Novel Use of Dual Guiding Catheters Technique to Prevent Distal Embolization and Slow Flow during PCI of Coronary Stent Thrombosis.

Despite having an incidence of 0.5 to 2%, stent thrombosis has an in-hospital mortality of 15% and myocardial infarction (MI) incidence of 67%. Even with the usage of thrombus aspiration devices and microvasculature vasodilators such as nitroprusside, verapamil, adenosine, and Gp2b/3a inhibitors, the angiographic result of percutaneous coronary intervention of coronary stent thrombosis remains frequently suboptimal due to distal embolization and subsequent slow flow. We describe a novel use of dual guide catheter technique, where one guide acts as conduit for thrombus aspiration catheter and the other for distal placement of balloon trap to prevent distal embolization while managing a case of coronary stent thrombosis to improve the angiographic outcome in this scenario.

Clinical expert consensus document on the use of percutaneous left ventricular assist devices during complex high-risk PCI in India using a standardised algorithm.

Over the past decade, percutaneous left ventricular assist devices (pLVAD), such as the Impella microaxial flow pump (Abiomed), have been increasingly used to provide haemodynamic support during complex and high-risk revascularisation procedures to reduce the risk of intraprocedural haemodynamic compromise and to facilitate complete and optimal revascularisation. A global consensus on patient selection for the use of pLVADs, however, is currently lacking. Access to these devices is different across the world, thus, individual health care environments need to create and refine patient selection paradigms to optimise the use of these devices. The Impella pLVAD has recently been introduced in India and is being used in several centres in the management of high-risk percutaneous coronary intervention (PCI) and cardiogenic shock. With this increasing utilisation, there is a need for a standardised evaluation protocol to guide Impella use that factors in the unique economic and infrastructural characteristics of India's health care system to ensure that the needs of patients are optimally managed. In this consensus document, we present an algorithm to guide Impella use in Indian patients: to establish a standardised patient selection and usage paradigm that will allow both optimal patient outcomes and ongoing data collection.

Transhepatic balloon mitral valvotomy in mitral stenosis with interrupted inferior vena cava.

A 38-year-old female was found to have severe mitral stenosis, severe pulmonary arterial hypertension with moderate tricuspid regurgitation, dilated right atrium, persistent left superior vena cava, and hugely dilated coronary sinus. The scheduled balloon mitral valvotomy via trans-femoral approach was abandoned after the venogram revealed the presence of left-sided inferior vena cava with hemi-azygos continuation draining into coronary sinus via left-sided superior vena cava. Balloon mitral valvotomy was attempted from the right trans-jugular route, but we were unable to puncture the inter-atrial septum due to the hugely dilated coronary sinus and right atrium. A transhepatic approach was used and balloon mitral valvotomy was successfully done with a standard balloon of 24 mm size without any complication. In patients with inferior vena cava anomalies or interruption, a percutaneous transhepatic approach is a feasible alternative for performing balloon mitral valvotomy.

Riata lead failure manifests as electrical storm with lead parameters showing unique postural variations: a case report.

BACKGROUND: Riata implantable cardioverter-defibrillator (ICD) leads are prone to a unique type of mechanical lead failure causing conductor externalization (CE) which may be complicated by a delayed-onset electrical lead failure (ELF). CASE SUMMARY: A 60-year-old male with symptomatic, severe ischaemic cardiomyopathy, and atrial fibrillation following a prior anterior wall myocardial infarction received a dual-chamber ICD with 7F-RiataST ventricular lead as a primary prevention strategy against sudden cardiac death in 2008. In 2017, a pulse generator replacement was performed for elective replacement indicator status. At that time, CE was noted in the ventricular lead but the electrical lead parameters were normal, hence lead replacement was decided against and the patient was closely followed up thereafter. Four years later, the patient presented with multiple ICD shocks within 48 h. Implantable cardioverter-defibrillator interrogation showed noise on the ventricular electrogram (EGM) channel that was detected as ventricular fibrillation (VF) episodes, triggering inappropriate ICD therapy (five ICD detected VF events within 24 h triggering three antitachycardia pacing therapies and one shock). Lead impedance and R-wave amplitude were within normal range in supine position but dramatically worsened in sitting posture. A new ventricular lead was implanted and the old lead abandoned. The patient has not experienced any device therapy in the follow-up period. DISCUSSION: An electrically inert CE of Riata ICD leads needs close follow-up because an ELF may occur even after several years. A careful analysis of EGMs including postural changes in lead parameters can aid in detection and better characterization of underlying electrical dysfunction following CE.

Effect of Mitral Regurgitation on Systemic Coagulation Activity in Rheumatic Heart Disease as Assessed by D-dimer Levels.

