Sunil Kumar Srinivas

Pulsatile Chest Swelling

A 45-year-old man presented with swelling on the right side of the chest, which he had had for the previous 3 months. Examination revealed pulsatile swelling in the right infraclavicular area.

Differential clubbing and cyanosis: classic signs of patent ductus arteriosus with Eisenmenger syndrome.

From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India. A 28-year-old woman with congenital heart disease presented with progressive dyspnea and fatigue during the past year. On examination, she had clubbing and cyanosis of the toes but not the fingers (Figure, A). Oxygen saturation was 84% in the toes and 96% in the fingers. The patient also had a left parasternal heave and a loud second sound but no murmur. The electrocardiogram showed sinus rhythm with a rightward axis and right ventricular (RV) hypertrophy

Isolated major aortopulmonary collateral artery in an infant presenting with recurrent lower respiratory tract infection.

A 5-month-old baby, weighing 4 kg presented with a 3-month history of failure to thrive and recurrent lower respiratory tract infection (RTI). She was delivered at term weighing 2.8 kg and the perinatal period was uneventful. Saturation and clinical examination was normal and there were no abnormal auscultation findings or murmur. Chest x-ray had normal cardiac and pulmonary contours while previous x-rays had evidence of lower RTI involving the right lung. An echocardiogram showed no evidence of congenital heart disease (CHD) with no shunts and there was no evidence of left ventricular volume overload …

Effect of thrombolytic therapy on the patterns of post myocardial infarction ventricular septal rupture

Objectives Ventricular septal rupture (VSR) is a rare but feared complication after myocardial infarction (MI). The objective of this study was to investigate the effects of thrombolytic therapy on the patterns of VSR following MI. Methods 30 consecutive patients admitted to a single tertiary level cardiac hospital with a diagnosis of acute MI and developed VSR in the hospital were included. The effect on thrombolytic therapy on the formation of VSR and its clinical outcome was studied. Results Out of 30 patients, 15 patients received thrombolytic therapy.10 received early (<12 h) and 5 received late (>12 h). The median time to post MI VSR formation was significantly shorter in thrombolysis group compared to non thrombolysis group at 1 vs 3 days(p = 0.026). The median time for VSR formation was shorter in early thrombolysis group compared to late thrombolysis group at 1 vs 3 days (p = 0.022). There was no difference between late and no thrombolytic therapy (3 vs 3 days, p = 0.672). There was no significant difference in the mortality between thrombolytic and no thrombolytic therapy (p = 0.690). Patients treated medically had a significant higher mortality compared to patients treated surgically (p = 0.005). Conclusion Thrombolytic therapy results in an earlier presentation of VSR after MI. This earlier presentation may be due to reduction in the number of patients developing late VSR after thrombolytic therapy, while the number of patients developing an early VSR remaining unaffected. Despite improvements in medical therapy and percutaneous and surgical techniques, mortality with this complication remains extremely high.

Incidence, Predictors, Clinical profile, Management and Outcome of Patients with Isolated Left Main Coronary Artery Ostial Disease

Objectives Isolated left main coronary artery (LMCA) ostial disease is a rare variant of LMCA disease. Earlier studies on this disease are limited by small number of patients enrolled. The aim of the present study was to analyze the incidence, risk factors, clinical profile and long term outcome of patients with isolated LMCA ostial disease. Methods 15,553 patients who underwent coronary angiogram in a single tertiary care cardiac hospital were analyzed for LMCA disease. 351(2.2%) patients were found to have significant LMCA disease out of which 28(0.18%) had isolated LMCA ostial disease. These 28 patients were compared with 323 non-ostial and non-isolated LMCA disease patients. Results The mean age of isolated LMCA ostial disease group was significantly less than the other group (p=0.009). Females were more affected than males (p=0.008). They also had low incidence of coronary risk factors (especially dyslipidemia, p=0.04). They tend to present more with stable angina and less with myocardial infarction. They had higher ejection fraction and normal regional wall motion (p=0.04). There was no mortality difference between two groups at the end of 1 year (p=0.234). Conclusion In one of the largest studies done in these patients, we found that isolated LMCA ostial disease is more common in middle aged females with few coronary risk factors. These patients also had a better ejection fraction and normal regional wall motion compared to patients with non-ostial and non-isolated LMCA disease. The clinical and angiographic profile of these patients suggests that they may represent a distinct clinical entity.

