Ajay Mahajan

Comparative randomized study on efficacy of losartan versus propranolol in lowering portal pressure in decompensated chronic liver disease

This study aimed to compare the efficacy of losartan, an angiotensin II receptor antagonist, with propranolol on portal hypertension in patients with decompensated chronic liver disease.

Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India

Santanu Guha*, Rishi Sethi, Saumitra Ray, Vinay K. Bahl, S. Shanmugasundaram, Prafula Kerkar, Sivasubramanian Ramakrishnan, Rakesh Yadav, Gaurav Chaudhary, Aditya Kapoor, Ajay Mahajan, Ajay Kumar Sinha, Ajit Mullasari, Akshyaya Pradhan, Amal Kumar Banerjee, B.P. Singh, J. Balachander, Brian Pinto, C.N. Manjunath, Chandrashekhar Makhale, Debabrata Roy, Dhiman Kahali, Geevar Zachariah, G.S. Wander, H.C. Kalita, H.K. Chopra, A. Jabir, JagMohan Tharakan, Justin Paul, K. Venogopal, K.B. Baksi, Kajal Ganguly, Kewal C. Goswami, M. Somasundaram, M.K. Chhetri, M.S. Hiremath, M.S. Ravi, Mrinal Kanti Das, N.N. Khanna, P.B. Jayagopal, P.K. Asokan, P.K. Deb, P.P. Mohanan, Praveen Chandra, (Col.) R. Girish, O. Rabindra Nath, Rakesh Gupta, C. Raghu, Sameer Dani, Sandeep Bansal, Sanjay Tyagi, Satyanarayan Routray, Satyendra Tewari, Sarat Chandra, Shishu Shankar Mishra, Sibananda Datta, S.S. Chaterjee, Soumitra Kumar, Soura Mookerjee, Suma M. Victor, Sundeep Mishra, Thomas Alexander, Umesh Chandra Samal, Vijay Trehan

Gerbode Defect-A Rare Defect of Atrioventricular Septum and Tricuspid Valve.

Left ventricular to right atrial communications (the Gerbode defect) are rare types of ventricular septal defect and present as direct or an indirect type. We hereby, report two cases, one direct and another indirect type. Cardiopulmonary bypass surgery was done and a successful suture closure of ventricularseptal defect using pericardial patch was performed.

Tetralogy of Fallot with Holt–Oram syndrome: case report and review

Holt–Oram syndrome was first reported in 1960 by Mary Clayton Holt and Samuel Oram, who detected an atrial septal defect in members of four generations of a family which was associated with a congenital anomaly of the thumb which lay in the same plane as the fingers [1]. The most common congenital heart defect is the ostium secundum atrial septal defect (60 %), seen in patients with Holt–Oram syndrome followed by the ventricular septal defect. The other associated findings include hand malformations and conduction disturbances, originally described by Holt and Oram [2]. The two most common complex heart defects in HOS are atrioventricular canal defects and tetralogy of Fallot [3]. Recently, we came across a case of the right hand and forearm malformation with cyanosis, which was later identified as tetralogy of Fallot. A 3-year-old male child presented with fatiguability, bluish discoloration, and growth retardation, since 6 months of age. The patient also had a right hand malformation in the form of radial deviation at the wrist and cubitus valgus deformity of right upper limb and hypoplastic right thumb being in the same plane as fingers (Fig. 1a). None of the other family members was affected. Patient had cyanosis, which increased on crying and did not improve on 100 % oxygen inhalation. Grade II clubbing was also present. Apex beat was within midclavicular line at the fifth intercostal space. A systolic thrill was present at the upper left intercostal space. Right ventricular inflow pulsations were present. Ejection systolic murmur was heard at mid and upper left third intercostal space. A single second heart sound (S2) was heard. Right thumb was hypoplastic in comparison to left thumb. Right hand was deviated radially at the wrist with flexion deformity of the wrist. The rest of the systemic examination did not reveal any abnormality. Lab findings included haemoglobin—18 mg/dl, total white blood cell count—11,200/mm, platelet count—124,000/ mm, haematocrit—69 %, mean corpuscular volume—71 fl. Radiograph right hand showed hypoplastic proximal phalanx of thumb, hypoplastic distal radius, radial deviation of the right wrist (Fig. 1b). Chest radiograph posterior–anterior view revealed no cardiomegaly (cardiothoracic ratio \50 %), boot-shaped heart (Coeur en sabot), main pulmonary artery inconspicuous (concave), decreased pulmonary vascularity (Fig. 1c). Electrocardiogram showed right ventricular hypertrophy, right axis deviation, sinus rhythm (Fig. 1d). Two-dimensional echocardiography with colour Doppler showed situs solitus, levocardia, large perimembranous subaortic ventricular septal defect with 40 % aortic override with right to left shunt (Fig. 2a), aorto-mitral continuity present, hypoplastic left pulmonary artery, dilated right pulmonary artery, predominantly infundibular pulmonary stenosis with peak gradient of 50 mmHg (Fig. 2b), interatrial septum is intact, right-sided aortic arch, no patent ductus arteriosus or any other defect seen. Cardiac computed tomography (Fig. 2c) and cardiac catheterization findings are consistent with echocardiogram. We concluded from the above findings that this was a case of tetralogy of Fallot associated with Holt–Oram syndrome. The patient is advised corrective surgery for & Abhay Tidake abhaytidake@gmail.com