Introduction Atrial fibrillation and mitral stenosis, especially in combination, increase the risk of left atrial thrombus formation and systemic embolization. However, whether severe mitral regurgitation (MR) improves systemic hypercoagulable state in these patients is unclear. remains unclear. The study aims to study the impact of severe MR on systemic coagulation by the use of D-dimer levels. Methods It was a prospective, cross-sectional study done on 400 subjects consisting of 350 cases and 50 controls. The cases were divided into seven groups on basis of valvular pathology, rhythm, and presence of a clot. The D-dimer level was compared in all the subgroups. Result The mean age of the study population was 32.32±7.30 years with a 48% male population. The highest level of D-dimer was found in patients with thrombus (1.71 ± 1.74 µg/ml). Patients with mitral stenosis had significantly higher plasma D-dimer levels than the control group (p <0.001) while regardless of rhythm, patients with MR had a D-dimer level similar to the control group in sinus rhythm. Conclusion Severe MR reduces plasma D-dimer levels to control levels reflecting the protective effect against thrombus formation and systemic embolization.

Epidemiological profile and management patterns of acute myocardial infarction in very young patients from a tertiary care center.

BACKGROUND: Cardiovascular disease is the leading cause of death in India. Previously it was thought to be a disease of the elderly but now an epidemiological transition is being seen with increasing incidence in the very young adults as well. Such patterns are not well studied in the South East Asian population. OBJECTIVE: To study the epidemiological profile of very young (≤35 years) adults presenting with an acute myocardial infarction (AMI) in comparison with an older cohort. METHODOLOGY: The present study included all patients presenting with AMI to the emergency or to the out-patient department of the G B Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi between January 2014 and October 2015. A total of 102 subjects ≤35 years with AMI comprised the study subjects (cases) and were compared with 104 subjects >35 years old with AMI (Controls). RESULTS & CONCLUSION: Most of the very young AMI patients presented with an anterior wall ST segment elevation myocardial infarction, a stable hemodynamic profile, single vessel disease and better left ventricular ejection fraction as compared with controls. Most of the patients were from urban and semi-urban areas, middle and lower middle socioeconomic status and were smokers but lacked other traditional risk factors.

Transradial access for coronary diagnostic and interventional procedures: Consensus statement and recommendations for India: Advancing Complex CoronariES Sciences through TransRADIAL intervention in India - ACCESS RADIAL™: Clinical consensus recommendations in collaboration with Cardiological Society of India (CSI).

Radial access for cardiac catheterization and intervention in India has been growing steadily over the last decade with favorable clinical outcomes. However, its usage by interventional cardiologists varies greatly among Indian operators and hospitals due to large geographic disparities in health care delivery systems and practice patterns. It also remains unclear whether the advantages, as well as limitations of transradial (TR) intervention (as reported in the western literature), are applicable to developing countries like India or not. An evidence-based review involving various facets of radial procedure for cardiac catheterization, including practical, patient-related and technical issues was conducted by an expert committee that formed a part of Advancing Complex CoronariES Sciences through TransRADIAL intervention (ACCESS RADIAL™) Advisory Board. Emerging challenges in redefining TR management based on evidence supporting practices were discussed to formulate these final recommendations through consensus.

Pulmonary artery-to-left atrial fistula discovered after the closure of atrial septal defect: A rare clinical scenario.

A case of the right pulmonary artery-to- left atrial fistula with atrial septal defect (ASD) is presented. The fistula was detected after the patient developed desaturation following surgical closure of the ASD. It was managed with a transcatheter (trans-RPA route) closure of the fistula using a 12-mm Amplatzer ventricular septal defect closure device.

First-in-human evaluation of a novel poly-L-lactide based sirolimus-eluting bioresorbable vascular scaffold for the treatment of de novo native coronary artery lesions: MeRes-1 trial.

AIMS: The MeRes-1 trial sought to study the safety and effectiveness of a novel sirolimus-eluting bioresorbable vascular scaffold (MeRes100 BRS) in treating de novo native coronary artery lesions by clinical evaluation and using multiple imaging modalities. METHODS AND RESULTS: The MeRes-1 first-in-human trial was a single-arm, prospective, multicentre study, which enrolled 108 patients with de novo coronary artery lesions (116 scaffolds were deployed to treat 116 lesions in 108 patients). At six months, quantitative coronary angiography revealed in-scaffold late lumen loss of 0.15±0.23 mm with 0% binary restenosis. Optical coherence tomography demonstrated minimum scaffold area (6.86±1.73 mm2) and percentage neointimal strut coverage (99.30%). Quantitative intravascular ultrasound analysis confirmed a 0.14±0.16 mm2 neointimal hyperplasia area. At one year, major adverse cardiac events, a composite of cardiac death, any myocardial infarction and ischaemia-driven target lesion revascularisation, occurred in only one patient (0.93%) and there was no scaffold thrombosis reported. At one year, computed tomography angiography demonstrated that all scaffolds were patent and in-scaffold mean percentage area stenosis was 11.33±26.57%. CONCLUSIONS: The MeRes-1 trial demonstrated the safety and effectiveness of MeRes100 BRS. The favourable clinical outcomes and effective vascular responses have provided the basis for further studies in a larger patient population. The MeRes-1 trial is registered at the Clinical Trials Registry-India.

