This article describes our initial clinical experience with time-resolved MR angiography (MRA) of the legs using the time-resolved imaging with stochastic trajectories (TWIST) technique with a half dose of gadolinium.
MATERIALS AND METHODS
Thirty-four patients underwent a TWIST examination of the legs at 3 T. Thirty-three patients also underwent a bolus-chase MRA examination in the same setting. Times elapsed between the start of contrast injection and the appearance of contrast material (tA) and peak enhancement of the arteries in the legs (tB) were analyzed. The number of patients with examinations affected by venous contamination was determined. The differences in tA and tB between cases in which venous contamination was present or absent were evaluated using a two-tailed Student t test.
The TWIST technique using a half dose of gadolinium provided diagnostic-quality images of all patients. The mean tA was 35.5 ± 8.8 (SD) seconds (range, 17.8–60.4 seconds), and the mean tB was 59.1 ± 15.1 seconds (range, 31–98.8 seconds). Venous contamination was observed in bolus-chase MRA images of 52.9% of patients. The relationship between venous contamination and tA was not statistically significant (p = 0.13). The incidence of venous contamination was higher in patients with lower values of tB (p = 0.01).
The described low-dose clinical experience with TWIST and the contrast dynamics information gained from this study could aid radiologists in planning protocols for leg MRA examinations.
contrast dynamics; leg MR angiography; lower extremity; time-resolved MRA; TWIST
Isolated unilateral absence of a proximal pulmonary main artery is a rare congenital lesion which is often associated with other cardiovascular abnormalities and a diverse clinical presentation. It is usually diagnosed in childhood. Patients who survive into adulthood is uncommon. We report a case of 46 year old hypertensive and obese female who presented with progressive dyspnea. She had features of pulmonary hypertension. The diagnosis was confirmed by CT pulmonary angiography which showed absence of right pulmonary artery and conventional pulmonary angiography which showed ipsilateral lung receiving collaterals from Right coronary artery and its branches. The purpose of this report is to highlight the fact that UAPA, although a rare entity, should be kept in mind in patients with unexplained PAH and prolonged respiratory symptoms unresponsive to routine treatment modalities.
Unilateral absence of pulmonary artery (UAPA); Pulmonary artery hypertension (PAH); Progressive Dyspnea
Post-catheterization PSA is one of the most commonly encountered vascular complications of cardiac and peripheral angiographic procedures. We report the case of patient who developed deep-seated profunda femoris artery pseudoaneurysm (PSA) following cardiac catheterization. Despite, repeated ultrasound guided compressions the PSA failed to close and instead produced local site pressure ulcers. The secondary infection followed which precluded use of percutaneous thrombin injection. The PSA was finally closed via a total endovascular technique combining intravascular thrombin injection and coil embolization, thus obviating the need for expensive measures like cover stents or invasive surgical repairs.
Pseudoaneurysm; Endovascular; Thrombin; Post-catheterization; Ultrasound guided compression
Aortopulmonary collaterals (APCs) are occluded either preoperatively or at the time of cardiac surgery in patients with pulmonary atresia and ventricular septal defect (PAVSD). If left untreated, APCs are an important cause of deterioration in the early postoperative period. We present here an unusual case with a large residual APC causing refractory low-output state in the early postoperative period. Usual arterial approach failed due to extensive angulation with ostial narrowing. The large residual APC was successfully closed with an Amplatzer duct occluder (ADO) device delivered through the transvenous route.
APCs; ADO; PAVSD; transvenous; transvenous device closure
In current cardiology practice, the importance of acute cardiorenal syndrome (CRS) in determining the outcome of patients with acute coronary syndrome (ACS) is well recognized. Certain groups of ACS patients are at higher risk of developing CRS. Data on the association between right ventricular (RV) functions and CRS after acute myocardial infarction (AMI) are scarce. The purpose of the current study was to evaluate the relation between RV function and the development of CRS in patients presenting with inferior wall AMI and RV involvement.
Patients and Methods
Patients with inferior wall AMI with RV involvement underwent echocardiography at admission to assess RV function. RV functions were quantified according to RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), and RV outflow tract fractional shortening (RVOTFS). The patients were followed up until discharge from hospital. All patients who developed CRS were included in group I, all patients who did not develop CRS were included in group II (controls). Multivariate analysis was carried out to determine the significance of the echocardiographic and clinical parameters in predicting the development of CRS in these patients.
