Vikas Mishra

Epicardial Adipose Tissue Thickness and Its Association With the Presence and Severity of Coronary Artery Disease in Clinical Setting: A Cross-Sectional Observational Study.

Background Obesity is an important risk factor for atherosclerotic cardiovascular disease (ASCVD). Estimation of visceral adipose tissue is important and several methods are available as its surrogate. Although correlation of epicardial adipose tissue (EAT) with visceral adipose tissue as estimated by magnetic resonance imaging (MRI) and/or CT is excellent, it is costlier and cumbersome. EAT can be accurately measured by two-dimensional (2D) echocardiography. It tends to be higher in patients with acute coronary syndrome than in subjects without coronary artery disease (CAD) and in those with stable angina. It also carries advantage as index of high cardiometabolic risk as it is a direct measure of visceral fat rather than anthropometric measurements. The present study evaluated the relationship of EAT to the presence and severity of CAD in clinical setting. Methods In this prospective, single-center study conducted in the Department of Cardiology, LPS Institute of Cardiology, Kanpur, India, 549 consecutive patients with acute coronary syndrome or chronic stable angina were enrolled. Sensitivity, specificity, and receiver operating characteristic (ROC) curve were estimated to find cut-off value of EAT thickness for diagnosing CAD using coronary angiographic findings as gold standard. Results Patients were diagnosed as CAD group (n = 464, 60.30 ± 8.36 years) and non-CAD group (n = 85, 54.42 ± 11.93 years) after assessing coronary angiograms. The EAT was measured at end-systole from the PLAX views of three cardiac cycles on the free wall of the right ventricle. Lesion was significant if > 50% in left main and > 70% in other coronary arteries. The mean EAT thickness in CAD group was 5.10 ± 1.06 and in non-CAD group was 4.36 ± 1.01 which was significant (P = 0.003). Significant correlation was demonstrated between EAT thickness and presence of CAD (P < 0.003). Higher EAT was associated with severe CAD and presence of multivessel disease. By ROC analysis, EAT > 4.65 mm predicated the presence of significant coronary stenosis by 71.6% sensitivity and 73.1% specificity. Conclusion EAT thickness measured using transthoracic echocardiography (TTE) significantly correlates with the presence and severity of CAD. It is sensitive, easily available, and cost-effective and assists in the risk stratification and may be an additional marker on classical risk factors for CAD.

Efficacy and Safety of Thrombolytic Therapy in Acute Submassive Pulmonary Embolism: Follow-Up Study

Background Thrombolysis in acute submassive pulmonary embolism (PE) remains controversial. So we studied impact of thrombolytic therapy in acute submassive PE in terms of mortality, hemodynamic status, improvement in right ventricular function, and safety in terms of major and minor bleeding. Method A single-center, prospective, randomized study of 86 patients was conducted at LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, India. Patients received thrombolysis (single bolus of tenecteplase) with unfractionated heparin (UFH, group I) or placebo with UFH (group II). Result Mean age of patients was 54.35 ± 12.8 years with male dominance (M:F = 70%:30%). Smoking was the most common risk factor seen in 29% of all patients, followed by recent history of immobilization (25%), history of surgery or major trauma within past 1 month (15%), dyslipidemia (10%) and diabetes mellitus (10%). Dyspnea was the most common symptom in 80% of all patients, followed by chest pain in 55% and syncope in 6%. Primary efficacy outcome occurred significantly better in group I vs. group II (4.5% vs. 20%; P = 0.04), and significant difference was also found in hemodynamic decompensation (4.5% vs. 20%; P = 0.04), the fall in mean pulmonary artery systolic pressure (PASP) (28.8% vs. 22.5%; P = 0.03), improvement in right ventricular (RV) function (70% vs. 40%; P = 0.001) and mean hospital stay (8.1 ± 2.5 vs. 11.1 ± 2.14 days; P = 0.001). There was no difference in mortality and major bleeding as safety outcome but increased minor bleeding occurred in group I patients (16% vs. 12%; P = 0.04). Conclusion Patients with acute submassive PE do not derive overall mortality benefit, recurrent PE and rehospitalization with thrombolytic therapy but had improved clinical outcome in form of decrease in hemodynamic decompensation, mean hospital stay, PASP and improvement of RV function with similar risk of major bleed but at cost of increased minor bleeding.

Coronary Angiography Safety between Transradial and Transfemoral Access

Background and Aim. The aim of study was to evaluate safety, feasibility, and procedural variables of transradial approach compared with transfemoral approach in a standard population of patients undergoing coronary catheterization as one of the major criticisms of the transradial approach is that it takes longer overall procedure and fluoroscopy time, thereby causing more radiation exposure. Method. Between January 2015 and December 2015, a total of 1,997 patients in LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, India, undergoing coronary catheterization were randomly assigned to the transradial or transfemoral approach. Result. Successful catheterization was achieved in 1045 of 1076 patients (97.1%) in the transradial group and in 918 of 921 patients (99.7%) in the transfemoral group (p = 0.001). Comparing the transradial and transfemoral approaches, fluoroscopy time (2.46 ± 1.22 versus 2.83 ± 1.31 min; p = 0.32), procedure time (8.89 ± 2.72 versus 9.33 ± 2.82 min; p = 0.56), contrast volume (67.52 ± 22.54 versus 71.63 ± 25.41 mL; p = 0.32), radiation dose as dose area product (24.2 ± 4.21 versus 22.3 ± 3.46 Gycm2; p = 0.43), and postprocedural rise of serum creatinine (6 ± 4.5% versus 8 ± 2.6%; p = 0.41) were not significantly different while vascular access site complications were significantly lower in transradial group than transfemoral group (3.9% versus 7.6%; p = 0.04). Conclusion. The present study shows that transradial access for coronary angiography is safe among patients compared to transfemoral access with lower rate of local vascular complications.

