Rohit Tandon

Clinical and echocardiographic diagnosis, follow up and management of right-sided cardiac thrombi.

BACKGROUND Right-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India. METHODS This is a retrospective, single center observational study of consecutive patients over the period January 2003-2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician. RESULTS The mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range--18-50 months). CONCLUSIONS Prompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.

Outcome of patients supported by extracorporeal membrane oxygenation for aluminum phosphide poisoning: An observational study.

Introduction Aluminum phosphide (AlP) poisoning has a high mortality rate despite intensive care management, primarily because it causes severe myocardial depression and severe acute respiratory distress syndrome. The purpose of this study was to evaluate the impact of the novel use of extracorporeal membrane oxygenation (ECMO), a modified “heart-lung” machine, in a specific subset of AlP poisoning patients who had profound myocardial dysfunction along with either severe metabolic acidosis and/or refractory cardiogenic shock. Methods Between January 2011 and September 2014, 83 patients with AlP poisoning were enrolled in this study; 45 patients were classified as high risk. The outcome of the patients who received ECMO (n = 15) was compared with that of patients who received conventional treatment (n = 30). Results In the high-risk group (n = 45), the mortality rate was significantly (p < 0.001) lower in patients who received ECMO (33.3%) compared to those who received conventional treatment (86.7%). Compared with the conventional group, the average hospital stay was longer in the ECMO group (p < 0.0001). In the ECMO group, non-survivors had a significantly (p = 0.01) lower baseline LV ejection fraction (EF) and a significantly longer delay in presentation (p = 0.01). Conclusion Veno-arterial ECMO has been shown to improve the short-term survival of patients with AlP poisoning having severe LV myocardial dysfunction. A low baseline LVEF and longer delay in hospital presentation were found to be predictors of mortality even after ECMO usage. Large, adequately controlled and standardized trials with long-term follow-up must be performed to confirm these findings.

Clinical and Echocardiographic Predictors of Cardiorenal Syndrome Type I in Patients with Acute Ischemic Right Ventricular Dysfunction

Background: In current cardiology practice, the importance of acute cardiorenal syndrome (CRS) in determining the outcome of patients with acute coronary syndrome (ACS) is well recognized. Certain groups of ACS patients are at higher risk of developing CRS. Data on the association between right ventricular (RV) functions and CRS after acute myocardial infarction (AMI) are scarce. The purpose of the current study was to evaluate the relation between RV function and the development of CRS in patients presenting with inferior wall AMI and RV involvement. Patients and Methods: Patients with inferior wall AMI with RV involvement underwent echocardiography at admission to assess RV function. RV functions were quantified according to RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), and RV outflow tract fractional shortening (RVOTFS). The patients were followed up until discharge from hospital. All patients who developed CRS were included in group I, all patients who did not develop CRS were included in group II (controls). Multivariate analysis was carried out to determine the significance of the echocardiographic and clinical parameters in predicting the development of CRS in these patients. Results: In our study, a history of diabetes mellitus, cardiogenic shock at admission, and RVFAC and TAPSE could significantly predict the development of CRS in patients presenting with inferior wall AMI and RV involvement. Conclusions: RV functions provide strong prognostic information regarding the development of CRS in patients of inferior wall AMI with RV involvement.

Gender bias in cardiovascular healthcare of a tertiary care centre of North India

Objectives To analyse the gender bias in paediatric patients referred for free cardiac treatment as part of School Health Programme at a tertiary care centre in North India. Methods A total of 537 children were referred for further management of congenital heart disease or rheumatic heart disease. Of these, 519 underwent cardiac intervention, and the data from their records were analysed retrospectively to determine any gender disparity in the utilisation of cardiac surgery. Results Of the 519 children studied, only 195 (37.6%) were girls, while the remaining 324 (62.4%) were boys (male-to-female ratio of 1.66:1, p<0.0001), indicating a large gender divide. Gender bias was found to be prevalent across all the age groups irrespective of the type of cardiac ailment. Moreover, no statistically significant difference was found between the urban and rural populations (male-to-female ratio of 1.64:1 in rural and 1.71:1 in urban populations; p=0.823) in terms of gender disparity. Conclusions Significant gender discrepancies exist in healthcare-seeking behaviour of patients in North India despite the provision of free cardiac treatment. An equal prevalence of gender bias in urban and rural communities points towards deep-rooted social norms beyond just the economic constraints. Healthcare policies ensuring equal treatment of male and female children should be promulgated to ensure a complete eradication of this social evil.