In our study, a history of diabetes mellitus, cardiogenic shock at admission, and RVFAC and TAPSE could significantly predict the development of CRS in patients presenting with inferior wall AMI and RV involvement.
RV functions provide strong prognostic information regarding the development of CRS in patients of inferior wall AMI with RV involvement.
Clinical predictors; Echocardiographic predictors; Cardiorenal syndrome; Acute ischemic right ventricular dysfunction
Right-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India.
This is a retrospective, single center observational study of consecutive patients over the period January 2003–2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician.
The mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range – 18–50 months).
Prompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.
Right atrium; Thrombus; Thrombolysis; Oral anticoagulation; Echocardiography; Cardiac; EICU, emergency intensive care unit; DVT, deep vein thrombosis; TEE, trans-esophageal echocardiography; ELISA, enzyme linked immunosorbent assay; VQ, ventilation perfusion; PA, pulmonary artery; RV, right ventricle; PAH, pulmonary arterial hypertension; CCP, chronic constrictive pericarditis; RA, right atrial; LA, left atrial; LV, left ventricle; CA, carcinoma; CTEPH, chronic thromboembolic pulmonary hypertension; HIV, human immunodeficiency virus; IVC, inferior vena cava; PFO, patent foramen ovale; PASP, pulmonary artery systolic pressure; STK, streptokinase; IV, intravenous; rtPA, recombinant tissue plasminogen activator; MI, myocardial infarction; BMV, balloon mitral valvotomy; MVR, mitral valve replacement; ATT, antitubercular treatment; RVOT, right ventricle outflow tract; CABG, coronary artery bypass grafting; ASD, atrial septal defect
Amplatzer vascular plugs (AVPs) are devices ideally suited to close medium-to-large vascular communications. There is limited published literature regarding the utility of AVPs in congenital cardiovascular malformations (CCVMs).
To describe the use of AVPs in different CCVMs and to evaluate their safety and efficacy.
Materials and Methods:
All patients who required an AVP for the closure of CCVM were included in this retrospective review of our catheterization laboratory data. The efficacy and safety of AVPs are reported.
A total of 39 AVPs were implanted in 31 patients. Thirteen (33%) were AVP type I and 23 (59%) were AVP type II. AVP type III were implanted in two patients and type IV in one patient. The major indications for their use included closure of pulmonary arteriovenous malformation (AVM) (n = 7), aortopulmonary collaterals (n = 7), closure of a patent Blalock-Taussig shunt (n = 5), systemic AVM (n = 5), coronary AVM (n = 4), patent ductus arteriosus (PDA) (n = 3), pulmonary artery aneurysms (n = 3), and venovenous collaterals (n = 2). Deployment of the AVP was done predominantly via the 5 – 7F Judkin's right coronary guide catheter. Overall 92% of the AVPs could be successfully deployed and resulted in occlusion of the target vessel in all cases, within 10 minutes. No procedure-related or access site complication occurred.
AVPs are versatile, easy to use, and effective devices to occlude the vascular communications in a variety of settings. AVP II is especially useful in the closure of tubular structures with a high flow.
Amplatzer vascular plug; congenital heart disease; device therapy
AIM: To assess role of combined modality of mechanical fragmentation and intralesional thrombolysis in patients with massive pulmonary embolism presenting subacutely.
METHODS: Eight of 70 patients presenting in tertiary care centre of North India with massive pulmonary embolism within 4 years had subacute presentation (symptom onset more than 2 wk). These patients were subjected to pulmonary angiography with intention to treat basis via mechanical breakdown and intra lesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h).
