Accuracy of 64-slice CT coronary angiography: our initial experience.

OBJECTIVE: The objective of our study was to evaluate the diagnostic accuracy of 64-slice computed tomography coronary angiography to detect haemodynamically significant stenosis (>50% luminal narrowing) in comparison to invasive coronary angiography and further analyze the result accounting for heart rate, coronary calcification and location of lesion in the coronary tree. METHODS AND RESULTS: Forty patients (39 male, 1 female; mean age 50.9 years) underwent both CT coronary angiography and invasive coronary angiography with in a gap of one day. All vessels were included in the study and no patient was excluded due to high heart rate. On per-segment based analysis with invasive coronary angiography as the gold standard, CT coronary angiography correctly identified 62 out of 78 significant stenoses with an overall sensitivity of 79.5% (62 of 78), specificity of 98.5% (532 of 540), positive predictive value of 88.6% (62 of 70) and negative predictive value of 97.1% (532 of 548). CONCLUSION: Our result suggests that 64-slice CT coronary angiography has high diagnostic accuracy to detect haemodynamically significant stenosis.

Very late stent thrombosis after implantation of drug eluting stent.

A case of late stent occlusion of a Sirolimus eluting Cypher stent (Cordis, Johnson and Johnson) presenting as acute ST elevation myocardial infarction 22 months after deployment is reported. The possible mechanisms are discussed.

Effects of Exogenous Ethinyl Estradiol on Endometrial Receptivity in Clomiphene Induced Cycles in Infertile Women with Polycystic Ovaries

To compare the effectiveness of clomiphene citrate used alone and in combination with ethinyl estradiol on endometrial receptivity in infertile women with polycystic ovaries (PCO). Color doppler ultrasonographic evaluation of endometrial thickness (ET) and pulsatility index (PI) was done for 27 infertile women with polycystic ovaries. These women were studied for one control unmedicated cycle and randomized to receive clomiphene citrate (CC) alone and CC with ethinyl estradiol (EE) in subsequent 2 cycles. The total duration of follow up of patients was 77 months in which 2 women conceived in control cycle and 1 conceived in CC+ EE cycle. On day of HCGinjection, mean ET was 6.96 + 1.63mmin control cycle, 7.25 + 1.64mmin CC and 8.53 + 1.36mmin CC + EE cycle, whereas, the mean pulsatility index (PI) of dominant uterine arteries was 4.09 + 0.97 in control cycle, 3.96 + 0.95 in CC cycle and 3.75 + 0.98 in CC + EE cycle. On day of HCG injection, mean PI of non-dominant uterine arteries was 4.06 + 1.01 in control, 4.00 + 1.02 in CC and 3.71 + 0.95 in CC + EE cycles. A statistically significant change (p< 0.05) was observed in ET and PI of dominant and non-dominant uterine arteries in control and CC+ EE cycle and those in CC and CC+ EE cycles. Addition of ethinyl estradiol to clomiphene induced cycles produces a favorable endometrial response in infertile women with PCO.

Delayed occurrence of restenosis in drug eluting stents: an evidence of delayed healing.

Drug eluting stents have made a significant impact on restenosis. However, there are concerns regarding delayed "catch-up" of restenosis. In this case report we present two such patients with delayed occurrence of restenosis after drug eluting stent implantation.

Management of acute myocardial infarction--primary angioplasty the treatment of choice!

The management goal of acute myocardial infarction is prompt revascularization. Recent years have seen improvements in both pharmacological and mechanical methods of revascularization of the infarct related arteries. This brief review summarises these developments and ongoing efforts.

Novel non-surgical method of managing cardiac perforation during percutaneous transvenous mitral commissurotomy.

We describe a new technique of sealing cardiac perforation resulting in cardiac tamponade during transvenous mitral commissurotomy by percutaneous instillation of cyanoacrylate glue at the perforation site, thus avoiding surgery.

Difficult percutaneous transvenous mitral commissurotomy: a new technique for left atrium to left ventricular entry.

Percutaneous transvenous mitral commissurotomy using Inoue balloon is an effective procedure for the management of patients with juvenile mitral stenosis. Inability to cross the mitral valve by the Inoue balloon catheter is one of the important reasons for failure of the procedure. We describe a new technique, facilitating left atrium to left ventricular entry using double loop of Inoue balloon catheter in a child with small left atrium.

