Pacing mode survival in patients with single chamber atrial pacemaker for sinus node dysfunction.

BACKGROUND: Single chamber atrial pacemaker should be sufficient for patients with sinus node dysfunction (SND) with normal atrioventricular (AV) conduction. However, most patients undergo dual chamber pacemaker implantation because of concern of new onset AV block. The annual incidence of new AV block has been reported from 0.6 to 4.4 % in various studies. OBJECTIVES: Our aim is to assess mode survival in sinus node dysfunction with normal AV conduction patients implanted with AAIR. METHODS: Patients who underwent single chamber atrial pacemaker implantation for SND with normal AV conduction between January 2014 and December 2021 were followed up for pacemaker device change, new onset AV block, bundle branch block, atrial fibrillation (AF), lead complications, reoperation and mortality rate. RESULTS: A total of 113 patients underwent single chamber atrial pacemaker implantation for SND during the study period. Mean age was 55.6 ± 12.7 years. During a mean follow up of 48.7 ± 24.9 months, none of the patients required pacemaker device change to VVIR/DDDR. Nine patients underwent reoperation, 5 for lead dislodgment, 1 for high threshold, 1 for pocket site erosion and 3 for pulse generator change. None developed AV block or AF with slow ventricular rate. Only 4 patients developed AF (3 paroxysmal,1 permanent). There were 3 deaths during follow up and none were sudden deaths. CONCLUSION: Single chamber atrial pacing is an acceptable mode of pacing in patients with SND in developing countries. Development of AV conduction abnormalities is rare in this relatively younger population.

Novel markers of COVID-19 mortality-A comparative study with patients of acute coronary syndrome.

Background: COVID-19 can cause severe pneumonia that can progress to multiple organ failure. It is believed that dysregulation of inflammation and cytokine storm, contributes to severe COVID-19. As inflammatory mediators play an important role in the pathogenesis of the severe disease, inflammatory markers like fever, leucocytosis, and C-reactive protein are known to predict severe disease. Various other biomarkers have been known to have prognostic value in patients with COVID-19 infection. Inflammation, both local and systemic plays an important role in the pathogenesis of acute coronary syndrome (ACS). Thus in this study, we aimed to compare and describe the various biomarkers, and mortality between patients admitted with COVID-19 infection and ACS patients without COVID-19 infection. Methods: In a retrospective observational case-control study, a total of 108 patients admitted to our hospital during the month of May 2021 with COVID-19 were enrolled. Patients of the acute coronary syndrome (tested negative for COVID-19 infection) admitted during the same month were enrolled (including both the intensive care unit and ward) as controls. Results: The median age of patients with COVID was significantly lower than that of patients with acute coronary syndrome [49 years (IQR, 36-62 years) and 60 years (IQR, 52-66 years)]. Left ventricular ejection fraction was significantly higher among patients with COVID infection (58.5 ± 6.3% versus 36.9 ± 9.3%). The total leukocyte count was significantly higher among patients with COVID-19 compared to those with acute coronary syndrome [13200 per microliter (8625-17500) vs 9800 per microliter (8150-12150), P < 0.001]. The blood urea level was significantly higher among patients with COVID infection [52.5 (IQR, 34.7-81.5) versus 20 (IQR, 16-31)]. Levels of C-reactive protein were significantly higher among patients with COVID [39 (IQR, 7.7-100) versus 2 (1.4-3.5)]. The mortality of patients hospitalized with COVID was 4 times higher than those with acute coronary syndrome [25.9% (28) versus 6.1% (6)]. Survivors of COVID-19 had higher hemoglobin levels than those who did not [12.5 g/dLvs 11.5 g/dL, P = 0.03]. Conclusions: Elevated total leukocyte counts reflect underlying secondary bacterial infection among patients with COVID-19 and help initiate appropriate antibiotics. Depletion of intravascular volume reflected by an increased urea/creatinine ratio increases the risk of mortality and warrants aggressive measures of rehydration and albumin infusion.

