Cholenahally Nanjappa Manjunath

Consensus statement on management of dyslipidemia in Indian subjects.

a Editor, Indian Heart Journal, Sr. Cardiologist, Indo US Superspeciality Hospital, Ameerpet, Hyderabad 500016, India b Senior Consultant e Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India c Head, Department of Cardiology, PRS Hospital, Trivandrum, Akashdeep, TC 17/881, Poojapura, Trivandrum, Kerala 695012, India d Sr. Consultant & HOD, Manipal Hospital, 133, JalaVayu Towers, NGEF Layout, Indira Nagar, Bangalore 560038, India e Head of Medicine and Director Research, Fortis Escorts Hospital, JLN Marg, Malviya Nagar, Jaipur 302017, India f Sr. Cardiologist, Sir Ganga Ram Hospital, New Delhi, India g Westfort H. Hospital, Poonkunnanm, Thrissur 680002, India h Sr. Cardiologist, Krishna Institute of Medical Science, Minister Road, Secunderabad, India i Director, Prof & HOD, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bannerghatta Road, Bangalore 560 069, India j MD DM FACC, Chairman Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India k Sr. Consultant & Chief Interventional Cardiologist, Sahara India Medical Institute, VirajKhand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India l Head, Department of Clinical and Preventive Cardiology and Research Centre Arihant Hospital, Indore, MP, India m Prof. of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India n Chairman, Clinical and Preventive Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India o Professor, Vivekanada Institute of Medical Sciences, Kolkata, India p Chief Co-ordinator, Academic Services (Cardiology), Narayana Hrudayalay, RTIICS, Kolkata, India q Consultant Cardiologist, Fortis Hospital, Kolkata, India r Chief Endocrinologist & CEO, Chellaram Diabetes Institute, Pune 411021, India s Consultant Endocrinology, Bharti Hospital & BRIDE, Karnal, Haryana, India t Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, New Delhi, India u Head, Public Health, National Diabetes, Obesity and Cholesterol Foundation (N-DOC), Diabetes Foundation (India), New Delhi, India v Head, Nutrition Research Group, Center for Nutrition & Metabolic Research (C-NET) & National Diabetes, Obesity and Cholesterol Foundation (N-DOC), New Delhi, India w Chief Project Officer, Diabetes Foundation (India), C-6/57, Safdarjung Development Area, New Delhi 110 016, India

Inferior vena cava obstruction: long-term results of endovascular management

BACKGROUND Hepatic venous outflow obstruction (HVOO) can have acute or chronic presentation. In the chronic variety of inferior vena cava (IVC) obstruction, endovascular management with balloon angioplasty and stent implantation has emerged as a feasible, safe alternative to surgery which has high incidence of mortality and morbidity. AIMS AND OBJECTIVES To study the feasibility and long-term follow-up of endovascular management of chronic IVC obstruction. METHODS We studied 12 cases of HVOO who underwent endovascular management (balloon dilatation ± stenting). In most of the cases, the cause of obstruction was not obvious, but one case had metastatic hepatic nodules compressing on IVC. Diagnosis was established by clinical examination, venous Doppler and was confirmed by venography and/or computed tomography (CT) angiography. Cases underwent balloon dilatation and/or stenting. RESULTS Out of 12 cases, six had membranous obstruction (four complete and two incomplete), five cases had segmental stenosis and one case had tumour compression. The lesion was crossed with either guide wire or Brockenbrough needle with Mullins sheath assembly and balloon dilatation was done with Inoue or Mansfield balloon. Seven cases underwent balloon dilatation alone while five cases underwent stenting. There was procedural success in all cases with reduction of gradient by 84%, disappearance of collaterals and clinical improvement. During the follow-up of 13 years, one case had restenosis, which was managed by stenting. CONCLUSION Endovascular management of IVC obstruction is safe with good long-term patency rates.

Incidence and Predictors of Left Atrial Thrombus in Patients with Rheumatic Mitral Stenosis and Sinus Rhythm: A Transesophageal Echocardiographic Study