Isolated thrombus producing tricuspid stenosis: an unusual presentation in primary antiphospholipid syndrome.

We report the case of a female patient who presented with signs and symptoms of tricuspid stenosis. Echocardiography revealed a sessile mass on the tricuspid valve. A diagnosis of primary cardiac tumor was made but histopathologic examination revealed the mass to be an organized thrombus. Subsequent serological tests showed elevated titers of anticardiolipin antibodies in the absence of any associated disease. This case highlights an unusual presentation of the primary antiphospholipid syndrome.

Post-stenotic dilatation: challenge in renal ostial stenting--a simple solution.

Stenting is the treatment of choice for treating stenotic renal ostial lesions. During the stenting of an ostial lesion in a renal artery with post-stenotic dilatation, we were faced with the problems of unavailability of a balloon of appropriate length and diameter, and determining the real reference vessel diameter. The problem was solved by a simple technique.

Stenting of a septal perforator for post-myocardial infarction angina.

Occlusion of a septal perforator branch alone, without the involvement of the left anterior descending coronary artery, leading to acute myocardial infarction is unusual. We report a case in which an isolated severely stenotic thrombus-containing first septal artery causing intractable post-myocardial infarction angina was successfully dilated and stented.

Unusual ST-t changes in Ebstein's anomaly with occlusion of a nondominant coronary artery.

We present a case report of a patient of Ebstein's anomaly presenting with unusual ECG changes during acute coronary syndrome. The patient had undergone radiofrequency ablation of right posteroseptal accessory pathway. Two years later, he presented with acute chest pain. His ECG revealed ST elevation of 6-7 mm in leads III, aVF. V3R and V1-V4 with atrioventricular dissociation. He was thrombolysed for the same. He subsequently underwent an angiogram for continuing angina. His angiogram showed a nondominant right coronary artery with a 95% stenosis. The left circumflex artery was dominant but without any stenosis. The left anterior descending artery was also normal. Angiogplasty and stenting were done for the right coronary artery lesion and the patient did well on follow-up. The ST segment elevation in the anterior precordial leads resulting from occlusion of a nondominant right coronary artery is unusual. The possible reason for this is the isolated right ventricular infarction in the absence of any left ventricular infarction. Thus the electrical current of injury resulting from the right ventricular infarction was unopposed by any counterbalancing current of injury from the inferior surface of the left ventricle.

Coronary stent implantation without lesion predilatation (direct stenting): our experience with this evolving technique.

BACKGROUND: Until recently, conventional intracoronary stent deployment required predilatation of the lesion with a balloon. However, "direct stenting" of the lesion without predilatation offers certain theoretical and practical advantages. We assessed the safety and feasibility of direct stenting in a select group of patients who were likely to benefit most from these advantages, namely, those with acute coronary syndromes. saphenous vein graft lesions, associated renal or left ventricular dysfunction and those requiring multivessel intervention. METHODS AND RESULTS: After direct stenting, intravascular ultrasound was used to assess the adequacy of stent expansion in 51 patients. One hundred and twenty patients with a total of 125 lesions (83.3% males, average age 54.6+/-12.4 years) were enrolled for direct stenting. Of these, 90% of patients had presented with acute coronary syndromes, 21.6% of patients had associated moderate-to-severe left ventricular systolic dysfunction, 6.7% of patients had associated renal dysfunction and 30.8% of patients required multivessel intervention. Angiographically visible thrombus was present in 35.2% of patients. The mean reference diameter of the lesion was 3.18+/-0.32 mm and mean percentage diameter stenosis was 76.4+/-11.2%. Almost all varieties of stents were used (8.8% bare and 91.2% mounted). Procedural success was achieved in 98.3% of patients (98.4% of lesions). In two cases, the lesion had to be predilated prior to stenting. On angiography, the need for postdilatation of the stent was apparent in 29 (23.6%) lesions. In contrast, on intravascular ultrasound evaluation done in 51 lesions after stent deployment, the need for postdilatation to optimize stent expansion was seen in 43 (84.3%) lesions. There was one instance of acute stent thrombosis and two instances of slow-flow phenomenon. There were no deaths, myocardial infarction or need for urgent bypass surgery. CONCLUSIONS: We conclude that direct stenting is feasible and safe in selected groups of patients. Optimization of stent expansion after direct stenting may often require aggressive postdilatation.

