Novel Technique of Transfemoral Venous Pacing in a Rare Case of Inferior Vena Cava Stenosis.

Temporary transvenous pacing is a simple and routinely performed invasive procedure for treatment of life threatening bradyarrhythmias. We present a novel technique for transfemoral venous pacing in a patient with rare co-occurrence of inferior vena cava stenosis, rheumatic mitral stenosis, left ventricular dysfunction and digitoxicity.

Congenitally Absent Left Circumflex Artery.

Congenital coronary anomalies are uncommon with rarest being absent left circumflex artery (LCX) having prevalence of 0.003%. We report a case of a 68 year old male having acute coronary syndrome and left ventricular dysfunction whose coronary angiogram showed an absent LCX with super dominant right coronary artery (RCA). Precise morphological evaluation is needed for best suited management strategy.

Young Hearts go Ischemic too.

INTRODUCTION: Young presentation of acute coronary syndrome (ACS) has been poorly described in literature. We hereby evaluate patients younger than 30 years. MATERIAL AND METHODS: In this prospective study we enrolled 1377 patients who underwent coronary angiography for symptoms concerning for acute coronary syndrome over a period of one year. RESULTS: Male predominance (100%) was seen among the young patients (less than 30 years) with most common presentation being chest pain. Incidence of ST elevation myocardial infarction (STEMI) was significantly higher (75%) than non-ST elevation myocardial infarction/ unstable angina (NSTEMI/UA). Most common associated risk factor was current smoking (41.6%). As compared to elderly, young patients were seen to have better outcome with percutaneous coronary interventions (PCI) and thrombolysis. CONCLUSIONS: Very young <30 years suffer from ischemia too and may differ in presentation, risk factors and outcome as compared to old. Primary prevention of avoidable risk factors should be aggressively promoted among young.

Massive Hematuria Due to Congenital Renal Arteriovenous Malformation Successfully Treated by Renal Artery Embolization.

Congenital renal arteriovenous malformations (AVMs) are rare benign vascular lesions and a rare cause of massive hematuria in females predominantly involving right kidney. Clinical presentation in a male with involvement of the left kidney is very rare. Only a few case series describing the outcome of congenital renal AVMs have been reported in the literature. We report a challenging case of a male patient with life threatening massive hematuria with congenital renal AVMs in left kidney. Successful embolization was performed using coils and gel foam.

Long-term Mortality in Patients with Permanent Pacemaker Implantation.

INTRODUCTION: The development of implantable technology for cardiac rhythm management remains one of the seminal achievements of the second half of the 20th century. The development of artificial pacemakers for the electrical control of the cardiac rhythm has greatly enhanced the physician's ability to treat cardiac dysrhythmias. An ageing population and the extension of indications will in all probability result in an increasing number of cardiac device implantations. OBJECTIVE OF STUDY: To study mortality and morbidity in patients with permanent pacemaker implantation at a tertiary care hospital in North India. MATERIAL ANDF METHODS: This was a two year prospective observational study conducted in the Department of Cardiology of Christian Medical College and Hospital, Ludhiana. This included a retrospective period of ten years from 1st July 2002 to 30th June 2012, and a prospective period of two years from 1st July 2012 to 31st July 2014. All patients admitted to Christian Medical College and Hospital, Ludhiana, who received a permanent pacemaker for bradyarrhythmias were included in the study. A detailed analysis of demographic profile, indications, complications and mortality data was performed. RESULTS: A total of 323 patients were included in the study of which more than 75% of the patients receiving the pacemaker were in the age group 56-85 yrs. Males received more pacemakers than females. The commonest presenting symptom was syncope. Complete heart block was the commonest ECG finding. Acquired A-V block was the most common indication of pacing. VVI was the commonest mode of pacemaker implantation. Complications were seen in 3.72% patients. During the entire study period death occurred in 7.1% patients. CONCLUSIONS: Permanent pacemaker implantation is a relatively safe procedure with low complication rates and low mortality particularly in patients who have been on a regular follow up.

Bilateral Coronary Artery Fistula.

Coronary artery anomalies include anomalies of origin, termination, structure or course. Coronary artery fistulae (CAF) are classified as abnormalities of termination and are considered a major congenital anomaly. A coronary artery fistula involves a sizable communication between a coronary artery, bypassing the myocardial capillary bed and entering either a chamber of the heart (coronary-cameral fistula) or a great vessel. Bilateral coronary artery fistula, are a rare variant. We describe a bilateral CAF with angina and significant coronary artery disease requiring percutaneous coronary intervention.

