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Objective: To assess the safety and efficacy of Novel tapered (BioMime™ Morph) sirolimus- eluting stent (SES) for left main PCI in a real-world scenario. Background: Currently, no data is available on clinical usefulness of tapered ultrathin stents in left main PCI. Methods: This was a prospective, non-randomised, single centre study carried out between February 2018 and May 2020 at a tertiary cardiac care centre in southern India. The study included patients treated with BioMime Morph tapered stent for distal de novo LMB lesion or ostial LAD/LCX lesions with significant size disparity between reference segments based on the eligibility criteria. Primary endpoint of the study was the cumulative incidence of major adverse cardiovascular events (MACE) composed of cardiac death, myocardial infarction, and clinically driven target-lesion revascularisation at follow-up. Results: A total of 41 patients (average age of 54.83±9.81 years) were included in the study. Average SS-2 score was 23.17±5.42. Majority of the lesions (n=31; 75.61%) were of medina class (0.1.0). Provisional single stent strategy was adopted for treatment of LMB lesions. TIMI flow-3 was achieved in 40 patients (97.56%). Median clinical follow-up was 20 months (range 6-34 months). There was no periprocedural complication or MACE during follow-up. Conclusion: Tapered stents may be an acceptable alternative for LM intervention in an anatomical subset of patients with tapered vessels.

There is significant variability in the worldwide epidemiology of chronic thromboembolic pulmonary hypertension (CTEPH). We thereby aim to determine the incidence and predictors of CTEPH, following an episode of acute pulmonary embolism (PE), using non-invasive modalities. Patients with acute PE were prospectively followed-up and after receiving at least 3 months of effective anticoagulation, persistently symptomatic patients with echocardiographic evidence of persistent pulmonary hypertension, were investigated further for CTEPH. Incidence of CTEPH was 8.19%. Delayed presentation, higher pulmonary artery pressures at presentation and discharge, and greater thrombotic burden were significant predictors for the development of CTEPH following acute PE.

Introduction Coronary artery disease (CAD) follows a different pattern in women and men, more so in the young (< 40 years). The gender differences in the risk factors, clinical presentation and diagnosis need to be understood, so that appropriate and timely treatment can be given. Objective The study contemplates to analyze the gender differences in the presence of major coronary risk factors, clinical presentation, diagnosis and immediate outcomes in patients who present with premature CAD (PCAD). Patients and Methods We evaluated 1,062 consecutive registry patients who presented with diagnosis of PCAD between 2018 to 2019 at our institution after satisfying the inclusion criteria. Results The study analyses 82 females and 980 males. The mean age of females was 35.4 ± 4.68 years and males was 34.2 ± 4.25 years. Males smoked more often (55.1%, p p p p Conclusions Conventional risk factors play a major role for CAD in Indians. Smoking was common in males and metabolic syndrome in females. Also, females had a higher threshold for seeking treatment and referral. Measures have to be taken for early diagnosis and referral of females. Recanalized and thrombotic coronaries were common, indicating predominant thrombus burden in the young

Background: A significant number of patients with prosthetic valve thrombosis have a prothrombin time international normalised ratio in the therapeutic range at presentation. Surgery may not be possible in many patients and traditionally a high international normalised ratio is considered a relative contraindication for fibrinolysis. Methods: We conducted an observational study in patients with left-sided obstructive prosthetic valve thrombosis with international normalised ratio at or above the therapeutic range at presentation who received fibrinolysis. The fibrinolytic regimens, timing of initiation, success of fibrinolysis, risk of major and minor bleeding and ischaemic stroke were evaluated in the study. Results: Of 30 patients included in the study 70% received immediate fibrinolysis and in 30% it was delayed. The majority of patients (90%) presented with New York Heart Association class III/IV symptoms. The mean international normalised ratio at fibrinolysis was 3.04 ± 0.70 in the immediate group and 2.42 ± 0.89 in the delayed group. Haemodynamically stable patients who had delayed initiation of fibrinolysis had a trend towards less bleeding without an increase in mortality. The rates of intracranial haemorrhage (0% vs. 7.7%), minor bleeding (12.5% vs. 25.1%) and ischaemic stroke (0% vs. 30.7%) were lower in patients who received low dose infusion compared to a conventional dose. Conclusions: Fibrinolysis can be considered in patients with prosthetic valve thrombosis with high international normalised ratio at presentation. For haemodynamically stable patients, delayed initiation of fibrinolysis is associated with a marginally lower bleeding risk without an increase in mortality. Low dose infusion may be considered over a conventional dose as it is associated with a lower incidence of ischaemic stroke and a good rate of valve function restoration with a trend towards less bleeding.

