Tom Devasia

Statin Induced Rhabdomyolysis with Non Oliguric Renal Failure: A Rare Presentation

Statins are safe, well tolerated, efficient and time tested drugs for the management of hypercholesterolemia, and thus play a cardinal role in the management of patients with heart disease. Although safe in clinical practice, they are associated with adverse effects, clinically the most important and most severe being muscle related complications/myotoxicity. Rhabdomyolysis, though rare, is the most severe form of myotoxicity. The US Food and Drug Administration (USFDA) adverse event reporting system reports rate of statin induced rhabdomyolysis at 0.3-13.5 cases per 1,000,000 patients. We present a case of a 74-year-old male who presented with an acute coronary syndrome and was initiated on atorvastatin. However, patient developed atorvastatin induced rhabdomyolysis, with non oliguric renal failure, which subsequently improved on cessation of medication.

Delayed Diagnosis of Left-Sided Diaphragmatic Hernia in an Elderly Adult with no History of Trauma.

Diaphragmatic Hernia (DH) is the herniation of abdominal contents into the thorax through a rent in the diaphragm. Acquired DH most commonly occurs following a blunt or penetrating trauma to the abdomen with former being common than the later. Very rarely DH can be spontaneous and be asymptomatic until its very extensive. A 78-year-old presented with breathlessness and chest pain of one month duration. There was dull note to percussion and absent breath sounds in left lower zone. Auscultation revealed bowel sounds in left infra-axillary and mammary area. Electrocardiogram and laboratory data suggested acute myocardial infarction. Coronary angiogram showed a triple vessel disease. Roentgenogram was simulating pneumonic consolidation but presence of air shadows was the thing against pneumonic consolidation. CT imaging of the thorax revealed an extensive left diaphragmatic hernia with viscera and left kidney as its contents. He was initially taken up for CABG and surgery for diaphragmatic hernia was planned at a later date. This case is important for its extensive nature and for its rarity as acquired DH rarely occurs spontaneously. Chest roentgenogram must be read cautiously in all such cases to look for this entity. Auscultation for bowel sounds in the thorax is a diagnostic clue.

A case of upper left extremity deep vein thrombosis with right side middle lobe syndrome

Upper extremity deep vein thrombosis is an extremely important clinical entity with potential for considerable morbidity and mortality. A 64-year-old woman was brought to the emergency department with complaints of left upper limb and neck swelling for 4 days. Ultrasonography of the neck showed thrombosis of the left internal jugular and other surrounding veins associated with local lymphadenopathy. Computed tomography (CT) of the neck also showed a hypodense 0.6 cm × 0.8 cm × 1.2 cm lesion in the right middle lobe bronchus, causing complete occlusion and collapse of the right middle lobe of the lung. Fine-needle aspiration cytology and a lymph node biopsy showed nongranulomatous lymphadenitis. The patient was started on fondaparinux 10 mg subcutaneously once daily. She was discharged on oral anticoagulants for 6 months. Repeat CT scan after 6 months showed dissolution of the lesion and reexpansion of the right lung.

Catastrophic superior vena caval thrombus with massive pulmonary thromboembolism.

A 60-year-old woman with no pre-existing illness was admitted with complaints of progressive dyspnoea of 3 days duration. On evaluation, the patient was orthopneic with significant tachycardia. Electrocardiogram showed sinus tachycardia and right axis deviation with S1Q3T3 pattern. Transthoracic echocardiography revealed right heart chambers’ enlargement with right ventricular dysfunction. d-Dimer …

Exercise based evaluations and rehabilitation in heart failure: An addendum to the Cardiology Society of India's management protocols for chronic heart failure.

We agree with the letter that Stevia may be the safest among the currently available artificial sweeteners, however there are some limitations to this product as well. They are more expensive than natural “sugar,” have some minor side effects (bloating, nausea, etc.) but most importantly have licorice flavor and somewhat bitter after-taste so much so that they are not liked by most. Interestingly, while Food and Drug Administration, USA has approved refined Stevia (product Rebaudioside A) as generally recognized as safe (GRAS), it has not approved leaf or extract of Stevia as GRAS because of possible effect on reproductive, renal or cardiovascular system. In any case robust, long term (5 years or so) data on clinical outcomes with Stevia is still lacking.

“The smiling valve”: Incidental fluoroscopic finding of a stented Hancock porcine bioprosthetic valve during coronary angiogram

A 60-year-old male patient with type 2 diabetes mellitus (DM)and hypertension presented to cardiology department (January2018) with exertional dyspnea [New York Heart Association(NYHA) class II] since last two months. General examinationrevealed pulsus parvus et tardus along with systolic blood pressure(SBP) of 90 mmHg in right hand supine position. Cardiovascu-lar examination revealed heaving apex, grade IV/VI late peakingsystolic murmur at aortic area with decreased intensity of aor-tic closure sound. Previously, in 2010 also he had presented withNYHA class II dyspnea and exertional giddiness.

