How does knowledge of the blood supply to an intracardiac tumour help?

Myxoma is a common benign tumour found in the heart. On reviewing literature, we found some left atrial myxomas receive blood supply from the right coronary artery. Performing a coronary angiogram in a cardiac tumour has the following uses: (1) it shows the vascularity that can be ligated by the surgeon at operation; (2) if there is a blood supply visible, it may not be an intracardiac thrombus; (3) the coronary angiogram may detect a myxoma even before an echocardiogram does so; (4) some myxomas may bleed into the right atrium or left atrium and this may be seen on coronary angiography. We show here the neovascularity of a left atrial myxoma and its blood supply from the right coronary artery. We recommend that all routine coronary angiograms be reviewed carefully for any signs of tumour vascularity or tumour blush as this would prevent missing early myxomas. Echocardiography is the gold standard for detection of myxomas but literature has a number of intracardiac tumours that were detected only by the tumour blush. Some left atrial tumours have been treated by occluding their blood supply.The absence of a blood supply on coronary angiography could rule out a benign cardiac tumour that usually has a blood supply.

Remote ischemic preconditioning for prevention of contrast induced nephropathy-Insights from an Indian study.

OBJECTIVES: To study if four cycles of remote ischemic preconditioning (RIPC) could offer protection against contrast induced nephropathy (CIN) and post procedural renal dysfunction in high risk patients undergoing percutaneous coronary intervention (PCI). METHODS: This was a prospective single blind randomized sham controlled trial where patients undergoing coronary angioplasty with stage III chronic kidney disease were randomized into sham preconditioning and remote ischemic preconditioning. The primary outcome was the reduction in the incidence of CIN. The secondary outcomes were the maximum improvement in eGFR, maximum reduction in serum creatinine and composite of requirement of hemodialysis, death and rehospitalization for heart failure up to 6 weeks after PCI. RESULTS: Eleven out of fifty patients in the study group developed CIN (22%) compared to eighteen out of the fifty control patients (36%) (p=0.123). There was a statistically significant improvement in the post procedure creatinine values at 24h (p=0.013), 48h (p=0.015), 2 weeks (p=0.003), 6 weeks (p=0.003) and post procedure glomerular filtration rate (eGFR) values at 24h (p=0.026), 48h (p=0.044), 2 weeks (p=0.015) and 6 weeks (p=0.011) in study group compared to control group. The secondary outcome composite of requirement of hemodialysis, death and rehospitalization for heart failure was not statistically significant (p: 0.646). CONCLUSION: RIPC does not result in significant reduction of CIN. However RIPC helps in the prevention of post procedural worsening in eGFR and serum creatinine even up to 6 weeks.

Coronary angioplasty in spontaneous coronary artery dissection-Strategy and outcomes.

OBJECTIVE: To study the clinical, angiographic and technical characteristics of patients with spontaneous coronary artery dissection (SCAD) undergoing percutaneous coronary intervention (PCI). METHODS: This was a retrospective single center study where patients with angiographically confirmed SCAD undergoing PCI over a period of 4 years (2013-2017) were analyzed. We also sought to identify the clinical and angiographic predictors of procedural failure during PCI. RESULTS: There were a total of 42 patients with angiographically confirmed SCAD during the study period of which 16 patients (38.1%) underwent PCI. 14 out of the 16 patients (87.5%) taken up for PCI had technical success. In all patients the lesion was initially attempted to cross with a floppy wire and if unsuccessful it was escalated to a hydrophilic wire and finally to a stiff wire The SCAD lesion was crossed with a floppy wire in 71.4% of patients, with a hydrophilic wire in 14.2% and a stiff wire in 7.1% of patients. Wire escalation was required in 5 patients (31.3%) and in 60% of cases there was a technical success after wire escalation. Presence of diabetes mellitus, hypertension, dyslipidemia, smoking, coexisting atherosclerosis, diffuse nature of the lesion, and baseline Thrombolysis in Myocardial Infarction (TIMI)≤2 flow did not predict procedural failure during PCI. CONCLUSION: PCI in SCAD is associated with a fair rate of technical success in our population. Choosing an initial floppy wire and then escalating to a hydrophilic wire followed by a stiff wire is an optimal revascularization strategy.

