Clinical Outcomes of Percutaneous Transcatheter Release of Stuck Mechanical Mitral Valve With Cerebral Embolic Protection.

BACKGROUND: Surgery or fibrinolysis is the currently available evidence-based treatment for obstructive mechanical valve thrombus. We reported the feasibility and short-term outcomes of percutaneous transcatheter therapy with cerebral embolic protection. Mid- and long-term outcomes remain unknown. METHODS: From 2020 to 2023, 24 patients underwent percutaneous transcatheter release of stuck leaflets with cerebral embolic protection for obstructive mitral mechanical valve thrombus. The indications for the transcatheter therapy were failed fibrinolysis, contraindications for fibrinolysis, not willing for fibrinolysis, or high risk for surgery. The study participants were followed up for a median period of 344.50 (65.00-953.75) days. RESULTS: Technical success was achieved in 91.67% (n=22) of procedures. During the follow-up, 12.50% (n=3) all-cause death, 4.17% (n=1) stroke, and 16.67% (n=4) recurrence were seen. The mean survival time free from death was 1101.48 (95% CI, 929.49-1273.47) days, stroke was 1211.38 (95% CI, 1110.40-1312.35) days, and recurrence was 907.71 (95% CI, 760.20-1055.21) days. CONCLUSIONS: Transcatheter release of the stuck mitral mechanical valve with cerebral embolic protection is an alternative therapy with promising mid-term outcomes where surgery or fibrinolysis is not possible or in failed fibrinolysis subsets.

Current status and barriers in pulmonary hypertension care delivery in India: A qualitative analysis.

Although pulmonary hypertension (PH) is widely prevalent in India, care delivery for this condition has unique challenges in a lower middle-income country (LMIC). To describe care delivery for patients with PH and associated barriers in India. We interviewed physicians across eight healthcare systems in India about PH clinical care using semi-structured enquiries to understand care delivery and associated challenges in their specific practice as well as the associated health system. Qualitative analysis was performed using content analysis methodology. Physicians reported that common causes for PH in their practice were rheumatic mitral valve disease, coronary artery disease, and congenital heart disease (CHD). No center had a dedicated PH program. Only one center had a specific protocol for PH management. Diagnostic evaluations were limited, and right heart catheterizations were recommended for patients with CHD. Pulmonary vasodilator therapy was used for severe symptoms or markers of severe disease. Agents used to treat PH were widely variable across physicians and prostacyclins are unavailable in India. Barriers included limited training in PH for physicians, lack of consensus guidelines for PH specific to LMIC, and lack of financial incentives for health care systems to organize dedicated PH programs. Other barriers included poor patient health literacy and socioeconomic barriers that limit ability to test and treat PH. PH care delivery in India is variable with widely differing clinical practices. Dedicated training in PH management and establishing guidelines specific to LMIC like India can form the first step forward.

'Egg-cased heart': a multimodality imaging approach to chronic constrictive pericarditis with egg-shell calcification: a case report.

BACKGROUND: Constrictive pericarditis (CP), also known as Pick's disease, is a sequela of chronic inflammation of the pericardium. Pericardial calcification is a common occurrence in CP; however, extensive egg-shell like calcification is rare. Our case, highlights, how a multi-modality imaging in a middle aged female helped to diagnose chronic constrictive pericarditis (CCP) with egg-shell like calcification encasing the heart. CASE SUMMARY: Middle aged female with features of right heart failure, was diagnosed as CP based on two-dimensional echocardiography and cardiac catheterization. Computed tomography (CT) scan chest showed extensive egg-shell like calcification encasing the heart, suggestive of calcific CP. Subsequently, she underwent pericardiectomy, through median sternotomy approach and is currently on follow-up with asymptomatic cardiac status. DISCUSSION: Extensive pericardial calcification encasing the heart like an egg-shell is rare in CCP. Likelihood of incomplete pericardial resection is high in calcific CP and hence a median sternotomy is preferred over anterolateral thoracotomy. A preoperative non-contrast CT scan defines the thickness, anatomic extent the calcification and its adherence to myocardium and surrounding structures. A reconstructed volume-rendered image delineates the extent of calcification precisely, thus determining the optimum surgical approach. A multi-modality imaging in CP, especially in calcific CP, is thus of paramount importance.