Comparison of electrocardiographic parameters between left bundle optimized cardiac resynchronization therapy (LOT-CRT) and left bundle branch pacing-cardiac resynchronization therapy (LBBP-CRT).

BACKGROUND: In patients undergoing cardiac resynchronization therapy using left bundle branch area pacing (LBBP-CRT), the addition of a coronary sinus lead, that is, Left bundle optimized CRT (LOT-CRT) might confer additional benefits. OBJECTIVES: To compare the electrocardiographic characteristics between LBBP-CRT and LOT-CRT MATERIALS AND METHODS: Patients with non-ischemic cardiomyopathy (NICMP) and left bundle branch block (LBBB) with left ventricular ejection fraction <35% who underwent implantation of an atrial lead, a left bundle lead, and a coronary sinus lead were included in this prospective study. Digital 12-lead electrocardiograms were recorded in three pacing modes-AAI, DDD with pacing from the LBB lead (LBBP-CRT), and DDD with pacing from both left bundle and coronary sinus leads (LOT-CRT). QRS duration (QRSd), QRS area, QT interval, and T peak-T end (TpTe) intervals were compared. RESULTS: Among 24 patients, QRSd reduced from 167 ± 21.2 ms to 134.5 ± 23.6 ms with LBBP-CRT (p < .001) and 129.5 ± 18.6 ms with LOT-CRT (p < .001) without a significant difference between LBBP-CRT and LOT-CRT (p = .15). Patients with QRS duration with LBBP-CRT > 131 ms showed a significant reduction in QRSd with LOT-CRT (p = .03). QT interval was reduced with both modes of CRT. LOT-CRT was associated with a greater reduction in QRS area (p = .001), TpTe interval (p = .03), and TpTe/QT ratio (p = .013) compared to LBBP-CRT. CONCLUSIONS: In patients with NICMP and LBBB, there was no significant difference in QRSd with LOT-CRT compared to LBBP-CRT. However, in patients with QRSd > 131 ms after LBBP-CRT, LOT-CRT resulted in a significantly narrower QRS.

Early dose of Adenosine, postRadiofrequency abLation of accessory pathwaY in determining acute procedural success (EARLY study).

INTRODUCTION: Post ablation of the accessory pathway (AP), the patient is observed in the catheterization laboratory for a variable period for resumption of pathway conduction. Aim of the study was to determine whether the administration of intravenous adenosine at 10 min after ablation of AP would have the same diagnostic accuracy as waiting for 30 min in predicting the resumption of AP conduction. METHODS: This was a prospective interventional study conducted in two centers. Post ablation of the AP, intravenous adenosine was administered at 10 min to look for dormant pathway conduction. The response was recorded as positive (presence of pathway conduction), negative (absence), or indeterminate (not able to demonstrate AV and VA block and inability to ascertain AP conduction). RESULTS: The study included 110 procedures performed in 109 patients. Adenosine administration at 10 min showed positive result in 3 cases (2.7%), negative result in 99 cases (90%) and indeterminate result in 8 cases (7.3%). Reconnection of accessory pathway at 30 min postablation was seen in 8 cases (7.3%). Of these 8 cases, 10 min adenosine administration showed positive test in 3 patients and negative test in 5 patients. Adenosine test at 10 min has a sensitivity, specificity, positive predictive value, and negative predictive value of 37.5%, 100%, 100%, and 94.9% in identifying the recurrence of accessory pathway conduction at 30 min, respectively. CONCLUSION: Absence of pathway conduction on administration of adenosine 10 min postablation does not help predict the absence of resumption of conduction thereafter.

Para-Hisian pacing: The eyes see what the mind knows.

A young male presented with pre-excited atrial fibrillation. During an electrophysiology study, preexcitation suggestive of a pathway in posteroseptal location was confirmed but no tachycardia was inducible. Para-Hisian pacing was done during sinus rhythm. Is there retrograde conduction through the accessory pathway?

A Patient With Palpitations-Exceptions Prove the Rule.

This case report describes a patient with sudden-onset, intermittent episodes of palpitations for the past year and no associated syncopal episodes or giddiness.

