Percutaneous Closure of Bilateral Pulmonary Artery Aneurysms in Behcet's Disease.

Behcet's disease is a multisystemic vasculitis. It can affect the pulmonary artery in 2% to 5% cases. We discuss a case of a young male diagnosed with Behcet's disease on immunosuppressive therapy who presented with bilateral pulmonary artery aneurysms which were closed with covered stent and other devices.

Quadricuspid aortic valve.

A 56-year-old man presented with typical angina for 1 day and a prior history of exertional dyspnea of 6 months duration. Clinically, he was diagnosed with severe aortic regurgitation (AR). Electrocardiogram showed left ventricular hypertrophy with volume overload.

Indicators and predictors of in-hospital mortality and survival in patients with ventricular septal rupture.

Background: Ventricular septal rupture (VSR), a mechanical complication of myocardial infarction (MI), usually presents with rapid clinical deterioration with acute heart failure or cardiogenic shock. VSR may occur within 24 h to several days after MI and can occur in both anterior and inferior wall MI. Although guidelines recommend emergent surgery, this is associated with a high mortality rate of up to 40%. Intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) stabilize patients in preparation for angiography and surgery. Delayed surgery allows better septal repair in scarring tissue but also carries the risk of rupture extension and death while waiting. Percutaneous closure of the defect with appropriately designed devices results in better survival in the subacute phase. Aims: To study the indicators and predictors of VSR in the current era of primary percutaneous coronary interventions and mechanical circulatory support. Methods: Of total of 34,681 patients presenting with MI, the incidence of VSR was 0.45%. We sought to evaluate the predictors of survival and death in VSR. Coronary angiography (CAG) was performed, hemodynamic support provided to unstable patients, and consenting patients were referred to definitive therapy, either surgery or percutaneous device closure. The previously postulated hypotheses of triple vessel disease (TVD), diabetes mellitus (DM), and concentric left ventricular hypertrophy (LVH) due to Hypertension (HTN) being protective against VSR were explored. Results: Of the 169 patients with VSR, we found that the group that survived was mostly men and the mean age was 61.5 years; this was in contrast to the non-survivors, who were mainly women, and the mean age was 65.2 years (p = 0.025); higher Killip Class was 111-1V (p = 0.001), lower LVEF (p = 0.010), apical VSR and LV aneurysm (p = 0.015 and p = 0.002, respectively) were predictors of death. 48 patients underwent CAG, with single vessel disease (SVD) with lower-grade Rentrop collateral flow being most common in the death group. 25 patients were subjected to definitive therapy with surgical patch closure or percutaneous device closure. The patients who died were older by approximately 7 years. The risk factors for coronary artery disease, such as HTN, diabetes, and smoking, were not statistically different between the two groups. Conclusion: Prevention of myocardial infarction is more important than managing a VSR, which carries a high mortality despite advanced mechanical support and definitive interventional therapy such as emergent surgery and percutaneous device closure.

Combined cardiac anomalies in Noonan syndrome: A case report.

INTRODUCTION: Noonan syndrome is the second most common syndromic cause of congenital heart disease. Most patients have an autosomal dominant inheritance, but some cases may be sporadic. Pulmonary stenosis is the most common cardiac manifestation in Noonan syndrome, associated with the atrial septal defect and hypertrophic cardiomyopathy. A combination of these three is present only in 5% of patients. PRESENTATION OF CASE: We report a case of a 21-year-old female who presented to our hospital concomitant cardiac lesions associated with pulmonary stenosis, atrial septal defect, and hypertrophic cardiomyopathy. This combination of cardiac defects is an infrequent manifestation of Noonan syndrome. The patient presented with complaints of exertion syncope over the past two years. 2D-Echocardiography showed biventricular hypertrophy, dysplastic pulmonary valve, severe pulmonary stenosis, asymmetric septal hypertrophy and large atrial septal defect. The genetic analysis report showed autosomal dominant inheritance with Ras/MAPK (mitogen-activated protein kinase) Positive. DISCUSSION: Due to the wide spectrum of symptoms and presentations in Noonan cases, accurate clinical and genetic diagnosis, and comprehensive management of the disorder are strongly recommended. CONCLUSION: We have described a case of rare combination of cardiovascular defects in Noonan Syndrome with a view to achieve better insight into the disease course and advantages of timely treatment and follow up. Our patient is currently in follow-up after treatment with percutaneous balloon pulmonary valvuloplasty, has improved symptoms, and is awaiting heart transplant.

Percutaneous Coronary Intervention in an Octogenarian With Anomalous Origin Arising From Right Sinus: A Rare Case Report.

