Sachin Kumar Amruthlal Jain

Feasibility and Safety of Same-Day Discharge after Implantable Cardioverter Defibrillator Placement for Primary Prevention: SAME DAY DISCHARGE ICD IMPLANTATION

In the current age of ever‐increasing healthcare costs, it is of utmost importance to adopt strategies that reduce hospital stay and cost, while still maintaining patient safety. In this study we review our approach of same‐day discharge following implantable cardioverter defibrillator (ICD) placement for primary prevention of sudden cardiac death (SCD).

A forgotten devil; Rupture of mitral valve papillary muscle.

Summary Background: Papillary muscle rupture is one of the catastrophic mechanical complications following myocardial infarction. Rupture leads to acute mitral valve regurgitation, pulmonary edema, and cardiogenic shock. Survival is dependent on prompt recognition and surgical intervention. Cases Report: We present two cases where acute myocardial infarction was complicated by papillary muscle rupture resulting in severe mitral regurgitation and cardiogenic shock. In both cases rupture occurred within one week of infarction. Both patients did not receive coronary revascularization; one patient presented late after the onset of chest pain, the other patient percutaneous revascularization attempted and was not successful. Both patients suffered an inferior wall infarction. Echocardiogram demonstrated severe mitral regurgitation with a jet directed posteriorly. In both cases rupture of the posteromedial papillary muscle resulted in flail of the anterior mitral valve leaflet, thus serving as a reminder that both the anterior and the posterior leaflets attach to both papillary muscles. Conclusions: While one case had a good outcome, the other reinforces the fact that this is a very serious complication requiring prompt recognition and treatment.

Degree of Beta-Blockade and Outcomes in Patients with Acute Coronary Syndrome

Objective: We sought to determine if the outcome benefit of beta blockade in the ACS population is associated with baseline HR, discharge HR, or a reduction in HR. Background: ACC guidelines recommend a resting HR goal of 50 to 60 bpm in ACS patients. This recommendation is not based on study outcomes, but rather on expert opinion. Evidence-based clinical trials investigating ideal target heart rate of beta blocker (BB) therapy in the ACS population are lacking. Methods: A retrospective analysis was performed of all ACS patients who underwent coronary angiography (with or without percutaneous coronary intervention) at Providence Hospital from September 2006 to August 2011 excluding patients with any contraindication to BB therapy. Discharge HR was used as the predictor variable for outcomes in these patients. Results: A total of 912 patients (403 ST elevation myocardial infarction MI (STEMI) and 509 Non STEMI patients were included. Discharge HR was divided into quintiles: quintile 1 (48 - 64 bpm), quintile 2 (65 - 70), quintile 3 (71 - 76), quintile 4 (77 - 83) and quintile 5 (84 - 119). There was a statistically significant difference seen between the quintile 1 composite endpoint and the other quintile endpoints. (p value <0.05) No differences were seen across quintiles in median TIMI risk index score at admission, systolic and diastolic blood pressure or beta-blocker dose at discharge. Patients in quintile 1 fared better overall with the observation of worse outcomes in patients with a discharge heart rate less than 55. Conclusion: In those with ACS, particularly STEMI and NSTEMI, a lower discharge HR conferred a decreased composite endpoint at 24 months with the best outcomes seen at a resting HR between 55-65. Further studies are needed to investigate the clinical benefit of optimal HR reduction in this population beyond 2 years.

Unloading of Right Ventricle and Clinical Improvement after Ultrasound-Accelerated Thrombolysis in Patients with Submassive Pulmonary Embolism

Acute pulmonary embolism (PE) can be devastating. It is classified into three categories based on clinical scenario, elevated biomarkers, radiographic or echocardiographic features of right ventricular strain, and hemodynamic instability. Submassive PE is diagnosed when a patient has elevated biomarkers, CT-scan, or echocardiogram showing right ventricular strain and no signs of hemodynamic compromise. Thromboemboli in the acute setting increase pulmonary vascular resistance by obstruction and vasoconstriction, resulting in pulmonary hypertension. This, further, deteriorates symptoms and hemodynamic status. Studies have shown that elevated biomarkers and right ventricular (RV) dysfunction have been associated with increased risk of mortality. Therefore, aggressive treatment is necessary to “unload” right ventricle. The treatment of submassive PE with thrombolysis is controversial, though recent data have favored thrombolysis over conventional anticoagulants in acute setting. The most feared complication of systemic thrombolysis is intracranial or major bleeding. To circumvent this problem, a newer and safer approach is sought. Ultrasound-accelerated thrombolysis is a relatively newer and safer approach that requires local administration of thrombolytic agents. Herein, we report a case series of five patients who underwent ultrasound-accelerated thrombolysis with notable improvement in symptoms and right ventricular function.

