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Background: We aimed to assess the utility of B-type natriuretic peptide (BNP) and 6-min walk test (6 MWT) together as predictors of re-hospitalization and mortality in acute decompensated heart failure (ADHF) patients. Methods: This prospective, observational, comparative study was conducted at a tertiary care center in India between October 2016 and March 2018. Patients (aged≥18 years) with ADHF and left ventricular systolic dysfunction were included in this study. The study group (N = 100 patients) consisted of patients undergoing a second BNP test along with the 6 MWT at the time of discharge and at 3-months of discharge. The control group (N = 100 patients) consisted of patients who did not undergo these tests at discharge and/or at 3-months of discharge. Study endpoints were re-hospitalization within 6-months, and in-patient and 6-month mortality. Results: Total 200 patients diagnosed with ADHF were enrolled. Mean age was 53.46 ± 10.12 years in the study group and 52.98 ± 9.88 years in the control group. ROC analysis of BNP level to predict re-hospitalization revealed AUC of 0.935 (p

The present study assessed incidence, risk factors, in-hospital and short-term outcomes associated with no-reflow in patients undergoing percutaneous coronary intervention (PCI) in STEMI, NSTEMI, unstable angina and stable angina. Out of 449 patients, 42 (9.3%) developed no-reflow. Hypertension, dyslipidemia, obesity and smoking were significant risk factors. There was significant association of no-reflow with left main disease, multiple stents, target lesion length≥ 20 mm and higher thrombus grade. Interestingly, 93 patients (23.4%) of normal flow had myocardial perfusion grade (MPG) of 0/1 with mortality in 9 (10%) patients. No-reflow is associated with poor in-hospital and short-term outcomes with higher incidence of death, cardiogenic shock, heart failure and MACE. Knowledge of risk factors of no-reflow portends a more meticulous approach to improve final outcomes. MPG could be better predictor of outcomes in these patients.

Objectives: This prospective, randomized study assessed short-term outcomes and safety of ultra-low contrast percutaneous coronary intervention(ULC-PCI) vs conventional PCI in high risk for contrast induced acute kidney injury(CI-AKI) patients presenting with acute coronary syndrome(ACS). Background: Patients at an increased risk of developing CI-AKI can be identified prior to PCI based on their pre-procedural risk scores. ULC-PCI is a novel contrast conservation strategy in such high risk patients for prevention of CI-AKI. Methods: 82 patients undergoing PCI for ACS were enrolled having estimated glomerular filtration rate(eGFR)

Percutaneous Coronary Intervention (PCI) is now the standard of care in patients with coronary artery disease. With advances in modern technology, the success of PCI has relatively increased, and so is its complication, specifically in complex coronary intervention. Coronary perforation is one of the most dreadful and life-threatening complications of PCI. The most vital step in the management of coronary perforation is its identification and quick action. Multiple methods for management are now recommended in the literature, but the mainstay of treatment is still prevention. This review discusses the incidence, risk factors, prevention, identification, and management of Coronary Artery Perforation (CAP).

Aim: Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India. Methods & Results: In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019.We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = −0·48; r2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively. Conclusions: The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

This case highlights the importance of proper identification of congenital anomalies of the coronary sinus for the successful placement of left ventricular lead during cardiac resynchronization therapy device implantation. We discuss an alternate route for left ventricular lead placement via the vein of Marshall when the coronary sinus ostium in the right atrium was atretic and was facing difficulty initially in detecting the anomaly.

Background and objectives: Quadripolar left ventricular (LV) leads in cardiac resynchronization therapy (CRT) offer multi-vector pacing with different pacing configurations and hence enabling LV pacing at most suitable site with better lead stability. We aim to compare the outcomes between quadripolar and bipolar LV lead in patients receiving CRT. Methods: In this prospective, non-randomized, single-center observational study, we enrolled 93 patients receiving CRT with bipolar (BiP) (n = 31) and quadripolar (Quad) (n = 62) LV lead between August 2016 to August 2019. Patients were followed for six months, and outcomes were compared with respect to CRT response (defined as ≥5% absolute increase in left ventricle ejection fraction), electrocardiographic, echocardiographic parameters, NYHA functional class improvement, and incidence of LV lead-related complication. Results: At the end of six months follow up, CRT with quadripolar lead was associated with better response rate as compared to bipolar pacing (85.48% vs 64.51%; p = 0.03), lesser heart failure (HF) hospitalization events (1.5 vs 2; p = 0.04) and better improvement in HF symptoms (patients with ≥1 NYHA improvement 87.09% vs 67.74%; p = 0.04). There were fewer deaths per 100 patient-year (6.45 vs 9.37; p = 0.04) and more narrowing of QRS duration (Δ12.56 ± 3.11 ms vs Δ7.29 ± 1.87 ms; p = 0.04) with quadripolar lead use. Lead related complications were significantly more with the use of bipolar lead (74.19% vs 41.94%; p = 0.02). Conclusions: Our prospective, non-randomized, single-center observational study reveals that patients receiving CRT with quadripolar leads have a better response to therapy, lesser heart failure hospitalizations, lower all-cause mortality, and fewer lead-related complications, proving its superiority over the bipolar lead.

