Anil Grover

Active infective endocarditis observed in an Indian hospital 1981–1991

Clinical data from 186 patients (133 males and 53 females) with 190 episodes of infective endocarditis (IE) occurring between January 1981 and July 1991 were studied retrospectively at a large referral hospital in Northern India with the intention of highlighting certain essential differences from those reported in the West. The mean age was much lower (25 +/- SD 12 years, range 2 to 75 years). Rheumatic heart disease was the most frequent underlying heart lesion accounting for 79 patients (42%). This was followed by congenital heart disease in 62 (33%) and normal valve endocarditis in 17 (9%). Twenty-four patients had either aortic regurgitation (n = 15) or mitral regurgitation (n = 9) of uncertain etiology. Prosthetic valve infection and mitral valve prolapse were present in only 2 patients each. A definite predisposing factor could be identified in only 28 patients (15%). Postabortal sepsis and sepsis related to childbirth accounted for 6 and 5 cases, respectively. Only 1 patient had history of intravenous drug abuse. Two-dimensional echocardiography showed vegetations in 121 patients (64%). Blood cultures were positive in only 87 (47%), with a total of 90 microbial isolates. Commonest infecting organisms were staphylococci (37 cases) and streptococci (34 cases). Except for a significantly higher number of patients with neurologic complications in the culture-negative group, there were no differences between patients with culture-positive and culture-negative IE. Of the 190 episodes of IE, the patients had received antibiotics before admission in 110 (58%) instances. A significantly greater number of culture-negative patients had received antibiotics than did culture-positive patients (87 vs 23, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Large Spontaneous Coronary Artery Dissections A Study of Three Cases, Literature Review, and Possible Therapeutic Strategies

Spontaneous coronary artery dissection is rare, but is now being increasingly recognized as a prominent cause of acute ischemic coronary events occurring usually in relatively young patients, predominantly females. The authors describe the clinical course of 3 patients (1 woman) in whom large spontaneous coronary artery dissections developed. All had diverse clinical presentations; 1 presenting with heart failure, the second with post-myocardial infarction angina, and the third with syncope. The second patient underwent coronary angioplasty with multiple overlapping stents while in the other two, it was the considered opinion to continue aggressive medical therapy. The 1-year follow-up was uneventful in all 3 patients. The risk factors ascertained in our patients were diabetes mellitus, smoking, and hypertension.

Myocardial ischemia secondary to dual coronary artery fistulas draining into main pulmonary artery

Bilateral coronary artery to pulmonary artery fistulas is an uncommon congenital anomaly. These fistulas have a clinical and embryological significance. We report a rare case of combination of right coronary and left circumflex coronary fistula draining into main pulmonary artery, who presented in the emergency room with acute pain chest. The fistula had significant 1.7:1 left to right shunt and also myocardial ischemia as demonstrated by exercise Thallium(201) SPECT myocardial imaging. He was managed conservatively during the last 5 years without any percutaneous or surgical intervention.

Profile of right-sided endocarditis: an Indian experience

The clinical profile of right-sided infective endocarditis in India was studied from a review of records of patients with infective endocarditis admitted to this hospital. From November 1982 to November 1989, 109 patients with infective endocarditis showed vegetations on cross-sectional echocardiography confirming the diagnosis of infective endocarditis. In 19 (17.4%) patients, only the right side of the heart was involved: specifically the tricuspid valve alone in 10; tricuspid and pulmonary valves in 4; tricuspid valve and right ventricular outflow tract in 1; tricuspid valve and right ventricular free wall in 1; pulmonary valve alone in 2; and bifurcation of pulmonary trunk in 1. Eleven patients (57.9%) had underlying congenital heart disease whereas the remaining 8 patients (42.1%) did not have any underlying heart disease. The latter group, therefore, had isolated right-sided infective endocarditis. Previous illnesses leading to isolated right-sided infective endocarditis were: puerperal sepsis in 4; septic abortion in 1; staphylococcal pneumonia in 2; and epididymoorchitis in one. Eight out of 11 patients with congenital heart disease did not report any previous illness. In the remaining 3, right-sided endocarditis followed cardiac surgery in one; dental extraction without prophylaxis in one; and pulmonary balloon valvoplasty in one. All patients with isolated right-sided infective endocarditis had features of septicaemia, but a murmur of tricuspid regurgitation was audible in only 4 (50%) of them. We conclude that, unlike western reports, the pattern of right-sided infective endocarditis in India is different. No drug addict with right-sided infective endocarditis was seen; puerperal sepsis and septic abortion were the commonest causes of isolated right-sided infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

A Randomized Controlled Clinical Trial to Evaluate the Efficacy, Safety, Cost-Effectiveness and Effect on PAI-1 Levels of the Three Low-Molecular-Weight Heparins – Enoxaparin, Nadroparin and Dalteparin

Background: Comparative data for efficacy and safety between various low-molecular-weight heparins (LMWHs) in patients with unstable angina is not available. The present study was conducted to compare the efficacy, safety, cost-effectiveness and effects on plasminogen activator inhibitor-1 (PAI-1) levels of three LMWHs – enoxaparin, nadroparin and dalteparin. Methods: The study was a prospective, randomized, comparative, open with blinded endpoints (PROBE design) assessment with a 30-day follow-up. The primary endpoint of efficacy was a composite of cardiovascular death, myocardial infarction, recurrent angina and need for intervention. Cost-effectiveness was calculated by calculating the incremental cost-effectiveness ratio. Plasma PAI-1 levels were estimated by ELISA. Results: A total of 150 patients were available for intention-to-treat analysis. There was no significant difference at 30 days in the primary endpoint or in any of the individual components in the three groups. The secondary endpoint of silent ischemia was also not significantly different. Adverse events were similar in the three groups. The PAI-1 levels were not significantly different in the three groups. The total cost of treatment in the three groups was similar. Conclusion: Any of the three LMWHs evaluated in this study were similar with respect to efficacy, safety, PAI-1 levels and cost-effectiveness.

