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Cases in Clinical Medicine Cardiology
Book · October 2021
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Milind S Phadke
Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College
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CASES IN CLINICAL MEDICINE
CARDIOLOGY
Ischemic Heart Disease
General Cardiology
Congenital Heart Disease
Valvular and Structural Heart Disease
Arrhythmias
SADANAND R SHETTY | MILIND S PHADKE
Founders CVD INDIA
(An Initiative of the Cardiovascular Diabetology Trust)
Foreword by Prof. C N Manjunath
CASES IN CLINICAL MEDICINE
CARDIOLOGY
Sadanand R Shetty
DM (Cardiology), MD, FACC, FSCAI, FCPS, FACA, FISE, FICC, FICP, FCSI
Emeritus Professor - Dr. DY Patil University School of Medicine, Nerul, Navi Mumbai
Head - Department of Cardiology, Somaiya Superspeciality Institute, Mumbai
CMD and Founder- Sadanand Healthy Living Center Ltd., Mumbai
Editor-in-Chief (India) - Cleveland Hall of Fame - Biography and Patient Education Book
Founder - CVD India
Milind S Phadke
MD, DM (Cardiology)
Additional Professor, Department of Cardiology
Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai
Consultant Cardiologist, Global Hospitals and Godrej Memorial Hospital, Mumbai, India
Co-Founder - CVD India
Dedication
To my parents Late Smt. Gulabi Shetty and Late Shri Raghunath Shetty
To my wife Mrs. Geeta Shetty and my daughters and sons-in-law Dr. Sadita and
Shri Chirag, Dr. Sandeeta and Dr. Rajarathna Hegde
-SRS
To my parents Mrs. Maya Phadke and Dr. Sudhir Phadke,
My wife Dr. Anjuman and my son Vedant
-MSP
To all our teachers and students - past, present and future
न चोरहाय� न च रा�हाय� न भ्रातृभा�ं न च भारकारी |
�ये कृते वध�त एव िन�ं िव�ा धनं सव�धन�धानम् ||
Thieves cannot steal it, nor kings take it away
It cannot be divided amongst brothers, nor is it heavy on your shoulders.
The more you spend, the more it grows
Truly, the wealth of knowledge is the greatest among all forms of wealth!
v
Foreword
In this era of digitalization and artificial intelligence, there is an explosion
of technology which is creating an atmosphere and attitude among some
physicians and cardiologists that many procedures are done without
proper evaluation. However, there cannot be a substitute to clinical
medicine, and therefore, even today, clinical examination of the patient is
relevant and extremely useful in making a provisional diagnosis, which is
usually the correct diagnosis in most cases.
The mantra of “Talk, Touch and Treat” continues to be a great approach. In these days
of aggressive interventional practice, one should always be aware of the consequences
and complications and should have the wisdom to know when to stop the procedure. The
physician should spend some time with the patients, and in many instances, proper history-
taking and good physical examination leads to the appropriate diagnosis. Our objective
should be focused on treating the patients and not treating the investigations and images.
There should not be any ego clashes in the Cathlab practice. Team effort and mutual discussions
go a long way in improving the skills and the outcome. Newer technologies and tools such
as OCT, IVUS, FFR, Debulking Devices, Valve Therapies and Rotablation Devices along with
wonder drugs such as P2Y2 Inhibitors have revolutionized Cardiovascular practices, hence
conquering many ports. Because of these recent advances, many contraindications have
become standard indications adding both life and years, resulting in better outcomes, as also
the quality of life with longer lifespans.
Interventional Cardiologists are under tremendous stress because of huge unrealistic
expectations from the patients and their relatives. Now this is popularly called as the “IDIOT”
i.e., Internet Derived Information Obstruction Treatment Syndrome.
