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Purpose: Earlier imaging techniques for coronary artery disease (CAD) focused primarily on either morphological or functional assessment of CAD. However, dual-energy computed tomography (DECT) can be used to assess myocardial blood supply both morphologically and functionally. We aimed to evaluate the diagnostic accuracy of DECT in detecting morphological and functional components of CAD, using invasive coronary angiography (ICA) and single photon emission computed tomography (SPECT) as reference standards., Methods: Twenty-five patients with known or suspicious CAD and scheduled for ICA were investigated by DECT and SPECT. DECT was performed during the resting state using retrospective electrocardiography (ECG) gating. CT coronary angiography and perfusion images were generated from the same raw data. All patients were evaluated for significant stenosis (≥50%) on both ICA and DECT coronary angiography, and for myocardial perfusion defects on SPECT and DECT perfusion. Comparison was done between ICA and DECT coronary angiography for detection of significant stenosis and between SPECT and DECT perfusion for detecting myocardial perfusion defects., Results: Using ICA as reference standard, sensitivity, specificity, and accuracy of DECT coronary angiography in detecting ≥50% stenosis of coronary artery lumen were 81.6%, 97.8%, and 95.0%, respectively, by segment-based analysis and 92.1%, 96.1%, and 93.7%, respectively, by vessel-based analysis. Using SPECT as the reference standard, the sensitivity, specificity, and accuracy of DECT perfusion in detecting myocardial perfusion defects were 70.4%, 86.4%, and 80.6%, respectively, on per-segment analysis and 90.7%, 66.6%, and 84.7%, respectively, on per-territorial basis., Conclusion: DECT accurately detected coronary artery stenosis and myocardial ischemia using ICA and SPECT as reference standards. In the same scan, DECT can accurately provide integrative imaging of coronary artery morphology and myocardial perfusion.

Extensive pericardial calcification is rare in patients with chronic constrictive pericarditis (CCP). We report the case of a young man who had CCP with "eggshell" calcification of the pericardium and the classic features of CCP on echocardiography and cardiac catheterization. The patient had an uneventful recovery following surgical pericardiectomy. ( Level of Difficulty: Intermediate. )., (© 2020 The Authors.)

Aim: The aim of this study was to evaluate the feasibility of heparinised saline as flushing media for frequency-domain optical coherence tomography (FD-OCT) image acquisition during percutaneous coronary intervention (PCI) optimisation., Methods and Results: Twenty-seven patients undergoing FD-OCT-guided PCI were enrolled. Heparinised saline was injected into the coronary during FD-OCT image acquisition. A total of 118 runs were analysed for image quality and diagnostic value. FD-OCT runs were categorised as follows: good runs (GRs), clinically usable runs (CURs) and clinically not usable runs (NURs); GRs and CURs were combined as clinically effective runs (ERs). Saline FD-OCT enabled visualisation of all possible coronary lesions. Of the 118 runs analysed, 61%, 27.1%, 11.9% and 88.1% were GRs, CURs, NURs and ERs, respectively. Sixty-one percent of total runs were left coronary system (LCS) and 39% were right coronary system (RCS) runs. Among LCS runs, 55.6%, 30.6%, 13.8% and 86.2% were GRs, CURs, NURs and ERs, respectively. Among RCS runs, 69.6%, 21.7%, 8.7% and 91.3% were GRs, CURs, NURs and ERs, respectively., Conclusion: This is the first study to demonstrate the technical feasibility of isolated saline FD-OCT for PCI optimisation., Competing Interests: Declaration of competing interest All authors have none to declare., (Copyright © 2020 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

A calcified nodule is an infrequent pathological substrate in acute coronary syndrome patients. This case demonstrates the technical challenges of intervening an eccentric, severely calcified, balloon-uncrossable coronary lesion.

Purpose: To describe non-bronchial causes of haemoptysis on imaging and the role of interventional radiology in their management from cases of haemoptysis archived from our database at a tertiary care, federally funded institution., Material and Methods: Retrospective analysis of cases that presented with haemoptysis in our institution from 2008 to 2013 was done, and details of cases in which the bleeding was from a non-bronchial source were archived and details of imaging and treatment were recorded., Results: Retrospective analysis of patients presenting with haemoptysis yielded 24 ( n = 24) patients having haemoptysis from non-bronchial sources. Causes of haemoptysis were: Rasmussen aneurysms (n = 12/24), costocervical trunk pseudoaneurysm ( n = 1/24), left internal mammillary artery pseudoaneurysm ( n = 1/24), left ventricular aneurysms ( n = 3/24), pulmonary arteriovenous malformations (AVMs) ( n = 5/24), and proximal interruption of pulmonary artery ( n = 2/24). Imaging and interventional radiology management are described in detail., Conclusions: Haemoptysis can be from non-bronchial sources, which may be either from systemic or pulmonary arteries or cardio-pulmonary fistulas. Bronchial computed tomography angiography (CTBA), if feasible, must always be considered before bronchial artery embolisation because it precisely identifies the source of haemorrhage and vascular anatomy that helps the interventional radiologist in pre-procedural planning. This circumvents chances of re-bleed if standard bronchial artery embolisation is done without CTBA., Competing Interests: The authors report no conflict of interest., (Copyright © Polish Medical Society of Radiology 2020.)

