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We report an extremely rare case of amyloid heart with classical “Starry Sky” appearance in echocardiography in a 52-year-old male presenting with systemic amyloidosis secondary to plasma cell dyscrasias. Interestingly, patient presented with diffuse myalgia unresponsive to traditional nonsteroidal anti-inflammatory drugs with effort dyspnea New York Heart Association Class II secondary to Grade II diastolic dysfunction of stiff myocardium infiltrated with amyloid protein. A starry sky pattern of an amyloid heart led to the retrospective diagnosis of plasma cell dyscrasias with presence of 30% plasma cells in bone marrow biopsy without the presence of M band in serum electrophoresis.

Flagellated bacteria are hydrodynamically attracted to rigid walls, yet past work shows a “hovering” state where they swim stably at a finite height above surfaces. We use numerics and theory to reveal the physical origin of hovering. Simulations first show that hovering requires an elongated cell body and results from a tilt away from the wall. Theoretical models then identify two essential asymmetries: the response of width-asymmetric cells to active flows created by length-asymmetric cells. A minimal model reconciles near- and far-field hydrodynamics, capturing all key features of hovering.

We present an extremely rare case of multivalvular endocarditis in an immunocompetent host which is not observed in routine clinical practice. Multivalvular endocarditis is extremely rare to find in today's era due to the widespread use of broad-spectrum antibiotics to treat pyrexia of unknown origin (PUO). Multivalvular involvement is usually encountered in immunocompromised individuals and is most often due to staphylococcal in origin. It is scarce to find our case of a 73-year-old elderly nondiabetic female with PUO who was diagnosed to be having endocarditis of both aortic and mitral valves showing large friable vegetations. In contrast, her urine and blood culture both had grown Enterococcus species. We successfully treated the patient with parenteral ampicillin and gentamycin for eight weeks, which made the patient afebrile and resolved the vegetation.

Persistent left-sided superior vena cava (PLSVC) is rare and is the most common systemic vein anomaly. It is mostly asymptomatic and often an incidental finding. It may pose a challenge in performing intervention through it due to its complex anatomy. We report a case of degenerative symptomatic complete atrioventricular node block in whom PLSVC was found incidentally during permanent pacemaker implantation. We also discussed the technical challenges and how to overcome these difficulties.

Abstract Insertion‐type layered Na2Ti3O7 has attracted the attention of the researchers and is considered to be one of the promising low‐voltage anode materiasl for sodium‐ion batteries. In spite of its fascinating electrochemical properties, the low electronic conductivity and structural instability of Na2Ti3O7 are major drawbacks that restrict its practical application. Surface modification with pyrolytic carbon is one of the effective ways to reduce irreversible capacity loss caused by electrolytic degradation. In this work, attempts have been made to investigate the effects of different carbon coating approaches on the electrochemical properties of sol‐gel‐synthesized Na2Ti3O7 microrods. The as‐synthesized Na2Ti3O7 rods are coated with a uniform carbon layer both by in‐situ and ex‐situ methods using citric acid and polyvinyl alcohol as carbon source, respectively. Ex‐situ carbon‐coated Na2Ti3O7 (Na2Ti3O7@C), due to better coating uniformity and higher graphitized carbon percentage, shows enhanced cyclability and rate performance compared to bare material and in‐situ carbon composite (Na2Ti3O7/C). Following the ex‐situ carbonization method using PVA as carbon source, it is found that increase of carbon content from 5wt% to 10wt% significantly improves its electrochemical properties. However, further increase in PVA amount has adverse effect on the cycling as well as rate performance of Na2Ti3O7@C. Surface modified Na2Ti3O7@C with optimum carbon content (10wt% C) shows improved cycling capacity (capacity retention ∼74.75% after100 cycle) and rate performance (∼67 mAhg‐1 at 1.5 Ag‐1). Both excess and inadequate carbon content have detrimental effect on the electrochemical properties of Na2Ti3O7 anode.

Mature mediastinal teratomas are infrequent, slow growing, and often asymptomatic. Traditionally, they present in the fourth decade or earlier and are found in the anterior mediastinum. These teratomas are often found incidentally on imaging, and surgical resection can be a challenge due to the size and location of the tumor; however, complete surgical excision is usually curative. Our case represents an infrequent benign giant (25 cm × 18 cm × 12 cm) mature intrathoracic mediastinal teratoma with uncommon clinical presentation of congestive heart failure and cardiac cachexia. The rare location of the tumor in the mid posterior mediastinum, very large teratoma, clinical presentation with right ventricular failure and cardiac cachexia, preoperative diagnostic dilemma, perioperative surgical challenge, and management marks this case unique.

Traditional dyeing procedures were used to color jute fabrics using a natural dye extracted from eucalyptus bark. A pre-mordanting method was followed to dye the jute fabric in the absence and presence of mordant. Alum, vinegar, copper sulfate (CuSO4), alum+CuSO4, vinegar+CuSO4, were used as mordants. Each of the dyed materials was examined in terms of color strength (K/S) and CIELab values. Dyed fabrics were tested for wash, rubbing (dry and wet), and light fastness values. Jute-dyed fabrics without mordants revealed a reddish-brown shade, whereas fabrics dyed with other mordants showed light brown to dark brown shades. Except for unmordanted fabrics that showed moderate to good wash fastness, all fabrics showed good colorfastness to washing. All fabrics showed excellent colorfastness under light and dry rubbing. Apart from the unmordanted fabrics, which had moderate to good wet rubbing fastness, the fabrics had good wet rubbing fastness.

