Minimizing Incision in Living Donor Liver Transplantation: Initial Experience and Comparative Analysis of Upper Midline Incision in 115 Recipients.

Living donor liver transplantation (LDLT) needs "Mercedes Benz" or "J-shaped" incision, causing short and long-term complications. An upper midline incision (UMI) is less invasive alternative but technically challenging. Reporting UMI for recipients in LDLT vs. conventional J-shaped incision. Retrospective analysis, July 2021 to December 2022. Peri-operative details and post-transplant outcomes of 115 consecutive adult LDLT recipients transplanted with UMI compared with 140 recipients with J-shaped incision. Cohorts had similar preoperative and intraoperative variables. The UMI group had significant shorter time to ambulation (3 ± 1.6 vs. 3.6 ± 1.3 days, p = 0.001), ICU stay (3.8 ± 1.3 vs. 4.4 ± 1.5 days, p = 0.001), but a similar hospital stay (15.6±7.6 vs. 16.1±10.9 days, p = 0.677), lower incidence of pleural effusion (11.3% vs. 27.1% p = 0.002), and post-operative ileus (1.7% vs. 9.3% p = 0.011). The rates of graft dysfunction (4.3% vs. 8.5% p = 0.412), biliary complications (6.1% vs. 12.1% p = 0.099), 90-day mortality (7.8% vs. 12.1% p = 0.598) were similar. UMI-LDLT afforded benefits such as reduced pleuropulmonary complications, better early post-operative recovery and reduction in scar-related complaints in the medium-term. This is a safe, non-inferior and reproducible technique for LDLT.

Incidence, clinical characteristics, electrophysiological characteristics and outcomes of patients with baseline PR prolongation undergoing radiofrequency ablation for Atrioventricular nodal reentrant tachycardia.

AIMS AND OBJECTIVES: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common supraventricular tachycardia (SVT). Prolonged PR interval(>200 ms) on baseline electrocardiogram (ECG) is uncommon in such patients. The aim of the current study was to evaluate the incidence, clinical, electrophysiological characteristics, and outcomes of patients with baseline prolongation of PR interval undergoing radio-frequency ablation (RFA) for AVNRT. METHODS: Over 10 years, out of the total number of 1435 patients with diagnosed AVNRT, 16 patients had prolonged PR intervals at baseline. All underwent elective RFA. A retrospective analysis of clinical, and electrophysiological characteristics and outcomes was done. The PR interval and atria-ventricular block cycle length values were compared with those patients with a normal interval at baseline and had undergone a successful slow pathway modification for AVNRT. RESULTS: Out of 1435 patients with AVNRT, 16 (0.9 %) patients had baseline PR prolongation on ECG. The mean(+SD) age of the study population was 62.9 + 15.9 years. 10 (62.5 %) were males. The average PR interval was 264.2 + 24.1 ms. Slow fast AVNRT was seen in all. The anatomical site of success for ablation was the lower part of Koch's triangle in all patients. During ablation, a good sustained junctional rhythm was noted in all, with no AV (Atrioventricular) block or PR prolongation noted during ablation in any of the patients. PR interval decreased by more than 20 ms in 10 (62.5 %) patients. AVBCL (AV node block cycle length) increased on an average of 58.7 ms post-ablation. Only one patient developed AV block on follow-up. CONCLUSION: A prolonged PR interval on baseline ECG is uncommon in patients with AVNRT. In these patients, slow pathway modification can be done safely and effectively. AVBCL (AV node block cycle length) increases immediately post-ablation. The risk of AV block though low persists on follow-up.

Analysis of ST segment depression in Supraventricular Tachycardia and its relationship with underlying mechanism.

