Vikrant Vijan

Use of Lung Ultrasound For Diagnosing Acute Heart Failure in Emergency Department of Southern India

INTRODUCTION Diagnosing heart failure is often a challenge for the healthcare providers due to its non-specific and usually subtle physical presentations. The outcomes for treatment are strongly related to the stage of the disease. Considering the importance of early and accurate diagnosis, it is important to have an easy, inexpensive, non-invasive, reliable and reproducible method for diagnosis of heart failure. Recent advancement in radiology and cardiology are supporting the emerging technique of lung ultrasound through B-line evaluation for identifying extravascular lung water. AIM To establish lung ultrasound as an easy, inexpensive, non-invasive, reliable and reproducible method for diagnosing Acute Decompensated Heart Failure (ADHF) in emergency department. MATERIALS AND METHODS The study was a cross-sectional, prospective, observational, diagnostic validation study of lung ultrasound for diagnosis of acute heart failure in an emergency department and was performed at Amrita Institute of Medical Science, Kochi, Kerala, India. A total of 42 patients presenting with symptoms suggestive of acute decompensated heart failure were evaluated by plasma B-type Natriuretic Peptide (BNP), Echocardiography (ECHO) and X-ray. Lung ultrasound was done to look for the presence of B-lines. STATISTICAL ANALYSIS Sensitivity, specificity and predictive value of diagnostic modalities were calculated using Mc Nemars Chi-square test for the presence and absence of heart failure. RESULTS Lung ultrasound showed a sensitivity of 91.9% and a specificity of 100% in diagnosing acute heart failure comparable to plasma BNP which had a sensitivity of 100% and a specificity of 60%. It was also superior to other methods of diagnosing ADHF namely X-ray and ECHO and showed a good association. CONCLUSION Lung ultrasound and its use to detect ultrasonographic B-lines is an early, sensitive and an equally accurate predictor of ADHF in the emergency setting as compared to BNP.

The iron man

Questions Chapter 1 1) What does the following sentence mean? ‘The wind sang through his iron fingers.’ 2) Why were his eyes shining different colours? 3) Why did he step off the cliff? 4) How did the seagull spot the Iron Man’s hand and eye? 5) What did the seagulls think they had found? 6) Where was the Iron Man’s missing ear? 7) Why did the Iron Man walk into the sea? 8) Why do you think the seagulls were circling over the Iron Man as he walked into the sea?

A case of asymptomatic large aortopulmonary window in an adult: Role of cardiac CT, CMRI, and 3D printing technology.

A 32-year-old, lean-built female presented with major complaints of heart failure (class II-III) ongoing for 4 months. She had experienced palpitations for 3 months, which was predominantly exertional, lasting for about 2 to 3 minutes, associated with dyspnea and sweating. No history of presyncope/syncope or cyanotic spells was observed, and no significant past medical history or family history was noted. Elsewhere, she had been diagnosed with severe PAH at 31 years of age, and was referred for further evaluation and management. A physical examination yielded normal vital signs. An electrocardiogram revealed biventricular hypertrophy with right atrial enlargement. A chest X-ray showed cardiomegaly with bilaterally-dilated pulmonary arteries. A transthoracic echocardiogram revealed a dilated right atrium, right ventricle, and main pulmonary artery; severe tricuspid regurgitation; a pulmonary artery systolic pressure of 125 mm Hg; severe PAH (pulmonary vascular resistance index: 20 dyn.s/cm5.m2) with good left ventricular systolic function; and an intact interventricular/interatrial septum. Multi-detector computed tomography (CT) with CT pulmonary angiography of the chest revealed no evidence of pulmonary thromboembolism, but showed the presence of a large APW with severe PAH (Fig. 1a, 1b, Fig. 2a). Subsequent cardiac magnetic resonance imaging (CMRI) revealed a large APW (3 cm, type I Mori classification) with severe PAH and right ventricular dysfunction (Fig. 2b, 2c). Flow studies from the CMRI revealed a predominant left-to-right shunt. The patient was scheduled for a catheterization study, followed by device/surgical closure. To more precisely evaluate the anatomical defect and to assess the feasibility of device closure/surgical closure, 3-dimensional (3D) printing technology (Anatomiz3D Healthcare, Mumbai, India) was utilized. The solid 3D anatomical model of the patient’s heart (Fig. 3a, 3b) revealed that the anatomical defect did not have an inner rim (Fig. 3c) and was not ideal for device closure. This was of use in the decision to consider surgical closure. Accordingly, a catheterization study was done. However, the patient was not considered suitable for surgical closure, as she exa