RESULTS: Eight patients, mean age 47.77 ± 12.20 years presented with subacute pulmonary embolism (mean duration of symptoms 2.4 wk). At presentation, mean heart rate, shock index, miller score and mean pulmonary pressures were 101.5 ± 15.2/min, 0.995 ± 0.156, 23.87 ± 3.76 and 37.62 ± 6.67 mmHg which reduced to 91.5 ± 12.2/min (P = 0.0325), 0.789 ± 0.139 (P = 0.0019), 5.87 ± 1.73 (P = 0.0000004) and 27.75 ± 8.66 mmHg (P = 0.0003) post procedurally. Mean BP improved from 80.00 ± 3.09 mmHg to 90.58 ± 9.13 mmHg (P = 0.0100) post procedurally. Minor complications in the form of local hematoma-minor hematoma in 1 (12.5%), and pseudoaneurysm (due to femoral artery puncture) in 1 (12.5 %) patient were seen. At 30 d and 6 mo follow up survival rate was 100% and all the patients were asymptomatic and in New York Heart Association class 1.
CONCLUSION: Combined modality of mechanical fragmentation and intralesional thrombolysis appears to be a promising alternative to high risk surgical procedures in patients with subacute massive pulmonary embolism.
Mechanical breakdown; Subacute; Thrombolysis; Thromboembolic; Intra pulmonary; Catheter directed
Most patients with total anomalous pulmonary venous connection have a set pattern of pulmonary venous drainage and predictable sites of obstruction. However, uncommon variations do exist and delineating the entire course is more important than just knowing the site of drainage. Azygos vein involvement in the circuit is nearly always associated with a complicated course, as was seen in our patient. This report reviews the drainage patterns when azygos vein forms a part of the circuit.
Azygos vein; infracardiac; total anomalous pulmonary venous connection; vertical vein
Cardiomyopathy, hypertrophic/complications; coronary disease/ultrasonography; heart aneurysm/diagnosis/etiology; heart ventricles/pathology; myocardium/pathology
To compare the outcome of restricted versus routine use of episiotomy in a tertiary care center.
A prospective observational study was conducted for singleton normal vaginal term deliveries. Deliveries managed with routine use of episiotomy formed the ‘Control Group’, while those managed with restricted use of episiotomy formed the ‘Study Group’. Data so obtained was analyzed.
Total number of deliveries analyzed was 458 (‘Control Group’: n=210, ‘Study Group’: n=248). Restricted use of episiotomy led to 64% (n=159) women delivering without any perineal laceration, in ‘Study Group’. This translated into 41% (n=38) reduction in the number of perineal lacerations in primipara, and 23% (n=36) in multipara, compared to the ‘Control Group’. Only 2% of primipara in ‘Study Group’ had severe third degree perineal tears.
Restricted use of episiotomy resulted in considerable reduction in maternal morbidity due to perineal lacerations.
episiotomy; perineal lacerations; perineal tears; restricted use; routine
Presence of coronary to pulmonary artery fistula is generally a feature of pulmonary atresia with ventricular septal defect. We present a rare case of left anterior descending coronary artery to pulmonary artery fistula in a patient of tetralogy of Fallot.
Congenital heart disease; coronary artery; pulmonary artery; tetralogy of Fallot
A persistent left inferior vena cava (IVC) is a rare anomaly, with a reported incidence of only 0.2-0.5%. When present, it courses between the superior mesenteric artery and the aorta to continue as the right IVC, similar to the course of a left renal vein (LRV). This anomaly is usually asymptomatic, but there may be vague abdominal complaints if the IVC is compressed in the mesoaortic angle. Although symptomatic compression of the LRV (anterior nutcracker syndrome) is well recognized, there has been only one report in the literature of a similar compression of a persistent left IVC. Because of its rarity, this anomaly may be missed or mistaken for other conditions on imaging. An accurate diagnosis is crucial as the presence of this anomaly may have implications for surgical treatment of aortic lesions or placement of an IVC filter. Magnetic resonance angiography and, more recently, multidetector computed tomography scan, can provide an exquisite three-dimensional demonstration of vascular abnormalities.
Inferior vena cava; multidetector computed tomography; ultrasound
Whey containing 4.4% (w/v) lactose was inoculated with Kluyveromyces marxianus MTCC 1389 for carrying out studies related to β-galactosidase production. β-galactosidase activity was found to be maximum after 30 h and further incubation resulted in decline in activity. The maximum cell biomass of 2.54 mg mL−1 was observed after 36 h of incubation. Lactose concentration dropped drastically to 0.04 % from 4.40% after 36 h of incubation. Out of the four methods tested for extraction of enzyme, SDS — Chlorofom method was found to be best followed by Toluene — Acetone, sonication and homogenization with glass beads in that order. It could be concluded through this study that SDS — Chloroform is cheap and simple method for enzyme extraction from Kluyveromyces cells, which resulted in higher enzyme activity as compared to the activity observed using the remaining extraction methods. The study could also establish that whey could effectively be utilized for β-galactosidase production thus alleviating water pollution problems caused due to its disposal into the water streams.