Aims To study the risk factors, clinical and angiographic profile of Indian rural youth (under 35yrs) presenting with Premature Coronary Artery Disease (PCAD). Subjects and Methods: The PCAD registry had 1628 patients who were aged below 35 years, of which 681 patients satisfied the entry criteria. The data was analysed by statistical software R version 3.5.0. Results The study enrolled 681 patients after satisfying the entry criteria. The mean age of patients was 30.85 years. There were 405 (59.5%) aged between 30 and 35 yrs, 205 (30.1%) between 25 and 30 yrs, 64 (9.4%) between 20 and 25 yrs and 7 (1.0%) were aged less than 20 yrs. Majority of them were males, 617 (90.6%). Nearly 411 (60.4%) were smokers, 56patients (8.2%) were diabetics and 97 (14.2%) were hypertensives. Around 441 (64.8%) patients had low HDL cholesterol levels and 218 (32.0%) had elevated triglyceride levels. Abdominal obesity was seen in 443 (65.1%) patients. Most common clinical presentation was ST elevation myocardial infarction (STEMI) seen in 536 (78.7%) patients. Around 40% patients had recanalized/non obstructive/thrombotic/normal coronaries on coronary angiogram. Conclusions Conventional risk factors such as smoking, low HDL levels and abdominal obesity play a major role in the causation of premature coronary artery disease among the rural youth. Thrombotic milieu in the coronaries was commonly noted in coronary angiograms. Lack of awareness, combined with urbanisation of rural lifestyle could be responsible for increasing incidence of premature coronary artery disease in rural youth.

Highlights • Noonan syndrome is the second most common syndromic cause of CHD. • We present a rare case of Noonan syndrome having a combination of ASD, PS and HCM. • Patient underwent balloon valvotomy for pulmonary stenosis. • The patient is under regular follow-up and awaiting heart transplant., Introduction Noonan syndrome is the second most common syndromic cause of congenital heart disease. Most patients have an autosomal dominant inheritance, but some cases may be sporadic. Pulmonary stenosis is the most common cardiac manifestation in Noonan syndrome, associated with the atrial septal defect and hypertrophic cardiomyopathy. A combination of these three is present only in 5% of patients. Presentation of case We report a case of a 21-year-old female who presented to our hospital concomitant cardiac lesions associated with pulmonary stenosis, atrial septal defect, and hypertrophic cardiomyopathy. This combination of cardiac defects is an infrequent manifestation of Noonan syndrome. The patient presented with complaints of exertion syncope over the past two years. 2D-Echocardiography showed biventricular hypertrophy, dysplastic pulmonary valve, severe pulmonary stenosis, asymmetric septal hypertrophy and large atrial septal defect. The genetic analysis report showed autosomal dominant inheritance with Ras/MAPK (mitogen-activated protein kinase) Positive. Discussion Due to the wide spectrum of symptoms and presentations in Noonan cases, accurate clinical and genetic diagnosis, and comprehensive management of the disorder are strongly recommended. Conclusion We have described a case of rare combination of cardiovascular defects in Noonan Syndrome with a view to achieve better insight into the disease course and advantages of timely treatment and follow up. Our patient is currently in follow-up after treatment with percutaneous balloon pulmonary valvuloplasty, has improved symptoms, and is awaiting heart transplant.

Aims: To study clinico-social, biochemical and angiographic profile of patients presenting with premature coronary artery disease (PCAD) who are drivers by profession. To highlight the impact of occupational hazard and air pollution in them. Subjects and Methods: Of 3450 patients registered in the PCAD registry till date, 755 (21.88%) were found to satisfy the inclusion criteria. The data was analyzed by statistical software R version 3.5.0. Further analysis of smokers versus nonsmokers was done. Results: The average age of the group was 33.10 years. Almost all 754 (99.8%) were males, of which 323 (42.78%) smoked. The group had 83 (10.95%) diabetics and 71 (9.4%) hypertensives. Around 99 (13.11%) had a family history of coronary artery disease (CAD). Majority of them, 440 (58.27%), were urban drivers with average driving of 10 h/day. In the group, 482 (63.8%) had abnormal body mass index (BMI) and 539 (71.41%) had abdominal obesity. Low HDL was seen in 508 (67%) patients. ST-elevation myocardial infarction was the most common presentation in 415 (54.96%). Obstructive atherosclerotic CAD was seen in 217 (34.22%). Further analysis of smokers versus nonsmokers showed that hypertension, diabetes, and abnormal BMI were less common among nonsmokers, indicating the probable role of air pollution in them. Conclusions: Occupational hazard due to the stress related to prolonged driving hours, obesity, smoking and the possible role of air pollution are the important cardiovascular (CV) risks which come to light in this group of patients. Furthermore, the majority of them presented with predominant thrombotic lesions, however, smokers, who also had other CV risk factors, presented more often with obstructive atherosclerotic CAD.

Aim: The aim is to study the clinical, social, biochemical, and angiographic profile of youth (under 35 years) with familial premature coronary artery disease (PCAD). Subjects and Methods: The PCAD registry is a prospective ongoing descriptive observational study of Indians aged below 40 years with coronary artery disease (CAD) which was started on April 1, 2017. Of 3450 patients registered in the PCAD registry till date, 1628 patients were aged 35 years or younger. Of these 1628 patients, 218 satisfied entry criteria. The entire clinical and angiographic profile of these patients was documented. The distribution of different lipid profile parameters was visualized by nonparametric density plot. The data were analyzed by statistical software R version 3.5.0. Results: Of 3450 patients registered in the PCAD registry till date, 1628 patients were aged ≤ 35 years. Two hundred and eighteen out of these 1628 patients (13.39%) belonged to the study group for this particular study. The mean age of all patients under the PCAD registry was 30.44 years, and 201 (92.2%) were males. 106 (48.62%) were smokers. Twenty-nine patients (13.33%) of them were diabetic. The most common index presentation of CAD in familial PCAD was with ST-elevation myocardial infarction (STEMI; 112 patients – 51.37%) and unstable angina/non-STEMI (58 patients – 26.6%). Forty-eight patients (22.01%) presented with evolved MI. Conclusions: Almost 14% of coronary events in younger age (under 35 years) were attributable to family history of CAD. Family history of CAD can be used as a criterion to select younger age population to perform targeted screening for cardiovascular diseases.

