Himanshu Mahla

Successful retrieval of fractured pressure wire tip (FFR) by hybrid technique

Coronary angiography and angioplasty are relatively safe procedures but not without complications. We report an interesting case of effort angina taken for angioplasty of the LCX and assessment of fractional flow reserve (FFR) for the LAD artery lesion in which the tip of the pressure wire was broken and embolised to the LCX while trying to retrieve it. This is the first case report using a hybrid technique with a slip catheter for the successful retrieval of a fractured FFR wire.

The naughty knot in catheterisation laboratory

A 60-year-old man presented to the emergency department with multiple syncopal episodes. A 12-lead ECG revealed complete heart block with a ventricular rate of 50 bpm (figure 1). Emergency temporary pacing was performed through the transjugular route without fluoroscopic guidance (as the patient arrived at our institute at night) and ventricular capture confirmed (figure 2). The patient did well overnight but at the time of morning rounds he started having giddiness again. ECG showed complete heart block with no pacing spikes. The patient was taken to the catheterisation laboratory. Flouroscopy revealed a knot in the pacing lead (figure 3 …

Coronary ectasia: manifesting as acute coronary syndrome

A 56-year-old woman presented with 2 days history of anginal chest pain. No risk factors for coronary artery disease, except family history in paternal uncle. Cardiac examination was normal. ECG showed ST segment depression in leads V1–V6. Echocardiography showed regional wall motion abnormality in left anterior descending artery (LAD) territory with adequate left ventricle ejection fraction. The patients troponin T test was positive according to reference laboratory standards. The patient was diagnosed as having acute coronary syndrome-non-ST segment elevation myocardial infarction. Coronary …

Unusual cause of acquired RBBB

A 34-year-old woman presented with a 3-day history of atypical chest pain. There were no risk factors for coronary artery disease. ECG showed right bundle branch block (RBBB) with normal sinus rhythm (figure 1). Troponin T test was positive according to reference laboratory standards. Echocardiogram (transthoracic) showed no regional wall motion abnormality with normal left ventricle (LV) ejection fraction (videos 1 and 2). Coronary angiogram showed isolated occlusion of septal artery with insignificant disease in left anterior descending (LAD; figures 2 and 3; video 3). Left-circumflex artery and right …

Transcatheter closure of coronary arterial fistula: A single-center experience

Background: Transcatheter closure of coronary artery fistula has emerged as an alternative to surgery. The management of coronary artery fistula is complicated, and recommendations have been based on anecdotal cases or very small retrospective series. Objective: The objective of this study is to determine the safety, feasibility, and immediate and intermediate follow-up results of the transcatheter closure of coronary arterial fistula. Methods: We reviewed the records of all patients presenting with significant coronary arterial fistulae between January 2011 and May 2014. Those with additional complex cardiac disease requiring surgical management were excluded from the study. A total of nine patients aged 11 months to 58 years with congenital coronary arterial fistulae underwent percutaneous transcatheter closure using various devices between January 2011 and March 2014. The immediate closure results and clinical follow-up were reviewed using information from a database or telephone calls to the center. Results: Fistulae originated from the right coronary artery in 4 patients (44.4%), left circumflex coronary artery in 3 patients (33.3%), and left anterior descending coronary artery in 2 patients (22.2%). The drainage site was the right atrium in 5 patients (55.6%), right ventricle in 2 patients (22.2%), left ventricle in 1 patient (11.1%), and coronary sinus in 1 patient (11.1%). All of the patients (100%) underwent successful transcatheter closure using the various devices. Angiography after device deployment revealed complete occlusion in 7 patients (77.7%) and trivial to mild residual flow in 2 patients (22.2%). Two patients (22.2%) had transient ST-T wave changes after the procedure. The Amplatzer Vascular Plug II was used in four patients (44.4%), Amplatzer Duct Occluder II was used in three patients (33.3%), and Lifetech Duct Occluder was used in two patients (22.2%). The left ventricular end-diastolic volume decreased from a mean baseline value of 82.77 ± 4.55 ml/m 2 to 77.22 ± 3.49 ml/m 2 at 1 month after the procedure (P = 0.001) and had normalized in all of the patients at 2 months postprocedure. The cardiothoracic ratio decreased from a mean baseline value of 0.57 ± 0.035 to 0.53 ± 0.02 at the 1-month follow-up and further decreased to 0.50 ± 0.007 at 2 months (P < 0.001). Follow-up was 100% complete and ranged from 2 months to 3 years (mean = 1.44 ± 0.79 years). There were no early or late deaths. All of the patients were asymptomatic at 1 month postclosure, except one patient (11%) who had a mild residual shunt until 3 months of follow-up and dyspnea on exertion that was medically managed. One patient (11%) had an associated ostium secundum atrial septal defect that was percutaneously closed. Conclusion: Transcatheter closure of coronary arterial fistula is feasible and safe in anatomically suitable vessels and is a promising alternative to surgery in most patients.

