A heart set in stone: A case of extensive cardiac calcification

Massive endocardial calcification is a rare entity. We describe a rare disease endomyocardial fibrosis associated with massive calcification of the left ventricle suspected on a chest X-ray and confirmed by echocardiography and computed tomography in an 18-year-old female presenting with breathlessness and congestive heart failure

Inoue balloon atrial septostomy in severe persistent pulmonary hypertension following surgical ASD closure

SummaryBalloon atrial septostomy (BAS), which involves artificially creating a communication across the interatrial septum following trans-septal puncture and repetitive balloon dilatation, is known to be associated with therapeutic benefit in patients with severe pulmonary artery hypertension (PAH). Adult patients with large shunts and consequent severe PAH are not uncommon in the developing world, since they often seek medical attention late in the course of the disease. Often PAH in such cases is reversible with amelioration of symptoms after closure of the defect. We report a case of large atrial septal defect (ASD) with severe PAH who developed gross right heart failure following surgical closure of the ASD. A successful bail out BAS was performed using an Inoue balloon, avoiding the need for a redo surgery. The case highlights for the first time the use of Inoue balloon for performing a successful BAS

A challenging case of patent ductus arteriosus device closure in an adult with unconventional views and catheters

Abnormally oriented patent ductus arteriosus is expected in adults, which can lead to difficulties while attempting a device closure. Alternate angiographic views like the “right anterior oblique view,” “retrograde approach” and in rare cases, as elicited in the following case scenario, special catheters like the “Tiger® catheter” can aid in crossing the lesion and completion of the procedure successfully

Left main PCI: An observational analysis from large single-centre experience

Background: Although trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data. Objectives: To study long-term outcome after uLMPCI and identify predictors of adverse outcome. Methods: Case details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained. Results: Mean follow-up duration was 669.8 ± 404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p = 0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p = 0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p = 0.001]. Syntax score >32 was the only independent predictor of adverse outcome. Conclusion: uLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32

Pharmacodynamic evaluation of clopidogrel reloading vs. switching to prasugrel or ticagrelor in clopidogrel resistant Indian patients

Objectives: To compare the pharmacodynamic effects of clopidogrel reloading vs. switching to prasugrel or ticagrelor in high on treatment platelet reactivity (HTPR) patients undergoing percutaneous coronary intervention (PCI). Methods: Prospective, single-centre study wherein consecutive patients undergoing nonemergent PCI showing HTPR on 600 mg clopidogrel loading were randomized to either clopidogrel reloading (300 mg load, 75 mg OD) or prasugrel (60 mg load, 10 mg OD-in patients > 60 kg) or ticagrelor (180 mg load, 90 mg BD). HTPR is defined as maximum platelet aggregation (MPA) > 46% assessed by 5 μmol/L adenosine diphosphate light transmission aggregometry (ADP-LTA) assay after more than 6 h of clopidogrel loading. Platelet function were assessed at baseline, 6 h or more after clopidogrel loading, 2 h after reloading, day 1 and day 30 post-PCI. Results: 107 patients enrolled in the study, 32 (29.9%) were found to have HTPR. 10 (9.3%) patients were reloaded with clopidogrel, 10 (9.3%) with prasugrel and 12 (11.2%) with ticagrelor. Mean MPA in clopidogrel, prasugrel and ticagrelor reloaded patients was 42.6 ± 12.5%, 15.8 ± 8.6% and 14.6 ± 7.2% respectively at 2 h after reloading and was 43.7 ± 13.5%, 15.4 ± 5.6% and 12.6 ± 4.6% on day 1 post-PCI. The MPA significantly reduced in prasugrel and ticagrelor cases and not in clopidogrel, also prasugrel and ticagrelor had almost similar MPA after the reload. There was no patient with continued HTPR with ticagrelor or prasugrel while 50% (5/10) of clopidogrel reloaded patients had HTPR. The pharmacodynamic efficacy of maintenance with prasugrel or ticagrelor was better than clopidogrel (MPA at day 30 post-PCI; 15 ± 9.7%, 13.9 ± 5.1% and 50.4 ± 13.1% respectively). Conclusion: In patients undergoing PCI exhibiting HTPR after clopidogrel loading, ticagrelor or prasugrel reloading produced improved platelet inhibition which was better than clopidogrel reload and this effect was sustained during maintenance phase