Restrictive physiology masked by cardiac tamponade: A rare cooccurrence in a child with lymphoblastic T-cell lymphoma.

Cardiac involvement in T-cell lymphoma is not uncommon. Pericardial effusion is the most common manifestation of cardiac involvement with restrictive cardiomyopathy (RCM) due to tumor infiltration being extremely rare. The presence of paroxysmal nocturnal dyspnea and orthopnea in a patient presenting with pericardial effusion could be related to tamponade or underlying myocardial disease. Hence, reevaluation after pericardiocentesis is warranted. We describe a 14-year-old boy with advanced T-cell lymphoma presenting with cardiac tamponade. Repeat echocardiography after pericardiocentesis revealed mediastinal mass infiltrating cardiac chambers and great vessels along with features of RCM secondary to tumor infiltration.

Multilobulated Sinus of Valsalva Aneurysm Dissecting into the Interventricular Septum (DAIS) and Rupturing into Left Ventricle: A Case Report.

BACKGROUND: Dissecting aneurysm of sinus of Valsalva (SOV) into the interventricular septum is a rare entity. Multilobulated form of dissection rupturing into the left ventricle (LV) has never been reported in the literature. CASE SUMMARY: A 52-year-old male presented with dyspnoea and palpitation with wide pulse pressure and peripheral signs of distal run-off and a continuous murmur along the left parasternal area. Echocardiography revealed dilated right coronary cusp (RCC), which burrowed into the interventricular septum (IVS), forming multi-loculated cystic lesion which ruptured into LV with associated restrictive ventricular septal defect (VSD) and severe aortic regurgitation. Computed tomography (CT) angiography confirmed a 4.8 cm × 5.3 cm × 5.4 cm multiseptated aneurysm. The surgery involved excision of the aortic valve (AV) with the sinus, ligation of its penetrating portion at the crest of IVS, closure of VSD, and AV replacement. Postoperative echocardiography showed the complete collapse of the IVS component of the SOV aneurysm and the normally functioning mechanical AV. DISCUSSION: Dissecting aneurysm into the IVS is a rare variant of SOV aneurysm, usually arising from RCC. It is mostly congenital in origin and has wide variety of presentations like congestive heart failure, palpitations, recurrent syncope, chest pain, sudden cardiac arrest, infective endocarditis, cerebral infarction, or asymptomatic. Aortic regurgitation is present in 30-50% of cases. Conduction disturbances from first-degree block to complete heart block are common. Echocardiogram, CT angio, and magnetic resonance imaging are useful for diagnosis. Surgical repair is the only option for treatment.

Left main revascularization with optical coherence tomography in a young male with newly diagnosed homozygous familial hypercholesterolemia.

Familial hypercholesterolemia is the most common primary lipid disorder responsible for coronary artery disease. A 22-year-old male presented with history of accelerating angina and extensive xanthomatous lesions all over the body. Coronary angiography showed significant left main and left anterior descending artery disease. Optical coherence tomography (OCT) imaging revealed areas of lipid rich plaque with thin capped fibrous atheroma, and inflammatory cell infiltration. Area of maximum stenosis showed fibrous plaque with dense lipid pool. OCT in this patient clarified plaque characteristics and achieved optimal procedural results. There were only few case reports which described OCT findings in patients with familial hypercholesterolemia. .

Intravascular ultrasound-supported percutaneous angioplasty of post-kidney transplant renal artery bifurcation stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) is an uncommon complication following renal transplantation. Its usual clinical presentation includes worsening hypertension and/or renal function, without any evidence of graft rejection. Bifurcation renal artery stenosis of the transplanted renal artery is rarely encountered. METHODS: Percutaneous transluminal renal angioplasty (PTRA) with or without stenting is the procedure of choice to treat TRAS. We hereby describe a patient, who presented with impaired renal functions, four months following the renal transplantation. He underwent intravascular ultrasound-guided PTRA of the bifurcation lesion of TRAS.Results and conclusion: Superior renal artery had coronary drug-eluting stent implantation, while inferior renal artery and side branch of the superior renal artery had balloon angioplasty, alone. Post-intervention, the raised serum creatinine level decreased from 2.9 mg% to 1.7 mg%. The index case described the successful PTRA and stenting of the bifurcation lesion of TRAS, the technical results of which was optimized with the use of intravascular ultrasound.

