Radial Artery Occlusion - Incidence, Predictors and Long-term outcome after TRAnsradial Catheterization: clinico-Doppler ultrasound-based study (RAIL-TRAC study).

Background and aim The purpose of this study was to assess incidence, predictors and outcome of radial artery occlusion (RAO) after transradial catheterization (TRC) based on clinical and Doppler ultrasound study. Methods A total of 1,945 consecutive patients undergoing transradial catheterization for diagnostic evaluation or intervention were included. Radial artery examination was based on palpation and colour Doppler study on the day before, 1 day (D1), 1 month (D30) and 6 months (D180) following the procedure. RAO was defined as absence of pulse on palpation and forward flow on Doppler study. Predictors of RAO were found by logistic regression analysis. Results Baseline demographic and procedural data were recorded. The mean radial arterial diameter was 2.56 ± 0.29 mm. On D1, radial artery Doppler examination revealed RAO in 339 patients (17.4%) but pulse was still palpable in 115 (34%) of them. At D30, these were 221 (11.4%) and 114 (52%), respectively, as no new RAO were noted. Interestingly, 118 (34.8%) patients had spontaneous recanalization of their radial artery as shown by catch-up in patency rate. At D180, these were 99 (5.1%) and 68 (69%), respectively, meaning further new catch-up implying further recanalization. Patients with persistent RAO remained asymptomatic. On multivariate analysis, female sex, diabetes, lower BMI, radial artery diameter ≤2.2 mm and radial artery-to-sheath ratio (AS ratio) < 1 were predictors of RAO. Conclusion TRC for coronary angiography, ad hoc and staged angioplasty can be performed with similar efficacy and safety though RAO occurs more frequently in patients with prior radial artery cannulation and with larger sheath size. Persistent RAO remains asymptomatic.

Accura balloon dilatation catheter for percutaneous balloon pulmonary valvuloplasty among adult patients-its protean use.

BACKGROUND: Percutaneous balloon pulmonary valvuloplasty (PBPV) is the treatment of choice for hemodynamically significant pulmonary stenosis (PS). Currently, the Tyshak balloon is preferred but requires multiple dilatations because of its instability across the valve leading to a watermelon seeding effect. Accura balloon (Vascular Concept, UK) offers an advantage in its self-positioning configuration, variable diameter, and rapid inflation-deflation sequence which shortens the procedural time and valve injury. METHOD: 43 patients with severe pulmonary valve stenosis underwent PBPV using an Accura balloon at LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, India from March 2018 to February 2022. The procedure was carried out using the standard technique but the metallic straightener was removed when the catheter reached the right atrium to facilitate its delivery across the pulmonary valve. Patients were followed up by 2D echo at 24 hours and 6 months. RESULT: Successful BPV was done in all 43 patients [with mean age 21.9 (range 18-41); 31 males and 12 females] among which 5 patients had dysplastic valves. The mean diameter of the annulus was 18.5 (range 15-21) mm. Immediate hemodynamic improvement was observed in 38 patients (88%) as peak systolic gradient reduced from 84±13 to 22±12 mmHg (P<0.005) while 5 patients (12%) had <50% reduction of resting gradient, though it came down significantly at 6 months. Fluoroscopy and procedural time were 5.2±1.9 min and 22.6±3.4 min respectively. Major complications (death, cardiac perforation, tamponade, tricuspid regurgitation, requirement of blood transfusion) were none. Minor complications (transient hypotension, ventricular premature contraction, transient bradycardia) were reported in all patients. Accura balloon being bulky were delivered over left atrial and super stiff Amplatz wire in 36 and 7 patients respectively. CONCLUSION: PBPV using Accura balloon is safe and effective for both stenosed and dysplastic valves. In a few patients, maximal effect will be observed over a period of 6 months.

Twelve-month clinical outcomes of "nano-crush technique" for the treatment of bifurcation lesions using ultra-thin (60 µm) sirolimus-eluting coronary stents.

BACKGROUND: Provisional stenting is preferred for bifurcation lesion; however, certain anatomical substrate does require two stents as a part of dedicated stent technique. Here, the present study evaluated outcomes of ultra-thin (60 µm) Supra family sirolimus-eluting stent (SES) (Sahajanand Medical Technologies Limited, Surat, India) for dedicated bifurcation lesions using nano-crush technique at 12 months angiographic follow-up. METHODS: This was prospective, single-center observational study which enrolled patients with de novo bifurcation lesion and underwent angioplasty with Supra family SES using nano-crush technique at a tertiary care center in India, between March-2017 and February-2019. Primary endpoint at 12 months was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (CD-TLR). Secondary endpoints included patient-oriented composite endpoint (POCE), all-cause death, any revascularization, clinically driven target vessel revascularization, stent thrombosis, periprocedural and spontaneous MI, and device failure. RESULTS: The study enrolled total 63 patients with a mean age of 62.5±4.9 years and had male dominance (89%). Left main (LM) bifurcation and non-LM bifurcation were observed in 21 (33%) and 42 (67%) patients, respectively. Total 50 (80%) patients had Medina class- 1,1,1. At 12 months, TLF occurred in 4 (6%) patients which included one cardiac death (1.5%), two (3.0%) TV-MI, and one CD-TLR (1.5%). POCE was observed in 6 (9.6%) patients. Stent failure was seen in 2 (3.1%) patient and one patient (1.5%) developed late stent thrombosis. Twelve months angiographic follow-up indicated intact stent patency in all other patients. On multivariate analysis, LM bifurcation, renal dysfunction, LM bifurcation with renal dysfunction, ejection fraction (<35%) and calcified lesion were found as predictors of TLF. CONCLUSIONS: Dedicated stenting with ultra-thin Supra family SES for complex bifurcation lesion using nano-crush technique reported acceptable clinical outcomes among real-world patients and can be performed safely with ease without any procedural complications.

