Navin Agrawal

Predictors of inhospital prognosis in acute pulmonary embolism: keeping it simple and effective!

The assessment of commonly available demographic, clinical, and easily calculable investigational parameters instead of the conventional complicated indices for prognosis in acute pulmonary embolism may help in triage in a simple and cost-effective way. Clinical, demographic, and investigational parameters were collected and utilized for the assessment of inhospital prognosis of acute pulmonary embolism in 200 consecutive patients admitted to our institute. Overall mortality was 18% and poor outcome at discharge was seen in another 18.5%. In univariate analysis, predominant presenting symptom of fatigue, sudden onset of symptoms, overt right ventricular failure, hypoxemia at admission, low SBP and DBP, coexistent pulmonary or cardiac illness, ECG evidence of right axis deviation, SIQ3T3 pattern, conduction blocks, echocardiographic evidence of right ventricular dysfunction, decreased inspiratory collapse of inferior vena cava, severe pulmonary arterial hypertension, visible thrombus in pulmonary artery, significant tricuspid regurgitation, computed tomographic evidence of total occlusion of major pulmonary arteries, diameter of main pulmonary artery, acute or chronic pulmonary embolism, renal and hepatic dysfunction, hyponatremia, hyperkalemia, troponin elevation, use of fibrin-specific agent, requirement of inotropic support, and mechanical ventilation were the variables found to significantly predict adverse outcome. In multivariate analysis, hypoxemia, no improvement after lysis, deranged liver function test, conduction blocks, and signs of right ventricular failure were the significant variables, while inotropic support requirement had a trend toward significance. Clinical, demographic, and routine investigational parameters help to risk-stratify the patients presenting with acute pulmonary embolism and to prognosticate and manage in a simpler yet effective way.

Dancing vegetations: Kocuria rosea endocarditis

We present images of a 35-year-old man with rheumatic mitral regurgitation. The patient presented with a 1 month history of continuous fever, worsened exertional dyspnoea and orthopnoea. With a clinical suspicion of infective endocarditis, the patient initially underwent a transthoracic echocardiogram, which revealed the possibility of vegetations attached to the mitral leaflets, though not definitively. In order to confirm the diagnosis, the patient was subjected to a transoesophageal echocardiogram, which showed an astounding image having multiple vegetations apparently dancing in …

Percutaneous coronary intervention in patients with anomalous origin of coronary artery presenting with acute coronary syndrome: A case series

Coronary artery anomalies are found in 0.6%-1.5% of patients undergoing diagnostic coronary angiogram. Intervention in these patients poses a particular technical challenge secondary to the aberrancies in the vessel origin and course. From March 2011 to February 2013, 13 cases with complex coronary artery anomalies were observed among 2482 patients undergoing CAG (0.52%) at our cath lab. Only three patients had severe stenosis in the anomalous artery sufficient to require an intervention and had presented with myocardial infarction. PCI was performed successfully in these 3 patients two of which had anomalous left circumflex artery and the other having an anomalous right coronary artery.

Gemella morbillorum endocarditis in hypertrophic cardiomyopathy: a rare organism causing a large vegetation and abscess in an uncommon setting.

Mitral valve endocarditis complicating hypertrophic cardiomyopathy is rare especially in the absence of significant mitral regurgitation. The occurrence of large vegetation and an abscess formation is even rarer. Endocarditis occurs predominantly on the left ventricular aspect of the anterior mitral leaflet. We report a case of a 34-year-old woman with asymptomatic obstructive hypertrophic cardiomyopathy who developed mitral valve endocarditis with large vegetation and subsequently an abscess caused by a rare organism Gemella morbillorum, following dental extraction. The patient underwent antibacterial therapy followed by successful mitral valve replacement for severe mitral regurgitation and her postoperative course has been asymptomatic so far. This case is unique in describing endocarditis by a rare organism as a cause of large vegetation and an abscess on an unusual site on the mitral valve leaflet without predisposition of haemodynamically significant mitral regurgitation and illustrates the potential lifesaving role of timely intervention.

