Guiding Principles for the Clinical Use and Selection of Microcatheters in Complex Coronary Interventions.

The use of microcatheters as a coronary interventional tool for a therapeutic approach to complex coronary interventions like bifurcation lesions, ostial location, tortuous anatomy, angled takeoffs, coronary calcification, and chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is growing among cardiologists across the country. During the treatment of such complex lesions, microcatheters play an essential part of the tool kit with both single-lumen and double-lumen microcatheters (DLMs) having their specific niche areas. The selection of microcatheters involves a detailed understanding of the microcatheter specification, lesion anatomy, lesion location, vessel tortuosity and trajectory, and crossing techniques. The selection of appropriate crossing techniques with different microcatheters increases success rates of PCI, reduces procedural time and contrast use, and lowers the radiation. However, the use of microcatheters and their technicalities have not yet fully realized by many operators and their true scope has not been fully explored. This article discusses and summarizes the thoughts and key opinions of experts in this field.

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial.

BACKGROUND: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). OBJECTIVES: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. METHODS: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks. RESULTS: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). CONCLUSIONS: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).

Effect of a 6-month intervention with cooking oils containing a high concentration of monounsaturated fatty acids (olive and canola oils) compared with control oil in male Asian Indians with nonalcoholic fatty liver disease.

OBJECTIVE: We investigated the effects of dietary intervention with canola or olive oil in comparison with commonly used refined oil in Asian Indians with nonalcoholic fatty liver disease (NAFLD). SUBJECTS AND METHODS: This was a 6-month intervention study including 93 males with NAFLD, matched for age and body mass index (BMI). Subjects were randomized into three groups to receive olive oil (n=30), canola oil (n=33), and commonly used soyabean/safflower oil (control; n=30) as cooking medium (not exceeding 20 g/day) along with counseling for therapeutic lifestyle changes. The BMI, fasting blood glucose (FBG) and insulin levels, lipids, homeostasis model of assessment for insulin resistance (HOMA-IR), HOMA denoting ß-cell function (HOMA-ßCF), and disposition index (DI) were measured at pre- and post-intervention. Data were analyzed with one-way analysis of variance (ANOVA) and Tukey's Honestly Significant Difference multiple comparison test procedures. RESULTS: Olive oil intervention led to a significant decrease in weight and BMI (ANOVA, P=0.01) compared with the control oil group. In a comparison of olive and canola oil, a significant decrease in fasting insulin level, HOMA-IR, HOMA-ßCF, and DI (P<0.001) was observed in the olive oil group. Pre- and post-intervention analysis revealed a significant increase in high-density lipoprotein level (P=0.004) in the olive oil group and a significant decrease in FBG (P=0.03) and triglyceride (P=0.02) levels in the canola oil group. The pre- and post-intervention difference in liver span was significant only in the olive (1.14 ± 2 cm; P<0.05) and canola (0.66 ± 0.33 cm; P<0.05) oil groups. In the olive and canola oil groups, post-intervention grading of fatty liver was reduced significantly (grade I, from 73.3% to 23.3% and from 60.5% to 20%, respectively [P<0.01]; grade II, from 20% to 10% and from 33.4% to 3.3%, respectively [P<0.01]; and grade III, from 6.7% to none and from 6.1% to none, respectively). In contrast, in the control oil group no significant change was observed. CONCLUSIONS: Results suggest significant improvements in grading of fatty liver, liver span, measures of insulin resistance, and lipids with use of canola and olive oil compared with control oils in Asian Indians with NAFLD.

Consensus physical activity guidelines for Asian Indians.

India is currently undergoing rapid economic, demographic, and lifestyle transformations. A key feature of the latter transformation has been inappropriate and inadequate diets and decreases in physical activity. Data from various parts of India have shown a steady increase in the prevalence of lifestyle-related diseases such as type 2 diabetes mellitus (T2DM), the metabolic syndrome, hypertension, coronary heart disease (CHD), etc., frequently in association with overweight or obesity. Comparative data show that Asian Indians are more sedentary than white Caucasians. In this review, the Consensus Group considered the available physical activity guidelines from international and Indian studies and formulated India-specific guidelines. A total of 60 min of physical activity is recommended every day for healthy Asian Indians in view of the high predisposition to develop T2DM and CHD. This should include at least 30 min of moderate-intensity aerobic activity, 15 min of work-related activity, and 15 min of muscle-strengthening exercises. For children, moderate-intensity physical activity for 60 min daily should be in the form of sport and physical activity. This consensus statement also includes physical activity guidelines for pregnant women, the elderly, and those suffering from obesity, T2DM, CHD, etc. Proper application of guidelines is likely to have a significant impact on the prevalence and management of obesity, the metabolic syndrome, T2DM, and CHD in Asian Indians.

