Anjith Vupputuri

Heart-type fatty acid-binding protein (H-FABP) as an early diagnostic biomarker in patients with acute chest pain.

BACKGROUND Heart-type fatty acid-binding protein (H-FABP) is an emerging biomarker, which was found to be sensitive for the early diagnosis of acute myocardial infarction (AMI). We prospectively investigated the usefulness of H-FABP determination for the evaluation of acute chest pain in patients arriving at the emergency department. METHODS Fifty-four patients presenting with acute ischemic chest pain were evaluated. H-FABP was estimated at admission using latex-enhanced immunoturbidimetric assay. Serial cardiac troponin I (cTnI), creatinine kinase-MB (CK-MB) determination, ischemia workup with stress testing, and/or coronary angiogram (CAG) were performed according to standard protocols. RESULTS The sensitivity and specificity of H-FABP was 89.7% and 68%, for cTnI it was 62.1% and 100%, and for CK-MB it was 44.8% and 92%, respectively for diagnosis of AMI. The sensitivity of H-FABP was found to be far superior to initial cTnI and CK-MB, for those seen within 6h (100% vs. 46.1%, 33% respectively). On further evaluation of patients with positive H-FABP and negative cTnI, 71.4% of the patients had significant lesion on CAG, indicating ischemic cause of H-FABP elevation. Six patients with normal cTnI and CK-MB with high H-FABP had ST elevation on subsequent ECGs and were taken for primary angioplasty. CONCLUSION H-FABP is a highly sensitive biomarker for the early diagnosis of AMI. H-FABP as early marker and cTnI as late marker would be the ideal combination to cover the complete diagnostic window for AMI. Detection of myocardial injury by H-FABP may also be applied in patients with unstable angina. H-FABP can also be used as a marker for early detection of STEMI before the ECG changes become apparent.

Use of Lung Ultrasound For Diagnosing Acute Heart Failure in Emergency Department of Southern India

INTRODUCTION Diagnosing heart failure is often a challenge for the healthcare providers due to its non-specific and usually subtle physical presentations. The outcomes for treatment are strongly related to the stage of the disease. Considering the importance of early and accurate diagnosis, it is important to have an easy, inexpensive, non-invasive, reliable and reproducible method for diagnosis of heart failure. Recent advancement in radiology and cardiology are supporting the emerging technique of lung ultrasound through B-line evaluation for identifying extravascular lung water. AIM To establish lung ultrasound as an easy, inexpensive, non-invasive, reliable and reproducible method for diagnosing Acute Decompensated Heart Failure (ADHF) in emergency department. MATERIALS AND METHODS The study was a cross-sectional, prospective, observational, diagnostic validation study of lung ultrasound for diagnosis of acute heart failure in an emergency department and was performed at Amrita Institute of Medical Science, Kochi, Kerala, India. A total of 42 patients presenting with symptoms suggestive of acute decompensated heart failure were evaluated by plasma B-type Natriuretic Peptide (BNP), Echocardiography (ECHO) and X-ray. Lung ultrasound was done to look for the presence of B-lines. STATISTICAL ANALYSIS Sensitivity, specificity and predictive value of diagnostic modalities were calculated using Mc Nemars Chi-square test for the presence and absence of heart failure. RESULTS Lung ultrasound showed a sensitivity of 91.9% and a specificity of 100% in diagnosing acute heart failure comparable to plasma BNP which had a sensitivity of 100% and a specificity of 60%. It was also superior to other methods of diagnosing ADHF namely X-ray and ECHO and showed a good association. CONCLUSION Lung ultrasound and its use to detect ultrasonographic B-lines is an early, sensitive and an equally accurate predictor of ADHF in the emergency setting as compared to BNP.

Coronary Stent Infection Successfully Diagnosed Using 18F-Flurodeoxyglucose Positron Emission Tomography Computed Tomography.

Infection of coronary stents is extremely rare. We report a case of a 60-year-old gentleman with recurrent fever after acute stent occlusion and reintervention. A coronary angiogram showed an occluded stented segment and the blood cultures were positive for infection. The presence of inflammation in the stented region was confirmed using 18F-flurodeoxyglucose positron emission tomography computed tomography. The patient underwent surgery and the diagnosis was proven by examination of the surgical material. This article highlights the need to have a high index of suspicion of stent infection, and the use of 18F-flurodeoxyglucose positron emission tomography computed tomography along with coronary angiogram in aiding the diagnosis.

The iron man

Questions Chapter 1 1) What does the following sentence mean? ‘The wind sang through his iron fingers.’ 2) Why were his eyes shining different colours? 3) Why did he step off the cliff? 4) How did the seagull spot the Iron Man’s hand and eye? 5) What did the seagulls think they had found? 6) Where was the Iron Man’s missing ear? 7) Why did the Iron Man walk into the sea? 8) Why do you think the seagulls were circling over the Iron Man as he walked into the sea?

