C.N. Manjunath

Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus.

To evaluate the safety and efficacy of balloon mitral valvotomy (BMV) in symptomatic rheumatic mitral stenosis (MS) patients with left atrial (LA) thrombus and to address the technical issues.

Prolonged Tpeak-end and Tpeak-end/QT ratio as predictors of malignant ventricular arrhythmias in the acute phase of ST-segment elevation myocardial infarction: A prospective case-control study

BACKGROUND Prolonged Tpeak-end (the interval from the peak of the T wave to the end of the T wave) and Tpeak-end/QT ratio have been shown to be markers of arrhythmogenesis in various cardiac disorders. OBJECTIVES The purpose of this study was to evaluate the utility of Tpeak-end and Tpeak-end/QT ratio at admission in patients with acute ST-segment elevation myocardial infarction (STEMI) in predicting malignant ventricular arrhythmias. METHODS The study group included 50 patients presenting with STEMI, in whom Tpeak-end and Tpeak-end/QT ratio were measured at admission; these patients were monitored for arrhythmias with a continuous electrocardiogram in the intensive care unit for 48 hours, and 50 healthy individuals acted as controls. RESULTS The Tpeak-end (0.11 ± 0.04 seconds vs 0.08 ± 0.006 seconds; P < .0010) and Tpeak-end/QT ratio (0.30 ± 0.06 vs 0.21 ± 0.02; P < .001) were prolonged in patients with STEMI. Three patients with STEMI who sustained ventricular fibrillation (VF) within 24 hours of admission had prolonged corrected QT interval (0.39 ± 0.04 seconds vs 0.46 ± 0.13 seconds; P = .019), Tpeak-end (0.10 ± 0.02 seconds vs 0.20 ± 0.11 seconds; P < .001), and Tpeak-end/QT ratio (0.26 ± 0.05 vs 0.41 ± 0.09; P < .001) as compared with patients with STEMI without VF. Tpeak-end > 0.1 seconds and Tpeak-end/QT ratio > 0.3 predicted VF with a sensitivity of 100%. However, the Tpeak-end/QT ratio had a higher specificity (82.9% for Tpeak-end/QT ratio vs 44.7% for Tpeak-end) and accuracy (84% for Tpeak-end/QT ratio vs 48% for Tpeak-end). CONCLUSION Tpeak-end and Tpeak-end/QT ratio are prolonged in patients with STEMI compared with healthy individuals, and Tpeak-end > 0.1 and Tpeak-end/QT ratio > 0.3 predict malignant ventricular arrhythmias within 24 hours of STEMI.

Catheter-Directed Thrombolysis Along with Mechanical Thromboaspiration versus Anticoagulation Alone in the Management of Lower Limb Deep Venous Thrombosis-A Comparative Study.

Catheter-directed thrombolysis (CDT) with assisted mechanical thrombolysis is now considered as the standard of medical care for deep vein thrombosis (DVT). The study was conducted to describe the immediate and long-term (6 months) safety and effectiveness of CDT in patient with lower limb DVT compared with the routine anticoagulation alone. All 12 to 85 years old patients with recent (0-8 weeks) DVT were included. In CDT group, thrombus was aspirated mechanically and streptokinase (STK) was given along with unfractionated heparin (UFH). After 6 months, deep venous patency and postthrombotic syndrome (PTS) was assessed by using duplex ultrasound and Villalta scale, respectively. Among 51 patients with completed data, 25 patients were allocated additional CDT given for a mean duration of 108 ± 32 hours and 26 patients were allocated standard treatment alone. Grade III (complete) lysis was achieved in 37% patients and grade II (50-90%) lysis in 63% of patients. Patients with partial lysis underwent percutaneous transluminal angioplasty and/or venous stenting. After 6 months, iliofemoral patency was found in 20 (80%) in the CDT group versus 7 (23%) in anticoagulation alone group (p < 0.01). PTS was seen in 5 (20%) in the CDT group versus 19 (77%) in anticoagulation alone group (p < 0.01). We conclude that CDT and conventional manual aspiration thrombectomy are an effective treatment for lower extremity DVT. STK infusion can be safely given up to 6 days. As addition of UFH can cause thrombocytopenia, so daily monitoring of complete blood counts is needed during CDT.

