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Objectives: This retrospective study sought to determine the feasibility of transcatheter atrial septal defect device closure in patients less than 15 kg, as well as to assess complication rates and the reasons for unsuccessful device closure., Background: In general, the risks associated with transcatheter atrial septal defect device closure are believed and reported to be relatively low, but the evidence stems from trials involving adults and older children. Current guidelines do not recommend atrial defect closure in device closure in children <15 kg, due to limited data available for feasibility and safety of device closure in this group of patients., Methods: Retrospective review of all patients who underwent elective transcatheter closure of ostium secundum atrial septal defect between September 2013 to February 2022. We excluded all children above 15 kg, as well as those with complex congenital heart defects. Major and minor complications were predefined and indications for referral were evaluated., Results: We identified 81 patients meeting criteria with a median procedural age of 3 years (1 year-8 years), and median weight of 12 kg (4-15 kg). Successful device closure was achieved in 95.1% (77/81) and in 4.9% (4/81), the procedure was aborted. There was 1 major (1.2%) and 1 minor (1.2%) complication, total complication rate (2.4%). 100% of the referrals had right heart enlargement and exertional dyspnoea, 18.5% had recurrent lower respiratory tract infection and 9.9% had failure to thrive. Rate of resolution of residual shunt was 95.1%. at post-procedure day 1 and 98.8% at post-procedure 3 and 6 months respectively., Conclusions: Percutaneous atrial septal defect closure can be done effectively and safely in symptomatic children weighing less than 15 kg in experienced centres. However, deferral for closure until the historically established timeline of around 4-5 years of age should be strongly considered in asymptomatic children., Competing Interests: Conflicts of interest: Nothing to declare., (© 2024 Saudi Heart Association.)

Background: In general, the risks associated with transcatheter atrial septal defect (ASD) device closure are reported to be relatively low, but the evidence stems from trials involving adults and older children. Current guidelines do not recommend ASD device closure in children with defect sizes >20 mm due to limited data available in this group of patients. This retrospective study sought to determine the clinical and procedural characteristics of successful transcatheter ASD device closure in small children with large defects and assess the complication rates and reasons for unsuccessful device closure., Methods: We retrospectively reviewed the data of all patients who underwent elective transcatheter closure of ostium secundum ASD in our department between September 2013 and February 2022. All children weighing <20 kg, requiring a device of size 20 mm or greater, were included. Major and minor complications were predefined and indications for referral were evaluated. Echocardiogram reports were reviewed from the time of referral, postcatheterization day 1, and at 1-year follow-up., Results: We identified 40 patients meeting inclusion criteria with a median (interquartile range [IQR]) procedural age of 5 (4-7) years and median (IQR) weight of 14 (12-18) kg. Successful device closure was achieved in 39 patients with a success rate of 97.5%. The total complication rate was 2.5% (95% confidence interval: 0.44%- I2.8%) with only 1 major complication. All children had right heart enlargement and exertional dyspnea, 30% of patients had recurrent lower respiratory tract infections, and 10% had failure to thrive. At 1-year follow-up, a transthoracic echocardiogram showed a well-endothelialized device in a stable position in all the patients, and none of the patients had a residual shunt., Conclusion: In experienced centers, percutaneous ASD closure of large defects in symptomatic small children can be done effectively and safely with a great degree of predictability and a low complication rate., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Annals of Pediatric Cardiology.)

