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   Table of Contents - Current issue
October-December 2022
Volume 12 | Issue 4
Page Nos. 147-199

Online since Monday, December 19, 2022

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Managing calcified coronaries: The bugaboo of percutaneous coronary intervention p. 147
Debabrata Dash, Sreenivas Reddy
Percutaneous coronary intervention of lesions with heavily coronary artery calcium (CAC) still is a challenging subset for interventionists, with incremented risk of immediate complications, late failure due to stent underexpansion and malapposition, and consequently poor clinical outcome. With the emergence of many novel devices and technologies, the treatment of such lesions has become increasingly feasible, safe, and predictable. It seems likely that combining enhanced intravascular imaging modalities with conventional or new dedicated tools for the treatment of CAC grants better lesion preparation. This optimizes delivery and deployment of drug-eluting stents translating into improved patient outcomes. In this focused review, we provide a summary of principles, techniques, and contemporary evidence for sundry subsisting and emergent plaque-modifying strategies.
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Incidence, management patterns, and outcomes of cardiovascular implantable electronic device-related infection – A retrospective registry-based analysis p. 156
Pravin K Goel, Paritosh Rajput, Ankit Kumar Sahu, Roopali Khanna, Naveen Garg, Satyendra Tewari, Sudeep Kumar, Aditya Kapoor
Introduction: Cardiovascular implantable electronic device (CIED) infection contributes to a significant clinical and financial burden. We sought to assess CIED postimplant infection rates and the effect of different treatment modalities on reinfection over a long-term follow-up. Methods: We retrospectively analyzed CIED recipients presenting with complications during 2010–2019 at our center. Data related to the different management modalities used as per the discretion of treating physician, were collected and patients were followed up telephonically. Results: A total of 3394 patients underwent CIED implantation of which 122 (3.5%) patients developing complications were included in the study. Mean age of the patients was 66.4 ± 12.5 years. Single-chamber ventricular pacing (VVI), dual-chamber (DDD) pacing, and biventricular pacing were seen in 68 (56.2%), 51 (41%), and 3 (2.8%) patients, respectively. CIED infection was seen in 61 patients (1.8%). Strategies used for CIED infection management included: new device implantation on contralateral side (n = 34; 55.7%), old device repositioning on same side (n = 14; 22.8%), antibiotic therapy alone (n = 5; 8.5%), resterilized device implantation on contralateral side (n = 3; 4.9%), epicardial lead placement (n = 3; 4.9%), and permanent device removal (n = 2; 3.3%). The CIED reinfection rates for the above strategies were 2.9%, 71.4%, 80%, 100%, 0% and 0%, respectively. Conclusion: Multiple strategies are being used in real-world practice for the management of CIED infection. Previously advocated strategy of reimplanting resterilized CIED is associated with high recurrence rates. The best practice still remains to implant a new device on the contralateral side post extraction of infected hardware.
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Prevalence of metabolic syndrome and its clinical and angiographic profile in patients with naive acute coronary syndrome p. 162
Anil P Kumar, Prakash Sadashivappa Surhonne, Rohith P Reddy, Manjunath Cholenahally Nanjappa
Objective: The objective of the study is to evaluate the prevalence of metabolic syndrome (MS) and its clinical and angiographic profile in patients with naive acute coronary syndrome (ACS). Furthermore, this study tried to evaluate the severity of coronary artery disease in patients with and without MS. Methods: This was a single-center, cross-sectional study which prospectively enrolled 500 patients with naive ACS during the period from January 2017 to December 2018 at a tertiary care center in India. They were divided into two groups according to the presence and absence of MS based on revised NCEP ATP III guidelines. The ACS was defined based on the Joint Committee of the American College of Cardiology. After clinical evaluation and investigations, the prevalence of MS in ACS patients was calculated. Results: Prevalence of MS in this study was 46.2% and was more frequent in males (81%) compared to females (19%). Maximum number of patients with MS were between the age group of 40–59 years (55%). Prevalence of diabetes (56.7%), hypertension (58.0%), and smoking (45.88%) were significantly higher in patients with MS (P < 0.001). Most prevalent components of MS were low high-density lipoprotein (HDL) levels, increased blood pressure, fasting blood sugar, and triglyceride levels (P < 0.001). Conclusion: Prevalence of MS was high in patients with ACS and was more often after the age of 40 years and most commonly seen in males. Low HDL levels, increased blood pressure, and blood sugar were most prevalent components in the criteria for MS. Patients with MS tend to have more complex coronary lesions.