Microcoil embolization in post-traumatic high-flow priapism.

An 18-year-old male developed post-traumatic priapism subsequent to a fall causing blunt perineal trauma. Color Doppler ultrasound showed a high-flow arterio-venous fistula with feeders from branches of the left internal iliac artery. Selective arteriography of the left internal pudendal artery demonstrated an arterio-venous fistula. A curved-tip 2.3 French microcatheter (Terumo Medical Corporation, Tokyo, Japan) was advanced proximal to the fistula over a 0.014″ flexible guidewire. The fistula was then embolized with 2 platinum 18-2-2 Hilal Embolization Microcoils (Cook, Bloomington, Indiana). Improvement was noted, with closure of the fistula at check angiography and significant detumescence on table. This was later confirmed on repeat color Doppler imaging. At follow-up 6 and 12 weeks later, he had normal erectile function. Transarterial embolization appears to be a safe and effective treatment for managing patients with high-flow priapism.

"Transcollateral" renal angioplasty for a completely occluded renal artery.

Percutaneous transluminal renal angioplasty with stenting has been effective in the control of hypertension, renal function, and pulmonary edema caused by atherosclerotic renal artery stenosis. However, the role of the procedure has not been fully established in the context of chronic total occlusion of renal artery. We report the successful use of this procedure in 57-year-old male patient who reported for evaluation of a recent episode of accelerated hypertension. A renal angiogram in this patient showed ostial stenosis of the right renal artery, which was filling by way of the collateral artery. Renal angioplasty for chronic total occlusion of right renal artery was successfully performed in a retrograde fashion through a collateral artery, thereby leading to improvement of renal function and blood pressure control.

Abdominal sonography in the medical evaluation of aviation aspirants.

BACKGROUND: Ultrasonography is increasingly used in elderly individuals for screening of occult malignancy and abdominal aortic aneurysm. Its utility as a screening tool in healthy asymptomatic individuals is not yet established. The current study was undertaken to evaluate the utility of abdominal and pelvic ultrasonographic screening as an adjunct to routine physical examination among young adults undergoing initial medical examination for aviation duties. METHODS: Abdominal ultrasound findings of 2598 candidates (2339 men, 259 women, mean age 20.3 +/- 1.8 yr) reporting for initial aircrew medical examination between January 2004 and December 2006 at two established medical evaluation centers were analyzed. RESULTS: Of the candidates, 90% (N=2339) screened were for cockpit aircrew duties. Sonographic abnormalities were noted in 6.0% of candidates. These included fatty infiltration of the liver in 2.9%, renal abnormalities in 1.57%, gallstones in 0.34%, and splenomegaly in 0.30%. Of the 259 female candidates, 7 were noted to have pelvic abnormalities which included ovarian cyst in 5, and uterine agenesis and fibroid uterus in 1 each. Of the aircrew who had abnormal findings on the initial ultrasonography, 71% required further testing. Based on the ultrasound findings 10 candidates were declared permanently unfit, 39 candidates were declared temporarily unfit, and the remaining were found fit for aviation duties. DISCUSSION: Abdominal sonographic screening in young healthy asymptomatic aircrew may be a valuable extension of the initial medical evaluation. It is particularly important in the high-risk subgroup of military aviators for determining long-term career prospects.

Thrombosuction for procedural acute thrombosis during high-risk carotid angioplasty--a case report.

Carotid endarterectomy in the presence of an occluded contralateral artery is associated with a high risk of perioperative stroke. Carotid stenting with neuroprotection devices has emerged as a safe procedure for revascularization in this circumstance. We performed high-risk carotid angioplasty in a patient with a history of recurrent transient ischemic attacks and 90% stenosis of left internal carotid artery with other occluded cerebral vessels. The final follow-up angiogram revealed thrombotic obstruction of the stent without any evidence of vasospasm, stent deformation or dissection. Direct thrombosuction was performed with the guiding sheath. Multiple suction passes yielded complete restoration of vascular patency and intracranial flows. A control angiogram performed 10 days later revealed no residual stenosis or thrombus. Thrombosuction using a guiding sheath leads to rapid revascularization in a patient with acute carotid stent thrombosis.

