Improved Diagnosis through Diastolic Hyperemia-Free Ratio (DFR) over Fractional Flow Reserve (FFR) in Intermediate Coronary Lesions.

Objectives: To compare the fractional flow reserve (FFR) and diastolic hyperemia-free ratio (DFR) measurements in a population with intermediate coronary artery stenosis and improve the diagnosis. Background: Visual assessment of coronary artery stenosis severity, particularly in intermediate lesions, is prone to errors in decision-making. FFR provides a reliable assessment of functional severity in these cases but requires hyperemia induction by adenosine, which has side effects and increased cost. DFR is a novel hyperemia-independent index, which could be used as an alternative to adenosine-based hyperemia induction. Methods and Results: Between September 2019 to March 2020, 25 patients with 38 intermediate coronary stenotic lesions were included in the study. All patients underwent assessment of whole cycle Pd/Pa (ratio of distal coronary pressure to proximal aortic pressure), DFR and FFR. Mean whole cycle Pd/Pa, DFR and FFR were 0.93±0.06, 0.88±0.09, and 0.85±0.08, respectively. A significant positive correlation between DFR and FFR [r = 0.74; p<0.001] was observed. Receiver operating characteristic analysis showed an area under the curve of 0.90. DFR-only strategy with a treatment cut-off of ≤0.89 showed a diagnostic agreement with the FFR-only strategy in 74% of lesions, with a sensitivity of 54%, specificity of 82%, a positive predictive value of 60%, and a negative predictive value of 79%. Conclusions: Real-time DFR measurements show a clinically reliable correlation with FFR. Hence, using DFR is likely to avoid adenosine administration as well as reduce the cost and procedural time. Further studies with a larger sample size would be ideal to evaluate specific cut-off values and endpoints.

Left ventricular apical mass after myocardial infarction-not always a thrombus: a diagnostic dilemma.

Myxomas arising from the left ventricle (LV) are extremely rare and can be easily mistaken for a thrombus. We report a case of a 35-year-old man who presented with an acute cerebrovascular accident, having had a prior history of an anterior wall myocardial infarction 2 years back with an echocardiographic evaluation showing mild LV systolic dysfunction. His present prothrombotic workup revealed hyperhomocystinaemia and elevated levels of factor VIII. Present echocardiography revealed a mass arising from a scarred LV wall. Considering the possibility of a thrombus, he was initially started on parenteral anticoagulation. Unfortunately, consequent echocardiogram evaluation showed no reduction in size of the LV mass hence surgical removal was done. Histopathological evaluation unveiled the mass to be a myxoma.

A Journey Across Oceans With a Heavy Heart: Rare Presentation of a Pediatric Malignancy.

Myeloid sarcoma, due to extramedullary deposition of myeloblasts, is one of the rare presentations in acute myeloid leukemia. We present an extremely rare case of a 5-year-old boy with cardiac myeloid sarcoma. Noninvasive mode of diagnosis, timely initiation of chemotherapy and meticulous supportive care are the keys to successful outcome. (Level of Difficulty: Intermediate.).

Clinical profile and management of patients with acute pulmonary thromboembolism - a single centre, large observational study from India.

Acute pulmonary thromboembolism is associated with high mortality, similar to that of myocardial infarction and stroke. We studied the clinical presentation and management of pulmonary thromboembolism in the Indian population. An analysis of 140 patients who presented with acute pulmonary thromboembolism at a large volume center in India from June 2015 through December 2018 was performed. The mean age of our study population was 50 years with 59% being male. Comorbidities including deep vein thrombosis, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease were present in 52.9%, 40%, 35.7% and 7.14% of patients, respectively. Out of 140 patients, 40 (28.6%) patients had massive pulmonary thromboembolism, 36 (25.7%) sub-massive pulmonary thromboembolism, and 64 (45.7%) had low-risk pulmonary thromboembolism. Overall, in-hospital mortality was 25.7%. Multivariate regression analysis found chronic kidney disease and pulmonary thromboembolism severity to be the only independent risk factors. Thrombolysis was performed in 62.5% of patients with a massive pulmonary thromboembolism and 63.9% of patients with a sub-massive pulmonary thromboembolism. In the massive pulmonary thromboembolism group, patients receiving thrombolytic therapy had lower mortality compared with patients who did not receive therapy (p=0.022), whereas this difference was not observed in patients in the sub-massive pulmonary thromboembolism group. We conclude that patients with acute pulmonary thromboembolism in India presented more than a decade earlier than our western counterparts, and it was associated with poor clinical outcomes. Thrombolysis was associated with significantly reduced in-hospital mortality in patients with massive pulmonary thromboembolism.

