Ruptured Sinus of Valsalva: An Unusual Cause of Heart Failure.

A 35-year-old male patient presented with heart failure. On examination, there was a continuous murmur over the left sternum. Transthoracic echocardiography revealed a ruptured aneurysm arising from the noncoronary sinus of Valsalva and draining into the right atrium.

A rare case of stenting of spontaneous dissection of Shepherd's Crook right coronary artery.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) and sudden death. It usually occurs in young women during the peripartum period; however, it had also been reported in older aged males having risk factors for atherosclerotic coronary artery disease. CASE REPORT: This case describes a 69-year-old male patient who presented with manifestations of ACS due to a spontaneous dissection of the Shepherd's Crook right coronary artery (RCA), which was successfully managed with percutaneous coronary intervention (PCI) and stenting. At the 6th month follow-up, the patient remained chest pain free. CONCLUSION: Patients with SCAD in the presence of ongoing ischemia can be treated with PCI and stenting.

Early clinical outcomes of primary percutaneous coronary intervention in bharatpur, Nepal.

BACKGROUND: Primary percutaneous coronary intervention represents one of the cornerstone management modalities for patients with acute ST-elevation myocardial infarction and has undergone tremendous growth over the past two decades. This study was aimed to determine the early clinical outcomes of primary percutaneous coronary interventions in a tertiary-level teaching hospital without onsite cardiac surgery backup. METHODS: This was a prospective descriptive study which included all consecutive patients who were admitted for primary percutaneous coronary interventions between March 2011 and January 2013 at the College of Medical Sciences and Teaching Hospital, Bharatpur, Nepal. Total 68 patients underwent primary percutaneous coronary interventions as a mode of revascularization. The primary end point of the study was to identify in-hospital as well as 30-day clinical outcomes of primary percutaneous coronary interventions. RESULTS: The mean age was 56.31 ± 11.47 years, with age range of 32 years to 91 years. Of the 68 primary percutaneous coronary interventions performed, 15 (22.05%) were carried out in women and 10 (14.70%) in patients over 75 years of age. Primary percutaneous coronary intervention for anterior wall myocardial infarction was more common than for non-anterior wall myocardial infarction (55.88% vs. 44.12%). Proximal artery stenting was performed in 38.50% and the non proximal artery stenting in 61.50%. The outcomes were mortality (5.88%), cardiogenic shock (5.88%), contrast-induced nephropathy requiring dialysis (2.94%), arrhythmias requiring treatment (4.41%), early stent thrombosis (2.94%) and minor complications (14.70%). CONCLUSION: Primary percutaneous coronary intervention improves the early clinical outcomes in patient with acute ST-elevation myocardial infarction. Despite having no onsite cardiac surgery backup, primary percutaneous coronary intervention was feasible with acceptable complications in a tertiary-care teaching hospital.

Percutaneous coronary intervention of an obstructive left anterior descending artery with anomalous origin of right coronary artery.

Coronary artery anomalies are a rare type of congenital anomalies with an incidence of 1.3% during routine cardiac catheterization. Anomalous origin of the coronary arteries is considered an incidental finding without clinical significance. This case describes a patient in whom evaluation of chest pain revealed an obstructive left anterior descending artery as well as an anomalous right coronary artery arising from the left coronary sinus. The patient underwent successful percutaneous coronary intervention of the left anterior descending artery and was discharged home free of angina 3 days later.

Percutaneous coronary intervention without onsite cardiac surgery backup.

INTRODUCTION: Mechanical revascularization by percutaneous coronary interventions has now become an established and preferable method of revascularization in patients with acute coronary syndromes. The aim of the study was to identify the clinical indications for percutaneous coronary interventions and in-hospital outcomes of percutaneous coronary interventions in a tertiary-level hospital without onsite cardiac surgery backup. METHODS: This was a prospective descriptive study. All consecutive patients who were admitted for percutaneous coronary interventions, including both primary as well as elective percutaneous coronary interventions, between March 2011 and December 2012 were included in the study. RESULTS: Total 101 percutaneous coronary interventions were performed. The mean age was 58.9 ± 12.3 years. The most frequent indication was ST-elevation myocardial infarction 72 (71.3%). Proximal artery stenting were performed in 39 (38.5%) and the non proximal artery stenting in 62 (61.5%). The outcomes were mortality 5 (4.9%), periprocedural myocardial infarction 2 (1.9%), cardiogenic shock 6 (5.9%), contrast induced nephropathy requiring dialysis in 3 (2.9%), minor complications which were managed conservatively in 13 (12.9%). CONCLUSIONS: Percutaneous coronary intervention was feasible with acceptable complications in a tertiary-level hospital without onsite cardiac surgery backup. ST-elevation myocardial infarction was the major indication and cardiogenic shock was the major complication observed, and non proximal artery stenting was more common than the proximal artery stenting.

