Santhosh Satheesh

Elevated levels of serum sialic acid and high-sensitivity C-reactive protein: markers of systemic inflammation in patients with chronic heart failure.

Abstract Heart failure (HF) is a common, debilitating disorder in which the heart is unable to pump an adequate blood supply to the tissues. Although it has been shown that inflammation occurs in HF, inflammatory markers have yet to be defined. Inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP), cytokines and serum sialic acid (SA) have been suggested as cardiovascular risk biomarkers. This study aims to assess the serum levels of inflammatory markers such as sialic acid and hs-CRP in chronic heart failure (CHF). Forty-eight patients with CHF and 30 healthy controls were recruited. Total sialic acid (TSA) and lipid-associated sialic acid (LASA), and the inflammatory marker hs-CRP, were assayed in all study subjects. N-terminal pro-brain natriuretic peptide (NT-proBNP) was assayed in the patient group only. Serum mean TSA and LASA were significantly higher in CHF patients when compared to healthy controls (P<0.01). Mean hs-CRP levels in CHF patients showed a significant elevation compared with healthy controls (P<0.01). There was a significant positive correlation between TSA and hs-CRP. Thus, TSA and hs-CRP would appear to be stable markers of systemic inflammation in chronic heart failure.

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.

Relationship of raised serum total and protein bound sialic acid levels with hyperinsulinemia and indices of insulin sensitivity and insulin resistance in non-diabetic normotensive obese subjects

AIMS Obesity is known to be associated with cardiovascular disease and interaction between inflammation and insulin resistance is reported to enhance the cardiovascular risk in these subjects. The present study was designed to assess indices of insulin sensitivity, insulin resistance and sialic acid levels and their association in non-diabetic normotensives obese subjects. MATERIALS AND METHODS The present study was conducted in 30 obese male subjects and results were compared with 30 subjects with normal body weight. Insulin, total sialic acid and protein bound sialic acid were estimated in all the subjects. Insulin resistance was calculated by using Homeostatic Model Assessment-insulin resistance formula. Insulin sensitivity was assessed by quantitative insulin check index and insulin sensitivity index. RESULTS Insulin resistance, serum total and protein bound sialic acid levels were significantly increased in obese cases as compared to non-obese controls. Total sialic acid showed significant positive correlation with HOMA-IR (p<0.01), BMI (p<0.01), waist and hip circumference (p<0.01) and negative correlation with QUICKI (p<0.01) and insulin sensitivity index (p=0.018). There was no significant correlation between protein bound sialic acid and indices of insulin resistance and insulin sensitivity. CONCLUSION Sialic acid levels are elevated in obese subjects and its association with insulin resistance and reduced insulin sensitivity may enhance the cardiovascular risk in these subjects.

Hyperhomocysteinemia and hyperlipoproteinemia (a) in obese south indian men: an indication for increased cardiovascular risk

Obesity is a pathological condition which increases the risk for cardiovascular disease. The present study was designed to evaluate homocysteine, lipoprotein (a) [Lp(a)], apolipoprotein-B (apo-B), apolipoprotein-A-I (apo-A-I) and lipid indices and their association if any in obese South Indian men. Thirty obese men and thirty age-matched males with normal body weight (controls) were recruited in the study. Plasma homocysteine, Lp(a), lipid profile, apo-A-I and apo-B were estimated in all the subjects. Lipid indices such as lipid pentad index (LPI), lipid tetrad index (LTI), atherogenic index of plasma (AIP), non-high density lipoprotein (non-HDL)/high density lipoprotein (HDL) ratio and apo-B/apo-A-I ratio were calculated in all study subjects. Homocysteine, Lp(a), apo-B, apo-B/apo-A-I ratio and lipid indices were significantly increased in obese men, compared to controls. Both homocysteine and Lp(a) were positively correlated with BMI, waist, hip circumference and apo-B and negatively correlated with apo-A-I. Also we found highly significant positive correlation between homocysteine and Lp(a) levels. The data from the present study concludes that non-conventional risk factors like homocysteine, Lp (a), apo-B/apo-A-I ratio, LTI, LPI, non-HDL/HDL ratio and AIP were significantly elevated in obese Indian men, suggesting they are more prone to develop cardiovascular disease, than the age-matched men with normal body weight.

Increased levels of markers of oxidative stress and inflammation in patients with rheumatic mitral stenosis predispose to left atrial thrombus formation.

