Factors associated with mortality among moderate and severe patients with COVID-19 in India: a secondary analysis of a randomised controlled trial.

OBJECTIVE: Large data on the clinical characteristics and outcome of COVID-19 in the Indian population are scarce. We analysed the factors associated with mortality in a cohort of moderately and severely ill patients with COVID-19 enrolled in a randomised trial on convalescent plasma. DESIGN: Secondary analysis of data from a Phase II, Open Label, Randomized Controlled Trial to Assess the Safety and Efficacy of Convalescent Plasma to Limit COVID-19 Associated Complications in Moderate Disease. SETTING: 39 public and private hospitals across India during the study period from 22 April to 14 July 2020. PARTICIPANTS: Of the 464 patients recruited, two were lost to follow-up, nine withdrew consent and two patients did not receive the intervention after randomisation. The cohort of 451 participants with known outcome at 28 days was analysed. PRIMARY OUTCOME MEASURE: Factors associated with all-cause mortality at 28 days after enrolment. RESULTS: The mean (SD) age was 51±12.4 years; 76.7% were males. Admission Sequential Organ Failure Assessment score was 2.4±1.1. Non-invasive ventilation, invasive ventilation and vasopressor therapy were required in 98.9%, 8.4% and 4.0%, respectively. The 28-day mortality was 14.4%. Median time from symptom onset to hospital admission was similar in survivors (4 days; IQR 3-7) and non-survivors (4 days; IQR 3-6). Patients with two or more comorbidities had 2.25 (95% CI 1.18 to 4.29, p=0.014) times risk of death. When compared with survivors, admission interleukin-6 levels were higher (p<0.001) in non-survivors and increased further on day 3. On multivariable Fine and Gray model, severity of illness (subdistribution HR 1.22, 95% CI 1.11 to 1.35, p<0.001), PaO2/FiO2 ratio <100 (3.47, 1.64-7.37, p=0.001), neutrophil lymphocyte ratio >10 (9.97, 3.65-27.13, p<0.001), D-dimer >1.0 mg/L (2.50, 1.14-5.48, p=0.022), ferritin ≥500 ng/mL (2.67, 1.44-4.96, p=0.002) and lactate dehydrogenase ≥450 IU/L (2.96, 1.60-5.45, p=0.001) were significantly associated with death. CONCLUSION: In this cohort of moderately and severely ill patients with COVID-19, severity of illness, underlying comorbidities and elevated levels of inflammatory markers were significantly associated with death. TRIAL REGISTRATION NUMBER: CTRI/2020/04/024775.

Study of immediate and late effects of successful PTMC on left atrial appendage function in patients with severe rheumatic mitral stenosis IN SINUS rhythm.

INTRODUCTION: Since its introduction in 1984, Percutaneous Transvenous Mitral Commissurotomy (PTMC) has become established as a safe and effective treatment for rheumatic Mitral Stenosis (MS).( Ben Farhat et al., 1998) 1 Chronic pressure and volume overload imposed by MS causes left atrial (LA) and Left Atrial Appendage (LAA) dysfunction. Risk of cerebrovascular accident (CVA) is increased approximately 17-fold in patients of MS in Atrial Fibrillation (AF) and is present even in patients of MS in sinus rhythm (SR). This study was undertaken to evaluate the effect of PTMC on LAA function by Trans-esophageal echocardiography (TEE) Doppler and Doppler Tissue Imaging (DTI). METHODS: Total 70 cases were enrolled in this study. Patients with symptomatic severe MS (Mitral Valve Area <1.5cm2), in SR, who underwent a successful PTMC during the period from May 2016 to May 2019 were selected. All the patients underwent Clinical examination, ECG, detailed TTE and TEE before, immediately after (within 24 h) & after 6 months of PTMC. RESULTS: There was non significant improvement in Left Atrial appendage fractional area change {LAAAC (%)} immediately Post PTMC but there was significant improvement at 6 months Post PTMC. There was significant increase in LAA PW Doppler velocities (LAAEDE, LAALDE and LAAF velocity) immediately Post PTMC which got further improved significantly at 6 months of follow up. There was significant increase in LAA DTI velocities (ELAA, ALAA and SLAA velocity) immediately Post PTMC which got further improved significantly at 6 months of follow up. CONCLUSION: PTMC improves left atrial appendage function in patients with mitral stenosis.