Rajesh Vijayvergiya

Pregnancy and Takayasu arteritis: A single centre experience from North India

Aim:  Takayasus syndrome is a chronic inflammatory arteriopathy of unknown origin which primarily affects women of reproductive age. We report the course and outcome of 37 pregnancies in 15 women with Takayasu arteritis during the period 1999–2008.

Midodrine and Clonidine in Patients With Cirrhosis and Refractory or Recurrent Ascites: A Randomized Pilot Study

OBJECTIVES:Splanchnic arterial vasodilatation and subsequent activation of anti-natriuretic and vasoconstrictive mechanisms have an important role in cirrhotic ascites. The aim of this study was to evaluate the effects of midodrine, clonidine, and their combination on systemic hemodynamics, renal function, and control of ascites in patients with cirrhosis and refractory or recurrent ascites.METHODS:Sixty cirrhotic patients with refractory or recurrent ascites were prospectively studied after long-term administration of clonidine (n=15) or midodrine (n=15), or both (n=15) plus standard medical therapy (SMT), or SMT alone (n=15), in a randomized controlled trial at a tertiary center.RESULTS:A significant increase in urinary volume, urinary sodium excretion, mean arterial pressure, and decrease in plasma renin activity (P<0.05) was noted after 1 month. There was also a significant decrease in cardiac output (P<0.05) and increase in systemic vascular resistance (P<0.05) in all groups, except clonidine. There was no change in glomerular filtration rate and model for end-stage liver disease score. Midodrine and a combination of midodrine and clonidine plus SMT were superior to SMT alone in the control of ascites (P=0.05), and there was a trend towards better control of ascites in the clonidine group (P=0.1). The mortality and frequency of various complications were similar in all groups.CONCLUSIONS:These results suggest that midodrine, clonidine, and their combination plus SMT improves the systemic hemodynamics without any renal or hepatic dysfunction, and is superior to SMT alone for the control of ascites. However, the combination therapy was not superior to midodrine or clonidine alone.

Mechanical valve prosthesis and anticoagulation regimens in pregnancy: a tertiary centre experience

OBJECTIVE This study was undertaken to analyze the maternal and perinatal outcome in women with prosthetic heart valves on different anticoagulant regimens. STUDY DESIGN A retrospective chart review of pregnancies in 40 women with mechanical valve prostheses at a tertiary referral centre from 1997 to 2010. The main outcome measures were major maternal complications and perinatal outcome. RESULTS The valves replaced were mitral (67.5%), aortic (15.0%), or both (17.5%). Forty-nine pregnancies (72.1%) resulted in live births, 3(4.4%) had stillbirths, and 13(19.1%) had spontaneous abortions and 1(1.4%) underwent therapeutic abortions. The live birth rate was higher in women on heparin (78.3%) compared with those on warfarin (66.9%). There were 2 maternal deaths due to acute mitral valvular thrombosis while on acenocoumarol in the second trimester. Hemorrhagic complications occurred in 3 patients on heparin in the postpartum period, 2 of whom required transfusion. In addition one patient who was on acenocoumarol developed secondary hemorrhage. CONCLUSION No anticoagulant regimen can be said to be entirely safe for use during pregnancy as there is a degree of risk with each regimen. Further larger studies are needed to come up with sufficient evidence-based recommendations for the best possible management of such patients to reduce the maternal risks after mechanical heart valve replacement without compromising fetal outcome.

Myocardial ischemia secondary to dual coronary artery fistulas draining into main pulmonary artery

Bilateral coronary artery to pulmonary artery fistulas is an uncommon congenital anomaly. These fistulas have a clinical and embryological significance. We report a rare case of combination of right coronary and left circumflex coronary fistula draining into main pulmonary artery, who presented in the emergency room with acute pain chest. The fistula had significant 1.7:1 left to right shunt and also myocardial ischemia as demonstrated by exercise Thallium(201) SPECT myocardial imaging. He was managed conservatively during the last 5 years without any percutaneous or surgical intervention.

Maternal complete heart block in pregnancy: analysis of four cases and review of management.

Aim:  Maternal complete heart block (CHB), which manifests for the first time during pregnancy and peurperium, poses a challenge to treating physicians. We present here four cases that were diagnosed during pregnancy and peurperium, and we discuss their management issues.

