Ranjan K Shetty

Evaluation of fetal echocardiography as a routine antenatal screening tool for detection of congenital heart disease

BACKGROUND Fetal echocardiography plays a pivotal role in identifying the congenital heart defects (CHDs) in utero. Though foetal echocardiography is mostly reserved for high risk pregnant women, its role as a routine prenatal screening tool still needs to be defined. Performing foetal echocardiography based on only these indications can lead to a significant numbers of CHD cases going undetected who will be deprived of further management leading to increased early neonatal mortalities. The aim of this study is to assess the incidence of CHDs by fetal echocardiography in an unselected population of pregnant women in comparison with pregnant women with conventional high risk factors for CHD. METHODS This study enrolled consecutive pregnant women who attended antenatal clinic between 2008 and 2012 in a tertiary care hospital. These pregnant women were categorized into two groups: high risk group included pregnant women with traditional risk factors for CHD as laid down by Pediatric Council of the American Society of Echocardiography and low risk group. Detailed fetal 2 D echocardiography was done. RESULTS A total of 1,280 pregnant women were included in study. The 118 women were categorized as the high risk group while remaining 1,162 were included in the low risk group. Twenty six cases of CHDs were detected based on abnormal foetal echocardiography (20.3 per 1,000). Two of the 26 cases of CHD occurred in high risk group whereas the remaining 24 occurred in low risk pregnancy. The difference in the incidence of CHDs between the two groups was not significant statistically (P=0.76). CONCLUSIONS Our study shows no difference in incidence of CHDs between pregnancies associated with high risk factors compared to low risk pregnancies. So we advocate foetal echocardiography should be included as a part of routine antenatal screening and all pregnant women irrespective of risk factors for CHDs.

Prognosis of Left Ventricular Systolic Dysfunction in Septic Shock Patients

INTRODUCTION The prognosis of myocardial dysfunction in critically ill patients with sepsis and its association with mortality is controversial. We aim to determine the significance of left ventricular systolic dysfunction in septic shock patients and their associated outcome. MATERIALS AND METHODS A prospective, single center, observational study was carried out at an intensive care unit of a tertiary care hospital. A total of 66 patients diagnosed with septic shock were enrolled in the study from September 2010 to June 2012. The 2D echocardiography was performed for all the patients. Ejection fraction <50% was the diagnosing parameter for the patients with systolic dysfunction in septic shock. Acute Physiology and Chronic Health Evaluation III (APACHE III) score was calculated. RESULTS The mean age of patients were found to be 53.71 ± 16.76 years. The mortality rate was found to be 48.48% and among them 43.75% patients had ejection fraction <50%. Non-survivors exhibited significantly lower mean blood pressure (74.19 ± 10.28 versus 80.59 ± 11.31; p = 0.008), lower ejection fraction (52.59 ± 16.37 versus 62.56 ± 8.31; p = 0.029) and higher APACHE III score (89.34 ± 15.41 versus 70.65 ± 13.27; p <0.001). The receiver operating characteristic curves APACHE III score (area under curve = 0.830) and ejection fraction (area under curve = 0.656) were used to predict the mortality in septic patients. CONCLUSION Low ejection fraction, a marker to measure left ventricular systolic dysfunction is a predictor of mortality in septic shock patients. However, more research is needed to confirm the findings.

Correlation of epicardial fat and anthropometric measurements in Asian-Indians: A community based study

