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Coronary intervention involving the region of bifurcation remains a challenging issue for the cardiologist as well as a complication. A number of factors including the angulation of side branch with the main branch determines the success. Though provisional strategy remains the best option in bifurcation intervention, at times a two-stent strategy cannot be avoided. We report a case in which percutaneous coronary intervention was performed on the left anterior descending artery (LAD) at its bifurcation with a major diagonal branch (> 2.5 mm). The ostium of the diagonal was diseased, and the branch took off from the LAD at an unfavorable angle (> 120°). We describe the use of the "shepherd's crook wire curve" approach, a modification of the reverse wire technique, which allowed us to successfully wire, dilate, and protect the diagonal and so named to reflect its resemblance to the shape of a shepherd's crook.

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Cardiac echinococcosis is a rare and severe manifestation of hydatid disease. It is caused by parasitic infestation by the Echinococcus species and can lead to life-threatening complications. Diagnosis is difficult due to nonspecific symptoms, but echocardiography is a highly sensitive diagnostic method. Albendazole treatment is effective in managing these cysts and can be an alternative to surgery. A patient with multiple cardiac hydatid cysts was successfully treated with albendazole, highlighting the importance of prompt diagnosis and treatment to prevent life-threatening complications.

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Stenosis in the anastomotic site or venous limb of an arteriovenous fistula (AVF) is the most frequent cause of AVF failure. Percutaneous angioplasty with a standard or high-pressure balloon is the first-line treatment for AVF stenosis due to its higher technical success rate (90%) and lower complication rate (4%). Almost 20% of stenosis cases are resistant or undilatable by regular-pressure balloon angioplasty due to fibrosis, leading to technical failure or restenosis. Alternative therapies, such as atherectomy devices or cutting balloons, are expensive and difficult to obtain in low-income developing countries. We successfully treated resistant AVF stenosis with a coronary OPN-NC® ultra-high-pressure balloon and produced a good angiographic result with technical success. Coronary hardware is easily available and relatively cheaper compared to dedicated peripheral balloons or devices in our country due to reuse, which can be a boon in such type of cases. According to the standard hospital protocol, Cathlab hardware was reused.

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Coronary artery anomalies are uncommon anatomical variations that are usually detected incidentally during a coronary angiogram or computed tomography angiography. We report a case of a diabetic and hypertensive middle-aged male who presented with chest discomfort. Coronary angiography revealed no signs of coronary artery disease but showed a left anterior descending artery (LAD) looping around the left ventricular apex and running through the posterior interventricular groove as a posterior descending artery (PDA) beyond the crux. The nondominant right coronary artery (RCA) and left circumflex artery (LCX) had no connection with the PDA. The patient's diabetic and hypertensive medications were adjusted, and he remained asymptomatic after 3 months. Interventionalists should be aware of the types of coronary anomalies that may complicate diagnosis and management during percutaneous coronary intervention.

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BACKGROUND: Although studies have proven that liver cirrhosis affects cardiac hemodynamics by means of circulatory overload, they present with definite cardiac functional alteration mostly with end-stage disease. There is limited data on relationship between progression of cirrhosis, cardiac mechanics and sub-clinical dysfunction. This study was done to assess ventricular myocardial mechanics using speckle tracking and deformation imaging among Child-Turcotte-Pugh (CTP) classification A and B cirrhosis. METHOD: Seventy patients with cirrhosis of Child-Pugh A/B class and sixty-two healthy subjects were prospectively evaluated by standard conventional echocardiography and deformation imaging with rotational echocardiography. Clinical stage of liver cirrhosis was assessed by model for end-stage liver disease (MELD) scores and CTP classification. RESULTS: Mean ages of patients with cirrhosis and controls were 55.64±14 years and 52.24±12 years, respectively. Though left ventricular (LV) dimensions (end diastolic dimension: 47.27±4.6 mm vs. 45.03±3.8 mm, p = 0.003; end systolic dimension: 30.33±4.9 mm vs. 28.40±2.91 mm, p = 0.006) and volumes (end diastolic volume: 82.08±22.53 mL vs. 68.18±15.75 mL, p = 0.001; end systolic volume: 28.60±8.42 mL vs. 22.18±7.48 mL, p = 0.001) were significantly higher in patients with cirrhosis, mean ejection fraction (EF) by Simpsons method was higher among controls (65.83±5.79% vs. 68.35±5.79%, p = 0.009). Left atrial volume was higher in cirrhosis group indicating presence of diastolic dysfunction (41.24±14.10 mL vs. 26.08±6.4 mL, p = 0.001). Global longitudinal strain as assessed by speckle tracking echocardiography did not show statistical significant difference between two groups (-22.35±4.08% vs. -21.80±2.54%, p = 0.348). Median value of torsion parameters in patients with cirrhosis did not differ compared to controls (torsion in degrees: 2.46 vs. 2.79, p = 0.268). CONCLUSION: Patients with Child-Pugh A and B stages of cirrhosis present with preserved longitudinal strain, normal torsion but with subtle diastolic dysfunction. Higher MELD score may correlate with increased longitudinal strain possibly due to hyperdynamic state.