A Clinical and Angiographic Profile and Assessment of Outcomes in Coronary Artery Ectasias: Single Centre Experience.

OBJECTIVE: To assess the clinical and angiographic profile of patients with coronary artery ectasias (CAE) and assess their outcomes. METHODS: One year retrospective and one year prospective study was carried out in the Department of Cardiology in CMC, Ludhiana from January 2011 to December 2012 on all patients undergoing coronary angiographies and each patient was followed up for 1 year. Their outcomes were noted and statistical analysis carried out. RESULTS: There were a total of 327 males (66.3%) and 166 females (33.7%) in the study. Mean age of patients were 51 to 60. The incidence of CAE was 79 (16.02%). 6.9% patients had pure ectasia without CAD. The distribution of CAE according to Markis classification was, Type 1 in 21 (26.5%), Type 2 in18 (22.7%) and Type 3 in 28 (35.44%) and Type 4 comprised of 12 (15.18%). Among all 3 categories UA was the commonest presentation (p=0.004). Hypertension was the commonest risk factor in both patients with CAE (44 patients, 55.7%) and CAD (167 patients, 52.6%) but not statistically significant. Regarding outcomes among Type 1, 84% patients remained asymptomatic, while 8.8% of patients were symptomatic with UA episodes. 4% were lost to follow up. Among Type 2, 68.8% remained asymptomatic while 24.4% had recurrence of symptoms. 6.6% were lost to follow up. Among the Type 3, 70.12% of patients remained asymptomatic while 20.12 % had recurrence of symptoms, 8.17% were lost to follow up. Five patients (1.57%) expired, all of whom were from Type 3. Most patients improved with the treatment opted by them over a 1 year period however the patients that remained symptomatic on treatment were three (8.8%) in category 1, 12 (24.4%) in category II and 55 (20.12%) in category III. Four in Category II required repeated hospitalization while 16 in category III required rehospitalizations. CONCLUSIONS: CAE is not an uncommon finding among patients presenting with acute coronary syndromes requiring invasive evaluation to confirm disease severity and decide management. However it is a benign entity requiring optimal medical management.

Gel Foam Renal Artery Embolization for Life-threatening Renal Haemorrhage.

INTRODUCTION: Renal artery embolization (RAE) is an important treatment option for patients with acute renal haemorrhage. Many types of embolic agents are presently available. We describe here the use of gel foam embolization for the treatment of acute renal haemorrhage. MATERIAL AND METHODS: A total of 12 patients (10 males and 2 females) underwent RAE. The indications in all cases were persistent renal haemorrhage which was secondary to renal biopsy (10 cases), blunt trauma to abdomen (1 case) and percutaneous nephrostomy (1 case). Embolic agent used was gel foam in all but one case. Embolization was done by selective catheterization of the feeding segmental / lobar renal artery branches. RESULTS: Successful obliteration of the vascular malformation with no post-procedure complications were achieved in all cases. CONCLUSION: RAE with gel foam is a relatively inexpensive, safe, effective and minimally invasive procedure for the treatment of life-threatening renal haemorrhage, preserving healthy renal parenchyma and renal function.

Impact of HbAlc on acute cardiac states.

OBJECTIVES: To find out the impact of HbAlc levels on the severity and short term complications of patients with heart disease admitted to the Intensive Coronary Care Unit (ICCU). METHODS: One hundred and sixty six patients admitted to ICCU in 2006 with acute cardiac states (unstable angina, acute myocardial infarction, heart failure, cardiomyopathy) were prospectively studied. Patients were divided into two groups--Group A (diabetics) and Group B (non diabetics). Patients were followed up till the time of discharge. RESULTS: Out of the 166 patients, 92 were diabetic (group A) and 74 were non diabetic (group B). The mean HbAlc of group A was 8.4+1.9% and that of group B was 5.7+0.6%. Risk factors like dyslipidemia, hypertension, previous history of heart disease and triple vessel disease were found more in group A than in group B. History of smoking, positive family history of heart disease, and angina as a presenting symptom were more in group B. Complications like heart failure and post infarction angina occurred significantly more in patients with diabetes. In group A, unstable angina, ST elevation myocardial infarction, cardiac failure, accelerated hypertension, dilated cardiomyopathy and triple vessel disease were seen in a significantly higher proportion of patients with poor glycemic control (HbAlc>or=7%) compared to patients with HbAlc level<7%. In group B, 72/74 (97.2%) patients had HbAlc levels>or=5%, 68.8% of whom had HbAlc levels of >or=5.6%. CONCLUSION: Severity and complications of heart disease were significantly higher in diabetics and showed a significant correlation with HbAlc. A large number of non diabetics presenting with acute cardiac states i.e. 97.2%, had HbAlc values>or=5%.