It is extremely rare to encounter primary malignant tumors of the heart. Rhabdomyoma constitutes approximately 20% of all primary malignant tumors of the heart. Rhabdomyoma commonly arises from the ventricular wall, and rarely, they arise from the atrial wall and mimic symptomatic atrioventricular valve stenosis. We describe an extremely rare case of left atrial (LA) rhabdomyosarcoma detected during the transesophageal echocardiography arising from the posterior wall of the left atrium protruding into the left ventricle causing obstruction of the mitral valve. Our case is a rare case of LA rhabdomyosarcoma presenting with mitral inflow obstruction and symptomatically mimicking severe rheumatic mitral stenosis with atrial fibrillation and fast ventricular rate with orthopnea secondary to LA failure and passive pulmonary venous congestion.

Environmental concerns about synthetic dyes and their carcinogenic properties renewed interest in eco-friendly natural dyes. Natural dyes produce a wide range of tints and shades with the same dye material. In this study, natural colorants from Lantana camara flowers, a Verbenaceae plant, have been applied to bleached cotton fabrics following pre-mordanting, simultaneous mordanting, and post-mordanting with different chemical mordants (copper sulfate, ferrous sulfate, nickel sulfate, potassium aluminum sulfate, potassium dichromate, stannous chloride). Dyed samples were tested for wash-fastness, light-fastness, and rubbing-fastness, as per Standard IS methods. The colors of dyed pieces were evaluated with color matching software using CIELAB (ΔL*, Δa*, Δb*) coordinates and K/S values for dye absorption on cotton. Pre-mordanting produced good dye uptake. The extracted natural dye was analyzed using Ultraviolet-Visible Spectroscopy, Fourier-Transform Infrared Spectroscopy, and Inductively Coupled Plasma Mass Spectrometry. This study demonstrated that the flowers of Lantana camara are an excellent source of eco-friendly natural dye, and the dye extract is free from heavy metals such as antimony, arsenic, cadmium, and lead. Cotton and natural fiber textiles can be commercially dyed with the dye extracted from the Lantana camara flowers using a variety of chemical mordants to achieve different color shades.

We report an extremely rare case of left ventricular noncompaction (LVNC) cardiomyopathy sparing the anterior ventricular wall in an interesting “necklace” pattern in parasternal short axis view in a 76-year-old female with frequent palpitation and shortness of breath for the last 6 months. Interestingly, the patient had a plethora of basal septal premature ventricular complexes (PVCs) both from the anterior and posterior aspects of the paradoxically thinned-out basal septum and they were not from the segment of noncompacted (NC) myocardium. Our case is unique and the first to describe the LVNC in an interesting shape of “necklace” sparing the left ventricular anterior, anteroseptal, and anterolateral wall and paradoxically arising plethora of septal PVCs from the thinned-out basal septum deteriorating the left ventricular function rapidly in an elderly female in her seventh decade of life. Although commonly in LVNC, the PVCs arise from the NC segment, in this unique case plethora of PVCs paradoxically arising from the basal septum were contributing toward rapid deterioration of left ventricular systolic function in an elderly patient in her seventh decade of life without the presence of conventional risk factors.

We report an extremely rare and peculiar case of symmetric peripheral small-vessel disease involving only the radial artery of the index finger sparing major vessels in an 80-year-old female with systemic sclerosis (SSc). Our case is the first literature description of bilateral small-vessel peripheral arterial disease only involving the radial artery of the index finger in an octogenarian with SSc. Symmetric small-vessel peripheral artery disease can also be a late manifestation of collagen vascular disease.

We report an extremely rare case of Williams–Beuren (WB) syndrome in a 10-year-old boy with supravalvular aortic stenosis (SVAS) secondary to a large fibrocalcific eccentric shelf in the ascending aorta with fibrocalcific severe supravalvular pulmonary stenosis, which has not yet been described in the literature. Although the presence of peripheral pulmonary stenosis is well described in Williams syndrome (WS), our case is the unique and first to demonstrate fibrocalcific severe supravalvular pulmonary stenosis in WS without the presence of peripheral pulmonary artery stenosis. Although regarded as a strong genetic insult with 27 gene deletions (almost like biting the gene), it has also bitten the heart in this index child and left a large chunk of supravalvular fibrocalcific mass in the ascending aorta causing SVAS.

We present a case of funnel-shaped aneurysmal dilatation of left main coronary artery (LMCA) with aggressive stenosis of osteoproximal left circumflex coronary artery presenting with lateral wall coronary ischemia in a 6-year-old school-going child who recovered from Kawasaki disease (KD) 1 month back. Although aneurysmal dilatation of LMCA during first 2 months of recovery from KD is well known, with median duration for the development of stenotic lesion in coronaries after KD is approximately 6 months and all the cases of coronary stenosis described so far have been described in the presence of large coronary artery aneurysm, our case is rare to illustrate aggressive stenosis of osteoproximal left circumflex coronary artery just after 1 month of recovery in spite of the presence of small coronary artery aneurysm.

