Isolated Partial Anomalous Pulmonary Venous Connection: Development of Volume Overload and Elevated Estimated Pulmonary Pressure in Adults.

OBJECTIVE: Partial anomalous pulmonary venous connection (PAPVC) is one of the rare congenital cardiac diseases with a prevalence of 0.4-0.7% of autopsies. The prevalence of a partial anomalous pulmonary venous connection is 0.2% in computed tomography (CT) among adults. We chose to study the association between isolated PAPVC and volume overload, estimated systolic pulmonary artery pressure in a tertiary care center for cardiovascular diseases. METHODS: CT report database was searched for keywords of partial anomalous pulmonary venous connection, pulmonary hypertension, dilated right atrium (RA), and right ventricle (RV). Both pediatric and adult population were considered. All the dedicated studies of non-coronary cardiac evaluation, pulmonary arteries, and thorax were included in the study. Echocardiography was performed in all the subjects. In adults, abnormalities searched were features of volume overload of RA and RV and estimated systolic pulmonary pressure of 45 mmHg. Biphasic studies were performed, and upper abdomen was included in the CT studies. RESULTS: Among the 110 subjects, 54 (49%) had isolated PAPVC. Of 54, 26 patients had volume overload of RA/RV or elevated estimated systolic pulmonary artery pressure. There is a significant association between drainage of anomalous veins to superior vena cava (SVC) and age >18 years (Chi-squared test P = 0.003). Among patients with isolated PAPVC, 18 had anomalous drainage to the SVC. Among isolated PAPVC cases, 38 were of the age >18 years. We found statistically significant association (P = 0.02) between isolated PAPVC in adults and pulmonary hypertension. CONCLUSION: Isolated PAPVC has association with the development of pulmonary hypertension in adults, approaching statistically significant p value. Because isolated PAPVC is a clinically significant independent risk factor, it should be actively treated to prevent the development of pulmonary hypertension later in life, which may result in severe clinical consequences.

The prevalence of myocardial bridging on multidetector computed tomography and its relation to coronary plaques.

PURPOSE: To test the hypothesis that the prevalence of myocardial bridging varies between ethnic groups, and that the segment proximal to the myocardial bridge is more prone to plaque formation. MATERIAL AND METHODS: A total of 4500 patients who had undergone computerised tomography (CT) coronary angiography at our institute were studied for myocardial bridging. Data on the clinical profile and indication for CT coronary angiography in myocardial bridging were collected. Patients with and without proximal disease were compared using the chi-square test for ordinal variables and Student's t-test for continuous variables. The length to depth ratio (RA-MA ratio) of the bridged segment was determined. RESULTS: The prevalence of atherosclerotic plaques in the segment proximal to the bridged segment was 37.8%, which was lower than the prevalence of 48.7% for plaques in the corresponding segments among patients without myocardial bridging. The average length of the bridged segment was 15.5 ± 5 mm, and that for patients with and without proximal plaques was 13 ± 4 and 16 ± 6 mm (p = 0.1), respectively. Similarly, the average depth of the segments with and without proximal plaques was 1.8 ± 0.6 mm and 1.4 ± 0.5 mm (p = 0.06), respectively. Only the RA-MA ratio (8 ± 3 vs. 13 ± 6, p = 0.01) was significantly lower in patients with atherosclerotic plaques. CONCLUSIONS: The prevalence in our study population was 10%, with mid left anterior descending artery (LAD) being the most common segment involved. Moreover, the prevalence and distribution of coronary plaques in LAD were similar in patients with and without myocardial bridging.

SYNTAX Score in Patients with High Computed Tomography Coronary Calcium Score.

