Rajiv Bharat Kharwar

Obstructive Sleep Apnea and Cardiovascular Events After Percutaneous Coronary Intervention

Background— There is a paucity of data from large cohort studies examining the prognostic significance of obstructive sleep apnea (OSA) in patients with coronary artery disease. We hypothesized that OSA predicts subsequent major adverse cardiac and cerebrovascular events (MACCEs) in patients undergoing percutaneous coronary intervention. Methods and Results— The Sleep and Stent Study was a prospective, multicenter registry of patients successfully treated with percutaneous coronary intervention in 5 countries. Between December 2011 and April 2014, 1748 eligible patients were prospectively enrolled. The 1311 patients who completed a sleep study within 7 days of percutaneous coronary intervention formed the cohort for this analysis. Drug-eluting stents were used in 80.1% and bioresorbable vascular scaffolds in 6.3% of the patients, and OSA, defined as an apnea-hypopnea index of ≥15 events per hour, was found in 45.3%. MACCEs, a composite of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned revascularization, occurred in 141 patients during the median follow-up of 1.9 years (interquartile range, 0.8 years). The crude incidence of an MACCEs was higher in the OSA than the non-OSA group (3-year estimate, 18.9% versus 14.0%; p=0.001). Multivariate Cox regression analysis indicated that OSA was a predictor of MACCEs, with an adjusted hazard ratio of 1.57 (95% confidence interval, 1.10–2.24; P=0.013), independently of age, sex, ethnicity, body mass index, diabetes mellitus, and hypertension. Conclusions— OSA is independently associated with subsequent MACCEs in patients undergoing percutaneous coronary intervention. Evaluation of therapeutic approaches to mitigate OSA-associated risk is warranted. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01306526.

Ruptured Anterior Mitral Leaflet Aneurysm in Aortic Valve Infective Endocarditis—Evaluation by Three‐Dimensional Echocardiography

Ruptured aneurysm of the anterior mitral leaflet is a rare but a devastating complication secondary to aortic valve infective endocarditis. We report a case of 30‐year‐old male with native aortic valve endocarditis who was referred to us for evaluation of worsening of heart failure after an initial period of responsiveness to antibiotics. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed ruptured anterior mitral leaflet aneurysm with severe eccentric mitral regurgitation along with a large vegetation on the aortic valve. The patient underwent successful surgical closure of the defect along with aortic valve replacement.

Persistent truncus arteriosus: a rare survival beyond the first decade.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] An 11-year-old cyanotic boy presented to our department with worsening effort intolerance. Two-dimensional transthoracic echocardiography with color Doppler ( A to D, [Online Video 1][5]) showed a common

Multimodality imaging of submitral left ventricular aneurysm.

Submitral left ventricular aneurysms are a rare nonischemic aneurysm thought to be developmental in origin. These aneurysms invariably occur at the site of posterior mitral annulus and lead to mitral valve incompetence. We hereby describe a case of a 30‐year‐old adult with a rare form of submitral left ventricular aneurysm involving whole of the posterior mitral annulus. Multimodality imaging with two‐dimensional echocardiography, three‐dimensional echocardiography, computed tomography and invasive left ventriculography helped the patient to undergo successful resection of the aneurysm along with mitral valve replacement.

Three‐Dimensional Echocardiographic Delineation of an Acquired Aorto‐Left Atrial Fistula Complicating Native Aortic Valve Endocarditis – “Advantage of Three Dimensions”

Aorto‐atrial fistulas are rare, but important complications resulting from aortic valve infective endocarditis, aortic valve surgery, or aortic dissection. We hereby report a case of a 20‐year male, referred to us with infective endocarditis of the native aortic valve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed aorto‐left atrial fistula secondary to the involvement of the mitral–aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aortic valve replacement, and mitral valve repair.