First-in-human evaluation of a novel poly-L-lactide based sirolimus-eluting bioresorbable vascular scaffold for the treatment of de novo native coronary artery lesions: MeRes-1 trial

AIMS: The MeRes-1 trial sought to study the safety and effectiveness of a novel sirolimus-eluting bioresorbable vascular scaffold (MeRes100 BRS) in treating de novo native coronary artery lesions by clinical evaluation and using multiple imaging modalities. METHODS AND RESULTS: The MeRes-1 first-in-human trial was a single-arm, prospective, multicentre study, which enrolled 108 patients with de novo coronary artery lesions (116 scaffolds were deployed to treat 116 lesions in 108 patients). At six months, quantitative coronary angiography revealed in-scaffold late lumen loss of 0.15±0.23 mm with 0% binary restenosis. Optical coherence tomography demonstrated minimum scaffold area (6.86±1.73 mm2) and percentage neointimal strut coverage (99.30%). Quantitative intravascular ultrasound analysis confirmed a 0.14±0.16 mm2 neointimal hyperplasia area. At one year, major adverse cardiac events, a composite of cardiac death, any myocardial infarction and ischaemia-driven target lesion revascularisation, occurred in only one patient (0.93%) and there was no scaffold thrombosis reported. At one year, computed tomography angiography demonstrated that all scaffolds were patent and in-scaffold mean percentage area stenosis was 11.33±26.57%...

Biochemical and genetic role of apelin in essential hypertension and acute coronary syndrome.

BACKGROUND: Apelin-APJ pathway has emerged as a potent regulator of blood pressure (BP) and blood flow in vasculature and heart. Variants in apelin gene may affect the vascular tone in peripheral circulation or heart, thereby predisposing to cardiovascular diseases. The aim of our study was to investigate the association of two apelin gene polymorphisms rs3761581 and rs2235312, and apelin levels in patients with essential hypertension (EH) and acute coronary syndrome (ACS). METHODS: The study comprised of three groups namely, (1) 118 healthy control subjects, (2) 92 EH patients, and (3) 60 ACS patients. DNA was extracted from peripheral blood leukocytes and genotyping was performed by SNaPshot method. Plasma apelin 13 levels were estimated using ELISA. RESULTS: EH and ACS patients had a significantly lower level of apelin 13, regardless of gender (p=0.003, p=0.017, respectively). Interestingly, the female EH and ACS patients had lower levels of apelin 13 than their male counterparts. The G allele of rs3761581 was more apparent in patients especially in ACS than the controls. CONCLUSION: Reduced apelin levels may enhance vasoconstriction to influence high BP and heart's workload in EH and ACS. Genetic involvement of apelin needs to be established in well-defined larger sample size.

Massive Bleeding from Guidewire Perforation of an External Iliac Artery: Treatment with Hand-made Stent-Graft Placement.

We report life-threatening bleeding from an external iliac artery perforation following guidewire manipulation in a patient with atherosclerotic iliac artery disease. This complication was successfully managed by indigenous hand-made stent-graft made from two peripheral stents in the catheterization laboratory.

Primary percutaneous coronary intervention in an anomalous single coronary trunk arising anomalously from ascending aorta.

A 45-year-old male patient presented with acute anterior wall myocardial infarction. Angiography revealed a single coronary trunk arising from the ascending aorta above the coronary sinuses and giving rise to right coronary artery, left circumflex artery and critical stenosis in the left anterior descending artery. This report also highlights the feasibility of performing percutaneous coronary intervention (PCI) in this rare anomaly and discusses the important technical considerations to be kept in mind while attempting such a case. This is the first report of such an anomalous origin of a single coronary trunk arising from ascending aorta.

Effect of heart rate control on coagulation status in patients of rheumatic mitral stenosis with atrial fibrillation--A pilot study.

