Balloon mitral valvuloplasty in low gradient severe rheumatic mitral stenosis: Immediate and short-term outcomes.

Background: Efficacy of balloon mitral valvuloplasty (BMV) in low gradient severe rheumatic mitral stenosis (MS) is not very well defined. This study was undertaken to evaluate the outcomes of BMV in low gradient severe rheumatic MS. Methods: Severe MS was defined as mitral valve area < 1.5 cm2. Low gradient was defined as mean diastolic trans-mitral gradient (MG) < 10 mmHg and low flow as stroke volume index < 35 ml/m2 on echocardiography. Sixty patients were divided into normal-flow/low-gradient (NFLG) (40) and low-flow/low-gradient (LFLG) (20) groups. Post-BMV parameters were recorded after 72 h and at the end of one year. Results: Mean age was 36.2 ± 6.6 years in NFLG group and 40.6 ± 2.6 years in LFLG group (p < 0.01) and females were 75 % (n = 30) in NFLG group as compared to 60 % (n = 12) in LFLG group. Patients in the LFLG group had higher Wilkins score (p < 0.02) and prevalence of atrial fibrillation (n = 8, 40 %) as compared to NFLG group (n = 7, 17.5 %; p < 0.01). A greater decrease in MG was observed in NFLG group (p < 0.01), whereas increase in MVA was comparable in both the groups (p > 0.05). Ninety percent (n = 36) patients improved in NFLG group in comparison to 70 % (n = 14) in LFLG group (p < 0.01). At the end of one-year, symptomatic improvement persisted in all patients who became asymptomatic post-BMV. Conclusion: Symptomatic improvement following BMV was better seen in NFLG group because of greater decrease in MG in comparison to LFLG group. Results of BMV were suboptimal in LFLG group because of higher sub-valvular obstruction, increased age and higher prevalence of AF.

Lipid Association of India 2023 update on cardiovascular risk assessment and lipid management in Indian patients: Consensus statement IV.

OBJECTIVE: In 2016, the Lipid Association of India (LAI) developed a cardiovascular risk assessment algorithm and defined low-density lipoprotein cholesterol (LDL-C) goals for prevention of atherosclerotic cardiovascular disease (ASCVD) in Indians. The recent refinements in the role of various risk factors and subclinical atherosclerosis in prediction of ASCVD risk necessitated updating the risk algorithm and treatment goals. METHODS: The LAI core committee held twenty-one meetings and webinars from June 2022 to July 2023 with experts across India and critically reviewed the latest evidence regarding the strategies for ASCVD risk prediction and the benefits and modalities for intensive lipid lowering. Based on the expert consensus and extensive review of published data, consensus statement IV was commissioned. RESULTS: The young age of onset and a more aggressive nature of ASCVD in Indians necessitates emphasis on lifetime ASCVD risk instead of the conventional 10-year risk. It also demands early institution of aggressive preventive measures to protect the young population prior to development of ASCVD events. Wide availability and low cost of statins in India enable implementation of effective LDL-C lowering therapy in individuals at high risk of ASCVD. Subjects with any evidence of subclinical atherosclerosis are likely to benefit the most from early aggressive interventions. CONCLUSIONS: This document presents the updated risk stratification and treatment algorithm and describes the rationale for each modification. The intent of these updated recommendations is to modernize management of dyslipidemia in Indian patients with the goal of reducing the epidemic of ASCVD among Indians in Asia and worldwide.

Efficacy of nicorandil and ranolazine in prevention of contrast-induced nephropathy in patients with mild-to-moderate renal dysfunction: a randomized controlled trial.

