Ultra-low CONtraSt PCI vs conVEntional PCI in patients of ACS with increased risk of CI-AKI (CONSaVE-AKI).

OBJECTIVES: This prospective, randomized study assessed short-term outcomes and safety of ultra-low contrast percutaneous coronary intervention(ULC-PCI) vs conventional PCI in high risk for contrast induced acute kidney injury(CI-AKI) patients presenting with acute coronary syndrome(ACS). BACKGROUND: Patients at an increased risk of developing CI-AKI can be identified prior to PCI based on their pre-procedural risk scores. ULC-PCI is a novel contrast conservation strategy in such high risk patients for prevention of CI-AKI. METHODS: 82 patients undergoing PCI for ACS were enrolled having estimated glomerular filtration rate(eGFR) < 60 ml/min/1.73 m2 and moderate to very high pre-procedural risk of developing CI-AKI as calculated by Maioli risk calculator. They were randomized into two groups of 41 patients each of ULC-PCI (contrast volume ≤ patient's eGFR) and conventional PCI (contrast volume ≤ 3xpatient's eGFR). Primary end point was development of CI-AKI. RESULTS: Baseline clinical and angiographic characteristics were similar between groups. Primary outcome of CI-AKI occurred more in patients of the conventional PCI group [7 (17.1%)] than in the ULC PCI group [(0 patients), p = 0.012]. Contrast volume (41.02 (±9.8) ml vs 112.54 (±25.18) ml; P < 0.0001) was markedly lower in the ULC-PCI group. No significant difference in secondary safety outcomes between two study arms at 30 days. IVUS was used in 17% patients in ULC PCI. CONCLUSION: ULC-PCI in patients with increased risk of developing CI-AKI is feasible, appears safe, and has the potential to decrease the incidence of CI-AKI specially in resource limited setting such as ours where coronary imaging by IVUS is not possible in every patient.

Outcome of submitral aneurysm.

INTRODUCTION: Submitral aneurysm is a rare cardiac entity with outpouching in relation to the posterior annulus of the mitral valve. Multiple etiology have been described with the role of infection and inflammation with varied clinical presentation in different case reports. However, the literature on clinical outcome and follow-up is lacking. MATERIAL AND METHOD: This retrospective, observational study included all the adult patients (>18 years) who were diagnosed with a submitral aneurysm. Epidemiological, demographic, laboratory, clinical management, and outcome data were extracted and followed for the endpoints of cardiac death, noncardiac death, recurrent hospitalization (due to heart failure, rupture, arrhythmic events, embolic events), surgical repair, and echocardiography parameters for mitral regurgitation or change in the size of the left ventricle for 1-year postdischarge from the index hospitalization. RESULTS: A total of 10 patients were enrolled in the study with a mean age of 31.2 ± 11.1 years. Possible etiology could be established in only five (50%) patients (two patients had tuberculosis and three patients had acute coronary syndrome). At index hospitalization, nine (90%) patients had heart failure, two (20%) patients had rupture of a submitral aneurysm, four patients underwent surgery, and one patient expired. On follow-up of 1 year, one more patient underwent surgical repair while three patients expired. CONCLUSION: A submitral aneurysm is a rare cardiac entity with poor outcomes. Surgical repair with or without mitral valve replacement plays a definitive role in management.

Trans-esophageal Echocardiographic Assessment of Left Atrial and Left Atrial Appendage Function in Atrial Fibrillation and Rheumatic Heart Disease.

