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.

Fibrinolysis in left-sided mechanical prosthetic valve thrombosis with high INR.

BACKGROUND: A significant number of patients with prosthetic valve thrombosis have a prothrombin time international normalised ratio in the therapeutic range at presentation. Surgery may not be possible in many patients and traditionally a high international normalised ratio is considered a relative contraindication for fibrinolysis. METHODS: We conducted an observational study in patients with left-sided obstructive prosthetic valve thrombosis with international normalised ratio at or above the therapeutic range at presentation who received fibrinolysis. The fibrinolytic regimens, timing of initiation, success of fibrinolysis, risk of major and minor bleeding and ischaemic stroke were evaluated in the study. RESULTS: Of 30 patients included in the study 70% received immediate fibrinolysis and in 30% it was delayed. The majority of patients (90%) presented with New York Heart Association class III/IV symptoms. The mean international normalised ratio at fibrinolysis was 3.04 ± 0.70 in the immediate group and 2.42 ± 0.89 in the delayed group. Haemodynamically stable patients who had delayed initiation of fibrinolysis had a trend towards less bleeding without an increase in mortality. The rates of intracranial haemorrhage (0% vs. 7.7%), minor bleeding (12.5% vs. 25.1%) and ischaemic stroke (0% vs. 30.7%) were lower in patients who received low dose infusion compared to a conventional dose. CONCLUSIONS: Fibrinolysis can be considered in patients with prosthetic valve thrombosis with high international normalised ratio at presentation. For haemodynamically stable patients, delayed initiation of fibrinolysis is associated with a marginally lower bleeding risk without an increase in mortality. Low dose infusion may be considered over a conventional dose as it is associated with a lower incidence of ischaemic stroke and a good rate of valve function restoration with a trend towards less bleeding.

Thrombolysis with reteplase in acute pulmonary embolism.

OBJECTIVE: Reteplase (recombinant plasminogen activator) is a mutant of alteplase. It has a longer half-life than its parent molecule and has shown better vessel patency rates in acute myocardial infarction. In this study, we analyzed the efficacy and safety of reteplase in acute pulmonary embolism (PE). METHODS: This observational study included patients with high- and intermediate-risk acute PE, presenting within 14 days of symptom onset. The patients were treated with reteplase, which was given in two bolus doses of 10 U each, 30 min apart, along with intravenous heparin. Patients with hemodynamic compromise (high-risk or massive PE) and normotensive patients with evidence of right ventricular (RV) dysfunction (intermediate-risk or submassive PE) on echocardiography or computed tomography were included in the study. The efficacy outcomes assessed were in-hospital death and improvement of RV function by echocardiography. The safety outcomes were major bleeding, minor bleeding, and ischemic or hemorrhagic stroke during hospitalization. RESULTS: Of the 40 patients included, 25% were classified as high risk with hemodynamic compromise and 75% were classified as intermediate risk. RV dysfunction was present in all the patients (100%). Concomitant lower extremity deep vein thrombosis was present in 55% of the patients. The mortality rate was 5%. There was significant improvement in RV function and reduction in pulmonary artery systolic pressure and tricuspid regurgitation severity. There was no major bleeding event or stroke, and 7.5% patients had minor extracranial bleeding. CONCLUSIONS: Double-bolus reteplase given with heparin is effective in the treatment of high- and intermediate-risk PE, with minimal risk of bleeding.

Angiographic profile and endovascular interventions in Takayasu's arteritis.

BACKGROUND: Takayasu's arteritis (TA) is a rare inflammatory, granulomatous vasculitis primarily involving the aorta and its major branches. Clinical and angiographic manifestations of the disease differ in various parts of the world. OBJECTIVES: To analyze the clinical features, angiographic profile, and endovascular interventions in TA patients (pts). METHODS: From January 2009 to March 2013, a total of 62 consecutive pts who were diagnosed with Takayasu's arteritis at our institute based on American College of Rheumatology Criteria were included in the study. Thirty-four pts underwent conventional angiography, while 28 were evaluated using computed tomographic angiography. Endovascular interventions were attempted for 24 lesions in 23 pts who were symptomatic and had significant stenotic lesions. RESULTS: The mean age of presentation was 28.4 ± 9.7 years, with 69.4% female. Limb claudication (52%) was the most common presenting symptom, followed by vertigo (35%) and constitutional symptoms. The most common angiography class was type V (37.1%), followed by type I (32.2%), type IV (17.7%), type IIa (8.1%), type III (3.2%), and type IIb (1.6%). The most common artery involved was the subclavian (64.5%), with the left subclavian more commonly involved than the right, followed by the abdominal aorta (51.6%) and renal artery (32.2%). Stenotic lesions were present in 59 pts (95%), while aneurysmal involvement was seen in 17 (27.4%), with isolated aneurysmal involvement in 3 of these. CONCLUSIONS: Our cohort of TA pts had more severe and widespread involvement. Despite a more advanced presentation, percutaneous balloon angioplasty with stent implantation is feasible, with good immediate results but slightly higher complication rates.

Prognostic significance of a multimarker strategy of biomarkers in acute heart failure.