Background: Cardiovascular manifestations are an important cause of mortality and morbidity in COVID-19 infections. Conduction system abnormality in the form of symptomatic bradyarrhythmia is underreported in the literature. Aim: To evaluate epidemiological, demographic, laboratory, clinical management, and outcome data of symptomatic bradyarrhythmia in COVID-19 patients. Methods: This was a retrospective, observational study including all the adult patients (>18 years) who were diagnosed with COVID-19 infection and had complete heart block (CHB) or symptomatic high-grade Atrio-Ventricular (AV) block requiring a temporary pacemaker insertion (TPI). Epidemiological, demographic, laboratory, clinical management, and outcome data were extracted from all the enrolled patients and studied for the primary clinical composite endpoint of all-cause death. Results: The study population included 15 patients, including 14 patients with CHB and 1 patient with 2:1 AV block. Syncope was the most common presentation. The clinical endpoint in the form of death was seen in 5 patients (33.3%), 3 patients reverted to sinus rhythm, and 7 patients required permanent pacemaker implantation. The markers of inflammation were raised in all patients; however trend toward more inflammation was seen in patients reaching the primary clinical endpoint. 3 out of 7 patients with narrow QRS rhythm reverted to normal sinus rhythm, while all 8 patients with broad complex QRS either died or required a permanent pacemaker insertion. Conclusion: Symptomatic bradyarrhythmia is associated with a high inflammatory state, and high mortality in COVID-19 infection and a transient conduction block in patients with narrow QRS rhythm may suggest local subclinical myocardial inflammation. Resumen: Antecedentes: Las manifestaciones cardiovasculares son una causa importante de mortalidad y morbilidad en las infecciones por COVID-19. La anomalía del sistema de conducción en forma de bradiarritmia sintomática no se informa en la literatura. Objetivo: Evaluar datos epidemiológicos, demográficos, de laboratorio, de manejo clínico y de resultado de la bradiarritmia sintomática en pacientes con COVID-19. Métodos: Este fue un estudio observacional retrospectivo que incluyó a todos los pacientes adultos (> 18 años) que fueron diagnosticados con infección por COVID-19 y tenían bloqueo cardíaco completo (HBC) o bloqueo auriculoventricular (AV) de alto grado sintomático que requería una inserción de marcapasos (TPI). Los datos epidemiológicos, demográficos, de laboratorio, de manejo clínico y de resultado se extrajeron de todos los pacientes inscritos y se estudiaron para el criterio de valoración clínico primario compuesto de muerte por cualquier causa. Resultados: La población del estudio incluyó a 15 pacientes, 14 de los cuales tenían HBC y uno tenía bloqueo AV 2:1. El síncope fue la presentación más común. El criterio de valoración clínico en forma de muerte se observó en 5 pacientes (33,3%), 3 pacientes revirtieron al ritmo sinusal y 7 pacientes requirieron implantación de marcapasos permanente. Los marcadores de inflamación se elevaron en todos los pacientes; sin embargo, se observó una tendencia hacia una mayor inflamación en los pacientes que alcanzaron el criterio de valoración clínico primario. Tres de cada 7 pacientes con QRS estrecho revirtieron al ritmo sinusal normal, mientras que los 8 pacientes con QRS de complejo ancho murieron o requirieron la inserción de un marcapasos permanente. Conclusión: La bradiarritmia sintomática se asocia con un estado inflamatorio alto y una alta mortalidad en la infección por COVID-19, y un bloqueo transitorio de la conducción en pacientes con ritmo QRS estrecho puede sugerir una inflamación miocárdica subclínica local.

