High Risk of Venous Thrombosis Recurrence in Fully Anticoagulated Patient with Antithrombin Deficiency during COVID-19: A Case Report

Coagulation dysfunction is a serious issue in patients with Coronavirus disease-19 (COVID-19). With regard to recently published studies, a high number of patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 developed life-threatening thrombotic complications despite anticoagulation. We report a case of young woman with the type-II heparin-binding site (HBS) antithrombin (AT) deficiency (Budapest 3-homozygous), who developed acute deep vein thrombosis on two occasions due to COVID-19 infection in the course of stable anticoagulation with vitamin K antagonist. The first thrombotic event was observed during mild COVID-19 infection, while the second thrombotic event she developed 2 months after she was negative for severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2). Our case highlights the complexity of the treatment in this particular type of thrombophilia and the need for precaution even in mild forms of viral infection. In the treatment of acute thrombosis, AT-deficient patients may benefit from the use of AT concentrate along with low-molecular weight heparin (LMWH), while in cases of type II-HBS, AT supplementation is mandatory.

Himalayan Fibrillatory Waves in Juvenile Rheumatic Mitral Stenosis

An 18-year-old girl, a known case of rheumatic mitral stenosis, presented with dyspnea and palpitations. Electrocardiogram was done, which revealed atrial fibrillation and a large amplitude atrial fibrillatory wave, which was more than the voltage of R wave V1, a finding which is quite uncommon. Echocardiography revealed a large left atrium which was 80 mm in diameter. The patient was started on oral anticoagulation and referred for mitral valve replacement with maze procedure.

Association between Endogenous Sex Hormones and Coronary Artery Disease in Postmenopausal Women

Background Incidence of coronary artery disease (CAD) increases significantly in postmenopausal women, which is assumed to be an imbalance between serum androgen and estrogen levels. However, studies assessing serum sex hormones and CAD are few and have shown conflicting results. Objective To compare serum sex hormone levels and traditional risk factors among postmenopausal women with angiographically proven CAD and without CAD. Method The study included consecutive postmenopausal women undergoing coronary angiography in our institute from May 2016 to June 2017. The clinical and coronary angiographic data and traditional risk factors were assessed. Fasting serum levels of estradiol (E2), testosterone (T), sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEA-S), and insulin were measured. Results A total of 121 postmenopausal women were included in the study; 69 were CAD and 52 without CAD. Single-vessel disease was most common (55.1%), followed by double-vessel disease (24.6%) and triple-vessel disease (20.3%). Women with CAD had significantly lower estradiol/testosterone (E2/T) ratio (3.7 ± 2.6 vs. 5.4 ± 4.2, p = 0.008) compared with non-CAD group. SHBG, DHEA-S, and insulin levels were similar in CAD and non-CAD groups. The serum level of estradiol predicted the E2/T ratio (r = 0.316, p < 0.001) and positively associated with DHEA (r = 0.181, p = 0.047). Testosterone was negatively associated with E2/T ratio (r = – 0.682, p < 0.001). There was no significant correlation of estrogen, testosterone, or E2/T ratio to lipid profile (total cholesterol, HDL, LDL) in women with CAD. Conclusion E2/T ratio was significantly lowered in postmenopausal women with CAD. E2/T ratio may be a used a predictor of CAD in postmenopausal women

Gender Differences in South Indians with Premature Coronary Artery Disease (< 40 Years)—Insights from the PCAD Registry

Introduction Coronary artery disease (CAD) follows a different pattern in women and men, more so in the young (< 40 years). The gender differences in the risk factors, clinical presentation and diagnosis need to be understood, so that appropriate and timely treatment can be given. Objective The study contemplates to analyze the gender differences in the presence of major coronary risk factors, clinical presentation, diagnosis and immediate outcomes in patients who present with premature CAD (PCAD). Patients and Methods We evaluated 1,062 consecutive registry patients who presented with diagnosis of PCAD between 2018 to 2019 at our institution after satisfying the inclusion criteria. Results The study analyses 82 females and 980 males. The mean age of females was 35.4 ± 4.68 years and males was 34.2 ± 4.25 years. Males smoked more often (55.1%, p < 0.001). Females more often had abnormal BMI (84.1%, p < 0.001), increased waist-hip ratios (97.6%, p < 0.001), diabetes (35.4%, p < 0.001), dyslipidemia (17.1% vs. 11%) and hypertension (15.9% vs. 11.5%). STEMI was the most common presentation among males (80.4% vs. 71.9%). Majority of females (74.6%) presented 6 hours after index pain. NSTEMI was more common among females (20.7% vs. 16%). Single-vessel involvement was common in both sexes (84.1% in males and 85.2% in females). Obstructive CAD was less common in both groups. Conclusions Conventional risk factors play a major role for CAD in Indians. Smoking was common in males and metabolic syndrome in females. Also, females had a higher threshold for seeking treatment and referral. Measures have to be taken for early diagnosis and referral of females. Recanalized and thrombotic coronaries were common, indicating predominant thrombus burden in the young

Left Main Coronary Artery Spasm: Case Report

Vasospasm of coronary artery is a well-known cause for acute coronary syndrome (ACS) but left main coronary artery (LMCA) spasm is very rare. It may be iatrogenic or spontaneous. Here we report a case of a 44-year-old female who presented with chronic stable angina and experienced LMCA vasospasm while undergoing coronary angiography.