Competing Interests: Competing interests: None declared.

A 42-year-old female with end-stage chronic kidney disease, who was on maintenance hemodialysis for the last 3 years, presented with facial and upper-limb swelling of 2-month duration. A computed tomography (CT) scan confirmed significant stenosis of the superior vena cava (SVC). Following discussion in a multidisciplinary meeting, it was proposed to perform a repeat endovascular intervention to relieve the SVC obstruction and manage the migrated stent.

The Absorb bioresorbable vascular scaffold (Abbott Vascular) does not have an artifact on computed tomography coronary angiography (CTCA); the extent/location of the stent in situ can only be assessed by localizing its radiopaque platinum markers in a non-contrast CTCA. The characteristic appearance of BVS on CTCA should be interpreted as the footprint of a resorbed BVS, instead of a calcified plaque.

We report a case series of 14 cases (mean age 54.14 ± 14.75 years) of successful percutaneous coronary intervention of anomalous left circumflex artery. While the intermediate-term follow-up (mean 36.0 ± 20.58 months) was uneventful in 12 patients, one died of a non-cardiac cause, while other lost to follow-up., Competing Interests: Declaration of Competing Interest All authors have none to declare., (Copyright © 2020 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Brucellosis is one of the most frequent zoonotic infections. Cardiac involvement is rare and when involved, affects aortic valve the most. The appearance of a new murmur on clinical examination during sepsis should suspect seeding on valves. Our patient had pulmonary valve endocarditis secondary to brucellosis which was managed with pharmacotherapy as there was no valvular pathology. Triple therapy is standard of care and usually given for months, non-response to pharmacological treatment warrants surgical intervention. Our patient completed the triple-drug regimen at 3 months and is asymptomatic at present., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Plasma brain natriuretic peptide levels were prospectively studied in pregnant women with heart disease., Methods: Fifty pregnant women with heart disease and 25 controls were evaluated at 24 weeks or under, 30-32 weeks, 34 weeks or more of gestation, and 6 weeks postpartum. Adverse maternal cardiac events were hospitalization for worsening heart failure, stroke, and death., Results: Thirty-eight (76%) women had rheumatic heart disease. Plasma brain natriuretic peptide levels were (in cases and controls) 118.3 ± 46.5 pg/ml and 66.3 ± 15.9 pg/ml (at 24 weeks or under), 124.8 ± 30.4 pg/ml and 68.4 ± 16.5 pg/ml (30-32 weeks), 135.8 ± 34.9 pg/ml and 68.6 ± 15.6 pg/ml (34 weeks or more), and 110.1 ± 21.9 pg/ml and 65.0 ± 16.1 pg/ml (6 weeks postpartum) (p = .0001). Eighteen women had adverse events. Of these, only 1 had a level less than 100 pg/ml, 12 were between 100 and 200 pg/ml, and 5 more than 200 pg/ml., Conclusions: Plasma brain natriuretic peptide levels were higher in women with heart disease at all periods of gestation as well as six weeks postpartum. No woman with a plasma brain natriuretic peptide levels of 98 pg/ml or less had an adverse event., (© The Author(s) 2019.)

Pulmonary haemorrhage is a rare but a life-threatening complication of thrombolytic therapy in patients with acute ST-elevation myocardial infarction (MI). It usually presents with anaemia, massive haemoptysis, acute-onset respiratory distress and diffuse bilateral lung infiltrates on imaging. We hereby describe two patients, who had pulmonary haemorrhage following streptokinase therapy for acute MI. The first patient improved with conservative treatment, while the second patient died due to respiratory failure. Streptokinase, a fibrin non-specific agent, is a widely used thrombolytic in low-income and middle-income countries. Pulmonary haemorrhage should be suspected in patients who develop sudden respiratory compromise after receiving thrombolytics, especially streptokinase. The management issues related to this uncommon life-threatening complication have been discussed in this article., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

This was an unusual case of a large renal artery pseudoaneurysm with impending rupture, which was successfully treated with an endovascular stent-graft in a solitary kidney.