Background: The status of vascular lesion treatment using percutaneous intervention (PI) in Takayasu arteritis (TAK) remains unresolved., Objectives: This study sought to develop PI strategies appropriate for TAK., Methods: A prospectively maintained single-center database of TAK PI procedures from 1996 to 2022 was analyzed retrospectively. Obstructive lesions were treated by elective stenting (using bare or covered stents), balloon angioplasty (BA), or cutting-balloon angioplasty (CBA), with adjunctive stenting for suboptimal BA or CBA results. PIs were repeated in restenotic lesions until sustained success was obtained. Aortic or peripheral aneurysms and spontaneous aortic dissections were treated with covered stents or endografts. Immunosuppressive therapy, started before PI, was continued long term., Results: A total of 942 patients underwent PI to treat 2,450 arterial lesions (2,365 stenoses or occlusions, 85 aneurysms or dissections) in 630 subclavian or axillary, 586 renal, 463 aortic, 333 carotid, 188 mesenteric, 116 iliac, 71 coronary, and 63 other arteries; 3,805 PIs were performed (1.55 PIs per lesion; range 1-7 PIs per lesion). Early success was obtained in 2,262 (92.3%), and late success in 1,460 (84.5%) of 1,727 lesions with a median of 39 months (IQR: 15-85 months) of follow-up. Repeated PIs increased late success in obstructive lesions from 48.6% to 83.3%. A total of 1,687 elective stenting lesions achieved 88% late success with 1.49 PIs per lesion; covered stents (1.18 PIs per lesion) restenosed less than bare stents (1.51 PIs per lesion; P < 0.001). A total of 183 (36%) of 513 BA-treated lesions had good outcomes without adjunctive stenting; 122 CBA-treated lesions had 19% dissections and 8% ruptures or pseudoaneurysm formations. Aneurysms or dissections had 91.3% late success after PI. A total of 472 complications occurred in 415 (17%) lesions; 375 (79%) were resolved., Conclusions: Most vascular lesions in TAK can be effectively, safely, and durably treated using predominantly stent-based PI strategies., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To achieve accurate rotational orientation and the axial position of unconstrained triple-fenestrated physician-modified endografts upon deployment in the aortic arch during total arch thoracic endovascular aortic repair (TA-TEVAR)., Materials and Methods: Following a detailed study of reconstructed computerized tomography angiography images of patients' arch anatomy, customized, sealable fenestrations with radio-opaque margins are created onsite on Valiant Captivia (Medtronic) endografts, transposing the arch branch ostial anatomic interrelationship onto the endograft precisely. Radio-opaque figure-of-8 markers, indicating the 12 o'clock (superior) position, are attached to the endograft on the surface and brought up to the surface under the endograft cover during resheathing. Resheathing without any twist in the endograft is achieved by lining up the welds in each endograft stent segment in a straight line. The fluoroscopic working view for arch endograft delivery and deployment is the left anterior oblique view that is orthogonal to the plane of the arch, which, in turn, is the right anterior oblique view in which parts of a stiff indwelling guidewire in the ascending and descending aorta precisely overlap. During introduction in the working view, the endograft delivery system is rotated in the descending thoracic aorta so that the 12 o'clock figure-of-8 markers are viewed on the edge and situated at the outer aortic curvature; continued advancement into the arch without any further rotation will ensure superior orientation of the figure-of-8 markers and, consequently, correct endograft rotational orientation. Proper axial endograft positioning requires locating the left common carotid artery (LCCA) fenestration just proximal to a taut externalized LCCA-femoral guidewire loop marking the posterior limit of the LCCA ostium. After endograft deployment during rapid cardiac pacing, the target arch branches are cannulated through their respective fenestrations using hydrophilic 0.035-inch guidewires that are externalized via distal sheaths to create femoral-arch branch (through-and-through) loops over which covered fenestrated stents are introduced and deployed., Results: This technique was used successfully in 31 consecutive patients undergoing TA-TEVAR; systemic blood pressure was obtained in all arch branches immediately after endograft deployment, indicating adequate blood flow. All arch branches were successfully cannulated and stented., Conclusion: This system enables accurate deployment of unconstrained triple-fenestrated arch endografts simply and reliably during TA-TEVAR.