We report an extremely rare association of left-sided inferior vena cava (IVC) in a 38-year-old female presenting with recurrent palpitation for the past 2 years with typical slow-fast atrioventricular reentrant tachycardia (AVNRT). We delineated the course of the left-sided IVC with pigtail injection and catheter course to the right atrium and successfully modified the slow pathway with conventional catheters with difficulty in ablation catheter maneuvering and his catheter stability was an issue. Our case is the first description of an unusual association of isolated left-sided IVC in a patient with typical AVNRT.

We report a rare case of hypertrophic obstructive cardiomyopathy (HOCM) presenting with mega coronary arteries with obstructive coronary artery disease. Interestingly, the patient had large septals, large diagonals, large obtuse marginal with a large left atrial branch, and a large conus almost mimicking a duplicate right coronary artery. Because of massive left ventricular hypertrophy, to overcome the supply-demand mismatch, coronary arteries may become large or with more arborization in hypertrophic cardiomyopathy but the same is rarely encountered in routine clinical practice. Our case is a rare illustration of the simultaneous presence of mega coronary arteries and critical obstructive coronary artery disease in HOCM in a young male of 38 years of age.

We report a unique association of rheumatic heart disease with left ventricular (LV) noncompaction cardiomyopathy in an octogenarian. He had severe mitral stenosis with severe LV systolic dysfunction secondary to noncompaction. Although the association of rheumatic heart disease with LV, noncompaction cardiomyopathy has been described sparsely in the literature, our case is a unique illustration of the presence of LV noncompaction cardiomyopathy contributing toward severe LV systolic dysfunction in rheumatic mitral stenosis in an octogenarian with no coronary artery disease.

We report a rare case of dense mitral annular calcification in a 26-year-old male presenting with recurrent palpitation for the last year with a plethora of mitral annular premature ventricular complexes (PVCs). PVCs had right bundle branch block morphology, were notched in inferior leads with negative QRS complexes in aVL suggestive of likely origin from the lateral mitral annulus. Patients with PVCs from mitral annulus are usually advised to undergo cardiac magnetic resonance imaging to localize the site of subtle mitral annular calcification and plan subsequent delivery of radiofrequency lesions at the same site during radiofrequency ablation. Dense calcification of the lateral mitral annulus is extremely rare to encounter in such a young age of below 30 years without the presence of any predisposing risk factors for calcification. Our case is the first illustration of dense mitral annular calcification secondary to the plethora of mitral annular PVCs in a symptomatic young person below the age of 30 years. PVCs-induced excessive local excursion with wear and tear phenomenon and secondary dystrophic calcification may be the plausible explanation behind this interesting presentation.

Although revascularization of a femoropopliteal (CTO) always remains challenging through a retrograde or contralateral crossover approach, we report a case of successful revascularization of a long-segment femoropopliteal CTO through antegrade femoral puncture which stands as the crux of the procedure. In routine peripheral intervention, long-segment femoropopliteal occlusion is usually approached from a contralateral femoral artery or ipsilateral brachial artery, antegrade revascularization of femoropopliteal CTO is not adapted by many in routine practice. Here, we describe the technique and the tips and tricks of antegrade puncture of common femoral artery. We will also discuss the literature review of antegrade technique versus retrograde and crossover technique for revascularization of femoropopliteal CTO which may be useful for budding young interventionists. Our case carries another important learning point about management of popliteal disease where revascularization with a stent is of concern due to high knee joint mobility.

We report an extremely rare co-occurrence of focal lipomatous hypertrophy of the interatrial septum (LHIS) with patent foramen ovale (PFO) in a neonate and electrocardiogram evidence of Lown-Ganong-Levine syndrome (LGL). Although atrial arrythmias in the form of supraventricular tachycardia like atrial premature contractions, atrial fibrillation, and atrioventricular block have been described in lipomatous hypertrophy interatrial septum, co-occurrence of LGL syndrome with LHIS has not been described in literature so far. Baby presented in the cardiology outpatient department for presurgical cardiological evaluation of congenital hydrocephalus. Typically, LHIS spares fossa ovalis and affects both side of the interatrial septum making interatrial septum dumbbell shaped. There is even no literature description of focal hypertrophy of interatrial septum in early infancy and child hood including neonatal period. Our case is a unique illustration of a rare co-occurrence of LGL syndrome in focal lipomatous hypertrophy of interatrial septum in a neonate with PFO.

We represent a case of interesting right coronary artery chronic total occlusion (CTO) revascularization where traditional wire upgradation failed to cross the CTO. Downgrading it to a Miracle 3 wire, the lesion was successfully crossed. It was further dilated with the smallest balloon (NIC Nano 0.85 mm × 6 mm), followed by serial dilation with bigger size balloons. The present manuscript conveys a message that the rule of thumb of wire upgradation during CTO revascularization does not yield in success always, it is the downgradation of the wire which can also achieve success. CTO revascularization although it has some fixed principles, sometimes, a permutation and combination even giving a fair try with wire downgradation can achieve success.

Relationship between moderator band (MB) calcification and infrahisian conduction system disease has not been described in the world literature so far. We report a case of a 74-year old male presenting with recurrent cardiogenic syncope 6 times is the last 2 months.He had echocardiographic evidence of dense moderator band calcification.Electrophysiology study revealed a His-Ventricular(HV) interval of 100 msec suggestive of significant infrahisian conduction system disease.He was put on a dual chamber pacemaker and he had no further episode of syncope during the follow up. Our description is unique and the first in the world literature that dense MB calcification in echocardiography may be an indirect clue to the presence of severe infrahisian conduction system disease.