There is growing global attention concerning the short and long term prognosis of acute coronary syndrome (ACS) in patients with prior coronary artery bypass grafting (CABG). Significant left main coronary artery (LMCA) disease occurs in 5%-7% of patients undergoing coronary angiography, which is associated with a worse prognosis. We report a series of 3 patients presenting with LMCA disease out of which one patient successfully underwent CABG, and two patients managed with optimal medical therapy.

Atrial septal defect (ASD) is one of the most common congenital heart defects. Intracardiac repair via midline sternotomy or right thoracotomy and cardiopulmonary bypass have been considered the standard treatment for the closure of atrial septal defects, but transcatheter closure with Amplatzer septal occluder has recently become an alternative option. Transcatheter device closure of secundum ASD is a more than a decade old technology. This has become an alternative to surgical therapy, and has been regarded as generally safe and effective device closure. Device embolization is a potential complication of every attempted ASD closure, and the causative factors include undersized device, floppy rim, and operator-related technical issues, such as malposition during a “push-pull” maneuver. In this paper, we report a 32-year-old HIV positive female patient who presented with gradual onsite of dyspnea, NYHA class II, and successfully underwent a device closure of large atrial septal defect.

Aims and Objectives of the Study: The type 2 diabetes mellitus (T2DM) prevalence is increasing worldwide at alarming rates. The prevalence of T2DM is expected to be more than 350 million people worldwide in next 20 yrs. The risk of coronary and peripheral artery disease increases by 2 to 4 fold, while the risk of stroke is increased by 10 fold in type 2 diabetes mellitus patients. In type 2 diabetes mellitus, dyslipidemia plays an important role in the pathogenesis of accelerated atherosclerosis. Hyperlipidemia in postprandial state is thought to play an important role in atherosclerosis, and concentrations of triglycerides(TG) in post prandial state are superior to those of fasting TG for predicting cardiovascular disease. Increase in serum ferritin levels are associated with insulin resistance(IR), systemic inflammation, metabolic syndrome(MetS), type 2 diabetes mellitus and cardiovascular disease. Elevated body iron stores may contribute to insulin resistance through chronic inflammation and oxidative stress. The present study is under taken to assess the implication of post prandial dyslipidemia in comparison to fasting dyslipidemia in the pathogenesis of cardiovascular disease and to show the importance of increased serum ferritin levels in type 2 diabetes patients which acts as a potential risk marker for coronary artery disease. Materials and Methods: Fifty type 2 diabetes mellitus patients and fifty normal adults between age group 30-75yrs attending Medicine OPD, Rajarajeswari Medical College and Hospital, Bangalore were scree ned for lipid profile using enzymatic method by ERBA 360 autoanalyzer and serum ferritin levels by chemiluminiscence method. The statistical analysis was done by students unpaired t-test. Results: Serum lipid profile including TGs, LDL-C, VLDL-C were significantly increased in the postprandial state as compared to the fasting state in cases with p elevated in cases, compared to controls with p state compared to fasting state in cases w

Introduction Myxomas are the most common type of cardiac benign tumors and most of them are located in the left atrium, followed by the right atrium. The majority of Myxomas is located in the left atrium and has a variable clinical presentation. Myxomas affect patients within a wide age range (15–80 years), and the average age is approximately 50 years. There is a female predominance in the sporadic form. Myxomas are usually pedunculated, solitary, and sporadic but may be associated with familial autosomal dominant syndromes. Case presentation We report a 38-year-old female presented with large myxoma in the right atrium and atypical presentation and successfully underwent surgical excision of right atrial myxoma. The patient was asymptomatic on 6 months follow up. Conclusion Cardiac myxomas are the most frequent finding among primary cardiac tumors. Clinical manifestations depend on the involvement in valvular obstruction, distant arterial embolisms, or nonspecific, constitutional symptoms. Transoesophageal Echocardiography is the cornerstone for diagnosis of atrial myxoma. Cardiac myxomas should be managed with surgical resection., Highlights • Myxomas are the most common type of cardiac benign tumors and most of them are located in the left atrium, followed by the right atrium. • We report a case of 40-year-old female patient, presented with chest pain, epigastric abdominal pain, vomiting for 3 days, easy fatigability since 1 yr, intermittent episodes of presyncope since 1 year. No constitutional disturbances such as fever, weight loss, skin rash, myalgia or arthralgia. Cardiovascular system examination was normal with no clinically detectable murmurs. • The patient underwent open surgical resection of the RA mass with no pre-operative or post-operative complications Gross macroscopic examination showed a nearly spherical gelatinous mass of the size of a cricket ball measuring around 4 cm in diameter with a smooth surface and elastic consistency. • Histo-pathological examination confirmed the diagnosis of cardiac myxoma. Microscopic showing tumor displaying myxoid change and stellate cells having bland nuclei arranged in reticular meshwork. The patient was asymptomatic on 6 months follow up. Our case is important because of the atypical size and location of cardiac myxoma in the right atrium. • RA myxoma is considered as differential diagnosis of right atrial thrombus. Early diagnosis and treatment prevent the complications of thromboembolic events.