N-terminal pro-BNP plasma levels before and after percutaneous transvenous mitral commissurotomy for mitral stenosis.

In this study, we investigated the change in N-terminal pro-brain natriuretic peptide (NT-pro-BNP) plasma levels among 44 consecutive patients with mitral stenosis, 10 min before and 24 h after undergoing percutaneous transvenous mitral commissurotomy (PTMC). The procedure was successful in all patients and a significant decline was noted in NT-pro-BNP levels. Reduction of NT-pro-BNP was more marked in patients in sinus rhythm as compared to those with atrial fibrillation. In conclusion, serial measurement of plasma NT-pro-BNP levels might be a useful noninvasive method for documenting the success of PTMC among patients in sinus rhythm.

Screening coronary angiography prior to surgery in rheumatic valvular heart disease: a study of 2,188 patients.

BACKGROUND AND AIM OF THE STUDY: The role of screening coronary angiography in Asian Indian patients with rheumatic heart disease (RHD) due to undergo valve replacement surgery is unclear. Hence, the study aim was to determine the prevalence of coronary artery disease (CAD), and to monitor its correlation with demographic variables and valvular lesion type, in this patient group. METHODS: A retrospective analysis of 2,188 consecutive patients (1,319 men, 869 women; mean age 48 +/- 7 years) with rheumatic valvular heart disease was conducted. The patients underwent preoperative coronary angiography in a tertiary care hospital between 1991 and 2004. RESULTS: The overall prevalence of CAD was 11% (12% in men, 8% in women). The prevalence of CAD in the age groups of 40-44, 45-49, 50-54, 55-59 and > 60 years was 4%, 5%, 9%, 15% and 20% in men, and 2%, 2%, 3%, 7% and 10% in women, respectively. Both, age and male gender were independently associated with the occurrence of CAD (p < 0.01). The unadjusted odds ratio of having CAD was highest in patients with aortic stenosis (2.08; p < 0.01), and lowest in those with aortic regurgitation (AR) (0.58; p = 0.018). Those patients with AR also showed an independent inverse association with the occurrence of CAD (p = 0.006). CONCLUSION: The overall prevalence of CAD among Asian Indian patients with RHD was lower than that in patients from western countries. The cut-off age to perform coronary angiographic screening should be maintained at 40 years for men, and 55 years for women. The prevalence of CAD may be lower in those patients with AR.

Impact of obesity on the left ventricular functions and morphology of healthy Asian Indians.

BACKGROUND: The aim of this study was to determine the impact of obesity on alteration of left ventricular (LV) functions and morphology in nondiabetic, nonhypertensive, and normo-lipidemic obese Asian Indians. A total of 239 consecutive Asian Indians (175 males and 64 females, ages 17-64 years) were divided into obese and nonobese groups based on body mass index (BMI), waist-to-hip circumference ratio (W-HR), and percentage of body fat (%BF). METHODS: Anthropometry (BMI, W-HR), %BF, and two-dimensional echocardiography including tissue Doppler imaging (TDI) were performed for all the subjects. The unpaired t-test was applied after matching age and gender in all the comparison groups. Nonobese subjects acted as controls for the obese subjects (cases). RESULTS: Obese subjects had a larger LV end-diastolic diameter (P < 0.001), LV end-systolic diameter (P < 0.001), and LV mass (P < 0.001) as compared to the nonobese subjects. Subclinical systolic dysfunction was apparent in obese subjects only on TDI in the form of reduced systolic mitral annular velocity (P = 0.009). Diastolic dysfunction, as suggested by a lower ratio of early to late transmitral ventricular filling velocity (E/A), lower early to late (Em/Am) diastolic mitral annular velocity, and a higher E/Em ratio (P < 0.001, p = 0.001 and P < 0.001, respectively), was noted in the obese cohort. In addition, the left atrial diameter (P < 0.001) was also increased in obese subjects. Alteration of LV morphology and function correlated with the anthropometric variables BMI, W-HR, and %BF. CONCLUSIONS: Asian Indians with uncomplicated obesity (without associated co-morbidities) had significant morphological and functional cardiac dysfunction (systolic and diastolic), which correlated with anthropometric variables.