Sanjay K Kohli

Prevalence of exercise-induced left ventricular outflow tract obstruction in symptomatic patients with non-obstructive hypertrophic cardiomyopathy

Background: Resting left ventricular outflow tract obstruction (LVOTO) occurs in 25% of patients with hypertrophic cardiomyopathy (HCM) and is an important cause of symptoms and disease progression. The prevalence and clinical significance of exercise induced LVOTO in patients with symptomatic non-obstructive HCM is uncertain. Methods and results: 87 symptomatic patients (43.3 (13.7) years, 67.8% males) with HCM and no previously documented LVOTO (defined as a gradient ⩾30 mm Hg) underwent echocardiography during upright cardiopulmonary exercise testing: 54 patients (62.1%; 95% CI 51.5 to 71.6) developed LVOTO during exercise (latent LVOTO); 33 (37.9%; 95% CI 28.4 to 48.5) had neither resting nor exercise LVOTO (non-obstructive). Patients with latent LVOTO were more likely to have systolic anterior motion of the mitral valve (SAM) at rest (relative risk 2.1, 95% CI 1.2 to 3.8; p = 0.01), and higher peak oxygen consumption (mean difference: 10.3%, 95% CI 2.1 to 18.5; p = 0.02) than patients with non-obstructive HCM. The only independent predictors of Δ gradient during exercise were a history of presyncope/syncope, incomplete/complete SAM at rest and Wigle score (all p<0.05). Subsequent invasive reduction of LVOTO in 10 patients with latent obstruction and drug refractory symptoms resulted in improved functional class and less syncope/presyncope (all p<0.05). Conclusions: Approximately two-thirds of patients with symptomatic non-obstructive HCM have latent LVOTO. This study suggests that all patients with symptomatic non-obstructive HCM should have exercise stress echocardiography.

How should I treat stent dislodgement in a STEMI patient resulting in dissection of left main and left circumflex arteries

BACKGROUND A 52-year-old female presented with acute anterior ST-elevation myocardial infarction (STEMI) within one hour of symptom onset to the emergency department. She was referred for urgent primary angioplasty. INVESTIGATION Physical examination, laboratory investigations, ECG, urgent percutaneous coronary intervention (PCI). DIAGNOSIS Single-vessel coronary artery disease (SVD). TREATMENT Intended to stent culprit lesion. However, stent dislodged in left main coronary artery (LMCA) during attempted PCI to diffuse mid segment of left anterior descending (LAD). Initial attempt failed to retrieve the dislodged stent with snare. Dislodged stent removed with multiple wire technique, complicated by severe dissection in LAD and left circumflex artery back into the LMCA. The stent was trapped at tip of 6 Fr right femoral sheath, unable to be withdrawn. What next?

Pituitary tumour apoplexy following acute coronary syndrome management.

An 85-year-old male presented with chest pain. The patient was bradycardic at 48 beats/min and hypotensive at 110/80 mm Hg. His past medical history included hypertension, currently treated with irbesartan. An electrocardiogram and cardiac bio markers (troponin I, 1.19 μg/l) confirmed a diagnosis of a non-ST elevation myocardial infarction. Conventional acute coronary management included clopidogrel, aspirin and low molecular …

An unusual case of palpitations

A 66 year old white man presented with a three year history of intermittent frequent (daily) palpitations and associated malaise, but no syncope. He was taking no drugs and had no family history of arrhythmia or of unexplained, sudden, or premature death. Clinically he was afebrile, in sinus rhythm at 60 beats/min, had blood pressure of 130/80 mm Hg, and had normal heart sounds. Serum electrolytes, including magnesium, and haematology and hepatic and thyroid function tests were normal. His electrocardiogram (ECG) is shown in the figure 1⇓. A seven day ECG event recorder showed two episodes (of 16 and 17 hours’ duration) of spontaneous atrial fibrillation at rates of up to 160 beats/min. These episodes coincided with symptoms. Chest x ray and cardiac imaging were entirely normal.