COVID-Inflicted Coagulopathy: Expert Consensus on Management with Novel Oral Anticoagulants in India.

Coronavirus disease 2019 (COVID-19) is a highly hypercoagulable viral infection complicated as COVID-inflicted coagulopathy (CIC), that is associated with increased risk of morbidity and mortality. International guidelines recommend low molecular weight heparin (LMWH) to treat CIC in both in-hospital and in-home settings. However, in India, using subcutaneous LMWH may not be a feasible option for a vast majority of patients under home management. Additionally, while some evidence advocates the use of novel oral anticoagulants (NOACs), in hospitalized settings, most guidelines find no role of NOACs in hospital settings. On the other hand, the resource crunch faced in recent COVID-19 pandemic in India forced physicians to treat many patients in home settings. These patients had been usually prescribed NOACs for ease of administration and adherence. Therefore, there is a need to form a consensus on the use of NOACs to manage CIC in India.

Heart rate recovery as a predictor of mortality with or without revascularization.

Increased heart rate during graded exercise is related to increased sympathetic activity and withdrawal of vagal tone. Return of heart rate towards baseline immediately after exercise is usually due to resurgence of vagal tone. As it is an established fact that cardiovascular morbidity and mortality in part has direct relation with parasympathetic dysfunction, it is natural that reduced heart rate recovery (HRR) after exercise, a parameter of parasympathetic dysfunction, could be a predictor of morbidity and mortality. Accordingly 390 TMT positive patients were analysed for HRR as per standard guidelines and followed up for 5 years. While 244(62.6%) showed a normal HRR, 146(37.4%) showed an abnormal HRR. Abnormal HRR was more common in the elderly, in patients with higher resting heart rate, hypertension, diabetes mellitus, current smoking and prior established coronary artery disease (CAD). There were a total of 36 deaths (9.23%) during the 5 year follow-up period. There was mortality advantage in patients who were subjected to revascularization procedure in general (7.5% deaths in revascularised arm vs 10.4% in conservative arm). Analysis reveals persistence of such benefit in patients having normal HRR (2.85% deaths in revascularised arm vs 7.25% in conservative arm). However, mortality benefit was not observed among both groups of patients with abnormal HRR(16.6% deaths in revascularised vs 15.2% in conservatively managed7rpar;. Secondary end points like recurrent angina, arrhythmia, acute myocardial infarction, hospitalization for cardiovascular cause and heart failure were observed in significantly more number of cases with abnormal HRR in comparison to normal. We therefore conclude the abnormal HRR after TMT is an adverse prognostic indicator in patients with symptomatic CAD on long term follow-up.

Study on the diagnostic accuracy of left atrial enlargement by resting electrocardiography and its echocardiographic correlation.

M-mode echocardiography has been accepted as gold standard for measuring left atrial (LA) size. Electrocardiography (ECG) offers a simple, non-invasive, cost-effective and reproducible method to assess LA size and it is mostly in agreement with echocardiography though discrepancies exist. ECGs and echocardiograms were obtained in 100 consecutive patients suspected of having left atrial enlargement due to different underlying heart diseases. The diagnostic accuracy of six ECG criteria of LA enlargement were evaluated comparing with LA size in M-mode echo study. Various criteria were found to be poor to mildly sensitive (8% to 78%) but highly specific (85% to 100%) for left atrial enlargement. Morris Index (PTFV1) was found to be the best criterion having 76% sensitivity and 92% specificity. Combination of criteria enhances the sensitivity at the cost of specificity. Overall predictive index of electrocardiogram for left atrial enlargement is not encouraging.

Percutaneous transatrial mitral commissurotomy by modified technique using a JOMIVA balloon catheter: a cost-effective alternative to the Inoue balloon.

BACKGROUND AND AIM OF THE STUDY: Percutaneous transatrial mitral commissurotomy (PTMC) is an established non-surgical treatment of rheumatic mitral stenosis. The study aim was to assess the safety and efficacy of PTMC using the Joseph mitral valvuloplasty (JOMIVA) balloon catheter, with a modified technique. METHODS: PTMC was performed in 252 patients (88 males, 164 females; mean age 39.2 +/- 13.8 years; range: 10-76 years) with symptomatic mitral stenosis. Among patients, 52 (20.6%), 182 (72.2%) and 18 (7.2%) were in NYHA classes II, III and IV, respectively. Atrial fibrillation was present in 52 patients (20.6%), and mild mitral regurgitation (MR) in 26 (10.3%); 92 patients (36.5%) had a mitral valve echo score > 8. Patients were followed up with detailed clinical and echocardiography studies at three-month intervals during the first year, and at six-month intervals thereafter. RESULTS: The procedure was technically successful in 247 patients (98%), and an optimal result was achieved in 228 (90.5%), with mean mitral valve area increased from 0.81 +/- 0.32 to 1.92 +/- 0.39 cm2 (p < 0.001). NYHA class was improved in most patients. Seven patients (2.8%) had cardiac tamponade during the procedure; one of these (0.4%) died from left ventricular tear. MR appeared (n = 10) or worsened (n = 20) in 30 patients (11.9%), among whom three (1.2%) developed severe MR. Each JOMIVA balloon catheter was used 10 to 20 times without being damaged. In total, 220 patients were followed up for between six and 54 months (mean 30 months). At follow up, 140 (63.6%) and 67 (30.5%) patients were in NYHA classes I and II, respectively. Seventeen patients (7.7%) developed mitral restenosis. CONCLUSION: PTMC using the JOMIVA balloon catheter is a cost-effective and safe alternative to the Inoue balloon when treating symptomatic severe mitral stenosis. The hemodynamic benefits were sustained long term in a majority of patients. In particular, cost is important factor in a less wealthy country such as India.