Effect of discontinuation of ticagrelor and switching-over to other P2Y12 agents in patients with acute coronary syndrome: a single-center real-world experience from India.

BACKGROUND: Dual antiplatelet therapy is the current standard of care after acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). We intended to study the pattern of use of ticagrelor in patients with acute coronary syndrome undergoing PCI and the effect of switching over to other P2Y12 receptor inhibition on clinical outcomes. RESULTS: All patients aged > 18 years who had been admitted with acute coronary syndrome and had been provided ticagrelor as the second antiplatelet agent were included as study participants. The primary outcome of the study was the composite outcome of death, recurrent myocardial infarctions, re-intervention, and major bleeding. We studied 321 patients (54 female patients, 16.82%). The mean age of the patients was 56.65 ± 11.01 years. Ticagrelor was stopped in 76.7% on follow-up. It was stopped in 6.3%, 13.5%, 13.1%, 21.9%, and 45.1% of patients during the first month but after discharge, between first and third months, between 3 and 6 months, between 6 and 12 months, and after 12 months, respectively. In the majority of patients, ticagrelor was replaced by clopidogrel (97.9%). It was stopped according to the physician's discretion in 79.3% of patients, whereas it was the cost of the drug that made the patient to get swapped to another agent in 18.6%. No difference in the primary composite outcome was observed between the groups where ticagrelor was continued post 12 months and ticagrelor was continued and ticagrelor was switched-over to another agent. Similarly, no difference in death, recurrent myocardial infarctions, re-interventions, or major bleeding manifestations was observed between the two groups. CONCLUSION: In patients with acute coronary syndrome who undergo PCI, we observed that early discontinuation of ticagrelor and switching over to other P2Y12 inhibitors after discharge did not affect clinical outcomes.

Revision using distal inflow for treatment of heart failure secondary to arteriovenous fistula for hemodialysis.

In patients on hemodialysis, cardiovascular disease can be precipitated or worsened by the presence of a high flow arteriovenous fistula. Fistula closure and banding are the traditional treatment methods of dialysis associated high output cardiac failure. We present a case of fistula-related high output cardiac failure treated by revision using distal inflow (RUDI).

A whole system approach to improving mortality associated with acute kidney injury.

BACKGROUND: Acute kidney injury (AKI) is in the main managed by non-nephrologists, many who feel challenged by or lack awareness of the complexity that the renal element adds to their patients' care. National reports have raised major concerns about the quality of care and have predicted that mortality reductions of 30% are achievable with good medical practice. AIM: This quality improvement project evaluated whether a whole system approach could improve outcomes for patients with AKI. DESIGN AND METHODS: Quality improvement methodology was used to understand hospital patterns, processes and professional knowledge. Change concepts were developed which included management of patients at risk, staff education and awareness program, development of a patient specific electronic alert to prompt diagnosis, easy to remember care bundle (ABCDE-IT), dedicated outreach team and patient and family empowerment leaflet. RESULTS: Statistical process control analysis was used to verify outcomes over time. A shift in the in-hospital mortality rate corresponded to a relative 23.2% reduction in mortality and was sustained over the next 33 months (P < 0.0001). The favourable shift in mortality was temporally distinct from the improved AKI detection rate. This timeframe corresponded to lying below the 99.8% lower confidence limit in comparison with all English acute trusts for comparative AKI specific SHMI/HSMR mortality rates. Length of stay also reduced shortly after onset of the project by 14.1% or 2.6 day reduction (P < 0.0001). CONCLUSION: This project demonstrated that an integrated, whole-system approach is necessary to ensure sustained improvements in AKI mortality and length of stay.

Tetralogy of Fallot in adults. A report on 147 patients.

