Spectrum of myocardial involvement in patients with COVID-19 - An echocardiography study.

Introduction: Covid-19 patients can have both regional and global ventricular dysfunction. We aim to study the spectrum of myocardial involvement in Covid-19 patients on echocardiography. Methods: This is a single center, observational study where wall motion abnormality patterns were studied in Covid-19 patients along with global and regional longitudinal strain analysis (GLS). Results: 30 Covid-19 patients were included in the study, with a mean age of 35.3±6.4 years. Echocardiography revealed characteristic wall motion abnormality involving hypokinesia of anterolateral and apical segments, which produced an operculum like appearance in all patients. Strain derived ejection fraction(EF) was lower in 4 chamber as compared to 2 chamber indicating regional myocardial dysfunction. Reduced GLS values in presence of normal EF indicates global systolic function impairment. Endocardial effacement was also noted in these segments along with stretching of interventricular septum. Conclusion: Specific myocardial involvement pattern can be detected on echocardiography, thus helping in diagnosis of Covid myocarditis.

Utility of 3D Echocardiography for Device Sizing During Transcatheter ASD Closure: A Comparative Study.

BACKGROUND: Two-dimensional (2D) transesophageal echocardiography (TEE) is commonly used for assessing patients undergoing transcatheter atrial septal defect (ASD) device closure. 3D TEE, albeit providing high resolution en-face images of ASD, is used in only a fraction of cases. We aimed to perform a comparative analysis between 3D and 2D TEE assessment for ASD device planning. METHODS: This was a prospective, observational study conducted over a period of one year. Patients deemed suitable for device closure underwent 2D and 3D TEE at baseline. Defect characteristics, assessed separately in both modalities, were compared. Using regression analysis, we aimed to derive an equation for predicting device size using 3D TEE parameters. RESULTS: Thirty patients were included in the study, majority being females (83%). The mean age of the study population was 40.5 ± 12.05 years. Chest pain, dyspnea and palpitations were the common presenting complaints. All patients had suitable rims on 2D TEE. A good agreement was noted between 2D and 3D TEE for measured ASD diameters. 3D TEE showed that majority of defects were circular in shape (60%). The final device size used had high degree of correlation with 3D defect area and circumference. An equation was devised to predict device size using 3D defect area and circumference. The mean device size obtained from the equation was similar to the actual device size used in the study population (p = 0.31). CONCLUSIONS: Device sizing based on 3D TEE parameters alone is equally effective for transcatheter ASD closure as compared to 2D TEE.

Culprit Lesion Morphology on Optical Coherence Tomography in ST-elevation Myocardial Infarction vs Non ST-elevation Myocardial Infarction - A Systematic Review of 7526 Patients.

Background: Patients with STEMI are postulated to have different culprit lesion morphology compared to NSTEMI. The use of OCT in ACS can help delineate lesion morphology. The aim of this systematic review was to analyze the available data on culprit plaque morphology in ACS patients. Methods: The available literature was systematically screened for studies on culprit lesion morphology in ACS patients. Data was extracted from the selected studies and analyzed for baseline characteristics as well as culprit lesion morphology on OCT. Lesion characteristics between STEMI and NSTEMI groups were compared. Results: A total of 32 studies were selected for the final analysis. The average age of the study population was 62.4 years. Majority of patients (66.6%) had STEMI on presentation. NSTEMI patients had a higher prevalence of diabetes compared to STEMI. Both STEMI and NSTEMI patients had similar prevalence of thin-cap fibroatheroma (44.9%). The mean fibrous cap thickness was 84.2 µm in the study. STEMI patients had higher prevalence of lipid plaques, macrophages and luminal thrombus as compared to NSTEMI patients. Plaque rupture was the predominant culprit lesion morphology in both STEMI and NSTEMI groups, with higher prevalence in STEMI patients. Plaque erosion was also more common in STEMI patients (34.4% vs 13.2%). Conclusion: Plaque rupture is the predominat culprit lesion morphology in both STEMI and NSTEMI patients, despite having differences in baseline characteristics. Use of OCT to determine plaque morphology in ACS patients can help guide management strategy in select cases. [PROSPERO CRD42021249742].

Thromboembolism after COVID-19 Vaccination: A Systematic Review of Such Events in 286 Patients.