INTRODUCTION: Rheumatic heart disease (RHD) is one of the most typical causes of atrial fibrillation in developing countries like India. The left atrial and left atrial appendage structure and function are deranged in atrial fibrillation and are a major source of thromboembolism. The goal of this study was to assess the left atrial and left atrial appendage function by transesophageal echocardiography in patients with atrial fibrillation and their comparison in patients with or without RHD. METHODS: A total of 172 consecutive patients with atrial fibrillation with or without RHD were subjected to trans-esophageal echocardiography to assess and compare left atrial (LA) and left atrial appendage (LAA) function. RESULTS: Out of 172 patients with atrial fibrillation, 100 were female (58.1%) and 72 were male (48.9%). The mean age was 54.11±12.3 years, and rheumatic heart disease (RHD) was the commonest cause of atrial fibrillation found in 121 (70.3%) patients. The mean left atrium diameter was significantly higher in RHD patients than in Non-RHD patients (52.08±10.13 vs. 46.67±6.78 mm, p=0.001). Mean left atrial ejection fraction was significantly lower in RHD patients as compared to Non-RHD patients (33.53±5.06 vs. 35.49±5.40%, p=0.024). The mean LAA orifice area of RHD patients was significantly higher than the Non-RHD patients (7.52±1.22 vs 6.94±1.17 mm2, p=0.005). Mean LAA emptying velocity was significantly lower in RHD patients than Non-RHD (20.49±3.95 vs. 22.8±5.96 ml/s, p=0.002). CONCLUSION: Rheumatic heart disease is still a common cause of atrial fibrillation in developing countries. LA and LAA function is impaired in atrial fibrillation, more in patients with rheumatic heart disease.

Effect of Mitral Regurgitation on Systemic Coagulation Activity in Rheumatic Heart Disease as Assessed by D-dimer Levels.

Introduction Atrial fibrillation and mitral stenosis, especially in combination, increase the risk of left atrial thrombus formation and systemic embolization. However, whether severe mitral regurgitation (MR) improves systemic hypercoagulable state in these patients is unclear. remains unclear. The study aims to study the impact of severe MR on systemic coagulation by the use of D-dimer levels. Methods It was a prospective, cross-sectional study done on 400 subjects consisting of 350 cases and 50 controls. The cases were divided into seven groups on basis of valvular pathology, rhythm, and presence of a clot. The D-dimer level was compared in all the subgroups. Result The mean age of the study population was 32.32±7.30 years with a 48% male population. The highest level of D-dimer was found in patients with thrombus (1.71 ± 1.74 µg/ml). Patients with mitral stenosis had significantly higher plasma D-dimer levels than the control group (p <0.001) while regardless of rhythm, patients with MR had a D-dimer level similar to the control group in sinus rhythm. Conclusion Severe MR reduces plasma D-dimer levels to control levels reflecting the protective effect against thrombus formation and systemic embolization.

Effect of Percutaneous Coronary Intervention on Diastolic Function in Coronary Artery Disease.

BACKGROUND: Left ventricle (LV) diastolic dysfunction is often present in patients with significant coronary artery disease (CAD), even in the absence of regional or global LV systolic dysfunction. It has been suggested that abnormalities in LV diastolic function may actually precede LV systolic dysfunction, and therefore, serve as an early and sensitive marker of ischemia. This study aims to find improvement of diastolic function after percutaneous coronary intervention (PCI) in patients with stable or unstable angina. METHODS: In this single-center hospital-based study, we enrolled 309 patients with either stable or unstable CAD and with normal systolic function who underwent successful PCI. Two-dimensional transthoracic echocardiography was performed at baseline (before PCI) and repeated 48 h after PCI. LV diastolic parameters were compared before and after PCI using paired samples t-test results. RESULTS: Mean age of study population was 56.65 ± 9.65 years. Majority of patients were male (63%). There was significant increase in mitral E-wave velocity (68.39 ± 17.52 cm/s vs. 71.64 ± 18.23 cm/s), E/A ratio (0.85 ± 0.29 vs. 0.89 ± 0.32), and early diastolic mitral annular motion (e') (7.02 ± 0.89 cm/s vs. 8.45 ± 0.86 cm/s) following PCI (P < 0.0001). Left atrial volume index (22.53 ± 4.43 vs. 20.81 ± 4.14), tricuspid jet velocity (0.91 ± 0.57 m/s vs. 0.76 ± 0.67 m/s), and E/e' ratio (10.03 ± 3.5 vs. 8.62 ± 2.61) decreased significantly following PCI (P < 0.001). CONCLUSION: This study suggests that LV diastolic filling pattern is modified significantly as early as 48 h after successful PCI. Improvement in impaired relaxation appears to be most likely explanation for these changes. PCI may be potential therapeutic target to improve diastolic function in patients with CAD.

