Ravindranath Ks

Incidence and Predictors of Left Atrial Thrombus in Patients with Rheumatic Mitral Stenosis and Sinus Rhythm: A Transesophageal Echocardiographic Study

Background: Rheumatic mitral stenosis (MS) predisposes to left atrial (LA) thrombus formation. The reported incidence of LA clot formation in sinus rhythm (SR) is 2.4–13.5% in small studies. Aim: To determine the incidence of LA thrombus in MS in SR in a large cohort of patients and to determine the factors that predict its development. Methods: Total of 848 consecutive patients with MS in SR who were being evaluated for percutaneous transvenous mitral commisurotomy were included in the study. Both transthoracic (TTE) and transesophageal echocardiograms (TEE) were performed to identify clot and other hemodynamic parameters. Results: The mean age of the study population was 34 ± 9 years and the mean mitral orifice area was 0.78 ± 0.18 cm2. Out of 848 patients 56 (6.6%) had LA thrombus on TEE. On univariate analysis there was a trend toward thrombus formation in individuals with age >44 years, LA inferosuperior dimension >6.9 cm, mean mitral gradient >18 mmHg and dense spontaneous echo contrast (SEC). On multivariate analysis none of the factors predicted clot formation. Conclusion: The incidence of LA thrombus in MS in SR is 6.6%. TEE is warranted in MS patients in SR when they are >44 years, LA inferosuperior dimension >6.9 cm and mean mitral gradient >18 mmHg. When SEC is absent on TEE, thrombus formation is unlikely. (Echocardiography 2011;28:457‐460)

Acute myocardial infarction following scorpion sting in a case with obstructive coronary artery disease.

The occurrence of an acute myocardial infarction (MI) following a scorpion sting has been very rarely reported in the previous literature. Possible pathogenetic mechanisms include severe hypotension due to hypovolaemic shock and coronary spasm with subsequent thrombosis of coronary vessels developed after the release of vasoactive, inflammatory and thrombogenic substances contained in the scorpion venom. All of the previously reported cases had normal coronary angiogram. We report a case of a 65-year-old woman who presented with severe scorpion sting and was treated with prazosin. But a few hours later, she developed acute anterior wall MI. Coronary angiogram revealed the presence of significant stenosis in coronary arteries. As acute MI owing to significant coronary artery disease can be evident after severe scorpion envenomation, so every case of acute coronary syndrome following scorpion sting needs early diagnosis, thorough cardiovascular evaluation and appropriate treatment.

Incidence and Predictors of Atrial Septal Defect after Percutaneous Transvenous Mitral Commissurotomy – A Transesophageal Echocardiographic Study of 209 Cases

Background: The incidence of atrial septal defect (ASD) after percutaneous transvenous mitral commissurotomy (PTMC) ranges from 15.2% to 92% in small studies. Aim: To estimate the incidence of atrial septal defect (ASD) following PTMC and to determine the factors contributing to its development. Methods: We studied 209 patients with mitral stenosis (MS) undergoing PTMC. Transesophageal echocardiography (TEE) with color Doppler examination was performed to detect ASD. Results: TEE demonstrated ASD in 139 (66.5%) of 209 patients. The mean diameter of the interatrial septal defect detected by TEE was 4.47 ± 1.7 mm. The most common site of septal puncture was the inferior vena caval side of the interatrial septum followed by fossa ovalis. Color flow imaging across the defect showed left to right shunting in all the patients (100%). We examined the relationship of age, Wilkins score, left atrial volumes, the mitral valve orifice area, mitral valve gradient, and the degree of mitral and tricuspid regurgitation between the group that developed ASD and the group without ASD and found that none of these factors predicted the development of ASD. A residual ASD was seen in 11 patients (8.7%) at 6‐month follow‐up. Conclusion: Incidence of residual atrial septal defect immediately following PTMC by TEE color flow Doppler imaging is 66.5%. Surrogate markers of elevated left atrial pressures do not determine the development of atrial septal defect after PTMC. The majority of the defects close spontaneously and a residual defect is observed in 8.7% patients at 6 months.

A patient of Ebstein’s anomaly associated with biventricular noncompaction presented with Wolf Parkinson White syndrome - A rare presentation

A 34 year-old male patient presented with recurrent attack of palpitation and chest pain due to Wolf Parkinson White syndrome (WPWS). Two dimensional echocardiography demonstrated features of Ebsteins anomaly along with biventricular non compaction. Color flow Doppler studies confirmed the presence of blood flow within the trabeculations. Biventricular myocardial non-compaction associated with Ebsteins anomaly who presented with WPWS is a very rare association. So far, Medline search revealed only three reported cases in the literatures. The patient was treated with radiofrequency ablation of right sided posteroseptal accessory pathway of WPWS and was asymptomatic in further follow-up.

