Idiopathic pulmonary vein thrombosis: an under-recognised source of embolic stroke.

Embolic stroke due to pulmonary vein thrombosis is rare but may be associated with lung and left atrial tumours, pulmonary surgery, atrial fibrillation and radiofrequency ablation. It is very rarely idiopathic. A 23-year-old man developed acute onset of a left partial third nerve palsy and left ataxic hemiparesis. His MR scan of the brain showed an acute infarct in the left midbrain and left thalamus. CT angiogram found no steno-occlusive disease and transthoracic echocardiogram was normal. However, a transoesophageal echocardiogram showed a hyperechoic mass projecting from the right inferior pulmonary vein, confirmed on cardiac MR scan to be a right inferior pulmonary vein thrombus. A cardiac loop recorder did not capture an atrial arrhythmia. CT scan of the chest found no significant abnormality in the pulmonary parenchyma. Investigations for hypercoagulable state were negative. He took dabigatran for 6 months with complete resolution of thrombus.

Acoustic Effect of Face Mask Design and Material Choice.

The widespread adoption of face masks is now a standard public health response to the 2020 pandemic. Although studies have shown that wearing a face mask interferes with speech and intelligibility, relating the acoustic response of the mask to design parameters such as fabric choice, number of layers and mask geometry is not well understood. Using a dummy head mounted with a loudspeaker at its mouth generating a broadband signal, we report the acoustic response associated with 10 different masks (different material/design) and the effect of material layers; a small number of masks were found to be almost acoustically transparent (minimal losses). While different mask material and design result in different frequency responses, we find that material selection has somewhat greater influence on transmission characteristics than mask design or geometry choices. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40857-021-00245-2.

Outflow-tract ventricular tachycardia: Can 12 lead ECG during sinus rhythm identify underlying cardiac sarcoidosis?

BACKGROUND: Patients with outflow tract ventricular tachycardia (OTVT) with normal echocardiogram are labeled as idiopathic VT (IVT). However, a subset of these patients is subsequently diagnosed with underlying cardiac sarcoidosis (CS). OBJECTIVE: Whether electrocardiogram (ECG) abnormalities in sinus rhythm (SR) can differentiate underlying CS from IVT. METHODS: We retrospectively analyzed the SR-ECGs of 42 patients with OTVT/premature ventricular complexes (PVC) and normal echocardiography. All underwent advanced imaging with cardiac magnetic resonance (CMR)/18FDG PET-CT for screening of CS. Twenty-two patients had significant abnormalities in cardiac imaging and subsequently had biopsy-proven CS (Cases). Twenty patients had normal imaging and were categorized as IVT (Controls). SR-ECGs of all patients were analyzed by 2 independent, blinded observers. RESULTS: Baseline characteristics were comparable. Among the ECG features analyzed - fascicular (FB) or bundle branch block (BBB) was seen in 9/22 Cases vs. 1/20 controls (p = 0.01). Among patients without FB or BBB, fragmented QRS (fQRS) was present in 9/13 cases but in none of the controls (p < 0.001). Low voltage QRS was more often seen among cases as compared to controls (10/22 vs. 3/20 p = 0.03). A stepwise algorithm based on these 3 sets of ECG findings helped to diagnose CS among patients presenting with OTVT/PVC with sensitivity of 91%, specificity of 75%, a PPV of 80%, and a NPV of 88%. CONCLUSIONS: In patients presenting with OTVT/PVC: FB/BBB, fQRS, and low QRS voltage on the baseline ECG were more often observed among patients with underlying CS as compared to true IVT. These findings may help to distinguish underlying CS among Cases presenting with OTVT/PVC.

Role and Relevance of Blood Pressure Variability in Hypertension Related Co-morbidities.

