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Submitral aneurysm is a rare cardiac entity with outpouching in relation to the posterior annulus of the mitral valve. Multiple etiology have been described with the role of infection and inflammation with varied clinical presentation in different case reports. However, the literature on clinical outcome and follow-up is lacking.This retrospective, observational study included all the adult patients (18 years) who were diagnosed with a submitral aneurysm. Epidemiological, demographic, laboratory, clinical management, and outcome data were extracted and followed for the endpoints of cardiac death, noncardiac death, recurrent hospitalization (due to heart failure, rupture, arrhythmic events, embolic events), surgical repair, and echocardiography parameters for mitral regurgitation or change in the size of the left ventricle for 1-year postdischarge from the index hospitalization.A total of 10 patients were enrolled in the study with a mean age of 31.2 ± 11.1 years. Possible etiology could be established in only five (50%) patients (two patients had tuberculosis and three patients had acute coronary syndrome). At index hospitalization, nine (90%) patients had heart failure, two (20%) patients had rupture of a submitral aneurysm, four patients underwent surgery, and one patient expired. On follow-up of 1 year, one more patient underwent surgical repair while three patients expired.A submitral aneurysm is a rare cardiac entity with poor outcomes. Surgical repair with or without mitral valve replacement plays a definitive role in management.

Background Percutaneous nephrolithotomy (PCNL) is a complex surgery and has a flat learning curve. Due to this and the ethical issues, trainees do not get enough hands on exposure. Virtual simulator is very expensive and bulky. Animal model requires legal clearance. This inexpensive portable homemade PERC Mentor (IPHOM) teaches all the major aspects of PCNL surgery. This article has shown the way to make this model and its validation study. Methods IPHOM can be made at home with carton box, ball bearings, LED torch and some hospital wastes. After a short demonstration of IPHOM, 14 residents and 4 urologists were given 8 tasks to perform on it followed by 15-min supervised practice exercise on day 0 and day 1. Their performance was reassessed on day 2 and 3. Response to 17 feedback points was recorded on a seven-point Likert scale. Results There was significant difference between the performance of expert and novice on day 0. Expert completed all the tasks in less time and no. of attempts. The time for tract dilatation and duration of radiation exposure were significantly less in the expert group. The performance of both expert and novice improved on day 2 and 3, but the improvement was significantly more in novice. Response to the feedback points showed no difference between expert and novice (p > .05). Conclusions We have found that training on IPHOM has improved the concept and skills of PCNL in residents. The simplicity and low cost of the model make it constructible at home.

BACKGROUND: Proficiency in laparoscopy is gradually achieved. After initial simulation, it is safe to move to real patients. Simulation improves the basic attributes of laparoscopy, and its non-availability hampers training. Virtual reality and commercial simulators are exorbitantly expensive. Cheaper non-commercial latest, mobile phone–based simulators appear ergonomically unsuitable. A need for a no-cost, home-based laparoscopic endotrainer was felt by authors. METHODS: The authors proposed the concept of smart TV and smart phone–based laparoscopy trainer (STELA), an almost zero cost, lightweight indigenous, cable-less box-type endotrainer, with a smart phone housed on the model, projecting to smart TV via Wi-fi direct. The simulation timings on STELA were compared with Universal Beetel endotrainer by a group of surgeons and residents using identical tasks like object transfer (OT) and knot making (KM). RESULTS: Data were analysed using SPSS, version 23.There was no significant difference in the mean timings of the residents (p > 0.05) on two endotrainers, for both tasks, and of surgeons for OT. Surgeons took significantly longer time (p

In the current era of echocardiography, early diagnosis and treatment of rheumatic heart disease make giant left atrium a rare condition, with a reported incidence of 0.3%, and following mainly with rheumatic mitral valve disease. We report a 50-year-old female, a known case of rheumatic heart disease who presented with breathlessness and dysphagia, and the cardiothoracic ratio on chest roentgenogram was 0.95. Echocardiography was suggestive of giant left atrium with a size of 19.4 x 18.3 cm, while magnetic resonance imaging revealed a size of 22.3 x 19.2 x 20.1 cm making it the largest left atrium to be reported in the literature.

Percutaneous Coronary Intervention (PCI) is now the standard of care in patients with coronary artery disease. With advances in modern technology, the success of PCI has relatively increased, and so is its complication, specifically in complex coronary intervention. Coronary perforation is one of the most dreadful and life-threatening complications of PCI. The most vital step in the management of coronary perforation is its identification and quick action. Multiple methods for management are now recommended in the literature, but the mainstay of treatment is still prevention. This review discusses the incidence, risk factors, prevention, identification, and management of Coronary Artery Perforation (CAP).