Background: Many studies have proposed the lack of Lewis antigen as a marker for coronary artery disease (CAD); on the contrary, some of the studies found no association in this regard. This study aims to assess the association of the expression of Lewis antigen as an independent risk factor for CAD separately in males and females., Materials and Methods: In this cross-sectional observational study, patients with angiographically proven CAD were taken as test group, and angiographically, negative patients were included as a control group. The individuals were examined for established CAD risk factor and Lewis antigen expression on red cell. Red cell Lewis phenotyping was done using microcolumn gel agglutination technology. Statistical tests were applied to see the association between lack of Lewis antigen expression and CAD., Results: Of these 232 patients included in the study, 161 patients had more than 50% luminal stenosis in a major epicardial artery on coronary angiography (Test Group), and 71 were normal on angiography (Control Group). When males and females were considered together, there was an increased frequency of Lewis-negative phenotype among the angiography-positive group (26.7%) as compared to angiography normal control group (16.9 %), though was not statistically significant ( P = 0.19). When males and females were segregated in multivariate analysis, Le (a-b-) females had a higher incidence of CAD ( P = 0.03) with the odds ratio of 4.97, though an association was not found significant in males ( P = 0.71)., Conclusion: The association between Lewis phenotypes and CAD was not significant in males and in among the overall study population, but this association was statistically significant in females. Further studies based on a larger sample size may substantiate as well as delineate the possible hypotheses., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Asian Journal of Transfusion Science.)

Objective: Diabetes mellitus (DM) is a risk factor for developing in-stent restenosis (ISR) following percutaneous coronary intervention (PCI). This study aimed to examine the presentation and outcomes of drug-eluting stent (DES) ISR in diabetics., Methods: This retrospective study included consecutive patients with clinical DES-ISR, who were hospitalized between January 2013 and December 2017 and who were grouped based on the presence or absence of DM. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI), and repeat-target lesion revascularization] were compared., Results: Baseline characteristics of the DM group (n=109) were comparable to the non-DM group (n=82), except for the higher prevalence of hypertension and dyslipidemia in the former (60.6% vs. 46.3%, p=0.050; 74.4% vs. 57.8%, p=0.034, respectively). Clinical presentation was similar in both groups [acute coronary syndrome (ACS): 62.4% vs. 61%, p=0.843; MI: 34.9% vs. 34.1%, p=0.918). Diabetics had a higher prevalence of stent-edge restenosis (20.3% vs. 9.2%, p=0.019). The treatment strategy was similar in both groups with 52.3% in the DM group and 57.3% in the non-DM group undergoing PCI (p=0.513). One-year outcomes of the DM group were not different from those of the non-DM group (14.7% vs. 17.1%, p=0.683). Age [hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.01-1.10; p=0.017], MI presentation (HR, 2.34; 95% CI, 1.14-4.80; p=0.020), and chronic kidney disease (CKD: HR, 2.82; 95% CI, 1.21-6.58; p=0.016) were predictors of poor outcomes., Conclusion: Stent-edge restenosis is more common in diabetics. Clinical presentation and 1-year outcomes following DES-ISR are similar in diabetics and non-diabetics. Age, MI presentation, CKD, and not DM were predictors of poor outcomes following DES-ISR.

Certain factors like ostial disease, chronic total occlusion, and long, multiple stents are the main causes of multiple stent fractures, as were present in this case. Such stent fractures are usually associated with significant in-stent restenosis; however, this patient had a patent lumen despite multiple fractures.

The common cause of renal artery stenosis in young is fibromuscular dysplasia or Takayasu arteritis. Recanalized thrombus, on the other hand, is a rare cause for renal artery stenosis in young patients. OCT imaging confirmed the diagnosis and optimized the renal stenting results.

A 34-year-old man was referred for percutaneous transvenous mitral commissurotomy (PTMC); he had undergone 2 PTMC attempts at another institute, but both attempts failed because of inability to cross the mitral valve with the balloon. We present an alternative reverse-loop technique for PTMC in patients with large left atrium.

