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   2020| July-September  | Volume 10 | Issue 3  
    Online since December 23, 2020

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Double kissing crush and nano crush stenting in left main coronary bifurcation lesions: Besting the rival techniques!
Debabrata Dash
July-September 2020, 10(3):105-110
Percutaneous coronary intervention of left main (LM) bifurcation can be technically demanding and is often associated with significant in-stent restenosis in contemporary practice. The heterogeneity of these lesions makes it difficult to establish a consensus as to the best interventional strategy. The provisional one-stent approach has shown a more favorable outcome than two-stent technique in terms of both efficacy and safety. In complex LM bifurcation lesions, double kissing has demonstrated its superiority over culotte and provisional-T in terms of restenosis making it one of the most performed techniques. On the other hand, the nano-crush technique has recently become part of the repertoire of two-stent techniques, providing evidence that the use of ultrathin-strut stents and very minimal crush would be beneficial for both the physiological and rheological properties of the complex LM bifurcations, leading to a lower rate of thrombosis and restenosis at both side branch and true carina. Finally, the newest generation of ultrathin-strut stents is gaining a reputation for its safe and effective use in this scenario thanks to an improved design with increased expansion rate capable of LM treatment up to 5–6 mm diameter. The modern crush techniques, such as double-kiss-crush and nano-crush, are providing excellent results on mid- and long-term follow-up, suggesting that minimal crushing obtained using ultra-thin stents is an excellent way to obtain surgical-like outcomes in the treatment of complex LM bifurcation disease.
  1,568 142 -
Safety and efficacy of streptokinase, tenecteplase, and reteplase in patients diagnosed with ST-elevation myocardial infarction: A comparative study
Bhargavi Neela, Vineeth Reddy Gunreddy, Mamatha Reddy Chandupatla, Venkateshwarlu Eggadi, Sheshagiri Sharvana Bhava Bandaru
July-September 2020, 10(3):134-138
Objective: Our primary objective was to compare the efficacy of streptokinase (SK), tenecteplase, and reteplase by studying patients' electrocardiogram Electrocardiogram(ECG) pre and post thrombolysis. The secondary objectives were to assess chest pain relief using Numerical Pain Rating Scale score and also to compare the side effects (bleeding, hypotension, and anaphylaxis) of three drugs. Materials and Methods: This study is a multicentric, prospective, randomized, comparative study. This study was conducted on 150 patients of ST-elevation myocardial infarction admitted in the wards/ICCU- Intensive Coronary Care Unit, Department of Cardiology, Mahatma Gandhi Memorial Hospital and Rohini Superspeciality Hospital. They were selectively divided into three groups. Group A consisted of patients who received SK (50), Group B who received tenecteplase (50), and Group C who received reteplase (50). The study period was 6 months. The follow-up was done in all the patients during their inhospital stay. Results: Post thrombolysis, reteplase, tenecteplase, and SK led to mean ST-Segment reduction of 64.9 ± 19.77, 52.43 ± 34.57, and 46.97 ± 33.09, respectively. The comparison between the three drugs revealed a significant difference (P = 0.0103). Conclusion: This study concluded that reteplase is most efficacious in the resolution of ST-elevation and also safer than other thrombolytics used.
  1,509 159 -
Prevalence of organic tricuspid valve disease and pattern of valvular involvement in rheumatic heart disease: An echocardiographic study
Santhosh Krishnappa, Chetana Krishnegowda, Jayasheelan Mambally Rachaiah, Harsha Mullusoge Mariappa, Purushothama Thanigebyle Siddaramu, Manjunath Cholenahally Nanjappa
July-September 2020, 10(3):111-115
Background: Rheumatic fever and rheumatic heart disease are still a major public health problem in developing countries. There is a growing interest in tricuspid valve disease because of its clinical outcome, difficulty in treating it, and upcoming interventional therapeutic options. The aim of the present study is to assess the organic involvement of tricuspid valve and echocardiographic pattern of other valvular involvement in rheumatic heart disease in a tertiary care center located in South India. Materials and Methods: This is a prospective observational study which was carried out over a period of 1 year. Transthoracic echocardiography data of patients, diagnosed with rheumatic heart disease during the study period, were reviewed for type and degree of valvular involvement. Results: During the study period, a total of 6612 patients were found to have rheumatic heart disease, and 4129 (62.45%) were female. The average age was 33.96 ± 12.21 years. On echocardiography, organic tricuspid valve involvement was seen in 684 (10.34%) patients. Mitral valve is the most common valve involved, both in isolation and in totality. Five thousand and thirty (76.07%) patients were diagnosed with mitral regurgitation, and 4497 (68.01%) patients were diagnosed with mitral stenosis. Two thousand nine hundred and ninety-three (45.27%) patients were diagnosed with aortic regurgitation, and 1085 (16.41%) patients were diagnosed with aortic stenosis. Conclusion: Mitral valve was most commonly affected, whereas isolated aortic valve was least commonly affected valve. A considerable number of patients showed involvement of organic rheumatic tricuspid valve disease. With the growing awareness of tricuspid valve disease causing significant morbidity and mortality, and therapeutic options under research, identifying organic tricuspid valve disease is of foremost important.