Treatment of congenital non-ductal shunt lesions with the amplatzer duct occluder II.

Amplatzer Duct Occluder II (ADO II) is especially designed for closing long ducts in infants. The experience with off‐label use of ADO II in non‐ductal positions is limited. Aim: To evaluate feasibility of use of ADO II in non‐ductal positions, incidence of complete heart block (CHB), advantages and disadvantages. Material and Results: Out of 79 defects closed with ADO II, 61 had perimembranous, 12 apical/mid‐muscular ventricular septal defects (VSD), 4 Gerbode defects, one each of coronary arterio‐venous fistula and aorto‐right ventricular tunnel. Age ranged from 8 months to 21 years (mean 8.9 ± 4.02 years, median 9 years). The mean fluoroscopy time was 5.2 ± 1.1 min with range 4.2–9.2 min. Complete closure was achieved in all. Three cases developed transient junctional bradycardia, treated with steroids. One patient who developed CHB (1.3%) needed temporary pacing. Discussion: ADO II is a low profile device. It can be easily delivered through a 5F guiding catheter and needs very short fluoroscopic time as arteriovenous loop is not needed. The cost is 1/3 of regular ventricular septal occluders. The CHB that is a major challenge for closure of VSDs is less common with soft, specially designed ADO II, which does not compress the conducting system. Conclusions: Use of the ADO II in non‐ductal positions can be achieved with high success and low complication rates, especially CHB; its use is also associated with significantly reduced procedure time and device cost. Device size availability restricts use of the ADO II to defects up to 6 mm in diameter.

Guidance on reuse of cardio-vascular catheters and devices in India: A consensus document

Reuse of medical device is accepted worldwide. Benefits of reuse include not only cost saving but a favorable impact on environment. However, certain requirements should be met for reuse to be safe and effective. The devices, which can be reused, should be clearly defined, a meticulous process for dis-infection and sterilization followed and its functionality ascertained before use. Further, an appropriate consent should be obtained where necessary and the cost saving entailed should be directly passed on to the patient.

Endovascular management of proximal lower limb deep venous thrombosis – A prospective study with six-month follow-up

Background Catheter-directed thrombolysis with assisted mechanical thrombolysis is the standard of medical care for proximal deep vein thrombosis. We studied the immediate and intermediate (six months) safety and effectiveness of catheter-directed thrombolysis in patients with proximal lower limb deep vein thrombosis. Methodology Thirty consecutive patients aged between 20 and 70 years with proximal lower limb deep vein thrombosis formed the study group. Catheter-directed thrombolysis was done with streptokinase infuse through a catheter kept in the ipsilateral popliteal vein. Unfractionated heparin was given along with streptokinase. Mechanical thromboaspiration using guiding catheter was performed in addition to thrombolytic therapy. After six months, post-thrombotic syndrome and deep venous patency were assessed by using Villalta scale and duplex ultrasound, respectively. Results Thirty patients with proximal lower limb deep vein thrombosis were treated with catheter-directed thrombolysis. Mean age of the study patients was 41.7 ± 15 years. Mean duration of illness was 13.3 ± 12 days. The mean duration of thrombolysis was 4.5 ± 1.3 days. Grade III (complete) lysis was achieved in 10 (33%) and Grade II (50–90%) lysis in 20 (67%) of patients. Patients with significant residual lesion in Grade II lysis following catheter-directed thrombolysis underwent percutaneous transluminal angioplasty alone (12/20) or venous stenting (8/20). All patients improved clinically following catheter-directed thrombolysis or assisted catheter-directed thrombolysis. Four patients (13%) developed pulmonary embolism during course of hospital stay and among them two (6.5%) patients died. Eleven patients (37%) had minor bleeding or hematoma at local site, and seven (23%) developed anemia requiring blood transfusion and four (13%) patients had thrombocytopenia. After six months, iliofemoral patency was found in 20 (72%) and post-thrombotic syndrome was seen in six (21%) patients. Two (6.5%) patients died during follow-up due to nephrotic syndrome and carcinoma breast. Conclusion Catheter-directed thrombolysis and conventional manual aspiration thrombectomy are an effective treatment for proximal lower extremity deep vein thrombosis with good short and intermediate outcome.