Anomalous origin of the coronary arteries: an account of six cases.

Anomalous origin of coronary arteries is a rare type of congenital anomalies with a low incidence. It is considered an incidental finding without clinical significance, however, these abnormalities may be responsible for angina pectoris, heart failure, arrhythmias and increased risk of sudden death. In this paper, six cases that were diagnosed with anomalous origin of coronary arteries confirmed by coronary angiography has been described and also briefly reviewed the literature concerning current views and therapy of this abnormality.

Unruptured left ventricular pseudoaneurysm following inferior wall myocardial infarction.

Left ventricular (LV) pseudoaneurysm is a rare but potentially lethal complication of acute myocardial infarction (MI). We report a very rare case of a 60 year-old woman with a ruptured myocardial wall, and a non-ruptured LV pseudoaneurysm. The patient presented with acutely worsening shortness of breath and exertional dyspnea of one month's duration, and palpitation. She had an inferior wall MI nine months previously. Coronary angiography showed severe stenosis at right coronary artery. Echocardiography, LV angiography, and computed tomography angiography revealed a large pseudoaneurysm postero-inferior to the LV. Surgical resection of the pseudoaneurysm was performed and repair of the ruptured LV wall done, with good results.

Neovascularization in left atrial myxoma.

ABSTRACT: We report a case with a left atrial mass who underwent coronary angiography to rule out coronary artery disease. Coronary angiography revealed an anomalous tortuous vascular structure originating from the left circumflex coronary artery to the left atrial tumor suggestive of neovascularization. Preoperative coronary angiography is useful for coronary artery evaluation and also provides additional information regarding the feeding vessel supplying the mass.

Clinical profile of patients hospitalized with heart failure in Bharatpur, Nepal.

INTRODUCTION: Heart failure (HF) is a common cardiovascular condition whose incidence and prevalence are increasing. Being a common reason for urgent hospital admission, it is a major cause of morbidity and mortality for the patients. In the developed countries coronary artery disease remains the leading cause of HF, whereas, in the underdeveloped countries, rheumatic heart disease leading to valvular lesion still remains the commonest causes of HF admission.The current study was designed to evaluate the clinical profile and medications prescribed reflecting the extent to which evidence based medicine is being practiced at our community. METHODS: Clinical profile and prescribed medications of patients with diagnosis of HF who were admitted in the cardiology department of College of Medical Sciences & Teaching Hospital (CMS-TH), Bharatpur, Nepal, April 2010 to May 2012, were analyzed. A total of 255 patients presented with HF during the studied period were included. RESULTS: Coronary artery disease, rheumatic heart disease, dilated cardiomyopathy, hypertensive heart failure, cor-pulmonale, and congenital heart disease leading to HF were found in 93 (36.5%), 65 (25.5%), 37 (14.5%), 22 (8.6%), 31 (12.2%),and 7 (2.7%) patients respectively. The commonest presenting symptom was shortness of breath (81%) and the commonest sign was bilateral basal crepitations (68%). From all patients, 89%, 64%, 51%, 16%, 48%, and 32% received loop diuretics, angiotensin-converting enzyme inhibitor, digoxin, angiotensin receptor blocker, spironolactone, and beta-blocking agents respectively. CONCLUSION: Coronary artery disease leading to HF was the commonest cause of HF admission in our centre. Despite current guidelines suggesting the use of beta-blocking agent in patients with HF, only 32% of our patients received this class of medications. Thus, many patients were not being managed fully in accordance with the evidence-based guidelines.

Cardiogenic shock complicating acute myocardial infarction--a review.

