Ajith Ananthakrishna Pillai

Reuse of pacemakers, defibrillators and cardiac resynchronisation devices

Objective Access to pacemakers remains poor among many patients in low/middle-income countries. Reuse of explanted pacemakers is a possible solution, but is still not widespread because of concerns regarding outcomes, especially infection. Our objective was to study early outcomes with implants using reused devices and compare them with those with implants using new devices. Methods We studied all patients who underwent implantation of a new or reused pacemaker, cardiac resynchronisation therapy (CRT) device or implantable cardioverter defibrillator (ICD) in the last 5 years at a single institution. We analysed outcomes related to infection, device malfunction and device-related death within 6 months after initial implantation. Results During the study period, 887 patients underwent device implant, including 127 CRT devices or ICDs. Of these, 260 devices (29.3%) were reused and the others were new. At 6 months, there were three device-related infections in implants using a new device. There were no infections among patients receiving a reused device. There were no device malfunctions or device-related deaths in either group. Conclusions We found no difference in rate of infection or device malfunction among patients getting a reused device as compared with those with a new device. This study reinforces the safety of reusing devices for implant including CRT and ICDs.

Utility of balloon assisted technique in trans catheter closure of very large (≥35 mm) atrial septal defects

BACKGROUND Very few published data is available on the outcomes of balloon assisted techniques (BATs) for trans catheter closure (TCC) of very large (Defined as ≥35 mm size) ostium secundum atrial septal defect (ASD). OBJECTIVE To study the utility of BAT as against conventional techniques (CT) in TCC of very large ostium secundum ASD (≥35 mm) over the past 5-year period and to find out the association of different morphological features of the defects in relation to TCC outcomes. STUDY DESIGN AND METHODS Descriptive single center retrospective study of patients with very large ostium secundum ASD (≥35 mm size) who were subjected to TCC. RESULTS Thirty-three out of 36 patients with ≥35 mm ASD and complex morphological features underwent successful TCC. The study patients had high prevalence of absent aortic and posterior rims with posterior mal-alignment of the septum. BAT was successful in 28/31 (90.3%) patients while CT had a success rate of 16%. The mean trans-esophageal echocardiography (TEE) ASD size with BAT success 37 (SD 1.3) mm and CT failure 36.2 (SD 1.1) mm was not different (P=0.06). On univariate analysis of different morphological features, posterior mal alignment of the septum was associated failure of CT (P=0.01). There was no urgent referral for surgery and patients did well on follow up. CONCLUSIONS Balloon assisted device closure of (≥35 mm) ASD had 90% success rate. BAT helps in controlled delivery and device alignment in very large ASD with posterior malalignment of the septum and is often helpful when CT fails.

Dedicated bifurcation stents.

Bifurcation percutaneous coronary intervention (PCI) is still a difficult call for the interventionist despite advancements in the instrumentation, technical skill and the imaging modalities. With major cardiac events relate to the side-branch (SB) compromise, the concept and practice of dedicated bifurcation stents seems exciting. Several designs of such dedicated stents are currently undergoing trials. This novel concept and pristine technology offers new hope notwithstanding the fact that we need to go a long way in widespread acceptance and practice of these gadgets. Some of these designs even though looks enterprising, the mere complex delivering technique and the demanding knowledge of the exact coronary anatomy makes their routine use challenging.

Maternal cardiovascular dysfunction in women with early onset preeclampsia and late onset preeclampsia: A cross-sectional study

OBJECTIVES To compare the cardiovascular changes associated with early onset (EOPE) and late onset (LOPE) subtypes of preeclampsia. METHODS A prospective matched cross-sectional study involving 50 women each with early and late onset subtypes of preeclampsia conducted in a tertiary hospital in South India. Cardiac function and remodelling were assessed by conventional 2D, M-mode and doppler echocardiography. RESULTS Women with EOPE had a significantly more altered left ventricular (LV) geometry, global LV diastolic dysfunction, impairment in myocardial contractility (40% vs. 24%) and a higher total vascular resistance index (863.0 vs 704.0 dynes/s/cm5/m2) compared to LOPE. Stroke volume index (55.3 vs. 62.2 ml/m2) and cardiac work index (520.7 vs. 584.9mmHg×L/min/m2) were higher in women with LOPE. However, the systolic function was found to be preserved in the LV in both the groups. CONCLUSIONS Women with EOPE have a more severe cardiac impairment than those with LOPE. The difference in the hemodynamic indices may provide a chance to tailor patient-specific treatment strategies to improve the pregnancy outcome as well as in early identification and initiation of preventive measures for those at risk of cardiovascular diseases later in life. KEY MESSAGE Adaptation of the heart in women with early onset subtype differs with that of late onset subtype of preeclampsia. Total vascular resistance is higher in early onset group compared to late onset group having a higher cardiac output. These differences in the hemodynamic indices may provide a chance to tailor patient-specific treatment strategies to improve the pregnancy outcome as well as in early identification and initiation of preventive measures for those at risk of cardiovascular diseases later in life.