Successful management of Ellis type III left anterior descending artery perforation following percutaneous coronary intervention by a covered stent: Successfully resolved the dramatic complication

Coronary artery perforation is a rare but catastrophic complication of percutaneous coronary intervention (PCI). Grade III coronary perforation and rupture invariably results in pericardial effusion and tamponade requiring urgent pericardiocentesis. Advances in coronary intervention have increased the opportunity to treat coronary artery perforation. We are reporting a case of 55 years old hypertensive female who presented with effort angina. Coronary angiogram revealed significant stenosis in the left anterior descending coronary artery. Post PCI, she had Ellis type III coronary perforation and pericardial tamponade and cardiogenic shock. The patient was resuscitated, pericardiocentesis done, autologous blood transfusion given and covered stent deployed.

Adenocarcinoma—a rare intruder into the superior vena cava and the right atrium

A 60-year-old woman presented with breathlessness for 6 months. On examination, she had dilated veins in the neck and chest with direction of blood flow downwards suggesting superior vena cava (SVC) obstruction (figure 1A). Chest auscultation revealed diminished breath sounds on the right side. Chest X-ray showed mediastinal widening with soft-tissue density lesion in upper-right hemithorax (figure 1B). Transthoracic echocardiogram showed globular mass in right atrium (RA) obstructing the tricuspid valve (figure 1C and online supplementary video 1). Transoesophageal echocardiogram revealed the mass extending from SVC and filling the RA (figure 1D,E-asterix …

Holt-Oram syndrome with aortopulmonary window--a rare association.

A 4-month-old male infant presented with recurrent cough for 2 months. He had a shortened right upper limb with absent right thumb and continuous murmur in the left parasternal area. The X-ray showed an absent radius and the first metacarpal and phalyngeal bones on the right side. Echocardiogram revealed aortopulmonary window and small secundum atrial septal defect. Aortopulmonary window was successfully treated by device closure. Holt-Oram syndrome with aortopulmonary window is an extremely rare association.

Giant left atrium due to rheumatic mitral regurgitation.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 38-year-old woman with a known history of rheumatic heart disease for 10 years presented with complaints of breathlessness, dysphagia, and hoarseness of voice for 6 months. On physical examination, she had an apical

Pinhole Mitral Stenosis

A 46-year-old male rheumatic heart disease (RHD) patient with history of balloon mitral commissurotomy 10 years back presented in cardiac arrest. He was successfully resuscitated. He was in NYHA class IV dyspnea for the past 3 months. On the day of presentation, he had developed fever which precipitated acute breathlessness. On the way to hospital, he had developed cardiac arrest. Postresuscitation cardiovascular examination revealed soft S1 with loud pulmonary component of S2. Opening snap and mid-diastolic murmur was not appreciated. Grade 3/6 pan systolic murmur at left lower parasternal area was audible. He was in sinus rhythm transiently after resuscitation, but later developed atrial fibrillation. Two-dimensional transthoracic echocardiogram (Philips iE33, Eindhoven, The Netherlands) showed severely thickened and calcified mitral leaflets with restricted mobility and fused commissures (Figs. 1, 2, 3[arrow]; movie clip for Figs. 2 and 3). Critical mitral stenosis was noted with pinhole opening of the valve (movie clip for Fig. 2). The mitral valve orifice area by planimetry was 0.14 cm (Fig. 3B). Massachusetts General Hospital score for mitral valve morphology was 16 (maximum score). Mean pressure gradient across the valve was 14 mmHg (Fig. 4A). Left atrial (LA) volume was 57.86 mL/m. There was severe tricuspid valve and mild aortic valve regurgitation. Tricuspid regurgitation peak gradient was 56 mmHg (Fig. 4B), with inferior vena cava dilated and noncollapsing suggesting severe pulmonary hypertension. The left ventricular (LV) internal diameter was 3.4 cm in diastole and 2.3 cm in systole. Right ventricle was dilated measuring 3.6 cm in parasternal long-axis view. Three-dimensional echocardiography confirmed the critical nature of the stenosis both from LA