Studies on pregnancy with rheumatic heart disease (RHD), still common in the developing world, are relatively old and small. This retrospective study was conducted to study the outcome of pregnancy in women with RHD and factors associated with poor outcome. We studied 353 pregnancies in 273 women. In 35% of the patients, the diagnosis was first made during index pregnancy. Women with severe MS had lesser gestational age at delivery and birth weight than those with mild-to-moderate MS. Women with NYHA III-IV status delivered at lesser gestational age had lesser birth weight and had higher perinatal and maternal mortality than NYHA I-II status. Pregnancy outcome was better among women who underwent Balloon mitral valvotomy (BMV) when indicated than those who did not. Cardiac complications were higher in women with severe MS and poor NYHA status. Early booking is important for the optimal outcome. BMV is safe during pregnancy and should be done when necessary. Impact statement What is already known on this subject? Rheumatic heart disease continues to be the major cause of maternal morbidity and mortality in developing countries. Most of the recent studies discuss pregnancy with heart disease as a whole with RHD being a part. What do the results of this study add? A large number of women in developing countries conceive with unknown underlying heart disease. Late access to antenatal care is associated with poor outcome. Cardiac and obstetric complications are significantly higher in women with severe mitral stenosis and poor NYHA functional status. Balloon mitral valvotomy (BMV) during pregnancy is safe and technically feasible. BMV averts major complications that may occur due to severe disease. Patients with RHD can undergo labour and vaginal delivery under vigilant monitoring. What are the implications for clinical practice? Thorough clinical examination by the clinician at initial visit is important to detect unknown heart disease. Symptoms pointing towards underlying heart disease should prompt evaluation. This study provides evidence for population-based screening for heart disease in women. Optimal management of compensated mitral stenosis requires weighing the risks and benefits of pharmacological therapy versus BMV in the context of maternal condition. BMV should be performed when necessary.

We present a rare case of very late in-stent restenosis of Cypher stents 12 years after PCI in a case of a single anomalous coronary.

Vascular complications such as renal artery or renal vein thrombosis and laceration and iliac artery dissection are rarely encountered after renal transplantation. Timely management of these vascular complications is important to prevent ischemic injury of a transplanted kidney. We hereby report a case of a 60-year-old male who had acute renal dysfunction due to iatrogenic left external iliac artery dissection after renal transplantation. An endovascular stenting of the dissected iliac artery resulted in a brisk flow across both iliac and transplanted renal arteries. The management issues related to this rare vascular complication is discussed in the article., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Eleven years after DES implantation, a patient presented with AMI despite continued dual-antiplatelet therapy. Coronary angiography revealed total occlusion of the proximal LAD.

Background: Renal artery stenosis (RAS) is a common cause of secondary hypertension. The most common aetiology is atherosclerosis; however, other causes like fibromuscular dysplasia (FMD) and Takayasu arteritis (TA) are also frequently encountered. The lesion characteristics and its response to percutaneous intervention depend upon the aetiology of RAS. Optical coherence tomography (OCT) is an excellent imaging modality to analyse coronary lesions during percutaneous coronary interventions. The data regarding the utility of OCT in renal artery imaging is limited, consisting of a few case reports., Case Summary: We hereby report four cases of RAS, each of different aetiology (atherosclerotic, FMD, post-transplant, and TA), who underwent OCT imaging of the renal artery along with percutaneous renal angioplasty., Discussion: The advantages of OCT imaging include demonstration of the arterial wall, pathological features of the disease, and to guide percutaneous interventions. The major limitation of OCT is its lower imaging depth, which may render imaging of large vessels difficult., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Purpose: To evaluate the outcome of endovascular procedures on ocular findings in patients with Takayasu arteritis., Methods: Retrospective study of patients who underwent percutaneous endovascular stenting of aortic arch arteries for Takayasu arteritis (TA) and who had documented retinopathy findings before and after the procedure. Change in visual acuity, regression of retinopathy, and development of complications after endovascular procedure were studied over a follow-up of 6 months., Results: Ten eyes of five patients were included. Eyes which had Stage II or less of retinopathy before the endovascular procedure had favorable outcome; however, those with advanced stage of retinopathy at presentation had poor outcomes. Patients who underwent revascularization of both-sided arteries within 1 month had better anatomical and functional outcomes as compared with those who underwent sequential endovascular procedures on their arteries after a gap of 3 months or more., Conclusion: Percutaneous endovascular stenting of aortic arch arteries, affected in TA, can lead to reversal of retinopathy changes and restoration of vision if done before neovascular complications set in.

Coral reef aorta (CRA) is a rare condition, characterised by rock-hard calcification of the juxta-renal and supra-renal aorta with luminal encroachment causing significant stenosis of the aorta and its branches. It usually presents as resistant hypertension, renal dysfunction, mesenteric ischaemia, limb claudication or embolic manifestations. Although surgical thrombo-endarterectomy along with bypass graft to the affected visceral arteries remains the cornerstone of treatment, it is associated with considerable mortality and morbidity, especially in patients with pre-existing comorbidities. Here we report an elderly female of resistant hypertension, who had successful endovascular aortic stenting using a non-graft self-expanding stent. Her blood pressure dramatically improved following endovascular management. In comparison to the conventional surgical approach, endovascular stenting can be an alternative, less invasive approach in selected CRA patients., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