Objective: No study among Indian population has proposed modification of existing cardiovascular disease (CVD) risk scores or novel risk scores as risk estimation using conventional risk calculators can’t be generalized because of epidemiological differences. Material and methods: A single center observational study was performed at a tertiary care center among participants having no evidence of CVD. Prevalence of various cardiac risk factors were analysed and 10-year risk was estimated using Framingham risk score (FRS), Q risk 2 score calculator (QRISK2) and Modified Q risk 2 (mQRISK2) which included smokeless tobacco consumption. QRISK2 and mQRISK2 were compared with FRS and participant’s eligibility for statin therapy as primary preventive measure was assessed. Results: Total of 4045 participants were enrolled from August 2016 to July 2019. 3520(87%) had no history of smoking in their lifetime while smokeless tobacco consumption was seen in 1153(28.5%), diabetes in 422(10.4%), hypertension in 1096(27.1%), obesity in 2035(50.3%), and family history of CVD in 353(8.7%) participants. High risk participants were found to be 826(20.4%), 627(15.5%), and 509(12.6%) by using FRS, mQRISK2 and QRISK2, whereas those eligible for statin therapy were maximum by mQRISK2 among 1323(32.7%) participants compared to QRISK2 (n = 1191; 29.4%) and FRS (n = 826; 20.4%) model. Krippendorff’s alpha for mQRISK2 was in better agreement with body mass index (BMI) and lipid FRS CVD scoring system as compared to QRISK2 risk model. Conclusion: CVD risk stratification based on smokeless tobacco use is first of its kind from this part of world and should be part of CV risk assessment.

Type 2 Diabetes Mellitus (T2DM) is associated with a high risk of atherosclerotic cardiovascular disease (ASCVD). Intensive blood glucose reduction with antidiabetic drugs significantly reduce microvascular complications but there is no strong evidence of reduction in cardiovascular (CV) events. In 2008, the US Food and Drug Administration (FDA) issued guidance to demonstrate cardiovascular safety of newer antidiabetic drugs in addition to reduction in blood glucose level. After which a number of CVOTs were conducted involving newer antidiabetic drugs. The newer drugs (e.g. GLP-1 RAs, SGLT2 inhibitors and DPP 4 inhibitors) might have potential effects on body weight, lipid parameters and blood pressure, as well as endothelial dysfunctions, inflammatory markers and oxidative stress. The current review summarizes the results of the main trials focused on the cardiovascular outcomes of traditional as well as newer antidiabetic drugs.

Background: The incidence of stuck rotational atherectomy (RA) burr is extremely low, and its description has been sporadic in the literature about the systemic management of this complication. Aims and Objective: The current study was designed to present the experience of our center and propose an algorithm for the retrieval of stuck RA burr. Materials and Methods: We retrospectively evaluated cases of RA between August 2018 to August 2020 at our center. An entrapped RA burr was defined as an inability to move the burr backward without any additional maneuvers during or after the rotablation of a coronary lesion. Angiographic and procedural details were reviewed in the identified cases of entrapped rotablator burr, details of maneuvers used to retract the burr was documented. We further analyzed the literature using PubMed search using the keywords “entrapment of rotablator burr”, “stuck rotablator” and “rotablation complications”. All the articles with entrapped rotablation burr were identified and scrutinized for the techniques used for percutaneous retrieval. Results: Out of the total 5780 Percutaneous coronary intervention (PCI) procedures, RA was performed in 75 patients and RA burr entrapment was confirmed in two cases. Both the cases were seen in patients with angulated and heavily calcified lesions. The cases were managed percutaneously by endovascular maneuvers. A total of 8 techniques were identified by analysis of available literature for burr retrieval with surgery being the favored one. Using the experience of our center and available literature we propose a simplified working algorithm towards systematic management of this complication. Conclusion: RA burr entrapment is rare, but a life-threatening complication, and the operator should be prepared with strategies for successful retrieval of stuck burr. Percutaneous retraction maneuvers should be used as the first-line management for retrieval of stuck burr followed by surgical referral. Using the proposed algorithm this rare complication can be managed systematically and effectively.

Objective: The study aimed at to find out prevalence of abnormal upper limb arterial anatomy and its correlation with access failure during transradial coronary angiography. Method: This was a prospective observational study of 1512 patients who had undergone transradial coronary angiography (CAG). Angiographic assessment of upper limb arterial tree was performed when the angiographic guidewire or the diagnostic catheter followed an abnormal path or got stuck in its course. Results: About 5.29% patients (80/1512) were noted to have abnormal upper limb arterial anatomy. The most common abnormality detected were radio-ulnar loop in 22 (1.46%) patients, tortuous upper limb arteries 19 (1.25%) and abnormal high origin of radial artery 10 (0.66%) patients. Access failure was encountered in 4.4% (67/1512) of total patients and 64.17% (43/67) access failure was due to abnormal upper limb arterial anatomy. Conclusion: Abnormal upper limb arterial anatomy was the most common cause of access failure in transradial coronary angiography in this study.