Minor anomalous left atrial branch originating from right coronary artery.

A 43-year-old man presented with effort angina Canadian cardiovascular society class III. The patient has been a chronic smoker and diabetic for 15 years. Cardiac examination and 12-lead ECG was normal. Echocardiogram revealed normal left ventricular ejection fraction with no regional wall motion abnormality. He was electively taken for coronary angiogram which revealed small calibre left circumflex (LCX) which was diminutive, diffusely diseased and subtotally occluded distally (figure 1; video 1). Left anterior descending artery (LAD; type II) had subtotal occlusion in mid segment (figure 2; video 2). Right coronary artery (RCA) was dominant with insignificant stenosis in proximal-to-mid RCA (figure 3; video 3). Posterior …

Ventricular tachycardia with regular capture beats.

A 30-year-old man presented with a 1-day history of sudden onset palpitations. He was haemodynamically stable. Twelve-lead electrocardiography showed wide complex tachycardia with right bundle branch block and left superior axis (figures 1 and 2). Every two wide complex beats were followed by a narrow complex beat and this cycle was repeating. Careful inspection revealed that narrow complex beats were having fixed relationship to wide complexes and among themselves, but there was atrioventricular (AV) dissociation. The patient’s echocardiographic examination was normal. He was reverted to normal sinus rhythm with DC …

Successful retrieval of fractured catheter tip during coronary angiogram

A 59-year-old man with effort angina NYHA (New York Heart Association) class III since 6 months was taken for elective coronary angiogram. While trying to cannulate the left main coronary artery (LMCA), we saw the radio-opaque tip portion of diagnostic 5F judkins 3.5 catheter (Cordis Corp, Florida, USA) lying in the left circumflex (LCX; figure 1 and video 1). The catheter was taken out but we observed that the tip of the catheter was broken. We took a guiding 6F Judkins 3.5 catheter and cannulated the LMCA. The broken tip was located proximal to the LCX and the major obtuse marginal junction (figure 2 and …

Rheumatic mitral stenosis simulating double-orifice mitral valve

A 46-year-old woman presented to us with symptoms of breathlessness New York Heart Association class II for 6 months on and off with a history of rheumatic fever in childhood. She was diagnosed in the periphery as having rheumatic heart disease for 20 years. The patient was on regular injectable penicillin prophylaxis (injection penicillin 1.2 million units every 21st day), β-blockers with intermittent diuretics. Cardiac examination revealed low pitched mid-diastolic rumble grade III/VI at apex with normal S1. Twelve-lead ECG showed atrial fibrillation with controlled ventricular rate. Echocardiogram revealed moderate mitral …

Anomalous hypertrophied muscle band in LV mimicking LV mass

A 37-year-old man referred for non-cardiac chest pain evaluation to our tertiary care centre. There were no risk factors for coronary artery disease. Clinical examination and 12-lead ECG were normal. Transthoracic echocardiogram revealed a finger-like projection in the paraseptal region towards the left ventricle (LV) measuring 5×1.4 cm (figures 1⇓⇓–4; videos 1⇓–4).Grossly, it was mimicking LV mass without any gradient across (as opposed to hypertrophic cardiomyopathy). There was no evidence of left ventricular hypertrophy (neither concentric nor eccentric). Echotexture was the same as that of …