Percutaneous hepatic vein recanalization in pediatric Budd-Chiari syndrome - 10 years' experience from a tertiary center.

Background: Budd - Chiari syndrome (BCS) due to hepatic venous outflow obstruction is a rare cause of liver disease with dismal outcome, often amenable to catheter intervention. Materials and Methods: This retrospective single-center study analyzed the clinical profile and medium-term outcome of interventional treatment with balloon angioplasty ± stenting in all pediatric BCS over a 10-year period. Clinical, laboratory, imaging, and interventional data were retrieved. Transhepatic (TH) access was utilized in the recent 3 years. Results: We included a total of 27 patients. Acute and subacute BCS comprised 93% of subjects. Ascites was the most common symptom. COVID-19 infection and Takayasu arteritis were two novel etiologies in our study. There was isolated hepatic vein (HV) narrowing in 11 (41%), isolated inferior vena cava obstruction in 4, and combined occlusion in 12 (44%). Intervention was successful in 22 (82%) patients. Stenting was required in 14 (64%) patients and the rest underwent balloon angioplasty. The immediate outcome was better with stenting than balloon (91% vs. 64%). Transhepatic access in 6 patients allowed HV cannulation in all and achieved patency in five patients. Two patients from the balloon group (25%) and 9 from the stent group (64%) are alive with patent veins at a median follow-up of 60 months, indicating a high attrition rate. Conclusion: Catheter interventions restored physiological blood flow in pediatric BCS. TH route improved cannulation of occluded HV compared to other accesses. Immediate and medium-term outcomes were better after stenting with lower rates of reinterventions than balloon angioplasty. Life-long surveillance is required as mortality is high on follow-up.

Changing pattern of admissions for acute myocardial infarction in India during the COVID-19 pandemic.

AIM: Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India. METHODS & RESULTS: In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = -0·48; r2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively. CONCLUSIONS: The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

Thiamine-responsive acute severe pulmonary hypertension in exclusively breastfeeding infants: a prospective observational study.

OBJECTIVES: Severe pulmonary hypertension (PH) causing right heart failure can occur due to thiamine deficiency in exclusively breastfeeding infants. This study describes the clinical profile and management of thiamine-responsive acute pulmonary hypertension. METHODS: A prospective observational study of infants presenting with severe PH without any other significant heart or lung disease. History of symptoms, clinical examination, echocardiography and basic investigations were performed. Dietary patterns of mothers were recorded. Thiamine was administered and serial echocardiography was performed. RESULTS: A total of 250 infants had severe PH and 231 infants responded to thiamine. The mean age was 3.2±1.2 months. Fast breathing, poor feeding, vomiting and aphonia were the main symptoms. Tachypnoea, tachycardia and hepatomegaly were found on examination. Echocardiogram revealed grossly dilated right heart with severe PH. Intravenous thiamine was administered to all the babies based on clinical suspicion. Clinical improvement with complete resolution of PH was noticed within 24-48 hours. Babies were followed up to a maximum of 60 months with no recurrence of PH. All the mothers consumed polished rice and followed postpartum food restriction. CONCLUSION: Thiamine deficiency is still prevalent in selected parts of India. It can cause life-threatening PH in exclusively breastfeeding infants of mothers who are on a restricted diet predominantly consisting of polished rice. It can contribute to infant mortality. Thiamine administration based on clinical suspicion leads to remarkable recovery. High degree of awareness and thiamine supplementation in relevant geographical areas is required to tackle this fatal disease.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design.

BACKGROUND: COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India. METHODS: In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic. CONCLUSIONS: This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

Congenital double mitral orifice with severe mitral regurgitation-associated rheumatoid arthritis: a case report.

BACKGROUND: A double orifice mitral valve (DOMV) represents a rare congenital malformation characterized by two valve orifices with two separate subvalvular apparatus. Double orifice mitral valve is congenital anomaly of the subvalvular mitral valve apparatus consisting of an accessory bridge of fibrous tissue, which partially or completely divides the mitral valve into two orifices. CASE SUMMARY: A 30-year young male presented with dyspnoea and palpitation for 4 years, joint pain for 2 years and weakness of right upper limb and lower limb for 6 months. On clinical examination, Boutonniere, Swan neck, and Z-deformity of hand and foot metatarsal bone deformities are noted, on further evaluation, patient was diagnosed as a case of DOMV and was managed conservatively since patient was not willing for surgery. DISCUSSION: Two-dimensional echocardiography is the best detection method, the parasternal short-axis view being most useful to show DOMV.

Clinical Characteristics, Management Strategies, and In-Hospital Outcomes of Acute Coronary Syndrome in a Low Socioeconomic Status Cohort: An Observational Study From Urban India.

