V. Vanajakshamma

Magnetic resonance angiography vs. angiography in tetralogy of Fallot.

Aim: To determine whether gadolinium-enhanced three-dimensional magnetic resonance angiography can provide a noninvasive alternative to diagnostic catheterization for evaluation of pulmonary artery anatomy in tetralogy of Fallot. Patients and methods: Thirty-five consecutive patients with tetralogy of Fallot, who attended the cardiology outpatient department between January 2008 and December 2009, were included in the study. There were 21 males and 14 females, with a mean age of 9 ± 4.15 years (range, 3–21 years). Thirty-two patients had tetralogy of Fallot with varying severities of valvular and infundibular stenosis. Three patients had tetralogy of Fallot with pulmonary atresia. All patients underwent both cardiac catheterization with X-ray angiography and 3-dimensional magnetic resonance angiography within one month. Results: Measurements of right and left pulmonary arteries and aortopulmonary collaterals were equal by both methods. There was a good correlation between magnetic resonance angiography and catheterization measurements of branch pulmonary arteries. Conclusion: Gadolinium-enhanced three-dimensional magnetic resonance angiography can be used as a reliable noninvasive alternative to X-ray cineangiography for delineation of pulmonary arterial anatomy in sick infants and young children, obviating the need for catheterization.

Factor V Leiden mutation is not a predisposing factor for acute coronary syndromes.

BACKGROUND The prevalence of Coronary artery disease (CAD) in India has increased considerably over the past few years and could become the number one killer disease if interventions are not done. Factor V Leiden (FVL) mutation and FII G20210A polymorphism are two recently described genetic factors with a propensity towards venous thrombosis. This warrants the investigations for thrombophilia in myocardial infarction patients in India. METHODS The study cohort consisted of 51 patients aged below 50 years presenting with acute coronary syndromes. In both patient group and normal individuals the major risk factors Protein C deficiency, Protein S deficiency, anticardiolipin antibodies, Fibrinogen and Lipoprotein [a] were studied. Factor V Leiden (FVL) G1691A mutation in both control and patient group was looked by using Polymerase chain reaction (PCR) followed by sequencing of the PCR products. RESULTS Our results indicated significantly higher levels of anticardiolipin antibodies and fibrinogen in the patients and absence of FVL (G1691A) mutation in our study cohort. One of the patients (H5) showed insertion of an extra A nucleotide in exon 10 of the Factor V gene resulting in frame shift mutation in this patient. CONCLUSION The results of present study showed absence of FVL mutation in our population. However, there is a need to confirm the above findings on patients from different populations from different parts of the country. The insertion of an extra A in exon 10 in the patient needs to be ascertained to confirm that it is one of its kinds or is prevalent in the population.

Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy.

BACKGROUND Balloon mitral valvotomy (BMV) is a safe and an effective treatment in patients with symptomatic rheumatic mitral stenosis. This study was conducted to validate the importance of assessing the morphology of mitral valve commissures by transoesophageal echocardiography and thereby predicting the outcome after balloon mitral valvotomy [BMV]. MATERIALS AND METHODS Study consisted of 100 patients with symptomatic mitral stenosis undergoing BMV. The Commissural Morphology and Wilkins score were assessed by transoesophageal echocardiography. Both the commissures (anterolateral and posteromedial) were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2) and calcification (score 0) and combined giving an overall commissural score of 0-4. Outcome of BMV was correlated with commissural score and Wilkins score. RESULTS The commissural score and outcome after BMV correlated significantly. 66 of 70 patients (94%) with a commissural score of 3-4 obtained a good outcome compared with only six (20%) patients of 30 with a commissural score of 0-2 (positive and negative predictive accuracy 94% and 80%, respectively, p < 0.001). Increase in 2DMVA post BMV was more in patients with higher commissural score (score of 3-4). Wilkins score <8 usually predicts a good outcome but even in patients with Wilkins score >8 a commissural score >2 predicts a 50% chance of a good result. CONCLUSIONS A higher commissural score predicts a good outcome after BMV hence it can be concluded that along with Wilkins score, commissural morphology and score should be assessed with TOE in patients undergoing BMV.

