Severe pulmonary arterial hypertension in a patient with hereditary hemorrhagic telangiectasia and multiple pulmonary and hepatic arteriovenous malformations.

Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder in which there is faulty development of the arteries. There is a high incidence of pulmonary hypertension (PH) in these patients, the pathophysiology of which is not fully known. An increase in cardiac output, causing high-output cardiac failure, and increased pulmonary vascular resistance secondary to genetic mutations are the main reasons. We report a 25-year-old male with HHT who presented with right heart failure secondary to PH in whom both the above mechanisms were operating. The coexistence of giant pulmonary arteriovenous malformations with severe PH is a rare scenario influencing management decisions that are discussed. In addition, this patient highlights the classical visceral vascular malformations in this rare disorder.

Unusual cause of tricuspid valve obstruction after surgical aortic valve replacement.

Unruptured sinus of Valsalva aneurysm can present with manifestations due to local compression or protrusion into the chambers. Right ventricular inflow obstruction is a rare manifestation. This image highlights the tricuspid valve obstruction due to a Valsalva aneurysm in a patient after surgical aortic valve replacement.

Post-operative Recurrent Ascending Aortic Pseudoaneurysm with Aorto-cutaneous Fistula- Endovascular management with an In-situ Stent-Graft Fenestration for the Innominate Artery.

Ascending aortic pseudoaneurysm is a known complication of previous cardiac surgery that needs surgical or endovascular intervention. The presence of arch branches complicates the later approach necessitating additional procedures, either hybrid surgical or endovascular modification of the grafts. We describe a patient who developed an ascending aortic pseudoaneurysm after mitral valve replacement, which recurred after surgical patch closure with the formation of a cutaneous fistula. This high-risk patient was managed by an endovascular approach with in-situ fenestration for the innominate artery by a simple technique.

Transvenous pacing through the pulmonary valve in a patient with cyanotic congenital heart disease after Glenn shunt - A case report.

Bradyarrhythmia requiring pacing is infrequently encountered in patients with complex cyanotic congenital heart disease. Even though epicardial pacing is the preferred mode, rarely, a need for endocardial lead implantation arises. Patients with cavopulmonary shunts limit access to the venous atria and ventricles, necessitating alternate methods of pacemaker implantation. We report transvenous endocardial lead implantation by an unconventional method in a patient with congenitally corrected transposition of great arteries after a bidirectional Glenn shunt.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design.

BACKGROUND: COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India. METHODS: In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic. CONCLUSIONS: This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

Unconventional deployment of atrial septal occluder in a patient with atrial septal defect, dextrocardia, and interrupted inferior vena cava.

An atrial septal defect is a rare anomaly in patients with interrupted inferior vena cava, which renders the percutaneous intervention more complex; and hence, innovative approaches should be sought. Dextrocardia further complicates the procedure, and traditional atrial septal device deployment methods cannot be employed. We report a successful percutaneous secundum atrial septal defect closure by a novel deployment strategy along with balloon dilation of associated severe valvular pulmonary stenosis in a patient with dextrocardia and interrupted inferior vena cava.

Reliability of Doppler echocardiography in the assessment of high pulmonary vascular resistance in patients with severe pulmonary arterial hypertension.

BACKGROUND: The objective is to assess whether the squaring of tricuspid regurgitation velocity (TRV) gives an improved estimate of pulmonary vascular resistance (PVR) or is equivalent to the ratio of TRV and time velocity integral of right ventricular outflow tract (TVIRVOT) (TRV/TVIRVOT) for assessing PVR in patients with high PVR values. METHODS: Thirty patients predicted to have PVR >6 WU by Doppler were included in the present study. TRV and TVIRVOT were measured by echo Doppler. TRV/TVIRVOT and TRV2/TVIRVOT were calculated. PVRCATH was estimated within 2 h of Doppler study. Regression equations for calculating PVR from TRV/TVIRVOT (PVRECHO1) and TRV2/TVIRVOT (PVRECHO2) were developed. Bland-Altman analysis for agreement between PVRCATH and PVRECHO1, PVRECHO2 was carried out. RESULTS: The mean value of PVRCATH was found to be 15.08 ± 7.03 WU. The calculated values of PVRECHO1 and PVRECHO2 were found to be 15.08 ± 6.34 WU and 15.05 ± 6.08 WU, respectively. The linear regression analysis carried out for PVRCATH and TRV/TVIRVOT showed good correlation (R = 0.84). Bland-Altman analysis showed excellent agreement between the two Doppler methods and invasive PVR with negligible bias. CONCLUSION: Noninvasive estimation of PVR by Doppler is reliable even in patients with high PVR (>6 WU) and, squaring TRV is not superior to TRV alone.

