Harinder K. Bali

Yoga - an ancient solution to a modern epidemic. Ready for prime time?

Cardiovascular disease (CVD), the leading cause of morbidity and mortality worldwide, is clearly of pressing clinical and economic significance, underscoring the need for effective primary prevention.1 Although genetic predisposition plays an important role, the main culprit responsible for the burgeoning epidemic of CVD are the modifiable risk factors related to lifestyle. They not only aid in the initiation but also in the progression and complications of atherosclerosis-related diseases. Hypertension, dyslipidemia and diabetes are all lifestyle-related conditions and are, therefore, modifiable. Metabolic syndrome has recently been recognized as an important risk factor particularly in the Indian subcontinent. Increased sympathetic activity, enhanced cardiovascular reactivity and reduced parasympathetic tone have been strongly implicated in the pathogenesis of metabolic syndrome and in the development and progression of atherosclerosis and cardiovascular disease. Recent research offers compelling evidence that chronic psychological stress and negative affective states contribute significantly to the pathogenesis and progression of insulin resistance, glucose intolerance, hypertension, dyslipidemia and other metabolic syndrome-related conditions and ultimately increase the risk for CVD morbidity and mortality. In the light of evidence of strong influence of psychosocial factors on the development of CVD, mind-body therapies may have considerable potential in its prevention and treatment. Of particular interest in this regard is Yoga, an ancient mind-body discipline which originated in our country almost 4000 years ago and has been widely used in the management of hypertension, diabetes and related chronic insulin resistance conditions. Of the seven major branches of yoga, Hatha (or forceful), Raja (or classical) and Mantra yoga are the best known and most widely practiced forms. Both Hatha and Raja yoga emphasize specific postures (asanas), including both active and relaxation poses as well as breath control (pranayama), concentration (dharanas) and meditation (dhyana). Yoga is a safe, simple-to-learn, noninvasive and inexpensive practice requiring little in way of equipment or professional training. However, as with most practices originating from the east, it was initially met with a lot of reluctance and resistance in Western countries. Moreover, lack of systemic studies did not help its cause. This has changed steadily in the last few decades with a growing body of evidence2–6 suggesting that practice of yoga may reduce risk factors for CVD and may attenuate signs, reduce complications and improve the prognosis of those with frank or underlying disease. Since 1970, more than 50 studies from different countries have been published in peer reviewed journals investigating the potential influence of yoga and yoga-based programs on one or more core indices of CVD including measures of insulin resistance, lipid profiles, body weight and composition and on blood pressure. Interventions ranged in length from 40 days to 12 months in various studies and they were carried out on healthy young adults as well as in patients with type II diabetes, hypertension and coronary artery disease.

A tale of early Reel syndrome caused by an over-enthusiastic masseuse.

Twiddler syndrome is a form of pacemaker lead dislocation caused by the coiling of the pacemaker leads due to pulse generator rotation on its long axis. Similar to Twiddler syndrome, Reel syndrome occurs due to rotation of the pulse generator on its transverse axis, leading to lead dislocation or fracture, followed by clinical symptoms of dislodged leads. We report a case of 75 years old woman with Reel syndrome presenting with syncope.

PCI in a case of dual (type IV) LAD with anomalous origin of the LCx from RCA

Dual left anterior descending coronary artery (LAD) originating from the left main stem and the right coronary artery (type IV LAD) is a rare congenital anomaly. Its association with an anomalous origin of the left circumflex (LCx) from RCA is even rarer. We describe a patient presenting with acute inferior wall myocardial infarction, who was subsequently found to have this coronary anomaly. He underwent staged PCI of the dominant RCA and anomalous LCx successfully through the radial route. We conclude that anomalous coronaries can be safely and successfully treated through the radial route after careful evaluation of origin and course of the anomalous vessels. CT coronary angiography is extremely useful in delineating the vessel course and particularly their relation to great arteries.

Collateral approach for LV lead implantation in a case with abnormal venous anatomy.

A 75-year-old man, 8 years after CABG, with ischemic cardiomyopathy underwent cardiac resynchronization therapy (CRT) for refractory heart failure. Retrograde occlusion venography revealed absence of lateral vein. A functionally occluded middle cardiac vein with branch to anterolateral vein was used for left ventricular lead implantation. Using a collateral route for left ventricular lead implantation is a new technique. Lead position was stable with excellent threshold. Follow-up at 6 months reveals continued stable lead position.