We present an extremely rare case of a 26-year-old young male, an engineering student and a staunch vegetarian from early childhood without conventional cardiac risk factors, with hyperhomocysteinemia presenting as acute lateral wall ST elevation myocardial infarction with angiographic evidence of focal critical occlusion of the first diagonal branch. Although homocysteinemia and its association with coronary artery disease is well known, hyperhomocysteinemia with very high level of plasma homocysteine (>100 μmol/l) presenting as an exclusive small vessel coronary artery disease like involving only diagonal branch sparing major coronary vessels has not yet been described in the literature. Our case is unique and the first description of an exclusive small vessel coronary artery disease sparing major coronary vessels in the presence of paradoxically very high-level serum homocysteine (in a young male without conventional cardiac risk factors). Vegetarians should be encouraged to take Vitamin B6 rich food like potatoes, bananas, and garbanzo beans to decrease the likelihood of having severe coronary artery disease secondary to hyperhomocysteinemia.

Takayasu arteritis is an arteritis of unknown etiology, resulting in stenosis or dilatation of the aorta and its major branches. .We report a rare case of a giant right common carotid artery aneurysm on the one side in a 29-year-old young male with refractory hypertension with severely stenotic, diffusely diseased, corkscrew appearance of the contralateral carotid artery, which has not been described in the literature so far. Our case is a unique demonstration of nature's paradox in vascular behavior in Takayasu arteritis in the right and left carotid arteries in an index patient; one having a giant aneurysm and the other one being severely stenotic, diffusely diseased with corkscrew appearance.

We report a rarely encountered case of premature and parallel posterior descending artery (PDA) and posterior left ventricular branch (PLVB) in a case of 22-year-old male with effort angina Class II for the last 6 months in whom treadmill test (TMT) was strongly positive for provocative coronary ischemia with structurally normal heart and good biventricular function. Interestingly, all the coronaries were normal without any obstructive coronary lesion. Paradoxically, those two prematurely separating branches were small making the distal right coronary artery (RCA) territory relatively ischemic attributing toward a strongly positive TMT. Small anomalous coronary is a well-known cause of demand ischemia, but our case is unique to describe small prematurely originating PDA and PLVB were the culprit behind coronary ischemia in a young male without conventional risk factors. Furthermore, much premature separation of PDA and PLVB is rarely encountered in routine clinical practice, and recognition of this anomaly is important as it should not be mistaken for duplicate RCA, dual RCA, or split RCA. Our case is also unique to illustrate the association of the premature and parallel PDA and PLVB with a conus crossing the right ventricular outflow tract without the presence of structural heart disease.

We report a rare case of anomalous origin of obtuse marginals (OMs) from a common trunk arising from the right coronary sinus in an interesting armchair shape in a 52-year-old female presenting with acute inferior wall myocardial infarction. During routine coronary angiography, the origin of the left anterior descending coronary artery was visualized and the origin of the left circumflex (LCX) coronary artery was not visualized with the sign of nonperfused myocardium in the LCX artery territory. Our case is a rare illustration of armchair OMs with nonperfused proximal and middle LCX coronary artery territory.

We describe a rare surface electrocardiogram (EKG) recorded sinus beat initiation of permanent junctional reciprocating tachycardia in a 40-year old female with structurally normal heart presenting with incessant tachycardia over last 48 hours refractory to intravenous amiodarone infusion. Our case is an interesting illustration of sinus beat initiation of PJRT which has been rarely reported.

Each research roves around the P value. A value less than 0.05 is considered to be statistically significant. Very few researchers are aware of the history, real-world significance, statistical insight, and in-depth criticism about this monumental alphabet of research. This article will provide detailed insight into the most common molecule of research which will be rewarding for the young students and researchers in the primary world of research. It is not a simple value; it is the longest and broadest description of research squeezed to a number for the ground level worker to the principal investigator. The present review will provide a detailed and unique insight into the P value which would be rewarding for the primary care physicians toward translating research into their clinical practice.

Coronary anomalies are not commonly encountered in routine clinical practice. This case report is of a 55-year-old female who presented with effort angina, Canadian Cardiovascular Society (CCS) class II, since last six months with shortness of breath. Echocardiography (ECG) revealed the presence of Non ST Elevation Myocardial Infarction (NSTEMI) and the presence of no Regional Wall Motion Abnormality (RWMA), with normal left ventricular systolic function. Right transradial coronary angiogram revealed the presence of separate origin of Left Anterior Descending (LAD) and Left Circumflex (LCX) coronary artery. Although separate origin of LAD and LCX is the most common benign coronary anomaly noted in clinical practice, interestingly both coronary arteries in this case were harboring significant atherosclerotic occlusion and were successfully revascularised with Drug Eluting Stents (DES). Coronary intervention in separate origin of LAD and LCX requires special maneuvers during guide catheter management for percutaneous intervention. Clockwise rotation of the guide catheter to selectively engage the LCX and anticlockwise rotation of the guide catheter to selectively engage the LAD is the key for procedural success during coronary intervention. This case is unique and the first to describe the separate origin of LAD and LCX presenting as NSTEMI with critically obstructive Coronary Artery Disease (CAD) in both of them and age being the only conventional cardiac risk factor behind it.

