Utility of 3D Echocardiography for Device Sizing During Transcatheter ASD Closure: A Comparative Study.

BACKGROUND: Two-dimensional (2D) transesophageal echocardiography (TEE) is commonly used for assessing patients undergoing transcatheter atrial septal defect (ASD) device closure. 3D TEE, albeit providing high resolution en-face images of ASD, is used in only a fraction of cases. We aimed to perform a comparative analysis between 3D and 2D TEE assessment for ASD device planning. METHODS: This was a prospective, observational study conducted over a period of one year. Patients deemed suitable for device closure underwent 2D and 3D TEE at baseline. Defect characteristics, assessed separately in both modalities, were compared. Using regression analysis, we aimed to derive an equation for predicting device size using 3D TEE parameters. RESULTS: Thirty patients were included in the study, majority being females (83%). The mean age of the study population was 40.5 ± 12.05 years. Chest pain, dyspnea and palpitations were the common presenting complaints. All patients had suitable rims on 2D TEE. A good agreement was noted between 2D and 3D TEE for measured ASD diameters. 3D TEE showed that majority of defects were circular in shape (60%). The final device size used had high degree of correlation with 3D defect area and circumference. An equation was devised to predict device size using 3D defect area and circumference. The mean device size obtained from the equation was similar to the actual device size used in the study population (p = 0.31). CONCLUSIONS: Device sizing based on 3D TEE parameters alone is equally effective for transcatheter ASD closure as compared to 2D TEE.

Clinical profile and outcomes of childhood dilated cardiomyopathy - A single-center three-decade experience.

Introduction and Aims: Dilated cardiomyopathy (DCM) is an important cause of heart failure (HF) among children. Research on pediatric DCM remains surprisingly scarce. The primary objective of the study was to evaluate the clinical profile and outcomes of pediatric DCM and the secondary objective was to study the predictors of outcome. Methods and Results: We enrolled all patients with cardiomyopathy who presented to us between 1990 and 2020 and were younger than 18 years. During the 30-year study period, we identified 233 cases of pediatric cardiomyopathy. One hundred and nineteen (51%) cases had DCM. This retrospective cohort was analyzed to study their outcome and the possible predictors of outcome. Nearly, 8% presented in the neonatal period, and 37% in infancy. The most common mode of presentation was dyspnea on exertion (71%). Ninety-three patients presented in heart failure (78%). The median left ventricular dimension z-score in diastole was 4.3 (range 2.5-9.06). The median left ventricle (LV) ejection fraction was 31%. Seventy-two percent of this cohort were on angiotensin-converting-enzyme inhibitors, 40% on aldosterone antagonists, and 47% on beta-blockers. One-third had syndromic, metabolic, genetic, or any secondary cause identified. Twenty-seven patients satisfied the three-tiered clinical classification for the diagnosis of probable acute myocarditis. Over a mean follow-up of 3.29 years, 27% were lost to follow-up. Among the remaining patients who were on follow-up (n = 86), 39 (45%) died, 31 (36%) recovered, and 16 (18%) had persistent LV dysfunction. Heart Failure was the most common cause of death. Eight patients in this cohort (4.2%) had thromboembolic phenomena. Nine had sustained ventricular arrhythmias and six had atrial/junctional arrhythmias. Among the various risk factors studied, only infantile onset had a significant relationship with death or ventricular arrhythmias (P value- 0.05). The 5-year survival rate of DCM patients was 59%. Conclusion: A reasonably good percentage of our population showed recovery of the left ventricular function (36%). Only infantile onset had a significant relationship with death or ventricular arrhythmias. The outcome in our DCM cohort is similar to other population cohorts.

Clinical profile and outcomes of pediatric hypertrophic cardiomyopathy in a South Indian tertiary care cardiac center: a three decade experience.