INTRODUCTION: Contrast-induced nephropathy (CIN) is a common complication after percutaneous coronary intervention (PCI). There is conflicting evidence regarding efficacy of nicorandil in CIN prevention. With respect to ranolazine, there is physiological possibility as well as data in animal study regarding its protective effect against CIN; there is, however, no human data till date. AIM AND OBJECTIVES: To assess the efficacy of nicorandil and ranolazine in preventing CIN. The secondary endpoint was to measure difference in postprocedure acute kidney injury (AKI) incidence across groups. Also, patients were followed up till 6 months for major adverse events. MATERIAL AND METHODS: This single-center randomized controlled study included 315 patients of coronary artery disease with mild-to-moderate renal dysfunction undergoing elective PCI. Eligible patients were assigned to either nicorandil (n = 105), ranolazine (n = 105) or control group (n = 105) in 1 : 1 : 1 ratio by block randomization. All enrolled patients were given intravenous sodium chloride at rate of 1.0 mL/kg/h (0.5 mL/kg/h for patients with left ventricular ejection fraction <45%) from 6 h before procedure till 12 h after procedure. Iso-osmolar contrast agent (iodixanol) was used for all patients. In addition to hydration, patients in nicorandil group received oral nicorandil (10 mg, 3 times/d) and those in ranolazine group received oral ranolazine (1000 mg, 2 times/d) 1 day before procedure and for 2 days after PCI. Patients in control group received only hydration. RESULTS: Total number of CIN was 34 (10.7%), which included 19 (18.1%) in control, 8 (7.6%) in nicorandil and 7 (6.6%) in ranolazine group. There was significant association of CIN reduction across groups ( P  = 0.012). On pairwise comparison also, there was significant benefit across control and ranolazine as well as control and nicorandil ( P  < 0.025). There was numerically higher incidence of AKI in controls; the difference, however, did not reach statistical significance after applying Bonferroni correction ( P  = 0.044). Over 6-month follow-up, adverse events were similar across groups. CONCLUSION: While this study adds to existing literature that supports role for nicorandil in CIN prevention, the efficacy of ranolazine in protecting against CIN has been demonstrated in humans for the first time.

Time-efficient etching of LR-115 SSNTD film for indoor radon, thoron quantification.

LR-115 Solid State Nuclear Track Detector (SSNTD) is commonly utilized for quantifying indoor radon-thoron levels, by tallying the tracks formed in the films by exposure to these gases. Conventionally, sodium hydroxide (NaOH) is used to etch LR-115 films for 90 min at 60°C. However, this study suggests a time-efficient alternative approach utilizing potassium hydroxide (KOH) as the etchant. In an initial investigation, the bulk etch rates of KOH were examined at different normalities and temperatures, revealing that KOH exhibited nearly double the bulk etch rates compared to NaOH. Subsequently, a specially designed controlled experiment was conducted to assess the efficacy of the technique by enumerating the tracks generated in the films. Both etchants demonstrated very similar track counts for identical controlled exposures, indicating the reliability of the method. A consistent behavior was observed in the real-case scenario of LR-115 films exposed indoors to alpha particles from radon and its decay products. In both experiments, the etching with KOH for 45 min gave track densities comparable to standard NaOH etching for 90 min, highlighting the time efficiency of this method. Investigations were carried out into track shape and size features, aspects crucial to the measurement technique, using microscopic imaging of samples treated with both etchants. Strikingly similar track shapes and sizes were observed, affirming the consistency in the track measurement technique. Collectively, these findings suggest that KOH etchant reduces the etching time, presenting itself as a time-efficient method for quantifying radon and thoron track density.

Effect of prasugrel versus ticagrelor on coronary microcirculation in patients undergoing pharmacoinvasive strategy - acute and short-term results.

INTRODUCTION: Both ticagrelor and prasugrel are class I recommendations for treatment of ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) [ 1 ]. But clinical outcomes with the two drugs are conflicting which might be due to differential effects on coronary microcirculation. No study to date had compared the effects of prasugrel or ticagrelor on coronary microcirculation in patients undergoing pharmacoinvasive PCI (pPCI). AIM AND OBJECTIVE: To compare the effects of prasugrel and ticagrelor on coronary microcirculation in STEMI patients undergoing pPCI as assessed by Myocardial Blush Grade (MBG). The secondary aim was to assess flow in the infarct-related artery by corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC) and whether a differential effect if detected on coronary microcirculation translated in improvement in left ventricular ejection fraction assessed at 6 months. MATERIAL AND METHODS: A total of 240 patients with STEMI were evaluated in this open-label randomized control trial who initially underwent thrombolysis and later PCI (from 24 to 48 h) post-successful thrombolysis. The study subjects were randomized to receive either ticagrelor ( n  = 120) or prasugrel ( n  = 120) in 1 : 1 ratio 2 h prior to elective PCI. Patients underwent PCI according to standard protocol and post-procedure cTFC and MBG were compared. Patients were also followed up for 6 months to compare ejection fractions in both groups. We also assessed the effect of the two drugs on bleeding complications during hospitalization and over 6-month follow-up period. RESULTS: There were no significant differences between the two groups with respect to baseline characteristics. Prasugrel administration resulted in higher MBG Grade 3 (50.86% vs 33.89%, P  = 0.012) and lower cTFC (17.14 ±â€…4.08 vs 19.3 ±â€…4.06, P  < 0.01). Improvement in ejection fraction was significantly higher with prasugrel compared to ticagrelor (10.29% ± 15.2 vs 4.66% ± 13.5, P  = 0.003). Bleeding events at 6 months follow-up according to TIMI classification were similar in both the groups (11.86% vs 6.9%, P  = 0.39). CONCLUSION: Prasugrel produces greater improvement in coronary microcirculation than Ticagrelor resulting in improved myocardial salvage in patients of STEMI undergoing pPCI.