Dr. Sadanand R Shetty in his book has emphasized and put lot of efforts, and presented
many clinical scenarios regarding selection of cases, approach and strategies which will be of
immense help to Interventional Cardiologists, as also practicing clinicians and postgraduate
students. He has covered all real time cases spreading over Ischemic Heart Diseases,
Congenital Heart Diseases and Valvular Heart Diseases and also the Arrhythmias. In this
process he has also provided useful tips and tricks of various procedures. Generally,
vii
Foreword
a standard textbook gives long descriptions and explanations which may not be readable
always, but Dr. Sadanand R Shetty has made sincere efforts to simplify the diagnostic and
management issues.
I appreciate Dr. Sadanand R Shetty and Dr. Milind S Phadke for publishing this book which
will be of immense help and act as a guide for Interventional Cardiologists and Post Graduate
Students.
“Decision making is more important “Treatment should not be more harmful
than performing any procedures” than the diseases”
“INTERPRETATION AND INTEGRATION OF SYMPTOMS HOLD THE KEY”
Dr. CN Manjunath
Professor of Cardiology & Director
Sri Jaydeva Institute of Cardiovascular Sciences and Research
Bangalore, India
viii
Contents
ISCHEMIC HEART DISEASE
1. Occluded IRA 48 Hours after MI: What Should be the Approach?................. 1
Sadanand R Shetty, Talha Abid and Avinash Guthe
2. A Case Illustrating the Clinical Utility of FFR................................................ 10
Brian Pinto and Neeraj A Desai
3. Approach to a Post-PCI Patient with Atrial Fibrillation................................. 18
Jamshed J Dalal
4. Current Practice of Rotational Atherectomy (Rotablation):
To Burr or Not to Burr...................................................................................... 23
Samuel Mathews and Ajit R Menon
5. A Case of Rotational Atherectomy in Saphenous Venous
Graft Intervention............................................................................................. 30
Manoj B Chopda and Amit Patel
6. A Case of ACS: How OCT Made a Difference................................................ 43
Rony Mathew and Anaz Bin Azeez
7. Tips and Tricks for Chronic Total Occlusion PCI.......................................... 53
Haresh Mehta and Ankur Phatarpekar
8. Elective Retrograde CTO Recanalization of Flush Ostial
Occlusion of Anomalous RCA........................................................................ 59
VT Shah
9. Anomalous Origin of the Right Coronary Artery from the
Left Aortic Sinus.............................................................................................. 65
Ketan Ambardekar and Milind S Phadke
10. Culprit-only vs. Complete Revascularization during Primary PCI............... 76
Dev B Pahlajani
xv
Contents
11. A Case of Complex PCI: How IVUS Helped in Decision Making.................. 85
Kirti Punamiya
12. Cardiogenic Shock in a Case of ST Elevation Myocardial Infarction.......... 92
Thomas Alexander
13. Post-CABG Coronary Steal Phenomenon.................................................... 100
Amit B Sanghvi and Jose F Diaz Fernandes
14. A Case of Bifurcation PCI: Modified TAP Technique................................... 105
Rajiv G Bhagwat and Ronak V Ruparelia
15. Robotics in Interventional Cardiology: A Case-based Approach...............111
Manoj B Chopda and Ganesh S Jagdale
16. Acute Ischemic MR Secondary to Papillary Muscle Rupture......................118
GR Kane
GENERAL CARDIOLOGY
17. Myocardial Infarction with Nonobstructive Coronary Arteries................... 128
Nitin Burkule
18. Transplant-related Renal Artery Stenosis: An Approach............................ 138
Praveen A Kulkarni and Milind S Phadke
19. Post PCI Infective Endocarditis: A Diagnostic and Therapeutic Dilemma......144
CK Ponde and Sumedh Ramteke
20. A Case Illustrating the Utility of Cardiopulmonary Testing........................ 150
Nitin Burkule
