Ajaz Lone

Does plasma copeptin level at admission predict final infarct size in ST-elevation myocardial infarction

BACKGROUND Copeptin is a novel biomarker of potential diagnostic and prognostic value in patients with ST-elevation myocardial infarction (STEMI). This study was conducted to investigate the relationship between plasma copeptin levels at admission and final infarct size in STEMI patients. MATERIALS AND METHODS This observational study was conducted in Sher-i-Kashmir Institute of Medical sciences, Srinagar, for a period of 1year. 60 patients with STEMI admitted within 24h of symptom onset were included in the study. Plasma copeptin concentrations were determined by ELISA from blood samples drawn at the time of admission. Infarct size was estimated on cardiac MRI after 5-14days of admission, in successfully reperfused patients. Correlations between plasma copeptin levels, infarct size and various clinico-hemodynamic variables were studied. RESULTS Plasma copeptin concentrations showed a significant positive correlation with MRI determined infarct size (r=0.957; p≤0.0001). Copeptin levels were significantly higher in patients with anterior wall infarction (p≤0.0001), longer symptom duration (p=0.018), advanced Killip class (p≤0.0001), higher body mass index (p=0.019) and extensive coronary artery disease (p≤0.0001). On multivariate analysis, copeptin levels at admission independently predicted final infarct size, irrespective of the clinico-hemodynamic profile of patients or mode of reperfusion (p≤0.0001). The only independent predictor of copeptin level was symptom duration (p=0.018). CONCLUSION Copeptin level at admission predicts final infarct size in STEMI patients. Further evidence is however needed before implementation of this biomarker into routine clinical practice.

Complete Transcatheter Repair of Fallot’s Trilogy: A Case Report

Fallot’s trilogy is a relatively uncommon form of cyanotic congenital heart disease characterized by severe valvular pulmonary stenosis (PS), right ventricular hypertrophy and right to left interatrial shunt via an atrial septal defect (ASD) or patent foramen ovale (PFO). Historically, patients with the combination of these lesions were routinely treated by surgical correction. In recent times, transcatheter repair has become an increasingly attractive modality of treating such patients. There is limited experience with such combined transcatheter interventions, and from the scarce data available in published literature it seems that such approach has promising safety and efficacy. Herein, we describe a case of an 18 year old cyanotic male patient who was diagnosed of having severe valvular PS with supra systemic right ventricular pressures and reversed interatrial shunt via a large secundum ASD. We successfully treated him percutaneously with serial balloon pulmonary valvuloplasty, using single balloon and Inoue balloon techniques, followed by Amplatzer device closure of the ASD. The outcome was excellent with marked reduction of trans-pulmonary valvular gradient, complete cessation of shunting across the ASD, dramatic improvement of symptoms and completes disappearance of cyanosis. There were no procedure related complications and the benefits were sustained at follow up of three years. Our case demonstrates that transcatheter repair is a feasible, safe and effective alternative to surgery in selected patients with Fallot’s trilogy. With further experience, it may well become the standard of care in the management of such patients.

Clinico-angiographic profile and procedural outcomes in patients undergoing percutaneous coronary interventions: The Srinagar registry

Background This study was aimed at exploring the clinical profile, angiographic characteristics and procedural outcomes in patients undergoing PCI at our institute. Methods This prospective observational study included all consecutive patients who underwent PCI at our hospital between January 2014 and December 2015. Data including clinico-demographic profile, angiographic details and lesion characteristics were recorded in all patients. Procedural details including devices and drugs used, procedure related complications, and in-hospital outcomes of these patients were analysed. Results A total of 624 patients (mean age- 59.30 ± 11.17 years) with 84.8% males and 15.2% females were included in the study. Smoking and hypertension were the most common risk factors, present in 79.8% and 74.8% patients respectively. Diabetes mellitus, dyslipidemia, and obesity were observed in 24.5%, 26.1%, and 25.0% patients respectively. Anterior wall MI was the most common mode of presentation (32.1%). Single Vessel Disease (SVD) was most common angiographic pattern, observed in 50.3% patients; left anterior descending artery (LAD) was the most frequently involved vessel (65.9%); and type B lesions were most prevalent (52.3%). Most of the procedures were elective (61.4%) and femoral route was used in the majority (82.6%). Drug eluting stents were deployed in 99.1% of the cases. The overall procedural success rate was 93.6%. Procedural mortality was 1.0% and periprocedural complications occurred in 9.9% patients. Conclusion This first prospective PCI registry from the state of Jammu & Kashmir provides an insight into the patterns of CAD among Kashmiri population, and highlights the spectrum of PCIs performed with their outcomes.

