Clinical usefulness and cost effectiveness of fractional flow reserve among Indian patients (FIND study).

OBJECTIVES: To study the clinical usefulness, cost benefit, and medium term outcome of fractional flow reserve (FFR) based management of coronary artery disease of intermediate severity. BACKGROUND: In spite of the advantages of FFR there is paucity of data in Indian population who have frequent diffuse, small and multivessel disease where it would probably be more beneficial in terms of cost and outcome. METHODS: The treating cardiologist's management decision with both FFR and angiographic data was compared with that of a reviewing cardiologist decision based on a retrospective analysis of angiogram alone. RESULTS: Eighty-one vessels with intermediate lesions in 59 patients required 26 stents lesser when FFR data was added to the angiogram. The concordance of management decision was about 58% which means that >40% of intermediate lesions would be misclassified as significant based on angiography alone. There were no major events at a mean follow up of 11 ± 5 months. The net cost benefit in favor of FFR based management was INR 8,57,600 (USD 15,600) in our centre. CONCLUSION: Indians with more severe form of CAD benefit from a FFR based management plan for intermediate lesions, both clinically and economically. © 2014 Wiley Periodicals, Inc.

Salvage of side branch by provisional "TAP technique" using Absorb™ bioresorbable vascular scaffolds for bifurcation lesions: first case reports with technical considerations.

Recent technological developments have led to the development of Absorb™ bioresorbable vascular scaffold (BVS) [Abbott Vascular, Santa Clara, USA] for percutaneous treatment of coronary artery disease by percutaneous coronary intervention (PCI). The BVS is now approved for use in many countries but experience in bifurcation lesions is limited and largely unreported and concerns still exist about its use across major side branches. We report for the first time, the successful use of the "T and Protrusion" (TAP) technique of deploying BVS into the side branch (SB) through the struts of main branch (MB) BVS to salvage a suboptimal result and threatened closure of a SB in three cases when treating bifurcation lesions with a planned single BVS strategy. The TAP technique was successful in all cases and there were no complications. All patients continue to do well at short-term follow-up. This case report provides information regarding the feasibility as well as technical and procedural insights when using BVS for bifurcation lesions.

Prevalence of atrial fibrillation on a 24-hour Holter in adult Indians.

OBJECTIVE: To evaluate paroxysmal atrial fibrillation (AF) prevalence in Indian adults who completed 24-Hour Holter monitoring. METHODS: A total of 23,847 patients (36.9 % women) were analyzed for AF duration using a software algorithm. RESULTS: AF was diagnosed in 4153 (17.4 %) patients with a median AF duration of 13 min and 55 s. CONCLUSION: AF prevalence was high and largely untreated. The short duration of AF episodes indicates a low likelihood of detection during clinical visits, highlighting its potential underestimation in Indian healthcare.

Intracoronary abciximab in STEMI using local drug delivery catheter - single center experience.

BACKGROUND: Despite restoration of epicardial flow during primary PCI in STEMI, microvascular obstruction may persist as a result of both atheromatous and thrombotic embolization and vasospasm. Compared with the systemic administration of IV pharmaco-therapies, highly localized administration of intracoronary pharmacotherapy may be associated with a several-hundred-fold increase in the local concentration of an agent in the epicardial artery and microcirculation. Despite restoration of epicardial flow during primary PCI in STEMI, microvascular obstruction may persist as a result of both atheromatous and thrombotic embolization and vasospasm. We are presenting our experience with use of intracoronary abciximab using local drug delivery catheter in STEMI patients. METHODS: We retrospectively evaluated 15 patients presented to us with STEMI undergoing primary PCI between March 2011 and September 2012 who had super selective intracoronary abciximab using local drug delivery catheter. With standard antiplatelet therapy, both Pre and Post TIMI flow, TMP grading were assessed. RESULTS: Mean age was 55 years. The TIMI flow increased by 3 grades in thirteen patients, TMP grading increased by 2 grades in five patients and by 3 grades in nine patients. Thus TIMI flow and TMP grading improved after super selective intracoronary abciximab. CONCLUSION: Super selective intracoronary abciximab using local drug delivery catheter during primary PCI in STEMI patients significantly improves TMP grading without increased risk of bleeding. This benefit is achieved even in patients without thrombus aspiration. We need to assess the long-term outcomes in the form of reduction in infarct size using this strategy in large group of patients.

Erosion/malapposition of a sirolimus eluting stent - optical coherence tomography image - a case report.

The presence of erosion/malapposition of a Sirolimus eluting stent was clearly visualized using Optical Coherence Tomography (OCT) imaging. The presence of erosion/malapposition and the absence of neointimal hyperplasia after 10 months of sirolimus eluting stent could constitute a potential thrombogenic substrate for late stent thrombosis.

Transcatheter Aortic Valve Implantation for Severe Bicuspid Aortic Stenosis - 2 Years Follow up Experience From India.