M1 and M2 macrophage balance in atherosclerosis has attracted much interest. Though, it remains unknown how macrophage heterogeneity is regulated. Moreover, the regulation of macrophage polarization and activation also involve DNA methylation. However, it remains ambiguous which genes are under direct regulation by DNA methylation. Our aim was to evaluate the gene-specific promoter DNA methylation status of M1/M2 polarization markers in PBMCs of CAD patients. A case-control study was performed with 25 CAD patients and 25 controls to study the promoter DNA methylation status of STAT1, STAT6, MHC2, IL12b, iNOS, JAK1, JAK2 and SOCS5 using MS-HRM analysis. Our data indicates that there was a clear-cut difference in the pattern of gene-specific promoter DNA methylation of CAD patients in comparison to controls. A significant difference was observed between the percentage methylation of STAT1, IL12b, MHC2, iNOS, JAK1 and JAK2 in CAD patients and control subjects. In conclusion, our data show that MS-HRM assay is a rapid and inexpensive method for qualitatively identifying aberrant gene-specific promoter DNA methylation changes in CAD. Furthermore, we propose that gene-specific promoter DNA methylation based on monocyte/macrophage might aid as diagnostic marker for clinical application or DNA methylation-related drug interventions may offer novel possibilities for atherosclerotic disease management.

Aim: To report our experience on complex percutaneous interventions of the abdominal aorta and its branches in six children with Takayasu arteritis (TA)., Methods: A review of records of children with TA, who underwent percutaneous interventions of the abdominal aorta and its major branches., Results: In this analysis, we included six children with TA who underwent intervention of the abdominal aorta and its major branches. The endovascular interventions were performed mostly for treatment-resistant renovascular hypertension and mesentery artery ischemia. Mean age (±SD) at time of intervention was 10.6 ± 2.5 years (four boys and two girls). Percutaneous interventions included stenting of abdominal aorta (n = 2), renal arteries (n = 4), mesenteric arteries (n = 2), repeat stenting for renal artery in-stent restenosis (n = 1), and renal autotransplantation (n = 4). All 13 interventions were successful and enabled us to obtain good control of blood pressure., Conclusion: We hereby report six children with TA who were successfully managed with complex percutaneous interventions of the abdominal aorta and its major branches. Balloon dilatation and stent placement constitutes the mainstay of management of TA with stenosis of the large vessels., (© 2018 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Budd-Chiari syndrome (BCS), also known as hepatic venous outflow tract obstruction includes a group of conditions characterized by obstruction to the outflow of blood from the liver secondary to involvement of one or more hepatic veins (HVs), inferior vena cava (IVC) or the right atrium. There are a number of conditions that lead to BCS-ranging from hypercoagulable states to malignancies. In up to 25% patients, no underlying disorder is identified. Diagnosis of BCS is based on a combination of clinical and imaging features. A major part of the literature in BCS has been devoted to interventions; however, a detailed description of various imaging manifestations of BCS is lacking. In this review, we highlight the importance of various imaging modalities in the diagnosis of BCS.

Renovascular hypertension is a common clinical presentation in Takayasu arteritis (TA), when the renal arteries are involved. Although most of the patients respond to optimal antihypertensive drug therapy, certain patients with TA require percutaneous or surgical renal artery revascularisation to manage renovascular hypertension. We, hereby, present a 45-year-old woman, who had resistant hypertension secondary to in-stent restenosis (ISR) of renal artery stent in a single functioning kidney. She had successful renal autotransplantation following a failed endovascular attempt to treat ISR. Endovascular and surgical interventions related to renal artery stenosis in TA are discussed in the article., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Cardiac involvement is not an uncommon manifestation in dengue fever and diagnosing it has always been a challenge to physicians owing to its constellation of clinical features and lack of standard screening methods. We studied the prevalence of cardiac involvement among fifty sequential adult patients of dengue fever admitted in our emergency department, PGIMER, Chandigarh, India, who were assessed clinically and classified based on the severity. They were studied for possible cardiac involvement by means of point-of-care testing for serum cardiac biomarkers (quantitative troponin-I, creatinine kinase - MB Isoform and cardiac myoglobin) and two-dimensional transthoracic echocardiogram (2D-echo). Evidence of myocardial involvement was present in 16% and 30% patients based on 2D-echo and biomarker testing respectively. On univariate analysis, the presence of cardiac symptoms (p = 0.009) and of shock (p = 0.003) showed statistically significant association with biomarker elevation. However, this and evidence of myocardial dysfunction by 2-D echo showed poor inter-correlation.

