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We evaluated the safety and feasibility of ipsilateral radial and ulnar artery cannulation during the same catheterization procedure. Crossover from radial to femoral was done in 122 patients. Both ipsilateral radial and ulnar catheterization were performed in 16 patients without any complications, which was further supported by Doppler ultrasonography.

Ischemic mitral regurgitation (IMR) has a profound negative effect on survival of patients following myocardial infarction. It occurs when the closing forces are overpowered by the tethering forces as a consequence of ventricular remodeling. Surgeons sought to correct moderate and severe IMR by mitral annuloplasty. Though short-term results were encouraging, survival after 2 years were not so. Higher recurrence rates were also noted with severe mitral regurgitation (MR). Parameters defining severity of IMR were initially formulated in 2003. These were revised enabling intervention in moderate MR in 2014. With the lack of positive medium and long-term evidence, 2017 guidelines have raised the bar, discouraging intervention in moderate IMR. Current guidelines have taken a conservative stance in advocating repair only for severe MR and very symptomatic patients. Till emergence of fresh evidence surgical enthusiasm for repair of IMR has to be restrained.

A 22-year-old woman presented with new-onset palpitation and dyspnea. Cardiovascular examination revealed continuous murmur at the left upper parasternal area. Echocardiographic evaluation revealed a connection from the aorta, tunneling up to the intra-atrial septum, which made a giant aneurysmal

Background: Pericardial tamponade, a life-threatening condition caused by the accumulation of fluid in the pericardial sac, can be acute or chronic. Mortality and morbidity can be minimized on prompt diagnosis and treatment with percutaneous drainage. Materials and methods: 246 patients admitted with cardiac tamponade between Jan 2010 and Aug 2014 was enrolled in the study. After clinical examination and echocardiographic assessment, all the patients were subjected to emergency pericardiocentesis (both diagnostic and therapeutic). Three samples of the aspirate were sent for biochemical, serological, and cytological analysis. The data collected was then analyzed.

Background The safety and efficacy of everolimus eluting bioabsorbable vascular scaffold (BVS) in the management of “ST” segment elevation myocardial infarction (STEMI) are yet to be established. Aims To evaluate immediate and short term safety and efficacy of the everolimus-eluting ABSORB BVS compared with non BVS drug eluting stent (DES) in patients with STEMI. Methods From December 2013 to December 2014, 220 patients with STEMI were included in this study. Among them, 35 patients treated with BVS were compared with a control group composed of 180 patients who underwent non BVS DES implantation in the same time period. The incidence of major adverse cardiac events (MACE: stent thrombosis: death, non-fatal myocardial infarction, or target vessel/lesion revascularization) before discharge and up to six months was evaluated. Results 1 vessel disease was more frequent whereas, 2 and 3 vessel disease was less frequent in BVS group. Procedural characteristics were also similar between groups, except for the use of post dilation (p = 0.04). Procedural success, in-hospital, and up to six-month MACE rates were similar between both groups. Definite or probable stent thrombosis did not occur (according to the ARC criteria) in BVS patients, though two patients during the index admission and another two patients in the first month after DES implantation had stent thrombosis. Conclusion The use of the ABSORB BVS for STEMI is feasible and associated with good procedural safety, and angiographic success rate.

The indications for implantable cardioverter defibrillators (ICDs) for the prevention of sudden cardiac death (SCD) have rapidly expanded over the past 15 years. Clinical trial data have quickly been implemented into guidelines. The recently introduced subcutaneous implantable cardioverter defibrillator (S-ICD) uses a completely subcutaneous electrode configuration to treat potentially lethal ventricular tachyarrhythmia. The device is now commercially available in India. Clinical trials have proven its effectiveness in detecting and treating ventricular fibrillation (VF) and tachycardia. The S-ICD offers the advantage of eliminating the need for intravenous and intracardiac leads and their associated risks and shortcomings. However, major disadvantages of this device include inability to provide bradycardia rate support and antitachycardia pacing to terminate ventricular tachycardia. As seen with other early examples of evolutionary technology, we hope improvements in design and manufacture will improve some of the drawbacks of the current generation device.