A study on carotid artery intima-media thickness and metabolic risk factors in overweight and obese Indian children.

INTRODUCTION: Carotid intima-media thickness (CIMT) serves as an early marker of atherosclerosis. Data on obesity-related risk factors and their association with carotid intima-media thickness among overweight and obese children are lacking. OBJECTIVES: To compare CIMT of overweight and obese children with CIMT of normal BMI children. To compare various anthropometric and metabolic risk factors associated with increased CIMT among overweight and obese children. METHODS: A descriptive study in a paediatric department of a tertiary care hospital including 50 age-matched normal BMI children and 50 overweight and obese children. Anthropometric data, blood pressure, CIMT (by B-mode ultrasonography), fasting blood sugar, fasting Insulin, fasting lipid profile, TSH, and FT4 were collected. HOMA-IR and fasting glucose-insulin ratio (FGIR) were calculated for insulin resistance. Cutoff for high CIMT was derived using ROC curve analysis. RESULTS: Overweight and obese children had higher mean CIMT than normal BMI children (0.5 ± 0.1 mm vs 0.34 ± 0.05 mm, respectively, P < 0.001). ROC analysis revealed 0.45 mm as the cutoff for high CIMT. Among overweight and obese children, 31 children (62%) had high CIMT. Among metabolic risk factors for increased CIMT, only FGIR was observed to be significant. Compared to overweight and obese children with normal CIMT, those with higher CIMT had low FGIR value (5.2 ± 2.2 mm vs 6.9 ± 2.6 mm, respectively, P < 0.05). CONCLUSION: Overweight and obese children had significantly higher CIMT than controls. Even among overweight and obese children, those with increased CIMT had low FGIR (implying insulin resistance) compared to those with normal CIMT.

Normal reference ranges for the left ventricular mass and left ventricular mass index in preterm infants.

OBJECTIVE: The objective of this study is to establish normal reference ranges for the left ventricular mass (LVM) and LVM index (LVMI) in preterm infants according to the body surface area (BSA) and assess their correlation with body weight and gestational age. SUBJECTS AND METHODS: In a prospective study, 268 preterm babies who fulfilled the criteria for inclusion were examined. Echocardiograms were performed to measure the LVM and LVMI on 0-6 day (s) of life and at weekly intervals until the babies reached 36 weeks. The preterm infants were divided into six groups according to their BSA: 0.07-0.08 m2, 0.09-0.10 m2, 0.11-0.12 m2, 0.13-0.14 m2, 0.15-0.16 m2, and 0.17-0.19 m2. RESULTS: The mean gestational age was 29.8 (±2.38 standard deviation [SD]) weeks, ranging from 24 to 35 weeks. The mean body weight was 1479 (±413 SD) g, ranging from 588 to 3380 g, and the mean BSA was 0.13 m2, ranging from 0.07 to 0.19 m2. The LVM correlated well with the gestational age, body weight, and BSA. The LVMI correlated well with body weight and BSA. Reference ranges with the mean ± SD, range, and interquartile range were calculated for the LVM and LVMI according to the BSA. A significant gradual increase was observed in a LVM with increasing BSA. Overall, a progressive and significant increase in the LVM was observed during the first 9 weeks of life. CONCLUSION: The LVM and LVMI exhibited a significant correlation with the BSA and body weight. This study provides reference data that can be used as a normal reference tool for the LVM and LVMI for preterm infants based on the BSA.

