'Digoxin conundrum - Time for validation?'

Despite no incontrovertible data, Digoxin use has been demonised. As a consequence, a lot of patients, stable on Digoxin, have been taken off it and offered alternative drugs. However, there is some light at the end of the tunnel for Digoxin, with the reporting of RATE-AF Trial at the recent European Society of Cardiology Congress. Compared to Bisoprolol, Digoxin use was associated with statistically significantly greater improvements in symptomatology and NT ProBNP levels making Digoxin a first line drug for rate control in permanent AF.

'Heart Team' Concept - A reality or a 'Platonic Illusion'.

Post Syntax Trial, 'Heart Team' Concept has been ensconsed class I recommendation in both the European and ACC/AHA guidelines and has gained increasing traction in context of complex and multi modality procedures. Despite an arrray of advantages including the much touted - 'the patient is central', there are a plethora of un-addressed issues, some of which sentinel to our country, which threaten to make the 'Heart Team' concept a perfunctory exercise. As it stands today, 'Heart Team' is more of a fictional euphemism, a kind of 'Platonic Illusion' rather than a pragmatic reality.

Cardiac tumours in infancy.

Cardiac tumours in infancy are rare and are mostly benign with rhabdomyomas, fibromas and teratomas accounting for the majority. The presentation depends on size and location of the mass as they tend to cause cavity obstruction or arrhythmias. Most rhabdomyomas tend to regress spontaneously but fibromas and teratomas generally require surgical intervention for severe haemodynamic or arrhythmic complications. Other relatively rare cardiac tumours too are discussed along with an Indian perspective.

Use of tenecteplase for left-sided prosthetic valve thrombosis.

INTRODUCTION: Prosthetic valve thrombosis (PVT) following cardiac valve replacement in rheumatic heart disease patients is a common cause for referral to tertiary care centre. Although surgery has been described as the traditional choice of therapy, thrombolytic therapy has reported high success rates in published literature. CASE REPORT: This is a case report of ten patients with left-sided PVT receiving tenecteplase. The mean dose of tenecteplase used was 1.01 mg/kg given as IV bolus injection along with enoxaparin, heparin and acenocoumarol. The diagnosis and response was assessed based on trans-thoracic echocardiography. The reduction in peak transvalvular gradient was in the range of 46% - 81% and in mean transvalvular gradient was in the range of 50% - 84%. There was normalization of valve motion in all patients. There was no incidence of mortality, intracerebral hemorrhage, systemic bleeding or embolism. CONCLUSION: To our knowledge, this is the largest published evidence so far showing efficacy and safety of tenecteplase for PVT.

Coronary artery bypass grafting in women--is OPCAB mandatory?

OBJECTIVE: There has been an explosive increase in our understanding of the natural history and progression of CAD in women. Women have a poorer prognosis and a more severe outcome than men after myocardial infarction, Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). The purpose of the present study was to evaluate the differences in the results of CABG in women as compared with men using Pump and Off Pump operating techniques. METHODS: Data of 3500 patients undergoing coronary artery bypass grafting by a single surgeon at two institutes over an 8-year period were analyzed. Clinical data including demographic and risk profile and perioperative data were obtained from case records, operation notes, ICU charts and out-patient records. Data were analyzed using 'chi square' test to calculate p value for various parameters. RESULTS: 14.6% of patients were women. Coronary artery size correlated with body surface area (BSA) but even with BSA > 1.5m2, it was smaller than the males. Inhospital mortality was higher in women as compared to men, being 2.92% versus 1.8% in men. The ventilation time, blood requirement, ICU stay, inotropic requirement and hospital stay were identical with results seen in men in our series. The commonest causes of mortality were low cardiac output and renal failure. Use of Off Pump technique reduces mortality (1.84% Vs 4.5% on Pump--p = 0.01) in women, besides reducing the blood requirement (2.5 +/- 1.2 units/pt in OPCAB Vs 4.3 +/- 1.4 units/pt in Pump group--p < 0.001; ICU stay (29.4 +/- 16.4 hrs Vs 38.3 +/- 17.3 hrs in Pump group--p < 0.0001); & hospital stay (6.81 +/- 1.6 days Vs 8.05 +/- 2.1 days in pump group--p < 0.0001). However, there was no statistically significant difference in the rates of mediastinitis, Arrhythmias, Neurological or Pulmonary complications between the OPCAB & Pump group. CONCLUSIONS: Women coming for coronary artery bypass surgery are a special risk group. The operative and early mortality of bypass surgery in women is higher than in men for conventional CABG. However, off pump techniques has negated this to a large extent. Our findings lead us to conclude that use of OPCAB promises to be gratifying enough to mitigate the early concerns in this group of patients.

Unruptured sinus of valsalva aneurysm presenting as acute coronary syndrome.

An unusual presentation of sinus of Valsalva aneurysm causing right ventricular outflow tract obstruction and presenting as acute coronary syndrome is reported. A 38-year-old lady presented with ischemic chest pain, probably due to embolization from an unruptured sinus of Valsalva aneurysm.

Myocardial revascularisation after acute myocardial infarction.