Purpose: Excessive accumulation of free fatty acids in the coronary arteries can lead to coronary artery disease (CAD). Quantification of epicardial adipose tissue (EAT) and pericardial adipose tissue (PAT) is beneficial to understand its relationship with CAD, hypertension (HT), and diabetes., Material and Methods: This retrospective study included 54 patients who underwent CT coronary angiogram using a multidetector row CT scanner. The EAT and PAT volumes from cardiac images were quantified using Image J software. The severity of CAD was graded using the CAD-RADS score., Results: Twenty-nine patients had no CAD, 21 patients had significant CAD, and 4 patients had insignificant CAD. Out of 21 patients with significant CAD, 14 had involvement of multiple coronary arteries. The EAT and PAT volumes were higher in patients with HT, DM, CAD-present group and significant-CAD-present group, but this was not statistically significant except the PAT volume with respect to diabetes. Significant correlation was found between EAT volume and calcium score ( p = 0.035) and between EAT volume and total cholesterol level ( p = 0.017). Significant differences in the EAT volumes were found in different CAD-RADS categories in the right coronary artery (RCA). From the threshold values, it was observed that CAD can develop in LAD even at lower of EAT and PAT volumes., Conclusions: Quantification of EAT and PAT volumes is beneficial in understanding its relationship with the presence and severity of coronary artery disease and its risk factors., Competing Interests: The authors report no conflict of interest., (© Pol J Radiol 2022.)

Trans-catheter device closure of atrial septal defects (ASD) is considered to be safe with minimal complications. But, there are certain complications that arise after these device closures which might require urgent or late surgical intervention. We have retrospectively analysed our experience. Out of 780 patients who underwent device closure, 11 (1.4%) patients required urgent surgical intervention to retrieve the embolized device. The size of the ASD, expertise of the cardiologist and the type of the device directly impacted the rate of device embolization. Early diagnosis and prompt surgical retrieval is paramount before any life threatening complications arise due to the embolized device. One patient developed infective endocarditis later, which required surgery. Regular long term follow up is needed after these procedures to diagnose the complications earlier so that prompt surgical intervention could be done., Competing Interests: Conflict of interestNone of the authors declare any conflict of interest., (© Indian Association of Cardiovascular-Thoracic Surgeons 2022.)

Patent foramen ovale closure (PFO) is an underutilized therapy, and our study explored the challenges and feasibility of PFO closure in the Indian setting. Eighty patients with Embolic Stroke of Undetermined Source (ESUS) were screened by transcranial Doppler (TCD) for PFO. Twenty-nine patients underwent successful closure. High-risk features of a long tunnel, inter-atrial septal aneurysm, and large defect were present in 31%, 28%, and 59%. Transcranial Doppler had a sensitivity and specificity of 78% and 53% (p = 0.02) to detect PFO. Anticoagulation was withdrawn in 85% of patients post closure. Two patients had residual shunts at follow-up of 19 (9,34) months., Competing Interests: Declaration of competing interest None of the authors have any conflicts of interest and there was no sponsorship or funding received for the preparation of this manuscript., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Objectives: To study the safety of stent avoidance, frequency of change in management decisions, and its cost implications while using a fractional flow reserve (FFR)-guided treatment strategy for intermediate-grade coronary artery stenosis., Background: The impact of FFR in guiding management decisions and its cost implications has not been studied after imposition of a ceiling on stent prices by the Government of India., Methods: In 400 patients with 477 intermediate-grade coronary lesions for whom coronary intervention was planned, functional assessment using FFR was done. Incidence of the primary composite endpoint (major adverse cardiac event [MACE], cardiac death, myocardial infarction, objective evidence of ischemia, and target vessel revascularization) in the stent avoided subset was compared with the stented group at follow-up. Micro-costing analysis was done using a computed model with current stent and FFR wire prices., Results: The overall incidence of MACE was 4.9%, 0.9% in the stent-avoided subset and 6.9% in stented group (p = 0.04, comparing the latter two) at a median follow-up of 21 months (interquartile range 12-31 months). Serious adverse events occurred only in 1% of patients receiving adenosine. The average cost saving was Indian rupees (INR) 51,847 [United States Dollar (USD) 746] per patient, resulting in total savings of INR 15,813,379 (USD 227,530). Cost savings persisted but were lower by 36% (INR 18,613/USD 268 per patient) after the ceiling of stent prices., Conclusion: FFR-guided percutaneous coronary intervention (PCI) strategy is safe and cost-effective in countries where majority of patients self-finance their health care, resulting in stent and PCI avoidance in approximately one in three patients referred for coronary angioplasty., (© 2020 Wiley Periodicals, Inc.)