Classical triad of Kearns-Sayre syndrome

We describe the images of a 27-year-old man presenting with recurrent syncope due to complete heart block (figure 1). The patient, on further examination, showed ophthalmoplegia, bilateral ptosis (figure 2) and pigmentary retinopathy (figure 3). Kearns-Sayre syndrome (KSS) is a rare mitochondrial genetic disorder with multisystem involvement. KSS usually presents before the age of 20 years. The triad of external opthalmoplegia, pigmentary retinopathy, and cardiac conduction defects are sufficient to make a confident diagnosis of …

Right‐Sided Endomyocardial Fibrosis with a Right Atrial Thrombus: Three‐Dimensional Transthoracic Echocardiographic Evaluation

Endomyocardial fibrosis is a form of restrictive cardiomyopathy mainly affecting poor children and young adults in geographically restricted areas of Latin America, Africa, and Southeast Asia. The pathophysiological hallmark of the disease is focal or diffuse endocardial thickening involving mainly the inflow, the apices, and the subvalvular region leading to valvular regurgitation, diastolic dysfunction and obliteration of the ventricular apex. Advanced right‐sided disease has slow flow of blood through chambers with propensity of thrombus formation especially in the right atria. Although two‐dimensional transthoracic echocardiography remains the cornerstone for the diagnosis of this disease, the case presented here shows how three‐dimensional transthoracic echocardiography can add substantial information regarding the region of involvement of the right ventricle as well as the various characteristics of the right atrial thrombus.

Real time three-dimensional transthoracic echocardiography of ruptured left sinus of Valsalva aneurysm to left ventricle.

Aneurysms arising from the sinus of Valsalva are a rare cardiac defect that can present with various signs and symptoms, and if not diagnosed and treated rapidly can lead to fatal outcomes. Unruptured aneurysms are usually asymptomatic and found incidentally during diagnostic studies. More commonly, aneurysm of sinus of Valsalva is detected after the occurrence of rupture. Echocardiography has become the investigative tool of choice for this condition, not only for diagnosis but also for quantification of severity. We hereby report a rare case of a 15‐year‐old patient presenting with complaints of effort dyspnea and palpitations. Two‐dimensional transthoracic echocardiography (TTE) showed aneurysmal dilatation of left sinus of Valsalva which had ruptured into the left ventricle. Also, there was an intimal flap within the sinus of Valsalva aneurysm. The anatomical relationship between the aorta, aneurysm, and the left ventricle as well as the intimal flap within the aneurysm was clearly delineated with the help of three‐dimensional TTE. After confirmation of the diagnosis with multidetector computed tomography, patient underwent successful surgical repair of the defect.

Huge Multilobulated Left Ventricular Outflow Tract Pseudoaneurysm Presenting with Ventricular Tachycardia

