Vimal Mehta

Pentoxifylline Therapy for Hepatopulmonary Syndrome: A Pilot Study

H epatopulmonary syndrome (HPS) is characterized by a triad of liver disease, hypoxemia, and intrapulmonary vascular dilations (IPVDs). Its prevalence is 4% to 47% in patients with cirrhosis. Patients with HPS demonstrate a significant reduction in exercise capacity due to abnormal pulmonary circulation. Anatomic arteriovenous shunts in the lung are used during exercise and lead to exercise-induced impairment in gas exchange and exercise-induced arterial hypoxemia. The pathogenesis of HPS is unclear. Cytokinemediated injury is alleged to play a key role. Endothelin-1 and tumor necrosis factor (TNF) interaction, occurring in the lung vasculature, contribute to the development of experimental HPS. Overproduction of TNF, due to endotoxin stimulation of Kupffer cells, might be a major mechanism leading to HPS. Pentoxifylline, a nonspecific phosphodiesterase-4 inhibitor, blocks TNF synthesis and TNF-induced macrophagic nitric oxide production. Pentoxifylline prevented the development of HPS and attenuated HPS in cirrhotic rats. However, to our knowledge, pentoxifylline has not been used clinically for the treatment of HPS. In this study, we tried pentoxifylline therapy in patients with HPS.

Endovascular stent implantation for severe pulmonary artery stenosis in aortoarteritis (Takayasu's arteritis)

Symptomatic pulmonary artery stenosis is a relatively uncommon manifestation of aortoarteritis. We describe a patient of aortoarteritis with severe proximal right pulmonary artery stenosis who presented with dyspnea on exertion and central cyanosis. The pulmonary artery stenosis was successfully relieved by percutaneous transluminal balloon angioplasty and implantation of a balloon‐expandable stent. This resulted in immediate improvement in oxygen saturation, disappearance of cyanosis, relief of dyspnea, and marked improvement in right lung perfusion as demonstrated by pre‐ and postangioplasty technetium lung ventilation‐perfusion scans. The changes in the pulmonary arterial wall morphology were detected precisely by intravascular ultrasound imaging. Catheter Cardiovasc Interv 2004;61:281–285.

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.

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.

Circulating level of regulatory T cells in rheumatic heart disease: An observational study.

BACKGROUND The regulatory T cell (Treg) is essential for prevention of autoimmunity. In a preliminary study, we showed significant deficiency of Tregs (CD4CD25 T cells) in rheumatic heart disease (RHD) patients (an autoimmune disease), but the markers used could not reliably differentiate Treg from nonregulatory conventional T cells (Tcon). The study aim was to reassess the level of circulatory Tregs by using more specific markers. METHODS 70 adults of RHD and 35 controls were studied. Patients were subdivided according to the extent of left-sided valvular involvement. 35 patients with significant mitral-valve disease only were enrolled in the univalvular group while 35 patents with significant involvement of both mitral and aortic-valves in the multivalvular group. Circulating Treg cell level was determined by flow-cytometry. RESULTS Level of Tregs (CD4+CD25(med-high)CD127(low) Foxp3(high)) in CD4+ T lymphocyte was significantly lower in RHD patients compared to controls (median 0.6% versus 3.2%; p=0.001) with no significant difference in Tcon cells (p=0.94). Within the study group Treg count was significantly lower in patients with multivalvular-disease only (median 0.1% versus 3.2%; p=0.001) with no significant difference in Treg cell count between the univalvular group and control (median 1.9% versus 3.2%, p=0.10). CONCLUSION There is significant deficiency of circulating Tregs in patients of chronic RHD and the deficiency is greater in patients with multivalvular than univalvular involvement.

An unusual cardiac mass resolving with antitubercular treatment

We present an interesting case of a 2½-year-old child with Tetrology of Fallot with a large intracardiac mass in the left ventricle presenting with fever and bilateral stroke, that resolving with antitubercular therapy alone.

Umbilical venous catheter retrieval in a 970 gm neonate by a novel technique.

Umbilical venous catheterization is a necessity for the advanced care of very low birth weight neonates. Even with utmost care, few complications cannot be avoided. Fractured and retained catheter fragments are one of them. Endoluminal retrieval of such a catheter is an uncommon and challenging procedure for the interventionist. The only alternative is an open exploration of these patients. Various techniques have been described for retrieval of such foreign bodies. We describe a novel technique for percutaneous retrieval of an embolized umbilical venous catheter from a very low birth weight neonate.

Pseudoaneurysm of the Left Ventricle in a Young Asymptomatic Female

We report a rare case of a 25‐year‐old asymptomatic female who was referred for evaluation of a cardiac murmur. She had recent history of treatment for pulmonary tuberculosis. On investigation, she was diagnosed with left ventricular pseudoaneurysm (PSA) likely secondary to rupture of myocardial tubercular abscess. She was operated successfully for the left ventricular PSA and was discharged from the hospital in a good condition. (Echocardiography 2010;27:329‐331)

Effect of heart rate control on coagulation status in patients of rheumatic mitral stenosis with atrial fibrillation – A pilot study☆

BACKGROUND AND AIM OF STUDY Systemic thromboembolism is a major complication in patients of mitral stenosis (MS) with atrial fibrillation (AF) due to induction of hypercoagulable state. The aim was to assess the relationship, if any, between control of ventricular rate and systemic coagulation factors. METHOD 70 patients of moderate to severe MS in AF were studied. 35 patients with average heart rate > 100 beats/min over a 24 hour period assessed by Holter monitoring were considered as having a uncontrolled ventricular rate (Group A) and those with average heart rate ≤ 100 beats/min as controlled ventricular rate (Group B). 30 healthy volunteers acted as controls. RESULTS Plasma concentration of prothrombin fragment 1+2 (PF1+2) 6600 pmol/ml [interquartile range (IQR) 5400.0-9500], thrombin antithrombin III 22.0 ng/ml [IQR 18.6-28.0], and plasminogen activator inhibitor 46.8 ng/ml [IQR 44.0-54.0] were elevated in Group A as compared to Group B (5400 pmol/ml [IQR 3600-7700] p = 0.009, 16.0 ng/ml [IQR 11.0-18.5] p<0.001, and 25.8 ng/ml [IQR 20.9-34.4] p < 0.001), respectively. A significant correlation was found between heart rate and all three coagulation markers. Multivariate multiple regression analysis showed only heart rate to be an independent predictor of systemic coagulation activation and risk of thrombus formation. CONCLUSION Control of ventricular rate in subjects of MS with AF produces significant reduction in the activation of the coagulation system and may decrease risk of thrombosis.