Myxomas are the most common type of primary cardiac tumor. They cause a variety of clinical manifestations depending on size and anatomical location. Sometimes, manifestations are atypical challenging differential diagnosis and the therapeutic approach. Left atrial myxomas are commonly missed clinically and often lead to grave consequences. We present here a series of 6 cases of left atrial myxomas with demographic and clinical characterization of the patients that were managed successfully.

Highlights • Aortic dissection has a high mortality rate. It is common in elderly males. Aortic dilatation definitely increases risk but is not a must in every case. Clinical manifestation of Aortic dissection can be variable, therefore its diagnosis is challenging. • Primary suspicion of Aortic dissection is usually based on a patient’s history which varies from typical complaints like a sharp, severe tearing kind of backache with chest pain to asymptomatic until associated with valvular regurgitation. • Consequent treatment with antiplatelet, antithrombin and thrombolytic agents can cause life-threatening to bleed. Apart from good blood pressure control, prevention of aortic dissection can be done by elective aortic surgery in patients with dilated ascending aorta. • The most important and common risk factor is the systemic hypertension which has been reported in the 70% of the patients with aortic dissection. Most of the aortic dissection observed in young women has been reported to be related to pregnancy., Introduction Typically a patient with acute aortic dissection presents with severe chest pain radiating to the back, tearing in nature. Rarely it can present as painless acute aortic dissection this is seen in iatrogenic cases or when associated with atherosclerosis, diabetes, or aortic aneurysm. Case presentation We hereby present a case of a 32-year aged female who presented with dyspnoea & palpitations (NYHA III) from last 6 months, diagnosed to have Aortic Aneurysm with Type A dissection & Severe AR. She eventually underwent BENTALL’S procedure with CABG and had an uneventful recovery. Discussion Clinical manifestation of Aortic dissection can be variable, therefore its diagnosis is challenging. 25% of cases, may have associated ECG changes suggestive of acute coronary syndrome leading to a possible misdiagnosis especially if associated ST elevation in ECG. Aorto arteritis is a non-atherosclerotic chronic inflammatory vascular disease of unknown etiology that affects the aorta, proximal parts of its major branches. In this case, there is a possibility that there was underlying spontaneous coronary artery dissection which in turn could be cause for silent ischemia in young women. Conclusion Acute aortic dissection is a life-threatening disease with a high rate of cardiovascular morbidity and mortality. The most important and common risk factor is systemic hypertension which has been reported in the 70% of the patients with aortic dissection. Most of the aortic dissection observed in young women has been reported to be related to pregnancy. Dissection should be suspected during any acute coronary syndrome, particularly Inferior wall MI.

Aim: This retrospective study compares admissions and outcomes due to acute decompensated heart failure (ADHF) during the COVID-19 pandemic from 25 March to 25 July 2020 with the historical patient control who were admitted during the same period in 2019. Methods and results: Data of the participating hospitals was collected and analysed from the ICC NHFR (Indian College of Cardiology National Heart Failure Registry) for 2019 and 2020. Total number of ADHF admissions, demographics, aetiology, co-morbid conditions and in-hospital mortality was compared and analysed. A significant decrease in the number of hospital admissions due to ADHF from 2019 to 2020 (1056 vs. 526 respectively) was noted. Incidence of admissions with 40% (EF) increased (27.6% and 19.8% in 2019 and 2020 respectively, p = 0.0005). Ischemic heart disease (IHD) was the most common aetiology (78.59% in 2019 and 80.98% in 2020, p = 0.268). The in-hospital mortality was numerically higher in 2020 (10%) than in 2019 (8%), but not statistically significant (p = 0.161). Conclusion: This study from the registry shows that the incidence of ADHF admissions during COVID-19 lockdown significantly reduced compared to the previous year. Demographic patterns remained similar but patients presenting with de-novo HF increased; IHD was the most common cause. The in-hospital mortality was numerically higher during the lockdown. The impact of lockdown perhaps led to fewer hospitalisations and this is to be factored in future strategies to address health care delivery during such crises.

Objective: To study the significance of ST-segment depression during ‘recovery’ compared to that ‘during stress’ and ‘both the phases’ in exercise stress test. Methods: Patients with positive exercise stress test who underwent coronary angiography (CAG) from 1st January 2017 to 31st December 2018 were studied. Patients were divided into 3 groups- Group A with ST-depression restricted to recovery phase, group B with ST-depression restricted to stress phase and group C with ST-depression seen both during exercise and recovery. All patients underwent CAG. Sensitivity, specificity, and predictive values of each of these groups in diagnosis of significant coronary artery disease (CAD) were analysed and compared. Results: Total 300 patients were studied. Mean age of the study population was 48.77 ± 7.94 years. 78.3% of patients with positive exercise stress test had significant CAD. 96% of patients in group A had significant CAD, which was higher than in group B (88.9%) & group C (70.1%). The specificity, positive predictive value and negative predictive value of ST-segment depression in group A (96.92%, 96% and 25.2% respectively) were higher than that of ST-depression in group B (89.23%, 88.89% and 24.47% respectively) and group C (13.85%, 70.05% and 7.96% respectively). Sensitivity and accuracy of ST-depression in group A were lower (20.43% and 37% respectively), compared to other 2 groups. Conclusion: Patient with ST-depression restricted to recovery phase had highest specificity, positive predictive value, and negative predictive value. However, accuracy was highest in group with both stress phase and exercise ST-segment depression.