BACKGROUND: Electrocardiographic diagnosis of causes of supraventricular tachycardia (SVT) is sometimes difficult and application of routine algorithms can lead to misdiagnosis in as many as 37% of patients. ST segment depression may be useful in diagnosing the nature of SVT. METHODS: We reviewed surface electrocardiogram (ECG) characteristics of 300 patients having SVT with 1:1 AV relationship and correlated findings with electrophysiology study (EPS) findings. Final diagnosis of AVNRT (Atrioventricular nodal reentrant tachycardia), Orthodromic AVRT (atrioventricular reentrant tachycardia) and atrial tachycardia (AT) was correlated with ECG parameters like heart rate, ST segment depressions and QRS morphology. RESULTS: Out of 300 patients, majority patients included in study, were having AVNRT or AVRT. ST depression predicted AVRT if the ST depression was > 2mm (overall sensitivity of 38.3% and specificity of 93.8% to predict AVRT) and was downsloping in morphology (sensitivity of 36.9% and specificity of 94.7% to predict AVRT). At heart rates >214 beats per minute (bpm) as measured by 7 small squares of ECG at 25mm/sec, downsloping ST depression >2mm had a sensitivity 37.9% of and specificity of 89.2% to predict AVRT. At heart rate <214 bpm, downsloping ST depression >2mm had sensitivity of 37.2% and specificity of 96.5% to predict AVRT. Downsloping ST depression of >2 mm helps to differentiate AVNRT from AVRT. CONCLUSION: A downsloping ST segment depression >2mm predicted SVT being an AVRT and can be used as a useful criteria in diagnosing the tachycardia.

1029 genomes of self-declared healthy individuals from India reveal prevalent and clinically relevant cardiac ion channelopathy variants.

BACKGROUND: The prevalence and genetic spectrum of cardiac channelopathies exhibit population-specific differences. We aimed to understand the spectrum of cardiac channelopathy-associated variations in India, which is characterised by a genetically diverse population and is largely understudied in the context of these disorders. RESULTS: We utilised the IndiGenomes dataset comprising 1029 whole genomes from self-declared healthy individuals as a template to filter variants in 36 genes known to cause cardiac channelopathies. Our analysis revealed 186,782 variants, of which we filtered 470 variants that were identified as possibly pathogenic (440 nonsynonymous, 30 high-confidence predicted loss of function ). About 26% (124 out of 470) of these variants were unique to the Indian population as they were not reported in the global population datasets and published literature. Classification of 470 variants by ACMG/AMP guidelines unveiled 13 pathogenic/likely pathogenic (P/LP) variants mapping to 19 out of the 1029 individuals. Further query of 53 probands in an independent cohort of cardiac channelopathy, using exome sequencing, revealed the presence of 3 out of the 13 P/LP variants. The identification of p.G179Sfs*62, p.R823W and c.420 + 2 T > C variants in KCNQ1, KCNH2 and CASQ2 genes, respectively, validate the significance of the P/LP variants in the context of clinical applicability as well as for large-scale population analysis. CONCLUSION: A compendium of ACMG/AMP classified cardiac channelopathy variants in 1029 self-declared healthy Indian population was created. A conservative genotypic prevalence was estimated to be 0.9-1.8% which poses a huge public health burden for a country with large population size like India. In the majority of cases, these disorders are manageable and the risk of sudden cardiac death can be alleviated by appropriate lifestyle modifications as well as treatment regimens/clinical interventions. Clinical utility of the obtained variants was demonstrated using a cardiac channelopathy patient cohort. Our study emphasises the need for large-scale population screening to identify at-risk individuals and take preventive measures. However, we suggest cautious clinical interpretation to be exercised by taking other cardiac channelopathy risk factors into account.

A unique location of the accessory pathway in a child with permanent junctional reciprocating tachycardia.

Permanent junctional reciprocating tachycardia (PJRT) is a rare supra ventricular tachycardia (SVT) due to an accessory pathway (AP), characterized by slow and decremental retrograde conduction, which is predominantly seen in infants and children. Although the typical site of AP in PJRT is a right posteroseptal region around or just within the coronary sinus (CS), atypical sites of AP have been described. We report a rare case of PJRT in a 7-year-old girl with an AP located in the superio-paraseptal (Para-Hsian) region that was successfully ablated through a non-coronary sinus.

Early repolarization syndrome, epilepsy, and atrial fibrillation in a young girl with novel KCND3 mutation managed with quinidine.

A 6-year-old girl presented with a difficult to control epilepsy syndrome. On evaluation, additional presyncope episodes associated with polymorphic ventricular tachycardia were also noted. A diagnosis of early repolarization syndrome (ERS) was made with an early repolarization pattern on electrocardiogram, documented VT episodes, and clinical presyncope (proposed Shanghai score 7). Paroxysmal atrial fibrillation (AF) was also noted on 24-h Holter recordings. The child was stabilized with isoprenaline infusion and was later discharged with arrhythmia control on quinidine and cilostazol. The genetic evaluation revealed a potassium channel KCND3 gene missense mutation. The case highlights the association of epilepsy syndrome and AF with ERS; the possible association of KCND3 gene mutation with a malignant phenotype; and management issues in a small child.

Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study.

BACKGROUND: Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association. METHODS: We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors. RESULTS: Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01). CONCLUSION: We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.

Miniseries 2-Septal and paraseptal accessory pathways-Part IV: Inferior paraseptal accessory pathways-lessons from surgical and catheter ablation.

Surgeons and electrophysiologists performing accessory pathway ablation procedures have used the term 'posteroseptal' region. This area, however, is neither septal nor posterior, but paraseptal and inferior; paraseptal because it includes the fibro-adipose tissues filling the pyramidal space and not the muscular septum itself and inferior because it is part of the heart adjacent to the diaphragm. It should properly be described, therefore, as being inferior and paraseptal. Pathways in this region can be ablated at three areas, which we term right inferior, mid-inferior, and left inferior paraseptal. The right- and left inferior paraseptal pathways connect the right and left atrial vestibules with the right and left paraseptal segments of the parietal ventricular walls. The mid-inferior paraseptal pathways take a subepicardial course from the myocardial sleeves surrounding the coronary sinus and its tributaries. Our review addresses the evolution of the anatomical concept of the inferior paraseptal region derived from surgical and catheter ablation procedures. We also highlight the limitations of the 12-lead electrocardiogram in identifying, without catheter electrode mapping, which are the pathways that can be ablated without a coronary sinus, or left heart approach.

Miniseries 2-Septal and paraseptal accessory pathways-Part III: Mid-paraseptal accessory pathways-revisiting bypass tracts crossing the pyramidal space.

The mid-paraseptal region corresponds to the portion of the pyramidal space whose right atrial aspect is known as the triangle of Koch. The superior area of this mid-paraseptal region is also para-Hisian, and is close to the compact atrioventricular node and the His bundle. The inferior sector of the mid-paraseptal area is unrelated to the normal atrioventricular conduction pathways. It is, therefore, a safe zone in which, if necessary, to perform catheter ablation. The middle part of the mid-paraseptal zone may, however, in some patients, house components of the compact atrioventricular node. This suggests the need for adopting a prudent attitude when considering catheter ablation in this area. The inferior extensions of the atrioventricular node, which may represent the substrate for the slow atrioventricular nodal pathway, take their course through the middle, and even the inferior, sectors of the mid-paraseptal region. In this review, we contend that the middle and inferior areas of the mid-paraseptal region correspond to what, in the past, was labelled by most groups as the 'midseptal' zone. We describe the electrocardiographic patterns observed during pre-excitation and orthodromic reciprocating tachycardia in patients with pathways ablated in the middle or inferior sectors of the region. We discuss the modification of the ventriculo-atrial conduction times during tachycardia after the development of bundle branch block aberrancy. We conclude that the so-called 'intermediate septal' pathways, as described in the era of surgical ablation, were insufficiently characterized. They should not be considered the surrogate of the 'midseptal' pathways defined using endocardial catheter electrode mapping.

Miniseries 2-Septal and paraseptal accessory pathways-Part II: Para-Hisian accessory pathways-so-called anteroseptal pathways revisited.

Surgeons, when dividing bypass tracts adjacent to the His bundle, considered them to be 'anteroseptal'. The area was subsequently recognized to be superior and paraseptal, although this description is not entirely accurate anatomically, and conveys little about the potential risk during catheter interventions. We now describe the area as being para-Hisian, and it harbours two types of accessory pathways. The first variant crosses the membranous septum to insert into the muscular ventricular septum without exiting the heart, and hence being truly septal. The second variant inserts distally in the paraseptal components of the supraventricular crest, and consequently is crestal. The site of ventricular insertion determines the electrocardiographic expression of pre-excitation during sinus rhythm, with the two types producing distinct patterns. In both instances, the QRS and the delta wave are positive in leads I, II, and aVF. In crestal pathways, however, the QRS is ≥ 140 ms, and exhibits an rS configuration in V1-2. The delta wave in V1-2 precedes by 20-50 ms the apparent onset of the QRS in I, II, III, and aVF. In the true septal pathways, the QRS complex occupies ∼120 ms, presenting a QS, W-shaped, morphology in V1-2. The delta wave has a simultaneous onset in all leads. Our proposed terminology facilitates the understanding of the electrocardiographic manifestations of both types of para-Hisian pathways during pre-excitation and orthodromic tachycardia, and informs on the level of risk during catheter ablation.

Idiopathic brachial plexopathy after pacemaker implant.

