Valvular heart disease in Antiphospholipid antibody syndrome: Isolated Tricuspid stenosis.

Antiphospholipid antibody syndrome (APLS) is a rare disorder characterized by a hypercoagulable state. Manifestations include arterial or venous thrombosis, recurrent fetal wastage, coronary artery disease, valvular heart disease, dilated cardiomyopathy, pulmonary artery hypertension, and intracardiac thrombus. Most commonly mitral valve is affected followed by aortic and then tricuspid valve. In this report, a rare case of spontaneous aortic thrombosis with tricuspid stenosis uncomplicated by other valve lesions is presented with clinical and echocardiographic studies and computed tomographic images.

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.

Percutaneous Stenting for Unprotected Left Main Chronic Total Occlusion.

PCI of a left main coronary artery chronic total occlusion followed by PCI of the right coronary artery was performed in a patient refusing CABG surgery.

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.

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).

Demographic and angiographic profile in premature cases of acute coronary syndrome: analysis of 820 young patients from South India.

BACKGROUND: Prevalence of acute coronary syndrome in young individuals is increasing progressively. Previous studies have focused on the analysis of risk factors and to some extent coronary angiographic profile in young vs. old patients with acute coronary syndrome, but no study compared the angiographic profile in young patients based on the type of acute coronary syndrome. So, this study was conducted to determine the differences in demographic and coronary angiographic profile of young patients with ST-elevated myocardial infarction (STEMI) vs. those with non-ST-elevated myocardial infarction (NSTEMI) or unstable angina (UA). METHODS: We retrospectively analyzed young patients (age <40 years) with acute coronary syndrome who underwent coronary angiography at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India between April 2010 and March 2011. Coronary risk factor profile and angiographic features were compared between STEMI and NSTEMI/UA patients. RESULTS: Of 8,268 patients who underwent coronary angiography during the study period, 820 (~10%) were ≤40 year age. Of them, 611 exhibited STEMI and 209 exhibited NSTEMI/UA. Angiographic analysis revealed that single-vessel disease was significantly more common in the STEMI group (56.6% vs. 36.6% respectively; P<0.001) whereas triple-vessel disease was significantly more common in the NSTEMI/UA group (3.6% vs. 10.5% respectively; P<0.001). Conversely, left anterior descending coronary artery was more commonly involved in the STEMI group (55.3% vs. 40.2% respectively; P<0.001), whereas left circumflex coronary artery was more commonly involved in the NSTEMI/UA group (11.8 vs. 23.4% respectively; P<0.001). Of note, smoking/tobacco consumption was the most significant coronary risk factor with prevalence as high as 65% in both groups. CONCLUSIONS: In the present study, significant differences were observed in coronary risk factor profile and angiographic features between young patients with STEMI and NSTEMI/UA. Larger studies will be required to establish specific associations between presentation of acute coronary syndromes and angiographic profiles in young patients.

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.

A rare case of left ventricular outflow tract mass.

Thrombus formation in left ventricular outflow tract (LVOT) of a normal heart is a very rare occurrence. A 23-year-old male who presented with syncope, on evaluation found to have obstructing mass in the LVOT. His heart was otherwise normal. His investigations were not contributory except for significant eosinophilia. Due to recurrence of syncope he underwent emergency surgery for extraction of the mass, which on histopathological examination was found to be organizing thrombus. His eosinophil count normalized after the surgery. Tests for hypercoaguable states and investigations for known cause of eosinophilia were normal. There was no recurrence of thrombus or eosinophilia at 6 months after surgery. He was diagnosed to have obstructive LVOT thrombus in a normal heart secondary to transient eosinophilia. Presentation of this interesting case with literature on left ventricular thrombus and eosinophilia is discussed.

A rare case of percutaneous coronary intervention in achondroplasia.

Achondroplastic individuals are associated with increased cardiac risk when compared to the general population. Coronary interventions in patients with achondroplasia have not been studied previously. We report the case of a 32-year-old male smoker with achondroplasia who presented with acute chest pain of 3 hours duration. He was diagnosed with acute inferior and right ventricular myocardial infarction and thrombolyzed with streptokinase. Since the patient continued to have pain and hypotension, he was taken for rescue percutaneous coronary intervention (PCI). Because of short stature and kyphoscoliosis, difficulties were faced in cannulating the coronaries and performing intervention. He had total occlusion of proximal right coronary artery, for which angioplasty with stenting was done. To our knowledge, this is the first case of PCI conducted in an achondroplastic patient.

