Left main coronary artery aneurysm occlusion presenting as myocardial infarction with cardiogenic shock: Patient saved by securing left anterior descending artery at cost the of other vessels.

Coronary artery aneurysms and ST-segment elevation myocardial infarction are rare in clinical practice, presenting a management challenge. To the best of our knowledge, this case appears to be the first successful percutaneous treatment of a completely obstructed aneurysmal left main coronary artery.

Reliability of Fractional Flow Reserve in Non-Infarct-Related Arteries in ST-Segment Elevation Myocardial Infarction Patients Undergoing a Pharmaco-Invasive Approach.

Objectives We investigated the reproducibility of fractional flow reserve (FFR) of significant stenoses (≥70% narrowing) in the non-infarct related artery (NIRA) during the pharmaco-invasive percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) within 24 hours of thrombolysis and at a follow up of 2-3 weeks. Background STEMI with multivessel disease has worse outcomes. The benefits of FFR-directed PCI of NIRA at the time of primary PCI are yet controversial. Assessing the hemodynamic severity of the NIRA may help in deciding the management strategy of these lesions, save time, and avoid complications. Methods Thirty-one patients undergoing PCI for STEMI under a pharmaco-invasive approach were prospectively recruited. The FFR measurements in 34 stenoses (≥70% diameter stenosis) were obtained immediately after PCI of the culprit stenosis and were repeated at a mean follow-up of 17.6 ± 3.55 (14-21) days. In addition, time to thrombolysis, time from symptom onset to PCI, left ventricular ejection fraction (LVEF), quantitative coronary angiographic measurements of the non-culprit stenoses, and thrombolysis in myocardial infarction (TIMI) flow were recorded. Results There was a significant change in FFR values at follow-up as compared to baseline (0.78 ± 0.08 (0.68-0.93) to 0.77 ± 0.08 (0.67-0.93)) (p = 0.014). In four of the lesions, the FFR values differed by >0.05 at follow-up. The follow-up FFR values led to a change in the management strategy in 5 out of 31 patients (15%) of the lesions. The TIMI flow, percentage diameter stenosis, minimum lumen diameter, and LVEF did not change. There were no predictors of this change in FFR values. Conclusions During the acute phase of STEMI, the severity of non-culprit coronary artery stenoses can not be reliably assessed by FFR. The prolonged jeopardized state of myocardium in pharmaco-invasive PCI as compared to primary PCI seems to be responsible.

Can digital health democratize health care?

Much has been said about the potential of digital health technologies for democratizing health care. But how exactly is democratization with digital health technologies conceptualized and what does it involve? We investigate debates on the democratization of health care with digital health and identify that democratization is being envisioned as a matter of access to health information, health care, and patient empowerment. However, taking a closer look at the growing pool of empirical data on digital health, we argue that these technologies come short of materializing these goals, given the unequal health outcomes they facilitate. Building on this evidence, we argue that not only debates on democratization need to be connected to concerns of social determinants of health but also debates on the impact of digital health need to go far beyond democratization and engage with concerns of health justice.

Optical Coherence Tomography Findings in Patients Presenting With In-Stent Restenosis: A Prospective Observational Study of Patterns of Neointimal Hyperplasia and Associated Risk Factors.

Introduction Morphological features of neointimal tissue play a pivotal role in the pathophysiology of in-stent restenosis (ISR) after percutaneous coronary intervention (PCI). This study was designed to qualitatively and quantitatively assess neointimal characteristics of lesions using optical coherence tomography (OCT) in patients presenting with ISR.  Methods This was a single-center, prospective, observational study performed at a tertiary-care center in India. Patients diagnosed with stable angina and acute coronary syndrome with post-procedural angiographically documented restenosis (>50%) were included. Results A total of 34 patients with ISR were studied. Neointimal hyperplasia was classified as (i) homogenous group (n = 18) and (ii) non-homogenous group (n = 16). Fourteen (77.8%) diabetics belonged to the homogenous group. Predominant plaque characteristics such as neoatherosclerosis, cholesterol crystals, and calcium were documented in 14 (77.8%), 12 (66.7%), and 11 (61.1%) patients in the homogenous group and 10 (62.5%), 10 (62.5%), and 9 (56.2%) patients in the non-homogenous group, respectively. Unexpanded stent struts were identified in 11 (61.1%) and 11 (68.8%) patients in the homogenous and non-homogenous groups, respectively. Mean strut thickness was 93.73 ± 31.03 µm and 83.54 ± 18.0 µm, ISR was 72.50 ± 15.93% and 65.37 ± 21.69%, the neointimal thickness was 588.06 ± 167.82 µm and 666.25 ± 218.05 µm, and neointimal hyperplasia was 54.54 ± 11.23% and 59.26 ± 8.86% in the homogenous and non-homogenous groups, respectively. Conclusion Neoatherosclerosis and stent underexpansion were predominantly observed in our study and only diabetes was found to be significantly associated with homogenous neointimal hyperplasia.