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Etiology, clinical profile, and 1-year outcome of patients presenting with nonischemic ventricular tachycardia: An observational study p. 168
S V. V Mani Krishna, Oruganti Sai Satish
Background: Although ventricular tachycardia and the ventricular fibrillation occur more often in adults with coronary artery disease, These ventricular arrhythmias may appear in young people, often early and late after surgery for congential heart disease or in association with a variety of cardiac disease ,autonomic imbalance, drugs, as well as in the absence of detectable cardiac desease, when serious ventricular tachyarrhythmias occur in the young they may be misdiagnosed as aberrantly conducting supraventricular tachycardias because of their presumed infrequency. Information on clinical characteristics and outcome of patients with NIVT in our patient population is limited. Aims and Objectives: This prospective observational study was aimed at patients presenting with NIVT to our tertiary care center and to analyze their clinical features, electrocardiogram (ECG) characteristics, underlying disease, management and clinical outcome at one year of follow up. Methods: It is an observational prospective study of 50 patients who presented with nonischaemic VT (NIVT) to our tertiary care center. History , physical examination ,chest X-RAY, electrocardiogram (ECG) and echocardiography were done. Details of electrophysiological studies and radio frequency ablation were collected. Antiarrhythmic drug history was noted. Patients were followed for a period of one year for their clinical outcome and their response to different modalities of treatment was noted. clinical Events defined as death, hospitalizations, DC shocks and recurrence of disease and time to event was also noted. Results: Among the total 50 patients, 27(54%) were males and 23(46%) were females. The mean age of presentation was 31 to 40 years.Most common presenting symptom was syncope (75%). Most common etiology was found to be idiopathic dilated cardiomyopathy with severe LV dysfunction (26%) followed by inflammatory cardiomyopathy (10%). post valvular replacement surgery for rheumatic heart disease , hypertrophic cardiomyopathy , idiopathic right ventricular outflow tract tachycardia were found in 6 percent of patients in each category. LBBB and RBBB morphology of VT in ECG seen in 37 and 44% of patients respectively. Immediate mortality rate was 12%, mainly seen in patients with electrolyte imbalance secondary to systemic infections and myocarditis related to covid 19 infection. Mean survival time in our study is 39.16 weeks with 95% confidence interval. Events have occurred in 30% of our patients most commonly in patients with idiopathic DCMP. Recurrent episodes of VT are more common in patients with DCMP ejection fraction less than 35 percent and also in ARVD patients after LV involvement. Conclusion: NIVT requires aggressive management to prevent mortality and morbidity.Recurrent episodes of VT can occur after disease progression in DCMP and these patients have poor prognosis. Aggressive management like cervical sympathetic denervation may be required in these patients when presented with VT storm. A comprehensive evaluation of patients with NIVT will allow recognition of underlying etiology and selection of appropriate treatment strategies like cervical sympathetic denervation ,radiofrequency ablation and AICD implantation apart from drug therapy for effective control of VT.
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Outcomes of Percutaneous Coronary Intervention in the Young p. 173
Satya Bharathi Lakshmi Vanaparty, Lalita Nemani, Jahangir Basha Sheik
Background: The incidence of coronary artery disease in the young is constantly rising. Understanding the outcomes of percutaneous coronary intervention (PCI) in young adults is necessary. This study aims to assess the procedural outcomes, inhospital and 1 year clinical outcomes of PCI in the young (<40-year-old). Methods: This is a prospective, observational study carried out in the Department of Cardiology at Nizam's Institute of Medical Sciences. The study included all subjects ≤40 years of age and has undergone PCI from January 1, 2019 to December 31, 2019 in our institute. Results: The study included 207 patients with a mean age of 36.01 ± 3.72 years and 72.46% males. Acute coronary syndrome was seen in 79.2% patients with ST elevation myocardial infarction (STEMI) being the most common. The median time interval of presentation in STEMI was 12–48 h (73%). Major adverse cardiac events (MACE) over 1-year were seen in 3.8% patients. Severe left ventricular (LV) dysfunction at presentation was an independent factor for acute (P = 0.04) and 1-year mortality (P = 0.0058). It was also associated with angina and chronic heart failure (CHF). Slow flow was significantly associated with mortality (P = 0.0254) and adverse 1 year outcomes. It was significantly associated with persistent LV dysfunction and recurrent CHF. Conclusion: Success rate after PCI is high in the young. 1 year outcome is very good with low mortality and MACE events. Severe LV dysfunction and slow flow are independent predictors of poor prognosis at 1 year.
