Neeraj Ganju

Epidemiological Study of Chronic Mountain Sickness in Natives of Spiti Valley in the Greater Himalayas

AIMS This study determined the prevalence of chronic mountain sickness (CMS) and its predisposing factors among natives of Spiti Valley in the northern state of Indian Himalayas. A cross-sectional survey study was conducted in natives of Spiti Valley aged ≥ 20 years residing at altitudes of 3000 to 4200 meters. CMS was diagnosed using Qinghai criteria. Demographics, behavioral characteristics, specified symptoms of CMS were recorded, including BP, anthropometrics, evidence of RHF, PAH, and severe cyanosis. ECG, echocardiography, PFT, and Sao2 were recorded, and Hb level was estimated with the cyanmethhemoglobin method. RESULTS 694 subjects free of cardiorespiratory diseases were analyzed. Prevalence of CMS was 28.7%, (95% C.I. of 25.9%-32.8%) and was higher in women than in men (36.6% vs. 15.7%, p<0.001). Erythrocythemia and hypoxemia were recorded in 10.5% and 7.5%, respectively. Age, truncal obesity, female gender, altitude of residence, and physical activity index were independent predictors of CMS with z statistics of 4.2, 2.29, -3.7, 2.8, and -2.8, respectively, and were statistically significant p<0.001. 6.2% of the surveyed population had HAPH. CONCLUSION 28.7% (95% C.I. of 25.9%-32.8%) of the natives of the Spiti Valley in the Indian Himalayas are affected with CMS. Higher prevalence of CMS amongst women needs further studies. Westernized lifestyle appears to have predisposition to CMS.

Prevalence of High Altitude Pulmonary Hypertension Among the Natives of Spiti Valley—A High Altitude Region in Himachal Pradesh, India

The study aimed to determine the prevalence of high altitude pulmonary hypertension (HAPH) and its predisposing factors among natives of Spiti Valley. A cross-sectional survey study was done on the permanent natives of Spiti Valley residing at an altitude of 3000 m to 4200 m. Demographic characteristics, health behavior, anthropometrics, and blood pressure were recorded. Investigations included recording of 12 lead electrocardiogram (ECG), SaO2 with pulse oximeter, spirometry and echocardiography study, and measurement of Hb levels using the cynmethhemoglobin method. HAPH was diagnosed using criteria; tricuspid regurgitation (TR) gradient of ≥46 mmHg. ECG evidence of RV overload on 12 lead ECG was documented based on presence of 2 out of 3 criteria; R>S in V1, right axis deviation or RV strain, T wave inversion in V1 and V2. Data of 1087 subjects were analyzed who were free of cardiorespiratory diseases to determine the prevalence of HAPH and its predisposing factors. HAPH was recorded in 3.23% (95% C.I. of 0.9-8.1%) and ECG evidence of right ventricular (RV) overload was 1.5% in the study population. Prevalence of HAPH was not different in men and women 2.63% vs. 3.54% p<0.2. Age (Z statistics of 3.4 p<0.0006), hypoxemia (Z statistics of 2.9 p<0.002), and erythrocythemia (Z statistics of 4.7 p<0.003) were independently associated with HAPH. Altitude of residence was not found to be significantly associated with HAPH, although there was a trend of increasing prevalence with increasing altitude. It can be concluded that HAPH is prevalent in 3.23% of natives of Spiti Valley. Increasing age, erythrocythemia and hypoxemia are independent predisposing factors.

Comparison of Risk Factor Profile and Angiographic Pattern AmongPre-Menopausal and Post-Menopausal Women Presenting with Angina:Results from a Prospective Single Center Observational Study