BACKGROUND: Development of vaccines with high efficacy against COVID-19 disease has ushered a new ray of hope in the fight against the pandemic. Thromboembolic events have been reported after administration of vaccines. We aim to systematically review thromboembolic events reported after COVID-19 vaccination. METHODS: The available literature was systematically screened for available data on thromboembolic events after COVID-19 vaccination. Data were extracted from selected studies and analyzed for site of thromboembolism as well as other risk factors. All data were pooled to determine cumulative incidence of thromboembolism at various sites after vaccination. RESULTS: A total of 20 studies were selected for the final analysis. The mean age of the population was 48.5 ± 15.4 years (females - 67.4%). The mean time to event after vaccination was 10.8 ± 7.2 days. Venous thrombosis (74.8%, n = 214/286) was more common than arterial thrombosis (27.9%, n = 80/286). Cerebral sinus thrombosis was the most common manifestation (28.3%, n = 81/286) of venous thrombosis followed by deep vein thrombosis (19.2%, n = 49/254). Myocardial infarction was common (20.1%, n = 55/274) in patients with arterial thrombosis followed by ischemic stroke (8.02%, n = 22/274). Concurrent thrombosis at multiple sites was noted in 15.4% patients. Majority of patients had thrombocytopenia (49%) and antiplatelet factor 4 antibodies (78.6%). Thromboembolic events were mostly reported after the AstraZeneca vaccine (93.7%). Cerebral sinus thrombosis was the most common among thromboembolic events reported after the AstraZeneca vaccine. Among the reported cases, mortality was noted in 29.9% patients. CONCLUSIONS: Thromboembolic events can occur after COVID-19 vaccination, most commonly after the AstraZeneca vaccine. Cerebral sinus thrombosis is the most common manifestation noted in vaccinated individuals.

Clinical outcomes of bileaflet St. Jude Medical and tilting disc TTK Chitra mechanical heart valve prosthesis: A comparative study.

BACKGROUND: Comparative data on the clinical outcomes of TTK Chitra mechanical heart valve prosthesis (CHVP), an indigenously developed low-cost tilting disc valve and commonly used bileaflet valve, the St. Jude medical (SJM) prosthesis are sparse. METHODS: We conducted a retrospective follow-up study of consecutive patients undergoing mitral (MVR) and aortic valve replacement (AVR) with SJM or CHVP mechanical prostheses over a 6-year period at our institution. RESULTS: Seven hundred and thirty-five patients who underwent isolated MVR (n = 510) or AVR (n = 225) were included in the study. Patients with CHVP were younger and belonged to a lower socioeconomic class. The study cohort was followed-up for 2836 patient-years (SJM: 1865.1, CHVP: 971.0). All-cause mortality (p = 0.894), valve-related mortality (p = 0.681), prosthetic valve thrombosis (p = 0.155), embolism (p = 0.210), hemorrhage (p = 0.959) and infective endocarditis (IE, p = 0.084) were similar between both valve on follow-up. Estimated event free survival was 2302 ± 1 days in SJM as compared to 2484 ± 65 days in CHVP group (p = 0.393). Valve type was not an independent predictor of adverse events after adjusting for baseline data, time in therapeutic range and aspirin use. Subgroup analysis of patients who underwent MVR and AVR showed similar functional improvement and outcomes, except for a higher incidence of IE with SJM at the aortic position (p = 0.041). CONCLUSION: The indigenously developed, low-cost CHVP has comparable midterm clinical performance as SJM in aortic or mitral positions.

Detection of cardiac allograft vasculopathy on dual source computed tomography in heart transplant recipients: comparison with invasive coronary angiography.

OBJECTIVE: We aimed to evaluate the diagnostic accuracy (DA) of dual-source CT coronary angiography (DSCTCA) against invasive coronary angiography (ICA) in assessing stenotic cardiac allograft vasculopathy (CAV) in heart transplant (HTX) recipients. METHODS: Consecutive HTX recipients(n = 38) on annual surveillance, underwent DSCTCA prior to ICA on a 192-detector 384-slice DSCT scanner. Cases were classified as no CAV (no stenosis), any CAV (any degree of stenosis) or significant CAV (>50% stenosis). RESULTS: Mean age was 33.66 ± 11.45 years (M:F = 27:11, median time from HTX-23.5 months). Prevalence of any CAV on DSCTCA and ICA was 44.7%(n = 17) and 39.5%(n = 15), respectively and that of significant CAV was 21.1%(n = 8) and 15.8%(n = 6), respectively. 557 (96.7%) segments were interpretable on DSCTCA. Mean radiation dose was 4.24 ± 2.15 mSv. At patient-level, the sensitivity, specificity, positive-predictive value, negative-predictive value (NPV), and DA of DSCTCA for detection of any CAV and significant CAV were 100%, 91.3%, 88.2%, 100%, 94.73% and 100%, 94%, 75%, 100%, 95% respectively. The same on segment-based analysis were 96%, 97.6%, 80%, 99.6%, 97.5% and 100%, 99.6%,86.7%,100%, 99.6%, respectively. There was excellent agreement between the two modalities for detection of any CAV and significant CAV [κ = 0.892 and 0.826 (patient-level), 0.859 and 0.927 (segment-level)]. CAC score correlated significantly with the presence of any CAV on both modalities. A diagnosis of rejection on biopsy did not correlate with any/significant CAV on DSCTCA or ICA. CONCLUSION: High sensitivity and NPV of DSCTCA in the evaluation of stenotic CAV suggests that it can be an accurate and non-invasive alternative to ICA for routine surveillance of HTX recipients. ADVANCES IN KNOWLEDGE: DSCTCA detects the stenotic CAV non-invasively in transplant recipients with high sensitivity, specificity and NPV when compared with catheter coronary angiography, at lower radiation doses. There is excellent agreement between CT angiography and catheter coronary angiography for detection of any CAV and significant CAV. A diagnosis of rejection on biopsy does not correlate with any/significant CAV on CT angiography or catheter angiography.