R wave peak time and no reflow following primary percutaneous coronary intervention: Immediate and short-term outcomes.

BACKGROUND: No reflow (NR) remains an important constraint in management of ST elevation myocardial Infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). Most ECG parameters validated till date including ST resolution are postprocedural. R wave peak time (RWPT) is a dynamic parameter and reflects conduction delay in ischaemic myocardium in selected leads supplied by infarct related artery (IRA). The present study was undertaken to see whether preprocedural RWPT per se or RWPT following primary PCI can predict persistence of NR along with immediate and short-term clinical outcome. METHODS: 200 patients were enrolled after exclusion. Clinical, Biochemical, ECG parameters including RPWT and angiographic parameters (pre- and post-procedure) were recorded. ECG papers was analysed using digital image processing software (http://imagej.nih.gov/ij/). All patients were followed up for 6 months. RESULTS: NR was observed in 35% of the patients. Age, Diabetes, symptom to balloon time, higher thrombus burden, peak CPK-MB level (pre and post procedure) were significantly higher in NR group. On ECG analysis, baseline RWPT, QRS duration and pathological Q wave were significantly higher in NR group. On multivariate analysis, age (OR 1.10 CI 1.00-1.21 P = 0.04), thrombus grade ≥ 3 in IRA (OR 12.38 CI 2.08-73.58 P = 0.006), symptom to balloon time (OR 2.18 CI 1.6-3.0 P < 0.001) and baseline RWPT on ECG [OR 1.86 CI 1.24-2.78, P = 0.003] were found to be independent predictors of NR. Increase in RWPT following primary PCI was found to both highly sensitive and specific for diagnosing persistence of NR after primary PCI. Follow up at the end of 6 months has shown that patients with increased RWPT following primary PCI had worse short-term cardiovascular outcomes compared to those with decreased RWPT following primary PCI. CONCLUSION: Baseline RWPT is a significant predictor of NR in patients of STEMI undergoing primary PCI. A persistently increased RWPT following primary PCI is also a highly sensitive and specific ECG marker of persistence of NR which is associated with adverse short-term clinical outcome.

Management of diabetic dyslipidemia in Indians: Expert consensus statement from the Lipid Association of India.

In 2021 an estimated 74 million individuals had diabetes in India, almost all type 2 diabetes. More than half of patients with diabetes are estimated to be undiagnosed and more 90% have dyslipidemia that is associated with accelerated development of atherosclerotic cardiovascular disease (ASCVD). Patients of Indian descent with diabetes have multiple features that distinguish them from patients with diabetes in Western populations. These include characteristics such as earlier age of onset, higher frequency of features of the metabolic syndrome, more prevalent risk factors for ASCVD, and more aggressive course of ASCVD complications. In light of the unique features of diabetes and diabetic dyslipidemia in individuals of Indian descent, the Lipid Association of India developed this expert consensus statement to provide guidance for management of diabetic dyslipidemia in this very high risk population. The recommendations contained herein are the outgrowth of a series of 165 webinars conducted by the Lipid Association of India across the country from May 2020 to July 2021, involving 155 experts in endocrinology and cardiology and an additional 2880 physicians.