Comparison of PESI, echocardiogram, CTPA, and NT-proBNP as risk stratification tools in patients with acute pulmonary embolism

Objective The aim of this study is to prospectively assess the diagnostic accuracy of pulmonary embolism severity index, echocardiogram, computed tomography pulmonary angiogram (CTPA), and N-terminal pro b-type natriuretic peptide (NT-proBNP) for predicting adverse events in acute pulmonary embolism patients. Methods Thirty consecutive acute pulmonary embolism patients were included in this study. Combined adverse events consisted of in-hospital death or use of escalation of care including cardiopulmonary resuscitation, mechanical ventilation, vasopressor therapy, or secondary thrombolysis during hospital stay. Results The outcomes were met in 30% of patients. Qanadli index (a measure of clot burden on CTPA) and NT-proBNP were significantly higher in patients with adverse events than those without (p = 0.005 and p = 0.009, respectively). PESI had moderate positive correlation with right ventricular dysfunction (RVD) (r = 0.449, p = 0.013) but there was no significant difference in PESI between patients with and without adverse events (p = 0.7). Receiver operating characteristic analysis indicated that Qanadli index was the best predictor of adverse events with area under the curve (AUC) of 0.807 (95% CI: 0.651–0.963) with a negative predictive value (NPV) of 100% and positive predictive value (PPV) of 47.4% at cut-off value of 19. Right ventricle to left ventricle ratio on CTPA was found to predict RVD with AUC of 0.94 (95% CI: 0.842–1.000), NPV (77.8%), and PPV (95.2%) at cut-off value at 1.15. Conclusion Qanadli index is more accurate predictor of adverse events than pulmonary embolism severity index, NT-proBNP, and RVD on echocardiogram and CTPA.

Study of clinical, radiological and echocardiographic features and correlation of Qanadli CT index with RV dysfunction and outcomes in pulmonary embolism

BACKGROUND There are no Indian studies correlating the CT pulmonary embolism index (Qanadli) with right ventricular function and outcome. In the present study we aimed to study the clinical manifestations of patients presenting with acute pulmonary thromboembolism and correlate the radiographic features with echocardiographic features and outcome. METHODS Thirty five patients presenting with symptomatic acute pulmonary thromboembolism in between 2011 and 2013 were studied for clinical, radiological and echocardiographic features and outcome (in-hospital & 1 month follow up). RESULTS The mean duration of presentation after onset of symptoms was 5.7 ± 3.7 days. Right ventricular dysfunction was observed in 11 (31.4%) patients. Out of 35 patients in whom CT pulmonary angiogram performed, 14 patients had Qanadli PE index >60% of whom 11 (78.6%) patients had right ventricular dysfunction. None had right ventricular dysfunction when PE index was <60% (p < 0.001). There was significant correlation between pulmonary vascular obstruction index and right ventricular dysfunction (p < 0.0001). Nine (25.7%) patients were thrombolysed with Streptokinase. Total mortality including in-hospital and 1 month follow up was 11.4% (4 patients). The mortality in patients with PE index >60% was 21.4% and was nil with <60% (p = 0.02). The mortality in patients with right ventricular dysfunction was 27.2% and was nil without right ventricular dysfunction (p = 0.0075). CONCLUSION A PE index which was shown to be a strong independent predictor of right ventricular dysfunction in PE, correlating linearly with different variables associated with higher morbidity and mortality, enabling accurate risk stratification and selection of patients for more aggressive treatment.

