Search

Background: Percutaneous balloon pulmonary valvuloplasty is the procedure of choice for uncomplicated severe or symptomatic pulmonary stenosis. The present study describes our experience in balloon pulmonary valvuloplasty using the Inoue balloon catheter in adolescent and adult patients. Aims: To assess the immediate and mid-term outcomes of percutaneous balloon valvuloplasty with Inoue balloon catheter in adolescent and adult patients. Methods and results: Between June 2010 and July 2015, we performed percutaneous balloon pulmonary valvuloplasty with Inoue balloon catheter in 32 patients (59.37% females) aged 8 to 54 years (mean 23.6 ± 11.5). Following the procedure, the mean right ventricular systolic pressure and the pulmonary valvular peak-to-peak systolic gradient decreased from (121.6 ± 42.4 to 61.19 ± 24.5 mmHg, p = 0.001) and (100.9 ± 43.3 to 36.4 ± 22.5 mmHg, p = 0.001), respectively. Twenty patients (Group A) showed immediate optimal results with post-procedure peak systolic gradient

Background: Quantification of mitral regurgitation (MR) has always required an “integrated approach” as there is no single gold-standard method. We investigated a new Doppler-derived parameter “left ventricular early inflow-outflow index (LVEIO)” for the quantification of MR and its likelihood to predict severe MR in correlation with already established parameters in an Indian population including a large subset of patients with rheumatic etiology. Methods: A prospective study was performed at a major tertiary care center in western India over a 5-month period. Five hundred patients diagnosed with isolated MR including 260 (52%) patients with rheumatic etiology were included in the study after applying exclusion criteria. We analyzed MR using color flow jet, effective regurgitant orifice area (EROA), and vena contracta (VC) width. LVEIO is a simplification of the regurgitant volume (RV) method, which was calculated as “E velocity divided by LV outflow velocity integrated over the systolic ejection period left ventricular outflow tract velocity time integral” and compared with the established parameters. Results: LVEIO was 4.65 ± 1.45, 6.56 ± 1.52, and 9.91 ± 3.70 among patients diagnosed with mild, moderate, and severe MR, respectively (p

Background: Chronic constrictive pericarditis (CCP) is the end result of chronic inflammation of the pericardium. Developing countries continue to face a significant burden of CCP secondary to tuberculous pericarditis. Surgical pericardiectomy offers potential cure. However, there is paucity of echocardiography data in post-pericardiectomy patients vis-a-vis their clinical status. We studied the changes in multiple echocardiographic parameters in these patients before and after pericardiectomy. Methods: Twenty-three patients (14 men, 9 women) who underwent pericardiectomy for CCP in the last 5 years (from January 2009 to December 2014) were subjected to detailed clinical and echocardiographic evaluation during the study period (between June 2013 and December 2014). Patients with residual symptoms of NYHA class II and below were considered as ‘responders’. The data thus obtained were compared to the pre-operative parameters. Results: After pericardiectomy, the incidence of vena caval congestion decreased from 100% to 15% (p

Femoral venous route is routinely used for percutaneous closure of atrial septal defects (ASDs). However, a situation may arise where transfemoral approach is not feasible. We describe a successful transjugular closure of a moderate-sized ASD in a 49-year-old symptomatic man with interrupted inferior vena cava, using a novel deployment technique, which helped in overcoming difficulties such as maintaining stable sheath position and minimizing risk of air embolism.

Background: Sudden cardiac death is a catastrophic event which leads to loss of young and middle-aged population with dire consequences. Sometimes, a careful history, physical examination and most importantly electrocardiogram (ECG) can help in suspecting the common causes in young population like underlying channelopathies and cardiomyopathies which can further be diagnosed using echocardiography, cardiac MRI and in some cases genetic tests. Case summary: A 33-year-old male presented with sycope and ventricular tachycardia leading to death. This patient was diagnosed to have Arrythmogenic right ventricular dysplasia (ARVD) on post mortem pathological examination with features of fatty infiltration and thinning of right ventricular myocardium. Furthermore, on histologically fatty infiltration with inflammatory infiltrates were visualized. Discussion: Clinical awareness amongst physicians about cardiomyopathies especially ARVD with its subtle yet suggestive ECG changes is the need of the hour. ARVD is a rare disease and can be diagnosed with certainty by analyzing ECG and adding imaging to it. When diagnosed cases are treated appropriately, at least a few cases of sudden cardiac death can be averted.

