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   Table of Contents - Current issue
July-September 2022
Volume 12 | Issue 3
Page Nos. 83-145

Online since Wednesday, September 14, 2022

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Multiple arterial thrombosis p. 83
Chaudappa Shakapur, Sagar Mali
Bleeding following any injury is due to damaged blood vessel and is usually kept in check by a process called hemostasis. At times, this process may be abnormally affected by pathological factors or causes subsequently leading to thrombus formation and occlusion of blood vessels. It can affect either arteries or veins. The events in the pathogenesis of thrombosis occur in a vicious cycle. We report a case of 38-year-old male with multiple arterial thrombosis involving brachial artery, common carotid artery, and main pulmonary artery. He had raised hemoglobin, hematocrit, mean corpuscular volume, and mean corpuscular hemoglobin on presentation. He was successfully treated with injection alteplase (recombinant tissue plasminogen activator), injection enoxaparin, and dual oral antiplatelet therapy.
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Current concepts of optical coherence tomography assessment of left main coronary artery during coronary interventions p. 89
Sridhar Kasturi
Conventional angiography is poor in assessing type of plaque, plaque volume, disease extent, severity and features associated with optimization of percutaneous coronary intervention (PCI), whereas Intra-Vascular Ultra-Sound (IVUS) and optical coherence tomography (OCT) overcome these limitations by providing cross sectional images of vessel wall, and longitudinal extent of disease. OCT provides high-resolution images at the cost of limited penetration compared with IVUS with an axial spatial resolution of 10–20 μm versus 100–200 μm, lateral resolution of 20 μm versus 200 μm, and penetration depth 1–2.5 mm versus 10 mm, respectively. OCT measurements were proved to be nearer to the actual luminal areas whereas IVUS measurements were overestimated and were less reproducible in the phantom model. OCT and IVUS are proved to be a valid guidance for optimization of PCI. However, usefulness of OCT in day to day practice is very limited in the assessment of Left Main disease. Both imaging technologies have different distinct features, these are complementary and should be opted carefully for each patient based on pros and cons, and clinical indications of each technique.
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Impact of Ayurveda-based ischemia reversal program on reduction of resting myocardial ischemia studied with speckle-tracking global longitudinal strain imaging p. 106
Rohit Sane, Pramod Manohar, Rahul Mandole, Gurudatta Amin, Pravin Ghadigaonkar, Dinesh Patil, Snehal Dongre, Rahul Jadhav, PrafullYanshwantrao
Background: Cardiovascular disease, commonly seen on a rise globally, is especially prevalent in the developing countries, whose numerous causes are improper diet and lifestyle. Ayurveda, the ancient medical practice, offers antidotes to major diseases. Its detoxification process, Panchakarma, boosts immunity, reduces stress, eliminates toxins from the body, etc., This study was conducted to establish the role of Ayurveda-based ischemia reversal program (IRP) in minimizing ischemic heart disease (IHD). Materials and Methods: A retrospective clinical study was conducted in cardiac hospital on patients, having a clinical evidence of IHD. During the 7-day study period, patients received, 14 IRP Panchakarma sessions comprising, Snehana, Svedana, and Gokshur Haridra Amalki Basti. In addition, the patients were given a calorie-controlled diet. The primary endpoint was change in the global longitudinal strain score as compared to baseline and secondary endpoint was reduced dependency on modern medicine with respect to weight, body mass index (BMI), left ventricular (LV) ejection fraction (EF), 6-min walk test, noninvasive cardiac output, and end diastolic volume. Results: Fifty-nine patients were involved in the study, belonging to 61.02 ± 11.47 years of age, with 74.58% being males. The primary endpoint, decreased from −10.26 ± 4.02, on day 1, to −10.99 ± 3.94, on day 7. Appreciable decrease was also observed for the abdominal girth, body weight, BMI, and dependency on modern medicines. Conclusion: This study revealed that IRP notably reduces heart disease, by influencing various parameters studied in this investigation. An increased EF, decreased LV mass, an improved 6-min walk test, decreased heart rate, normal systolic and diastolic blood pressures, and other parameters indicate an improvement in the existing disease of the heart.
