Sharad Chandra

Obstructive Sleep Apnea and Cardiovascular Events After Percutaneous Coronary Intervention

Background— There is a paucity of data from large cohort studies examining the prognostic significance of obstructive sleep apnea (OSA) in patients with coronary artery disease. We hypothesized that OSA predicts subsequent major adverse cardiac and cerebrovascular events (MACCEs) in patients undergoing percutaneous coronary intervention. Methods and Results— The Sleep and Stent Study was a prospective, multicenter registry of patients successfully treated with percutaneous coronary intervention in 5 countries. Between December 2011 and April 2014, 1748 eligible patients were prospectively enrolled. The 1311 patients who completed a sleep study within 7 days of percutaneous coronary intervention formed the cohort for this analysis. Drug-eluting stents were used in 80.1% and bioresorbable vascular scaffolds in 6.3% of the patients, and OSA, defined as an apnea-hypopnea index of ≥15 events per hour, was found in 45.3%. MACCEs, a composite of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned revascularization, occurred in 141 patients during the median follow-up of 1.9 years (interquartile range, 0.8 years). The crude incidence of an MACCEs was higher in the OSA than the non-OSA group (3-year estimate, 18.9% versus 14.0%; p=0.001). Multivariate Cox regression analysis indicated that OSA was a predictor of MACCEs, with an adjusted hazard ratio of 1.57 (95% confidence interval, 1.10–2.24; P=0.013), independently of age, sex, ethnicity, body mass index, diabetes mellitus, and hypertension. Conclusions— OSA is independently associated with subsequent MACCEs in patients undergoing percutaneous coronary intervention. Evaluation of therapeutic approaches to mitigate OSA-associated risk is warranted. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01306526.

Congenital Aorta Right Atrial Fistula: Successful Transcatheter Closure With the Amplatzer Occluder

A 12-year-old girl with a 4-year history of effort dyspnea and palpitations was referred to our institution for evaluation. Physical examination of the patient showed a continuous grade 3/6 heart murmur best heard along the right upper sternal border. A two-dimensional echocardiogram exhibited a small interatrial septal defect (diameter, 4 mm) with a bidirectional shunt and a high velocity jet in the dilated right atrium. A computed tomographic (CT) angiogram of the patient showed anomalous tortuous communication between the ascending aorta and the right atrium arising adjacent to the right coronary artery (Fig. 1). An ascending aortogram combined with selective angiography confirmed the presence of a large fistula with a broad origin (diameter, 5.6 mm) from the right aortic sinus anterior to the right coronary artery and a narrow termination into the posterior wall of the right atrium (Fig. 2). Cardiac catheterization showed the presence of a left-toright shunt with a pulmonary-to-systemic blood flow ratio (Qp:Qs) of 3:1. Coronary angiography demonstrated normal coronary arteries arising from the respective sinuses. Because the fistula had a separate anterior origin and a narrow terminal ending into the right atrium, a decision was made in favor of transcatheter device closure. The fistula was hooked antegradely using an Amplatzer right 1 (AR-1) catheter (Medtronic Inc., Minneapolis, MN, USA), and a standard percutaneous transluminal coronary angioplasty (PTCA) guidewire balance middle weight (BMW) was passed through the tortuosity of the fistula toward the right atrial end. The wire then was retrieved from the right atrial end with a snare and exteriorized from the right femoral vein. A long sheath available with the device then was passed through the right femoral venous route to the right atrium. An Amplatzer duct occluder (AGA Medical Corporation, Plymouth, MN, USA) size 8 9 6 mm was chosen for closure of the fistula and passed through the sheath with the help of the Amplatzer 1808 delivery system (Fig. 3). The fistula was successfully closed using the occluder with its large end placed through the fistula toward the aortic side. After deployment of the device, no residual flow through the fistula was demonstrated (Fig. 4).