Presented here is the clinical and hemodynamic profile of 147 patients, above the age of 18 with tetralogy of Fallot. Cardiac catheterization and selective cineangiocardiography were performed in all. Infundibular pulmonary stenosis, a subaortic large infracristal ventricular septal defect, mitral-aortic fibrous continuity and equal pressures in both the ventricles and aorta were considered mandatory for the diagnosis of tetralogy of Fallot. Cardiac enlargement was seen in 25.8 per cent of the patients, and 15.6 per cent were in congestive cardiac failure; 9.5 per cent had systemic hypertension, and aortic regurgitation was present in 6.7 per cent. A reticular pattern in the lung fields due to bronchial collaterals was seen in 23.1 per cent. The incidence of right aortic arch (19.9 per cent), absent left pulmonary artery (2.8 per cent), absent right pulmonary artery (0.7 per cent) and dextrocardia (1.4 per cent) is brought out. The right atrial mean pressure was increased in 4.8 per cent and a prominent "a" wave greater than 10 mm Hg was present in 10.9 per cent. The right ventricular end-diastolic pressure was increased in 23.8 per cent and the left ventricular end-diastolic pressure in 25.9 per cent of the patients.

Transatrial correction of origin of both great vessels from right ventricle with pulmonary hypertension.

The operative treatment of seven patients with origin of both great vessels from the right ventricle plus pulmonary hypertension is discussed. Except for one patient with an atrioventricular canal type of ventricular septal defect (VSD), all patients had subaortic VSDs. All had transatrial repair, and none died. The clinical and operative findings and the merits of a transatrial approach are discussed.

Influence of ribose on adenine salvage after intense muscle contractions.

The influence of ribose supplementation on skeletal muscle adenine salvage rates during recovery from intense contractions and subsequent muscle performance was evaluated using an adult rat perfused hindquarter preparation. Three minutes of tetanic contractions (60 tetani/min) decreased ATP content in the calf muscles by approximately 50% and produced an equimolar increase in IMP. Effective recovery of muscle ATP 1 h after contractions was due to reamination of IMP via the purine nucleotide cycle and was complete in the red gastrocnemius but incomplete in the white gastrocnemius muscle section. Adenine salvage rates in recovering muscle averaged 45 +/- 4, 49 +/- 5, and 30 +/- 3 nmol. h(-1). g(-1) for plantaris, red gastrocnemius, and white gastrocnemius muscle, respectively, which were not different from values in corresponding nonstimulated muscle sections. Adenine salvage rates increased five- to sevenfold by perfusion with approximately 4 mM ribose (212 +/- 17, 192 +/- 9, and 215 +/- 14 nmol. h(-1). g(-1) in resting muscle sections, respectively). These high rates were sustained in recovering muscle, except for a small (approximately 20%) but significant (P < 0.001) decrease in the white gastrocnemius muscle. Ribose supplementation did not affect subsequent muscle force production after 60 min of recovery. These data indicate that adenine salvage rates were essentially unaltered during recovery from intense contractions.

Restenosis of the mitral valve: surgical considerations and results of operation.

Our experience over an eight-year period with 63 consecutive patients with mitral restenosis who underwent operation forms the basis for this report. Striking clinical disability was a notable finding. A majority of the patients were less than 30 years old. Embolic phenomena were rare. Closed transventricular valvotomy offers excellent low-risk palliation and good long-term results. Follow-up showed excellent or good results in 90.5% of the patients and poor results in 9.5%. Hemodynamic study of 6 patients demonstrated a pronounced decrease in the pulmonary artery pressure. Open valvotomy was performed in 6 subjects. The presence of intracardiac calcification together with mild mitral incompetence in 2 patients made valve replacement mandatory. The problem of restenosis of the mitral valve is complex, and only after further long-term results are available will the superiority of any one method be demonstrated.

Percutaneous transvenous mitral commissurotomy for significant calcific mitral stenosis: utility of the stepwise balloon dilatation technique and follow-up results.

