Prevalence of carotid artery disease in candidates undergoing coronary bypass graft seen at Madras Medical Mission

Background: Significant carotid artery disease in candidates going for coronary artery bypass graft (CABG) increases the risk of developing peri-operative neurologic events. Therefore, a pre-operative carotid Doppler ultrasonography, which is simple, non-invasive, and cheap may be indispensable. In this study, we report the prevalence of carotid disease in candidates for CABG and assessed the correlates between carotid artery disease and coronary artery disease (CAD). Materials and Methods: Seventy three consecutive patients undergoing elective CABG were recruited over 7 months, January to July 2007. All participants underwent pre-operative carotid Doppler assessment for level of stenosis and site of carotid plaque. Using the criteria defined by the Society of Radiologists in the Ultrasound Consensus, the degree of stenosis was stratified into the categories of normal (no stenosis), 50% non-obstructive carotid disease, 50-69% significant stenosis, 70% critical stenosis to near occlusion, near occlusion, and total occlusion. Patients with previous CABG, congestive cardiac failure, and high-risk surgery were excluded. Results: The mean age of patients was 65.0 ± 7.2 years with male-female ratio of 9:1. Twenty one (28.8%) patients had normal carotid arteries 45 (61.6%) had non-obstructive carotid artery disease 4 (5.5%) had significant carotid stenosis and 3 (4.1%) had critical carotid stenosis. Carotid bulb was the most common site of plaque formation while left internal carotid artery was the commonest site of both significant and critical carotid stenosis. Patients with significant carotid artery disease had 3 times the odd of having severe CAD (left main disease/triple vessel disease). However, this was not statistically significant (OR 2.75, P = 0.284). Conclusion: The high frequency of carotid artery disease in this study underscores the need for routine ultrasonic carotid assessment in candidates for CABG to ensure early detection and prompt management of carotid disease in a candidate of CABG which may prevent untoward peri-operative neurologic events

Coronary intervention in anomalous origin of the right coronary artery (ARCA) from the left sinus of valsalva (LSOV): A single center experience

Objective: To assess the technical challenges in percutaneous coronary intervention of Anomalous right coronary artery arising from the left sinus of valsalva. Methods: Between year 2008 and 2012, a total of 17 patients underwent PCI for an angiographically significant lesion in the right coronary artery of an anomalous origin in the LSOV. Their procedure details such as usage of catheters, radiation time, amount of contrast used were assessed. Results: A total of 17 patients with anomalous right coronary artery underwent PCI during the above mentioned period. 8 patients had type A origin, 3 had type B origin and the remaining 6 had type C origin. Type A origin RCA were successfully cannulated in 6 patients with Judkins left 5.0 and in 2 patients using Judkins left 4.0. Extra back up (EBU) 3.5 were doing well in 2 patients of Type B origin and the remaining one patient was successfully cannulated using Judkins left 4.0. In type C origin 4 patients had successful cannulation with Amplatz Left 1.0, 1 patient with Amplatz Left 2.0 and 1 patient with Judkins left 4.0. The mean fluoroscopic time was 20.7 min and amount of contrast used was 210 ml. Conclusion: PCI of anomalous RCA origin from LSOV requires appropriate guide catheter selection according to the anatomy of origin for successful cannulation and to reduce the contrast usage and radiation exposure

Outcome of primary PCI – An Indian tertiary care center experience

Objective: To assess the feasibility and outcomes of primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) in Indian Scenario. Methods: Between January 2005 and December 2012, consecutive STEMI patients who underwent PPCI within 12 h of onset of chest pain were prospectively enrolled in a PPCI registry. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital and 30 day major adverse cardiovascular events (MACE) [death, reinfarction, bleeding, urgent coronary artery bypass surgery (CABG) and stroke] were assessed. Results: A total of 672 patients underwent PPCI during this period. The mean age was 52 ± 13.4 years and 583 (86.7%) were males, 275 (40.9%) were hypertensives and 336 (50%) were diabetics. Thirty one (4.6%) patients had cardiogenic shock (CS). Anterior myocardial infarction was diagnosed in 398 (59.2%) patients. The median chest pain onset to hospital arrival time, door-to-balloon time and total ischemic times were 200 (10–720), 65 (20–300), and 275 (55–785) minutes respectively. In-hospital adverse events occurred in 54 (8.0%) patients [death 28 (4.2%), reinfarction 8 (1.2%), major bleeding 9 (1.3%), urgent CABG 4 (0.6%) and stroke 1 (0.14%)]. Nineteen patients with CS died (mortality rate – (61.3%)). At the end of 30 days, 64 (9.5%) patients had MACE [death 35 (5.2%), reinfarction 10 (2.1%), major bleeding 10 (1.5%), urgent CABG 4 (0.6%) and stroke 1 (0.1%)]. Conclusion: Our study has shown that PPCI is feasible with good outcomes in Indian scenario. Even though the recommended door-to-balloon time can be achieved, the total ischemic time remained long. CS in the setting of STEMI was associated with poor outcomes

Predictors of short-term outcomes in patients undergoing percutaneous coronary intervention in cardiogenic shock complicating STEMI—A tertiary care center experience

Background: Studying the outcomes in patients presenting with cardiogenic shock with ST-segment elevation myocardial infarction (CS-STEMI) and undergoing primary or rescue percutaneous coronary intervention (PCI) may give an insight to the unmet needs in STEMI-care in our region and may help in future recommendations in improving survival. Materials and methodolgy: During the period from January 2001- June 2017, there were 114 patients included in the study. The demographic, clinical and angiographic characteristics were compared between the survivors and non-survivors. All these variables were also compared between two-time frames (Phase 1- January 2001 to June 2007; Phase 2- July 2007 to June 2017). Results: Among patients undergoing PCI for STEMI, 7.5% were in cardiogenic shock. In-hospital mortality for the patients included in the study was 53.5%. Total ischemic time (OR = 0.99, 0.99–1; p = 0.02), left ventricular ejection fraction (LVEF) (OR = 0.90, 0.82–0.98; p = 0.02), need for cardio-pulmonary resuscitation (OR = 0.12, 0.24–0.66; p = 0.01), and post PCI TIMI flows (OR = 0.08, 0.02–0.29; p < 0.001) were the significant determinants of in-hospital mortality in the regression analysis. There was no significant change in mortality between the two phases of the study, though there was a reduction in total ischemic and door-to-balloon times, transfer admissions, use of thrombolytics, glycoprotein IIb/IIIa inhibitors, intra-aortic balloon pump, and mechanical ventilation in phase 2. Conclusion: Patients presenting in CS-STEMI and undergoing PCI continue to experience high mortality rates, despite improvements in total ischemic times. Further improvement in the systems-of-care are required to bring about reduction in mortality in this high-risk subset. Keywords: STEMI, Cardiogenic shock, Primary PCI, Mortality, TIMI flo