Vivek Singla

Acute myocardial infarction following scorpion sting in a case with obstructive coronary artery disease.

The occurrence of an acute myocardial infarction (MI) following a scorpion sting has been very rarely reported in the previous literature. Possible pathogenetic mechanisms include severe hypotension due to hypovolaemic shock and coronary spasm with subsequent thrombosis of coronary vessels developed after the release of vasoactive, inflammatory and thrombogenic substances contained in the scorpion venom. All of the previously reported cases had normal coronary angiogram. We report a case of a 65-year-old woman who presented with severe scorpion sting and was treated with prazosin. But a few hours later, she developed acute anterior wall MI. Coronary angiogram revealed the presence of significant stenosis in coronary arteries. As acute MI owing to significant coronary artery disease can be evident after severe scorpion envenomation, so every case of acute coronary syndrome following scorpion sting needs early diagnosis, thorough cardiovascular evaluation and appropriate treatment.

Mycotic aneurysm: a rare and dreaded complication of infective endocarditis

Mycotic cerebral aneurysm is a rare and potentially fatal complication of infective endocarditis. A young man was diagnosed with culture negative infective endocarditis of mitral valve with cerebral aneurysm. The patient was started on conservative management, but he died owing to intracerebral haemorrhage. In the absence of large randomised trials, there is a lack of consensus regarding the management of unruptured aneurysms. Since mycotic aneurysms are known to resolve or decrease in size with antimicrobial therapy, several institutions advice the conservative approach. A few case reports like the present case have shown that the risk of aneurysmal rupture and death is considerably high with the conservative approach. Endovascular therapy has shown to reduce the mortality in this subgroup. These patients should be managed aggressively with endovascular or surgical procedure along with antimicrobial therapy.

A patient of Ebstein’s anomaly associated with biventricular noncompaction presented with Wolf Parkinson White syndrome - A rare presentation

A 34 year-old male patient presented with recurrent attack of palpitation and chest pain due to Wolf Parkinson White syndrome (WPWS). Two dimensional echocardiography demonstrated features of Ebsteins anomaly along with biventricular non compaction. Color flow Doppler studies confirmed the presence of blood flow within the trabeculations. Biventricular myocardial non-compaction associated with Ebsteins anomaly who presented with WPWS is a very rare association. So far, Medline search revealed only three reported cases in the literatures. The patient was treated with radiofrequency ablation of right sided posteroseptal accessory pathway of WPWS and was asymptomatic in further follow-up.

Percutaneous Device Closure of Patent Ductus Arteriosus with Pulmonary Artery Hypertension: Long-Term Results

UNLABELLED Device closure of patent ductus arteriosus (PDA) is treatment of choice. But device closure in presence of pulmonary artery hypertension (PAH) remains a challenge. Data on patient selection, technical considerations, and complications are limited. AIM To know the challenges and efficacy of device closure of PDA with PAH. MATERIALS AND RESULTS Out of 1,325 cases of device closure of PDA, 246 (18.6%) with PAH formed the study material. To test the feasibility, chosen device is used to occlude PDA for ten minutes without oxygen inhalation. The device is released only if PAH reduced. PAH decreased in all except in 1 patient after closure with muscular ventricular septal occluder (MVSDO), pulmonary artery pressure (PAP) transiently increased (became supra-systemic), without significant reduction in aortic pressure. Device embolized in 8 patients (3.3%). Percutaneous retrieval was done in 4 (by snare in 2 and by fixing the cable to device in 2) and replaced with bigger devices. The surgical removal of the embolized MVSDO and ligation was done in 4 cases. All patients were on oral sildenafil and bosentan until PAP regressed to normal. Follow up was from 6 months to 9 years. No residual shunt in any patient on follow-up. The PAP regressed to normal in all except 5 cases (2.03%) of Downs syndrome with systemic PAP. CONCLUSIONS Device closure of PDA with PAH is feasible, safe in all age groups. Temporary PDA occlusion with device is effective and time saving for evaluating pulmonary vascular reactivity. Device embolization in aorta is higher with severe PAH. Novel method of retrieval is effective.

Wellens’ syndrome: a classical electrocardiographic sign of impending myocardial infarction

We describe a case of previously healthy 72-year-old man, who presented with rest angina. The ECG revealed sinus rhythm, biphasic T waves with preserved R waves in V1–V4 precordial leads. Subsequent evaluation revealed the normal serum cardiac marker levels and echocardiography with the coronary angiography showing a critical lesion in the proximal left anterior descending artery. Thus it was diagnosed as Wellens’ syndrome. In our case, we highlight the subtle though classical ECG findings of Wellens’ syndrome and its specific angiographic correlation. It can be of vital importance to identify these changes and intervene in time appropriately so as to avoid the development of myocardial infarction that carries a substantial morbidity and mortality. Important aspects of diagnosis and management have also been reviewed.

