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A man in his 40s with a history of coronary artery disease status after percutaneous coronary intervention of the left anterior descending artery (LAD) in 2015 was admitted with a diagnosis of unstable angina. He underwent a coronary angiogram which showed a patent stent in the mid LAD (figure 1A). Contrast injection of the right coronary artery (RCA) is shown in figure 1B (online supplementary movie I). ### Supplementary video [heartjnl-2020-318495supp001.avi] Figure 1 Left anterior oblique cranial view of the left coronary artery (A) demonstrating a patent stent in the mid-left anterior descending artery (arrow) without evidence of obstructive coronary artery disease. Right anterior oblique 30 view of the right coronary artery (arrowhead) …

OBJECTIVE: To determine prevalence of methylenetetrahydrofolate reductase (MTHFR) mutations in apparently healthy individuals residing in Mumbai and patients with deep vein thrombosis (DVT) and coronary artery disease (CAD) and to correlate these polymorphisms with homocysteine (Hcy) levels. MATERIALS AND METHODS: This case–control study was initiated after receiving ethical approval and following the participant's written consent. One hundred and twenty unmatched healthy volunteers and 240 patients with arterial and venous thrombosis were enrolled. The prevalence of C677T and A1298C MTHFR mutations was detected using polymerase chain reaction-restriction fragment length polymorphism technique. Serum Hcy concentration and lipid levels were determined using biochemical kits. RESULTS: Allele frequency of 677T was 7%, 15%, and 14% in healthy controls, DVT, and CAD patients, respectively, while for 1298C allele, it was 31%, 33%, and 29%, respectively. The lipid markers in CAD patients were significantly low in comparison to the controls while the Hcy level in patients with thrombosis was higher in comparison with the controls. Highest Hcy levels were observed in participants with TT genotype followed by CT genotype and CC genotype in all the three groups. A higher risk of raised Hcy levels was seen in the variants (CT + TT) as compared to CC genotype in DVT (odds ratio [OR] = 3.39, 95% confidence interval [CI] = 1.39–8.2,P < 0.01) and CAD (OR = 21.67, 95%CI = 4.87–96.47,P < 0.0001). The risk observed for A1298C was 2.28 and 2.12 times higher in variants (AC + CC) of both DVT and CAD (OR = 2.28, 95%CI = 1.09–4.75 and OR = 2.12, 95%CI = 1.02–4.40, respectively). CONCLUSIONS: The prevalence of variants was more in thrombosis patients as compared to unmatched controls. Our study highlights the fact that MTHFR C677T polymorphism as compared to A1298C significantly affects Hcy levels in patients with thrombosis indicating that patients with mutant variants are at higher risk of rapid progression of their disease condition.

A 59-year-old man with diabetes presented with exertional dyspnea and angina for 3 months. He had a history of inferior wall myocardial infarction 9 months previously, with percutaneous intervention of an 80% tubular lesion of the mid-right coronary artery (RCA) with a 3.5 × 28 mm drug eluting

Objective: Congenital coronary artery anomalies (CCAs) are rare, clinically benign, and majority are diagnosed incidentally during coronary angiography or an autopsy. Identification of CCA is important for management by cardiologists or cardiac surgeons, and also few cases of CCA are potentially serious which may cause sudden cardiac death. We performed a retrospective, single-center study to evaluate the clinical profile, incidence, pattern, and atherosclerotic involvement of CCA in patients undergoing coronary angiography. Methods: Coronary angiographies performed in adult patients during the study period of 2 years were screened for CCA. These patients were retrospectively analyzed in terms of clinical characteristics and angiographic profiles. Results: Of 4481 angiograms screened, 86 patients were found to have CCA with the incidence of 1.91%. Nearly 76.7% were male and 23.3% were female, with a mean age of 53.02 ± 10 years. Anomalies of origin and course were most common (94.18%) followed by anomalies of termination (5.81%), with right coronary artery (RCA) being the most common artery. Anomalous origin of RCA from the left sinus of Valsalva and separate origin of left anterior descending artery and left circumflex artery were both found to be the most common types. The incidence of atherosclerosis in anomalous vessels was 52.32%. Conclusions: CCAs were diagnosed incidentally during coronary angiography and had male predominance with conventional risk factors. The incidence of CCA was slightly higher than that of the previous angiographic studies, but the pattern of anomalies was similar with majority being benign. Anomalous vessels did not predispose to atherosclerotic involvement as compared to normal vessels in the same patients.