Background: Rheumatic mitral stenosis (MS) predisposes to left atrial (LA) thrombus formation. The reported incidence of LA clot formation in sinus rhythm (SR) is 2.4–13.5% in small studies. Aim: To determine the incidence of LA thrombus in MS in SR in a large cohort of patients and to determine the factors that predict its development. Methods: Total of 848 consecutive patients with MS in SR who were being evaluated for percutaneous transvenous mitral commisurotomy were included in the study. Both transthoracic (TTE) and transesophageal echocardiograms (TEE) were performed to identify clot and other hemodynamic parameters. Results: The mean age of the study population was 34 ± 9 years and the mean mitral orifice area was 0.78 ± 0.18 cm2. Out of 848 patients 56 (6.6%) had LA thrombus on TEE. On univariate analysis there was a trend toward thrombus formation in individuals with age >44 years, LA inferosuperior dimension >6.9 cm, mean mitral gradient >18 mmHg and dense spontaneous echo contrast (SEC). On multivariate analysis none of the factors predicted clot formation. Conclusion: The incidence of LA thrombus in MS in SR is 6.6%. TEE is warranted in MS patients in SR when they are >44 years, LA inferosuperior dimension >6.9 cm and mean mitral gradient >18 mmHg. When SEC is absent on TEE, thrombus formation is unlikely. (Echocardiography 2011;28:457‐460)

Hutchinson-Gilford progeria syndrome with severe calcific aortic valve stenosis.

Hutchinson–Gilford progeria syndrome (HGPS) is a rare premature aging syndrome that results from mutation in the Laminin A gene. This case report of a 12-year-old girl with HGPS is presented for the rarity of the syndrome and the classical clinical features that were observed in the patient. All patients with this condition should undergo early and periodic evaluation for cardiovascular diseases. However, the prognosis is poor and management is mainly conservative. There is no proven therapy available. Mortality in this uniformly fatal condition is primarily due to myocardial infarction, strokes or congestive cardiac failure between ages 7 and 21 years due to the rapidly progressive arteriosclerosis involving the large vessels.

Dancing vegetations: Kocuria rosea endocarditis

We present images of a 35-year-old man with rheumatic mitral regurgitation. The patient presented with a 1 month history of continuous fever, worsened exertional dyspnoea and orthopnoea. With a clinical suspicion of infective endocarditis, the patient initially underwent a transthoracic echocardiogram, which revealed the possibility of vegetations attached to the mitral leaflets, though not definitively. In order to confirm the diagnosis, the patient was subjected to a transoesophageal echocardiogram, which showed an astounding image having multiple vegetations apparently dancing in …

First-in-human evaluation of a novel poly-L-lactide based sirolimus-eluting bioresorbable vascular scaffold for the treatment of de novo native coronary artery lesions: MeRes-1 trial

AIMS The MeRes-1 trial sought to study the safety and effectiveness of a novel sirolimus-eluting bioresorbable vascular scaffold (MeRes100 BRS) in treating de novo native coronary artery lesions by clinical evaluation and using multiple imaging modalities. METHODS AND RESULTS The MeRes-1 first-in-human trial was a single-arm, prospective, multicentre study, which enrolled 108 patients with de novo coronary artery lesions (116 scaffolds were deployed to treat 116 lesions in 108 patients). At six months, quantitative coronary angiography revealed in-scaffold late lumen loss of 0.15±0.23 mm with 0% binary restenosis. Optical coherence tomography demonstrated minimum scaffold area (6.86±1.73 mm2) and percentage neointimal strut coverage (99.30%). Quantitative intravascular ultrasound analysis confirmed a 0.14±0.16 mm2 neointimal hyperplasia area. At one year, major adverse cardiac events, a composite of cardiac death, any myocardial infarction and ischaemia-driven target lesion revascularisation, occurred in only one patient (0.93%) and there was no scaffold thrombosis reported. At one year, computed tomography angiography demonstrated that all scaffolds were patent and in-scaffold mean percentage area stenosis was 11.33±26.57%. CONCLUSIONS The MeRes-1 trial demonstrated the safety and effectiveness of MeRes100 BRS. The favourable clinical outcomes and effective vascular responses have provided the basis for further studies in a larger patient population. The MeRes-1 trial is registered at the Clinical Trials Registry-India.

Clinical characteristics, angiographic profile and in hospital mortality in acute coronary syndrome patients in south indian population

