Vijay Trehan

Phosphodiesterase-5 Inhibitor in Eisenmenger Syndrome A Preliminary Observational Study

Background— Phosphodiesterase-5 inhibitors produce a significant decrease in pulmonary vascular resistance in patients with idiopathic pulmonary arterial hypertension. We studied the effects of tadalafil, a phosphodiesterase-5 inhibitor, on short-term hemodynamics, tolerability, and efficacy over a 12-week period in patients of Eisenmenger syndrome having a pulmonary vascular pathology similar to idiopathic pulmonary arterial hypertension. Methods and Results— Sixteen symptomatic Eisenmenger syndrome patients (mean age, 25±8.9 years) were assessed hemodynamically at baseline and 90 minutes after a single dose of tadalafil (1 mg/kg body weight up to a maximum of 40 mg). The same dose was then continued daily for 12 weeks, and the patients were restudied. There was a significant decrease in mean pulmonary vascular resistance immediately (24.75±8.49 to 19.22±8.23 Woods units; P<0.005) and at 12 weeks (19.22±8.23 to 17.02±6.19 Woods units; P=0.03 versus 90 minutes). Thirteen of 16 patients (81.25%) showed a ≥20% decrease in pulmonary vascular resistance and were defined as responders. The mean systemic oxygen saturation improved significantly both immediately (84.34±5.47% to 87.39±4.34%; P<0.005) and at 12 weeks (87.39±4.34% to 89.16±3.8%; P<0.02 versus 90 minutes) without a significant change in systemic vascular resistance. None of the patients had a fall in systemic arterial pressure, worsening of systemic oxygen saturation, or any adverse reactions to the drug. The mean World Health Organization functional class improved from 2.31±0.47 to 1.25±0.44 (P<0.0001), and the 6-minute walk distance improved from 344.56±119.06 to 387.56±117.18 m (P<0.001). Conclusions— Preliminary evaluation of tadalafil has shown efficacy and safety in selected patients with Eisenmenger syndrome, warranting further investigation in this subgroup of patients.

Percutaneous transatrial mitral commissurotomy: Immediate and intermediate results

OBJECTIVES The purpose of this study was to evaluate the immediate and follow-up results of percutaneous transatrial mitral commissurotomy in 600 patients with rheumatic mitral stenosis. BACKGROUND Percutaneous transatrial mitral commissurotomy has emerged as an effective nonsurgical technique for patients with symptomatic mitral stenosis. Several studies have shown that the immediate results are comparable to closed and open mitral valvotomy. METHODS Percutaneous transatrial mitral commissurotomy was performed in 600 patients with rheumatic mitral stenosis by the double-balloon (290 patients [48.3%]) and flow-guided Inoue balloon (310 patients [51.7%]) techniques. There were 154 male (25.6%) and 446 female (77.4%) patients with a mean [+/- SD] age of 27 +/- 8 years (range 8 to 60). Atrial fibrillation was present in 26 patients (4.3%), mitral regurgitation < or = grade 2 in 62 (10.3%) and densely calcific valve in 12 (2%). All patients had clinical and echocardiographic (two-dimensional, continuous wave Doppler, color flow imaging) follow-up at 3-month intervals. RESULTS Percutaneous transatrial mitral commissurotomy was successful in 589 patients (98.1%), and optimal commissurotomy was achieved in 562 (93.6%), with an increase in mitral valve area from (mean +/- SD) 0.75 +/- 0.18 to 2.2 +/- 0.38 cm2 (p < 0.001) and a decrease in transmitral end-diastolic gradient from 27.3 +/- 6.1 to 3.8 +/- 4.2 mm Hg (p < 0.001). Mitral regurgitation developed or increased in 208 patients (34.6%). Six patients (1%) with mitral regurgitation required mitral valve replacement. Cardiac tamponade occurred in 8 patients (1.3%). Six patients (1%) died. Restenosis developed in 10 patients (1.7%) during a mean follow-up period of 37 +/- 8 months (range 6 to 66). CONCLUSIONS Percutaneous transatrial mitral commissurotomy is an effective, safe procedure with gratifying intermediate results. It should be considered the treatment of choice for rheumatic mitral stenosis.

Successful device closure of an acquired Gerbode defect

Left ventricle to right atrial communications, collectively known as Gerbode defects, are usually congenital defects and surgical closure remains the treatment of choice. We report a rare case of Gerbode defect acquired following surgical closure of a ventricular septal defect. The defect was successfully closed percutaneously with an Amplatzer ventricular septal occluder. The patient remained symptom free with optimal result on echo at 6 months of follow‐up. This is the first reported case of successful device closure of an acquired Gerbode defect.

Intracoronary fracture and embolization of a coronary angioplasty balloon catheter: Retrieval by a simple technique

We report a technique for retrieval of a balloon along with a portion of its shaft from the coronary system using a simple technique that does not involve the use of snare or any other retrieval tool. An additional angioplasty wire and a balloon catheter were used to remove the balloon from the coronary system. Cathet Cardiovasc Intervent 2003;58:473–477.

