Long-term, real world experience of ventricular tachycardia and granulomatous cardiomyopathy.

BACKGROUND: Granulomatous cardiomyopathy (GCM) is relatively uncommon in patients presenting with ventricular tachycardia (VT). Sarcoidosis and tuberculosis are the most common causes of GCM with VT. The aim of study was to evaluate their clinical characteristics and the long-term outcomes. METHODS: We retrospectively analyzed patients from March 2004 to January 2020, presenting with VT and subsequently diagnosed to have GCM. Patients were divided into three groups (sarcoid, tuberculosis and indeterminate) based on serologic tests, imaging and histopathology. The response to anti-arrhythmic and disease specific therapy on long-term follow-up were analyzed. RESULTS: There were 52 patients, comprising 27 males and 25 females, age 40 ± 10 years. The follow-up period was 5.9 ± 3.9 years. Sarcoidosis was diagnosed in 20 (38%); tuberculosis (TB) in 15(29%) and 17(33%) patients were indeterminate. Left ventricular ejection fraction (LVEF) of the entire cohort was 0.45 ± 0.14. Erythrocyte Sedimentation Rate(ESR) was found to be significantly higher in TB(43.6 ± 18.4) patients vs sarcoid(18.9 ± 6.7)p < 0.0001, but not the indeterminate group (36.2 ± 21.1), p = 0.3. Implantable Cardioverter Defibrillator (ICD) implantation was performed in 12/20(60%) patients in the sarcoid group, in 4/15(27%) patients in the TB group and in 10/17(59%) patients in the indeterminate group. At a mean follow-up of six years, VT recurrences were noted in 6, 2, and 7 patients in the sarcoid, TB and indeterminate groups respectively. CONCLUSION: Despite the advances in diagnostic modalities for tuberculosis and sarcoidosis, in real-world practice, almost one-third of the patients with VT and GCM have uncertain etiology. Long term outcomes of patients presenting with GCM and VT with mild left ventricle dysfunction treated appropriately seems favorable.

A case report: metastatic complete heart block.

BACKGROUND: Though primary malignant tumours of the heart are rare, secondary metastatic affection of the heart is quite common. Common presentations include pericardial effusion, obstruction of inflow and outflow tracts and arrhythmias, most notably tachyarrhythmias, and very rarely complete heart blocks (CHBs). CASE SUMMARY: A 28-year-old man suffering from carcinoma of the tongue underwent a surgery in the form of radical hemimandibulectomy. He presented with recurrent syncope and CHB with broad complex escape rhythm. After performing echocardiography, he was found to have malignant infiltration of the interventricular septum. This was confirmed by performing cardiac positron emission tomography (PET). It was decided that a permanent pacemaker would then be implanted. Post-implantation of permanent pacemaker patient succumbed to massive haemoptysis after 5 days. DISCUSSION: Although CHBs are rare in malignancy and careful assessment of ECGs especially looking for first degree heart blocks which may progress to CHB later on is prudent. One must rule out hypercalcaemia as it is a reversible cause of CHB. Careful echocardiogram can show hyper enhancement on interventricular septum and presence of pericardial effusion. Further imaging like cardiac magnetic resonance imaging or cardiac PET is confirmatory.

A survey of cardiac implantable electronic device implantation in India: By Indian Society of Electrocardiology and Indian Heart Rhythm Society.

BACKGROUND: There is limited data regarding the demographics and type of cardiac implantable electronic device (CIED) in India. AIM: The aim of this survey was to define trends in CIED implants, which included permanent pacemakers (PM), intracardiac defibrillators (ICD), and cardiac resynchronization therapy pacemakers and defibrillators (CRT-P/D) devices in India. METHODS: The survey was the initiative of the Indian Society of Electrocardiology and the Indian Heart Rhythm Society. The type of CIED used, their indications, demographic characteristics, clinical status and co-morbidities were collected using a survey form over a period of 1 year. RESULTS: 2117 forms were analysed from 136 centers. PM for bradyarrhythmic indication constituted 80% of the devices implanted with ICD's and CRT-P/D forming approximately 10% each. The most common indication for PM implantation was complete atrio-ventricular block (76%). Single chamber (VVI) pacemakers formed 54% of implants, majority in males (64%). The indication for ICD implantation was almost equal for primary and secondary prevention. A single chamber ICD was most commonly implanted (65%). Coronary artery disease was the etiology in 58.5% of patients with ICD implants. CRT pacemakers were implanted mostly in patients with NYHA III/IV (82%), left ventricular ejection fraction <0.35 (88%) with CRT-P being most commonly used (57%). CONCLUSION: A large proportion of CIED implants in India are PM for bradyarrhythmic indications, predominantly AV block. ICD's are implanted almost equally for primary and secondary prophylaxis. Most CRT devices are implanted for NYHA Class III. There is a male predominance for implantation of CIED.

Professor of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh.

Atrial fibrillation (AF) is the most common supraventricular tachycardia and its incidence increases with age. The pathophysiology of AF has been studied extensively and is a subject of continuing research. The primary pathologic change seen in AF is progressive fibrosis of the atria and hence structural remodeling, is the mainstay in many forms of AF. Dilation of the atria can be due to almost any structural abnormality of the heart which includes valvular heart disease, hypertension or congestive heart failure. Electrical remodeling promotes AF by acting on fundamental arrhythmia mechanism: focal ectopic activity and reentry. Rapidly firing foci initiating paroxysmal AF arise most commonly from the atrial myocardial sleeves that extend into pulmonary veins. The evolution of AF from paroxysmal to persistent to permanent forms through atrial remodeling can be caused by the arrhythmia itself and/or progression of underlying heart disease. The development of functional reentry substrates contribute to persistent AF. AF-related reentry is currently thought to occur through two main concepts: (1) the leading- circle concept and (2) spiral wave reentry. The multiple wavelets hypothesis, particularly in advanced structural and electrical remodelling are present, maintains AF survival, causing the most frequent common final pathway in sustained AF.