The present study examined the utility of the stepwise balloon dilatation technique in 41 patients with significant calcific mitral stenosis undergoing percutaneous transvenous mitral commissurotomy (PTMC). Thirty-five patients (85.4%) had a successful procedure; one patient developed cardiac tamponade and underwent mitral valve replacement. The mitral valve area increased from 0.9 +/- 0.2 cm2 to 1.7 +/- 0.3 cm2 following PTMC. Increase in mitral regurgitation (MR) was seen in 11 patients (26.8%). All patients showed improvement in functional class of > or =1 level following PTMC, which was sustained in 34 patients at follow-up. At a mean follow-up period of 20 +/- 12 months (range 3-51 months) in 35 patients, 26 patients (74.3%) were in New York Heart Association (NYHA) functional Class I, 8 patients (22.9%) were in NYHA Class II, and 1 patient (2.8%) was in NYHA Class III. The cumulative 4-year cardiac event-free survival rate was 81.8%. However, patients with grade 4+ calcification had only 50% event-free survival rate. At follow-up, an increased incidence of cardiac events was seen in female patients as compared with male patients (83.3% versus 16.7%). Restenosis was seen in 3 patients (8.6%). One patient underwent repeat PTMC 37 months after the initial procedure. There was no incidence of death or mitral valve replacement at follow-up. We conclude that the stepwise balloon dilatation technique can be safely and effectively applied for patients with significant calcific mitral stenosis to achieve an optimal mitral valve area with low incidence of significant increase in MR. Favorable long-term benefits also accrue in the form of improved functional status and low incidence of repeat procedures (repeat PTMC or mitral valve replacement). The majority of patients (74.3%) were in NYHA functional class I without medication. Patients with grade 4+ calcification show less benefit from PTMC and may be considered for mitral valve replacement. Cardiac events occur more frequently in female patients than in male patients during follow-up.

Angioplasty and stenting of solitary supra-aortic artery and aortoplasty by kissing balloon technique.

A child presented with symptoms of compromise to cerebral blood flow and cardiac failure. On diagnostic angiography, he was found to have a discrete coarctation and related ostial stenosis of the left subclavian artery, which acted as the sole source of cerebral blood flow. The subclavian lesion was initially dilated with a 6 mm x 50 mm balloon. The discrete coarctation was then dilated with an 8 mm x 50 mm balloon. Since significant residual stenosis was present at the subclavian origin, it was stented with a 20 mm Palmaz-Schatz stent (Cordis Corporation, Miami Lakes, Florida). Since the coarcted segment required further dilatations, the kissing balloon technique was used, wherein the 6 mm balloon was placed extending from the left subclavian lesion distally to the related aortic lesion proximally, along with another 10 mm balloon in the aorta. The end result was acceptable and the patient's symptoms improved significantly after the procedure.

Intracardiac repair of tetralogy of Fallot in adults.

This study demonstrates that total surgical correction in tetralogy of Fallot is a gratifying procedure even with advancing age especially when one reckons that a great majority of these patients showed pronounced disability at the time of surgery without the benefit of previous palliative procedures. However, there are technical difficulties in accomplishing repair in the fibrotic hearts of older patents. The early mortality and long term benefits in this age group closely parallel those in our over all experience with surgery for this anomaly. There was a 12.5% early and 10% late mortality in this series. Surviving patients have been followed up for a period ranging from 1 to 10 years (mean 18 months) and are found to be leading normal active lives.

Intralobar sequestration of upper lobe of right lung--case reports.

Two cases of intralobar sequestration of the right upper lobe, which is supplied by a major anomalous collateral artery from the descending thoracic aorta and also by the upper lobe branch of the right pulmonary artery, are presented. Both cases underwent surgical correction. The plexus of abnormal vessels in the right upper lobe of the lung communicating to the anomalous collateral artery was unexpected. The return pathway into the right pulmonary artery was most unusual. The embryologic explanation of the anomaly and the surgical implications are discussed. The return pathway of the left-to-right shunt by a branch of the pulmonary artery is most unusual and has hitherto not been reported in English literature to the best of the authors' knowledge.

Familial cardiac myxoma: Carney's complex.