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Assessment of quality of life and drug prescription pattern in acute coronary syndrome p. 111
Nikhilesh Andhi, Prathyusha Desham, C Madavi, S Bhavana, D Naresh
Objectives: To assess the health-related quality of life (QOL) in patients with acute coronary syndrome (ACS) and predict those patients who may have worsened QOL 6 months later and also observe the prescribing patterns of drugs given in their treatment. Materials and Methods: A prospective observational study was conducted at the cardiology department in a tertiary care hospital. The data were collected in both inpatient and outpatient cardiology departments based on our inclusion and exclusion criteria for a period of 6 months. A total of 240 patients were analyzed with a data collection form by interviewing the patients about their sociodemographic details, laboratory parameters, and diagnostic reports. The MacNew Heart Disease Questionnaire, Medical Research Council Breathlessness Scale, and New York Heart Association (NYHA) Functional Scale were used for assessing the QOL in patients with ACS. We calculated Global Registry of Acute Coronary Events Score and Thrombolysis in Myocardial Infarction Score for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) patients for identifying the mortality risk. Results: Urban people were more prone to ACS than rural people, according to our data. According to the NYHA Functional Classification, ability to do physical activity was more considerably affected in NSTEMI patients than STEMI and angina. Most of the patients had Grade 2 shortness of breath. 35% of the patients had a high mortality risk. Based on the MacNew Questionnaire data, 23% of the patients with ACS were doing emotionally poor, 45% of the patients had shown physically impaired symptoms, 28% of the patients were socially dependent, 8% of the patients showed poor gastric condition. 49% of the patients were given reperfusion therapy with either percutaneous coronary intervention (PCI) or coronary artery bypass graft, 25% of the patients were managed with dual-anticoagulant therapy, and 6% of the patients were treated with single-anticoagulant therapy. Commonly prescribed drug classes were statins (90%), antiplatelets (86%), anticoagulants (75%), antianginal (55%), beta-blockers (50%), diuretics (35%), angiotensin-converting enzyme inhibitors (18%), and angiotensin receptor blockers (16%). Conclusion: QOL was significantly affected in ACS patients. Most of the patients had risk factors for ACS. Patients explained impairments in all the four domains used in the questionnaire such as emotional, physical, social, and gastric impairments. QOL was more affected in STEMI patients and they had a high mortality risk. Most of the patients had NSTEMI. Low-risk patients were given single-anticoagulant therapy and medium-risk patients were treated with dual-anticoagulant therapy. PCI was preferred in almost all the patients.
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Coronary artery dimensions in normal adult Indian population by computed tomography coronary angiography p. 119
Vyom Mori, Arun Mohanty, Anurag Yadav, Aman Makhija, Jitendra P S. Sawhney, Bhuwanesh Kandpal, Rajiv Passey, BS Vivek, SC Manchanda, Raja Ram Mantri
Introduction: In any given population, coronary artery diameter is highly variables. It has been postulated that Indians have an increased risk of coronary artery disease (CAD) due to smaller diameter of arteries in them. However, small diameter can be due to smaller body surface area (BSA). Hence, we tried to assess whether smaller coronary artery dimensions in Indians are due to their smaller BSA or not. Methodology: In this observational study, patients undergoing computed tomography coronary angiography and having normal angiogram were included in this study. Patients' coronary artery diameters in major epicardial vessels were measured and indexed to BSA. Analysis was done to assess for any significance compared to Caucasians. Results: A total of 250 patients were part of this study. The mean diameters of proximal left main (LM), distal LM, left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA) were 4.27 ± 0.78, 4.26 ± 0.79, 3.47 ± 0.6, 2.99 ± 0.64, and 3.33 ± 0.63 mm, respectively. On indexing to BSA, the measurements in proximal LM, distal LM, LAD, LCX, and RCA were 2.31 ± 0.4, 2.31 ± 0.4, 1.89 ± 0.32, 1.62 ± 0.35, and 1.81 ± 0.34 mm/BSA, respectively. When they were compared to other Indian and Caucasian studies, the diameters were not found to be statistically significant. Conclusion: Thus, the authors conclude that Indians do not have an increased risk for CAD because of their smaller diameters, but it is because of their smaller BSA. This study helped us evaluate the reference range of major epicardial vessel diameters in Indian population.
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Management of densely calcified coronary lesions using OPN–NC balloon and shockwave intravascular lithotripsy procedure: A single-center study p. 123
Manjunath Venkataramaiah Bagur
Background: Calcified coronary lesions are challenging to the interventional cardiologists to manage. Debulking the calcified lesions with Rotablation is a well known strategy. Shockwave intravascular lithotripsy (IVL) is the newer novel therapeutic procedure found to be very effective in PCI of calcified lesions. Aims and Objectives: To assess the clinical utility of Shockwave IVL in densly calcified coronary lesions. Materials and Methods: Four patients underwent PCI with Shockwave IVL for densly calcified lesions between Febraury and March of 2020 and were followed up clinically in our centre. Results: All patients are doing well clinically without any coronary events. Conclusion: Shockwave IVL is safe and accepted modality of debulking the densly calcified coronary lesions and prepare the bed for optimal stent deployment.