Accura balloon rupture during percutaneous trans-septal mitral commissurotomy: a rare and potentially fatal complication.

Percutaneous transseptal mitral commissurotomy (PTMC) is the treatment of choice in rheumatic mitral stenosis. The reuse of sterilised PTMC balloon catheters is widely practised to bring down the procedure cost and have proven safety and efficacy. The reused balloons may deform and are prone to rupture causing fatal complications like embolism either of the torn balloon material or air. We report a first case of Accura balloon rupture during PTMC to the best of our knowledge. Fortunately, there was no complication in our patient. Thus, during the balloon preparation it should be examined for any deformity or tear and air should be removed completely to prevent fatal outcome. The repeated use of the hardware should be limited and an informed consent regarding the possible complications of the reused hardware should be taken.

Successful percutaneous removal of broken mitral valvuloplasty coiled tip guidewire.

Complications related to hardware malfunction during balloon mitral valvuloplasty (BMV) are rarely met in catheterization laboratory. However, the consequences can be grave including death. We report an extremely rare complication of fracture of BMV coiled tip guidewire, which was successfully retrieved percutaneously with a relatively simple technique. Finally the procedure was completed without any complication.

Large pericardial effusion :a clinical dilemma!

A 55yr old gentleman known diabetic and hypertensive presented with breathlessness and tingling sensation of both upper and lower limbs with strong family history of similar neurological problems. On extensive evaluation he was found to have amyloidic peripheral neuropathy with large pericardial effusion. Tubercular etiology was confirmed by pericardial fluid PCR and culture. Here the diagnostic dilemma was whether Amloidosis is primary, secondary to Tubercular pericardial effusion or Hereditary Amyloidosis. In the end, how we have arrived at the diagnosis of Hereditary Amyloidosis based upon the strong family history and nerve biopsy is interestingly presented in the following case report.

Pulmonary hypertension due to presence of isolated partial anomalous pulmonary venous connection: A case report.

Anomalous pulmonary venous return is an uncommon congenital malformation which can be broadly categorized into partial or total, of which the former is more common. The anomaly is considered to be partial if some of the pulmonary veins drain into the systemic circulation and total if all the pulmonary veins drain into systemic circulation. Isolated partial anomalous pulmonary venous return (PAPVC) is an uncommon finding and is a very uncommon cause of pulmonary arterial hypertension. Whilst many patients with PAPVC remain asymptomatic, some may present at a later age with symptoms related to left-to-right shunt, pulmonary hypertension and right heart failure. We are presenting an interesting case report of an 18 years old patient who presented with exertional dyspnea and fatigue conforming to NYHA class II symptom status. Trans-esophageal echocardiography revealed isolated obstructive PAPVC as the cause for pulmonary hypertension without other demonstrable left-to-right shunts.

Successful management of Ellis type III left anterior descending artery perforation following percutaneous coronary intervention by a covered stent: Successfully resolved the dramatic complication.

Coronary artery perforation is a rare but catastrophic complication of percutaneous coronary intervention (PCI). Grade III coronary perforation and rupture invariably results in pericardial effusion and tamponade requiring urgent pericardiocentesis. Advances in coronary intervention have increased the opportunity to treat coronary artery perforation. We are reporting a case of 55 years old hypertensive female who presented with effort angina. Coronary angiogram revealed significant stenosis in the left anterior descending coronary artery. Post PCI, she had Ellis type III coronary perforation and pericardial tamponade and cardiogenic shock. The patient was resuscitated, pericardiocentesis done, autologous blood transfusion given and covered stent deployed.

Flail tricuspid valve secondary to blunt chest trauma.

A 78-year-old man admitted with complaints of breathlessness of 1 year and typical chest pain of 2 months duration. He had a blunt chest trauma 7 years back. Transthoracic echocardiography revealed severe tricuspid regurgitation due to a flail anterior leaflet of the tricuspid valve. It also revealed global left ventricular dysfunction. Flail tricuspid valve causing severe regurgitation is usually due to mechanical trauma. Since it is well tolerated for years, the diagnosis may be delayed or missed entirely. Echocardiography has allowed easier diagnosis of this condition resulting in earlier and, hence, more effective treatment.