Surgical treatment for coronary artery aneurysm: a single-centre experience

OBJECTIVES Coronary artery aneurysm is a rare condition with a reported incidence of 0.14-4.9% in patients undergoing coronary angiography and 0.3-5.3% in patients after percutaneous transluminal coronary angioplasty (PTCA). Optimum surgical therapy for this entity is difficult to standardize. We present here a series of 4 cases with the aim of establishing an optimal surgical therapy for this rare entity. METHODS Four cases of coronary artery aneurysm were admitted in the Department of Cardiology and Department of Cardiothoracic and Vascular Surgery, King Georges Medical University, Lucknow, from April 2010 to April 2012. All patients underwent a surgical procedure that involved ligation and plication of the aneurysm with coronary artery bypass grafting. RESULTS Out of the four coronary artery aneurysm patients, 1 was atherosclerotic and the remaining 3 patients developed coronary artery aneurysm after PTCA with a drug eluting stent to the left anterior descending artery. After surgery, all patients recovered uneventfully without any recurrence of symptoms in the follow-up. CONCLUSIONS Coronary artery aneurysm is a rare entity and is being seen more frequently with the increasing use of stents during PTCA. Proximal ligation and plication of the aneurysm with coronary artery bypass grafting in the present series provided good results. With this case series, we seek to establish an optimal surgical therapy for this rare entity.

Delineation of Anatomy of the Ruptured Sinus of Valsalva with Three-Dimensional Echocardiography: The Advantage of the Added Dimension

The rupture of sinus of Valsalva is a rare complication of infective endocarditis. Three‐dimensional (3D) echocardiography represents an important adjunctive tool to demonstrate the ruptured sinus of Valsalva with better delineation of its characteristics. We present an adult patient with rupture of right sinus of Valsalva aneurysm due to infective endocarditis of the aortic valve, in whom the two‐dimensional (2D) transthoracic echocardiogram erroneously localized the site of rupture into the right atrium. Whereas, 3D transthoracic echocardiogram accurately delineated the site of rupture into the right ventricle and it was confirmed on subsequent cardiac catheterization and angiogram. In addition, 3D echocardiography clearly showed the size and shape of the defect, which helped in successful transcatheter closure of the defect with amplatzer duct occluder device. (Echocardiography 2012;29:E148‐E151)

Left Hemitruncus With Tetralogy of Fallot and Right Aortic Arch: Rare Survival Beyond the First Decade

Hemitruncus is an uncommon congenital anomaly that has been described in isolation or in association with other congenital cardiac malformations. This report describes a rare case of left hemitruncus with tetralogy of Fallot and a right-sided aortic arch. The patient presented to us in the early second decade. The diagnosis was suspected with echocardiography and confirmed with cardiac catheterization. The patient underwent successful surgical correction of the anomaly.

Persistent truncus arteriosus: a rare survival beyond the first decade.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] An 11-year-old cyanotic boy presented to our department with worsening effort intolerance. Two-dimensional transthoracic echocardiography with color Doppler ( A to D, [Online Video 1][5]) showed a common

Effect of Ivabradine on Heart Rate and Duration of Exercise in Patients With Mild-to-Moderate Mitral Stenosis: A Randomized Comparison With Metoprolol.

Background: Symptoms in mitral stenosis (MS) are heart rate (HR) dependent. Increase in HR reduces diastolic filling period with rise in transmitral gradient. By reducing HR, beta-blockers improve hemodynamics and relieve symptoms, but the use may be limited by side effects. The present randomized crossover study looked at comparative efficacy of ivabradine and metoprolol on symptoms, hemodynamics, and exercise parameters in patients with mild-to-moderate MS (mitral valve area, 1–2 cm2) in normal sinus rhythm. Material and Methods: Baseline clinical assessment, treadmill stress testing, and an echocardiographic Doppler evaluation were performed to determine resting HR, total exercise duration, mean gradient across mitral valve, and mean pulmonary artery systolic pressure (PASP). Patients were then allocated to either metoprolol or ivabradine to maximal tolerated doses over 6 weeks (metoprolol: 100 mg twice a day, ivabradine: 10 mg twice a day). Reevaluation was done at the end of this period, and all drugs stopped for washout over 2 weeks. Thereafter, the 2 groups were crossed over to the other drug that was continued for another 6 weeks. Assessment was again performed at the end of this period. Results: Thirty-three patients of 34 completed the protocol. Fifteen were male, mean age was 28.9 ± 6.6 years, all were in New York Heart Association class 2, and mean resting HR was 103.5 ± 7.2/min. Mean mitral valve area was 1.56 ± 0.16 cm2, mean PASP was 38.1 ± 5.1 mm Hg, and mean gradient across mitral valve was 10.6 ± 1.6 mm Hg. Significant decrease in baseline and peak exercise HR was observed at the end of follow-up with both drugs. Reduction in mitral valve gradient after ivabradine (42%) and metoprolol (37%) and reduction in PASP after both ivabradine (23%) and metoprolol (27%) were to a similar extent. Significant reduction in total exercise duration after both ivabradine and metoprolol therapy was observed. One patient developed blurring of vision with ivabradine therapy but did not require discontinuation of drug. An improvement in dyspnea of one grade was observed in all the patients by treatment with both ivabradine and metoprolol. Conclusions: Both metoprolol and ivabradine reduced symptoms and improved hemodynamics significantly from baseline to a similar extent. Ivabradine thus can be used effectively and safely in patients with MS in normal sinus rhythm who are intolerant or contraindicated for beta-blocker therapy.

