Incidence, predictors, clinical profile, management and outcome of patients with isolated left main coronary artery ostial disease.

OBJECTIVES: Isolated left main coronary artery (LMCA) ostial disease is a rare variant of LMCA disease. Earlier studies on this disease are limited by small number of patients enrolled. The aim of the present study was to analyze the incidence, risk factors, clinical profile and long term outcome of patients with isolated LMCA ostial disease. METHODS: 15,553 patients who underwent coronary angiogram in a single tertiary care cardiac hospital were analyzed for LMCA disease. 351(2.2%) patients were found to have significant LMCA disease out of which 28(0.18%) had isolated LMCA ostial disease. These 28 patients were compared with 323 non-ostial and non-isolated LMCA disease patients. RESULTS: The mean age of isolated LMCA ostial disease group was significantly less than the other group (p=0.009). Females were more affected than males (p=0.008). They also had low incidence of coronary risk factors (especially dyslipidemia, p=0.04). They tend to present more with stable angina and less with myocardial infarction. They had higher ejection fraction and normal regional wall motion (p=0.04). There was no mortality difference between two groups at the end of 1 year (p=0.234). CONCLUSION: In one of the largest studies done in these patients, we found that isolated LMCA ostial disease is more common in middle aged females with few coronary risk factors. These patients also had a better ejection fraction and normal regional wall motion compared to patients with non-ostial and non-isolated LMCA disease. The clinical and angiographic profile of these patients suggests that they may represent a distinct clinical entity.

Effect of thrombolytic therapy on the patterns of post myocardial infarction ventricular septal rupture.

OBJECTIVES: Ventricular septal rupture (VSR) is a rare but feared complication after myocardial infarction (MI). The objective of this study was to investigate the effects of thrombolytic therapy on the patterns of VSR following MI. METHODS: 30 consecutive patients admitted to a single tertiary level cardiac hospital with a diagnosis of acute MI and developed VSR in the hospital were included. The effect on thrombolytic therapy on the formation of VSR and its clinical outcome was studied. RESULTS: Out of 30 patients, 15 patients received thrombolytic therapy.10 received early (<12h) and 5 received late (>12h). The median time to post MI VSR formation was significantly shorter in thrombolysis group compared to non thrombolysis group at 1 vs 3 days(p=0.026). The median time for VSR formation was shorter in early thrombolysis group compared to late thrombolysis group at 1 vs 3 days (p=0.022). There was no difference between late and no thrombolytic therapy (3 vs 3 days, p=0.672). There was no significant difference in the mortality between thrombolytic and no thrombolytic therapy (p=0.690). Patients treated medically had a significant higher mortality compared to patients treated surgically (p=0.005). CONCLUSION: Thrombolytic therapy results in an earlier presentation of VSR after MI. This earlier presentation may be due to reduction in the number of patients developing late VSR after thrombolytic therapy, while the number of patients developing an early VSR remaining unaffected. Despite improvements in medical therapy and percutaneous and surgical techniques, mortality with this complication remains extremely high.

Holt-Oram syndrome with aortopulmonary window--a rare association.

A 4-month-old male infant presented with recurrent cough for 2 months. He had a shortened right upper limb with absent right thumb and continuous murmur in the left parasternal area. The X-ray showed an absent radius and the first metacarpal and phalyngeal bones on the right side. Echocardiogram revealed aortopulmonary window and small secundum atrial septal defect. Aortopulmonary window was successfully treated by device closure. Holt-Oram syndrome with aortopulmonary window is an extremely rare association.

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.

A false-positive ST segment elevation during exercise stress test.

A 56-year-old man with multiple risk factors undergoing evaluation for chest pain developed ST elevations in multiple leads during exercise stress test. These ST elevations were not classical of ischaemic pattern. The coronary angiogram showed normal coronaries. The false-positive ST elevation was due to an error in the computer-synthesised averaging algorithm.

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.