Background: Cardiovascular manifestations are an important cause of mortality and morbidity in COVID-19 infections. Conduction system abnormality in the form of symptomatic bradyarrhythmia is underreported in the literature. Aim: To evaluate epidemiological, demographic, laboratory, clinical management, and outcome data of symptomatic bradyarrhythmia in COVID-19 patients. Methods: This was a retrospective, observational study including all the adult patients (>18 years) who were diagnosed with COVID-19 infection and had complete heart block (CHB) or symptomatic high-grade Atrio-Ventricular (AV) block requiring a temporary pacemaker insertion (TPI). Epidemiological, demographic, laboratory, clinical management, and outcome data were extracted from all the enrolled patients and studied for the primary clinical composite endpoint of all-cause death. Results: The study population included 15 patients, including 14 patients with CHB and 1 patient with 2:1 AV block. Syncope was the most common presentation. The clinical endpoint in the form of death was seen in 5 patients (33.3%), 3 patients reverted to sinus rhythm, and 7 patients required permanent pacemaker implantation. The markers of inflammation were raised in all patients; however trend toward more inflammation was seen in patients reaching the primary clinical endpoint. 3 out of 7 patients with narrow QRS rhythm reverted to normal sinus rhythm, while all 8 patients with broad complex QRS either died or required a permanent pacemaker insertion. Conclusion: Symptomatic bradyarrhythmia is associated with a high inflammatory state, and high mortality in COVID-19 infection and a transient conduction block in patients with narrow QRS rhythm may suggest local subclinical myocardial inflammation. Resumen: Antecedentes: Las manifestaciones cardiovasculares son una causa importante de mortalidad y morbilidad en las infecciones por COVID-19. La anomalía del sistema de conducción en forma de bradiarritmia sintomática no se informa en la literatura. Objetivo: Evaluar datos epidemiológicos, demográficos, de laboratorio, de manejo clínico y de resultado de la bradiarritmia sintomática en pacientes con COVID-19. Métodos: Este fue un estudio observacional retrospectivo que incluyó a todos los pacientes adultos (> 18 años) que fueron diagnosticados con infección por COVID-19 y tenían bloqueo cardíaco completo (HBC) o bloqueo auriculoventricular (AV) de alto grado sintomático que requería una inserción de marcapasos (TPI). Los datos epidemiológicos, demográficos, de laboratorio, de manejo clínico y de resultado se extrajeron de todos los pacientes inscritos y se estudiaron para el criterio de valoración clínico primario compuesto de muerte por cualquier causa. Resultados: La población del estudio incluyó a 15 pacientes, 14 de los cuales tenían HBC y uno tenía bloqueo AV 2:1. El síncope fue la presentación más común. El criterio de valoración clínico en forma de muerte se observó en 5 pacientes (33,3%), 3 pacientes revirtieron al ritmo sinusal y 7 pacientes requirieron implantación de marcapasos permanente. Los marcadores de inflamación se elevaron en todos los pacientes; sin embargo, se observó una tendencia hacia una mayor inflamación en los pacientes que alcanzaron el criterio de valoración clínico primario. Tres de cada 7 pacientes con QRS estrecho revirtieron al ritmo sinusal normal, mientras que los 8 pacientes con QRS de complejo ancho murieron o requirieron la inserción de un marcapasos permanente. Conclusión: La bradiarritmia sintomática se asocia con un estado inflamatorio alto y una alta mortalidad en la infección por COVID-19, y un bloqueo transitorio de la conducción en pacientes con ritmo QRS estrecho puede sugerir una inflamación miocárdica subclínica local.

