Under-utilization of pacemaker therapy for sinus node dysfunction - Real world data from South Asia.

OBJECTIVE: Chronic symptomatic sinus node dysfunction (SND), the most common bradyarrhythmia, can be effectively managed by permanent cardiac pacing. Yet the care pathway and barriers to adoption of pacing therapy are not well understood - particularly in low volume implanting countries. The IMPROVE Brady study is a quality improvement initiative being conducted at centers in South Asia, Latin America, and Russia. We assessed the rates of SND diagnosis and pacemaker treatment for SND in the South Asia cohort. METHODS: The prospective study enrolled patients with heart rate of ≤50 beats per minute presenting with symptoms including syncope, dizziness, and/or dyspnea from ten centers in India and Bangladesh. Patients were followed to identify the proportion diagnosed with SND and subsequently treated with pacemaker therapy. RESULTS: A total of 508 patients meeting criteria were enrolled and followed on average for 8.3±8.0months. Patients were on average 58 years of age, 77% were male, and 91% had completed at least primary education. An SND diagnosis was made in 368 (72%) of patients, with the majority (80%) of diagnoses occurring within 1 month of enrollment. Of the patients with an SND diagnosis, 63 (17%) were treated with a pacemaker. Reasons for not receiving treatment were: subject refusal or deferred decision (45%), unaffordability (34%), physician determined - not-indicated (20%), and other (1%). Older age, female gender, history of hypertension, lower resting heart rate, and syncopal or pre-syncopal symptoms were associated with a higher probability of implant. CONCLUSIONS: In a care pathway assessment for the diagnosis and treatment of symptomatic SND in South Asia only 1 in 6 patients received pacemaker indicated therapy, largely due to patient refusal and physician decision. Phase II of the study will be aimed to improve this treatment rate.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry.

AIM: A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes. METHODS: A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed. RESULTS: The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance - 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF. Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively. Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%. CONCLUSIONS: In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

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.

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.

Rapid onset of pulmonary arteriovenous malformations after cavopulmonary anastomosis.

The reported incidence of pulmonary arteriovenous malformations after superior cavopulmonary anastamosis in patients with heterotaxia syndrome is 18%-21%. The manifestation is usually in young children and the onset is gradual. We report an unusual case of pulmonary arteriovenous malformations developing within 72 hours of bilateral superior cavopulmonary anastamosis (Kawashima procedure) in an adolescent with heterotaxia syndrome.

Pre-operative short-term pulmonary rehabilitation for patients of chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery.

The role of pre-operative short-term pulmonary rehabilitation in patients with chronic obstructive pulmonary disease who undergo coronary artery bypass graft surgery has been assessed for the first time prospectively. Forty-five patients posted for coronary artery bypass graft surgery were randomised to receive either short-term pulmonary rehabilitation (group I) or no such programme (group II). Patients of both the groups were evenly matched with respect to age, sex, body surface area, duration and severity of chronic obstructive pulmonary disease and coronary artery disease. Normal individuals who evenly matched with the study group were assessed for normal respiratory function parameters. Pre-operative and post-operative peak expiratory flow rate, inspiratory capacity, post-operative ventilation time, post-operative pulmonary complication and hospital stay were determined in both the groups. Peak expiratory flow rate (220.0 +/- 12.9 and 324.3 +/- 84.3 in group I, 218.0 +/- 16.4 and 260.5 +/- 35.2 in group II) and inspiratory capacity (844.0 +/- 147.4 and 1100.0 +/- 158.1 in group I, 830.0 +/- 117.4 and 1090 +/- 137 in group II) were significantly lower before and after surgery respectively in both groups compared to normal values. Even though both groups showed a significant rise in post-operative peak expiratory flow rate and inspiratory capacity after surgery, the post-operative peak expiratory flow rate and inspiratory capacity in group I was significantly higher than in group II. In group I, the post-operative ventilation time (24.5 +/- 6.00 hours), post-operative complications (n = 4) and hospital stay (12.4 +/- 3.6 days) were significantly lower than in group II (35.2 +/- 22.3 hours, n = 11, 18.8 +/- 6.6 days respectively). These data suggest that short-term pulmonary rehabilitation is feasible and effective in improving pulmonary functions before and after surgery and in reducing surgical morbidity and cost of medical care significantly.