BACKGROUND Rheumatic mitral stenosis (MS) causes stagnation of blood flow, leading to thrombus formation in the left atrium (LA), which may lead to systemic thromboembolic complications. We compared alterations in circulating levels of pro-/anti-oxidants and markers of inflammation in patients of severe rheumatic MS with and without LA thrombus and studied their predictive power to detect the presence of LA thrombus in patients with rheumatic MS. MATERIAL AND METHODS This is a cross-sectional study of 80 patients with rheumatic MS, evaluated for percutaneous mitral commisurotomy. Group 1 comprised of patients with rheumatic MS with LA thrombus (n=35) and Group 2 included patients with rheumatic MS without LA thrombus (n=45). The following oxidative stress markers-malondialdehyde (MDA), protein carbonyls, total oxidant status and total antioxidant status and inflammation markers-high sensitivity C-reactive protein (hs-CRP), total sialic acid (TSA) and protein-bound sialic acid (PBSA) were estimated in all study subjects. RESULTS Levels of plasma MDA, protein carbonyl and total oxidant status were significantly elevated, whilst the total antioxidant status levels were significantly lowered, in Group 1, as compared with Group 2. hs-CRP, TSA and PBSA levels showed a significant rise in Group 1 patients, as compared with Group 2. CONCLUSION Our results suggest that circulating levels of MDA, protein carbonyl and PBSA were independent predictors of occurrence of LA thrombus in patients with rheumatic MS.

The metamorphosis of vascular stents: passive structures to smart devices

Drug-eluting stents (DES) represent a major milestone in stent technology, saving the lives of millions worldwide afflicted with cardiovascular disease. Though a wide range of therapeutic approaches has been employed for treatment of coronary artery diseases, stent deployment has become the most extensively practiced method to open blocked arteries in comparison with surgical revascularisation. In recent years, the bare metal stent has evolved into more effective drug-eluting systems and the encouraging results from initial clinical trials have instilled hope among cardiologists to reduce the number of fatalities caused by cardiovascular diseases through the deployment of drug-eluting stents. Over the years, the stents have evolved from a passive framework that maintained blood flow through the blood vessels into multi-functional devices that could also serve to mitigate conditions leading to the blockage of the blood vessels while promoting re-endothelialization of the blood vessel. This review traces the evolution of the stents from the first generation structures to the modern versions that overcome their limitations. A glimpse into the exciting future of stent technology is also provided.

Cardiac syndrome X: Clinical characteristics revisited

BACKGROUND Cardiac syndrome X includes a heterogenous group of patients with angina but normal epicardial coronaries in angiography. OBJECTIVE Our objective was to study the clinical characteristics of patients with cardiac syndrome X. METHODS Data of patients who underwent coronary angiography over a period of one year was retrospectively analyzed. Those with normal or non-obstructive coronaries in angiography with chest pain were included in this study. RESULTS 1203 patients underwent coronary angiography during the study period. 105 (8.7%) patients fulfilled the inclusion criteria. There were 52 (49.5%) males and 53 (50.5%) females including 31 (29.5%) postmenopausal women. Many patients had atherosclerotic risk factors. Typical angina and atypical chest pain were reported by 63 (60%) and 42 (40%) patients, respectively. ECG was normal in 46 (43.8%) and abnormal in 59 (56.2%) patients. The most common abnormal finding in ECG was ST-T changes seen in 49 (46.7%) patients. Regional wall motion abnormality with mild left ventricular systolic dysfunction was seen in 4 (3.8%) patients while 101 (96.2%) patients had normal ventricular function in echocardiography. TMT was positive for inducible ischemia in 35 (33.3%) patients and inconclusive in 10 (9.5%) patients. Angiography showed normal epicardial coronaries in 85 (80.9%) patients. CONCLUSIONS Cardiac syndrome X constitutes a significant subset of patients undergoing coronary angiography. It is essential to identify and treat them specifically for microvascular angina. Many of them have atherosclerotic risk factors but their presentation is different from those with obstructive coronaries.

Elevated fibrinogen and lowered homocysteine-vitamin determinants and their association with left atrial thrombus in patients with rheumatic mitral stenosis

ABSTRACT Mitral stenosis (MS) causes stagnation of blood flow, leading to thrombus formation in the left atrium (LA), which may lead to systemic thrombo-embolic complications and stroke. We compared the alterations in echocardiographic and procoagulant parameters in patients with severe rheumatic MS with and without LA thrombus. The study was a cross-sectional study of patients with rheumatic MS, being evaluated for percutaneous mitral commisurotomy. Group 1 patients comprised of patients with rheumatic MS with LA thrombus (n=35) and Group 2 patients had rheumatic MS without LA thrombus (n=45). Platelet aggregability, fibrinogen, homocysteine, vitamin B12 and folate; mitral valve area (MVA), mean mitral gradient and pulmonary artery pressure (PAP) were assessed in all study subjects. Significant increase in fibrinogen, homocysteine and platelet aggregation and fall in homocysteine-associated determinants were seen in Group 1, as compared with Group 2. Raised fibrinogen, lowered homocysteine-vitamin determinants and lowered mitral valve area were associated independently, with presence of LA thrombus in rheumatic MS. In this study, fibrinogen, vitamin B12 and folate were independently associated with the occurrence of thrombus in patients with rheumatic MS. Hence, our results suggest that increase in procoagulant mechanisms contribute to increased risk of thrombosis in the left atrium in patients with rheumatic MS.

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.