Myocardial infarction in a nonagenarian is a morbid cardiac illness that can lead to significant mortality unless properly dealt with management aspects. Many comorbid or family-related issues might be part of holdbacks in management of such a group of patients. Hence, myocardial infarction in a nonagenarian where intervention is better treatment option forms an uncommon combination and has many preprocedural, periprocedural and postprocedural difficulties related to multiple issues. Here, we present a case of nonagenarian who presented with extensive anterior wall MI and was successfully dealt with primary percutaneous coronary intervention despite periprocedural and intraprocedural difficulties., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

CLINICAL INTRODUCTION: A 14-year-old boy presented with history of decreased appetite and bilateral swelling of feet for 6 months. He did not give any associated history of orthopnoea or paroxysmal nocturnal dyspnoea. He was born by a normal delivery after a non-consanguineous marriage. He had an unremarkable birth and childhood health history. There was no family history of significant cardiovascular illness or sudden death. Clinical examination showed an average built boy with elevated jugular venous pressure with prominent v wave and bilateral pitting pedal oedema. Cardiovascular examination showed normal first (S1) and second (S2) heart sounds and a short early systolic murmur over tricuspid region. Other systems examination was remarkable for soft tender hepatomegaly.ECG showed sinus rhythm with tall, peaked p waves. Chest X-ray revealed enlargement along the right cardiac border. Transthoracic echocardiographic images are shown in figure 1A (apical four-chamber view) and figure 1B (tricuspid inflow Doppler). There was no colour Doppler evidence of interatrial shunt.heartjnl;105/5/405/F1F1F1Figure 1(A) Transthoracic echocardiographic apical four-chamber view. (B) Tricuspid inflow continuous wave Doppler image. QUESTION: What is the most likely diagnosis of his condition? Endomyocardial fibrosis (EMF)Ebstein's anomalyArrhythmogenic right ventricular dysplasia (ARVD)Idiopathic dilatation of right atriumRestrictive cardiomyopathy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

The radiation dose from complex cardiac procedures is of concern due to the lengthy fluoroscopic screening time and vessel complexities. This study intends to assess radiation dose based on angiographic projection and vessel complexities for clinical protocols used in the performance of percutaneous transluminal coronary angioplasty (PTCA). Dose-area product (DAP), reference air kerma (K a,r ) and real-time monitoring of tube potentials and tube current for each angiographic projection and dose setting were evaluated for 66 patients who underwent PTCA using a flat detector system. The mean DAP and cumulative K a,r were 32.71 Gy cm 2 (0.57 Gy), 51.24 Gy cm 2 (0.9 Gy) and 102.03 Gy cm 2 (1.77 Gy) for single-, double- and triple-vessel PTCA, respectively. Among commonly used angiographic projections, left anterior oblique 45°-caudal 35° reached 2 Gy in 55 min using a low-dose fluoroscopy setting and 21 min for a medium-dose setting. Use of a low-dose setting for fluoroscopic screening showed a radiation dose reduction of 39% compared with a medium-dose setting.

Objective: The objective was to study whether the incidence of composite end points (mortality, cardiogenic shock and re-myocardial infarction [re-MI]) in pharmacoinvasive strategy was noninferior to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI)., Methods: This was an observational study which included 138 patients. The study included patients admitted with a diagnosis of STEMI within 24 h of symptom onset, who underwent primary PCI or pharmacoinvasive therapy in a single center over a 9-month period. Primary end points (death within 30 days, re-MI within 30 days, and cardiogenic shock) and secondary end points (arrhythmias, bleeding manifestations, ischemic stroke, ejection fraction, mechanical complications, and duration of hospital stay) were compared between the two groups at 1 month after intervention., Results: At one month follow-up, the incidence rate for primary end points was 5 events per 43 patients (11.6%) in pharmacoinvasive arm and 18 events per 95 patients (18.9%) in primary PCI arm, a difference of - 7.3% (95% confidence interval: 18.5, 7.1). This finding shows that pharmacoinvasive strategy as compared with primary PCI in the management of STEMI was equivalent in terms of composite primary outcome. There was no significant difference between the secondary outcomes between the two groups. Use of thrombus aspiration device and in turn the thrombus burden was significantly lower in the pharmacoinvasive arm., Conclusion: This observational study showed that pharmacoinvasive strategy was as good as primary PCI in STEMI, in our setting, where primary PCI may be delayed or not possible at all due to financial and logistic constraints., Competing Interests: There are no conflicts of interest