Successful nonsurgical removal of a knotted and entrapped pulmonary artery catheter

Knotting of a balloon-tipped, flow-directed catheter leading to difficulty in its removal is a rare but serious complication. Several methods have been used to remove such catheters with nonsurgical techniques. A case of knotted catheter that was also entrapped in a surgical suture in a patient undergoing emergency mitral valve replacement is presented and a method for its nonsurgical removal is described.

Biochemical and genetic role of apelin in essential hypertension and acute coronary syndrome

BACKGROUND Apelin-APJ pathway has emerged as a potent regulator of blood pressure (BP) and blood flow in vasculature and heart. Variants in apelin gene may affect the vascular tone in peripheral circulation or heart, thereby predisposing to cardiovascular diseases. The aim of our study was to investigate the association of two apelin gene polymorphisms rs3761581 and rs2235312, and apelin levels in patients with essential hypertension (EH) and acute coronary syndrome (ACS). METHODS The study comprised of three groups namely, (1) 118 healthy control subjects, (2) 92 EH patients, and (3) 60 ACS patients. DNA was extracted from peripheral blood leukocytes and genotyping was performed by SNaPshot method. Plasma apelin 13 levels were estimated using ELISA. RESULTS EH and ACS patients had a significantly lower level of apelin 13, regardless of gender (p=0.003, p=0.017, respectively). Interestingly, the female EH and ACS patients had lower levels of apelin 13 than their male counterparts. The G allele of rs3761581 was more apparent in patients especially in ACS than the controls. CONCLUSION Reduced apelin levels may enhance vasoconstriction to influence high BP and hearts workload in EH and ACS. Genetic involvement of apelin needs to be established in well-defined larger sample size.

First-in-human evaluation of a novel poly-L-lactide based sirolimus-eluting bioresorbable vascular scaffold for the treatment of de novo native coronary artery lesions: MeRes-1 trial

AIMS The MeRes-1 trial sought to study the safety and effectiveness of a novel sirolimus-eluting bioresorbable vascular scaffold (MeRes100 BRS) in treating de novo native coronary artery lesions by clinical evaluation and using multiple imaging modalities. METHODS AND RESULTS The MeRes-1 first-in-human trial was a single-arm, prospective, multicentre study, which enrolled 108 patients with de novo coronary artery lesions (116 scaffolds were deployed to treat 116 lesions in 108 patients). At six months, quantitative coronary angiography revealed in-scaffold late lumen loss of 0.15±0.23 mm with 0% binary restenosis. Optical coherence tomography demonstrated minimum scaffold area (6.86±1.73 mm2) and percentage neointimal strut coverage (99.30%). Quantitative intravascular ultrasound analysis confirmed a 0.14±0.16 mm2 neointimal hyperplasia area. At one year, major adverse cardiac events, a composite of cardiac death, any myocardial infarction and ischaemia-driven target lesion revascularisation, occurred in only one patient (0.93%) and there was no scaffold thrombosis reported. At one year, computed tomography angiography demonstrated that all scaffolds were patent and in-scaffold mean percentage area stenosis was 11.33±26.57%. CONCLUSIONS The MeRes-1 trial demonstrated the safety and effectiveness of MeRes100 BRS. The favourable clinical outcomes and effective vascular responses have provided the basis for further studies in a larger patient population. The MeRes-1 trial is registered at the Clinical Trials Registry-India.

Nonsurgical Management of Cardiac Tamponade Caused by a Temporary Pacemaker Lead

Right ventricular perforation secondary to temporary pacemaker lead, resulting in cardiac tamponade, is a rare but life‐threatening complication. Surgery is usually the definitive management described for such cases. We describe successful sealing of such a perforation by percutaneous instillation of cyanoacrylate glue, through a guiding catheter in the pericardial sac at the perforation site.

Aortic rupture during aortoplasty in Takayasu arteritis – A rare complication: Case report and review of literature

Balloon angioplasty of the stenosed aorta is usually a relatively simple, yet potentially a catastrophic procedure. Aortic rupture during aortoplasty, though uncommon, carries a high mortality. We report case of a 39-year-old female with aortoarteritis with multiple arterial stenoses whose infra-renal abdominal aorta ruptured during balloon dilatation of the stent deployed in that segment. The site of aortic rupture was temporarily occluded by low-pressure inflation of the same balloon and then was sealed using a stent-graft introduced by contra-lateral femoral arterial access.

Iatrogenic Iliac Artery Rupture: Emergency Management by Longer Stent-Graft on a Shorter Balloon

Rupture of an iliac artery during percutaneous transluminal coronary angioplasty is a rare but potentially devastating complication. We report a case of iatrogenic external iliac artery rupture that was successfully treated by temporary balloon occlusion followed by endovascular stent graft placement in an unusual manner. Limited availability of the hardware necessitated the use of a longer bare stent graft mounted on a relatively shorter balloon.