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Archive for April, 2009

Yes , we can .         Abstract : Link to Indian heart journal

b1

Vegetation Negative Infective-Endocarditis

S Venkatesan, G Gnanavelu, G Karthikeyan, V Jaganathan,  R Alagesan,
M Annamalai, S Shanmugasundaram, S Geetha, A Balaguru, G Anuradha

Madras Medical College, Chennai


The definitive diagnosis of infective endocartitis (IE) remains a contentious clinical issue. Many diagnostic criteria have been advanced. However, none has withstood the test of time. Currently Duke’s criteria is considered as de facto standard. Documentation of vegetation within the cardiac chambers and positivity of blood culture is the sine qua non of IE and evidently they constitute the major criteria. Ironically, according to Duke’s criteria, IE could still be diagnosed in the absence of vegetation, provided it fulfils other major criteria of culture positivity. In this context, we report our analysis of patients with IE without vegetation. Out of 24 patients admitted between 2004-2005 in our hospital with the diagnosis of IE, 4 patients failed to show vegetations. All had rheumatic heart disease (RHD) and presented with prolonged fever. All had severe eccentric mitral regurigitation (MR). One had severe aortic regurgitation (AR) also. One had flail posterior mitral leaflet (PML). All had blood culture positive – 3 for staphylococcus auerus 1 for pseudomonas. None had vegetations on the first echocardiographic examination. Transesophageal echcardiography (TEE) also failed to detect a vegetation or abscess. The diagnosis of IE was made on the basis of Duke’s criteria (1 major and 3 minor features). Treatment was started based on culture positivity and sensitivity. All patients underwent serial echocardiography every week for 6 weeks. New mobile vegetation was detected in 1 patient in anterior mitral leaflet (AML) measuring 12 mm after 2 weeks. Three patients never showed any evidence of vegetation. One patient developed cerebral vasculitis and another renal insufficiency during the course of treatment. Two patients stabilized with medical management. One expired and other had refractory cardiac failure and was referred for emergency surgery. The mechanism of absence of vegetation in IE could be varied. Simple temporal dissociation between appearance of vegetation and the clinical syndrome should be the first possibility. Further, vigorous antimicrobial treatment might have prevented the formation of vegetation. But, as we have seen in few patients, it never appeared. This was possibly due to layered vegetation like that of a thrombus on the surface of the valve or adjacent myocardium. The process of vegetation formation need not be endoluminal, it can burrough into the tissue plane intramurally without projecting into the cavity. Spontaneous rupture of chordae secondary to inflammation without any vegetation is another possibility.

We conclude , even though vegetations are considered sine quo non of IE in many clinical situations, IE occurs without vegetation. The mechanisms could be varied.

Download full  PPT presentation

infective-endocarditis-csi-2005

infective-endocarditis-csi-2005

infective-endocarditis-vegetation-csi-2005

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ebstein-anomaly

Down load high resolution PDF file

ebstein-anomaly

Ref:

An excellent article from H.Watson in british heart journal

HERNANDEZ FA  The intracavitary electrocardiogram in the diagnosis
of Ebstein’s anomaly. Amer J Cardiol 1: 181,  1958

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A perfect illustration  to understand

What will happen if the aorta is obstructed at the level of isthumus ?

One of the great illustrations I have come across

co-arctation-collaterals

collaterals-in-coarctation-21

Courtesy

Dr.Jesse Edwards (Fowler’s Text book of cardiology )

To  Download a PDF version and Zoom into the Aorta  as deep as you would like !

collaterals in coarctation of aorta

Also watch

Collateral in co arctation   : A video

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PDA is a common congenital heart disease.It results in progressive left to right shunting.

Development of pulmonary hypertension is the major complication.PDA need to be closed once the diagnosis is made.Until recently surgery was the only option.Now we have device, coil closure   available. Not all ducts are amenable to device closure.

For a duct to be closed by device we have to know the exact anatomy of the ductus.echocardiography has  limitation to  accurately image the ductus. Angiogram is the specific method.

What is  the normal length of patent ductus  arteriosus ?

The length of duct is very variable it can vary between 1 mm to 35  mm.

A 2 mm PDA is nothing but direct adherence of aorta and pulmonary artery (Ultra short form , similar to AP window )

pda-size-ductus

What is the branching angle of ductus from aorta and the entry angle at the pulmonary artery ?

This is an important determinant of technical success of device closure .Very abtuse or acute angled ductus can

face difficulty in deploying devices. The normal angle in lateral view is between 30-60 d

How do you classify PDA ? .

There is only one classification of PDA available  based on angiogram .Krichenko*

pda-4

pda-2

pda-31

Taken from  *Krichenko A,. Angiographic classification of the isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion. Am J Cardiol. 1989; 63: 877–879

Review article on PDA

http://www.circ.ahajournals.org/cgi/content/full/114/17/1873

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British Bifurcation Coronary Study: Old, New, and Evolving Strategies (BBC ONE)  concludes complex crush ,   culotte technique are to be  avoided  . Single  stent  is better than two stents  in bifurcation lesions .

Unanswered question

If  single stent is better than two , is  it not logical ,  ” No stent” would be better than single  stent ?

This question may sound a straw man like ! But the truth is  the success of  medical management  in COURAGE and OAT study  may  be  due this concept !

BBC ONE: Fewer MACE with provisional T-stenting for bifurcations

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