One hundred and twenty-three patients had coronary artery bypass grafting (CABG) within 30 days of acute myocardial infarction (AMI) from May 1992 to November 1997. Commonest infarct was anterior transmural (61.8%) and commonest indication of surgery was post-infarct persistent or recurrent angina (69.1%). Ten patients were operated within 48 h and 36 between 48 h to 2 weeks of having MI. Out of these, nine patients were having infarct extension and cardiogenic shock at the time of surgery. Pre-operatively fourteen patients were on inotropes of which six also had intra-aortic balloon pump (IABP) support. All patients had complete revascularisation with 3.8+/-1.2 distal anastomoses per patient. By multivariate analysis, we found that independent predictors of post-operative morbidity [inotropes >48 h, use of IABP, ventilation >24 h, ICU stay >5 days] and complications [re-exploration, arrhythmias, pulmonary complications, wound infection, cerebrovascular accident (CVA)] were left ventricular ejection fraction (LVEF) <30%, Q-wave MI, surgery <48 h after AMI, presence of pre-operative cardiogenic shock and age >60 years (P < or = 0.01). Mortality at 30 days was 3.3%. LVEF <30%, Q-wave MI, surgery <48 h after AMI, presence of pre-operative cardiogenic shock and age >60 years were found to be independent predictors of 30 days mortality (P < or = 0.01). Ninety patients were followed up for a mean duration of 33 months (1 to 65 months). There were three late deaths and five patients developed recurrence of angina. To conclude, CABG can be carried out with low risk following AMI in stable patients for post-infarct angina. Patients who undergo urgent or emergent surgery and who have pre-operative cardiogenic shock, IABP, poor left ventricular functions, age >60 years and Q-wave MI are at increased risk.

Mechanism of stroke complicating cardiopulmonary bypass surgery.

BACKGROUND: Stroke is a devastating complication of cardiopulmonary bypass (CPB) surgery which occurs in 1 to 5% of cases. Strategies to reduce its incidence require a knowledge of the underlying pathology and aetiology. AIMS: To determine the incidence, pathology and aetiology of stroke complicating CPB. METHODS: Prospective review of clinical, operative and cranial CT scan findings in all cases of stroke complicating CPB procedures in our institution over an 18 month period. RESULTS: Twenty-one (1.6%, 95% CI 0.9-2.3%) cases of stroke were identified from 1336 CPB procedures. Cranial CT scan, performed in all but one patient, was normal in three patients or consistent with ischaemic stroke in 17 patients. There were no cases of haemorrhagic infarction or intracerebral haemorrhage. It was difficult to differentiate embolic and borderzone infarcts in two cases. After considering the clinical, operative and CT scan features together, 12 (57%, 95% CI 36-78%) of the cases were felt to be embolic in origin and nine (43%, 95% CI 22-64%) due to hypoperfusion in a borderzone. CONCLUSIONS: This study demonstrates that stroke remains an important complication of CPB procedures with an incidence in our series of 1.6%. The pathologic type of stroke is predominantly ischaemic in nature due to either cerebral embolism or borderzone infarction. Strategies for stroke prevention in patients undergoing CPB should be targeted primarily at these two mechanisms.

Plasma platelet activating factor degradation and serum lipids after coronary bypass surgery.

OBJECTIVE: Platelet activating factor (PAF) is a potent mediator in inflammatory responses and maybe involved in various disease states. Degradation of PAF in plasma results from the action of a specific, lipoprotein associated, acetylhydrolase. The aim was to determine plasma acetylhydrolase activity under optimised conditions, PAF half life, phospholipase A2 activity, the lyso-derivative of PAF (lyso-PAF), and lipids in patients undergoing coronary artery bypass grafting. METHODS: The study variables were determined 3 d and 7 d following coronary artery surgery and compared to presurgical values in 15 males, age 55(SEM 4) years. RESULTS: Three days following coronary bypass grafting, total, LDL and HDL cholesterol fell significantly by 30%, 45%, and 15% respectively (p less than 0.001), all decreases correlating with bypass time (p less than 0.025). Concentrations remained low at 7 d (p less than 0.005). Acetylhydrolase activity fell by 38% (p less than 0.001) at 3 d post-surgery and remained depressed, but plasma PAF half life did not change after surgery. The inverse relationship between acetylhydrolase activity and plasma PAF half life preoperatively (p less than 0.01) was not evident after surgery. There was a direct linear relationship between acetylhydrolase activity and both total (p less than 0.002) and LDL cholesterol (p less than 0.001) before surgery. The fall in acetylhydrolase activity correlated with the fall in these lipids (p less than 0.01) but not with that of HDL cholesterol. Plasma lyso-PAF decreased by 65% (p less than 0.001) at 3 d and remained depressed (p less than 0.001). Plasma phospholipase A2 activity increased by 60% (p less than 0.01) and remained raised (p less than 0.05), the increase at 3 d being related to bypass time (p less than 0.05). CONCLUSIONS: The large fall in plasma acetylhydrolase activity after coronary bypass grafting is consistent with the fall in plasma lipids. However, the absence of a significant change in the measured PAF half life in plasma raises questions as to the pathophysiological significance of the decrease in acetylhydrolase activity.