Optical coherence tomography (OCT) is slowly but surely gaining a foothold in the hands of interventional cardiologists. Intraluminal and transmural contents of the coronary arteries are no longer elusive to the cardiologist's probing eye. Although the graduation of an interventionalist in imaging techniques right from naked eye angiographies to ultrasound-based coronary sonographies to the modern light-based OCT has been slow, with the increasing regularity of complex coronary cases in practice, such a transition is inevitable. Although intravascular ultrasound (IVUS) due to its robust clinical data has been the preferred imaging modality in recent years, OCT provides a distinct upgrade over it in many imaging and procedural aspects. Better image resolution, accurate estimation of the calcified lesion, and better evaluation of acute and chronic stent failure are the distinct advantages of OCT over IVUS. Despite the obvious imaging advantages of OCT, its clinical impact remains subdued. However, upcoming newer trials and data have been encouraging for expanding the use of OCT to wider indications in clinical utility. During percutaneous coronary intervention (PCI), OCT provides the detailed information (dissection, tissue prolapse, thrombi, and incomplete stent apposition) required for optimal stent deployment, which is the key to successfully reducing the major adverse cardiovascular event (MACE) and stent-related morbidities. The increasing use of OCT in complex bifurcation stenting involving the left main (LM) is being studied. Also, the traditional pitfalls of OCT, such as additional contrast load for image acquisition and stenting involving the ostial and proximal LM, have also been overcome recently. In this review, we discuss the interpretation of OCT images and its clinical impact on the outcome of procedures along with current barriers to its use and newer paradigms in which OCT is starting to become a promising tool for the interventionalist and what can be expected for the immediate future in the imaging world.

Large intracoronary thrombus has been reported in significant number of patients with STEMI. Primary PCI is the current standard of care in patients of STEMI. Despite the availability of dual antiplatelets, GP IIb/IIIa inhibitor and effective anticoagulation regimens, large intracoronary thrombus remains one of the biggest challenge to interventional cardiologists during primary PCI. Large intracoronary thrombus may lead to distal embolization, no/slow reflow or embolization into a non-culprit vessel and is associated with adverse cardiovascular outcome. There is no ideal management strategy. We hereby discuss the current available methods/strategies to deal with large thrombus burden encountered during primary PCI, in the current manuscript.

Aims: This study aims to study the impact of coronavirus disease 2019 (COVID-19) lockdown on catheterization laboratory (Cath Lab) utilization for cardiac patients. Subjects and Methods: In this retrospective observational study, a total number of procedures in Cath Lab during COVID-19 lockdown were compared with pre-COVID-19 lockdown time to see the impact of the pandemic on cardiac patients undergoing interventions. Results: A total of 1982 procedures (1788 in prelockdown vs. 194 in lockdown; P < 0.001) were performed in the catheterization laboratory during the 6 months' time frame of this study. There was an alarming drop in procedures by 89.1% in the lockdown period with the maximum reduction seen in diagnostic coronary angiography (96.6%), elective angioplasty decreased by 96.4%, and primary angioplasty by 82.08%. There was an increase in rescue angioplasty by 80% (P < 0.001) during the lockdown phase. There was a fall of 83.9% in admissions of acute coronary syndrome and 62.76% reduction in heart failure admissions during the lockdown period. During the study period, there were a total of 2111 admissions in the cardiac care unit (1882 in pre vs. 229 in lockdown; P < 0.001), which showed an 87.14% reduction when compared to the prelockdown group. Conclusions: We report an alarming reduction in total admissions and catheterization laboratory procedures as an impact of COVID-19-related lockdown. This represents a serious problem regarding the handling of this pandemic by the health-care system and can be used to devise proper strategies for the recovery phase of the COVID-19 pandemic.

Management of symptomatic rheumatic mitral stenosis (MS) by nonsurgical techniques has been the therapeutic modality of choice in low- and middle-income countries such as India. In comparison to surgical interventions, catheter-based balloon dilatation has been preferred in cases of rheumatic MS. Various scoring systems, including three-dimensional (3D), 2D transthoracic, and transesophageal echo and fluoroscopy, have been summarized in this review for the evaluation of the morphology of the valve apparatus, including calcification, and subvalvular involvement for predicting favorable outcomes.

