Satish Karur

Accelerated coronary atherosclerosis and H syndrome.

A 12-year-old boy with insulin dependent diabetes mellitus, presented with acute myocardial infarction. Intracoronary thrombolysis with urokinase restored TIMI III flow in the culprit vessel. After stabilisation with medical therapy, unusual clinical findings in the form of cutaneous hyperpigmentation and hypertrichosis, affecting the lower extremities, were appreciated. These and other phenotypic features were consistent with H syndrome, a recently described autosomal recessive genodermatosis, and confirmed by mutation analysis. Despite being on optimal medical therapy for coronary artery disease, the patient presented 3 months thereafter, with unstable angina which was successfully managed with percutaneous coronary intervention. An unusual occurrence of coronary artery disease with accelerated atherosclerosis in a child with H syndrome is presented herein. Identification of further patients with this novel disorder will clarify the possible association, suggested here, with increased risk for coronary or other vascular events.

Transcatheter closure of perimembranous ventricular septal defects with ductal occluders.

BACKGROUND To study the feasibility and complications associated with the use of ductal occluders for closure of perimembranous ventricular septal defects. METHODS A total of 126 patients, ranging from 1 to 41 years of age (median - 8 years), underwent closure of ventricular septal defects from August 2010 to April 2013. Small- and moderate-sized defects were closed using first-generation Patent ductus arteriosus occluders or Amplatzer Duct Occluder-II. Patients were followed up for the development of complications such as heart block, aortic regurgitation, and tricuspid regurgitation. RESULTS Patent ductus arteriosus occluders were used in 81 patients, and the Amplatzer Duct Occluder-II device in 45 patients. The devices were successfully deployed in 99.2% of the cases. One patient had embolisation of an Amplatzer Duct Occluder-II device soon after deployment. There was one case of transient complete heart block (0.8%) needing temporary pacing, and two cases of isoarrhythmic atrioventricular dissociation (1.6%). One patient developed late-onset complete heart block 15 months after the procedure and underwent permanent pacemaker implantation. There were no instances of new-onset aortic regurgitation. New-onset mild tricuspid regurgitation was seen in two patients. Of the patients, three had small residual shunts on follow-up, without haemolysis. CONCLUSIONS Duct occluders can be used to effectively close small- and moderate-sized ventricular septal defects. The incidence of complete heart block and valvular regurgitations are much less than reported with other devices, and they are cost-effective.

Free floating right atrial thrombus with massive pulmonary embolism:near catastrophic course following thrombolytic therapy

A 28-year-old policeman presented with left lower limb deep vein thrombus, pulmonary embolism and a highly mobile right atrial clot. Thrombolytic therapy with IV Tenecteplase was administered. Within a few minutes after the Tenecteplase bolus, the patients condition worsened dramatically with severe hypotension and hypoxemia. Immediate bedside transthoracic echocardiogram revealed that the mobile right atrium clot had disappeared completely presumably having migrated to the pulmonary circulation thus worsening the clinical condition. With intensive supportive measures the patients condition was stabilized and he made a complete recovery. Prior to discharge, the echocardiogram revealed normal right ventricular function and a CT pulmonary angiogram performed after 2 months revealed near complete resolution of pulmonary thrombi. Thrombolytic therapy for right heart thrombus with pulmonary embolism can be a reasonable first line therapy but may be associated with hemodynamic worsening due to clot migration.

Infective endocarditis: a rare organism in an uncommon setting.

Facklamia hominis is a rare causative organism of infective endocarditis (IE). Only few cases of infection due to F. hominis have been reported in the literature. We describe a case of IE due to Gram-positive, alpha-haemolytic, catalase-negative coccus F. hominis in an adult patient with rheumatic mitral stenosis. Isolated mitral stenosis is an uncommon valve lesion predisposing to IE. The following paper is being presented to emphasize the possibility of IE due to F. hominis, and laboratories need to be alert of the potential significance in appropriate clinical setting.

Spontaneous asymptomatic coronary artery dissection in a young man

Spontaneous coronary artery dissection (SCAD) is a rare condition that most often presents as acute coronary syndrome or sudden cardiac death. Here we present the case of a young man of 25 years, who had remained asymptomatic in spite of SCAD. This case highlights the fact that spontaneous dissections can occur at a young age and can involve more than one coronary artery, without producing clinical symptoms.

Percutaneous coronary intervention in patients with anomalous origin of coronary artery presenting with acute coronary syndrome: A case series

Coronary artery anomalies are found in 0.6%-1.5% of patients undergoing diagnostic coronary angiogram. Intervention in these patients poses a particular technical challenge secondary to the aberrancies in the vessel origin and course. From March 2011 to February 2013, 13 cases with complex coronary artery anomalies were observed among 2482 patients undergoing CAG (0.52%) at our cath lab. Only three patients had severe stenosis in the anomalous artery sufficient to require an intervention and had presented with myocardial infarction. PCI was performed successfully in these 3 patients two of which had anomalous left circumflex artery and the other having an anomalous right coronary artery.