Although newer pharmacologic and interventional therapies for the treatment of Heart failure continue to evolve, the optimum strategy of management for the patients with cardio renal syndrome is still unanswered. Various pathophysiologic mechanisms have been proposed including the low output hypothesis and the raised renal venous pressure hypothesis. These mechanisms have been tested and challenged in many trials. Although, modest benefit has been achieved with management strategies targeting these hypotheses. Role of biomolecules and neurohormones such as BNP, adenosine has provided newer insights in mechanisms of Cardio-renal syndrome (CRS). However, when studied in clinical trials, drugs targeting these pathways did not have significant clinical outcomes. Diuretics remain cornerstone of management. But their propensity to cause AKI and electrolyte disturbances when used at higher dosages limits their use. Vasodilator proves of clinical benefit in raised CVP states. But risk of hypotension and constant hemodynamic monitoring preclude their use in many clinical situations. Ultrafiltration had modest success in the initial studies, but recent trials have questioned their role in patients with ADHF. Pharmacologic therapies such as nesiritide, adenosine antagonists and vasopressin antagonists are still in trial phases and benefit has not yet been proved. Thus, our knowledge of CRS still needs depth and understanding of pathophysiologic mechanisms which when achieved may result in improved clinical outcomes and patient care. This review article on focuses on pathophysiology and management strategies of patients with CRS.

Sheehan’s syndrome, also called Simmond’s syndrome, postpartum apoplexy, postpartum pituitary necrosis, and postpartum panhypopituitary syndrome, is the name given to postpartum hypopituitarism. The syndrome is caused by an infarction in the adenohypophysis, usually precipitated by massive uterine haemorrhage and hypovolemic shock during or after childbirth. Extensive destruction of pituitary cells results in varying degree of hypopituitarism. Acute loss of adenohypophysis function can be fatal without glucocorticoid and thyroid replacement therapy and survivors will require life time hormonal replacement therapy. Most cases present in the postpartum period with lactation failure or after months to years after the delivery. In many affected women, anterior pituitary dysfunction is not diagnosed for many years. Dyselectrolytemia is one of a common presentation in Sheehan’s syndrome. Herein, we report a case of a 35-year old female with a history of obstetric hysterectomy 2 years ago in view of severe postpartum haemorrhage with history of failure of lactation and three episodes of syncope since last 1½ years and now presented with polymorphic ventricular tachycardia which required DC cardioversion. She was referred as a case of long QT syndrome. On investigating further, she had hypokalaemia secondary to hypopituitarism due to Sheehan’s syndrome.

Background Balloon mitral valvotomy (BMV) is a well-established therapeutic modality for rheumatic mitral stenosis (RMS). However, there are chances of procedural failure and the more ominous post-procedural severe mitral regurgitation. There are only a few prospective studies, which have evaluated the pathogenic mechanisms for these major complications of BMV, especially in relation to the subvalvular apparatus (SVA) pathology. Methods All symptomatic patients of RMS suitable for BMV by echocardiographic criteria in a span of 1 year were selected. In addition to the standard echocardiographic assessment of RMS (Wilkins score and score by Padial et al.), a separate grading and scoring system was assigned to evaluate the severity of the SVA pathology. The SVA score was ‘I’, when none of the two SVAs had severe disease, ‘II’ when one of the two SVAs has severe disease, and ‘III’ when both SVAs had severe disease. With these scoring systems, the outcomes of BMV (successful procedure, failure, and post-procedural mitral regurgitation) were analyzed. Emergency valve replacement was performed depending on clinical situation, and in cases of replacement, the pathology of the excised mitral valves were compared with echocardiographic findings. Results Of the 356 BMVs performed in a year, 43 patients had adverse outcomes in the form of failed procedure (14 patients) and mitral regurgitation (29 patients). Forty-one among these had a SVA score of III. The sensitivity and specificity of the MR score was lesser than the SVA score (sensitivity 0.34 vs. 1.00, specificity 0.92 vs. 0.99, respectively). The mitral valvular morphology in 39 patients who underwent post-procedural valve replacements correlated well with echocardiography findings. Conclusion It is important to assess the degree of SVA pathology in the conventional echocardiographic assessment for RMS, as BMV would have adverse events when both SVAs were severely diseased.