Cardiogenic shock is characterized by inadequate tissue perfusion due to cardiac dysfunction and is the leading cause of death in patients hospitalized with acute myocardial infarction. Mortality from cardiogenic shock still remains high. The development of cardiogenic shock is rarely unexpected; most patients who develop cardiogenic shock do so within 48 hrs of admission, with only 10% shocked on arrival. Mortality rate is exceedingly high and reaches 70-80% in those treated conservatively. Early revascularization is the cornerstone treatment of acute myocardial infarction complicated by cardiogenic shock. According to the guidelines, revascularization is effective up to 36 hours after the onset of cardiogenic shock and performed within 18 hours after the diagnosis of cardiogenic shock. Primary percutaneous coronary intervention is the most efficient therapy to restore coronary flow in the infarct-related artery. However, invasive strategy in a developing country like ours is not only costly but also technically demanding. We present a case of acute myocardial infarction complicated with cardiogenic shock that underwent primary percutaneous coronary intervention and also review the incidence, pathophysiology, management and outcome of cardiogenic shock complicating acute myocardial infarction.

Bradycardia and severe hypotension caused by wild honey poisoning.

Wild honey is taken as an alternative medicine for the treatment of gastrointestinal diseases as well as for coronary artery disease. However, wild honey made from the nectar of some species of rhododendron may be poisonous. The cause of the poisoning is the toxin grayanotoxin. Grayanotoxin is a naturally occurring sodium channel toxin that causes life-threatening bradycardia, hypotension, and altered mental status. Complete heart blocks may occur in some patients. We present an interesting case of bradycardia and hypotension due to wild honey ingestion. The symptoms, mechanism, and management of wild honey poisoning are discussed.

Primary Percutaneous Coronary Intervention (PPCI) in acute myocardial infarction complicated with cardiogenic shock in a newly emerging cardiac center in Nepal.

BACKGROUND: Acute myocardial infarction (AMI) is complicated by cardiogenic shock in 7~10% of patients. Mortality rate is exceedingly high and reaches 70-80% in those treated conservatively. Large thrombolytic trials demonstrate 60% mortality with most effective thrombolytic agent. METHODS: In between September 2005 to August 2008 total PCI in Shahid Gangalal National Heart Center (SGNHC) in Nepal was 452. Among them primary PCI (PPCI) in AMI with cardiogenic shock was done in only 16 patients (3.5%). RESULTS: This study showed in-hospital mortality of 50% (n = 8). Of 50% (n = 8) alive patients with cardiogenic shock who underwent PPCI, 6 patients are in routine follow-up over 12 months and 2 were doing well in subsequent 6 months but not in follow up after that. CONCLUSION: Primary PCI in AMI complicated by cardiogenic shock has lower mortality and improved outcome. High cost, high in-hospital mortality and lack of trained personnel are major limitations.

Potential role of adipocytokine leptin in acute coronary syndrome.

By activating immune cells or a direct action on the vascular wall, leptin may affect the initiation and progression of atherosclerosis. We investigated whether plasma leptin concentration is associated with coronary artery disease, with particular focus on the relationship between plasma leptin and the development of an acute coronary syndrome. Plasma leptin, interleukin-6 and high-sensitivity C-reactive protein were measured in 34 patients with acute coronary syndrome and 21 with stable angina. Their results were compared with those of 21 normal controls. Plasma leptin levels were significantly higher in the acute coronary syndrome group (13.36 +/- 5.02 ng.mL(-1)) compared to the stable angina group (8.97 +/- 4.06 ng.mL(-1)) or normal controls (5.14 +/- 2.75 ng.mL(-1)). Interleukin-6 and high-sensitivity C-reactive protein were also higher in the acute coronary syndrome group, and leptin correlated positively with interleukin-6 and high-sensitivity C-reactive protein. These findings suggest that plasma leptin levels may be a useful marker of systemic inflammation, and measurement of plasma leptin may be helpful in assessing the risk of developing coronary heart disease.

Association of plasma leptin levels and complexity of the culprit lesion in patients with unstable angina.

