The interplay of cardiac hemodynamics in rheumatic triple valve stenosis.

Rheumatic heart disease is among the common causes of cardiovascular morbidity in developing countries. Here we present the hemodynamic interplay of stenotic rhematic involvement of aortic, mitral, and tricuspid valves in a 35-year-old female. Though noninvasive imaging by echocardiography and doppler has taken the upper hand today, this case illustrates the crucial role of cardiac catheterization in understanding the hemodynamics and patient management of rheumatic multivalvular heart disease.

Comparison of electrocardiographic parameters between left bundle optimized cardiac resynchronization therapy (LOT-CRT) and left bundle branch pacing-cardiac resynchronization therapy (LBBP-CRT).

BACKGROUND: In patients undergoing cardiac resynchronization therapy using left bundle branch area pacing (LBBP-CRT), the addition of a coronary sinus lead, that is, Left bundle optimized CRT (LOT-CRT) might confer additional benefits. OBJECTIVES: To compare the electrocardiographic characteristics between LBBP-CRT and LOT-CRT MATERIALS AND METHODS: Patients with non-ischemic cardiomyopathy (NICMP) and left bundle branch block (LBBB) with left ventricular ejection fraction <35% who underwent implantation of an atrial lead, a left bundle lead, and a coronary sinus lead were included in this prospective study. Digital 12-lead electrocardiograms were recorded in three pacing modes-AAI, DDD with pacing from the LBB lead (LBBP-CRT), and DDD with pacing from both left bundle and coronary sinus leads (LOT-CRT). QRS duration (QRSd), QRS area, QT interval, and T peak-T end (TpTe) intervals were compared. RESULTS: Among 24 patients, QRSd reduced from 167 ± 21.2 ms to 134.5 ± 23.6 ms with LBBP-CRT (p < .001) and 129.5 ± 18.6 ms with LOT-CRT (p < .001) without a significant difference between LBBP-CRT and LOT-CRT (p = .15). Patients with QRS duration with LBBP-CRT > 131 ms showed a significant reduction in QRSd with LOT-CRT (p = .03). QT interval was reduced with both modes of CRT. LOT-CRT was associated with a greater reduction in QRS area (p = .001), TpTe interval (p = .03), and TpTe/QT ratio (p = .013) compared to LBBP-CRT. CONCLUSIONS: In patients with NICMP and LBBB, there was no significant difference in QRSd with LOT-CRT compared to LBBP-CRT. However, in patients with QRSd > 131 ms after LBBP-CRT, LOT-CRT resulted in a significantly narrower QRS.

Double-chambered right ventricle masquerading as bipartite right ventricle.

A 10-day-old neonate with pulmonary consolidation was referred for echocardiography to rule out CHD. At first glance, the morphology appeared to be a bipartite right ventricle with normal tricuspid and pulmonary valves. In-depth analysis, however, of the images showed a double-chambered right ventricle, in which the inlet and outlet portions of the right ventricle were isolated from the apical component of the right ventricle, which itself communicated with the left ventricle through a ventricular septal defect. There was a normal pulmonary valve and tricuspid annulus.

Unusual presentation of mitral prosthetic heart valve thrombosis managed with low dose tenecteplase infusion.

A 11-year-old with history of mitral valve replacement presented with low-grade fever, breathlessness and multiple episodes of haemoptysis for 2 days. Detailed echocardiographic evaluation revealed possible prosthetic valve thrombosis, which was confirmed by fluoroscopy. She was thrombolysed with low dose infusion of tenecteplase. Post thrombolysis her symptoms improved, valve mobility was restored, and haemoptysis subsided. Left sided prosthetic valve thrombosis presenting predominantly with haemoptysis is very rare.

An unusual angiogram finding in a patient with rheumatic heart disease.

A woman in her early fifties with a known case of severe rheumatic mitral stenosis presented to the out-patient department with increasing breathlessness.

Fingers on the Wrist and Taming the Funny Current, Rejuvenate the Wounded Heart: Ivabradine-Responsive Atrial Tachycardia.

A 19-year-old male presented with dyspnea on exertion (New York Heart Association [NYHA] class II) and occasional palpitations for six months. He had initially been evaluated at another facility and diagnosed with dilated cardiomyopathy. Despite treatment, there was no improvement in his symptoms. On evaluation at our centre, his previous electrocardiograms appeared normal. However, palpation of his radial pulse for one minute revealed runs of regular tachycardia, interspersed with a normal pulse rate. A 30-second rhythm strip electrocardiogram (ECG) showed multiple runs of ectopic tachycardia originating from the right atrial appendage, interspersed with ectopic atrial rhythms. Echocardiography showed severe left ventricle (LV) dysfunction with an ejection fraction of 20-25%. Radio-frequency ablation was recommended, but the patient declined. Instead, he was started on Ivabradine. After a month, his symptoms fully resolved. The ECG displayed a normal sinus rhythm with no tachycardia, and his left ventricular ejection function improved.

A curious case of pulmonary hypertension in a child.

BACKGROUND: Pulmonary hypertension in young children can be due to a myriad of conditions. Few aetiologies of pulmonary hypertension are potentially reversible. An extensive workup for the cause of pulmonary hypertension is a must before attributing it to idiopathic pulmonary hypertension. We describe an uncommon aetiology of pulmonary hypertension in a young boy. CASE PRESENTATION: A 12-year-old child, with past history of tubercular pleural effusion, presented with dyspnoea on exertion and easy fatiguability for 2 years. He was evaluated elsewhere and was being treated as primary pulmonary hypertension with pulmonary vasodilators. The child was revaluated since the clinical features were not completely favouring the diagnosis. On detailed evaluation, a diagnosis of constrictive pericarditis was made. He was referred for pericardiectomy. CONCLUSIONS: Constrictive pericarditis presenting with severe pulmonary hypertension without congestive symptoms is very rare. In patients presenting with pulmonary hypertension, always look for a reversible cause before labeling them as idiopathic PAH.