Rotablation-Assisted Staged Culottes Bifurcation Stenting of Left Main Chronic Total Occlusion.

Left main coronary artery chronic total occlusion is an unusual finding discovered on coronary angiography. Historically, coronary artery bypass graft has been the preferred treatment. However, recent studies have revealed the role of left main percutaneous coronary intervention in selected patients. This is a case of staged left main coronary artery chronic total occlusion percutaneous coronary intervention. (Level of Difficulty: Advanced.).

Feasibility and efficacy of delayed pharmacoinvasive therapy for ST-elevation myocardial infarction.

BACKGROUND: ST-elevation myocardial infarction (STEMI) refers to a clinical syndrome that features symptoms of myocardial ischemia with consequent ST-elevation on electrocardiography and an associated rise in cardiac biomarkers. Rapid restoration of brisk flow in the coronary vasculature is critical in reducing mortality and morbidity. In patients with STEMI who could not receive primary percutaneous coronary intervention (PCI) on time, pharmacoinvasive strategy (thrombolysis followed by timely PCI within 3-24 h of its initiation) is an effective option. AIM: To analyze the role of delayed pharmacoinvasive strategy in the window period of 24-72 h after thrombolysis. METHODS: This was a physician-initiated, single-center prospective registry between January 2017 and July 2017 which enrolled 337 acute STEMI patients with partially occluded coronary arteries. Patients received routine pharmacoinvasive therapy (PCI within 3-24 h of thrombolysis) in one group and delayed pharmacoinvasive therapy (PCI within 24-72 h of thrombolysis) in another group. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) within 30 d of the procedure. The secondary endpoints included major bleeding as defined by Bleeding Academic Research Consortium classification, angina, and dyspnea within 30 d. RESULTS: The mean age in the two groups was comparable (55.1 ± 10.1 years vs 54.2 ± 10.5 years, P = 0.426). Diabetes was present among 20.2% and 22.1% of patients in the routine and delayed groups, respectively. Smoking rate was 54.6% and 55.8% in the routine and delayed groups, respectively. Thrombolysis was initiated within 6 h of onset of symptoms in both groups (P = 0.125). The mean time from thrombolysis to PCI in the routine and delayed groups was 16.9 ± 5.3 h and 44.1 ± 14.7 h, respectively. No significant difference was found for the occurrence of measured clinical outcomes in the two groups within 30 d (8.7% vs 12.9%, P = 0.152). Univariate analysis of demographic characteristics and risk factors for patients who reported MACCE in the two groups did not demonstrate any significant correlation. Secondary endpoints such as angina, dyspnea, and major bleeding were non-significantly different between the two groups. CONCLUSION: Delayed PCI pharmacoinvasive strategy in a critical diseased but not completely occluded artery beyond 24 h in patients who have been timely thrombolyzed seems a reasonable strategy.

Correlation of lipoprotein (a) levels and plaque morphology in very young acute coronary syndrome patients using optical coherence tomography.

INTRODUCTION: Levels of lipoprotein (LP) (a) are useful marker for risk stratification of cardiovascular disease. This genetic biomarker is suggestive of patient predisposition to acute coronary event. The present study was to study correlation of LP(a) levels and plaque morphology in very young patients (<35 years) with acute coronary syndrome (ACS). METHODS: A prospective, single-center, observational study consisting of very young patients with ACS and fit for optical coherence tomography (OCT) guided invasive coronary angiography was conducted at tertiary-care centre. LP(a) levels were compared between healthy controls and very young ACS patients. Correlation of LP(a) levels and plaque characteristics in very young ACS patients was done using OCT imaging. RESULTS: Out of enrolled 80 subjects, 40 were very young ACS and 40 were matched healthy controls. In very young patients, plaque rupture and erosion were mechanism of ACS in 67.5% and 32.5% patients, respectively. Mean levels of LP(a) were 28.10 ± 13.96 nmol/l in healthy controls and 47.19 ± 29.85 nmol/l in very young patients with ACS (p = 0.022). Among very young ACS patients, patients with LP(a) levels<75 nmol/l and ≥75 nmol/l had mean thin cap fibroatheroma thickness of 117.08 ± 52.542 µm and 95.00 ± 36.286 µm, respectively (p = 0.2355). CONCLUSION: Higher levels of LP(a) were seen in younger patients with ACS compared with matched healthy individuals. Plaque rupture was the commonest mechanism of ACS in very young ACS patients. Patients with high LP(a) levels had lesser thickness of fibrous cap in OCT imaging compared with low levels of LP(a).

