Intravenous immunoglobulin is frequently used in the treatment of autoimmune and hematologic disorders. While generally well tolerated, intravenous immunoglobulin administration can rarely precipitate serious cardiovascular events, including acute coronary syndrome, particularly in patients with preexisting atherosclerotic disease. We report the case of a 61-year-old woman with systemic lupus erythematosus, prior coronary artery disease, and immune thrombocytopenic purpura who developed non-ST elevation myocardial infarction following high-dose intravenous immunoglobulin therapy. Coronary angiography revealed critical stenoses in the left anterior descending and left circumflex arteries, and successful percutaneous coronary intervention was performed. This case highlights the importance of careful cardiovascular assessment prior to intravenous immunoglobulin initiation in high-risk individuals and the need for monitoring for ischemic symptoms during infusion in susceptible populations.

Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is standard following PCI. Ticagrelor is increasingly preferred due to its potent, reversible platelet inhibition. While generally safe, ticagrelor has been associated with conduction abnormalities, including sinus pauses and atrioventricular (AV) block, though clinically significant bradyarrhythmias remain rare. We report a rare case of symptomatic 2:1 Mobitz type II AV block following ticagrelor initiation post-PCI and emphasize the importance of timely recognition to avoid unnecessary pacemaker implantation. We describe a 68-year-old woman presenting with unstable angina. Coronary angiography revealed significant mid-RCA disease, and PCI with a sirolimus-eluting stent was performed successfully. She was discharged on aspirin and ticagrelor, without rate-limiting drugs, as her baseline heart rate was 60 bpm. Two weeks later, she developed dizziness and dyspnea (NYHA III). ECG showed 2:1 Mobitz type II AV block with a ventricular rate of 40 bpm. Repeat angiography confirmed a patent stent, and thyroid profile was normal. Holter monitoring corroborated persistent AV block. Ticagrelor was discontinued and replaced with clopidogrel, resulting in the restoration of sinus rhythm. On follow-up, the patient remained asymptomatic with normal ECG findings. Ticagrelor can rarely induce clinically significant AV block even in the absence of other rate-limiting drugs. Clinicians should maintain a high index of suspicion when post-PCI patients on ticagrelor present with bradyarrhythmias. Withdrawal of ticagrelor should be considered before resorting to pacemaker implantation, thereby preventing unnecessary interventions.

Prosthetic valve endocarditis, though a rare complication, carries a high risk of morbidity and mortality. Mycotic aneurysms are even less common and have been reported in association with femoral access (femoral artery aneurysms) following transcatheter aortic valve replacement (TAVR). We describe a rare case of a mycotic aneurysm that developed in the ascending aorta after a TAVR procedure.

BACKGROUND:Coronary microvascular dysfunction is implicated in ∼two-thirds of ischaemia with no obstructive coronary artery disease (INOCA) cases and is significant due to its association with a higher risk of major adverse cardiac events (MACE). While invasive techniques are the gold standard for diagnosing coronary microvascular dysfunction (CMD), positron emission tomography (PET) offers a noninvasive approach to quantifying myocardial blood flow (MBF) and detecting CMD. This study aimed to quantify myocardial flow reserve (MFR) using PET in INOCA patients to identify CMD and to correlate it with thrombolysis in myocardial infarction (TIMI) and TIMI myocardial perfusion grade (TMPG) angiographic flow grades. METHODS:Thirty INOCA patients with angiographic evidence of non-obstructive coronaries and slow flow were prospectively enrolled and underwent dynamic rest and stress cardiac 13N-NH3 PET with MBF and MFR quantification. Patients with MFR values below 2.3 were classified as having CMD. Angiographic flow grades (TIMI and TMPG) were correlated with MFR and MBF. RESULTS:The mean global stress MBF and MFR for the study cohort were 2.54 ± 0.72 mL/minute/gm and 2.91 ± 0.81, respectively. No significant correlation was found between MFR and TIMI (r = -0.140, P = 0.108) or MFR and TMPG (r = -0.06, P = 0.446). Among the participants, 8 (27 %) had reduced global MFR less than 2.3 (mean: 1.80 ± 0.36), indicating CMD. The remaining 22 patients (73 %) had normal MFR values. Within the CMD group, 3 patients had functional CMD with elevated resting MBF, while 5 had classic CMD with blunted hyperaemic response to vasodilator stress. CONCLUSIONS:PET is an excellent noninvasive modality for diagnosing CMD. Coronary slow flow in angiographically normal arteries does not correlate with 13N-NH3 PET MFR values and is not a reliable marker for identifying CMD as indicated by the study's findings.

