Angiographic quantification of aortic regurgitation following myval octacor implantation; independent core lab adjudication.

BACKGROUND: The balloon expandable Myval transcatheter heart valve (THV) showed encouraging results regarding residual aortic regurgitation (AR) from multiple observational studies. The newly designed Myval Octacor has been introduced recently, aiming for a reduction in AR and improved performance. OBJECTIVES: The focus of this study is to report the incidence of AR using the validated quantitative Videodensitometry angiography technology (qLVOT-AR%) in the first in human use of the Myval Octacor THV system. METHODOLOGY: We report on the first in human use of the Myval Octacor THV system in 125 patients in 18 Indian centres. Independent retrospective analysis of the final aortograms following implantation of the Myval Octacor was performed using the CAAS-A-Valve software. AR is reported as a regurgitation fraction. The previously validated cutoff values have been used to identify ≥moderate AR (RF% >17%), mild (6% < RF% ≤17%), and none or trace AR (RF% ≤ 6%). RESULTS: Final aortogram was analysable for 103 patients (84.4%) among the 122 available aortograms. 64 (62%) patients, had tricuspid aortic valve (TAV), 38 (37%) with bicuspid AV (BAV), and one with unicuspid AV. The median absolute RF% was 2% [1, 6], moderate or more AR incidence was 1.9%, mild AR in 20.4%, and none or trace AR in 77.7%. The two cases with RF% >17% were in the BAV group. CONCLUSION: The initial results of Myval Octacor using quantitative angiography-derived regurgitation fraction demonstrated a favourable outcome regarding residual AR, possibly due to improved device design. Results must be confirmed in a larger randomised study, including other imaging modalities.

Clinical characteristics and 30-day outcomes in patients with acute decompensated heart failure: Results from Indian College of Cardiology National Heart Failure Registry (ICCNHFR).

BACKGROUND: Acute decompensated heart failure (ADHF) is a challenging medical emergency with high mortality and its prevalence is increasing in India. There is paucity of data on ADHF in the country. METHODS: Indian College of Cardiology National Heart Failure Registry (ICCNHFR) is an on-going observational registry on ADHF contributed by 22 hospitals across India; and we present the in-hospital and 30-day outcomes of ADHF patients enrolled from August 2018 to July 2019. Major objective included capturing demographics, comorbid conditions, aetiology, prescription patterns and assessing clinical outcomes. RESULTS: Of 5269 patients (mean age: 61.90 ± 13.85 years) enrolled in this study, males were predominant (67.09%). Mean duration of hospitalization was 5.74 ± 4.74 days. Ischemic heart disease was the most common (75.44%) aetiology. Abnormal electrocardiogram readings were found in most patients (89.86%). LVEF of ˂40% was found in 68.29% of patients. In-hospital mortality rates were 6.98%. The 30-day cumulative mortality was 12.35% and 30-day rehospitalization rate was 7.98%. At discharge, all guideline-based medical therapy (GDMT) were prescribed only to 24.99% of patients and 23.72% adhered to the prescription until 30 days. Older age, high serum creatinine levels and poor LVEF contributed to high mortality and rehospitalization. CONCLUSION: Patients with ADHF were younger and predominantly males. Usage of GDMT in ADHF patients was low (24.99%) and the in-hospital mortality was high. Older age, high serum creatinine levels, poor LVEF contributed for 30-day mortality and rehospitalization. This data on ADHF, could help in developing strategies to improve outcomes for HF patients in India.

Acute decompensated heart failure (ADHF) during COVID-19 pandemic-insights from South India.

AIM: This retrospective study compares admissions and outcomes due to acute decompensated heart failure (ADHF) during the COVID-19 pandemic from 25 March to 25 July 2020 with the historical patient control who were admitted during the same period in 2019. METHODS AND RESULTS: Data of the participating hospitals was collected and analysed from the ICC NHFR (Indian College of Cardiology National Heart Failure Registry) for 2019 and 2020. Total number of ADHF admissions, demographics, aetiology, co-morbid conditions and in-hospital mortality was compared and analysed. A significant decrease in the number of hospital admissions due to ADHF from 2019 to 2020 (1056 vs. 526 respectively) was noted. Incidence of admissions with <40% ejection fraction (EF) reduced in 2020 (72.4% and 80.2% in2020 and 2019)and >40% (EF) increased (27.6% and 19.8% in 2019 and 2020 respectively, p = 0.0005). Ischemic heart disease (IHD) was the most common aetiology (78.59% in 2019 and 80.98% in 2020, p = 0.268). The in-hospital mortality was numerically higher in 2020 (10%) than in 2019 (8%), but not statistically significant (p = 0.161). CONCLUSION: This study from the registry shows that the incidence of ADHF admissions during COVID-19 lockdown significantly reduced compared to the previous year. Demographic patterns remained similar but patients presenting with de-novo HF increased; IHD was the most common cause. The in-hospital mortality was numerically higher during the lockdown. The impact of lockdown perhaps led to fewer hospitalisations and this is to be factored in future strategies to address health care delivery during such crises.