Aortic velocity propagation: A novel echocardiographic method in predicting atherosclerotic coronary artery disease burden

Background The major burden of cardiovascular disease mortality around the globe is due to atherosclerosis and its complications. Hence its early detection and management with easily accessible and noninvasive methods are valuable. Aortic velocity propagation (AVP) through color M-mode of the proximal descending aorta determines aortic stiffness, reflecting atherosclerosis. The aim of this study was to find the utility of AVP in predicting coronary artery disease (CAD) burden assessed through SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score and compared with carotid intima-media thickness (CIMT), which is an established surrogate marker of atherosclerosis. Methods In this cross-sectional comparative study, we measured AVP by color M-mode and CIMT by using Philips QLAB-IMT software in 100 patients, who underwent conventional coronary angiogram (CAG) between May 2013 and November 2014. Coronary artery disease is considered significant if >50% diameter stenosis is present in any epicardial coronary artery and insignificant if otherwise. Results Initially, to know the normal range we measured AVP and CIMT in 50 patients without any major risk factors for CAD but CAG was not done. Aortic velocity propagation ranged from 46 cm/s to 76 cm/s (mean = 58.62 ± 6.46 cm/s), CIMT ranged from 0.50 mm to 0.64 mm (mean = 0.55 ± 0.03 mm). Among 100 patients who underwent CAG we found 69% had significant CAD, 13% had insignificant CAD, and 18% had normal coronaries. Those with significant CAD had significantly lower AVP (41.65 ± 4.94 cm/s) [F (2,97) = 44.05, p < 0.0001] and significantly higher CIMT (0.86 ± 0.11 mm) [F (2,97) =35.78, p < 0.0001]. AVP had significant strong negative correlation with CIMT (r = −0.836, p < 0.0001, n = 100) and SYNTAX score (r = –0.803, p < 0.0001, n = 69), while CIMT was positively correlated with SYNTAX score significantly (r = 0.828, p < 0.0001, n = 69). Conclusions AVP and CIMT can predict CAD burden in a robust way. AVP may emerge as an exquisite bedside tool to predict atherosclerotic burden and guide in implementing preventive therapy for cardiovascular disease.

Evaluation of prolonged safety and efficacy of biodegradable polymer coated sirolimus-eluting coronary stent system: 1-year outcomes of the INDOLIMUS Registry

BACKGROUND The main aim is to evaluate prolonged safety and efficacy of the Indolimus (Sahajanand Medical Technologies Pvt. Ltd.) sirolimus-eluting coronary stent system. METHODS It was a single center, non randomized, retrospective registry. Out of total 530 patients involved in the INDOLIMUS Registry, follow-up of 523 patients were obtained at 1-year The primary end-point of this was major adverse cardiac events, which is a composite of cardiac death, target lesion revascularization, target vessel revascularization, myocardial infarction and stent thrombosis, at 1-year follow-up. RESULTS Cardiac death, target lesion revascularization and myocardial infarction at 1-year were reported in 19 (3.6%), 2 (0.4%), and 2 (0.4%) patients respectively, while stent thrombosis was reported in 1 (0.2%) patient. The resultant major adverse cardiac events at 1-year were reported to be 24 (4.5%). CONCLUSIONS The lower incidence of MACE in uncontrolled and more complex cohorts at 1-year follow-up clearly depicts the prolonged safety and efficacy of the Indolimus sirolimus-eluting stent (SES) system.

Percutaneous transcatheter treatment of Lutembacher syndrome

Lutembacher syndrome is a rare combination of congenital ostium secundum atrial septal defect (ASD) and acquired rheumatic mitral stenosis. The gold standard treatment for this condition is the surgical closure of ASD and mitral valve replacement. Here, we report a case of Lutembacher syndrome treated percutaneously with a combined ASD closure with Cocoon septal occluder and balloon mitral valvotomy.

