Paul V. George

Giant Pulmonary Artery Aneurysm With Dissection in a Case of Marfan Syndrome

![Figure][1] [![Graphic][3] ][3] A 40-year-old man presented with left-sided chest pain of 1 week in duration. He had tachycardia, tachypnea, and an early diastolic murmur with Marfanoid features. Chest x-ray showed gross cardiomegaly and a prominent main pulmonary artery (A) .

Radiation doses and estimated risk from angiographic projections during coronary angiography performed using novel flat detector

Coronary angiography (CA) procedure uses various angiographic projections to elicit detailed information of the coronary arteries with some steep projections involving high radiation dose to patients. This study intends to evaluate radiation doses and estimated risk from angiographic projections during CA procedure performed using novel flat detector (FD) system with improved image processing and noise reduction techniques. Real‐time monitoring of radiation doses using kerma‐area product (KAP) meter was performed for 140 patients using Philips Clarity FD system. The CA procedure involved seven standard projections, of which five were extensively selected by interventionalists. Mean fluoroscopic time (FT), KAP, and reference air kerma (Ka,r) for CA procedure were 3.24 min (0.5–10.51), 13.99 Gycm2 (4.02–37.6), and 231.43 mGy (73.8–622.15), respectively. Effective dose calculated using Monte Carlo‐based PCXMC software was found to be 4.9 mSv. Left anterior oblique (LAO) 45° projection contributed the highest radiation dose (28%) of the overall KAP. Radiation‐induced risk was found to be higher in females compared to males with increased risk of lung cancer. An increase of 10%–15% in radiation dose was observed when one or more additional projections were adopted along with the seven standard projections. A 14% reduction of radiation dose was achieved from novel FD system when low‐dose protocol during fluoroscopy and medium‐dose protocol during cine acquisitions were adopted, compared to medium‐dose protocol. PACS number(s): 87.50.cm, 87.55.de, 87.55.N, 87.59.cf, 87.59.DjCoronary angiography (CA) procedure uses various angiographic projections to elicit detailed information of the coronary arteries with some steep projections involving high radiation dose to patients. This study intends to evaluate radiation doses and estimated risk from angiographic projections during CA procedure performed using novel flat detector (FD) system with improved image processing and noise reduction techniques. Real-time monitoring of radiation doses using kerma-area product (KAP) meter was performed for 140 patients using Philips Clarity FD system. The CA procedure involved seven standard projections, of which five were extensively selected by interventionalists. Mean fluoroscopic time (FT), KAP, and reference air kerma (Ka,r) for CA procedure were 3.24 min (0.5-10.51), 13.99 Gycm2 (4.02-37.6), and 231.43 mGy (73.8-622.15), respectively. Effective dose calculated using Monte Carlo-based PCXMC software was found to be 4.9 mSv. Left anterior oblique (LAO) 45° projection contributed the highest radiation dose (28%) of the overall KAP. Radiation-induced risk was found to be higher in females compared to males with increased risk of lung cancer. An increase of 10%-15% in radiation dose was observed when one or more additional projections were adopted along with the seven standard projections. A 14% reduction of radiation dose was achieved from novel FD system when low-dose protocol during fluoroscopy and medium-dose protocol during cine acquisitions were adopted, compared to medium-dose protocol. PACS number(s): 87.50.cm, 87.55.de, 87.55.N, 87.59.cf, 87.59.Dj.

Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction - MI3 Trial

Background & objectives: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 108 autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy. Methods: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI). Results: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 × 108(n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study. Interpretation & conclusions: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Optimization and audit of radiation dose during percutaneous transluminal coronary angioplasty

The percutaneous transluminal coronary angioplasty (PTCA) is one of the interventional procedures which impart high radiation doses to patients compared to the other cardiologic procedures. This study intends to audit and optimize radiation dose imparted to patients undergoing PTCA. Forty-four patients who underwent PTCA involving single or multiple stent placement guided under cardiovascular X-ray machine were included in the study. Radiation doses were measured using dose area product (DAP) meter for patients undergoing single and multiple stent placements during PTCA. A dose reduction of 27-47% was achieved using copper filters and optimal exposure parameters. The mean DAP values before optimization were 66.16 and 122.68 Gy cm(2) for single and multiple stent placement respectively. These values were 48.67 and 65.44 Gy cm(2) respectively after optimization. In the present scenario, due to the increase in the number of PTCAs performed and the associated risk from radiation, periodical audit of radiation doses for interventional procedures are recommended.

Transition from image intensifier to flat panel detector in interventional cardiology: Impact of radiation dose

Flat panel detector (FPD) technology in interventional cardiology is on the increase due to its varied advantages compared to the conventional image intensifier (II) systems. It is not clear whether FPD imparts lower radiation doses compared to II systems though a few studies support this finding. This study intends to compare radiation doses from II and FPD systems for coronaryangiography (CAG) and Percutaneous Transluminal Coronary Angioplasty (PTCA) performed in a tertiary referral center. Radiation doses were measured using dose area product (DAP) meter from patients who underwent CAG (n = 222) and PTCA (n = 75) performed using FPD angiography system. The DAP values from FPD were compared with earlier reported data using II systems from the same referral center where the study was conducted. The mean DAP values from FPD system for CAG and PTCA were 24.35 and 63.64 Gycm 2 and those from II system were 27.71 and 65.44 Gycm 2 . Transition from II to FPD system requires stringent dose optimization strategies right from the initial period of installation.

