Anand Gnanaraj

Apical ballooning syndrome in first degree relatives.

Apical ballooning syndrome (Takotsubo cardiomyopathy) is an unusual stress-related reversible cardiomyopathy occurring commonly in postmenopausal females. Genetic etiology of this condition is uncertain. A 68-year-old female and her daughter aged 43 got admitted to our institute simultaneously with acute chest pain following demise of one of their close relative. Both had features typical of Takotsubo cardiomyopathy and recovered completely. This reports point to the possible genetic predisposition to this abnormality.

Outcome of primary PCI – An Indian tertiary care center experience

Objective To assess the feasibility and outcomes of primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) in Indian Scenario. Methods Between January 2005 and December 2012, consecutive STEMI patients who underwent PPCI within 12 h of onset of chest pain were prospectively enrolled in a PPCI registry. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital and 30 day major adverse cardiovascular events (MACE) [death, reinfarction, bleeding, urgent coronary artery bypass surgery (CABG) and stroke] were assessed. Results A total of 672 patients underwent PPCI during this period. The mean age was 52 ± 13.4 years and 583 (86.7%) were males, 275 (40.9%) were hypertensives and 336 (50%) were diabetics. Thirty one (4.6%) patients had cardiogenic shock (CS). Anterior myocardial infarction was diagnosed in 398 (59.2%) patients. The median chest pain onset to hospital arrival time, door-to-balloon time and total ischemic times were 200 (10–720), 65 (20–300), and 275 (55–785) minutes respectively. In-hospital adverse events occurred in 54 (8.0%) patients [death 28 (4.2%), reinfarction 8 (1.2%), major bleeding 9 (1.3%), urgent CABG 4 (0.6%) and stroke 1 (0.14%)]. Nineteen patients with CS died (mortality rate – (61.3%)). At the end of 30 days, 64 (9.5%) patients had MACE [death 35 (5.2%), reinfarction 10 (2.1%), major bleeding 10 (1.5%), urgent CABG 4 (0.6%) and stroke 1 (0.1%)]. Conclusion Our study has shown that PPCI is feasible with good outcomes in Indian scenario. Even though the recommended door-to-balloon time can be achieved, the total ischemic time remained long. CS in the setting of STEMI was associated with poor outcomes.

Percutaneous coronary intervention in cardiogenic shock complicating acute ST-elevation myocardial infarction—a single centre experience

BACKGROUND Mortality in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) approaches 70 - 80%, regardless of the type of pharmacological treatment. Early revascularisation improves survival in AMI with CS. Our aim is to assess the predictors of mid-term outcome after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and CS. METHODS Forty-one patients who underwent primary or rescue PCI for CS were analysed comparing their baseline, angiographic, PCI data, 30-day and 1-year survival. RESULTS There were no significant differences between survivors and non-survivors in baseline characters, except for more number of transfer admissions (P= 0.0005), and cardiopulmonary resuscitations (P= 0.015) in the later group. The mean time between myocardial infarction (MI) onset to shock and MI onset to revascularisation were 12.8 ± 12.9 hours and 17.0 ± 16.8 hours, respectively. Patients with better pre-procedure thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery (IRA) had better survival (P= 0.0005). Successful PCI was achieved in 48.8% of patients. The 30-day mortality was 56.1% and all were prior to hospital discharge. Patients with successful PCI had better short-term survival in comparison with patients with failed PCI (80% vs 9.6%). Eighteen patients who survived at 30 days were followed up for 12-72 months (mean 28.5 ± 5.4 months). Fifteen patients survived at 1 year after PCI and all were in good functional status. CONCLUSION Mortality remains high even with PCI. Achieving IRA patency with TIMI 3 flow is the main determinant of survival. Survival and functional status are good in patients who are discharged from hospital.

Stuck Mitral Bio-Prosthetic Valve

A 26-year-old lady was evaluated at our hospital for rheumatic mitral valve disease in March 2007. She underwent Mitral Valve Replacement (MVR) with a bio-prosthetic valve (Bio-cor 27 mm) in April 2007. She was discharged on the 9th day with stable hemodynamics and optimized INR values. During follow up she had optimal INR values and normal gradients across the valve. After three months of adequate anticoagulation her warfarin was stopped since she was in sinus rhythm. She continued to take aspirin and remained in sinus rhythm. She was advised infective endocarditis prophylaxis. Eleven months after MVR she developed breathlessness over one week, which gradually worsened to orthopnoea. On admission she had pulmonary edema and the gradients across the bio-prosthetic mitral valve were increased (Maximum of 34 mmHg and Mean of 24 mmHg). Her previous echocardiogram in July 2007 showed normal gradients across the valve. Her transthoracic and transesophageal echocardiograms were suggestive of a stuck mitral prosthesis (Echo figures). There was a mobile membranous structure that appeared like a detached valve apparatus but could not be clearly delineated pre-operatively. We assumed that it was an unstable prosthetic structure. The intra-operative echocardiogram also showed similar features.

ROLE OF ECHO DOPPLER IN DETECTION OF RADIAL ARTERY ANOMALIES PRIOR TO TRANSRADIAL ACCESS FOR INTERVENTIONS

Methods: 250 consecutive patients undergoing interventions via transradial access in our institution from 01 April 2008 were enrolled into the study. All patients were screened pre procedurally by ECHO-Doppler and the presence of radial artery anomalies were documented, which were confirmed by radial arteriography. The incidence of procedural failure and need for alternative access was studied in these patients.

Bicuspid Aortic Valve Stenosis and Postaortotomy Calcified Saccular Aortic Aneurysm

A 27-year-old male, who had undergone surgical aortic valvotomy in 1991, presented with breathlessness, chest pain, and palpitations. His chest X-ray revealed two calcified masses adjacent to the ascending aorta (Fig. 1). Echocardiography demonstrated severe aortic stenosis, moderate aortic regurgitation, and dilated ascending aorta. His computerized tomographic (CT) angiogram showed two large saccular aneurysms with the anterior sac measuring 7.7 cm and the posterior one measuring 7.9 cm (Figs. 2A–C), probably arising from the previous aortotomy site. A bicuspid aortic valve (BAV) with severe aortic stenosis (systolic aortic valve area – 0.5 cm2) was also seen. The patient underwent redo surgery during which two saccular aneurysms with calcified walls involving the ascending aorta were confirmed. The aneurysmal sacs were removed subtotally, the aortic valve was excised, and Bentall’s procedure was completed with a 26-mm aortic allograft and a 23-mm St. Jude mechanical valve (St. Jude Medical, Sylmar, CA, USA). The patient made an uneventful recovery. Ascending aortic aneurysm associated with BAV is usually fusiform. Saccular aneurysms are rare. Presence of extensive calcification is also unusual. Previous surgery and altered flow dynamics of aortic stenosis