A novel risk score for predicting 6-months mortality at the time of hospital discharge in patients admitted with acute coronary syndrome.

BACKGROUND: In patients with ACS, risk assessment at hospital discharge has not received much consideration in prior risk scoring systems. Hence, there is a need for a reliable and simple tool to identify patients with high mortality risk at discharge form the hospital. METHODS: In a 1-year observational, prospective study, 1012 patients admitted with ACS were followed up for 6 months after discharge. From 26 potential variables, a new risk score to predict 6-month mortality was developed. RESULTS: A multi-variant Cox regression analysis with forward stepwise variable selection was performed and 10 highly significant independent predictors of 6-month mortality were identified. These include previous history of ACS, higher Killip class at admission, NYHA class at discharge, recurrent ischemia during hospital stay, heart failure, requiring ionotropic supports, requiring hemodialysis, presence of arrhythmia, left ventricular dysfunction detected on echocardiography and elevated admission blood glucose levels. Points were given to each variable and a total score was calculated. A risk score of 0-4 (low risk) predicted a mortality of 3.7%,a risk score of 5-15 (Intermediate risk) predicted a mortality of 16.4% and a risk score of 11-15 predicted a mortality of 32.0% over a 6-month period. The new risk score was noninferior to GRACE risk score in its predictive accuracy of 6-month mortality in the same cohort of patients (p < 0.05). CONCLUSION: The risk score developed in our study can be easily calculated at the bedside and is aimed at identifying high risk patients who require more intense follow up after discharge.

Hyphema: A Rare Complication of Periprocedural Antiplatelets and Anticoagulants Following Percutaneous Coronary Intervention.

Hemorrhagic complications are one of the major complications encountered with reperfusion therapies. However, ocular hemorrhage, especially hyphema, i.e., bleeding into the anterior chamber of the eye is one of the rarest bleeding manifestations. Bleeding manifestations in the periprocedural period can be devastating for the patient as antiplatelets and anticoagulants may need to be stopped and this can lead to stent thrombosis. We present a case of a 55-year-old lady, who was a known diabetic and hypertensive and developed hyphema with periprocedural antiplatelets and anticoagulants following percutaneous coronary intervention (PCI). She was managed medically and the dose of antiplatelets was reduced. She was discharged once there was evidence of a reduction in hyphema. Two weeks post-discharge her hyphema had completely resolved.

Changes in vitamin C and vitamin E during oxidative stress in myocardial reperfusion.

Injury to the myocardial tissue due to ischemia and reperfusion occurs because of imbalance between the formation of oxidants and available antioxidants in the heart. Levels of vitamin C (ascorbic acid) and vitamin E (alpha--tocopherol) were evaluated in 52 patients of acute myocardial infarction (AMI) treated by streptokinase. They were further divided into reperfused group (39 patients) and non-reperfused group (13 patients). Twenty normal healthy subjects served as controls. Vitamin C and vitamin E were estimated in study group before and after thrombolytic therapy and in controls. Vitamin C levels were low in AMI cases as compared to controls (8.74 +/- 1.87 and 10.63 +/- 3.26 mg/L, respectively, P < 0.001). Trend of fall in vitamin C levels in the two study groups was not statistically significant. Vitamin E levels declined from 12.19 +/- 6.71 to 9.96 +/- 6.50 mg/L by 4 hours which was significant (P < 0.01) in the reperfused group, but the change in non-reperfused group (9.28 +/- 6.37 to 9.35 +/- 6.07 mg/dL by 4 hours) was non-significant. This is because of increased consumption of this antioxidant in suppressing the oxidative stress which occurs with reperfusion. Vitamin E can be proposed as a valid marker for reperfusion.

Ischemia modified albumin: A novel marker for acute coronary syndrome.