Background: Catheter based treatment has gained wide acceptance for management of patent ductus arteriosus (PDA) ever since its introduction. Percutaneous closure in adults can be challenging because of anatomical factors including large sizes, associated pulmonary arterial hypertension (PAH) and co-morbidities. This study aimed to provide comprehensive contemporary data on the safety and efficacy of percutaneous device closure of PDA in adult and adolescent population at a large referral center., Methods: This single-center retrospective analysis included 70 patients (33 adolescents and 37 adults) who underwent successful percutaneous device closure of PDA between January 2011 and February 2017.Baseline patient demographics, clinical characteristics, procedural and device related variables, and immediate outcomes during hospital stay were recorded. Patients were followed up for residual shunt and complications., Results: Of 70 PDA device closure cases, 71.4% were females; the mean age was 23 years (range:10-58years). Devices used were 4-Cook's detachable coils, 64-occluders (ADO-I and II, Lifetech, Cardi-O-Fix), 1-vascular plug and 1-ventricular septal occluder device. Device success was achieved in all including those with very large PDAs. At 24-h post-procedure, the success rate of transcatheter intervention was 95.7%. At 6-months follow up, complete closure was observed in all (mean follow up duration-531days). In patients with severe PAH, significant immediate and sustained reduction of the mean pulmonary pressure was observed(77mmHg to 33mmHg;P=0.014). No procedure-related complications including death, device embolization and stenosis of aorta or pulmonary artery occurred., Conclusions: In contemporary practice, percutaneous device closure is an effective and safe treatment option for adolescent and adult PDA patients., (Copyright © 2017. Published by Elsevier B.V.)

Balloon mitral valvotomy (BMV) performed by the conventional transfemoral approach can be difficult or even impossible in the presence of structural impediments such as severe kyphoscoliosis, gross cardiac anatomic distortion and inferior vena caval anomalies. A 25-year-old woman with severe thoracolumbar kyphoscoliosis due to poliomyelitis presented with symptomatic rheumatic mitral valve stenosis. After the failure of transfemoral BMV, the procedure was attempted from the right jugular access, using a modified septal puncture technique. The left atrium was entered from the jugular access and the mitral valve was crossed and dilated successfully using over the wire balloon technique. Transjugular BMV is an effective alternative in patients with kyphoscoliotic spine that preclude transfemoral approach. The detailed technique used for the procedure, its advantages as well as the other percutaneous treatment options are also discussed., (Copyright © 2016. Published by Elsevier B.V.)

Coronary angiography (CA) procedure uses various angiographic projections to elicit detailed information of the coronary arteries with some steep projections involving high radiation dose to patients. This study intends to evaluate radiation doses and estimated risk from angiographic projections during CA procedure performed using novel flat detector (FD) system with improved image processing and noise reduction techniques. Real-time monitoring of radiation doses using kerma-area product (KAP) meter was performed for 140 patients using Philips Clarity FD system. The CA procedure involved seven standard projections, of which five were extensively selected by interventionalists. Mean fluoroscopic time (FT), KAP, and reference air kerma (Ka,r) for CA procedure were 3.24 min (0.5-10.51), 13.99Gycm2 (4.02-37.6), and 231.43 mGy (73.8-622.15), respectively. Effective dose calculated using Monte Carlo-based PCXMC software was found to be 4.9mSv. Left anterior oblique (LAO) 45° projection contributed the highest radiation dose (28%) of the overall KAP. Radiation-induced risk was found to be higher in females compared to males with increased risk of lung cancer. An increase of 10%-15% in radiation dose was observed when one or more additional projections were adopted along with the seven standard projections. A 14% reduction of radiation dose was achieved from novel FD system when low-dose protocol during fluoroscopy and medium-dose protocol during cine acquisitions were adopted, compared to medium-dose protocol.