Effectiveness of Amlodipine on Blood Pressure Control in Hypertensive Patients in India: A Real-World, Retrospective Study from Electronic Medical Records.

BACKGROUND: The effectiveness of amlodipine has been reported in clinical trials in India. However, real-world data on the effectiveness of amlodipine in India is limited. OBJECTIVE: To provide real-world evidence regarding the effectiveness of amlodipine as monotherapy or in combination with other antihypertensive drugs (AHDs) in Indian patients with essential hypertension. METHODS: Electronic medical record data of adult patients who were diagnosed with essential hypertension (≥ 140/90 mmHg) and were prescribed amlodipine as monotherapy or add-on therapy were retrospectively analyzed. Patients were classified based on the number of AHD classes prescribed on initiation of amlodipine. Change in systolic (SBP) and diastolic (DBP) blood pressure from baseline was the primary endpoint. Evaluation of proportion of patients who achieved treatment goals as per 2018 European Society of Cardiology/European Society of Hypertension guidelines was the secondary endpoint. Readings were obtained before initiating amlodipine and after at least a month of therapy with amlodipine. RESULTS: Among the 462 included patients, the majority (90.7%) were on amlodipine monotherapy or amlodipine + 1AHD. Mean (95% confidence interval [CI]) change in the amlodipine monotherapy group was: SBP (- 12.1 [- 14.9, - 9.3] mmHg) and DBP (- 7.5 [- 8.9, - 6.1] mmHg) and mean (95% CI) change in the amlodipine + 1AHD group was: SBP (- 17.8 [- 21.0, - 14.6] mmHg) and DBP (- 9.5 [- 11.0, - 8.0] mmHg) (P < 0.001 for all). SBP and DBP goals were achieved by 31.4% and 42.9% of patients on amlodipine monotherapy and by 38.9% and 51.8% of patients on amlodipine + 1AHD, respectively. Among patients aged ≤ 45 years, mean (95% CI) change in the amlodipine monotherapy group was: SBP (- 11.7 [- 16.0, - 7.4] mmHg; P < 0.001) and DBP (- 7.2 [- 9.7, - 4.7] mmHg; P < 0.001) and mean (95% CI) change in the amlodipine + 1AHD group was: SBP (- 14.6 [- 21.9, - 7.3] mmHg; P < 0.05) and DBP (- 10.6 [- 14.8, - 6.4] mmHg; P < 0.01). SBP and DBP goals were achieved by 35.4% and 33.8% of patients on amlodipine monotherapy and by 48.0% and 56.0% of patients on amlodipine + 1AHD, respectively. Among patients aged ≥ 65 years, mean (95% CI) change in the amlodipine monotherapy group was: SBP (- 13.9 [- 20.2, - 7.6] mmHg; P < 0.01) and DBP (- 8.5 [- 11.4, - 5.7] mmHg; P < 0.001) and mean (95% CI) change in the amlodipine + 1AHD group was: SBP (- 22.4 [- - 28.8, - 16.0] mmHg; P < 0.001) and DBP (- 10.8 [- 14.0, - 7.6] mmHg; P < 0.001). SBP and DBP goals were achieved by 25.5% and 13.7% of patients on amlodipine monotherapy and by 29.8% and 14.0% of patients on amlodipine + 1AHD. CONCLUSION: Amlodipine prescribed as monotherapy or add-on therapy during routine clinical practice significantly reduced BP in ≤ 45- and ≥ 65-year-old Indian patients with mild to moderate hypertension, emphasizing that amlodipine may be a good candidate for BP control in Indian patients with essential hypertension in these age groups.

Usefulness of ambulatory blood pressure measurement for hypertension management in India: the India ABPM study.