Catheter-directed thrombolysis (CDT) with assisted mechanical thrombolysis is now considered as the standard of medical care for deep vein thrombosis (DVT). The study was conducted to describe the immediate and long-term (6 months) safety and effectiveness of CDT in patient with lower limb DVT compared with the routine anticoagulation alone. All 12 to 85 years old patients with recent (0–8 weeks) DVT were included. In CDT group, thrombus was aspirated mechanically and streptokinase (STK) was given along with unfractionated heparin (UFH). After 6 months, deep venous patency and postthrombotic syndrome (PTS) was assessed by using duplex ultrasound and Villalta scale, respectively. Among 51 patients with completed data, 25 patients were allocated additional CDT given for a mean duration of 108 ± 32 hours and 26 patients were allocated standard treatment alone. Grade III (complete) lysis was achieved in 37% patients and grade II (50–90%) lysis in 63% of patients. Patients with partial lysis underwent percutaneous transluminal angioplasty and/or venous stenting. After 6 months, iliofemoral patency was found in 20 (80%) in the CDT group versus 7 (23%) in anticoagulation alone group (p

Background:Cyanotic CHD comprises up to 25% of cases of all causes of CHD.Rationale:There is lack of data about the present spectrum of congenital cyanotic heart disease in the paediatric age group.Objective:The present study was undertaken to determine the spectrum of patients with congenital cyanotic heart disease in the paediatric age group in tertiary paediatric cardiac care clinic.Design:Prospective observational study.Setting:Paediatric cardiac clinic of a tertiary cardiac care centre.Methods:All children aged 0–18 years with suspected cyanotic CHD were provisionally included in this study. They underwent a thorough echocardiographic evaluation, and those patients who had definitive diagnosis of congenital cyanotic heart disease were included for final analysis.Results:A total of 119 children met the inclusion criteria. Tetralogy of Fallot and its variant were the most common congenital cyanotic heart disease with proportion of about 44%. Other common malformations were double outlet right ventricle (14%), pulmonary atresia with ventricular septal defect (8%), total anomalous pulmonary venous connection (7%), d-transposition of the great arteries (9%), tricuspid valve anomalies − tricuspid atresia and Ebstein’s anomaly − hypoplastic left-heart syndrome, truncus arteriosus, and complex CHD such as single ventricle.Conclusion:Tetralogy of Fallot and its variants were the most common cyanotic heart disease diagnosed in our patients. As there were a significant proportion of cases with complex cyanotic CHD, paediatric cardiologists should be familiar with the diagnosis and management of all these complex congenital malformations of the heart.

Background Catheter-directed thrombolysis with assisted mechanical thrombolysis is the standard of medical care for proximal deep vein thrombosis. We studied the immediate and intermediate (six months) safety and effectiveness of catheter-directed thrombolysis in patients with proximal lower limb deep vein thrombosis. Methodology Thirty consecutive patients aged between 20 and 70 years with proximal lower limb deep vein thrombosis formed the study group. Catheter-directed thrombolysis was done with streptokinase infuse through a catheter kept in the ipsilateral popliteal vein. Unfractionated heparin was given along with streptokinase. Mechanical thromboaspiration using guiding catheter was performed in addition to thrombolytic therapy. After six months, post-thrombotic syndrome and deep venous patency were assessed by using Villalta scale and duplex ultrasound, respectively. Results Thirty patients with proximal lower limb deep vein thrombosis were treated with catheter-directed thrombolysis. Mean age of the study patients was 41.7 ± 15 years. Mean duration of illness was 13.3 ± 12 days. The mean duration of thrombolysis was 4.5 ± 1.3 days. Grade III (complete) lysis was achieved in 10 (33%) and Grade II (50–90%) lysis in 20 (67%) of patients. Patients with significant residual lesion in Grade II lysis following catheter-directed thrombolysis underwent percutaneous transluminal angioplasty alone (12/20) or venous stenting (8/20). All patients improved clinically following catheter-directed thrombolysis or assisted catheter-directed thrombolysis. Four patients (13%) developed pulmonary embolism during course of hospital stay and among them two (6.5%) patients died. Eleven patients (37%) had minor bleeding or hematoma at local site, and seven (23%) developed anemia requiring blood transfusion and four (13%) patients had thrombocytopenia. After six months, iliofemoral patency was found in 20 (72%) and post-thrombotic syndrome was seen in six (21%) patients. Two (6.5%) patients died during follow-up due to nephrotic syndrome and carcinoma breast. Conclusion Catheter-directed thrombolysis and conventional manual aspiration thrombectomy are an effective treatment for proximal lower extremity deep vein thrombosis with good short and intermediate outcome.