Aims: The aim was to study the clinical profile, risk factors prevalence, angiographic distribution, and severity of coronary artery stenosis in acute coronary syndrome (ACS) patients of South Indian population. Materials and Methods: A total of 1562 patients of ACS were analyzed for various risk factors, angiographic pattern and severity of coronary heart disease, complications and in hospital mortality at Sri Jayadeva Institute of Cardiovascular Research and Sciences, Bengaluru, Karnataka, India. Results: Mean age of presentation was 54.71 ± 19.90 years. Majority were male 1242 (79.5%) and rest were females. Most patients had ST elevation myocardial infarction (STEMI) 995 (63.7%) followed by unstable angina (UA) 390 (25%) and non-STEMI (NSTEMI) 177 (11.3%). Risk factors; smoking was present in 770 (49.3%), hypertension in 628 (40.2%), diabetes in 578 (37%), and obesity in (29.64%) patients. Angiography was done in 1443 (92.38%) patients. left anterior descending was most commonly involved, left main (LM) coronary artery was least common with near similar frequency of right coronary artery and left circumflex involvement among all three groups of ACS patients. Single-vessel disease was present in 168 (45.28%) UA, 94 (56.29%) NSTEMI and 468 (51.71%) STEMI patients. Double-vessel disease was present in 67 (18.08%) UA, 25 (14.97%) NSTEMI and 172 (19.01%) STEMI patients. Triple vessel disease was present in 28 (7.55%) UA, 16 (9.58%) NSTEMI, 72 (7.95%) STEMI patients. LM disease was present in 12 (3.23%) UA, 2 (1.19%) NSTEMI and 9 (0.99%) STEMI patients. Complications; ventricular septal rupture occurred in 3 (0.2%), free wall rupture in 2 (0.1%), cardiogenic shock in 45 (2.9%), severe mitral regurgitation in 3 (0.2%), complete heart block in 11 (0.7%) patients. Total 124 (7.9%) patients died in hospital after 2.1 ± 1.85 days of admission. Conclusion: STEMI was most common presentation. ACS occurred a decade earlier in comparison to Western population. Smoking was most prevalent risk factor. Diabetic patients had more of multivessel disease. Complications and in hospital mortality was higher in females and elderly population.

Transesophageal Doppler Echocardiography Study of Pulmonary Venous Flow Pattern in Severe Mitral Stenosis and the Changes Following Balloon Mitral Valvuloplasty

The studies of pulmonary venous flow‐pattern in mitral stenosis (MS) have given conflicting data about the type of abnormality. This study was undertaken to assess the pulmonary venous flow‐pattern in severe MS and to study the changes occurring after balloon mitral valvuloplasty (BMV). There were 51 patients of MS with sinus rhythm with the mean age of 32.5 ± 9.35 years, 18 males and 33 females. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed before and after BMV. Pulmonary venous flow was recorded by TEE from left upper pulmonary vein (PV). Peak velocities (V) and velocity time integrals (VTI) of systolic wave (S), diastolic wave (D), and atrial reversal wave (A) were measured. The Sv/Dv and SVTIIDVTI were calculated. Mitral valve area (MVA) increased from 0.81 ± 0.18 cm2 to 2.02 ± 0.46 cm2, left atrium (LA) mean decreased from 28.55 ± 6.68 mmHg to 13.88 ± 4.89 mmHg, and cardiac output increased from 3.1 ± 0.86 L/min to 3.7 ± 1.02 L/min. The S, D, and A velocities increased from 33.84 ± 13.55 cm/s, 37.24 ± 11.55 cm/s, and 20.53 ±6.7 cm/s to 59.86 ± 18.25 cm/s, 48.43 ± 12.55 cmls, and 24.94 ± 9.14 cmls, respectively. The VTIs ofS, D, and A waves increased from 4.88 ± 2.24 cm, 6 ± 2.45 cm, and 2 ± 0.88 cm to 10.46 ± 4.23 cm, 8.82 ± 3.61 cm, and 2.34 ± 1.29 cm, respectively. MS leads to reduction in pulmonary flow velocities during all the phases. Successful BMV resulted in improvement of all these velocities, with improvement in systolic fraction being the maximum. These improved flows after BMV appear to be secondary to reduction in LA pressure and improved cardiac output.

Amplatzer duct occluder ii for closure of congenital Gerbode defects

Congenital left ventricle to right atrial communications (Gerbode defects) are extremely rare (0.08%) type of ventricular septal defects. They were traditionally closed by surgery in the past. There are few case reports and small series of acquired and congenital Gerbode defects, closed with various types of devices. Aim of our study is to assess the feasibility, efficacy, and complications of transcatheter closure of congenital Gerbode defects with Amplatzer duct occluder II (ADO II).

Thrombolytic therapy in prosthetic valve thrombosis during early pregnancy

Regardless of the improvements in the design of prosthetic heart valves and the use of anticoagulation, systemic embolism and valve thrombosis remains the most dreaded complications of mechanical heart valve replacement. A course of thrombolytic therapy may be considered as a first-line therapy for prosthetic heart valve thrombosis. The safety of thrombolysis in early pregnancy is not known. We describe a primigravida with mitral valve replacement status presenting with acute prosthetic valve thrombosis and treated successfully with intravenous streptokinase.