Background and objectives Quadripolar left ventricular (LV) leads in cardiac resynchronization therapy (CRT) offer multi-vector pacing with different pacing configurations and hence enabling LV pacing at most suitable site with better lead stability. We aim to compare the outcomes between quadripolar and bipolar LV lead in patients receiving CRT. Methods In this prospective, non-randomized, single-center observational study, we enrolled 93 patients receiving CRT with bipolar (BiP) (n = 31) and quadripolar (Quad) (n = 62) LV lead between August 2016 to August 2019. Patients were followed for six months, and outcomes were compared with respect to CRT response (defined as ≥5% absolute increase in left ventricle ejection fraction), electrocardiographic, echocardiographic parameters, NYHA functional class improvement, and incidence of LV lead-related complication. Results At the end of six months follow up, CRT with quadripolar lead was associated with better response rate as compared to bipolar pacing (85.48% vs 64.51%; p = 0.03), lesser heart failure (HF) hospitalization events (1.5 vs 2; p = 0.04) and better improvement in HF symptoms (patients with ≥1 NYHA improvement 87.09% vs 67.74%; p = 0.04). There were fewer deaths per 100 patient-year (6.45 vs 9.37; p = 0.04) and more narrowing of QRS duration (Δ12.56 ± 3.11 ms vs Δ7.29 ± 1.87 ms; p = 0.04) with quadripolar lead use. Lead related complications were significantly more with the use of bipolar lead (74.19% vs 41.94%; p = 0.02). Conclusions Our prospective, non-randomized, single-center observational study reveals that patients receiving CRT with quadripolar leads have a better response to therapy, lesser heart failure hospitalizations, lower all-cause mortality, and fewer lead-related complications, proving its superiority over the bipolar lead.

Objective Although thin-strut drug-eluting stents (DES) with a more flexible design are easily obtainable, data regarding using ultralong DES (≥40 mm) for long coronary lesions are limited in the literature. Therefore, the current study assessed the safety and efficacy of an ultralong (≥40 mm) and ultrathin (60 μm) biodegradable polymer-coated sirolimus-eluting stent (SES), Supralimus Grace, with a unique Long Dual Z-link (LDZ-link) design (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) in real-world patients with long coronary lesions. Methods The assigned stents were implanted in 684 patients. The primary endpoint was target lesion failure (TLF), which is a composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularization (TLR), whereas periprocedural secondary endpoints included device failure (failure of stent delivery, change of stent, and stent fracture) and patient-oriented composite endpoint (POCE), which is a composite of all deaths, any MI, and any revascularization, and stent thrombosis (ST). These outcomes were analyzed at one-year follow-up and during the procedure. Results The patients' mean age was 52.7±15.9 years; 537 (78.5%) were males. 626 (91.5%) patients suffered from acute coronary syndrome and 58 (8.5%) patients from chronic coronary syndrome (CSS). 989 lesions were removed. The mean numbers of lesions and stents implanted per patient were 1.3±0.2 mm and 1.4±0.3 mm, respectively. TLF occurred in 42 (6.1%) as a result of cardiac death, target vessel MI, and TLR in 9 (1.3%), 20 (2.9%), and 13 (1.9%) patients, respectively. POCE was observed in 131 patients (19.1%) at one-year follow-up, mainly in 63 (9.2%) patients because of any revascularization. Stent failure was seen in 21 patients (3.1%) as a result of delivery failure (2.2%), edge dissection (0.8%), and fracture (0.1%). Definite and probable ST were observed in 8 (1.1%) and 9 (1.3%) patients, respectively. Conclusion Ultralong (≥40 mm), ultrathin (60 μm) Supralimus Grace stent can be safely implanted in vessels having long and multiple lesions.

Intravesical foreign body is a rarity. Studies have reported several items in urinary bladder like gauze pieces, worms, electrical wires, chicken bones, thermometers, pieces of Foley catheter, batteries and snakes. Herein, a case of an electrical wire inserted in male urethra and coiled in the bladder is presented. A seventeen-year-old male presented with history of insertion of electric wire per-urethra. The wire got stuck when he tried to pull it. He had made several unsuccessful attempts to remove it. On examination, the wire was seen protruding from external urethral meatus. An X-ray demonstrated the wire coiled and knotted inside the bladder. Considering high chances of endoscopic treatment failure, suprapubic cystotomy was performed and the wire was removed. The most common reason for self-insertion of a foreign body into male urethra is of erotic or sexual nature. In majority of cases, patient feels guilty and humiliated; therefore, he delays medical help. Many authors advocate psychiatric evaluation of these patients, considering it an indication of self-punishing and impulsive behaviour. However, it is controversial as many of these patients are psychologically normal. The definite management is complete removal of the foreign body by endoscopic or open approach. However, choosing the optimal technique depends upon the patient’s condition, urinary tract injuries and the size, shape and material of foreign body. A self-inflicted foreign body in urethra and bladder is rarity. Endoscopic manipulation is the preferred treatment, and if unsuccessful, open procedures may be necessary.

Introduction The role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR. Methods It was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes. Results The mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively. Conclusion CR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.