Anomalous coronary artery origins are not common in routine clinical practice. The incidence of coronary anomalies in patients undergoing coronary angiography is less than 1%. The greatest challenges faced in the management are delays in identification and difficulty engaging the anomalous coronary artery. Operator experience in promptly identifying the anomaly and selection of the appropriate catheter is critical for successful intervention. We are presenting a case of acute inferior and posterior wall myocardial infarction (MI) with an anomalous origin of the left circumflex artery from the right coronary sinus. Learning objective is that percutaneous coronary intervention (PCI) in an anomalous left circumflex can be technically difficult because selective cannulation of the vessel may not be easy. An anomalous left circumflex artery has a rare presentation of ST-elevation myocardial infarction (STEMI). Complicated STEMI with cardiogenic shock is not commonly seen in anomalous coronary artery origin from the right sinus. Percutaneous intervention in patients with STEMI with an anomalous left circumflex artery has a high risk and is technically challenging.

Cricket ball in the right heart: A case report of right atrial myxoma.

INTRODUCTION: Myxomas are the most common type of cardiac benign tumors and most of them are located in the left atrium, followed by the right atrium. The majority of Myxomas is located in the left atrium and has a variable clinical presentation. Myxomas affect patients within a wide age range (15-80 years), and the average age is approximately 50 years. There is a female predominance in the sporadic form. Myxomas are usually pedunculated, solitary, and sporadic but may be associated with familial autosomal dominant syndromes. CASE PRESENTATION: We report a 38-year-old female presented with large myxoma in the right atrium and atypical presentation and successfully underwent surgical excision of right atrial myxoma. The patient was asymptomatic on 6 months follow up. CONCLUSION: Cardiac myxomas are the most frequent finding among primary cardiac tumors. Clinical manifestations depend on the involvement in valvular obstruction, distant arterial embolisms, or nonspecific, constitutional symptoms. Transoesophageal Echocardiography is the cornerstone for diagnosis of atrial myxoma. Cardiac myxomas should be managed with surgical resection.

Tough, but not impossible - Retrieval of large atrial septal occluder devices embolized to left atrium.

Atrial septal defect (ASD) is a congenital heart defect that is being increasingly treated using percutaneous interventions. However, these techniques are not devoid of complications. One such complication is device embolization. Removal of such closure device poses tremendous risk and consequent complications both by percutaneous retrieval and surgical removal. Herein, we present two cases of ASDs that were closed using atrial septal occluder, but the devices were subsequently embolized into left atrium. These devices were then percutaneously retrieved without any further complication or injury.

Coronary stent concertina in proximal left anterior descending artery: An unusual case.

Since the emergence of stents, there has been persistent improvement in flexibility and deliverability of stents with modifications in its design and number of connectors. This has unfortunately created negative effect on longitudinal strength of stent resulting into a recently recognized and unaccustomed complication, longitudinal stent deformation (LSD). It is an abrupt shortening of the stent along its longitudinal axis, usually after deployment, due to various reasons. We present a case of LSD in Promus Element stent implanted at proximal left anterior descending artery. The stent shortening was about 25%-30% of its actual length. As this led to exposure of a part of lesion, it was successfully managed by overlapping another stent.

Incidental Detection of Arteria Lusoria During Transradial Coronary Intervention.

Transradial access has become popular and preferred approach in coronary interventions due to high success rate, low risk of complications and patients' comfort. However various anatomical variations and anomalies may pose technical challenge. Arteria lusoria is an uncommon condition which is technically challenging and may warrant cross-over to alternate access. We report a middle aged male presenting with acute coronary syndrome in which arteria lusoria was incidentally detected during right transradial coronary intervention.

Aortoiliac reconstruction in the setting of in-stent restenosis.

Complex iliac artery obstructions, particularly bilateral stenosis or total iliac artery occlusions, are usually treated with aortofemoral or aortobifemoral graft surgery. However, surgical treatment is associated with 3% mortality rate and significant morbidity such as intestinal ischemia, spinal cord injury, and ureteral damage. Percutaneous interventions of aortic bifurcation offer a promising alternative to surgery with potentially lower morbidity and mortality risk. We report a case of peripheral artery disease who had underwent right transfemoral iliac angioplasty with femoropopliteal bypass presented again with bilateral lower limb ischemia, who was successfully treated with stent implantation with the kissing balloon technique.

Unusual non progressive idiopathic giant ascending aortic aneurysm-A rarity.

INTRODUCTION: Ascending aortic aneurysm is the second most common aortic aneurysm to abdominal aortic aneurysm. Most ascending aortic aneurysm is diagnosed in sixth or seventh decade of life. Majority of patients of ascending aortic aneurysm do not have any clinical manifestations. CASE PRESENTATION: 45year old female patient presented with Dyspnoea on exertion (NYHA class II-III), palpitation and vague chest pain since 2 years. Patient had worsening of symptoms NYHA IV dyspnoea since last 1 month and the patient managed with medications since the patient was not willing for surgery. Patient is on regular follow up on medications since last 2 years. DISCUSSION: Aneurysms are usually dilation of an arterial segment. It involves extensive area of the aorta and is a challenging surgical procedure especially when it involves aortic root. Computed Tomography (CT), and especially multi-detector CT (MDCT), is the most popular radiological modality for evaluating aortic aneurysms. CONCLUSION: Aortic aneurysms are localized dilation of the wall of aorta. They can rupture or dissect involving the pericardium, aortic valve. Open surgical repair remains the standard approach to treating most large aortic aneurysm and results are believed to be more predictable and satisfactory.

