Echocardiographic evaluation of ventricular dyssynchrony in patients with left bundle branch block.

OBJECTIVE: To test whether patients with left bundle branch block (LBBB) and low ejection fraction (EF) have greater dyssynchrony than those with LBBB and normal LV systolic function. METHODS: From a group of patients with LBBB, 38 patients with low EF (<50%) and 31 with normal LV systolic function (EF > or = 50%), all comparable in age and sex underwent standard Doppler echo, ECG and tissue Doppler imaging (TDI). The precontraction time (PCTm) was calculated as an index of myocardial systolic activation in 5 different basal myocardial segments (LV anterior, inferior, septal, lateral walls and RV lateral wall). Intraventricular systolic dyssynchrony was analyzed by difference of PCTm in different LV myocardial segments. Interventricular activation delay was calculated by the difference of PCTm between the most delayed LV segment and RV lateral wall. RESULTS: Patients with low LV EF showed increased QRS duration, intraventricular delay (p = 0.03) and interventricular dyssynchrony (p = 0.006). Patients with normal EF also had evidence of some dyssynchrony. The LV basal lateral segment was significantly delayed when compared to all other segments in the low EF group. The PCTm was greater for those with low EF when compared to the normal EF group. CONCLUSIONS: All patients with LBBB on baseline ECG had some degree of cardiac dyssynchrony; those with lower EF had more dyssynchrony. TDI is an effective non-invasive technique for assessing the severity of regional delay in activation of ventricular walls in patients with LBBB.

Nonresponders to clopidogrel therapy among Indian patients undergoing elective/adhoc angioplasty.

BACKGROUND: Clopidogrel has become the standard antiplatelet drug along with aspirin in patients undergoing coronary angioplasty; however, data regarding the nonresponse rate to clopidogrel therapy in Indian patients are limited. METHODS AND RESULTS: Platelet aggregation was measured at baseline and 2 and 24 hours post administration of bolus dose of 300 mg clopidogrel, followed by 75 mg once daily in patients undergoing elective or adhoc coronary angioplasty. Baseline platelet aggregation with 2.5 and 10 micromol/L ADP was 27.91 +/- 20.9% and 53.45 +/- 22.44%. Platelet aggregation at 2 hours and 24 hours with 2.5 micromol/L of ADP was 19.65 +/- 16.9% and 10.44 +/- 11.9%. The corresponding values with 10 micromol of ADP were 48.81 +/- 25.3% and 27.04 +/- 22.4%. Platelet aggregation was maximally inhibited at 24 hours with both 2.5 and 10 micromol/L of ADP. Marked interpatient variability in platelet aggregation in response to clopidogrel administration was observed and varied from -43 to 65%, -32 to 85% with 2.5 micromol/L at 2 hours and 24 hours and -65 to 53%, -35 to 97% with 10 micromol/L ADP at 2 hours and 24 hours. Nonresponse rate 2 hours after clopidogrel administration was 47.7%, and decreased to 29.2% at 24 hours post drug administration. CONCLUSION: Clopidogrel nonresponse is prevalent among Indian patients, and there is wide interpatient variability in platelet inhibition among individual patients. However, the clinical implications of these findings need to be substantiated in larger studies with clinical end points.

Buddy catheter--to overcome difficulty in coronary sinus cannulation.

Coronary sinus cannulation during an electrophysiology study can be quite challenging. This article describes a new technique that we use to cannulate the coronary sinus in cases where cannulation is not easy. The technique involves using a deflectable quadripolar catheter as a buddy to enable the decapolar catheter to slip in. It is easy and quickly performed. It also avoids the use of contrast. We hence, recommend that this method be adopted to place the decapolar catheter in the coronary sinus in all difficult cases.

Audit of radiation dose to patients during coronary angiography.

BACKGROUND: There is widespread concern about radiation doses imparted to patients during cardiology procedures in the medical community. The current study intends to audit and optimize radiation dose to patients undergoing coronary angiography (CA) performed using two dedicated cardiovascular machines. MATERIALS AND METHODS: One hundred and forty nine patients who underwent CA are reported in this study. Dose auditing was done by implementing dose reduction strategies using spectral filters and by evaluating work practices of operators involved in performing CA. STATISTICAL ANALYSIS: A Student's 't' test was used to analyze the statistical significance. RESULTS AND CONCLUSION: The radiation dose imparted to patients was measured using dose area product (DAP) meter. The mean DAP values during CA before optimization was 55.86 Gy cm2 and after optimization was 27.71 Gy cm2. No ill-effects of radiation were reported for patients who underwent CA. Use of copper filtration may be recommended for procedures performed using cardiovascular machines.

Recanalization of a single functioning kidney.

For patients with renal artery stenosis, percutaneous transluminal angioplasty is generally the treatment of choice. This report describes the case of an elderly lady with type III aortoarteritis whose right renal artery was successfully recalized and stented. There was satisfactory improvement in renal function and blood pressure post-procedure, and at one-month follow-up.

Prevalence of coronary artery disease in patients with rheumatic heart disease in the current era.

BACKGROUND: This study was undertaken to determine the prevalence of coronary artery disease in patients with rheumatic heart disease undergoing valve surgery. METHODS AND RESULTS: Consecutive patients with rheumatic heart disease (n=376) who were above the age of 40 years, and scheduled for valve surgery underwent diagnostic coronary angiogram to delineate coronary arteries. The patients were divided into three groups based on valve involvement (mitral valve, aortic valve, and combined aortic and mitral valve). Significant coronary artery disease was considered to be present if one or more coronaries showed 50% or more luminal stenosis. There were 287 (76.3%) males and 89 (23.7%) females. The mean age of the study population was 51.2+/-8.2 years. Eighty-nine (23.8%) patients had typical chest pain, 116 (30.6%) patients had atypical chest pain and 171 (45.5%) patients had no chest pain. Hypertension was noted in 88 (23.4%) patients, 65 (17.3%) patients had diabetes, 98 (26.1%) patients were smoker, and 66 (17.6%) patients had dyslipidemia, and 15 (4.0%) patients gave past history of myocardial infarction. Of the total 376 patients, 46 (12.2%) patients were found to have significant coronary artery disease. In patients with mitral vale disease the prevalence was 13.5% (13/96), while it was 15.3% (19/124) in patients with aortic valve disease and 9% (14/156) in those with combined mitral and aortic valve disease. CONCLUSIONS: Our results suggest that the overall prevalence of coronary artery disease in a group of patients with rheumatic heart disease undergoing valve surgery in the current era is 12.2%. This prevalence is much lower than the figures reported earlier in the Western literature.

Multivessel cutting balloon angioplasty in a patient with type III nonspecific aortoarteritis.

A 23-year-old female patient with type III nonspecific aortoarteritis (Takayasu's arteritis) presented with multiple obstructive lesions and severe congestive heart failure. Large, cutting balloons 5-8 mm in diameter were used to dilate lesions in the abdominal aorta, both renal arteries, right common carotid artery, proximal left subclavian artery, and ostium of the left vertebral artery. Wide luminal expansion without residual stenosis, substantial dissection or need for adjunctive stenting was achieved at all six angioplasty sites. The use of cutting balloons appears suitable for treating obstructive lesions in aortoarteritis.