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   Table of Contents - Current issue
July-September 2021
Volume 11 | Issue 3
Page Nos. 93-159

Online since Wednesday, August 25, 2021

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Prevention of thromboembolism in elderly p. 93
Panchanan Sahoo, BN Padhee, Anupam Jena, HN Mishra
Venous and arterial thrombosis and thromboembolism are a leading cause of suffering in elderly population. The prevalence of venous and arterial thrombosis (formation of blood clot) and thromboembolism (breakage of thrombus to travel somewhere in circulation) is high in elderly population those above 60 years and poses important cause of morbidity and mortality. Annual incidence of venous thrombosis is 1 in 1000 which rises after age of 45 years and arterial thrombosis as high as 20% as per pooled MPN. Spectrum of thromboembolism (TE) is diverse and etiology, and pathogenesis is varied ranging from atrial fibrillation, hypertension, diabetes mellitus (DM), dilated cardiomyopathy and ischemic cardiomyopathy (ICM), congestive heart failure, acute coronary syndrome, and cases of fracture immobilization leading to deep venous thrombosis and pulmonary embolism or else arterial occlusion leading to cardiac or cerebral strokes Aim of the update is to bring a broad overview of the problem to prevent late disastrous outcomes, putting forth two exemplary case studies of imminent TE risk. Case 1 – elderly hypertensive presenting with paroxysmal AF with high CHA2DS visual analog scale score needing anticoagulation and Case 2 – case of DM, post- percutaneous transluminal coronary angioplasty (PTCA), ICM, severe left ventricular (LV) dysfunction with LV thrombus in sinus rhythm needing anticoagulation. Elderly population suffer from diseases of diverse etiology exposing to high risk of TE and at the same time high bleeding risk of the anticoagulants. Elderly population with diverse disease ailments exposed to high risk of TE and bleeding complications and hence should be dealt with utmost care and sympathy to avoid TE and bleeding complications.
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Acute Coronary syndrome following honey bee sting: A series of 6 cases of “kounis syndrome” with literature review p. 98
Sachin T Rao, Harsha Basappa, Hema Raveesh, Srinidhi Hegde, CN Manjunath
Kounis syndrome (KS) refers to acute coronary syndrome secondary to a hypersensitivity reaction as a result of exposure to various allergens. Multiple bee stings as a cause of KS is rarely reported in the literature. Its diagnosis in allergic reactions is of utmost importance, as it leads to an entirely different line of management. We report a series of six cases who presented with the diagnosis of KS due to multiple bee stings.
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Angiographic profile and therapeutic approach of prior coronary artery bypass graft patients presenting with acute coronary syndromes p. 104
Sathyamurthy Immaneni, T Manikandan, K Kirubakaran, KN Srinivasan, Rajeswari Nayak, Abraham Oomman, K Pramod Kumar, Sengottuvelu Gunasekaran
Objectives: Patients presenting as acute coronary syndromes (ACS) after coronary artery bypass graft (CABG) surgery are different subset with multiple comorbidities. Reappearance of symptoms could be due to either native vessel, graft disease, or both. The aim of the present study was to evaluate the mode of presentation, angiographic profile, and management strategies followed in them. Methods: One hundred consecutive patients presenting with ACS during 2 years' period at a tertiary care hospital were studied. ST segment elevation myocardial infarction (STEMI) was noted only in 7 cases, rest had either non-STEMI or unstable angina. Their comorbid risk factors, echocardiographic left ventricular ejection fraction were noted. All of them undergone invasive coronary angiography followed by revascularization as indicated. Results: Fifty percent of cases presented with reappearance of symptoms within 10 years after surgery. Culprit vessel identified was saphenous vein graft (SVG) in 49% followed by native vessel in (22%), both SVG and native vessel in 15%. Only 14% showed left internal mammary artery (LIMA) graft block at distal anastomotic site. Percutaneous coronary intervention was done in 47, redo CABG surgery in 8 cases. Rest were continued on optimal medical treatment. Of the 47 who have undergone PCI, 14 were done for SVGs and in 4 to LIMA graft to the left anterior descending. PCI to native vessel was done in 22 cases and in 7 one SVG and one native vessel. Conclusions: Post-CABG surgery patients are high risk subset with multiple comorbidities including impaired renal functions. Presentation as STEMI was less common. Majority of them can be managed with PCI of grafts or native vessels or both. Optimal medical treatment was advised in whom intervention or redo CABG is not feasible. More studies are needed comparing post-CABG ACS patients with de novo cases in Indian patients.