Predictors of contrast induced nephropathy and the applicability of the Mehran risk score in high risk patients undergoing coronary angioplasty-A study from a tertiary care center in South India.

OBJECTIVE: To study the incidence and predictors of Contrast induced nephropathy (CIN) in high risk patients undergoing coronary angioplasty. To study the applicability of the Mehran Risk Score (MRS) in the prediction of CIN in our population. METHODS: This was a prospective observational study where patients with an estimated glomerular filtration rate (eGFR) between 30 and 60ml/mt undergoing elective percutaneous coronary intervention (PCI) over a period of 15 months were evaluated prospectively for the development of CIN. The patients who developed CIN were then analysed for the presence of specific risk factors. The patients were categorized into the 4 risk groups based on the MRS. RESULTS: 100 high risk patients underwent PCI during the study period. The incidence of CIN was 29%. On multivariate analysis, the presence of anemia (p=0.007), increased contrast volume usage (as defined by >5* B.Wt/S.cr) (p=0.012) and usage of loop diuretics (p=0.033) were independently found to confer a significant risk of CIN. In patients belonging to the high Mehran risk group (MRS10- 15) and very high risk group (MRS >15) the risk of CIN was 3 fold (OR: 3.055, 95% CI: 1.18-7.94, p=0.022) and 24 fold (OR: 24, 95% CI: 2.53-228.28, p=0.006) higher respectively when compared to intermediate and low risk patients (MRS <10). CONCLUSION: The incidence of CIN in high risk patients undergoing PCI is substantially higher in our population compared to similar studies in the west. The MRS risk prediction is pertinent even in an Indian population.

Angiographic predictors of success in antegrade approach of Chronic Total Occlusion interventions in a South Indian population in the contemporary era.

Chronic Total Occlusion (CTO) intervention is a challenging area in interventional cardiology. Presently about 70% of CTO interventions are successful. MATERIALS AND METHODS: This was a single center prospective study of a cohort of all patients undergoing percutaneous coronary intervention (PCI) as elective or adhoc procedure for CTO from August 2014 to June 2015. Only antegrade CTO interventions were included. In all patients the following data were recorded. RESULTS: A total of 210 (8.9% of total PCI (2353) during the study period) CTO patients were followed up. The mean age was 56.54±8.9. In the study sixty nine patients (32.9%) presented with chronic stable angina and rest of the patients had history of acute coronary syndrome of which 22.9% (n=48) had unstable angina (UA) or non ST elevation myocardial infarction (NSTEMI) and 44.2% (n=93) had ST Elevation Myocardial Infarction (STEMI). In those with history of ACS, 64.78% (n=92) had ACS during the previous year and remaining 35.22% (n=49) had ACS prior to that. Single vessel CTO was seen in 89.5% (n=188) and two vessel CTO in 10.5% (n=22). LAD was involved in 36.7% (n=77), RCA in 48.1% (n=101), and LCX in 15.2% (n=32). Procedural success in the first attempt was 68.1% (n=143), which increased to 71.42% (n=150) after the second attempt. CTO interventions were more frequently successful when the calcium was absent or minimal (p-0.05), CTO length was <10mm (p<0.01) and good distal reformation (p<0.01).

Geographical variation in the clinical presentation of endomyocardial fibrosis in India?

