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Introduction: Some pacemaker implanted patients have an atherosclerotic disease which promotes conduction system ischemia and conduction disturbances. The aim of this study was to determine prevalence of coronary artery disease (CAD) and its risk factors in patients undergoing permanent pacemaker implantation (PPI). Methods: This prospective, single-center hospital based study examined patients older than 40 years who required PPI. Presence of atherosclerotic risk factors and CAD was examined. Results: Of 258 patients undergoing PPI, CAD was present in 50 (19.37 %) patients. CAD was more common among middle age and elderly patients (P = 0.03). Patients older than or equal 76.5 years had specificity of 78.8% for an association with CAD. Multivariate analysis showed that age (odds ratio: 1.042; 95% confidence interval: 1.009–1.075; P = 0.01) and diabetes (odds ratio: 3.437; 95% confidence interval: 1.618–7.303; P = 0.001) had a statistically significant association with CAD. Of 169 patients with involvement of the atrioventricular (AV) node, 28 (16.6 %) had associated left anterior descending artery (LAD) involvement with P = 0.01, suggesting an association between LAD disease and chronic degenerative changes in the AV node. Conclusion: CAD was present in 19.4% of patients undergoing PPI. Age and diabetes had a strong association with CAD. LAD stenosis was significantly more prevalent in AV nodal/ infra-hisian disease compared with sinus nodal disease.

Aim: The relationship between QT prolongation and myocardial ischemia is well known, however not many studies have correlated corrected QT interval and heart rate recovery with the severity of coronary artery disease (CAD). Methods: This was a single-center, prospective, observational study which included 127 patients with CAD and 124 patients without CAD. Results: Corrected QT variability from peak to recovery correlated well with CAD with a p value of 0.03. Receiver operative characteristic analysis did not show any significant diagnostic accuracy with any heart rate or QT parameters for predicting the presence or severity of CAD. Conclusion: Coronary artery disease is predicted by reduced ability of the heart rate to rise from rest to peak exercise and reduced recovery of heart rate and corrected QT from peak exercise to recovery at 1 min.

Polycythemia Vera (PV) is a chronic myeloproliferative disorder which is characterised by a high risk of developing arterial as well as venous thromboembolic complications like deep vein thrombosis, stroke, cortical vein thrombosis and rarely acute Myocardial Infarction (MI). PV has a risk rate of major thrombosis as high as 50%. Bleeding, thrombotic, and vascular complications are the major causes of morbidity and mortality, occurring in 40 to 60% of these patients. MI with heart failure is the most common cause of death in these patients. Congenital Protein S deficiency is an autosomal dominant disease. Venous thrombosis develops in 60- 80% of patients who are heterozygous for Protein S deficiency. Hereditary Protein S deficiency is a well known risk factor not only for venous thrombosis but also for arterial thrombosis including MI and stroke. However, association of Protein S deficiency with arterial thrombosis is less appreciated. Very rarely, we find all the varied thrombotic complications in one patient. We hereby present a case who had varied thrombotic presentations due to underlying polycythemia with Protein S deficiency.

Sinus node dysfunction, as the sole manifestation of an acute coronary syndrome, is rare. We report a case of ischemic dysfunction of the sinus node in a patient who had previously undergone coronary artery bypass grafting for triple vessel disease. Intermittent rest angina with a junctional rhythm was noted in spite of patent grafts to all three vessels, which resolved after percutaneous revascularization of the right coronary artery.

Extrinsic compression of the Left Main Coronary Artery (LMCA) by a dilated pulmonary artery is a rare but a treatable cause of angina in patients with Pulmonary Artery Hypertension (PAH). In majority of these patients, angina is attributed to right ventricular or left ventricular demand ischemia and in the absence of cardiovascular risk factors for atherosclerosis, they rarely undergo a coronary angiogram. So this rare diagnosis may be missed in such patients and optimal management delayed. In this case report we describe a patient of PAH secondary to Patent Ductus Arteriosus (PDA), presenting with heart failure and complaining of persistent angina, due to extrinsic compression of the ostial LMCA by the dilated pulmonary artery, treated successfully by Percutaneous Coronary Intervention (PCI). This case reminds us that in all patients of pulmonary hypertension presenting with angina and left ventricular dysfunction, this rare but treatable cause should be identified by coronary angiography and treated with PCI.

The anomalous origin of the entire coronary system from the right coronary sinus is a very rare anomaly. Here a patient with this rare anomaly, who developed acute coronary syndrome, requiring revascularization, is presented and treated successfully. His coronary angiographic findings are also discussed. We would like to highlight the rarity of the origin of all 3 coronary arteries from a single coronary trunk. The case also highlights the importance of using Amplantzer AR1 guiding catheter for such anatomical variations arising in the right coronary cusp.

Drug-drug interactions (DDIs) are defined astwo ormoredrugs interacting in such a mannerthatthe effectiveness ortoxicity of one or more drugs is altered. DDI in patients receiving multidrug therapy is a major concern. The aim of the present study was to assess the incidence and riskfactors of DDIs in patients admitted in cardiology unit of a teaching hospital. A prospective, observational study was carried outfora period of 3 months (April-July 2009). During the study period, a total of 600 prescriptions were analyzed and it was found that 88 patients had at least one DDI. The percentage of DDIs was higher in females compared to maies (56.82% vs. 43.18%). DDIs were observed more in the age group of 60 years and above (57.96). Patients with more than 10 prescribed drugs developed DDIs more frequently [58 (65.91%)]. Heparin [55 (62.25%)] and aspirin [42 (47.72%)] were the most common drugs responsible for DDIs. Bleeding was the commonest clinical consequence [76 (86.63%)] found in this study population. On assessment of severity of DDIs, majority of the cases were classified as moderate in severity (61.36%). Aging, female gender and increase in concurrent medications were found to be associated with increased DDIs. Patients having these risk factors can be actively monitored during their stay in the cardiology department to identify DDIs.