BACKGROUND: It is increasingly evident that visceral adipose tissue plays a leading role in the pathogenesis of the metabolic syndrome. Unfortunately, accurate quantification of intra-abdominal visceral fat is cumbersome and expensive. Epicardial fat represents the component of visceral fat distributed around the heart, and is readily and non-invasively assessed by echocardiography. AIMS: To determine the correlation of epicardial fat with anthropometric parameters in a healthy population of Asian-Indians. MATERIALS AND METHODS: A prospective, cross-sectional study was conducted as part of a community outreach program from December to March 2011. Individuals over 18 years of age were included in the study. Anthropometric data was collected for all patients. Epicardial fat was assessed in parasternal long and short axes. RESULTS: 350 healthy individuals were included in the study. Of them, 66.7% were males. Mean age was 42.7 ± 15.3 years (range 18-84). Mean body-mass index (BMI) and waist circumference were 23.3 ± 4.5 kg/m2 (range 15.2-34.3) and 80.2 ± 13.3 cm (range 43-115) respectively. Mean epicardial fat in both axes was 2.6 ± 1.3 mm (range 0.3-7.0). Epicardial fat measured in both axes correlated well with weight (r = 0.399, P < 0.001), waist circumference (r = 0.522, P < 0.001) and BMI (r = 0.471, P < 0.001). Epicardial fat also correlated with age (r = 0.559, P < 0.001). CONCLUSIONS: There is an excellent correlation between epicardial fat measured by echocardiography and anthropometric parameters of metabolic syndrome.

Automated screening of congestive heart failure using variational mode decomposition and texture features extracted from ultrasound images

Heart is an important and hardest working muscular organ of the human body. Inability of the heart to restore normal perfusion to the entire body refers to cardiac failure, which then with symptoms results in manifestation of congestive heart failure (CHF). Impairment in systolic function associated with chronic dilation of left ventricle is referred as dilated cardiomyopathy (DCM). The clinical examination, surface electrocardiogram (ECG), chest X-ray, blood markers and echocardiography play major role in the diagnosis of CHF. Though the ECG manifests chamber enlargement changes, it does not possess sensitive marker for the diagnosis of DCM, whereas echocardiographic assessment can effectively reveal the presence of asymptomatic DCM. This work proposes an automated screening method for classifying normal and CHF echocardiographic images affected due to DCM using variational mode decomposition technique. The texture features are extracted from variational mode decomposed image. These features are selected using particle swarm optimization and classified using support vector machine classifier with different kernel functions. We have validated our experiment using 300 four-chamber echocardiography images (150: normal, 150: CHF) obtained from 50 normal and 50 CHF patients. Our proposed approach yielded maximum average accuracy, sensitivity and specificity of 99.33%, 98.66% and 100%, respectively, using ten features. Thus, the developed diagnosis system can effectively detect CHF in its early stage using ultrasound images and aid the clinicians in their diagnosis.

Lithium-induced sinus node dysfunction at therapeutic levels

Lithium is used as an antimanic and mood-stabilising drug. It can cause various adverse effects such as nausea, vomiting, polyuria, fine tremors, myocarditis and arrhythmias. We are describing a case of lithium induced sinus-node dysfunction in a patient with serum lithium levels in therapeutic range.

Automated technique for coronary artery disease characterization and classification using DD-DTDWT in ultrasound images

Abstract Heart is one of the important as well as hardest working organ of human body. Cardiac ischemia is the condition where sufficient blood and oxygen will not reach the heart muscle due to narrowed arteries of the heart. This condition is called coronary artery disease. Several non-invasive diagnostic tests fail to reveal exact impact of coronary artery disease on myocardial segments. The ultrasound images can explore major impact on ventricular muscle segments due to ischemia and complication of acute coronary syndrome. Computer aided diagnosis tools can predict coronary artery disease in its early stage so that patients can undergo treatment and save their life. This paper presents a novel computer aided diagnosis system for the automated detection of coronary artery disease using echocardiography images taken from four chamber heart. Proposed method uses double density-dual tree discrete wavelet transform (DD-DTDWT) to decompose the images into different frequency sub-bands. Then various entropy features are extracted from these sub-bands. The obtained dimension of the features is reduced using marginal fisher analysis (MFA) and optimal features are selected using feature ranking methods. The proposed method achieved promising accuracy of 96.05%, sensitivity of 96.12%, and specificity of 96.00% for linear discriminant classifier using entropy ranking method with twelve features. We have also proposed coronary artery disease risk index (CADRI) to categorize diseased subjects from normal subjects using a single value. Thus, it can be used as a diagnosis tool in hospitals and polyclinics for confirming the findings of clinicians.