Short term efficacy and safety of low dose tolvaptan in patients with acute decompensated heart failure with hyponatremia: a prospective observational pilot study from a single center in South India

Background: In acute decompensated heart failure (ADHF), diuretic use, the mainstay therapy for congestion, is associated with electrolyte abnormalities and worsening renal function. Vasopressin mediates fluid retention in heart failure. In contrast to diuretics, the vasopressin antagonist tolvaptan may increase net volume loss in heart failure without adversely affecting electrolytes and renal function. Hyponatremia (serum sodium concentration, <135 mEq/L) is a predictor of death among patients with heart failure. Objective: We prospectively observed the short term efficacy and safety of low dose (15 mg) tolvaptan in admitted patients with hyponatremia and ADHF in Indian population. Methodology: A total of 40 patients with ADHF along with hyponatremia (<125 mEq/L) on standard therapy were treated with 15 mg of tolvaptan at a single oral dose for 7 days. Results: Serum sodium concentrations increased significantly after treatment with tolvaptan from baseline (P < 0.02). There was a significant improvement in symptoms and New York Heart Association (NYHA) class after starting tolvaptan (P ≤ 0.05). Total diuretic dose and mean body weight was reduced non-significantly at 7 th day from the baseline. Side-effects associated with tolvaptan included increased thirst, dry mouth and increased urination. Few patients had worsening renal function. However, several patients developed hypernatremia. Conclusion: In this small observational study, tolvaptan initiation in patients with ADHF with hyponatremia in addition to standard therapy may hold promise in improvement in NYHA class and serum sodium. At the same time, we observed that serious adverse events such as renal function deterioration and hypernatremia developed after tolvaptan treatment, which needs to be addressed in future by randomized study with larger sample size.

Demographic and angiographic profile in premature cases of acute coronary syndrome: analysis of 820 young patients from South India

BACKGROUND Prevalence of acute coronary syndrome in young individuals is increasing progressively. Previous studies have focused on the analysis of risk factors and to some extent coronary angiographic profile in young vs. old patients with acute coronary syndrome, but no study compared the angiographic profile in young patients based on the type of acute coronary syndrome. So, this study was conducted to determine the differences in demographic and coronary angiographic profile of young patients with ST-elevated myocardial infarction (STEMI) vs. those with non-ST-elevated myocardial infarction (NSTEMI) or unstable angina (UA). METHODS We retrospectively analyzed young patients (age <40 years) with acute coronary syndrome who underwent coronary angiography at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India between April 2010 and March 2011. Coronary risk factor profile and angiographic features were compared between STEMI and NSTEMI/UA patients. RESULTS Of 8,268 patients who underwent coronary angiography during the study period, 820 (~10%) were ≤40 year age. Of them, 611 exhibited STEMI and 209 exhibited NSTEMI/UA. Angiographic analysis revealed that single-vessel disease was significantly more common in the STEMI group (56.6% vs. 36.6% respectively; P<0.001) whereas triple-vessel disease was significantly more common in the NSTEMI/UA group (3.6% vs. 10.5% respectively; P<0.001). Conversely, left anterior descending coronary artery was more commonly involved in the STEMI group (55.3% vs. 40.2% respectively; P<0.001), whereas left circumflex coronary artery was more commonly involved in the NSTEMI/UA group (11.8 vs. 23.4% respectively; P<0.001). Of note, smoking/tobacco consumption was the most significant coronary risk factor with prevalence as high as 65% in both groups. CONCLUSIONS In the present study, significant differences were observed in coronary risk factor profile and angiographic features between young patients with STEMI and NSTEMI/UA. Larger studies will be required to establish specific associations between presentation of acute coronary syndromes and angiographic profiles in young patients.

Chronic thromboembolic pulmonary hypertension in a case with multi-drug resistant pulmonary tuberculosis

Chronic thromboembolic pulmonary hypertension in a case with multi-drug resistant pulmonary tuberculosis Pulmonary tuberculosis is very common and multidrug resistance (MDR) is emerging in the developing country. The association with chronic pulmonary embolism is a rare entity. We are reporting a case of 19-years old female with MDR tuberculosis, had severe pulmonary hypertension and right heart failure due to chronic pulmonary embolism.

Catheter-directed thrombolysis in management of postpartum lower limb deep venous thrombosis - A case series.

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in the management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all five cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.