  926 64 -
Angiographic pattern of patients with left bundle branch block: A comparative cross-sectional study
Islam Elsayed Shehata, Ahmed Abdel-Aziz Mohamed, Tarek Ahmed Naguib, Amroo Abdul-Monem Ateya, Ahmed Saeid Eldamanhory
July-September 2020, 10(3):128-133
Objectives: We purposed to determine the relationship between left bundle branch block (LBBB) and coronary artery disease (CAD) site, severity, and CAD risk factors. Methods: Eighty patients with LBBB were sorted into two groups based on coronary angiography (CA) findings: Group 1: 56 patients with CAD (stenosis ≥70% in ≥1 epicardial vessel) and Group 2: 24 patients with normal coronaries. Results: Our observations confirm male preponderance of LBBB and affirm hypertension and diabetes as common risk factors for CAD within this subpopulation. Hence, these risk factors can be considered a strong predictor of CAD in LBBB. Cardiac echocardiography data suggest that LBBB and CAD are associated with regional hypokinesia and decreased ejection fraction. The most frequently diseased vessel was left anterior descending (LAD), followed by left circumflex then right coronary artery. Our study CA showed single-vessel disease (SVD) in 37 participants (46.3%), two-vessel disease in 16 subjects (20%), three-vessel disease in 3 subjects (3.8%), and normal vessels in 24 participants (30%). Hence, SVD frequency was high in our study. Conclusion: The risk for left ventricular dysfunction and SVD more commonly LAD artery involvement had increased in the presence of LBBB in electrocardiogram. CA present only in tertiary centers, which considered a major and invasive diagnostic tool for CAD, so selection criteria are required to predict patients with LBBB who are prone to be at risk of CAD and need this invasive procedure, on the other hand, avoid CAD overdiagnosis, unnecessary admissions to hospital, and antianginal drugs consumption.
  890 58 -
COVID-19 targeting heart: The perspective of injuring the vulnerable
Keyur P Vora
July-September 2020, 10(3):101-104
In a clinical bulletin published by American College of Cardiology in February 2020, it was revealed that the case fatality rate of coronavirus disease 2019 (COVID-19) pandemic for patients with cardiovascular disease is 10.5%. Heart failure (HF) is a global pandemic affecting at least 26 million people worldwide and is increasing in prevalence. Looking at the historical prospectus of practice of clinical cardiology in most countries, patients with left ventricular ejection fraction (LVEF) < 40% presented periodically to exhibit worsening signs and symptoms. The superimposition of novel respiratory tract pathogens like COVID-19 can have accelerated inflammatory injury. Immunosenescense, overactive immune response or direct viral toxicity are hypothetical mechanisms of cardiac injury. Undoubtedly, all countries have to proactively approach their cardiovascular disease (CVD) patient population due to high vulnerability from individual and epidemiological risk factors.
  804 68 -
Evaluation of N-terminal pro B-type natriuretic peptide and echocardiographic parameters in congestive heart failure patients with pre- and post-cardiac resynchronization therapy
Amrendra Pandey, Praveen Singh, Vrishank Bajaj, Smita Gulati, Michelle Siew
July-September 2020, 10(3):121-127
Introduction: Cardiac resynchronization therapy (CRT) has rapidly evolved as a standard therapy for heart failure (HF) patients. Higher levels of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) are typically used in the diagnosis of HF. Materials and Methods: A prospective, observational study of 60 patients with CRT was evaluated with clinical, laboratory and echocardiographic parameters. All patients underwent clinical examination, 6-min walk test, 12-lead electrocardiogram, two-dimensional echocardiographic with Doppler evaluations and NT-proBNP determination. Results: After effective CRT in patients, there was significant improvements in New York Heart Association functional class and 6-min walked distance along with significant decrease in mean QRS width and NT-proBNP plasma levels at 3 and 6 months' follow-up (P < 0.05). The repeat echocardiogram at 3 and 6 months' follow-up showed a significant reduction in the left ventricular end-systolic volume, left ventricular end diastolic volume, and significant left ventricular ejection fraction (LVEF) improvement (P < 0.05). No significant reduction in left ventricle (LV) diameters over 3 and 6 months' follow-up with a significant reduction in the MR severity after 6 months were observed (P < 0.05). At 6 months' follow-up, 75% patients (n = 45) were responders showing concordance between clinical, echocardiographic and NT-proBNP definitions of CRT response while 25% patients (n = 15) were nonresponders. The change in NT-proBNP levels between pre-CRT and 6 months' post CRT was significantly more important in responders than in nonresponders (P < 0.001). Conclusion: The present study shows the clinical benefit of treating patients with CRT and points to the reverse ventricular remodeling, with sustained decrease in LV volumes, plasma NT-proBNP, increase in LVEF, and decrease of the severity of mitral valve regurgitation.