Giant coronaries: coronary ectasia as an isolated cause of exertional angina and positive stress test

Coronary artery ectasia (CAE) is characterised by segmental or diffuse dilation of the coronary artery to more than 1.5 times its diameter.1 CAE has been classified by Markis on the basis of the extent of ectasia.2 More than half of CAE cases are related to atherosclerotic coronary artery disease. Ectasia is restricted to a single coronary in 75% cases and is usually segmental.2 We present an interesting case of a middle-aged patient with a history of exertional chest pain with a positive exercise ECG stress test. The patient was taken for a diagnostic coronary angiogram which revealed the presence of diffuse ectasia involving all three coronary arteries as …

Classical windsock deformity of ruptured sinus of Valsalva: an unusual appearance on transthoracic echocardiography.

Aneurysm of sinus of Valsalva is a rare anomaly which arises from a congenital defect of the aortic media or due to damage caused by bacterial endocarditis. It is more prevalent in men and people of Asian descent.1 Ruptured sinus of Valsalva (RSOV) is a relatively uncommon cause of acute haemodynamic worsening which is usually seen in young-aged or middle-aged individuals. We present a case of a 23-year-old man who presented with a 20-day history of symptoms of worsening breathlessness; examination showed elevated jugular venous pressure, high volume pulse, S3 and a continuous murmur. The patients echocardiogram showed RSOV from the right coronary sinus …

McConnell's sign: an early and specific indicator of acute pulmonary embolism

A 76-year-old woman was admitted with acute onset of breathlessness with lethargy since the last 3 days. She was a known patient with hypertension and diabetes. On clinical examination, she had an engorged neck vein, tachycardia and tachypnoea, hypotension, oxygen saturation of 92% in room air and right ventricular S3 gallop with pansystolic murmur in the left lower parasternal area. ECG showed sinus tachycardia with an S1Q3T3 pattern. Chest X-ray did not reveal any significant abnormality. There was no elevation of cardiac biomarkers. Echocardiography revealed the presence …

Left arm–left leg lead reversal in a case of inferior wall myocardial infarction mimics as high lateral wall infarction

A 56-year-old male patient was admitted with an evolved inferior wall myocardial infarction (IWMI). Electrocardiogram (ECG) showed presence of ST elevation and T wave inversion in the inferior leads. ECG taken on the next day surprisingly showed features suggestive of acute high lateral wall myocardial infarction (LWMI), without features suggestive of re-infarction which was finally diagnosed to be an artefact due to lead reversal. Lead reversal between left arm and left leg can mimic as high LWMI in a case with IWMI and we should aware of this situation before misdiagnosing it as re-infarction.

Rare occurrence of a transient isolated unilateral partial third nerve palsy after angioplasty

We report a rare case of isolated unilateral partial oculomotor nerve palsy in an elderly woman a day after radial angioplasty presenting with diplopia and ptosis. A 65-year-old woman with diabetes and hypertension presented with the acute onset transient partial third cranial nerve palsy presenting as diplopia and ptosis after 1 day of undergoing a double vessel angioplasty which spontaneously improved after a day of its occurrence. The patient was in normal sinus rhythm and there was no echocardiographic evidence of any thrombus in the left-sided cardiac chambers. An ocular examination revealed ptosis with paresis …

Super dominant left anterior descending artery with origin of both posterior descending artery and posterior left ventricular artery from septal branch

The posterior descending artery (PDA) arises from the right coronary artery (RCA) in approximately 85% of people in right dominant circulation. Whereas only in 10–15% of cases, it arises from the circumflex artery (LCX) or from both RCA and LCX.1 Rarely the posterior descending artery can arise from the left anterior descending (LAD) coronary artery.2 ,3 A 65-year-old man presented with new onset effort angina of Canadian Cardiovascular Society class II severity. He was hypertensive and a smoker. Exercise treadmill test was positive in 9.1 metabolic equivalents of task (METS). Blood investigations revealed only the presence of hyperlipidaemia (low …