Background: There is a dearth of data regarding the appropriateness of elective percutaneous coronary intervention (PCI) in a limited-resource country such as India. In an attempt to rationalise the use of PCI, Appropriate Use Criteria (AUC) were developed for cardiovascular care in the USA. In the Indian context, considering the high prevalence of coronary artery disease, the dramatic rise in the number of revascularization procedures and an increasing role of government/private reimbursements, application of AUC could potentially guide policy to optimize the utilization of resources and the benefit-risk ratio for individual patients. Objectives: The study sought to determine the overall and year-wise trends in the appropriateness of elective PCI using the AUC and also understand the impact of the government health insurance scheme (GHIS). Material and Methods: The inpatient records of all patients undergoing elective PCI, at a single large tertiary care centre in Western India, from January 2009 to December 2014 were retrospectively analysed (n=972, 759 males, 213 females) by a neutral observer. The AUC scores and subsequent ranking were calculated using the dedicated web-based software and each PCIwas ranked as either ‘appropriate’, ‘uncertain’ or ‘inappropriate’. Elective PCI performed within a month after the index acute coronary syndrome (ACS) was considered as 'ACS' while applying the AUC. All other indications were considered as 'non-ACS'. Nearly 95% of elective PCI performed after July 2012 were covered under theGHIS and therefore the period January 2009–June 2012 was compared with the July 2012– December 2014 to assess the impact of this scheme. Results: A total of 894 elective PCI (379 and 515 PCI in the ACS setting and non-ACS setting respectively) performed on 857 patients were analysed. The elective PCI performed in the pre-GHIS and GHIS period were 458 and 436 respectively. As per AUC, 352 (39.6 ± 4.4 %) of the overall elective PCI were ranked as ‘appropriate’, while 487 (55.3 ± 4.1 %) cases as ‘uncertain’ and 55 (5.1 ± 0.6 %) cases as ‘inappropriate’. An overall year-wise temporal trend in the proportion of cases in any of the AUC rankings did not show any significant trends(p > 0.05). However, 80.4 ± 7.3 % of elective PCI in the ACS setting were categorised as ‘appropriate’ and 82.6 ± 6.9 % of elective PCI in non-ACS setting were ranked as ‘uncertain’. With state-wide implementation of the GHIS, the total number of elective PCI increased by 50% (436 in the 3½ year pre-GHIS study period as against 458 in the 2½ year GHIS study period). The introduction of GHIS led to a marginal increase (p > 0.05) in the average annual number of elective PCI in non-ACS setting as opposed to a 120% rise in the number of elective PCI done in the ACS setting (p < 0.001) and the delay in performing PCI after coronary angiogram reduced from 55.8 ± 43.6 days to 33 ± 22.9 days (p < 0.01). Also, the ratio of men: women undergoing elective PCI rationalised from 5.4:1 to 2.7:1 (p < 0.001). With the introduction of the GHIS, the share of ‘inappropriate’ elective PCI in the ACS setting increased from 1.34 % to 4.81 % (p =0.065). However, there was also a fall in ‘appropriate’ elective PCI in the non-ACS setting from 15.0 ± 3.2% to 7 ± 1.6% (p < 0.001). Conclusion: On applying the 2012 updated AUC, about 5 % of overall elective PCI were deemed as ‘inappropriate’. About four in every five elective PCI in the non-ACS setting were of ‘uncertain’ appropriateness. The implementation of the GHIS not only significantly reduced the gender bias and delay in seeking interventional coronary care but also led to a significant rise in the proportion of PCI performed in the ACS setting. However, there was also a rise in ‘inappropriate’ PCI in the ACS setting and a significant fall in ‘appropriate’ PCI in the non-ACS setting after introduction of the GHIS..