Leucocytoclastic vasculitis as a late complication of clopidogrel therapy

We describe a case of leucocytoclastic vasculitis manifested as exanthematous rash in a 57-year-old woman on long-term therapy with clopidogrel. The diagnosis was confirmed by skin biopsy. The patient was managed symptomatically with oral antihistaminics and topical steroids in consultation with dermatologists. Clopidogrel therapy was discontinued on suspicion of drug-induced vasculitis. The rash resolved completely within 2 weeks of withdrawal of clopidogrel, satisfying criteria for a probable adverse drug reaction. Leucocytoclastic vasculitis is an unusual adverse effect of clopidogrel therapy and even rarer as a late complication.

Spontaneous coronary artery dissection as the first presentation of systemic lupus erythematosus.

A 33-year-old woman with no premorbidities presented to us with chest pain and worsening dyspnoea since 1 week. Systemic examination was suggestive of acute pulmonary oedema and preliminary investigations revealed evolved anterior wall myocardial infarction (MI). The patient was stabilised and taken up for angiography which revealed spontaneous coronary artery dissection (SCAD) of the left anterior descending (LAD) artery. She underwent percutaneous coronary intervention (PCI) for the same. Further investigation into the cause for the SCAD came strongly positive for systemic lupus erythematosus (SLE). She had no prior symptoms suggestive of SLE and the SCAD was its very first clinical manifestation.

Association of thyroid function with severity of coronary artery disease in euthyroid patients

INTRODUCTION Thyroid hormone exerts multiple effects on the heart and vascular system. Variations of free T3 have been linked to coronary artery disease. We conducted a study to observe whether there is a relationship between the variation of the serum thyroid hormone levels (TSH, FT3 and FT4) and the presence and severity of CAD in the euthyroid patients. AIM To study association of serum TSH, FT4 and FT3 levels within the normal range with presence and severity of coronary artery disease. MATERIALS AND METHODS A total of 100 euthyroid patients with stable angina, who underwent coronary angiography were enrolled in the study. Coronary artery disease was defined as >50% stenosis in the luminal diameter in at least one major epicardial coronary artery. The Gensini scoring system was used to define the severity of the CAD and serum TSH, FT3 and FT4 levels were measured by the chemiluminescence method. RESULTS Single vessel disease was found in 23%, double vessel disease in 15% and triple vessel disease in 17% of patients. TSH and FT4 levels were also comparable between the groups. Normal coronary group had significantly higher mean FT3 values than triple vessel disease (p=0.004) and FT3 levels showed an inverse relation with Gensini score (Pearsons correlation =- 0.30) (p =0.002). A level of FT3 ≤ 2.7 predicted the severity of CAD with a 70% sensitivity and 60% specificity (area under curve (AUC): 0.755, p=0.001). CONCLUSION In the absence of primary thyroid disease and acute coronary syndrome, the occurrence of CAD is associated with lower serum levels of FT3. FT3 and not the FT4 and TSH levels may be used as an indicator of increased risk for severe CAD. The present study clearly shows the existence of a strong association between the reduction of biologically active T3 and severity of coronary artery disease. However, low T3 state could be at first interpreted as just a biological risk factor of severe coronary artery disease; only the demonstration of beneficial effects on cardiovascular, end points of long term T3 replacement in CAD patients with low T3 state can answer this fundamental issue.

Unprotected distal left main bifurcation drug eluting stent restenosis: first successful experience with simultaneous kissing balloon dilatation using sirolimus coated balloon

Treatment of unprotected left main (ULM) in-stent restenosis (ISR) in patients with prior drug eluting stent implantation is challenging. Treatment usually involves complex stenting procedures or bypass grafting. Drug coated balloon (DCB) is relatively new concept which is usually used in treatment of ISR. In a patient of ULM ISR, use of DCBs is a safe, economic and a technically simple option with relatively good outcomes. We report use of simultaneous kissing balloon dilatation with novel sirolimus coated balloons (SCBs) via radial artery to treat ULM ISR.