OBJECTIVES: To compare the clinical presentation, clinical profile and survival of two groups of endomyocardial fibrosis patients. METHODS: The study was a prospective cohort study, or a prospective case series, comparing all consecutive echocardiographically proven patients with endomyocardial fibrosis seen in Medical College Trivandrum with the patients seen in Medical College Hospital, Alappuzha(Alleppey) (or TD Medical College). In all patients the clinical details like age, sex, type of endomyocardial fibrosis, the presence of anaemia, eosinophilia, neutrophilia and type of rhythm(Sinus or atrial fibrillation) etc were compared by both simple X2 and by Kaplan Meier survival curves. RESULTS: The mean age and the sex distribution was same in both places Briefly the incidence of biventricular endomyocardial fibrosis was more from Trivandrum than Alleppey, 64.9% vs 14.3% (p<0.0.001), the incidence of atrial fibrillation was more in Trivandrum 44.2% vs 16.3%. (p<0.001)The overall survival of Trivandrum patients was poorer (p<0.0001). The six year survival was 61% in the Trivandrum population whereas it was 91.5% in the Alleppey population. CONCLUSIONS: These differences may have been due to the better nutrition of the Alleppey patients due to a higher exposure to fish compared to the Trivandrum population. Better nutrition would protect against Magnesium deficiency and prevent the absorption of Cerium in the patients from Alleppey, compared to those from Trivandrum.

Open-labeled randomized controlled trial to evaluate the 1-year clinical outcomes of polymer-free sirolimus-eluting coronary stents as compared with biodegradable polymer-based sirolimus-eluting coronary stents.

BACKGROUND: Head to head trials of clinical outcomes of sirolimus eluting polymer free vs. biodegradable polymer stents are lacking. METHODS: Single centre prospective open labeled randomised controlled clinical trial. Basis for sample size calculation was the rate of MACE from the ISAR TEST 3 trial in which the absolute difference was 10.25% with a standard deviation of 0.24. Assuming null hypothesis, 80% power and 5% alpha error, to detect a 10% difference, adjusting for 10% loss of follow up, sample size was 204. INCLUSION CRITERIA: Patients with stable coronary artery disease or recent acute coronary syndrome ( >1 week from the date of STEMI), being taken up for elective angioplasty. END POINTS: Primary end point was MACE at 1 year and secondary end points at the end of 1 year were cardiac death, urgent target lesion revascularization, acute coronary syndrome, stroke and in-stent re-stenosis. RESULTS: 204 patients were enrolled between January 2013 to July 2014, 91 in the polymer-free group and 113 in the biodegradable polymer group. Baseline characteristics were comparable between both groups. 21 patients (10.29%), were lost to follow up. MACE at 1 year were comparable in both the groups 3 of 85(3.52%) in the polymer-free group and 3 of 98(3.06%) in the biodegradable polymer group, p = 0.859. The secondary end points were also comparable between the two groups- Death- 1 of 85(1.17%) vs. 2 of 98(2.04%), p = 0.646, Stroke 0 of 85 vs. 2 of 98(2.04%), p = 0.185 and acute coronary syndrome - 2 of 85(2.35%) vs. 1 of 98(1.02%), p = 0.204. There were no instances of urgent target lesion re-vascularisation or definite stent thrombosis in either groups. In stent re-stenosis was found in 7 of 85(8.2%) in the polymer-free group vs. 6 of 98(6.12%) in the biodegradable polymer group. CONCLUSION: The 1 year MACE rates are comparable in patients who underwent elective coronary revascularization using sirolimus eluting polymer-free and biodegradable polymer stents.

Predictors of no- reflow during primary angioplasty for acute myocardial infarction, from Medical College Hospital, Trivandrum.