Comparative analysis of Nε-carboxymethyl-lysine and inflammatory markers in diabetic and non-diabetic coronary artery disease patients.

BACKGROUND: Coronary artery disease (CAD) is a major cause of death worldwide, and India contributes to about one-fifth of total CAD deaths. The development of CAD has been linked to the accumulation of Nε-carboxymethyl-lysine (CML) in heart muscle, which correlates with fibrosis. AIM: To assess the impact of CML and inflammatory markers on the biochemical and cardiovascular characteristics of CAD patients with and without diabetes. METHODS: We enrolled 200 consecutive CAD patients who were undergoing coronary angiography and categorized them into two groups based on their serum glycosylated hemoglobin (HbA1c) levels (group I: HbA1c ≥ 6.5; group II: HbA1c < 6.5). We analyzed the levels of lipoproteins, plasma HbA1c levels, CML, interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and nitric oxide. RESULTS: Group I (81 males and 19 females) patients had a mean age of 54.2 ± 10.2 years, with a mean diabetes duration of 4.9 ± 2.2 years. Group II (89 males and 11 females) patients had a mean age of 53.2 ± 10.3 years. Group I had more severe CAD, with a higher percentage of patients with single vessel disease and greater stenosis severity in the left anterior descending coronary artery compared to group II. Group I also exhibited a larger left atrium diameter. Group I patients exhibited significantly higher levels of CML, TNF-α, and IL-6 and lower levels of nitric oxide as compared with group II patients. Additionally, CML showed a significant positive correlation with IL-6 (r = 0.596, P = 0.001) and TNF-α (r = 0.337, P = 0.001) and a negative correlation with nitric oxide (r=-4.16, P = 0.001). Odds ratio analysis revealed that patients with CML in the third quartile (264.43-364.31 ng/mL) were significantly associated with diabetic CAD at unadjusted and adjusted levels with covariates. CONCLUSION: CML and inflammatory markers may play a significant role in the development of CAD, particularly in diabetic individuals, and may serve as potential biomarkers for the prediction of CAD in both diabetic and non-diabetic patients.

Unmet Need for Further LDL-C Lowering in India despite Statin Therapy: Lipid Association of India Recommendations for the Use of Bempedoic Acid.

Lipid-lowering therapy plays a crucial role in reducing adverse cardiovascular (CV) events in patients with established atherosclerotic cardiovascular disease (ASCVD) and familial hypercholesterolemia. Lifestyle interventions along with high-intensity statin therapy are the first-line management strategy followed by ezetimibe. Only about 20-30% of patients who are on maximally tolerated statins reach recommended low-density lipoprotein cholesterol (LDL-C) goals. Several factors contribute to the problem, including adherence issues, prescription of less than high-intensity statin therapy, and de-escalation of statin dosages, but in patients with very high baseline LDL-C levels, including those with familial hypercholesterolemia and those who are intolerant to statins, it is critical to expand our arsenal of LDL-C-lowering medications. Moreover, in the extreme risk group of patients with an LDL-C goal of ≤30 mg/dL according to the Lipid Association of India (LAI) risk stratification algorithm, there is a significant residual risk requiring the addition of non-statin drugs to achieve LAI recommended targets. This makes bempedoic acid a welcome addition to the existing non-statin therapies such as ezetimibe, bile acid sequestrants, and PCSK9 inhibitors. A low frequency of muscle-related side effects, minimal drug interactions, a significant reduction in high-sensitivity C-reactive protein (hsCRP), and a lower incidence of new-onset or worsening diabetes make it a useful adjunct for LDL-C lowering. However, the CV outcomes trial results are still pending. In this LAI consensus document, we discuss the pharmacology, indications, contraindications, advantages, and evidence-based recommendations for the use of bempedoic acid in clinical practice.

Gender differences in genotypic distribution of endothelin-1 gene and endothelin receptor A gene in pulmonary hypertension associated with rheumatic mitral valve disease.