Accura balloon rupture during percutaneous trans-septal mitral commissurotomy: a rare and potentially fatal complication

Percutaneous transseptal mitral commissurotomy (PTMC) is the treatment of choice in rheumatic mitral stenosis. The reuse of sterilised PTMC balloon catheters is widely practised to bring down the procedure cost and have proven safety and efficacy. The reused balloons may deform and are prone to rupture causing fatal complications like embolism either of the torn balloon material or air. We report a first case of Accura balloon rupture during PTMC to the best of our knowledge. Fortunately, there was no complication in our patient. Thus, during the balloon preparation it should be examined for any deformity or tear and air should be removed completely to prevent fatal outcome. The repeated use of the hardware should be limited and an informed consent regarding the possible complications of the reused hardware should be taken.

Quadri-chamber cardiac thrombi in alcoholic cardiomyopathy: a rare though ominous finding.

Alcoholic cardiomyopathy is a cause of reversible cardiomyopathy, in which long-term abuse of alcohol leads to ventricular dysfunction. Multiple mechanisms have been attributed to the development of alcoholic cardiomyopathy such as mitochondrial damage and oxidative stress, though coexistent nutritional deficiencies like thiamine deficiency, tobacco abuse and other comorbidities such as hypertension can contribute to ventricular dysfunction. Ventricular thrombus formation can occur secondary to akinesia or hypokinesia of the ventricular wall. We report a case of alcoholic cardiomyopathy with an alarming finding of thrombi in all cardiac chambers. Echocardiographic evidence of quadri-chamber intracardiac thrombi has rarely been described in the literature. A 48-year-old man with history of chronic alcoholism presented with progressive breathlessness of 1 years duration. Cardiovascular examination showed sinus tachycardia and evidence of congestive …

Paradoxical embolism via a patent foramen ovale

A 32-year-old man recently had a right-sided hemiparesis; a head CT scan revealed left middle cerebral artery (MCA) territory infarct. The patient was haemodynamically stable, with no clinical evidence of deep venous thrombosis (DVT) and was referred for cardiac evaluation. The patients routine workup including carotid Doppler was normal. ECG showed normal sinus rhythm. Two-dimensional transthoracic echocardiography (figures 1 and 2) performed revealed a thrombus attached to the interatrial septum (IAS) prolapsing into the right ventricle through the tricuspid valve and traversing into the left atrium through a foramen ovale and prolapsing into the left ventricle. A soft clot (figure 3) was …

‘Bird-beak sign’ of left atrial thrombus: a guide to management

A 24-year-old man presented with history of dyspnoea on exertion (New York Heart Association class III) of 4 months duration. After evaluation the patient was diagnosed as severe rheumatic mitral stenosis (MS) (mitral valve area 0.9 cm2) with dilated left atrium and atrial fibrillation (AF). The valve morphology was suitable for percutaneous trans-septal mitral commissurotomy (PTMC). Transesophageal echocardiography showed a large thrombus in left atrial appendage (type Ib) …

Incidence, predictors, and long term clinical outcome of angiographic definite stent thrombosis in real world scenario - A prospective cohort study

BACKGROUND The occurrence of stent thrombosis (ST) in real world scenario is far different from that mentioned in the literature. Our study identifies the various parameters of ST. METHODS This is a prospective observational-cohort study where-in consecutive patients who received successful percutaneous transluminal angioplasty (PTCA) over the study period of 1-year was included and were followed for 1-year from the primary procedure. RESULTS The overall incidence of definite ST was 1.4% and 1.7% at 30 days and 1 year respectively. The most common mode of presentation of ST was ST-elevation myocardial infarction (82.6%). The history of prior PTCA, multi-vessel disease, emergent PTCA, acute coronary syndrome and type B2/C lesions were found to be the independent predictors for definite ST. The incidence of late ST was significantly higher with bare metal stent (BMS) than drug-eluting stent (DES) (OR-2.4, 95% CI:1.3-4.5). At mean follow-up of 13.9 months after ST, the overall mortality was 36.9%. The independent predictors of mortality after ST were post-PTCA thrombolysis in myocardial infarction (TIMI) flow grade < 3, and cardiogenic shock at the time of presentation. CONCLUSION The overall incidence of definite ST is high in the real world scenario and the DES fared better than BMS. ST carries a bad prognosis especially so if the patients present in cardiogenic shock, or unable to achieve TIMI-3 flow after PTCA.