Tiger Stripes in Carditis of Rheumatic Origin.

"Tiger stripes" or "Zebra stripes" are multiple band-like signals noted on Doppler spectral recordings and have been associated with intracardiac oscillating structures. They have been attributed to flail prosthetic valve leaflet, native valve regurgitation without flail leaflet, papillary muscle rupture in acute coronary syndrome, and possibly Lambl's excrescences. To our knowledge, there is only one case report in the English literature that had identified this sign in rheumatic carditis. We present the case of a 14-year-old boy, who was known to have rheumatic heart disease and presented with worsening dyspnea of recent onset. His antistreptolysin O, C-reactive protein, and erythrocyte sedimentation rate titer were raised. Echocardiography revealed severe eccentric mitral regurgitation with multiple high-intensity signals (tiger stripes) on continuous wave (CW) Doppler. The patient was managed as rheumatic carditis with steroids. Repeat echocardiography after 1 month showed the resolution of tiger stripes. Upon tapering, steroids patient's symptoms worsened and echocardiography revealed the reappearance of tiger stripes. We propose that these high-intensity signals in spectral Doppler reflect valvulitis and are the echocardiographic counterpart of musical overtones. We suggest that these signals on CW Doppler in a patient with established rheumatic heart disease be taken as a marker of carditis and the patient should be managed accordingly. We refer to this sign as a "Fingerprint sign" due to its resemblance to it and to differentiate it from Tiger strips because of its dynamic nature. This sign can be used to identify and follow carditis in a rheumatic scenario.

Assessment of the Left Atrial Reservoir Function and Left Atrial Volume After Percutaneous Balloon Mitral Valvuloplasty Using Peak Atrial Longitudinal Strain.

Objective To evaluate the impact of successful percutaneous balloon mitral valvuloplasty (BMV) on left atrial (LA) reservoir function and LA volume in patients with severe mitral stenosis (MS) using peak atrial longitudinal strain (PALS). Method This was a prospective, non-randomized observational study conducted at the Laxmipat Singhania (LPS) Institute of Cardiology, Kanpur from August 2018 to February 2020 among patients with severe rheumatic MS undergoing BMV to assess LA reservoir function and its volume after BMV using PALS. Inclusion criteria were symptomatic severe rheumatic MS (NYHA ≥II), normal ventricular systolic function, and suitable valve morphology. Exclusion criteria were the coexistence of aortic valve involvement, left atrial appendage clot, mitral leak more than mild, pregnancy, hypertension, diabetes, and coronary artery disease. To assess LA reservoir function and its volume after BMV, PALS was used. LA was divided into six regions of interest and longitudinal strain curves of individual segments together with global strain were recorded. PALS was calculated at baseline 24 hours following the intervention, and at three months of follow-up. Result Successful BMV was performed in 260 patients (109 or 41.9% males and 151 or 58.1% females), resulting in significant improvement in mitral valve area (MVA) (0.89±0.11 cm2 vs. 1.83±0.3 cm2; p<0.001). The mean age of patients was 26.7±4.7 years; 214 (82.3%) patients were in normal sinus rhythm (NSR) while 46 (17.7%) had atrial fibrillation (AF). Significant improvement in PALS was noted immediately following the procedure (6.5±11.6% vs. 7.7±10.5%; p< 0.001) and it continued to improve at three months of follow-up (6.5±11.6% vs. 11.3±12.5%; p<0.001), which was 24% and 74% improvement from baseline respectively. Significant reduction in indexed left atrial (LA) volume was observed immediately following the procedure (56.8±14.3 ml/m2 vs 48.4±12.5 ml/m2; p=0.003), and at three months of follow-up (56.8±14.3 ml/m2 vs. 45.4±13.3 ml/m2; p=0.002). Those with AF had lesser improvement in PALS in comparison to those with NSR (60% vs. 84%; p=0.044) at three months of follow-up. At three months, the increase in PALS was also lower in patients with a history of stroke as compared to those without it (55% vs 80%; p=0.039). Both LA volume and indexed LA volume reduced significantly immediately at 24 hours and during follow-up. Conclusion LA reservoir function, as assessed by PALS, is reduced in patients with severe MS. It improved significantly within 24 hours following BMV and continued to improve at three months of follow-up. It is an underutilized modality among patients of MS for decision-making prior to intervention and to assess the effect of the intervention.