Largest giant left atrium in rheumatic heart disease.

In the current era of echocardiography, early diagnosis and treatment of rheumatic heart disease make giant left atrium a rare condition, with a reported incidence of 0.3%, and following mainly with rheumatic mitral valve disease. We report a 50-year-old female, a known case of rheumatic heart disease who presented with breathlessness and dysphagia, and the cardiothoracic ratio on chest roentgenogram was 0.95. Echocardiography was suggestive of giant left atrium with a size of 19.4 x 18.3 cm, while magnetic resonance imaging revealed a size of 22.3 x 19.2 x 20.1 cm making it the largest left atrium to be reported in the literature. .

Comparing the Modified Frailty Index with conventional scores for prediction of cardiac resynchronization therapy response in patients with heart failure.

OBJECTIVE: The aim of the study was to compare, Modified Frailty Index (mFI), EAARN (LVEF <22%, Atrial Fibrillation, Age ≥70 years, Renal function (eGFR <60 mL/min/1.73m2), NYHA class IV), and ScREEN (female Sex, Renal function (eGFR ≥60 mL/min/1.73m2), LVEF ≥25%, ECG (QRS duration ≥150 ms) and NYHA class ≤III) score for predicting cardiac resynchronization therapy (CRT) response and all-cause mortality. METHODS: In this prospective, non-randomized, single-center, observational study we enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant scores were calculated, and patients were followed for six months. Performance of each score for prediction of CRT response (defined as ≥15% reduction in left ventricular end-systolic volume [LVESV]) and all-cause mortality was compared. RESULTS: Optimal CRT response was seen in seventy patients with nine deaths. All the three scores exhibited modest performance for prediction of CRT response and all-cause mortality with AUC ranging from 0.608 to 0.701. mFI has an additional benefit for prediction of prolonged post-procedure stay and 30-day rehospitalization events. CONCLUSION: mFI, ScREEN and EAARN score can be used reliably for predicting all-cause mortality and response to CRT.

Lead one ratio: A new electrocardiogram marker for cardiac resynchronization therapy response.

BACKGROUND: Wider QRS duration and presence of left bundle branch block (LBBB) predict better cardiac resynchronization therapy (CRT) response. Despite strict patient selection, one-third of patients have a sub-optimal response. We aim to evaluate the impact of lead one ratio (LOR) on CRT response. METHODS: We enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant 12-lead electrocardiogram (ECG) was recorded, and LOR was derived by dividing the maximum positive deflection of QRS complex in ECG lead I by the maximum negative deflection in lead I; cut-off value of 12 was used to divide the cohort into two groups. Patients were followed for 6 months, and outcomes were compared for CRT response, New York Heart Association (NYHA) class improvement, all-cause mortality, and heart failure (HF) hospitalization events. RESULTS: At the end of 6-month follow-up, LOR ≥ 12 was associated with significantly better CRT response (75.76% vs. 51.85% in LOR < 12, P = 0.02), lower mortality per 100 patient-years (9.09 vs. 14.81 in LOR < 12, P = 0.012), and more improvement in HF symptoms (NYHA improvement) (78.79% vs. 55.56% in LOR < 12, P = 0.02). Patients with LOR < 12 had more HF hospitalization events (2.04 vs. 1.81 episodes in LOR ≥ 12, P = 0.029) and less QRS narrowing (∆5.74 ± 2.09 vs. ∆7.10 ± 3.97 ms in LOR ≥ 12, P = 0.01). QRS duration and LBBB morphology were predictors of response in both groups of patients. CONCLUSION: LOR ≥ 12 was associated with better response to CRT, less HF hospitalization, and more relief in HF symptoms. This ratio helps to identify possible sub-optimal response among patients with an indication for CRT.

Different Manifestations of Rare Cases of Unruptured Sinus of Valsalva Aneurysm-Case Series and Literature Review.