Despite maintaining mean blood pressure at optimal levels, cardiovascular complications still occur in hypertensive patients. Blood pressure variability (BPV) has been implicated as a prominent factor responsible for incurring this additional risk. In this review we attempted to generate a consensus on the importance of BPV in the hypertension management and to evaluate different therapeutic options available to reduce BPV. Panel comprising of 11 leading experts from India in different areas of clinical practice (including nephrology, diabetes and endocrinology, cardiology, and critical care medicine) was convened. The board reviewed up to date literature on BPV, shared personal experiences from their clinical practice, and debated their opinions on the significance of BPV in hypertension management and also on various therapeutic options available to control it. The reviewers agreed that BPV is frequently observed in hypertensive individuals and it is a critical factor in hypertension management. Blood pressure variability can be measured by ambulatory blood pressure monitoring, home blood pressure monitoring, and office blood pressure monitoring. Members concurred that variations in blood pressure that are 10 standard deviations above the mean blood pressure should be considered as pathologically significant and such variations should be reduced using pharmacological therapies. The board opined that Angiotensin II Receptor Blockers,Calcium Channel Blockers etc such as Olmesartan, Nifedipine can be used to reduce BPV. As a way forward, the panel recommends to bridge the evidence gap that establishes a possible direct relationship between BPV and cardiovascular complications. Blood pressure variability has paramount role in the current hypertension management scenario. To reduce disease burden and increase quality of life of hypertensive individuals, physicians should consider lowering BPV along with physiological BP levels.

Clinical Decision Pathway for the Use of Fondaparinux in the Management of Acute Coronary Syndrome (ACS) in Hospitals with and Without Catheter Laboratories: An Expert Opinion from India.

The current recommendations by Indian experts who are focused on the challenges in the management of patients with acute coronary syndrome (ACS) in rural areas, due to limited catheterization (CATH) lab facilities and interventional cardiologist coverage across the country, are described. 120 cardiologist experts drafted recommendations during ten advisory board meetings conducted from April to May 2022. Experts framed statements based on experience, collective clinical judgment from practical experience, and available scientific evidence regarding ACS. The consensus positioned fondaparinux as highly useful in non-CATH-lab-based hospitals for patients diagnosed with non-ST elevation acute coronary syndrome (NSTE-ACS) and ST elevation acute coronary syndrome (STE-ACS) patients who cannot be shifted to percutaneous coronary intervention (PCI)-capable centres, or for patients who are thrombolysed at peripheral centres.

Development and Validation of a Deep Learning System for Sound-based Prediction of Urinary Flow.

BACKGROUND: Uroflowmetry remains an important tool for the assessment of patients with lower urinary tract symptoms (LUTS), but accuracy can be limited by within-subject variation of urinary flow rates. Voiding acoustics appear to correlate well with conventional uroflowmetry and show promise as a convenient home-based alternative for the monitoring of urinary flows. OBJECTIVE: To evaluate the ability of a sound-based deep learning algorithm (Audioflow) to predict uroflowmetry parameters and identify abnormal urinary flow patterns. DESIGN, SETTING, AND PARTICIPANTS: In this prospective open-label study, 534 male participants recruited at Singapore General Hospital between December 1, 2017 and July 1, 2019 voided into a uroflowmetry machine, and voiding acoustics were recorded using a smartphone in close proximity. The Audioflow algorithm consisted of two models-the first model for the prediction of flow parameters including maximum flow rate (Qmax), average flow rate (Qave), and voided volume (VV) was trained and validated using leave-one-out cross-validation procedures; the second model for discrimination of normal and abnormal urinary flows was trained based on a reference standard created by three senior urologists. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Lin's correlation coefficient was used to evaluate the agreement between Audioflow predictions and conventional uroflowmetry for Qmax, Qave, and VV. Accuracy of the Audioflow algorithm in the identification of abnormal urinary flows was assessed with sensitivity analyses and the area under the receiver operating curve (AUC); this algorithm was compared with an external panel of graders comprising six urology residents/general practitioners who separately graded flow patterns in the validation dataset. RESULTS AND LIMITATIONS: A total of 331 patients were included for analysis. Agreement between Audioflow and conventional uroflowmetry for Qmax, Qave, and VV was 0.77 (95% confidence interval [CI], 0.72-0.80), 0.85 (95% CI, 0.82-0.88) and 0.84 (95% CI, 0.80-0.87), respectively. For the identification of abnormal flows, Audioflow achieved a high rate of agreement of 83.8% (95% CI, 77.5-90.1%) with the reference standard, and was comparable with an external panel of six residents/general practitioners. AUC was 0.892 (95% CI, 0.834-0.951), with high sensitivity of 87.3% (95% CI, 76.8-93.7%) and specificity of 77.5% (95% CI, 61.1-88.6%). CONCLUSIONS: The results of this study suggest that a deep learning algorithm can predict uroflowmetry parameters and identify abnormal urinary voids based on voiding sounds, and shows promise as a simple home-based alternative to uroflowmetry in the management of patients with LUTS. PATIENT SUMMARY: In this study, we trained a deep learning-based algorithm to measure urinary flow rates and identify abnormal flow patterns based on voiding sounds. This may provide a convenient, home-based alternative to conventional uroflowmetry for the assessment and monitoring of patients with lower urinary tract symptoms.