We report a case of Carney's complex in a 12-year-old boy who had the characteristic features of multiple cutaneous tumors, pigmentation, and biatrial myxoma. His large right atrial myxoma almost occluded the tricuspid valve and presented a life-threatening emergency. Surgery saved his life, but recurrence of myxoma was noted on follow-up. The familial nature of the condition is highlighted by the case of the patient's 44-year-old mother, who also presented with features of Carney's complex: multiple cutaneous tumors and a tiny, asymptomatic, left atrial myxoma, which was detected during routine echocardiographic screening.

Left ventricular pseudoaneurysm caused by coronary spasm, myocardial infarction, and myocardial rupture.

We report a very rare case of a 47-year-old man who had coronary spasm that resulted in a silent myocardial infarction, a ruptured myocardial wall, and a nonruptured left ventricular pseudoaneurysm. The patient presented with a 6-month history of dyspnea on exertion, without evidence of fixed coronary artery stenosis. Coronary angiography showed severe coronary spasm of the left anterior descending and left circumflex arteries; the spasm was relieved promptly by nitroglycerin. Echocardiography and left ventricular angiography revealed the large left ventricular pseudoaneurysm posterolateral to the left ventricle. We performed surgical resection of the pseudoaneurysm and patch repair of the ruptured left ventricular wall, with excellent results. We present this case because of the highly unusual sequence of events. Early surgical intervention resulted in the patient's recovery.

Results of 130 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures in single and multiple vessel coronary artery disease (CAD).

Over the last 1-year period, we performed 130 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures in 108 patients, 103 of them were males and 5 females. Their mean age was 50.9 +/- 6.83 years (range 33-70). All of them were symptomatic, manifested by acute infarction in 18 (17%), chronic stable angina in 30 (28%), unstable angina in 5 (5%) and post-myocardial infarction angina in 55 (51%) cases. Among these patients, single-vessel CAD was present in 42 (39%), double-vessel in 37 (34%) and triple-vessel CAD in 11 (10%) patients. Nine patients (8.3%) had total occlusion, and 18 (16.6%) had tandem or bifurcation lesions of target artery. Of the 112 PTCA procedures (excluding those in acute infarction), 53 (47%) were performed on LAD, 29 (26%) on RCA, and 30 (27%) on circumflex artery, with success rates of 86.7%, 83.3% and 82.7% respectively. The overall success rate was 85% (95 of 112). The PTCA was successful in 36 of 42 (85.7%), 32 of 37 (86.5%) and 9 on 11 (82%) patients with single, double and triple-vessel CAD respectively. The mean diameter stenosis reduced from 67.1 +/- 16.54% to 19.9% +/- 10.9%. PTCA was unsuccessful in 17 (15%) due to failure to cross the lesion in 11 (9.7%), failure to dilate in 1 (0.9%) and abrupt reclosure of dilated segment in 5 (4.4%). Four (3.5%) patients underwent CABG. Two patients had redo PTCA owing to restenosis at about 6 months of first PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Subaortic stenosis associated with anomalous right ventricular muscle bundle and ventricular septal defect.

A rare case of biventricular outflow tract obstruction in the form of discrete subaortic membrane and hypertrophic anomalous right ventricular muscle bundle associated with ventricular septal defect is presented.

Myocardial bridge (MB): an angiographic curiosity?

The coronary angiograms of 1,500 cases performed between 1981 and 1989 were analysed to find out the incidence of Myocardial Bridge (MB) and its significance as regards myocardial ischemia. Sixteen of these (1.06%) were found to have MB. Their ages ranged from 27-70 years (m = 49.2) and male:female ratio was 13:3. Out of 16 patients, 7 (group A) had associated coronary artery disease (CAD) (7 of 1421; 0.49%) and remaining 9 (group B) had no associated CAD (9 of 79; 11.39%). All the MB were found on left anterior descending artery (LAD) (3 on proximal LAD and 13 on mid LAD). No MB was found on right coronary artery (RCA) or circumflex arteries. The location of the MB did not affect the pattern of CAD. Chronic stable angina was the commonest presenting symptom in group A patients (5 out of 7) and atypical angina in group B patients (5 out of 9). Majority of group B patients had either normal or nonspecific ST-T changes in ECG (7 out of 9). However, the presence of previous myocardial infarction or ECG evidence of 'Q' wave infarction (2 out of 2) was always associated with significant CAD. Similarly, regional wall motion abnormalities on echocardiogram were always found in patients with significant CAD and old myocardial infarction. All 9 patients with MB and normal coronary arteries were managed conservatively with good relief of symptoms, whereas other seven patients were managed on the merits of the underlying CAD. In conclusion, the MB is a normal variant found incidentally on coronary angiography, and does not have any definite clinical correlations or pathological significance.

