Open Access Case Report

Intraoperative Hypertensive Crisis in a Patient with Normotensive Primary Aldosteronism. Lessons from a Clinical Case

Agnieszka Kuzior, Manuel Esteban Nivelo-Rivadeneira, Paula Fernandez-Trujillo-Comenge, Esperanza Perdomo-Herrera, Alba Lucia Tocino-Hernandez, Marta Martin-Perez, Paula Gonzalez-Diaz, Maria Victoria Sainz de Aja-Curbelo, Ana Delia Santana-Suarez, Francisco Javier Martinez-Martin

Cardiology and Angiology: An International Journal, Page 1-7
DOI: 10.9734/ca/2019/v8i430107

Primary hyperaldosteronism is the most frequent cause of secondary hypertension. However, it can also be found in apparently normotensive patients, often associated with recurrent hypokalemia and isolated hypertensive episodes.

We hereby present the case of a normotensive 50-year-old female patient with a surgical left kidney mass; however, after anaesthetic induction, surgery was aborted due to a severe hypertensive crisis. She was referred to our Hypertension Outpatient Clinic to rule out pheochromocytoma/ paraganglioma. The anamnesis revealed unexplained episodes of hypokalemia. Ambulatory blood pressure monitoring showed normal mean values of blood pressure and heart rate, with an isolated hypertensive peak. Plasma glucose, ions, creatinine, lipids, metanephrines and chromogranin A were normal, but plasma aldosterone was clearly elevated with suppressed plasma renin activity and high aldosterone/renin activity ratio. Primary aldosteronism was confirmed by the captopril test. Abdominal CT was compatible with left adrenal hyperplasia. Treatment with low-dose spironolactone was well tolerated and resulted in normal blood pressure, normokalemia and unsuppressed plasma renin activity. The patient underwent successful laparoscopic removal of a renal oncocytoma. 

We conclude that normotensive primary aldosteronism is not harmless; it can be associated with severe hypokalemia, anxiety, depression, hypertensive crisis and cardiovascular damage. Patients can also develop resistant hypertension. Adequate treatment can decisively improve the survival and quality of life of the patients with primary aldosteronism, but a correct diagnosis is needed first. Therefore, it must be considered as a diagnostic possibility in normotensive patients with unexplained hypokalemia or isolated hypertensive episodes.

Open Access Case Report

A Rare Case of Left Ventricular Outflow Tract Obstruction 18 Years after a Mechanical Mitral Valve Replacement

Fathia Mghaieth Zghal, Selim Boudiche, Abdeljelil Farhati, Ali Bonkano, Manel Ben Halima, Bassem Rekik, Sana Ouali, Mohamed Sami Mourali

Cardiology and Angiology: An International Journal, Page 1-7
DOI: 10.9734/ca/2019/v8i430110

Background: Left ventricular outflow tract (LVOT) obstruction is a serious complication that can occur after various mitral-valves, surgical or percutaneous, interventions.

It was rarely described in mechanical mitral valve replacements.

Aim: to describe a rare case of late LVOT obstruction after a mitral valve replacement by a low-profile mechanical prosthesis.

Case Presentation: A 48-year woman, with a history of rheumatic mitral valve disease and mechanical mitral replacement by a hemi-disc valve 18 years ago, presented for a recent dyspnea. Echocardiography showed a narrowing of the LVOT, with anterior position of the mitral prosthesis, aorto-mitral annular angulation, septal thickening and remnant native sub-valvular tissue attached to the septum in the LVOT region. This resulted in LVOT obstruction with a peak gradient of 75 mmHg. The heart team opted for a redo surgery, but the surgical decision was refused by the patient.

Discussion: This is a rare case of late LVOT obstruction after mitral valve replacement by mechanical low-profile prosthesis. Preserved native mitral valve tissue, which is the main described cause of LVOT obstruction after mechanical mitral valve replacements was not the unique cause of obstruction in this patient who had also a septal thickening and anterior prosthetic position. Aorto-mitral annular angulation that was identified as a risk factor of LVOT obstruction after trans-catheter mitral valve replacements, should be, probably, also took into account and assessed pre-operatively in patients undergoing surgical mitral replacements.

Conclusion: LVOT obstruction can occur after mechanical mitral replacements event with low profile prosthesis. In patients with identified risk factors of LVOT obstruction, preservation mitral anterior leaflet should be avoided, and preservation of other native mitral tissue should be discussed.