Background: We are presenting a rare case of an elderly female who had been asymptomatic until the age of 56 years and had successfully completed three pregnancies. She presented with an episode of acute onset chest pain of moderate intensity and was initially suspected to have an evolved inferior wall myocardial infarction on the basis of the electrocardiogram. The echocardiogram performed subsequently surprisingly revealed the presence of a severe form of Ebstein`s anomaly. Methods & Results: Various forms of electrocardiographic abnormalities and conduction defects are reported in Ebstein’s anomaly but the presence of a normal ECG pattern or pseudoinfarct pattern with the absence of any associated conduction blocks or axis deviation is highly unlikely especially in severe forms of the disease. There are three aspects of this cases which make it rare. Firstly, the presentation of a patient with severe form of Ebstein`s anomaly with an isolated evolved inferior wall myocardial infarction pattern on the ECG ,secondly the presence of an extra-ordinarily long asymptomatic period and thirdly the presentation with angina as the presenting symptom with normal epicardial coronaries. Key words : Ebstein`s pseudoinfarct pattern angina inferior wall infarction pattern normal coronaries.

Background: We are presenting a rare case of large non-familial left atrial myxoma in a fourteen year old girl which presented clinically similar to severe mitral stenosis which was the first clinical differential diagnosis which was considered initially. She had symptoms of progressively worsening orthopnea and exertional dyspnea since the last 2-3 months (NYHA class III symptom status). The final diagnosis which was made after echocardiography was surprising and the girl was diagnosed to have a large atrial myxoma which was causing obstruction of the mitral valve preventing normal inflow across the mitral valve. The patient had no family history of being diagnosed of a cardiac tumor nor there were any cutaneous manifestations in the form of lentigenes or any symptoms suggestive of and systemic or cerebral embolization of tumor fragments. The patient subsequently underwent surgical excision of the tumor which was eventually confirmed to be an atrial myxoma histopathologically. Presence of atrial myxoma in an adolescent patient is an extremely rare occurrence and has seldom been reported. Key words: Atrial myxoma, non familial echocardiography.

We are presenting an interesting case of a 30-year-old patient taken for percutaneous transvenous mitral commissurotomy (PTMC) for severe rheumatic mitral stenosis in which there was a collection of four unusual occurrences during the course of a procedure. She had recurrent generalized tonic–clonic seizures immediately after femoral sheath insertion requiring the patient to be mechanically ventilated. Subsequently, the pressure tracings recorded with catheters in the aorta and the pulmonary artery showed transient unusually high supra-systemic pulmonary artery pressure. During inflation the Accura PTMC balloon which was used to dilate the mitral valve ruptured and the procedure subsequently had to be completed using another balloon catheter. During the procedure the presence of a distended stomach due to insufflations of air during positive pressure ventilation which subsided subsequently was another unusual documentation on fluoroscopy. The final outcome of the procedure was successful. This case presents an interesting collection of unusual occurrences during a PTMC procedure which started on an unusual note but ended on a successful one. Careful assessment and appropriate management of complications can lead to successful outcome of procedures as in our case.

Severe neurological complications are associated with falciparum malaria. We describe the case of an eight-year-old male child with severe falciparum malaria with high-level parasitemia and severe thrombocytopenia. There were features of abnormal gait, speech difficulty and altered behavior pattern during the recovery phase. This occurred even after receiving antimalarial therapy. MRI showed bilateral cerebellar atrophy.

Background Procedural and clinical outcomes in patients with very long (>30mm) coronary lesions who underwent stent-based percutaneous coronary interventions are still unfavorable. Therefore, we compared the relative efficacy and safety of resolute zotarolimus-eluting stents (R-ZES) and Xpedition everolimus-eluting stents (X-EES) for patients with de novo very long coronary lesions. Methods This comparative single-centre, retrospective study compared long R-ZES and X-EES in consecutive patients admitted with very long (≥30mm) native ACC/AHA type C coronary lesions in 2014. All patients were followed up clinically at 1, 3, 6 and 12months. In this study, only symptom-driven angiogram was advised. The study end point was to evaluate immediate procedural success and one-year rate of target lesion failure (TLF), which is a composite of cardiac death, target lesion myocardial infarction, or target lesion revascularization (TLR). Results Total number of patients enrolled in this study was 185 (R-ZES=107; X-EES=78). The baseline characteristics and post procedural success rate were similar between R-ZES and X-EES groups, including the post stenting lesion lengths (36.6±1.92mm vs 40.71±6.175mm, P =0.09). At 12-month follow-up, there were no significant between-group differences in the rate of adverse clinical events (death, myocardial infarction, stent thrombosis, target lesion revascularization, and composite outcomes). Procedural success was achieved in 94% in R-ZES group and 93% in X-EES group ( P =0.24). The incidence of TLF was 5% in R-ZES and 4% in X-EES groups (HR-1.25; 95% CI-0.86-5.6; P =0.19). Conclusion Patients with de novo long coronary artery disease, R-ZES implantation showed similar clinical outcome as compared with X-EES implantation.

