Naresh Kumar Sood

Mechanical breakdown and thrombolysis in subacute massive pulmonary embolism: A prospective trial.

AIMnTo assess role of combined modality of mechanical fragmentation and intralesional thrombolysis in patients with massive pulmonary embolism presenting subacutely.nnnMETHODSnEight of 70 patients presenting in tertiary care centre of North India with massive pulmonary embolism within 4 years had subacute presentation (symptom onset more than 2 wk). These patients were subjected to pulmonary angiography with intention to treat basis via mechanical breakdown and intra lesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h).nnnRESULTSnEight patients, mean age 47.77 ± 12.20 years presented with subacute pulmonary embolism (mean duration of symptoms 2.4 wk). At presentation, mean heart rate, shock index, miller score and mean pulmonary pressures were 101.5 ± 15.2/min, 0.995 ± 0.156, 23.87 ± 3.76 and 37.62 ± 6.67 mmHg which reduced to 91.5 ± 12.2/min (P = 0.0325), 0.789 ± 0.139 (P = 0.0019), 5.87 ± 1.73 (P = 0.0000004) and 27.75 ± 8.66 mmHg (P = 0.0003) post procedurally. Mean BP improved from 80.00 ± 3.09 mmHg to 90.58 ± 9.13 mmHg (P = 0.0100) post procedurally. Minor complications in the form of local hematoma-minor hematoma in 1 (12.5%), and pseudoaneurysm (due to femoral artery puncture) in 1 (12.5 %) patient were seen. At 30 d and 6 mo follow up survival rate was 100% and all the patients were asymptomatic and in New York Heart Association class 1.nnnCONCLUSIONnCombined modality of mechanical fragmentation and intralesional thrombolysis appears to be a promising alternative to high risk surgical procedures in patients with subacute massive pulmonary embolism.

Hepatic vascular injury: Clinical profile, endovascular management and outcomes

BACKGROUNDnEndovascular management using angiographic embolization (AE) has been widely used with success as non operative management (NOM) in blunt hepatic trauma. We, in a tertiary care hospital in North of India, assess our use of endovascular management in patients of blunt and post operative trauma with active hepatic vascular bleeding and unstable hemodynamics in controlling bleeding.nnnMETHODSnA retrospective review of inpatients from January 2006 to July 2012 requiring transarterial embolization/stenting for active hepatic vascular bleeding was done. All patients had evidence of ongoing hemorrhage as proved by clinical, laboratory and radiological findings in emergency settings. Angiographic intervention in an interventional suite with ongoing resuscitation was performed following which patients were monitored for morbidity and mortality benefits on intermediate follow up.nnnRESULTSn10 adults and 3 children underwent AE with polyvinyl alcohol particle (PVA)/soft metal coil whereas 1 adult underwent revascularization with a covered stent for arterial bleeding. The mean age of case series was 36.18 ± 20.90 years with a mean liver injury computed tomography (CT) grade of 3.8 ± 0.83 in blunt trauma patients. The mean length of hospital stay was 9.62 ± 7.83 days and the mean follow up period of the group was 25.25 ± 21.02 months. All patients showed significant clinical improvement with prompt endovascular management resulting in no procedure related mortality.nnnCONCLUSIONnPrompt endovascular management is the modality of choice in comparison to NOM without AE in both pediatric and adult patients with hemodynamically compromised inaccessible intra hepatic vascular trauma.

Clinical and echocardiographic diagnosis, follow up and management of right-sided cardiac thrombi.

BACKGROUNDnRight-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India.nnnMETHODSnThis is a retrospective, single center observational study of consecutive patients over the period January 2003-2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician.nnnRESULTSnThe mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range--18-50 months).nnnCONCLUSIONSnPrompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.

TEE-guided left ventricular epicardial pacing lead placement for cardiac resynchronization therapy

Biventricular pacing has demonstrated improvement in cardiac functions in treating congestive cardiac failure patients. Recent trials have proven the clinical and functional benefits of cardiac resynchronization therapy in severe heart failure and intraventricular cardiac delays, mainly left bundle branch block. Biventricular pacing improves the exercise tolerance, quality of life, systolic heart function, reduces hospitalization and slows progression of the disease. A 54-year-old lady, a known case of dilated cardiomyopathy, was on biventricular pacing since 2 years. She presented in emergency with sudden deterioration of dyspnea to NYHA class III/IV. When investigated, the coronary sinus lead was found displaced; thus, left ventricle (LV) was not getting paced. After multiple failures to reposition the coronary sinus lead, it was decided to surgically place the epicardial lead for LV pacing under general anesthesia. Lateral thoracotomy was done and LV pacing lead was placed at different sites with simultaneous monitoring of cardiac output (CO) and stroke volume (SV) by transesophageal echocardiography (TEE). Baseline CO and SV were 1.9 l/min and 19.48 ml respectively and increased at different sites of pacing at LV, the best CO and SV were 4.2 l/min and 42.39 ml respectively on lateral surface. Intraoperative TEE can calculate beat to beat stroke volume and thus CO and helps to choose optimal site for placement of epicardial pacing lead.

A cost effective endovascular approach for management of post-catheterization profunda femoris artery pseudoaneurysm using thrombin.

Post-catheterization PSA is one of the most commonly encountered vascular complications of cardiac and peripheral angiographic procedures. We report the case of patient who developed deep-seated profunda femoris artery pseudoaneurysm (PSA) following cardiac catheterization. Despite, repeated ultrasound guided compressions the PSA failed to close and instead produced local site pressure ulcers. The secondary infection followed which precluded use of percutaneous thrombin injection. The PSA was finally closed via a total endovascular technique combining intravascular thrombin injection and coil embolization, thus obviating the need for expensive measures like cover stents or invasive surgical repairs.

TCT-4 Impact of Catheter Fragmentation followed by Local Intrapulmonary Thrombolysis in Acute High risk Pulmonary Embolism as Primary Therapy: Acute and Long term outcomes

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