The Edwards Sapien (Edwards Lifesciences, Irvine, CA, USA) transcatheter heart valves (THVs) and the Myval THVs (Meril Life Sciences, Vapi, Gujarat, India) are two balloon-expandable valve systems used for transcatheter aortic valve implantation (TAVI). This systematic review and meta-analysis aimed to compare the clinical and hemodynamic outcomes at 30 days after TAVI using the Myval versus the Edwards Sapien 3 valve in patients with severe aortic stenosis (AS). We conducted a systematic search of PubMed, Embase, Cochrane Library, and clinicaltrials.gov up to June 21, 2025. The inclusion criteria were observational studies or interventional trials comparing Myval or Myval Octacor with Edwards Sapien 3 or Sapien 3 Ultra in patients with severe AS undergoing TAVI. The risk of bias was assessed using the Cochrane Risk of Bias Tool 2 for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale for observational studies. Pooled estimates were derived using a random-effects model. The primary outcomes were all-cause mortality, new permanent pacemaker implantation (PPI), and major vascular complications assessed at 30 days. A predefined subgroup analysis was performed based on the study design. The study protocol was registered on the INPLASY database (INPLASY202560110). Four studies (two retrospective cohort and two RCTs) with 1973 patients (18.6% in observational and 81.4% in RCTs) met the inclusion criteria. Out of the total, 1081 (54.8%) patients received Myval and 892 (45.2%) received Sapien 3 valves. No significant difference was observed in all-cause mortality (risk ratio (RR): 1.14, 95% CI: 0.55-2.37; p = 0.73; I2 = 0), rate of new PPI (RR: 0.92, 95% CI: 0.49-1.74; p = 0.81; I2 = 82%), or major vascular complications (RR: 0.70, 95% CI: 0.19-2.52; p = 0.58; I2 = 33%) at 30 days. The findings were consistent in the subgroup analysis among observational studies and RCTs. Moderate to severe aortic regurgitation (AR) (RR: 2.58, 95% CI: 1.14-5.84; p = 0.02; I² = 0%) and new-onset atrial fibrillation (AF) (RR: 2.0, 95% CI: 1.10-3.63; p = 0.02; I² = 0%) were higher with Myval. Mean gradient was lower (mean difference: -2.85 mmHg, 95% CI: -3.88 to -1.82 mmHg; p < 0.001; I² = 82%) and effective orifice area was larger (mean difference: 0.28 cm2, 95% CI: 0.16-0.40 cm2; p < 0.001; I² = 84%) with Myval. Other secondary outcomes and procedural outcomes were comparable. To conclude, primary outcomes were comparable between the two THVs. The Myval had better hemodynamic parameters at 30 days but a higher rate of moderate to severe AR and new-onset AF. Further studies are needed to assess medium- and long-term outcomes between the two valves.

Aim: The index study aimed to investigate the clinical impact of initial high-sensitivity C-reactive protein (hs-CRP) on outcomes in nonvalvular atrial fibrillation (AF). Methods: Single-center, prospective, observational study recruiting all recently diagnosed treatment-naive AF patients. Hs-CRP was measured at baseline and patients were followed for 24 months. Results: A total of 126 patients with a mean age of 66.2 (±12.0) years were enrolled. The composite outcome of major adverse cardiac or cerebrovascular events (MACCE) occurred in 19 (17.7%) at 24 months. Raised initial hs-CRP emerged as an independent predictor of MACCE on regression analysis (OR: 1.569, 95% CI: 1.289-1.912; p < 0.001). Conclusion: Raised hs-CRP was an independent predictor of MACCE at 24 months. It allows for early identification of high-risk patients.