Delayed embolization of Amplatzer septal occluder device: an unknown entity--a case report.

A case of delayed embolization of Amplatzer septal occluder, occurring at 2 weeks postim plantation in a 10-year-old girl with an oval-shaped secundum atrial septal defect is reported. The structurally intact device dislodged into the left atrium owing to reversal of transatrial pressure gradients and embolized to the left ventricular outflow tract from where it was retrieved surgically.

Safety of intrauterine contraceptive device (copper T 200 B) in women with cardiac disease

BACKGROUND Women with cardiac disease have need for effective long-lasting reversible contraception. Women with cardiac disease are at increased risk for bacterial endocarditis. There is limited research regarding the use of intrauterine contraceptive devices (IUD) in women with cardiac disease. STUDY DESIGN In a prospective study, the IUD copper (Cu T200B) was inserted in 40 women with cardiac disease. Infective endocarditis prophylaxis was given 1 h before IUD insertion. The IUD was inserted under aseptic conditions. Ten milliliters of venous blood was obtained for culture of aerobic and anerobic bacteria within 1 h of insertion of the copper T IUD. Women were contacted for follow-up at frequent intervals. RESULTS There was no incidence of uterine perforation, hemorrhage or spontaneous expulsion of the IUD. All blood cultures were sterile. There were no cases of infective endocarditis. Four women (10%) had menorrhagia at the 6-month follow-up which responded to medical management. One woman had PID for which antibiotics were given. Five women had mild cramps and five had spotting after insertion of the IUD. Patient adherence was excellent as none returned for removal for reasons other than desire for another pregnancy. CONCLUSION The Cu T200B IUD is a reasonably safe and effective method of temporary contraception in women with cardiac disease who are not receiving anticoagulant therapy.

Assessment of IVC filter efficacy in prevention of pulmonary thrombo-embolism by 99mTc-MAA lung perfusion scintigraphy—A case series and review of literature

INTRODUCTION Anticoagulant therapy is the standard treatment of venous thrombo-embolism (VTE). Permanent inferior vena cava (IVC) filter is an important adjunctive therapy in these patients to prevent the complications like potentially fatal pulmonary embolism and chronic thrombo-embolic pulmonary hypertension. We studied patients with proximal deep vein thrombosis (DVT) of lower limbs and recurrent pulmonary thrombo-embolism (PTE), who were put on permanent IVC filters for the prevention of further episodes of PTE. The efficacy of filters in prevention of PTE was assessed by clinical history and was supported by follow-up (99m)Tc-MAA lung perfusion scintigraphy. METHODS AND RESULTS We prospectively enrolled 7 patients of PTE, who were put on IVC filter from July 2002-April 2005. All patients had (99m)Tc-MAA lung perfusion scan before filter implantation. Percutaneous IVC filter placement in infra-renal position was done. All patients were put on adequate oral anticoagulant treatment with target INR of 2.0-3.0. At follow-up two patients died - one died of intractable right heart failure at 6 months and other died of carcinoma colon metastasis after 16 months. The mean follow-up of rest of five patients was 3.5 years (range 20-54 months), and none of them had clinically evident further episode of DVT or PTE. Their repeat lung perfusion scan at 1 year of follow-up showed marked improvement in perfusion with no evidence of additional fresh/new defects. CONCLUSION Follow-up (99m)Tc-MAA lung perfusion scan in PTE patients, who are on IVC filter, can demonstrate the significant improvement in lung perfusion secondary to prevention of further pulmonary embolism episodes and resolution of pulmonary thrombus by continued anticoagulant therapy.

Endovascular Management of Isolated Axillary Artery Aneurysm: A Case Report

The purpose of this paper is to report a case of axillary artery aneurysm, successfully treated by percutaneous transfemoral self-expandable polytetrafluoroethylene (PTFE) covered Wallgraft™ stent. A 20-year-old man presented with sudden-onset, severe aching pain of left upper limb that occurred while doing isometric exercise. He had feeble left brachial and radial pulses. Angiography revealed a 21 x 14 mm left axillary artery aneurysm with a 15 mm neck. There was an organized clot in the midpart of the left brachial artery. The aneurysm was successfully closed with a self-expandable 10 x 30 mm Wallgraft™ endoprosthesis PTFE graft stent, via the right femoral route. A check angiogram at 6 weeks of follow-up showed a patent stent with no endovascular leak. At 1 year of follow-up, the patient was asymptomatic with normal upper limbs pulsations. Axillary artery aneurysm may be treated with a stent graft, which is an effective, rapid, and definite treatment and is an acceptable alternative to standard open surgical repair.

Clinical, echocardiographic, and angiographic profile of patients with double-chambered right ventricle: experience with 48 cases.

Forty-eight patients with double-chambered right ventricle (DCRV) were prospectively studied over a 3-year period. Clinical, echocardiographic, hemodynamic, and angio graphic studies were done in all. Three patients were studied postoperatively also. Fifteen patients underwent surgery confirming the diagnosis. Echocardiography detected anomalous muscle bundles (AMBs) in 39/41 patients in whom this study was carried out. Angiographically AMBs were best demonstrated in anteroposterior views in a systolic frame. Common associated anomalies found with DCRV were ventricular septal defects (69%), pulmonary valve stenosis (38%), and double-outlet right ventricle (10%).