Background: Coronary artery disease (CAD) has become the major killer in women. The exact mechanism of postmenopausal increase in CAD is still under research. Limited data exists on the comparison of risk factor profiles and angiographic disease patterns in premenopausal and postmenopausal women. Methods: This prospective study included a total of 674 consecutive female patients who underwent coronary angiogram for suspected ischemic heart disease over a period of 2 years from March 2015. Detailed risk factor profiles and angiographic patterns of disease were recorded and analyzed using EPIINFO statistical software. Results: Out of total 674 patients, 137(20.3%) were in the premenopausal group with mean age of (42.05 ± 4.40) years, and 537(79.7%) in the postmenopausal group with mean age of (59.05 ± 8.01) years. Premenopausal women were more likely to be obese (57.7% vs 46.9%, p=0.0), hypothyroid (23.4% vs 10.2%, p 3 risk factors more frequently (42.1% vs 30.7%, p=0.009). Atypical chest pain was more common as presenting diagnosis among premenopausal women (23.4% vs 10.2%, p<0.0001). They were also more likely to have positive exercise stress test (62.1% vs 38.3%, p<0.0001) and normal coronary angiogram (59.9% vs 32%, p<0.0002) with endothelial dysfunction (84.7% vs 66.8%, p<0.0001) than post-menopausal women. Post-menopausal women had greater burden of obstructive CAD characterized by more prevalent multivessel disease in the form of double vessel (17.5% vs 8%, p=0.06) and triple vessel disease (20.5% vs 5.8%, p<0.0002). Conclusion: There is a distinct difference between the risk factor profile and angiographic disease pattern among women according to the status of menopause. Recognition of these differences would help in better understanding of relationship of menopause to development of CAD.

A constellation of cardiac anomalies: Beyond shone's complex

Shones anomaly is a very rare congenital cardiac malformation characterized by four serial obstructive lesions of the left side of the heart (i) Supravalvular mitral membrane (ii) parachute mitral valve (iii) muscular or membranous subaortic stenosis and (iv) coarctation of aorta. We report a unique presentation of Shones complex in a 14-year-old adolescent male. In addition to the four characteristic lesions the patient had bicuspid aortic valve, aneurysm of sinus of valsalva, patent ductus arteriosus, ventricular septal defect, persistent left superior vena cava opening into coronary sinus and severe pulmonary artery hypertension. This case report highlights the importance of a strong clinical suspicion of the coexistence of multiple congenital cardiac anomalies in Shones complex and the significance of a careful comprehensive echocardiography.

Aneurysm of an anomalous splenic artery arising from splenomesentric trunk: a rare presentation

A 30-year-old man presented with recurrent episodes of abdominal pain. Ultrasound revealed an aneurysm of the aberrant splenic artery. A CT scan showed a 32×26 mm saccular aneurysm just 3 mm after the origin of the splenic artery from the superior mesenteric artery (SMA) (figure 1). Absence of focal arterial disruption, perivascular inflammation and an irregular aneurysmal wall ruled out pseudo-aneurysm. Detailed work-up for pancreatitis, vasculitis, collagen vascular disease and infection was negative. There was no history of trauma. A selective angiogram was performed for consideration of endovascular intervention (figure 2 and video 1). On selective angiogram of the celiac artery, …

Prevalence, risk determinants and consequences of atrial fibrillation in rheumatic heart disease: 6 years hospital based-Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry

Objective To report the prevalence, risk factors and consequences of atrial fibrillation (AF) in patients of rheumatic heart disease (RHD). Methods The Himachal Pradesh- Rheumatic Fever/Rheumatic Heart Disease (HP-RF/RHD) Registry database of 1918 patients was analyzed. AF was diagnosed with 12-lead ECG recording at entry in to the registry. The association of AF with nature and severity of valvular dysfunction was analyzed, adjusted for age, left atrial (LA) dimension and pulmonary arterial hypertension using multivariable logistic regression model and strength of association was reported as odds ratio (OR) with 95% confidence intervals (C. I.). Results The study population consisted of young (40.2 ± 14.3 years), predominantly females (72.3%) from rural area (94.1%). Prevalence of AF was 23.9% (95% C. I. 22.1%–25.8%). The independent determinants AF were age (OR 1.04, 95% C.I. 1.03–1.06), LA size (OR 1.10, 95% C.I. 1.08–1.11). The association of AF with age, New York Heart Association functional class, mitral stenosis severity and tricuspid regurgitation was statistically significant and graded. Mitral regurgitation and aortic valve disease had no significant independent association with AF. The prevalence of heart failure, stroke, peripheral embolism and mortality was significantly higher among patients with AF (p < .01). Conclusion AF is common in RHD patients and is significantly associated with heart failure and systemic thromboembolism. Age, mitral stenosis severity, tricuspid regurgitation and LA size were independently associated with AF.