BACKGROUND: Primary angioplasty (PCI) for acute myocardial infarction is associated with no-reflow phenomenon, in about 5-25% of cases. Here we analysed the factors predicting no reflow . METHODS: This was a case control study of consecutive patients with acute myocardial infarction who underwent Primary PCI from August 2014 to February 2015. RESULTS: Of 181 patients who underwent primary PCI, 47 (25.9%) showed an angiographic no-reflow phenomenon. The mean age was 59.19±10.25years and females were 11%. Univariate predictors of no reflow were age >60years (OR=6.146, 95%CI 2.937-12.86, P=0<0.001), reperfusion time >6h (OR=21.94, 95%CI 9.402-51.2, P=<0.001), low initial TIMI flow (≤1) (OR=12.12, 95%CI 4.117-35.65, P<0.001), low initial TMPG flow (≤1) (OR=36.19, 95%CI 4.847-270.2, P<0.001) a high thrombus burden (OR=11.04,95%CI 5.124-23.8, P<0.001), a long target lesion (OR=8.54, 95%CI 3.794-19.23, P<0.001), Killip Class III/IV(OR=2.937,95%CI 1.112-7.756,P=0.025) and overlap stenting(OR=3.733,95%CI 1.186-11.75,P=0.017). Multiple stepwise logistic regression analysis predictors were: longer reperfusion time>6h (OR=13.844, 95%CI 3.214-59.636, P=<0.001), age >60 years (OR=8.886, 95%CI 2.145-36.80, P=0.003), a long target lesion (OR=8.637, 95%CI 1.975-37.768, P=0.004), low initial TIMI flow (≤1) (OR=20.861, 95%CI 1.739-250.290, P=0.017). CONCLUSIONS: It is important to minimize trauma to the vessel, avoid repetitive balloon dilatations use direct stenting and use the shortest stent if possible.

Possible complication of bee stings and a review of the cardiac effects of bee stings.

We report the case of a patient who, ∼3 weeks after multiple bee stings, developed a prolonged heart block, syncope and cardiac arrest. This required a temporary pacemaker to be implanted, which was later replaced with a permanent pacemaker. An ECG taken following surgery for a fractured humerus 6 years earlier was reportedly normal. The patient had been a rubber tapper who walked ∼1.5 km/day, but after the bee attack he was no longer able to walk or get up from the bed without experiencing syncope. We presume that the bee venom caused these signs, as well as the resulting heart block, which persisted long after the bee sting had subsided. Since his coronary angiogram was normal we believe he had a Kounis type involvement of the cardiovascular system, namely profound coronary spasm that caused complete heart block that did not recover. Another probable reason for the complete heart block could have been that the bees had consumed the pollen of a rhododendron flower, causing 'grayanotoxin' poisoning and severe heart block. The other effects of bee sting are discussed briefly.

Rheumatic Heart Disease in Kerala: A Vanishing Entity? An Echo Doppler Study in 5-15-Years-Old School Children.

Background. Early detection of subclinical rheumatic heart disease by use of echocardiography warrants timely implementation of secondary antibiotic prophylaxis and thereby prevents or retards its related complications. Objectives. The objective of this epidemiological study was to determine prevalence of RHD by echocardiography using World Heart Federation criteria in randomly selected school children of Trivandrum. Methods. This was a population-based cross-sectional screening study carried out in Trivandrum. A total of 2060 school children, 5-15 years, were randomly selected from five government and two private (aided) schools. All enrolled children were screened for RHD according to standard clinical and WHF criteria of echocardiography. Results. Echocardiographic examinations confirmed RHD in 5 children out of 146 clinically suspected cases. Thus, clinical prevalence was found to be 2.4 per 1000. According to WHF criteria of echocardiography, 12 children (12/2060) were diagnosed with RHD corresponding to echocardiographic prevalence of 5.83 cases per 1000. As per criteria, 6 children were diagnosed with definite RHD and 6 with borderline RHD. Conclusions. The results of the current study demonstrate that echocardiography is more sensitive and feasible in detecting clinically silent RHD. Our study, the largest school survey of south India till date, points towards declining prevalence of RHD (5.83/1000 cases) using WHF criteria in Kerala.

A prominent 'A' notch in the pulmonary valve M mode-one more cause of the same.

The M mode echocardiogram is not the main priority, during routine echocardiographic evaluation now-a-days. However, there are still a few classical conditions where this remains instructive and educative. One such situation is the presence of an 'a' wave in the pulmonary valve M mode tracing in normals and it's absence in pulmonary hypertension. In valvular pulmonary stenosis we expect a deeper 'a' wave. We describe one more cause of a prominent 'a' wave in the pulmonary valve M mode. We describe this in a common tropical disease, endemic to Kerala.