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The value of admission C-reactive protein in prediction of both SYNTAX score and thrombolysis in myocardial infarction flow in STEMI patients undergoing primary percutaneous coronary intervention p. 127
Kirollos Philops, Tarek Ahmed Naguib, Mohammad Mustafa Al-Daydamony, Ahmed Said Eldamanhory, Elshaimaa Aly M. Elsadek Seaoud
Introduction: C-reactive protein (CRP) has come to prominence in the cardiovascular field with the inflammatory hypothesis of atherosclerosis. Many studies evaluated the role of CRP as a prognostic marker in ST-segment elevation myocardial infarction (STEMI). The aim of our work was to study the relation between admission CRP level and the angiographic severity of coronary artery disease in patients presenting with acute ST elevation myocardial infarction. Patients and Methods: Admission CRP was measured for 100 STEMI patients before primary percutaneous coronary intervention (PCI). Complexity of coronary lesion was assessed using both Syntax score and thrombolysis in myocardial infarction (TIMI) flow. Results: Syntax score was significantly higher in the 3rd CRP tertile (20.24 ± 5.6 and P = 0.000), TIMI 0 flow was the highest in the 3rd tertile (24% and P = 0.001). We found a significant positive correlation between Syntax score and CRP and a significant negative correlation between CRP and TIMI flow (P = 0.001 and 0.005, respectively). Receiver operating characteristic curve constructed to determine the sensitivity of admission CRP to determine intermediate to high risk SYNTAX score showed a level ≥8.4 mg/dl as 71% sensitive (area under the curve [AUC] =0.65 and a P = 0.02) and an admission CRP of ≥4.8 mg/dl to be 81% sensitive in determining no or faint antegrade flow (TIMI 0 and 1) (AUC = 0.71. P =0.001). Conclusion: There is a strong positive correlation between admission CRP and the syntax score and TIMI flow in STEMI patients undergoing primary PCI, thus adding CRP to the risk scoring systems used to assess STEMI patients before PPCI can help better risk stratify patients before going into the cath laboratory.
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Guide catheter tip-induced type-II aortocoronary dissection bailed out by stenting the left main coronary artery p. 133
Dibyasundar Mahanta, Jogendra Singh, Rudra Pratap Mahapatra, Ramachandra Barik
Left main coronary artery dissection induced by the tip of the guide catheter (Razor blade effect) with or without extension into the adjacent aortic wall can result in no flow. It is being a life threatening, complication and must be time timely detected and treated by stenting or surgery. A 59-year-old male patient presented with crescendo angina having a history of stenting to left anterior descending coronary artery (LAD) using 3 mm × 23 mm drug-eluting stent 5 years back. Coronary angiogram revealed 100% instent re-stenosis of the LAD. Left circumflex (LCX) coronary artery had proximal chronic total occlusion with J-CTO score of ≥2.The dominant right coronary artery was normal. LMCA dissection was noticed like an invisible dragon from nowhere after stenting of the proximal LCX followed by abrupt retrograde extension into aorta, resulting in no flow in the left coronary artery. The true lumen of LMCA was re-wired, and timely bailout stenting from LMCA to LCX was performed.
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Ostial stenosis of anomalous origin of the left coronary artery from the pulmonary artery in an adult: Lives from constraints and dies from freedom p. 136
Pankaj Jariwala, Kartik Pandurang Jadhav
An anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), a rare congenital anomaly, the enlarged right coronary artery supplies the left ventricle through retrograde collaterals before preferentially directing into the lower-pressure pulmonary artery system, resulting in coronary steal. The infant type is characterized by the absence of collateral vessels, and global myocardial ischemia is a major cause of death in infancy. If not treated, up to 90% of them will die during the 1st year of life. Myocardial ischemia or infarction left ventricular (LV) dysfunction with or without mitral regurgitation, life-threatening arrhythmias, or sudden cardiac death may all be manifestations of symptomatic adult-type ALCAPA. In those patients who have survived to adulthood without surgery, pathophysiological mechanisms enabling adequate LV perfusion, such as a large number of well-formed functioning collaterals, and in a few cases, the presence of ostial stenosis of the left coronary artery (LCA), provide selective survival advantage. We review the correlation between clinical presentation, pathophysiological findings, and angiographic features of ostial stenosis of LCA in the setting of adult-type ALCAPA.
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Challenges in balloon pulmonary valvotomy for severe pulmonary stenosis presenting with cyanosis and ventricular dysfunction p. 139
Anil Kumar Singhi, Soumya Kanti Mohapatra, Somnath Dey, Dipanjan Chatterjee, Arnab De
Valvular pulmonary stenosis (PS) can present with cyanosis and right heart failure in older children and adults. Transcatheter balloon pulmonary valvuloplasty is a standard intervention for severe valvular PS in all age groups. Balloon dilatation in critical PS like presentation in older age groups has unique challenges in management. These cases are associated with right ventricular dysfunction, cyanosis, pulmonary edema, injury to right ventricular structure, and arrhythmia. Imaging is an essential component for diagnosis and management. We present two such cases of older children who presented with cyanosis and right ventricular dysfunction. Detailed imaging and team approach of care helped in managing the challenges of balloon pulmonary valvuloplasty in older sick substrates.
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Broken guidewire during percutaneous transluminal coronary angioplasty retrieved properly and nightmare became a good lesson and experience p. 143
Sudeb Mukherjee, Kaushik Paul
Percutaneous transluminal coronary angioplasty is associated with less complications compared to the open surgical technique. Fractured guidewire inside coronary arteries is not common during the procedure. It should be removed with proper technique. Nonremoval of such fractured wire may pose several complications. Different techniques can be used to remove such fractured wires. Here, we have reported a case of such incidence and its removal successfully percutaneous safely.
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