BACKGROUND AND AIM OF STUDY: Systemic thromboembolism is a major complication in patients of mitral stenosis (MS) with atrial fibrillation (AF) due to induction of hypercoagulable state. The aim was to assess the relationship, if any, between control of ventricular rate and systemic coagulation factors. METHOD: 70 patients of moderate to severe MS in AF were studied. 35 patients with average heart rate > 100 beats/min over a 24 hour period assessed by Holter monitoring were considered as having a uncontrolled ventricular rate (Group A) and those with average heart rate ≤ 100 beats/min as controlled ventricular rate (Group B). 30 healthy volunteers acted as controls. RESULTS: Plasma concentration of prothrombin fragment 1+2 (PF1+2) 6600 pmol/ml [interquartile range (IQR) 5400.0-9500], thrombin antithrombin III 22.0 ng/ml [IQR 18.6-28.0], and plasminogen activator inhibitor 46.8 ng/ml [IQR 44.0-54.0] were elevated in Group A as compared to Group B (5400 pmol/ml [IQR 3600-7700] p = 0.009, 16.0 ng/ml [IQR 11.0-18.5] p<0.001, and 25.8 ng/ml [IQR 20.9-34.4] p < 0.001), respectively. A significant correlation was found between heart rate and all three coagulation markers. Multivariate multiple regression analysis showed only heart rate to be an independent predictor of systemic coagulation activation and risk of thrombus formation. CONCLUSION: Control of ventricular rate in subjects of MS with AF produces significant reduction in the activation of the coagulation system and may decrease risk of thrombosis.

Rapid guiding catheter swapping for management of rupture during percutaneous venoplasty for idiopathic occlusion of superior vena cava.

Treatment for superior vena cava syndrome (SVCS) by percutaneous interventions has become established as a definitive therapy. However, there is a significant risk of rupture during SVC intervention. We describe an uncommon case that developed SVC rupture during percutaneous intervention for idiopathic SVCS. This was managed successfully with pericardiocentesis and rapid implantation of covered stent in SVC by rapid guiding catheter swapping technique. This, however, led to inadvertent obstruction of left innominate vein which was successfully treated by kissing balloon inflation. At 18-month follow-up, he is asymptomatic with a well apposed patent stent-graft in the SVC.

Absent right coronary artery: A case of single coronary artery or congenital ostial atresia?

Atresia of the right coronary artery ostium is a rare anatomic variant of the coronary circulation. It is often difficult to differentiate from single coronary artery. Its presence unassociated with any other anomaly has never been described in an adult individual. We report this unusual anomaly and discuss its anatomical and pathophysiological significance and possible ways to differentiate from single coronary artery.

Relook at lipoprotein (A): independent risk factor of coronary artery disease in north Indian population.

AIMS: Lipoprotein (a) [Lp(a)] levels have shown wide ethnic variations. Sparse data on mean Lp(a) levels, its link with clinical variables and severity of coronary artery disease (CAD) in North Indian population needed further studies. METHODS: 150 patients, each of single vessel disease (SVD), double vessel disease (DVD) and triple vessel disease (TVD) with 150 healthy controls were drawn for the study. Serum Lp(a) estimation was performed by immunoturbidimetric method. RESULTS: Lp(a) had a skewed distribution. Median Lp(a) level was significantly raised in cases as compared to controls (median 30.30 vs. 20 mg/dl, p < 0.001). Cases with acute coronary syndrome (ACS, 55.8%) had significantly higher median Lp(a) levels as compared to those with chronic stable angina (35.4 mg/dl vs. 23 mg/dl, p < 0.001). Significant difference in median Lp(a) levels were observed in patients with DVD or TVD versus control (30, 39.05 vs 20 mg/dl, p < 0.008). Lp(a) level was found to be an independent risk factor for CAD (AOR{adjusted odds ratio} 1.018, 95% CI 1.010-1.027; p < 0.001). Analysis using Lp(a) as categorical variable showed that progressive increase in Lp(a) concentration was associated with increased risk of CAD [AOR from lowest to highest quartile (1, 1.04, 1.43 and 2.65, p value for trend = 0.00026)]. Multivariably AOR of CAD for subjects with Lp(a) in the highest quartile (above 40 mg/dl) compared to those with Lp(a) ≤40 mg/dl was 2.308 (95% CI 1.465-3.636, p < 0.001). CONCLUSION: Lp(a) above 40 mg/dl (corresponding to 75th percentile)assessed by an isoform insensitive assay is an independent risk factor for CAD. Raised Lp(a) level is also associated with increased risk of ACS and multivessel CAD.

Aortic rupture during aortoplasty in Takayasu arteritis--a rare complication: case report and review of literature.

Balloon angioplasty of the stenosed aorta is usually a relatively simple, yet potentially a catastrophic procedure. Aortic rupture during aortoplasty, though uncommon, carries a high mortality. We report case of a 39-year-old female with aortoarteritis with multiple arterial stenoses whose infra-renal abdominal aorta ruptured during balloon dilatation of the stent deployed in that segment. The site of aortic rupture was temporarily occluded by low-pressure inflation of the same balloon and then was sealed using a stent-graft introduced by contra-lateral femoral arterial access.