Outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis.

OBJECTIVE: Carotid endarterectomy is superior to medical therapy in patients with significant extracranial carotid artery stenosis. This modality of treatment has its own complications. The principal objective of this study is to assess efficacy, feasibility and outcomes of carotid artery stenting in both symptomatic and asymptomatic carotid artery stenosis. METHODS: Our study is a retrospective analysis of 45 consecutive patients with 56 lesions who underwent carotid angioplasty with stenting from January 2000 to June 2007 for carotid artery stenosis of more than 70%. All patients underwent detailed neurological examination and carotid Doppler evaluation by using Sonos 5500. Computed tomography of brain was done in those patients who were symptomatic in the past. RESULTS: The mean age of the study population was 65 +/- 9.2 years. There were 34 (79%) patients with coronary artery disease and out of them 31 (68%) patients had undergone coronary artery bypass grafting. All patients with common carotid artery, 13 (81%) patients with right internal carotid stenosis and 12 (66%) patients with left internal carotid artery stenosis had ostioproximal stenosis. Contralateral lesion was found in 9 patients and 2 patients had total occlusion. There were no post-procedural neurological events. Only one patient died in our study population due to non-cerebral cause. CONCLUSION: Carotid artery stenting is a safe procedure. The 30 days' outcomes are similar in both symptomatic and asymptomatic patients with significant carotid artery stenosis.

Repeated fracture of pacemaker leads with migration into the pulmonary circulation and temporary pacemaker wire insertion via the azygous vein.

Repeated implantation of pacemaker in the same patient is a common occurrence because of the increased longevity of patients. However, repeated lead fracture in the same patient and migration of the pacemaker lead into the pulmonary circulation is rare. We describe a 56-year-old gentleman who had undergone pacemaker implantations thrice due to repeated lead fractures (thrice) and also had migration of the pacemaker lead into the pulmonary circulation. He also had an azygous vein which was noticed while placing the temporary pacemaker wire.

High intensity exercise training programme following cardiac transplant.

A 26-year-old male patient who presented with symptoms of end stage cardiac failure as a result of dilated cardiomyopathy, had an orthotopic cardiac transplantation. A comprehensive cardiac rehabilitation programme was provided to him and he was introduced to a sport (tennis). The exercise training programme progressed from low intensity training to high intensity programme over a period of 15 months. A cardio-pulmonary exercise test done 22 months after surgery suggested that he was able to achieve the aerobic capacity comparable to that of a normal South Indian subject. He participated successfully in the World Transplant Games in Sydney and returned safely. This suggests that after a proper cardiac rehabilitation programme, patients undergoing heart transplantation can achieve normal physiological responses to lead a normal active life.

Elective stenting in superior vena cava syndrome caused by idiopathic fibrosing mediastinitis: use of self-expandable wallstent.

We present a case of superior vena cava obstruction caused by idiopathic fibrosing mediastinitis treated with a self-expandable Wallstent. A Gortex jump graft had been used previously, which was totally occluded. This procedure relieved symptoms and alleviated the need for re-operation.

Prospective evaluation of the risk of bacteremia induced by transesophageal echocardiography.

BACKGROUND: The incidence of bacteremia induced by transesophageal echocardiography is controversial in the Indian population. This study aimed to find out the occurrence of bacteremia following transesophageal echocardiography. METHODS AND RESULTS: Between February 2000 and January 2001, 47 patients (26 males and 21 females) were enrolled for the study. Their ages ranged from 13 to 61 years (mean: 35 +/- 11.4 years). Patients with prosthetic valves, suspected infective endocarditis and those on antibiotics were excluded. For each procedure, two sets of blood cultures were obtained immediately before and after the procedure. For each blood culture, 10 ml of blood was evenly inoculated into brain-heart infusion broth and biphasic infusion medium and incubated for 7 days. Transesophageal echocardiography was carried out under oropharyngeal anesthesia (xylocaine gel and spray). Two blood cultures taken before the procedure were positive and excluded from the final analysis. Of the remaining 45 patients whose preprocedure blood cultures were sterile, 6 samples (13.3%) were positive after the procedure diphtheroids in 3, micrococci in 2 and aerobic spore formers in 1. CONCLUSIONS: This study demonstrates that the incidence of bacteremia related to transesophageal echocardiography is not insignificant, as reported in previous studies. Though routine antibiotic prophylaxis before transesophageal echocardiography is not advocated, it should be recommended in high-risk patients such as those with prosthetic valves, multivalvular involvement or those with a past history of infective endocarditis.