Sasidharan Bijulal

Trans-catheter closure of atrial septal defect: Balloon sizing or no balloon sizing - single centre experience

Background: Selecting the device size using a sizing balloon could oversize the ostium secundum atrial septal defect (OSASD) with floppy margins and at times may lead to complications. Identifying the firm margins using trans-esophageal echocardiography (TEE) and selecting appropriate-sized device optimizes ASD device closure. This retrospective study was undertaken to document the safety and feasibility of device closure without balloon sizing the defect. Methods: Sixty-one consecutive patients who underwent trans-catheter closure of OSASD guided by balloon sizing of the defect and intra procedural fluoroscopy (group I) and 67 consecutive patients in whom TEE was used for defect sizing and as intraprocedural imaging during device deployment (group II) were compared. The procedural success rate, device characteristics, and complications were compared between the two groups. Results: The procedure was successful in 79.7 % patients. The success rate in group II (60 of 67, 89.6%) was significantly higher than in group I (41 of 61, 67.2 %) (P = 0.002). Mean upsizing of ASD device was significantly lower in group II (P < 0.001). TEE also provided better success rate with smaller device in subjects with large ASD (>25 mm) and in those who were younger than 14 years of age. There were four cases of device embolization (two in each group); of which one died in group II despite successful surgical retrieval. Conclusion: Balloon sizing may not be essential for successful ASD device closure. TEE-guided sizing of ASD and device deployment provides better success rate with relatively smaller sized device.

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%, pu200a=u200a0.03), but these differences were attenuated after adjustment (ORu200a=u200a0.86 (0.62, 1.19)). Neither the outcome of 30-day mortality (ORu200a=u200a1.40 (0.62, 3.16)) nor MACE (ORu200a=u200a1.00 (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.

Percutaneous closure of patent ductus arteriosus in children: Immediate and short-term changes in left ventricular systolic and diastolic function

Objective: To evaluate the effect of percutaneous closure of patent ductus arteriosus (PDA) on left ventricular (LV) systolic and diastolic function in children. Background: Limited studies are available on alteration in LV hemodynamics, especially diastolic function, after PDA closure. Methods: Thirty-two consecutive children with isolated PDA treated by trans-catheter closure were studied. The LV systolic and diastolic function were assessed by two-dimensional (2D) echocardiography and tissue Doppler imaging 1 day before the PDA closure, on day 1, and on follow-up. Results: At baseline, none of the patients had LV systolic dysfunction. On day 1 post-PDA closure, 8 (25%) children developed LV systolic dysfunction. The baseline LV ejection fraction (LVEF), LV end-systolic dimension (LVESD), and PDA diastolic gradient predicted the post-closure LVEF. Patients who developed post-closure LV systolic dysfunction had poorer LV diastolic function than those who did not. LV diastolic properties improved after PDA closure; however, the improvement in LV diastolic properties lagged behind the improvement in the LV systolic function. All children were asymptomatic and had normal LVEF on follow up of >3 months. Conclusions: Percutaneous closure of PDA is associated with the reversible LV systolic dysfunction. Improvement in the LV diastolic function lags behind that in the LV systolic function.

Unusual Coarctation—the PHACE Syndrome: Report of Three Cases

OBJECTIVESnTo report the clinical features, nature of vasculopathy observed and the management instituted in three cases of PHACE syndrome.nnnRESULTSnAll three patients were noted to have diffuse vasculopathy and aortic arch hypoplasia in addition to aortic coarctation adding substantial surgical risk or making surgery palliative.nnnCONCLUSIONnPHACE syndrome should be considered in the differential diagnosis of aortic coarctation associated with aortic arch hypoplasia.

Tako-tsubo cardiomyopathy in a patient with myasthenia gravis crisis: a rare clinical association.

Tako-tsubo cardiomyopathy (TTC) is increasingly being recognised as transient left ventricular dysfunction following various hyperadrenergic states such as emotional or physical stressors. The association of this rare clinical entity with myasthenia gravis (MG) has been reported only twice in the literature, both following plasmapheresis for MG crisis. Here we describe a unique case of TTC in a 40-year-old woman with MG admitted with MG crisis managed conservatively. This case suggests that plasmapheresis is unlikely to have a causative role in the development of TTC in these patients. Patients with MG crisis may be at potential risk of developing TTC and careful clinical and electrocardiographic monitoring is necessary while treating them. The possible role of stress as the common precipitating factor in both conditions is also discussed.