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Percutaneous coronary intervention using rotational atherectomy and new-generation drug-eluting stents in mild versus moderate-to-severe chronic kidney disease patients with coronary artery disease p. 109
Fazila-Tun-Nesa Malik, Md Kalimuddin,, Nazir Ahmed, Mohammad Badiuzzaman, Abdul Kayum Khan, Ashok Dutta, Tawfiq Shahriar Huq, Dhiman Banik, Mir Nesaruddin Ahmed, Md Habibur Rahman, Md Abu Tareq Iqbal
Background: The presence of calcified lesions in chronic kidney disease (CKD) patients adversely affects the outcomes of percutaneous coronary interventions (PCIs). Lesion modification using rotational atherectomy (RA) followed by drug-eluting stent (DES) implantation may, therefore, be a suitable strategy to treat heavily calcified coronary lesions in CKD patients. Aim: The aim of the study was to compare the effectiveness and safety of PCI using RA and new-generation DES for treating calcified coronary lesions in patients with mild versus moderate-to-severe CKD. Methods: This was a single-center, retrospective study. Data were collected from the medical records of all CKD patients with calcified coronary artery lesions who underwent RA + DES implantation from November 2014 to October 2019. The primary outcomes were the rates of in-stent restenosis (ISR), repeat revascularization (RR), and major adverse cardiovascular and cerebrovascular events. Secondary outcomes included procedural success, death after intervention, and procedural/in-hospital complications. Results: A total of 77 and 126 patients with mild and moderate-to-severe CKD were treated with RA + DES. Patients with moderate-to-severe CKD were significantly older when compared to patients with mild CKD (mean age: 66.6 ± 8.2 vs. 59.5 ± 7.7 years, respectively, P < 0.0001). Body mass index was significantly lower in moderate-to-severe CKD group compared to the mild CKD group. The number of patients in whom postdilatation was performed after stent implantation was significantly higher in the moderate-to-severe CKD group compared to the mild CKD group (100% vs. 96%, P = 0.025). Overall procedural success was 97.5% with minimal periprocedural complications. The rates of ISR and RR were not significantly different between patients with mild and moderate-to-severe CKD. The two groups did not differ significantly in terms of procedural success, postprocedural complications, and procedural mortality. Conclusion: RA followed by DES implantation is an effective and safe strategy to treat calcified coronary artery lesions in patients with CKD, regardless of the degree of renal dysfunction.
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Correlation of the severity of obstruction in coronary arteries with serum free testosterone level p. 116
AK Badrinath, M Venkatram, S Suresh Babu, J Karthik
Background: Coronary artery disease (CAD) is the leading cause of death in India. There was increased incidence and prevalence of CAD in males than in females. There have been several studies going on across the globe to find a similar equation in males between testosterone and CAD. This study aimed at correlating the serum free testosterone level in CAD patients with the severity of obstruction of the coronary arteries proven by coronary angiogram. This was the first study in South India to correlate the serum free testosterone levels with the severity of obstruction of coronaries. Objective: This study was designed to correlate the serum free testosterone level in male patients above 40 years with proven or newly diagnosed CAD with the severity of obstruction of coronary arteries as evidenced from coronary angiogram. Materials and Methods: This was a hospital-based cross-sectional study conducted from November 2015 to August 2017 in a rural-based teaching tertiary care hospital in Puducherry, India. The sample size was 40, calculated using the formula n = 4 × σ2/d2 from the previous study of serum free testosterone in men with coronary artery atherosclerosis done by Lucyna Siemińska et al. Results: Of 40 patients in the study group, 30% had CAD, 20% had hypertension (HTN), 45% had diabetes mellitus, 45% were smokers, 37.5% were alcoholic, and only 5% had family history of (H/o) CAD. In the study, ejection fraction was < 60 in 80% and ≥ 60 in 20%. In the study, 42.5% had single-vessel disease, 27.5% had double-vessel disease, and 30% had triple-vessel disease. The mean serum testosterone was 4.5 ± 3.1 and the median serum testosterone was 3.3, which showed that most of the patients with CAD had their testosterone levels in the lower range of normal. Conclusion: From the observations made in this study, it was clear that the skewing of serum free testosterone levels toward the lower side of normal can be taken as an indirect evidence that serum free testosterone is inversely related to CAD. There was no significant difference in median testosterone levels with respect to the type of disease. However, a statistically significant positive association between H/o systemic HTN and serum free testosterone level was observed in patients with CAD.