Background: Transcatheter aortic valve implantation (TAVI) is challenging in bicuspid aortic valve (BAV) anatomy. The patients are young, morphological phenotypes are many, calcium burden is high and there are technical challenges for best outcomes. Observational studies and registries are available with favorable data and experiences from around the world sharing methodologies and algorithms for sizing and implantation. We, therefore, analysed our data of procedural and in-hospital outcomes of TAVI in Bicuspid Aortic Valve cases performed at two high volume centres in India and their follow up for two years. Methods and Results: The data were collated and analysed from two centres (Fortis Escorts Heart Institute, New Delhi and Apollo Hospitals, Chennai) in India for patients who underwent TAVI in a BAV anatomy. It included a total of 70 cases from 2 centres. All symptomatic severe AS patients more than and equal to 65 years having bicuspid anatomy were included in the study irrespective of their STS score. Patients under 65 years of age were advised TAVI only if they were at high risk for open heart surgery. These patients were followed for a period of 2 years and the data were analysed. Pre TAVI imaging tools utilised were 2D echo, transthoracic echocardiography (TTE), trans oesophageal echocardiography (TEE), and ECG gated multi slice CT (MSCT) scan imaging. MSCT was utilised for confirmation of the anatomy and classifying the morphological type of valve, measuring, and evaluating all anatomic determinants of aortic root complex for planning the procedure and choice of the valve and its size. Sizing in balloon expanding valve (BEV) and self-expanding valve sizing (SEV) were based primarily on annulus area and perimeter, respectively. The SEV used in our study were the Core Valve and Evolut R (Medtronic, United States) and the BEVs included Sapien3 (Edwards Lifesciences, United States) and Myval (Meril Lifesciences, India). The BAV cohort constituted 24.4% of the total 287 TAVI cases, followed up for 2 years. The mean age of these patients was 72 years. The incidence of male patients was 68.57% and female patients was 31.4%. The Sievers type 1 included 78.5%, type 0 were 21.4% of the cases and there was no case of type 2 in the study. The procedural success was to the tune of 98%. Patients with normal left ventricular ejection fraction (LVEF) improved their symptoms class after TAVI and remained so at 2 years follow up. The poor LVEF subset of patients did not have heart failure admissions and also had improvement in their symptom status. The peak-to-peak aortic valve gradient decreased to 0 mmHg at the end of the procedure in most of the cases. The mean pressure gradient (PG) across the new valve ranged between 0 and 15 mmHg and the aortic valve area (AVA) was close to 2 cm2. These numbers were consistent at 2 years follow up. Significant paravalvular leak (PVL) 24.28% was seen immediately after deployment of the valve in heavily calcified anatomy but it reduced to mild or trivial PVL after post-dilation and one patient needed a second valve to treat PVL. No patient had more than mild PVL with either type of valve at the end of the procedure. Permanent pacemaker implantation (PPI) was required in 11.4% of the patients within 24 h to 7 days of the procedure. No one needed a PPI in the 2 year follow up. Coronary occlusion did not happen to any patient. No patient had a disabling stroke. Non-disabling stroke was seen in 10% of cases and mostly in the first week or 30 days of the procedure and the incidence was more with BEV (14%) as compared to SEV (8%). There was one case of valve embolisation after 24 h of the procedure, which needed a surgical valve replacement. There was no case of annular injury or injury to other parts of the aortic root complex. Two cases had access vessel (femoral artery) thrombosis at end of the procedure and a third patient had proglide related residual stenosis. Two cases had acute kidney injury and needed dialysis. There was no major bleeding complication in any patient. Peri procedural mortality occurred in two patients. Valve thrombosis was seen in one patient after 3 months, which was treated with oral anticoagulation. Valve degeneration and failure or infective endocarditis were not seen in any patient. Conclusion: The patients with BAV stenosis who underwent TAVI in this study had good procedural success rates and clinical outcomes. The haemodynamics achieved with both SEV and BEV were good at 2 years. The rates of PVL, PPI, and stroke are similar to that of many other studies and registries. PPI rate and non-disabling stroke incidence appear to be higher similar to many studies done. There was no case of coronary occlusion in the study. Meticulous CT analysis of the aortic root complex, selection of appropriate type and size of the valve, and best implantation practices along with cerebral protection will probably be the key to safer and more successful TAVI in this population.

Can OCT change the therapeutic strategy in ACS due to plaque erosion?

The pathophysiology of acute coronary syndromes was thought to be coronary thrombosis over a plaque rupture. Autopsy studies revealed that not all cases were due to plaque rupture, even denuded endothelium or calcific nodule can beget a thrombus. Introduction of OCT made, in vivo recognition of lesion morphology clear. Plaque ruptures are most common and need primary angioplasty. Recent studies established plaque erosion is responsible for ACS in one third of the cases and majority of them present as Non ST elevation myocardial infarction and commonly found in young patients without major risk factors. Evidence from recent studies suggested that stenting can be deferred and they can be managed conservatively with good long term outcomes. More randomized trials are needed comparing plaque rupture and plaque erosion as regards conservative versus invasive management. If these studies substantiate the concept of conservative management, it will lead to a paradigm shift in their management.