A case series of young patients with completely reversed severe pulmonary hypertension

Pulmonary Arterial Hypertension (PAH) is a progressive symptomatic disorder, which may ultimately lead to death if left untreated. Although majority of PAH cases are idiopathic, pulmonary hypertension resulting due to certain underlying conditions are also observed frequently. In such cases, it becomes essential to identify any potentially treatable or reversible causes for PAH. There have been significant advances in the medical management of PAH and various medicines have been approved by US Food and Drug Administration (FDA) for various stages of PAH. With these therapies, there can be varying degrees of improvement in the pulmonary artery pressures and hemodynamic profile. Therefore, physiologic reversal can and does occur, sometimes to the point of normalization. We hereby present three such cases of severe PAH in patients below 50 years of age due to various aetiologies like left heart disease, isolated unilateral absence of right pulmonary artery with hypoplastic right lung and factor V Leiden mutation associated pulmonary thromboembolism, all of whose pulmonary artery pressures are completely normalised with adequate treatment of the underlying disease and with optimised medications for PAH, ultimately leading to tapering and stoppage of PAH medications.

Comparison of Clinical Effectiveness of Ticagrelor and Clopidogrel in Post Percutaneous Transluminal Coronary Angioplasty (PTCA) Patients Approaching A Tertiary Care Hospital in South India

Introduction: Dual antiplatelet therapy is recommended for prevention of secondary cardiovascular events in acute coronary syndrome patients who undergo percutaneous transluminal coronary angioplasty (PTCA). This therapy includes aspirin with either of a P 2 Y 12 platelet receptor inhibitor like clopidogrel or ticagrelor. Methodology: A retrospective cohort study with 1 year follow up which compared clopidogrel and ticagrelor for determining clinical effectiveness in post PTCA patients through the incidence of primary and secondary end points. Primary end points included cardiovascular death, Myocardial Infarction (MI), unstable angina, secondary revascularization and Congestive Heart Failure (CHF). Secondary end points were bleeding and dyspnea. Results: Age, gender, cardiovascular risk factors, concomitant medications administered and angioplasty specifications like the number of stents, type of stents and approach route were in comparable between clopidogrel and ticagrelor groups. The primary end points, a composite of cardiovascular death, unstable angina and secondary revascularization occurred more in the clopidogrel group (9%) than in ticagrelor group (5%) in 12 months follow up period. The secondary end points, a composite of bleeding and dyspnea were observed more in the ticagrelor group (11%) compared to clopidogrel group (5%). Conclusion: The use of ticagrelor prevents the incidence of secondary cardiovascular events in post PTCA patients to a greater degree than clopidogrel in comparable risk groups. Our observation revealed that ticagrelor was found to be better drug than clopidogrel as a prophylactic antiplatelet drug though there was increased incidence of dyspnea and bleeding in ticagrelor group. Key words: Antiplatelets, Ticagrelor, Clopidogrel.

A Rare Case of Fatal Endocarditis and Sepsis Caused by Pseudomonas aeruginosa in a Patient with Chronic Renal Failure

Nosocomial catheter-related and Arteriovenous fistula (AV)-related infections are significant concern in patients undergoing haemodialysis. These infections are associated with multiple complications as well as mortality and demands immediate and appropriate management. While coagulase-negative staphylococci, S.aureus, and Escherichia coli are the most common causes of catheter-related infections in haemodialysis patients, such infections caused by Pseudomonas aeruginosa are relatively rare. Here, we present an unusual case of 36-year-old male patient with chronic renal failure, who developed endocarditis and sepsis from Pseudomonas aeruginosa infection of the left hand arteriovenous fistula. The bacteraemia in the present case caused multiple complications including dry gangrene of bilateral lower limbs, stroke, endophthalmitis, left brachial artery thrombosis and vegetations on the interventricular septum and aortic wall. Despite antibiotic treatment, the patient suffered a cardiac arrest and could not be revived.

