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   Table of Contents - Current issue
Coverpage
October-December 2020
Volume 9 | Issue 4
Page Nos. 77-110

Online since Thursday, December 24, 2020

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ORIGINAL ARTICLES  

2D Speckel Tracking of RV Function after CABG and CPB Time p. 77
Mohammad Khani, Maryam Hamidzad, Fariba Bayat, Morteza Abdar Esfahani, Fatemeh Saffarian, Hooman Bakhshande, Seyed Mehdi Talebzade
DOI:10.4103/rcm.rcm_26_20  
Aim: To investigate the relation between the postoperative RV dysfunction and cardiopulmonary bypass time (CPB time) and aortic cross clamp time by comparing new echocardiographic parameter (2D speckel tracking). Methods and Results: We included 38 patients who underwent CABG between March 2019 and November 20019 in the Academic Medical Centre in Tehran. Before and one week after CABG, patients had TEE,71% were male. There was statistically significant decrease in RVGLS from (-19 to -11) after CABG. There w ere significant correlation between Pre op TAPES and FAC (P value=0.002), pre op FAC and Sv (P value=0.001), Pre op TAPES and GLS (P value=0.011) and Pre op Sv and GLS (P value=0.013) And there was significant correlation between post op TAPES and FAC (P value=0.045) and Post op Sv and GLS (P value=0.04), Conclusion: There is not significant correlation between decline in RV function parameter (TAPES, GLS, FAC, Sv) and cardiopulmonary bypass time and aortic cross clamp time.
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Acute Clinical and Procedural Outcome of Rajaie Cardiovascular Medical and Research Center Acute Coronary Syndrome Registry p. 83
Mohammad Javad Alemzade-Ansari, Feridoun Nouhi, Majid Maleki, Majid Kiavar, Hossein Ali Basiri, Ehsan Khalilipur, Mohammad Mehdi Peighambari, Ata Firouzi, Bahram Mohebbi, Parham Sadeghipour, Mohsen Madaani, Ali Zahedmehr, Farshad Shakerian, Reza Kiani, Zahra Hosseini, Alireza Rashidinejad, Hooman Bakhshandeh
DOI:10.4103/rcm.rcm_27_20  
Introduction: Most fatal presentation of coronary artery disease (CAD) has been related to acute coronary syndrome (ACS), and we as a referral center in the country decide to launch a registry of patients with ACS to monitor the way they are managed and the way they are treated. Materials and Methods: Rajaie Cardiovascular, Medical and Research Center ACS registry (RHC-ACS registry) launched on December 2015 with enrolling all ACS patients referred or presented to the center. All patients' demographic variables, presenting symptoms, known risk factors, past medical history, past CAD records, serial ischemic electrocardiogram (ECG) changes, presenting echocardiographic data (such as left ventricular ejection fraction [LVEF], valvular abnormality, and mechanical complication of myocardial infarction [MI]), laboratory assessment (biochemistry, complete blood count, cardiac markers, and inflammatory indicators), and their angiographic and angioplasty data were recorded. Results: Recordings showed in the RHC-ACS registry, most patients were men (73.2%), with mean age of 59.16 ± 11.64 years, hypertension were the most known cardiac risk factor. Most patients were non-ST elevation MI patients (43.2%), 32.8% were in premature CAD group, and typical retrosternal chest pain were complained in 83.5% of our registry population. Most patients had no new ECG changes (51.7%) and from whom with new ECG changes, anterior territory ECG changes were the most common pattern (28.2%). LVEF was reported 30% or less in 171 (16.6%) of patients. Angiographic findings revealed femoral access was most common access (63.9%), most involved vessel was left anterior descending with 49.3% of the patients, percutaneous coronary intervention was performed in 48% of patients with drug-eluting stent implantation in 99.3% of these patients, dissection was the most angiographic-related complication in our registry (1%), and in-hospital death was reported in six patients (0.5%). Conclusion: RHC-ACS registry as a real-world middle-east running ACS registry would help cardiologists justify their revascularization strategy in ACS patients and would have a promising impact in future multi-center studies.
