Ashish Agarwal

Dancing vegetations: Kocuria rosea endocarditis

We present images of a 35-year-old man with rheumatic mitral regurgitation. The patient presented with a 1 month history of continuous fever, worsened exertional dyspnoea and orthopnoea. With a clinical suspicion of infective endocarditis, the patient initially underwent a transthoracic echocardiogram, which revealed the possibility of vegetations attached to the mitral leaflets, though not definitively. In order to confirm the diagnosis, the patient was subjected to a transoesophageal echocardiogram, which showed an astounding image having multiple vegetations apparently dancing in …

Successful percutaneous removal of broken mitral valvuloplasty coiled tip guidewire

Complications related to hardware malfunction during balloon mitral valvuloplasty (BMV) are rarely met in catheterization laboratory. However, the consequences can be grave including death. We report an extremely rare complication of fracture of BMV coiled tip guidewire, which was successfully retrieved percutaneously with a relatively simple technique. Finally the procedure was completed without any complication.

Sinus node dysfunction complicating viper bite

Viper venom toxicities comprise mainly bleeding disorders and nephrotoxicity. Cardiotoxicity is a rare manifestation of viper bite. We describe the case of a previously healthy 35-year-old man who developed coagulopathy and sinus node dysfunction following a viper bite. Electrocardiography showed sinus arrest and junctional escape rhythm. This is the first account of sinus node dysfunction caused by a viper bite.

Pulmonary hypertension due to presence of isolated partial anomalous pulmonary venous connection: A case report

Anomalous pulmonary venous return is an uncommon congenital malformation which can be broadly categorized into partial or total, of which the former is more common. The anomaly is considered to be partial if some of the pulmonary veins drain into the systemic circulation and total if all the pulmonary veins drain into systemic circulation. Isolated partial anomalous pulmonary venous return (PAPVC) is an uncommon finding and is a very uncommon cause of pulmonary arterial hypertension. Whilst many patients with PAPVC remain asymptomatic, some may present at a later age with symptoms related to left-to-right shunt, pulmonary hypertension and right heart failure. We are presenting an interesting case report of an 18 years old patient who presented with exertional dyspnea and fatigue conforming to NYHA class II symptom status. Trans-esophageal echocardiography revealed isolated obstructive PAPVC as the cause for pulmonary hypertension without other demonstrable left-to-right shunts.

Coronary artery disease in patients undergoing cardiac surgery for non-coronary lesions in a tertiary care centre

Background The objective of the present study was to determine the prevalence of coronary artery disease (CAD) in patients undergoing surgery for various valvular as well as non-valvular cardiac pathologies. Methods Patients with various valvular and non-valvular pathologies were selected. All patients with age ≥40 years and an indication for open heart surgery underwent pre-operative coronary angiogram and were included in the study. Results The mean age was 51.5 ± 9.02 years. 178 (59.3%) patients were males and 122 (40.7%) patients were females. Out of 300 patients, 270 (90%) patients had valvular heart disease (VHD) and 30 (10%) patients had non-valvular heart disease. Rheumatic heart disease (RHD), mitral valve prolapse (MVP), degenerative aortic valve disease (DAVD) and bicuspid aortic valve (BAV) was present in 161 (53.7%), 17 (5.7%), 60 (20%) and 32 (10.7%) patients respectively. Overall, 26 (8.7%) patients were found to have significant CAD. CAD was significantly more common in patients with VHD as compared to patients with other etiologies (1 patient, 3.3%, p < 0.05). In the valvular group, DAVD patients had maximum prevalence of CAD (14 patients, 23.4%, p < 0.05). In the group with CAD, the presence of variables such as age >60 years, male sex, typical angina, HT, dyslipidemia and smoking were significantly greater as compared to those with normal coronaries. Conclusion The overall prevalence of CAD among patients undergoing non-coronary cardiac surgery is 8.7%. Coronary artery disease is relatively uncommon in patients with rheumatic VHD (4.9%), while its prevalence is highest in DAVD (23.4%).