INTRODUCTION: The female gender is a risk factor for idiopathic pulmonary arterial hypertension. However, it is unknown whether females with rheumatic mitral valve disease are more predisposed to develop pulmonary hypertension compared to males. AIM: We aimed to investigate whether there was a difference in genotypic distribution of endothelin-1 (ET-1) and endothelin receptor A (ETA) genes between female and male patients of pulmonary hypertension associated with rheumatic mitral valve disease (PH-MVD). METHODS: We compared prevalence of ET-1 gene (Lys198Asn) and ETA gene (His323His) polymorphisms according to gender in 123 PH-MVD subjects and 123 healthy controls. RESULTS: The presence of mutant Asn/Asn and either mutant Asn/Asn or heterozygous Lys/Asn genotypes of Lys198Asn polymorphism when compared to Lys/Lys in females showed significant association with higher risk (odds ratio [OR] 4.5; p =0.007 and OR 2.39; p =0.02, respectively). The presence of heterozygous C/T and either mutant T/T or heterozygous C/T genotypes of His323His polymorphism when compared to wild C/C genotype in females showed a significant association with higher risk (OR 1.96; p =0.047 and OR 2.26; p =0.01, respectively). No significant difference was seen in genotypic frequencies in males between PH-MVD subjects and controls. Logistic regression analysis showed that mutant genotype Asn/Asn (p =0.007) and heterozygous genotype Lys/Asn of Lys198Asn polymorphism (p =0.018) were independent predictors of development of PH in females. CONCLUSIONS: ET-1 and ETA gene polymorphisms were more prevalent in females than males in PH-MVD signifying that females with rheumatic heart disease may be more susceptible to develop PH.

Evidence for intensive LDL-C lowering for acute coronary syndrome: Recommendations from the Lipid Association of India.

Patients with acute coronary syndrome (ACS) have a high risk of subsequent adverse cardiovascular outcomes, particularly within the first 30 days. Although it is well documented that initiation of statin therapy in the setting of ACS improves short- and long-term cardiovascular outcomes, and achievement of lower levels of low density lipoprotein cholesterol (LDL-C) incrementally improves outcomes, many patients with ACS have persistent hypercholesterolemia after discharge from the hospital. This is a missed opportunity that prompted the Lipid Association of India to develop recommendations for earlier initiation of more aggressive LDL-C lowering treatment, particularly for patients of South Asian descent who are well-documented to have earlier onset of more aggressive atherosclerotic cardiovascular disease. The Lipid Association of India recommends individualized aggressive LDL-C goals after ACS, which can be rapidly achieved with high intensity statin therapy and subsequent goal-directed adjunctive treatment with ezetimibe and PCSK9 inhibitors. Improved treatment of hypercholesterolemia achieved within weeks after ACS has the potential to reduce the high rate of morbidity and mortality in these high risk patients.

Endothelin-1 gene and endothelin receptor A gene polymorphisms in severe pulmonary hypertension associated with rheumatic mitral valve disease.

INTRODUCTION: Endothelin-1 (ET-1) gene polymorphisms are implicated in pathogenesis of idiopathic pulmonary arterial hypertension. METHODS: We studied ET-1 (Lys198Asn and 3A/4A) and endothelin receptor A (ETA) gene (His323His) polymorphisms in 123 subjects with pulmonary hypertension associated with rheumatic mitral valve disease (PH-MVD) and 123 healthy controls. RESULTS: The mutant homozygous Asn/Asn genotype in Lys198Asn and T/T genotype in His323His polymorphism was more prevalent in the PH-MVD group. Presence of Asn/Asn genotype was significantly associated with an increased risk (odds ratio 3.9). CONCLUSIONS: ET-1 and ETA gene polymorphisms are prevalent in the PH-MVD group suggesting that they may predispose to the development of PH.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India.

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Nonstatin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals with statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Left atrial function by two-dimensional speckle tracking echocardiography in patients with severe rheumatic mitral stenosis and pulmonary hypertension.

We studied left atrial (LA) function in severe rheumatic mitral stenosis (MS) patients using two-dimensional speckle tracking echocardiography (STE). Eighty patients with isolated severe MS in sinus rhythm and 40 controls underwent comprehensive echocardiography including STE derived LA strain [reservoir strain (LASr), conduit strain (LAScd) and contractile strain (LASct)]. The mean MVA was 0.93 ± 0.21 cm2. The mean values of LASr (14.73 ± 8.59%), LAScd (-7.61 ± 4.47%) and LASct (-7.16 ± 5.15%) in patients were significantly lower (p < 0.001) vs. controls 44.11 ± 10.44%, -32.45 ± 7.63%, -11.85 ± 6.77% respectively and showed decreasing trend with increasing MS severity and higher NYHA class. In conclusion, LA dysfunction is prevalent in severe MS irrespective of NYHA functional class.