Echocardiographic parameters for assessing successful balloon mitral valvuloplasty in juvenile age groups.

BACKGROUND: Different echocardiographic parameters have been studied and validated for assessing the severity of mitral stenosis; however, scant data are available for these markers in the context of balloon mitral valvuloplasty in juvenile age groups (ages ⩽20 years). OBJECTIVES: The aim of the present study was to find out the utility of echocardiographic parameters such as mitral valve separation index, left atrial volume, right ventricular systolic pressure, tricuspid annular plane systolic excursion, tricuspid annular systolic velocity, and right ventricular Tei index in predicting success of balloon mitral valvuloplasty and their relation to mitral valve area in juvenile mitral stenosis. METHODS: We carried out a prospective single-centre study involving 52 juvenile mitral stenosis patients undergoing elective valvuloplasty. Success was defined as an increase in mitral valve area ⩾50% or ⩾1.5 cm2. Echocardiographic measurements were taken before and 24 hours after the procedure and statistical analyses were carried out. RESULTS: The mean age of the study population was 14.3 years (SD ±4.55), ranging from 7 to 20 years. Valvuloplasty was successful in 49 out of 52 patients. The mean valve area improved from 0.89 (SD ±0.16) to 1.73 (SD ±0.22) cm2/m2 (p<0.01), and the mean mitral valve gradient decreased from 19.87 (SD ±7.89) to 7.45 (SD ±2.07) (p=0.021). All the surrogate parameters improved favourably after valvuloplasty (p<0.01). The decrease in right ventricular systolic pressure was a better indicator of the success followed by the increase in valve separation index (area under the curve 0.81 and 0.76, respectively). CONCLUSIONS: All the surrogate markers studied showed favourable improvement, and right ventricular systolic pressure reduction and improved mitral valve separation index were better indicators of successful valvuloplasty.

Pace mapping in the atrium using bipolar electrograms from widely spaced electrodes.

BACKGROUND: Pace mapping is a useful tool but is of limited utility for the atrium because of poor spatial resolution. We investigated the use of bipolar electrograms recorded from widely spaced electrodes in order to improve the resolution of pace mapping. METHODS: This prospective study included patients undergoing a clinical electrophysiology study. Unipolar pacing from either the superior or inferior lateral right atrium was performed to simulate atrial tachycardia. Twelve-lead electrocardiograms were recorded during pacing as a template. In addition, three intracardiac bipolar electrograms from a set of widely spaced electrodes were also recorded. Subsequently, unipolar pacing was performed from electrodes at known distances from the initial pacing site, and the morphology of P waves in the electrocardiogram and bipolar electrograms were compared with that of the template. Morphological comparison was performed by a cardiologist and by automated computerized matching. Spatial resolution was calculated as the minimum distance at which there was no match. RESULTS: Fifteen patients participated in the study. Distance at which differences in morphology were noted was smaller in the bipolar electrograms compared to that indicated by P waves in the electrocardiogram, when matched by the cardiologist (6.1±3.8 mm vs. 9.9±5.2 mm, p=0.012) or by automated analysis (4±0 mm vs. 9.9±4 mm, p<0.001). CONCLUSIONS: Use of three bipolar electrograms recorded from a set of widely spaced electrodes in the right atrium improves the resolution of pace mapping compared to that using P waves from surface electrocardiograms alone.