A 30-year-old male presented to our emergency department with recurrent episodes of syncope for one day. Pulse was feeble with a rate of 200 per minute and systolic blood pressure was 80 mm Hg. Electrocardiogram (Fig. 1) showed a monomorphic ventricular tachycardia originating from the left ventricular outflow tract (LVOT) region (Fig. 1A). Emergency 200 J synchronized defibrillator shock was given and the rhythm reverted back to normal sinus rhythm with bifascicular block (Fig. 1B). There was no history of infective endocarditis, previous cardiac surgery or chest trauma. Cardiac auscultation revealed an early diastolic murmur at the aortic area. Chest and other systemic examination was within normal limits. Cardiac markers (troponin I and creatinine phospokinase) were negative. Chest X-ray showed cardiomegaly with multiple calcified shadows within the cardiac silhouette (white arrows, Fig. 2). Poor transthoracic acoustic window necessitated transesophageal echocardiography, which showed a huge calcified structure near the LVOT region which was compressing the left ventricuar (LV) cavity and leading to aortic regurgitation (Fig. 3, Supplementary movie 1 and 2). To further delineate the anatomy, a multidetector computed tomography was done which showed a giant (7.0 × 9.0 × 7.5 cm), calcified, multilobulated and partially thrombosed LVOT pseudoaneurysm (Fig. 4). The pseudoaneurysm had its origin in the LVOT from the mitral aortic intervalvular fibrosa region and extended anteriorly, laterally and superiorly. Invasive left ventriculogram showed a giant calcified LVOT pseudoaneurysm with only partial filling due to thrombosis within the cavity of the pseudoaneurysm (Fig. 5A and B, Supplementary movie 3 and 4). Invasive coronary angiography showed extrinsic compression (60% diameter stenosis) of the proximal left anterior descending coronary artery (Fig. 5C and D, Supplementary movie 5). Treadmill test was done which was negative for stress induced ischemia. Patient was started on amiodarone therapy and is now planned for possible surgical correction. Fig. 1 The presenting electrocardiogram of the patient showing monomorphic ventricular tachycardia originating from the left ventricular outflow tract region (A). Post direct current cardioversion, patient regained normal sinus rhythm but with bifascicular block ... Fig. 2 Chest X-ray showing cardiomegaly with a bulge at the upper left cardiac border along with multiple calcified round to oval shadows (white arrows) within the cardiac silhouette. Fig. 3 Transesophageal echocardiography with color Doppler. The mid esophageal four chamber view showing a large calcified mass in the basal septal region compressing the LV cavity (A) leading to mild mitral regurgitation (B). The aortic valve was tri-leaflet ... Fig. 4 Multidetector computed tomography. The communication of the pseudoaneurysm with the LVOT can be clearly seen in the axial section (A). The multilobulated nature, the calcified rims and the thrombosed lumen of the pseudoaneurysm can also be seen in the ... Fig. 5 Invasive left ventriculography in the right anterior oblique projection (A) and in the left anterior oblique (LAO) projection with cranial angulation (B) showing the calcified, multilobulated LVOT pseudoaneurysm filling partially due to the thrombosed ... Pseudoaneurysms arising from LVOT region are a rare entity and exact incidence and prevalence is not known as only case reports are described in the literature. The mitral-aortic intervalvular fibrosa (MAIVF) is a fibrous triangular area in the LVOT connecting the base of the anterior mitral leaflet and the posterior aortic root.1) The relative avascular nature of MAIVF makes it susceptible to infection and injury leading to secondary pseudoaneurysm formation. Usually a prior history of either infective endocarditis, cardiac surgical intervention, chest injury or prosthetic aortic valve implantation is present.2) The patient in the present case was asymptomatic before he presented to us. The most common clinical presentation is congestive cardiac failure followed by chest pain, dyspnea and hepotysis; in some cases sudden cardiac death can be the first presenting feature.3) The pseudoaneurysm can enlarge and produce clinical features from obstruction of the surrounding structures like coronary arteries, pulmonary artery, left atrium and bronchus.4) These pseudoaneurysm also predispose to embolization and infection. Congestive cardiac failure and rupture into the surrounding structures can lead to death.4) Presentation with ventricular tachycardia, as in our case is scarcely reported. The pathophysiology of the ventricular tachycardia in the present case seem to be due to myocardial involvement per se and not due to ischemia as the cardiac markers and exercise stress test were negative for ischemia. The presence of right bundle branch block along with left axis deviation in the baseline electrocardiogram suggest erosion into the septal area by the LVOT pseudoaneurysm. Although transthoracic and transesophageal echocardiography can make a reliable diagnosis of LVOT pseudoaneurysm,5) the patient in the present case had such a huge pseudoaneurysm that it required further imaging with computed tomography and invasive LV angiography along with coronary angiography. The natural history of LVOT pseudoaneurysm is not properly know. The rate of growth of these pseudoaneurysm is also not known as no large scale echocardiographic or other imaging modality follow is available. Whether surgical correction is required in asymptomatic patients and in patients without rapid growth is debated. The surgical correction in such patients is complex often requiring aortic valve replacement, aortic root reconstruction, mitral valve repair and MAIVF reconstruction. These pseudoaneurysms are associated with high morbidity and mortality due to high risk of serious and potentially fatal complications.6) Based on this findings, most studies advice for surgical correction, without which the survival is low.6)

Cleft anterior mitral leaflet with supravalvular aortic stenosis a rare association

A 20 year old female was referred to us for evaluation of effort dyspnoea of NYHA class II with feeble left common carotid, left brachial and left radial artery as compared to other sides. Detail evaluation with two dimensional (2D) transthoracic echocardiographic, 2D transesophageal echocardiography and multidetector computed tomography (MDCT) delineated Cleft AML and diffuse type of supravalvular aortic stenosis. To the best of our knowledge, no such case have been described in the literature where these anomalies co-existed in the same patient.