Audit of radiation dose during balloon mitral valvuloplasty procedure

Radiation doses to patients during cardiological procedures are of concern in the present day scenario. This study was intended to audit the radiation dose imparted to patients during the balloon mitral valvuloplasty (BMV) procedure. Thirty seven patients who underwent the BMV procedure performed using two dedicated cardiovascular machines were included in the study. The radiation doses imparted to patients were measured using a dose area product (DAP) meter. The mean DAP value for patients who underwent the BMV procedure from one machine was 19.16 Gy cm(2) and from the other was 21.19 Gy cm(2). Optimisation of exposure parameters and radiation doses was possible for one machine with the use of appropriate copper filters and optimised exposure parameters, and the mean DAP value after optimisation was 9.36 Gy cm(2).

Right internal jugular vein approach as an alternative in balloon pulmonary valvuloplasty.

Transjugular balloon pulmonary valvuloplasty was safely and successfully performed in five patients, two of whom had severe right heart failure. Crossing the stenotic pulmonary valve from the right internal jugular vein was consistently easy and quick. This approach should be considered whenever difficulties are experienced or anticipated in the femoral approach. Cathet. Cardiovasc. Intervent. 46:425–429, 1999.

Testosterone as a marker of coronary artery disease severity in middle aged males

Historically, higher levels of serum testosterone were presumed deleterious to the cardiovascular system. In the last two decades, studies have suggested that low testosterone levels are associated with increased prevalence of risk factors for cardiovascular disease (CVD), including dyslipidemia and diabetes. This is a cross sectional study. The aim of our study was to determine the relationship between serum testosterone levels and angiographic severity of coronary artery disease (CAD). Serum testosterone levels were also correlated with flow mediated dilation of brachial artery (BAFMD) – an indicator of endothelial function. Consecutive male patients, aged 40–60 years, admitted for coronary angiography (CAG) with symptoms suggestive of CAD, were included in the study. Out of the 92 patients included in the study, 32 patients had normal coronaries and 60 had CAD on coronary angiography. Severity of CAD was determined by Gensini coronary score. The group with CAD had significantly lower levels of total serum testosterone (363 ± 147.1 vs 532.09 ± 150.5 ng/dl, p < 0.001), free testosterone (7.1215 ± 3.012 vs 10.4419 ± 2.75 ng/dl, p < 0.001) and bioavailable testosterone (166.17 ± 64.810 vs 247.94 ± 62.504 ng/dl, p < 0.001) when compared to controls. Adjusting for the traditional risk factors for CAD, a multiple linear regression analysis showed that low testosterone was an independent predictor of severity of CAD (β = −0.007, p < 0.001). This study also showed that levels of total, free and bioavailable testosterone correlated positively with BAFMD %.

Effect of a government scheme on reperfusion trends in a tertiary care centre in South India.

AIMS Coronary artery disease is the leading cause of mortality and morbidity in our country, of which ST elevation myocardial infarction (STEMI) accounts for the major part of health spending. We sought to study the effect of induction of government health insurance scheme on the trends of reperfusion in patients of acute STEMI. METHODS AND RESULTS 1133 patients presenting with acute STEMI enrolled. 1079 (95.1%) received some form of reperfusion therapy. Primary PCI was used in 60.6% of patients as the primary reperfusion modality, a six fold increase as compared to previous years. Government health insurance accounted for the one third of all. 34.5% patients underwent pharmacological reperfusion, most commonly with streptokinase. 4.9% patients of STEMI did not receive any form of reperfusion therapy in contrast to 14% during previous years. CONCLUSION Introduction of government health insurance along with increased awareness has resulted in dramatic changes in the management of STEMI patients.

Feasibility of Angioplasty and Stenting for Abdominal Aortic Lesions Adjacent to Previously Stented Visceral Artery Lesions in Patients with Takayasu Arteritis

Two young female patients with Takayasu arteritis presented with symptomatic long-segment abdominal aortic stenosis in the vicinity of previously deployed celiac and renal artery stents that projected markedly into the narrowed aortic lumen. Crushing or distortion of the visceral artery stents during aortic angioplasty was avoided by performing simultaneous or alternating balloon dilatations in the aorta and in the visceral artery stents. Consequently, the visceral artery stents remained patent and shortened longitudinally, allowing unhindered deployment of Wallstents in the adjacent aorta and abolition of a pressure gradient across the aortic lesions. Access to side branches covered by the Wallstent was obtained without difficulty, enabling the performance of balloon dilatation in multiple side branches and ostial stent deployment in a renal artery. These techniques could increase the scope of endovascular therapy in the treatment of patients with Takayasu arteritis.