Risk factor profile of calcific aortic stenosis.

BACKGROUND: Calcific aortic stenosis and coronary artery disease share common risk factors. In some of the previous studies statins have been used to retard the progression of aortic stenosis, but the results were inconsistent. METHODS: One hundred and ten patients of CAS above the age of 40 years have undergone clinical, biochemical and echocardiographic evaluation. Coronary angiograms were done in 66% of them. RESULTS: Male to female ratio was 2:1. Patients of CAS with CAD showed higher prevalence of diabetes, hypertension, dyslipidemia, smoking and family history of CAD. Prevalence of obesity and bicuspid aortic valve by echocardiogram was high in those without CAD. CONCLUSIONS: On comparison of prevalence of risk factor in those with and without associated CAD, there was higher prevalence of diabetes (65% vs 30%), hypertension (52% vs 43%), dyslipidemia (69% vs 52%), smoking (24% vs 18%) and family history of CAD (34% vs 16%) in those with associated CAD. The incidence of obesity was higher in those without CAD (20% vs 30%). The difference observed in diabetes alone was found to be statistically significant.

Role of PET-CT in the assessment of myocardial viability in patients with left ventricular dysfunction.

AIM: Role of PET-CT in assessment of myocardial viability in patients with LV dysfunction. METHODS: This prospective study included 120 patients with LV dysfunction who underwent 99mTechnetium-Sestamibi myocardial perfusion SPECT-CT and 18FFDG cardiac PET-CT. They also underwent serial echocardiography and coronary angiography along with myocardial perfusion and FDG PET study. RESULTS: Thirty-three patients had single vessel disease, 48 had triple vessel disease, and rest had double vessel disease. Among 786 segments, matched defects were seen in 432 (55%) and mismatched defects in 354 (45%) segments. 78 patients were surgically managed, and 42 were medically managed. The change in LVEF after surgical management was statistically significant compared to medical management. CONCLUSION: Viability assessment should be performed in patients who present after 12h of acute myocardial infarction or with LV dysfunction due to ischemic heart disease to decide upon appropriate surgical management.

Current practices of Asia-Pacific cardiologists in the utilization of bioresorbable scaffolds.

BACKGROUND & AIMS: Although Absorb Bioresorbable Vascular Scaffolds (A-BVS) are routinely used in the Asia-Pacific, there is little information on patient selection or deployment technique here. This document investigates the experiences of leading interventional cardiologists from the Asia-Pacific region with a focus on patient characteristics, deployment techniques and management. METHODS AND RESULTS: A detailed questionnaire was distributed to 28 highly-experienced interventional cardiologists ('Authors') from 13 Asia-Pacific countries. The results were discussed at a meeting on patient selection, technical consideration, deployment practices and patient management. Potential patient benefits of Absorb compared to metallic DES, the learning curve for patient selection and preparation, device deployment, and subsequent patient management approaches are presented. CONCLUSIONS: Current practices are derived from guidelines optimized for European patients. Differences in approach exist in the Asia-Pacific context, including limited access to imaging and frequency of occurrence of complex lesions. Nevertheless, the use of the Absorb BVS ('Absorb') in certain Asia-Pacific countries has flourished and practices here are continuing to mature.

Cardiological Society of India practice guidelines for angiography in patients with renal dysfunction.

PREAMBLE: The potential risk of contrast-induced acute kidney injury (CI-AKI) has made utilization of coronary angiography in the work-up for the diagnosis of coronary artery disease in CKD quite low.(1) This is in contrast to increasing prevalence and severity of CAD as the serum creatinine rises.(2) In fact most CKD patients will succumb to CAD and not to ESRD.(3) Thus the judicious use of CAG/PCI in this setting is of prime importance but underused. The CSI began to develop guidelines for Indian context as most guidelines are those developed by ACC/AHA or ESC. The aim was to assist the physicians in selecting the best management strategy for an individual patient under his care based on an expert committee who would review the current data and write the guidelines with relevance to the Indian context. The guidelines were developed initially in June 2010 as an initiative of Delhi CSI. Three interventional cardiologist (SB, AS, KKS), one nephrologist (SCT) and two clinical cardiologists (ST, RG) along with Dr. Roxana Mehran (New York) and Dr. Peter McCullough (Missouri), U.S.A.; were involved in a three-way teleconference to discuss/debate the data. This was presented by SB, and over the next two hours each data subset was debated/agreed/deleted and this resulted in the "Guidelines for CAG in Renal Dysfunction Patients". These were then written and re- circulated to all for final comments. Further, these guidelines were updated and additional Task Force Members nominated by Central CSI were involved in the formation of the final CSI Guidelines. Both (Roxana Mehran and Peter McCullough) reviewed these updated Guidelines in October 2012 and after incorporating the views of all the Task Force members-the final format is as it is presented in this final document.