AngioNet: a convolutional neural network for vessel segmentation in X-ray angiography.

Coronary Artery Disease (CAD) is commonly diagnosed using X-ray angiography, in which images are taken as radio-opaque dye is flushed through the coronary vessels to visualize the severity of vessel narrowing, or stenosis. Cardiologists typically use visual estimation to approximate the percent diameter reduction of the stenosis, and this directs therapies like stent placement. A fully automatic method to segment the vessels would eliminate potential subjectivity and provide a quantitative and systematic measurement of diameter reduction. Here, we have designed a convolutional neural network, AngioNet, for vessel segmentation in X-ray angiography images. The main innovation in this network is the introduction of an Angiographic Processing Network (APN) which significantly improves segmentation performance on multiple network backbones, with the best performance using Deeplabv3+ (Dice score 0.864, pixel accuracy 0.983, sensitivity 0.918, specificity 0.987). The purpose of the APN is to create an end-to-end pipeline for image pre-processing and segmentation, learning the best possible pre-processing filters to improve segmentation. We have also demonstrated the interchangeability of our network in measuring vessel diameter with Quantitative Coronary Angiography. Our results indicate that AngioNet is a powerful tool for automatic angiographic vessel segmentation that could facilitate systematic anatomical assessment of coronary stenosis in the clinical workflow.

Comparison of Reperfusion Strategies for ST-Segment-Elevation Myocardial Infarction: A Multivariate Network Meta-analysis.

Background We systematically reviewed trials comparing different reperfusion strategies for ST-segment-elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST-segment-elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as "facilitated PCI" when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a "pharmacoinvasive approach" when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61-0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59-1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment-elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment-elevation myocardial infarction, is not available.

Cardiological Society of India: Document on acute MI care during COVID-19.

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

Therapeutic experience of ticagrelor in Indian patients with acute coronary syndrome: A non-interventional, prospective, and observational study.

OBJECTIVE: This observational study was designed to understand the usage pattern of ticagrelor in real-life clinical practice among a large number of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or medical management (MM). The study also recorded clinical events, i.e., bleeding, dyspnea, and cardiovascular (CV) events, reported by the investigator during the follow-up period. METHODS: The ACS patients aged ≥18 years hospitalized for ACS and were prescribed ticagrelor upon discharge or ≤1 month and patients who underwent PCI, CABG, or MM for ACS were enrolled. The subjects were followed up for a period of up to 12 months. The data were collected on a case report form. RESULT: The study recruited 2997 subjects from 49 sites in India. Approximately half of the ACS subjects had ST segment elevation myocardial infarction (48.9%), and PCI was used as management in 92.4% subjects. The mean (±SD) duration of use of ticagrelor was 314 (±110.2) days over a period of 12 months. Of 136 subjects (4.5%) who experienced any clinical events, CV deaths were reported in 20 (0.7%), myocardial infraction in 19 (0.6) subjects and ischemic stroke in 23 (0.8%) subjects, and severe dyspnea was reported in 68 (2.2%) subjects. Out of 33 bleeding cases, 25 (0.8%) subjects had thrombolysis in myocardial infarction (TIMI) minimal, seven (0.2%) had TIMI minor, and one TIMI major. Platelet inhibition and patient outcomes (PLATO) major was reported in two subjects and CABG bleed in one subject. The incidence of PLATO defined major and minimal bleeding were lower in subjects undergoing fibrinolysis than overall population. CONCLUSION: Ticagrelor has been used across ACS types and in different management strategies in real world settings in India. The incidence of clinical events was lower as compared with data in literature. ClinicalTrials.gov Identifier: NCT02408224.

2013 consensus statement for early reperfusion and pharmaco-invasive approach in patients presenting with chest pain diagnosed as STEMI (ST elevation myocardial infarction) in an Indian setting.

