Hiten Patel

Arrythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) and cathecholaminergic polymorphic ventricular tachycardia (CPVT): A phenotypic spectrum seen in same patient.

ARVD/C and CPVT are rare inheritable sudden cardiac death syndromes predominantly expressed in younger individuals. ARVD/C is characterized by a progressive fibrofatty replacement of the myocardium that predisposes to ventricular tachycardia while CPVT is characterized by exercise induced bidirectional/polymorphic ventricular tachycardia (VT) and a structurally normal heart. A mutation in different genes causes these syndromes but recently, mutation in a common gene RYR2 has been associated with both disorders and it has been suggested that CPVT and ARVD/C represent a phenotypic spectrum. We present a case unique in expressing both these phenotypes.

Intracoronary adenosine-induced ventricular arrhythmias during fractional flow reserve (FFR) measurement: case series and literature review

Fractional flow reserve (FFR) is a standardized and well-established method frequently used in clinical practice to evaluate the hemodynamic significance of epicardial coronary stenosis identified by coronary angiography. It is based on the change in the pressure gradient across the stenosis after the achievement of maximal hyperemia of the coronary circulation which is commonly induced by intravenous (IV) or intracoronary (IC) administration of adenosine. Here, we have described three cases of IC adenosine-induced ventricular arrhythmias during FFR measurement from our institution, and after literature review we found that all the cases of ventricular arrhythmias induced by adenosine during FFR measurement were observed where it was administered via IC route. Although a causal relationship between the use of IC adenosine during FFR measurement and the induction of ventricular arrhythmias is not yet established, we suggest using IV adenosine as the preferred route of administration until we better understand the incidence and mechanism underlying this phenomenon.

Pulmonary artery catheterization use and mortality in hospitalizations with HFrEF and HFpEF: A nationally representative trend analysis from 2005 to 2014

BACKGROUND The aim of our study was to analyze the trends in use of pulmonary artery catheterization (PAC) in heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) and adjusted mortality from 2005 to 2014 using National Inpatient Sample (NIS) database. METHODS The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes were used to identify patients with HFrEF and HFpEF from the National Inpatient Sample database. RESULTS We identified a total of 3,225,529 hospitalizations with HFrEF and 3,419,834 hospitalizations with HFpEF. Per 1000 hospitalizations, use of PAC declined from 2005 to 2010 in both HFrEF (12.9 to 7.9, Ptrend < 0.001) and HFpEF (12.9 to 5.5, Ptrend < 0.001). However, from 2010 to 2014, the use of PAC per 1000 hospitalizations increased in both HFrEF (7.9 to 9.7, Ptrend < 0.001) and HFpEF (5.5 to 6.7, Ptrend < 0.001). We noted a temporal decline in risk-adjusted mortality during the study period for HFrEF (odds ratio, 3.93 in 2005-06 to 2.7 in 2013-14, Ptrend < 0.001) and HFpEF (odd ratio, 2.72 in 2005-06 to 2.62 in 2013-14, Ptrend < 0.001). The length of stay and cost were significantly higher with PAC use in both HFrEF and HFpEF. CONCLUSION The use of PAC declined from 2005 to 2010 in both HFrEF and HFpEF but has since increased from 2010 to 2014 in both HFrEF and HFpEF. There is also a temporal decline in excess mortality associated with PAC use in both HFrEF and HFpEF from 2005 to 2014.

USE OF SUPRA RENAL RETRIEVABLE INFERIOR VENA CAVA (IVC) FILTER IN CONJUNCTION WITH EKOS FOR TREATMENT OF EXTENSIVE IVC THROMBOSIS

Inferior vena cava (IVC) thrombosis is an underdiagnosed condition associated with a mortality rate approaching twice that of lower extremity deep venous thrombosis (DVT). A 49-year-old female presented to emergency room with complaint of bilateral leg and abdominal pain. Her past medical history

Delayed spontaneous recanalization of chronic total occlusion of left anterior descending artery after attempted but failed revascularization during percutaneous coronary intervention

ABSTRACT Chronic total occlusion (CTO) of coronary artery remains the Achilles heel of the interventional cardiologist and is present in a significant proportion of referrals for coronary artery bypass graft surgery (CABG); however, with the development and standardization of modern CTO recanalization techniques, it has been able to achieve excellent success while coping with lesions of increasing complexity. Nevertheless, failure to recanalize despite the development of new techniques still remains one of the challenges in the field of interventional cardiology. Spontaneous recanalization has been described in nonocclusive coronary artery dissections in detail; none has addressed the possibility of spontaneous recanalization after failed percutaneous coronary intervention (PCI). We report a case of spontaneous but delayed recanalization of CTO of left anterior descending artery 3 years after attempted but failed revascularization during PCI.

Deciphering a case of pulmonary hypertension in a young female: Partial anomalous pulmonary venous drainage the culprit

Partial anomalous pulmonary venous drainage (PAPVD) is a rare congenital cardiac defect and is associated with sinus venosus atrial septal defect. While most cases are asymptomatic, a patient can present with pulmonary hypertension (PHTN) and it can be difficult to diagnose. Here, we discuss the case of a young female with PHTN who was found to have two right-sided PAPVD. Through this case, authors try to emphasize the importance of meticulous and thorough investigation when evaluating PHTN, which allows for correct diagnosis and a timely intervention before PHTN becomes irreversible.

