Search

Bifurcation lesions in anomalous coronary arteries are rare. Percutaneous intervention in such lesions is challenging and necessitates use of nonstandard hardware like GuideLiner catheter (Vascular Solutions) for adequate access and support.

We report a rare percutaneous intervention to the Left Anterior Descending (LAD) and Right Coronary Artery (RCA) bifurcation in a 77 year old with anomalous origin of the RCA from mid LAD and Medina 1,1,1 bifurcation disease. The LAD/RCA bifurcation lesion was successfully treated using Mini crush technique.

Purpose Takayasu's arteritis (TA) is a non-specific, chronic, inflammatory panarteritis, affecting the aorta, its major branches and pulmonary arteries. The percutaneous or surgical revascularization in these patients is often difficult and challenging because of diffuse and multi-vessel involvement, difficulty in management of disease activity, and high rate of restenosis and re-intervention. Case report We report a 33-year-old man, a case of TA with fulminant active disease and multi-vessel involvement. His disease activity could not be suppressed with steroid treatment. He had multiple sequential bailout interventions of carotid, left main coronary and mesenteric arteries secondary to cerebro-vascular event, angina and mesenteric ischemia, respectively. Conclusion Despite comprehensive multi-specialty approach in management and also the global revascularization, he ultimately died of acute mesenteric ischemia. To our knowledge, there is no similar type of case being published in world literature till date.

The occurrence of silent myocardial ischemia (SMI) and serious arrhythmias during hemodialysis (HD) has been well documented. However, it is unclear whether these changes are due to epicardial coronary artery disease (CAD). We conducted a prospective study to assess whether SMI and arrhythmias during HD correlated with angiographically demonstrable CAD. Twenty-three patients with end-stage renal disease on maintenance HD underwent 48-hour Holter monitoring, beginning 24 hours prior to a HD session. All patients underwent biochemical evaluation, coronary angiography, and echocardiography. Holter monitoring showed SMI during HD in 22% cases. A significant increase in the frequency of ventricular ectopics (VEs) was noted during and after HD. Patients who showed SMI during HD and VEs prior to initiation of dialysis were more likely to develop significant ventricular arrhythmias during and after HD. Epicardial CAD was documented in four patients, and it did not correlate with SMI. To conclude, HD is an arrhythmogenic process. SMI during dialysis is probably not due to epicardial CAD but predisposes to clinically significant ventricular arrhythmias during and after HD. The cause of SMI during HD in patients without demonstrable CAD needs further investigation.

Cardiac arrhythmias are noted in a significant proportion of chronic renal failure (CRF) patients on hemodialysis (HD), and may contribute to cardiovascular mortality. A number of factors have been implicated in the genesis of these arrhythmias. The role of silent myocardial ischemia (SMI), however, has not been evaluated systematically. We prospectively studied 38 unselected CRF patients on regular HD by continuous Holter monitoring starting 24 hours before HD, lasting through the dialysis session and continued for 20 hours thereafter. The recordings were analyzed for frequency, timing and severity of supraventricular and ventricular arrhythmias and SMI as identified by ST-segment depression. Ventricular arrhythmias during HD were noted in 11 (29%) patients (group I), and were potentially life-threatening (Lown Class III and IVa) in 13%. The remaining 27 patients (group II) had no ventricular arrhythmias during HD. There was no difference in the age, sex ratio, duration of HD, blood pressure, fluctuations in weight, hematocrit, predialysis creatinine, sodium, potassium, calcium or inorganic phosphate levels between patients in the two groups. The number of patients with clinical ischemic heart disease was significantly greater in group I. SMI was noted in 72% and 33% of group I and II patients respectively (p = 0.026). 46% of those with and 25% of those without ST changes during HD developed ventricular arrhythmias during HD. Both SMI and ventricular arrhythmias were noted most frequently during the last hour of dialysis. Hypertension, diabetes mellitus and ischemic heart disease were observed more frequently amongst patients with SMI. Ventricular arrhythmias are detected in a significant proportion of CRF patients on HD. These are probably related to coronary artery disease since silent myocardial ischemia is also noted more frequently during HD in these patients. Further studies incorporating coronary angiography are needed in a larger number of patients to establish a definite causal relationship.