INTRODUCTION: Although much research has been done on adult hypertrophic cardiomyopathy, data on pediatric hypertrophic cardiomyopathy is still limited. METHODS AND RESULTS: The study enrolled all patients with cardiomyopathy who presented to us between 1990 to 2020 and were younger than 18 yrs. During the thirty-year study period, we identified 233 cases of pediatric cardiomyopathy. Sixty-three cases (27%) had hypertrophic cardiomyopathy. Out of the 63 HCM cases, 12% presented in the neonatal period and 37% presented in the first year of life. The median age of presentation was 7 yrs (Range 0.1-18 yrs). Sixteen patients had proven syndromic, metabolic, or genetic disease (25%). LV outflow obstruction was present in 30 patients (47%). Noonan syndrome was present in 9 of the 63 patients (14%). Dyspnea on exertion was the most common mode of presentation. Cardiac MRI was done in 28 patients, out of which 17 had late gadolinium enhancement (LGE). Mid myocardial enhancement was the most common pattern. Four patients had LGE of more than 15%. Over a mean follow-up period of 5.6 years (0.1-30 years), twenty-one were lost to follow-up (33%). Among the patients whose outcome was known, eleven died (26%), and thirty-one (73%) were alive. The 5-year survival rate of HCM patients was 82%, and the 10-year survival rate was 78%. Seven died of sudden cardiac death, three from heart failure, and one from ventricular arrhythmias. Sustained ventricular arrhythmias were seen in three patients and atrial arrhythmias in two. First-degree AV block was seen in 10 patients (15%) and bundle branch blocks (BBB) in five (8%). Eight patients required ICD or transplant (12.7%). Two patients underwent ICD for primary prevention, and one underwent PPI for distal AV conduction disease. Among the various clinical, echocardiographic, and radiological risk factors studied, only consanguinity showed a trend towards higher events of death or ventricular arrhythmias (P-value 0.08). CONCLUSION: More than one-third of our HCM cohort presented in infancy. LV outflow tract obstruction is common (47%). Mid myocardial enhancement was the most common pattern of late gadolinium enhancement. SCD was the most common cause of death. The outcome in our HCM cohort is good and similar to other population cohorts. Only Consanguinity showed a trend towards higher events of death or ventricular arrhythmias.

Three-dimensional electroanatomical mapping guided right bundle branch pacing in congenitally corrected transposition of great arteries.

AIMS: The ideal pacing strategy has been the Achilles' heel for patients with congenitally corrected transposition of great arteries (ccTGA) with bradycardia. Various pacing modalities were documented in the literature. This article describes a novel pacing strategy and its feasibility in ccTGA with an intact ventricular septum. METHODS AND RESULTS: We prospectively recruited three patients with ccTGA who presented with symptomatic complete heart block to our institute and were evaluated. All patients were planned for conduction system pacing. Those who had more than moderate or severe systemic atrioventricular regurgitation and systemic ventricular dysfunction were planned for conduction system pacing with an additional lead in the coronary sinus (CS) tributary, i.e. bundle branch pacing optimized cardiac resynchronization therapy with the intention to achieve incremental benefit. Since right bundle pacing is not described previously and in view of anatomical complexity in location, three-dimensional (3D) anatomical mapping was done with the EnSite system and later right bundle capture is identified conventionally as that of a left bundle in a normal heart. All three patients have stable lead positions and adequate thresholds at short-term follow-up. CONCLUSION: In this report, we demonstrated the feasibility of permanent physiological pacing of the systemic ventricle by capturing the right bundle with 3D anatomical mapping guidance, which results in physiological activation of the systemic ventricle.

Clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in southern India.

BACKGROUND: Semi-permanent pacing (SPP) includes the placement of a permanent lead through the internal jugular vein and connection to a pulse generator on the skin outside the venous access site. AIM: To evaluate the clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in Southern India. METHODS: This is a retrospective observational study. All patients admitted and requiring management with semi-permanent pacing from January 2017 to June 2020 were included. RESULTS: From January 2017 to June 2020, 20 patients underwent semi-permanent pacing (SPP) with a median age of 54 (21-74) years. Males comprised a majority of the patients (55%). Hypertension was noted in 50% of patients and 30% were diabetic. The right internal jugular vein was the most common access in 95% of patients. The most common indication for semi-permanent pacing was pocket site infection in 30% of patients. There were no procedural complications. The median duration on SPP was 7 (5-14) days and the median duration of hospital stay was 13 (8-21) days. Permanent pacemaker implantation was done in 55% of patients. Mortality in our study group was 15% with 10% dying due to cardiogenic shock (post resuscitated cardiac arrest) and 5% dying due to non-cardiac cause (Epidural hematoma). CONCLUSION: In our study, semi-permanent pacing was noted to be a safe procedure and was more commonly indicated in emergent conditions with complete heart block secondary to underlying reversible causes and in the management of pocket site infection.