Oleaginous microalga Chlorella is a promising microbial cell factory for producing lipids, transesterifiable to biodiesel, and phytochemical, high-value molecules (HVMs). To better understand the stress-induced oleaginous mechanism of Chlorella sp. FC2 IITG that closely matches with Chlorella sorokiniana based on 18s rRNA gene sequence, we performed 'Algomics' by systematically integrating metabolomics and proteomics data in response to time-resolved nitrogen-limitation: 40 h (mild), 88 h (moderate), and 120 h (severe). Ten HVMs belonging to four biological classes: triacylglycerol (TAG), polyunsaturated fatty acids (PUFA), phytosterols, and terpenoids were annotated using untargeted metabolomics and MS/MS fragmentation pattern match to the spectral library. In particular, the study evidenced 4× and 6× increased accumulation of two different PUFA: 9(S)HpOTrE and dihomo-gamma-linolenic acid, respectively, in nitrogen-limitation conditions. Co-extraction of TAG and PUFA could lower the biodiesel production cost for feasible commercialization. The investigation found a maximum accumulation of TAG 59:10 at 40 h, while that for TAG 54:4 was recorded at 88 h, which suggests different TAG species could be induced by regulating nitrogen-limitation severity. Elevated ꞵ-oxidation, glycolysis, and tricarboxylic acid (TCA) cycle identified in proteomics analysis could provide the substrates, phosphoenolpyruvate, pyruvate, and acetyl CoA, for different phytochemical accumulation in response to nitrogen limitation. The multiomics data unraveled a metabolic tug-of-war ongoing between biomass and storage lipid (TAG) accumulation during nitrogen-limitation, which involved multiple processes including hindered CO2 fixation, the supply of energy, reductants, and carbon reallocation from proteins and membrane lipids. These findings provide distinct oleaginous mechanisms in non-model microalgae, Chlorella sp. FC2 IITG, and engineerable targets for microalgal trait improvements.

Abstract Antimony (Sb) anodes explored for high energy density sodium cells are prone to rapid capacity decay during (de)alloying owing to reversible phase transformation (Sb⇌Na3Sb) induced volume expansion necessitates rationale materials and electrode design. Herein, we design a yolk‐shell structure where surfactant‐stabilized and pH modulated Sb nanoparticles (SbNPs) are carefully coated with Stöber silica and resorcinol‐formaldehyde resin at room temperature. Upon pyrolysis under argon followed by careful etching of the intermediate layer from Sb@SiO2@C double core‐shell leads to the formation of Sb@void@C yolk‐shell possessing SbNPs confined within mesoporous conductive carbon shells with sufficient void space allowing Sb to realize its full potential and display superior sodium storage behavior. Moreover, binder‐free electrodes fabricated by electrophoretic deposition deliver superior performance in a sodium cell with improved rate capability. A full cell fabricated with Prussian blue type NaxFe[Fe(CN)6] cathode paired with Sb@void@PC anode delivers a practical energy density of ∼142 Whkg–1 operating at ∼1.95 V. The favorable results of yolk‐shell Sb@void@C anodes in sodium‐ion battery demonstrate the structural superiority for future energy storage applications

We present an extremely rare case series of two short dual right coronary arteries (RCAs), causing coronary ischemia without the presence of obstructive coronary artery disease. We describe here the presence of short dual RCA in a 55-year-old nondiabetic, nonhypertensive, and nondyslipidemic male presenting with effort angina New York Heart Association Class II for the last 6 months with strongly positive stress test and another 40-year-old athlete (Central Reserve Police Force Army) without conventional risk factors with effort angina Class II for the last 3 months also with strongly positive stress test. Dual RCA, otherwise known as double RCA, duplicate RCA, or split RCA is extremely rare to encounter in routine clinical practice. The patient had a significant effort angina; in spite of nonatherosclerotic coronaries, small dual RCA terminating much earlier than the intended area of supply was the reason behind coronary ischemia with strongly positive provocative stress test. Short normal dual RCA can be a cause of coronary ischemia although mentioned in the literature; there has been no case report in the world literature till now about short dual nonatherosclerotic RCA causing coronary ischemia. Our case is unique and first to describe short dual RCA terminating much earlier than the intended area of supply can attribute to demand ischemia in the intended area of supply without the presence of obstructive coronary artery disease. We treated the patient with nicorandil to improve myocardial microvascular flow in ischemic region with symptomatic improvement of the patient.

We present an extreme rare case of cristal atrial tachycardia (AT) in a 23-year-old male presenting with recurrent refractory palpitation since last 1 year treated with betablocker metoprolol 50 mg twice daily. We subjected the patient for electrophysiologic study and radiofrequency ablation and A wave in the mid cristal region preceded the surface P-wave by 16 ms. Ablation here terminated the tachycardia but interestingly patient turned up with recurrent palpitation after 1 month. In view of mid cristal AT, we treated the patient with Ivabradine 5 mg twice daily after which the patient was asymptomatic in follow up. Our case is a unique demonstration of sinus node funny current inhibitor Ivabradine being effective to relieve symptoms even in failed cases of radiofrequency ablation with partial modification of mid cristal region in a case of recurrent mid cristal AT. Our take home message from this electrophysiology experience is that even in cases with partial modification of crista terminalis or failed radiofrequency ablation of Cristal atrial tachycardia Ivabradine can serve as an alternative before proceeding to 3D ablation.