Coumel's sign reversed: What is the mechanism?

A patient presented with documented narrow QRS tachycardia. During electrophysiological study, he has orthodromic reciprocating tachycardia with atrial activation consistent with left free wall accessory pathway. With induction of tachycardia, beats with LBBB morphology have shorter cycle length than those with narrow QRS. What is the mechanism?

Successful Endovascular Rescue Using the Brockenbrough Needle Following Inadvertent Stent-Graft Deployment in the False Lumen.

Inadvertent deployment of stent grafts into the false lumen during thoracic endovascular aortic repair (TEVAR) is rare and is associated with catastrophic consequences. We present a case of accidental stent-graft deployment from the true lumen into the false lumen during TEVAR, resulting in hemodynamic collapse and visceral malperfusion. We successfully performed a bailout using the Brockenbrough needle to create new access from the true lumen to the false lumen and implanted another overlapping stent graft.

One-year outcomes of novel BioMime Morph tapered stent in long and multiple coronary artery lesions.

OBJECTIVE: Even with the immense progress achieved in the field of percutaneous coronary interventions (PCIs), treatment of diffuse long atherosclerotic coronary artery disease continues to remain a challenge for durable outcomes. The downstream reduction in diameter along the lesion length of a coronary artery may compel the cardiologist to use either 2 overlapping stents of different diameters or a single long stent leading to stent-vessel mismatch at the edges. Recently, Meril Life Sciences Pvt. Ltd., India, has introduced a long-tapered sirolimus-eluting stent (SES) system, BioMime Morph, which conforms to the normal tapered geometry of coronary arteries along with adequate lesion coverage. In this study, we aimed to provide real world experience regarding the safety and efficacy of the BioMime Morph SES over a follow-up of one year. METHODS: This was a single center, retrospective study involving 172 participants who underwent PCI with the BioMime Morph SES. Mean length of the target lesion was 34.4±10.4 mm, and mean stent length was 53.2±8.7 mm. The most frequent revascularized vessel was the left anterior descending artery (LAD) in 97 lesions (54.4%). RESULTS: Major adverse cardiac events (MACE) (defined as a composite of target vessel myocardial infarction, target lesion revascularization, and death due to a cardiac cause) at 1, 6, and 12 months were seen in 4 (2.3%), 7 (4.0%), and 8 (4.7%) patients, respectively. Overall, 5 cardiac deaths and 2 definite stent thrombosis were observed in the study. CONCLUSION: The study suggests that the novel BioMime Morph SES is an effective and a safe option for PCI in the treatment of long diffuse atherosclerotic lesions.

Epidemiological and clinical profile, management and outcomes of young patients (≤40 years) with acute coronary syndrome: A single tertiary care center study.

OBJECTIVE: To study the epidemiological and clinical profile, angiographic patterns, reasons for the delay in presentation, management, and outcomes of the acute coronary syndrome (ACS) in young patients (≤40yrs) presenting to a tertiary care hospital in North India. METHODS: We included a total of 182 patients aged ≤40 years and presenting with ACS to the cardiology critical care unit of our department from January 2018 to July 2019. RESULTS: The mean age of the study population was 35.5 ± 4.7years. 96.2% were males. Risk factors prevalent were smoking (56%), hypertension (29.7%), family history of premature coronary artery disease (18.2%), and diabetes (15.9%). The median time to first medical contact and revascularization was 300 (10-43200) minutes and 2880 (75-68400) minutes, respectively. ST-elevation ACS (STE-ACS) accounted for 82% and Non-ST-elevation ACS (NSTE-ACS) accounted for 18% of cases. Thrombolysis was done in 51.7% of the cases. Coronary angiography was done in 91.7% and percutaneous coronary intervention (PCI) in 52.2% (95/182) of the total cases. Coronary artery bypass surgery (CABG) was done in 2 patients (1.1%). Among those who underwent coronary angiography, single-vessel disease (SVD) was seen in 53% of the cases. There were no deaths in hospital, and only one patient died during the 30 days follow up. CONCLUSIONS: STE-ACS was the most common presentation of ACS in the young population. Smoking was the most common risk factor. The majority of the patients had single-vessel disease, and there was a significant delay in first medical contact and revascularization.