Left ventricular function by echocardiogram in children with sickle cell anaemia in Mumbai, Western India.

INTRODUCTION Cardiovascular events and complications are the leading cause of mortality and morbidity in patients with sickle cell disease. Cardiac abnormalities occur frequently and at an early stage in sickle cell anaemia patients, despite being more evident in adulthood. Sickle cell anaemia patients are increasingly able to reach adulthood owing to improved healthcare, and may, therefore, suffer the consequences of chronic cardiac injury. Thus, the study of cardiac abnormalities is essential in children OBJECTIVE The aim of this study was to determine the echocardiographic changes in left ventricular function in children suffering from sickle cell disease in Mumbai, Western India. METHODS The study comprised of 48 cases of sickle cell anaemia and 30 non-anaemic controls with normal haemoglobin and electrophoresis pattern. M-mode, two-dimensional, and Doppler echocardiographic measurements of patients and controls were performed according to the criteria of the American Echocardiography Society. RESULTS On Doppler study, the A wave height was increased and the E/A ratio was decreased, whereas the deceleration and isovolumetric relaxation times were prolonged, which is typically seen in slowed or impaired myocardial relaxation (p<0.001). Although chamber dilatations were present, echocardiographic parameters showed no statistically significant correlation with severity of anaemia and age among the sickle cell patients. CONCLUSIONS We conclude that the increased left ventricular stiffness, compared with controls, might be due to fibrosis related to ischaemia caused by SS disease in addition to wall hypertrophy.

Congenital left atrial appendage aneurysm associated with a systemic embolism.

A 20 year-old woman presented with systemic embolisation. On subsequent investigation, she was diagnosed with a congenital left atrial appendage aneurysm. Few case reports are reported in the literature. This cardiac malformation presents a diagnostic challenge in patients with cardiomegaly.

Is accelerated idioventricular rhythm a good marker for reperfusion after streptokinase

