Dr. Ajit Desai

Background: Complete atrioventricular block (CAVB) is a rare condition during pregnancy that poses significant risks to both the mother and the fetus. Its management requires a multidisciplinary approach to ensure maternal and fetal safety. Case summary: A 27-year-old primigravida at 28 weeks of gestation presented with recurrent syncopal episodes. Electrocardiography confirmed complete atrioventricular block, and 24-hour Holter recording showed advanced atrioventricular block. Given her symptomatic presentation, a single-chamber permanent pacemaker was implanted under local anesthesia. The procedure was uneventful, and the patient remained hemodynamically stable throughout the intrapartum and postpartum periods. Close monitoring was maintained, and she delivered a healthy baby trans-vaginally at term. Discussion: The management of CAVB during pregnancy is challenging because of the physiologic changes in pregnancy and the potential impact on the fetus. Although asymptomatic patients may be managed conservatively, pacemaker implantation is necessary for symptomatic cases to prevent complications such as syncope, heart failure, or sudden cardiac arrest. The literature highlights the safety and efficacy of permanent pacemaker implantation during pregnancy when performed with appropriate precautions. This case underscores the importance of early recognition, prompt intervention, and a collaborative approach among specialists to optimize outcomes for both the mother and the fetus. Take-home messages: CAVB during pregnancy requires individualized management, and symptomatic cases benefit from timely pacemaker implantation. A multidisciplinary approach is critical for successful maternal and fetal outcomes.

Intra-procedural stent thrombosis (IPST) is defined as the development of occlusive or non-occlusive new thrombus in or adjacent to a recently implanted stent before the PCI procedure is completed. The frequency of occurrence currently ranges between 0.5 – 1.7% of all PCI procedures and it seems to be considerably reduced with newer drug eluting stents and improved techniques. The occurrence of IPST is relatively rare, even in ACS patients, and is related strongly to clinical presentation and procedural factors (e.g., anticoagulation regimen, lesion type, presence of thrombus at baseline, stent under expansion and edge dissection etc.) than to baseline demographic characteristics. Imaging modalities like IVUS or OCT can prevent as well as identify the underlying cause for IPST. IPST not only decreases success rate of PCI but is also associated with higher rates of slow flow or no reflow, distal embolization and side branch closure. It is also associated with higher mortality, myocardial infarction, ischemia driven revascularisation and stent thrombosis on follow up. IPST can be managed immediately in cath lab and involves use of GP2b3a inhibitors, optimising stent apposition by repeat balloon dilatation, use of imaging to identify the cause and accordingly corrective measures to be taken. Rarely emergency CABG may be required if underlying cause cannot be corrected. Prevention is the key. IPST can be prevented by using newer anti-platelets, use of GP2b3a inhibitors especially in presence of ACS or high thrombus load, preparing the lesion well before stenting, use of atherectomy devices when needed, appropriate stent size selection and use of imaging modalities in complex lesions to optimise stent selection and apposition. We describe three cases of the intra procedural stent thrombosis under different clinical scenarios and its management.