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Scoring balloon versus drug-eluting balloon in coronary intervention for very small coronary vessels p. 127
Yasser Gaber Metwally, Khaled Y Elnady
Background: The optimal therapeutic strategy for coronary intervention in very small coronary vessels (<2.5 mm.) remains controversial and challenging. Objective: The aim of this study is to assess the 12 months outcome of scoring balloon (SB) versus drug-eluting balloon (DEB) in very small (<2.5 mm) coronary interventions. Patients and Methods: Seventy-seven patients referred for coronary intervention with reference vessel diameter <2.5 mm were assigned to either SB or DEB. The primary endpoint was target vessel revascularization (TVR) at 12 months follow-up. Results: Out of 77 patients enrolled, 37.7% were assigned to SB, while 62.3% were assigned to DEB. Sever dissection rate was significantly higher among the DEB group (0% vs. 12.5%, P = 0.048); while TVR rate was significantly lower among the SB group (0% vs. 12.5%, P = 0.048). Similarly, the target vessel-related myocardial infarction rate was significantly lower among the SB group (0% vs. 12.5%, P = 0.048). On the other hand, there were no significant differences in the rates of deaths or restenosis between the two groups. Conclusion and Recommendations: SB is superior to the DEB with better both safety and efficacy for coronary intervention in very small coronary vessels (<2.5 mm). Larger scaled prospective multicenter randomized trials are needed for confirming our favorable results of using SB for coronary intervention in very small coronary vessels <2.5 mm.
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Online consultation in the COVID epoch in India: Experience of 1597 appointments – new order cometh Highly accessed article p. 133
Prabhakar Dorairaj
Introduction: Online consultation is the latest challenge in clinical medicine during the COVID pandemic. We utilized our preexisting electronic medical record, video calling, and online payment for online consultation. Methodology: Consultations between April 15, 2020, and July 31, 2020, were compared with a similar period in 2019 to see the change in the pattern of consultation. Results: Between April 15, 2020, and July 31, 2020, there were a total of 1597 appointments compared to 2945 in the previous year a 45% fall in 2020. In the current model, all patients had to compulsorily have an online consultation. Online consultation was first done for 1130 patients, of whom 396 had a physical consultation in the clinic. There were no online consultations in the previous year. The real-world problems with online consultations and how they were overcome are discussed. Analyzing the data month wise, there was a progressive increase in the appointments this year indicating better acceptance for online consultation increasing from 350 appointments in May to 628 in July 2020, which translated into 40% and 70% of 2019 appointments indicating better acceptance over time. Cancellations were 5.2% for online consultation and 2.2% for physical consultation in the clinic. The reasons for cancellations were also analyzed and the most common causes were inability to reach the patient on mobile and blood pressure not recordable nearby. 0.7% had to make an emergency visit before they could complete an online consultation. Conclusions: Simple method of online consultation can be implemented in any clinic. No special app is required. The number of patients undergoing consultation is increasing with every passing month. This should be a motivation for more physicians to start online consultation during the COVID Epoch.
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Bilateral watershed infarcts in infective endocarditis p. 137
Soumya Sathyan, NN Abdul Kharim
A 62-year-old male who is on maintenance hemodialysis for end-stage renal disease presented with sudden onset weakness of bilateral lower limbs, confusion, and disorientation overnight. Investigations revealed methicillin-resistant staphylococcus aureus in the blood culture and echocardiographic features suggestive of infective endocarditis. Imaging of brain revealed bilateral watershed infarcts in various sites.
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Massive hemothorax following failed internal jugular vein access during an electrophysiological procedure: “Early detection – catastrophe averted” p. 139
Ponnana Hemanth Harish, Oruganti Sai Satish
We report an unusual case of massive hemothorax in a female patient undergoing electrophysiological (EP) procedure for drug-refractory supraventricular tachycardia. She underwent percutaneous intervention with a drug-eluting stent to the right coronary artery 6 months back and was on dual antiplatelet drugs. Timely detection and management of hemothorax prevented a major catastrophe in this patient. This case highlights the importance of keeping a strict vigil for possible occurrence of life-threatening bleeding complications during EP procedure in patients on multiple antiplatelet drug therapy.