BACKGROUND: Heart failure (HF) is a growing public health problem. Patients often present to emergency department (ED) with acute onset dyspnea where a rapid triage is required to avoid misdiagnosis and to institute appropriate therapy. An objective risk-stratification in the ED is warranted to identify patients at high risk of adverse outcomes, so that more intensive therapy and vigilant follow-up after discharge are instituted. METHODS AND RESULTS: Fifty two consecutive acute HF (AHF) patients in NYHA class III/IV were enrolled for the present study. N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hsTropT), high-sensitivity C-reactive protein (hsCRP) and Uric acid (UA) were evaluated at admission; a second sample for NT-proBNP and hsTropT was obtained 48h later. The end-point of the study, a composite of cardiovascular death, rehospitalisation for worsening HF symptoms and refractory HF was reached in 32.7% of patients during a median follow-up of 4.8mnth. Although, hsTropT (>0.014ng/ml), hsCRP (>0.5mg/dl) and UA (>5.6mg/dl for females and >7 mg/dl for males) were elevated in the vast majority of patients (92.3%, 75% and 63.5% respectively), baseline and changing patterns of NT-proBNP following treatment were the only predictors of adverse outcomes on follow-up. A significant correlation between hsTropT, hsCRP and UA was observed suggesting a link between inflammation, myocyte injury and oxidative stress in AHF. CONCLUSION: Baseline and changing patterns of NT-proBNP predicted adverse outcomes on follow-up suggesting that a strategy of serial measurement of NT-proBNP could prove invaluable in early risk stratification. Further research is needed to understand the link between inflammation, myocyte injury and oxidative stress in AHF which could provide potential therapeutic targets.

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.

Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience.

BACKGROUND: Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with rheumatic heart disease (RHD) being the dominant form of valvular heart disease (VHD) in developing nations. The current study was undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo). METHODS: Among the 136,098 first-time Echocardiograms performed between January 2010 and December 2012, an exclusion criterion of trivial and functional regurgitant lesions yielded a total of 13,289 cases of organic valvular heart disease as the study cohort. RESULTS: In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Isolated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS + MR > MS + AR > MR + AR > AS + AR > MR + AS > MS + AS. Overall, 9.7% of cases had organic tricuspid valve disease. CONCLUSION: RHD contributed most to the burden of VHD in the present study with calcific degeneration, myxomatous disease and BAV being the other major forms of VHD. Multiple valves were affected in more than a third of all cases.

Acute myocardial infarction following scorpion sting in a case with obstructive coronary artery disease.

The occurrence of an acute myocardial infarction (MI) following a scorpion sting has been very rarely reported in the previous literature. Possible pathogenetic mechanisms include severe hypotension due to hypovolaemic shock and coronary spasm with subsequent thrombosis of coronary vessels developed after the release of vasoactive, inflammatory and thrombogenic substances contained in the scorpion venom. All of the previously reported cases had normal coronary angiogram. We report a case of a 65-year-old woman who presented with severe scorpion sting and was treated with prazosin. But a few hours later, she developed acute anterior wall MI. Coronary angiogram revealed the presence of significant stenosis in coronary arteries. As acute MI owing to significant coronary artery disease can be evident after severe scorpion envenomation, so every case of acute coronary syndrome following scorpion sting needs early diagnosis, thorough cardiovascular evaluation and appropriate treatment.

A clinically masked normotensive aortic coarctation.

A rare variety of aortic coarctation in which both the left subclavian and aberrant right subclavian arteries arose at the coarcted segment is described. Clinically this case was misleading since pulse volume and the blood pressure in all four limbs were equal and chest radiograph was lacking classical features of coarctation of aorta. Multi slice CT aortogram typically demonstrated the relationship of major aortic arch branches. Later he underwent balloon coarctoplasty and stenting with success. The literature relating to unusual coarctation is reviewed in brief

Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus.

OBJECTIVES: To evaluate the safety and efficacy of balloon mitral valvotomy (BMV) in symptomatic rheumatic mitral stenosis (MS) patients with left atrial (LA) thrombus and to address the technical issues. BACKGROUND: LA thrombus in patients with MS has long been regarded as a contraindication for BMV. There are few reports of BMV in presence of LA appendage (LAA) thrombus and reports of BMV in presence of LA body thrombus are still rare. METHODS: 2,763 patients with suitable valve morphology were screened for BMV. 194 patients had LA/LAA thrombus and were put on adequate anticoagulation for 8-12 weeks. A total of 108 patients with persistent LA thrombus who satisfied the inclusion criteria (LA thrombus type Ia, Ib, and IIa) formed the study group and the remaining 2,622 patients who did not have any LA thrombus constituted the control group. All patients in the study group underwent BMV by modified over the wire technique. RESULTS: There was significant and comparable improvement in the mitral valve area, mitral valve gradient, LA mean and pulmonary artery systolic pressure following the procedure in both groups. In the study group, there were no thromboembolic episodes during the procedure. However, there was one case of transient ischemic attack in the study group which occurred 6 hr after a successful BMV. In the study group, one patient had cardiac tamponade needing aspiration and there was no in-hospital death. CONCLUSIONS: In selected patients of mitral stenosis with LA thrombus (type Ia, Ib, and IIa), BMV can be performed safely with the modified over the wire technique. Systemic thromboembolism, technical failures and other complications are very rare when performed by experienced operators.

Pseudo-atrial flutter/fibrillation in Parkinson's disease.

We report a case of an elderly male with Parkinson's tremor whose electrocardiogram (ECG) simulated atrial flutter/fibrillation. We also highlight the difficulty in correctly identifying a tremor-induced ECG artifacts due to the diverse range of possible electrocardiographic patterns presented by patients with this condition.