Isolated rheumatic severe tricuspid regurgitation

Severe isolated tricuspid regurgitation (TR) is very rare, with most cases of TR being functional and secondary to pulmonary hypertension from left heart pathologies. We report an unusual case of a young Nigerian male, who presented to us with dyspnea, repeated hospital admissions for heart failure, and a childhood history of rheumatic fever. Echocardiogram showed massively dilated right atrium and ventricle, noncoaptation of thickened tricuspid valve with torrential free tricuspid regurgitation. Other valves were normal. Cardiac MRI showed normal right ventricular function and viability. Patient underwent tricuspid valve replacement with 35‐mm St. Jude valve.

An Unusual Case of Biatrial Myxoma in a Young Female

Myxoma, a rare type of intracardiac tumor, forms a very small percentage of the cardiac cases. Reports of biatrial myxoma are rarer, with cases of single tumor reaching both atria being more common. Here, we present an unusual case of two independently growing atrial myxoma in a 29-year-old female. We emphasize that early recognition of symptoms, confirmation of diagnosis by transesophageal echocardiography, and prompt surgical excision remain vital in the management of such patients. The patient in the present case was managed successfully with no evidences of recurrence at the last follow-up.

Surviving All Odds: A Unique Case of Multiple Congenital Unruptured Sinus of Valsalva Aneurysms Involving Both Left and Right Coronary Sinuses with Biventricular Dysfunction and Heart Block

Aneurysms of the sinus of Valsalva are very uncommon, with an incidence ranging from 0.1 to 3.5% of all congenital heart defects. Very few cases have been reported in the literature that presented with involvement of two or more sinuses. We report a case of 27-year-old male with a history of exertional breathlessness of one-month duration. After complete evaluation using transesophageal echocardiography (TEE) and multiple detector computed tomography (MDCT) scanning, the patient was diagnosed to have large congenital unruptured sinus of Valsalva aneurysms involving both left and right coronary sinuses with extension into the interventricular septum. The patient also displayed second-degree heart block (Mobitz type 2) and biventricular dysfunction. The patient was managed successfully. We present the case with an aim to highlight the management challenges including intraoperative and postoperative complications that are associated with unruptured sinus of Valsalva aneurysms of ≥2 sinuses.

Visual Assessment by Seasoned Operators versus Fractional Flow ReserveGuided Stenting in Patients with Multivessel Disease in Indian Patients

Background: The benefit of revascularization is less clear in stenotic lesions that do not induce ischemia and medical therapy alone is likely to be equally effective. FFR (Fractional Flow Reserve) identifies stenoses that are causing reversible ischemia and thereby the operator can guide interventions to the lesions responsible for the patient’s problem, saving time, cost and optimizing clinical outcome. The main aim is to compare FFR and visual assessment with respect to decision making, requirements of stents and corresponding outcomes in patients with multivessel coronary artery disease. Method: This was a prospective, observational, single centre study, which included 38 patients randomized into 2 groups: one group that underwent FFR guided stenting for the borderline lesions, if the FFR value was found to be significant and for the other group the decision to go ahead with stenting for borderline lesions was based on independent opinion of 4 cardiologists participating in the study, based on visual assessment. The patients were followed up at 3 and 6 months. The primary endpoint of the study was death due to any cause or ACS (Acute Coronary Syndrome). The number of stents saved, cost savings and symptomatic improvement were the secondary outcomes that were studied. Inter-observer variation within the 4 operators in both the FFR and visual arms was also analysed. Results: There were no deaths or ACS during 3 and 6 months follow-up in the 38 patients that were included in the two groups. There was no statistical difference with regards to number of stents saved, cost savings, and functional outcomes such as angina; which were our secondary end points between the visual assessment by seasoned operators and FFR guided stenting groups. There was inter-observer variation between all the 4 operators in our study with regards to visual assessment of the borderline lesions. Conclusion: FFR is important in decision making in borderline lesions and it should be used more often, especially where there are single operators.