DEVICE CLOSURE OF VENTRICULAR SEPTAL DEFECT

DEVICE CLOSURE OF VENTRICULAR SEPTAL DEFECT (VSD)

A 14 years old boy presented with complaints of palpitation, shortness of breath and exercise intolerance. On auscultation, the patient had a pansystolic murmur. Echocardiography showed the presence of 8mm muscular ventricular septal defect (VSD). The patient was initially advised for surgery, however, on evaluation it was found to be amenable to device closure. Successful device closure of the VSD was done by Dr. Anupam Jena at The Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha.

The detailed step by step procedure

  1. Echocardiography to confirm the presence of Ventricular Septal Defect (VSD)

vsd echoFigure 1. Color Doppler showing VSD.

2. Left Ventricular Angiography showed the presence of VSD. VSD was crossed from LV side and the wire was then snared from the Pulmonary artery to create an A-V loop, as shown in the images below

IMG-0004-00001

3. 10mm Amplatzer Muscular VSD Device was deployed to completely occlude the VSD

 

4. Post Device closure Echocardiography shows, VSD device in situ closing the VSD and no residual flow

IMG-0002-00001

There were no procedural complications and the boy was discharged after 2 days.

Conclusion:

Ventricular Septal Defect or VSD is a congenital defect of the heart, where there is an abnormal communication between the Left ventricle and right ventricle. Such defects cause symptoms of palpitation, shortness of breath, exercise intolerance etc. Complications include Infective endocarditis, Aortic regurgitation, Eisenmenger syndrome etc. Device closure can be done in many cases of VSD. Device closures of various congenital defects or hole in the heart are successfully done by Dr. Anupam Jena at Bhubaneswar, Odisha. The biggest advantage of device closure is, it obviates the need for open heart surgery and the risks associated with it. Currently, worldwide device closure of ASD, VSD, PDA etc. is the preferred mode of treatment for such diseases. Dr. Anupam Jena is routinely performing such procedures in Bhubaneswar, Odisha.

TAVI/TAVR (TRANSCSTHETER AORTIC VALVE IMPLANTATION/REPLACEMENT)

In a landmark advancement in the medical field in Odisha, The Kaling Institute of Medical Sciences (KIMS) has done the first case of Transcatheter Aortic Valve Replacement (TAVR). This state of the art procedure was done at KIMS by Cardiologist Dr. Anupam Jena and his team. The patient was discharged after 3 days.

IMG-0004-00119

Transcatheter Aortic Valve Replacement (TAVR)  or transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure that repairs the Aortic valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve’s place. Somewhat similar to a stent placed in an artery, the TAVR approach delivers a fully collapsible replacement valve to the valve site through a catheter. Once the new valve is expanded, it pushes the old valve leaflets out of the way and the tissue in the replacement valve takes over the job of regulating blood flow. This procedure is fairly new and is FDA approved for people with symptomatic aortic stenosis who are considered an intermediate or high risk patient for standard valve replacement surgery. Usually valve replacement requires an open heart procedure with a “sternotomy.”, in which the chest is surgically separated (open) for the procedure. The TAVR or TAVI procedures can be done through very small puncture in the femoral arteries at the groin leaving all the chest bones in place. A TAVR procedure provides beneficial treatment options to people who may not have been candidates for them a few years ago while also providing the added bonus of a faster recovery in most cases. A patient’s experience with a TAVR procedure may be comparable to a balloon treatment or even an angiogram in terms of downtime and recovery, and will likely require a shorter hospital stay (average 3-5 days).

Keywords: TAVI, TAVR, Cardiac Intervention, Aortic Stenosis, Transcatheter Valve Therapy

Asia Pacific Heart Rhythm Society (APHRS 2016)


I had this great opportunity to attend the 9th Asia Pacific Heart Rhythm Society Annual Conference 2016, at Seoul, South Korea. It was a great experience to listen to renowned authorities in the field of Cardiac Electrophysiology.

It was attended by around 3000 delegates from around the world.

That’s my mentor, Prof. Young-Hoon Kim. A great electrophysiologist and human being also the principal force behind the successful organization of APHRS.

I had the opportunity to participate in a session on Difficult Transseptal Punctures.

That’s me

The best part for me was that I got a Young Investigator award for our study on repeat VT ablations

 Wow, that was an experience to remember.

Finally, there was a live case of AF ablation from our center.