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Background: Single coronary artery (SCA) is a rare anomaly with a prevalence of 0.024-0.066%. Some anomalies are merely benign anatomical variants, whereas some can result in myocardial ischemia or life-threatening arrhythmia. Case Presentation. We described seven cases in which all three major coronaries emerged from the right sinus of Valsalva via a single ostium and supplied the vast majority of the myocardium. A smaller branch arising from the left sinus supplied a modest quantity of myocardium in some of those few cases. These SCA variations do not exactly fit into any existing classification. It is unclear whether we need to modify previous classification systems or newer classification systems. Conclusions: SCA is divided based on its anomalous course and is usually a benign condition but it may present with cardiovascular complications. Clinicians should be aware of this entity along with the role of CT angiogram in its diagnosis and management.

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BACKGROUND: COVID-19 has spread rapidly across the world, producing significant morbidity and mortality. We investigated the cardiovascular complications and association of laboratory parameters with severity and mortality predictors in COVID-19 hospitalized patients. METHODS: Between May 2020 and June 2021, 730 COVID-19 patients were included in this retrospective observational study in the Coastal Karnataka region of South India. Acute coronary syndrome (ACS), myocarditis, arrhythmias, and all-cause mortality were reported as cardiovascular consequences. Neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), serum creatinine, D-dimer, troponin T, N-terminal pro-brain natriuretic peptide (NT-ProBNP), serum ferritin, and serum lactate dehydrogenase (LDH) were among the laboratory parameters measured. RESULTS: Most common electrocardiogram (ECG) changes were prolonged QTc interval (45.6%) followed by ST-T changes (40.7%) and sinus tachycardia (24.2%). 9.2% patients presented with ACS, with 38.8% having ST-elevation myocardial infarction (STEMI) and 61.2% having non-ST elevation myocardial infarction (NSTEMI). In non-survivors, NLR (p < 0.001) and PLR (p = 0.001) were significantly higher. Multivariable regression analysis showed that age (OR:1.019, 95% CI 1.003-1.034; p = 0.017), acute kidney injury (OR:3.562, 95% CI 1.737-7.301; p = 0.001), white blood cell count (WBC) (OR = 1.100, 95% CI 1.035-1.169; p = 0.002), platelet count (OR = 0.994, 95% CI 0.990-0.997; p = 0.001), PLR (OR = 1.002, 95% CI 1.000-1.004; p = 0.023) and severe COVID-19 (OR = 9.012, 95% CI 3.844-21.129; p = 0.001) were independent predictors of mortality in COVID-19 patients. CONCLUSIONS: Age, WBC count, neutrophil%, NLR, PLR, creatinine, D-dimer, ferritin, LDH, tachycardia, and lymphocytes% strongly correlated with the severity of the disease. Age, acute kidney injury, elevated WBC count, a greater PLR, low platelet count, and COVID-19 severity were independent predictors of mortality.