BACKGROUND: Coronary artery disease is the leading cause of mortality in India. There is scarcity of data on demographic profile and outcomes of acute coronary syndrome (ACS) in low socioeconomic status (SES) population of India. OBJECTIVES: This study was undertaken to determine the clinical presentation, management strategies, and in-hospital outcomes of ACS in low SES population. METHODS: We conducted 1-year prospective observational cohort study of ACS patients admitted at Employees State Insurance Corporation unit of our tertiary care cardiac center. Clinical parameters, management strategies, and in-hospital outcomes of 621 patients enrolled during the study period from February 2015 to January 2016 were studied. RESULTS: Mean age of patients was 56.06 ± 11.29 years. Majority (62%) of the patients had ST elevation myocardial infarction (STEMI), whereas Non-ST elevation acute coronary syndrome (NSTE-ACS) was seen in 38% of the patients. Median time from symptom onset to hospital admission was 285 min with wide range from 105 to 1765 min. Coronary angiography was performed in 81% of patient population. Single-vessel disease (SVD) was the most common pattern (seen in 43.3%) of coronary artery involvement with left anterior descending coronary artery (LAD) being the most frequently involved vessel (62.8%). Pharmaco-invasive approach was the preferred strategy. Overall percutaneous coronary intervention (PCI) rates were 59.1% (62.1% in STEMI and 54.2% in NSTE-ACS). Overall in-hospital mortality was 3.2%, being significantly higher in STEMI (4.2%) as compared with NSTE-ACS (1.7%). CONCLUSIONS: With implementation of evidence-based pharmacotherapy and interventions, outcomes comparable with developed countries can be achieved even in low SES populations of developing world.

Acute myocardial infarction in dextrocardia - A diagnostic and therapeutic challenge. Can dextrocardia be a risk factor?

Acute myocardial infarction in dextrocardia may present several challenges either in electrocardiographic diagnosis or coronary intervention or both, due to abnormal location of the heart, mirror images o the aorta and its branches, and abnormal coronary origin and orientation. Also, dextrocardia as a risk factor for coronary artery disease is less well established. We report the case of a young patient with dextrocardia and situs inversus without any risk factor who presented with acute extensive anterior wall myocardial infarction diagnosed after lead reversal and who successfully underwent coronary intervention using "double inversion technique". .

Incidence, predictors, clinical profile, management and outcome of patients with isolated left main coronary artery ostial disease.

OBJECTIVES: Isolated left main coronary artery (LMCA) ostial disease is a rare variant of LMCA disease. Earlier studies on this disease are limited by small number of patients enrolled. The aim of the present study was to analyze the incidence, risk factors, clinical profile and long term outcome of patients with isolated LMCA ostial disease. METHODS: 15,553 patients who underwent coronary angiogram in a single tertiary care cardiac hospital were analyzed for LMCA disease. 351(2.2%) patients were found to have significant LMCA disease out of which 28(0.18%) had isolated LMCA ostial disease. These 28 patients were compared with 323 non-ostial and non-isolated LMCA disease patients. RESULTS: The mean age of isolated LMCA ostial disease group was significantly less than the other group (p=0.009). Females were more affected than males (p=0.008). They also had low incidence of coronary risk factors (especially dyslipidemia, p=0.04). They tend to present more with stable angina and less with myocardial infarction. They had higher ejection fraction and normal regional wall motion (p=0.04). There was no mortality difference between two groups at the end of 1 year (p=0.234). CONCLUSION: In one of the largest studies done in these patients, we found that isolated LMCA ostial disease is more common in middle aged females with few coronary risk factors. These patients also had a better ejection fraction and normal regional wall motion compared to patients with non-ostial and non-isolated LMCA disease. The clinical and angiographic profile of these patients suggests that they may represent a distinct clinical entity.

Successful device retrieval using simple balloon method during cardiac procedures.

OBJECTIVES: Although rare, incidents of broken/dislodged fragment of various angioplasty hardwares, including catheters, guidewires, angioplasty balloons, and stents, are being increasingly reported in recent years. Since these broken fragments may cause life-threatening consequences for a patient, it is vital for an interventional cardiologist to be acquainted with different retrieval techniques. Here, we are reporting our observations of several incidents of device dislodgement/fracture during cardiac interventions and their retrieval using simple balloon method. METHODS: We present a study of eight patients in whom we attempted to retrieve dislodged/fractured cath-lab hardwares during cardiac interventions, using simple balloon method. These cases include two cases of balloon, three cases of stent, and three cases of guidewire dislodgement/fracture. RESULTS: Fractured/dislodged cath-lab hardwares were successfully retrieved using a simple balloon method in six out of eight cases (75%), without any need of other retrieval hardwares. We observed no major complications in any patient. CONCLUSIONS: The balloon-assisted retrieval method is a simple, safe, and cost-effective way to avoid complications of endothelial injury, myocardial infarction, emergency coronary artery bypass graft, and sudden cardiac death. This study, particularly the context of retrieval technique used in each case, will offer valuable information to fellow interventional cardiologists.

Effect of thrombolytic therapy on the patterns of post myocardial infarction ventricular septal rupture.