BACKGROUND Accelerated idioventricular rhythm (AIVR) is a common arrhythmia observed in patients with ST segment elevation myocardial infarction (MI). It is not clear how much value AIVR has in predicting successful reperfusion, since there have been conflicting data regarding this in the past. Streptokinase (STK) even today is the commonest thrombolytic agent used in the public health care set-up in India.(1) Most data for the use of STK are from the 1990s, which had showed that at best it is effective in only 50% of patients in restoring adequate flow.(2) It is probable that with the current dual-antiplatelet loading dose regimen and other newer medications, this figure could be higher. Also, rescue angioplasty for failed thrombolysis is the standard of care now, unlike before. Hence, we need reliable non-invasive markers to judge successful reperfusion in the present era. While ST segment resolution is the standard marker for reperfusion used in thrombolytic trials, in several instances it is not definitive. An additional marker would thus be very useful, especially in such cases. METHODS This was a prospective observational study carried out at a public teaching hospital. 200 consecutive patients with a diagnosis of acute MI who were given STK within 12h of index pain were included. The STK dose was 1.5 million units, infused over 30min; the ECG was again recorded after 90min of completion of the infusion. Continuous ECG monitoring for the first 24h of ICCU stay was performed and AIVRs during this period were documented. Early AIVR was defined as that occurring within 2h of completing the STK infusion. Echocardiography was performed 24h after presentation. The time course of AIVR was studied vis-a-vis the outcome of thrombolysis. RESULTS AIVR was seen in 41% of the patients. Though AIVR was found to have low sensitivity (45%) and specificity (64%) as a predictor of successful thrombolysis, early AIVR was a reliable sign of successful thrombolysis (p<0.05). The sensitivity (45%) of early AIVR was low; however, the specificity (94%) and positive predictive value (94%) were very good. CONCLUSION AIVR is a common arrhythmia in the setting of STEMI receiving thrombolytic therapy. Early AIVR is more common with successful thrombolysis, with an excellent positive predictive value. Thus, early AIVR can be used as an additive criterion to ST segment resolution as a non-invasive marker of successful thrombolysis with STK.

Absent right bundle branch block: Is it a clue of pre-excitation in Ebstein's anomaly?

A 14-year-old male with a history of symptomatic tachycardia was referred for ablation. Sinus rhythm electrocardiogram was not showing any pre-excitation. Tachycardia episode was showing antidromic tachycardia with left bundle branch block morphology. Echocardiographic examination was showing Ebsteins anomaly with septal tricuspid leaflet displaced 24 mm apically. The right bundle branch block (RBBB) was concealed during sinus rhythm. The RBBB was revealed with ablation of right posterior atriofascicular accessory pathway.

Prevalence and predictors of ventriculo-atrial conduction in structurally normal hearts

Background The prevalence of ventriculo-atrial (VA) conduction varies from 20% to 90%, depending on the population studied (Militianu et al., 1997; Inoue et al., 1985; Kazmierczak et al., 1993; Ciemniewski et al., 1990; Hayes and Furman, 1983; Westveer et al., 1984). This wide range is mostly based on studies done in patients with implanted devices or impaired atrioventricular conduction. However, the prevalence of VA conduction in structurally normal heart has not been well documented till date. Objective To study the prevalence and identify predictors of retrograde conduction via the His-Purkinje system and AV node in structurally normal hearts. Methods We included 54 consecutive adults without structural heart disease who underwent electrophysiological (EP) study for various tachycardias. The basic parameters including PR, AH and HV intervals, atrioventricular Wenckebach point (AVWP) and anterograde effective refractory period (ERP) of atrioventricular node (AVNERP), were measured after ablation. The VA conduction was assessed basally and if absent, after isoprenaline. The VA Wenckebach point (VAWP) and retrograde ERP(VAERP) were recorded in patients showing VA conduction. Results The mean age was 37.1 ± 12.6years. Twenty five (46%) of the patients were men. VA conduction was present in 30 (55%) patients at baseline. Of the remaining 24 patients, 18 (34%) showed VA conduction after isoprenaline. Only 6 (11%) patients failed to reveal VA conduction even after adequate response to isoprenaline. Amongst all clinical and EP variables analysed, only the HV interval was shorter (p < 0.01) in patients with VA conduction. Conclusion In structurally normal hearts, VA conduction was present at baseline in 55% of patients. Isoprenaline unmasked VA conduction in an additional 34% of the subjects. The HV interval was longer in patients without VA conduction.

Tetralogy of Fallot with restrictive ventricular septal defect by accessory tricuspid leaflet tissue.

In tetralogy of Fallot septal defect is usually large because of malalignment of outlet septum, restrictive defect has been reported rarely. We present a case of tetralogy of Fallot with accessory tricuspid leaflet tissue restricting ventricular septal defect. The report includes echocardiographic and catheter images of this rare presentation of tetralogy of Fallot.