Aims Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. Methods and results PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=, In this largest meta-analysis consisting of 15 studies, comparing 6093 patients in PCI group and 4943 patients in OMT group, it has been found that, PCI of CTO has a better long term outcome in terms of MACE, cardiac death and all causes of mortality with similar unplanned revascularization. Higher age, TVD, CKD independently contribute to higher MACE in CTO patients undergoing PCI in multivariate logistic meta-regression analysis.

Introduction: Cystitis cystica et glandularis (CCG) is a hyper proliferative condition, likely representing a local immune response to chronic inflammatory stimulus. It has been hypothesized as a potential precursor of adenocarcinoma; however, a definite association has not been demonstrated. We aimed to determine whether CCG is a precursor to malignancy and to study the correlation of its two histological variants: the typical and the intestinal metaplasia (IM) type CCG. Materials and Methods: In this retrospective study, all the cases of CCG diagnosed and treated between January 2012 and December 2019 were analyzed. All the cases were followed up cystoscopically and biopsies were taken if the lesion persisted. The development of adenocarcinoma during the follow-up was noted. The patients were divided into two groups based on the histological subtype, i.e., the typical type and the IM type, and the two groups were also compared in terms of presentation, cystoscopic appearance, and development of adenocarcinoma. Results: A total of 64 patients, with 52 in the typical and 12 in the IM group were analyzed. The commonest symptom was hematuria (59.38%), followed by irritative bladder symptoms (51.56%). The median follow-up period was 5 years and 5 months (range: 7–96 months) and no patient progressed to adenocarcinoma. On comparing the two groups, the lesions weresignificantly more extensive in the IM group (50% vs. 15.38%). However, there were no differences in the symptoms or the development of malignancy between the two groups. Conclusions: At a median of 5 years and 5 months of follow up, CCG (including the IM-type) did not show any increase in the risk of malignancy.

Provisional stenting is preferred for bifurcation lesion however, certain anatomical substrate does require two stents as a part of dedicated stent technique. Here, the present study evaluated outcomes of ultra-thin (60 μm) Supra family sirolimus-eluting stent (SES) (Sahajanand Medical Technologies Limited, Surat, India) for dedicated bifurcation lesions using Nano-crush technique at 12 months angiographic follow-up.This was prospective, single-center observational study which enrolled patients with de novo bifurcation lesion and underwent angioplasty with Supra family SES using Nano-crush technique at a tertiary care center in India, between March-2017 and February-2019. Primary endpoint at 12 months was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (TV-MI), and clinically-driven target lesion revascularization (CD-TLR). Secondary endpoints included patient-oriented composite endpoint (POCE), all-cause death, any revascularization, clinically-driven target vessel revascularization, stent thrombosis, periprocedural and spontaneous MI, and device failure.The study enrolled total 63 patients with a mean age of 62.5 ± 4.9 years and had male dominance (89%). Left main (LM) bifurcation and non-LM bifurcation were observed in 21 (33%) and 42 (67%) patients, respectively. Total 50 (80%) patients had Medina class-1,1,1. At 12 months, TLF occurred in 4 (6%) patients which included one cardiac death (1.5%), two (3.0%) TV-MI, and one CD-TLR (1.5%). POCE was observed in 6 (9.6%) patients. Stent failure was seen in 2 (3.1%) patient and one patient (1.5%) developed late stent thrombosis. Twelve months angiographic follow-up indicated intact stent patency in all other patients. On multivariate analysis, LM bifurcation, renal dysfunction, LM bifurcation with renal dysfunction, ejection fraction (35%) and calcified lesion were found as predictors of TLF.Dedicated stenting with ultra-thin Supra family SES for complex bifurcation lesion using Nano-crush technique reported acceptable clinical outcomes among real-world patients and can be performed safely with ease without any procedural complications.

Objective To evaluate the impact of successful percutaneous balloon mitral valvuloplasty (BMV) on left atrial (LA) reservoir function and LA volume in patients with severe mitral stenosis (MS) using peak atrial longitudinal strain (PALS). Method This was a prospective, non-randomized observational study conducted at the Laxmipat Singhania (LPS) Institute of Cardiology, Kanpur from August 2018 to February 2020 among patients with severe rheumatic MS undergoing BMV to assess LA reservoir function and its volume after BMV using PALS. Inclusion criteria were symptomatic severe rheumatic MS (NYHA ≥II), normal ventricular systolic function, and suitable valve morphology. Exclusion criteria were the coexistence of aortic valve involvement, left atrial appendage clot, mitral leak more than mild, pregnancy, hypertension, diabetes, and coronary artery disease. To assess LA reservoir function and its volume after BMV, PALS was used. LA was divided into six regions of interest and longitudinal strain curves of individual segments together with global strain were recorded. PALS was calculated at baseline 24 hours following the intervention, and at three months of follow-up. Result Successful BMV was performed in 260 patients (109 or 41.9% males and 151 or 58.1% females), resulting in significant improvement in mitral valve area (MVA) (0.89±0.11 cm