Retroaortic Coronary Artery: Possible Contraindication for Device Closure of Atrial Septal Defect

Anomalous origin of the coronary artery from the opposite aortic sinus is an infrequently encountered clinical problem. Incidence of this abnormality was approximately 1.69% in the angiographic study by Angelini et al. [1]. This abnormal vessel can have a retroaortic course before it reaches the atrioventricular or interventrivular groove. Atrial septal defect is one of the common forms of congenital heart disease, and percutaneous device closure is an alternative to surgery. The presence of adequate rims around the defect, except for the aortic rim, is an essential prerequisite for device closure because the device splays over the atrial roof onto either side of the aorta. However, an abnormal coronary artery arising from the opposite aortic sinus with retroaortic course will be in close relation to the aortic rim of the defect. When the left circumflex artery arises from the right coronary sinus, it usually has a retroaortic course. This anomaly was observed in 0.67% of patients in the series by Angelini et al. [1]. Abnormal origin of the left coronary artery from the right sinus can also be associated with a retroaortic course. These coronary anomalies may coexist with atrial septal defect, and the retroaortic vessel may be in relation to the aortic rim of the defect; thus, coronary compression by the device is possible. Careful echocardiographic screening for these anomalies and their confirmation by angiographic studies can prevent these complications. We report a 6-year-old boy with retroaortic circumflex artery close to the aortic rim of the defect in whom device closure was not performed due to this anomaly. Case Report

Membranous Septal Aneurysm: An Unusual Cause for Right Ventricular Outflow Tract Obstruction in a Malaligned Ventricular Septal Defect with Aortomitral Discontinuity (Double-Outlet Right Ventricle) Associated with Visceral Heterotaxy

The development of a septal aneurysm in the natural history of membranous ventricular septal defects usually makes the defect hemodynamically less significant. This report describes a case of severe right ventricular outflow obstruction produced by a membranous septal aneurysm in a patient who had an anterior malaligned ventricular septal defect with aortomitral discontinuity (double-outlet right ventricle). This patient did not have pulmonary stenosis other than the dynamic obstruction produced by the septal aneurysm. In this patient, the septal aneurysm produced both favorable and unfavorable hemodynamic effects. A reduction in the size of the ventricular septal defect produced a favorable effect, whereas a right ventricular outflow obstruction led to the unfavorable situation of right ventricular hypertension and hypertrophy. The large septal aneurysm in the presence of an already compromised right ventricular outflow tract related to an anteriorly malaligned septum resulted in severe obstruction.

Clinical Outcomes of patients with coronary artery disease who underwent FFR evaluation of intermediate coronary lesionS– COFFRS study

Background We undertook this study to validate the impact of FFR-guided coronary interventions among Indian patients, which is not readily available as of date. Our patients differ from their western counterparts, both in terms of risk profile (younger, more metabolic syndrome, lipid rich diet) as well as their coronary size. Methods We retrospectively evaluated 282 patients with intermediate stenosis in their coronary arteries, who underwent FFR to assess the functional severity of the lesion. There were 3 groups: Group 1–FFR > 0.8 and kept on medical follow-up; Group 2–FFR ≤ 0.8 and underwent revascularisation; and Group 3–FFR ≤ 0.8 and refused to undergo revascularization. 281(99.6%) patients had regular follow-up in our clinic. Results Median age-57 years (range = 28–78). Males = 230, 90 patients were in Group 1, 175 in group 2 (PCI in 144 & CABG in 31) and 17 in group 3. Median follow-up of patients was 17.9 months (2 to 56 months). Three patients(3.4%) in Group 1 had MACE (1 STEMI, 2 UA); 4 patients (2.3%) in Group 2 had Non-STE-ACS; 7 patients (41%) in Group 3 had MACE (3 deaths with acute LVF, 2 NSTEMI, 2 STEMI) Conclusion In our experience, MACE events were not higher in patients with FFR > 0.8 and kept under medical therapy and were similarly lower in patients with FFR ≤0.8 and underwent revascularisation (p = 0.73). Also MACE events were higher in patients with FFR ≤ 0.8 and did not undergo revascularisation compared to other two appropriately treated groups (p = 0.03). FFR based revascularization decision appears to be a safe strategy in Indian patients.