Cardiovascular response in anemia.

OBJECTIVE: To study the functional consequences of nutritional anemia by evaluating the exercise performance in these children. METHODS: The study was conducted on 30 each of anemic and normal children of both sexes aged between 7 and 14 years. Relevant history was taken, and detailed examination was done. These children were classified according to severity of anemia based on hemoglobin estimation as mild (10-11.9 g/dl), moderate (7-9.9 g/dl) and normal (>12 g/dl). Children with severe anemia (Hb < 7g/dl), heart disease, non-nutritional anemia, acute febrile or respiratory illness were excluded. The subjects were tested on Mortara X Scribe colour stress treadmill using the modified Bruce protocol. Continuous computerised electrocardiographic analysis was done. The parameters studied included heart rate, systolic blood pressure, double product (DP = HRxSBP), ECG changes, metabolic equivalents (METS) and exercise duration. The end point of the test was a HR of 170/min (non-fatigue group) or inability to perform further (fatigue group). Statistical analysis was done by appropriate tests. RESULTS: Fifteen children each with mild and moderate anemia and 30 age-matched controls were enrolled in the study. There was no significant difference in the resting HR, exercise duration or DP between the cases and controls. Thirty-one children reached the target HR (non-fatigue group). The end-point HR was significantly lesser among the anemic children in the fatigue group (P 0.04). The percent gain of SBP, at peak exercise (P 0.0007) and recovery SBP as percent of resting SBP (p 0.006) were significantly more in the anemic children, more so in the mildly anemic ones. Lesser METS was achieved by anemics as compared to controls (P 0.04). ECG changes occurred significantly more often in anemic children, 53.8% of those with changes being moderately anemic, the main abnormality being ST depression. None developed arrhythmia during exercise testing. CONCLUSION: The cardiovascular response to physical exercise is compromised in children with nutritional anemia and hence these children may never attain their full potential in various school activities. Prevention of anemia should be a priority in school going children.

Primary angioplasty for cardiogenic shock complicating acute myocardial infarction.

To evaluate the role of primary percutaneous transluminal coronary angioplasty in cardiogenic shock, 53 patients admitted with the diagnosis of acute myocardial infarction and cardiogenic shock were studied. Thirty-five (66.0%) patients received intravenous thrombolytic therapy (streptokinase 15 lac units) and 18 (34.0%) underwent primary percutaneous transluminal coronary angioplasty. There was no significant difference in the mean age, risk factor profile, presence of prior myocardial infarction, site of myocardial infarction and cardiac enzyme levels at presentation between the two groups. More male patients were present in the group undergoing primary percutaneous transluminal coronary angioplasty (94.44% vs 68.57%; p = 0.04). The time delay between the onset of symptoms and presentation to the hospital did not differ significantly between the two groups (318.9 vs 320.0 minutes; p = NS). In the primary percutaneous transluminal coronary angioplasty group, 17 patients had a single infarct-related artery and one had both left anterior descending and right coronary artery occlusion. Thus in 18 patients, 19 vessels were attempted. Angiographic success (< 50% residual stenosis) was achieved in 15 (78.94%) vessels of which TIMI III flow was achieved in 10 (52.63%) vessels and TIMI II flow in five (26.31%). Intra-aortic balloon pump was needed in five (27.77%) patients undergoing coronary angioplasty. In-hospital mortality was 27.77 percent in patients undergoing primary percutaneous transluminal coronary angioplasty and 57.14 percent in patients receiving intravenous thrombolytic therapy (p = 0.04). In the thrombolytic therapy group, mortality was higher (85.91%) in patients presenting six hours or later after the onset of symptoms as compared to those presenting in less than six hours of the onset of symptoms (50%). In primary percutaneous transluminal coronary angioplasty group, mortality was 21.42 percent in patients with successful and 50 percent in patients with failed angioplasty. Thus, in patients with acute myocardial infarction and cardiogenic shock, an aggressive invasive strategy with primary percutaneous transluminal coronary angioplasty, as compared to intravenous thrombolytic therapy, is helpful in reducing in-hospital mortality.

Correlation of Braunwald's clinical classification of unstable angina pectoris with angiographic extent of disease, lesion morphology and intra-luminal thrombus.

One hundred consecutive patients (81 male and 19 female) with unstable angina pectoris undergoing coronary angiography were divided according to Braunwald's clinical classification. Seventeen (17%) patients had new onset angina (class I), 68 (68%) sub-acute angina (class II) and 15 (15%) had acute rest angina (class III). Twenty-seven (27%) patients had secondary unstable angina pectoris (class A), 49 (49%) primary unstable angina (class B) and 24 (24%) had post-infarction unstable angina (class C). ST-T wave changes on ECG were present in 54 (54%) while absent in 46 (46%) patients. On coronary angiography, 26 (26%) patients had single vessel disease, 30 (30%) double vessel disease and 39 (39%) patients had triple vessel disease. Five (5%) patients were found to have normal coronaries. Classification of patients according to Braunwald's clinical classification showed single vessel disease to be higher in class I as compared to class II (47% vs 22%; p = 0.04) and classes III (47% vs 20%; p<0.01). Single vessel disease was found to be higher in class C as compared to class B (41.7% vs 16.4; p = 0.01). Double vessel disease was higher in class B as compared to class A (40.8% vs 18.5%, p = 0.04). Triple vessel disease incidence was not found to be significantly different among different clinical classes. Morphology of coronary artery lesions was classified according to Ambrose's classification. Out of the total of 248 lesions in the whole study group, there were 68 (27.42%) concentric lesions, 55 (22.18%) eccentric type I lesions, 23 (9.27%) eccentric type II lesions, 42 (16.94%) multiple irregularity lesions and 60 (24.19%) totally occluded lesions. Concentric lesions were found to be higher in class C as compared to class B (40% vs 19.8%; p = 0.014). Statistically significant difference was not present in the distribution of other morphological type of lesions among different clinical classes. In the whole study group, intra-luminal thrombus was found to be present in 17 (17%) of patients. Distribution of intra-luminal thrombus according to Braunwald's classification showed that none of the patients in class I had intra-luminal thrombus, while 13 (19.1%) patients in class II and 4(26.7%) in class III had intra-luminal thrombus. The difference in the occurrence of intra-luminal thrombus between class I and class II (p = 0.004) and class I and class III (p = 0 .03 was found to be significant. Thus, majority of patients undergoing coronary angiography had primary sub-acute rest angina. Single vessel disease was higher in new onset angina. Patients with unstable angina pectoris and ST-T changes on ECG had higher number of lesions per patient and higher eccentric type I lesions. Intra-luminal thrombus was more frequently encountered with acute rest angina. However, the distribution of different morphological type of lesions on coronary angiography did not differ significantly in different clinical classes of unstable angina pectoris divided according to Braunwald's classification.