Aortoarteritis presenting with hypoparathyroidism.

Clinical manifestations of aortoarteritis (Takayasu's arteritis) are varied, depending on the involved segment of the aorta and its branches. A case of a young Indian woman with aortoarteritis presenting primarily with hypoparathyroidism is reported. Aortogram showed total occlusion of the arch arteries. To the best of our knowledge, the occurrence of hypoparathyroidism in aortoarteritis has not been reported. Possible mechanisms of such an involvement are discussed.

Management of chronic stable angina pectoris from a sceptic's view point.

Ischaemic heart disease is a leading cause of death in the world. It has clinically defined phases as: Asymptomatic, stable angina, progressive angina and unstable angina. It is important to differentiate patients of angina into those with stable and unstable angina--risk stratification and management differ in the two groups. Risk stratification of patients with stable angina using clinical parameters helps in development of clearer indication of referral for exercise testing and cardiac catheterisation. Chronic stable angina patients with history of documented myocardial infarction of Q waves on ECG should have measurement of left ventricular systolic function (ie, ejection fraction) as it is important for choosing the appropriate medical or surgical therapy. Symptomatic patients with suspected or known coronary artery disease should usually undergo exercise testing to assess the risk of future cardiac events. The treatment of stable angina has two purposes: To prevent myocardial infarction and death and therapy directed towards preventing death. Pharmacotherapy consists of: Aspirin, lipid lowering agents, beta-blockers, nitrates, short acting dihydropyridine calcium antagonists, etc. For surgery, there are two well established approaches of revascularisation. One is coronary artery by-pass grafting and the other is percutaneous transluminal coronary angioplasty. Studies comparing different treatment modalities are elaborated in this article. In conclusion, it can be said that patients having severe symptoms affecting quality of life despite optimal medical therapy should be referred for revascularisation surgery.

Recording of double atrial potentials as a marker for isthmus block during ablation of atrial flutter.

Radiofrequency ablation is an established method for treatment of type I atrial flutter. The assessment of creation of complete bidirectional isthmus block following linear ablation of the isthmus is an integral part of ablation procedure. Conventionally, bidirectional isthmus block is tested by pacing on either side of ablation line and looking for reversal of activation sequence in the right atrium. We looked at the feasibility of recording double potentials, separated by an isoelectric interval along the ablation line as an alternative method to demonstrate bidirectional isthmus block. An attempt was made to record the double potentials following linear ablation of the cavotricuspid isthmus. Following ablation, bidirectional isthmus block was also tested by pacing from the coronary sinus os and the low-lateral right atrium. We could demonstrate double potentials in 9 of the 11 patients in whom we attempted to record them following linear ablation of flutter. The presence of bidirectional block by pacing from coronary sinus os and low lateral right atrium could be demonstrated in 10 (91%) patients. Thus, double atrial potentials, separated by an isoelectric interval can be demonstrated following ablation of atrial flutter. Double potentials, if demonstrable on coronary sinus os and low lateral right atrium pacing, could serve as an alternative marker of isthmus block.

Coronary stent thrombosis: time course and clinical outcome.

The current clinical practice of stent implantation has changed over the last few years. We analysed the incidence and time course of stent thrombosis in patients undergoing successful coronary angioplasty and stenting over the last three years. All the patients were treated with aspirin and ticlopidine. A total of 13 patients experienced stent thrombosis. The mean age was 52+/-12 years; 12 were smokers and 10 had a recent history of myocardial infarction. None of these patients had received abciximab. The median time from stent implantation to stent thrombosis was 10 hours, with all the stent occlusions occurring within 18 hours of stent implantation procedure. All the patients underwent a repeat intervention at a median time of 30 minutes after the clinical suspicion of stent occlusion. On follow-up of 1 to 24 months, three patients developed reocclusion. In the present era of coronary angioplasty and stenting, when interventional procedures are not pre-planned and patients are treated with aspirin and ticlopidine or clopidogrel at the time of stent implantation, the incidence of stent thrombosis is low; it is seen mainly in patients with recent myocardial infarction, majority of them being smokers, and occurs within 18 hours in all the patients.