We report an extremely rare case of medium vessel thrombosis (ulnar and popliteal artery) in a 26-year-old female presenting with recurrent abortion and gangrenous right ring finger and pregangrenous toes of the left feet. Medium vessel thrombosis i.e. selective involvement of ulnar and popliteal vessels is an extremely rare phenomenon described in the literature of antiphospholipid antibody (APLA) syndrome. We conservatively managed the patient with antiplatelets and anticoagulants which substantially improved the ischemia of the finger and toes. Our case is a unique description of ulnar and popliteal artery thrombosis in APLA syndrome which has not been described in world literature so far.

Background: Atherogenic index of plasma (AIP), a logarithm of ratio of triglycerides and high-density lipoprotein-cholesterol is associated with the risk of cardiovascular diseases. The cardiovascular complication in Type 2 diabetes is often assessed by the left ventricular ejection fraction (LVEF). Aim: This study aimed to observe and to find any correlation between LVEF and AIP in newly diagnosed Type 2 diabetes mellitus patients. Materials and Methods: In this cross-sectional observational study, we recruited 140 (male 81, female 59) newly diagnosed Type 2 diabetes mellitus patients from a tertiary care hospital. Plasma lipids were measured from venous blood after 12-h fasting. The LVEF was measured by echocardiography. Data were presented as mean, standard deviation, and statistically tested by Chi-square and Pearson correlation coefficient in IBM SPSS Statistics 20. Results: The mean age of the participants was 53.95 ± 11.63 years (male 53.85 ± 11.12 years, female 54.08 ± 12.39 years, unpaired t-test P = 0.91). The mean LVEF was 0.59 ± 0.06 and 0.6 ± 0.05 (unpaired t-test P = 0.17) in males and females, respectively. The AIP was 0.57 ± 0.07 and 0.57 ± 0.07 (unpaired t-test P = 0.97) in males and females, respectively. There was a negative correlation (r = −0.56, P < 0.001) between LVEF and AIP. Conclusion: Newly diagnosed type 2 diabetes mellitus patients showed a high AIP. Hence, serum lipid profile may be tested early in these patients. Patients with a higher AIP may have lower LVEF. Hence, diabetic patients with a high AIP may be screened for LVEF periodically for early detection and management of heart failure.

We report a rare case of anomalous origin of right coronary artery (RCA) from the left coronary sinus with a peculiar medusa head pattern of left coronary system in an octogenarian presenting with inferior wall myocardial infarction. Although anomalous origin of RCA from the left coronary sinus is the most common anomaly to be reported, this rare association of extensive arborization of left coronary system appearing like a medusa head is not reported in literature so far. The anomalous RCA harbored critical mid-RCA lesion, but the crux of coronary intervention was that we engaged the anomalous RCA with extra back up guide catheter in place of conventionally used Judkins right guide catheter to engage the anomalous origin and accomplished the coronary intervention with buddy wire technique. Our case is unique and the first to describe the association of medusa head appearance of left coronary circulation in a case of anomalous origin of RCA from the left coronary sinus.

We present a simple novel technique of crossing the calcium spur at right-angle bend in coronary artery by deploying a noninflated balloon over the calcium spur where the tip of the passing stent frequently hits and create difficulty in negotiation of the stent forward. When we deploy a balloon over the calcium spur, the tip of the stent does not hit the edge of the calcium spur and the stent gently slides over the hydrophilic slippery balloon forward with ease. We describe a rare case of intervention in anomalous anterior origin of right coronary artery where we were not able to pass the stent across two 90° bends which were harboring calcium spur. In spite of we adopted buddy wire and triple wire technique to make the bend straight, we were not able to move the stent forward, each time it was hitting at the edge of the calcium spur. We put a 2 mm × 10 mm noninflated semicompliant balloon each time while crossing the right-angle bend with calcium spur which covered the calcium spur and over the balloon we were easily able to slide the stent forward, deployed the stent across the lesion, and achieved distal TIMI III flow. We describe this simple novel technique of “sliding the stent over the balloon technique” to cross the calcium spur remaining at 90°-angle bend causing difficulty in forward negotiation of the stent.

Right coronary artery after origin from right coronary sinus traverses horizontally to run in right atrioventricular groove till the crux of the heart where it divides into posterior descending artery and posterior left ventricular branch. When the right coronary artery after its origin takes an acute high take off from the ostium and then abruptly descends down making a hairpin loop to run in the right atrioventricular groove, it is known as Shepherd's crook right coronary artery which is extremely rare to encounter in routine clinical practice. This interesting coronary artery deformity has great significance per se so far as the coronary physiology and intervention is concerned. We present a case of Shepherd's crook right coronary artery in the most elderly patient of 84 years of age in world literature and detailed review of this peculiar anatomy. Review literature about Shepherds Crook deformity is yet not there in the literature except some case reports and this review article will be providing the interventional cardiologists a detailed insight into the right coronary ischemia secondary to this interesting anomaly.