Unguided temporary pacing via jugular/subclavian vein in an emergency department of a high-volume tertiary care hospital of India: its safety, efficacy, and practicability.

BACKGROUND: Temporary pacing is usually performed by cardiologists under fluoroscopic, echocardiographic, or ECG guidance. However, in the developing world, there are inadequate number of cardiologists, and C-arm, catheterization laboratories, or echocardiography are not available at primary or secondary healthcare facilities. In addition, in emergencies option of fluoroscopy and echocardiography is limited. So these patients are transferred to a facility where cardiologists and these facilities are available. Crucial time is lost in transit, which leads to increased mortality. In this study, we aimed to evaluate the safety, efficacy, and practicability of unguided temporary pacemaker insertion. RESULTS: A total of 1093 patients were enrolled in this study. After cannulating the internal jugular vein or subclavian vein, the pacing lead attached to the pulse generator was advanced blindly till ventricular pacing was achieved. Procedural success was taken as the primary endpoint. Secondary endpoints included the number of attempts taken for successful central venous puncture and procedural time. Complications and mortality were assessed for safety outcomes. Finally, the position of the pacing lead was assessed after the procedure on X-ray or fluoroscopy. The procedure was successful in all but one patient in whom a femoral vein approach was required because of brachiocephalic vein obstruction. Right internal jugular access was achieved in 981 (89.75%) patients. The mean number of attempts taken for achieving successful venous accesses was 1.54 ± 0.85; however, in 726 (66.42%) patients it was achieved in the first attempt. The mean procedural time was 11.5 ± 2.1 min. Overall, 117 (10.70%) patients developed complications; however, most of them were minor. Pneumothorax developed in 12 (1.1%) patients, of whom 2 needed an intercostal tube. Pericardial effusion was seen in 21 (1.92%) patients. Pacing lead tip was located in the right ventricular cavity abutting interventricular septum or free wall in 843 (77.20%) patients. No mortality attributable to procedure occurred. CONCLUSIONS: Unguided temporary pacing via jugular or subclavian venous approach in an emergency setting is possible with high success and a low complication rate. Thus, it is a safe and effective procedure, and clinicians working at primary and secondary healthcare levels should be encouraged to perform this procedure. Trial registration UMIN Clinical Trials Registry, UMIN000046771. Registered 28 January 2022-Retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053348.

Transcatheter closure of secundum atrial septal defect using Cocoon septal occluder: immediate and long-term results.

BACKGROUND: Atrial septal defect (ASD) is one of the common congenital heart defects. Its management has transformed dramatically in the last 4 decades with the transition from surgical to percutaneous transcatheter closure for most secundum-type ASDs. Various devices are available for transcatheter closure of ASD with Amplatzer atrial septal occluder being most commonly used worldwide. Cocoon septal occlude has a nanocoating of platinum using nano-fusion technology over nitinol framework that imparts better radiopacity and excellent biocompatibility and prevents leaching of nickel into circulation, and by smoothening nitinol wire makes this device very soft and smooth. The aim of this study was to evaluate feasibility, effectiveness, safety, and long-term outcome of transcatheter closure of ASD using Cocoon septal occluder (Vascular Innovation, Thailand). RESULTS: All patients undergoing transcatheter closure of hemodynamically significant ASD between September 2012 and July 2019 in our institute were included into this single-center, prospective study. Exclusion criteria were defect > 40 mm, unsuitable anatomy, Eisenmenger syndrome, and anomalous pulmonary venous return. Three hundred and twenty patients underwent device closure, of which 238 (74%) were female. The mean age was 14.6 years (range 6-29), and the median weight was 30.2 kg (range 10-53 kg). Procedure was performed under fluoroscopy using transthoracic and transesophageal echocardiography in 298 (93.1%) and 22(6.9%) patients, respectively. Balloon-assisted technique was used, when septal defect was ≥ 34 mm, in 9 (2.8%) patients. The mean diameter of defect and device was 21.4 mm (range 12-36 mm) and 26.9 mm (range 14-40 mm), respectively. Aortic rim was absent in 11 (3.4%) patients. Primary success was achieved in 312 (97.5%) patients. Early embolization to right ventricle was noted in 2 (0.6%) patients. In both cases, 40-mm device was attempted for defect of 36 mm with inadequate aortic rim using balloon-assisted technique. One (0.3%) patient developed perforation of right atrium. All were surgically repaired. Three (0.9%) patients developed complete heart block following device deployment requiring device retrieval. Two patients had had moderate residual shunt at 6 months of follow-up. After mean follow-up of 50.92 months (range 12.5-89 months), no erosion, allergic reactions to nickel, or other major complications were reported. CONCLUSIONS: Percutaneous transcatheter closure of ASD by Cocoon septal occluder (up to 36 mm) is safe and feasible with high success rate and without any significant device-related major complications over long-term follow-up. With unique device design and excellent long-term safety, it could be preferred dual-disk occluder for transcatheter closure of atrial septal defect. In most of the patients, ASD device can be safely deployed under transthoracic echocardiographic guidance.

