Arunkumar Panneerselvam

Incidence and Predictors of Left Atrial Thrombus in Patients with Rheumatic Mitral Stenosis and Sinus Rhythm: A Transesophageal Echocardiographic Study

Background: Rheumatic mitral stenosis (MS) predisposes to left atrial (LA) thrombus formation. The reported incidence of LA clot formation in sinus rhythm (SR) is 2.4–13.5% in small studies. Aim: To determine the incidence of LA thrombus in MS in SR in a large cohort of patients and to determine the factors that predict its development. Methods: Total of 848 consecutive patients with MS in SR who were being evaluated for percutaneous transvenous mitral commisurotomy were included in the study. Both transthoracic (TTE) and transesophageal echocardiograms (TEE) were performed to identify clot and other hemodynamic parameters. Results: The mean age of the study population was 34 ± 9 years and the mean mitral orifice area was 0.78 ± 0.18 cm2. Out of 848 patients 56 (6.6%) had LA thrombus on TEE. On univariate analysis there was a trend toward thrombus formation in individuals with age >44 years, LA inferosuperior dimension >6.9 cm, mean mitral gradient >18 mmHg and dense spontaneous echo contrast (SEC). On multivariate analysis none of the factors predicted clot formation. Conclusion: The incidence of LA thrombus in MS in SR is 6.6%. TEE is warranted in MS patients in SR when they are >44 years, LA inferosuperior dimension >6.9 cm and mean mitral gradient >18 mmHg. When SEC is absent on TEE, thrombus formation is unlikely. (Echocardiography 2011;28:457‐460)

Acute severe mitral regurgitation following balloon mitral valvotomy: Echocardiographic features, operative findings, and outcome in 50 surgical cases

To analyze the echocardiographic and operative findings with respect to mitral valve anatomy in individuals undergoing emergency surgery for acute severe mitral regurgitation (MR) following balloon mitral valvotomy (BMV). In addition, the clinical profile and outcomes are highlighted.

Spontaneous asymptomatic coronary artery dissection in a young man

Spontaneous coronary artery dissection (SCAD) is a rare condition that most often presents as acute coronary syndrome or sudden cardiac death. Here we present the case of a young man of 25 years, who had remained asymptomatic in spite of SCAD. This case highlights the fact that spontaneous dissections can occur at a young age and can involve more than one coronary artery, without producing clinical symptoms.

Incidence and Predictors of Atrial Septal Defect after Percutaneous Transvenous Mitral Commissurotomy – A Transesophageal Echocardiographic Study of 209 Cases

Background: The incidence of atrial septal defect (ASD) after percutaneous transvenous mitral commissurotomy (PTMC) ranges from 15.2% to 92% in small studies. Aim: To estimate the incidence of atrial septal defect (ASD) following PTMC and to determine the factors contributing to its development. Methods: We studied 209 patients with mitral stenosis (MS) undergoing PTMC. Transesophageal echocardiography (TEE) with color Doppler examination was performed to detect ASD. Results: TEE demonstrated ASD in 139 (66.5%) of 209 patients. The mean diameter of the interatrial septal defect detected by TEE was 4.47 ± 1.7 mm. The most common site of septal puncture was the inferior vena caval side of the interatrial septum followed by fossa ovalis. Color flow imaging across the defect showed left to right shunting in all the patients (100%). We examined the relationship of age, Wilkins score, left atrial volumes, the mitral valve orifice area, mitral valve gradient, and the degree of mitral and tricuspid regurgitation between the group that developed ASD and the group without ASD and found that none of these factors predicted the development of ASD. A residual ASD was seen in 11 patients (8.7%) at 6‐month follow‐up. Conclusion: Incidence of residual atrial septal defect immediately following PTMC by TEE color flow Doppler imaging is 66.5%. Surrogate markers of elevated left atrial pressures do not determine the development of atrial septal defect after PTMC. The majority of the defects close spontaneously and a residual defect is observed in 8.7% patients at 6 months.

Ruptured mitral-aortic intervalvular fibrosa aneurysm with flail aortic valve.

Rupture of mitral-aortic intervalvular fibrosa aneurysm is a rare complication of aortic valve endocarditis.1 A 43-year-old man presented with persistent fever and progressive dyspnoea of 3 months duration. On admission, he was in florid pulmonary oedema and clinical examination showed findings of severe aortic regurgitation. His electrocardiogram revealed complete heart block with junctional escape rhythm. The echocardiogram showed an aneurysm of mitral-aortic intervalvular fibrosa in parasternal long-axis …

Cardiac tumour in a patient with rheumatic heart disease.

A 45-year-old female known to suffer from rheumatic heart disease (RHD), presented with breathlessness of 1 year duration. Two-dimensional echocardiography revealed significant mitral and aortic valve disease mandating double valve replacement. In addition, an unusual finding in the form of a well-defined, densely calcified intramyocardial left ventricular mass was noted on echocardiography. The nature and extent of the mass was assessed by additional imaging modalities. Patient underwent excision of the mass followed by double valve replacement. Histopathology was consistent with cardiac calcific amorphous tumour (CAT). An unusual occurrence of CAT in a patient with RHD is presented herein. This rare tumour has not been previously described in patients with RHD.

Novel transcatheter closure of internal iliac arteriovenous malformation

Arteriovenous malformations arising from iliac arteries are rare anomalies. Percutaneous embolization of such malformations is an established therapeutic option. In this paper, we will describe a case, wherein the internal iliac artery feeding a giant arteriovenous fistula was closed using a patent ductus arteriosus (PDA) duct occluder percutaneously. The PDA duct occluder is a versatile device that can be used as an alternative to vascular plugs.

Tombstone-like electrocardiographic changes during exercise stress test

A 45-year-old man showed tombstone-like electrocardiographic change during stage 1 of stress testing, using Bruce protocol. The raw rhythm strip did not show any ST-T changes. These pseudochanges were probably the result of computer-synthesized averaging algorithm errors.

ST-segment elevation in right precordial leads in acute pulmonary embolism

A 58-year-old male presented with sudden onset of chest pain and breathlessness with hypotension. Electrocardiography demonstrated sinus tachycardia, right bundle branch block (RBBB) and ST-segment elevation in V1 and right precordial leads. These findings were suggestive of right ventricular myocardial infarction (RVMI). However, echocardiography revealed a large clot in main pulmonary artery with severe right ventricular dysfunction and no wall motion abnormality. Coronary angiogram demonstrated the normal left and right coronary system. Pulmonary angiogram revealed clots in right side branch pulmonary arteries. ST-segment elevation in right precordial leads is a rare finding in acute pulmonary embolism that mimics RVMI.

Gelatin sponge mimicking left atrial clot in rheumatic mitral stenosis

We report the case of a 23-year-old female who underwent balloon mitral valvotomy for severe symptomatic mitral stenosis. Following septal puncture, the patient developed cardiac tamponade, which warranted sternotomy to suture the rent in the inferior vena cava-right atrial junction. The postoperative echocardiogram revealed nonhomogenous irregular opacities within the left atrium suggesting the possibility of thrombus formation. As the patient was in sinus rhythm and peri-procedural activated clotting time was in therapeutic range, clot formation was unlikely. A review of operative notes revealed placement of absorbable hemostatic gelatin sponge within the pericardium, which was mimicking left atrial clot. This potential pitfall has to be recognized in echocardiograms, as it will avoid inappropriate anticoagulant therapy.