Introduction--A observational study was conducted in the Department Of Respiratory Medicine in a tertiary care centre who were taking ATT under DOTS or had history of ATTconsumption in the past. Aim :Aim of the study was to evaluate the status of a retrieval mechanism for patients who are lost to follow-up and to identify the strengths and weakness in the dispersal of medications, monitoring and follow-up of patients and status of retrieval mechanism. Materials and Methods: The study was carried out among 201 patients coming to the Department of Respiratory Medicine who were on ATTunder DOTS or had received ATTin the past. Demographic details and clinical ndings were noted. Data collected was entered into Excel spread sheet and quantitative data were expressed as number and percentage. Results- Among 201 participants 17.4% missed their doses whereas 82.6% of the participants took their medications regularly. Among the patients who missed their doses retrieval actions were taken in only 42.9%participants.Among those participants in whom retrieval actions were taken 14.3% were lost to follow up,97.14 % of the participants who missed their doses received multiple days medications. Besides this, 80% of the participants who missed their doses suffered from adverse effects of ATTduring their course of treatment. Conclusion—From this study we conclude that under NTEPmajority of patients are taking ATT regularly but regular follow-up of patients on ATT and retrieval action is not upto the mark and it should be strengthened to prevent development of DRTB and its spread in the community.

Introduction: Rheumatic heart disease (RHD) is one of the most typical causes of atrial fibrillation in developing countries like India. The left atrial and left atrial appendage structure and function are deranged in atrial fibrillation and are a major source of thromboembolism. The goal of this study was to assess the left atrial and left atrial appendage function by transesophageal echocardiography in patients with atrial fibrillation and their comparison in patients with or without RHD. Methods: A total of 172 consecutive patients with atrial fibrillation with or without RHD were subjected to trans-esophageal echocardiography to assess and compare left atrial (LA) and left atrial appendage (LAA) function. Results: Out of 172 patients with atrial fibrillation, 100 were female (58.1%) and 72 were male (48.9%). The mean age was 54.11±12.3 years, and rheumatic heart disease (RHD) was the commonest cause of atrial fibrillation found in 121 (70.3%) patients. The mean left atrium diameter was significantly higher in RHD patients than in Non-RHD patients (52.08±10.13 vs. 46.67±6.78 mm, p=0.001). Mean left atrial ejection fraction was significantly lower in RHD patients as compared to Non-RHD patients (33.53±5.06 vs. 35.49±5.40%, p=0.024). The mean LAA orifice area of RHD patients was significantly higher than the Non-RHD patients (7.52±1.22 vs 6.94±1.17 mm2, p=0.005). Mean LAA emptying velocity was significantly lower in RHD patients than Non-RHD (20.49±3.95 vs. 22.8±5.96 ml/s, p=0.002). Conclusion: Rheumatic heart disease is still a common cause of atrial fibrillation in developing countries. LA and LAA function is impaired in atrial fibrillation, more in patients with rheumatic heart disease.

Incidence of mucormycosis suddenly surged in India after the second wave of COVID-19. This is a crippling disease and needs to be studied in detail to understand the disease, its course, and the outcomes.Between 1st March and 15th July 2021, our network of hospitals in North India received a total of 155 cases of COVID-associated mucormycosis cases as all of them reported affliction by COVID-19 earlier or concurrent. Their records were retrieved from the Electronic Health Records system of the hospitals and their demographics, clinical features, treatments, and outcomes were studied. More than 80% (125 cases) had proven disease and the remaining 30 were categorized as ‘possible’ mucormycosis as per the EORTC criteria.More than two-thirds (69.0%) of the cases were males and the mean age was 53 years for either sex. Nearly two-thirds (64.5%) had symptoms of nose and jaws and 42.6% had eye involvement. Some had multiple symptoms. As many as 78.7% had diabetes and 91.6% gave history of use of steroids during COVID-19 treatment. The primary surgery was functional endoscopic sinus surgery (FESS) (83.9%). Overall mortality was 16.8%, which is one-and-a-half times the mortality in hospitalized COVID-19 patients in the corresponding population. Occurrence of mucormycosis was associated with diabetes and use of steroids, but mortality was not associated with either of them. Cases undergoing surgery and on antifungal had steeply lower mortality (11.9% vs. 50.0%, P < 0.001) than those who were exclusively on antifungal drugs. Treatment by different drugs did not make much of a difference in mortality.