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A left ventricular (LV) thrombus is a relatively common and well-known condition associated with significant LV systolic dysfunction. However, LV thrombosis is unusual in the absence of kinetic abnormalities. The elderly gentleman presented with subacute onset of bilateral lower limb discomfort and cold extremities, but no gangrene. With normal LV function, an echocardiogram revealed a massive movable LV apical clot. He was treated with dual antiplatelets and heparin at first. He switched to dabigatran 110 mg twice a day in combination with dual antiplatelets. The thrombus had entirely vanished and leg problems had improved after a 2-week follow-up. For the next six months, he was treated with aspirin and dabigatran and was asymptomatic at follow-up. There are no specific guidelines for treating an intracardiac thrombus. Experts agree that a hypermobile and pedunculated LV thrombus with a high embolic risk should be surgically removed as soon as possible. According to ESC/ACC guidelines, all patients with LV thrombus associated with myocardial infarction should be treated with anticoagulation. Warfarin requires regular International Normalized Ratio (INR) monitoring and has a small therapeutic window; hence a direct oral anticoagulant (DOAC) could be a viable therapeutic solution. However, there are no guideline recommendations to date to guide DOAC therapy for this indication.

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OBJECTIVE: Diabetes mellitus (DM) is a risk factor for developing in-stent restenosis (ISR) following percutaneous coronary intervention (PCI). This study aimed to examine the presentation and outcomes of drug-eluting stent (DES) ISR in diabetics. METHODS: This retrospective study included consecutive patients with clinical DES-ISR, who were hospitalized between January 2013 and December 2017 and who were grouped based on the presence or absence of DM. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI), and repeat-target lesion revascularization] were compared. RESULTS: Baseline characteristics of the DM group (n=109) were comparable to the non-DM group (n=82), except for the higher prevalence of hypertension and dyslipidemia in the former (60.6% vs. 46.3%, p=0.050; 74.4% vs. 57.8%, p=0.034, respectively). Clinical presentation was similar in both groups [acute coronary syndrome (ACS): 62.4% vs. 61%, p=0.843; MI: 34.9% vs. 34.1%, p=0.918). Diabetics had a higher prevalence of stent-edge restenosis (20.3% vs. 9.2%, p=0.019). The treatment strategy was similar in both groups with 52.3% in the DM group and 57.3% in the non-DM group undergoing PCI (p=0.513). One-year outcomes of the DM group were not different from those of the non-DM group (14.7% vs. 17.1%, p=0.683). Age [hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.01-1.10; p=0.017], MI presentation (HR, 2.34; 95% CI, 1.14-4.80; p=0.020), and chronic kidney disease (CKD: HR, 2.82; 95% CI, 1.21-6.58; p=0.016) were predictors of poor outcomes. CONCLUSION: Stent-edge restenosis is more common in diabetics. Clinical presentation and 1-year outcomes following DES-ISR are similar in diabetics and non-diabetics. Age, MI presentation, CKD, and not DM were predictors of poor outcomes following DES-ISR.

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Lithium is a commonly used drug in psychiatric practice. It is used in the treatment of depression and bipolar disorder. It has a narrow therapeutic index with documented adverse effects even near therapeutic levels. It has myriad of manifestations at toxic levels. The cardiovascular effects range from relatively benign ST-T wave changes to fatal arrhythmias. We describe a case of lithium toxicity which presented as a junctional rhythm and later showed a variety of manifestations such as complete heart block, atrial fibrillation, sinus bradycardia, and finally reverted to sinus rhythm at par with serum lithium levels.

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In this era of an ever increasing number of interventions in cardiology, there is a parallel increase in the number of complications associated with these interventions, such as broken catheter tip and guide wire embolisation. The most commonly used and effective method for the percutaneous retrieval of such broken fragments is a goose neck snare. However in cases where this technique has been a failure, newer and novel innovations have been implemented for the retrieval of such broken fragments. We present a case of seven-year-old female child with a 3mm peri-membranous ventricular septal defect who was taken up for device closure. During the procedure the internal mammary catheter was broken in the left ventricle and subsequently the broken fragment was embolised to the left common carotid artery. The broken fragment was snared down upto the common iliac but could not be retrieved out of the sheath. A novel approach was used, consisting of negotiating a coronary guide wire across the broken catheter and inflating a balloon in the catheter fragment which helped to achieve a co-axial alignment with the arterial sheath and hence by which it was possible to retrieve the broken catheter fragment out of the circulatory system.