The conference concluded on 15th October 2016, but the lasting impression will remain with me for a long time.

DR. ANUPAM JENA
INTERVENTIONAL CARDIOLOGIST & ELECTROPHYSIOLOGIST
KALINGA INSTITUTE OF MEDICAL SCIENCES
BHUBANESWAR, ODISHA
INDIA
EMAIL: drjena@live.com

Ventricular Tachycardia – Classification

Ventricular Tachycardia – Classification

Ventricular tachycardia is a common arrhythmia. The manifestations include mild symptoms of palpitation to sudden death. In next few blog posts, we will try to understand the basics of ventricular tachycardia/fibrillation and we will discuss management of these arrhythmias.

Definition:

Ventricular arrhythmias are defined as arrhythmias that originate below the bifurcation of His bundle, in the specialized conduction system, the ventricular muscle, or in combination of both tissues.

electrocardiogram_of_ventricular_tachycardia

Ventricular Tachycardia ECG

(Image created by Karthik Sheka, M.D. [CC BY-SA 2.5 (http://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons)

There are different classifications of ventricular arrhythmias, according to their duration, morphology of QRS complexes, and clinical characteristics.

Classification According to Duration

(1) Premature ventricular complexes (PVC): isolated complexes originating from the His-Purkinje system or ventricular myocardium.
(2) VT: 3 or more consecutive QRS complexes at a rate greater than 100 beats per minute.
(3) Nonsustained VT: VT that terminates spontaneously within 30 seconds.
(4) Sustained VT: continuous VT lasting for ≥30 seconds or that requires an intervention for termination (such as cardioversion).

Classification According to Morphology of QRS Complexes

(1) Monomorphic VT: VT that has a similar QRS configuration from beat to beat. Some variability in QRS morphology at initiation is not uncommon.
(2) Multiple monomorphic VT: more than one morphologically distinct monomorphic VT, occurring as different episodes or induced at different times.
(3) Polymorphic VT: VT that has a continuously changing QRS configuration indicating a changing ventricular activation sequence.
(4) Pleomorphic VT: VT that has more than one morphologically distinct QRS complex occurring during the same episode of VT, but the QRS is not continuously changing.
(5) Ventricular flutter: rapid VT that has a sinusoidal QRS configuration that prevents identification of the QRS morphology.
(6) VF: ventricular tachyarrhythmia that has a totally chaotic
morphology.

Classification According to Clinical Characteristics

(1) Clinical VT: VT that has occurred spontaneously based on analysis of 12-lead ECG QRS morphology and rate.
(2) Hemodynamically unstable VT: VT that causes hemodynamic compromise requiring prompt termination.
(3) Incessant VT: continuous sustained VT that recurs immediately despite repeated spontaneous or therapeutic termination.
(4) Repetitive monomorphic VT: continuously repeating episodes of self-terminating nonsustained VT.
(5) VT storm: 3 or more separate episodes of sustained VT within 24 hours, each requiring termination by an intervention.
(6) Unmappable VT: VT that does not allow interrogation of multiple sites to define the activation sequence or perform entrainment mapping. It may be due to hemodynamic
intolerance that necessitates immediate VT termination, spontaneous, or pacing-induced transition to other morphologies of VT, or repeated termination during mapping.

In the next post, we will discuss clinical features and ECG features.

DR. ANUPAM JENA
CONSULTANT INTERVENTIONAL CARDIOLOGIST & ELECTROPHYSIOLOGIST
KALINGA INSTITUTE OF MEDICAL SCIENCES
BHUBANESWAR, ODISHA
INDIA
EMAIL: drjena@live.com

Primary prevention ICD in Nonischemic cardiomyopathy

There is a recent online first article in NEJM  ( Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure – DANISH Study). The study is summarized below:

Summary:

The benefit of an implantable cardioverter–defibrillator (ICD) in patients with symptomatic systolic heart failure caused by coronary artery disease has been well documented. However, the evidence for a benefit of prophylactic ICDs in patients with systolic heart failure that is not due to coronary artery disease has been based primarily on subgroup analyses. The management of heart failure has improved since the landmark ICD trials, and many patients now receive cardiac resynchronization therapy (CRT).

Methods

In a randomized, controlled trial, 556 patients with symptomatic systolic heart failure (left ventricular ejection fraction, ≤35%) not caused by coronary artery disease were assigned to receive an ICD, and 560 patients were assigned to receive usual clinical care (control group). In both groups, 58% of the patients received CRT. The primary outcome of the trial was death from any cause. The secondary outcomes were sudden cardiac death and cardiovascular death.