Neurological manifestations such as seizures although rare are well recognized presentations of cardiac arrhythmias. Almost always, such events are primarily generalized in nature leading on to loss of consciousness. Rarely however, cardiac seizures can manifest with focal neurological events. We report a case of a sexagenarian who presented with recurrent focal seizures with secondary generalization, who was misdiagnosed and treated as seizure disorder; only a careful history and focussed investigations helped in realising a precise diagnosis.

A direct right pulmonary artery to left atrial fistula is a rare congenital condition in which patients usually present with isolated cyanosis in the absence of abnormal cardiovascular findings. We report the percutaneous closure of such a defect in a young woman who presented with severe cyanosis. This was achieved without making a conventional venovenous loop and was performed using an Amplatzer vascular plug. We believe, in patients with a suitable anatomy, closure with vascular plug without a venovenous loop should be the method of choice for treating this malady in view of the technical ease., (2015 BMJ Publishing Group Ltd.)

Background & Objectives: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 10 [8] autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy., Methods: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI)., Results: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 X 10 [8] (n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study., Interpretation & Conclusions: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Flat panel detector (FPD) technology in interventional cardiology is on the increase due to its varied advantages compared to the conventional image intensifier (II) systems. It is not clear whether FPD imparts lower radiation doses compared to II systems though a few studies support this finding. This study intends to compare radiation doses from II and FPD systems for coronaryangiography (CAG) and Percutaneous Transluminal Coronary Angioplasty (PTCA) performed in a tertiary referral center. Radiation doses were measured using dose area product (DAP) meter from patients who underwent CAG (n = 222) and PTCA (n = 75) performed using FPD angiography system. The DAP values from FPD were compared with earlier reported data using II systems from the same referral center where the study was conducted. The mean DAP values from FPD system for CAG and PTCA were 24.35 and 63.64 Gycm(2) and those from II system were 27.71 and 65.44 Gycm(2). Transition from II to FPD system requires stringent dose optimization strategies right from the initial period of installation.

Erdheim Chester disease is a very rare histiocytic disorder characterised by tissue infiltration by lipid laden histiocytes. The most common presentation is bone pains typically involving the long bones. Over time almost 50% of the patients develop extraosseous involvement. The prognosis depends on the extent and distribution of the extraskeletal manifestations. Cardiovascular involvement is seen in up to 40% of the patients and the most common manifestations are periaortic fibrosis and pericardial involvement. Respiratory distress, extensive pulmonary fibrosis, and cardiac failure are the most common causes of death in these patients. Cardiac tamponade has also been documented to cause death in these patients. We describe a patient of Erdheim Chester disease who presented with recurrent and very rapidly occurring cardiac tamponade in a short duration of time and benefited from timely recognition and management., (Copyright © 2012 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background and Objective: A large number of patients with ST elevation myocardial infarction (STEMI) continue to receive streptokinase (SK) in the developing countries. High levels of antistreptokinase (ASK) antibodies can result in failure of thrombolysis. This study was conducted to assess the presence of ASK antibodies in the general population and its effect on the outcome of thrombolysis with SK., Design: Prospective observational study., Setting: A tertiary care medical institute in Vellore, India., Patients: 148 patients presenting with STEMI undergoing thrombolysis with SK were recruited., Main Outcome Measures: The response to SK was assessed by reperfusion markers in the patients and they were categorised as good responders, probable responders and non-responders. Those who responded to SK and probable responders were considered to have benefited from thrombolysis., Results: 60 patients (40%) had ASK antibody titres higher than the median. In patients with a window period <6 h, 73% of patients who benefited from thrombolysis had low ASK titres while 100% of the patients who did not benefit had high ASK titres (p=0.001). Similarly, in patients with a window period >6 h, 89% of patients who benefited from thrombolysis had low ASTK titres while 54% of those who did not benefit had high ASK titres (p=0.002)., Conclusions: ASK antibodies are present in significant titres in a large proportion of patients in developing countries, which leads to failure of thrombolysis in such patients. In endemic areas with high endemic streptococcal infection, alternative agents should be used for thrombolysis in STEMI.