Candida parapsilosis is a rare cause of endocarditis, which is seen to affect the native valves in patients who are known intravenous drug abusers or following contamination during surgery for prosthetic valves. We discuss a unique constellation of autopsy findings in a 35-year-old chronic opium abuser who presented with left-sided weakness followed by low-grade fever. He was diagnosed to have C. parapsilosis native valve endocarditis with septic emboli involving the myocardial vessels, left middle cerebral artery, spleen, and common iliac artery. In addition, autopsy highlighted a right basal ganglia infarct, focal segmental glomerulonephritis, and talc granulomatosis in the lungs and liver., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the quality of life (QoL), psychiatric comorbidities in patients with rheumatic heart disease-mitral stenosis (RHD-MS), and the impact of balloon mitral valvotomy (BMV) on the QoL and psychiatric morbidity., Materials and Methods: Fifty consecutive patients of RHD-MS were evaluated for QoL and psychiatric morbidity prior to BMV and at 3 months after the procedure., Results: The mean age of the study sample was 34.9 years (standard deviation, 11.1 years). At baseline assessment, majority (94%) had New York Heart Association Class II/III symptoms and QoL scores below average, that is, 50. About two-fifth (19 out of 50) of the patients had one or more psychiatric comorbidity, that is, depression (32%), anxiety (16%), and somatoform disorder (12%). Those with psychiatric comorbidity had poor QoL scores in social, emotional, and mental subscales ( P < 0.05) at the baseline. At 3-month follow-up, there were significant improvement in symptoms and transmitral pressure gradients ( P < 0.05), QoL scores ( P < 0.05), and psychiatric comorbidities ( P < 0.05) after BMV. Improvements in QoL were irrespective of the baseline psychiatric comorbidity., Conclusions: High prevalence of psychiatric illness and poor QoL scores were observed in patients with RHD-MS. BMV significantly improves the QoL and psychiatric comorbidities., Competing Interests: There are no conflicts of interest.

Premenopausal women are known to have less heart disease than their menopausal counterparts and men. However, there is a rising prevalence of coronary artery disease (CAD) in premenopausal females, which necessitates determination of risk factors that negate the effects of hormonal protection. There are few studies describing the prevalence of traditional and emerging risk factors in premenopausal women with CAD. Thus, our objective was to explore the prevalence of traditional and emerging risk factors and features of coronary lesions in premenopausal women with CAD in an Indian population. Forty premenopausal female patients with angiographically proven CAD and undergoing treatment with conventional therapies and 40 age-matched premenopausal females without any evidence of CAD were enrolled. Premenopausal females with CAD most commonly had the single-vessel CAD and the left anterior descending artery was most commonly involved. The prevalence of hypertension, diabetes, obesity, metabolic syndrome, family history of CAD and 10-year risk score was higher in premenopausal females with CAD than controls. Even after treatment with conventional therapies, premenopausal women with CAD had dyslipidemia and significantly elevated levels of emerging risk factors such as ApoB, ApoB/ApoA1 ratio, hsCRP, lipoprotein (a), uric acid, T4, fibrinogen, and total leukocyte count as compared to controls (p < 0.05). Further, they had significantly lower levels of HDL-C, and Apolipoprotein A1 and T3 which are protective markers for vascular risk. Multivariate regression analysis demonstrated that low levels of Apo A1 and high levels of fibrinogen, hsCRP and TG drive the vascular risk, and therefore these factors should be considered as candidates for better diagnosis, early detection, and intervention of CAD in premenopausal women.