Point density exclusion mapping-A useful tool for mapping arrhythmias arising from the endocavitary structures.

Ventricular tachycardia arising from the papillary muscles and other endocavitary structures are preferably ablated under intracardiac echocardiographic (ICE) guidance whenever feasible. However, the availability, need of trained operators, and the expenses involved restrict the routine use of ICE in many cath labs. Point density exclusion (PDX) mapping is a simple technique that doesn't demand any additional expense or tool apart from the routine electroanatomical mapping and thus can be widely applied in mapping of arrhythmias arising from endocavitary structures. The following report describes such a case and explains the method of performing PDX mapping.

Long term outcomes after bare metal stent implantation.

Long term outcome data after BMS implant is not available from the Indian subcontinent. This is a prospective observational study which aims to study long term outcomes after BMS implant at a tertiary care centre. 100 consecutive patients underwent BMS implant and were followed up for 20 years. LAD was the most common vessel involved and different types of BMS were implanted. All-cause mortality was noted in 21% (n = 21) whereas cardiac mortality was seen in 16% (n = 16). Cumulative revascularisation free survival at 20 years was 71%. The study showed that long term outcomes after BMS implant were fare and acceptable.

Conduction abnormalities post alcohol septal ablation for hypertrophic cardiomyopathy - A single center experience.

Conduction abnormalities are commonly noted after alcohol septal ablation (ASA). This was a retrospective, observational study where we studied the incidence of new onset conduction abnormalities post ASA. 23 patients, who underwent ASA over a period of 5 years, were included in the study. Baseline conduction abnormalities were noted in 26% patients (n = 6). Transient complete heart block (CHB) was noted in 21.7% (n = 5) whereas new onset right bundle branch block (RBBB) was seen in 60.8% (n = 14). Left bundle branch block was uncommon (4.3%,n = 1). Permanent pacemaker implantation was done in 4.3% (n = 1) for CHB. Conduction anomalies are frequent after ASA with RBBB being most common.

Early and long-term outcomes of decompensated heart failure patients in a tertiary-care centre in India.

AIM: Long-term outcome data of acute decompensated heart failure (HF) are scarce from India. The aim of the study was to collect in-hospital and long-term outcome data of HF patients admitted during 2001-2010 in a tertiary-care centre in South India. METHODS AND RESULTS: Consecutive patients admitted with first episode of decompensated HF were part of the registry. Data regarding diagnosis, risk factors, treatment, early (in-hospital), and late (5 and 10year) mortality outcomes were captured. During this period, 1502 patients were admitted with first episode of decompensated HF [37.7% of women, mean age of 51.1 (SD = 14.3) years]. Common causes were ischaemic heart disease (36.2%), rheumatic heart disease (34.3%), and cardiomyopathies (9.9%). HF with reduced ejection fraction (HFrEF) was present in 26.9% of patients, and 33.8% had atrial arrhythmias. Diabetes, hypertension, and renal dysfunction were prevalent in 27.4%, 28.6%, and 37.4%, respectively. Median duration of hospitalization was 6 days (interquartile range: 3-10), and 247 patients (16.4%) died during index admission. The total time at risk was 6248 person years, and 1051 patients died during the study period with a median survival time of 3.7 years. Overall mortality rate was 16.8 per 100 person years (95% CI: 15.8-17.9 per 100 person years). Older age [hazard ratio (HR) = 1.08, 95% CI: 1.02-1.14, P = 0.007], anaemia (HR = 1.34, 95% CI: 1.08-1.65, P = 0.007), renal dysfunction (HR = 1.38, 95% CI: 1.20-1.59, P < 0.001), HFpEF (HR = 0.61, 95% CI: 0.52-0.73, P < 0.001 against HFrEF), and the use of guideline-directed therapies (GDT; beta blockers: HR = 0.57, 95% CI: 0.49-0.66, P < 0.0001; and angiotensin converting enzyme inhibitor/angiotensin receptor blocker: HR = 0.59, 95% CI: 0.51-0.69, P < 0.001) were important predictors of mortality. Patients with HF and mid-range EF also benefited from GDT. CONCLUSION: In our cohort, ischaemic and rheumatic heart diseases were the leading contributors for HF. Anaemia, renal dysfunction, poor ejection fraction, and suboptimal prescriptions of GDT were the main predictors of long-term mortality. Both patients with HFrEF and mid-range EF benefited from GDT.