Study of Safety and Efficacy of Novel Sirolimus-Eluting Stent Incorporating Properties of Drug Coating Balloon Among Real World Patients Focusing Younger Population (<35 years).

OBJECTIVE: Aim of study was to evaluate safety and efficacy of abluminal Mitigator DES + Sirolimus Eluting Stent (Envision Scientific, Surat, India) incorporating novel technology of fusion coating of bioresorbable polymer on both abluminal surface of stent and exposed parts of balloon among real world patients specially focusing younger patients (<35 years). METHOD: 1293 patients received Mitigator DES + at LPS Institute of Cardiology, Kanpur, India. Primary outcome was target lesion failure (TLF)- composite of cardiovascular death, target vessel myocardial infarction (TVMI), and target lesion revascularization (TLR) and secondary end points including peri-procedural device failure (failure of stent delivery, change of stent, stent fracture), target vessel failure (TVF), and patient oriented composite end point (POCE)-composite of all deaths, MI, and revascularization and stent thrombosis (ST) at 1-year follow-up. RESULT: Younger population comprised of 374 (29%) patients. Various indications of interventions were STEMI (n = 614; 47.4%), NSTEMI (n = 416; 32.2%), UA (n = 161; 12.5%), and CCS (n = 102; 7.9%). TLF at 1 year in young and overall population were 3.4% and 3.5% respectively which was driven by TVMI and TLR in 1.3% and 1.1% patients respectively. POCE was observed in 9.5% in each group mainly contributed by any revascularization (3.9%). Device failure was significantly lower in young group than overall population (1.3% vs. 2.2%; p = 0.04) which was mainly driven by stent delivery (1.1%) and edge dissection (0.5%). Definite and probable ST was 1.3% and 1.7% respectively which was not significant. Young patients showed insignificantly lower TLF, TVF, ST and POCE and significantly lower device failure (1.3% vs. 2.6%; p = 0.04) when compared to patients >35 years. On multivariate regression analysis, complex lesion, in-stent restenosis, failure of stent delivery and edge dissection were independent predictors of events or device success rate. CONCLUSION: Mitigator DES+™ is safe among real world patients, including young population.

Telecardiology and its outcome among patients with implantable cardiac devices during COVID-19 pandemic.

BACKGROUND: During ongoing coronavirus disease 2019 (COVID-19) pandemic, social isolation and lockdown measures were implemented to prevent spread of virus which created enormous challenges to patient healthcare. In order to overcome these challenges, teleconsultation (telecardiology) was initiated. Objective of this study was to assess outcome of telecardiology using audio/visual/audio-visual consultation among patients with implantable cardiac devices. METHODS: Telecardiology was performed (either physician-initiated or patient-initiated) among 1200 patients over a five-month period (July 13 to December 13, 2020) to review health status of patients to decide further course of treatment and to access their satisfaction level with telecardiology. RESULTS: Teleconsultation was cardiologist- and patient-initiated in 1042 (86.8%) and 158 (13.2%) cases, respectively. 1117 (93.2%) patients were stable, while scheduled admission, urgent hospitalization, and death were noted in 20 (1.8%), 45 (3.9%), and 18 (1.5%) patients, respectively. Next visit was rescheduled in 986 (82.2%), while 127 (10.6%) were called earlier because of battery depletion. Majority (n = 1077, 89.8%) were satisfied. CONCLUSION: Telecardiolgy is an effective option during COVID-19 to minimize interpersonal contact, spread of disease, psychological stress, and burden on already stretched healthcare.

Perforated balloon technique mediated intracoronary delivery of nicorandil to treat coronary no-reflow phenomenon: a novel pharmacological solution to precarious situation.

BACKGROUND: Coronary no-reflow (NRF) following percutaneous coronary intervention (PCI) is infrequent but one of the most dreaded complication which results from impaired flow of microvascular bed. It is associated with adverse outcome if flow is not restored. Objective of this study was to find safety, effectiveness and outcome of intracoronary nikorandil (IC) administered using perforated balloon technique (PBT) to reverse NRF. METHOD: 2-4 mg of nicorandil was diluted with 5 ml of normal saline and administered using PBT over 5-minute. Its effectiveness was evaluated after 10 minute qualitatively using TIMI flow and quantitatively corrected TIMI frame count (cTFC) method. RESULT: Study comprised of 84 patients (out of 1789 patients undergoing PCI between January 2019 and February 2020). Their mean age was 57.8±17.9 years. Following PBT, TIMI III flow was successfully normalized in 71 subjects (84.5%), ten (12%) patients had TIMI II flow and it was not successful in three (3.5%) patients. TIMI flow grade got bettered from 1.03 to 2.58 and cTIMI frame count regressed from 52.9±11 to 16.5±5 (P < 0.001). PBT was well tolerated except short lived drop in blood pressure (n=10; 11.9%). CONCLUSION: This study, for the first time to the best our knowledge, demonstrated that PBT mediated intracoronary administration of nikorandil distally was rapid, safe, and efficacious method to deal with NRF.