Safety and feasibility of intravascular ultrasound guided zero-contrast percutaneous coronary intervention-A prospective study.

BACKGROUND: There are published reports of safety and feasibility of percutaneous coronary intervention (PCI) without contrast, using intravascular ultrasound (IVUS) and coronary physiology guidance in chronic kidney disease population. We prospectively evaluated the safety and feasibility of zero-contrast PCI technique. METHODS: In this prospective study, we hypothesized that PCI is feasible without contrast, using IVUS guidance alone without mandatory coronary physiology to rule out slow-flow or no-flow at the end of PCI in a population at risk of contrast-induced acute kidney injury (CI-AKI). In this study, we included 31 vessels in 27 patients at risk of CI-AKI and assessed the primary outcome of technical success at the end of PCI. Major adverse cardio-cerebro vascular events (MACCE) and percent change in estimated glomerular filtration rate(eGFR) one month after PCI were the secondary outcomes of the study. RESULTS: The primary outcome was met in 87.1%(n = 27) of the procedures. Technical failure was seen in 12.9%(n = 4) of the procedures. None of the patients developed MACCE at one-month follow-up. The median percent change in eGFR at one-month follow-up was -8.19%(-24.40%, +0.92%). There was no newer initiation of renal replacement therapy at one-month follow-up. CONCLUSIONS: Zero-contrast PCI is safe and feasible in selective coronary anatomies with IVUS guidance. Coronary physiology is not mandatory to rule out slow-flow or no-flow at the end of procedure. Contrast may be needed to tide over the crisis during the possible complications, namely slow-flow, geographical miss and intraprocedural thrombus.

Registry for Acute Coronary Events in Nigeria (RACE-Nigeria): Clinical Characterization, Management, and Outcome.

Background Coronary artery disease was hitherto a rarity in Africa. Acute coronary syndrome (ACS) accounts for coronary artery disease-related morbidity and mortality. Reports on ACS in Africa are few. Methods and Results We enrolled 1072 indigenous Nigerian people 59.2±12.4 years old (men, 66.8%) with ACS in an observational multicentered national registry (2013-2018). Outcome measures included incidence, intervention times, reperfusion rates, and 1-year mortality. The incidence of ACS was 59.1 people per 100 000 hospitalized adults per year, and comprised ST-segment-elevation myocardial infarction (48.7%), non-ST-segment-elevation myocardial infarction (24.5%), and unstable angina (26.8%). ACS frequency peaked 10 years earlier in men than women. Patients were predominantly from urban settings (87.3%). Median time from onset of symptoms to first medical contact (patients with ST-segment-elevation myocardial infarction) was 6 hours (interquartile range, 20.1 hours), and only 11.9% presented within a 12-hour time window. Traditional risk factors of coronary artery disease were observed. The coronary angiography rate was 42.4%. Reperfusion therapies included thrombolysis (17.1%), percutaneous coronary intervention (28.6%), and coronary artery bypass graft (11.2%). Guideline-based pharmacotherapy was adequate. Major adverse cardiac events were 30.8%, and in-hospital mortality was 8.1%. Mortality rates at 30 days, 3 months, 6 months, and 1 year were 8.7%, 9.9%, 10.9%, and 13.3%, respectively. Predictors of mortality included resuscitated cardiac arrest (odds ratio [OR], 50.0; 95% CI, 0.010-0.081), nonreperfusion (OR, 34.5; 95% CI, 0.004-0.221), pulmonary edema (OR, 11.1; 95% CI, 0.020-0.363), left ventricular diastolic dysfunction (OR, 4.1; 95% CI, 0.091-0.570), and left ventricular systolic dysfunction (OR, 2.1; 95% CI, 1.302-3.367). Conclusions ACS burden is rising in Nigeria, and patients are relatively young and from an urban setting. The system of care is evolving and is characterized by lack of capacity and low patient eligibility for reperfusion. We recommend preventive strategies and health care infrastructure-appropriate management guidelines.