A 23-year-old male came to the outpatient department with a history of intermittent palpitations and headaches for the past six to eight months. He was diagnosed with hypertension and had a junctional rhythm on an electrocardiogram (ECG). On further workup for his hypertension, he was found to have elevated levels of serum metanephrines and computed tomography (CT) and positron emission tomography (PET) scan revealed pheochromocytoma. He was subsequently operated upon and his arrhythmia subsided after surgery. We discuss our approach to this scenario, which leads us to a rather rare cause of sinus node dysfunction.

Background Cardiovascular manifestations are one of the most common complications in coronavirus disease 2019 (COVID-19) infection and are associated with increased mortality. However, the impact of COVID-19 infection on thrombus burden and the outcome of acute myocardial infarction (AMI) has not been studied. Methods This was a retrospective, observational study that included all adult patients (>18 years) diagnosed with AMI with or without COVID-19 infection. Epidemiological, laboratory, clinical, interventional, and outcome data were extracted and the impact of COVID-19 on thrombus burden and the primary clinical composite endpoint of all-cause death during hospital admission or 30 days after discharge was studied. Results The study population included 336 patients, including 56 patients with COVID and AMI and 280 patients with AMI without COVID-19 infection. Chest pain was the most common symptom (84.8%) while one or more co-morbidity was present in 117 (34.8%) patients. Forty-eight patients in the AMI with COVID group had ST-segment elevation myocardial infarction (STEMI) while 256 patients in the AMI without COVID group had STEMI, eight patients in the AMI with COVID group had non-ST-segment elevation myocardial infarction (NSTEMI), and 24 in the AMI without COVID group had NSTEMI. Patients with COVID-19 co-infection had a higher thrombus burden as compared to the patients without COVID-19 AMI group (p-value 0.008). The primary outcome in the form of all-cause mortality was seen in 13 (3.9%) patients, which was also more in the AMI with COVID group. Conclusion COVID-19 in AMI is a state of high thrombus burden associated with higher mortality, especially in patients with chronic co-morbidities.

The development of acute severe mitral regurgitation (MR) requiring surgery is one of the most dreaded complications of percutaneous transmitral commissurotomy. We present the case of a 29 year-old female with severe rheumatic mitral stenosis whose mitral valve dilatation was performed using an Accura balloon. Once the balloon catheter had crossed the mitral valve to reach the left ventricle, it was facing away from the apico-mitral axis. It was inflated in distal portion, and mitral valve dilatation was done in the usual fashion. She developed acute severe MR. As it was misaligned with the apico-mitral axis, it caused a chordae rupture of the postero-medial papillary muscle which was identified during surgery. We conclude that a misaligned Accura balloon catheter during balloon inflation can pluck the chordae tendinae and can cause acute severe mitral regurgitation, and therefore can unearth the underlying subvalvular pathology.

Acute stent recoil or radial collapse of a stent is a rare phenomenon leading to subsequent acute stent thrombosis or in-stent restenosis as delayed sequelae. Reduced strut thickness, a larger stent/vessel ratio, and a larger balloon/stent ratio are factors leading to stent recoil. Here, we report a case of acute recoil or radial collapse of Promus Element Plus, a third-generation everolimus-eluting stent with thin stent struts in a 66 year-old male who underwent bifurcation percutaneous coronary intervention of left anterior descending artery (LAD) and diagonal branch (D1). Following kissing balloon inflation at 16 atm pressure after deployment of stents in LAD and D1, acute radial collapse of stent in proximal LAD was noted. It was successfully bailed out by further multiple, short sequential inflations using same size noncompliant balloon. Acute radial collapse probably occurred due to inflation at higher pressure with an oversized balloon, and relatively thin struts of the stent.

Percutaneous trans-mitral commissurotomy (PTMC) using an Accura balloon is an effective procedure for the mana- gement of patients with rheumatic mitral stenosis. It is not infrequent to encounter an aneurysmal left atrium (LA), especially in the developing world where patients often present very late. This is a technically challenging procedure as the septum often bulges into the right atrial side, making the puncture often difficult. Furthermore, it bulges anteriorly and inferiorly so it becomes even more challenging. Because of the vertical lie of the septum, the needle often dissects the septum rather than puncturing it. Here, we describe the case of a 17 year-old boy with severe mitral stenosis with a giant, aneurysmal left atrium (LA — 13.5 × 16 cm) where an inter-atrial septal puncture was achieved by probing the fossa ovalis to enter the left atrium instead of a conventional transseptal puncture. PTMC was successfully done, increasing the mitral valve area from 0.8 cm2 to 1.9 cm2.