Determinants of total ischemic time in primary percutaneous coronary interventions: A prospective analysis

Objective To assess the factors contributing to longer total ischemic times in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). Methods Three hundred forty-six patients who underwent PPCI from July 2016 to June 2017 were studied. From time for the patient to recognize the symptoms, time was divided into 11 stages, any reason for delay was observed. Results Mean window period was 6.7 ± 9.8 hours. Mean time to recognize the symptoms, reach first medical contact and prehospital management were 150.2 ± 140.5 min, 58.5 ± 57.0 min and 36.3 ± 38.0 min, respectively. Mean time for the patients brought in ambulance was 82.4 ± 59.8 min whereas for those transported in other vehicles was 130.4 ± 59.7 min (p = < 0.0001). Mean door to electrocardiogram (ECG) time, decision for PPCI, consent time and STEMI team activation time were 6.2 ± 3.1 min, 8.3 ± 4.5 min, 12.6 ± 16.2 min and 10.7 ± 8.2 min, respectively. Mean time for financial process and mean sheath to balloon time were 9.1 ± 6.9 min and 21.8 ± 11.7 min, respectively. Door to balloon time (DTB) was <90 min in 81% of the patients, mean DTB was 72.0 ± 33.0 min. Mean DTB for cases performed during night was 72.6 ± 32.9 min, whereas for those performed during day was 60.3 ± 30.2 min (p < 0.05). Total 30 day mortality was 2.9%. Mortality among DTB <90 min was 1.4%, mortality among DTB > 90 min was 9% (p < 0.05). Conclusions The main contributor for longer total ischemic time was the time taken for the patient to recognize the symptoms. DTB of <90 min can be achieved with effective hospital strategies.

A comparative study of clinical profile and outcomes of patients with ischemic and non-ischemic complete heart block

Background: Complete heart block (CHB) is a medical emergency and usually requires immediate intervention. Either cardiac ischemia or non-ischemic conditions can cause CHB. Aim: To compare baseline clinical characteristics associated with ischemic versus non-ischemic causes of CHB and their outcomes. Materials and Methods: This was a single centre retrospective, observational study. Consecutive 250 patients with CHB from January-December 2016 were included. Patients were characterized into non-ischemic and ischemic groups based on cardiac marker elevation, electrocardiogram changes and/or cardiac catheterization findings. In all patients, demographics, pre-existing comorbidities, prior use of nodal blocking agents and ejection fraction (EF) were recorded. The primary outcome was all-cause mortality and secondary outcome was pacemaker implantation. Statistics Analysis: Mean and standard deviation were calculated for all continuous variables. Percentages were calculated for all categorical variables. Unpaired student’s ‘t’ test was utilized to find out the difference between means and to calculate the significance level and p-value. RESULTS: Out of 250 patients, 137 had ischemic and 113 had non-ischemic CHB. The mean age was 60.54 years in ischemic group and 61.32 years in the non-ischemic group (p=0.58). Patients with ischemic CHB had a lower mean EF [44.2%v/s 55.2% (p<0.01)]. In the ischemic group 55 patients (40%) presented with cardiogenic shock compared to 6 (0.07%) in the non-ischemic group (p<0.001). There was no statistically significant difference in terms of gender, hypertension, thyroid dysfunction, prior usage of nodal blocking agents and electrolytes and statistically significant difference was present between ischemic and non ischemic groups in diabetes mellitus (DM) (56.9% vs 45%p=0.006), dyslipidaemia (13.1%vs0.5%p=0.001) and smoking (31.3%v/s14.1%p<0.001). In the ischemic group 112 patients had inferior wall myocardial infarction (IWMI) (81.7%) and 21 had anterior wall myocardial infarction (AWMI) (15.3%). RCA was the most common culprit vessel (73%). Seventy patients underwent percutaneous coronary intervention and 10 were referred for CABG. For outcomes,8 out of 113 (0.07%) patients with non-ischemic CHB died compared to 33 out of 137 (24.1%) ischemic CHB (p<0.001). Permanent pacemaker (PPI) was implanted in 76 out of 113 patients (67.2%) in the non-ischemic group compared to 14 out of 137 (10.2%) in the ischemic group (p<0.001). Out of the patients who underwent PPI, 9 had AWMI and 5 had IWMI. Conclusion: Patients with ischemic CHB have lower mean EF with majority having IWMI and had higher mortality. Risk factors like DM, dyslipidaemia and smoking are more frequent in the ischemic group and they are less likely to get a permanent pacemaker compared to non-ischemic CHB. In the ischemic group patients with AWMI got more PPI than IWMI.