Incidence of atrial high rate episodes after dual-chamber permanent pacemaker implantation and its clinical predictors.

Atrial high rate episodes (AHRE) confers increased morbidity and mortality amongst patients with permanent pacemaker implantation (PPI). The incidence of AHREs and it's clinical predictors in Indian patients without prior history of atrial fibrillation (AF) are not well understood. A total of 100 dual-chamber PPI patients, who had no prior history of AF, underwent pacemaker interrogation starting from a minimum of 1 month after implantation to detect any AHREs. The incidence of AHREs was 17% at a mean follow up 15.2 ± 7.5 months. Only right ventricular apical lead position was found to have an independent association with AHREs (OR: 3.50, 95% CI: 1.02-12.03; p = 0.04).

Rotatripsy: synergistic effects of complementary technologies: a case report.

BACKGROUND: Percutaneous coronary intervention (PCI) to calcified coronary lesions (CCLs) remains one of the most complex procedures. Latest modality to modify calcium, intravascular lithotripsy (IVL), has shown good safety and efficacy in preliminary research. However, it may be associated with acute complications, and as standalone therapy, is not sufficient for all CCLs. CASE SUMMARY: Eighty-two-year-old man, known case of coronary artery disease and multiple comorbidities, presented with worsening angina of 1 month duration. Coronary angiography revealed heavily calcified triple vessel disease with critical distal left main (LM) involvement. Owing to high surgical risk, he was offered intravascular ultrasound (IVUS) guided PCI with intra-aortic balloon support. While the diffuse, circumferential calcified lesions in LM and left anterior descending (LAD) artery were modified with rotablation (RA) followed by IVL with 3.5 and 3.0 mm balloons; ostial-proximal lesion in left circumflex (LCX) artery was treated with 3.0 mm IVL balloon as a standalone therapy. During second cycle of shockwave therapy in LCX, the 3.0 mm IVL balloon ruptured with type C dissection extending upto LM ostium which required emergent LM bifurcation stenting. We had a good angiographic result which was confirmed with IVUS. DISCUSSION: ntravascular lithotripsy and RA are complementary technologies in treating CCLs. Rotablation with a relatively small-sized burr is safe and can favourably modify superficial calcium which helps in smooth delivery of IVL balloon and ensures safe shockwave therapy, if required. Unselected upfront use of IVL without intravascular imaging may be associated with complications as described in this case.

Spontaneous pulmonary artery thrombus in a neonate.

BACKGROUND: Pulmonary artery thrombosis is rare in neonates and mimics as persistent pulmonary hypertension or congenital heart disease. Risk factors include septicemia, dehydration, polycythemia, maternal diabetes, asphyxia, and inherited thrombophilias. They present with cyanosis and respiratory distress. Careful echocardiogram assessment helps in identifying the thrombus in the pulmonary artery and its branches. Computed tomography pulmonary angiography confirms the diagnosis. CASE PRESENTATION: We present a case of term neonate who presented with respiratory distress and cyanosis and a detailed echocardiogram revealed thrombus in the origin of left pulmonary artery. The neonate was managed initially with unfractionated heparin and later with low molecular weight heparin with which there was significant resolution of the thrombus CONCLUSION: Spontaneous pulmonary artery thrombosis though rare should be suspected in any cyanotic neonate with respiratory distress. Management in these cases depends on the haemodynamic instability and lung ischemia.

Epidemiological profile, management and outcomes of patients with acute coronary syndrome: Single centre experience from a tertiary care hospital in North India.

BACKGROUND: Cardiovascular disease is the leading cause of death in India. Our aim is to study the clinical, epidemiological profile and in-hospital outcomes of patients presenting with acute coronary syndrome. METHODS: We did a prospective single center observational study of the 1203 patients presenting with ACS to a tertiary referral center in North India over a period of one year (July 2018-June 2019). RESULTS: The mean age of study population was 58.4 ± 12.5 years. STEMI and NSTE-ACS accounted for 69.9% and 31.1% respectively. 62.1% of our patients were from rural background. The median time to hospital admission was 600 min for STEMI patients, thrombolysis was performed in 52% of cases. Cardiogenic shock at presentation was noted in 18%. Coronary angiography and percutaneous coronary intervention were done in 1062 (88.3%) and 733 (60.9%) patients respectively. The overall in-hospital mortality was 7.6%. STEMI patients had higher mortality than NSTE-ACS (8.9% vs 4.5% p < 0.001). Female gender (OR-3.306 C.I. 1.87-5.845), severe MR (OR-4.65, C.I.-1.187-18.18), acute kidney injury (AKI) at admission (OR-5.15, C.I.-2.5-10.63), higher Killip class (class III/IV) (OR-3.378,C.I.-1.292-8.849), AF (OR-3.25, C.I.-1,18-8.92), complete heart block (CHB) (OR-4.44,C.I.-2.09-9.43) and right bundle branch block (RBBB) (OR-2.86, C.I.-1.2-6.8) were significant predictors of in hospital mortality. CONCLUSIONS: Our study represents the predominance of STEMI as the initial ACS presentation with a considerable delay in first medical contact and higher prevalence of cardiogenic shock (CS). STEMI patients had higher mortality. Female sex, severe MR, AKI, higher Killips class, AF, CHB, RBBB being predictors of high in-hospital mortality in ACS patients.