Subvalvular apparatus and adverse outcome of balloon valvotomy in rheumatic mitral stenosis.

BACKGROUND: Balloon mitral valvotomy (BMV) is a well-established therapeutic modality for rheumatic mitral stenosis (RMS). However, there are chances of procedural failure and the more ominous post-procedural severe mitral regurgitation. There are only a few prospective studies, which have evaluated the pathogenic mechanisms for these major complications of BMV, especially in relation to the subvalvular apparatus (SVA) pathology. METHODS: All symptomatic patients of RMS suitable for BMV by echocardiographic criteria in a span of 1 year were selected. In addition to the standard echocardiographic assessment of RMS (Wilkins score and score by Padial et al.), a separate grading and scoring system was assigned to evaluate the severity of the SVA pathology. The SVA score was 'I', when none of the two SVAs had severe disease, 'II' when one of the two SVAs has severe disease, and 'III' when both SVAs had severe disease. With these scoring systems, the outcomes of BMV (successful procedure, failure, and post-procedural mitral regurgitation) were analyzed. Emergency valve replacement was performed depending on clinical situation, and in cases of replacement, the pathology of the excised mitral valves were compared with echocardiographic findings. RESULTS: Of the 356 BMVs performed in a year, 43 patients had adverse outcomes in the form of failed procedure (14 patients) and mitral regurgitation (29 patients). Forty-one among these had a SVA score of III. The sensitivity and specificity of the MR score was lesser than the SVA score (sensitivity 0.34 vs. 1.00, specificity 0.92 vs. 0.99, respectively). The mitral valvular morphology in 39 patients who underwent post-procedural valve replacements correlated well with echocardiography findings. CONCLUSION: It is important to assess the degree of SVA pathology in the conventional echocardiographic assessment for RMS, as BMV would have adverse events when both SVAs were severely diseased.

Percutaneous tricuspid valvotomy for pacemaker lead-induced tricuspid stenosis.

Permanent pacemaker lead-induced tricuspid regurgitation is extremely uncommon. We report a patient with severe tricuspid stenosis detected 10 years after permanent single chamber pacemaker implantation in surgically corrected congenital heart disease. The loop at the level of the tricuspid valve may have caused endothelial injury and eventually led to stenosis. Percutaneous balloon valvotomy for such stenosis has not been reported from India.

Classical Cardiovascular Manifestations of Marfan Syndrome.

Presence of multiple cardiovascular manifestations of the Marfan syndrome in the same patient is not commonly encountered. We present a 49 year-old lady with this syndrome who presented with decompensated heart failure. Evaluation revealed presence of extensive Stanford type A aortic dissection alongwith severe aortic and mitral incompetence. However, the patient declined surgery and was discharged on medical management. At a year's follow-up, she had dyspnea of NYHA class II with persistent cardiovascular findings.

Can carbonated lime drink intake prior to myocardial perfusion imaging with Tc-99m MIBI reduce the extracardiac activity that degrades the image quality and leads to fallacies in interpretation?

BACKGROUND: During myocardial perfusion imaging with Tc-99m sestamibi, intestinal and hepatic radiotracer activity commonly interfere with visualization of the inferior wall of the myocardium leading to difficulties in interpretation. This study was undertaken to assess if carbonated lime drink ingestion prior to imaging prevents the said interference and improves the quality of images. MATERIALS AND METHODS: The study group comprised 33 consecutive patients including 26 males (age range: 30-80 years) and 7 females (42-62 years) who were referred for myocardial perfusion imaging. Of 33 patients, 21 (18 males, 3 females) were imaged at rest, 5 patients (3 males, 2 females) underwent physical stress, and 7 patients (5 males, 2 females) had pharmacological stress with adenosine. Five to 10 minutes after intravenous injection of 296 to 444 MBq (8-12 mCi) Tc-99m MIBI, anterior, and left anterior oblique (LAO) 45 degree planar views were acquired with a gamma camera using LEHR collimator. Each view was acquired for 100 seconds in a 256 x 256 matrix in all patients. Thereafter each patient was administered about 250 mL of a carbonated lime drink and repeat views were acquired within 5 minutes with the same parameters. Quantitative assessment of counts in the inferior wall of myocardium (M) to those in adjacent abdomen (A) was performed on both pre- and postintervention studies by drawing an ROI of about 50 +/- 5 pixels. M/A ratios were recorded for each patient in both the groups. The student t test was performed to evaluate the significance of difference between pre- and postintervention images. P < 0.05 was considered significant. All patients underwent myocardial perfusion single photon emission computed tomography. RESULTS: It was found that the inferior wall of the myocardium was better visualized, and there was no interference from gut or hepatic tracer activity in postintervention planar and single photon emission computed tomography reconstructed views as compared with preintervention images in all patients. The M/A ratio expressed as mean +/- SD was significantly higher in the postintervention group, viz. 2.19 +/- 0.71 in the anterior and 2.07 +/- 0.70 in the LAO45 views as compared with those of preintervention values of 1.50 +/- 0.59 in the anterior and 1.41 +/- 0.49 in the LAO 45 views, respectively (P < 0.001). CONCLUSION: We conclude that intake of carbonated lime drink is a simple and an effective technique to improve the image quality of the inferior wall of the myocardium on myocardial perfusion imaging with Tc-99m MIBI. This technique may also help in reducing the time interval between injection of radiotracer and imaging, which is otherwise delayed in routine practice.