Consensus statement for implantation and follow-up of cardiac implantable electronic devices in India.

Cardiac implantable electronic device (CIED) procedures are being done by many operators/centers and it is projected that this therapy will remarkably increase in India in the coming years. This document by IHRS, aims at guiding the Indian medical community in the appropriate use and method of implantation with emphasis on implanter training and center preparedness to deliver a safe and effective therapy to patients with cardiac rhythm disorders and heart failure.

Cardiac resynchronization therapy is associated with improvement in clinical outcomes in Indian heart failure patients: Results of a large, long-term observational study.

BACKGROUND: Heart failure (HF) is a common health problem in South Asia, and its incidence and prevalence are projected to rise. Cardiac resynchronization therapy (CRT) has been shown to improve mortality, reduce hospitalizations, and improve symptoms in selected patients with HF. The South Asian Systolic Heart Failure Registry (SASHFR) was designed to be a large and comprehensive registry of Indian HF patients with the purpose of enhancing the quality of care and clinical outcomes of HF patients by promoting the adoption of evidence-based, guideline-recommended therapies, in particular CRT. METHODS: Overall, 471 patients on optimized medical therapy and meeting CRT implantation guidelines were followed up in 12 Indian hospitals. During the 2-year follow-up period, clinical response in terms of clinical composite score, overall performance and changes in HF performance metrics, mortality and hospitalizations rates were evaluated. RESULTS: Of 471 patients, 116 (24.6%) accepted to be implanted with a CRT device, while 355 (75.4%) refused, financial constraints being the main reason for refusing a CRT device. The study met its primary outcome, as the number of patients associated with an improvement in clinical composite score at 24 months was significantly higher (69.1%) in the CRT group than in the no-CRT group (44.7%) [odds ratio = 2 (95% confidence interval 1.25-3.20), p = 0.004]. Also, changes in HF metrics, mortality and hospitalizations rates indicated a more favorable response among patients who underwent CRT. CONCLUSIONS: The results from the SASHFR registry show a clear superiority of CRT over optimal pharmacological therapy in terms of improvement in clinical conditions among HF patients. The low rate of CRT acceptance, in patients indicated to this therapy, highlights the need for new health-care policies to improve awareness about HF disease and its therapies and possibly to enhance financial coverage of indicated therapies.

What is cardiac resynchronisation therapy and who will benefit?

Cardiac Resynchronisation Therapy (CRT) has been used extensively over the last years in the therapeutic management of the patients with end stage heart failure based on the data of large randomized trials on CRT. CRT improves symptoms, exercise capacity, quality of life and echocardiographic indices of severe systolic heart failure besides reduction in heart failure related hospitalizations and improvement in survival. However, there may be some non-responders as well. There is on-going research, which will identify patients without conventional indications for CRT so as to improve the responder rate. Tissue Doppler Imaging (TDI) techniques will assume an important role in identifying patients for CRT.

Implantable cardioverter defibrillatory implantation in a patient with persistent left superior vena cava and right superior vena cava atresia.

Persistence of a left superior vena cava has been observed in 0.3% of the general population as established by autopsy findings. In the adult population. it is an important anatomic finding if a left or right superior vena cava approach to the heart is considered for device implantation. We present a case with persistent left superior vena cava and right superior vena cava atresia in whom a dual chamber implantable cardioverter defibrillator was implanted and was technically challenging.

Coronary-to-coronary bypass using a free internal mammary artery: an alternative.

Paucity of conduit of adequate length or quality poses a dilemma in the occasional patient. We report such a patient, in whom we used a modified anastomotic technique using the normal right coronary artery for the proximal anastomotic site of a free right internal mammary artery graft.

Clinical and coronary arteriographic features and outcome of recent onset unstable angina.

Fifty consecutive patients (43 male and seven female; mean age 51.8 years) with recent onset angina (24.6% of all admissions for unstable angina during a 1-year period) underwent coronary arteriography. Most patients (96.8%) presented with severe angina (Canadian Cardiovascular Society Class III-IV) with admission ECG changes of myocardial ischemia in 46%. Echocardiography (within 2 days of admission) showed normal left ventricular function (LVEF > 50%) in 80% and mild or moderate impairment (LVEF 35-49%) in 12% of patients. Segmental wall motion abnormalities were noted in a small number (12.9%). Coronary angiography revealed significant (> or = 70% diameter stenosis) disease in one vessel in 14 (28%), in two vessels in seven (14%), three vessels in 22 (44%) and no disease in seven (14%) patients. Significant left main stenosis (> or = 50% diameter stenosis) was present in two (5%) patients. Left anterior descending artery was more commonly involved (66%) as compared to the other arteries. A significantly higher incidence of multivessel disease was observed in patients with diabetes mellitus (P < 0.003) and in smokers (P < 0.04). Multiple coronary artery involvement was more common in patients with three or more risk factors for coronary artery disease (P < 0.005). In-hospital non fatal myocardial infarction occurred in three (6%) patients. During follow-up (average 13 +/- 1.28 months) 30 (60%) patients underwent coronary artery bypass surgery, 13 (26%) required coronary angioplasty while seven (14%) were managed by drugs alone with no further mortality and significant symptomatic relief. Patients with recent onset angina, in our setting, frequently have severe multiple vessel coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary-to-coronary artery bypass using a free right internal mammary artery: an alternative.