Study of vitamin D deficiency prevalence in acute myocardial infarction

Background Deficiency of 25-hydroxy vitamin D [25(OH)D] is a treatable condition that has been associated with coronary artery disease and many of its risk factors. A practical time to assess for 25(OH)D deficiency, and to initiate treatment, is at the time of an acute myocardial infarction(AMI). The prevalence of 25(OH)D deficiency and the characteristics associated with it in patients with acute myocardial infarction are unknown. Methods In this study 25(OH)D was assessed in 314 subjects enrolled in a Sri Jayadeva Institute of Cardiovascular Science and Research(SJICS&R). Patients enrolled from December 1, 2011 to February 28, 2012 had serum samples sent to a centralized laboratory for analysis using the ELECYS assay. Normal 25(OH)D levels are ≥ 30 ng/ml, and patients with levels < 30 and > 20 ng/ml were classified as insufficient and those with levels ≤ 20 ng/ml as deficient. Vitamin D and other baseline characteristics were analyzed with T-test and chi-squared test. Results Of the 314 enrolled patents, 212 (67.5%) were 25(OH)D deficient and 50(16%) were insufficient, for a total of 83.5% of patients with abnormally low 25(OH)D levels. No significant heterogeneity was observed among age or gender sub groups but 25(OH)D deficiency was more commonly seen in those with lower socioeconomic status, lower activity levels, diabetes, hypercholesterolemia(LDL), hypertriglyceridemia and in smokers. Conclusion Vitamin D deficiency is present in most of the patients with acute myocardial infarction and it is associated with many of its risk factors in our study.

Multiple Fractures With Pseudoaneurysm Formation in a Subclavian Artery Stent

A 50-year-old right-handed man (ex-smoker) with a history of left upper limb claudication for the previous 6 years underwent successful left subclavian artery (LSA) angioplasty with stent implantation (8×59 Genesis Stent [Cordis, Warren, NJ]) for 99% ostial and proximal stenosis of the LSA with use of a combined anterograde and retrograde approach (Figure 1A through 1D). The erythrocyte sedimentation rate and the C-reactive protein were normal. No other vascular system was affected. After an asymptomatic period of 4 months, the patient presented with a history of high-grade fever for 7 days, pain and swelling of the left hand, bluish discoloration of finger tips and palms, and restriction of movements of the fingers of left hand (Figure 2A). All left upper limb pulses were well felt. A Doppler arterial study of the left upper limb was also normal. At the diagnostic angiogram, fluoroscopy revealed that the LSA stent had transected at multiple levels (4 levels) (Figure 3A and Movie I of the online-only Data Supplement). The angiogram revealed the presence of 2 pseudoaneurysms, one at the origin …

Balloon Mitral Valvotomy in Juvenile Rheumatic Mitral Stenosis: Comparison of Immediate Results with Adults

AIMS The objective of the study was to study and compare the clinical, echocardiographic and haemodynamic profile of juvenile rheumatic mitral stenosis (age ≤20 years) with severe mitral stenosis in adults, both before and immediately after balloon mitral valvotomy and also to evaluate the safety and efficacy of the procedure in juvenile patients. METHODS Forty juvenile patients aged 20 years or younger were analysed with 40 consecutive adult patients who underwent balloon mitral valvotomy using Accura balloon in our institution. The procedure was successful in all the patients. The clinical, echocardiographic and haemodynamic parameters were compared pre- and post-balloon mitral valvotomy in both the groups. RESULTS New York Heart Association functional class was comparable in both the groups (II and III, 62.5% and 37.5% vs. 60% and 40%). Atrial fibrillation was not seen in the juvenile group whereas 25% of the adult group had atrial fibrillation (p<0.001). Mitral valve deformity was comparable (Wilkins Score - 8.57±0.67 vs. 8.6±0.67, p=NS). Mitral valve area index by 2D echo was 0.62±0.097 cm2/m2 in the juvenile group and 0.621±0.097 cm2/m2 in the adult group (p=0.72) and was larger in the juvenile group (1.38±0.19 vs 1.29±0.18 cm2/m2) after the procedure (p value <0.03). Mitral valve gradient (19.85±7.31 mm hg vs. 14.63±5.33 mm hg. P value<0.001) and mean PASP (70.15±1+.2 mm hg vs. 60.10±19.32 mm of hg. P value <0.02) was higher in the juvenile group before balloon mitral valvotomy, after balloon mitral valvotomy the values were 7.45±2.57 vs. 5.78±2.24 mm of hg, (P<0.003) and 40.48±10.30 vs. 41±15.62 respectively (p=0.85). The mean value for left atrial pressure was comparable in both the groups both pre- and post-balloon mitral valvotomy (P value 0.076 and 0.54 respectively). There was no significant difference in the procedural success (95% vs 100%, p value <0.15). CONCLUSION Balloon mitral valvotomy is safe and effective in young with rheumatic mitral stenosis and provides better immediate results compared to adults.

Left arm–left leg lead reversal in a case of inferior wall myocardial infarction mimics as high lateral wall infarction

A 56-year-old male patient was admitted with an evolved inferior wall myocardial infarction (IWMI). Electrocardiogram (ECG) showed presence of ST elevation and T wave inversion in the inferior leads. ECG taken on the next day surprisingly showed features suggestive of acute high lateral wall myocardial infarction (LWMI), without features suggestive of re-infarction which was finally diagnosed to be an artefact due to lead reversal. Lead reversal between left arm and left leg can mimic as high LWMI in a case with IWMI and we should aware of this situation before misdiagnosing it as re-infarction.