Rheumatic fever (RF) and rheumatic heart disease (RHD) are major health hazards in developing countries. Affection with RF-RHD in preschool years is uncommon, but prognostically worse as management is technically difficult. We report a rare early presentation of rheumatic valve disease in a 2-year-old child. This is probably the youngest case of rheumatic mitral obstruction documented in literature till date. It highlights that RF-RHD is still a very prevalent disease in India yet is underdiagnosed and underreported.

Background: It is well established fact that acute coronary occlusion leads to diastolic dysfunction, followed by systolic dysfunction when myonecrosis occur. It is also proven that primary percutaneous coronary intervention (PPCI) is an excellent therapy for ST elevation myocardial infarction (STEMI) to improve outcomes. However there is a paucity of information on efficacy of PPCI in improving diastolic function. Evaluation of the role of PPCI in improving diastolic dysfunction is required. Methods: 61 patients with first anterior wall STEMI who underwent PPCI to left anterior descending artery were included. Echocardiographic evaluation was performed within 24 h of PPCI and then on day 15, 3 months and 6 months after PPCI. We evaluated the prevalence of diastolic dysfunction after PPCI and its recovery during 6 months along with effect of duration of chest pain on diastolic function. Results: 54.1% of patients had diastolic dysfunction after PPCI whereas it was only 21.3% after 6 months (p value

Introduction: Right Ventricular Myocardial Infarction (RVMI) along with inferior wall left ventricular (LV) dysfunction or Inferior Wall Myocardial Infarction (IWMI) is found in 30-50% of the cases. Isolated Right Ventricular (RV) dysfunction or infarction is rare except in iatrogenic (interventional) procedures. RVMI is being more commonly diagnosed retrospectively in the era of primary angioplasty, when these patients post-procedure fail to improve satisfactorily as compared to isolated IWMI patients. Clues to identify early RV involvement in acute IWMI patients will help in better management and less morbidity in this group of patients. Aim: The study was undertaken to search for any correlation between cardiac biomarkers {Troponin I (Trop I), Creatinine Kinase-MB (CK-MB), Brain Natriuretic Peptide (BNP)} and RV involvement using echocardiographic parameters in inferior Acute Myocardial Infarction (AMI), with and without associated RVMI, in patients who underwent primary Percutaneous Coronary Intervention (PCI). Materials and Methods: This was a cross-sectional study, conducted from September, 2018 to August, 2019, in the Cardiology Department of ABVIMS and Dr. Ram Manohar Hospital. A total of 294 patients, presenting with acute IWMI, were included in the study. Samples for Trop-I, CK-MB and BNP were taken immediately after admission. One hundred and thirty two patients had an associated RVMI. Two-dimensional Echocardiography was done within the first 12 hours of admission. Electrocardiography (ECG) and Echocardiography (EEG) assessments were used to determine RV involvement. Comparison was done first between patients with and without RV involvement, followed by comparison among groups for quantitative parameters, especially biomarkers, for finding correlation between biomarker levels and echocardiographic parameters (both RV and LV functions). Results: Patients presenting with IWMI with an associated RVMI had increased LV E/E’ ratio. Also, as predicted, they had a low Tricuspid Annulus Plane Systolic Excursion (TAPSE) and a low RV fractional area change, as well, due to stunning of right ventricle in the acute phase. In the group with higher BNP levels (≥400 pg/mL), the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/E’) was increased; on the other hand LV ejection fraction and TAPSE were decreased. There was negative correlation between RSm (RV systolic wave), TAPSE and BNP levels. BNP, Trop I and CKMB levels showed a positive correlation with E/E’ at higher levels. Hypotension was more in patients presenting with RVMI, but it did not reach statistical significance. The mortality was 4.5% in the inferior Myocardial Infarction (MI) with RV involvement group versus 1.8% in isolated inferior MI group (during hospital stay). Conclusion: In acute Inferior wall MI, higher levels of BNP, CKMB, Trop I, alone or in combination, might be used for prediction of RV involvement. BNP levels ≥400 pg/mL, Trop I levels ≥1.1 ng/ mL, and CK-MB levels ≥4.5 ng/mL, along with hypotension and higher E/E’ ratio were observed in such cases and were associated with RV dysfunction and increased mortality.