Masquerading Bundle Branch Block: A Poor Prognostic Sign Revisited

Masquerading bundle branch block is a rare but important finding on the Electrocardiogram (ECG). It is an indication of severe and diffuse conduction system disease and usually indicates poor prognosis. The precordial leads show a Right Bundle Branch Block (RBBB) pattern while the limb leads resemble a Left Bundle Branch Block (LBBB). This finding on an ECG is almost invariably associated with severe underlying heart disease. It is extremely important to be aware of this finding as it is a marker of poor cardiac outcomes. We report the case of a 68-year-old gentleman, who presented with progressive dyspnoea on exertion over three months. ECG showed a broad QRS complex with a RBBB pattern on the precordial leads and a LBBB pattern on the limb leads (suggestive of masquerading bundle branch block). A coronary angiogram revealed severe Triple Vessel Disease (TVD). The patient was scheduled for an early Coronary Artery By-Pass Grafting Surgery. However, his clinical condition deteriorated and he died while awaiting the surgery.

Native Triple Valve Endocarditis as Complication of Post-Abortal Sepsis

Infective endocarditis (IE) is a highly morbid condition in pregnancy which poses both maternal and fetal risk. In majority of cases, endocarditis occurs only on single valve and usually occurs on valve with structural disease or prosthetic valve. Multi-valvular involvement is not common and so we report a case of native triple valve endocarditis as a complication of post abortal sepsis which was successfully treated medically.

Hammer in the Heart on Coronary Angiography

Here we report a 51-year-old female who presented for evaluation of dyspnoea on exertion and frequent palpitations since 1 month. Patient was diabetic and hypertensive and was on regular treatment. There was no history of fever, cough or pedal oedema. On general examination she had tachycardia, tachypnea and hypoxia on room air. Systemic examination showed grade 3 left parasternal heave and mid diastolic murmur at apex, additional sound (opening snap/tumour plop) was heard but was not able to be differentiated clinically. Chest roentenogram showed straightening of left heart border [Table/Fig-1]. [Table/Fig-1]: Chest roentgenogram PA view showing straightening of left heart border. Electrocardiogram showed atrial fibrillation, so possibility of mitral stenosis was considered. Trans thoracic echocardiogram (TTE) showed large (4*2.4 cm) left atrial mass found attached to inter atrial septum with cyst within prolapsing in and out of left ventricle causing dynamic mitral valve obstruction [Table/Fig-2] and [video-1] there was associated eccentric mitral regurgitation and severe pulmonary artery hypertension. Transoesophangeal echocardiography (TEE) showed the same findings. On coronary angiography LV myxoma was moving in and out of the LV simulating to and fro motion of hammer on left anterior oblique cranial view [video-2,3]. [Table/Fig-2]: Tran’s thoracic echocardiography apical four chamber view showing left atrial mass prolapsing into left ventricle. To the best of our knowledge, description of left atrial myxoma movement micmicking hammer in the heart was not reported previously. A study done by Vincelj J on 14 patients with atrial mass showed that TEE had 100% sensitivity and specificity in detecting them [1]. So diagnosis can be suspected by TTE and confirmed with TEE. Primary cardiac tumours are rare, 75% of them are benign and most of them are constituted by myxomas [2]. Myxomas occur most frequently in left atrium (93.5%) than in other regions [3]. Our patient had myxoma arising from inter atrial septum which is commonly seen. Once the suspicion of myxoma arises diagnosis can be made by TTE or TEE. Early diagnosis is required as it is not uncommon to see patients with signs of systemic embolisation as presenting symptom. Diagnosis of myxoma makes cause treatable and surgery is the treatment of choice with most series reporting an operative death rate of fewer than 5% [4]. As prognosis is good this possibility should always be suspected and ruled out with appropriate investigations. Our patient underwent successful resection and histopathology was consistent with myxoma. Post excision patient was symptomatically better and undergoing cardiac rehabilitation.

Early strength training using theraband exercises for phase-1 cardiac rehabilitation in a patient with a fractured femur: a case report

The effectiveness of exercise-based cardiac rehabilitation (CR) following an acute coronary syndrome (ACS) is well established. However, ACS complicated by an orthopedic limitation, poses greater challenges to early mobilization. Thus, there is a need for an alternative rehabilitation approach to improving exercise capacity and in preventing and reducing associated complications during convalescence. This case report highlights the value and utility of using low level resistance exercises to the upper limb with theraband exercise during an inpatient or phase-1 CR program. A low intensity theraband regimen for the upper limb was administered based on the number of repetitions performed to fatigue. The functional improvements observed and the ability of the patient to tolerate the therapy suggests a potential role for theraband exercises in phase-1 CR in ACS patients with selected orthopedic limitations.