We present the case of a 35-year-old female with small restrictive ventricular septal defect (VSD) presenting with prolonged fever for the last 1 month with vegetation on the right coronary cusp (RCC) of the aortic valve with flail aortic leaflet causing severe aortic regurgitation (AR). Her echocardiography done 1 year back had revealed the presence of small restrictive VSD with a gradient of 80 mm Hg without any prolapse of RCC or presence of AR. She did not have any early diastolic murmur of AR during 3 monthly routine follow-up in the cardiology outpatient department suggestive of previous aortic valve prolapse with AR in the aforesaid period before the infective endocarditis episode. Common sites of the vegetation in small restrictive VSD are right ventricular side of the interventricular septum, undersurface of the tricuspid valve, free wall of the right ventricle, and rarely the pulmonary valve on the low-pressure site of the shunt where the turbulent jet containing the bacteria slows down, and bacteria adhere the underlying endocardium. Normally, vegetation across any turbulent jet does not occur on the high-pressure site due to the reason that bacteria can not adhere to the wall across the turbulent jet in high-pressure zone, which sweeps away all the bacteria from the high-pressure zone to low-pressure zone. Paradoxical finding in our case was that vegetation was noted on the RCC of the aortic valve which was a high-pressure zone, which may be explained by only Bernoulli's phenomenon. Our case illustrates paradoxical vegetation on the RCC of the aortic leaflet in a patient with small restrictive VSD and is also a unique demonstration of left-sided endocarditis in a patient with left-to-right shunt.

We report a rare case of inadvertent distal small diagonal branch perforation noted postleft anterior descending coronary artery revascularization, rescued by Gelfoam closure in a 43-year diabetic male presenting with acute anterior wall ST elevated myocardial infarction. Intermittent balloon inflation for 30 min was not able to seal off the perforation; because of impending late (3–6 h) cardiac tamponade, we closed the perforation with Gelfoam embolization through Caravel microcatheter. Although rarely practiced, this armamentarium should be there in the interventional cardiology laboratory to deal with small vessel perforation (

We describe an interesting fluoroscopic calcification of the aortic knuckle assuming a reverse “C” shape in an atherosclerotic aorta in a 42-year-old male presenting with anterior wall ST-elevation myocardial infarction with dyslipidemia. Although calcification of the aortic knuckle and dilatation of the aorta is a common phenomenon in the elderly population, otherwise known as the “unfolding of aorta,” we observed this interesting pattern of calcification in a middle-aged person in an atherosclerotic aorta with calcification. The patient had double-vessel coronary artery disease with chronic total occlusion in the left anterior descending coronary artery and significant stenosis in the mid-segment of the right coronary artery, which we revascularized with drug-eluting stents and achieved TIMI III flow. Although calcium sign or C sign is described in aortic dissection and it is not specific to it, we observed this interesting pattern of calcification in a middle-aged person in the atherosclerotic aorta with dyslipidemia.

Background: Medical records are important documents that should be stored for at least 3 years after the commencement of the treatment of an adult patient in India. In a health care facility, patients' data is saved in an online or offline retrieval system. However, in the case of the primary care physician, the data is not commonly kept in an easily retrievable system. Aim: To test the feasibility of using a set of free web-based services in digitization, preservation, and retrieval of prescription on a smartphone by primary care physicians. Methods: This study was conducted with 12 primary care physicians. They were provided hands-on guides on creating an online form for uploading a prescription and using an application for retrieval of the prescription on a smartphone. Their feedback on the training material was collected by a telephonic survey, which had a 10-point Likert-type response option. Then, an in-depth interview was conducted to ascertain their perception on the tutorial and the process of digitization and retrieval system. Results: All of the participants were able to create an online form on their smartphone. They uploaded their prescription and associated data and were able to retrieve it. The physicians opined positively on the “cost of the system,” “portability” on a smartphone and ease of the “tutorial”. They opined negatively on the “limited storage,” chances of “loss of data,” and “time constraints” for entry of the patients' data. Conclusion: Free web-based and smartphone applications can be used by a primary care physician for personal storage and retrieval of prescriptions. The simple tutorial presented in this article would help many primary care physicians in resource-limited settings.

Background: Noninvasively jugular venous pressure (JVP) is measured at bedside commonly by card and ruler. New tools have been developed for the measurement of JVP with the basis of this method. However, these tools have some limitations. Aim: The aim of this study was (1) to develop a JVP scale which would be devoid of common problems faced with currently available devices and (2) to test the provisional validity and reliability of the device in the estimation of JVP. Materials and Methods: We used two common plastic rulers – one as vertical and one as horizontal. The vertical ruler was cut at the level of 5 cm mark. A piece of aluminum sheet was used to make an adapter in which the vertical ruler can slide. This adapter was attached to the horizontal ruler. Both the rulers were equipped with spirit-level capsules. This device was used by 16 raters to measure JVP on five individuals twice. Inter-rater, intra-rater, and test–retest reliability were checked by the intraclass correlation coefficient (ICC) in IBM® SPSS® Statistics Version 20 software package. Results: For average measures, inter-rater ICC was 0.998 (P < 0.001), intra-rater ICC was 0.981 (P < 0.001), and test–retest ICC was 0.829 (P = 0.001). Inter- and intra-rater reliability was “excellent,” whereas test–retest reliability was “good.” Conclusions: Developed JVP scale is low cost and easy to build at any resource-limited settings. This would be an adjunct tool for bedside cardiovascular examination of patients with good to excellent reliability. This would also be used for teaching cardiovascular physiology for medical and allied science students.