Dehiscence of mechanical prosthetic valve is rare complication reported in 0.1–1.3% of patients undergoing valve replacement with infective endocarditis being the commonest cause.1,2 In spite of rapid diagnosis and prompt initiation of treatment, outcome is often poor due to fulminant course of the disease. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are used to diagnose valvular dehiscence. Cine-fluoroscopy can be useful in cases when TEE is not available or not feasible due to hemodynamic instability. Abnormal rocking motion of the prosthetic valve is characteristic of dehiscence on cine-fluoroscopy. We report a patient who presented with near complete dehiscence of aortic mechanical prosthetic valve, diagnosed on TTE and confirmed with cine-fluoroscopy. The patient succumbed before he could be operated despite aggressive medical management. The case is being reported because of the rarity of such extensive valve dehiscence allowing any opportunity for imaging.

Background: Cardiac catheterization procedures are sometimes associated with unanticipated serious complications related to intravascular devices (IVD) which include embolization, displacement, knotting, entrapment etc. Percutaneous management is difficult and may even warrant surgical extraction. We evaluated clinical profile, causes, management and outcomes of percutaneous retrieval of such complicated IVD Methods and Findings: In this retrospective, single-center study, medical and procedural records of all patients who had undergone percutaneous retrieval of complicated IVD using combination of guide catheters and snares between January 2013 and January 2018 were examined. A total of 11 patients with complicated IVD were diagnosed, with mean age of 48.27±15 years. Eight (72.7%) patients were asymptomatic, while three (27.3%) patients had clinical findings including hematuria, hypotension and bradyarrhythmia. Complicated IVD involved were central venous pressure guide wires in four (36.4%), coronary stents in two (18.2%) and patent ductus arteriosus closure device, atrial septal defect closure device, ventricular septal defect closure device, temporary pacing lead and 0.035” guidewire each in one case. Probable mechanisms that could have led to complications were loss of control in five (45.5%), migration due to incorrect deployment in two (18.2%), migration due to complex coronary anatomy in two (18.2%), blind insertion without fluoroscopy in one (9.1%), and incorrect sizing or device malfunction in one (9.1%) case. Percutaneous retrieval was successful in 10 (90.9%) patients, while one (9.1%) patient with migrated coronary stent required opensurgical retrieval. There were no procedure-related complications. Conclusions: Patients with complicated IVD, warranting retrieval, may have variable clinical presentation and multifactorial causes. Percutaneous retrieval of such devices has a higher success rate with minimal complications.

Congenital coronary anomalies are rare and reported to occur in 0.64-1.3% of patients undergoing coronary angiography. The dual left anterior descending coronary artery (LAD) is a rare coronary anomaly defined as the presence of two LADs in the anterior interventricular sulcus (AIVS). It consists of a short LAD that ends high in the AIVS and a longer LAD that enters the distal AIVS and feeds apex. Percutaneous interventions are even more uncommon in dual LAD especially Type V LAD. Thus we describe an interesting case of percutaneous transluminal coronary angioplasty (PTCA) with stenting to Type V dual LAD in a patient with chronic stable angina who was refractory to maximal anti-anginal medications. Our case was unique for these aspects - 1)Type V dual LAD is rare.2)Ramus artery is present in fewer cases of dual LAD.3)Long LAD had a myocardial bridge.4)Few cases have been reported of PTCA with stenting to short LAD. .

In patients with pulmonary thromboembolism, right heart thrombi are uncommon or underdiagnosed. They may form in situ or arise due to migration from the peripheral venous system. Their presence in pulmonary embolism indicates a grave prognosis and complicates treatment decisions. We report a case of mobile right ventricular thrombus with massive pulmonary thromboembolism who had a rapid fatal course despite early treatment.