Persistent Left Superior Vena Cava Draining into Left Atrium as a Cause of Persistent Systemic Desaturation after Surgery

Persistent left superior vena cava (LSVC) is a rare congenital anomaly which usually produces no physiologic derangements if it drains into the right atrium via the coronary sinus, but it may cause significant desaturation when it drains into the left atrium (LA). Failure to diagnose LSVC communicating with the LA preoperatively may lead to serious consequences. We are describing an interesting case of a boy who presented with systemic desaturation due to an undetected LSVC after having undergone corrective surgery for atrioventricular canal defect. We have demonstrated that echocardiography with agitated saline contrast is a simple, accurate, and inexpensive diagnostic modality.

Total anomalous systemic venous drainage to coronary sinus

Congenital anomalies of the systemic venous return forms a spectrum of malformations with a diverse physiological consequence1 which may occur independently or as part of complex isomerisms.2 We report a case of a 12-year-old boy, who had history undergone percutaneous balloon coarctoplasty a year previously at a different centre of which specific procedure-related details were not available, and presented for routine follow-up at our centre. He was asymptomatic with an arterial saturation of 98%. Transthoracic echocardiography revealed situs solitus with the aorta and hemiazygous vein on the left side of the spine and absence of the inferior vena cava (IVC) (figure 1). Hepatic veins were draining directly into the right atrium (RA) and aorta and hemiazygous veins were arranged in an anteroposterior orientation (figure 1). The right superior vena cava (SVC) was absent and …

Large vegetation in a case of bacterial endocarditis by a rare commensal organism: Kocura rosea

Large vegetations are usually seen in cases of fungal endocarditis and most cases of bacterial endocarditis are associated with a single or multiple small vegetations, most of which are usually too small to be visible on a transthoracic echocardiogram. We present a case of a middle-aged man with a prior history of moderate rheumatic mitral regurgitation who had a history of having received complete treatment for …

Giant Right Atrium in a Case with Rheumatic Heart Disease

Massive right atrium (RA) enlargement is certainly more common in children than in adults, owing to rare congenital anomalies and most commonly due to Ebstein’s anomaly. RA could be enlarged in a case of rheumatic heart disease especially when associated with severe mitral valve disease, pulmonary hypertension, or severe tricuspid stenosis. We are presenting a case of 25-year-old female patient who presented with features of congestive heart failure. Clinical examination revealed engorged and pulsatile jugular vein with prominent “V”-wave and large “Y” descent, grade III/VI pansystolic murmur at left lower parasternal area and pulsatile hepatomegaly. Transthoracic echocardiography (TTE) (Philips HD7 XE System, Eindhoven, The Netherlands) at apical long-axis view revealed a giant RA, measuring 12.1 9 10.5 cm (Fig. 1A) with RA area of about 97.5 cm (Fig. 1B). There was presence of severe organic tricuspid regurgitation (TR) along with thickened mitral cusp with trivial mitral regurgitation (movie clip S1). Rheumatic etiology was also confirmed by parasternal long-axis view by the thickening of both mitral and aortic leaflets (movie clip S2). Apical five-chamber view showed mild aortic regurgitation (AR) along with giant RA (movie clip S3). Tricuspid valve (TV) annulus was measured as 5.17 cm (Fig. 2). Continuous-wave (CW) Doppler image at TV showed TR jet of 25 mmHg and there was mild tricuspid stenosis with gradient of 5/2 mmHg (Fig. 3). Severe TR was confirmed by the presence of late systolic flow reversal of TR jet into hepatic vein (movie clip S4) in subcostal echocardiography at long-axis view and also confirmed by pulse-wave Doppler wave at the level of hepatic vein (Fig. 4). The RA volume measured in our case was about 1000 mL which is the largest description so far described in the literature. So far, 5 cases reported in the literature other than those cases aneurysm or diverticulum of RA, but nowhere etiology was due to rheumatic heart disease. A