Hema Kulkarni

Control of heart rate versus rhythm in rheumatic atrial fibrillation: a randomized study.

Background: Patients with rheumatic heart disease with atrial fibrillation incur significant morbidity and mortality. Which approach, ventricular rate control or maintenance of sinus rhythm, in this setting might be superior is not known. The role of amiodarone in this patient population for maintaining sinus rhythm has not been evaluated. Methods and Results: We prospectively studied 144 patients with chronic rheumatic atrial fibrillation in a double-blind protocol in which rhythm control (group I), comprising 48 patients each with amiodarone (group Ia) and placebo (group Ib), were compared with each other and with patients in a ventricular rate control group (group II) in which the effects by diltiazem were determined (n = 48, open-label). Direct current cardioversion was attempted in group I. The mean age of the study population was 38.6 ± 10.3 years, left atrial size, 4.7 ±0.6 cm; atrial fibrillation duration, 6.1 ± 5.4 years; and 72.9% had valvular interventions performed. At 1 year, 45 patients with sinus rhythm in group I compared with 48 in group II demonstrated an increase in exercise time (2.6 ± 1.9 vs. 0.6 ± 2.5 min, P = .001), improvement in New York Heart Association class of 1 or more (P = .002), and improvement in the quality-of-life score of one or greater (P = 0.01) with no difference in hospitalizations, systemic bleeds, or thromboembolism. Five patients died in group II; none died in group I (P =.02). In group I, 73 of 87 (83.9%) patients converted to sinus rhythm and 45 of 86 (52.3%) patients maintained the rhythm at 1 year. Conversion rates were 38 of 43 (88.4%) with amiodarone versus 34 of 44 (77.3%) with placebo (P = .49); the corresponding rate for maintaining sinus rhythm was 29 of 42 (69.1%) versus 16 of 44 (36.4%) (P = .008). A larger number of electrical cardioversions were required in the placebo group (2.1 vs. 1.4, P = .011). Conclusions: Maintenance of sinus rhythm is superior to ventricular rate control in patients with rheumatic atrial fibrillation with respect to effects on exercise capacity, quality of life, morbidity, and possibly mortality. Sinus rhythm could be restored in most patients, and amiodarone was superior to placebo in the restoration and maintenance of sinus rhythm.

New technique using temporary balloon occlusion for transcatheter closure of patent ductus arteriosus with Gianturco coils

We describe our early experience with a new technique involving temporary balloon occlusion for transcatheter closure of patent ductus arteriosus (PDA) using single or multiple Gianturco coils. Coil occlusion was attempted in 21 patients of median age 3 (range 1-11) years, and angiographic PDA diameter 3.0 mm +/- 0.87 mm. The inflated balloon of a pulmonary wedge pressure catheter over a transductal wire was used to mechanically hold the first extruded loop of the coil at the pulmonary end of the duct. If a residual shunt persisted after the delivery of the first coil, additional coils were delivered with or without the balloon support. One to nine coils (median 2) of different sizes varying between 3-12 mm diameter and 4-15 cm length were used. Immediate angiographic occlusion rate was 47.6%. However color Doppler (CD) at 24 hours and at 6 weeks revealed complete closure in 66.6% and 80.9%, respectively. Blood transfusion was required in 2 (9.5%) patients. Three out of 56 coils (5.4%) embolized during deployment. The use of balloon occlusion is effective and safe in the treatment of ducti up to 4.7 mm. Residual shunts lend to occlude with time.

Follow-up after coil closure of patent ductus arteriosus

A prospective serial follow-up after coil closure of patent ductus arteriosus in 84 patients showed a cumulative duct closure up to 96% at the end of 2 years. Five patients underwent transient recanalization, and 4 patients required repeat procedure for residual shunt or recanalization.

Acutely blocked Blalock-Taussig shunt following cardiac catheterization: Successful recanalization with intravenous streptokinase

bolytic therapy, the patient underwent an emergency pulmonary embolectomy from which he recovered uneventfully. The pathologic specimen was described as a tubular pulmonary embolus measuring 1 cm by 30 cm, that appeared to have originated in the lower extremity (Fig. 3). Prior reportsle3, 5, 6 have described right-sided masses that were pedunculated, coiled and string-like, or fusiform. There is one prior report4 of a right-sided intracavitary lesion that was described as serpentine, located in the right atrium and prolapsing through the tricuspid valve during diastole. 2D-Echo detection of a pulmonary embolus with a serpentine structure that traverses the right ventricle and extends into the main pulmonary artery and left pulmonary artery branch has, to our knowledge, not been reported. Thus the diagnosis of pulmonary embolism origmating from the lower extremity veins should be considered when a tubular, mobile mass is visualized by 2D-Echo m the right-sided heart chambers or in the pulmonary artery. Given the potentially life-threatening nature of this pathology, consideration should be given to rapid institution of emergency therapy when this echocardiographic appearance is seen.

Transcatheter closure of patent ductus arteriosus in children weighing <10 kg with Gianturco coils using the balloon occlusion technique

We evaluated the immediate and intermediate follow-up results of transcatheter closure (TCC) of patent ductus arteriosus (PDA) using Gianturco coils in children weighing < 10 kg. The results of PDA < or = 2.5 mm (group I, n = 18) and > 2.5 mm (group II, n = 16) were compared. Coils were deployed sequentially by transarterial route using a temporary balloon occlusion technique. The immediate clinical success rate in both groups was comparable. There was no significant difference in the number of coils required per patient and in the embolization rate between the two groups. Both groups had comparable occlusion rates at intermediate-term follow-up. At intermediate follow-up, one patient had developed left pulmonary artery stenosis while obstruction of the descending aorta was not seen in any; in 4 children the PDA had recanalized. Spontaneous reocclusion was observed in 3 of the latter at the last follow-up. We conclude that TCC of PDA is feasible and safe in children weighing < 10 kg with gratifying intermediate-term results.

Spontaneous coronary artery dissection in a young man with inferior wall myocardial infarction

Fig. 2. Proximal stenosis of left anterior descending coronary artery (LAD) (left upperpaneD assessed by new system for quantitative analysis of three-dimensional intracoronary ultrasound images.~, 4 Cross-sectional ultrasound images were reconstructed in two perpendicular longitudinal sections (I and II, right upper panels) and computerized contour detection was performed providing a three-dimensional view (left lowerpaneD and dimensions of lumen, plaque, and total vessel, calculated from area measurements. Mean diameter measurements (ram) of 200 consecutive ultrasound frames (right lowerpaneD are displayed, with plaque shown as white area between total vessel and lumen diameter. Note reduction of total vessel diameter from distal reference (mid-LAD) to target stenosis. Arrowheads in three-dimensional view and angiogram indicate site of stenosis, which is also displayed in cross-sectional ultrasound view (mid-left upper panel). LM, Left main coronary artery; PROX, proximal.

Pre-natal echocardiographic diagnosis and neonatal balloon dilatation of severe valvar pulmonic stenosis.

A case is presented below where pre-natal echocardiographic diagnosis of critical pulmonic valvar stenosis was made at 36 weeks of gestation. In view of the severe heart failure, successful balloon valvotomy was performed on day 4 of life. The child was asymptomatic at one month follow-up.

Coil occlusion of a residual ductus arteriosus remaining after implantation of a buttoned device

A 20-mo-old boy presented with persistence of significant shunt 13 mo after patent ductus arteriosus closure using the Sideris buttoned device. This residual shunt through the ductus arteriosus was successfully occluded using a Gianturco coil.