Acute myocardial infarction in very young adults: A clinical presentation, risk factors, hospital outcome index, and their angiographic characteristics in North India-AMIYA Study.

BACKGROUND: India is currently in the fourth stage of epidemiological transitions where cardiovascular disease is the leading cause of mortality and morbidity. Purpose of the present study was to assess the risk factors, clinical presentation, angiographic profile including severity, and in-hospital outcome of very young adults (aged ≤ 30 years) with first acute myocardial infarction (AMI). METHODS: Total of 1,116 consecutive patients with ST-segment elevation acute myocardial infarction (STEMI) were studied between March 2013 and February 2015 at LPS Institute of Cardiology, Kanpur, Uttar Pradesh, India. RESULTS: Mean age of the patients was 26.3 years. Risk factors were smoking (78.5%), family history of premature coronary artery disease (CAD) (46.8%), obesity (39.1%), physical inactivity (38.7%) and stressful life events (29.6%). The most common symptom and presentation was chest pain and anterior wall myocardial infarction (AWMI) in 94.8% and 58.8%, respectively. About 80.6% of patients had obstructive CAD with single vessel disease (57.6%), double-vessel disease (12.9%) and left main involvement (3.2%). Left anterior descending (LAD) was commonest culprit artery (58.1%) followed by right coronary artery in 28.2%. In-hospital mortality was 2.8%. Percutaneous coronary intervention was performed in 71.6% of patients. Median number and length of stent were 1.18 and 28 ± 16 mm, respectively. CONCLUSION: AMI in very young adult occurred most commonly in male. Smoking was the most common risk factor. AWMI owing to LAD artery involvement was the most common presentation. Mean time of presentation after symptom onset was 16.9 hours. In contrast to western population, it is characterised by earlier onset, delayed presentation, more severity, diffuse disease, and more morbidity but with favourable in-hospital mortality.

Efficacy and Safety of Thrombolytic Therapy in Acute Submassive Pulmonary Embolism: Follow-Up Study.

BACKGROUND: Thrombolysis in acute submassive pulmonary embolism (PE) remains controversial. So we studied impact of thrombolytic therapy in acute submassive PE in terms of mortality, hemodynamic status, improvement in right ventricular function, and safety in terms of major and minor bleeding. METHOD: A single-center, prospective, randomized study of 86 patients was conducted at LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, India. Patients received thrombolysis (single bolus of tenecteplase) with unfractionated heparin (UFH, group I) or placebo with UFH (group II). RESULT: Mean age of patients was 54.35 ± 12.8 years with male dominance (M:F = 70%:30%). Smoking was the most common risk factor seen in 29% of all patients, followed by recent history of immobilization (25%), history of surgery or major trauma within past 1 month (15%), dyslipidemia (10%) and diabetes mellitus (10%). Dyspnea was the most common symptom in 80% of all patients, followed by chest pain in 55% and syncope in 6%. Primary efficacy outcome occurred significantly better in group I vs. group II (4.5% vs. 20%; P = 0.04), and significant difference was also found in hemodynamic decompensation (4.5% vs. 20%; P = 0.04), the fall in mean pulmonary artery systolic pressure (PASP) (28.8% vs. 22.5%; P = 0.03), improvement in right ventricular (RV) function (70% vs. 40%; P = 0.001) and mean hospital stay (8.1 ± 2.5 vs. 11.1 ± 2.14 days; P = 0.001). There was no difference in mortality and major bleeding as safety outcome but increased minor bleeding occurred in group I patients (16% vs. 12%; P = 0.04). CONCLUSION: Patients with acute submassive PE do not derive overall mortality benefit, recurrent PE and rehospitalization with thrombolytic therapy but had improved clinical outcome in form of decrease in hemodynamic decompensation, mean hospital stay, PASP and improvement of RV function with similar risk of major bleed but at cost of increased minor bleeding.

Patent Ductus Arteriosus With Eisenmenger Syndrome: Difficult Diagnosis Made Easily With Saline Contrast Echocardiography.

The diagnosis of patent ductus arteriosus (PDA) with Eisenmenger syndrome is difficult. We report a case of 35-year-old male who came to our outpatient department (OPD) for evaluation of repeated hemoptysis and dyspnea on exertion. He had already completed two courses of ATT. On examination, grade 3 ejection systolic murmur was audible over precordium. Transthoracic echocardiography (TTE) showed enlargement of right atrium (RA) and right ventricular (RV) with severe tricuspid regurgitation (TR). On agitated saline contrast injection, agitated saline was seen in pulmonary artery followed by filling of abdominal aorta without filling of ascending aorta, thus confirming the diagnosis of right to left shunt with PDA.

