Sivasubramanian Ramakrishnan

Prevalence and outcome of subclinical rheumatic heart disease in India: The RHEUMATIC (Rheumatic Heart Echo Utilisation and Monitoring Actuarial Trends in Indian Children) study

Objective To study the prevalence and medium term outcome of subclinical rheumatic heart disease (RHD) in India. Design Cross sectional echocardiographic screening study. Setting School children aged 5–15 years living in rural areas of north India. Patients A cross sectional echocardiographic screening study was carried out among 6270 randomly selected school children aged 5–15 years (10.8±2.6 years; 52.7% male). Of all the abnormal cases, 100 children (78%) were restudied at a mean follow-up of 15.4±6.6 months. Intervention Echocardiographic screening. Main outcome measure Echocardiography–Doppler criteria based prevalence of RHD. Results Clinical examination detected mitral regurgitation in five patients and the estimated prevalence of clinical RHD was 0.8/1000 school children. Echocardiography–Doppler diagnosed RHD in 128 cases, giving a prevalence of 20.4/1000 school children (95% CI 16.9 to 23.9/1000 children). On multivariate analysis, older age (OR 1.93, 95% CI 1.29 to 2.88; p=0.001), female sex (OR 1.84, 95% CI 1.25 to 2.72; p=0.002) and government funded school student, which is a surrogate measure of lower socioeconomic status (OR 1.55, 95% CI 1.02 to 2.34; p=0.039) were found to be independent predictors of RHD. On follow up, the severity of subclinical RHD was non-progressive in 68 children (68%) while it worsened in four (4%) and regressed in 28 children (28%). Conclusions The prevalence of RHD is several fold higher using echocardiographic screening compared with clinical examination. The prevalence is higher among girls and children of lower socioeconomic status. In the majority of cases, subclinical RHD appears to be non-progressive on medium term follow up. Routine echocardiographic screening may be indicated in populations at high risk of RHD.

Gender differences in the utilisation of surgery for congenital heart disease in India

Background Corrective surgery for congenital heart disease may be life-saving, but its utilisation depends upon several social and economic factors. Girls with cardiac defects may not receive equitable care in India, but this has not been systematically studied. Methods In this prospective study, parents or guardians of 405 consecutive children aged up to 12 years (mean±SD age 3.43±3.44 years; 271 boys) who had been advised to undergo elective paediatric cardiac surgery were interviewed using a validated questionnaire. The status of the patients was reviewed after a year and the factors associated with non-compliance with treatment were analysed. In a qualitative sub-study the parents of 20 children who had not undergone surgery were interviewed. Qualitative data were analysed using an inductive analytical approach. Results Of the 405 patients studied, 44% (59/134) of girls had undergone surgery at 1 year compared with 70% (189/271) of boys (χ2=24.97; p<0.001). Independent predictors for non-compliance with surgery included female gender (OR 3.46, 95% CI −2.06 to 5.80; p<0.0001), lower socioeconomic classes (lower-middle: OR 18.62, 95% CI −2.14 to 161.8, p=0.008; upper-lower: OR 34.27, 95% CI −3.72 to 316.0, p=0.002) and higher cost of surgery (OR 1.92, 95% CI −1.06 to 3.47, p=0.03). In the in-depth interviews, apprehensions about future matrimonial prospects of girls and lack of social support emerged as the major factors responsible for delays in undergoing surgery. Conclusions Female gender is an important determinant of non-compliance with paediatric cardiac surgery. Deep-seated social factors underlie this gender bias.