Despite diagnostic and therapeutic advances, mortality and morbidity associated with infective endocarditis (IE) remains high. Congestive heart failure and complications such as septic embolization and aortic root abscess are the main causes. Although aortic root abscess is a common complication of IE involving the aortic valve, acute myocardial infarction (AMI) is a rare complication in patients with endocarditis, whether in the acute or later phase of infection. In most cases, the infarction is either anterior or anterolateral. To the best of the present authors' knowledge, only one case of infarction at a purely inferior site has been reported previously. In the present case, IE with an aortic root abscess presented clinically as an acute inferior wall myocardial infarction.

Background: Clopidogrel has become the standard antiplatelet drug along with aspirin in patients undergoing coronary angioplasty; however, data regarding the nonresponse rate to clopidogrel therapy in Indian patients are limited., Methods and Results: Platelet aggregation was measured at baseline and 2 and 24 hours post administration of bolus dose of 300 mg clopidogrel, followed by 75 mg once daily in patients undergoing elective or adhoc coronary angioplasty. Baseline platelet aggregation with 2.5 and 10 micromol/L ADP was 27.91 +/- 20.9% and 53.45 +/- 22.44%. Platelet aggregation at 2 hours and 24 hours with 2.5 micromol/L of ADP was 19.65 +/- 16.9% and 10.44 +/- 11.9%. The corresponding values with 10 micromol of ADP were 48.81 +/- 25.3% and 27.04 +/- 22.4%. Platelet aggregation was maximally inhibited at 24 hours with both 2.5 and 10 micromol/L of ADP. Marked interpatient variability in platelet aggregation in response to clopidogrel administration was observed and varied from -43 to 65%, -32 to 85% with 2.5 micromol/L at 2 hours and 24 hours and -65 to 53%, -35 to 97% with 10 micromol/L ADP at 2 hours and 24 hours. Nonresponse rate 2 hours after clopidogrel administration was 47.7%, and decreased to 29.2% at 24 hours post drug administration., Conclusion: Clopidogrel nonresponse is prevalent among Indian patients, and there is wide interpatient variability in platelet inhibition among individual patients. However, the clinical implications of these findings need to be substantiated in larger studies with clinical end points.

A four-month-old baby presented with failure to thrive and congestive cardiac failure precipitated by a lower respiratory tract infection. He was found to have a large ostium secundum atrial septal defect measuring 18 mm. This was successfully closed percutaneously by a device (Blockaid). A month after the device deployment the child developed typical atrial flutter. Despite rate control drugs the ventricular rate remained 140/min over the next several months. In view of the incessant atrial flutter with fast ventricular response, the child underwent radiofrequency ablation at the age of 2 years. An isthmus block was created which successfully terminated the tachycardia.

: 1. Centrally acting imidazoline antihypertensive agents clonidine and moxonidine also act peripherally to contract blood vessels. While these agents act at both I(1)-imidazoline and alpha 2 adrenergic receptors centrally, the receptor types by which they mediate contraction require further definition. We therefore characterized the receptor subtype by which these agents mediate contraction of proximal rat-tail artery. 2. Dose-response curves were determined for phenylephrine and for several imidazoline ligands, using endothelium denuded, isolated ring segments, of tail arteries from adult male Sprague-Dawley rats. Ring segments were mounted on a force transducer with platinum wires and immersed in a tissue bath containing Krebs solution, to which drugs could be added. Signals were digitized and recorded by a computer. 3. Tail artery contractions expressed as a percent of contraction to 106 mM potassium were phenylephrine (96%), moxonidine (88%), clonidine (52%), and UK14304 (30%). Neither rilmenidine nor harmane caused contraction. Contraction of tail artery to moxonidine or clonidine could be blocked by alpha 1 antagonist urapidil or prazosin, and also by alpha 1A subtype selective antagonist WB4101. Schild plots were generated and a calculated pA2 value of 9.2 for prazosin in the presence of clonidine confirms clonidine as an agonist at alpha 1A receptors in proximal segments of rat-tail artery. 4. Our work suggests that clonidine and moxonidine are promiscuous compounds at micromolar concentrations and that harmane and rilmenidine are more selective compounds for in vivo imidazoline research.