OBJECTIVES: Ventricular septal rupture (VSR) is a rare but feared complication after myocardial infarction (MI). The objective of this study was to investigate the effects of thrombolytic therapy on the patterns of VSR following MI. METHODS: 30 consecutive patients admitted to a single tertiary level cardiac hospital with a diagnosis of acute MI and developed VSR in the hospital were included. The effect on thrombolytic therapy on the formation of VSR and its clinical outcome was studied. RESULTS: Out of 30 patients, 15 patients received thrombolytic therapy.10 received early (<12h) and 5 received late (>12h). The median time to post MI VSR formation was significantly shorter in thrombolysis group compared to non thrombolysis group at 1 vs 3 days(p=0.026). The median time for VSR formation was shorter in early thrombolysis group compared to late thrombolysis group at 1 vs 3 days (p=0.022). There was no difference between late and no thrombolytic therapy (3 vs 3 days, p=0.672). There was no significant difference in the mortality between thrombolytic and no thrombolytic therapy (p=0.690). Patients treated medically had a significant higher mortality compared to patients treated surgically (p=0.005). CONCLUSION: Thrombolytic therapy results in an earlier presentation of VSR after MI. This earlier presentation may be due to reduction in the number of patients developing late VSR after thrombolytic therapy, while the number of patients developing an early VSR remaining unaffected. Despite improvements in medical therapy and percutaneous and surgical techniques, mortality with this complication remains extremely high.

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.

The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India.

There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India.

PTMC in post-MV repair status.

MV repair in the rheumatic population is feasible with acceptable long-term results.1 Incidence of mitral stenosis (MS) following mitral valve (MV) repair for severe rheumatic mitral regurgitation (MR) and usefulness of percutaneous transluminal mitral valvuloplasty (PTMC) in these patients is not described in literature. We report a case of successful PTMC in severe MS following MV repair for severe rheumatic MR.

An unusual case of Corynebacterium striatum endocarditis in a patient with congenital lymphedema and rheumatic heart disease.

Corynebacterium striatum (C. striatum) is a ubiquitous saprophyte with a potential to cause bacteremia. We report the first case of C. striatum endocarditis in a patient with congenital lymphedema and rheumatic heart disease.

Percutaneous Coronary Intervention of Hidden Coronary Artery-Unusual Type of Isolated Single Coronary Artery.

Single coronary artery is a rare congenital coronary artery anomaly, the incidence of which is 0.024-0.066% as described in literature. Report of cases having single coronary artery along with acute myocardial infarction are scanty and reports of percutaneous intervention in such a situation are even fewer, technically challenging and potentially cataclysmic. As single coronary artery supplies the entire myocardium, occlusion of this can result in significant ischemic insult, resulting in severe biventricular dysfunction. Percutaneous Coronary Intervention (PCI) of single coronary artery is technically challenging and carries high risk which may be equated to left main intervention. We report a rare interesting case of L1 variety of single coronary artery which presented as acute inferoposterior myocardial infarction with successful rescue PCI to Left Circumflex Artery (LCx).

Right atrial spindle cell sarcoma as a rare cause of tricuspid stenosis.

Spindle cell sarcomas of the right atrium are extremely rare primary cardiac tumours with very few cases reported in the medical literature. The prognosis of this malignant neoplasm remains poor due to delay in diagnosis, early metastasis and few available therapeutic options. It responds poorly to chemotherapy and radiotherapy. Surgical excision is the mainstay of treatment. We report a 42-year-old man, who presented to emergency room with dyspnoea and fatigue (New York Heart Association classification II) since 1 month. Transthoracic echocardiogram showed massive pericardial effusion with tamponade. The patient underwent emergency pericardiocentesis; postpericardiocentesis echocardiogram showed large right atrial mass involving the right ventricle and the tricuspid valve causing tricuspid stenosis. Findings were confirmed by cardiac CT scan. Percutaneous transvenous biopsy was carried out which revealed spindle cell sarcoma.

Successful balloon mitral valvotomy in a rare coexistence of Ebstein's anomaly and rheumatic mitral stenosis.

Co-existence of Ebstein's anomaly of the tricuspid valve with rheumatic mitral stenosis is a very rare occurrence. We report the case of a young man who presented with progressive dyspnoea and was found to have rheumatic mitral stenosis with pulmonary hypertension and Ebstein's anomaly of the tricuspid valve. The patient underwent successful balloon mitral valvotomy resulting in marked improvement of symptoms.

Imaging essentials before transcatheter closure of an atrial septal defect: Detection of an unusual contraindication.

Currently there are few contraindications to transcatheter closure of secundum atrial septal defects (ASDs). Known device-related complications of percutaneous ASD closure are worsening of aortic regurgitation and cardiac erosion. Interference of a septal occluder with anatomic variant coronaries is a rare but important complication that can result in post-interventional fatalities. We report a woman with ASD and anomalous left circumflex artery arising from the right sinus of Valsalva with a retro-aortic course. Device closure was not attempted in her due to concerns about coronary compression by the device occluder and hence she underwent surgical closure. .