OBJECTIVES: To study the conventional coronary angiogram ( CA) findings in patients with high coronary calcium on multidetector computed tomogram. MATERIALS AND METHODS: Fifty patients with coronary calcium high enough in its extent and location to interfere with the interpretation of a contrast-filled coronary artery for a significant lesion were studied with conventional CA. Framingham risk score (FRS), computed tomography (CT) coronary calcium score (CCS), and SYNTAX score (SS) from the CA were calculated by separate investigators who were blinded to other scores. Effectively, 250 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery and posterior descending artery in each subject) with calcium scores were studied for lesions on CA. RESULTS: Thirty-five subjects had high FRS, 10 had intermediate FRS, and 5 had low FRS. Eight subjects of 25 (32%) with CCS between 350 and 1000 had no significant coronary artery disease (CAD). Overall, the CCS and the SS had a strong agreement with each other (r = 0.68, P < 0.01) that persisted in those with very high scores >1000 (r = 0.55, P < 0.01, n = 30), but only a nonsignificant weak correlation with scores between 350 and 1000 (r = 0.1, P = 0.62, n = 20). Individual vessel calcium scores correlated strongly for the presence of any lesion (r = 0.52, P < 0.01) in the same artery but only weakly for a significant lesion (r = 0.29, P = 0.05). CONCLUSION: High CT CCS in this cohort of intermediate to high (Framingham score) risk patients correlated strongly with the subject's global burden of the CAD as derived by the SS, more so for subjects with very high scores. Similarly, CCS correlated strongly with the presence of any lesion but only weakly for a significant stenosis; also, about one-third of patients with CCS between 350 and 1000 may not have significant disease on conventional CA.

Wine Glass Sign and Empty Delta Sign: A Rare Imaging Presentation of Postpartum Encephalopathy in Dehydration.

Rapid correction of hyponatremia is a well-known cause of central pontine and extrapontine myelinolysis. But uncommonly seen and rarely reported in Hypernatraemia. We report a rare case presenting as postpartum psychosis, wherein imaging revealed myelinolysis of corticospinal tracts in wine glass distribution and empty delta sign due to cortical venous thrombosis. At follow-up 3 months later, revealed significant neurological improvement. Concurrance occurrence of this dual pathology is not been described, which in our case was due to high serum sodium levels at presentation and dehydration.

Normal Proximal Coronary Artery Diameters in Adults from India as Assessed by Computed Tomography Angiography.

INTRODUCTION: The normative data of coronary artery size among Indians are sparse. It is often essential to know the coronary dimensions especially during interventions such as stenting to choose the appropriate size of the stent and to decide the very need for stenting. In current practice it is the luminal angiography which is most widely employed to assess the coronary artery size. However, luminal angiography is not very accurate in estimating the epicardial coronary artery size as it does not take into account the mural thickness of the arterial wall. Hence it is prudent to assess coronary artery size by other methods such as Computed Tomography (CT) coronary angiography, quantitative coronary angiogram, Magnetic Resonanace (MR) angiogram, etc. In this study we chose computed tomography as it demonstrates mural thickness along with lumen of the vessels and hence measures the diameter more accurately. AIM: To establish normative data for diameters of the proximal coronary artery segments during life by using MDCT in a cohort of individuals without any structural heart disease. MATERIALS AND METHODS: Between October 2012 and April 2013, 168 consecutive patients who did not have any structural heart disease underwent CT coronary angiography for evaluation of Coronary Artery Disease (CAD) with atypical symptoms with low pretest probability. Patients who were found to have no coronary artery disease on CT-CAG were recruited in this study. The baseline clinical status and demographic data were obtained from the hospital records. RESULTS: In our study we found that the mean indexed diameter to BSA among females for LMCA 2.32±0.12mm, LAD 1.95±0.15mm, LCX 1.73±0.20mm and RCA 1.84±0.22mm. For males the values were LMCA 2.33±0.13mm, LAD 1.94±0.16mm, LCX 1.74±0.21mm, and RCA 1.79±0.20mm. These values are comparable to other studies. CONCLUSION: We attempted to establish normative data for normal proximal coronary artery dimensions among South Indian population. Coronary artery dimensions in Indians (in-dexed to BSA) for proximal major epicardial coronary arteries are similar to that reported in the West.

Angiographic profile and endovascular interventions in Takayasu's arteritis.

