Cardiac Amyloidosis: A Case Series from India.

OBJECTIVE: Cardiac amyloidosis (CA) is not well recognized in Indian literature. The aim of this communication is to highlight the difficulties in diagnosis. METHODS: A retrospective analysis of data of six patients of CA diagnosed during 2008 to 2015 was done. Clinical, investigative, management and follow-up data is analyzed. RESULTS: The mean age was 51 years with male preponderance. Heart failure was the commonest manifestation. Atrial arrhythmias were seen in 33%. Syncope, peripheral neuropathy and macroglossia were striking features. A speckled inter-ventricular septum (66%) or thickened inter-atrial septum (16%) on echocardiography strongly favoured CA. Other echocardiography features include thickened ventricular wall, enlarged atria and pericardial effusion (PE). Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) was characteristic of CA. Plasma cell dyscrasia confirmed light chain amyloidosis. Abdominal fat pad and rectal biopsy confirmed the diagnosis. Chemotherapy for plasma cell dyscrasia was administered in 50% of patients. CONCLUSION: Echocardiography and CMR imaging enable the diagnosis of CA in background of strong clinical suspicion. Abdominal fat pad biopsy is a simple and reliable method for confirming the diagnosis. IMPLICATIONS AND PRACTICE: The awareness of this entity can enable an early diagnosis and improve the survival with timely novel chemotherapy.

Tricuspid valve endocarditis in non-drug abusers: A case series from India.

OBJECTIVE: The etiology of tricuspid valve endocarditis (TVE) seems to be different in our country as intravenous (IV) drug abuse is not known to be a major health hazard. The objective of this communication is to study the risk factors, clinical profile, follow-up data of TVE patients and focus on the difficulties in diagnosis and variations encountered. METHODS: A retrospective analysis of data of 10 patients of TVE managed in a tertiary care center during January 1992 to June 2015 was done. RESULTS: TVE was encountered in a diverse subset of patients with cardiac implantable electronic device (CIED) (group I; 3 patients), immunocompromised state with indwelling central venous catheter (CVC) (group II; 2 patients), congenital heart disease (CHD) (group III; 3 patients) and in apparently healthy individuals (group IV; 2 patients). Blood cultures were negative in half the patients. In group I early surgical extraction of leads, device and vegetation provided excellent results. Prognosis was poor with 100% mortality in immunocompromised patients. Patients in group III did well on medical management. The overall mortality was high (30% in hospital and additional 20% within one year). CONCLUSIONS: TVE is rare and can occur in different clinical scenarios. Indiscriminate use of antibiotics modifies the clinical picture causing delay in diagnosis and referral to speciality care. Echocardiography remains the main modality and should be used serially to facilitate early diagnosis. The prognosis is guarded. Early surgery is recommended in pacemaker lead, fungal endocarditis, persistent sepsis or hemodynamic instability for favorable prognosis.

Aorto - Left atrial fistula after mitral valve replacement.

Acquired aorto-left atrial fistula is uncommon. A rare case of aorto-left atrial fistula following mitral valve replacement is reported with echocardiographic, computed tomograpic and angiographic images.

Spontaneous coronary artery dissection: Case series and review of literature.

AIM: Spontaneous coronary artery dissection (SCAD) is a less recognized cause of ST elevation myocardial infarction (STEMI) in clinical practice. The aim of this communication is to describe a case series in South Asian population and highlight on the long-term clinical outcomes on conservative management. METHODS: A retrospective analysis of data of five patients (6 instances) of SCAD managed in a tertiary care center during January 1994 to June 2015 was done. Clinical, angiographic, therapeutic, and follow-up data till end of June 2015 are analyzed. RESULTS: All patients were young (mean - 33 years) and predominantly male. Etiology of SCAD was diverse and included peripartum state, vigorous activity and atherosclerosis. Left anterior descending (LAD) coronary artery was predominantly involved and the majority had angiographic type 1 SCAD. Medical treatment provides excellent long-term benefits. Coronary stenting provided symptomatic benefit in a patient with favorable anatomy. CONCLUSIONS: Clinical recognition of SCAD is difficult. It should be suspected in peripartum state, young females and in presence of other precipitating factors. Coronary angiography is essential for establishing the diagnosis. Medical treatment provides favorable long-term survival. IMPLICATIONS AND PRACTICE: The awareness of SCAD is important for all clinicians involved in STEMI care. A prompt suspicion can avoid administration of thrombolytic therapy. Early coronary angiography will provide an accurate diagnosis and help in deciding appropriate therapy. Percutaneous intervention can be challenging.