Detecting cardiac sarcoidosis; a potentially life-threatening condition is challenging and requires a multimodality imaging approach using echocardiography, PET/CT and CMR. Although 18F-FDG is the recommended PET tracer for evaluating cardiac sarcoidosis, it is limited by physiological cardiac FDG uptake and requires stringent patient preparation/ dietary modifications before imaging. We hereby present a case of cardiac sarcoidosis demonstrating myocardial FAPI uptake on cardiac PET, highlighting the potential role of 68Ga-FAPI PET in the evaluation of cardiac sarcoidosis.

Background: COVID-19 can cause severe pneumonia that can progress to multiple organ failure. It is believed that dysregulation of inflammation and cytokine storm, contributes to severe COVID-19. As inflammatory mediators play an important role in the pathogenesis of the severe disease, inflammatory markers like fever, leucocytosis, and C-reactive protein are known to predict severe disease. Various other biomarkers have been known to have prognostic value in patients with COVID-19 infection. Inflammation, both local and systemic plays an important role in the pathogenesis of acute coronary syndrome (ACS). Thus in this study, we aimed to compare and describe the various biomarkers, and mortality between patients admitted with COVID-19 infection and ACS patients without COVID-19 infection. Methods: In a retrospective observational case-control study, a total of 108 patients admitted to our hospital during the month of May 2021 with COVID-19 were enrolled. Patients of the acute coronary syndrome (tested negative for COVID-19 infection) admitted during the same month were enrolled (including both the intensive care unit and ward) as controls. Results: The median age of patients with COVID was significantly lower than that of patients with acute coronary syndrome [49 years (IQR, 36-62 years) and 60 years (IQR, 52-66 years)]. Left ventricular ejection fraction was significantly higher among patients with COVID infection (58.5 ± 6.3% versus 36.9 ± 9.3%). The total leukocyte count was significantly higher among patients with COVID-19 compared to those with acute coronary syndrome [13200 per microliter (8625-17500) vs 9800 per microliter (8150-12150), P < 0.001]. The blood urea level was significantly higher among patients with COVID infection [52.5 (IQR, 34.7-81.5) versus 20 (IQR, 16-31)]. Levels of C-reactive protein were significantly higher among patients with COVID [39 (IQR, 7.7-100) versus 2 (1.4-3.5)]. The mortality of patients hospitalized with COVID was 4 times higher than those with acute coronary syndrome [25.9% (28) versus 6.1% (6)]. Survivors of COVID-19 had higher hemoglobin levels than those who did not [12.5 g/dLvs 11.5 g/dL, P = 0.03]. Conclusions: Elevated total leukocyte counts reflect underlying secondary bacterial infection among patients with COVID-19 and help initiate appropriate antibiotics. Depletion of intravascular volume reflected by an increased urea/creatinine ratio increases the risk of mortality and warrants aggressive measures of rehydration and albumin infusion.