Use of BioMime Morph stent in treating left main triple vessel disease: a case report.

BACKGROUND: Diffuse long coronary lesions require long overlapping stents which produce less than optimal long-term results. Sizing of long stents becomes difficult owing to tapering of coronaries and overlapping with excessive metal which makes restenosis a nagging problem on long-term follow-up. The optimal stent sizing becomes even more important when left main (LM) needs to be treated along with left ascending artery (LAD) or left circumflex artery (Lcx). The chronic total occlusions (CTO) represent other complex diffuse coronary lesions which not only require higher expertise and better hardware but also usually long lengths of overlapping stents. The long-tapered sirolimus-eluting stent system (BioMime Morph) has been successfully used in long diffuse lesions in individual coronaries including CTO but the use of the same in LM-LAD/LM-Lcx diffuse lesions has not been explored well where its tapered design can really be favourable. CASE PRESENTATION: We here present a case of a 51-year-old hypertensive male presented with NSTEMI and angiography showing left main triple vessel disease with CTO of right coronary artery (RCA). We successfully stented the LM-LAD and RCA (staged) using a long-tapered BioMime Morph system. IVUS was used for optimising the LM-LAD stent. At 6 months follow-up, the patient was doing well on double anti-platelets. CONCLUSION: Complex coronary disease, involving the left main and LAD diffusely and CTO of RCA, can be well managed by using a single long-tapered stents thereby avoiding multiple stenting strategy. The stents with decremental diameter will provide better adaptation to the vessel size and their natural tapering. The usage of intravascular imaging helps in better optimisation of stents.

Transcatheter closure of Patent ductus arteriosus in a child with IVC interruption through standard femoral access: a case report.

BACKGROUND: Portsmann and co. performed the first PDA device closure in 1967. The technique and the devices used have evolved since then and are the first choice in managing anatomically feasible patent ductus arteriosus (PDA) for the last 20 years. Though catheter-based closure of PDA is generally a simple procedure, there are instances when the interventionist faces challenges, especially in smaller children, with syndromic features and venous anomalies even when defects are small and pulmonary artery pressures are normal. Although the femoral vein is the relatively risk-free standard access, internal jugular vein, femoral artery, and transhepatic IVC can be used to close the PDA in different anomalies. The rare venous anomaly of infrahepatic interruption of the IVC with azygous continuation poses technical challenges when percutaneous closure of PDA was attempted through the standard femoral access. CASE PRESENTATION: We report a rare case of PDA device closure in a syndromic child with a short neck having interrupted IVC via femoral-azygous venous approach. CONCLUSION: Knowledge of the IVC course and its anomalies should be known to the operator before the percutaneous closure of PDA. Although other approaches are available, femoral vein approach can be used in case of interrupted IVC for percutaneous closure of PDA.

Outcomes of transcatheter closure of patent ductus arteriosus with the off-label use of large occluders (≥16 mm).

OBJECTIVE: Transcatheter closure is the first-choice strategy for the management of appropriate patients with patent ductus arteriosus (PDA). The management of large PDAs is challenging due to the limited available sizes of approved devices and the inherent risks of surgical ligation, especially in adults with calcified PDAs. This study aimed to assess the outcomes of the off-label use of large occluders at a tertiary center. METHODS: This retrospective review included patients who underwent transcatheter PDA closure with large occluders (≥16 mm) over 16 years. The baseline patient data, procedural details, angiograms, and immediate outcomes were recorded and patients were followed up at 3, 6, 12 months after the intervention and annually thereafter. RESULTS: Of the 685 patients who underwent transcatheter PDA closure, 36 patients (mean age 16.6 ± 12.5 years) needed occluders ≥ 16 mm in size. Cocoon duct occluder, Cera duct occluder, Amplatzer atrial septal occluder (ASO), and Cera muscular ventricular septal defect occluders were used for PDA closure. There was no device embolization, one patient in whom ASO was used had residual shunt with intravascular hemolysis requiring surgery, and one patient had mild left pulmonary artery narrowing after the intervention, which was managed conservatively. No patient had residual shunt and one patient had persistent pulmonary hypertension at an intermediate duration of follow-up. CONCLUSION: Transcatheter PDA closure with the use of large devices, which are available in Asia and Europe, is an effective and safe method, especially in adolescents and adults. However, a close follow-up of these patients is mandatory.

Mystery still unresolved: Untouched "Blue heart" presenting at 40yrs of age.

The modern-day surgical techniques and strategies have changed the outlook of patients with dextro-transposition of great arteries (d-TGA). The survival of an unrepaired d-TGA into late adulthood is difficult to explain. Even when large intracardiac shunts are present, it still remains a lethal cyanotic congenital heart disease if it is not surgically corrected soon after birth. Here, we report an extremely rare case of d-TGA presenting at 40 years of age, with moderately elevated pulmonary artery pressures and relatively stable symptoms.