Quadricuspid aortic valve is a rare entity. Left ventricular noncompaction is an uncommon cause of cardiomyopathy. Combination of these two conditions is very rare. We report a case of quadricuspid aortic valve and moderate aortic regurgitation with left ventricular noncompaction who had presented with ventricular tachycardia.

A dual left anterior descending (LAD) coronary artery is a rare, and benign congenital anomaly. In this anomaly, there is the presence of two LADs in the anterior inter ventricular sulcus (AIVS). One of the LADs is a short one that ends high in the AIVS. The other longer one enters the distal AIVS and feeds the apex. To date, 9 types of dual LAD variants, and one novel type X has been reported. Herein, we report a case of type X dual LAD with a literature review.

There have been no published recommendations for management of Low Risk Chest Pain in Emergency Departments across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in Emergency Departments. Risk stratification of patients utilizing an Accelerated Diagnostic Protocol has been shown to decrease hospitalizations by approximately 40% with a low 30 day risk of Major Adverse Cardiac Events. The Experts Group of Academic Leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with Academic Experts in Emergency Medicine and Cardiology from leading Institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in Emergency Departments across India.

Aim: Spontaneous coronary artery dissection (SCAD) is a rare cause of angina, myocardial infarction (MI), and sudden cardiac death (SCD) and may frequently manifest as acute coronary syndrome (ACS). The diagnosis of SCAD relies on angiographic visualization of a radiolucent intimal flap. Therapeutic options include medical therapy, percutaneous coronary interventions, and bypass surgery. The aim of this study is to analyze the clinical profile, inhospital outcomes, management, and follow-up of patients with angiographic SCAD. Methods: About 19,676 diagnostic coronary angiograms (CAGs) were reviewed retrospectively during a 2-year period; 64 patients had SCAD and were included in the study. Complete medical histories before and during the event as well as treatment regimens were obtained from patients' hospital files. Results: A total of 64 cases of SCAD were considered for the study within an age range of 25–70 years. Fifty-eight patients presented with ACS, two patients presented with unstable angina, one patient presented with rheumatic mitral stenosis in atrial fibrillation, one patient presented with non-ST-elevation myocardial infarction, one patient with dilated cardiomyopathy with left ventricular dysfunction, and one patient with effort. Out of 64 patients, four patients died and the average hospital stay is 3–5 days. Conclusion: SCAD occurs in 0.32% of patients undergoing CAG for evaluation of coronary artery disease. Majority of SCAD occurs in men. The left coronary artery is most commonly affected. The inhospital outcomes are good. Most of the patients with SCAD have good prognosis following optimal medical therapy.

Bicuspid aortic valve, the most common congenital cardiac lesion, is frequently associated with infective endocarditis (IE), and this combination is notoriously associated with increased prevalence of periannular complications. Mitral valve involvement as a “kissing” lesion secondary to aortic valve endocarditis is a very rare entity. Only few case reports are available describing this lesion. We report a case of recurrent IE involving both cusps of bicuspid aortic valve complicated by “kissing” lesion of the anterior mitral leaflet leading to aneurysm formation. The patient presented with severe aortic regurgitation and moderate mitral regurgitation. The patient was treated successfully with surgical aortic valve reconstruction (Ozaki procedure) with mitral valve repair.

Objective: Reteplase (recombinant plasminogen activator) is a mutant of alteplase. It has a longer half-life than its parent molecule and has shown better vessel patency rates in acute myocardial infarction. In this study, we analyzed the efficacy and safety of reteplase in acute pulmonary embolism (PE). Methods: This observational study included patients with high- and intermediate-risk acute PE, presenting within 14 days of symptom onset. The patients were treated with reteplase, which was given in two bolus doses of 10 U each, 30 min apart, along with intravenous heparin. Patients with hemodynamic compromise (high-risk or massive PE) and normotensive patients with evidence of right ventricular (RV) dysfunction (intermediate-risk or submassive PE) on echocardiography or computed tomography were included in the study. The efficacy outcomes assessed were in-hospital death and improvement of RV function by echocardiography. The safety outcomes were major bleeding, minor bleeding, and ischemic or hemorrhagic stroke during hospitalization. Results: Of the 40 patients included, 25% were classified as high risk with hemodynamic compromise and 75% were classified as intermediate risk. RV dysfunction was present in all the patients (100%). Concomitant lower extremity deep vein thrombosis was present in 55% of the patients. The mortality rate was 5%. There was significant improvement in RV function and reduction in pulmonary artery systolic pressure and tricuspid regurgitation severity. There was no major bleeding event or stroke, and 7.5% patients had minor extracranial bleeding. Conclusions: Double-bolus reteplase given with heparin is effective in the treatment of high- and intermediate-risk PE, with minimal risk of bleeding. Keywords: Acute pulmonary embolism, Reteplase, Thrombolysis

Kounis syndrome (KS) refers to acute coronary syndrome secondary to a hypersensitivity reaction as a result of exposure to various allergens. Multiple bee stings as a cause of KS is rarely reported in the literature. Its diagnosis in allergic reactions is of utmost importance, as it leads to an entirely different line of management. We report a series of six cases who presented with the diagnosis of KS due to multiple bee stings.