Results

After a median follow-up period of 67.6 months, the primary outcome had occurred in 120 patients (21.6%) in the ICD group and in 131 patients (23.4%) in the control group (hazard ratio, 0.87; 95% confidence interval [CI], 0.68 to 1.12; P=0.28). Sudden cardiac death occurred in 24 patients (4.3%) in the ICD group and in 46 patients (8.2%) in the control group (hazard ratio, 0.50; 95% CI, 0.31 to 0.82; P=0.005). Device infection occurred in 27 patients (4.9%) in the ICD group and in 20 patients (3.6%) in the control group (P=0.29).

Conclusions

In this trial, prophylactic ICD implantation in patients with symptomatic systolic heart failure not caused by coronary artery disease was not associated with a significantly lower long-term rate of death from any cause than was usual clinical care.

This is the summary of the study. This study proves the point that primary prevention ICD doesn’t reduce the all cause mortality. But there are few points to consider in this very well designed study:

  1. SCD was the cause of death in 24 out of 120 (20%) total deaths in the ICD group. SCD was the cause of death in 46 out of 131 (35%) total deaths in the non-ICD (usual care group). So that means majority of mortality even in the non-ICD usual care group are due to non arrhythmic causes.
  2. The number of non-arrhythmic mortality in the ICD group is 96 out of total of 120 (80%) and in the non-ICD group is 65%.
  3. The question still remains that – How is a device (i.e. ICD) which prevents arrhythmic deaths, is expected to reduce the All Cause Mortality (the primary end point of this study) when the majority of deaths are due to non-arrhythmic causes.
  4. When considering the sudden cardiac deaths, ICD definitely reduced the mortality [Sudden cardiac death occurred in 24 patients (4.3%) in the ICD group and in 46 patients (8.2%) in the control group (hazard ratio, 0.50; 95% CI, 0.31 to 0.82; P=0.005)].

This study is a landmark study. It shows that the present indications for primary prevention ICD in non-ischemic cardiomyopathy are likely  include patients who may not after all benefit from a primary prevention ICD. It further shows that ICD is effective in preventing SCD in non-ischemic cardiomyopathy.

So to conclude this important study shows that we need to find markers of SCD in non-ischemic cardiomyopathy so that ICD implantation can be more effectively done in patients who are at high risk of SCD.

(Disclaimer: The views expressed are entirely personal of the author of this blog and are aimed towards an educational discussion on the study. These opinions are not meant for application in medical practice and are for the purpose of discussion only)

Keywords: Electrophysiology, Cardiomyopathy, Implantable cardioverter defibrillator, Sudden cardiac death

Arrhythmia or Disorders of Heart Rhythm

Arrhythmias or disorders of heart rhythm are a group of diseases characterized by abnormality of heart beat. Our heart is expected to beat in a certain way. In an adult individual the heart normally beats 60 t0 100 times per minute, in a regular manner (that means a nearly constant interval between two beats ). There are some normal variations, like in children the heart beat is faster, in some healthy persons and trained athelets the heart beat can be slower, during sleep the heart beat is normally slower.

Definition of Arrhythmia:

Arrhythmia is defined as any deviation from this normal pattern of heart beat.

What are the types of Arrhythmia?

Heart rhythm disorders are basically of two types. When the Heart rate is abnormally high it is called TACHYCARDIA. When the heart rate is abnormally slow it is called BRADYCARDIA. There can be irregular heart beats even if the heart rate is between 60-100, those cases are also Arrhythmic.

What is the relation of arrhythmias to other heart diseases?

Arrhythmias can be divided into two types based on heart diseases

  1. Arrhythmias occurring in persons having no underlying structural heart disease are called- IDIOPATHIC ARRHYTHIMAS
  2. Arrhythmia also arise in persons who have underlying structural heart diseases.

What are the symptoms of Arrhythmia?

Arrhythmias due to slow heart rate (Bradycardia) commonly cause

  1. Lethargy
  2. Fatigue
  3. Palpitation
  4. Light headedness
  5. Syncope (Transient loss of consciousness followed by full recovery)
  6. Sudden death

Arrhythmias due to fast heart rate (Tachycardia) commonly produce symptoms of

  1. Palpitation
  2. Faintness and light headedness
  3. Syncope (Transient loss of consciousness followed by full recovery)
  4. Sudden death
  5. Reduced pumping capacity of heart and related symptoms
  6. Some arrhythmias like atrial fibrillation can produce abnormal clotting of blood inside heart which can migrate to brain to cause stroke and paralysis.