Association between Clinical Features and Magnetic Resonance Imaging Findings in Patients with Temporal Lobe Epilepsy.

BACKGROUND: Temporal lobe epilepsy (TLE) is the most common cause of partial seizures. However, there is a paucity of data on the correlation of clinical and semiological features of TLE with specific imaging findings on magnetic resonance imaging (MRI). OBJECTIVE: In this study, we sought to evaluate the association between the semiology of TLE with specific etiological findings as identified on MRI. MATERIALS AND METHODS: This was a single-center, observational study in which consecutive patients presenting with clinical features diagnostic of TLE underwent a brain MRI on a 1.5 T scanner. The data collected from the various MR parameters were then correlated with history. RESULTS: A total of 90 patients were included in the study. The mean age of the study population was 29.1 years. Females comprised 45% of the study population. Mesial temporal sclerosis (MTS) was the most common imaging finding in about 60% of patients. Four out of five patients had aura whereas 70% had automatisms. The presence of aura in TLE patients was significantly associated with MTS on MRI (p = 0.042). The presence of automatism and history of childhood febrile seizure did not have a significant association with any specific etiological findings on MRI (p = 0.254 and 0.731, respectively). Drug-refractory epilepsy was commonly associated with the presence of MTS on MRI (p = 0.004). The presence of dual pathology on MRI was associated with drug-refractory epilepsy (p = 0.031). CONCLUSIONS: The presence of aura and drug-refractory epilepsy point towards the presence of MTS. Dual pathology, on MRI, in TLE patients may be a risk factor for drug-refractory epilepsy.

Mesenteric ischemia in patients with COVID-19: an updated systematic review of abdominal CT findings in 75 patients.

BACKGROUND: Acute mesenteric ischemia (AMI) is a less common but devastating complication of COVID-19 disease. The aim of this systematic review was to assess the most common CT imaging features of AMI in COVID-19 and also provide an updated review of the literature on symptoms, treatment, histopathological and operative findings, and follow-up of these patients. METHODS: A systematic literature search of four databases: Pubmed, EMBASE, WHO database, and Google Scholar, was performed to identify all the articles which described abdominal CT imaging findings of AMI in COVID-19. RESULTS: A total of 47 studies comprising 75 patients were included in the final review. Small bowel ischemia (46.67%) was the most prevalent abdominal CT finding, followed by ischemic colitis (37.3%). Non-occlusive mesenteric ischemia (NOMI; 67.9%) indicating microvascular involvement was the most common pattern of bowel involvement. Bowel wall thickening/edema (50.9%) was more common than bowel hypoperfusion (20.7%). While ileum and colon both were equally involved bowel segments (32.07% each), SMA (24.9%), SMV (14.3%), and the spleen (12.5%) were the most commonly involved artery, vein, and solid organ, respectively. 50% of the patients receiving conservative/medical management died, highlighting high mortality without surgery. Findings on laparotomy and histopathology corroborated strikingly with CT imaging findings. CONCLUSION: In COVID-19 patients with AMI, small bowel ischemia is the most prevalent imaging diagnosis and NOMI is the most common pattern of bowel involvement. Contrast-enhanced CT is a powerful decision-making tool for prompt diagnosis of AMI in COVID-19, thereby potentially improving time to treat as well as clinical outcomes.

Pulmonary Hypertension Registry of Kerala, India (PRO-KERALA): One-year outcomes.

BACKGROUND: Short term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India. METHODS: We conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite end-point of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome. RESULTS: Mean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35-2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04-0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28-0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29-2.51) were associated with primary composite outcome at one-year (p < 0.05). CONCLUSION: In the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptimal in the study population. Quality improvement programmes to improve guideline directed therapy may improve clinical outcomes of PH patients in India.