Background: Pericardial tamponade, a life-threatening condition caused by the accumulation of fluid in the pericardial sac, can be acute or chronic. Mortality and morbidity can be minimized on prompt diagnosis and treatment with percutaneous drainage. Materials and methods: 246 patients admitted with cardiac tamponade between Jan 2010 and Aug 2014 was enrolled in the study. After clinical examination and echocardiographic assessment, all the patients were subjected to emergency pericardiocentesis (both diagnostic and therapeutic). Three samples of the aspirate were sent for biochemical, serological, and cytological analysis. The data collected was then analyzed.

Background and Aim: Chronic rheumatic heart disease (RHD) patients who undergo valve replacement with mechanical valves require lifelong anticoagulation. Acenocoumarol, a vitamin K antagonist has a narrow therapeutic range and wide inter-individual variability. Our aim was to investigate the influence of polymorphisms of VKORC1 and CYP2C9 genes on the mean daily dose requirement of acenocoumarol. Methods: 205 chronic RHD patients, with mechanical heart valves and on acenocoumarol therapy, were recruited. Genotyping for VKORC1 (−1639G>A and 1173C>T) and CYP2C9 (*2 & *3 alleles) polymorphisms was done by PCR-RFLP. There was complete linkage disequilibrium between VKORC1 polymorphisms (r2 = 0.98, D′ = 1.0, LOD = 74.02). VKORC1 genotype distribution for GG/CC, GA/CT, and AA/TT were 57.6%, 36.1%, and 6.3%, respectively. CYP2C9 genotype distribution for *1/*1, *1/*3, *1/*2, *2/*2, and *2/*3 were 78.5%, 14.1%, 6.3%, 0.5%, and 0.5%, respectively. Patients with a wild type of both VKORC1 (−1639GG and 1173CC) and CYP2C9 gene variants required higher acenocoumarol dose compared to those with mutant genotype ( P = 0.023 and P = 0.008 respectively). On combined genotype analysis, patients having a combination of wild type of VKORC1 with wild type of CYP2C9 (44.4%) required higher daily dose compared to patients bearing heterozygous VKORC1 (−1639GA & 1173CT) with wild type of CYP2C9 (30.2%, P = 0.008). Conclusion: Presence of a mutant allele of VKORC1 (−1639A & 1173T) and CYP2C9 genes increased the odds of requiring a lower mean dosage of acenocoumarol. Studying the combination of genotypes in RHD patients could predict acenocoumarol dose requirement more accurately.

Surgical ventricular restoration is a procedure designed to restore or remodel the left ventricle.

Background: The PCI target vessel and corresponding outcomes in prior CABG patients are poorly studied. The study aims to determine the predictors and outcomes of native coronary artery and bypass graft percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass graft surgery (CABG).Methods: The factors associated with native and bypass graft PCI were analyzed in prior CABG patients undergoing PCI between July 2011 and December 2013, at Sri Jayadeva Institute Of Cardiovascular Sciences and Research, Bengaluru. Clinical/procedural characteristics and immediate procedural outcomes were recorded and analyzed.Results: During the study period, 76 patients underwent PCI who were before CABG patients. The PCI target was a native coronary artery in 73.6% and a bypass graft in 28.9%. The majority of patients presented more than five years after the CABG (64.4%). Post PCI angina was seen in 7(9.2%), and in 6(7.8%) patients, procedural complications seen. It was found that most PCI was done in patients who presented more than five years after CABG.Conclusions: Most PCIs performed in prior CABG patients are done in native coronary artery lesions.

Pregnancy with mechanical valves requires anticoagulation, the risk of bleeding and embryopathy associated with oral anticoagulation must be weighed against the risk of valve thrombosis. In the presence of a mechanical valve thrombosis, an appropriate treatment modality must be selected. Prosthetic valve thrombosis during pregnancy requires immediate therapy such as valve replacement, thrombolytic therapy, or surgical thrombectomy. A course of thrombolytic therapy may be considered as a first-line therapy for prosthetic heart valve thrombosis. We describe a primigravida (second trimester) with mitral valve replacement status presenting with acute prosthetic valve thrombosis and treated successfully with intravenous streptokinase.

Background: Acute heart failure (AHF) is a common and growing medical problem associated with major morbidity and mortality. It is the leading reason for hospital admission among patients over age 65 years. Not much of data is available from India, there are a lot of differences between the western data and available Indian data. Prompt diagnosis, identification of reversible causes and supportive management in ICU is of paramount importance.Methods: This study was conducted at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka after the institutional ethics committee approval. Those patients who were diagnosed to have AHF, were evaluated and treated as per the institution protocols in ICU and standard medical care which includes diuretics, inotropes and vasopressors. All the patients were prospectively studied; investigated for the etiology of AHF.Results: Majority of patients presenting as Acute Heart Failure are of 60 years mean age, with 63% males. Ischemic heart disease is the leading cause of Acute Heart Failure. Shortness of breath was the commonest presentation followed by crackles. Abdominal pain was the most common (28%) non cardiac symptom. There is no significant correlation between the presence of anemia and mortality. Hyponatremia had relation with mortality. 22% had HFpEF, rest had HFrEF. The mean hospital stay was 8.3 days. The study mortality was 9 % and the 30-day mortality was 13 % in our study.Conclusions: Current available data from Indian studies and registries has a lot of difference from the western data with regards to causes, response to treatment, and more such data is needed to frame regional guidelines for better understanding of presentation of heart failure ,treatment and risk factors for mortality.

