Coronary angiogram and intervention through transulnar approach.

BACKGROUND: This study was conducted to assess the safety and feasibility of a transulnar approach in performing diagnostic and interventional percutaneous coronary procedures. METHODS AND RESULTS: In the year 2004, a total of 100 patients underwent diagnostic angiography (n=64) and percutaneous coronary interventions (n=36) through transulnar approach. The patients' age ranged from 40 to 70 years and male to female ratio was 7.3:1. The cases of percutaneous coronary interventions were mostly elective procedures and emergency intervention was done in only 2 patients. The procedure was successful in 95 (95%) patients and unsuccessful in 5 (4 diagnostic and 1 percutaneous coronary intervention). The procedure was done through right ulnar artery in all except one patient in whom it was done through left ulnar artery. The total procedure time ranged between 25-45 min. Among the cases of percutaneous coronary interventions, single vessel angioplasty was performed in 23 (65.7%) patients, double vessel in 11 (31.4%) patients and triple vessel in 1 (3%) patient. All percutaneous coronary intervention patients received aspirin, clopidogrel and intravenous enoxaparin. Glycoprotein IIb/IIIa inhibitors were used in 7 patients. Complications such as local hematoma, ulnar artery perforation and reversible parasthesia occurred in one patient each. CONCLUSIONS: Tansulnar approach is a safe and easy alternative technique to perform diagnostic and therapeutic coronary interventions.

Mycophenolate mofetil: a promising immunosuppressive agent.

With avaibility of newer immunosuppressive agents, incidence of acute graft rejection has decreased. Mycophenolate mofetil is one such new drug, now available in the Indian market It has been found to be useful in prevention and treatment of acute and chronic rejection after transplantation. Besides transplant it has been used successfully in primary and secondary glomerulopathies (e.g. SLE) and other autoimmune diseases. The drug is well tolerated with side effects limited mainly to gastrointestinal system in the form of epigastric pain, vomiting and diarrhoea.

Bleeding complication during coumarin therapy due to amiodarone and azithromycin.

A patient with mechanical heart valves developed bleeding, after the introduction of amiodarone and azithromycin. Though the anticoagulant effect could be neutralized, the patient succumbed to heart failure. Any new drug prescribed to patients on anticoagulant must be assessed for its potential for interaction and warrants frequent prothrombin time testing.

Mechanical heart valves: an insight into thrombotic complications.

The purpose of this retrospective analysis was to improve the follow-up care of patients with mechanical heart valves. Clinical data of 88 patients who had undergone valve replacement surgery in various cardiothoracic centres in the country and followed up in Tata Main Hospital, Jamshedpur, India were analysed. The incidences of thrombotic complications with Starr-Edwards, St. Jude and Medtronic-Hall valves placed in mitral, aortic or both the sites were studied. In the single valve replacement group, St. Jude valve in mitral position had the highest thromboembolic risk of 12.5 per 100 patient-years. In the double valve replacement group, all the three prostheses had high thrombotic risk: St. Jude 22.2, Medtronic-Hall 12.5 and Starr-Edwards 8.6 per 100 patient-years. The high thrombotic incidence with St. Jude and Medtronic Hall in this series was correlated with early post-operative period. Subtherapeutic antiocoagulation was the key factor for thrombotic complications. Some of the commonly used drugs and diet rich in vitamin K interfere with anticoagulation, causing thrombosis in those who were more prone. Education of patients as well as the primary care physician is required to reduce life threatening thromboembolic complications, as more centres are replacing damaged valves with prostheses in patients who return to their hometown for follow-up care.

Fast track thrombolysis in acute myocardial infarction: a quality improvement project.

Thrombolytic therapy for acute myocardial infarction has been proved to be most effective if given very early in the course of evolving infarction. This study was undertaken to optimise such treatment by overcoming the in-hospital delay in the existing set-up of an industrial hospital. A quality improvement project was undertaken to analyse the existing system of thrombolysing 46 consecutive patients of acute myocardial infarction treated in six months. By following the breakthrough sequence and proceeding in steps, the causes for delay in door to needle time were identified and rectified over two months. Impact of such measures in 32 patients of acute myocardial infarction thrombolysed consecutively in the next five months was studied. Door to needle time in the baseline group (n = 46) was in the range of 15-145 minutes and the average was 48.9 minutes. Only 32.6 percent of the patients in this group were thrombolysed within 30 minutes of arrival in the hospital. After the corrective measures were implemented in a study group of 32 patients, 27 with clear indication on admission were thrombolysed on the fast track i.e. with minimum delay. Five patients with doubtful need were put on the slow track and subsequently thrombolysed. Patients with no indication or a contra-indication for thrombolysis were excluded from this study. In the fast group, door to needle time reduced to an average of 22.56 minutes with a range of 7 to 67 minutes and 75 percent of the thrombolysed patients received the infusion within 30 minutes of arrival in the hospital. Differences in door to needle time between the two groups were statistically significant. Streamlining the hospital systems and procedures can help reduce the door to needle time in thrombolysing patients of acute myocardial infarction. This could be achieved within the existing resources by applying the principles of total quality improvement.