Tetralogy of Fallot with hypertrophic cardiomyopathy--an unknown combination.

A hitherto unknown association of Tetralogy of Fallot (TF) and Hypertrophic Cardiomyopathy (HCM) diagnosed by two dimensional echocardiography, cardiac catheterization and angiocardiography is reported. Patient underwent emergency aortopulmonary shunt successfully. The literature is reviewed in brief.

Ventricular septal defect with aortic regurgitation: a hemodynamic and angiographic profile in Indian subjects.

The records of 362 patients of Ventricular Septal Defect (VSD) were analysed to find out the incidence of aortic regurgitation (AR) and their hemodynamic and angiographic features. Thirty-seven patients (10.2%) were found to have AR, whose mean age was 13.4 years (range: 2-45) and male to female ratio was 5:1. Of the 37 cases 31 (84%) had infracristal and 6 (16%) had supracristal VSD. In 31 patients with infracristal VSD the prolapsing cusp was Right Coronary Cusp (RCC) in 14 (48%), Noncoronary Cusp (NCC) in 12 (41%) and both RCC and NCC in 3 (11%). Of the 6 patients with supracristal VSD the prolapsing cusp was RCC in 5 (83%) and NCC in 1 (17%). In two patients the AR was due to bicuspid aortic valve. The pulmonary artery pressure was normal in 26 of 37 (70.2%) patients and the left to right shunt was 1.5:1 or less in 23 of 37 (62%) patients. Nineteen of the 37 patients (51.3%) had grade I or II AR and the remaining 18 (48.7%) had grade III or IV AR. There was no relationship between the severity of AR and the location of the VSD. In conclusion, in this series, the incidence of VSD+AR is relatively higher and that of supracristal VSD is lower. In majority of patients the left to right shunt is small and pulmonary artery pressure within normal limits. The prolapse of RCC is more common in supracristal VSD and there is no relation between the severity of AR and the location of the VSD.

Detection of silent myocardial ischemia by Holter monitoring and its relation to severity of coronary artery disease.

Thirty-five patients of chronic stable angina, unstable angina and post MI angina, who were on medical treatment, underwent 24 hours Holter monitoring and coronary angiography to find out the incidence of Silent Myocardial Ischemia (SMI) and its relation to anatomic severity of coronary artery disease. Total duration of Holter monitoring was 835.32 hours (average 23.40 hours per patient) with 48 ischemic episodes out of which 16 were painful and 32 painless. Total duration of painful episodes was 189 minutes and that of painless episodes was 428 minutes (70% was constituted by SMI). Out of 35 patients, 6 (17.14%) had SMI; 2 of 17 (11.7%) of chronic stable angina, 2 of 8 (25%) of unstable angina, and 2 of 10 (20%) of post-infarction angina patients. On analysis of coronary angiogram, all 6 (100%) patients with SMI, and only 22 out of 29 (76%) without SMI, had severe multiple coronary artery disease. Thus, although the overall incidence of SMI in this series is low, its presence invariably indicates a severe degree of coronary artery disease.

Severe syphilitic aortic regurgitation with bilateral critical coronary ostial stenosis.

A forty-year-old male with syphilitic severe aortic regurgitation and critical bilateral coronary ostial stenosis, proved by cardiac catheterization and angiocardiography, is presented. He underwent successful aortic valve replacement and coronary artery bypass grafting with gratifying results.