A middle-aged woman presented with symptomatic complete heart block and underwent an uneventful dual chamber pacemaker implantation. Three weeks post procedure, she developed left arm pain and weakness, with neurological localization to the lower trunk of left brachial plexus. Possibilities of traumatic compression by the device/leads or postoperative idiopathic brachial plexopathy were considered. After ruling out traumatic causes, she was started on oral steroids, to which she responded remarkably. This case highlights the importance of recognizing this rare cause of brachial plexopathy following pacemaker implantation, because not only does an expedited diagnosis and medical treatment lead to prompt recovery with minimal neurological deficits, but it also circumvents an unnecessary surgical re-exploration.

Atresia of the coronary sinus ostium with persistent left superior caval vein.

We describe a case of a 33-year-old woman with congenitally corrected transposition where computed tomography angiography incidentally detected ostial atresia of the coronary sinus with dilatation of the terminal parts of the middle cardiac vein and great cardiac vein and retrograde drainage of the coronary sinus into the persistent left superior caval vein, the intercommunicating vein, then to the right superior caval vein, and ultimately into the right atrium.

Artificial Intelligence-assisted chest X-ray assessment scheme for COVID-19.

OBJECTIVES: To study whether a trained convolutional neural network (CNN) can be of assistance to radiologists in differentiating Coronavirus disease (COVID)-positive from COVID-negative patients using chest X-ray (CXR) through an ambispective clinical study. To identify subgroups of patients where artificial intelligence (AI) can be of particular value and analyse what imaging features may have contributed to the performance of AI by means of visualisation techniques. METHODS: CXR of 487 patients were classified into [4] categories-normal, classical COVID, indeterminate, and non-COVID by consensus opinion of 2 radiologists. CXR which were classified as "normal" and "indeterminate" were then subjected to analysis by AI, and final categorisation provided as guided by prediction of the network. Precision and recall of the radiologist alone and radiologist assisted by AI were calculated in comparison to reverse transcriptase-polymerase chain reaction (RT-PCR) as the gold standard. Attention maps of the CNN were analysed to understand regions in the CXR important to the AI algorithm in making a prediction. RESULTS: The precision of radiologists improved from 65.9 to 81.9% and recall improved from 17.5 to 71.75 when assistance with AI was provided. AI showed 92% accuracy in classifying "normal" CXR into COVID or non-COVID. Analysis of attention maps revealed attention on the cardiac shadow in these "normal" radiographs. CONCLUSION: This study shows how deployment of an AI algorithm can complement a human expert in the determination of COVID status. Analysis of the detected features suggests possible subtle cardiac changes, laying ground for further investigative studies into possible cardiac changes. KEY POINTS: • Through an ambispective clinical study, we show how assistance with an AI algorithm can improve recall (sensitivity) and precision (positive predictive value) of radiologists in assessing CXR for possible COVID in comparison to RT-PCR. • We show that AI achieves the best results in images classified as "normal" by radiologists. We conjecture that possible subtle cardiac in the CXR, imperceptible to the human eye, may have contributed to this prediction. • The reported results may pave the way for a human computer collaboration whereby the expert with some help from the AI algorithm achieves higher accuracy in predicting COVID status on CXR than previously thought possible when considering either alone.

Pneumothorax leading to pneumopericardium after transvenous lead implantation in a patient with previous epicardial lead.

A 44-year-old lady, a follow-up case of idiopathic dilated cardiomyopathy and cardiac resynchronization therapy defibrillator device implantation with epicardial left ventricular (LV) lead, underwent a transvenous LV lead revision in view of epicardial lead malfunction. A chest X-ray after this, done for worsening dyspnea, revealed pneumopericardium along with left pneumothorax. The computed tomography (CT) revealed a communication between the left pleural and pericardial cavities, around the old epicardial lead. Drainage of the left pleural cavity resolved both the pneumothorax and pneumopericardium and the patient remained well on follow up.

Is the right ventricular function affected by permanent pacemaker?

