Jacob Jose

Electrical remodelling of the left and right atria due to rheumatic mitral stenosis

AIMS To characterize the atrial remodelling in mitral stenosis (MS). METHODS AND RESULTS Twenty-four patients with severe MS undergoing commissurotomy and 24 controls were studied. Electrophysiological evaluation was performed in 12 patients in each group by positioning multi-electrode catheters in both atria to determine the following: effective refractory period (ERP) at 10 sites at 600 and 450 ms; conduction time; conduction delay at the crista terminalis (CT); and vulnerability for atrial fibrillation (AF). P-wave duration (PWD) was determined on the surface ECG. In the remaining 12 patients in each group, electroanatomic maps of both atria were created to determine conduction velocity and identify regions of low voltage and electrical silence. Patients with MS had larger left atria (LA) (P < 0.0001); prolonged PWD (P = 0.0007); prolonged ERP in both LA (P < 0.0001) and right atria (RA) (P < 0.0001); reduced conduction velocity in the LA (P = 0.009) and RA (P < 0.0001); greater number (P < 0.0001) and duration (P< 0.0001) of bipoles along the CT with delayed conduction; lower atrial voltage in the LA (P < 0.0001) and RA (P < 0.0001); and more frequent electrical scar (P = 0.001) compared with controls. Five of twelve with MS and none of the controls developed AF with extra-stimulus (P = 0.02). CONCLUSION Atrial remodelling in MS is characterized by LA enlargement, loss of myocardium, and scarring associated with widespread and site-specific conduction abnormalities and no change or an increase in ERP. These abnormalities were associated with a heightened inducibility of AF.

Association between gender, process of care measures, and outcomes in ACS in India: results from the detection and management of coronary heart disease (DEMAT) registry.

Background Studies from high-income countries have shown that women receive less aggressive diagnostics and treatment than men in acute coronary syndromes (ACS), though their short-term mortality does not appear to differ from men. Data on gender differences in ACS presentation, management, and outcomes are sparse in India. Methods and Results The Detection and Management of Coronary Heart Disease (DEMAT) Registry collected data from 1,565 suspected ACS patients (334 women; 1,231 men) from ten tertiary care centers throughout India between 2007–2008. We evaluated gender differences in presentation, in-hospital and discharge management, and 30-day death and major adverse cardiovascular event (MACE; death, re-hospitalization, and cardiac arrest) rates. Women were less likely to present with STEMI than men (38% vs. 55%, p<0.001). Overall inpatient diagnostics and treatment patterns were similar between men and women after adjustment for potential confounders. Optimal discharge management with aspirin, clopidogrel, beta-blockers, and statin therapy was lower for women than men, (58% vs. 65%, p = 0.03), but these differences were attenuated after adjustment (OR = 0.86 (0.62, 1.19)). Neither the outcome of 30-day mortality (OR = 1.40 (0.62, 3.16)) nor MACE (OR = 1.00 (0.67, 1.48)) differed significantly between men and women after adjustment. Conclusions ACS in-hospital management, discharge management, and 30-day outcomes did not significantly differ between genders in the DEMAT registry, though consistently higher treatment rates and lower event rates in men compared to women were seen. These findings underscore the importance of further investigation of gender differences in cardiovascular care in India.

Giant Pulmonary Artery Aneurysm With Dissection in a Case of Marfan Syndrome

![Figure][1] [![Graphic][3] ][3] A 40-year-old man presented with left-sided chest pain of 1 week in duration. He had tachycardia, tachypnea, and an early diastolic murmur with Marfanoid features. Chest x-ray showed gross cardiomegaly and a prominent main pulmonary artery (A) .

Aspirin resistance in Indian patients with coronary artery disease and cardiovascular events.

BACKGROUND Aspirin resistance is a major problem and its incidence and clinical significance in Indian patients with documented coronary artery disease are not known. AIM We sought to study the incidence of aspirin resistance and its clinical significance in a cohort of Indian patients with coronary heart disease on therapy with aspirin using urinary 11-Dehydrothromboxane B2 levels as a surrogate marker for antiplatelet efficacy. SETTING AND DESIGN Non randomized single center prospective study in cohort of patients with stable cardiovascular disease on chronic aspirin therapy attending the cardiology outpatient clinic of a tertiary care hospital. MATERIALS AND METHODS Urinary dehydrothromboxane levels were analyzed in a cohort of 63 patients with stable documented coronary artery disease and in 21 healthy volunteers. The cases were followed up prospectively for a median period of 36 (1-53) months. The clinical endpoint was a composite of acute coronary syndrome, stroke, revascularization and death. STATISTICAL ANALYSIS Comparison of urinary dehydrothromboxane concentration values between various risk factors was done using Mann Whitney U test, a non parametric alternative of independent t test. All statistical analyses were done using SPSS 11.0 (Chicago, USA) software. RESULTS The median (range) absolute values of urinary11- dehydrothromboxane B2 levels for the healthy volunteers and cases were 440 (286-2050) pg/ml and 320 (72-2600) pg/ml (P=0.007). The corresponding normalized values were 87.3 (43-143) and 60.8 (16.7-943) ng/mmol of creatinine (P=0.131). Among the various vascular risk factors, patients who were overweight had higher absolute levels of 11- urinary dehydrothomboxane B2 levels (P=0.016). There were significantly more clinical events in patients with absolute urinary 11-dehydrothromboxane B2 levels in the upper two quartiles compared to the lower two quartiles (P=0.04). CONCLUSION The incidence of aspirin resistance in the cohort of patients with documented heart disease was 38.1%. Patients with elevated absolute urinary dehydrothomboxane levels (>320 pg/ml) on chronic aspirin therapy constitute a high risk subset for recurrent vascular events.

Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction - MI3 Trial

Background & objectives: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 108 autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy. Methods: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI). Results: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 × 108(n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study. Interpretation & conclusions: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Assessment of left ventricular systolic function by velocity vector imaging.

OBJECTIVES To study the usefulness of a novel echocardiographic technique, velocity vector imaging (VVI) in the measurement of left ventricular ejection fraction (LVEF). BACKGROUND Ejection fraction measured by echocardiography forms the cornerstone in the assessment of LV systolic function. Errors in measurement of EF by routine two-dimensional echocardiography (2D ECHO) limit its utility. The VVI is a new technology which uses speckle tracking and other algorithms to track the endocardial border. This may help in more accurate assessment of EF. METHODS Global and regional LVEF was measured in 49 patients using VVI, 2D ECHO and radionuclide-gated single photon emission computed tomography (SPECT). Results were categorised as normal, mild, moderate, or severe LV systolic dysfunction based on American Society of ECHO classification. The results were analysed by appropriate statistical tests for correlations. RESULTS The mean EF was 35 ± 12.08% by VVI, 54.2 ± 19.51% by SPECT (P< 0.001 vs VVI) and 50.3 ± 8.92% by 2D ECHO (P < 0.001 vs VVI). There was weak linear positive correlation between EF measured by VVI and the other modalities (Pearsons correlation coefficient 0.577 for SPECT and 0.573 for 2D; P=0.01). The VVI systematically underestimated the EF compared to SPECT. Greater number of patients had moderate or severe LV systolic dysfunction by VVI (37; 74.5%) than by SPECT (17; 34.7%; P=0.037). We derived a correction factor to calculate SPECT EF from VVI EF as follows: EF (SPECT) = EF (VVI) × 0.9 + 21 or approximately VVI (EF) + 20. CONCLUSION Measurement of EF by VVI is feasible. The VVI underestimated the EF when compared to nuclear-gated SPECT in this study. The accuracy of this technology and the need for a correction factor needs to be assessed in future studies.

Pseudoaneurysm of the left atrium following infective endocarditis

Transthoracic echocardiogram of a 3-year-old child showed a hypoechoic cavity in the posterior wall of the left atrium communicating with the left ventricle through an orifice in the mitral annulus, suggestive of pseudoaneurysm (Ps), probably the result of infective endocarditis. Three-dimensional echocardiography was helpful to confirm the diagnosis and assess the anatomical relationship of the Ps.

Incidentally detected large neonatal ductus arteriosus aneurysm.

A 2-day-old neonate was incidentally detected to have heart murmur. Chest radiography showed cardiomegaly but no ductal bump. Echocardiography revealed a 10 15-mm ductus arteriosus aneurysm as a dilated vascular structure that protruded to the left of the aortic arch, and on color Doppler, there was swirling of blood within the aneurysm and a left-to-right shunt into the main pulmonary artery through the constricted pulmonary end of the patent ductus arteriosus (Figure 1, Video 1, Video 2). The border of the aneurysm was not delineated on echocardiography. Computed tomography angiography confirmed the echocardiography findings (Figure 2). Surgical resection of a ductus arteriosus aneurysm may be considered if it remains patent beyond the neonatal period or is associated with connective tissue Asian Cardiovascular & Thoracic Annals 2016, Vol. 24(9) 900–901 The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315585046 aan.sagepub.com

The Shadow Within: A Colossal Left Atrium

A 32-year-old male, who was diagnosed with rheumatic heart disease 9 years prior, presented with progressively worsening exertional dyspnea and palpitations for 2 years. Clinical examination revealed atrial fibrillation with features of severe mitral regurgitation (MR). His chest x-ray (in posteroanterior view) exposed an enormously enlarged cardiac silhouette with a cardiothoracic ratio of 0.88. There was splaying of the carinal angle and distinct double shadows along the right heart border indicative of left an enlarged atrium (LA) (Fig. 1A). Transthoracic echocardiogram (Philips iE33, Philips Medical Systems, Andover, MA, USA) disclosed a thick calcified rheumatic mitral valve together with severe MR and mild aortic regurgitation. As presumed from the x-ray projections, the LA was hugely distended measuring 15.2 9 12.8 cm (Fig. 1B and movie clip S1). Cardiac magnetic resonance imaging (1.5 Tesla MRI scanner, GE Medical Systems, Milwaukee, WI, USA) was also performed which demonstrated the LA compressing all other cardiac chambers with a calculated volume of 1950 mL (Fig. 2). The patient has been advised valve replacement and is presently awaiting surgery. The LA is ordinarily located in the posterior aspect of the mediastinum and does not contribute to any cardiac border on a posteroanterior view of the normal chest roentgenogram. However, abnormal enlargement of the LA proceeds in a rightward direction and may even about the right chest wall, mimicking a pleural effusion. A giant LA is defined by a diameter larger than 8 cm in the transthoracic echocardiogram in parasternal long-axis view, and is almost always due to rheumatic mitral valve disease. The plausible etiology is postulated to be pancarditis of rheumatic origin involving the left atrial wall. The left atrial size depicted in this case appears to