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Challenges in the implementation of telemedicine p. 178
P Krishnam Raju, Prasad G Sistla
Background: There is a constant search across the globe for optimal healthcare solutions with affordability, accessibility, availability, and quality of healthcare services being the burning issue for mankind. The pandemic has further necessitated the need of use of the Telemedicine platform to address healthcare issues which are also non Covid related. Though Telemedicine has been in use for over two decades in India, there have been various challenges and adoption issues which have not yet made the technology an effective solution to address the current healthcare issues. There has been phenomenal growth in the Information and Communication Technology (ICT) over the last decade and its utilization in the healthcare field. Methods: Internet research on the various adoption strategies by healthcare providers coupled with our own experience for using this technology along with guidelines provided by the information and communication technology providers. The Telemedicine Guidelines of 2020 released by the Ministry of Health and Family welfare, India, provides a framework for the implementation of healthcare delivery through this technology. Results: This paper mentions our telemedicine experience in governmental and private institutes and highlights the implementation challenges of this technology and some solutions that made a difference in the execution. However, we discuss to a larger extent the possible challenges and barriers in the implementation of this technology in India. Conclusion: Despite successful work in the field of telemedicine, it is yet to become an integral part of healthcare system because challenges related to adaptability of healthcare users and lack of proper training to fast growing technologies. The future is going to compel the usage of this kind of technology and it is essential for setting up infrastructure and having trained personnel to man these departments to encash the full potential of the telemedicine technology.
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A Rare Case of Primary Cardiac Synovial Sarcoma with Thromboctopenia p. 184
Nrushen Peesapati, Ashok Kumar Redrouthu
Primary cardiac tumors are of rare presentation. We present a case of primary cardiac synovial sarcoma of the right atrium admitted to our hospital. An initial diagnosis of right atrial myxoma or hydatid cyst was made based on echocardiographic and radiological features. Intraoperatively, an irregular mass was excised, and histopathologically, it was reported as monophasic synovial sarcoma. Immunohistochemistry was positive for TLE-1, BCL-2, and MIC-2.
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Internal jugular vein perforation due to blind temporary pacing lead insertion: Pitfall of a blind procedure p. 189
Najeeb Ullah Sofi, Santosh Kumar Sinha, Mohit Sachan
Temporary pacing lead is placed through the internal jugular, subclavian or femoral vein under fluoroscopic, echocardiographic, or electrocardiographic guidance. However, in most of the developing world, this procedure is done without fluoroscopic guidance. Blind procedures are known to be associated with more complications as compared to guided procedures. Here, we report a case of the right internal jugular vein perforation while placing the temporary pacing lead in an 80-year-old male patient who had permanent pacemaker implantation done 10 years back and had developed right subclavian and brachiocephalic vein stenosis. Clinicians need to be aware of this rare complication and preferably do these procedures under fluoroscopic guidance and avoid an overzealous approach if the pacing lead does not pass through easily. Patients who had undergone any procedure through their central venous system, especially with retained catheters and pacing leads in situ in the past should undergo a venogram before planning any reintervention from the ipsilateral side to avoid such complications.
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Mitral annular calcification leading to severe mitral stenosis in a patient with severe calcific aortic stenosis and complete heart block: Different shades of calcium in heart p. 192
Najeeb Ullah Sofi, Santosh Kumar Sinha, Mohit Sachan
Calcium deposition in the heart can present in various ways. Mitral annular calcification (MAC) can cause mitral regurgitation but severe mitral stenosis has been reported very rarely. Mitral stenosis in the Indian subcontinent is mostly caused by rheumatic heart disease; however, here, we present a case of severe mitral stenosis due to MAC in a hypertensive and diabetic female that also had severe calcific aortic stenosis and conduction defect. Clinicians need to be aware of other causes of acquired mitral stenosis that include systemic lupus erythematosus, antiphospholipid antibody syndrome, carcinoid syndrome, mucopolysaccharidosis, Whipple disease, radiation, and MAC. Although MAC usually causes mitral regurgitation, severe mitral stenosis has been reported very rarely. However, when MAC is the cause of severe mitral stenosis, those patients are poor candidates for mitral valve replacement. Differentiating the etiology of mitral stenosis is of therapeutic and prognostic significance.
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Postoperative chylothorax and left internal jugular vein thrombus after complex cyanotic heart disease surgery p. 196
Dhan Raj Bagri, Kailash Meena, Jeetam Singh Meena, Umesh Gurjar, Balveer Jeengar
Chylothorax is the accumulation of lymphatic fluid in pleural space following traumatic injury to lymphatic vessels, systemic venous obstruction, dysfunction of the right ventricle, thrombosis of the duct, superior vena cava or subclavian vein, or postoperatively. A 2 ½-year-old male child operated for transposition of great arteries (TGA), tricuspid atresia (TA), and hypoplastic right ventricle 15 days ago developed chylothorax and left internal jugular vein thrombus. The child was initially managed conservatively with nutritional management, anticoagulation, and octreotide followed by interventional radiological management with lipoidol injection. Early suspicion and diagnosis are crucial. The management was difficult owing to a lack of proper guidelines. Further research is warranted.
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