Open Access Case Report

Successful Percutaneous Balloon Dilatation of Membranous Sub-aortic Stenosis in a 22 Year Old Pregnant Patient

Gurkirat Singh, Mahesh Bodkhe, Akshat Jain, Aditya Gupta, Arun Bade, Narender Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-9
DOI: 10.9734/ca/2019/v8i430112

Congenital obstruction of the left ventricular outflow tract comprises a heterogeneous group of disorders, with obstruction potentially occurring below, above, or at the level of the aortic valve. Subvalvular stenosis is the second most common type of left ventricular outflow tract obstruction, of which discrete membranous type is the most common. Although surgical resection of the subaortic membrane is the treatment of choice in discrete membranous subaortic stenosis, in selected patients with isolated membranous subaortic stenosis, without significant aortic insufficiency, percutaneous balloon tearing of the membrane results in reduction in the degree of left ventricular outflow tract obstruction and symptomatic relief. We report a case of 22 year old pregnant patient admitted with NYHA class III breathlessness, found to have discrete membranous subaortic stenosis. Balloon aortic valvuloplasty was performed in the patient with good result. Patient underwent normal vaginal delivery at 38 weeks. Both mother and newborn were asymptomatic. Patient is asymptomatic on subsequent follow-ups.

Open Access Case Report

Successful Primary PCI in a Patient with Acute Myocardial Infarction and Cardiogenic Shock with Super-dominant Right Coronary Artery and Absent Left Circumflex Artery

Gurkirat Singh, Mahesh Bodkhe, Akshat Jain, Aditya Gupta, Narender Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-5
DOI: 10.9734/ca/2019/v8i430114

Super-dominant right coronary artery and the absent left circumflex artery is a rare congenital coronary anomaly, with only a few cases reported in the literature. Left anterior descending artery arises directly from the left anterior coronary cusp. Rare coronary anomalies are sometimes encountered during primary percutaneous interventions, which may lead to changes in the course of action. We report a case of a 38-year-old patient admitted with acute anterior wall myocardial infarction and cardiogenic shock. Coronary angiography revealed super-dominant right coronary artery and absent left circumflex artery. There was thrombotic occlusion of the proximal left anterior descending artery. The patient underwent successful primary percutaneous intervention of the left anterior descending artery with a good result, was discharged after 5 days. Our case also shows the importance of taking coronary angiogram of the contralateral artery first, before taking the shoot of the infarct-related artery.

Open Access Case Report

Serial Electrocardiographic Changes in a Young Female with Acute Myocarditis

Gurkirat Singh, Mahesh Bodkhe, Akshat Jain, Narender Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-7
DOI: 10.9734/ca/2019/v8i430117

Electrocardiographic changes in myocarditis mimic a wide range of ECG diagnoses ranging from ST-elevation myocardial infarction to complete heart block. We report a case of acute myocarditis in a young female with a wide range of ECG changes that mimic ST-elevation myocardial infarction and atrioventricular block.

Open Access Case Report

Ruptured Sinus of Valsalva Aneurysm Presenting as Complete Heart Block - A Rare Presentation

Gurkirat Singh, Mahesh Bodkhe, Aditya Gupta, Narender Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-5
DOI: 10.9734/ca/2019/v8i430118

The dissection of the sinus of Valsalva aneurysm into the interventricular septum leading to complete heart block is a rare complication with only few cases reported in the literature. We report a case of young farm laborer, who presented with multiple episodes of syncope. Upon clinical evaluation, we found third-degree atrioventricular block due the rupture of right sinus of Valsalva into the interventricular septum.

Open Access Case Study

Unmasking Brugada Syndrome with Oral Flecainide Provocation. A Case Series of Three Patients

R. Singla, A. Udyavar, A. Gupta, A. Bade, K. Munde, N. O. Bansal

Cardiology and Angiology: An International Journal, Page 1-6
DOI: 10.9734/ca/2019/v8i430108

The present case series discuss three patients who had brugada type 2/ type 3 like ECG pattern that was converted to type 1 pattern with oral flecanide challenge test. Brugada syndrome is associated with a high incidence of sudden cardiac death,   typical ECG pattern being ST-segment elevation in the right precordial leads with T wave inversion. Pharmacological provocation should only be performed when the baseline ECG is not diagnostic of Brugada Syndrome. PR prolongation in the baseline ECG is also a contraindication because of the risk of inducing AV block. Drug challenge is performed under strict monitoring of BP and 12-lead ECG and facilities for cardio version and resuscitation are available. Atypical RBBB pattern/type 2/3 Brugada pattern on ECG in patients of syncope or family history of sudden cardiac arrest is commonly encountered by a cardiologist. This can be performed to provoke type 1 brugada pattern on ECG. Diagnosed cases of Brugada may be treated with ICD with proper indication if needed and thus prevent sudden cardiac death.