21. A Case of a Pregnant Patient with Pulmonary Hypertension . .................. 162
Prashant Bobhate and Sylvia Colaco
22. An Interesting Case of Heart Failure............................................................ 169
Mrinal Kanti Das and Jayanta Sharma
23. Constrictive Pericarditis: Clinical and Hemodynamic Approach............... 182
Ajit G Desai and Nikesh Jain
24. Infiltrative Cardiomyopathy Secondary to Amyloidosis:
The Role of Cardiac MRI . ............................................................................. 190
Bhavin Jankharia and Deepti Naik
xvi
Contents
25. Role of LV Strain Quantification in Cardio-oncology.................................. 196
Malav Jhala and Darshan Jhala
26. A Case of Aortoarteritis................................................................................. 202
Manotosh Panja and Madhu Panja
CONGENITAL HEART DISEASE
27. Large Atrial Septal Defect in an Adult: When not to Close......................... 214
Kshitij Sheth and Bharat Dalvi
28. A case of Multiple Left-sided Obstructive Lesions: Shone Complex........ 224
Varun Bhatia and Milind S Phadke
29. Percutaneous Pulmonary Valve Replacement ........................................... 232
Maulik Parekh and Bharat Dalvi
30. Practical Approach to Percutaneous Closure of Coronary AV Fistulae.... 243
Ajay U Mahajan and Zeeshan Ahmed Mumtaz
31. A Child with Unexplained LV Systolic Dysfunction..................................... 253
Snehal Kulkarni
32. A Case of Hypertensive PDA......................................................................... 261
Jay Relan and Sivasubramanian Ramakrishnan
VALVULAR AND STRUCTURAL HEART DISEASE
33. Approach to a Pregnant Patient with a Prosthetic Heart Valve.................. 273
PJ Nathani and Umesh Hange
34. A Case of Low-flow Low-gradient Aortic Stenosis...................................... 279
Malav Jhala and Darshan Jhala
35. Percutaneous Closure of Iatrogenic RV Perforation................................... 283
Shantanu Deshpande and Ameya S Chavan
36. Alcohol Septal Ablation in HOCM: A Step-by-step Approach.................... 289
Prafulla G Kerkar and Dhiraj Kumar
37. Case Selection in TAVR: The Role of Imaging............................................. 297
Anoop Titus and Ramesh Daggubati
xvii
Contents
38. A Challenging Case of Trans-septal Puncture............................................. 305
Ajith Ananthakrishna Pillai, Kabilan S Jagadheesan and
Balachander Jayaraman
39. A Case of Percutaneous Closure of Paravalvular Leak.............................. 314
JS Dugal and Ajit Mehta
40. Thoracic Aortic Aneurysm Repair: Role of EVAR........................................ 324
Rahul Sheth
41. Left Atrial Appendage Closure: Indications and Technique....................... 329
Ranjan Shetty
42. An Unusual Case of Aortic Regurgitation.................................................... 341
Kunal Sinkar and Robin Pinto
ARRHYTHMIAS
43. Bradycardia after Neurosurgery: Not Always Raised ICT.......................... 348
Milind S Phadke, Praveen A Kulkarni and Yash Lokhandwala
44. An Unusual Cause of Atrial Fibrillation........................................................ 354
Keerthika Ravella and Yash Lokhandwala
45. AICD: A Case Illustrating Practical Troubleshooting.................................. 362
Kaustubh Mahamine and Ameya Udyavar
46. Approach to a Patient on DOAC Presenting with Bleeding........................ 373
Ajay S Chaurasia, Jaywant M Nawale and Digvijay D Nalawade
47. Drug-induced QT Prolongation: A Case Report.......................................... 381
Vickram Vignesh R and Narsimhan Calambur
48. A Case of Ventricular Tachycardia in a Structurally Normal Heart............ 385
Pranav Oza and Ameya Udyavar
49. A Case of Tachycardia-induced LV Systolic Dysfunction ......................... 395
Rajesh Dhopeshwarkar
50. An Interesting Case of Bradyarrhythmia .................................................... 403
Chinmay Kulkarni and Amit Vora
xviii
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