Nagendra Boopathy Senguttuvan

Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies

AIMS Left-sided prosthetic valve thrombosis (PVT) occurs frequently in developing countries and causes major morbidity and mortality. Fibrinolytic therapy (FT) is most commonly used as treatment, but increases the risk of stroke and bleeding. Urgent surgery may be more efficacious and cause fewer complications. Our aim was to compare the efficacy and safety of urgent surgery and FT for the treatment of left-sided PVT. METHODS AND RESULTS We searched EMBASE and MEDLINE for articles which included at least five patients each treated with surgery and FT. The primary outcome was complete restoration of valve function. Other outcomes were in-hospital death, thrombo-embolism (stroke, transient ischaemic attack, or non-CNS systemic embolism), major bleeding, and recurrence of PVT on follow-up. We calculated odds ratios (ORs) for each outcome and pooled them using a random effects model. We included seven eligible studies with 690 episodes of PVT, 446 treated with surgery, and 244 with FT. There was no significant difference in the occurrence of the primary outcome (86.5 vs. 69.7%, OR 2.53, 95% CI 0.94-6.78, P = 0.066, I(2) = 74%) or death (13.5 vs. 9%, OR 1.95, 95% CI 0.63-5.98, P = 0.244, I(2) = 59%) between the two treatments. However, compared with FT, urgent surgery was associated with significant reductions in thrombo-embolism (1.6 vs. 16%, OR 0.10, 95% CI 0.04-0.24, P < 0.001, I(2) = 0%), major bleeding (1.4 vs. 5%; OR 0.27, 95% CI 0.08-0.98, P = 0.046, I(2) = 0%), and recurrent PVT (7.1 vs. 25.4%; OR 0.25, 95% CI 0.08-0.74, P = 0.013, I(2) = 59%). CONCLUSION Urgent surgery was not superior to FT at restoring valve function, but substantially reduced the occurrence of thrombo-embolic events, major bleeding, and recurrent PVT. In experienced centres, urgent surgery should probably be preferred over FT for treating left-sided PVT, pending the results of randomized controlled trials.

A Comparison of Lead Placement Through the Subclavian Vein Technique With Fluoroscopy-Guided Axillary Vein Technique for Permanent Pacemaker Insertion

BACKGROUND The intrathoracic subclavian venous technique for pacemaker implantation may be associated with serious complications. We describe an alternative technique for obtaining venous access for pacemaker implantation through axillary vein under fluoroscopic guidance and compare it with the conventional, subclavian approach. METHODS We conducted a single-centre, prospective, nonrandomized study. All adult patients with indication for permanent pacing who consented were recruited during a 3-year period. To access the axillary vein, we used the alternative technique with a new fluoroscopic landmark. The subclavian access was obtained as per the usual approach. RESULTS We studied 478 lead placements during 3 years; 315 lead placements through axillary venous technique (group 1) were compared with 163 lead placements through subclavian venous technique (group 2). Both routes had a high and comparable success rate, 98.09% in group 1 and 96.93% in group 2. The axillary approach was successful at the first attempt in 194 punctures (61.6%), as vs 60 in group 2 (36.8%) P < 0.0001. The average number of attempts in group 1 was 2.06 per patient and 2.56 in group 2 (P < 0.001). There were 3 (2.94%) pneumothoraxes in group 2 and none in group 1. During a mean follow-up period of 3.2 months in group1 and 3.7 months in group 2, 1 patient in group 2 had a lead fracture. CONCLUSIONS The fluoroscopically guided axillary venous approach for implanting permanent pacemakers is equivalent to the traditional anatomic landmark-guided intrathoracic subclavian approach and has fewer complications and shorter procedural time to access the vein.