Primary transcatheter closure of post-myocardial infarction ventricular septal rupture using amplatzer atrial septal occlusion device: A study from tertiary care in South India

Objective The study investigated effectiveness of transcatheter closure of post-myocardial infarction (MI) ventricular septal rupture (VSR) using atrial septal device (ASD) occluder in a cohort of patients admitted at our institute. Method This was a retrospective, observational and single center study, which included patients who were treated with transcatheter closure for post-MI VSR at our tertiary care center between May 2000 and August 2014 depending upon inclusion and exclusion criteria. Primary outcome was all-cause mortality at 30-days follow-up. The MELD-XI (Model for End Stage Liver Disease) score was used as a predictor for poor outcome in these patients. Results A total of 21 patients (mean age 66.4 ± 5.9 years) were included in the study. Study cohort predominantly included male patients (n = 15; 71.4%) and patients with single vessel disease (n = 15; 71.4%). Revascularization of the culprit lesion, before VSR closure, was attempted in 6 patients. Except one patient (treated with Cera® occluder), all patients were treated with Amplatzer® ASD occluders. Average diameter of VSR was 20.8 ± 6.9 mm. Diameter of the device used in the study ranged from 10 mm to 30 mm. Residual defect was detected in 13 patients (62%). All-cause mortality at 30-day follow-up was observed in 9 (42.9%) patients. Time to VSR closure, diameter of VSR, and serum creatinine levels were significantly related to the 30-day mortality. MELD-XI score was found to be strongly associated with increased risk of mortality. Conclusion Primary transcatheter VSR closure using ASD occluders is a feasible approach which can provide reasonable survival outcomes along with equitable mortality rates.

Supra-Hisian Conduction Block As An Unusual Presenting Feature of Takotsubo Cardiomyopathy.

Atrioventricular (AV) block is rare in Takotsubo cardiomyopathy (TC).

A Rare Case of Fatal Endocarditis and Sepsis Caused by Pseudomonas aeruginosa in a Patient with Chronic Renal Failure

Nosocomial catheter-related and Arteriovenous fistula (AV)-related infections are significant concern in patients undergoing haemodialysis. These infections are associated with multiple complications as well as mortality and demands immediate and appropriate management. While coagulase-negative staphylococci, S.aureus, and Escherichia coli are the most common causes of catheter-related infections in haemodialysis patients, such infections caused by Pseudomonas aeruginosa are relatively rare. Here, we present an unusual case of 36-year-old male patient with chronic renal failure, who developed endocarditis and sepsis from Pseudomonas aeruginosa infection of the left hand arteriovenous fistula. The bacteraemia in the present case caused multiple complications including dry gangrene of bilateral lower limbs, stroke, endophthalmitis, left brachial artery thrombosis and vegetations on the interventricular septum and aortic wall. Despite antibiotic treatment, the patient suffered a cardiac arrest and could not be revived.

An unusual type of accessory pathway in tricuspid atresia

The occurrence of pre-excitation in tricuspid atresia (TA) is slightly more common than that in normal children. The accessory pathway (AP), when it occurs in the setting of congenital atrioventricular valvar disease, is usually ipsilateral to the side of the abnormal valve. This report describes a patient with TA who had pre-excitation due to a left-sided AP that masked and modified the typical electrocardiographic features. The electrophysiological study confirmed an epicardial left posterior AP that was successfully ablated with radiofrequency energy, through the coronary sinus. Left-sided APs including epicardial ones may rarely be seen in TA and can potentially cause difficulties due to lack of vascular access to the heart after the Fontan surgery if arrhythmias occur. They are amenable to successful radiofrequency ablation and need to be dressed prior to Fontan surgery. <Learning objective: Pre-excitation may become manifest during follow-up even if minimal at initial presentation. Accessory pathways may occur in the left side of the heart in tricuspid atresia, in contrast to the usual notion that APs occur ipsilateral to the side of the abnormal valve. Electrophysiological study may be useful prior to Fontan-type procedures as this helps in identifying and to prognosticate pre-excitation so that ablation of the pathway can be performed prior to the Fontan procedure.>.

An Unusual Case of Biatrial Myxoma in a Young Female

Myxoma, a rare type of intracardiac tumor, forms a very small percentage of the cardiac cases. Reports of biatrial myxoma are rarer, with cases of single tumor reaching both atria being more common. Here, we present an unusual case of two independently growing atrial myxoma in a 29-year-old female. We emphasize that early recognition of symptoms, confirmation of diagnosis by transesophageal echocardiography, and prompt surgical excision remain vital in the management of such patients. The patient in the present case was managed successfully with no evidences of recurrence at the last follow-up.

Visual Assessment by Seasoned Operators versus Fractional Flow ReserveGuided Stenting in Patients with Multivessel Disease in Indian Patients

Background: The benefit of revascularization is less clear in stenotic lesions that do not induce ischemia and medical therapy alone is likely to be equally effective. FFR (Fractional Flow Reserve) identifies stenoses that are causing reversible ischemia and thereby the operator can guide interventions to the lesions responsible for the patient’s problem, saving time, cost and optimizing clinical outcome. The main aim is to compare FFR and visual assessment with respect to decision making, requirements of stents and corresponding outcomes in patients with multivessel coronary artery disease. Method: This was a prospective, observational, single centre study, which included 38 patients randomized into 2 groups: one group that underwent FFR guided stenting for the borderline lesions, if the FFR value was found to be significant and for the other group the decision to go ahead with stenting for borderline lesions was based on independent opinion of 4 cardiologists participating in the study, based on visual assessment. The patients were followed up at 3 and 6 months. The primary endpoint of the study was death due to any cause or ACS (Acute Coronary Syndrome). The number of stents saved, cost savings and symptomatic improvement were the secondary outcomes that were studied. Inter-observer variation within the 4 operators in both the FFR and visual arms was also analysed. Results: There were no deaths or ACS during 3 and 6 months follow-up in the 38 patients that were included in the two groups. There was no statistical difference with regards to number of stents saved, cost savings, and functional outcomes such as angina; which were our secondary end points between the visual assessment by seasoned operators and FFR guided stenting groups. There was inter-observer variation between all the 4 operators in our study with regards to visual assessment of the borderline lesions. Conclusion: FFR is important in decision making in borderline lesions and it should be used more often, especially where there are single operators.