Background: There is limited data available about the effectiveness of thrombolysis in prosthetic valve thrombosis (PVT). Therefore, this study aimed to evaluate the efficacy and safety of thrombolytic treatment in PVT patients.Methods: This was an observational study conducted at a tertiary-care centre in India between March 2013 and April 2014. Total of 56 patients with either recurrent PVT or with confirmed left-sided PVT was included in the study. Thrombolytic therapy was administered as an intravenous infusion of streptokinase or urokinase, initially at a loading dose of 2.5L IU/hour over 30 minutes, followed by 1L IU/hour for 48–78 hours depending upon the clinical and 2D-Echo observation. Primary endpoint was considered as the occurrence of a complete clinical response. Secondary endpoint was considered as a composite of death, major bleeding or embolic stroke.Results: Mean age of the patients was 37±13 years. Most of the patients presented with NYHA-II (51.7%), III (39.2%), and IV (8.9%) symptoms. Mitral and aortic valve thrombosis were observed in 40(71.4%) and 11(28.6%) patients. Forty-nine (73.3%) patients were treated with streptokinase. Whereas, rethrombosis patients were treated with urokinase [6(16%)] and tenecteplase [1(1.3%)]. Two (3.6%) patients died, 1(1.8%), 1(1.8%), 2(3.6%), and 1(1.8%) patient had peripheral embolism, central nervous system bleeding, stroke, and embolic complications.Conclusions: Thrombolytic therapy can be used as the first-line treatment for thrombolysis in PVT patients. All PVT patients can be treated with streptokinase unless specific contraindications exist. Urokinase or tenecteplase is an alternative thrombolytic agent in rethrombosis patients.

Background: Spontaneous coronary artery dissection (SCAD) is rarely encountered as a primary cause of acute coronary syndrome (ACS). There is a paucity of studies involving SCAD, especially in the Indian population. Aims: We aim to study the clinical and angiographic characteristics and in-hospital outcomes of ACS patients whose angiogram incidentally shows SCAD as the cause of ACS and the management strategies opted. Methods: This is a prospective and retrospective observational study. All coronary angiograms of patients with ACS, either ST-segment elevation myocardial infarction (STEMI) or unstable angina non-STEMI, underwent within 72 h of admission, were analyzed and those patients with Saw classification Type I SCAD were included in the study. Clinical and angiographic characteristics, in-hospital outcomes, and management strategies of patients with SCAD were recorded. Results: Of the total 70 cases with SCAD included in the study, 66 (94.28%) were male. Smoking was the most common risk factor seen in 22 (31.4%) cases. STEMI was the most common presentation seen in 44 (62.8%) subjects. Single-vessel involvement was seen in 67 (95.7%) patients. Significant stenosis, i. e., >70% luminal narrowing was seen in 40 (57.1%) patients. Root cause analysis (RCA) is the most common artery to be involved with 35 (50%) cases. Majority of the cases, i.e., 60 (85.7%) cases had thrombolysis in myocardial infarction 3 flow. The majority was managed conservatively. Percutaneous transluminal coronary angioplasty (PTCA) was done successfully in 18.5% of patients. Conclusion: Indian subjects, as observed in this study, differ significantly in their profile compared to the Western population. Indian subjects are predominantly middle-aged males with a significant proportion having traditional risk factors, and they tolerate thrombolysis better, success rates of PTCA are much higher, RCA is the most commonly involved artery as opposed to left anterior descending in Western population and more than half of the patients have atherosclerotic disease involving other arteries.

An aortic aneurysm is a rare clinical entity since most patients will present with complications of dissection or rupture before the size of aneurysm reaches that magnitude. The classical presentation of a patient with acute aortic dissection (AAD) is characterized by severe chest, back, or abdominal pain, ripping or tearing in nature (mimics myocardial infarction). However, some patients present with painless AAD. We hereby present a case report of a 28-year aged female who presented with palpitation from the past 2 years, diagnosed to have aortic aneurysm with dissection and severe aortic regurgitation. She eventually underwent Bentall's procedure and had an uneventful recovery.

Aims: Heart Failure (HF) is a growing epidemic globally and a challenging situation particularly for a country like India. There is paucity of data in the Indian context and the Indian College of Cardiology National Heart Failure Registry (ICCNHFR) would be the first of its kind in understanding the aetiology, demographics and treatment pattern in the country. The rationale and design of the study is described. Methods and Results: This is a prospective observational registry study of Acute Decompensated Heart Failure (ADHF) across various hospitals in India. This would include data of consecutive adult patients admitted with acute heart failure in the hospitals. This study is from Sep 2019 to Sep 2021 and is expected to enroll about 10000 patients. The primary data would be to analyse the demographics, aetiology, comorbid conditions, inhospital mortality, 30 day and one year mortality and rehospitalisation. The secondary aim would be understand the diagnostic patterns and therapeutic options offered for these patients.Conclusion: The present registry is designed to analyse the national data on ADHF. This would identify gaps in HF care and therapy. This would help in improving quality of heart failure care in the country and better resource utilization. This will help in the reduction of mortality and morbidity rate related to HF

Hypertrophic cardiomyopathy (HCM) with left ventricular non-compaction (LVNC) is unusual. Atherosclerotic coronary artery disease in these is rare. We reported a case of HCM with LVNC presenting as stable angina pectoris. Multimodality imaging studies will help to diagnose and guide the management of this uncommon condition.