Combined Thrombophilia in a Young Male Presenting as Life Threatening Pulmonary Embolism.

Combined hereditary thrombophilia is an uncommon entity associated with higher risk of early onset thrombosis. We report a case of 39-year-old male with combined deficiency of natural anticoagulants (protein C, S and anti thrombin) along with hyper homocystenemia and factor V Leiden mutation, presenting with life threatening bilateral pulmonary embolism. The clinical implications of combined thrombophilia are also discussed.

Wuchereria bancrofti: Unusual Presentation as Pancytopenia.

Wuchereria bancrofti is an endemic filarial nematode spread by a mosquito vector. The clinical manifestations vary from asymptomatic microfilaremeia to lymhoedema. We report two cases of microfilaria of Wuchereria bancrofti in bone marrow presenting as peripheral pancytopenia. The patient did not have any classical features of lymphoedema or elephantiasis. The diagnostic demonstration of microfilaria with unusual presentations has been done in cytology specimens from various sites. Microfilaria infection in association with peripheral blood pancytopenia has been rarely reported. An aetiopathological co-relation of these haematological manifestations of microfilaria needs further investigation.

Eltrombopag therapy in newly diagnosed steroid non-responsive ITP patients.

Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterised by isolated thrombocytopenia (peripheral blood platelet count <100 × 10(9)/L) in the absence of other causes or disorders that may be associated with thrombocytopenia. The upfront treatment in newly diagnosed ITP patients is steroids; however, about one-third patients do not respond, and require other treatment, including IVIg, anti-D, or splenectomy. Previous studies have shown decreased platelet production in some ITP patients, aside from the evidence of enhanced platelet destruction. Thrombopoietin receptor agonists (TPO-RA), such as eltrombopag have been shown to provide good response in steroid non-responsive chronic ITP patients. We have studied response to eltrombopag in 25 newly diagnosed steroid non-responsive ITP patients; 80 % patients showed response at the end of 1 month, and 76 % sustained response at the end of 3 months. The platelet count rose from a mean value of 17.5 ± 3.6-152.5 ± 107.9 × 10(9)/L at the end of 1 month. Our results suggest a possible role of eltrombopag in newly diagnosed steroid non-responsive ITP patients. However, our study is limited in that it is a single-centre study, with a small sample size, and lacks a long-term safety profile. Our findings highlight the potential value of a larger prospective study on the upfront use of TPO-RA in patients of ITP.

Megakaryocyte morphology and its impact in predicting response to steroid in immune thrombocytopenia.

Pathogenetic mechanisms of primary immune thrombocytopenia (ITP) include antibody-mediated destruction of platelets; cell-mediated destruction and suppressed thrombopoiesis. Various morphological changes in megakaryocytes are reported in ITP patients, but never these were correlated with the response to various forms of therapy. In the present study, we intended to find out the impact of megakaryocytic abnormalities on the response to steroid, the first line of treatment. The mean age of patients (n = 33) was 28.9 ± 7.6 years. Male/female ratio was 1/1.8. The mean platelet count at presentation was 5.6 ± 4.4 × 10(9)/L. 63.6% (21/33) patients showed response to steroid. The non-responders were given 50 mg/d TPO-RA (eltrombopag) in addition to steroid, to which, 83.3% (10/12) responded. Two-third patients (66.7%, n = 22) had normal megakaryocyte morphology. Those with abnormal morphology commonly had hypolobated forms and micromegakaryocytes. Ninety-five percent of steroid responders had normal megakaryocytic morphology. Among steroid non-responders, most patients (n = 10, 83.3%) had abnormal megakaryocytic morphology. 80% steroid non-responders with abnormal morphology responded to the addition of eltrombopag. The findings suggest that the abnormal megakaryocyte morphology can be an evidence of dominant pathogenetic mechanism and thereby can help us in individualizing the treatment of ITP.

Visceral leishmaniasis with HIV co-infection and cervical lymphadenopathy.

Visceral leishmaniasis (VL) is prevalent worldwide. In the past there has been steep rise in the incidence of VL in southern Europe and Africa. Factors attributed for this are economic development, a shift of the reservoir of Leishmania, immunodeficiency due to HIV infection and intravenous drug abuse. The co-infection of VL and HIV is common in southern European-African countries and is proposed that it should be included as an AIDS-defining illness. VL is not only considered to be an opportunistic infection in HIV-infected individuals but it may also reactivate latent infection. This case is worth reporting as it highlights increasing incidence of VL-HIV co-infection and its sparse literature from India, changing ecology and possible evolving epidemic in the Indian subcontinent. Additionally an atypical presentation such as lymphadenopathy in VL should arouse suspicion of HIV co-infection and vice versa.