Persistent Truncus Arteriosus (PTA) is an extremely rare defect accounting for under 1% of all congenital heart disease, and over 85% of patients succumb to heart failure in infancy. We report a case of van Praagh type A3 PTA, which represents its rarest variant and accounts for only 8–10% of all patients with PTA. The presence of ductal stenosis in such cases is further exceedingly rare.

Presence of multiple cardiovascular manifestations of the Marfan syndrome in the same patient is not commonly encountered. We present a 49 year-old lady with this syndrome who presented with decompensated heart failure. Evaluation revealed presence of extensive Stanford type A aortic dissection alongwith severe aortic and mitral incompetence. However, the patient declined surgery and was discharged on medical management. At a year's follow-up, she had dyspnea of NYHA class II with persistent cardiovascular findings.

A 26 year primigravida, 8 days after delivering a still born baby presented with gradually progressive dyspnea from New York Heart Association (NYHA) class II to class III over a period of 1 week. 2D-Echocardiography showed severely compromised left ventricular systolic function with evidence of thrombi in three different chambers of the heart. All the clots disappeared after an effective anticoagulation therapy without any embolic complications. The hypercoagulable state of the peripartum period and the severe biventricular dysfunction led to the formation of clots. Learning objective: This case underscores the importance of careful screening of the right side of the heart in cases of peripartum cardiomyopathy. In cases of doubt, cardiac magnetic resonance imaging can be performed to determine the nature of the masses. This case also highlights the importance of effective anticoagulation therapy and the need to be vigilant for any thromboembolic phenomenon during the anticoagulation therapy.>

Factors related to discussing prognosis by nurses at heart failure clinics in Sweden and the Netherlands

Permanent pacemaker lead-induced tricuspid regurgitation is extremely uncommon. We report a patient with severe tricuspid stenosis detected 10 years after permanent single chamber pacemaker implantation in surgically corrected congenital heart disease. The loop at the level of the tricuspid valve may have caused endothelial injury and eventually led to stenosis. Percutaneous balloon valvotomy for such stenosis has not been reported from India.

A 41-year-old female presented with exertional presyncope without palpitation and easy fatigability since 7 years. On examination she had cyanosis, clubbing, and room air oxygen saturation of 88%. The electrocardiogram showed 2 : 1 atrioventricular (AV) block. Transthoracic ( Panels A–C and see Supplementary data online, Video S1 and S2 ) and transoesophageal ( Panel D , arrowhead and see Supplementary data …

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] An 18 year-old man presented with gradually progressive dyspnea. Examination revealed grade 3 clubbing and cyanosis of all extremities except the right upper limb (A) . Left parasternal heave and palpable

Late left ventricle (LV) rupture with pseudoaneurysm after mitral valve replacement is rare. We report its early diagnosis by advanced technologies, e.g. MRI and successful repair of a type I AV rupture through left atrial approach.

A 52-year-old woman presented with exertional dyspnoea NYHA class III and chest pain for 15 days. The clinical examination revealed an irregular pulse and a continuous precordial murmur. The ECG was suggestive of atrial fibrillation. The chest X-ray revealed significant cardiomegaly ( Panel A ). The 2D echocardiography and colour Doppler ( Panel B ) showed a dilated left main and the left circumflex artery (LCX) ( Panels …

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5][![Graphic][6] ][6] A 20-year-old male presented with exertional dyspnoea and exertional presyncope of 7 months duration, 1 episode of syncope 6 months ago with worsening dyspnea since 1 week.