Prevalence of Metabolic Syndrome and Its Clinical and Angiographic Profile in Patients With Naive Acute Coronary Syndrome in North Indian Population.

BACKGROUND: Data of isolated metabolic syndrome as risk factor in patients presenting with acute coronary syndrome (ACS) especially in context to Indian subcontinent are sparse. Therefore, we studied the prevalence of metabolic syndrome (MetS), and its clinical and angiographic profile in naive ACS patients in North Indian population. METHODS: A single-center, prospective, observational study of 324 patients was conducted at LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, India with newly diagnosed ACS patients with MetS, as per modified NCEP-ATP III criteria. They were divided into two groups with and without MetS, and their clinical and angiographic profiles were studied. RESULTS: Prevalence of MetS in our study was 37.65%. Patients with MetS were significantly older than without MetS (60.3 ± 8.4 vs. 57.6 ± 7.9), and had females preponderance (35.24% vs. 24.25%), less tobacco abuse (30.32% vs. 42.57%), more non-ST-segment elevation ACS (58.19% vs. 36.14%), less ST-segment elevation myocardial infarction (STEMI) (41.80% vs. 63.86%), more cardiogenic shock (27.04% vs. 17.32%), recurrent ischemia (14.75% vs. 7.42%) and on angiogram, lesser single vessel disease (21.13% vs. 53.96%), more double vessel disease (39.34 vs. 24.26%), triple vessel disease (19.67% vs. 10.39%), left main (13.11% vs. 4.45%) and complex coronary lesions (tubular 40.98% vs. 31.68%; diffuse 26.23% vs. 18.32%). However, there was a trend of lower but insignificant mortality with MetS (5.44% vs. 6.55%). CONCLUSION: There was high prevalence of MetS among patients with ACS in North Indian population with more advanced coronary artery disease. To the best of our knowledge, this is the first study from North India documenting clinical and angiographic profile of patients with MetS and ACS.

Prognostic Importance of Exercise Brain Natriuretic Peptide in Asymptomatic Chronic Organic Severe Mitral Regurgitation: An Observational Study.

BACKGROUND: The optimal timing of surgery in patients with chronic organic severe mitral regurgitation (MR) continues to be debated, especially for those who are asymptomatic. The aim of the study was to determine independent and additive prognostic value of exercise brain natriuretic peptide (eBNP) in patients with severe asymptomatic MR and normal left ventricular ejection fraction (LVEF). METHODS: Two hundred twenty-three consecutive patients with severe MR defined by effective regurgitant orifice (ERO) area ≥ 40 mm2 and/or residual volume ≥ 60 mL, LVEF > 60%, and normal LV end-systolic diameter < 40 mm underwent symptom limited exercise treadmill test (TMT). Echocardiography was done immediately after exercise. Data were obtained within 3 minutes of peak exercise. BNP levels were assessed before echo (after 30 minutes of supine rest) and at exercise (i.e., within the 3 minutes of the end of effort). Patients were followed up every 3 months up to 15 months for major adverse cardiac events (MACEs) (cardiovascular death, need for mitral valve surgery and hospitalization for acute pulmonary edema or heart failure). RESULTS: Mean age was 31.2 ± 9 years (range: 18 - 40) with majority being male (n = 153; 68%). Etiologies were rheumatic (n = 201; 90%), mitral valve prolapse (n = 17; 7.6%) and hypertrophic cardiomyopathy (n = 5; 2.4%). BNP level significantly increased from rest (65.24 ± 43.92 pg/mL; median: 43.5 pg/mL) to exercise (100.24 ± 98.24 pg/mL; median: 66.5 pg/mL; P < 0.001). Patients were divided into three tertiles according to eBNP levels (T1 = 15 - 44; T2 = 45 - 104; T3 = 105 - 400). There was trend for significantly lower exercise time in T3. During TMT, 66 (29.5%) stopped exercise due to dyspnea. They had similar resting BNP level compared with others but had significantly higher eBNP level (136 ± 109.7 pg/mL vs. 84.88 ± 90.2 pg/mL; P < 0.001). During follow-up (15 months), MACE occurred in 83 patients (37.2%): mitral valve replacement (MVR) in 59 patients (symptomatic: 43; LV dilatation or dysfunction: 9; both symptoms and dilatation/dysfunction: 7), 17 hospitalizations for congestive heart failure, five patients developing acute pulmonary edema and atrial fibrillation in remaining two patients. This was 7.6%, 35% and 69% in T1, T2 and T3, respectively and had significantly higher eBNP level than without any event (165 ± 119 pg/mL vs. 57 ± 48 pg/mL; P < 0.001). Using receiver operating characteristic curve analysis, the best cut-off value of eBNP level to predict cardiac events was 90 pg/mL (sensitivity: 75%; specificity: 88.6%; positive predictive value: 79%; negative predictive value: 83.9%). CONCLUSION: In asymptomatic patients, eBNP level provides incremental prognostic value beyond echocardiographic data and those with elevated eBNP should be considered at high risk for reduced event-free survival and might be considered for early MVR.