+Ophitoxaemia and myocardial infarction--the issues during primary angioplasty: a review.

'The Big four' are the most poisonous snakes in India, and especially in Kerala. These include the cobra, the viper, the krait and the sea snake. Most of the poisonous snakebites in India occur in Kerala. We believe there are only a few reports of myocardial infarction after snakebites and most of these are viper bites. We believe this is the second case of primary angioplasty for a snakebite. There are at least a few potential issues in performing a primary angioplasty in a snakebite case, namely (1) Is it a thrombus or a spasm? (2) Are the bleeding parameters deranged? Will the patient tolerate tirofiban and other glycoprotein (GB) 2b3a inhibitors? Will he develop dangerous bleeding due to the high dose of heparin needed? Further, would we save the patient from myocardial infarction only to lose him to renal failure, both due to the nephrotoxicity of the venom, the kidney being further damaged by the contrast media used for the angioplasty? We discuss all these issues as they crossed our mind, and hope it will help further treatment in others. We would like to review the available literature on these points and describe a recent case of ours.

New onset S wave in pulmonary embolism: revisited (something old and something new).

We report a case of a young man who had a new onset S wave in lead 1 in his ECG with typical symptoms of acute onset of dyspoena 2 months after an episode of deep vein thrombosis, S wave disappeared 6 days after thrombolysis. We report this case as the clinical course was very typical plus we have reviewed the literature regarding diagnosis and risk stratification of pulmonary embolism for the student, or the casualty medical officer.

What is this? VT versus SVT.

We present a patient who had a wide QRS tachycardia; it was initially difficult to determine whether it was superventricular tachycardia (SVT) or ventricular tachycardia (VT). By some criteria (sinus capture beats, pseudo-δ waves and wide QRS) the patient's ECG was suggestive of VT of epicardial origin. On the coronary angiogram it was found that this patient had significant coronary artery disease. He was stented with three stents and later had a full electrophysiological study .We present here the ECGs and the differential diagnosis and a brief review of the diagnostic features of epicardial VT.

Yet more knots in the radial artery, unravelling purely by counter clockwise rotation.

We describe here two more radial knots that could be unravelled by counter-clockwise rotation alone. We and others have previously described radial knots that occur when trying to engage the right coronary artery (RCA). Here, we show two knots that were unravelled purely by counter-clockwise rotation. One occurred during RCA catheterisation and the other occurred during left coronary angiography via the radial route. In one of the patients, severe pain occurred in the right shoulder. This occurred even though the artery was not in spasm. We were able to move the catheter. Therefore it is possible that pain combined with the ability to move the catheter may be a marker of an intravascular knot.

Acute MI in a young hypertensive woman: could it be due to tranexamic acid?

The case report illustrates an acute myocardial infarction (MI) in a 41-year-old hypertensive woman possibly because of an intake of a combination of tranexamic acid and mefenamic acid for dysmenorrhoea and menorrhagia. There are multiple case reports of MI occurring in the setting of the use of antifibrinolytic agents including tranexamic acid. The present case serves as a warning that, even in patients with an apparently low risk for arterial thrombosis, these drugs may be implicated as a precipitant of MI.

Knots in the cath lab, an embarrassing complication of radial angiography.

Most case reports or series describe knots in the venous system such as knots of Swan-Ganz catheters, pacing wires or thermodilution catheters. Knots during radial angiography are relatively rare. Here we describe a simple method of unravelling a radial knot via the femoral route, together with a review of the literature on knots in the catherisation laboratory and the techniques to deal with them.

An uncommon picture of endomyocardial fibrosis: no embolism yet.

We present here a review of the various gradings of endomyocardial fibrosis from autopsy (Shaper's types). Echocardiography accurately delineates the extent of fibrosis of either the right or left ventricle and we have illustrated a typical classical case. We have images of the same patient from 2010, 2011 and 2012 and so we use this to illustrate the echocardiographic gradings.