Lack of a conduit of adequate length or quality poses a dilemma in the occasional patient. We report such a case in whom we applied a modified anastomotic technique using the normal right coronary artery for the proximal anastomotic site of a free right internal mammary artery graft.

Cardioprotective effects of diltiazem infusion in the perioperative period.

OBJECTIVE: To evaluate the perioperative effects of intravenous diltiazem infusion on left ventricular functions, hemodynamics and as an anti-ischemic and antiarrhythmic agent in patients undergoing coronary artery bypass grafting (CABG). METHODS: A double blind, randomised study was performed on 71 patients undergoing elective CABG. Infusion of diltiazem (0.1 mg/kg per h, n = 34) or nitroglycerin (1 microgram/kg per min, n = 37) was given for 24 h starting from onset of cardiopulmonary bypass. Holter monitoring, electrocardiogram and serum cardiac enzymes levels were used to diagnose myocardial ischemia. Myocardial function was assessed by perioperative transesophageal echocardiography. RESULTS: The two groups did not differ with respect to preoperative and operative data. Diltiazem had no influence on hemodynamic parameters except for significant reduction in post operative heart rate and pulse pressure rate. Transient ischemic events (dilitiazem 10.2% versus nitroglycerin 33.3%, P = 0.15) and transient coronary spasm (diltiazem-6.8% versus nitroglycerin 25.9%, P = 0.15) were reduced in the diltiazem group as compared with the nitroglycerin group. The postoperative incidence of atrial fibrillation (diltiazem 3% versus nitroglycerin 22%, P = 0.03), supra ventricular tachycardia (diltiazem-3% versus nitroglycerin-22%, P = 0.03) and average ventricular premature contraction per h (diltiazem-40.2 +/- 10.2 versus nitroglycerin 53.8 +/- 12.3, P < 0.01) were significantly lower in the diltiazem group. Transesophageal echocardiography showed no significant difference in left ventricular functions and better preservation of left ventricular diastolic functions in post cardiopulmonary bypass period in diltiazem group. In addition mean deceleration time for the E wave on a 12 h post cardiopulmonary bypass period was significantly lower in the diltiazem group as compared with nitroglycerin (diltiazem 131 +/- 6 versus nitroglycerin 171 +/- 6, P < 0.01). CONCLUSION: The present study demonstrates that diltiazem infusion provides superior anti-ischemic protection and control of supraventricular arrhythmias as compared to nitroglycerin and does not produce any negative inotropic effect, as demonstrated by transesophageal echocardiography.

Mammary coronary artery anastomosis without cardiopulmonary bypass through minithoracotomy: one year clinical experience.

OBJECTIVE: The recent concept of minimally invasive coronary artery surgery in selected patients has dramatically affected surgical management of coronary artery disease. We explored the possibility of coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy on beating heart. METHOD: Minithoracotomy and direct coronary artery surgery without cardiopulmonary bypass (CPB) was attempted in 116 patients. The procedure was completed in 108 cases while in eight cases minithoracotomy was converted to mid sternotomy. In 107 cases, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery anastomosis was done through left anterior minithoracotomy and in one case LIMA to LAD and right internal mammary artery (RIMA) to right coronary artery (RCA) anastomosis was done through bilateral minithoracotomy. Left anterior minithoracotomy through 4th intercostal space and right anterior minithoracotomy through 5th intercostal space was used for left and right internal mammary artery dissection respectively. With this approach 4-8 cm length of mammary artery was easily dissected. Mammary coronary artery anastomosis were performed on a beating heart without CPB through window pericardiotomy. Two patients also underwent left carotid endarterectomy along with LIMA to LAD anastomosis. In two patients complementary percutaneous transluminal coronary angioplasty (PTCA) to circumflex artery was done 5 days after minithoracotomy and LIMA to LAD anastomosis. RESULTS: Forty-two patients were extubated in the operating room and 66 in the intensive care unit 2-10 h after surgery. Blood transfusion was used in one case who was reexplored for postoperative bleeding due to a displaced hemoclip from the internal mammary artery branch. None of these patients required inotropic support. Postoperative predischarge check angiogram in 53 cases revealed adequate mammary coronary flow in 51 cases, the remaining two had anastomotic problems, one was subjected to PTCA and the other for redo coronary bypass grafting through mid sternotomy. Doppler flow assessment of anastomosis was done in 102 cases, of which two showed problems which was confirmed on check angiography. One-hundred and six patients are in our regular follow-up (mean follow-up 10+/-1.5 months), 98 of them are in functional class I. CONCLUSION: In our experience mammary coronary artery anastomosis without CPB through minithoracotomy is a safe, simple and minimally invasive procedure. Favorable cost/benefit ratio, has been achieved due to no early/late mortality and minimal early morbidity. Postoperative check angiogram and Doppler flow study revealed excellent mid term results.