Hepatic artery pseudoaneurysm and hemobilia following laparoscopic cholecystectomy.

Iatrogenic or accidental injury to the right hepatic artery or its branches can result in formation of pseudoaneurysm, which may rupture into the biliary system, leading to life-threatening hemobilia. We describe one such case following laparoscopic cholecystectomy and discuss its management.

Angiographic severity and morphological spectrum of coronary artery disease in non insulin dependent diabetes mellitus.

Coronary angiographic profile of 75 patients (63 males and 12 females) with noninsulin dependent diabetes mellitus (NIDDM) and CAD was compared with 75 nondiabetic patients (63 males and 12 females) with CAD. No difference was present between the mean age (56.2 +/- 7.4 vs 56.1 +/- 7.7 years; p = NS), presenting complaints (67 unstable angina and 8 stable angina with positive TMT in both the groups) and other coronary risk factors between the two groups. Severity and diffuseness of coronary artery involvement was assessed by a coronary artery score (CAS) using the segmental distribution method for coronary artery lesions. Diabetic patients with CAD had a higher CAS (18.7 +/- 10.3) as compared to the nondiabetic patients with CAD (12.7 +/- 9.6) (p < 0.01). Diabetic patients with CAD had a higher number of TVD [43 (57.3%) vs 31 (41.3%); p < 0.01] while the DVD and SVD was not significantly different. As compared to the nondiabetic group, diabetics had a higher total number of coronary artery lesions (300 vs 200; p < 0.001), a higher lesion per patient ratio (4.0 lesions/patient vs 2.6 lesions/patient; p < 0.001), a higher number of concentric lesions, [151 (50.3%) vs 90 (45%); p < 0.01] and a higher number of multiple irregularity lesions, [36 (21%) vs 27 (9%); p < 0.05]. The diffuse involvement of vessels was not significantly different between the two groups in LAD (12.1% vs 5.3%; p = NS), LCx (14.2% vs 5.8%; p = NS) and RCA (10.5% vs 5.0%; p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Role of two-dimensional echocardiography in early diagnosis of suspected acute dissection of ascending aorta.

Seven patients with acute dissection of ascending aorta are presented and the role of two-dimensional echocardiography in the early diagnosis of this condition is emphasized. There were 5 male and 2 female patients. The mean age of the patients was 36.7 +/- 11.2 years. The presenting symptoms were chest pain in 7, associated interscapular pain in 4, dyspnoea in 4 and syncopal episodes in 2 patients. Examination revealed hypertension in 3, pulses paradoxus in 2, asymetrically weak carotid and brachial pulses in 3, aortic regurgitation in 5 and neurological deficit in 2 patients. Echocardiography showed aortic root diameter of 42mm and the presence of an intimal flap in all the 7 patients and flap oscillations in 6 patients. Echocardiographic evidence of pericardial effusion was present in 6, cardiac tamponade in 3, aortic regurgitation in 5 and regional left ventricular wall motion abnormality in 1 patient. Surgical correction was done in 5 patients with 60% success rate. Two patients received only medical treatment. Aortic root dilatation of 60 mm, presence of an oscillating flap, evidence of cardiac tamponade and regional wall motion abnormality were found to be associated with poor prognosis.

Colour Doppler echocardiographic quantification of prosthetic aortic valve regurgitation in patients with normally functioning Bjork-Shiley prostheses.

Colour Doppler echocardiographic studies were performed in 46 patients (age range 16-35 years, mean 26 +/- 8; male 31, female 15) with normally functioning Bjork-Shiley prostheses in aortic position to estimate transprosthetic regurgitation. Regurgitant jet length and height were measured and assessed in multiple views. All patients showed prosthetic regurgitation of varying degree. Regurgitant jets were central in all but 3 (6.5%) patients. Single jets were seen in 28 (61%) and double jets in 18 (39%). Jet height in parasternal long axis view ranged from 0.4 to 1.2 cm (mean 0.7 +/- 0.4 cm) and jet height to left ventricular outflow tract diameter ratio was 0.22 to 0.48 (mean 0.38 +/- 0.13). Prosthetic regurgitation was < or = 2/4 grades in 42 (91%) patients, and combined height of double jets (n = 18) was less than that of the single jets (n = 28) (0.5 +/- 0.3 cm vs 0.8 +/- 0.4 cm, p < 0.05). In conclusion, colour Doppler examination frequently detects prosthetic regurgitation in patients with aortic Bjork-Shiley prostheses; regurgitation is grade 2/4 or less in most of the patients, is overestimated in patients with a single jet and weakly correlates with prosthesis size.