Intermediate-term results of percutaneous transvenous mitral commissurotomy in children less than 12 years of age

The objectives of this study were to review the efficacy of percutaneous transvenous mitral commissurotomy (PTMC) in young children less than 12 years of age and to provide intermediate‐term follow‐up data. There is a paucity of information regarding the long‐term efficacy of PTMC done in children less than 12 years of age. The data of 100 consecutive children less than 12 years of age (mean, 11.1 ± 1.2 years) who underwent PTMC using Inoue balloon were analyzed retrospectively. Serial clinical and echocardiographic follow‐up information of more than 6 months was available in 94 patients. The procedure was successful in 94 patients. The mean calculated mitral valve area (MVA) increased from 0.72 0.14 to 1.7 0.35 cm2 (P 0.0001). Echocardiographic restenosis (MVA ≤ 1 cm2 or > 50% gain loss) occurred in 14 of 94 patients (16%) over a mean follow‐up of 34.4 25.9 (range, 2–115) months. The improvement in New York Heart Association (NYHA) functional class was maintained in most patients (from a mean of 2.87 0.5 pre‐PTMC to 1.42 0.6 at follow‐up). Seven out of 14 patients with restenosis underwent a re‐PTMC. The actuarial rate of good functional status (survival, no repeat interventions, and NYHA class 1 or 2) at 100 months was 75.4% 8.7%. PTMC provides excellent intermediate‐term palliation even in young children with rheumatic mitral stenosis. Catheter Cardiovasc Interv 2005;64:487–490.

Unidirectional valved patch closure of ventricular septal defects with severe pulmonary arterial hypertension.

Delayed presentation of ventricular septal defect (VSD) is common in developing countries. Such patients often have severe pulmonary arterial hypertension (PAH), which increases post-operative morbidity and mortality. To address these problems, we used our technique of unidirectional valved patch (UVP) for closure of VSD. Between January 2006 and December 2010, 17 patients (age 2-23 years, median 9 years) with a large VSD and severe PAH underwent VSD closure with UVP. Pre-operative mean indexed pulmonary vascular resistance (PVRI) was 10.9 ± 2.2 Wood units and mean pre-operative systemic saturation was 93.4 ± 2.6%. Shunt was bidirectional in 15 patients and predominantly right to left in two. After VSD closure, intra-operative transoesophageal echocardiography revealed a right to left shunt across the patch in three patients 2, 7 and 9 years of age who had pre-operative PVRI of 9.5, 9.8 and 11.1 Wood units, respectively. There were no in-hospital deaths and all patients had uneventful recovery. Mean follow-up was 30 ± 14.7 months and all patients are well without cyanosis. Echocardiography showed no shunt across the patch and all have systemic saturation >95%. We conclude that UVP is a promising technique in patients with large VSD and severe PAH.

Echocardiography in acute rheumatic fever

E-mail: ramakgmc@rediffmail.com nearly 40-50% of th e patients with acute carditis and are shown to disappear following treatment of carditis.[9,10] Nodules may be more useful for diagnosing recurrence of RF among patients with established RHD, but the sensitivity and specificity of these nodules is not known. The utility of any other structural abnormality for the echocardiographic diagnosis of acute rheumatic carditis in the absence of pathological valvular regurgitation is not well established. A recent study had used a composite score of 8 echocardiographic parameters and concluded that a score of 6 out of 16 identifies echocardiographic carditis precisely.[11] However, the majority of the patients with carditis in that study had pathological mitral or aortic regurgitation.

Preoperative balloon dilatation of obstructed total anomalous pulmonary venous connection in a neonate

Prompt recognition and early surgical correction are mandatory in neonates presenting with obstructed total anomalous pulmonary venous connection (TAPVC). Preoperative balloon angioplasty of obstructed TAPVC in a sick neonate is rarely reported. We describe successful short‐term palliation with balloon angioplasty of a critically ill neonate with obstructed supracardiac TAPVC. Catheter Cardiovasc Interv 2004;61:128–130.

The report on the Indian coronary intervention data for the year 2011--National Interventional Council.

The National interventional council of Cardiological Society of India has conventionally been presenting the data on various forms of cardiac interventions performed in the previous year at its annual meeting. Here we are reporting the data on coronary interventions done in India during the year 2011.