Angioplasty of pedicled right gastroepiploic artery graft through a six French diagnostic catheter.

Pedicled right gastroepiploic artery is increasingly being used as a conduit for coronary artery bypass surgery. We describe an interesting case in which balloon angioplasty for stenosis in such a graft was performed through a 6 French diagnostic catheter.

Aortoarteritis with systemic lupus erythematosus and secondary antiphospholipid antibody syndrome: a rare association.

A 41-year-old woman diagnosed with aortoarteritis since 1988 was admitted with unstable angina. She also had anemia, thrombocytopenia, aortic regurgitation and pulmonary artery hypertension. She gave a history of recurrent fetal loss and myocardial infarction, following which angioplasty to the left anterior descending artery had been done. After investigation, a diagnosis of aortoarteritis with systemic lupus erythematosus and associated antiphospholipid antibody syndrome was made. Aortoarteritis may coexist with systemic lupus erythematosus and associated antiphospholipid antibody syndrome.

Catheter ablation of left free wall accessory pathway in a patient with inferior vena cava interruption.

Access to the right side of the heart for diagnostic and interventional procedures is usually obtained via the femoral vein and inferior vena cava. Anatomic variations or obstruction of the inferior vena cava can make this access difficult. In such cases, alternative routes to the right side of the heart such as the azygos vein and the superior vena cava can be used.

Percutaneous intraaortic balloon pulsation for management of life threatening emergencies in an intensive coronary care unit.

The indications for the outcome of use of intraaortic balloon pulsation (IABP) in 66 patients (65 males, 1 female), in addition to the usual conventional medical therapy, are reported here. IABP was used for treatment of cardiogenic shock (5 patients), acute myocardial infarction with rupture of interventricular septum (2 patients), acute myocardial infarction with refractory left ventricular failure (2 patients), resistant ventricular tachyarrhythmias (5 patients), refractory angina (50 patients) and for hypotension following high risk coronary angiography (2 patients). A Datascope 10.5 F percutaneous balloon was inserted in all, mostly using the left femoral artery. Either definitive treatment (coronary artery bypass surgery or coronary angioplasty) was offered when feasible or the balloon was weaned off. Twelve patients underwent coronary angiography on IABP; while 31 patients had undergone the angiography earlier. Surgery was possible in 33 patients with 90% survival rate. The non surgical group showed 30% survival rate. The complications of IABP encountered were: leg ischaemia (2 patients), septicemia (4 patients) and balloon rupture (2 patients). Our experience suggests that percutaneous IABP is a very useful management procedure for seriously sick high risk patients prior to definitive therapy. Patients who could have a definitive treatment while on IABP, especially the group with refractory angina, did best on a short term follow up. Vascular complications are minimal while on IABP.

Coronary artery fistulae without audible murmur in adults.

Retrospective analysis of 4886 adults undergoing coronary arteriography for evaluation of angina between October 1988 and December 1991, revealed coronary artery fistulae in eight patients (all men, aged 36-69 years). No murmur was audible in any of these eight patients. Associated significant coronary artery disease was detected in five patients. The feeder arteries to the fistula were both the left main coronary artery and the left anterior descending artery (LAD) in two, the LAD in six, and the right coronary artery in two patients. The fistula terminated in the pulmonary artery in seven patients and in the right atrium in one patient. Successful operative treatment (coronary artery bypass grafting and ligation of the fistula) was undertaken in four patients with severe obstructive coronary artery disease with satisfactory results. Follow-up for up to 2 years of the three patients with coronary artery fistula and no associated coronary artery disease who did not undergo surgery revealed continuing good prognosis. We conclude that coronary artery fistula in adults is a distinct, though rare (incidence in present series 0.11%) entity, without audible murmur, commonly associated with coronary artery obstructive disease, and that the diagnosis is mostly incidental during routine coronary arteriography.