The present paper reports differences between office blood pressure (BP) measurement (OBPM) and ambulatory blood pressure measurement (ABPM) in a large multi-centre Indian all comers' population visiting primary care physicians. ABPM and OBPM data from 27,472 subjects (aged 51 ± 14 years, males 68.2%, treated 45.5%) were analysed and compared. Patients were classified based on the following hypertension thresholds: systolic BP (SBP) ≥ 140 and/or diastolic BP (DBP) ≥90 mmHg for OBPM, and SBP ≥ 130 and/or DBP ≥ 80 mmHg for 24-h ABPM, and SBP ≥ 120 and/or DBP ≥ 70 mmHg for night-time ABPM and SBP ≥ 135 and/or DBP ≥ 85 mmHg for daytime ABPM, all together. White coat hypertension (WCH) was seen in 12.0% (n = 3304), masked hypertension (MH) in 19.3% (n = 5293) and 55.5% (n = 15,246) had sustained hypertension. Isolated night-time hypertension (INH) was diagnosed in 11.9% (n = 3256). Untreated subjects had MH relatively more often than treated subjects (23.0% vs. 14.8%, p < 0.0001; respectively). Females had higher relative risk (RR) of having WCH than males (RR 1.16 [CI 95, 1.07-1.25], p < 0.0001). Whereas, males had higher RR of MH than females (RR 1.09 [CI 95, 1.02-1.17] p < 0.01). INH subjects had lower average systolic and diastolic dipping percentages (0.7 ± 6.6/ 2.2 ± 7.9 vs. 9.0 ± 7.3/11.9 ± 8.5, p < 0.001) than those without INH. In conclusion, for diagnosis of hypertension there was a contradiction between OBPM and ABPM in approximately one-third of all patients, and a substantial number of patients had INH. Using ABPM in routine hypertension management can lead to a reduction in burden and associated costs for Indian healthcare.

Aortoiliac reconstruction in the setting of in-stent restenosis.

Complex iliac artery obstructions, particularly bilateral stenosis or total iliac artery occlusions, are usually treated with aortofemoral or aortobifemoral graft surgery. However, surgical treatment is associated with 3% mortality rate and significant morbidity such as intestinal ischemia, spinal cord injury, and ureteral damage. Percutaneous interventions of aortic bifurcation offer a promising alternative to surgery with potentially lower morbidity and mortality risk. We report a case of peripheral artery disease who had underwent right transfemoral iliac angioplasty with femoropopliteal bypass presented again with bilateral lower limb ischemia, who was successfully treated with stent implantation with the kissing balloon technique.

Clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis - A single centre experience.

OBJECTIVE: Aim of the study was to evaluate clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis. BACKGROUND: Takayasu's arteritis is a chronic inflammatory vasculitis affecting the aorta and its major branches. Although it is more prevalent in Asia, the distribution of the disease is worldwide with different vascular involvement patterns and clinical manifestations. METHODS: In this prospective study a total of 50 consecutive patients who were reported as having Takayasu's arteritis between January 2010 and April 2016 were evaluated. Detailed clinical presentation and angiograms of all patients were analysed. RESULTS: 50 patients were analysed during study period. Among 50 patients, 43(86%) were female and 7 (14%) were male. Average age of presentation was 26.92years. Most common clinical presentation was claudication (74%) followed by, musculoskeletal symptoms (48%), fatigue (46%), weight loss (22%), headache (22%), visual disturbances (16%), syncope (10%), dyspnoea (20%). Most common features were absent/diminished pulses (80%), difference in blood pressure (80%), followed by bruit (70%)hypertension (64%), cerebrovascular accident (8%),heart failure (8%) and aortic regurgitation (4%). According to the new angiographic classification, angiographic type I (40%) was encountered most frequently, followed by type III (30%), type V (16%), type IIb (8%), type IIa (2%), and type IV is (4%). Angioplasty was the main stay of treatment in 66% of the patients, remaining 34% of them were treated medically either with corticosteroids or methotrexate. CONCLUSION: Takayasu's arteritis is a rare disease, affects mainly women, manifestations range from asymptomatic disease, found as a result of impalpable pulses or bruits, to catastrophic neurological impairment. Takayasu's arteritis is the common cause of renovascular hypertension. Angiography remains the gold standard for diagnosis. Angiographic evaluation and percutaneous transluminal angioplasty with stenting is useful in selected cases.