Correlation between the Clinical Profile and Angiographic Severity of Coronary Artery Disease in ST Elevation Myocardial Infarction and Non-ST Elevation Myocardial Infarction Patients

Background and Aim: The correlation between clinical profile and angiographic severity in acute coronary syndrome (ACS) patients has been poorly documented. Hence, the present study aimed to study the clinical profile and correlate that with vessel burden, as witnessed by coronary angiography, in patients presenting to the hospital with ACS (ST-segment elevation myocardial infarction [STEMI]/non-ST-segment elevation [NSTE]-ACS) Materials and Methods: The study had enrolled 209 patients who had been diagnosed with ACS. All subjects were those who presented to the Emergency Medicine Department in a tertiary care center (south India). Coronary angiogram done for these patients by cardiologists was reviewed with a SYNTAX CALCULATOR (I AND II). Patient's baseline characteristics and clinical examination and interventional diagnosis details were obtained. Results: The clinical profile gathered from this geographical territory implied an increase in the angiographic severity of the coronary artery disease as measured by the SYNTAX score 1, with an increase in the duration of the said risk factor. Male gender was predominant and the major age group for ACS was 30 to 60 years. The most common presentation in ACS was STEMI. Diabetes and hypertension were the main risk factors for ACS. There was a striking occurrence of ACS among the young. Conclusion: STEMI was the major ACS presentation in this study population. The main risk factors noted were diabetes and hypertension. Besides smoking and alcohol abuse (in any study population), dyslipidemia was also a key risk factor observed. Mild left ventricular systolic dysfunction was predominant in this study. The SYNTAX score 1 increased with duration of observed and recorded risk factors.

Treatment of an Unyielding Central Vein Stenosis using Valvuloplasty Balloon in a Young Female Presenting with Ineffective Hemodialysis

Percutaneous balloon venoplasty is widely employed for the management of central vein stenosis (CVS), a condition frequently encountered in patients on maintenance hemodialysis (MHD). The hypertrophied and fibrotic venous stenotic lesions often pose a challenge for interventionists, due to resistance to dilatation and high-elastic recoil. We report here successful utilization of mitral valvuloplasty balloon for percutaneous treatment of an unyielding brachiocephalic vein stenosis. Repeated failure of conventionally used peripheral balloon dilatation catheter prompted the use of a mitral valvuloplasty balloon that could exert higher radial pressure while preventing melon-seeding and hence successfully achieve stenosis dilatation. The mitral valvuloplasty balloon can be effectively and safely used for lesions resistant to repeated dilatations by conventional peripheral balloons. Rheological stress on central veins from ipsilateral arteriovenous fistula (AVF) may result in development of stenotic lesions, even in the absence of prior venous catheterization of the affected vein; therefore, in the presence of relevant symptoms, this diagnosis should not be excluded on the basis of absence of prior direct trauma at the stenosis site.

A Case Report of Ortner's Syndrome, Cardiovocal Hoarseness—An Infrequent Entity in the Contemporary World

Rheumatic fever (RF) and rheumatic valvular disease remain prevalent and are still significant health hazards in developing nations. Hoarseness of voice, although a common symptom in ENT, is a rare finding in cardiac patients. However, hoarseness of voice due to recurrent laryngeal nerve paralysis is an infrequent finding secondary to mitral stenosis. This case illustrates an unusual presentation of rheumatic heart disease (RHD) in young women. This case report highlights the importance of early reporting and diagnosis of RHD-RF, being very prevalent in developing nations and yet neglected.

Myocardial Infarction or Takotsubo Cardiomyopathy? A Case Report of a Rare Clinical Dilemma in the Setting of Atrial Myxoma

Background Acute myocardial infarction (AMI) secondary to coronary embolization is one of the rare complications of atrial myxoma. Takotsubo cardiomyopathy (TCM), a close mimic of AMI, is extremely rare in the setting of atrial myxoma. We report a patient with atrial myxoma presenting with features leading to a clinical dilemma between these two entities. Case summary A 60-year-old woman presented with acute chest pain with ST segment elevation. Echocardiogram revealed left ventricular (LV) apical ballooning which is typical of TCM, coexisting with a fragile left atrial mass. Emergency coronary angiogram showed a hazy lesion in the circumflex ostium and an intermediate lesion in ramus without any obstruction. Surgical excision of the tumor was done due to features of recurrent coronary embolism. The histopathology examination confirmed it as a myxoma. Regional wall motion abnormalities reversed within a month and LV function normalized. Cardiac magnetic resonance (CMR) imaging at follow-up suggested myocardial infarction. Discussion TCM can occur very rarely in the setting of atrial myxoma. In a patient with atrial myxoma presenting with features of TCM, differentiating it from coronary embolization is important.

Saphenous Vein Graft Disease Interventions

In the current era, coronary artery bypass grafting (CABG) is being increasingly performed using total arterial revascularization or a hybrid procedure of stenting of non-LAD disease and minimal access left internal mammary artery (LIMA) to LAD grafts, in order to minimize the need for vein grafts. Still, we encounter saphenous vein graft (SVG) disease, and it might require PCI, which often presents with unique challenges. The current favored strategy is to attempt PCI of the native coronary, if feasible, especially in long degenerated SVG disease, as it has shown better short- and long-term outcome. PCI is preferred over repeat CABG for early recurrent symptoms after CABG in patent LIMA graft and amenable anatomy patients. Balloon predilatation is not recommended unless delivery of an EPD or stent is not possible. Distal protection should be considered the standard of care for percutaneous coronary intervention (PCI) in most patients with older vein grafts, as periprocedural myocardial infarction and no reflow are the Achilles heel of SVG PCI. Intragraft vasodilators should be used liberally, even before balloon angioplasty/stenting. Avoid postdilatation, and usage of undersized but a longer stent length to reduce plaque extrusion through stent struts is preferred. Consider thrombectomy in lesions with a heavy thrombus burden. Keep activated clotting time on the higher side than in conventional PCI. Prolonged dual antiplatelet therapy (DAPT) based on the DAPT score is recommended. With all the precautions and care, we still need a fair wind in our favor to sail through the vein grafts disease.