Association of Serum Cyclophilin A Levels with Severity of Coronary Artery Disease.

Objective The disequilibrium between oxidant and antioxidant systems causes oxidative stress. Further, it disrupts the cell and releases reactive oxygen species (ROS), which in turn damages the vascular functions. Cyclophilin A (CypA), an immunophilin, is released in a highly regulated manner from vascular smooth muscle cells and multiplies the deleterious effects of ROS, associated with cardiovascular diseases. Thus, the aim of the present study is to correlate serum CypA levels with the severity of coronary artery disease (CAD). Materials and Methods Study participants composed of 103 adult subjects, among whom 73 subjects were cases who were diagnosed as CAD angiographically. Thirty years of age and gender-matched subjects were taken as controls. The cases were further divided into single, double, and triple vessel disease subgroups. Blood samples were collected for the estimation of serum CypA, malondialdehyde (MDA), high-sensitive C-reactive protein (hsCRP), lipid profile, and plasma-glycated hemoglobin (HbA1C) by relevant biochemical methods. Statistical Analysis The analysis was done using SPSS version 25. The data were expressed as median/mean and interquartile range/standard error. The groups were compared using the Mann-Whitney U-test and the Kruskal-Wallis test. p -Value less than 0.05 was considered statistically significant. Comparison of area under the curve (AUC) in receiver operating characteristic (ROC) curves was performed. A correlation was done by Spearman rank correlation. Results The mean levels of serum CypA, hsCRP, and MDA in cases were significantly higher than those of controls (38 vs. 27 ng/mL, 18 vs. 5.1 mg/L, and 26 vs. 14 nmol/mL, p < 0.001). A positive correlation was observed between serum levels of CypA versus hsCRP and CypA versus MDA ( r = 0.36 p = 0.00, r = 0.52, p = 0.00). At cut-off values greater than 33 ng/mL and 2.1 mg/L, serum CypA and hsCRP have 71% sensitivity, 93% specificity (AUC = 0.83), 84% sensitivity, and 70% specificity (AUC = 0.78) respectively. The number of occluded vessels was positively correlated with both CypA and hsCRP. Also, Serum CypA showed a significant positive correlation with HbA1C. Conclusion Serum CypA can be used as a valuable biomarker for CAD.

Thiamine mediated reversal of left ventricular dysfunction in patients with alcoholic cardiomyopathy.

This study aimed to evaluate the effect of thiamine supplementation on left ventricular (LV) systolic function in patients of alcoholic cardiomyopathy(ACM) presenting with acute heart failure(HF). 11 newly diagnosed patients were included. They were treated with 3 days of intravenous(IV) therapy with thiamine followed by oral supplementation. LVEF was 30% at baseline which improved by 45% and 53% along with reduction in LV dimensions over 3 and 6 months respectively. The study suggests the benefit of thiamine supplementation on LVEF in ACM patients with HF.

Clinicomicrobiological spectrum of infective endocarditis - from a tertiary care centre in south India.

BACKGROUND AND OBJECTIVES: Infective endocarditis (IE) is a microbial infection of the endothelial surface of the cardiac-valves. Rapid diagnosis, effective treatment and prompt recognition of complications are essential, in order to improve the outcome. We retrospectively reviewed and determined the clinical characteristics, microbiological profile and management strategies of IE cases, changing microbial spectrum of pathogens and outcome in Native Valve Endocarditis (NVE) and Prosthetic Valve Endocarditis (PVE) cases. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 191 patients, clinically diagnosed with IE, based on modified Dukes criteria, from January 2011 to December 2016. Blood cultures received from all these patients were processed, using BacT/Alert system (bioMerieux, Marcy l'Etoile, France). RESULTS: Sixty eight (68/191) cases were positive for bacterial pathogens. Twenty four (24/191) cases had PVE and 167/191 had NVE. Nineteen cases (19/24, 79.1%) were PVE positive and forty nine (49/167, 29.3%) were NVE positive. Culture negative endocarditis cases were 123/191 (64.39%). The most common pathogen isolated from NVE cases, in our study was Streptococcus mitis, followed by methicillin-resistant coagulase negative staphylococcus (MRCONS) in PVE. The NVE were treated intravenously with a combination of a ß-lactam or glycopeptide with an aminoglycoside, for prolonged period of 4-6 weeks, with a successful outcome. The PVE cases were treated with the appropriate antibiotics as per the antibiotic susceptibility report. CONCLUSION: The high morbidity and mortality rates are associated with IE and hence accurate identification of aetiological agents and appropriate antimicrobial therapy is required.

Early Repolarisation Changes in ECG: Are they Benign or Malignant?