AIMS: The effect of right ventricular (RV) pacing on left ventricular (LV) function has been extensively evaluated, but the effect on RV function per se has not been evaluated systematically. We aimed to assess the effect of dual chamber pacemaker on RV function. METHODS AND RESULTS: All consecutive patients undergoing dual chamber pacemaker from January 2018 to March 2019 for AV block with a structurally normal heart were included. They underwent pre-procedure detailed echocardiography (including three-dimensional [3D] RV ejection fraction [RVEF]), a screening echocardiogram 2 days after pacemaker implantation and again a detailed echocardiogram at 6-month follow-up. We compared the baseline echocardiographic RV parameters with those 6 months after the pacemaker implantation. A total of 60 patients underwent successful pacemaker implantation. At 6 months, most of the patients were pacemaker dependent with pacing percentage of 98.9% ± 2.4%; there was a significant increase in TR and a mean drop in RVEF by 2.8 ± 5%, with 23 (38.3%) having at least a 5% decrease in RVEF. The drop in RVEF positively correlated with TR vena contracta at 6 months but did not correlate with pulmonary artery systolic pressure at 6 months. CONCLUSION: Our study shows the presence of demonstrable RV dysfunction as early as 6 months in a majority of patients who have undergone pacemaker implantation.

Unruptured sinus of valsalva aneurysm in a case of large vessel vasculitis: A diagnostic dilemma.

BACKGROUND: Takayasu arteritis and tuberculous aortitis, both can result in aneurysmal disease of the aorta. The overlapping imaging features in case of large vessel vasculitis can create a diagnostic dilemma. AIM: We present a case of large vessel vasculitis and chronic empyema with unruptured sinus of valsalva aneurysm. METHODS AND RESULTS: A 30-year-old man presented with acute onset shortness of breath, palpitations, and gradually progressing pedal edema. The echocardiography and CT angiogram revealed features of large vessel vasculitis and chronic empyema along with unruptured sinus of valsava aneurysms. Patient underwent emergency Bentall procedure and the histopathology confirmed the diagnosis of takayasu arteritis. DISCUSSION: Tuberculosis being an endemic disease with varied presentations should always be considered a differential diagnosis, whenever appropriate. An unruptured sinus of valsalva aneurysm can be clinically silent or can cause compression symptoms. Although there are no specific guidelines regarding surgical correction, symptomatic and aneurysms of size >5.5cm are usually managed surgically. CONCLUSION: Unruptured sinus of valsalva aneurysms can be seen in Takayasu arteritis, which complicates the methodology and timing of the surgical management.

Simultaneous cardiac and pulmonary central cyanosis in a young girl: the double trouble.

A 14-year-old girl admitted for corrective surgery for tetralogy of Fallot was found to have pulmonary arteriovenous malformations on pre-operative evaluation. In anticipation of a complicated postoperative course, percutaneous closure of the pulmonary arteriovenous malformations was undertaken first followed by a successful surgical outcome. Importance of this rare association and its clinical implication is hereby highlighted.

Persistent left superior caval vein draining into right atrium, but not through the coronary sinus.

Persistence of the left superior caval vein is the most commonly reported thoracic venous anomaly. The vein usually drains into the right atrium through the coronary sinus, reflecting its developmental origin. We describe an unusual variant, in which the vein drained directly into the right atrium.

QRS alternans during right ventricular pacing while ablating a concealed left sided accessory pathway.

A 16-year-old boy was referred for an electrophysiological study for documented regular narrow complex tachycardia. A diagnosis of a concealed left lateral accessory pathway was made with an eccentric atrial activation sequence both during tachycardia and right ventricular (RV) pacing. The pathway was mapped at the left posterior mitral vestibule during RV pacing, performed through the distal tip of the His bundle catheter pushed into right ventricular outflow tract. An unusual response to ventricular stimulation with alternation of QRS complex width and morphology was noted. The possible mechanisms are hereby discussed.

Small Bowel Amyloidosis.

PURPOSE OF REVIEW: The goal of this paper is to review the literature on small bowel amyloidosis. Our review focuses on the underlying etiology, histopathology, clinical features, endoscopic and radiologic findings, and the mainstay of management. RECENT FINDINGS: The latest research shows changing epidemiological trends of different types of amyloidosis. It also reveals a better understanding of its pathophysiology and shows improvement in treatment outcomes. Amyloidosis is a group of diseases of multiple etiologies and clinical presentations. It is characterized by pathological deposition of insoluble fibrillar proteins within various organs leading to disruption of their structure and function. The classification of amyloidosis includes primary, secondary, dialysis-related, senile, and hereditary. Amyloidosis can be systemic or localized. The incidence of AA amyloidosis is declining in frequency. If the gastrointestinal (GI) tract is involved, the small intestine is the most commonly affected site. Overall, outcomes among patients with newly diagnosed amyloidosis have improved. This article focuses on small bowel amyloidosis.