A 55-year-old man with a history of coronary artery bypass graft surgery presented to us with unstable angina. Preliminary investigations showed new ST depressions in inferior leads and elevated cardiac enzymes (Trop T and CKMB). A coronary angiogram was performed showing an occluded venous graft to the right coronary artery (RCA), with a haemodynamically significant heavily calcified lesion in the proximal and mid RCA (figure 1A). Angioplasty and stenting to the native RCA was planned. After adequate predilation of the lesion, the RCA was stented with a 3.5×28 mm everolimus eluting stent. As there was a residual lesion distal to the stented segment, we planned to stent the distal segment …

Objective This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes. Methods A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken. Results In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2 %), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%. Conclusion Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.

A 53-year-old woman diagnosed with rheumatic mitral stenosis (at the age of 40 years) presented with worsening dyspnoea New York Heart Association class III of 1 month duration. She was on regular treatment with diuretics, β-blockers and warfarin (in view of valvular atrial fibrillation). However, 1 month prior to presentation, she was off all medications except warfarin, which she was compliant on. Blood investigations revealed the presence of subclinical hypothyroidism with an optimal international normalised ratio of 2.64. ECG …

Coronary arteriovenous fistulae are a rare but potentially curable cause of ischaemic heart disease and should be considered as a differential diagnosis especially in patients lacking classical risk factors for coronary artery disease. We discuss one such case of cardiac ischaemia resulting from a coronary arteriovenous fistula. While there are sporadic case reports of similar patients in medical literature, our patient is the first reported case of ST-elevation myocardial infarction secondary to the fistulous connection.

Aim: To compare the results of percutaneous mitral valvuloplasty (BMV) for mitral restenosis in post-BMV versus postclosed mitral valvotomy (CMV) patients. Methods and Results: Ninety-two patients who underwent BMV for mitral restenosis were followed up prospectively. Of these, 28 patients had undergone previous percutaneous mitral valvuloplasty (PRIOR BMV) and 64 patients had undergone previous closed mitral valvotomy (PRIOR CMV). BMV for mitral restenosis was a success in 59% patients (57.1% PRIOR BMV, 59.3% PRIOR CMV, P = 1.0). Incidence of severe mitral regurgitation was 3.25%, all in the PRIOR CMV group. In univariate analysis, the major predictor of successful BMV for mitral restenosis was Wilkins score (P = 0.004). At a follow up of 3.47 + 2.07 years, mitral valve area was similar between groups (1.45 ± 0.22, 1.46 ± 0.26, P = 0.35). The combined end points of mitral valve replacement (MVR), need for rerepeat BMV for mitral restenosis or death was higher in the PRIOR CMV group (31.2% PRIOR CMV, 7.1% PRIOR BMV, P = 0.027). Event-free survival at follow up was lower in the PRIOR CMV group (69% PRIOR CMV, 92.8% PRIOR BMV) mainly due to the higher need for MVR (11 vs. 0 patients, P = 0.03). Conclusions: In conclusion, following BMV for mitral restenosis, patients with PRIOR BMV are found to have lesser event rates on follow-up compared to patients with PRIOR CMV, though procedural success rates are similar. © 2010 Wiley-Liss, Inc.

A 55-year-old man presented with a 6-month history of New York Heart Association II exertional dyspnoea. There was no history of diabetes mellitus or hypertension. Being a reformed smoker, he was on treatment for obstructive airway disease. General and cardiovascular examinations were unremarkable. ECG showed loss of R wave progression in precordial leads. Echocardiography was normal. Coronary angiogram revealed selective opacification of two right coronary arteries arising from separate ostia of the same sinus coursing towards …

Coronary bypass grafting using conduits with multiple distal anastomoses continues to demand scrutiny. While on one hand these techniques allow the surgeon to avoid or minimise aortic manipulation, the unique flow and pressure characteristics lead to complex forms of graft failure if the anatomy of the target vascular bed is not carefully taken into consideration. We report three cases of graft failure in patients with coronary bypass grafting performed using multiple distal anastomoses, and percutaneous revascularisation in one patient.

A 71-year-old male patient presented to us with a history of repeated episodes of syncope. On evaluation, he was found to have complete heart block, for which we decided to go ahead with transvenous dual chamber pacemaker implantation. We went ahead with the extrathoracic subclavian venous puncture for endocardial lead insertion. Once the lead was introduced via the 7 F peel away sheath, patient had sudden onset of respiratory distress with desaturation. On fluoroscopy we noticed massive amount of air inside the right ventricular outflow tract and pulmonary artery (figure 1 and video 1) suggestive of iatrogenic air embolism. Opening and …

Cor triatriatum is an uncommon but surgically correctable cause of pulmonary venous hypertension and congestive cardiac failure, with a reported incidence of 0.1% among children with congenital heart diseases. Association with partial atrioventricular canal defect (PAVCD) is even rarer, with only anecdotal reports appearing in the literature. In the classic form, cor triatriatum is characterized by the presence of a fibromuscular diaphragm that subdivides the left atrium into a proximal accessory chamber and a distal true chamber.

Rheumatic heart disease is the most common cause of mitral stenosis, and percutaneous balloon mitral valvotomy (BMV) has stood the test of time as the standard therapy for the same. We describe a very unusual complication of cardiac catheterisation that occurred during an otherwise uneventful procedure. A 65-year-old woman was diagnosed with severe mitral stenosis due to rheumatic heart disease. She was in atrial fibrillation and was admitted for BMV. She had a …