was induced. At 1 year follow-up after radiofrequency ablation, he is asymptomatic.