Epidemiological profile, management and outcomes of patients with acute coronary syndrome: Single centre experience from a tertiary care hospital in North India.

BACKGROUND: Cardiovascular disease is the leading cause of death in India. Our aim is to study the clinical, epidemiological profile and in-hospital outcomes of patients presenting with acute coronary syndrome. METHODS: We did a prospective single center observational study of the 1203 patients presenting with ACS to a tertiary referral center in North India over a period of one year (July 2018-June 2019). RESULTS: The mean age of study population was 58.4 ± 12.5 years. STEMI and NSTE-ACS accounted for 69.9% and 31.1% respectively. 62.1% of our patients were from rural background. The median time to hospital admission was 600 min for STEMI patients, thrombolysis was performed in 52% of cases. Cardiogenic shock at presentation was noted in 18%. Coronary angiography and percutaneous coronary intervention were done in 1062 (88.3%) and 733 (60.9%) patients respectively. The overall in-hospital mortality was 7.6%. STEMI patients had higher mortality than NSTE-ACS (8.9% vs 4.5% p < 0.001). Female gender (OR-3.306 C.I. 1.87-5.845), severe MR (OR-4.65, C.I.-1.187-18.18), acute kidney injury (AKI) at admission (OR-5.15, C.I.-2.5-10.63), higher Killip class (class III/IV) (OR-3.378,C.I.-1.292-8.849), AF (OR-3.25, C.I.-1,18-8.92), complete heart block (CHB) (OR-4.44,C.I.-2.09-9.43) and right bundle branch block (RBBB) (OR-2.86, C.I.-1.2-6.8) were significant predictors of in hospital mortality. CONCLUSIONS: Our study represents the predominance of STEMI as the initial ACS presentation with a considerable delay in first medical contact and higher prevalence of cardiogenic shock (CS). STEMI patients had higher mortality. Female sex, severe MR, AKI, higher Killips class, AF, CHB, RBBB being predictors of high in-hospital mortality in ACS patients.

Submitral aneurysm of varied aetiologies: a case series.

BACKGROUND: Submitral aneurysm is a rare disease initially described in the African population. It is usually considered congenital in origin, due to a defect in the posterior portion of the mitral annulus. However, it can be seen in other diseases like ischaemic heart disease, rheumatic heart disease, infective endocarditis, tuberculosis, and syphilis. CASE PRESENTATION: Case 1 was a 29-year-old female, hypertensive undergoing maintenance haemodialysis for chronic kidney disease and on anti-tubercular therapy. She was found to have a large submitral aneurysm with severe mitral regurgitation, moderate left ventricular dysfunction, and pericardial effusion on echocardiogram. Case 2 was a 58-year-old gentleman presented with inferior wall ST-elevation myocardial infarction and was thrombolyzed with streptokinase for the same. Echocardiogram done 6 months later for evaluation of dyspnoea showed a large inferobasal aneurysm. Case 3 was a 56-year-old hypertensive presented with dyspnoea on exertion and echocardiogram showed a large posterolateral region with transmural late gadolinium enhancement. Case 4 was a 13-year-old boy presented with fever and cerebrovascular accident. Echocardiogram revealed vegetation in the mitral valve and a small submitral aneurysm with vegetation inside it. DISCUSSION: Submitral aneurysm is usually considered congenital in origin. However, it can be due to ischaemic heart disease, rheumatic heart disease, Takayasu arteritis, and tuberculosis. Top dimensional echocardiogram is the investigation of choice. Cardiac magentic resonance imaging helps in identifying the underlying aetiology and delineating the surrounding structures.

