Multiple myeloma (MM) can present with involvement of the central nervous system in the form of nerve palsy, plasma cell masses or, rarely, with endocrinological effects due to involvement of the pituitary gland. Usually, in such cases, the disease has a rapid progression and poor prognosis. We report a 52-year-old man who was admitted to the Kolkata Medical College, Kolkata, India, in 2016 with a prolonged low-grade fever and hypernatremia. Shortly afterwards, the patient began to complain of increased urinary frequency and drowsiness. The hypernatremia was treated with intranasal desmopressin and free water replacement. Serum protein electrophoresis and an immunofixation study revealed an immunoglobulin G-κ monoclonal band. Magnetic resonance imaging of the pituitary gland revealed the absence of a posterior bright spot and spotty infiltration of the pituitary fossa. A bone marrow biopsy confirmed a diagnosis of cranial diabetes insipidus due to posterior pituitary MM infiltration.

Background Coronary artery pseudoaneurysms (PSAs) are uncommon and have poorly understood natural history. Unlike true aneurysms, PSAs do not have all the three layers of the vessel in the aneurysmal wall. PSAs are most commonly seen after an overzealous percutaneous coronary intervention (PCI) which causes damage to the vessel wall. They usually develop slowly after PCI and PSAs within a month of a PCI are not so common. PSA may be asymptomatic or present with recurrent angina. Case summary Here, we report a case of symptomatic PSA to right coronary artery (RCA). The patient had a myocardial infarction for which a PCI was performed to deploy a drug eluting stent (DES) in the RCA. The patient had in-stent restenosis (ISR) within a week of PCI for which plain old balloon angioplasty (POBA) was performed. The patient continued to have unstable angina and within a month of POBA was diagnosed as a case of PSA by intravascular ultrasound. A covered stent was deployed which effectively sealed off the PSA and resumed normal blood flow to distal vessel. Patient has been doing well on medication (aspirin75  mg once daily, atorvastatin 80  mg once daily, and P2Y12 platelet inhibitor [Ticagrelor] 90  mg twice daily). Discussion PSA usually tale six to nine months to develop. However, PSAs have been reported within one to two months of PCI. This case also shows that PSAs can occur within a month of PCI. It is possible that over-aggressive and/or high pressure dilatation and/or deep engagement during POBA performed to open up the ISR could have damaged the struts of the DES and compressed it against the vascular wall. The resultant vascular wall injury could have been the cause of early PSA formation in this case. Hence, cardiologists should be vigilant enough to suspect PSA, especially in a patient presenting with angina. The case also shows that covered stents are a viable option to treat early presentations of PSA.

Acute Pulmonary Thromboembolism [PE] is associated with high mortality, similar to that of myocardial infarction and stroke. We studied the clinical presentation and management of PE in the Indian population. An analysis of 140 patients who presented with acute PE at a large volume center in India from June 2015 through December 2018 was performed. The mean age of our study population was 50 years with 59% being male. Comorbidities including Deep Vein Thrombosis [DVT], diabetes mellitus, hypertension, and Chronic Obstructive Pulmonary Disease [COPD] were present in 52.9%, 40%, 35.7% and 7.14% of patients, respectively. Out of 140 patients, 40 [28.6%] patients had massive PE, 36 [25.7%] sub-massive PE, and 64 [45.7%] had low risk PE. Overall, in-hospital mortality was 25.7%. Multivariate regression analysis found chronic kidney disease and PE severity to be the only independent risk factors. Thrombolysis was performed in 62.5% of patients with a massive PE and 63.9% of patients with a sub-massive PE. In the massive PE group, patients receiving thrombolytic therapy had lower mortality compared with patients who did not receive therapy[p=0.022], whereas this difference was not observed in patients in the sub-massive PE group. We conclude that patients with acute PE in India presented more than a decade earlier than our western counterparts, and it was associated with poor clinical outcomes. Thrombolysis was associated with significantly reduced in-hospital mortality in patients with massive PE.