Anomalous coronary arteries, especially when they are right with a high take-off, are challenging substrates for percuta- neous coronary intervention (PCI). Here, we report the case of a 63 year-old female who had a critical lesion in proximal anomalous right coronary artery having an abnormal take-off, where the ostium failed to get cannulated using multiple guiding catheters. Successful PCI was done using a 5 F TIG diagnostic catheter (Optitorque, Terumo, Japan) through the transfemoral route. The unique shape of the TIG diagnostic catheter allowed coaxial engagement of anomalous right coronary artery, with adequate lesion assessment and stent delivery.

Sinus of Valsalva aneurysm, usually a congenital anomaly, almost always ruptures into the right sided cardiac chambers, causing a left-to-right shunt with profound haemodynamic consequences. With the availability of the current genera- tion of devices and hardware, transcatheter closure has gradually replaced the surgical route. To date, most closures have been performed using an Amplatzer duct occluder (ADO). Here, we report the case of a 21 year-old male where a very large (18 mm) rupture of a sinus of Valsalva aneurysm from non-coronary cusp to right ventricle was closed by a percutaneous approach using a 20/18 mm Cocoon duct occluder (CDO; Vascular Innovations, Nonthaburi, Thailand).

The retroesophageal right subclavian artery (ROSRA; arteria lusoria) is one of the anatomical abnormalities encountered at innominate-arch junction during transradial catheterization by right route. Here, we report a case of a 49-year old female who presented with chronic stable angina (Canadian Cardiovascular Society class-III) despite guideline directed medical treatment. Coronary arteries were cannulated with difficulty showing critical lesion of proximal left anterior descending artery (LAD). During angiography, diagnostic catheter has a peculiar cobra loop in the ascending aorta. As the left subclavian artery also has critical lesion at the proximal part, percutaneous coronary intervention of proximal LAD artery was successfully performed with 3.5×23 mm Xience Prime Everolimus eluting stent (Abott, USA) through right femoral route. Multi detector computed tomography (MDCT) contrast aortography showed the origin of the right subclavian artery in the right posterior side of the horizontal aorta with a tortuous course, proximal stenosis of left subclavian artery (LSC), and a bicarotid truncus. This abnormality can be easily detected by angiographic visualization, in the anteroposterior projection, of the angle of the catheter when it engages the ascending aorta, and by manual angiography at the ostium of the right subclavian artery. In such a case, selective catheterization of both coronary arteries may be very difficult, time consuming, and require more catheters. In such cases, one should not be hesitant to switch to transfemoral route if left radial route cannot be utilised.

A 10 year-old girl was admitted to hospital for evaluation of sudden onset chest pain of three days’ duration. There were no co-morbidities or family history of coronary artery disease. There was a disparity of blood pressure in the upper limbs, while pulses in the lower limbs were barely palpable. Her electrocardiogram revealed ST segment elevation in II, III, and aVF leads. Laboratory tests showed elevated troponin T (0.8 ng/mL), total leukocyte count (13,800/ μ L), C-reactive protein (94 mg/L), and erythrocyte sedimentation rate (56 mm in first hr). Echocardiography showed mildly impaired left ventricular systolic function with an ejection fraction of 58%. Aortogram showed total occlusion of the brachiocephalic trunk, diffuse thoraco-abdominal coarctation, and osteo-proximal stenosis (80%) of the left renal artery. Coronary angiography revealed total occlusion of the left circumflex artery and tubular lesion of the proximal left anterior descending artery with 70% stenosis. Based on these findings, she was diagnosed to be in the active phase of juvenile Takayasu’s arteritis having acute inferior wall myocardial infarction. Her treadmill test for reversible ischaemia (modified Bruce protocol) was negative, and she was discharged on medication (antiplatelets, corticosteroids, and immunosuppressive agents).