Background: Anomalous origin of the right coronary artery (AORCA) from the left sinus of Valsalva (LSOV) accounts for 6%–27% of all coronary anomalies. Systematic planning and selection of appropriate catheters are pertinent for successful results. On many occasions, it is not possible to selectively cannulate the vessel despite the use of multiple catheters or modified curves in them. Situation worsens in acute coronary syndrome scenario where valuable time is lost just trying to delineate the diseased coronary anatomy. Aims and Objectives: to study the guide catheter selection in cases of (Anomalous RCA) AORCA arising from left sinus of valsalva (LSOV). Materials and Methods: We encountered six cases of AORCA from left sinus of valsalva with significant coronary lesions in one year. Results: Three cases were done through transfemoral access and in three others cases the access was switched from transfemoral to right radial access. In two of these cases we adopted a double length coronary wire for performing the percutaneous transluminal coronary angioplasty (PTCA) as compared to the regular technique. Conclusion: In order for PTCA to be successful in anomalous coronary arteries, optimal guide catheter seating and catheter back up should be achieved, both of which may require modification in either the technique or change in access or alteration in the guiding catheter employed. While performing primary PCI, the operators and the ancillary staff need to be aware of this anomaly and be prepared. Exchanging guide catheter on coronary double length wire though cumbersome can ensure successful outcome. Change to right radial approach may confer an additional advantage of cannulating the vessel as the catheter gets support from the contralateral aortic wall.

Mesenteric ischemia is an infrequent condition that presents either acutely or chronically. Endovascular treatment of mesenteric artery stenosis or short-segment occlusion by balloon dilation or stenting represents a less invasive therapeutic alternative to open surgical intervention, particularly in patients with comorbidities. We describe a case of ostio proximal celiac artery occlusion that was treated using balloon-expandable stent through the left brachial approach.

Coronary arteries anomalies are rare. We report a case of anterior wall myocardial infarction with anomalous left anterior descending artery (LAD) and left circumflex artery (LCX), with LAD originating from right coronary sinus and LCX from right coronary artery. We did successful percutaneous coronary intervention with stenting to LAD using Amplatzer AR1-catheter.

Objectives The aim of the present study was to study the feasibility and approaches to device closure of ruptured sinus of Valsalva (RSOV). We have compared the advantages and disadvantages of different devices and techniques and discussed complications which might occur during or after the procedure. Background There are only a few case series of transcatheter closure of RSOV, with most cases being traditionally referred for surgery. We have employed different devices used for treatment of congenital shunt lesions to achieve closure. Reasons for failure and need for surgical referral have also been analyzed. Methods Transcatheter closure was attempted in a total of 25 patients of RSOV who presented to us over a period of 4 years. Different devices were deployed using antegrade and retrograde approaches. All patients have been on regular follow-up. Results The procedural success rate was 84%. Two patients presenting in cardiogenic shock were effectively treated by device closure. There was one case of device embolization and two patients had residual leak. Three patients were referred for surgery. There was one case of device induced severe aortic regurgitation. Ventricular septal defect and RSOV were closed simultaneously in one patient. Conclusions Different approaches and devices may be used for transcatheter closure of RSOV. We prefer antegrade closure using duct occluders in most cases while muscular VSD occluders may be used in select situations. ADO II devices should hardly ever be used on their own for device closure of RSOV. © 2015 Wiley Periodicals, Inc.

Acute pulmonary embolism is a potentially fatal disease associated with a number of cardiac and non-cardiac predisposing factors. The association of rheumatic mitral valvular with right atrial thrombus in the absence of right ventricle dysfunction is extremely rare but is a possibility and a crucial differential diagnosis which needs to be kept in mind in a patient presenting with acute worsening of dyspnoea. Here we are presenting a case of a 37 year old female with severe rheumatic mitral stenosis in atrial fibrillation who presented to us with acute pulmonary thromboembolism with a large right atrial clot a month after she underwent a PTMC procedure. The patient had been on oral anticoagulation after the procedure and the INR was found to be therapeutic at the time of admission. The presence of a large right atrial clot was an unexpected finding in this case in the absence of right ventricular dysfunction and any other obvious pro-thrombotic predisposing factor except for atrial fibrillation. The occurrence of delayed right atrial thrombus may be related to instrumentation for septal puncture during PTMC for which the interventionists should be vigilant about in the immediate post-procedure period.

Left main coronary artery stenosis is the most challenging lesion in patients with acute coronary syndromes. Since the amount of myocardium at risk is very high, the patient is often in cardiogenic shock, and the risk of death is high and even more so in left dominant coronary system. Left main stenosis is a Class I indication for CABG -ACC/AHA guidelines and has been a relative contraindication to PCI. We report an elderly patient presenting with ACS with ECG showing ST elevation in lead a VR. Coronary angiogram revealed left dominant system with left main stenosis and ostioproximal LAD and LCX disease. Double stenting of the unprotected left main with bifurcation disease done with SKS technique with simultaneous stenting and post balloon dilatation was done with good results. Current guidelines still indicate CABG as optimal treatment for LMCA lesions. The choice of stenting technique for LMCA bifurcations should be based on bifurcation morphology.