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Clinical Characteristics, Angiographic Profile, and Hospital Outcomes of Acute Coronary Syndrome in Women Less than 55 Years of Age in a Tertiary Care Hospital of Northern Kerala p. 89
Ashraf S Manzil, PC Pramod
DOI:10.4103/rcm.rcm_36_20  
Background: Despite the fact that the incidence of cardiovascular disease is more pronounced in women, there is a lack of evidence-based studies that investigate the characteristics of acute coronary syndrome (ACS) in Indian women. Aim: The study aimed to assess the clinical characteristics, angiographic profile, and hospital outcomes of ACS in women <55 years of age in a tertiary care hospital of Northern Kerala. Materials and Methods: This was an observational study. In total, 179 women with <55 years of age, who had experienced the first episode of ACS were included in the study. Baseline characteristics including demography, risk factor, clinical presentation, and therapeutic management were reported. Results: Out of 179 female patients, 102 (57%) patients were postmenopausal. The most common risk factors of ACS in our population were found to be dyslipidemia (64.80%), followed by diabetes mellitus (58.10%) and hypertension (41.34%). The most frequent clinical presentation of ACS was non-ST-elevation myocardial infarction (STEMI) (49.16%), followed by STEMI (26.26%) and unstable angina (24.58%). Regarding the severity of disease, single-vessel disease (32%) was more common, followed by double-vessel disease (28%) and triple-vessel disease (24%). Left anterior descending artery (116 patients) was the most frequently involved artery in female patients, followed by right coronary artery (72 patients). Postprocedure complications associated with the study were as follows: hematoma (two patients), pseudoaneurysm (one patient), and takotsubo cardiomyopathy (one patient). Deaths were reported in two patients. Conclusions: The epidemiological trend of ACS, especially in the postmenopausal women, has been continuously rising in developing countries including India. Hence, more emphasis should be given on the identification of risk factors, clinical presentation, and diagnosis in this vulnerable group, which is ultimately beneficial for therapeutic management as well as reduces mortality and morbidity.
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Relevance of Cardiac Troponin in Predicting Postoperative Myocardial Infarction p. 94
Manish Pangi, Satish Govindaiah, Vivekananda Siddaiah, Jedidaiah Samraaj
DOI:10.4103/rcm.rcm_37_20  
Introduction: The aim of this study was to assess the validity of using early cardiac troponin (cTn) levels for the identification of postoperative myocardial infarction (MI) in patients undergoing off-pump coronary artery bypass (OPCAB) graft surgery, identify influencing factors, and determine optimal cut-off values for early identification. Materials and Methods: Patients undergoing OPCAB by a single surgical unit from January 2018 to January 2020 were included in this prospective study. Their preoperative and intraoperative characteristics were noted. The cTn was collected at 12 h and the in-hospital outcome was studied. Results: A total of 370 patients were included in the study. Eleven patients had MI determined by other criteria (2.9%), but 220 patients (60%) were identified using cTn consensus cut-off value, as per the universal definition of MI. This indicated significant mislabelling of coronary artery bypass graft-related MI and need for the recalculation to have a realistic cut-off value. The optimal cut-off levels at for identifying postoperative MI was found to be 1.8 ng/ml at 12 h, with a higher negative predictive value to exclude mislabeling. Using a cTn range, rather than a single cut-off value, would be more helpful. The factors causing significant mislabeled elevation of postoperative cTn were found to be preoperative high levels and intraoperative findings of iatrogenic hematoma secondary to suction stabilizer, surgical maneuvers for intramyocardial target vessels. Conclusion: The cTn levels were affected by the various patient and operative factors and measurements using higher cut-offs were needed to rule out MI. Certain factors peculiar to OPCAB were found to be significantly responsible. It will help identify patients needing earlier invasive re-intervention or focused intensive care.