SUPPORT-1 (Subjects Undergoing PCI and Perioperative Reperfusion Treatment): A Prospective, Randomized Trial of CMX-2043 in Patients Undergoing Elective Percutaneous Coronary Intervention.

OBJECTIVE: The natural molecule α-lipoic acid has been shown to be partially cytoprotective through antioxidant and antiapoptotic mechanisms. To obtain an initial assessment of the safety and potential efficacy of a synthetic derivative, CMX-2043, in preventing ischemic complications of percutaneous coronary intervention (PCI) we conducted the Subjects Undergoing PCI and Perioperative Reperfusion Treatment (SUPPORT-1) trial, the first patient experience with this agent. METHODS AND RESULTS: SUPPORT-1 was a phase 2a, 6-center, international, placebo-controlled, randomized, double-blind trial. A total of 142 patients were randomized to receive a single intravenous bolus dose of drug or placebo administered 15-60 minutes before PCI. Cardiac biomarker assessments included serial measurements of creatine kinase myocardial band (CK-MB) at 6, 12, 18, and 24 hours after PCI and a single measurement of troponin T (TnT) at 24 hours. Peak concentrations of CK-MB and TnT were significantly reduced in the 2.4 mg/kg group compared with placebo (P = 0.05 and 0.03, respectively). No subject administered 2.4 mg/kg of CMX-2043 had an increase of CK-MB to ≥3X upper limit of normal versus 16% for placebo (P = 0.02); 16% of the 2.4-mg/kg dose group developed an elevation of TnT to ≥3X upper limit of normal versus 39% in the placebo group (P = 0.05). No drug-related serious adverse events were observed in any group. CONCLUSION: These data suggest that CMX-2043 may reduce PCI periprocedural myonecrosis and support further clinical evaluation of this novel agent for its potential cytoprotective effects.

Radiation doses during cardiac catheterisation procedures in India: a multicentre study: Radiation dose study.

AIMS: Established, evidence-based measures of radiation are required to minimise its hazards, while maintaining adequate image quality. The aim of this study is to evaluate radiation data and generate reference radiation levels for commonly performed coronary catheterisation procedures in India. METHODS AND RESULTS: In this prospective, observational study, all procedures were performed in accordance with the established standards using Innova IGS 520/2100-IQ catheterisation laboratories. Demographic, procedural and radiation data were collected. Dose reference limits (DRL) were established as the 75th percentile of the total distribution. There were 2,906 coronary angiograms (CAG), 750 percutaneous coronary interventions (PCI) and 715 CAG+PCI. DRLs for dose area product were: 19.6 Gy·cm2 for CAG, 49.8 Gy·cm2 for PCI and 72.0 Gy·cm2 for CAG+PCI, respectively. Median cumulative air kerma levels were: 185 mGy for CAG, 533mGy for PCI, and 891 mGy for CAG+PCI. Male gender, higher BMI, combining CAG+PCI, fluoroscopy time, number of cine frames, and image acquisition settings were significant contributors to increased radiation dose. CONCLUSIONS: This study established reference radiation dose levels for diagnostic and interventional coronary procedures in India, which were comparable to and in the lower range of international standards.

Role of surgical ventricular restoration post surgical treatment of heart failure (STICH) trial.