UNLABELLED: In India, the prevalence of ST elevation myocardial infarction (STEMI) is rising exponentially leading to cardiovascular morbidity and mortality. Despite advancement in reperfusion therapy (pharmacologic and interventional), the overall utilization, system of care and timely reperfusion remains suboptimal. JUSTIFICATION AND PURPOSE: Alarming treatment delays exist in patients presenting with chest pain observed in real-world and published evidences. Time to diagnose STEMI and initiation of reperfusion therapy at various first medical contacts in India is variable mandating immediate attention. We intend to provide evidence based explicit recommendations for practicing clinicians about time-dependent early management and the concept of pharmaco-invasive (PI) approach, contextualized to the situation in India. PROCESS: Pre-prepared guidance document by expert steering committee was discussed and commented by over 150 experts representing from 16 states in India at regional level. The moderators of these meetings arrived at a consensus on the evaluation and management of STEMI patients by PI approach to improve clinical outcomes. RECOMMENDATIONS: In addition to patient awareness and education for early symptom identification, education is required for general practitioners and physicians/intensivists to implement early time dependent STEMI management. Percutaneous Coronary Intervention (PCI) is the gold standard, yet it remains inaccessible to majority of patients, hence early reperfusion by initial use of fibrinolytics is recommended followed by coronary intervention. Fibrinolytics are easily available, economical and evaluated in several clinical studies and hence we recommend a PI approach (early fibrinolysis followed by PCI 3-24 hours later). We recommend a time guided 'Protocol/Plan of Action' for early fibrinolysis and implementing a PI approach at the level of general practitioners, non-PCI hospitals/nursing homes with intensive care facility and in PCI capable centers. For STEMI patients with symptom duration < 6 hours, we suggest administration of fibrinolytics either tenecteplase (Grade1A), reteplase (Grade1B), alteplase (Grade1C) or streptokinase (Grade 2B) alongside contemporary adjunctive medical therapy for PI approach. The aim of this Consensus Statement is * To provide explicit recommendations for practicing clinicians about the early management of STEMI and concept of pharmaco-invasive approach * To provide recommendations based on the best available evidences, contextualized to the situation in India. It must be recognized that even when randomized clinical trials have been undertaken, treatment options may be limited by resources. The Cardiocare STEMI experts realize that the recommended diagnostic examinations and treatment options may not be available or affordable in all parts of India. Cost-effectiveness is becoming an increasingly important issue when deciding upon therapeutic strategies. As always with guidelines/consensus statement, they are not prescriptive. Clinical scenario and patients vary so much from one another that individual care is paramount, and there is still an important place for clinical judgment, experience, and common sense. The mandate of the Cardiocare STEMI expert consensus is to recommend evidence-based standards of care, related targets and strategies for implementation of standards in the management of STEMI. CONTEXT AND USE: This document should be taken as consensus recommendations by qualified experts, not as rigid rules. It comprises of published evidence and may not cover every eventuality; new evidence is published every day. Furthermore, this should not be used as a legal resource, as the general nature cannot provide individualized guidance for all patients under all clinical circumstances.

Repeated fracture of pacemaker leads with migration into the pulmonary circulation and temporary pacemaker wire insertion via the azygous vein.

Repeated implantation of pacemaker in the same patient is a common occurrence because of the increased longevity of patients. However, repeated lead fracture in the same patient and migration of the pacemaker lead into the pulmonary circulation is rare. We describe a 56-year-old gentleman who had undergone pacemaker implantations thrice due to repeated lead fractures (thrice) and also had migration of the pacemaker lead into the pulmonary circulation. He also had an azygous vein which was noticed while placing the temporary pacemaker wire.

Outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis.

OBJECTIVE: Carotid endarterectomy is superior to medical therapy in patients with significant extracranial carotid artery stenosis. This modality of treatment has its own complications. The principal objective of this study is to assess efficacy, feasibility and outcomes of carotid artery stenting in both symptomatic and asymptomatic carotid artery stenosis. METHODS: Our study is a retrospective analysis of 45 consecutive patients with 56 lesions who underwent carotid angioplasty with stenting from January 2000 to June 2007 for carotid artery stenosis of more than 70%. All patients underwent detailed neurological examination and carotid Doppler evaluation by using Sonos 5500. Computed tomography of brain was done in those patients who were symptomatic in the past. RESULTS: The mean age of the study population was 65 +/- 9.2 years. There were 34 (79%) patients with coronary artery disease and out of them 31 (68%) patients had undergone coronary artery bypass grafting. All patients with common carotid artery, 13 (81%) patients with right internal carotid stenosis and 12 (66%) patients with left internal carotid artery stenosis had ostioproximal stenosis. Contralateral lesion was found in 9 patients and 2 patients had total occlusion. There were no post-procedural neurological events. Only one patient died in our study population due to non-cerebral cause. CONCLUSION: Carotid artery stenting is a safe procedure. The 30 days' outcomes are similar in both symptomatic and asymptomatic patients with significant carotid artery stenosis.

High intensity exercise training programme following cardiac transplant.

A 26-year-old male patient who presented with symptoms of end stage cardiac failure as a result of dilated cardiomyopathy, had an orthotopic cardiac transplantation. A comprehensive cardiac rehabilitation programme was provided to him and he was introduced to a sport (tennis). The exercise training programme progressed from low intensity training to high intensity programme over a period of 15 months. A cardio-pulmonary exercise test done 22 months after surgery suggested that he was able to achieve the aerobic capacity comparable to that of a normal South Indian subject. He participated successfully in the World Transplant Games in Sydney and returned safely. This suggests that after a proper cardiac rehabilitation programme, patients undergoing heart transplantation can achieve normal physiological responses to lead a normal active life.