Same-day dual radial artery puncture examination in patients requiring percutaneous coronary intervention and the incidence of radial artery occlusion

Background: We sought to investigate the rate of radial artery occlusion (RAO) after same-day dual radial artery puncture. The trans-radial arterial approach (TRA) for diagnostic and interventional procedures has risen significantly in the United States. Although becoming more commonly performed, TRA is not without risk, and a potential complication is RAO. The rate of RAO after same-day dual artery puncture is unknown. Methods: A retrospective analysis of 27 patients who underwent same-day dual radial artery puncture for percutaneous coronary intervention (PCI) at our institution (Providence Heart Institute in Southfield, MI, USA) from November 2011 to December 2013 were included after initially presenting for cardiac catheterization at a non-PCI-capable facility. The study patients were asked to follow up for evaluation of the radial artery, including obtaining a duplex ultrasound evaluation. Results: The mean age of the patients was 65 years old with 66% of the patients being male. Of the 27 study participants, there were no symptoms reported that were related to RAO. Overall, one (3.7%) patient had an absent radial pulse. The modified Allen’s test was normal in all of the patients with a mean return of palmar flush time of 4 seconds. Duplex ultrasound revealed subtotal RAO in four (14.8%) patients and no patients experienced total occlusion following the intervention. Conclusion: Dual radial artery puncture appears to be a well-tolerated and viable strategy in patients that are transferred to a PCI-capable hospital for coronary interventions.

A missed malignant right coronary artery anomaly detected post-cardiac event in an adult patient.

Aims: We present this case to raise awareness of this unusual presentation of a malignant anomalous right coronary artery arising from the left coronary cusp in a patient older than 50 years. We describe a useful imaging modality and discuss therapy. Presentation of the Case: We report a case of a 63-year-old male with an interarterial coursing right coronary artery arising from the left coronary cusp with a history of a mechanical aortic valve replacement. The patient presented to our emergency department after being resuscitated from a cardiac arrest and later had a normal coronary angiogram. High suspicion of his right coronary artery angulation, he underwent a computed tomography with angiogram that revealed his anomalous course and anatomy. Discussion: We discuss the importance of coronary artery anomaly detection in the young at risk population (athletics), pathophysiology, diagnostic modalities, and treatment recommendations. Surgical revascularization has been advocated in malignant coronary anomalies, however, the lack of large randomized clinical trials for patients older than 50year-old left this topic controversial. Medical therapy augmented with implanted cardioverter defibrillator (ICD) was utilized in this case. Medical management could be considered in centers that don’t have surgical experience or in adult patients who are a Case Study British Journal of Medicine & Medical Research, 4(1): 501-509, 2014 502 poor surgical candidate because of other comorbidities or life expectancy. Conclusion: Computed tomography with angiogram seems to be the best noninvasive modality to delineate coronary course and anatomy. There is a need for randomized clinical trials to determine the best management of anomalies arising from opposite sinus with an interarterial course in adults >50-year-old.

Cervical spinal cord compression as an initial presentation of prostate cancer: a case report

Prostate cancer is notorious for its atypical presentation. However, spread to the cervical spine is uncommon. We herein describe the findings in a 57-year-old African American gentleman, who presented with neck pain and right-sided weakness. Examination revealed neck tenderness with numbness in the distribution of C6 region on right side. An MRI of the neck imaged a 3.4cm extradural soft tissue mass in the C6 region extending into the spinal-canal, causing spinal cord compression. At this point, differential diagnosis included: metastatic cancer vs. chronic granulomatous vs. primary CNS lesion. Management included high dose intravenous steroids and mass resection with cervical-spine fusion. The prostate specific antigen (PSA) was 1815 ng/mL (normal less than 4 ng/mL) with a repeat value of 1666 ng/mL, and the pathology findings confirmed the mass to be metastatic prostate carcinoma. This case illustrates an unusual presentation of metastatic prostate cancer, lytic in nature, presenting as cord compression, and sparing the bone and lymph nodes in the cervical region. Metastatic lesions of prostate cancer to the bone are most often blastic rather than lytic in nature [11]. Cervical involvement is seen in only 5% of cases. Regardless of this atypical presentation, early diagnosis of cord compression is of utmost importance because neurologic status upon presentation has important prognostic value. It is important to consider prostate cancer metastasis in any compressive neuropathy, or findings of an atypical mass affecting the cervical spine.

Myocardial Infarction in a Young Female with Palindromic Rheumatism: A Consequence of Negative Remodeling

Palindromic rheumatism is a rare disease associated with systemic inflammation. Negative or constrictive coronary artery remodeling is typically not seen until the 7th or 8th decade of life. We report a case of a young female with palindromic rheumatism who suffered a non-ST segment elevation myocardial infarction secondary to a flow-limiting lesion that demonstrated negative remodeling by intravascular ultrasound (IVUS).

Register and Roll: A Novel Initiative to Improve First Door-to-Balloon Time in ST Elevation Myocardial Infarction.

Objective. We examined the cause of transfer delay in patients with an acute ST-segment myocardial infarction (STEMI) from non percutaneous coronary intervention (PCI) capable to PCI capable hospitals. We then implemented a novel, simple, and reliable initiative to improve the transfer process. Background. Guidelines established by the ACC/AHA call for door-to-balloon times of ≤90 minutes for patients with STEMI. When hospital transfer is necessary, this is only met in 8.6% of cases. Methods. All patients presenting with STEMI to a non-PCI capable hospital from April 2006 to February 2009 were analyzed retrospectively. After identifying causes of transfer delay the “Register and Roll” initiative was developed. An analysis of effect was conducted from March 2009 to July 2011. Results. 144 patients were included, 74 pre-initiative and 70 post- initiative. Time to EMS activation was a major delay in patient transfer. After implementation, the EMS activation time has significantly decreased and time to reperfusion approaches recommended goal (Median 114 min versus 90 min, P < 0.001), with 55% in <90 minutes. Conclusion. “Register and Roll” streamlines the triage process and improves hospital transfer times. This initiative is easily instituted and reliable in a community hospital setting where resources are limited.