Early identification of patients with acute myocardial infarction is of prime importance due to the associated very high mortality. Only 22% of the patients presenting at emergency cardiology care with chest pain have coronary disease. A number of biochemical tests like CKMB and Troponin-T/I have been introduced for early detection of the coronary syndrome (ACS). Ischemia modified albumin (IMA) has been recently introduced as a marker of myocardial ischemia. We estimated serum IMA in four sequential samples from 25 patients admitted to ICCU. Twenty five healthy volunteers formed the control group from which the normal range was derived. IMA was significantly raised in ischemia patients than in controls as well as compared to the patients who did not have cardiac ischemia. IMA demonstrated good discrimination between the ischemic and the non-ischemic patients with an Odds Ratio of 16.9 (6.29-46.87) than CKMB which showed an Odds Ratio of 2.07 (1.18-6.08). Sensitivity and specificity of IMA for the detection of ACS was 78.0% and 82.7% compared to 58.0% and 60.0%, respectively for the CK-MB assay. The area under the ROC curve of IMA for ischemic v/s non-ischemic patients was 0.834. IMA appears to be developing into a new and very potent marker, of cardiac ischemia.

Are Biomarkers Predictive of Anthracycline-Induced Cardiac Dysfunction?

BACKGROUND: The early detection of anthracycline- induced cardiotoxicity is very important since it might be useful in prevention of cardiac decompensation. This study was designed with the intent of assessing the usefulness of cardiac troponin T (cTnT) and NT- Pro BNP estimation in early prediction of anthracycline induced cardiotoxicity. MATERIALS AND METHODS: In this prospective study histologically proven breast cancer patients who were scheduled to receive anthracycline containing combination chemotherapy as a part of multimodality treatment were enrolled. Baseline cardiac evaluation was performed by echocardiography (ECHO) and biomarkers like cardiac troponin T (cTnT) and N terminal- pro brain natriuretic peptide (NT- Pro BNP). All patients underwent cTnT and NT- Pro BNP estimation within 24 hours of each cycle of chemotherapy and were followed up after 6 months of initiation of chemotherapy. Any changes in follow up ECHO were compared to ECHO at baseline and cTnT and NT- Pro BNP levels after each cycle of anthracycline-based chemotherapy. RESULTS: Initial data were obtained for 33 patients. Mean change in left ventricular diastolic diameter (LVDD) within 6 months was 0.154± 0 .433 cms (p value=0.049). Seven out of 33 patients had an increase in biomarker cTnT levels (p value=0.5). A significant change in baseline and follow up LVDD was observed in patients with raised cTnT levels (p value=0.026) whereas no change was seen in ejection fraction (EF) and left atrial diameters (LAD) within 6 months of chemotherapy. NT- Pro BNP levels increased in significant number of patients (p value ≤0.0001) but no statistically significant change was observed in the ECHO parameters within 6 months. CONCLUSIONS: Functional monitoring is a poorly effective method in early estimation of anthracycline induced cardiac dysfunction. Estimation of biomarkers after chemotherapy may allow stratification of patients in various risk groups, thereby opening window for interventional strategies in order to prevent permanent damage to the myocardium.

Quantification of coronary risk score.

OBJECTIVE: To quantify the coronary risk score in children and/or grandchildren of patients with coronary artery disease (CAD). METHODS: One hundred and fifty children with positive family history of CAD (cases) and age and sex matched children with no such history (controls) were enrolled in the study. Fasting blood sugar, serum cholesterol and triglycerides were estimated on all children and a risk score was calculated using Nora's scheme. RESULT: The cases and controls were similar with respect to mean age, six distribution, mean weight and mean height. None of the child was hypertensive. Mean serum levels of triglycerides were 164.7 m/dl and 105.7 mg% respectively in cases and controls (p < 0.005). Prevalence of hypertriglyceridemia was three times more in cases (p < 0.001). Cases had a significantly higher risk scores (p < 0.00001) and this was mainly attributable to higher biochemical risk (P < 0.0006). CONCLUSION: Children and grand children with a positive family history of CAD had significantly higher risk scores for future CAD. The increased risk was mainly due to biochemical derangements.

Successful laser-assisted removal of an infected ICD lead with a large vegetation.

Infective endocarditis involving transvenous pacing leads is an uncommon but potentially lethal complication of implantable cardioverter-defibrillator (ICD) implantation. Complete removal of the device and the leads is presently considered to be the optimal treatment in such patients and laser-assisted lead removal is an effective and safe nonthoracotomy approach. However, large vegetations (>10 mm) attached to the lead limit nonthoracotomy explantation because of the potential for hemodynamically embarrassing pulmonary embolization. Laser extraction of leads with vegetation area >300 mm2 has rarely been reported. In this case report, we describe a patient with an infected ICD lead with vegetation greater than 41 x 12.5 mm (512 mm2) in size that was explanted with laser-assistance. The resulting pulmonary embolus produced a 33 x 20 mm pulmonary infarction without hemodynamic or respiratory compromise.