Implantation of temporary pacemaker lead is commonly performed procedure and is usually safe, but can sometimes develop rare and serious complication like intracardiac lead knotting which may require challenging retrieval techniques. We report a case of successful percutaneous retrieval of unusually knotted right internal jugular venous temporary pacing lead via left femoral transvenous approach using snare over a long sheath after cutting the electrode proximally and thus avoiding any surgical intervention. Keywords: Electrode, Knotted, Pacemaker, Snare, Temporary pacemaker lead

We describe a rare case of pulmonary valve endocarditis associated with a double-chambered right ventricle in an adolescent male highlighting the two-dimensional and three-dimensional transthoracic echocardiographic findings. He was managed with aggressive antibiotic therapy followed by surgery. The echocardiographic findings were confirmed during surgery.

Percutaneous balloon tricuspid valvotomy was successfully performed in a 45-year-old female with congenitally corrected transposition of great arteries with severe rheumatic left atrioventricular (tricuspid) valve stenosis. Technical modifications in the standard procedure were made keeping in mind the left-handed ventricular loop, left and anterior aorta, wedged pulmonary valve between the interatrial septum and the mitral valve with deviation of the atrial septum away from the ventricular septum, side-by-side positioned ventricles with an added superoinferior obliquity produced by excessive tilting, and an abnormal orientation of ventricular mass in relation to the thorax, with the apex pointing slightly rightwards. A final valve area of 1.4 cm(2) and a fall in the peak/mean left atrial pressures from 37/32 mm Hg to 13/10 mm Hg were achieved without complications. This case of percutaneous transvenous commissurotomy is unique in view of the rarity of the combination of this congenital heart disease and rheumatic heart disease and successful commissurotomy in such an unusual cardiac anatomy using the Inoue technique.

Objective: Prosthetic valve thrombosis (PVT) is a potentially life-threatening complication. Fibrinolytic therapy is the first line of treatment in the developing countries mainly due to financial constraints and limited surgical availability. We performed a retrospective, single-center study to evaluate the clinical profile of patients with PVT treated with fibrinolysis. Methods: Data of 21 consecutive patients admitted with PVT and treated with fibrinolysis during 1-year study period (January 2017–January 2018) were retrospectively analyzed in terms of clinical characteristics and outcomes. Results: Out of 21 patients with 21 PVT episodes, there were 13 females (62%) and 8 males (38%) with a mean age of 35.2 ± 12.2 years (age range: 18–57 years). Presenting complaint in all patients was dyspnea with majority (90.5%) presenting in the New York Heart Association (NYHA) Class III/IV. Subtherapeutic international normalized ratio (

Aim Present study aims to study the occurrence of cirrhotic cardiomyopathy and its correlation to hepatorenal syndrome by assessing the cardiac status in patients with cirrhosis of liver and healthy controls. Methods Thirty alcoholic cirrhotic, thirty non-alcoholic cirrhotic and thirty controls were enrolled for the study. Cardiac parameters were assessed by color doppler echocardiography. Patients were followed up for twelve months period for development of hepatorenal syndrome. Results Mild diastolic dysfunction was present in 18 cirrhotic patients (30%): grade I in fifteen patients and grade II in three. Diastolic dysfunction was unrelated to age; sex and etiology of cirrhosis. Among all the echocardiographic parameters, only deceleration time was found to be statistically significant. Echocardiographic parameters in systolic and diastolic function were not different in compensated vs decompensated patients in different Child-Pugh classes or cirrhosis aetiologies. At one year follow-up, no significant differences were found in survival between patients with or without diastolic dysfunction. Hepatorenal syndrome developed in only two patients and its correlation with diastolic dysfunction was not statistically significant. Conclusions Present study shows that although diastolic dysfunction is a frequent event in cirrhosis, it is usually of mild degree and does not correlate with severity of liver dysfunction. There are no significant differences in echocardiographic parameters between alcoholic and non-alcoholic cirrhosis. HRS is not correlated to diastolic dysfunction in cirrhotic patients. There is no difference in survival at one year between patients with or without diastolic dysfunction. Diastolic dysfunction in cirrhosis is unrelated to circulatory dysfunction, ascites and HRS.