Introduction Myxomas are the most common among the primary cardiac neoplasms, seen mainly in adult population, and are typically attached to the interatrial septum, on the left side. Myxomas arising from other sites are designated as “atypical myxomas.” In this article, we describe the clinicopathologic features of 28 such lesions, resected in 20 patients. Methods A 15-year study (1995–2009) of all cardiac myxomas, received as surgical excisions in our institution, was performed. Atypical myxomas were selected on the basis of their atypical sites of origin, and a systematic review and comparison of their clinicopathologic features with all typical myxomas excised during the same period were done. Results Among a total of 84 patients who had undergone cardiac myxoma excisions in this 15-year duration, 64 patients had typical myxomas, while atypical myxomas (30 tumors) were diagnosed in 20 patients (23.8%). None of them had a family history of similar symptoms. There were six children. In the atypical subset, there were 12 males and eight females; the mean age of diagnosis was 33.7 years. This demography differed from the typical myxoma group where there were more females than males and the mean age of diagnosis being 40.8 years. The symptoms of dyspnea, episodic chest pain, and palpitation were common in both cohorts of patients, and all showed a mass lesion with varying degrees of valvular regurgitation and obstruction on echocardiography. Five of the 20 patients with atypical myxomas had multifocal or multicentric tumors. Grossly, like typical myxomas, the atypical ones also exhibited solid and papillary patterns with the usual histological features. Four patients had recurrence of the disease. Conclusions Atypical myxomas are rare lesions having clinical and pathological features, not entirely different from those of typical myxomas. With the advent of modern diagnostics, it is now imperative to do genetic studies and screen the relatives of patients having atypical myxomas to rule out additional occult familial cases as they are now known to occur more in this “atypical” group.

Aims To assess the immediate and mid-term outcome of transcatheter closure (TCC) using the first-generation Amplatzer duct occluder (ADO) in patients with ruptured sinus of Valsalva aneurysm (SOVA). Ruptured SOVA is a rare cardiac shunt lesion, with scant data about its TCC. Methods and results Twenty patients (8 females and 12 males) aged 17–52 years (median 27 years) with ruptured SOVA were selected for TCC. Most (13/20) were in symptomatic NYHA class III or IV. Three had previous cardiac surgeries. Associated defects were bicuspid aortic valve in one, trivial pre-existing aortic regurgitation (AR) in five, coarctation of the aorta in one, and secundum atrial septal defect in one. Patients with co-existing ventricular septal defect or significant AR requiring surgery were excluded. Echocardiography revealed ruptured SOVA from right coronary sinus to right atrium (RA) in 4 and right ventricular (RV) outflow in 5, whereas non-coronary sinus ruptured into RA in 10 and RV inflow in 1. At cardiac catheterization, the defect was 4–11 mm (median 9 mm) at its aortic end as measured by online transoesophageal echocardiography or angiography. The Q p/ Q s ratio ranged from 1.5 to 3.2 (mean 2.32 ± 0.53). In all patients, the defect was closed from the venous side, using ADOs 2–4 mm larger than the aortic end of the defect. The ADO sizes ranged from 8/6 to 16/14 mm (median 13/11 mm). The procedure was successful in 18 out of 20 patients (90%). Of these 18, 13 had a complete closure at discharge. Five had a residual shunt (four small and one moderate with self-abating haemolysis). Trivial AR occurred in four. On a median follow-up of 24 months (range 1–60 months), 15 patients were in NYHA class I and 3 in class II. The residual shunt disappeared in three and was small in two; procedure-related AR vanished in two of four. There was no AR progression, recurrence, infective endocarditis, or device embolization. Conclusion In appropriately selected patients with ruptured SOVA, TCC is an attractive alternative to surgery with encouraging short- and mid-term outcomes.