Till recently, ST segment elevation in the absence of conduction abnormalities or chest pain occurring particularly in young bradycardia individuals has been considered a normal variant called early repolarisation (ER). However, recent studies suggest a more worrisome picture as patients with history of idiopathic ventricular fibrillation showed increased prevalence of ER in ECG. ER is an ECG pattern characterised by elevation of the QRS-ST junction (J point) ≥ 2 mv from baseline in the inferior (II, III, aVF) or lateral (I, aVL, V4-V6) leads manifested as QRS slurring or notching. The ER pattern describes the patient with appropriate ECG findings in the absence of symptomatic arrhythmias. The Early Repolarisation Syndrome (ERPS) applies to the patient with both appropriate ECG findings and symptomatic arrhythmias. The current experimental data support the concept that J-point elevation is a marker of increased transmural heterogeneity of ventricular .repolarisation, which increases the vulnerability to ventricular tachyarrhythmias. Male gender, history of syncope or sudden cardiac death (SCD) in family, ER in inferior leads or global ER pattern, terminal notching of QRS complex, J wave amplitude of more than 0.2 mv, horizontal or downward direction of ST segment elevation signify higher risk features for SCD in ER patients. Patients with ER pattern on ECG should have complete cardiac evaluation. The management options for ERPS include anti arrhythmic drugs, implantable cardioverter-defibrillator (ICD) and radiofrequency ablation. There is a need for the physicians to be aware of this entity, hitherto considered as variant of normal ECG pattern especially in young adults and understand its implications, identify high risk subsets and manage with appropriate strategy.

Diagnosis of Non-ST-Elevation Acute Coronary Syndrome by the Measurement of Heart-Type Fatty Acid Binding Protein in Serum: A Prospective Case Control Study.

A prospective case control study was undertaken to evaluate the diagnostic performance of serum heart-type fatty acid binding protein (HFABP) in comparison to cardiac TnT and TnI in 33 patients admitted with chest pain, diagnosed as NSTE-ACS (non ST elevation acute coronary syndrome) and 22 healthy controls. Area under the receiver operating curve (AUC) was highest for H-FABP (AUC 0.79; 95% CI 0.66-0.89) versus cTnI (AUC 0.73; 95% CI 0.59-0.84) and cTnT (AUC 0.71; 95% CI 0.57-0.83). The H-FABP level above 6.5 ng/mL showed 56.7% (CI 37.4-74.5) sensitivity, 0.5 (95% CI 0.3-0.7) negative likelihood ratio (-LR), 100% (CI 84.6-100.0) specificity, and 100% (CI 79.4-100.0) positive predictive value (PPV), 62.9% (CI 44.9-78.5) negative predictive value (NPV). cTnI level above 0.009 µg/L had 40% (CI 22.7-59.4) sensitivity, 0.6 (95% CI 0.4-0.8) -LR, 100% (CI 84.6-100.0) specificity, 100% (CI 73.5-100.0) PPV, and 55% (CI 38.5-70.7) NPV. cTnT showed 46.7% (CI 28.3-65.7) sensitivity, 0.5 (95% CI 0.4-0.7) -LR, 100% (CI 84.6-100.0) specificity, 100% (CI 76.8-100.0) PPV, and 57.9% (CI 40.8-73.7) NPV at level above 9 µg/L. +LR were 12.5 (95% CI 1.8-86.8), 1.7 (95% CI 1.0-3.0), and 1.2 (95% CI 0.8-1.9) for H-FABP, cTnI, and cTnT respectively. In conclusion measurement of H-FABP is a valuable tool in the early diagnosis of patients with chest pain (6-8 hrs) and seems to be a preferred biomarker in the differential diagnosis of NSTE-ACS. More studies are needed to determine whether serum H-FABP further improves diagnostic performance.

Electrocardiographic features of ventricular pacing lead in the middle cardiac vein vs. right ventricular apex in a patient with persistent left superior vena cava.

A 53-year-old woman with sinus node dysfunction underwent dual-chamber pacemaker implantation through a persistent left superior vena cava draining into the coronary sinus, which was detected at the time of implantation. We managed to fix the ventricular lead in the right ventricular (RV) apex by forming a clockwise loop in the right atrium. Inadvertently, the lead was placed in the middle cardiac vein resembling RV apical position under fluoroscopic guidance. The paced QRS complex showed a pattern of tall R in V(1) through V(3), RS in V(4) through V(5), and QS in V(6). The pacing lead was carefully manipulated back into the RV apex, with the paced QRS complex showing a pattern of right bundle branch block, rR' in V(1) through V(2), and QS in V(3) through V(6). Careful attention to the surface electrocardiogram helps in distinguishing the pacing site even in those patients showing a pseudo-right bundle branch block pattern with RV apical pacing.

Right ventricular lead ring capture in sequential biventricular pacing with pseudo-bipolar left ventricular lead configuration: an unwanted effect.

We report here on three patients who underwent biventricular pacing (BVP) for severe heart failure and the problems encountered with pseudo-bipolar left ventricular (LV) lead configuration. With this configuration, right ventricular anode capture with simultaneous biventricular stimulation was noted at higher output during the isolated LV pacing mode in these patients, which forced us to program the LV pacing to unipolar configuration in one patient. The implication of this phenomenon in sequential BVP therapy is discussed.