OBJECTIVE: To compare the outcomes of isolated coronary artery bypass grafting (CABG) versus surgical ventricular restoration (SVR) with or without CABG for patients with ischemic cardiomyopathy (ICM). METHODS: Retrospectively, 49 patients with ICM and severe LV dysfunction (LVEF < 35%) who underwent SVR with or without CABG from January 2009 to December 2016 at a single institution was compared with 49 patients who underwent isolated CABG. The two groups were matched for preoperative clinical and echocardiographic parameters including left ventricular end-diastolic diameter (LVIDd), left ventricular end-systolic diameter (LVIDs), left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), and left ventricular end-systolic volume (LVESV). Primary outcomes analyzed included early mortality, late mortality, and major adverse cardiac or cerebrovascular events (MACCE). Secondary outcomes analyzed included echocardiographic parameters of left ventricular volume and function-indexed left ventricular end-diastolic volume (LVEDVi), indexed left ventricular end-systolic volume (LVESVi), and LVEF. Cox and survival analysis was performed. RESULTS: Early and late mortality in SVR vs. CABG groups were 4 (8.1%) and 6 (12.2%) vs. 1 (2%) and 5 (10.2%) respectively. Mean improvement in LVEF was 3.39 ± 7.51 compared to 4.97 ± 5.45 between the two groups at 3-month follow-up. Mean improvement in LVEF was 5.1 ± 8.3 in the SVR group vs 5.9 ± 7.1 in the CABG group at the last follow-up. There was no statistically significant improvement between the two groups in terms of LVEF at 3 months or the last follow-up. There were statistically significant differences between LVEDVi and LVESVi between the two groups at 3 months and the last follow-up. The 5-year rates of survival were 85 ± 6 and 82 ± 9% for SVR and CABG groups respectively. The 5-year rates of freedom from MACCE were 75 ± 7 and 60 ± 11% for SVR and CABG groups respectively. CONCLUSION: Compared with isolated CABG, SVR plus CABG results in equivalent late mortality and better left ventricular reverse remodeling (as evidenced by LV volume reduction) and better freedom from MACCE at 5-year follow-up.

Reperfusion of myocardial infarction in India: Notions for México / Reperfusión del Infarto del Miocardio en India: Nociones para México

Abstract In India and México, cardiovascular diseases are the first cause of death and potential years of life lost. Close similarities exist between these two countries when facing the difficulties to establish a universal reperfusion program for ST elevation myocardial infarction (STEMI). This paper describes the situation of STEMI treatment in both countries, and examines the lessons that Mexico's health care system could adopt from the recent advances accomplished by the STEMI initiative in India. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Resumen En India y México, las enfermedades cardiovasculares constituyen la primera causa de muerte y pérdida de años potenciales de vida. Existen similitudes cercanas entre estos 2 países en cuanto a las dificultades a enfrentar al establecer un programa de reperfusión universal para el infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Este artículo describe la situación del tratamiento del IAMCEST en ambas naciones y explora las lecciones que el sistema de salud de México podría adoptar de los recientes avances logrados por la iniciativa STEMI India. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Epidermal bulla: A dermatology complication of radial artery compression band.

Patent hemostasis technique is used with the trans radial (TR) band to prevent radial artery occlusion following diagnostic coronary angiogram or percutaneous coronary intervention using radial artery access. We report epidermal bulla as a complication of TR band usage and a modified patent hemostasis technique using barbeau test to prevent this complication.

Zero contrast optical coherence tomography-guided percutaneous coronary intervention for in-stent restenosis of the saphenous vein graft using a non-contrast flush medium.

Percutaneous coronary intervention (PCI) is often denied for individuals with coronary artery disease who are prone to develop contrast-induced acute kidney injury. We report a 73-year-old, stage 3 chronic kidney disease patient (CKD), who underwent coronary artery bypass surgery and saphenous vein graft (SVG) stenting in the past, presented with in-stent restenosis (ISR) of SVG stent. Zero contrast optical coherence tomography (OCT) guided-PCI was successfully performed using low molecular weight dextran-40 (LMWD-40) as the flush medium. Our report suggests the safety and feasibility of LMWD-40-based OCT-guided zero contrast PCI in ISR of SVG in a CKD patient, although further prospective studies are needed to evaluate this technique.

Reperfusion of myocardial infarction in India: Notions for México.

In India and México, cardiovascular diseases are the first cause of death and potential years of life lost. Close similarities exist between these two countries when facing the difficulties to establish a universal reperfusion program for ST elevation myocardial infarction (STEMI). This paper describes the situation of STEMI treatment in both countries, and examines the lessons that Mexico's health care system could adopt from the recent advances accomplished by the STEMI initiative in India.