Normal reference ranges for aortic diameters in preterm infants.

OBJECTIVE: To establish normal reference ranges and Z-scores for aortic diameters in preterm infants according to the body surface area and assess their correlation with body weight, body surface area, and gestational age. PATIENTS AND METHODS: In a prospective study, 268 preterm infants who fulfilled the criteria for inclusion were examined. Echocardiograms were performed to measure the ascending aorta, transverse aorta, and aortic isthmus diameters on 0 days to 6 days of life and at weekly intervals until the babies reached 36 weeks. Body surface area was divided into 13 groups from 0.07 m2 to 0.19 m2. RESULTS: The mean gestational age was 29.8 [± 2.38 standard deviation (SD)] weeks, ranging from 24 weeks to 35 weeks. The mean body weight was 1479 (± 413 SD) g, ranging from 588 g to 3380 g, and the mean body surface area was 0.13 m2, ranging from 0.07 m2 to 0.19 m2. All the aortic diameters correlated well with both body weight and body surface area. Reference ranges with the mean ±â€¯SD, range, and Z-scores were calculated for aortic diameters according to the body surface area. A significant gradual increase was observed in ascending aorta, transverse aorta, and aortic isthmus diameters with increasing body surface area. Overall, a progressive and significant increase in ascending aorta, transverse aorta, and aortic isthmus diameters was observed during the first 9 weeks of life. CONCLUSION: The ascending aorta, transverse aorta, and aortic isthmus diameters exhibited a significant correlation with the body surface area and body weight. This study provides reference data with Z-scores that can be used as a normal reference tool for the ascending aorta, transverse aorta, and aortic isthmus diameters for preterm infants based on the body surface area.

Normal reference ranges for cardiac valve cross-sectional areas in preterm infants.

OBJECTIVE: To establish normal reference ranges for cardiac valve crosssectional areas (CSAs) in preterm infants and their correlation with gestational age, body weight, and chronological age. MATERIALS AND METHODS: In a prospective study, 268 preterm babies fulfilling the criteria for inclusion were examined. Echocardiograms were performed to measure aortic, pulmonary, mitral, and tricuspid valve CSAs on 0-6 day (s) of life and at weekly intervals until they reached 36 weeks. Gestational age was divided into three groups, 24-27, 28-31, and 32-35 weeks, and body weight was divided into five groups, ≤999, 1000-1499, 1500-1999, 2000-2499, and ≥2500 g. Overall group differences were compared for each period of life: 0-6 days and 1-2, 3-4, and ≥5 weeks. RESULTS: The mean gestational age was 29.8 (±2.38 standard deviation [SD]) weeks, ranging between 24 and 35 weeks, and the mean body weight was 1479 (±413 SD) g, ranging between 588 and 3380 g. All cardiac valve CSAs correlated well with body weight. A significant gradual increase was observed in all valve CSAs with body weight during each period of life. Overall, a progressive and significant increase in all valve CSAs was observed during the first 9 weeks of life. CONCLUSIONS: Cardiac valve CSAs were found to be significantly correlated with body weight. The study also provides reference data, which can be used as a normal reference tool for valve CSAs in preterm infants against gestational age, body weight, and chronological age.

Normal Reference Ranges for Pulmonary Artery Diameters in Preterm Infants.

To establish normal reference ranges and Z-scores for pulmonary artery diameters in preterm infants and their correlation with body surface area, body weight, and chronological age. In a prospective study, 268 preterm infants, who fulfilled the inclusion criteria were examined. Echocardiograms were performed to measure the main pulmonary artery, right pulmonary artery, and left pulmonary artery diameters on day(s) 0 to -6 of life and at weekly intervals until they reached 36 weeks of age. Body surface area was divided into thirteen groups from 0.07 to 0.19 m2. The mean gestational age was 29.8 (±2.38 SD) weeks, ranging between 24 and 35, the mean body weight was 1479 (±413 SD) grams, ranging between 588 and 3380, and the mean body surface area was 0.13 m2, ranging between 0.07 and 0.19 m2. All the pulmonary artery diameters correlated well with both body weight and body surface area. Reference ranges, with mean ± SD, range, and Z-scores for aortic diameters according to body surface area were calculated. A significant gradual increase was observed in main and branch pulmonary artery diameters with increasing body surface area. Overall, a progressive and significant increase for main and branch pulmonary artery diameters was observed during the first nine weeks of life. The main and branch pulmonary artery diameters were found to have significant correlation with body surface area. The study also provides reference data with Z-scores, which can be used as a normal reference tool for measuring the main pulmonary artery, right, and left pulmonary artery diameters of preterm infants against body surface area.