Transradial access for coronary diagnostic and interventional procedures: Consensus statement and recommendations for India: Advancing Complex CoronariES Sciences through TransRADIAL intervention in India - ACCESS RADIAL™: Clinical consensus recommendations in collaboration with Cardiological Society of India (CSI).

Radial access for cardiac catheterization and intervention in India has been growing steadily over the last decade with favorable clinical outcomes. However, its usage by interventional cardiologists varies greatly among Indian operators and hospitals due to large geographic disparities in health care delivery systems and practice patterns. It also remains unclear whether the advantages, as well as limitations of transradial (TR) intervention (as reported in the western literature), are applicable to developing countries like India or not. An evidence-based review involving various facets of radial procedure for cardiac catheterization, including practical, patient-related and technical issues was conducted by an expert committee that formed a part of Advancing Complex CoronariES Sciences through TransRADIAL intervention (ACCESS RADIAL™) Advisory Board. Emerging challenges in redefining TR management based on evidence supporting practices were discussed to formulate these final recommendations through consensus.

Long-term effects of cardiac resynchronization therapy on electrical remodeling in heart failure-A prospective study.

INTRODUCTION: Effects of cardiac resynchronization therapy (CRT) on arrhythmogenicity and sudden death have not been fully ascertained. CRT has been shown to increase transmural dispersion of repolarization (TDR) immediately on implantation, which may favorably remodel on long-term follow-up. However, such a hypothesis has not been prospectively evaluated. METHODS AND RESULTS: We included 35 consecutive patients who underwent CRT implantation between September 2013 and August 2014 (mean age 56.8 ± 11.09 years; 71.43% males). QT and Tpeak-Tend (Tp-e) intervals were measured during endocardial (RVendoP), epicardial (LVepiP), and biventricular pacing (BiVP) at CRT implantation and 1-year follow-up. Compared to RVendoP (130.41 ± 16.75 ms), Tp-e was significantly prolonged during BiVP (142.06 ± 21.98 ms; P < 0.001) and LVepiP (183.45 ± 27.87 ms; P < 0.001) at baseline. There was a significant decrease in Tp-e during BiVP on follow-up (117.93 ± 15.03 ms; P < 0.001). High responders had significantly lower Tp-e at 1 year compared to low responders (113.16 ± 14.3 ms vs 129.59 ± 9.75 ms, P  =  0.004). Tp-e at 1 year had strong negative correlation with reduction in LV end-systolic volumes (r  =  - 0.51; P  =  0.003). Seven patients with sustained ventricular arrhythmias during follow-up had significantly longer baseline Tp-e compared to those without arrhythmias (158.19 ± 17.59 ms vs 139.72 ± 20.94 ms, P  =  0.043). A baseline Tp-e value of ≥ 148 ms had a specificity of 75% and sensitivity of 71% to predict ventricular arrhythmias. CONCLUSIONS: Baseline TDR is greater during BiVP and LV epiP compared with RVendoP in patients with heart failure. However, BiVP causes a significant reduction in TDR reflective of reverse electrical remodeling on long-term follow-up.