Chronic thromboembolic pulmonary hypertension in a case with multi-drug resistant pulmonary tuberculosis

Chronic thromboembolic pulmonary hypertension in a case with multi-drug resistant pulmonary tuberculosis Pulmonary tuberculosis is very common and multidrug resistance (MDR) is emerging in the developing country. The association with chronic pulmonary embolism is a rare entity. We are reporting a case of 19-years old female with MDR tuberculosis, had severe pulmonary hypertension and right heart failure due to chronic pulmonary embolism.

Sinus node dysfunction complicating viper bite

Viper venom toxicities comprise mainly bleeding disorders and nephrotoxicity. Cardiotoxicity is a rare manifestation of viper bite. We describe the case of a previously healthy 35-year-old man who developed coagulopathy and sinus node dysfunction following a viper bite. Electrocardiography showed sinus arrest and junctional escape rhythm. This is the first account of sinus node dysfunction caused by a viper bite.

Acute Pulmonary Embolism in Young: A Prospective Observational Study on Clinical Implication of Age on the Presentation and Management of Patients with Acute Pulmonary Embolism

Acute Pulmonary Embolism in Young: A Prospective Observational Study on Clinical Implication of Age on the Presentation and Management of Patients with Acute Pulmonary Embolism Prevalence of acute pulmonary embolism is increasing in general population especially in old population. Prevalence of acute pulmonary embolism in young adults is unknown.

Coronary artery disease in patients undergoing cardiac surgery for non-coronary lesions in a tertiary care centre

Background The objective of the present study was to determine the prevalence of coronary artery disease (CAD) in patients undergoing surgery for various valvular as well as non-valvular cardiac pathologies. Methods Patients with various valvular and non-valvular pathologies were selected. All patients with age ≥40 years and an indication for open heart surgery underwent pre-operative coronary angiogram and were included in the study. Results The mean age was 51.5 ± 9.02 years. 178 (59.3%) patients were males and 122 (40.7%) patients were females. Out of 300 patients, 270 (90%) patients had valvular heart disease (VHD) and 30 (10%) patients had non-valvular heart disease. Rheumatic heart disease (RHD), mitral valve prolapse (MVP), degenerative aortic valve disease (DAVD) and bicuspid aortic valve (BAV) was present in 161 (53.7%), 17 (5.7%), 60 (20%) and 32 (10.7%) patients respectively. Overall, 26 (8.7%) patients were found to have significant CAD. CAD was significantly more common in patients with VHD as compared to patients with other etiologies (1 patient, 3.3%, p < 0.05). In the valvular group, DAVD patients had maximum prevalence of CAD (14 patients, 23.4%, p < 0.05). In the group with CAD, the presence of variables such as age >60 years, male sex, typical angina, HT, dyslipidemia and smoking were significantly greater as compared to those with normal coronaries. Conclusion The overall prevalence of CAD among patients undergoing non-coronary cardiac surgery is 8.7%. Coronary artery disease is relatively uncommon in patients with rheumatic VHD (4.9%), while its prevalence is highest in DAVD (23.4%).

Clinico-Etiological Profile of Cardiac Tamponade in a Tertiary Care Centre

Background: Pericardial tamponade, a life-threatening condition caused by the accumulation of fluid in the pericardial sac, can be acute or chronic. Mortality and morbidity can be minimized on prompt diagnosis and treatment with percutaneous drainage. Materials and methods: 246 patients admitted with cardiac tamponade between Jan 2010 and Aug 2014 was enrolled in the study. After clinical examination and echocardiographic assessment, all the patients were subjected to emergency pericardiocentesis (both diagnostic and therapeutic). Three samples of the aspirate were sent for biochemical, serological, and cytological analysis. The data collected was then analyzed.

Absent pulmonary valve: a case with rare presentation treated with bioprosthetic valve replacement.

Congenital absence of the pulmonary valve is a rare congenital cardiac malformation, usually seen in association with tetralogy of Fallot. Patients generally present early in life with respiratory distress or recurrent respiratory tract infections, failure to thrive, cyanosis, infective endocarditis, or heart failure. Isolated absent pulmonary valve is quite rare and may be discovered in older age-group as in our patient, a nine-year-old male child who presented with atypical symptoms of exertional chest pain. Unusual echocardiographic features in this case include intact ventricular septum and prominent trabeculations of the right ventricle. Surgical implantation of a bioprosthetic valve was followed by hemodynamic and symptomatic improvement.