Long term outcomes after bare metal stent implantation.

Long term outcome data after BMS implant is not available from the Indian subcontinent. This is a prospective observational study which aims to study long term outcomes after BMS implant at a tertiary care centre. 100 consecutive patients underwent BMS implant and were followed up for 20 years. LAD was the most common vessel involved and different types of BMS were implanted. All-cause mortality was noted in 21% (n = 21) whereas cardiac mortality was seen in 16% (n = 16). Cumulative revascularisation free survival at 20 years was 71%. The study showed that long term outcomes after BMS implant were fare and acceptable.

Conduction abnormalities post alcohol septal ablation for hypertrophic cardiomyopathy - A single center experience.

Conduction abnormalities are commonly noted after alcohol septal ablation (ASA). This was a retrospective, observational study where we studied the incidence of new onset conduction abnormalities post ASA. 23 patients, who underwent ASA over a period of 5 years, were included in the study. Baseline conduction abnormalities were noted in 26% patients (n = 6). Transient complete heart block (CHB) was noted in 21.7% (n = 5) whereas new onset right bundle branch block (RBBB) was seen in 60.8% (n = 14). Left bundle branch block was uncommon (4.3%,n = 1). Permanent pacemaker implantation was done in 4.3% (n = 1) for CHB. Conduction anomalies are frequent after ASA with RBBB being most common.

Causal Relationship of the Transverse Left Ventricular Band and Bicuspid Aortic Valve.

OBJECTIVES: Bicuspid aortic valve (BAV) is the most common congenital lesion found in adults. It can be seen in combination with a transverse left ventricular (LV) band. This study aimed to find an essential relationship between the presence of transverse ventricular band and BAV. METHODS: A total of 13 patients from a tertiary care centre in India with transverse LV band were investigated during a six-month period from January 2019 to July 2019. LV band thickness and gradients at the site of the LV band were evaluated as part of its effect on LV haemodynamics. The morphology of the aortic valve and LV outflow tract gradients was assessed. RESULTS: The mean age of the participants was 41 years. A majority had a BAV (n = 11). Average thickness of the LV band was 6.2 mm and the average mean aortic gradient was 4 mmHg. Sequestration of blood was noted at the level of the transverse band in all the patients with two separate jets at the left ventricular outflow tract. The anterolateral jet was deflected from the transverse band and showed higher velocity compared to the other jet, causing turbulence at the BAV. No correlation was found between the thickness of the transverse band and aortic valve gradient. CONCLUSION: Presence of a robust transverse LV band can serve as a surrogate marker for BAV.

A curious case of stent fracture and left ventricular pseudoaneurysm - A rare association in the background of cardiac tuberculosis.

Cardiac involvement in tuberculosis mainly affects the pericardium, with the myocardium being rarely involved. Coronary stent infection in patients with tuberculosis is rarely described. Myocardial involvement in tuberculosis can lead to complications such as ventricular granuloma, or dysrhythmias. Here, we present the case of a 60-year-old gentleman who had a history of multiple percutaneous coronary angioplasty, and pericardiectomy for constrictive tubercular pericardial effusion. Nine months after surgery, he presented with a left ventricular pseudoaneurysm and multiple stent fractures in the right coronary artery. Myocardial involvement in tuberculosis can cause ventricular pseudoaneurysms due to contiguous involvement from the pericardium. Stent fractures are commonly associated with pyogenic infections but can occur in cardiac tuberculosis. The occurrence of a stent fracture and ventricular pseudoaneurysm in the background of cardiac tuberculosis is, however, very rare. Patients with a history of cardiac tuberculosis should always be followed for late sequelae and complications, which may be bizarre.

Cardiac Magnetic Resonance Imaging in Coronavirus Disease 2019 (COVID-19): A Systematic Review of Cardiac Magnetic Resonance Imaging Findings in 199 Patients.