LEFT ATRIAL VOLUME INDEX OVER LATE DIASTOLIC MITRAL ANNULAR VELOCITY: A NEW NON-INVASIVE PARAMETER FOR MEASUREMENT OF LEFT VENTRICULAR END DIASTOLIC PRESSURE

Background: Over the years many non-invasive methods for prediction of elevated left ventricular end diastolic pressure (LVEDP) have attracted attention. The aim of this study is to see the correlation between a new non-invasively obtained parameter- Left Atrial Volume Index Over Late Diastolic

A rare case of late onset saphenous vein graft spasm

ABSTRACT Spasm following coronary artery bypass graft surgery has been well established in arterial grafts, especially in grafts utilizing the internal mammary. Venous graft spasms are uncommon and are only observed in vein grafts during or soon after the coronary artery bypass surgery. It is exceedingly rare to see spasm of venous graft beyond one year of surgery. We report a 72-year-old female who had coronary artery bypass graft three years ago and presented with new onset chest pain for one month. The coronary angiogram revealed severe spasm of the proximal aspect of a patent saphenous venous graft which was relieved by intracoronary nitroglycerine. Patient was successfully managed using combination of anti-spasmodic medications (nitrates and calcium channel blockers) leading to long-term resolution of her anginal symptoms.

Septal thrombus following blunt cardiac injury

Septal thrombus following blunt cardiac injury Rahul Vasudev, Upamanyu Rampal, Hiten Patel, Mahesh Bikkina & Fayez Shamoon To cite this article: Rahul Vasudev, Upamanyu Rampal, Hiten Patel, Mahesh Bikkina & Fayez Shamoon (2017) Septal thrombus following blunt cardiac injury, Acta Cardiologica, 72:2, 232-233, DOI: 10.1080/00015385.2017.1291178 To link to this article: http://dx.doi.org/10.1080/00015385.2017.1291178

Regular QRS complex tachycardia: think outside the box

A 23-year-old male with no past medical history presented to the emergency department (ED) for the evaluation of intermittent palpitations associated with sub-sternal chest discomfort since one day. There was no history of syncope or any family history of syncope, arrhythmias or sudden cardiac death. Neither there was any history of smoking, alcohol or any illicit drug use. Patient’s heart rate was 190 bpm and physical exam was benign. Electrocardiogram (ECG) on presentation in ED (Figure 1: Panel A) shows regular wide QRS complex tachycardia, right bundle branch (RBBB) morphology, left anterior fascicular block (LAFB) configuration and superior QRS axis. This suggests an idiopathic posterior fascicular ventricular tachycardia (VT), which is a type of an idiopathic VT arising from the left ventricle (LV) and is sensitive to verapamil. Note that patient’s prior ECG (Figure 1: Panel B) is normal. Patient received intravenous adenosine 6mg followed by 12mg with no response. Patient was then given intravenous verapamil, which gradually slowed the VT rate (Figure 1: Panel C) before it converted to normal sinus rhythm (Figure 1: Panel D). Patient’s transthoracic echocardiogram was normal. Electrophysiology study confirmed this idiopathic VT. He was treated medically and discharged home in stable condition, with a plan to resort to ablation upon failure of medical therapy. Idiopathic VT is defined as monomorphic VT in patients without structural heart disease or coronary disease and accounts for 10% of the cases of VT. Idiopathic VTs have any one of several characteristic electrocardiographic morphologies representing three distinct entities based on the location of the VT: outflow tract tachycardias, annular tachycardias and fascicular tachycardias. The prognosis for all forms of idiopathic monomorphic VT without structural heart disease is favourable. The idiopathic posterior fascicular LV VT, as seen in this patient, is also known as Belhassen’s VT and is typically seen in young patients. It’s a re-entrant tachycardia involving the Purkinje system as well as slowly-conducting, calcium-sensitive myocardium and hence it’s sensitive to verapamil. The resting ECG is usually normal and the QRS during VT typically has RBBB with LAFB configuration and superior axis. In contrast to VT associated with structural heart disease, the QRS duration during Belhassen’s VT is relatively narrow (<140 to 150ms), and the RS interval (the duration from the beginning of the QRS to the nadir of the S wave) in the precordial leads is relatively short (60 to 80ms); thus, the VT is frequently called ‘fascicular’ VT. Right ventricular outflow tract (RVOT) VT (a type of an idiopathic VT) has left bundle branch block configuration and inferior axis. Importantly, adenosine can terminate RVOT VT but it has no effect on fascicular VT. Later should also be differentiated from supraventricular tachycardia with bifascicular block aberrancy, and one of the clues is no response to high doses of adenosine. Intravenous verapamil is the treatment of choice to terminate this VT. It is important to ensure there is no pre-excitation (delta wave) on prior ECGs, and verapamil should not be given unless the diagnosis of fascicular VT is highly likely. Direct cardioversion is less effective than verapamil because it can increase sympathetic surge and cause immediate recurrence of fasiscular VT. Radiofrequency ablation is highly effective and is recommended for patients with severe or recurrent symptoms.