Evolocumab in patients with homozygous familial hypercholesterolemia in India.

BACKGROUND: Evolocumab is a fully human monoclonal antibody inhibitor of proprotein convertase subtilisin/kexin type 9 approved in India for treatment of homozygous familial hypercholesterolemia (HoFH) in patients aged ≥12 years. OBJECTIVE: RAMAN (NCT03403374) was a single-country, open-label, phase 4 study evaluating the safety and tolerability of evolocumab in patients with HoFH in India. METHODS: Patients ≥12 to ≤80 years of age on stable lipid-lowering therapy with fasting low-density lipoprotein cholesterol (LDL-C) >3.4 mmol/L (>130 mg/dL) received evolocumab 420 mg subcutaneously monthly (every 2 weeks if on apheresis). The primary endpoint was patient incidence of treatment-emergent adverse events. Secondary endpoints included percent changes at week 12 in LDL-C and other lipids. RESULTS: Of 30 enrolled patients, 13 were <18 years of age. Mean±SD baseline levels of LDL-C, apolipoprotein B, and lipoprotein(a) were 12.3 ± 3.5 mmol/L (473.5 ± 135.2 mg/dL), 2.8 ± 0.7 g/L (275.3 ± 69.1 mg/dL), and 201.3 ± 177.6 nmol/L, respectively. Ten patients (33%) reported treatment-emergent adverse events, with 2 (7%) serious adverse events and none leading to discontinuation; no deaths occurred during evolocumab treatment. At week 12, mean (SE) percent changes from baseline in LDL-C, apolipoprotein B, and lipoprotein(a) were -6.4% (4.2), -6.0% (3.7), and -0.2% (4.9), respectively. Reductions in LDL-C among individual patients were variable and greatest in patients ≥18 years of age and with baseline LDL-C <13 mmol/L (<500 mg/dL). CONCLUSIONS: Evolocumab was safe and well tolerated in patients with HoFH in India with smaller reductions in LDL-C and other lipids than those observed in previous studies with HoFH and different populations.

Prevalence and predictors of left atrial appendage inactivity in patients of rheumatic mitral stenosis in sinus rhythm: An observational study.

BACKGROUND: Systemic thromboembolism is a known complication of rheumatic mitral stenosis (RMS) in sinus rhythm (SR). Left atrial appendage (LAA), the commonest site of thrombus formation is usually hypocontractile (inactive) in such patients. We aimed to study the prevalence of LAA inactivity (LAAI) in severe RMS and assess its independent predictors. METHODS: The study population consisted of 100 patients of severe RMS in SR. Transthoracic and transesophageal echocardiography were done to assess LAA contractile function. Patients with LAA-peak emptying velocity < 25 cm/seconds were defined as having LAAI. RESULTS: The mean age of study subjects was 31.66±8.69 years and 56% were females. 73% patients had LAAI (Group A), while remaining 27% had normal LAA function (Group B). Mitral-valve area (MVA) and lateral annulus systolic velocity (Sa-wave) were significantly lower while mitral valve mean gradient (MVMG) and serum fibrinogen were significantly higher (all p-values < 0.001) in group A patients. On multivariate binary logistic regression analysis, MVMG (p < 0.001), Sa-wave (p = 0.02), and serum fibrinogen (p = 0.005) were independent predictors of LAAI. Optimal cut-off values of MVMG, Sa-wave and serum fibrinogen for predicting LAAI were 11.5 mm Hg, 6.8 cm/seconds and 300 mg/dl, respectively. Sixty-Seven (90.55%) patients in group A compared to 13(48.1%) in group B had LA/LAA smoke. LAAI was the only independent predictor of left atrium (LA)/LAA smoke with or without associated thrombus. CONCLUSION: There is high prevalence of LAAI in patients of severe MS in SR. MVMG, Sa-wave, and serum fibrinogen levels are independent predictors of LAAI. LAAI is an independent predictor of LA/LAA smoke with or without associated thrombus.