Catheter-Directed Thrombolysis Is a Safe and Alternative Therapeutic Approach in the Management of Postpartum Lower Limb Deep Venous Thrombosis.

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all four cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.

Outcome of venous stenting following catheter directed thrombolysis for acute proximal lower limb venous thrombosis: a prospective study with venous Doppler follow-up at 1-year.

Functional outcome of venous stent placement for the management of acute iliofemoral deep vein thrombosis (DVT) following catheter-directed thrombolysis (CDT), remain undefined. The purpose of this study was to assess immediate and intermediate term outcomes among patients treated with venous stenting following CDT in patients with proximal lower limb DVT. Thirty consecutive patients aged between 20-70 years with proximal lower limb DVT formed the study group. The mean duration of CDT done with streptokinase was 4.5 ± 1.3 days. Patients with residual venous obstruction and/or large clot burden were treated further with venous angioplasty and/or stenting. Primary endpoint was to evaluate the safety, efficacy and patency of venous stenting in the management of incomplete result following CDT. After 12 months, post-thrombotic syndrome (PTS) was assessed clinically using Villalta scale and deep venous patency was assessed through duplex ultrasound. We studied 8 (5 female and 3 male) patients with 9 (3 left and 6 right) limb involvement and 13 stent (4 balloon expandable and 9 self expandable) placement. All patients improved clinically immediately following venous stenting. Technical success was achieved in all patients. One patient developed pulmonary embolism during course of hospital stay. One patient had stent thrombosis and PTS and another patient died due to carcinoma breast during follow-up. Deep venous stenting is an effective mode of treatment in proximal acute lower limb DVT with high late patency rate up to 1-year.

Catheter-directed thrombolysis in management of postpartum lower limb deep venous thrombosis - A case series.

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in the management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all five cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.

Thrombolysis With Single Bolus Tenecteplase Compared With Streptokinase Infusion in the Treatment of Acute Pulmonary Embolism: A Pilot Study.

OBJECTIVE: This study was planned to compare the efficacy of bolus regimens of tenecteplase (TNK) and 24 hours infusion of streptokinase (STK) in acute pulmonary embolism (APE) in a resource-poor setting. INTERVENTIONS: In all, 25 patients received injection of TNK, and 75 patients received infusion of STK over 24 hours. RESULTS: Pulmonary artery systolic pressure and right ventricular function were improved separately and significantly (P = .01) in both the study groups of patients from baseline at 24 hours or at seventh day and was comparable among the TNK and STK groups of patients. Mean duration of stay in intensive care unit was significantly less (2.2 ± 0.8 vs 3.2 ± 1.3 days; P = .04), and bleeding risk was also found to be nonsignificantly less in the TNK group. CONCLUSION: These results suggest that a 24-hour infusion regimen of STK is as effective as bolus TNK in the treatment of patients with APE in countries with limited resources.

Endovascular management of proximal lower limb deep venous thrombosis - A prospective study with six-month follow-up.

BACKGROUND: Catheter-directed thrombolysis with assisted mechanical thrombolysis is the standard of medical care for proximal deep vein thrombosis. We studied the immediate and intermediate (six months) safety and effectiveness of catheter-directed thrombolysis in patients with proximal lower limb deep vein thrombosis. METHODOLOGY: Thirty consecutive patients aged between 20 and 70 years with proximal lower limb deep vein thrombosis formed the study group. Catheter-directed thrombolysis was done with streptokinase infuse through a catheter kept in the ipsilateral popliteal vein. Unfractionated heparin was given along with streptokinase. Mechanical thromboaspiration using guiding catheter was performed in addition to thrombolytic therapy. After six months, post-thrombotic syndrome and deep venous patency were assessed by using Villalta scale and duplex ultrasound, respectively. RESULTS: Thirty patients with proximal lower limb deep vein thrombosis were treated with catheter-directed thrombolysis. Mean age of the study patients was 41.7 ± 15 years. Mean duration of illness was 13.3 ± 12 days. The mean duration of thrombolysis was 4.5 ± 1.3 days. Grade III (complete) lysis was achieved in 10 (33%) and Grade II (50-90%) lysis in 20 (67%) of patients. Patients with significant residual lesion in Grade II lysis following catheter-directed thrombolysis underwent percutaneous transluminal angioplasty alone (12/20) or venous stenting (8/20). All patients improved clinically following catheter-directed thrombolysis or assisted catheter-directed thrombolysis. Four patients (13%) developed pulmonary embolism during course of hospital stay and among them two (6.5%) patients died. Eleven patients (37%) had minor bleeding or hematoma at local site, and seven (23%) developed anemia requiring blood transfusion and four (13%) patients had thrombocytopenia. After six months, iliofemoral patency was found in 20 (72%) and post-thrombotic syndrome was seen in six (21%) patients. Two (6.5%) patients died during follow-up due to nephrotic syndrome and carcinoma breast. CONCLUSION: Catheter-directed thrombolysis and conventional manual aspiration thrombectomy are an effective treatment for proximal lower extremity deep vein thrombosis with good short and intermediate outcome.