Ductal recanalization and stenting for late presenters with TGA intact ventricular septum

Introduction: The ideal management strategy for patients presenting late with transposition of great arteries (TGA), intact ventricular septum (IVS), and regressed left ventricle (LV) is not clear. Primary switch, two-stage switch, and Senning operation are the options. Left ventricular retraining prior to arterial switch by ductal stenting may be effective, but the experience is very limited. Methods: Five of six children aged 3–6 months with TGA-IVS and regressed LV underwent recanalization and transcatheter stenting of ductus arteriosus. The ductal stent was removed during arterial switch surgery. Results: The procedure was successful in 5/6 patients. All the patients had totally occluded ductus and needed recanalization with coronary total occlusion hardware. The ductus was dilated and stented with coronary stents. In all the patients, there was significant luminal narrowing despite adequate stent placement and deployment. Two patients needed reintervention for abrupt closure of the stent. Ductal stenting resulted in left ventricular preparedness within 7–14 days. One patient died of progressive sepsis after 14 days of stenting, even though the LV was prepared. Four patients underwent successful uneventful arterial switch surgery. During surgery, it was observed that the mucosal folds of duct were protruding through the struts of the stent in one patient. Conclusions: Ductal stenting is a good alternative strategy for left ventricular retraining in TGA with regressed LV even in patients with occluded ducts.

How should I treat guidewire-induced distal coronary perforation?

*Corresponding author: Department of Cardiology, All India Institute of Medical Sciences, New Delhi 110 029, India. E-mail: ramakgmc@rediffmail.com PRESENTATION OF THE CASE A 45-year-old hypertensive male had presented with recent onset NYHA class II angina and dyspnoea on exertion of six-weeks duration. The exercise treadmill test was strongly positive with significant ischaemic changes occurring in stage 1 of Bruce protocol. Angiogram showed a total occlusion of left circumflex artery and obtuse marginal branch (OMB) (Figure 1). The patient underwent PCI after an informed consent. The patient was given 600 mg clopidogrel one day prior and 5,000 U intravenous heparin was given at the start of the procedure. A Judkins left (JL) 3.5 guiding catheter (Cordis Corp., Johnson & Johnson, Miami Lakes, FL, USA) was used to hook the left main artery. As a soft coronary wire could not be negotiated through the lesion, a hydrophilic Crosswire® NT (Terumo Medical Corporation, Somerset, NJ, USA) was used to cross the lesion. The distal end of the guidewire was parked in a moderate sized OM branch. The lesion was stented with Bx SonicTM (Cordis Corporation, Johnson & Johnson, Miami Lakes, FL, USA) 2.75×28 following predilatation. The stent was postdilated with a PowerlineTM 3×10 balloon (Biosensors Interventional Technologies Pte Ltd, Singapore). The end result appeared satisfactory (Figure 2). Intravenous tirofiban (0.4 μg/kg/min over 30 min followed by 0.1 μg/kg/min continuous infusion) was given. The patient had hypotension two hours later, which was not associated with chest pain or any electrocardiogram (ECG) change. Echocardiography showed significant pericardial effusion CASE SUMMARY

Treatable diffuse pulmonary arteriovenous fistula - An unusual cause

A 4 year old boy was referred for evaluation of failure to thrive and mild cyanosis. He was found to have a structurally normal heart with evidence of microscopic pulmonary arterio-venous (AV) fistulae. Later, he was diagnosed to have congenital porto-systemic shunt, a very rare cause of pulmonary AV fistula.

Clapping atrio-ventricular valves

We describe a 30-year-old male who presented with progressively increasing effort intolerance since his adolescence. On examination, he was cyanosed with a pulse rate of 50 /min. He was found to have …

Cannon waves in atrioventricular nodal re-entry tachycardia

A 52-year-old woman presented to the emergency department with palpitations associated with uneasiness and nausea. She was a nonsmoker. She reported having one previous episode of palpitations, without precipitating factors, which had lasted for about 15 minutes and resolved spontaneously.

Percutaneous transvenous angioplasty of left innominate vein stenosis following right side permanent pacemaker implantation- a left femoral vein to left axillary vein approach.

Central venous stenosis after the insertion of a permanent pacemaker is a well recognized complication. This late complication is encountered when there is a need to change the pacemaker lead or extract it. We describe a young male who had such a complication after many years after right side pacemaker implantation. The lesion was managed percutaneously leading to placement of a new lead from the left side.

Aorta to right ventricular tunnel: a rare cause of holodiastolic flow reversal in aorta in an infant

A 40-day-old baby presented with tachypnoea, failure to thrive without cyanosis. His pulse rate was 150/min and respiration rate was 66/min with a normal capillary filling time. The cardiac examination revealed a loud, continuous murmur at the left second/third intercostal places. Electrocardiogram showed sinus tachycardia and chest X-ray showed increased pulmonary blood flow with cardiomegaly. A …