Acute renal artery embolisation: role of local catheter-based intra-arterial thrombolysis

A 45-year-old man without previous comorbidity presented to us with acute onset right-sided flank pain for last 14 hours. His general physical and systemic examination was unremarkable, and there were no clinical signs of peritonitis. The ultrasonography did not reveal any evidence of nephrolithiasis or hydronephrosis. His contrast-enhanced CT scan revealed hypoattenuated areas of right kidney and evidence of right renal artery thrombosis. He was immediately shifted to cardiac catheterisation lab, and his renal angiography showed thrombotic occlusion of right renal artery. The bolus dose of streptokinase (250 000 IU) was given locally in renal artery by right judkins catheter followed by systemic infusion of streptokinase (100 000 IU/hour) for 24 hours. After that he was started on low molecular weight heparin. Repeat renal angiography done after 5 days showed completely normal right renal artery. His cardiac and thrombophilia work up was negative, and he was discharged on antiplatelets, oral anticoagulants and statins.

Massive Pericardial Effusion-Rare and Only Presentation of Hypothyrodism-Myxedematous Heart

Cardiovascular symptoms are often predominant features in patients with hyperthyroidism. But cardiovascular findings in hypothyroidism are more subtle. Hypothyroidism mainly presents as lethargy, cold intolerance, constipation, proximal muscle weakness, weight gain, decreased appetite, coarse dry skin, hair loss and nonpitting edema. Cardiovascular findings in hypothyroidism are mild degree of bradycardia, diastolic hypertension and narrow pulse pressure. Mild degree of pericardial effusion is seen in up to 30% of overtly hypothyroid patients. There are several case reports on myxedema ascites, but only few case reports of hypothyroidism presenting as massive pericardial effusion. We report a case of 54-year-old female presenting with breathlessness and found to have massive pericardial effusion without tamponade. After extensive workup, she was found to have primary hypothyroidism. In contrast, she had no other symptoms and clinical signs suggestive of hypothyroidism. She was improved after treatment with levothyroxine.

Left Atrial Mass in a Patient with Rheumatic Mitral Stenosis and AtrialFibrillation-Thrombus or Myxoma?

A 38-year-old female presented for evaluation of dyspnea on exertion. She also complained of palpitations but gave no history of edema, chest pain, cardioembolism, fever, arthralgia or weight loss. She was in atrial fibrillation (AF) with a controlled ventricular rate. Cardiac auscultation revealed a loud S1 with an opening snap and a mid-diastolic rumbling murmur at the apex. There was no presystolic accentuation and no postural variations. Transthoracic echocardiogram revealed thickening and restricted motion of mitral valve leaflets associated with doming of anterior mitral leaflet and severe subvalvular deformity. Mitral valve area was 0.8 cm2. These findings were consistent with severe rheumatic mitral stenosis (MS). Left atrium (LA) was dilated with a large spherical mass (50 mm × 46 mm) originating from the interatrial septum, occupying more than two-third of LA (Figure 1). This mass was immobile and non-pedunculated with no stalk visible even on transesophageal echocardiography. It was characterized by multiple echolucent areas interspersed in an echogenic background. LA appendage was clear. The size, location and echogenecity suggested it to be a myxoma while the mobility and absence of stalk in the presence of rheumatic severe MS and AF suggested it to be a thrombus. We gave a trial of oral anticoagulation for 6 weeks but there was no regression in the size. Mitral valve replacement with surgical excision of mass was eventually performed. Gross examination of the resected LA mass revealed soft, gelatinous tissue with areas of haemorrhage (Figure 2). Histopathology confirmed it to be a myxoma (Figure 3). A cardiac mass in association of rheumatic MS and AF is much more suggestive for a thrombus than a myxoma. This case highlights the diagnostic dilemmas in such a rare co-existence of atrial myxoma and rheumatic MS [1]. Histopathology will always be the gold standard in such situations [2]. Patient Consent

Right paratracheal mass on chest X-ray: an important part of the checklist before cardiac catheterisation.

Infrahepatic inferior vena cava (IVC) interruption with azygos continuation is a rare congenital anomaly with a prevalence of 0.6–2.0% in patients with congenital heart disease.1 Many of these patients are expected to undergo cardiac catheterisation through the femoral vein. For this, the catheter must pass up the IVC to the azygos vein and then down into the superior vena cava (SVC), making the procedure technically more difficult. A 19-year-old male patient with patent ductus arteriosus with severe pulmonary arterial hypertension was subjected to cardiac catheterisation to test the reactivity of the pulmonary vascular bed. Chest X-ray revealed a smooth mass at the right tracheobronchial angle (figure 1). During right heart catheterisation, there was difficulty in …