Open Access Case Study

Percutaneous Balloon Mitral Valvotomy and Percutaneous Coronary Intervention of Left Anterior Descending Artery in Combined Procedure

Akshat Jain, Gurkirat Singh, Aditya Gupta, Vishal Patil, Narendra Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-7
DOI: 10.9734/ca/2019/v8i430111

In countries like India rheumatic heart disease (RHD) is still a common problem, and with improvements in diagnosis and treatment, the lifespan of these patients is increased. With increase in the lifespan, these patients may develop coronary artery disease (CAD) and present as acute coronary syndrome (ACS). In some cases especially RHD with severe mitral stenosis (MS), thrombus that develop in left atrium may embolize in one of the coronary arteries, leading to acute coronary syndrome. We report a case of 51 year old female who was a known case of rheumatic heart disease and now presented with acute coronary syndrome. Patient was hemodynamically unstable and underwent percutaneous balloon mitral valvotomy (PBMV) and percutaneous coronary intervention (PCI) simultaneously. We here discuss the possible complications that need to be addressed in such scenario and how can we approach such cases. This is first of such intervention at our institute and also there are very few such records available online. Patient tolerated the procedure well with significant clinical improvement.

Open Access Case Study

Complete Heart Block Due to Coronary Air Embolism during Trans-catheter Closure of Atrial Septal Defect

Mahesh Bodkhe, Shakil Shaikh, Nagesh Waghmare, Vikas Mishra, Anil Kumar, Narendra Bansal

Cardiology and Angiology: An International Journal, Page 1-5
DOI: 10.9734/ca/2019/v8i430113

Coronary air embolism is a dreadful complication of cardiac intervention despite careful prevention. In literature reported complications of coronary air embolism ranges from clinically non significant events to cardiogenic shock, myocardial infarction and death. We report a case of massive coronary air embolism in right coronary artery, which results in hypotension and complete heart block in a 33 -year-old female undergoing elective closure of atrial septal defect (ASD) by percutaneous transcatheter intervention. The patient stabilized after timely measures like oxygen support, dopamine infusion, cardiac compression and repeated bolus injection of heparinized saline. She then underwent successful percutaneous ASD device closure.

Open Access Case Study

Successful Percutaneous Retrieval of Embolised Septal Occluder Device and Device Closure of Atrial Septal Defect in Combined Procedure

Gurkirat Singh, Mahesh Bodkhe, Akshat Jain, Narender Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-9
DOI: 10.9734/ca/2019/v8i430115

Transcatheter device closure is the treatment of choice in patients with secundum atrial septal defects with adequate rims. It is technically safe, feasible and has the obvious advantage of being a nonsurgical technique. Patient is free from the scar especially young, unmarried females. It is not free of complications. Device embolization and arrhythmias are the major complications. Embolised device can cause hemodynamic compromise by obstructing the blood flow if it gets embolised in pulmonary artery. We report a case of 24 year old female, taken for device closure of atrial septal defect. Device gets embolised in pulmonary artery causing hemodynamic compromise by causing obstruction to blood flow. This embolised device was successfully retrieved percutaneously. The atrial septal defect was closed with one size larger device, in the same sitting. Patient is asymptomatic and is free from any scar.

Open Access Case Study

Successful Percutaneous Device Closure of Ventricular Septal Rupture in a Patient with Acute Anterior Wall Myocardial Infarction and Cardiogenic Shock

Gurkirat Singh, Mahesh Bodkhe, Akshat Jain, Narender Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-5
DOI: 10.9734/ca/2019/v8i430119

Post-infarction ventricular septal rupture (VSR) is a rare but lethal mechanical complication of acute myocardial infarction. The incidence of VSR has decreased from 1-3% following ST-segment elevation myocardial infarction in the pre-reperfusion era to 0.17-0.31% following primary percutaneous coronary intervention. Survival to 1 month without intervention is 6%. We report a case of a 60-year-old male, admitted in a peripheral hospital with acute anterior wall myocardial Infarction. He was thrombolized with streptokinase. He developed breathlessness at rest and shifted to our hospital for further management. On evaluation in intensive care unit found to have VSR. The patient was in cardiogenic shock. The ventricular septal rupture was successfully closed with a septal occluder device. After which the patient stabilized hemodynamically and was discharged after 8 days.