BACKGROUND: Angiographically visible complex lesions which are associated with plaque vulnerability have been shown to correlate strongly with clinical severity of unstable angina (UA). By activating different immune/inflammatory cells or directly acting on the vessel wall leptin has been shown to play a potential role in the development of acute coronary syndrome. However, the relationship between leptin and simple or complex lesion morphology in UA has not been investigated. Therefore, we designed this study to determine the association between plasma leptin level and simple or complex lesions in patients with UA and to see any correlation between leptin and other inflammatory markers in these patients. METHODS: Plasma concentrations of leptin, interleukin (IL)-6, IL-10 and high-sensitivity C-Reactive Protein (hsCRP) were analyzed in 47 patients with UA. These patients were also angiographically studied and divided into two groups: simple lesion (n=18) and complex lesion (n=29) based on the coronary plaque morphology. We further compared them with 20 control subjects having no evidence of coronary artery diseases. RESULTS: Plasma leptin concentrations were higher in patients having complex lesions compared to those having simple lesions as well as normal controls. Similarly IL-6 and hsCRP were also higher in complex lesion group compared to simple lesion group and controls, and leptin was positively correlated with IL-6 and hsCRP. Concentrations of IL-10 were lower in simple and complex lesion groups compared to the controls and leptin was negatively correlated with IL-10, but no significant difference between simple and complex lesions was found. Furthermore, leptin was found to be an independent predictor for the complex lesion morphology in UA patients. CONCLUSION: These findings suggested that angiographically visible complex lesions are associated with increased concentrations of leptin, and thus leptin can be a useful biomarker for risk stratification in UA.

Effects of simvastatin on NF-kappaB-DNA binding activity and monocyte chemoattractant protein-1 expression in a rabbit model of atherosclerosis.

To observe the effects of simvastatin on nuclear factor kappaB (NF-kappaB)-DNA binding activity and on the expression of monocyte chemoattractant protein-1 (MCP-1) in atherosclerotic plaque in rabbits and to explore the anti-atherosclerotic properties beyond its lipid-lowering effects. Thirty-six New Zealand male rabbits were randomly divided into low-cholesterol group (LC), high-cholesterol group (HC), high-cholesterol+simvastatin group (HC+S) and then were fed for 12 weeks. At the end of the experiment, standard enzymatic assays, electrophoretic mobility shiftassay (EMSA), immunohistochemical staining, and morphometry were performed to observe serum lipids, NF-kappaB-DNA binding activity, MCP-1 protein expression, intima thickness and plaque area of aorta respectively in all three groups. Our results showed that the serum lipids, NF-kappaB-DNA binding activity, expression of MCP-1 protein, intima thickness, and plaque area of aorta in the LC and HC+S groups were significantly lower than those in the HC group (P<0.05). There was no significant difference in the serum lipids between the LC and HC+S groups (P>0.05), but the NF-kappaB-DNA binding activity, the expression of MCP-1 protein and the intima thickness and plaque area of aorta in the HC+S group were significantly decreased as compared to the LC group (P<0.05). This study demonstrated that simvastatin could decrease atherosclerosis by inhibiting the NF-kappaB-DNA binding activity and by reducing the expression of MCP-1 protein.

Role of leptin in atherogenesis.

The pathogenesis of atherosclerosis involves multiple cellular events, including endothelial cell dysfunction, inflammation, proliferation of vascular smooth muscle cells and matrix alteration that is subsequently characterized by hardening, thickening, loss of elasticity and, finally, a reduction in the vessel's lumen. Leptin, a peptide hormone, is produced by adipocytes, and the majority of obese individuals have high plasma leptin concentrations. Leptin regulates food intake as well as metabolic function. Originally thought to be a satiety factor, leptin is a pleiotropic molecule. In addition to its metabolic effects, leptin regulates the production of several pro- and anti-inflammatory cytokines by activating immune cells. It is associated with increased plasma C-reactive protein concentrations, vascular proliferation, calcification and decreased arterial distensibility. Leptin also increases oxidative stress. Moreover, leptin contributes to increases in blood pressure, and thus, probably plays an important role in the initiation and progression of atherosclerosis. 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) lower lipid concentrations and also decrease endothelial apoptosis, inhibit smooth muscle cell proliferation, and lower concentrations of C-reactive protein and proinflammatory cytokines; moreover, it is now known that statins can inhibit leptin release by adipocytes. Therefore, statins have been shown to be beneficial in atherosclerosis. The present review mainly focuses on the various evidence that suggest a potential atherogenic mechanism of leptin, and also briefly addresses the beneficial role of statins in atherosclerosis.