Ezhilan Janakiraman

Coronary intervention in anomalous origin of the right coronary artery (ARCA) from the left sinus of valsalva (LSOV): A single center experience

OBJECTIVE To assess the technical challenges in percutaneous coronary intervention of Anomalous right coronary artery arising from the left sinus of valsalva. METHODS Between year 2008 and 2012, a total of 17 patients underwent PCI for an angiographically significant lesion in the right coronary artery of an anomalous origin in the LSOV. Their procedure details such as usage of catheters, radiation time, amount of contrast used were assessed. RESULTS A total of 17 patients with anomalous right coronary artery underwent PCI during the above mentioned period. 8 patients had type A origin, 3 had type B origin and the remaining 6 had type C origin. Type A origin RCA were successfully cannulated in 6 patients with Judkins left 5.0 and in 2 patients using Judkins left 4.0. Extra back up (EBU) 3.5 were doing well in 2 patients of Type B origin and the remaining one patient was successfully cannulated using Judkins left 4.0. In type C origin 4 patients had successful cannulation with Amplatz Left 1.0, 1 patient with Amplatz Left 2.0 and 1 patient with Judkins left 4.0. The mean fluoroscopic time was 20.7 min and amount of contrast used was 210 ml. CONCLUSION PCI of anomalous RCA origin from LSOV requires appropriate guide catheter selection according to the anatomy of origin for successful cannulation and to reduce the contrast usage and radiation exposure.

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.

Left aortic sinus to right atrial tunnel

A 21-year-old asymptomatic lady detected to have heart disease at 12 years of age during a routine medical examination referred to us for further evaluation. The clinical examination was normal except for a grade 3/6 continuous murmur over the right sternal border. Echocardiogram showed minimal dilatation of the right-sided chambers and a fistulous tract originating from the left aortic sinus and draining into right atrium ( Panel A ). To define the anatomy precisely, a computed tomographic angiogram was done which showed a dilated and elongated left aortic sinus with a fistulous communication to the right atrium near the …

Characteristics, treatment and one-year outcomes of patients with acute coronary syndrome in a tertiary hospital in India.

BACKGROUND Coronary artery disease (CAD) is a major cause of death in India. Data on outcome of CAD is scarce in the Indian population. This study determined the characteristics, treatment and one-year outcomes of acute coronary syndrome (ACS) in an Indian Cardiac Centre. METHODS We carried out a cross sectional retrospective analysis of 1468 ACS patients hospitalized between January 2008 and December 2010 and followed up for 1 year in the Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai. Mortality at 1 year, its determinants and 1 year major adverse cardiac events (MACE) were determined. RESULTS The patients were aged 62.2 ± 11.2 years; males (75.2%) and had ST segment elevation myocardial infarction (STEMI) (33.9%), non ST segment elevation myocardial infarction (44.2%) and unstable angina (21.9%). Key pharmacotherapy included aspirin (98.2%), clopidogrel (95.1%), statins (95.6%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (50.6%) and beta blocker (83.1%). Angiography rate was 80.6%. In the STEMI group, 53.3% had primary angioplasty, 20.3% were thrombolysed and 16.1% received sole medical therapy. Overall coronary artery bypass graft rate was 12.4%. At one year, all-cause mortality and composite MACE were 2.5% and 9.7%, respectively. MACE included death (2.5%), reinfarction (4.0%), resuscitated cardiac arrest (1.8%), stroke (1.1%) and bleeding (0.4%). Main factors associated with mortality were combined left ventricular systolic and diastolic dysfunction (OR = 20.0, 95% CI = 6.63-69.4) and positive troponin I (OR = 12.56, 95% CI = 1.78-25.23). Troponin I independently predicted mortality. CONCLUSIONS ACS population was older than previously described in India. Evidence-based pharmacotherapy and interventions, and outcomes were comparable to the developed nations.

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.

Concurrent Endovascular Repair of Extensive Thoracic Aortic and Infra-renal Aorto-iliac Aneurysms

A 60 year-old woman presented with large extensive aneurysms in the thoracic aorta and infra-renal abdominal aorta with a normal segment of visceral aorta in between; the entire right common iliac artery was also aneurysmal. Concurrent endovascular repair of all aneurysmal regions was successfully performed using a left common iliac artery conduit to access the aorta, and multiple stent-grafts; a chimney graft preserved blood flow into the left subclavian artery. There were no features of spinal cord ischaemia despite coil embolisation of the right hypogastric artery. CT angiogram at six months showed patent stent-grafts with no endoleaks. The patient continued to do well at one-year clinical follow-up. Concurrent endovascular repair of thoracic and abdominal aortic aneurysms can be safely and successfully performed when anatomically feasible, and is an attractive alternative to staged or hybrid repair.