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CASE REPORTS Top

Left Subclavian Arterial Thrombosis Presenting as Acute Limb Ischemia in a Coronavirus Disease 2019 Patient – An Extreme Rarity p. 100
Akshay Ashok Bafna, Meenakshi Gajbiye, Kishore Deore, Swenil Shah, Varun Bafna
DOI:10.4103/rcm.rcm_24_20  
The peak of the coronavirus disease 2019 (COVID-19) crisis has exposed a substantial number of patients presenting with manifestations of venous and arterial thrombosis. Here, described is an extremely rare case of subclavian arterial thrombosis in a COVID-19 patient. Moreover, the patient presented with normal D-dimer, antinuclear antibody, fibrinogen, and serum ferritin levels, prothrombin time and platelet count. To the best of our knowledge, this is the first such case reported till date.
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A Case Report of the Shone Syndrome in Association with Coronary Abnormality p. 103
Shahin Rahimi, Ata Firouzi, Iman Harirforoosh, Mohammad Esmaeel Zangenehfar, Zahra Khajali
DOI:10.4103/rcm.rcm_33_20  
Shone syndrome or complex is defined by sequential left-sided heart stenosis, including supravalvular mitral membrane, valvular mitral stenosis (MS) by a parachute mitral valve, subaortic stenosis, and aortic coarctation. It is a rare entity which occurs most frequently in its incomplete form, a 31-year-old man who referred to our adult congenital clinic with a chief complaint of recent chest discomfort. He had a history of hypertension since last year. Echocardiography revealed congenital severe MS (parachute-like mitral valve), two papillary muscles with decreased space between them and underdeveloped lateral papillary muscle. Other findings of echocardiography were bicuspid aortic valve (fusion of the right coronary cusp [RCC] and left coronary cusp) with moderate-to-severe aortic stenosis (AS) and moderate eccentric aortic insufficiency. Deformed aortic arch (gothic arch) and aortic coarctation were also reported in transthoracic echocardiography. We also found an abnormal vessel like density in 5-chamber view that suggested bleb sign and retroaortic course of the left circumflex (LCX). The patient was scheduled for coronary angiography and intervention for coarctation of the aorta, which revealed an abnormally originated LCX from RCC, significant coarctation of the aorta, and significant AS. Aortic coarctoplasty with CP STENT 8 × 39 mounted on balloon Altosa-XL-Gemini 26 × 40 was done in this session. Shone complex is a rare anomaly that may need multiple procedures for correction. Echocardiography is a specially important modality in these patients for diagnosis and evaluation of severity. By this modality, even we can diagnose some coronary artery origin abnormality.
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Triple-Vessel Coronary Artery Disease Associated with Familial Hyperhomocysteinemia p. 107
Suvir Singh, Bishav Mohan
DOI:10.4103/rcm.rcm_34_20  
Homocysteine is a sulfhydryl containing amino acid implicated in the pathogenesis of cardiovascular disease in multiple epidemiologic studies. However, elevated homocysteine in isolation is not known to lead to severe coronary artery disease requiring emergency intervention. We report a previously asymptomatic 55-year-old gentleman who presented with an acute myocardial infarction with bradycardia and was found to have triple-vessel coronary artery disease on angiography. After stabilization, he underwent a coronary artery bypass grafting in view of the severity of disease. A thorough evaluation revealed the absence of all traditional risk factors except elevated serum homocysteine. The evaluation of family members also revealed elevated homocysteine levels in both his sons and wife. Mutation testing of the methylenetetrahydrofolate reductase (MTHFR) gene showed homozygous Q429A mutation in the patient and heterozygous A222V and Q429A mutation in both his sons. The patient was discharged successfully and is well after 9 months of follow-up. Homocysteine has been implicated in the pathogenesis of cardiovascular disease in synergy with other traditional risk factors. This is a rare presentation of familial hyperhomocysteinemia presenting with severe coronary artery disease and elevated homocysteine levels in all family members. Elevated homocysteine levels in isolation may lead to significant cardiovascular disease and should be checked if no other risk factors are present. It may be useful to screen the patient and family members for underlying MTHFR mutations. In the absence of prospective evidence, there appears to be little harm in providing multivitamins to attempt to reduce homocysteine levels.
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