This study was undertaken to analyze autonomic functions in restrictive cardiomyopathies. Restrictive cardiomyopathies have clinical and hemodynamic similarity with chronic constrictive pericarditis. Autonomic dysfunction has been described in the latter.Autonomic function analysis has not been reported in restrictive cardiomyopathy. Six consecutive patients with restrictive cardiomyopathy were included in this study (5 men, 1 woman, mean age 35+/-5.4 years). The tests performed were designed to test the sympathetic efferent pathway, that is, by cold hand immersion and loud noise tests, parasympathetic efferent pathway by Valsalva ratio and expiration/inspiration ratio and the baroreceptor function by testing their sensitivity slope. The results were compared with 20 patients with chronic constrictive pericarditis and with 10 healthy age- and sex-matched control subjects previously studied. The rise of systolic blood pressure after cold hand immersion and sudden loud noise was not significantly different compared with control subjects. The expiration/inspiration ratio was 1.1+/-0.01 compared with 1.57+/-0.1 in the control group (p0.01). The Valsalva ratio was significantly lower (1.1+/-0.04) compared with control subjects (1.83+/-0.1, p0.01). The baroreceptor sensitivity was not reduced compared with that in control subjects. In comparison to constrictive pericarditis, sympathetic efferent pathway is preserved in restrictive cardiomyopathy (p0.0001). The parasympathetic efferent pathway is borderline abnormal in restrictive cardiomyopathy but not significantly as compared with constrictive pericarditis (p=not significant). The baroreceptor sensitivity slope is normal in patients with restrictive cardiomyopathy as compared with significant depression seen in constrictive pericarditis (p0.05). Autonomic functions are better preserved in patients with restrictive cardiomyopathies compared with chronic constrictive pericarditis.Autonomic dysfunction is localized to parasympathetic efferent pathway. This is in comparison to constrictive pericarditis, in which severe autonomic dysfunction is a universal feature and includes all segments of autonomic nervous system.

A 34-year-old woman presented with congestive heart failure 3 months after her third pregnancy. She was stabilized in New York Heart Association functional class II with digoxin and diuretics for 21 years. She was readmitted with worsening symptoms and found to have a regional contraction abnormality. With the addition of angiotensin-converting enzyme inhibitors to her medication, she has been maintained in functional class III for a further 4 years.

Large congenital ventricular septal defects have an unfavorable natural history and survival to 60 years of age with a large left-to-right shunt is very uncommon; surgical closure of such a defect in the elderly is even rarer. We report the case of a 60-year-old female who presented with a large left-to-right shunt across a congenital subaortic ventricular septal defect and underwent successful surgical closure.

Increased Plasma Nitrite Level in Cardiac Failure. Nitric oxide is implicated in the pathogenesis of cardiac failure. Plasma nitrite level (an end product of nitric oxide metabolism) is studied in 15 patients of chronic rheumatic valvular heart disease with myocardial contractile dysfunction and cardiac failure (Group I), 15 patients of chronic rheumatic valvular heart disease with similar valvular lesions, normal myocardial contractile function and without cardiac failure (Group II) and 15 healthy controls (Group III). Patients in Group I had higher nitrite level (242.2+/-31.7 n m) compared to Group II (142.6+/-24.4 n m) and Group III (102.7+/-15.9 n m). Among the patients with rheumatic heart disease, increasing nitrite level correlated significantly with worsening of contractile function [Nitrite v End systolic volume/Body surface area (T(xy.z)=0.23), Nitrite v End systolic dimension/Body surface area (T(xy.z)=0.32), Nitrite v left ventricular ejection fraction (T(xy.z)=-0.24), Nitrite v tricuspid annular plane systolic excursion (T(xy.z)=-0. 29)] and worsening New York Heart Association (NYHA) functional class (r(s)=0.5). We conclude that plasma nitrite, a stable end product of nitric oxide metabolism is increased in patients of rheumatic valvular heart disease with cardiac failure, suggesting increased nitric oxide production. Increased level of nitric oxide might be playing a significant role in myocardial contractile dysfunction and alteration of vascular response in cardiac failure.

Eleven patients with Takayasu Arteritis (TA) underwent angioplasty and stent placement in aorta, renal, carotid, subclavian and coronary arteries. Five wall stents were deployed in aorta in four patients. Indications for angioplasty and stent placement in aorta included hypertension in four patients and claudication and erectile impotence in one patient each. Post-procedure the peak systolic pressure gradient across the stenotic segment in the aorta disappeared. Six patients underwent angioplasty and stent placement in carotid arteries. Indications were syncope in 6 patients, loss of vision, stroke, transient ischaemic attack and seizures in one patients each. There was a marked improvement in symptoms in the patients following the procedure. For chronic total occlusion of subclavian arteries, two stents were deployed in two patients. Following the stent placement pulses in upper limb reappeared. Stents were also deployed to treat near total occlusion of right coronary artery and flow limited dissection of renal artery in one patient each. Complications of the procedure included pain in the back, mild hypertension, transient bradycardia and conduction block in one patient each. In conclusion, the stenotic and obliterative vascular lesions in TA can be managed successfully with angioplasty and stent placement. A long term follow up is required to determine the re-stenosis rate.