Background: Modern microscopes are equipped with built-in illuminator. However, during a power outage, microscopy is not possible with extra mirror system if an alternative light source is not available. Smartphone torch can serve as a light source. Holding it under the microscope is difficult when both hands are engaged in microscopy. Aim: The aim of the study was to develop a stand for smartphone torch and to check the applicability of smartphone torch-based light source in microscopy. Materials and Methods: A stand was made with cardboard for keeping the smartphone on it. An optical diffuser was made with white polyethylene plastic. Smartphone with the stand and optical diffuser can serve as a soft light source. A convenient sample of 16 faculty member rated 11 slides first under the microscope with its built-in light source and then twice with the new device as a light source on 10-point Likert type scale. Applicability of the device was checked by validity and reliability by Intraclass Correlation Coefficients (ICC) with α = 0.05. Results: The raters were able to examine the slides under the microscope with the new devices as a light source. An overall score (11 slides, 16 observers) for the image quality was 9.36 ± 0.86 (range 6-10). Interrater, intrarater, and test-retest ICC were 0.939 (P < 0.001), 0.853 (P = 0.003), and 0.889 (P < 0.001) respectively which indicate “good” to “excellent” level of reliability. Conclusion: Developed smartphone torch stand with an optical diffuser can serve as an emergency light source in microscopy. This may be a useful tool for settings with a frequent power outage.

Background: In academic teaching, we need exercise protocols with moderate and vigorous intensity for observing cardiorespiratory changes in different grades of exercise. Aim: We aimed to formulate exercise protocols with moderate- and vigorous-intensity for apparently healthy adult subjects for undergraduate practical teaching to be used in the observation of cardiorespiratory changes in different grades of exercise. Methods: We hypothesized that 50 m brisk walking (to and fro, four times in a clinical physiology classroom) is moderate-intensity exercise and spot jogging with full effort and verbal encouragement for 1 min is vigorous-intensity exercise. We measured heart rate (HR) immediately after moderate-intensity and vigorous-intensity exercise and compared it with the standards where attainment of 50%–70% of maximum achievable HR (HRmax) is moderate-intensity exercise and 71%–85% of HRmaxis vigorous-intensity exercise. Results: Data of 85 participants (male = 59, female = 26) with mean age 19.56 ± 1.13 years were analyzed. The percentage of HRmaxachieved in the moderate-intensity exercise was 58.19 ± 7.55, and vigorous-intensity exercise was 78.19 ± 8.48. About 85.88% of participants were within 50%–70% of HRmaxin the moderate-intensity exercise and 72.94% of participants were within 71%–85% of HRmaxin the vigorous-intensity exercise. Conclusion: A brisk walking for a distance of 50 m can be considered as moderate-intensity and a spot jogging with full effort for 1 min can be considered as a vigorous-intensity exercise for observing cardiovascular changes in different grades of exercise. These protocols can be used for physiology practical teaching in a small practice room without using any instrument in resource-limited settings.

Background: Reusable suction-cup electrodes are used for recording a 12-lead electrocardiogram (ECG) in resource-limited settings. These electrodes may easily detach if those are attached on a hirsute chest. Additionally, the suction pressure may cause erythema and pain. Aim: The aim of this study was to develop a low-cost strap for holding the suction-cup-based precordial electrodes and to test its applicability to the recording of ECG. Materials and Methods: A scrap rubber tube was cut in size so that it can cover all the precordial electrode positions. Slit openings (electrodes can be inserted through these opening) were made on this rubber strap. A cloth and a hook-and-loop fastener were used to make an adjustable fastener. ECG was recorded first on 16 non-hairy males with electrodes placed on the chest with the strap and then with electrodes attached by suction. After that, ECG was recorded on 16 males with hirsute chest first with the electrodes placed with the help of the strap and then with suction (without strap) on the shaved chest. Results: The outcome of this study is a low-cost ECG chest strap for a hirsute chest. Both the negative and positive QRS voltages in six precordial leads recorded with electrodes placed with the strap were similar to that of suction-attached electrodes in both non-hairy and hirsute chest. Conclusion: Developed rubber chest strap can be made with minimal cost and expertise in any resource-limited settings. This would help in recording the ECG of a patient with a hirsute chest. This prototype strap has scope for further improvement.

Supracristal Ventricular Septal Defect (VSD) develops Aortic Regurgitation (AR) with the passage of time due to prolapse of the right coronary cusp. It brings clinical attention in early child hood with an incidental continuous murmur, recurrent respiratory tract infection of failure to thrive. This report is about a rare case of 52-year-old female who presented with increased fatiguability since the last six months. Clinical examination revealed the presence of cardiomegaly with holosystolic-diastolic murmur in Left Upper Sternal Border (LUSB). Echocardiography revealed the presence of supracristal VSD with moderate AR without prolapsing aortic leaflet or dilatation of aortic sinus. In view of presence of moderate AR, the patient was advised to be on Angiotensin Receptor Blocker (ARB) with regular follow-up to monitor the progression of AR. Such a late index presentation of supracristal VSD with moderate AR in fifth decade of life has not been described in literature so far. To conclude, nature retards the natural history with bless in disguise.

We present a rare case of left ventricular noncompaction (LVNC) in a 23-year-old female with recurrent syncope with electrocardiography documentation of apical septal ventricular tachycardia (VT). Abnormal embryological myocardial maturation presenting as LVNC with electrogenic heterogenity across the noncompacted spongiform segments result in recurrent VT and mandates automated intracardiac defibrillator implantation (AICD). These subsets of patients in spite of AICD implantation require life-long broad-spectrum antiarrythmic in the form of amiodarone and beta-blocker to prevent a crisis of VT storm or sudden cardiac death.