Whey; β-galactosidase activity; Lactose; Biomass; SDS-Chloroform
Diluted cane molasses having total sugar and reducing sugar content of 9.60 and 3.80% (w/v) respectively was subjected to ethanol production by Saccharomyces cerevisiae MTCC 178. Incorporation of dried Cauliflower Waste (CW) in molasses at the level of 15 % increased ethanol production by nearly 36 % compared to molasses alone. Addition of 0.2 % yeast extract improved ethanol production by nearly 49 % as compared to molasses alone. When the medium containing diluted molasses and 0.2 % yeast extract was supplemented with 15 % CW, 29 % more ethanol was produced compared to molasses with 0.2 % yeast extract. Cell biomass, ethanol production, final ethanol concentration and fermentation efficiency of 2.65 mg mL−1, 41.2 gL−1, 0.358 gg−1 and 70.11 % respectively were found to be best at 15% CW supplementation level besides reduction in fermentation time but further increase in CW level resulted in decline on account of all the above parameters. This is probably the first report to our knowledge, in which CW was used in enhancing ethanol production significantly using a small quantity of yeast extract.
Molasses; Cauliflower waste; Yeast extract; Ethanol production; Total sugars; Fermentation efficiency
To present a protocol of a prospective, cohort study in which four groups of spinal cord injury (SCI) patients will participate. (Patients with indwelling urethral catheter; patients who perform intermittent catheterisation without wearing a penile sheath; patients who perform intermittent catheterisation and wear penile sheath as well; and patients with penile sheath drainage).
(1) What is the incidence of symptomatic urinary infection in men with spinal cord injury who use different types of bladder drainage? (2) Which are predisposing factors for the occurrence of symptomatic urinary infection in men with spinal cord injury who practise different methods of bladder drainage? (3) What is the incidence of catheter and urinary drainage system-related adverse events in the four groups of SCI patients?
The criteria for inclusion are as follow: (1) Male patients with neuropathic bladder due to spinal cord injury, who are registered with the Regional Spinal Injuries Centre, Southport, England. (2) Age: 18 years or above. (3) Patients who are willing to give informed consent for participation in the study. (4) Patients willing to be contacted every two weeks by a staff of the spinal unit for 36 months. (5) Patients who are willing to maintain an accurate record of adverse events related to urinary catheter and urinary drainage system and predisposing factors for the occurrence of symptomatic urinary infection. (6) Patients, who are stabilised in a particular method of bladder drainage, and therefore, unlikely to make a permanent change in the method of bladder drainage (e.g. from penile sheath drainage to the use of long-term indwelling catheter) during a foreseeable future.
The participants will be observed for a period of 36 months. A staff of the spinal injuries unit will contact the participants by telephone every two weeks on a mutually agreed day and time. The information obtained during this standardised telephonic interview conducted once in two weeks will be entered in a database. When a participant develops symptom(s) suggestive of urinary infection, he will undergo urine and blood tests, and imaging studies of the urinary tract.
This study will provide information regarding the occurrence of symptomatic urinary infection, predisposing factors for development of urinary infection, and adverse events related to urinary catheter and urinary drainage system in SCI patients using different methods of bladder drainage.
Forty patients suffering from mild to moderate degree of hypertension were put on felodipine. Their lipid profile was analysed before the start of their therapy and consecutively at two and four months after starting felodipine. There was a statistically significant fall in the levels of serum cholesterol, serum triglycerides and serum total lipids; though no appreciable variation was observed in HDL and LDL cholesterol levels. At baseline there were a few patients who had higher than the normal range of the serum lipid profile. Analysis of these patients showed a highly significant fall in the levels of serum cholesterol, serum triglycerides, serum LDL-cholesterol and serum total lipids i.e. felodipine modified the lipid profiles of hypertensive patients in a positive way.
Felodipine; Lipid Profile; Hypertension