Introduction: The primary line of management for symptomatic accessory pathway is catheter ablation. For effective mapping and ablation, accurate localization of the Accessary Pathway (AP) is critical but usually challenging, especially for the posteroseptal region. Aim: We aimed at studying the accuracy of different surface ECG algorithms in determining the site of posteroseptal AP in comparison with Electrophysiological study (EPS) and the ablation approach. Methods: We included 65 patients with possible manifest posteroseptal AP in a prospective observational study. Provisional determination of the site of AP was done using the Arruda et al. algorithm, the Fitzpatrick et al. algorithm, and the Pambrun et al. algorithm in both basal and maximal preexcitation conditions (using atrial pacing during EPS) and compared with the EPS localization. The ablation approach, either left or right was also recorded. Results: The current study included 65 patients with manifest posterospetal AP. Among them 48.5% were males with a mean age of 33±11 years. We have found that Pambrun's algorithm and Fitzpatrick’s algorithm (during resting ECG) had perfect agreement and accuracy [k 0.879 & 0.844, accuracy 95.4% (CI 87.1–99.0%) & 93.9% (CI 84.9–98.3%) respectively] and ablation approach [k 0.953 &0.864, accuracy 98.5% (CI 91.7– 99.9%) & 96.9% (CI 89.3–99.6%) respectively], followed by Fitzpatrick’s algorithm (during maximal preexcitation). However, Arruda's algorithm had moderate agreement both during resting and maximal preexcitation conditions. Conclusion: Pambrun’s and Fitzpatrick’s algorithms (resting ECG) showed the highest accuracy and strongest agreement with EPS for localization of posteroseptal AP and ablation approach, indicating their superior reliability for noninvasive prediction of the posteroseptal AP site.
Background: Acute myocardial infarction (AMI) in adults younger than 45 years is rising globally, and in South Asian populations it is a leading cause of disability-adjusted life-years lost. The pathophysiology is often distinct. Dyslipidemia, and in particular an elevated lipoprotein(a), together with hyperhomocysteinemia, thrombophilia and pro-thrombotic lifestyle factors, makes a greater contribution in older patients. Angiography frequently demonstrates a high thrombus burden in an otherwise minimally diseased coronary tree. In such patients, primary Percutaneous Coronary Intervention (PCI) alone may be complicated by distal embolization, no-reflow and stent thrombosis. Adjunctive strategies such as manual aspiration, glycoprotein IIb/IIIa inhibitors and, in selected cases, Intracoronary (IC) thrombolysis remain relevant. Case presentation: We report a 38-year-old previously healthy South Indian man who presented with anterior-wall ST-Elevation Myocardial Infarction (STEMI, Killip class I). Emergency coronary angiography demonstrated single-vessel disease with an 80–90% thrombotic lesion extending from the distal left main coronary artery into the proximal Left Anterior Descending artery (LAD), with distal TIMI II flow. Given the massive thrombus burden with preserved distal flow, 10 mg of IC tenecteplase was administered through the guide catheter into the left coronary system. A planned check angiogram on day 5 demonstrated complete recanalization of the LAD with no residual thrombus, and the patient was discharged on guideline-directed medical therapy without stent implantation. Metabolic evaluation identified marked elevation of lipoprotein(a) (151.5 nmol/L; reference 0–75), homocysteine (33.3 μmol/L; reference 5.4–16.2), LDL cholesterol (176 mg/dL) and mildly elevated thyroid-stimulating hormone (4.9 μIU/mL), providing a mechanistic explanation for coronary thrombosis in a young patient without traditional risk factors. Conclusion: This report contextualizes the case within contemporary evidence on young MI, non-traditional risk factors and IC thrombolysis, and proposes an algorithmic approach for the young STEMI patient presenting with a massive coronary thrombus burden.
The emergence of transcatheter valve-in-valve (ViV) procedures has fundamentally changed the management of bioprosthetic valve degeneration, providing a less invasive alternative to high-risk surgical reoperation. However, the long-term clinical success of future transcatheter interventions is largely predetermined at the time of the initial surgical valve replacement. This commentary discusses how initial prosthetic choice—type, design, and intraoperative sizing—impacts the patient’s lifelong therapeutic journey. While contemporary consensus guidelines present comprehensive frameworks balancing patient age, desire for pregnancy, frailty, and contraindications to oral anticoagulation, we emphasize an important geometric link. In patients with small annular anatomy, where the size of the implanted heart valve prosthesis is already borderline for severe prosthesis-patient mismatch (PPM), mechanical valves remain a reasonable, evidence-based alternative to maintain long-term hemodynamic stability when anticoagulation is feasible and tolerated. Conversely, larger rings foster a bioprosthetic approach focused on future transcatheter horizons. By integrating hydrodynamic evidence with international clinical guidelines, we present a conceptual strategic framework to guide modern heart teams.
Cardiac CT angiography (CCTA) has become a mainstream and integral part of many cardiology practices based on a vast base of literature supporting and validating its clinical utility. It is now recommended as a first-line test for the evaluation of chest pain according to the American Heart Association (AHA) and the American College of Cardiology (ACC). As the technology continues to advance, coronary imaging has improved in stride. Unfortunately, despite an arsenal of tests available to detect clinically significant coronary artery disease, many people continue to suffer acute myocardial infarction (MI) and other acute coronary syndromes, leading to significant morbidity and mortality due to unstable coronary artery disease (CAD). These unstable, “vulnerable” or high-risk plaques (HRP) continue to plague cardiologists across the globe. The ability to identify HRP has been a step in the right direction increasing more aggressive therapy. A large body of evidence supporting the utility of CCTA in plaque imaging has emerged and has defined characteristics of HRPs and their relationship to future coronary events. The potential of CCTA plaque imaging exists to not only identify HRP that can lead to more aggressive therapy, but to observe the transformation to stable plaque through follow-up CCTA imaging.
Background: Heart Failure with preserved ejection fraction (HFpEF) accounts for up to half of all heart failure and is increasing in prevalence. Unlike heart failure with reduced ejection fraction (HFrEF), HFpEF lacks a defining systolic abnormality, making diagnosis challenging—particularly when comorbidities mimic or confound the presentation. Objective: To provide general internists with a practical framework for integrating clinical judgement, laboratory data, and echocardiographic tools to diagnose and manage HFpEF. Methods: Current guidelines and key literature on HFpEF pathophysiology, diagnostic algorithms, and echocardiographic parameters were synthesized. A hypothetical case illustrates diagnostic and management decision points; all clinical data are fictional. Conclusion: Earlier recognition of HFpEF—using validated scoring systems, natriuretic peptides, targeted echocardiographic tools, and multidisciplinary collaboration—combined with guideline directed therapy can improve outcomes.