Background Coronary artery aneurysms after drug eluting stents are rare. We present a case series of type II coronary aneurysms after implantation of Everolimus eluting stents including patients developing giant aneurysms with a toxic course. Case presentation Over a span of 3.5 years at our center 2572 patients were implanted Everolimus eluting stents out of which 4 patients developed coronary type II aneurysms an incidence of 0.00156 whereas 5838 patients were implanted Sirolimus eluting 2nd generation stents out of which 2 patients developed similar aneurysms with an incidence of 0.00034. The slight increase in incidence in Everolimus stents does not reach statistical significance (p = 0.054) and is limited by single centre non randomized study. We also propose a hypothesis that the slight increase in the incidence maybe due to allergy to Methacrylate present in Everolimus eluting Xience stent’s primer which is absent in other Sirolimus eluting stents used at our center but that needs to be further investigated. We also found some patients who developed giant aneurysms including Left main aneurysms. In our series operative repair of these patients had better outcomes than covered stent deployment but larger trials maybe needed to confirm the same. Conclusions Coronary artery aneurysms after stent implantation are rare but occasionally giant aneurysms are formed with a toxic course. The incidence and morphology of aneurysms after Everolimus and Sirolimus eluting stent deployment do not differ much.

Funding Acknowledgements Type of funding sources: None. Background Assessment of cardiac viability based revascularization has not convincingly demonstrated, to improve patient outcomes statistically even by large trials like STITCH and PPAR-2 using SPECT and PET analysis. Here we used cardiac viability by cardiac MRI to guide us for revascularization and also found out problems arising in the statistical analysis for the same Methods It is a retrospective observational longitudinal follow up study whereby patients who had ischemic cardiomyopathy (confirmed with coronary angiogram) and who were admitted with features of heart failure or with acute coronary syndrome and who subsequently underwent cardiac MRI viability testing during the period from 1/02/2017 to 31/01/2020 were included. Patients were excluded who had non ischemic cardiomyopathy. Using cardiac MRI- LVEF, RVEF, Wall motion severity Index and Total viability percentage were additionally computed and analyzed. Patients were deemed having viable myocardium on ≤50% LGE in cardiac MRI and final treatment of CABG, PCI or only medical management was analyzed for the Primary end points of CV mortality, non-fatal CVA and non-fatal AMI  Results Based on the criteria total of 94 patients were selected for the study, 53 patients kept on only medical management, 19 patients underwent PCI and 22 patients had CABG. The baseline characteristics of the study population were an average age of 60years, male (76%) with Diabetes Mellitus(69%) and Hypertension (41.5%) in them. Coronary Angiogram showed that 10.6% patients had LM involvement, 92% had LAD disease, 72% patients had LCX lesion and 74% had RCA disease. While average Echo LVEF was 35.82%, Cardiac MRI based mean LVEF was 30.78%. It was found that patients who were kept only on medical management had higher Wall motion Severity Index (2.05) over patients who  were treated with PCI (1.94) or CABG (1.80) (p = 0.006). Also it was found that the Total viability percentage was less in patients kept only on medical management (74%) vs patients who were treated with PCI (78%) or CABG (77.8%)(p = 0.08) .It was found by cardiac MRI that patients with significant LAD lesions with viable LAD territory, those who underwent CABG or PCI based therapy had lesser mortality(7.69%,10%) over patients kept only on medical management (23%) (p = 0.407). Among patients with significant LAD lesions with non-viable LAD territory, those who underwent CABG or only medical management had lesser mortality (11.5%) than patients who underwent PCI (50%) (p = 0.137). Conclusion(s) Cardiac MRI based viability testing may guide the physician for optimal treatment but it does not reach statistical significance. The reasons maybe different arterial segments having different viability and anatomical hazards acting as cofounding factors. Viability being a continuum process does not follow a strict cut off of 50% LGE and 100% acute occluded vessel may not allow LGE.