Prevalence of parameters of suboptimal scaffold deployment following angiographic guided bioresorbable vascular scaffold implantation in real world practice - an optical coherence tomography analysis.

AIM: To assess the prevalence of suboptimal bioresorbable vascular scaffold (BVS, Abbott Vascular, Santa Clara, California) deployment in real world practice with intracoronary optical coherence tomography (OCT) imaging. METHODS: Consecutive patients who underwent percutaneous coronary intervention using BVS and the final optimization assessed with OCT imaging in two tertiary care centers between December 2012 and February 2015 were evaluated for parameters of suboptimal scaffold deployment by OCT. RESULTS: Overall, 36 scaffolds were implanted in 27 patients during this period. Mean age of the population was 54.7±8.2years and 19 (70.4%) were type B2/C lesions. The prevalence of parameters of suboptimal scaffold deployment were: underexpansion-22(61.1%), geographic miss-3(8.3%), tissue prolapse-7(25.9%), scaffold pattern irregularity-1(2.8%), longitudinal elongation-7(38.8%). Of the 7 overlaps imaged: excessive overlap was observed in 3 and scaffold gap in one. The median duration of follow up was 679days (range 193-963days). There were four events during this period. None were associated with suboptimal scaffold deployment. CONCLUSION: OCT based parameters of suboptimal scaffold deployment are common in real world scenario and were not associated with adverse outcomes on long term follow up. These findings need to be confirmed in larger studies.

ICAM-1 molecular mechanism and genome wide SNP's association studies.

Macrophages transformed foam cell formation occurs as a result of leukocyte accumulation mediated through intercellular adhesion molecule 1 (ICAM1), vascular cell adhesion molecule 1 (VCAM1), and E-selectin, secreted by inflamed or damaged endothelium. The key molecule is the ICAM-1, member of the adhesion immunoglobulin super family that maps to chromosome 19 p13.2-p13.3 codes for 505 amino acids have five extracellular domains including circulatory leukocytes binding site (primarily monocytes) for recruiting it at the sites of inflammation and the tight adhesion with vascular endothelium for the above mentioned pathogenesis as an initial step. Hence the objective of the current paper is to review the Genome Wide Association (GWA) studies and summarizes its understanding of functional Single Nucleotide Polymorphism (SNP's) of ICAM-1 clinical association to provide better guidance for the clinicians and researchers of the merits, demerits of the current results and direct them to do research on larger number of population for better prospective.

Papillary fibroelastoma of tricuspid valve presenting as pulmonary embolism.

A 65-year-old gentleman was admitted with recurrent dyspnea. Two-dimensional and transesophageal echocardiography revealed a highly mobile echogenic mass attached to the tricuspid valve. A (99m)Tc lung perfusion scan was suggestive of pulmonary embolism. The patient underwent surgical resection of the mass. Histopathological examination revealed a papillary fibroelastoma.

Apical ballooning syndrome in first degree relatives.

Apical ballooning syndrome (Takotsubo cardiomyopathy) is an unusual stress-related reversible cardiomyopathy occurring commonly in postmenopausal females. Genetic etiology of this condition is uncertain. A 68-year-old female and her daughter aged 43 got admitted to our institute simultaneously with acute chest pain following demise of one of their close relative. Both had features typical of Takotsubo cardiomyopathy and recovered completely. This reports point to the possible genetic predisposition to this abnormality.

Single coronary artery from the right coronary sinus with proximal origin of the left anterior descending coronary artery and left circumflex as distal continuation of the right coronary artery: a rare variant.

A single coronary artery is a rare coronary anomaly. A 68-year-old male underwent coronary angiography for recent inferior wall myocardial infarction. It revealed a common coronary trunk arising from the right sinus of Valsalva and bifurcated into the right coronary artery (RCA) and anterior descending coronary arteries. The RCA, after its usual distribution in the right atrioventricular groove, continued as the left circumflex artery in the left atrioventricular groove. There were significant stenoses in the mid and distal RCA, which were treated percutaneously.