BACKGROUND: Wider QRS duration and presence of left bundle branch block (LBBB) predict better cardiac resynchronization therapy (CRT) response. Despite strict patient selection, one-third of patients have a sub-optimal response. We aim to evaluate the impact of lead one ratio (LOR) on CRT response.METHODS: We enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant 12-lead electrocardiogram (ECG) was recorded, and LOR was derived by dividing the maximum positive deflection of QRS complex in ECG lead I by the maximum negative deflection in lead I; cut-off value of 12 was used to divide the cohort into two groups. Patients were followed for 6 months, and outcomes were compared for CRT response, New York Heart Association (NYHA) class improvement, all-cause mortality, and heart failure (HF) hospitalization events.RESULTS: At the end of 6-month follow-up, LOR ≥ 12 was associated with significantly better CRT response (75.76% vs. 51.85% in LOR < 12, P = 0.02), lower mortality per 100 patient-years (9.09 vs. 14.81 in LOR < 12, P = 0.012), and more improvement in HF symptoms (NYHA improvement) (78.79% vs. 55.56% in LOR < 12, P = 0.02). Patients with LOR < 12 had more HF hospitalization events (2.04 vs. 1.81 episodes in LOR ≥ 12, P = 0.029) and less QRS narrowing (∆5.74 ± 2.09 vs. ∆7.10 ± 3.97 ms in LOR ≥ 12, P = 0.01). QRS duration and LBBB morphology were predictors of response in both groups of patients.CONCLUSION: LOR ≥ 12 was associated with better response to CRT, less HF hospitalization, and more relief in HF symptoms. This ratio helps to identify possible sub-optimal response among patients with an indication for CRT.

We present a case of sinus venosus atrial septal defect in a patient who was previously diagnosed as having primary pulmonary hypertension in a tertiary care center. Our findings are based on 2-dimensional trans-thoracic echocardiography, chest X–ray and surface electrocardiogram. A 26-year-old man, previously diagnosed as a case of primary pulmonary hypertension, presented to the emergency department (ED) with chest pain and breathlessness on exertion. Cardiac biomarkers were within their normal ranges. Surface electrocardiogram showed right atrial and ventricular overload with right axis deviation. Chest imaging noted enlarged central pulmonary vascularity with bilateral plethoric lung fields. Trans-thoracic echocardiography showed a dilated right atria and ventricle with severe tricuspid regurgitation and severe pulmonary artery hypertension with an intact atrial septum. Surprisingly, the transoesophageal echocardiogram revealed the presence of a sinus venous superior vena cava-type atrial septal defect with the right pulmonary vein draining into the right atria. In this full-text version, we present a more detailed discussion of sinus-venous atrial septal defect associated with partial anomalous pulmonary venous return that was wrongly diagnosed as a case of primary pulmonary hypertension in a tertiary care center.

Atrial septal defects of Ostium Secundum type with suitable anatomy and margins are commonly closed with septal occluder devices. With the increasing number of catheterization laboratories and increasing availability of different devices, the device closure procedure is very commonly performed in different institutes. Embolization of the septal occluder is one of the most dreaded complications of this procedure, which usually occurs in the early hours or days after the procedure. We report a case of silent embolization of the Amplatzer septal occluder, detected seven months after its use to close an Ostium Secundum atrial septal defect, which was detected during pre-anaesthetic evaluation and echocardiography for non-cardiac surgery. The patient denied having any symptom in-between. The device was retrieved and the defect was closed surgically.

Left ventricular lead placement in the appropriate branch of coronary sinus is the key to successful cardiac resynchronization therapy (CRT) and this step is technically challenging. We describe a case of non-ischemic cardiomyopathy with heart failure, taken up for cardiac resynchronization therapy with defibrillator (CRT-D) implantation. The quadripolar left ventricular lead was impossible to advance into the target lateral branch of the coronary sinus. We made a veno-venous loop, advancing the coronary guidewire through the middle cardiac vein to coronary sinus and then to superior vena cava. The guidewire then snared through the same left subclavian vein and exteriorized. Over this loop, the left ventricular lead of the CRT-D device was implanted successfully. This novel approach can be used to successfully implant the LV lead in difficult to implant situations, obviating the need for thoracotomy or other methods of LV lead implantation.

Isolated annular dilatation is an extremely uncommon cause of congenital mitral regurgitation. We report a case of a 5-year-old child with idiopathic isolated annular dilatation causing severe congenital mitral regurgitation.