Comparison of ranolazine and trimetazidine on glycemic status in diabetic patients with coronary artery disease - a randomized controlled trial.

INTRODUCTION Cardiovascular diseases have become the leading cause of death around the globe and diabetes mellitus (DM) is considered to be a coronary artery disease (CAD) risk equivalent. Ranolazine, an anti anginal drug has been found to reduce Glycated haemoglobin (HbA1c) in diabetes patients with chronic angina. However the effect of another antianginal drug trimetazidine, on glycemic status is not clear. AIM To compare the effect of ranolazine and trimetazidine on glycemic status in diabetic patients with CAD. SETTINGS AND DESIGN Patients diagnosed with CAD and diabetes mellitus attending Cardiology Out Patient Department (OPD), Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India were recruited for this randomized open label parallel arm trial. MATERIALS AND METHODS The study conducted from January-2012 to April-2013 had 47 eligible patients diagnosed with CAD and diabetes mellitus. They were randomized to receive either ranolazine 500 mg BD or trimetazidine 35 mg BD for 12 weeks. HbA1c levels, fasting blood glucose (FBG), lipid profile, QT and QTc intervals were measured at baseline and after 12 weeks. STATISTICAL ANALYSIS Unpaired t-test was used to compare the baseline characteristics of between the groups while comparison within the groups were done using Paired t-test. Wilcoxon and Mann Whitney U-tests were used for non parametric data. Graph pad instat version-3 was used for statistical analysis. Values were expressed as mean ± SD. A p < 0.05 was considered statistically significant. RESULTS The study could not find any change in HbA1c levels in both ranolazine and trimetazidine groups. The adverse effects reported from patients on ranolazine include angina, constipation, postural hypotension, headache, dizziness, nausea and weakness while patients on trimetazidine complained of constipation, weakness, palpitations, angina, dizziness, nausea, dyspepsia, headache, gastric discomfort, joint pain, etc. CONCLUSION In patients with chronic angina and diabetes mellitus Ranolazine 500mg BD and Trimetazidine 35mg BD did not show any effect on HbA1c and fasting blood glucose lebel.

Techniques and outcomes of transcatheter closure of complex atrial septal defects - single center experience.

Objective To prospectively study the techniques and outcomes of transcatheter closure of complex Atrial septal defects (ASD). Study design and settings Prospective single center study with experience in catheter closure of ASD. All patients with complex ASD suitable for device closure. Objective Analysis of outcomes of transcatheter closure of complex ASD in JIPMER Hospital over the past 5-year period. Methods Complex ASD was predefined and patients satisfying inclusion and exclusion criteria are included. All the patients had meticulous Transesophageal echocardiography (TEE) imaging beforehand. Modifications of the conventional techniques were allowed on a case per case basis according to operator preference. Successfully intervened patients were followed up clinically. Results Out of the 75 patients enrolled, 69 patients had successful device closure (success rate 92%) despite challenging anatomy. Fifty-six (74%) patients had ASD ≥25 mm. Fifteen patients (20%) had defect size ≥35 mm and 20 patients (26.6%) had devices implanted with ≥35 mm waist size. Fifty percent of patients had complete absence of aortic rim and 25% had deficient posterior rim. Twenty percent of patients had malaligned septum. Mean follow up period was 3.2 years. Conclusions Trans catheter closure is feasible in anatomically complex substrates of Secundum ASD. Careful case selection, scrupulous imaging protocol, and expertise in modified techniques are mandatory for successful outcomes.

Pace mapping in the atrium using bipolar electrograms from widely spaced electrodes

Pace mapping is a useful tool but is of limited utility for the atrium because of poor spatial resolution. We investigated the use of bipolar electrograms recorded from widely spaced electrodes in order to improve the resolution of pace mapping.

386. Care of pregnant women with prosthetic heart valves: Still a formidable challenge in low to middle income countries?

Introduction Patients with mechanical heart valves require lifelong anticoagulation and pregnancy being a pro-thrombotic state poses additional risk of thromboembolic complications. In pregnancy, anticoagulation regimes using Coumadin derivatives or various heparins offers advantage over each other remains inconclusive. Especially in low to middle income countries cost of medication/monitoring and compliance remains a major challenge. We report a single center experience of managing pregnancy in women with prosthetic heart valve from South India. Methods We collected demographic, medical and obstetric details of pregnant women with prosthetic heart valve admitted to a regional tertiary center catering to rural population of South-eastern India from Jan 2011 to March 2018. Outcomes assessed were maternal complications such as maternal mortality, prosthetic valve thrombosis, and perinatal complications such as miscarriages or rates of congenital malformation. Data was expressed as mean with standard deviation or frequency with percentages as appropriate. Results We collected data of 73 pregnancies in 59 women with prosthetic heart valve during the time period. Majority of the women (84%) had valve replacement in mitral position and were replaced with ttk Chitra (titling disc) valve (80%). Five women developed thrombotic complication; three while on unfractionated heparin and two on warfarin therapy. Among three women with prosthetic valve thrombosis, two underwent thrombolysis while one succumbed to the disease. Two third of women were on warfarin therapy in first trimester. One fetus was diagnosed with warfarin-embryopathy and 4 had miscarriages. Cesarean section rates were 16.4%. Hemorrhagic complications occurred in six women in the postpartum period; four of them were on heparin. Conclusion Pregnancy in women with prosthetic mechanical heart valves can lead to life-threatening complications. Anticoagulation regimes should take into consideration fetal risk concerns, cost or treatment/ monitoring which will ensure a better compliance especially in low to middle income countries.