Open Access Case Study

Stent Crushing as a Novel Therapeutic Option In-Stent Entrapment

Aniruddha Kaushik, Rahul Singla, Arun Bade, Kalyan Munde, Shakil Shaikh, N. O. Bansal

Cardiology and Angiology: An International Journal, Page 1-6
DOI: 10.9734/ca/2019/v8i430121

Stent Entrapment is a rare complication of Percutaneous Coronary Intervention if left in situ may cause intracoronary or systemic embolization, thrombus formation, emergent coronary artery bypass graft surgery, or death. We here present a case of 2 unexpanded Drug eluting stent entrapment during the procedure leading to hemodynamic instability and Its treatment using stent crushing as a life-saving procedure.

Open Access Case Study

Successful Transcatheter PDA Device Closure in an Adult with Retrograde Wiring and Antegrade Snaring Approach

Aditya Gupta, Gurkirat Singh, Vishal Patil, Rahul Singla, Akshat Jain, Narendra Omprakash Bansal

Cardiology and Angiology: An International Journal, Page 1-5
DOI: 10.9734/ca/2019/v8i430122

Patent ductus arteriosus accounts for 5 – 10% of all congenital heart disease in children.  Currently, transcatheter closure is standard of care. Device closure in PDA is usually done by an antegrade technique where PDA is crossed from the PA side. In some patients, this universal procedure may not be successful due to anatomical differences. In such patients, the retrograde technique with retrograde wiring and antegrade snaring approach followed by PDA device closure may be used successfully to close PDA. We report such a case of difficult PDA device closure where the antegrade technique was not successful and PDA device closure was completed by retrograde approach.

Open Access Minireview Article

Nursing Diagnostics in the Chagas Cardiomyopathy Carrier: Integrative Literature Review

Daniele Melo Sardinha, Ana Gracinda Ignácio Da Silva, Dayara De Nazaré Rosa De Carvalho, Vviane Ferraz Ferreira De Aguiar, Alziney Simor

Cardiology and Angiology: An International Journal, Page 1-7
DOI: 10.9734/ca/2019/v8i430116

Chagas' cardiomyopathy is a complication of Chagas' disease that presents in the cardiac form, which involves the manifestation of a clinical picture of dilated cardiomyopathy, with global left ventricular dysfunction and heart failure syndrome. In this context, the aim is to describe the Nursing Diagnosis evidenced in the literature in patients with Chagasic Cardiomyopathy. This is a descriptive and exploratory study of the Integrative Literature Review (ILR), with a qualitative approach. We searched the LILACS and PubMed databases for articles published without time limit, in Portuguese, English, and Spanish, with the descriptors: Chagasic Cardiomyopathy; Nursing Diagnosis; Nursing Care. Data were analyzed by tabulation. Three articles were sought for the sample. The following Nursing diagnoses were highlighted: Decreased Cardiac Output; Intolerance to Activity; Poor Knowledge; Sleep and Rest impaired; Anxiety; Excessive fluid volume; Risk of impaired skin integrity; and Comfort impaired. It is concluded that the diagnoses are directly related to heart failure caused by ventricular damage, and that interventions are essential for the improvement in the quality of life of patients. It is also noteworthy that the applicability of the Systematization of Nursing Care in these patients only improves the quality of service and has repercussions on patient safety, being also a way to promote the health of patients.

Open Access Original Research Article

Risk Factors of Cardiovascular Disease among Ghanaian Police Officers

Miriam Essien, Herman Erick Lutterodt, Reginald Adjetey Annan

Cardiology and Angiology: An International Journal, Page 1-9
DOI: 10.9734/ca/2019/v8i430109

Background: Cardiovascular diseases continue to be a global public health burden among occupational groups like Police officers. Police officers play important roles to ensure law and order in countries. However, the nature of police work exposes them to violence and stress. Again, irregular food habits, irregular exercise, inadequate sleep, smoking and drinking are lifestyles which makes police officers prone to high incidence of cardiovascular disease (CVD).

Aim: This study looked at the prevalence of CVD risk factors among police officers in Kumasi, Ghana.

Study Design: Cross- sectional.

Place and Duration of study: Ashanti Regional Police Headquarters, Kumasi, Ghana, between September, 2017 to July, 2018.