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Septic arthritis of the hip after percutaneous coronary intervention: A rare and morbid complication p. 142
Gopala Krishna Koduru, Hari Krishna Basineni, Srinivas Dandamudi, Raghuram Palaparti, Suman Pendyala, PS S. Chowdary
Infective complications of cardiac catheterization have come down significantly in the past few decades but are occasionally reported. We report one such complication in an elderly female who developed septic arthritis of the hip due to Staphylococcus aureus infection following percutaneous coronary intervention through right femoral access. After an initial conservative strategy with girdlestone excision arthroplasty, she underwent a total hip replacement surgery as a staged procedure after the complete resolution of infection. With the increasing usage of femoral vascular access and vascular closure devices for various complex cardiac interventions in the present-day cardiac catheterization laboratory, a morbid complication like septic hip arthritis should be borne in mind whenever a patient presents with fever and hip joint pain, particularly when there are disproportionate or no significant local findings. Strict aseptic precautions, early identification by considering a magnetic resonance imaging scan early in the clinical course, and aggressive management are the key to better outcomes.
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Balloon inflation-assisted trapping and successful retrieval of partially fractured and entrapped guidewire p. 145
Santosh Kumar Sinha, Mahmodullah Razi, Awadesh Kumar Sharma, Umeshwar Pandey
Guidewire fracture (either partial or complete) is an exceedingly rare complication of which is mostly encountered in percutaneous coronary intervention (PCI) of complex lesions. It can be managed mostly with using percutaneous techniques, but at times requires a surgical approach as well. Here, we report a case of a 67-year-old male who underwent PCI of totally occluded proximal left anterior descending artery. Due to excessive manipulation, tip of Sion blue wire (polymer-jacket guidewire) got trapped into the lesion. To unloop the wire, spring tip got partially fractured. The guiding catheter was pushed over the fractured wire near the fracture point and a 2.5 mm × 10 mm Sapphire semi-compliant balloon (Orbus Neisch, Netherland) was inflated near the tip of guiding catheter at 12 atm pressure, and whole assembly was pulled out to successfully retrieve the partially fractured and retained wire.
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Pulmonary vein isolation in a case of common drainage of a persistent left superior caval vein and the left-sided pulmonary veins into the left atrium p. 148
Dirk Grosse Meininghaus, Claudia Waniek, Thomas Schulz, Anton Kushnir
Preprocedural imaging before catheter ablation of atrial fibrillation is often limited. We present a case of a 67-year-old female with unsuspected anatomy relevant to procedure planning. Routine computed tomography revealed an undetected persistent left-sided superior caval vein (LpSVC). All left-sided pulmonary veins drained with the LpSVC by way of a common vessel at the roof of the left atrium (LA). This common vein exhibited low-amplitude signals connected to the LA beyond 25 mm. Both right-sided caval veins and the coronary sinus drained to the right atrium. We struggled to keep the ablation lesions distant from the common vein to avoid an increase of the left-to-right shunt by unintended narrowing of this vessel. The encircling ablation lines around the right-sided pulmonary veins and the common vein were close together so an additional roof line was done. In summary, imaging definitively helped to prepare the ablation procedure and to avoid complications.
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Cardiac hydatid disease: An unusual pathology in an st-elevation myocardial infarction patient p. 151
Venkata R. S. Subrahmanya Sarma Palaparthi, D Srinivas, P Raghuram, K Gopalakrishna, G Somasekhar, K Purnachandrarao, M Boochibabu, Y Sasidhar, M Prasad
Hydatid disease, is an infection caused by the larval stage (metacestode) of the cestode Echinococcus granulosus. In humans it may result in a wide spectrum of clinical manifestations ranging from asymptomatic infection to severe, even fatal disease. Echinococcal cysts are found in the liver in approximately 70 % of cases, and the lungs in approximately 25 % of cases. Cardiac hydatid disease is seen in 0.5–5% of total hydatid disease patients, the present case highlights the unusual presentation of Hydatid cyst in a different clinical scenario.
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Do not accept diagnosis of “Idiopathic dilated cardiomyopathy” in pediatric age group: Before comprehensive p. 155
Mahua Roy, Pooja Sinha, Amitabha Chattopadhyay
Idiopathic dilated cardiomyopathy in children is a hopeless disease; most of the time, patients are destine to die or ultimately become transplant candidate. In our case series, on meticulous re-examination, treatable conditions such as obstructive disease (aortic stenosis, coarctation of aorta) or coronary artery abnormality (anomalous origin of the left coronary artery from the pulmonary artery and coronary artery occlusion by thrombus) or rhythm abnormality (supraventricular tachycardia) were diagnosed, and all patients were improved after successful correction of underlying cardiac disease.
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