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Infective endocarditis by Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia is a common association and carries a high mortality. However, rising Minimum Inhibitory Concentrations (MICs) for vancomycin amongst MRSA strains is an emerging threat which carries poor prognosis and higher mortality. Here, we report a case of 41-year-old young non-addict gentleman presenting with fever of 3 days duration following recovery from an acute kidney injury necessitating haemodialysis. Systemic examination revealed signs of mitral regurgitation and left sided cerebellar signs. Laboratory investigations revealed anaemia, MRSA bacteraemia and transthoracic echocardiogram showed a mitral valve vegetation. He was diagnosed with MRSA mitral valve endocarditis with acute left cerebellar infarct. He was initially treated with intravenous vancomycin based on MIC at the dose of one gram every twelfth hourly. As the MRSA strain was shown to demonstrate a vancomycin creep phenomemon along with worsening clinical condition of the patient, treatment was changed to intravenous daptomycin at dose of 9mg/kg as per blood culture and sensitivity pattern which was administered for 6 weeks. Following initiation of daptomycin patient became afebrile and vegetations reduced in size and finally disappeared.

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Chronic Mesenteric Ischemia (CMI) presenting as acute abdomen can be treated percutaneously. An endovascular intervention has surpassed surgical revascularization over the past decade due to its lesser perioperative complication rate. Trans-femoral approach of revascularising is limited by its difficulty in coaxial alignment of the guiding catheter and hence, brachial artery and recently the radial approach have been utilized for mesenteric artery revascularisation for over a decade. Here by we report a case of chronic mesenteric ischemia having total occlusion of two and 70% occlusion of one of the three mesenteric vessels. The patient had presented with acute abdomen which in turn was percutaneously revascularised via the left brachial artery for the two major abdominal visceral vessels being superior mesenteric artery and inferior mesenteric artery.

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BACKGROUND: Atrial fibrillation (AF) is one of the most common arrhythmias accounting for significant mortality and morbidity, especially in elderly. Though oral anticoagulation (OAC) is an effective mode of prevention of stroke in patients of AF, bleeding complication remains a major concern. Because of these issues, a significant proportion of patients either does not receive or receive suboptimal doses of OAC. METHODS: In such patients, percutaneous left atrial appendage (LAA) closure remains an interesting option. Experience and literature of this procedure from India have been sparse. We report the first single center experience, from India, of percutaneous LAA closure with Amplatzer Cardiac Plug in 10 patients of non-valvular AF. These patients had contraindications for OAC or had high risk of bleeding or labile international normalized ratio (INR) on therapy. RESULTS: We successfully deployed the devices in all of the cases with no major complications perioperatively and on short-term follow-up. We also report a comprehensive review on the technique of percutaneous LAA closure using Amplatzer Cardiac Plug, including some novel modification with our experience of doing percutaneous mitral balloon valvuloplasty.

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A 41-year-old man presented with dyspnoea and giddiness on exertion for the last 1 month. A resting ECG during showed trifascicular block with complete right bundle branch block, left anterior fascicular block and a prolonged PR interval of >0.24 s. His echocardiography showed no evidence of wall motion abnormality. He was subjected to a treadmill test for exercise-induced ischaemia, which showed complete atrioventricular (AV) block during first stage of Bruce protocol. His symptoms of dyspnoea and giddiness were also reproduced. The test was terminated and ECG returned to trifascicular block, similar to that at his baseline ECG during recovery. Coronary angiogram (CAG) was performed to rule out any ischaemic cause for this exercise-induced AV block, which was normal. In view of his reproducible symptoms and demonstration of complete AV block on exercise, a dual-chamber pacemaker (DDD) was implanted. His symptoms disappeared and he remained asymptomatic on follow-up.

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