Unusual Survival of Anomalous Left Coronary Artery From the Pulmonary Artery With Severe Rheumatic Mitral Stenosis in Septuagenarian Women: Foes Becoming Friends?

ALCAPA syndrome (anomalous origin of the left coronary artery from the pulmonary artery) is a rare disease but lethal with clinical expression from myocardial infarction, congestive heart failure to death during early infancy and unusual survival to adulthood. We report a 73-year-old woman with ALCAPA who presented with exertional dyspnea (NYHA functional class II) over past 2 years. Physical examination revealed soft S, long mid diastolic rumbling murmur and apical pan-systolic murmur. Electrocardiography displayed biatrial enlargement and poor R progression and normal sinus rhythm. Echocardiography established calcified severe mitral stenosis (MS), presence of continuous flow entering the pulmonary trunk, turbulent continuous flow in inter-ventricular septum with left to right shunt in contrast echocardiography and normal systolic function. Coronary angiogram showed absence of left coronary artery (LCA) originating from aorta, dilated and tortuous right coronary artery (RCA) and abundant Rentrop grade 3 intercoronary collateral communicating with LCA originating from pulmonary trunk which was also confirmed on coronary CT angiogram thus establishing diagnosis of ALCAPA. It is exceedingly rare to be associated with severe MS. However, such a long survival in our patient can be explained by the severe pulmonary arterial hypertension which may be contributing to lesser coronary steal.

Radial Artery Occlusion – Incidence, Predictors and Long-term outcome after TRAnsradial Catheterization: clinico-Doppler ultrasound-based study (RAIL-TRAC study)

Background and aim The purpose of this study was to assess incidence, predictors and outcome of radial artery occlusion (RAO) after transradial catheterization (TRC) based on clinical and Doppler ultrasound study. Methods A total of 1,945 consecutive patients undergoing transradial catheterization for diagnostic evaluation or intervention were included. Radial artery examination was based on palpation and colour Doppler study on the day before, 1 day (D1), 1 month (D30) and 6 months (D180) following the procedure. RAO was defined as absence of pulse on palpation and forward flow on Doppler study. Predictors of RAO were found by logistic regression analysis. Results Baseline demographic and procedural data were recorded. The mean radial arterial diameter was 2.56 ± 0.29 mm. On D1, radial artery Doppler examination revealed RAO in 339 patients (17.4%) but pulse was still palpable in 115 (34%) of them. At D30, these were 221 (11.4%) and 114 (52%), respectively, as no new RAO were noted. Interestingly, 118 (34.8%) patients had spontaneous recanalization of their radial artery as shown by catch-up in patency rate. At D180, these were 99 (5.1%) and 68 (69%), respectively, meaning further new catch-up implying further recanalization. Patients with persistent RAO remained asymptomatic. On multivariate analysis, female sex, diabetes, lower BMI, radial artery diameter ≤2.2 mm and radial artery-to-sheath ratio (AS ratio) < 1 were predictors of RAO. Conclusion TRC for coronary angiography, ad hoc and staged angioplasty can be performed with similar efficacy and safety though RAO occurs more frequently in patients with prior radial artery cannulation and with larger sheath size. Persistent RAO remains asymptomatic.

Percutaneous transmitral commissurotomy in calcified, restenosed mitral valve: a technical challenge

Address for correspondence: Dr. Santosh Kumar Sinha, Department of Cardiology, LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, 208002 India, fax: +91-0512-2556199, 2556521, e-mail: fionasan@rediffmail.com Conflict of interest: none declared Kardiologia Polska Copyright

TCT-750 Radial Artery Occlusion - Incidence, Predictors and Long term outcome after TRAnsradial Catheterization: Clinico-Doppler ultrasound based Study (RAIL-TRAC Study)

To assess incidence, predictors and outcome of radial artery occlusion (RAO) after transradial catheterization (TRC) based on clinical and Doppler ultrasound study. A total of consecutive 1945 patients undergoing trans-radial catheterization for diagnostic or interventions were included. Radial

Unusual trifurcation of a single left coronary artery

Congenital coronary artery anomalies are rare and usually an incidental finding during coronary angiography. Most of the anomalies are benign in nature; however, some are malignant and may result in sudden cardiac death. A 46-year-old woman with diabetes and hypertension underwent coronary angiography for evaluation of exertional angina, which revealed an unusual trifurcation of a single left coronary artery with an anomalous origin of the right coronary artery from the left anterior descending artery but no significant coronary narrowing. The patient was managed conservatively.

Aorto-renal Bifurcation Stenting in a Juvenile Non-specific Aorto-Arteritis: case report

Takayasu Arteritis (TA) is a granulomatous inflammation of unknown aetiology affecting the aorta and its major branches with usual affliction among patients younger than 50 years and rarely among children. We present a 7-years old boy referred for evaluation of hypertension. He had a significant blood pressure difference between right arm, left arm and lower limbs. Computed tomography imaging of thorax and abdomen showed stenosis of left subclavian artery, left renal artery and juxtareanl aorta which was subsequently confirmed on aortogram. He underwent percutaneous endovascular therapy with aorto-renal bifurcation stenting with reduction of blood pressure and gradient. Renal angioplasty with stenting remains a challenging procedure in patients with tight ostial lesion, and juxtarenal aortic involvement in lieu of precise stent placement and avoiding side branch occlusion.

TCT-638 Non-pharmaco, Non-invasive approach in treatment of coronary No-reflow phenomenon

No-reflow is a common complication of percutaneous coronary intervention (PCI) (primary, acute coronary syndrome, stable coronary disease and graft vessel disease) with adverse outcomes. Microvascular obstruction of downstream bed is the culprit. Intracoronary administration of various calcium