Immediate effect of percutaneous transvenous mitral commissurotomy on atrial electromechanical delay and P-wave dispersion in patients with severe mitral stenosis.

BACKGROUND Mitral stenosis (MS) is associated with prolonged inter- and intra-atrial electromechanical delays and increased P-wave dispersion, which are markers of atrial fibrillation (AF) risk. This study was conducted to assess the immediate effect of successful percutaneous transvenous mitral commissurotomy (PTMC) on these parameters. METHODS This single center observational study included 25 patients with severe MS (aged 34.1 ± 7.1 years, with mean mitral valve area (MVA) of 0.74 ± 0.13 cm(2)), in sinus rhythm, who underwent successful PTMC at our hospital. P-wave dispersion (PWD) was calculated by subtracting minimum P-wave duration (P min) from maximum P-wave duration (Pmax), measured on a 12-lead surface ECG obtained from each patient in supine position at a paper speed of 50mm/s and 20mm/mV. Inter-atrial (AEMD), left intra-atrial (L-IAEMD), and right intra-atrial (R-IAEMD) electromechanical delays were measured on tissue Doppler imaging. PTMC was performed using the standard Inoue Balloon technique. All these parameters were evaluated and compared before and 24-48 h after PTMC. RESULTS Successful PTMC led to significant reduction in AEMD (p < 0.001), L-IAEMD (p < 0.001), and R-IAEMD (p < 0.001). There were no changes in Pmax, Pmin, and PWD immediately after PTMC. CONCLUSIONS Successful PTMC has a favorable early impact on inter- and intra-atrial electromechanical delays, which are considered as novel parameters of atrial electromechanical remodeling in MS patients. Prospective large-scale studies are required to confirm whether improvement in these markers translates into reduced long-term AF risk.

Atrial Fibrillation, Clinical Profile and Adherence to Guidelines

Background: Even in developed countries suboptimal anticoagulation and low adherence to guidelines is frequently observed in Atrial fibrillation (AF) patients. There is no data from our regional population and very scarce Indian data about the utilization patterns and adherence to guidelines for stroke prevention in AF. Aims and Objectives: To characterize clinical profile and assess adherence to guidelines in stroke prevention in AF in north Indian population. Material and Methods: It was a single centre observational study. All patients presenting to outpatient department or admitted in cardiology wards from May 2014 to April 2016 with AF were included. Detailed history, examination and relevant investigations were carried out .CHADS2 score was used for risk stratifying and prescribing oral anticoagulants in nonvalvular AF. The effectiveness of oral anticoagulant was assessed by INR. Result: Total of 446 patients were included. Mean age of our patients was 60.83±16.86 years. 48% were males and 52% were females. Rheumatic heart disease was most common (37.2%) ethology followed by hypertensive cardiovascular disease (18.2%). Mean CHADS2 score was 2.63±1.5 in non valvular AF. Out of 446 patients, 409(92%) patients were found to have indication for prescription of OAC as per guidelines, out of which only 290 (71%) patients actually received OAC. OAC prescription was significantly higher in valvular vs. non valvular AF ( p=0.0001).The rates of OAC prescription in our patients in age group, ≤65, 66-75, >75 years were 84.4%, 65% and 60.2% respectively Out of 290 patients who were eligible for OAC ,only 102(25%) patients were optimally anti-coagulated. Conclusion: Discordance between guidelines and practice was found regarding prescription of OACs and maintenance of optimal anticoagulation for stroke prevention in our population. Optimal anticoagulation needs to be emphasized on both patients as well as physicians to prevent strokes and achieve better outcomes.