Retrospective analysis of outcome of pregnancy in women with congenital heart disease: single-centre experience from North India.

Objective: To study maternal and perinatal outcome in congenital heart disease (CHD) and to compare outcome between cyanotic and acyanotic CHD.

Role of Helicobacter pylori infection in pathogenesis of atherosclerosis.

Though a century old hypothesis, infection as a cause for atherosclerosis is still a debatable issue. Epidemiological and clinical studies had shown a possible association but inhomogeneity in the study population and study methods along with potential confounders have yielded conflicting results. Infection triggers a chronic inflammatory state which along with other mechanisms such as dyslipidemia, hyper-homocysteinemia, hypercoagulability, impaired glucose metabolism and endothelial dysfunction, contribute in pathogenesis of atherosclerosis. Studies have shown a positive relations between Cytotoxic associated gene-A positive strains of Helicobacter pylori and vascular diseases such as coronary artery disease and stroke. Infection mediated genetic modulation is a new emerging theory in this regard. Further large scale studies on infection and atherosclerosis focusing on multiple pathogenetic mechanisms may help in refining our knowledge in this aspect.

Ebstein's anomaly in pregnancy: Maternal and neonatal outcomes

Aim:  Ebsteins anomaly is a rare congenital cardiac abnormality, associated with cyanosis and arrhythmia. Patients often reach childbearing age and pregnant women pose a challenge to the treating physician. We describe the course and outcome of pregnancy in women with Ebsteins anomaly and discuss the related management issues.

Assessment of IVC filter efficacy in prevention of pulmonary thrombo-embolism by 99mTc-MAA lung perfusion scintigraphy—A case series and review of literature

INTRODUCTION Anticoagulant therapy is the standard treatment of venous thrombo-embolism (VTE). Permanent inferior vena cava (IVC) filter is an important adjunctive therapy in these patients to prevent the complications like potentially fatal pulmonary embolism and chronic thrombo-embolic pulmonary hypertension. We studied patients with proximal deep vein thrombosis (DVT) of lower limbs and recurrent pulmonary thrombo-embolism (PTE), who were put on permanent IVC filters for the prevention of further episodes of PTE. The efficacy of filters in prevention of PTE was assessed by clinical history and was supported by follow-up (99m)Tc-MAA lung perfusion scintigraphy. METHODS AND RESULTS We prospectively enrolled 7 patients of PTE, who were put on IVC filter from July 2002-April 2005. All patients had (99m)Tc-MAA lung perfusion scan before filter implantation. Percutaneous IVC filter placement in infra-renal position was done. All patients were put on adequate oral anticoagulant treatment with target INR of 2.0-3.0. At follow-up two patients died - one died of intractable right heart failure at 6 months and other died of carcinoma colon metastasis after 16 months. The mean follow-up of rest of five patients was 3.5 years (range 20-54 months), and none of them had clinically evident further episode of DVT or PTE. Their repeat lung perfusion scan at 1 year of follow-up showed marked improvement in perfusion with no evidence of additional fresh/new defects. CONCLUSION Follow-up (99m)Tc-MAA lung perfusion scan in PTE patients, who are on IVC filter, can demonstrate the significant improvement in lung perfusion secondary to prevention of further pulmonary embolism episodes and resolution of pulmonary thrombus by continued anticoagulant therapy.

Endovascular Management of Isolated Axillary Artery Aneurysm: A Case Report

The purpose of this paper is to report a case of axillary artery aneurysm, successfully treated by percutaneous transfemoral self-expandable polytetrafluoroethylene (PTFE) covered Wallgraft™ stent. A 20-year-old man presented with sudden-onset, severe aching pain of left upper limb that occurred while doing isometric exercise. He had feeble left brachial and radial pulses. Angiography revealed a 21 x 14 mm left axillary artery aneurysm with a 15 mm neck. There was an organized clot in the midpart of the left brachial artery. The aneurysm was successfully closed with a self-expandable 10 x 30 mm Wallgraft™ endoprosthesis PTFE graft stent, via the right femoral route. A check angiogram at 6 weeks of follow-up showed a patent stent with no endovascular leak. At 1 year of follow-up, the patient was asymptomatic with normal upper limbs pulsations. Axillary artery aneurysm may be treated with a stent graft, which is an effective, rapid, and definite treatment and is an acceptable alternative to standard open surgical repair.