Gurappa G. Shetty

Intra-aortic balloon pump in toxic myocarditis due to aluminum phosphide poisoning.

IntroductionAluminum phosphide (ALP) is a pesticide that is highly toxic. It is a mitochondrial toxin that causes death by cardiac and metabolic toxicity. The most ominous effect is cardiac toxicity, which may range from minor electrocardiographic abnormalities to severe depression of cardiac contractility secondary to toxic myocarditis. There is no documented report of the use of Intra-aortic Balloon Pump (IABP) for toxic myocarditis from ALP poisoning, although it has been used effectively for toxic myocarditis due to other toxins.Case ReportWe are reporting a young female who presented with ALP poisoning, in cardiogenic shock due to myocarditis. We used an IABP for cardio-circulatory support until the effects of ALP resolved. She is the only reported survivor of ALP poisoning, presenting with cardiogenic shock.DiscussionSeveral reports describe the use of IABP for cardiogenic shock due to toxic myocarditis. There is no report in the medical literature using IABP for cardiogenic shock caused by ALP toxin-induced myocarditis. Our patient presented with cardio-circulatory shock, necessitating the use of inotropes and mechanical ventilation. As she did not improve despite ventilation and maximal doses of inotropes, IABP was used for cardio-circulatory support until the effects of ALP resolved.

Transcatheter closure of aortopulmonary window using Amplatzer device

Two cases of transcatheter closure of aortopulmonary window (APW) using an Amplatzer duct occluder in one and a septal occluder device in the second are described. Transcatheter device closure of APW should be considered when anatomy is favorable in terms of location and size of the defect with absence of associated anomalies. Cathet Cardiovasc Intervent 2003;59:402–405.

A look into Lee's score: peri-operative cardiovascular risk assessment in non-cardiac surgeries-usefulness of revised cardiac risk index.

OBJECTIVE The revised cardiac risk index (RCRI/Lees score) was designed for peri-operative risk assessment before elective major non-cardiac surgeries. Through this article, we report the usefulness of RCRI in our daily practice, while evaluating patients undergoing surgeries of varying risk. METHODS Only referred patients, aged ≥ 40 years, were included. Risk stratification was done using RCRI scoring system. Patients were categorised into 4 classes depending on 0, 1, 2, and ≥3 risk predictors (risk predictors were high-risk surgery, history of ischaemic heart disease (IHD), diabetes on insulin, history of stroke (cerebrovascular accident [CVA]), history of congestive heart failure (CHF) and serum creatinine of >2 mg%). Electrocardiograms (ECG) were done in all patients, while troponin I in intermediate and high-risk patients, and in others if symptomatic. Perioperative cardiovascular events were managed appropriately. RESULTS Of the 920 patients included, only 853 patients were analysed as 67 patients were not operated upon. The mean age was 59 ± 11years and 46% of the patients were women. Two hundred and ninety-two underwent high-risk surgeries, 97 patients had history of IHD, 89 had history of CHF, 36 gave history of CVA, 269 patients were diabetics on insulin and 68 had serum creatinine >2 mg%. Number of patients in Lees classes I, II, III, and IV were 311, 347, 150, and 52, respectively. 26 out of 853 patients had peri-operative events. Of the six variables in RCRI, only history of IHD was an independent predictor of events. Event rates increased as the RCRI class increased, i.e. 1.7%, 2.0%, 6.7%, and 7.7% for classes I-IV, respectively. Age >70 years, poor general medical condition, emergency surgery and left bundle branch block (LBBB) on ECG, were significantly associated with peri-operative events. CONCLUSION The RCRI is a useful tool in pre-operative risk stratification. It should perhaps be further updated to improve its predictive accuracy.

Visceral adiposity in young patients with coronary artery disease—a case control study

AIMS Central obesity is associated with an increased cardiovascular risk. We carried out a hospital based case control study in young patients with coronary artery disease (CAD) to assess the importance of visceral fat METHODS Coronary artery disease was established by coronary angiogram in all cases. Controls were age- and sex-matched subjects with normal coronary angiogram. Computed tomography scan performed at the level of the umbilicus to measure subcutaneous and visceral fat area (VFA). RESULTS Cases and controls were well matched in height, weight, and body mass index (BMI). Visceral fat area was significantly higher (122.58 ± 37.59 vs. 88.4 ± 36.95 cm(2); P=0.003) in cases whereas subcutaneous fat area was similar in cases and controls. Visceral fat area was an excellent predictor of cardiovascular risk (area under receiver operating characteristics curve 0.915 cm(2)). Visceral fat area correlated with BMI, waist hip ratio, blood sugar, triglycerides, and C-reactive protein significantly. CONCLUSION Visceral adiposity is associated with an increased risk of CAD and it correlated with anthropometric, metabolic, and inflammatory markers.

Syphilitic Aortitis: An Uncommon Cause of Acquired Aortopulmonary Fistula

Cardiovascular syphilis has become a medical curiosity with the advent of widespread use of penicillin for the treatment of early syphilis. We report a case of a 37-year-old man who presented with sudden onset breathlessness that worsened insidiously for 1 year. Diagnosis of syphilitic aortopulmonary fistula was confirmed by aortography, contrast computed tomography, and histopathology. The patient underwent successful surgical correction. A high level of suspicion and awareness is needed for the diagnosis of this now rare disease. This entity is only amenable to surgical correction, even as existing surgical techniques need constant improvisation and individualization to each patient.

Validation of the GRACE score for prognosis in Indian patients with acute coronary syndromes

AIM To validate the global registry of acute coronary events (GRACE) score in acute coronary syndromes (ACS) patients and study its angiographic correlation. METHODS AND RESULTS Two-hundred and thirty-five ACS patients were studied for the combined endpoint of all-cause in-hospital mortality and non-fatal infarction/reinfarction. We tested the predictive accuracy of the composite GRACE score using the receiver operating characteristics (ROC) curve. Lower systolic blood pressure (SBP) (odds ratio [OR] 7.93, P=0.005), ST-segment deviation (OR 7.79, P=0.02) and cardiac biomarker positivity (OR > 6.52, P=0.01) were significantly associated with events. Serum creatinine > 1.4 mg/dL showed a trend towards statistical significance (OR 4.14, P=0.05), whereas age > 50 years (OR 3.62, P=not significant [NS]) and Killips class 4 (OR 2.71, P=NS) showed good association. The best value for predicting events was a GRACE score of > 217 and these patients were more likely to have double/triple vessel disease (P = 0.0009). The C statistic for the GRACE score was 0.75. CONCLUSION Higher GRACE score predicts in-hospital events and more severe angiographic coronary artery disease (CAD).