A 20-year-old man was referred to us for assessment of a 1 year history of dyspnoea on exertion. At the age of 9 years, he had had two episodes of migratory polyarthritis suggestive of rheumatic fever. Cardiovascular examin ation showed a grade III/VI pansystolic murmur at the apex (see video). We noticed he had painless, correctable deformities of his hands and feet (fi gure A and B). He did not know his hands were deformed. His joints were enlarged but there was no evidence of active joint infl ammation or functional impairment, and no subcutaneous nodules. The erythro cyte sedimentation rate Lancet 2013; 381: 2108

Background Electrocardiographic abnormalities mimicking myocardial ischemia have been reported in intra-abdominal conditions, including acute pancreatitis. However, the occurrence of ST-elevation myocardial infarction (STEMI) is rare. Objectives To present a case report of a young man with acute pancreatitis subsequently complicated by acute STEMI. The diagnosis and management of STEMI in acute pancreatitis can present unique diagnostic and therapeutic challenges, which are reviewed. Case Report A 31-year-old man with no conventional coronary risk factors presented with acute abdominal pain, elevated pancreatic enzymes, and computed tomography scan findings of acute pancreatitis. The patient developed chest discomfort and presented to us on Day 2 with electrocardiographic evidence of an evolved extensive anterior wall myocardial infarction. Cardiac troponin I levels were elevated, and the electrocardiogram showed regional wall motion abnormalities in the left anterior descending territory (LAD). Coronary angiography done after stabilization showed a thrombus in the LAD, with no atherosclerotic lesions whatsoever. Hemostatic abnormalities are known in acute pancreatitis, and the development of a transient hypercoagulable state may be responsible for thrombotic complications. The overlap of some of the symptoms of the two conditions may cause diagnostic difficulty. Management issues include the choice of revascularization therapy, the safety of antiplatelet and anticoagulant therapy, intravenous fluid administration, and the use of cardiac medications that potentially can cause hypotension. Conclusion The diagnosis and management of STEMI in the setting of acute pancreatitis can be challenging. In the absence of guidelines, a multidisciplinary approach individualized to the patient’s clinical situation may be most appropriate.

A 63-year-old, nonalcoholic man presented with abdominal distension, edema of the lower extremities, and weight loss of 6 months duration. Examination revealed a cachectic and icteric patient with elevated jugular venous pressure. Ultrasonography of abdomen revealed a large hyperechoic mass in the right lobe of the liver infiltrating the intrahepatic part of the inferior vena cava. Transthoracic echocardiography revealed a mass of size 2.73 9 4.8 cm occupying the right ventricular cavity with no intrinsic mobility and without any right ventricular outflow tract gradient. Modified subcostal view taken to visualize the inferior vena cava showed tumor thrombi along the vessel wall. There was no mass in the right atrium (RA), although the right atrial wall appeared thick (Fig. 1). Contrastenhanced thoracoabdominal computerized tomographic imaging confirmed the presence of a well-defined lobulated moderately enhancing mass lesion in the right lobe of liver on arterial phase, approximately measuring 5 9 7 cm. Cardiac computerized tomography demonstrated a nodular subcentimeter homogeneous right ventricular mass infiltrating the ventricular wall, tricuspid valve, and interventricular septum (Fig. 2). The differential diagnoses in this case were thrombus, Loeffler syndrome, and tumor with metastasis of hepatic malignancy to the right ventricle (RV) being the most likely possibility. Computerized tomography-guided aspiration cytology of the hepatic mass confirmed the diagnosis of hepatocellular carcinoma (HCC). The patient underwent two cycles of systemic chemotherapy; however, he subsequently developed progressive hepatic failure and died of the same after 3 months. The patient’s next of kin denied consent for post mortem.