How serious are Arrhythmias?

Some arrhythmias are benign and non life threatening, but they cause troublesome symptoms of palpitation and skipped beats.

Some arrhythmias are life threatening and can cause even sudden death. It all depends on the origin and type of arrhythmias and any other underlying heart disease.

How to diagnose arrhythmia?

Arrhythmias are commonly diagnosed by

  • ECG
  • Holter monitoring
  • Sometimes long term monitoring like – event recorders, loop recorders etc.
  • In some case Cardiac Electrophysiological study is required to diagnose a rhythm disorder.

What are the treatments available?

  1. Some transient arrhythmias terminate on their own and don’t need any specific therapy
  2. Underlying cause needs to be treated like- drugs, electrolyte disturbances, etc
  3. Medicines are usually the first line treatment
  4. Catheter Ablation: It is a procedure done in cardiac cathlab where an arrhythmia is ablated commonly by application of radiofrequency energy inside the heart. It is a safe procedure with prospect for complete cure of the arrhythmia.

 

DR. ANUPAM JENA
CONSULTANT INTERVENTIONAL CARDIOLOGIST & ELECTROPHYSIOLOGIST
KALINGA INSTITUTE OF MEDICAL SCIENCES
BHUBANESWAR, ODISHA
INDIA
EMAIL: drjena@live.com

 

 

 

 

 

Cardiology MCQ – 14.05.2016


What is the most probable site of origin of the tachycardia in a patient with structurally normal heart ?

MA VT epicardial1. Right ventricular outflow tract

2. Mitral annular VT

3. Tricuspid annulus

4. Idiopathic left fascicular VT

Atrial septal defect and Pregnancy – Patient Information

What is atrial septal defect (ASD)

Atrial Septal defect is an abnormal communication between the upper two chambers of the heart namely left atrium and right atrium. Normally the left and right atrium are separated by the interatrial septum. So in atrial septal defect (ASD)  a part of the interatrial septum is missing. See the image below

Atrial Septal Defect

(Source : www.wikipedia.org)

In patients with ASD there is mixing of oxygenated blood of left side with venous blood on the right side.

Pregnancy Issues:

Patients with even a large unrepaired secundum atrial septal defect usually tolerate pregnancy without complications. In cases where the ASD has been closed either by surgery or by device, the course of pregnancy is similar to a normal female without heart disease, except when there are preexisting problems with heart rhythm or pulmonary hypertension.

Complications:

The complications include

1- Disorders of heart rhythm – e.g. Atrial fibrillation

2. Pulmonary hypertension – where there is increased pressure in the blood vessels of the lung.

3. Paradoxical embolism – Sometimes blood clots formed in the leg veins (increased chances in pregnant females) can pass through the defect in the heart and get lodged in the brain and can cause stroke .

Precautions:
  1. Elective closure of ASD before contemplating pregnancy is advisable
  2. Meticulous attention should be paid to the maternal leg veins, particularly during peridelivery, because deep venous thrombosis could precipitate a paradoxical embolus and stroke.
  3. In case of any complication like atrial fibrillation, pulmonary hypertension, close follow-up with a cardiologist is recommended.
Keywords: Congenital heart disease, pregnancy and heart disease, Patient information, atrial septal defect.

Xray chest showing thickened and calcified pericardium

Eggshell calcification of the heart in constrictive pericarditis

 Eggshell calcification of the heart in constrictive pericarditis

Rajesh Vijayvergiya, Ramalingam Vadivelu, Sachin Mahajan, Sandeep S Rana, Manphool Singhal

World J Cardiol 2015 September 26; 7(9): 579-582

43/M presented with dyspnoea on exertion NYHA class III since 6 months. No other positive history.

On Examination:

HR-100/min  BP- 100/64   JVP- elevated, 18 cm; prominent X and Y descent

CVS: S1 S2 normal, Pericardial knock +

CXR : Calcified pericardium seen. See image

Echo: Thick, calcified pericardium.   > 25%  respiratory variation of mitral inflow velocities . Significant LV diastolic dysfunction