Percutaneous Mitral Valvotomy in a Case of Situs Inversus Totalis and Juvenile Rheumatic Critical Mitral Stenosis: Case Report.

Situs inversus totalis is a rare congenital disorder where the heart being a mirror image is situated on the right side of the body. Distorted cardiac anatomy makes fluoroscopy-guided percutaneous mitral valvotomy (PMV) technically challenging and there are only few reports of PMV in situs inversus totalis. Here we report a case where PMV was successfully done for situs inversus totalis with rare coincidence of juvenile rheumatic severe mitral stenosis in a 12-year-old boy with a few modifications of standard Inoue technique. He had exertional dyspnea of NYHA class III with initial mitral valve area (MVA) of 0.6 cm(2) and severe pulmonary arterial hypertension with features suitable for PMV. Femoral vein was accessed from the left side to align the septal puncture needle and balloon to facilitate left ventricular entry. Septal descent and puncture by Brockenbrough needle was performed in the right anterior oblique view with the needle facing 5 o'clock position. Accura balloon was negotiated across mitral valve in left anterior oblique and procedure was successfully executed. Echocardiography showed a well-divided anterior commissure with an MVA of 2.0 cm(2) and mild mitral regurgitation. In summary, PMV is safe and feasible in the rare patient with situs inversus totalis with few modifications of the Inoue technique.

Epicardial Adipose Tissue Thickness and Its Association With the Presence and Severity of Coronary Artery Disease in Clinical Setting: A Cross-Sectional Observational Study.

BACKGROUND: Obesity is an important risk factor for atherosclerotic cardiovascular disease (ASCVD). Estimation of visceral adipose tissue is important and several methods are available as its surrogate. Although correlation of epicardial adipose tissue (EAT) with visceral adipose tissue as estimated by magnetic resonance imaging (MRI) and/or CT is excellent, it is costlier and cumbersome. EAT can be accurately measured by two-dimensional (2D) echocardiography. It tends to be higher in patients with acute coronary syndrome than in subjects without coronary artery disease (CAD) and in those with stable angina. It also carries advantage as index of high cardiometabolic risk as it is a direct measure of visceral fat rather than anthropometric measurements. The present study evaluated the relationship of EAT to the presence and severity of CAD in clinical setting. METHODS: In this prospective, single-center study conducted in the Department of Cardiology, LPS Institute of Cardiology, Kanpur, India, 549 consecutive patients with acute coronary syndrome or chronic stable angina were enrolled. Sensitivity, specificity, and receiver operating characteristic (ROC) curve were estimated to find cut-off value of EAT thickness for diagnosing CAD using coronary angiographic findings as gold standard. RESULTS: Patients were diagnosed as CAD group (n = 464, 60.30 ± 8.36 years) and non-CAD group (n = 85, 54.42 ± 11.93 years) after assessing coronary angiograms. The EAT was measured at end-systole from the PLAX views of three cardiac cycles on the free wall of the right ventricle. Lesion was significant if > 50% in left main and > 70% in other coronary arteries. The mean EAT thickness in CAD group was 5.10 ± 1.06 and in non-CAD group was 4.36 ± 1.01 which was significant (P = 0.003). Significant correlation was demonstrated between EAT thickness and presence of CAD (P < 0.003). Higher EAT was associated with severe CAD and presence of multivessel disease. By ROC analysis, EAT > 4.65 mm predicated the presence of significant coronary stenosis by 71.6% sensitivity and 73.1% specificity. CONCLUSION: EAT thickness measured using transthoracic echocardiography (TTE) significantly correlates with the presence and severity of CAD. It is sensitive, easily available, and cost-effective and assists in the risk stratification and may be an additional marker on classical risk factors for CAD.

Bi-Luminal Mitral Valve: Incidence, Clinical Features, Associated Anomaly and Echocardiographic Evaluation.

OBJECTIVE: The aim of the study was to know the incidence, clinical features, associated anomaly and echocardiographic evaluation of bi-luminal mitral valve (also known as double orifice mitral valve or DOMV) in patients with suspected mitral valve disease, continous murmur or left-to-right shunt. METHODS: Twenty-eight patients with DOMV were diagnosed by transthoracic echocardiography (TTE) in a retrospective review of 52,256 echocardiographic studies in 45,898 patients performed between 2000 and 2015. RESULTS: The mean age was 20.1 years (15 - 34 years) with female preponderance (M/F: 1:1.8). Dyspnea and diastolic murmur were the most common symptoms found in 19 (67.8%) and 19 (67.8%) of patients, respectively. Normal sinus rhythm was the most common electrocardiographic finding. Twenty-five (89%) patients had complete bridge, while three (11%) had incomplete bridge type of DOMV. Twenty-one (75%) had severe mitral stenosis (MS) including severe tricuspid regurgitation (n = 13, 61%), ventricular septal defect (VSD, n = 3, 14%), complete endocardial cushion defect (ECD, n = 3, 14%), and mild to moderate mitral regurgitation (MR) (n = 2, 11%), moderate MS and moderate MR were found in four (16%) patients among complete bridge type of DOMV, while all patients with incomplete bridge type had severe MS and patent ductus arteriosus (PDA) as associated lesions. Overall, 24 (85%) had severe and four (15%) had moderate MS. CONCLUSIONS: DOMV as a cause of symptomatic mitral valve disease was seen in young and middle-aged patients with estimated incidence of 0.06%. Dyspnea and diastolic murmur were the most common symptoms. Mostly, it was an isolated anomaly but in majority, associated with VSD, complete ECD and PDA. TTE examination is a reliable and sufficient means of diagnosing DOMV and determining its type.

