Hetan Shah

Septal thrombus in the left atrium: is the left atrial septal pouch the culprit?

cardioembolic strokes are responsible for more than 20% of all ischemic strokes. The examination of atrial sources of cardioembolic strokes has focused almost exclusively on the left atrial appendage (LAA) and the pathophysiology of thrombus formation at this site is well understood. However,

Validation of ‘left ventricular early inflow-outflow index’: A novel echocardiographic method for quantification of mitral regurgitation in an Indian population with special focus on rheumatic etiology

Background Quantification of mitral regurgitation (MR) has always required an “integrated approach” as there is no single gold-standard method. We investigated a new Doppler-derived parameter “left ventricular early inflow-outflow index (LVEIO)” for the quantification of MR and its likelihood to predict severe MR in correlation with already established parameters in an Indian population including a large subset of patients with rheumatic etiology. Methods A prospective study was performed at a major tertiary care center in western India over a 5-month period. Five hundred patients diagnosed with isolated MR including 260 (52%) patients with rheumatic etiology were included in the study after applying exclusion criteria. We analyzed MR using color flow jet, effective regurgitant orifice area (EROA), and vena contracta (VC) width. LVEIO is a simplification of the regurgitant volume (RV) method, which was calculated as “E velocity divided by LV outflow velocity integrated over the systolic ejection period left ventricular outflow tract velocity time integral” and compared with the established parameters. Results LVEIO was 4.65 ± 1.45, 6.56 ± 1.52, and 9.91 ± 3.70 among patients diagnosed with mild, moderate, and severe MR, respectively (p < 0.001). Those with LVEIO ≥8 were the most likely to have severe MR (positive likelihood ratio: 10.42). LVEIO had specificity of 93.25% for diagnosis of severe MR with positive predictive value of 86.36%. There was positive correlation observed between LVEIO and VC width (r = 0.591), RV (r = 0.410), and EROA (r = 0.778) (all p < 0.001) in the Pearson correlation test. The specificity of LVEIO remained consistent in diagnosing severe MR in patients with rheumatic etiology. Conclusion LVEIO is a simple yet specific Doppler echocardiographic parameter for estimation of severity of MR including that of rheumatic etiology.

Catastrophic Sudden Cardiac Death. Are there Lessons to be Learnt

Background: Sudden cardiac death is a catastrophic event which leads to loss of young and middle-aged population with dire consequences. Sometimes, a careful history, physical examination and most importantly electrocardiogram (ECG) can help in suspecting the common causes in young population like underlying channelopathies and cardiomyopathies which can further be diagnosed using echocardiography, cardiac MRI and in some cases genetic tests. Case summary: A 33-year-old male presented with sycope and ventricular tachycardia leading to death. This patient was diagnosed to have Arrythmogenic right ventricular dysplasia (ARVD) on post mortem pathological examination with features of fatty infiltration and thinning of right ventricular myocardium. Furthermore, on histologically fatty infiltration with inflammatory infiltrates were visualized. Discussion: Clinical awareness amongst physicians about cardiomyopathies especially ARVD with its subtle yet suggestive ECG changes is the need of the hour. ARVD is a rare disease and can be diagnosed with certainty by analyzing ECG and adding imaging to it. When diagnosed cases are treated appropriately, at least a few cases of sudden cardiac death can be averted.