Assessment of inferior vena cava diameter by echocardiography in normal Indian population: A prospective observational study.

BACKGROUND: The assessment of the IVC diameter is self explanatory for evaluation of the individuals' volume status. Studies regarding IVC diameter estimation in normal individuals are scarce. AIM: The present study aimed to define normal criteria of size and dynamics of the inferior vena cava (IVC) by M-mode echocardiography in normal individuals. METHODS: This was a prospective, single-center, observational study carried out at Sri Jayadeva Institute of Cardiovascular Sciences and Research between December 2011 and April 2014. A total of 4126 consecutive individuals were enrolled. Normal IVC diameter was measured both during inspiration and expiration by M-mode echocardiography in subcostal view. RESULTS: The IVC diameter varied from 0.46 to 2.26cm in the study individuals. The IVC diameter ranged from 0.97 to 2.26cm during expiration and from 0.46 to 1.54cm during inspiration. A strong correlation was observed between IVC diameter and height, weight and BMI of the individuals, calculated using Pearson correlation. The correlation coefficients for expiratory and inspiratory IVC diameters as a function of BMI were 0.686 and 0.7, respectively. CONCLUSIONS: Our findings corroborate the correlations between height, weight and BMI with IVC diameter. Future studies could be focused to bring about a steadfast formula for calculating IVC diameter based on demographic parameters of an individual.

Successful Retrieval of Uncoiled Coronary Guidewire Using Simple Balloon Method.

Breakage of angioplasty device in coronary artery can cause panic in the catheterization laboratory. These broken fragments may serve as a nidus for thrombus formation; hence, removal of these fragments becomes mandatory. Since the incidence of guidewire fracture during angioplasty are rarely reported, evidence-based approaches are not available for the management of such incidental conditions. Here, we report an interesting case of entrapment and unravelling of guidewire. We successfully retrieved unravelled guidewire using a noncompliant balloon inflated in the guiding catheter. Subsequently, the procedure was completed successfully with an implantation of a stent in the culprit lesion. We are of opinion that this novel technique is quite easy and less cumbersome than other described techniques reported earlier.

Dual-artery stenting of a type III single coronary artery from right aortic sinus.

A single coronary artery presenting with stenosis in two of the three vessels arising from a common ostium is a rare anomaly Lipton et al. proposed a classification, which was modified by Yamanaka and Hobbs. In our case, a single coronary artery was giving rise to the LAD, left circumflex (LCx), and the right coronary artery (RCA). There was 80% stenosis in the ostium of the LCx. The RCA in the mid and distal segment had stenosis of 80% and 70%, respectively. We were able to successfully stent the three stenotic segments.

A patient with rheumatic heart disease presented with central cyanosis due to acquired methemoglobinemia during late pregnancy - A rare association.

A 21-year-old pregnant female of known rheumatic heart disease presented to us for evaluation of central cyanosis during her late pregnancy. Though she was investigated for any associated congenital heart disease or pulmonary arteriovenous fistula, but incidentally she was diagnosed of having acquired methemoglobinemia. Her serum methemoglobin level was 33% which was far above the normal range. Ultimately, she was managed conservatively and delivered through elective caesarean section. Though the delivered baby was lethargic after birth, but later he was improved and discharged. This was the first case reported so far that a pregnant patient of rheumatic heart disease developed cyanosis due to methemoglobinemia.

Acute myocardial infarction being the presentation of dengue myocarditis.

Dengue fever is one of the most common vector-borne viral infections in tropical countries. Myocarditis is an uncommon complication of severe dengue fever. Sometimes, dengue myocarditis masquerades as acute myocardial infarction. We report here a case of a 22-year-old female, who presented with acute chest pain five days after the onset of a febrile episode. Initially she was diagnosed as acute myocardial infarction depending on the biochemical and echocardiography evidence. However, later investigation confirmed she was suffering from myocarditis due to dengue fever, which mimicked acute myocardial infarction. A Medline search revealed only few other reported cases of dengue myocarditis that mimicked of acute myocardial infarction.

Tendon xanthomas as indicators of atherosclerotic burden on coronary arteries.

The presence of tendon xanthomas is an almost certain indicator of familial hypercholesterolemia (FH). They also reflect coronary atherosclerotic burden and therefore must be treated aggressively. Tendon xanthomas also occur in two rare conditions, cerebrotendinous xanthomatosis and sitosterolemia, which are not easily confused with FH, can be easily differentiated with clinical history and biochemical tests.

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.