Normal Reference Ranges for Cardiac Valve Annulus in Preterm Infants.

OBJECTIVE: The purpose of this study was to establish normal reference ranges for the cardiac valve annulus size in preterm infants and their correlation with gestational age, body weight and chronological age. SUBJECTS AND METHODS: In a prospective study, 268 pre-term babies, who fulfilled the criteria for inclusion, were examined in Kuwait during the years 2008-2010. Echocardiograms were performed to measure the aortic, pulmonary, mitral and tricuspid valve annulus size on 0-6 day(s) of life and at weekly intervals until they reached 36 weeks. The gestational age was grouped into three: 24-27, 28-31 and 32-35 weeks, and body weight into five: ≤999, 1000-1499, 1500-1999, 2000-2499 and ≥2500 g. The overall group differences were compared for each period of life: 0-6 days, 1-2, 3-4 and ≥5 weeks. RESULTS: The mean gestational age was 29.8 (±2.38 SD) weeks, ranging between 24 and 35, and the mean body weight 1479 (±413 SD) grams, ranging between 588 and 3380. At the first scan (0-6 days of life), all cardiac valve measurements correlated well with both body weight and gestational age (P < 0.001). In the subsequent weeks valve diameters correlated well with body weight, while gestational age was found to have significant correlation (P < 0.01) with aortic and mitral valves only. A significant gradual increase was noticed in all valve annulus measurements with body weight during each period of life. Overall, a progressive and significant increase for all four cardiac valve annulus measurements was observed during the first nine weeks of life. CONCLUSION: The cardiac valve annulus measurements were found to have significant correlation with body weight. All the cardiac valve measurements correlated well with gestational age (P < 0.01) only up to 2 weeks. The study also provides reference data, which can be used as a normal reference tool for cardiac valve diameters for preterm infants against the gestational age, body weight and chronological age.

Novel Cannulation Strategy for Repair of an Ascending Aortic Pseudoaneurysm in a 2.8-kg Infant.

Pseudoaneurysm of the ascending aorta is rare in infants, with few cases reported in the literature. These aneurysms are usually mycotic, occurring after cardiac surgery, or caused by mediastinitis. They have high risk of spontaneous rupture. Surgery is usually complex because of the need for peripheral cannulation in small infants. We report an ascending aortic pseudoaneurysm in a less than 3-month-old infant that occurred within a month after repair of type 2 truncus arteriosus and was managed successfully with a modified cardiopulmonary bypass strategy.

Normal reference ranges for left ventricular dimensions in preterm infants.

OBJECTIVE: To establish normal reference ranges for the left ventricular dimensions in preterm infants and their correlation with gestational age, body weight and chronological age. MATERIALS AND METHODS: In a prospective study, 268 preterm babies, who fulfilled the criteria for inclusion, were examined in Kuwait during the years (2008-2010). Echocardiograms were performed to measure the left ventricular dimensions on 0-6 day(s) of life and at weekly intervals until they reached 36 weeks. The gestational age was grouped into three: 24-27, 28-31 and 32-35 weeks, and body weight into five: ⩽999, 1,000-1,499, 1,500-1,999, 2,000-2,499 and ≥2,500 grams. The overall group differences were compared for each period of life: 0-6 days, 1-2, 3-4 and ≥5 weeks. RESULTS: The mean gestational age was 29.8 (± 2.38 SD) weeks, ranging between 24 and 35, and the mean body weight 1,479 (± 413 SD) grams, ranging between 588 and 3380. At the first scan (0-6 days of life), all the left ventricular measurements correlated well (P < 0.001) with body weight, and the same was observed with gestational age, except for left ventricular posterior wall thickness at end-systole and end-diastole. A significant gradual increase was noticed in all the dimensions with body weight during each period of life. However, with respect to gestational age, an increase was observed in all the dimensions during first four weeks, but the rate of increase became less after 5 weeks of life. Overall, a progressive and significant increase in all left ventricle measurements was observed during the first nine weeks of life. CONCLUSION: The left ventricular dimension measurements were found to have significant correlation with both gestational age and body weight. The study also provides reference data, which can be used as normal reference tool for left ventricular dimensions for preterm infants against the gestational age, body weight and chronological age.