Cardio-Renal Syndrome

Although newer pharmacologic and interventional therapies for the treatment of Heart failure continue to evolve, the optimum strategy of management for the patients with cardio renal syndrome is still unanswered. Various pathophysiologic mechanisms have been proposed including the low output hypothesis and the raised renal venous pressure hypothesis. These mechanisms have been tested and challenged in many trials. Although, modest benefit has been achieved with management strategies targeting these hypotheses. Role of biomolecules and neurohormones such as BNP, adenosine has provided newer insights in mechanisms of Cardio-renal syndrome (CRS). However, when studied in clinical trials, drugs targeting these pathways did not have significant clinical outcomes. Diuretics remain cornerstone of management. But their propensity to cause AKI and electrolyte disturbances when used at higher dosages limits their use. Vasodilator proves of clinical benefit in raised CVP states. But risk of hypotension and constant hemodynamic monitoring preclude their use in many clinical situations. Ultrafiltration had modest success in the initial studies, but recent trials have questioned their role in patients with ADHF. Pharmacologic therapies such as nesiritide, adenosine antagonists and vasopressin antagonists are still in trial phases and benefit has not yet been proved. Thus, our knowledge of CRS still needs depth and understanding of pathophysiologic mechanisms which when achieved may result in improved clinical outcomes and patient care. This review article on focuses on pathophysiology and management strategies of patients with CRS.

A rare and treatable cause of hypertension in pregnancy

Dear Editor A 25yearold pregnant patient in the 24th gestational week was referred for evaluation of resistant hypertension. There was significant obstetric history of one premature delivery with neonatal death and two instances of intrauterine fetal loss. The patient was asymptomatic except for occasional headaches. Hypertension, diagnosed during the first gestation 4 years ago, was poorly controlled in spite of the use of multiple antihypertensive agents. Clinical examination revealed a significant blood pressure difference in the upper and lower extremities (upper limb 178/106 mm Hg vs lower limb 120/94 mm Hg) with weak lower limb pulses. As part of the standard workup for secondary hypertension, echocardiography with color Doppler was performed, which revealed concentric left ventricular hypertrophy with good biventricular function. Interrogation of the abdominal aorta revealed marked narrowing with turbulent flow (Figure A and B). Levels of Creactive protein and erythrocyte sedimentation rate were both within the normal range. A provisional diagnosis of aortoarteritis involving the abdominal aorta was made—the socalled middle aortic syndrome.1 Cardiac catheterization with aortography was performed at the 28th gestational week with adequate measures to minimize fetal radiation exposure, confirming the presence of long segment narrowing of the abdominal aorta (Figure C) with pressure gradients of 86 mm Hg. A selfexpandable stent of 14 mm×70 mm (Epic, Boston Scientific) was deployed at the site of maximum narrowing (Figure D). Immediately following the procedure, the aortic pressure gradient decreased by more than half to 40 mm Hg. Thereafter, hypertension could be adequately controlled with monotherapy and the patient had an uneventful caesarean section at term with good outcome. To our knowledge, this is the first case describing interventional therapy for middle aortic syndrome during pregnancy with excellent fetomaternal outcome. Middle aortic syndrome may be secondary either to a congenital anomaly or acquired conditions such as Takayasu arteritis, infection, obliterative panarteritis, neurofibromatosis, retroperitoneal fibrosis, fibromuscular dysplasia, and mucopolysaccharidosis.2 Changes in the aortic wall during pregnancy, coarctationassociated aortopathy, and longstanding hypertension combine to increase the risk of aortic rupture/dissection. Also, poorly controlled hypertension leads to adverse fetal (growth retardation, placental abruption, and premature delivery) and maternal (renal failure and hypertensive crisis) outcomes.3 Given the unsatisfactory response to multiple antihypertensive agents and their adverse effect, intervention with stenting is preferred over a conservative approach.4 The procedure was carried out during the 28th week of gestation to minimize the effect of radiation on fetal organogenesis as well as the risk of preterm labor. The procedure is generally associated with low risk and subsequently enables adequate blood pressure control with good pregnancy outcome.

Absent right bundle branch block: Is it a clue of pre-excitation in Ebstein's anomaly?

A 14-year-old male with a history of symptomatic tachycardia was referred for ablation. Sinus rhythm electrocardiogram was not showing any pre-excitation. Tachycardia episode was showing antidromic tachycardia with left bundle branch block morphology. Echocardiographic examination was showing Ebsteins anomaly with septal tricuspid leaflet displaced 24 mm apically. The right bundle branch block (RBBB) was concealed during sinus rhythm. The RBBB was revealed with ablation of right posterior atriofascicular accessory pathway.