BACKGROUND:Coronavirus disease 2019 (COVID-19) pandemic unmasked the huge deficit in healthcare resources worldwide. It highlighted the need for efficient risk stratification in management of cardiovascular emergencies.AIM:To study the applicability of the old, available and affordable nonconventional biomarkers: albumin and fibrinogen in their ability to predict angiographic severity and clinical outcomes in patients with acute coronary syndrome (ACS).METHODS:In this prospective, observational study, 166 consecutive patients with ACS were enrolled. Fibrinogen, albumin and their ratio were determined from serum. Patients with underlying chronic liver disease, active malignancy, autoimmune disease, active COVID-19 infection and undergoing thrombolysis were excluded.RESULTS:Mean age of the population was 60.5 ± 1.5 years, 74.1% being males. ST elevation myocardial infarction (STEMI) was most common presentation of ACS seen in 57% patients. Fibrinogen albumin ratio (FAR) ≥ 19.2, had a sensitivity of 76.9% and specificity of 78.9 % [area under the receiver operating characteristic curves (AUROC) = 0.8, P = 0.001] to predict ≤ thrombolysis in myocardial infarction (TIMI) 1 flow in culprit artery in STEMI patients. Even in non-STEMI patients, FAR ≥ 18.85 predicted the same with 80% sensitivity and 63% specificity (AUROC = 0.715, P = 0.006).CONCLUSION:Novel biomarkers, with their high cost, lack of availability and long turn over time are impractical for real-world use. Identifying ≤ TIMI 1 flow in the culprit artery has significant impact of management and outcome. Our study has shown that readily available biomarkers like fibrinogen and albumin can help identify these high-risk patients with good accuracy. This allows risk-stratification and individualization of treatment in ACS.

BACKGROUND:The presence of angiographic thrombus is associated with poor outcomes in contemporary cardiology practice. Percutaneous coronary intervention (PCI) in such lesions is associated with slow flow and no-reflow phenomenon which translate into poor clinical outcomes.METHODS:This was a single-centre, prospective, open-label, randomized controlled study with 50 patients each in intervention group and control group. Patients with angiographically proven large thrombus burden were recruited. In the intervention group, patients were given loading dose of intracoronary tirofiban (25 mcg/kg infused over 5 minutes) followed by prolonged infusion of tirofiban (0.15 mcg/kg/min for 12-18 hours) followed by PCI after 48-72 hours interval. In control group patients were taken up directly for PCI during the index procedure. Outcomes were assessed angiographically and in terms of clinical endpoints.RESULTS:The primary composite-endpoint of recurrent angina, myocardial infarction, cardiovascular death, target lesion revascularization and unscheduled CABG was significantly lower in the intervention arm compared to control arm (4% vs 16%, p = 0.04). Amongst the secondary endpoints, a statistically significant 30-day increase in ejection fraction from baseline was observed in the intervention group compared to the control group (1.6 ± 1.3 vs 0.2 ± 0.4, p = 0.0001). Overall mortality was similar in the two groups (4% vs 8%, p = 0.39). The primary safety endpoint of major bleeding was also similar in the 2 groups (2% vs 0%, p = 0.31).CONCLUSIONS:Tirofiban use prior to PCI in high thrombus burden was associated with improved clinical and angiographic endpoints with similar adverse events compared to controls.

Introduction: Contemporary evidence suggest the comparable performance of biodegradable polymer sirolimus eluting stents (BPSES) with that of second generation durable polymer drug eluting stents. This study was done to evaluate the performance of BPSES in all comer patients undergoing percutaneous intervention (PCI) in real world setting over a period of three years. Materials & Methods: This was a prospective observational study, wherein all comer consecutive patients undergoing PCI with BPSES (Yukon Choice Elite stent by Translumina Therapeutics, India) were enrolled and followed up for 3 years. The study's primary endpoint was the Device Oriented Composite Endpoint (DOCE), which included cardiac death, target vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR); the co-primary endpoint was the Patient-Oriented Composite Endpoint (POCE), which included all-cause mortality, any MI , and any repeat revascularization and the secondary endpoint was definite or probable stent thrombosis (DST & PST). Results: 301 patients with 502 lesions were treated with 485 BP-SES. Mean age of the study cohort was 61.6± 9.3 yrs and males were 79.1%. 18.6% patients were diabetic, 29.6% had ejection fraction less than 40% and 73.1% patients presented with acute coronary syndrome (ACS). Majority of the patient had triple vessel disease (TVD) (51.8%), multivessel PCI was done in 15.6% and complex PCI in 26.2% patients. A mean of 1.6 ±0.8 stents per patient with mean diameter 3.0 ± 0.3 mm and mean length of 27.2 ± 0.8 mm were placed. DOCE & POCE occurred in 7.9% (cardiac death-4.8%, TLR-2.6% & target vessel MI-0.4%) and 12.8% (All deaths-9.7%, any MI- 0.4% and any revascularisation-2.6%) patients respectively at three years follow-up. DST & PST rate was 0.9% and 0.4% respectively in the study cohort. All the cases of stent thrombosis occurred within 30 days. Kaplan Meier analysis revealed that diabetes mellitus, low ejection fraction (EF), acute coronary syndrome (ACS), long stents and complex intervention had no impact on occurrence of DOCE & POCE while using BP-SES in all-comer patient population. Conclusion: Present study showed favourable long term safety and efficacy profile of BP-SES for all-comer patients undergoing PCI.

