Suresh Madhavan

Maternal and fetal outcomes in pregnant women undergoing balloon mitral valvotomy for rheumatic mitral stenosis

Background Rheumatic mitral stenosis constitutes a major cause of acquired heart disease complicating pregnancy in India. In the present study, we have studied the fetal and maternal outcomes of women undergoing balloon mitral valvotomy during pregnancy. Methods and results 49 pregnant ladies were included in this study in whom balloon mitral valvotomy was performed. The mean age of these patients was 25.7 ± 3.1 years. The mean gestational age was 23.5 ± 5.2 weeks (12–36 weeks). The procedure was successful in 48 patients (95.9%). Mean two-dimensional MVA increased from baseline value of 0.93 ± 0.17 cm2 to 1.75 ± 0.27 cm2 (p value <0.0001). Pre-procedure peak pulmonary artery pressure was 43.05 ± 15.88 mmHg, which decreased to 22.31 ± 6.36 mmHg (p value <0.0001). Hemodynamic data showed pre-BMV left atrial mean pressure of 29.6 ± 6.6 mmHg, which decreased to 13.7 ± 4.8 mmHg after the procedure (p value <0.0001). Mean fluoroscopy time was 6.4 ± 1.2 min. There was no maternal mortality in our study. One procedure had to be abandoned, because of failed septal puncture. One of the patients developed cardiac tamponade and another patient developed severe mitral regurgitation, which were managed medically. The patient who developed severe mitral regurgitation later underwent mitral valve replacement. Post-procedure follow-up showed an improvement in NYHA status by at least one class in 81.3% of patients. Thirty-nine (81.3%) patients had a term normal vaginal delivery and 8 (16.7%) underwent cesarean section for obstetric indications. One of the patients had abortion on the second day of the procedure. Conclusion Percutaneous mitral valvotomy during pregnancy is safe and provides excellent symptomatic relief and hemodynamic improvement. This should be considered as the treatment of choice when managing pregnant women with severe mitral stenosis.

Blood cyst of the anterior mitral leaflet causing severe mitral regurgitation

We report a case of blood cyst of the anterior mitral leaflet leading to severe mitral regurgitation and heart failure in a 70-year-old woman with no other factors that could explain the severe mitral regurgitation.

Cystic mediastinal mass

Case presentation A 32-year-old woman with no other medical history presented with 1-month history of fever, weight loss and dyspnoea. On examination she had elevated jugular venous pressure and tachycardia. Her chest X-ray posterioranterior view (figure 1A) showed a rounded mass in the right cardiophrenic angle obscuring the right atrial margin, producing a ‘silhouette’ sign. Echocardiography showed a large cystic mass with thickened pericardium, lateral to the right atrium, causing right atrial compression (figure 1B). CT image of the chest showed a cystic lesion compressing the right atrium with thickened pericardium (figure 2A). There were no other lesions found in the lungs or other organs. Laboratory tests showed elevated erythrocyte sedimentation rate (ESR: 96 mm/hour) and C reactive protein (CRP: 32 mg/L). Excision of the mass with partial pericardiectomy was done. Intraoperatively, there was a cyst with thickened pericardial wall and thick yellowish brown fluid. Histopathology of the tissue is shown in figure 2B. Figure 1 (A) Chest X-ray posterioranterior view showing a rounded mass in the right cardiophrenic angle. (B) Transthoracic echocardiography apical four-chamber view showing the cystic mass. Figure 2 (A) CT of the chest sagittal view showing cystic lesion compressing the right atrium with thickened pericardium. (B) Histopathology specimen of the pericardial tissue. Question What is the diagnosis and what should be the management strategy? Congenital pericardial cyst and no further evaluation required. Features are suggestive of tuberculous pericardial cyst and needs treatment with antituberculosis regimen. Features suggestive of pericardial hydatid cyst and requires treatment with albendazole. Features are suggestive of viral pericarditis with encysted effusion.

PREVALENCE AND PREDICTORS OF CORONARY ARTERY DISEASE IN SEVERE AORTIC STENOSIS PATIENTS UNDERGOING SURGERY

BACKGROUND The present study is to find out the prevalence of CAD in severe Aortic Stenosis (AS) patients undergoing aortic valve replacement and the relation between the conventional risk factors and CAD in them. Calcific aortic stenosis is associated with the same risk factors as coronary artery disease. Studies on calcific aortic stenosis and CAD are rarely reported from India. The aim of the study is to find out the predictive value of angina for presence of CAD in severe aortic stenosis.