Case report of isolated congenital absence of right pulmonary artery with collaterals from coronary circulation

Isolated unilateral absence of a proximal pulmonary main artery is a rare congenital lesion which is often associated with other cardiovascular abnormalities and a diverse clinical presentation. It is usually diagnosed in childhood. Patients who survive into adulthood is uncommon. We report a case of 46 year old hypertensive and obese female who presented with progressive dyspnea. She had features of pulmonary hypertension. The diagnosis was confirmed by CT pulmonary angiography which showed absence of right pulmonary artery and conventional pulmonary angiography which showed ipsilateral lung receiving collaterals from Right coronary artery and its branches. The purpose of this report is to highlight the fact that UAPA, although a rare entity, should be kept in mind in patients with unexplained PAH and prolonged respiratory symptoms unresponsive to routine treatment modalities.

A rare case of double orifice mitral valve with perimembranous ventricular septal defect: Application of three-dimensional echocardiography for clinical decision making

Double orifice mitral valve (DOMV) is an uncommon anomaly of surgical importance characterized by a mitral valve with a single fibrous annulus with two orifices opening into the left ventricle (LV). Subvalvular structures, especially the tensor apparatus, invariably show various degrees of abnormality. Associated congenital heart defects are common, though DOMV can occur as an isolated anomaly. Two-dimensional echocardiography is useful for diagnosis but combining it with real-time three-dimensional echocardiography helps in a more detailed evaluation of mitral valve and subvalvular structures as is shown in this case description.

The prevalence, clinical spectrum and the long term outcome of ST-segment elevation myocardial infarction in young - A prospective observational study

INTRODUCTION Incidence of coronary artery disease at the younger age is rising. We studied the prevalence, clinical spectrum and long term outcome of ST-segment elevation myocardial infarction in young. MATERIAL AND METHODS This is a prospective observational study, performed at a tertiary care center from January 2015 to June 2016. Of the total 977 consecutive patients with ST segment elevation myocardial infarction (STEMI), 130 patients aged ≤45 years were included. All patients were followed-up for at least 1-year from the index admission. RESULTS The overall prevalence of STEMI among younger patients was 12.8%. There was male dominance (96.8%). Smoking (37.6%) was observed to be the most common risk factor for young STEMI, followed by diabetes mellitus (16.8%) and hypertension (16%). Younger patients with acute MI had preponderance to anterior wall (68.8%), single-vessel disease (50%) and left anterior descending artery being the culprit lesion (67.3%). Near normal/normal coronary arteries were observed in 12.9% of cases. The most commonly used management strategy was mechanical revascularisation (43.2%), followed by thrombolysis (28.8%) and medical management (28%). The overall mortality and combined MACCE rates at 1 year were 3.2% and 18.4% respectively. Outcome was better in patients who received mechanical revascularization/thrombolysis than those who received medical management only, with a lower MACCE rates (hazard ratio: 0.36; 95% CI: 0.16-0.8, p = 0.01. CONCLUSION The young MI patients are unique in having male dominance, better outcome, more of single-vessel disease with significant number of normal coronaries, better response to mechanical as well as pharmacological revascularization.

Atrial Septal Abscess in Early-Onset Prosthetic Mitral Band Endocarditis: A Case for Multimodality Imaging

Graphical abstract

A cost effective endovascular approach for management of post-catheterization profunda femoris artery pseudoaneurysm using thrombin.

Post-catheterization PSA is one of the most commonly encountered vascular complications of cardiac and peripheral angiographic procedures. We report the case of patient who developed deep-seated profunda femoris artery pseudoaneurysm (PSA) following cardiac catheterization. Despite, repeated ultrasound guided compressions the PSA failed to close and instead produced local site pressure ulcers. The secondary infection followed which precluded use of percutaneous thrombin injection. The PSA was finally closed via a total endovascular technique combining intravascular thrombin injection and coil embolization, thus obviating the need for expensive measures like cover stents or invasive surgical repairs.

Contents Vol. 3, 2013

S. Brietzke, Columbia, Mo. M. Bursztyn, Jerusalem K.C. Dellsperger, Augusta, Ga. V. DeMarco, Columbia, Mo. J.P. Dwyer, Nashville, Tenn. K.C. Ferdinand, New Orleans, La. J.M. Flack, Detroit, Mich. E.P. Gomez-Sanchez, Jackson, Miss. M.R. Hayden, Camdenton, Mo. E.J. Henriksen, Tucson, Ariz. J.M. Luther, Nashville, Tenn. F. Murad, Washington, D.C. C. Ronco, Vicenza N. Stern, Tel Aviv C.S. Stump, Tucson, Ariz. A.T. Whaley-Connell, Columbia, Mo. Founded 2011 by J.R. Sowers CardioRenal Medicine