Catheter-Directed Thrombolysis Along with Mechanical Thromboaspiration versus Anticoagulation Alone in the Management of Lower Limb Deep Venous Thrombosis-A Comparative Study.

Catheter-directed thrombolysis (CDT) with assisted mechanical thrombolysis is now considered as the standard of medical care for deep vein thrombosis (DVT). The study was conducted to describe the immediate and long-term (6 months) safety and effectiveness of CDT in patient with lower limb DVT compared with the routine anticoagulation alone. All 12 to 85 years old patients with recent (0-8 weeks) DVT were included. In CDT group, thrombus was aspirated mechanically and streptokinase (STK) was given along with unfractionated heparin (UFH). After 6 months, deep venous patency and postthrombotic syndrome (PTS) was assessed by using duplex ultrasound and Villalta scale, respectively. Among 51 patients with completed data, 25 patients were allocated additional CDT given for a mean duration of 108 ± 32 hours and 26 patients were allocated standard treatment alone. Grade III (complete) lysis was achieved in 37% patients and grade II (50-90%) lysis in 63% of patients. Patients with partial lysis underwent percutaneous transluminal angioplasty and/or venous stenting. After 6 months, iliofemoral patency was found in 20 (80%) in the CDT group versus 7 (23%) in anticoagulation alone group (p < 0.01). PTS was seen in 5 (20%) in the CDT group versus 19 (77%) in anticoagulation alone group (p < 0.01). We conclude that CDT and conventional manual aspiration thrombectomy are an effective treatment for lower extremity DVT. STK infusion can be safely given up to 6 days. As addition of UFH can cause thrombocytopenia, so daily monitoring of complete blood counts is needed during CDT.

Absent pulmonary valve: a case with rare presentation treated with bioprosthetic valve replacement.

Congenital absence of the pulmonary valve is a rare congenital cardiac malformation, usually seen in association with tetralogy of Fallot. Patients generally present early in life with respiratory distress or recurrent respiratory tract infections, failure to thrive, cyanosis, infective endocarditis, or heart failure. Isolated absent pulmonary valve is quite rare and may be discovered in older age-group as in our patient, a nine-year-old male child who presented with atypical symptoms of exertional chest pain. Unusual echocardiographic features in this case include intact ventricular septum and prominent trabeculations of the right ventricle. Surgical implantation of a bioprosthetic valve was followed by hemodynamic and symptomatic improvement.

Recurrent myocardial infarction in a case of congenital afibrinogenemia.

Afibrinogenemia is a rare autosomal recessive bleeding disorder with an estimated prevalence of 1:1,000,000. Usual presentation of this disorder is spontaneous bleeding, bleeding after minor trauma and excessive bleeding during interventional procedures. Paradoxically, few patients with afibrinogenemia may also suffer from severe thromboembolic complications. The management of these patients is particularly challenging because they are not only at risk of thrombosis but also of bleeding. We are presenting a case of 33-year-old male patient of congenital afibrinogenemia who had two episodes myocardial infarction in a span of two years. The patient was managed conservatively with antiplatelet therapy and thrombolytic therapy was not given due to high risk for bleeding.

Acute pulmonary embolism being the first presentation of undetected HIV infection: report of two cases.

Though HIV infection is considered as a hypercoagulable state, but occurrence of acute pulmonary embolism (PE) is rare and usually seen in the advanced stage of the disease. PE as a presentation in a case where there is no previous history of having HIV infection is very rare; a Medline search revealed only one case reported previously. We describe two cases who presented with acute PE and were treated; they were subsequently diagnosed as having HIV infection.