Unusual Survival of Anomalous Left Coronary Artery From the Pulmonary Artery With Severe Rheumatic Mitral Stenosis in Septuagenarian Women: Foes Becoming Friends?

ALCAPA syndrome (anomalous origin of the left coronary artery from the pulmonary artery) is a rare disease but lethal with clinical expression from myocardial infarction, congestive heart failure to death during early infancy and unusual survival to adulthood. We report a 73-year-old woman with ALCAPA who presented with exertional dyspnea (NYHA functional class II) over past 2 years. Physical examination revealed soft S, long mid diastolic rumbling murmur and apical pan-systolic murmur. Electrocardiography displayed biatrial enlargement and poor R progression and normal sinus rhythm. Echocardiography established calcified severe mitral stenosis (MS), presence of continuous flow entering the pulmonary trunk, turbulent continuous flow in inter-ventricular septum with left to right shunt in contrast echocardiography and normal systolic function. Coronary angiogram showed absence of left coronary artery (LCA) originating from aorta, dilated and tortuous right coronary artery (RCA) and abundant Rentrop grade 3 intercoronary collateral communicating with LCA originating from pulmonary trunk which was also confirmed on coronary CT angiogram thus establishing diagnosis of ALCAPA. It is exceedingly rare to be associated with severe MS. However, such a long survival in our patient can be explained by the severe pulmonary arterial hypertension which may be contributing to lesser coronary steal.

Fragmented QRS as a Marker of Electrical Dyssynchrony to Predict Inter-Ventricular Conduction Defect by Subsequent Echocardiographic Assessment in Symptomatic Patients of Non-Ischemic Dilated Cardiomyopathy.

BACKGROUND: Left ventricular (LV) dyssynchrony frequently occurs in patients with heart failure (HF). QRS ≥ 120 ms is a surrogate marker of electrical dyssynchrony, which occurs in only 30% of HF patients. In contrary, in those with normal QRS (nQRS) duration, LV dyssynchrony has been reported in 20-50%. This study was carried out to investigate the role of fragmented QRS (fQRS) on the surface electrocardiography (ECG) as a marker of electrical dyssynchrony to predict the presence of significant intraventricular dyssynchrony (IVD) by subsequent echocardiographic assessment. METHODS: A total of 226 consecutive patients with non-ischemic cardiomyopathy were assessed for fQRS on surface ECG as defined by presence of an additional R wave (R prime), notching in nadir of the S wave, notching of R wave, or the presence of more than one R prime (fragmentation) in two contiguous leads corresponding to a major myocardial segment. Tissue Doppler imaging (TDI) was performed in the apical views (four-chamber, two-chamber and long-axis) to analyze all 12 segments at both basal and middle levels. Time-to-peak myocardial sustained systolic (Ts) velocities were calculated. Significant systolic IVD was defined as Ts-SD > 32.6 ms as known as "Yu index". RESULT: Of the total patients, 112 had fQRS (49.5%), while 114 had nQRS (50.5%) with male dominance (M/F = 71:29). Majority of patients were in NYHA class II (n = 122, 54%) followed by class III (n = 83; 37%), and class IV (n = 21; 9%). There were no significant differences among both groups for baseline parameters except higher QRS duration (102.42 ± 14.05 vs. 91.10 ± 13.75 ms; P = 0.001), higher Yu index (35.64 ± 12.79 vs. 20.45 ± 11.17; P = 0.01) and number of patients with positive Yu index (78.6% vs. 21.1%; P = 0.04) in group with fQRS compared with group with nQRS. fQRS complexes had 84.61% sensitivity and 80.32% specificity with positive predictive value of 78.6% and negative predictive value of 85.9% to detect IVD. On detailed segmental analysis for fQRS distribution, inferior segment had maximum (37%), followed by anterior (23%), lateral (19%), inferior and lateral (11%), anterior and inferior (8%), and anterior and lateral (2%). Among 104 patients with significant dyssynchrony, 88 patients (84.6%) had fQRS in the dyssynchronic segment. CONCLUSION: Fragmentation of QRS complex is an important predictor of electro-mechanical dyssynchrony. It is also helpful in localizing the dyssynchronous segment. In future, larger studies may be carried out to investigate the role of fQRS as a predictor of response to cardiac resynchronization therapy (CRT) in this subgroup of HF patients with narrow QRS.