Aim: Kawasaki disease (KD) is the most common cause of acquired heart disease in children in Japan, North America and Europe. Undiagnosed and untreated KD can have clinically significant consequences later in life. The clinical spectrum of missed childhood KD is frequently being recognized during adulthood. We report four adult cases of acute coronary events, in which coronary angiography was suggestive of sequelae of KD., Methods: Four adults who presented with acute coronary events, had coronary angiography for evaluation. Indoor-admission files were analyzed for the clinical details of individual cases., Results: Two cases were below 40 years of age. None of the patients had any known conventional risk factors for atherosclerosis. Case 4 had a clinical history of childhood KD. Coronary angiography revealed ectasia of multiple coronary arteries and stenosis in distal segments in the first three cases and large thrombosed aneurysm with calcified walls in the fourth case., Conclusion: We hereby report four adult cases with acute coronary events, who had markedly dilated coronary artery segments suggestive of possible sequelae of childhood KD., (© 2017 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Background: Splanchnic arterial vasodilatation and subsequent sodium and water retention play an important role in cirrhotic ascites. Midodrine and tolvaptan have been used separately in these patients. However, there are no reports on the use of combination of midodrine and tolvaptan in the control of ascites. The aim of this study was to evaluate the safety and efficacy of midodrine, tolvaptan and their combination in control of refractory or recurrent ascites in cirrhotics., Methods: Fifty cirrhotic patients with refractory or recurrent ascites were randomised to receive midodrine (n=13), tolvaptan (n=12) or both (n=13) plus standard medical therapy (SMT) or SMT alone (n=12)., Results: A significant increase in urinary volume and urinary sodium at 1 and 3 months (P<.05) was observed in all groups except SMT. There was no worsening of renal or hepatic function in any group. There was deterioration of model for end-stage liver disease (MELD) in SMT. Midodrine as well as combination of midodrine and tolvaptan but not tolvaptan alone was superior to SMT in control of ascites at 3 months (P<.05). The combination therapy was also superior to midodrine in the control of ascites at 1 month. The morbidity and mortality were similar in all the groups except SMT., Conclusions: The results of this pilot study suggest that midodrine and combination with tolvaptan better controls ascites without any renal or hepatic dysfunction. The combination therapy rapidly controls ascites as compared to midodrine or tolvaptan alone., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: There has been a significant decrease in the number of published reports of classical polyarteritis nodosa (PAN) in the post-Chapel Hill consensus conference (CHCC) nomenclature era with only two series published from Asia. We report a case series of PAN from north India., Patients and Methods: A retrospective study of all patients diagnosed to have PAN according to American College of Rheumatology criteria/CHCC nomenclature. The details of clinical presentation, investigation findings, treatment details and outcomes were noted from the records. These findings between the hepatitis B positive and negative groups were compared., Results: Twenty-seven patients (20 male, seven female) were diagnosed as having PAN, out of which seven (25.9%) were hepatitis B surface antigen positive. Nervous system involvement was most common with 24 patients (88.9%) having mononeuritis multiplex. Weight loss was present in 20 (74%), fever in 14 (51.9%), renal involvement in 16 (59.3%), cutaneous in nine (33.3%), peripheral gangrene in eight (29.6%), gastrointestinal (GI) involvement in eight (29.6%), testicular pain in 6/20 (30%) and cardiac involvement in four (14.8%). Twenty-three (85.2%) patients recovered, three died (11.1%) and one was lost to follow-up. Median follow-up duration was 37 (interquartile range 22.00-69.75) months. The cumulative survival was 114.16 months (95% CI: 98.27-129.95). There was no significant difference in five factor score (FFS) or revised FFS between those patients who died and those who survived (P = 0.248, 0.894, respectively). Hepatitis B-related PAN had a lower FFS compared to non-hepatitis B-related PAN (P = 0.039). No other significant differences were noted between the two groups., Conclusion: In comparison to classic PAN in other populations, classic PAN in north India is associated with higher neurological involvement and lower GI involvement., (© 2016 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Objective: To study endothelial dysfunction in patients with psoriatic arthritis (PsA) without risk factors for cardiovascular disease., Methods: Forty patients with PsA according to Classification Criteria for Psoriatic Arthritis (CASPAR) criteria and forty age- and sex-matched controls were included. Patients with risk factors for cardiovascular disease were excluded. Endothelial function was assessed by measuring endothelial-dependent flow-mediated vasodilatation (FMD%) and endothelial-independent nitroglycerin-mediated dilatation (NMD%) in the brachial artery., Results: There was a significant impairment of FMD% in patients as compared to controls (mean 8.3% vs. 10.8%, P = 0.007), but there was no significant difference in NMD%., Conclusions: There is presence of endothelial dysfunction in patients with PsA independent of risk factors for cardiovascular disease., (© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