Correlation of Vitamin D Deficiency With Severity of Chronic Heart Failure as Assessed by Functional Class and N-Terminal Pro-Brain Natriuretic Peptide Levels.

Introduction Chronic heart failure (CHF) is a major cause of mortality and morbidity in spite of tremendous advances in medical therapies. Vitamin D deficiency has been increasingly recognised in heart failure and its therapeutic as well as prognostic implications are debated. This study was carried out to examine the relationship of Vitamin D levels with severity of heart failure as assessed by NYHA functional class and serum N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels in vitamin D deficient patients with CHF. Methodology and results In this cross-sectional analysis, 119 patients of symptomatic CHF presenting to the outpatient/inpatient department of cardiology in a tertiary care institute in North India were screened. Patients were categorised according to their functional class as New York Heart Association (NYHA) class II, III, IV and their serum levels of vitamin D and NT-pro-BNP were measured. Out of 119 patients, 107 (90%) were found to have low vitamin D levels which were classified as insufficient (20-30 ng/ml) (n=25, 23%) or deficient (<20 ng/ml) (n=82,77%). The mean NT-pro-BNP levels increased significantly across functional class as 3783±6132 pg/ml, 7866±4383 pg/ml, 21115±11905 pg/ml in NYHA class II, III and IV respectively (p=0.000). The respective mean serum Vitamin D3 levels of 11.6±5.8ng/ml, 12.2±7.9 ng/ml, 14.4±8.9 ng/ml were not significantly different between classes (p=0.234). We found no correlation between serum NT-pro-BNP and serum vitamin D levels in the study cohort across various NYHA classes. In multivariate regression model, after adjusting for various co-variates, vitamin D levels were not significantly associated with NT-pro-BNP or functional class in patients with CHF. Conclusion Patients with CHF have a high prevalence (90%) of vitamin D deficiency. Although NT-pro-BNP levels increase significantly, vitamin D levels do not vary significantly with worsening NYHA classes. Further, no consistent significant correlation of vitamin D deficiency with NT-pro-BNP across different NYHA classes was observed. Thus, low levels of vitamin D didn't predict the severity and prognosis of patients with heart failure. .

Prognostic role of procalcitonin in ST-elevation myocardial infarction complicated by cardiogenic shock.

OBJECTIVE: Cardiogenic shock accounts for the majority of deaths amongst patients with ST-elevation myocardial infarction. Procalcitonin is elevated in acute myocardial infarction, especially when complicated by left heart failure, cardiogenic shock, resuscitated cardiac arrest, and bacterial infections. However, the prognostic utility of procalcitonin in ST-elevation myocardial infarction complicated by cardiogenic shock has not been systematically evaluated. METHODS: We performed a retrospective registry review of 125 patients with ST-elevation myocardial infarction and cardiogenic shock over 2 years at a tertiary referral hospital to examine the prognostic value of serum procalcitonin measurement at 24 hours after the onset of infarction for in-hospital mortality. RESULTS: The mean age of the study population was 57.75 ± 11.1 years, and the median delay from onset to hospital admission was 15 hours. The in-hospital mortality was 28.8%. Receiver operating characteristic analysis revealed a strong relationship between elevated procalcitonin and in-hospital mortality (area under the curve = 0.676; p = 0.002). Although procalcitonin was found to be higher in non-survivors in univariate analysis, it was not an independent predictor of mortality in multivariate regression analysis. Acute kidney injury, left ventricular ejection fraction, and non-revascularization were independently associated with mortality after adjusting for covariates. CONCLUSION: Although procalcitonin was higher in non-survivors, static procalcitonin measurement at 24 hours after the onset of ST-elevation myocardial infarction complicated by cardiogenic shock was not an independent predictor of in-hospital mortality. Additional prospective studies are required to assess the role of serial procalcitonin monitoring in ST-elevation myocardial infarction complicated by cardiogenic shock.