Elective stenting in superior vena cava syndrome caused by idiopathic fibrosing mediastinitis: use of self-expandable wallstent.

We present a case of superior vena cava obstruction caused by idiopathic fibrosing mediastinitis treated with a self-expandable Wallstent. A Gortex jump graft had been used previously, which was totally occluded. This procedure relieved symptoms and alleviated the need for re-operation.

Prospective evaluation of the risk of bacteremia induced by transesophageal echocardiography.

BACKGROUND: The incidence of bacteremia induced by transesophageal echocardiography is controversial in the Indian population. This study aimed to find out the occurrence of bacteremia following transesophageal echocardiography. METHODS AND RESULTS: Between February 2000 and January 2001, 47 patients (26 males and 21 females) were enrolled for the study. Their ages ranged from 13 to 61 years (mean: 35 +/- 11.4 years). Patients with prosthetic valves, suspected infective endocarditis and those on antibiotics were excluded. For each procedure, two sets of blood cultures were obtained immediately before and after the procedure. For each blood culture, 10 ml of blood was evenly inoculated into brain-heart infusion broth and biphasic infusion medium and incubated for 7 days. Transesophageal echocardiography was carried out under oropharyngeal anesthesia (xylocaine gel and spray). Two blood cultures taken before the procedure were positive and excluded from the final analysis. Of the remaining 45 patients whose preprocedure blood cultures were sterile, 6 samples (13.3%) were positive after the procedure diphtheroids in 3, micrococci in 2 and aerobic spore formers in 1. CONCLUSIONS: This study demonstrates that the incidence of bacteremia related to transesophageal echocardiography is not insignificant, as reported in previous studies. Though routine antibiotic prophylaxis before transesophageal echocardiography is not advocated, it should be recommended in high-risk patients such as those with prosthetic valves, multivalvular involvement or those with a past history of infective endocarditis.

Iliac artery stenosis causing post-renal transplant hypertension: successful management by percutaneous angioplasty and stent implantation.

Atherosclerotic occlusion of the native iliac arteries and/or transplant renal artery is a major cause of post-transplant hypertension. Iliac artery stenosis mimics renovascular hypertension and may cause renal dysfunction in transplant recipients. We report a case of a 61-year-old renal transplant recipient with native bilateral iliac artery stenoses and coronary artery disease. He presented with severe hypertension and was managed successfully with angioplasty and stenting of native iliac arteries.

Transcatheter closure of post-myocardial infarction ventricular septal defect with Amplatzer septal occluder.

Rupture of the interventricular septum is an uncommon but often fatal complication of acute myocardial infarction. Transcatheter closure is an established method of treating selected congenital defects but clinical experience on transcatheter closure of postinfarction ventricular septal defects (VSDs) is minimal. We report a case of successful transcatheter closure of postinfarction VSD using the Amplatzer septal occluder.

Successful thrombolysis of prosthetic mitral valve thrombosis in early pregnancy.

Prosthetic valve thrombosis occurring during pregnancy is a life-threatening complication. Surgical treatment requires clot removal or valve replacement under cardiopulmonary bypass, and carries a high mortality. We report successful thrombolytic therapy with streptokinase for prosthetic valve thrombosis in a pregnant, 28-year-old woman. The patient, who had undergone mitral valve replacement (St. Jude Medical prosthesis) two years previously for restenosis after closed mitral valvotomy, was successfully thrombolyzed during the first trimester (6-8 weeks) for prosthetic valve thrombosis, and without any complication. The patient delivered a normal healthy child at nine months' gestation. Although thrombolysis in pregnancy has been reported previously, this is the first case in which it was performed during the first trimester for prosthetic valve thrombosis.

Sclerosing mediastinitis caused by Aspergillus terreus.

A case of Aspergillus terreus causing sclerosing mediastinitis which presented with symptoms of cardiorespiratory compromise and compressive myelopathy is described. The diagnosis was established by culturing and isolating the fungus in pure culture from the tissue and was also confirmed by demonstration of sepcific precipitating antibodies against Aspergillus terreus in patient's serum.

Peripheral vascular disease in Behcet's syndrome.

We describe a patient with Behcet's syndrome who had peripheral vascular disease involving the left subclavian artery for which angioplasty with stent placement was performed and reangioplasty done for in-stent restenosis. She presented with recurrence one year after stent placement; angiography revealed diffuse disease of the axillary and radial arteries with mild to moderate restenosis at the site of stent placement.