Outcomes following balloon mitral valvuloplasty in pregnant females with mitral stenosis and significant sub valve disease with severe decompensated heart failure

BACKGROUND Mitral stenosis may present with decompensated heart failure during pregnancy. Many patients do have advanced sub valve disease and present late with decompensated state. The outcomes of balloon mitral valvuloplasty (BMV) in such advanced sub valve disease with severe heart failure in pregnancy has not been specifically studied till now. METHODS A descriptive study looking at the immediate and long-term outcomes of pregnant patients with MS who presented with severe heart failure and sub valve disease who had undergone BMV. RESULTS Ninety-six patients were studied. The mean gestational age was 23.4 ± 10.9 weeks .Mean SpO2 was 89% at admission,17% were in cardiogenic shock and 33.33 were on mechanical ventilation. The mean Wilkins score was 9.71 ± 2.1 and sub valve score was 3.3 ± 0.12. BMV was successful in 77 (80.2%) patients and failed in 19. In 5.2% cases, acute severe MR occurred. There were 11 maternal deaths (six in failed and five in success group). A successful obstetric outcome was seen in 71 patients in success (92%) and 11/19 (57%) in failed (P < 0.001). The obstetric outcomes were better in success versus failure group. Anova post hoc analysis showed sustained gradient reductions at 1 and 5 year follow-up (P = 0.03) in success group. CONCLUSIONS BMV offers substantial improvement in clinical outcomes among pregnant patients with MS and heart failure even with severe sub valve disease. The morality rate among failed was high at 31%. The obstetric outcomes were poor after a failed BMV. Outcomes following balloon mitral valvuloplasty in pregnant females with mitral stenosis and significant sub valve disease with severe decompensated heart failure.

Honeycomb-like appearance on optical coherence tomography in right coronary artery

coherence tomography (OCT) from middle to proximal portion of the RCA showed multiple small channels of varying size in communication with each other (Fig. 1, Panel a–f, Video 1). These channels were separated by septa of high signal intensity and low attenuation giving honeycomb-like appearance which is characteristic of recanalized thrombus. Percutaneous coronary intervention was done through right femoral artery. Using 6F Judkins right 3.5 coronary catheter (Cordis Corporation), RCA was hooked. Predilatation was done with 2 × 12 mm Sprinter® Legend RX semicompliant Balloon (Medtronic Inc. USA) following which drug eluting stent, Taxus Liberte (Boston scientific, Natick, Massachusetts) Paclitaxel-Eluting stent of size 3.5 × 38 mm in proximal RCA and 3.0 × 38 mm in distal RCA was deployed. Post dilatation was done with 3.5 × 38 mm NC SprinterTM noncompliant balloon (Medtronic Inc. USA). Post dilatation TIMI 3 flow was achieved. In recanalized thrombus, angiography findings like multiple irregular filling defects and intraluminal haziness are not specific and difficult to differentiate from spontaneous coronary artery dissection. Better resolution of OCT clearly shows honeycomb-like or cheese-like appearance, which is characteristic of recanalized thrombus [1, 2]. A 37-year-old female came with history of palpitation since one year. Patient was a known case of diabetes mellitus. She had a history of acute inferior wall myocardial infarction 2 years back for which she received streptokinase thrombolytic therapy at the dose of 1.5 million IU. After thrombolysis, she was started on dual antiplatelet therapy aspirin, clopidogrel along with atorvastatin, betablocker and enalapril. In past one year, she developed two episodes of palpitation for which she was DC cardioverted at another hospital. During palpitation, ECG was suggestive of ventricular tachycardia with right bundle branch block morphology with right axis deviation whereas during sinus rhythm, QS complex in lead II, III, avF was present. On 2D Echocardiography, hypokinesia of inferior, inferoseptal, posterior wall was noted and left ventricular ejection fraction was found to be 50%. Coronary angiography showed multiple linear irregular filling defect from proximal to middle portion of the right coronary artery (RCA) with the possibility of either spontaneous coronary artery dissection or recanalized thrombus (Fig. 1, Inlet). Patient underwent CARTO (Biosense Webster, Diamond Bar, CA, USA) guided 3D electroanatomical mapping and ablation of scar related ventricular tachycardia. Optical