Sinus of Valsalva aneurysm (SVA) is rare, and aneurysm of the left sinus of Valsalva is extremely rare cardiovascular disease. Clinical presentation can vary from mostly asymptomatic to catastrophic life-threatening emergency. We report four extremely rare cases of SVA with different manifestations of which one case involved left aortic sinus with large unruptured aneurysm causing severe mitral regurgitation (MR) and severe aortic regurgitation (AR). The second case aneurysm was from right sinus presented with trifascicular block with intermittent complete heart block (CHB). Third was a diagnosed case of unruptured right SVA and while awaiting for surgery he had sudden cardiac death (SCD) at home. Therefore, SVA can present from asymptomatic to life-threatening condition, such as SCD. To the best of our knowledge, there are individual case reports in literature, and this is the first case series of unruptured SVA in literature highlighting the rarity of this disease.

Massive right atrial myxoma presenting as congestive heart failure: an unusual presentation of a rare tumour.

Cardiac myxomas are the most common type of primary cardiac tumour. The most common location of cardiac myxoma is left atrium. Right atrial myxomas are very rare and usually asymptomatic or sometimes present with dyspnoea. Right atrial myxoma presenting as a right-sided heart failure is very rare. We report a very rare case of a 52-year-old man of right atrial myxoma presented unsually as right-sided heart failure.

Dissection flap masquerading as double aortic valve: an acquired complication.

Aortic dissection usually presents as an acute emergency and less commonly presents as chronic dissection. Two-dimensional and transoesophageal echocardiographic features of aortic dissection generally show dissection flap, dilated aorta and aortic regurgitation. We report a very unusual and extremely rare case of a 40-year-old female patient with chronic aortic dissection presenting as functional double aortic valve.

Massive Bleeding from Guidewire Perforation of an External Iliac Artery: Treatment with Hand-made Stent-Graft Placement.

We report life-threatening bleeding from an external iliac artery perforation following guidewire manipulation in a patient with atherosclerotic iliac artery disease. This complication was successfully managed by indigenous hand-made stent-graft made from two peripheral stents in the catheterization laboratory.

Iatrogenic left main coronary artery dissection due to pin-hole balloon rupture: Not to be panicked .

Iatrogenic left main coronary artery (LMCA) dissection is a rare complication and may have devastating consequences if not immediately intervened. The management includes urgent revascularization mostly with percutaneous coronary intervention (PCI) with bail-out stenting and rarely requires coronary artery bypass graft (CABG) surgery. In clinically and hemodynamically stable patients, a conservative approach may be preferred. Here, we present a rare case of iatrogenic retrograde LMCA dissection due to pin-hole rupture of angioplasty balloon that was managed conservatively.

Rapid guiding catheter swapping for management of rupture during percutaneous venoplasty for idiopathic occlusion of superior vena cava.

Treatment for superior vena cava syndrome (SVCS) by percutaneous interventions has become established as a definitive therapy. However, there is a significant risk of rupture during SVC intervention. We describe an uncommon case that developed SVC rupture during percutaneous intervention for idiopathic SVCS. This was managed successfully with pericardiocentesis and rapid implantation of covered stent in SVC by rapid guiding catheter swapping technique. This, however, led to inadvertent obstruction of left innominate vein which was successfully treated by kissing balloon inflation. At 18-month follow-up, he is asymptomatic with a well apposed patent stent-graft in the SVC.

Balloon pulmonary valvotomy--not just a simple balloon dilatation.

Balloon pulmonary valvotomy is the preferred mode of treatment in patients with isolated pulmonary valvar stenosis and has shown good long term results. It is generally considered a safe procedure with few complications. There have been however, case reports of potentially fatal acute severe pulmonary edema occurring after the procedure in some patients. The cause of this complication and its pathophysiology is still not clear. Its occurrence is also infrequent with less than 5 cases reported till now. We report a case of pulmonary valvar stenosis which developed acute severe refractory pulmonary edema immediately after balloon pulmonary valvotomy.

Aortic rupture during aortoplasty in Takayasu arteritis--a rare complication: case report and review of literature.

Balloon angioplasty of the stenosed aorta is usually a relatively simple, yet potentially a catastrophic procedure. Aortic rupture during aortoplasty, though uncommon, carries a high mortality. We report case of a 39-year-old female with aortoarteritis with multiple arterial stenoses whose infra-renal abdominal aorta ruptured during balloon dilatation of the stent deployed in that segment. The site of aortic rupture was temporarily occluded by low-pressure inflation of the same balloon and then was sealed using a stent-graft introduced by contra-lateral femoral arterial access.