Aortico–left ventricular tunnel (ALVT) is a rare congenital paravalvular communication between the aorta and the left ventricle (LV), with few hundred odd cases reported till date. Most commonly the tunnel arises from the right aortic sinus. We herein report a case of AVLT in a 28-year old male where a common pouch, which was communicating to both the left, as well as right aortic sinus, was draining to the left ventricle. He presented with progressive heart failure where a long diastolic murmur was audible. The patient succumbed to death because of progressive cardiac decompensation before surgical correction could have been performed. This is a first ever report of AVLT where proximal chamber as a common sac, communicating with both the left, as well as right aortic sinus, was communicating distally to the left ventricle. Key words- Aortico- left ventricular tunnel, Congenital heart defect, Aortic regurgitation; Diastolic murmur; Cardiac decompensation

Background: Lesion characteristics (anatomy, calcification, tortuosity and angulation), vessel morphology, and lack of support add complexity of coronary intervention. Guidezilla catheter, acting as an extension of guide catheter system (mother-in-child catheter), helps to overcome these complexities by enhancing backup during complex intervention. Methods: The present retrospective, single-center study included 13,157 consecutive patients who underwent percutaneous coronary intervention (PCI) through both transfemoral and transradial routes from January 2015 to July 2019 at LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, Uttar Pradesh, India among which Guidezilla™ catheter (Boston Scientific, Natick, MA, USA) was used in 156 patients. Study endpoints were target lesion crossing, procedural success, and complications. The clinical, angiographic and procedural data of all 156 patients were evaluated to assess safety and efficacy of Guidezilla extension catheter (GEC). Results: The mean age of the enrolled patients was 61.2 ± 8.67 years. Type-C lesion was commonest (69.9%) followed by B2 (22.4%) and B1 (7.7%). The commonest indication for its use was tortuosity (30.1%) followed by calcification (21.1%), angulation (18.8%), chronic total occlusion (17.9%), distally located lesion (8.3%), and anomalous origin of vessel in 3.8%. The right coronary artery (39.2%) was most commonly intervened artery followed by left anterior descending (LAD) (30.8%), left circumflex (LCX) (19.9%), multivessels (7.6%), and saphenous vein graft in 2.5%. The mean depth of intubation was 4.2 ± 1.9 cm. Mean diameter of stents was 34.2 ± 14.4 mm while mean length of stents was 31.2 ± 10.2 mm. Lesions were modified using aggressive pre-dilatation in 87.8%, followed by cutting balloon in 10.9%. GEC was delivered across the lesion using buddy wire technique (9.6%), balloon-assisted tracking (BAT) in 30.1%, and balloon-assisted sliding and tracking (BLAST) in 4.5% of patients. Stent implantation was successful in 151 out of 156 patients with success rate of 96.7%. Overall failure rate was 3.3% which was contributed by extreme tortuosity, angulation, and severe calcification. Guidezilla-associated procedural complication (dissection, stent dislodgement, shaft breakage) were reported in three patients (1.9%) who were successfully managed. Conclusion: Guidezilla system acting as mother-in-child extension catheter is a safe and effective tool which provides additional backup support and increases success rate of PCI for complex coronary lesions. Cardiol Res. 2019;10(6):336-344 doi: https://doi.org/10.14740/cr949

A small portion of lesions are refractory even when very high pressures are used to deploy the stent. Here, we report a 7-years old boy referred for evaluation of refractory hypertension. There was a bruit on auscultation on the back in lumber region. Renal angiogram revealed bilateral renal artery stenosis. Right and left renal arteries were stented with 7x23 mm and 7x19 mm Hippocampus bare metal stent (Medtronic, USA). Despite delivering stent in left renal artery at 10 atm pressure, it didn’t open up properly. We successfully attempted the technique of hugging balloons or two noncompliant balloons- 4x10 mm each, inflated simultaneously side by side at 20 atm to successfully dilate the stent. This technique enables success as the geometry of two kissing balloons is different from one balloon. This altered geometric configuration may be important in successfully dilating a stent refractory to standard dilating techniques. Higher pressures can be attained with two smaller balloons as the burst pressure is higher in smaller balloons compared to larger balloons.

Anomalies of the coronary arteries are reported in 1–2% of patients who undergo a diagnostic angiogram. An ectopic origin of the right coronary artery from the opposite sinus is one of these anomalies, and while most are benign, at times it may be malignant. We report the case of a 43-year-old female who underwent primary percutaneous coronary intervention for acute inferior wall myocardial infarction where an ectopically arising right coronary artery (RCA) with abnormally high take-off was the culprit. We describe the various technical challenges faced during intervention, from cannulation to tracking of hardware. The RCA was cannulated using the floating wire technique and revascularised by the deployment of a 3.5 × 33 mm Xience Prime drug-eluting stent (Abbott Vascular, Santa Clara, CA, USA). In such a scenario where a conventional technique fails and where door-to-balloon time must be kept as short as possible, a little improvisation should resolve the problem.