Prospective validation of San Francisco Syncope Rule in Indian population

Context: The San Francisco Syncope Rule (SFSR) was proposed as a risk stratification tool for patients presenting to the emergency department (ED) with syncope. Aims: The aim of this study was to validate the SFSR in Indian population for predicting serious outcomes in patients presenting with syncope or near syncope. Secondary aim was to identify whether the admission rate can be safely reduced by applying this rule in the ED. Settings and Design: This was a prospective observational study conducted among patients attending the ED of a teaching hospital with syncope or near syncope. Subjects and Methods: Physicians prospectively applied the SFSR after usual evaluation, and patients were followed up to determine whether they had a serious outcome within 30 days of their ED visit. Statistical Analysis Used: Sensitivity, specificity, positive and negative predictive values of the rule for predicting serious outcomes were calculated. Results: A total of 210 patients were included in the study. There were 86 (41%) males and 124 (59%) females. Average age was 60.6 years. A total number of patients admitted were 110 out of 210 patients (52%). At least one SFSR predictor was positive in 90 (43%) patients out of 210. A total of 23 patients (11%) had at least one serious outcome at 30 days of ED visit. SFSR had a sensitivity of 95.65% and a specificity of 63.64% to predict serious outcome in the study population. Conclusions: The SFSR is valid in Indian population and application of the rule could reduce the hospital admission rates for syncope.

Severe pulmonary arterial hypertension in a patient with small ventricular septal defect

A boy aged 16 years presented to our hospital with a history of dyspnoea on exertion and haemoptysis. His cardiovascular examination revealed features of severe pulmonary artery hypertension (PAH). He had no cyanosis. His transthoracic echocardiogram showed dilated right atrium and ventricle with the interventricular septum bulging to the left side. There was a small perimembraneous ventricular septal defect (VSD) with right-to-left shunt (figure 1 and video 1). The left atrium and ventricle were of normal size. Continuous wave Doppler evaluation showed right-to-left shunting with a peak …

Effect of Thrombus Aspiration on Angiography and Outcome in Patients Undergoing Primary Coronary Angioplasty

Thrombus exerts a major impact on the performance and outcome of primary and rescue interventions in acute ST-elevation myocardial infarction. Although the optimal treatment of thrombotic lesions is still controversial, thrombus aspiration provides an effective method to achieve successful reperfusion during primary angioplasty. We compared clinical and angiographic outcomes in 286 patients with acute ST-elevation myocardial infarction undergoing primary percutaneous transluminal coronary angioplasty (PTCA) and thrombus aspiration with those who underwent conventional PTCA without thrombus aspiration. Thrombus aspiration during primary percutaneous coronary intervention in patients with high thrombus burden resulted in better Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the infarct-related artery and helped achieve faster ST-segment resolution on the electrocardiogram compared with conventional angioplasty without thrombus aspiration.

Benign neoplasms in the right ventricular outflow tract

We describe benign neoplasms in the right ventricular outflow tract in two patients: one, a 2-month-old male with a rhabdomyoma, and the other, a 48-year-old woman with a myxoma. Each of these tumors is rare in that location.

Cardiac Autonomic Neuropathy and QTc Interval in Type 2 Diabetes

Context: An association between cardiac autonomic neuropathy and QT interval prolongation was demonstrated in many studies and it may predispose to sudden death in diabetes mellitus. Aims: To find out the prevalence of cardiac autonomic neuropathy and its relation to QTc interval and QTc dispersion in type 2 diabetes. Settings and Design: Observational study. Materials and Methods: Fifty patients with type 2 diabetes mellitus of more than 5-years duration and 30 age- and sex-matched controls without any history of diabetes were selected. A battery of five autonomic function tests was done in all cases. Heart rate, QTc values, and QTc dispersion were measured and compared among patients with and without autonomic neuropathy and controls. Statistical analysis used: Students t test/Chi-square test. Results: Among the 50 patients in the study population, 21 (42%) had severe autonomic neuropathy and 12 (24%) had early autonomic neuropathy. Mean heart rate was significantly more in patients with autonomic neuropathy than those without neuropathy. Diabetics with autonomic neuropathy had significantly higher QTc mean and QTc max values compared to diabetics without autonomic neuropathy and controls. QTc dispersion was significantly more among patients with autonomic neuropathy compared to those without autonomic neuropathy and controls. Conclusions: Diabetic autonomic neuropathy is associated with increase in resting heart rate and prolongation of QTc intervals. QTc max was correlating with severity of autonomic neuropathy. QTc dispersion is significantly high in diabetes mellitus with autonomic neuropathy.

Left main coronary artery ostial occlusion in a young man: late sequelae of Kawasaki's disease?

A 26-year-old man was admitted with a history of New York Heart Association (NYHA) class II dyspnoea of 2 months’ duration. An electrocardiogram showed diffuse ST segment depression and ST segment elevation in aVR. Echocardiography showed anterior wall hypokinesia with moderate left ventricular dysfunction. Coronary angiography showed a normal right coronary artery (RCA) (figure 1A) and near total occlusion of the …