Patient initials or identifier number MR ### Relevant clinical history and physical exam A 42-years old man presented with effort angina. He was a smoker, hypertensive and dyslipidemic. Cardiovascular and other system examination didn't reveal any significant abnormality. His blood pressure

Dilated cardiomyopathy (DCM) is an uncommon complication of Takayasu arteritis (TA) with a prevalence of about 6%. We report a case of 14-year-old girl who presented with dyspnea, bipedal edema, loss of weight, and easy fatigability for three months. She was being treated for DCM for the same duration. Clinical examination revealed absence of both upper limb pulses. Echocardiography revealed features of DCM with severe biventricular dysfunction (ejection fraction 30%). Computed tomography angiogram confirmed the diagnosis of TA and revealed the presence of bilateral renal artery stenosis. Bilateral renal angioplasty was done, and immunosuppressant therapy with oral prednisolone and weekly oral methotrexate was started.

Preventive therapy for tuberculosis in children is an important strategy to control pediatric TB in addition to early diagnosis and treatment of infectious cases in the community. In low burden countries, it is an important tool for preventing TB at all ages as the opportunities for re-infection are few. In contrast in high burden countries, preventive therapy though effective in preventing occurrence of disease among infected, can not prevent re-infection--an event of fairly high occurrence in these settings. Children under 5 years of age or immuno-compromised children of any age who have the highest risk of developing infection and disease when exposed are the main focus for preventive therapy in high burden settings. A 6 months therapy with INH continues to be the preferred modality of preventive therapy as efforts are being made to identify a short course preventive therapy using Rifampicin and other drugs.

Wheezing is common among infants and young children due to peculiar anatomical and physiological properties of their lungs. Gastro-oesophageal reflux (GER) has been incriminated as one of the cause of non-asthmatic wheezing in this age group. The present study evaluates the magnitude of GER and its causal relationship with wheezing in early childhood. All recurrent and persistent wheezers (under two years) were investigated for GER and treated medically where tests were positive. The subjects were further profiled to identify any predictors for GER. Sixty-seven children of less than 2 years age with recurrent or persistent wheezing were evaluated for GER. Mean age of the study subjects at enrolment was 10.8 months and at onset of wheezing was 7.1 (± 3.8 S.D) months. Asthma and wheeze associated lower respiratory tract infection (WALRI) was diagnosed in about 1/3 each of the patients studied. GER studies were positive in over one-third (25/67) of cases. Forty-two percent of children who wheezed by 1 year of age had a positive GER study. Interestingly, nearly half (12/25) of the patients with an abnormal study did not have any clinical suggestion of regurgitation ("silent" GERs). The severity of wheezing was higher among those who had GER versus those who did not (p ≤ 0.048; OR: 3.2). However, only 32% patients showed significant response to anti reflux treatment alone while others had partial response. GER, therefore, is an important cause for recurrent wheezing among children less than 2 years of age, either singularly or as a co-morbidity. The study findings justify investigations for GER among early wheezers; particularly for those who have onset of symptoms by 12 months of age or those who have severe disease.

OBJECTIVE: To compare the diagnostic value of Gastro-intestinal (GI) scintiscan with 24-h pH study in detecting gastro-esophageal reflux (GER) among infantile wheezers. SUBJECTS: Fifty-two children < 2 years of age. METHODS: All patients, irrespective of symptom underwent study to evaluate for GER. RESULTS: GER studies were positive in almost 45% of cases. The agreement between positivity of these two tests is best among children between 7 and 12 months of age (κ = 0.591, p = 0.002). Overall GI scintiscan was a better test with higher sensitivity and specificity as compared to 24-h pH study when compared with the history suggestive of reflux and clinical response with anti-reflux treatment as standard (p ≤ .001). CONCLUSION: Both GER scan and 24-h pH study are complimentary to each other, however, if both the tests are available then GI scintiscan is better as a single test for GER in these early wheezers.

Afibrinogenemia is a rare autosomal recessive bleeding disorder with an estimated prevalence of 1:1,000,000. Usual presentation of this disorder is spontaneous bleeding, bleeding after minor trauma and excessive bleeding during interventional procedures. Paradoxically, few patients with afibrinogenemia may also suffer from severe thromboembolic complications. The management of these patients is particularly challenging because they are not only at risk of thrombosis but also of bleeding. We are presenting a case of 33-year-old male patient of congenital afibrinogenemia who had two episodes myocardial infarction in a span of two years. The patient was managed conservatively with antiplatelet therapy and thrombolytic therapy was not given due to high risk for bleeding.