Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.

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.

Percutaneous Closure of an Iatrogenic Aorta to Right Ventricle Fistula Acquired Following Intracardiac Repair.

Iatrogenic aortocardiac fistulae have been described rarely following intracardiac repair. This 28 year-old-male presented to our facility with dyspnea going on 20 days after closure of ventricular septal defect (VSD) and resection of subaortic membrane. A communication was noticed between the aorta and the right ventricle (RV) upon transthoracic echocardiography. Cardiac catheterisation revealed a significant shunt and an aortogram revealed a 6 mm communication between aorta and right ventricle. Percutaneous closure of this defect was attempted under local anaesthesia through right femoral access. An alpha arteriovenous loop was formed despite repeated attempts, hence a retrograde approach for device delivery was considered. An 8 mm Amplatzer muscular VSD occluder device was deployed across the defect achieving a complete closure through an 8F delivery sheath. To the best of our knowledge this is the first report of an iatrogenic aorta to RV fistula occurring in a patient following an intracardiac repair which has been successfully treated percutaneously.

N-terminal pro-brain natriuretic peptide levels and short term prognosis in acute ischemic stroke.

BACKGROUND: Sparse published data are available regarding the prognostic importance of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with acute ischemic stroke. MATERIALS AND METHODS: We prospectively studied 74 consecutive patients presenting with acute ischemic stroke within 24 hours of onset. All of them underwent laboratory and imaging evaluation and were treated as per guidelines. In all subjects, plasma NT-proBNP levels were measured at initial admission and again on day 7. RESULTS: Their mean age was 54 ± 13.5years; there were 49 males; 18 (24%) patients died during the hospital stay. A statistically significant negative correlation between log NT-proBNP and Glasgow coma scale (GCS) score (P < 0.001); and a significant positive correlation between log NT-proBNP and National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001) were observed. Baseline log NT-proBNP levels were higher among non-survivors compared with survivors (6.7 ± 0.47 vs. 5.37 ± 0.62; P = 0.06); day 7 log NT-proBNP levels were significantly higher in non-survivors compared with survivors (7.3 ± 0.26 vs. 4.5 ± 0.4; P = 0.000). In survivors, there was a statistically significant decline in log NT-proBNP levels from baseline to day 7 (5.3710 ± 0.620 vs. 4.5320 ± 0.451; P < 0.001). In contrast, among non-survivors, log NT-proBNP levels showed a statistically significant increase from baseline to day 7 (4.5322 ± 0.451 vs. 7.2992 ± 0.263; P < 0.001). On receiver operator characteristic curve (ROC) analysis, at a cut-off value of ≥ 6.0661, log NT-proBNP had a sensitivity and specificity of 98.2 and 88.9, respectively, in predicting death. CONCLUSIONS: Plasma log NT-pro-BNP level appears to be a useful biological marker for predicting in-hospital mortality inpatients presenting with acute ischemic stroke.

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.

Multiple ruptures of left sinus of Valsalva aneurysm into main pulmonary artery.

Sinus of Valsalva aneurysm is a rare congenital glitch. We report an extremely rare case of left sinus of Valsalva aneurysm compressing and rupturing into the main pulmonary artery with 2 communications. The 34-year-old man also had severe aortic regurgitation and severe tricuspid regurgitation. He underwent successful polytetrafluoroethylene patch repair and aortic valve replacement. The rarity of this case highlights the need for a precise preoperative diagnosis, the roles of transthoracic echocardiography, transesophageal echocardiography, and 3-dimensional echocardiography, and the importance of prompt surgical management.

Three-dimensional echocardiographic assessment before and after percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Real-time three-dimensional transthoracic echocardiography (RT3DE) is a relatively recent imaging technique that provides excellent image quality of the mitral valve. It has been suggested that this new echocardiographic modality, which allows a precise cross-section of the mitral orifice at the tips of the leaflets with correct plane orientation, may provide a more accurate assessment of rheumatic mitral stenosis (MS) than two-dimensional echocardiography (2DE), before and after percutaneous transvenous mitral commissurotomy (PTMC). METHODS: A total of 50 patients with symptomatic mitral stenosis who underwent PTMC was evaluated prospectively. Patients in all age groups, with evidence of severe MS admitted to the authors' institution, in whom PTMC was feasible were included. RESULTS: A good valve opening was observed in 45 patients (90%). The mitral valve area (MVA) assessed before PTMC with 3DE (3D-MVA) correlated well with that assessed with 2DE (2D-MVA) (0.85 +/- 0.12 cm2 versus 0.86 +/- 0.13 cm2, p < 0.001); the mean difference between methods was small (0.01 +/- 0.11 cm2) and correlation excellent (r = 0.64, p < 0.001). After PTMC, values of 3D-MVA did not differ from, and correlated well with, values of 2D-MVA (1.79 +/- 0.20 cm2 versus 1.74 +/- 0.18 cm2, p = 0.006); the mean difference between methods was small (0.05 +/- 0.02 cm2) and correlation excellent (r = 0.76, p = 0.0001). Before PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.01 +/- 0.11 cm2, lower limit -0.24, upper limit 0.22). After PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.05 +/- 0.13 cm2, lower limit -0.3, upper limit 0.2). Evaluation of the commissural opening after PTMC, using RT3DE, showed that excellent commissural evaluation was possible in all patients. Compared with RT3DE, an underestimation of the degree of commissural fusion using 2DE was observed in 32%, with a weak agreement between methods. CONCLUSION: RT3DE provided accurate measurements of MVA, similar to 2D planimetry. RT3DE also improved the description of valvular anatomy and provided a unique assessment of the extent of commissural splitting.

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.