Gelatin sponge mimicking left atrial clot in rheumatic mitral stenosis

SummaryWe report the case of a 23-year-old female who underwent balloon mitral valvotomy for severe symptomatic mitral stenosis. Following septal puncture, the patient developed cardiac tamponade, which warranted sternotomy to suture the rent in the inferior vena cava–right atrial junction. The postoperative echocardiogram revealed nonhomogenous irregular opacities within the left atrium suggesting the possibility of thrombus formation. As the patient was in sinus rhythm and peri-procedural activated clotting time was in therapeutic range, clot formation was unlikely. A review of operative notes revealed placement of absorbable hemostatic gelatin sponge within the pericardium, which was mimicking left atrial clot. This potential pitfall has to be recognized in echocardiograms, as it will avoid inappropriate anticoagulant therapy

Myocardial FFR (Fractional Flow Reserve) in patients with angiographically intermediate coronary artery stenosis - an initial institutional experience

Background: The clinical significance of coronary artery stenosis of intermediate severity can be difficult to determine. The management of intermediate coronary lesions, defined by a diameter stenosis of ≥40% to ≤70%, continues to be a therapeutic dilemma for cardiologists. The 2-dimensional representation of the arterial lesion provided by angiography is limited in distinguishing intermediate lesions that require stenting from those that simply need appropriate medical therapy. In the era of drug-eluting stents, some might propose that stenting all intermediate coronary lesions is an appropriate solution. However, the possibility of procedural complications such as coronary dissection, no reflow phenomenon, in-stent restenosis, and stent thrombosis requires accurate stratification of patients with intermediate coronary lesions to appropriate therapy. Myocardial fractional flow reserve (FFR) is an index of the functional severity of coronary stenosis that is calculated from pressure measurements made during coronary angiography. The objective of the study is to evaluate the usefulness of FFR in patients with angiographically intermediate coronary artery stenosis.Methods: 20 patients with intermediate coronary stenosis and chest pain of uncertain origin. The Exercise Electrocardiography (TMT), Myocardial Perfusion Imaging study (MPI), Quantitative Coronary Angiography (QCA) were compared with the results of FFR measurements.Results: 20 patients were undergone FFR measurement during the study period. With the mean age of 57.25±11.2 and male patients were 16 (80%), female patients 4 (20%), in all 13 patients with an FFR of 0.75 tested negative for reversible myocardial ischemia on TMT and MPI study. No revascularization procedures were performed in 7 (35%) patients, and no adverse cardiovascular events were noted in all these patients during 6 months of follow-up.Conclusions: In patients with coronary stenosis of intermediate severity, FFR appears to be a useful index of the functional severity of the stenosis and the need for coronary revascularization.

Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial

Aims The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether aliskiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post-discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM). Methods and results ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P = 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64-0.99; DM: HR: 1.16, 95% CI: 0.91-1.47; P = 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50-0.94; DM: HR: 1.64, 95% CI: 1.15-2.33; P < 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldosterone relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71-1.93; DM: HR: 2.39, 95% CI: 1.30-4.42; P = 0.07 for interaction). Conclusion This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without D

Xanthoma tuberosum in homozygous familial hypercholesterolemia

Familial homozygous hypercholesterolemia is one of the high risk factors that can result in premature coronary arterial disease leading to severe morbidity and premature death in children and young adults. We describe a rare example of extensive xanthoma tuberosum in a case of familial homozygous hypercholesterolemia

Holt-oram syndrome associated with double outlet right ventricle: A rare association

Holt-Oram syndrome is a rare inherited disorder that causes abnormalities of the hands, arms, and the heart. Most commonly, there are defects in the carpal bones of the wrist and in the bones of the thumb along with cardiac defects such as atrial or ventricular septal defects. We report a case of Holt-Oram syndrome with a rare association of double outlet right ventricle