OBJECTIVE: Cardiac magnetic resonance imaging (CMR) with its new quantitative mapping techniques has proved to be an essential diagnostic tool for detecting myocardial injury associated with coronavirus disease 2019 (COVID-19) infection. This systematic review sought to assess the important imaging features on CMR in patients diagnosed with COVID-19. MATERIALS AND METHODS: We performed a systematic literature review within the PubMed, Embase, Google Scholar, and WHO databases for articles describing the CMR findings in COVID-19 patients. RESULTS: A total of 34 studies comprising 199 patients were included in the final qualitative synthesis. Of the CMRs 21% were normal. Myocarditis (40.2%) was the most prevalent diagnosis. T1 (109/150; 73%) and T2 (91/144; 63%) mapping abnormalities, edema on T2/STIR (46/90; 51%), and late gadolinium enhancement (LGE) (85/199; 43%) were the most common imaging findings. Perfusion deficits (18/21; 85%) and extracellular volume mapping abnormalities (21/40; 52%), pericardial effusion (43/175; 24%), and pericardial LGE (22/100; 22%) were also seen. LGE was most commonly seen in the subepicardial location (81%) and in the basal-mid part of the left ventricle in inferior segments. In most of the patients, ventricular functions were normal. Kawasaki-like involvement with myocardial edema without necrosis/LGE (4/6; 67%) was seen in children. CONCLUSION: CMR is useful in assessing the prevalence, mechanism, and extent of myocardial injury in COVID-19 patients. Myocarditis is the most common imaging diagnosis, with the common imaging findings being mapping abnormalities and myocardial edema on T2, followed by LGE. As cardiovascular involvement is associated with poor prognosis, its detection warrants prompt attention and appropriate treatment.

Coronavirus Disease-19 (COVID-19) and Heart Failure: Current Perspective.

COVID-19 has been the biggest pandemic which the world has seen in recent times. The SARS-Cov-2 infection has the potential to cause multi-organ dysfunction. Though the virus predominantly affects the lungs, it can affect the heart in myriad ways. Heart failure (HF) is one such complication caused by the virus, both in patients with and without cardiovascular diseases. Different mechanisms have been proposed for the pathogenesis of HF in COVID-19 ranging from direct viral injury to indirect immune mediated damage. Patients can have different clinical presentations with either acute heart failure or chronic heart failure. Early recognition and prompt management is the need of the hour to prevent any mortality and morbidity. Summary: COVID-19 can affect the heart in many ways. This article describes the mechanisms, clinical presentations and management of heart failure caused by COVID-19 infection.

CT in coronavirus disease 2019 (COVID-19): a systematic review of chest CT findings in 4410 adult patients.

OBJECTIVE: The objective of this systematic review was to evaluate the key imaging manifestations of COVID-19 on chest CT in adult patients by providing a comprehensive review of the published literature. METHODS: We performed a systematic literature search from the PubMed, Google Scholar, Embase, and WHO databases for studies mentioning the chest CT imaging findings of adult COVID-19 patients. RESULTS: A total of 45 studies comprising 4410 patients were included. Ground glass opacities (GGO), in isolation (50.2%) or coexisting with consolidations (44.2%), were the most common lesions. Distribution of GGOs was most commonly bilateral, peripheral/subpleural, and posterior with predilection for lower lobes. Common ancillary findings included pulmonary vascular enlargement (64%), intralobular septal thickening (60%), adjacent pleural thickening (41.7%), air bronchograms (41.2%), subpleural lines, crazy paving, bronchus distortion, bronchiectasis, and interlobular septal thickening. CT in early follow-up period generally showed an increase in size, number, and density of GGOs, with progression into mixed areas of GGOs plus consolidations and crazy paving, peaking at 10-11 days, before gradually resolving or persisting as patchy fibrosis. While younger adults more commonly had GGOs, extensive/multilobar involvement with consolidations was prevalent in the older population and those with severe disease. CONCLUSION: This review describes the imaging features for diagnosis, stratification, and follow-up of COVID-19 patients. The most common CT manifestations are bilateral, peripheral/subpleural, posterior GGOs with or without consolidations with a lower lobe predominance. It is pertinent to be familiar with the various imaging findings to positively impact the management of these patients. KEY POINTS: • Ground glass opacities (GGOs), whether isolated or coexisting with consolidations, in bilateral and subpleural distribution, are the most prevalent chest CT findings in adult COVID-19 patients. • Follow-up CT shows a progression of GGOs into a mixed pattern, reaching a peak at 10-11 days, before gradually resolving or persisting as patchy fibrosis. • Younger people tend to have more GGOs. Older or sicker people tend to have more extensive involvement with consolidations.

Encephalitis Due to Dengue Virus Infection Mimicking Japanese B Encephalitis: Two Case Reports.

Dengue virus induced encephalitis is a very rare entity and its full clinicoradiological profile is still unknown. We here report two cases of dengue encephalitis from Eastern India. The first one is a 20 year old female and the second one is a 13 year old boy. Both of them presented with altered consciousness and seizures. Blood and CSF study for dengue IgM were positive. MRI of brain showed T2 hyperintensity in the Thalami along with similar changes in other parts of the brain. Both patients responded to conservative therapy but residual neurological deficit were variably present. Relevant literature pertaining to dengue encephalitis have also been discussed.