Giant Aorto–Right Ventricular Fistula With Single Coronary Artery

A 15-year-old boy with symptoms of dyspnea and fatigue since early childhood was referred to our institution for evaluation. Physical examination of the patient showed long, slender extremities and a pectus carinatum deformity of the chest (Figure 1A). His arm span–to-height ratio was 1.03, and his upper segment–to–lower segment ratio was 0.82. He had blood pressure of 126/70 mm Hg, with a heart rate of 96 bpm; a grade 4/6 continuous murmur was present in the right lower parasternal area. A 12-lead ECG showed right bundle-branch block (Figure 2), and chest radiography (posteroanterior view) revealed mild cardiomegaly. Radiography of the thoracolumbar spine of the patient disclosed a mild degree of scoliosis (inset, Figure 1A). Two-dimensional echocardiography (parasternal long-axis view) showed a large fistula (2 cm in diameter) arising from the right aortic sinus (Figure 1B; online-only Data Supplement Movie I). A tilted apical 4-chamber view showed a turbulent jet (velocity 3.5 m/s) at the free wall of the right ventricle (Figure 1C; online-only Data Supplement Movie II). Three-dimensional echocardiography in a tilted apical 5-chamber view showed a broad tunnel arising from the aorta (Figure 1D; online-only Data Supplement Movie III). Computed tomographic cardiac angiography revealed the presence of a …

Optimal fluid amount for haemodynamic benefit in cardiac tamponade.

Objectives: The present study was undertaken to assess the effect of volume expansion on cardiac haemodynamics in patients with cardiac tamponade and to ascertain an optimum amount of fluid that can produce the maximum benefit in tamponade patients. Background: In patients of tamponade, interim measures may occasionally be needed when facilities for pericardial fluid drainage are not immediately available. Intravascular volume expansion is the most commonly advocated measure but with limited scientific data. Methods: Patients ≥16 years of age with large circumferential pericardial effusion and showing echocardiographic evidence of cardiac tamponade were included. Haemodynamically unstable patients, those with structural heart diseases, pregnant females, and those undergoing haemodialysis were excluded. The various haemodynamic parameters were measured using Edwards Life Sciences Vigilance II monitor, Swan Ganz CCO catheter, intrapericardial access, and arterial access at baseline and after each 250 ml fluid over 5 min (total 1000 ml in 20 min). The entire fluid was drained at the end of the procedure. Results: A total of 28 patients constituted the study group, all of whom exhibited an improvement in haemodynamic parameters (systolic blood pressure, cardiac output) and a rise of the intracardiac pressures with volume expansion. Significant (p<0.05 ) increase in systolic and diastolic blood pressure, cardiac output, and cardiac index occurred up to 250–500 ml bracket; above which the significance was lost. A higher resting heart rate, a lower SBP at presentation, a higher initial intrapericardial pressure, and a lower cardiac index were the statistically significant predictors of a >15% increase in cardiac index. Conclusions: Rapid infusion of as little as 250 ml intravenous normal saline may improve the cardiac haemodynamics in a significant proportion of tamponade patients.

Three‐Dimensional Echocardiographic Delineation of an Acquired Aorto‐Left Atrial Fistula Complicating Native Aortic Valve Endocarditis – “Advantage of Three Dimensions”

Aorto‐atrial fistulas are rare, but important complications resulting from aortic valve infective endocarditis, aortic valve surgery, or aortic dissection. We hereby report a case of a 20‐year male, referred to us with infective endocarditis of the native aortic valve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed aorto‐left atrial fistula secondary to the involvement of the mitral–aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aortic valve replacement, and mitral valve repair.