  800 42 -
Comparing long-term effect of right ventricular septal versus apical pacing on left ventricular function
Akhlaque Ahmed, Ankit Kumar Sahu, Pravin K Goel
July-September 2020, 10(3):116-120
Background: Right ventricular (RV) apical pacing is the standard technique for permanent pacemaker implantation and is known to cause detrimental effects on left ventricular (LV) function in long term. Limited data are available on alternative pacing sites which may help preserve LV function. We aimed to compare the long-term effect of RV septal versus apical pacing on LV function. Materials and Methods: A total of 93 consecutive patients were enrolled, of whom 52 received RV apical pacing and 41 RV septal pacing over a period of 2 years. LV assessment was done at regular follow-up including measurement of LV ejection fraction (LVEF), left atrial volume index (LAVi), and 2D LV longitudinal strain. Clinical outcomes included all-cause mortality and heart failure-related hospitalization. Results: Over a median follow-up was 6 years with interquartile range of 4–9 years, LVEF in the apical and septal pacing group was 48.1% ± 10.3% and 51.5% ± 10.2%, respectively (P = 0.112). However, RV septal pacing was significantly better than RV apical pacing with respect to global longitudinal strain (−17.2 ± 2.0 vs. −15.1 ± 2.9; P < 0.001) and LAVi (in RV apical group and 35.5 ± 5.8 ml/m2 vs. 42.7 ± 5.8 ml/m2; P < 0.001). Clinical endpoints, however, did not differ between the two groups. Conclusions: Long-term RV septal pacing was associated with fairly preserved LV function and lesser adverse LA remodeling as compared to RV apical pacing. Larger randomized studies are required to demonstrate the beneficial effect of septal pacing on clinical cardiovascular outcomes.
  718 60 -
An interesting case of normal variant misinterpreted as left atrial mass
Rajesh Natuva, Sudeep Verma, TN C. Padmanabhan
July-September 2020, 10(3):142-144
Coumadin ridge is a normal anatomical variant that is found in the left atrium (LA). We present a case of a LA mass in a 69-year-old patient, diagnosed during preoperative evaluation for total knee replacement and hence referred for surgical resection of the atrial mass. Detailed and meticulous transthoracic and transesophageal echocardiographic examination revealed it as a prominent Coumadin ridge between the left superior pulmonary vein and LA appendage with a bulbous tip, confused initially as an LA mass. The echocardiographic appearance of Coumadin ridge is described as “Q-tip sign.” It can be differentiated with other structures, such as thrombus/atrial mass, because of its property of being at a specific location, lack of mobility, and unique linear structure with a rounded bulbous tip. This case highlights the importance of proper knowledge and the need for careful evaluation of normal structural variants to avoid unnecessary workup and treatment.
  630 47 -
Anomalous left main coronary artery arising from the right sinus of valsalva in a young male: A rare anomaly of the origin of the coronary arteries
Pankaj Jariwala
July-September 2020, 10(3):139-141
The left coronary artery culminating from the right sinus of Valsalva is a rare congenital anomaly of the coronary artery. A high level of clinical suspicion is required in younger patients presenting with a chest pain and positive stress test. A 34-year-old male with a previous family history of premature coronary artery disease, a diagnosis of the anomalous aortic origin of the coronary arteries, needs thorough evaluation. A future fatal outcome can be prevented if diagnosed with the aid of coronary angiography and should be treated promptly. Noninvasive tests, such as echocardiography and computed tomography, can help in the diagnosis and is becoming incredibly popular.
  476 108 -
Intracardiac thrombus extending from the right atrium to the left ventricle in patient presenting with pulmonary embolism
Mullusoge Mariappa Harsha, Santhosh Krishnappa, Kanchanahalli Siddegowda Sadananda, Manjunath Cholenahally Nanjappa
July-September 2020, 10(3):145-147
Thrombus in transit straddling foramen ovale with impending systemic embolization is a rare event. Most cases are reported during the evaluation of stroke. Such thrombus in patients presenting with pulmonary embolism is extremely rare. We report such a rare case with large thrombus extending from the right atrium to left atrium through patent foramen ovale, prolapsing across mitral valve up to mid left ventricle.
  522 37 -