The presence of angiographic thrombus is associated with poor outcomes in contemporary cardiology practice. Percutaneous coronary intervention (PCI) in such lesions is associated with slow flow and no-reflow phenomenon which translate into poor clinical outcomes.This was a single-centre, prospective, open-label, randomized controlled study with 50 patients each in intervention group and control group. Patients with angiographically proven large thrombus burden were recruited. In the intervention group, patients were given loading dose of intracoronary tirofiban (25 mcg/kg infused over 5 minutes) followed by prolonged infusion of tirofiban (0.15 mcg/kg/min for 12-18 hours) followed by PCI after 48-72 hours interval. In control group patients were taken up directly for PCI during the index procedure. Outcomes were assessed angiographically and in terms of clinical endpoints.The primary composite-endpoint of recurrent angina, myocardial infarction, cardiovascular death, target lesion revascularization and unscheduled CABG was significantly lower in the intervention arm compared to control arm (4% vs 16%, p = 0.04). Amongst the secondary endpoints, a statistically significant 30-day increase in ejection fraction from baseline was observed in the intervention group compared to the control group (1.6 ± 1.3 vs 0.2 ± 0.4, p = 0.0001). Overall mortality was similar in the two groups (4% vs 8%, p = 0.39). The primary safety endpoint of major bleeding was also similar in the 2 groups (2% vs 0%, p = 0.31).Tirofiban use prior to PCI in high thrombus burden was associated with improved clinical and angiographic endpoints with similar adverse events compared to controls.

BACKGROUND:To determine the accuracy of global longitudinal strain and territorial longitudinal strain in determining myocardial viability in comparison to single-photon emission computed tomography in out of window period anterior wall myocardial infarction patients.METHODS:This was a single-center, prospective study carried out in a tertiary care center in northern India. All patients presenting with anterior wall myocardial infarction-out of window period without ongoing chest pain and akinetic left-anterior descending territory on echocardiography were recruited. All patients underwent strain echocardiography and the determination of both global longitudinal strain and territorial longitudinal strain within 12-48 hours of anterior wall myocardial infarction. In addition, all underwent single-photon emission computed tomography to determine the viability status of the anterior myocardium.RESULTS:Fifty-one patients of anterior wall myocardial infarction-out of window period were enrolled and underwent strain imaging with speckle tracking and single-photon emission computed tomography for viability determination. Gobal longitudinal strain and territorial longitudinal strain were significantly reduced in patients with nonviable myocardium (P < .001). On receiver-operating curves, a gobal longitudinal strain of <10.45% had a sensitivity of 77.8% and specificity of 93.9% (AUC=0.889) in predicting nonviability on single-photon emission computed tomography. Similarly, a territorial longitudinal strain of <7.60% had a sensitivity of 77.8% and specificity of 84.8% (AUC=0.825) in predicting nonviability.CONCLUSIONS:Treatment strategies in patients presenting with anterior wall myocardial infarction, outside the window period is largely guided by the hemodynamic status and influenced by the viability status of the myocardium. Strain echocardiography using speckle tracking provides gobal longitudinal strain and territorial longitudinal strain, both of which have good sensitivity and specificity in predicting viability and can be performed safely and quickly in high-risk group of patients.