Methodology: Weight, height, Body Mass Index (BMI), waist circumference, lipid profile, systolic and diastolic blood pressure of 120 officers were measured. Additionally, lifestyle and dietary factors such as exercise and intake of fruits of Police officers were assessed. Data were analyzed by SPSS version 22.0.

Results: Slightly more than half (63, 52.5%) of the officers were females and the remaining (57,47.5%) were males. The mean of the various CVD risk factors among the total study participants are as follows; BMI 28.184±4.461 kg/m2, waist circumference 92.702±10.941 cm, systolic blood pressure (SBP) 128.121±17.047 mmHg, diastolic blood pressure (DBP) 85.569±10.854 mmHg, fasting blood sugar 5.387±1.756 mmol/l, high density lipoprotein (HDL) 1.546±0.211 mmol/l, low density lipoprotein 2.321±0.706 mmol/l (LDL) and total cholesterol (TC) 4.362±0.906 mmol/L.  Prevalence of obesity among male and female officers were 43.9% and 36.5% respectively. With regards to hypertension, policemen and women recorded 31.6% and 20.6% respectively and dyslipidemia among males and females were 43.9% and 85.7% respectively.

Conclusion: The officers were generally overweight, with over a quarter having hypertension and about two-thirds having dyslipidemia, making their risk for CVDs high. Further studies to elucidate the causes are required, routine medical screening and nutritional support are recommended.

Open Access Original Research Article

Thrombus Aspiration Plus Intracoronary Abciximab vs Intracoronary Abciximab Alone in Patients with STEMI Undergoing Primary PCI

Prem Krishna Anandan, K. Tamilarasu, G. Rajendran, Shanmuga Sundaram, P. Ramasamy, R. B. Vidyakar

Cardiology and Angiology: An International Journal, Page 1-10
DOI: 10.9734/ca/2019/v8i430120

Background: Thrombus embolization during the Percutaneous Coronary Intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) is common and results in suboptimal myocardial perfusion and increased infarct size. Two strategies proposed to reduce distal embolization and improve outcomes after primary PCI is bolus intracoronary Abciximab and manual aspiration thrombectomy. There are several factors which influence the decision of primary PCI in a patient with AMI in developing countries. Cost of therapy and affordability is probably the most important factor. The additional cost for thrombus aspiration needs to be considered against the additional advantages in terms of better clinical outcome. 

Objectives: To compare the use of a combination of intracoronary Abciximab with manual thrombus aspiration to intracoronary Abciximab alone, in patients with STEMI undergoing primary PCI.

Patients and Methods:  This is a prospective observational study of patients with STEMI who underwent primary PCI between June 2018 to May 2019. A pre-approved study protocol was designed to determine the eligibility of STEMI patients to be included in the study. Patients with The patients have analysed in two groups: 84 patients received a combination of intracoronary Abciximab with manual thrombus aspiration  &  80 patients received intracoronary Abciximab alone. 

The primary endpoint was the assessment of myocardial perfusion parameters namely Myocardial Blush Grade (MBG) in the culprit vessel & ST-segment resolution of >70% on ECG at 90 min after PCI. Secondary endpoints were the improvement in LV ejection fraction, cardiovascular mortality & recurrent MI at one-month post-procedure.

Results: Result of the 84 patients who received combination of intracoronary Abciximab with manual thrombus aspiration, the primary endpoints namely the myocardial blush grade (MBG) of 2/3 was achieved in 72 patients (90.74%) & ST-segment resolution of >70% at 90 min was seen in 66 patients (78.57%) (p<0.001). Of the 80 patients who received only intracoronary Abciximab without thrombus aspiration, MBG 2/3 was achieved in 38 patients (47.5%) & ST-segment resolution of >70% at 90 min was seen in 28 patients (35%). At one month of follow up the secondary endpoints namely the LVEF in the combination group improved from 43.42±3.73 to 47.88±4.16% (p=0.12)and in the Abciximab group improved from 44.78±3.34 to 46.20±3.63%. Recurrent MI was seen in one patient in the combination group (p<0.001) & two patients in the ic Abciximab group. There was no cardiovascular mortality noted in the present study (p<0.001).

Conclusion: Intracoronary Abciximab + manual thrombus aspiration reduces thrombus burden with better results in microvascular perfusion assessed by ST-segment resolution of >70% at 90 min & higher Myocardial Blush Grade compared to intracoronary Abciximab alone in patients with STEMI undergoing primary PCI.