The impact of interruption of anomalous systemic arterial supply on scimitar syndrome presenting during infancy.

OBJECTIVES: We sought to evaluate the impact of interruption of anomalous systemic arterial supply (ASAS) on clinical course and management outcome of scimitar syndrome (SS) presenting during infancy. BACKGROUND: No systematic study has been reported so far on this subject, although there are conflicting sporadic reports indicating variable effect. METHODS: Out of 23 children diagnosed to have SS during the past 25 years, 16 symptomatic infants had ASAS. After interrupting ASAS (coil embolization -14, surgical ligation -2), they were prospectively followed up to define their clinical course and management outcome. RESULTS: All 16 infants had sizable ASAS and 9 had variable scimitar vein (SV) stenosis. Fifteen (94%) had pulmonary hypertension and significant left to right shunt. Post intervention, there was variable reduction of shunt in 14 and pulmonary artery pressure in 15 cases. All showed varying clinical improvement. One died of septicemia shortly afterwards. Definitive surgery was deferred for optimal results in seven children for a mean period of 8 months (range 1 month to 3 years). Remaining eight children did not require definitive surgery. One among them had closure of stenosed partial SV by Amplatzer duct occluder ("physiologic correction"). Two children on short term and six children on long term follow-up (mean 5.2 years; range 3.3-10.3 years) are doing well. CONCLUSION: Interruption of ASAS helps to avoid or defer definitive surgery for SS during infancy. Therefore, we recommend coil embolization of ASAS as initial palliation, and long term surveillance to assess need for further intervention.

Transcatheter closure of large pulmonary arteriovenous fistula including pulmonary artery to left atrial fistula with Amplatzer septal occluder.

OBJECTIVES: We sought to evaluate the safety and efficacy of Amplatzer septal occluder (ASO) to close very large pulmonary arteriovenous fistula (PAVF). BACKGROUND: Transcatheter coil embolization, the standard treatment for PAVF, has potential complications particularly in patients with very large fistulas. Several recently available devices have been tried effectively, however, they too have limitations. METHODS: During 2004, three patients (aged 17-56 years), diagnosed with large PAVF including one with pulmonary artery (PA) to left atrial (LA) fistula, had interventional closure prospectively using ASO. Following hemodynamic evaluation and angiographic localization of PAVF, the feeding artery (FA) was selectively cannulated with Amplatzer delivery sheath. ASO, with the right atrial (RA) disc diameter equal to or up to 4 mm larger than the maximum diameter of FA, was delivered through it in such a way that the left atrial disc assumed an oblong shape and the right atrial disc retained its designed flat configuration for better anchorage and thrombogenicity. RESULTS: All patients had very large PAVF fed by a single FA (size 12-24 mm), which was closed completely, without complications, using ASO (size 7-16 mm; RA disc diameter 15-26 mm). Their arterial saturation rose from mean 72.3% to 97.3%. Follow up (1.5-3 years) showed disappearance of the radiological shadows and stable arterial saturations (mean 97.7%). CONCLUSIONS: We conclude that, using the new criteria for device size selection and modified technique of implantation, very large PAVFs including PA to LA fistula can be closed safely, effectively and nonsurgically with ASO.