Primary Percutaneous Thrombus Aspiration Alone as Definitive Intervention for Left Main Coronary Artery Occlusion Presenting as Acute Anterior Wall ST Elevation Myocardial Infarction

Primary angioplasty and stenting remains the standard of care for patients presenting with acute ST-segment elevation myocardial infarction. Recently, thrombus aspiration has been shown to improve the myocardial perfusion and outcomes in STEMI. In a subset of patients thrombus aspiration may result in optimal perfusion and minimal residual stenosis. These patients may be managed without additional stenting. Three patients with anterior wall STEMI were successfully managed with thrombus aspiration alone without additional stenting. All three are doing well at 30 day follow up with significant improvement in left ventricular ejection fraction.

Epidermal bulla: A dermatology complication of radial artery compression band

Patent hemostasis technique is used with the trans radial (TR) band to prevent radial artery occlusion following diagnostic coronary angiogram or percutaneous coronary intervention using radial artery access. We report epidermal bulla as a complication of TR band usage and a modified patent hemostasis technique using barbeau test to prevent this complication.

☆Predictors of short-term outcomes in patients undergoing percutaneous coronary intervention in cardiogenic shock complicating STEMI—A tertiary care center experience

Background Studying the outcomes in patients presenting with cardiogenic shock with ST-segment elevation myocardial infarction (CS-STEMI) and undergoing primary or rescue percutaneous coronary intervention (PCI) may give an insight to the unmet needs in STEMI-care in our region and may help in future recommendations in improving survival. Materials and methodolgy During the period from January 2001- June 2017, there were 114 patients included in the study. The demographic, clinical and angiographic characteristics were compared between the survivors and non-survivors. All these variables were also compared between two-time frames (Phase 1- January 2001 to June 2007; Phase 2- July 2007 to June 2017). Results Among patients undergoing PCI for STEMI, 7.5% were in cardiogenic shock. In-hospital mortality for the patients included in the study was 53.5%. Total ischemic time (OR = 0.99, 0.99–1; p = 0.02), left ventricular ejection fraction (LVEF) (OR = 0.90, 0.82–0.98; p = 0.02), need for cardio-pulmonary resuscitation (OR = 0.12, 0.24–0.66; p = 0.01), and post PCI TIMI flows (OR = 0.08, 0.02–0.29; p < 0.001) were the significant determinants of in-hospital mortality in the regression analysis. There was no significant change in mortality between the two phases of the study, though there was a reduction in total ischemic and door-to-balloon times, transfer admissions, use of thrombolytics, glycoprotein IIb/IIIa inhibitors, intra-aortic balloon pump, and mechanical ventilation in phase 2. Conclusion Patients presenting in CS-STEMI and undergoing PCI continue to experience high mortality rates, despite improvements in total ischemic times. Further improvement in the systems-of-care are required to bring about reduction in mortality in this high-risk subset.

Prevalence of parameters of suboptimal scaffold deployment following angiographic guided bioresorbable vascular scaffold implantation in real world practice - an optical coherence tomography analysis

AIM To assess the prevalence of suboptimal bioresorbable vascular scaffold (BVS, Abbott Vascular, Santa Clara, California) deployment in real world practice with intracoronary optical coherence tomography (OCT) imaging. METHODS Consecutive patients who underwent percutaneous coronary intervention using BVS and the final optimization assessed with OCT imaging in two tertiary care centers between December 2012 and February 2015 were evaluated for parameters of suboptimal scaffold deployment by OCT. RESULTS Overall, 36 scaffolds were implanted in 27 patients during this period. Mean age of the population was 54.7±8.2years and 19 (70.4%) were type B2/C lesions. The prevalence of parameters of suboptimal scaffold deployment were: underexpansion-22(61.1%), geographic miss-3(8.3%), tissue prolapse-7(25.9%), scaffold pattern irregularity-1(2.8%), longitudinal elongation-7(38.8%). Of the 7 overlaps imaged: excessive overlap was observed in 3 and scaffold gap in one. The median duration of follow up was 679days (range 193-963days). There were four events during this period. None were associated with suboptimal scaffold deployment. CONCLUSION OCT based parameters of suboptimal scaffold deployment are common in real world scenario and were not associated with adverse outcomes on long term follow up. These findings need to be confirmed in larger studies.