Acute Effects of Tobacco Chewing on the Systemic, Pulmonary and Coronary Circulation

BackgroundTobacco use is highly prevalent in India, with almost half of adult men consuming tobacco in either smoke or smokeless forms (particularly chewing). Although cigarette smoking is known to produce acute hemodynamic effects, there is a lack of data concerning such effects of chewing tobacco.ObjectiveThe aim of this study was to determine the acute hemodynamic and coronary vasomotor effects of chewing tobacco.MethodsTwelve habitual tobacco chewers (mean±SD age 51.3±6.9 years) undergoing elective coronary angiography were included in the study. Following coronary angiography, a 7F thermodilution Swan Ganz continuous cardiac output pulmonary artery catheter was used to continuously measure the right heart pressures and cardiac output. Having obtained baseline hemodynamic data, 1g of tobacco was given to be chewed. Subsequently, hemodynamic data were obtained periodically over a period of 60 minutes. A repeat left coronary injection was performed, 10 minutes after giving the tobacco, in the right anterior oblique view to estimate the diameter of the left anterior descending (LAD) artery by quantitative coronary angiography.ResultsChewing tobacco led to a significant acute increase in heart rate (from 68.3±12.4 beats/min to 80.6 ± 14.6 beats/min, peaking at 10 minutes) and cardiac output (from 3.8 ± 0.45 L/min to 4.7 ± 0.64 L/min, peaking at 15 minutes). There were no significant changes in the right atrial, pulmonary artery, or wedge pressures and hence no change in the pulmonary vascular resistance. More importantly, chewing tobacco was associated with coronary vasoconstriction (proximal LAD diameter change from 3.17 ±0.43 mm to 2.79±0.37 mm; p-value 0.02; mid LAD diameter change from 2.75±0.36 mm to 2.40±0.22 mm; p-value 0.03).ConclusionChewing smokeless tobacco leads to coronary vasoconstriction and also produces significant hemodynamic alterations. These changes may have a bearing on excess vascular disease.

‘Classic’ supravalvular aortic stenosis

A 16-year-old boy with a history of gradually progressive dyspnoea on exertion was referred as a case of severe aortic stenosis. On examination he was found to have a 4/6 ejection systolic murmur at the base of the heart radiating to both carotids and decreased pulses on the left upper limb. EKG revealed features of left ventricular hypertrophy. Echocardiography showed …

Amplatzer vascular plugs in congenital cardiovascular malformations

Background: Amplatzer vascular plugs (AVPs) are devices ideally suited to close medium-to-large vascular communications. There is limited published literature regarding the utility of AVPs in congenital cardiovascular malformations (CCVMs). Aims: To describe the use of AVPs in different CCVMs and to evaluate their safety and efficacy. Materials and Methods: All patients who required an AVP for the closure of CCVM were included in this retrospective review of our catheterization laboratory data. The efficacy and safety of AVPs are reported. Results: A total of 39 AVPs were implanted in 31 patients. Thirteen (33%) were AVP type I and 23 (59%) were AVP type II. AVP type III were implanted in two patients and type IV in one patient. The major indications for their use included closure of pulmonary arteriovenous malformation (AVM) (n = 7), aortopulmonary collaterals (n = 7), closure of a patent Blalock-Taussig shunt (n = 5), systemic AVM (n = 5), coronary AVM (n = 4), patent ductus arteriosus (PDA) (n = 3), pulmonary artery aneurysms (n = 3), and venovenous collaterals (n = 2). Deployment of the AVP was done predominantly via the 5 – 7F Judkins right coronary guide catheter. Overall 92% of the AVPs could be successfully deployed and resulted in occlusion of the target vessel in all cases, within 10 minutes. No procedure-related or access site complication occurred. Conclusions: AVPs are versatile, easy to use, and effective devices to occlude the vascular communications in a variety of settings. AVP II is especially useful in the closure of tubular structures with a high flow.