We report the case of a middle aged lady with dilated cardiomyopathy, presenting with recurrent syncope due to torsade de pointes. Further evaluation revealed that she had a pheochromocytoma which caused the arrhythmia.

Background: This study was undertaken to determine the prevalence of coronary artery disease in patients with rheumatic heart disease undergoing valve surgery., Methods and Results: Consecutive patients with rheumatic heart disease (n=376) who were above the age of 40 years, and scheduled for valve surgery underwent diagnostic coronary angiogram to delineate coronary arteries. The patients were divided into three groups based on valve involvement (mitral valve, aortic valve, and combined aortic and mitral valve). Significant coronary artery disease was considered to be present if one or more coronaries showed 50% or more luminal stenosis. There were 287 (76.3%) males and 89 (23.7%) females. The mean age of the study population was 51.2+/-8.2 years. Eighty-nine (23.8%) patients had typical chest pain, 116 (30.6%) patients had atypical chest pain and 171 (45.5%) patients had no chest pain. Hypertension was noted in 88 (23.4%) patients, 65 (17.3%) patients had diabetes, 98 (26.1%) patients were smoker, and 66 (17.6%) patients had dyslipidemia, and 15 (4.0%) patients gave past history of myocardial infarction. Of the total 376 patients, 46 (12.2%) patients were found to have significant coronary artery disease. In patients with mitral vale disease the prevalence was 13.5% (13/96), while it was 15.3% (19/124) in patients with aortic valve disease and 9% (14/156) in those with combined mitral and aortic valve disease., Conclusions: Our results suggest that the overall prevalence of coronary artery disease in a group of patients with rheumatic heart disease undergoing valve surgery in the current era is 12.2%. This prevalence is much lower than the figures reported earlier in the Western literature.

To investigate whether alpha1-adrenergic receptors were involved in the contractile response of tail arteries to moxonidine, isolated ring segments of tail arteries from male adult Sprague-Dawley rats were studied. Moxonidine (EC50 = 1.3 microM) and the alpha1-agonist phenylephrine (EC50 = 2.5 microM) increased tension development in the rat-tail artery similarly. The response to moxonidine (1 microM) could be blocked by both alpha1-adrenoceptor blockers prazosin (IC50 = 1 nM), and urapidil (IC50 = 14 nM), and also by alpha2-adrenoceptor blockers, yohimbine (IC50 = 49 nM) and efaroxan (IC50 = 49 nM). Combination drug treatment (urapidil and yohimbine, or yohimbine and prazosin) was more effective in blocking the contractile response to moxonidine, than treatment with prazosin or urapidil alone. Comparison of pA2 values for prazosin in the presence of moxonidine (9.35) or phenylephrine (10.2) confirm that alpha1-adrenergic receptors are involved in the contractile response of rat-tail artery to moxonidine.

Ten patients who had anatomic alterations that cause impediments to successful completion of conventional transfemoral balloon mitral valvuloplasty (BMV) underwent transjugular BMV. They included six patients in whom conventional BMV could not be completed due to cardiac anatomic distortion; two patients with dextrocardia (one with visceroatrial situs solitus and the other with situs inversus); two patients with venous abnormalities (one with azygous continuation of the inferior vena cava and the other with bilateral iliac/femoral vein occlusion). Transjugular BMV was successful in all 10 patients (mean mitral valve area increasing from 0.68 +/- 0.17 to 1.92 +/- 0.40 cm(2); range, 1.56-2.76 cm(2)); it was quick (mean total fluoroscopy time, 10.5 +/- 2.7 min; range, 7.3-15.2 min); and it was safe (no major or minor complications except one patient who developed severe mitral regurgitation that only required medical therapy). The jugular approach to BMV overcomes many of the technical problems caused by anatomic changes that are encountered in transfemoral BMV and complements the latter approach., (Copyright 2002 Wiley-Liss, Inc.)