A distortion of implanted coronary stent along its longitudinal axis during coronary intervention is known as longitudinal stent deformation (LSD). LSD is frequently seen with newer drug eluting stents (DES), specifically with PROMUS Element stent. It is usually caused by impact of guide catheter tip, or following passage of catheters like balloon catheter, IVUS catheter, guideliner, etc. We hereby report a case of LSD during coronary bifurcation lesion intervention, using two-stents technique. Patient had acute stent thrombosis as a complication of LSD, which was successfully managed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The present study aimed at estimating the prevalence of metabolic syndrome (MetS) and prospectively, evaluating cardiovascular events among Asian Indians type 2 diabetic subjects., Methods: The sample comprised 1522 type 2 diabetic mellitus (T2DM) subjects aged 25-91years, who participated in the North Indian Diabetes and Cardiovascular Disease Study (NIDCVD). The participants were screened for hypertension, dyslipidemia, obesity and cardiovascular events. Anthropometric, clinical and biochemical measurements were done in all subjects. The prevalence of MetS was estimated in all the subjects according to the harmonized criteria of 2009., Results: The prevalence of MetS among urban Indian diabetic subjects was 71.9% and was significantly higher in females (86%) as compared to males (57.9%). To determine the independent predictors of the MetS in diabetic sample, binary logistic regression analyses were performed using demographic and biochemical parameters. Significant differences in the indices of generalized and abdominal obesity and lipids (total cholesterol, high density lipoprotein) were observed (p<0.01) in male:female and MetS and non-MetS comparisons. Regression analysis for prediction of CAD showed that family history, age, body mass index (BMI), SBP, physical inactivity and hypertension independently and significantly predicted the disease outcome. Binary logistic regression analysis revealed that MetS may be an independent risk/predictor of CAD (odd ratio (OR)=3.44, CI 1.31-9.01, p=0.012) along with higher age groups, BMI and hypertension in Indian population., Conclusion: The study demonstrated that the high prevalence of MetS and its different components were positively associated with a higher risk of CAD in north Indian diabetic subjects. Nevertheless, MetS is a major health problem in India, comprehensive population studies are warranted for estimation of incidence and prevalence, and education should be provided on its prevention and control to reduce the diabetes-related morbidity and mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Percutaneous Transvenous Mitral Commissurotomy (PTMC) is a standard treatment for critical mitral stenosis. In certain situations such as large left atrium (LA) or low trans-septal puncture, there is technical difficulty in crossing a PTMC balloon across the mitral valve, leading to high failure rate. I hereby describe a case of PTMC successfully performed by using double loop technique to cross the mitral valve., (Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Coumarin derivatives such as warfarin and acenocoumarol are used in various disorders such as deep venous thrombosis, pulmonary embolism, atrial fibrillation and artificial heart valves. They have improved prognosis of patients with thromboembolic disease. An individual's response to coumarins depends on several factors. The non-genetic factors include age, gender, body mass index, diet and interacting drugs. Among the genetic factors, the cytochrome P450 system and vitamin K epoxide reductase complex subunit 1 play a key role in drug metabolism. This was a prospective hospital based study in which allele and genotypic frequencies of CYP2C9 gene polymorphisms; 430C>T and 1075A>C and VKORC1 gene polymorphisms; 1639G>A, 9041G>A and 6009C>T in 106 alleles of north Indian patients with valve replacement on acenocoumarol were determined and their effect on acenocoumarol dosing was studied. To the best of our knowledge, this is first report of VKORC1 9041G>A and 6009C>T gene polymorphisms and their effect on acenocoumarol dosing from north India. In 53 patients with valve replacement on acenocoumarol with stable INR, the allele frequency of CYP2C9*2 and CYP2C9*3 gene polymorphisms was 0.05 and 0.17 respectively and that of VKORC1 *2,*3 and *4 gene polymorphisms was 0.15, 0.72 and 0.11 respectively. The presence of CYP2C9*3 or VKORC1*2 gene polymorphism were associated with decrease in acenocoumarol dose requirements (p values 0.03 and 0.02 respectively).This study confirmed the association of lower mean weekly dosages of acenocoumarol in patients with CYP2C9*3 and VKORC1*2 gene polymorphisms. An unusually high frequency of 9041A polymorphism in VKORC1 was found in study population.

Aim: To compare the atrio-ventricular (AV/PV) delay optimization by echocardiography and intra-cardiac electrocardiogram (IEGM) based QuickOpt algorithm in complete heart block (CHB) patients, implanted with a dual chamber pacemaker., Methods: We prospectively enrolled 20 patients (age 59.45 ± 18.1 years; male: 65%) with CHB, who were implanted with a dual chamber pacemaker. The left ventricular outflow tract velocity time-integral was measured after AV/PV delay optimization by both echocardiography and QuickOpt algorithm method. Bland-Altman analysis was used for agreement between the two techniques., Results: The optimal AV and PV delay determined by echocardiography was 155.5 ± 14.68 ms and 122.5 ± 17.73 ms (P < 0.0001), respectively and by QuickOpt method was 167.5 ± 16.73 and 117.5 ms ± 9.10 ms (P < 0.0001), respectively. A good agreement was observed between optimal AV and PV delay as measured by two methods. However, the correlation of the optimal AV (r = 0.0689, P = 0.77) and PV (r = 0.2689, P = 0.25) intervals measured by the two techniques was poor. The time required for AV/PV optimization was 45.26 ± 1.73 min by echocardiography and 0.44 ± 0.08 min by QuickOpt method (P < 0.0001)., Conclusion: The programmer based IEGM method is an automated, quick, easier and reliable alternative to echocardiography for the optimization of AV/PV delay in CHB patients, implanted with a dual chamber pacemaker.

Constrictive pericarditis (CP) is an inflammatory disease of pericardium. Pericardial calcification in X-ray provides a clue for the diagnosis of CP. An extensive "eggshell" type of calcification is rarely seen in CP. We hereby report a case of CP with eggshell calcification of pericardium, encircling whole of the heart. A need for multimodality imaging and hemodynamic assessment followed by surgical pericardiectomy is discussed.