Permanent pacing using a coronary sinus lead in a patient with univentricular physiology: an extended application of biventricular pacing technology.

In the past, patients requiring permanent pacing with difficult right ventricular (RV) access were usually subjected to epicardial pacing by a surgical approach. This report describes a young patient with univentricular physiology following repeated palliative surgery for complex congenital heart disease. The patient had symptomatic complete heart block and a dual chamber pacemaker with transvenous atrial and ventricular leads was implanted successfully. The ventricle was paced through the posterolateral cardiac vein with a lead specially designed for cardiac resynchronization therapy. This case illustrates an extended application of the recently developed coronary sinus lead in selected patients, when conventional RV endocardial pacing is impossible.

Focal right ventricular tachycardia originating from the subtricuspid septum.

Ventricular tachycardia originating from the right ventricular septum is very uncommon. In a 54-year-old male patient with right ventricular tachycardia, the focus of the ventricular tachycardia was localized to the subtricuspid septum of the right ventricle, which could be successfully eliminated with radiofrequency catheter ablation. The patient's echocardiogram and coronary angiogram were normal. The available literature on idiopathic right ventricular tachycardia is reviewed.

Cardiac resynchronisation therapy versus dual site right ventricular pacing in a patient with permanent pacemaker and congestive heart failure.

A 46-year-old male patient who had long-term right ventricular (RV) pacing for symptomatic complete heart block, initially by an epicardial, later with an endocardial pacing lead at the RV apex, developed congestive heart failure (CHF) and chronic atrial fibrillation 7 years following the pacemaker implantation and was medically treated. During follow-up, his pacemaker was upgraded to a cardiac resynchronisation therapy (CRT) device, because of uncontrolled CHF symptoms, New York Heart Association (NYHA) functional class IV, while on drugs. The patient's symptomatic status improved to NYHA functional class II with CRT. After 17 months of CRT, the battery became depleted, because of the high capture threshold of the left ventricular lead. The patient was then given dual site RV pacing (RV outflow tract+RV apex) in place of CRT, which showed similar efficacy at 12 weeks follow-up.

Radiofrequency catheter ablation therapy of swallowing-induced atrioventricular nodal reentrant tachycardia: report of two cases.

We describe two patients who presented with a history of recurrent palpitations on swallowing of solid food. The event-recorder and Holter monitoring documented episodic supraventricular tachycardia (SVT) initiated by atrial premature contractions (APCs). During electrophysiological study (EPS), swallowing of solid food consistently induced APCs and their activation sequence, morphology of P wave were suggestive of their right atrial origin in them. Drug challenge did not affect the APC onset during the swallowing. During EPS, slow-fast variety of atrioventricular nodal reentrant tachycardia (AVNRT) was induced and successful radiofrequency (RF) catheter ablation of slow pathway resulted in total relief of their symptoms.

Brugada syndrome--an update.

A diagnostic triad characterizes Brugada syndrome. It consists of a right bundle branch block, ST-segment elevation in leads V1-V3 and sudden cardiac death (SCD). Approximately 50% of patients with Brugada syndrome noted to have familial occurrence, this suggests a genetic component of the disease. Mutations in gene SCN5A, an encoder for human cardiac sodium channel on chromosome 3p21, causes Brugada syndrome. Before considering the diagnosis of Brugada syndrome, exclude precordial ST-segment elevation secondary to acute coronary syndrome, electrolyte imbalance, myocarditis, drug over dosage (cocaine, tricyclic antidepressants), and arrhythmogenic right ventricular cardiomyopathy/dysplasia. Intravenous administration of ajmaline, flecainide, and procainamide may exaggerate the ST-segment elevation, or unmask it when it is initially absent in patients with suspected Brugada syndrome. Programmed electrical stimulation (PES) may help in risk stratification, and in some cases, establish the diagnosis. However, the accuracy of PES in predicting outcome is debatable, especially in patients showing an asymptomatic Brugada ECG, and reporting no family history of SCD. Treatment with an implantable cardioverter-defibrillator (ICD) is the only established effective therapy for the disease. With ICD therapy, the mortality rate at a 10 year follow-up was 0%. Supporting data for long-term pharmacological therapy with quinidine, or isoproterenol for prevention of SCD, in these patients, is uncomplete. Future advances in understanding the molecular mechanisms of Brugada syndrome may provide answers to many of the controversial issues in the management of this disease.

Premature ventricular contraction-induced concealed mechanical bradycardia and dilated cardiomyopathy:.

Left ventricular (LV) dysfunction due to frequent isolated premature ventricular contractions (PVCs) has been rarely reported. LV dysfunction and concealed mechanical bradycardia resolved in a patient with idiopathic dilated cardiomyopathy after the focal source of PVCs in the LV was eliminated by radiofrequency ablation (RFA). The patient remained free from PVCs and maintained normal LV function over 36-month follow-up. In a subset of patients with idiopathic dilated cardiomyopathy with frequent isolated PVCs, RFA of the arrhythmic focus restores normal LV function that can be long lasting.