Diagnostic utility of Gadolinium enhanced Coronary CT Angiography comparedto Conventional Invasive Coronary Angiography in detection of obstructiveCoronary Artery Disease

Background: The current gold standard for assessment of coronary artery disease, Invasive Coronary Angiography (ICA), has inherent risks of an invasive procedure including that of death. In addition use of Iodinated contrasts in ICA and Coronary CT Angiography is often contraindicated due to its renal toxicity and hypersensitivity reactions. Gadolinium, though primarily an MRI contrast, has been shown to produce vascular luminal enhancement making it an attractive alternative contrast agent for use in angiography.Objectives: To assess the possibility of use of Gd-enhanced 64-slice cardiac CT (CCT) for the diagnosis of obstructive coronary artery disease in comparison to invasive coronary angiography.Methods: A total of 25 patients of CAD underwent Gadolinium Enhanced Coronary CT Angiography followed by Invasive Coronary Angiography. The data was analyzed by comparing coronary segments with ≥ 50% stenosis detected by ICA versus detection of the same by Gd-Enhanced CTA, as well as comparison on Per-Vessel basis.Results: Mean age of patients in our study was 53.52 years (range 41-70 years). The total number of coronary segments evaluated by invasive coronary angiography was 379 of which 57 showed ≥ 50% stenosis. Gd-Enhanced CTA detected 47 of these lesions. In comparison to ICA, on Per-segment basis, Gd- Enhanced CTA showed Sensitivity of 82.46%, Specificity of 97.50%, PPV of 85.45% and NPV of 96.95%. Weighted Kappa value was 1, suggestive of strong agreement between the two modalities, excluding agreement by chance.Conclusions: Our study shows Gadolinium Enhanced Coronary CT Angiography is safer alternative for assessment of CAD in patients who have a contraindication for ICA or Iodinated Contrasts with acceptable sensitivity and specificity. Results depend on BMI and coronary calcification.

Prevalence and characterization of coronary artery disease in patients with symptomatic bradyarrhythmias requiring pacemaker implantation

Background This study was conducted to assess the prevalence and characterization of CAD in high risk patients requiring pacemaker implantation for symptomatic bradyarrhythmias. Methods This study included 100 patients with symptomatic sinus node dysfunction or atrioventricular block, who were at high risk of CAD or had previously documented atherosclerotic vascular disease (ASCVD). Coronary angiography was performed before pacemaker implantation. CAD was defined as the presence of any degree of narrowing in at least one major coronary artery or its first order branch. Obstructive CAD was defined as ≥50% diameter stenosis. CAD was categorized as single vessel disease (SVD), double vessel disease (DVD), or triple vessel disease (TVD); and obstructive CAD in the arteries supplying the conduction system was sub-classified according to Mosseris classification. Results Out of 100 patients (mean age 64.6 ± 10.7 years), 45 (45%) had CAD. 29% patients had obstructive CAD while 16% had non-obstructive CAD. 53.3% patients had SVD, 15.6% had DVD and 31.1% had TVD. Among patients with obstructive CAD; Type I, II, III and IV coronary anatomies were present in 6.9%, 34.5%, 10.3% and 48.3% patients respectively. Presence of CAD significantly correlated with dyslipidemia (p = 0.047), history of smoking (p = 0.025), and family history of CAD (p = 0.002). Conclusion Angiographic CAD is observed in a substantial proportion of patients with symptomatic bradyarrhythmias and risk factors for CAD. It could be argued that such patients should undergo a coronary work-up before pacemaker implantation. Treatment of concomitant CAD is likely to improve the long term prognosis of these patients.

Lymphoma Presenting as Severe Left Ventricular Systolic Dysfunction: A Case Report

Lymphoma involving the heart is rare. This is a case report on non-Hodgkin lymphoma where the patient presented for the first time with heart failure and severe left ventricular systolic dysfunction due to lymphoma infiltrating the heart muscle and had simultaneous bilateral involvement of kidneys. This type of presentation has never been described in world literature and is the first reported case.

Combined severe valvular aortic and valvular pulmonary stenosis and its management - A case report and literature review.

Isolated congenital valvular stenosis of either aortic or pulmonary valve is commonly seen yet the presence of both these lesions in the same patient is rare. This combination presents unusual diagnostic as well as management problems. Apart from a few case reports, there is little in the literature on the combined stenosis of both semilunar valves. We present here a case report of a three and half year old boy diagnosed as a combined congenital severe valvular aortic stenosis with valvular pulmonary stenosis. The patient underwent successful balloon dilatation of both these valves in the same sitting.