Isolated Cardiac Sarcoidosis in a Patient with a Rare Coronary Anomaly Presenting with MINOCA and Heart Block: The Devil Is in the Detail.

A middle-aged pre-menopausal female presented with shortness of breath and syncope. She had a past history of acute onset chest pain with elevated cardiac enzyme, regional wall motion abnormality on echocardiography, and a coronary anomaly in angiogram. She was being treated as a case of coronary artery disease. On current evaluation, she had right bundle branch block with intermittent 2 : 1 AV block on ECG and a hyperechoic and hypo- kinetic interventricular septum with moderate left ventricular systolic dysfunction on echo- cardiography. Coronary angiogram revealed hyperdominant left anterior descending with right coronary artery ostial atresia. The patient was diagnosed to have cardiac sarcoidosis on the basis of epicardial late gadolinium enhancement (LGE) on MRI and increased use of 68-Gallium DOTANOC PET scan. Patient underwent dual-chamber ICD implantation and then steroids were started.

Left Ventricular Angiogram in Constrictive Pericarditis.

A 14-year-old boy presented with dyspnea on exertion and easy fatiguability for 1 year. He also had an episode of pedal edema 6 months prior, which resolved with diuretics. He had a history of tuberculosis treated with a 6-month course of antitubercular therapy. After a series of tests and analyses, it was evident that longitudinal contraction of the left ventricle was preserved, whereas the circumferential contraction was severely impaired. Pericardial calcification also could be seen encircling the left and right ventricles. Pericardial calcification is evident in around 25% of cases of constrictive pericarditis and predominantly seen in those with tubercular and pyogenic etiology. The subepicardial myocardial fibers are responsible for radial shortening and subendocardial fibers are responsible for longitudinal shortening. In constrictive pericarditis, the involvement of the subepicardial fibers leads to reduction in the circumferential shortening. The patient was referred for pericardiectomy.

Effect of Yoga on Clinical Outcomes and Quality of Life in Patients With Vasovagal Syncope (LIVE-Yoga).

OBJECTIVES: This study aims to determine the impact of yoga as an adjunct to standard therapy versus standard therapy alone on the symptomatic burden in patients with recurrent vasovagal syncope (VVS). BACKGROUND: There is a significant reduction in the quality of life (QoL) of patients with recurrent VVS. Existing management therapies have been largely ineffective. Recent trials have demonstrated the efficacy of yoga in diseases with autonomic imbalance, suggesting its possible utility in VVS. METHODS: Patients with recurrent VVS were randomized to receive either a specialized yoga training program in addition to current guideline-based therapy (intervention arm, group 1) or current guideline-based therapy alone (control arm, group 2). The primary outcome was a composite of the number of episodes of syncope and presyncope at 12 months. Secondary outcomes included QoL assessment by World Health Organization Quality of Life Brief Field questionnaire (WHOQoL-BREF) scores and Syncope Functional Status Questionnaire scores at 12 months, head up tilt test, and heart rate variability at 6 weeks. RESULTS: A total of 55 patients underwent randomization. The mean number of syncopal or presyncopal events at 12 months was 0.7 ± 0.7 in the intervention arm compared to 2.52 ± 1.93 in the control arm (P < 0.01). In the intervention arm, 13 (43.3%) patients remained free of events versus 4 (16.0%) patients in the control arm (P = 0.02). QoL at 12 months showed significant improvement of all Syncope Functional Status Questionnaire scores and 2 domains of WHOQoL-BREF scores (P < 0.05). CONCLUSIONS: Yoga as adjunctive therapy is superior to standard therapy alone in reducing the symptomatic burden and improving QoL in patients with recurrent VVS.

Acute Vessel Closure in Rescue Percutaneous Coronary Intervention.

Guidewire-induced coronary spasm might be life threatening, as demonstrated in the present case. Balloon dilation might worsen the situation by enhancing the spasm. Prompt recognition and generous administration of coronary vasodilators are the mainstay of management.

Acute Dyspnea After Inferior-Wall Myocardial Infarction.

A 57-year-old woman presented with acute-onset dyspea with a duration of more than 2 days. Four days earlier, she had been thrombolyzed with streptokinase for inferior wall myocardial infarction in a nearby hospital. On examination, we found that the patient had elevated jugular venous pressure and systolic murmur in left lower parasternal region. In addition, there was a ventricular septal rupture in the posterobasal interventricular septum, with at least 2 exit points into the right ventricle. Timely identification of ventricular septal rupture before PCI is of paramount importance, as it has major implications in management of the patient.

Supreme dominance of right coronary artery in a patient with typical angina.

A 50-year-old woman presented to our hospital with Canadian Cardiovascular Society grade III angina of 4 months duration. Coronary angiography of the patient showed the absence of left main coronary artery from the left coronary sinus. There was a single right coronary artery (RCA) with a super dominant course from right coronary sinus. It also showed a left main coronary and left anterior descending artery arising separately from proximal RCA, with retroaortic and prepulmonic course, respectively. There was another independently arising small septal branch from the proximal RCA that supplied the proximal interventricular septum. The patient was managed with optimal medical therapy and had symptomatic relief.

Point-of-Care Ultrasonography in Suspected Acute Coronary Syndrome.

This case report presents the ECG findings of a patient in their 40s with post-tubercular bronchiectasis who presented with acute exacerbation of dyspnea and no chest pain.