BACKGROUND: Takayasu's arteritis (TA) is a rare inflammatory, granulomatous vasculitis primarily involving the aorta and its major branches. Clinical and angiographic manifestations of the disease differ in various parts of the world. OBJECTIVES: To analyze the clinical features, angiographic profile, and endovascular interventions in TA patients (pts). METHODS: From January 2009 to March 2013, a total of 62 consecutive pts who were diagnosed with Takayasu's arteritis at our institute based on American College of Rheumatology Criteria were included in the study. Thirty-four pts underwent conventional angiography, while 28 were evaluated using computed tomographic angiography. Endovascular interventions were attempted for 24 lesions in 23 pts who were symptomatic and had significant stenotic lesions. RESULTS: The mean age of presentation was 28.4 ± 9.7 years, with 69.4% female. Limb claudication (52%) was the most common presenting symptom, followed by vertigo (35%) and constitutional symptoms. The most common angiography class was type V (37.1%), followed by type I (32.2%), type IV (17.7%), type IIa (8.1%), type III (3.2%), and type IIb (1.6%). The most common artery involved was the subclavian (64.5%), with the left subclavian more commonly involved than the right, followed by the abdominal aorta (51.6%) and renal artery (32.2%). Stenotic lesions were present in 59 pts (95%), while aneurysmal involvement was seen in 17 (27.4%), with isolated aneurysmal involvement in 3 of these. CONCLUSIONS: Our cohort of TA pts had more severe and widespread involvement. Despite a more advanced presentation, percutaneous balloon angioplasty with stent implantation is feasible, with good immediate results but slightly higher complication rates.

Thrombolysis With Single Bolus Tenecteplase Compared With Streptokinase Infusion in the Treatment of Acute Pulmonary Embolism: A Pilot Study.

OBJECTIVE: This study was planned to compare the efficacy of bolus regimens of tenecteplase (TNK) and 24 hours infusion of streptokinase (STK) in acute pulmonary embolism (APE) in a resource-poor setting. INTERVENTIONS: In all, 25 patients received injection of TNK, and 75 patients received infusion of STK over 24 hours. RESULTS: Pulmonary artery systolic pressure and right ventricular function were improved separately and significantly (P = .01) in both the study groups of patients from baseline at 24 hours or at seventh day and was comparable among the TNK and STK groups of patients. Mean duration of stay in intensive care unit was significantly less (2.2 ± 0.8 vs 3.2 ± 1.3 days; P = .04), and bleeding risk was also found to be nonsignificantly less in the TNK group. CONCLUSION: These results suggest that a 24-hour infusion regimen of STK is as effective as bolus TNK in the treatment of patients with APE in countries with limited resources.

Predictors of inhospital prognosis in acute pulmonary embolism: keeping it simple and effective!

The assessment of commonly available demographic, clinical, and easily calculable investigational parameters instead of the conventional complicated indices for prognosis in acute pulmonary embolism may help in triage in a simple and cost-effective way. Clinical, demographic, and investigational parameters were collected and utilized for the assessment of inhospital prognosis of acute pulmonary embolism in 200 consecutive patients admitted to our institute. Overall mortality was 18% and poor outcome at discharge was seen in another 18.5%. In univariate analysis, predominant presenting symptom of fatigue, sudden onset of symptoms, overt right ventricular failure, hypoxemia at admission, low SBP and DBP, coexistent pulmonary or cardiac illness, ECG evidence of right axis deviation, SIQ3T3 pattern, conduction blocks, echocardiographic evidence of right ventricular dysfunction, decreased inspiratory collapse of inferior vena cava, severe pulmonary arterial hypertension, visible thrombus in pulmonary artery, significant tricuspid regurgitation, computed tomographic evidence of total occlusion of major pulmonary arteries, diameter of main pulmonary artery, acute or chronic pulmonary embolism, renal and hepatic dysfunction, hyponatremia, hyperkalemia, troponin elevation, use of fibrin-specific agent, requirement of inotropic support, and mechanical ventilation were the variables found to significantly predict adverse outcome. In multivariate analysis, hypoxemia, no improvement after lysis, deranged liver function test, conduction blocks, and signs of right ventricular failure were the significant variables, while inotropic support requirement had a trend toward significance. Clinical, demographic, and routine investigational parameters help to risk-stratify the patients presenting with acute pulmonary embolism and to prognosticate and manage in a simpler yet effective way.

Idiopathic dilatation of the pulmonary artery-a case report.

Idiopathic dilatation of the pulmonary artery (IDPA) is a rare anomaly presenting with enlargement of the pulmonary artery in the absence of an identifiable cause. The natural history of this silent but potentially life-threatening disease can be unpredictable. We report a case of IDPA in an 80-year-old female with a massively dilated pulmonary artery.