Systemic and local levels of fetuin-a in calcified mitral valves of rheumatic heart disease.

BACKGROUND AND AIM OF THE STUDY: Fetuin-A is a circulating glycoprotein that inhibits ectopic calcification. The study aim was first, to assess serum fetuin-A level in patients with calcified rheumatic mitral valve disease (RMVD), and second, to demonstrate the presence of fetuin-A by immunohistochemistry (IHC) in calcified RMVD which, to date, has not been verified in other studies. METHODS: The study group comprised 68 adult patients with isolated RMVD and normal renal function. Of these patients, 34 (27 males, seven females; mean age 33.44 +/- 9.0 years) had severe calcification (Wilkins calcium score 3 or 4) and 34 (25 males, nine females; mean age 30.8 +/- 8.5 years) had mild calcification (Wilkins calcium score 1 or 2). A group of 32 age- and gender-matched healthy subjects (25 males, seven females; mean age 29.5 +/- 4.6 years) served as controls. Baseline serum fetuin-A levels were measured using an enzyme-linked immunosorbent assay (ELISA), while Wilkins calcium scores were assessed using either transthoracic or transesophageal echocardiography. Serum levels of calcium, phosphorus and alkaline phosphatase were assessed in all subjects. Histopathological examinations of ten severely calcific rheumatic mitral valves were made and compared with 10 non-calcified rheumatic mitral valves, all of which had undergone mitral valve replacement. RESULTS: Serum fetuin-A levels were significantly lower in RMVD patients than in controls (108.83 +/- 7.1 versus 114.46 +/- 3.32 ng/ml; p = 0.014). However, there was no significant difference in fetuin-A level between patients with severe (C3/C4) versus mild calcification (C1/C2) (108.84 +/- 7.82 versus 108.82 +/- 6.36 ng/ml; p = NS). No correlation of fetuin-A was seen with serum high-sensitivity C-reactive protein, calcium, phosphorus and alkaline phosphatase, or with Wilkins' calcium score. IHC analyses revealed the presence of fetuin-A in the mesenchymal matrix and calcified area of calcific valves, while minimal to absent fetuin-A deposition was detected in the mesenchymal matrix of non-calcified mitral valves. CONCLUSION: Serum fetuin-A levels were significantly decreased in patients with calcific RMVD. The present study was the first to demonstrate fetuin-A in the calcified mitral valve of rheumatic etiology, and suggests its possible role in the pathophysiology of calcific mitral valve disease. Further studies are required, however, to determine therapeutic implications.

Hepatic vein anchor-wire technique to prevent stent migration during inferior vena cava stenting for Budd-Chiari syndrome.

Inferior vena cava (IVC) stenting in patients suffering from Budd-Chiari syndrome (BCS) is sometimes complicated by stent migration or misplacement. Here, we describe a novel stent anchoring technique to prevent this complication while using balloon-mounted Palmaz stent for angioplasty of short-segment stenosis in the IVC.

Retrieval of impacted broken balloon by balloon inflation in guiding catheter.

Broken catheter fragment in a coronary artery during percutaneous coronary angioplasty is a rare complication. It can result in serious problems as a result of thrombus formation and embolization of broken fragment. We report an unusual complication of a broken balloon catheter during angioplasty, which was successfully retrieved by balloon inflation in guiding catheter technique.

Percutaneous retrograde revascularization of the occluded celiac artery for chronic mesenteric ischemia using intravascular ultrasound guidance.

A 47-year-old male presented with a triad of postprandial abdominal pain, food fear and significant weight loss since 1 year suggestive of chronic mesenteric ischemia. CT angiogram revealed chronic total occlusion of the celiac artery (CA), inferior mesenteric artery and 80-90 % stenosis of the proximal superior mesenteric artery (SMA). After SMA stenting, successful retrograde recanalisation of chronically occluded CA through pancreatico-duodenal arcade using intravascular ultrasound (IVUS) guidance was done when standard tools failed. The role of IVUS in such challenging lesions is described in the following case report.