A Rare Association of Patent Ductus Arteriosus (PDA) With Persistent Left Superior Vena Cava (PLSVC) and Unroofed Coronary Sinus (UCS) Terminating Into Left Atrium (LA): A Case Report of an Indian Infant.

Unroofed coronary sinus syndrome (UCSS), also named coronary sinus (CS) septal defect, is a rare type of atrial septal defect (ASD) with the incidence less than 1% of the total number of ASDs. It is caused by incomplete formation of left atrial venous folds during embryonic development. There is communication between the CS and left atrium (LA) due to the presence of a left superior vena cava (LSVC) along with an incomplete or complete loss of the CS roof draining into the LA. It usually presents as mild breathlessness on exertion and the appearance of murmurs on auscultation. A case that is diagnosed as an unroofed CS (UCS) related to a continuous LSVC terminating into the CS, which further terminates into LA, along with a large patent ductus arteriosus (PDA) is a rare presentation.

Ellis-Van Creveld Syndrome: A Rare Case Report of an Indian Child With Rare Cardiac Anomalies and Normal Intelligence.

Ellis-Van Creveld syndrome (EVCS) is an abnormal genetic condition of the EVC2 gene located on chromosome 4. In this case, the person presents with bone growth abnormalities, thus having a short stature, short arms and legs (more commonly the forearm and lower leg), a narrow chest with short ribs, polydactyly, spoon-shaped or malformed nails, abnormalities in dentition, and congenital heart defects like atrial septal defects and ventricular septal defects. In this case report, we present a 4.5-year-old female child who presented with cough and cyanosis as signs and tachypnea, tachycardia, facial oedema, cold, and clubbing as symptoms with polydactyly and short stature focuses on a rare presentation of a syndromic disease known as EVCS.

Resurgence of hypertension and cardiovascular diseases in patients recovered from COVID-19: An Indian perspective.

Objective: The aim of this study was to understand the prevalence, extent, clinical approach of hypertension and cardiovascular disease (CVD) in patients recovered from COVID-19. Methods: The round table meetings (RTMs) and survey convened a diverse panel of specialists including cardiologists, endocrinologists, diabetologists, consultant physicians, and family physicians from various geographical zones of India. A standard questionnaire including 10 questions was developed pertaining to the resurgence of hypertension and CVD in patients recovered from COVID-19. The RTMs and survey were held virtually. The collected opinions and recommendations were compiled to derive a consensus document. Results: A total of 3066 health-care practitioners (HCPs) participated. Hypertension was the most prevalent comorbidity in patients recovered from COVID-19 followed by diabetes, dyslipidemia, and coronary artery disease. Almost two-thirds of HCPs reported that 10%-30% newly diagnosed hypertension in patients recovered from COVID-19. Uncontrolled hypertension in 10-20% of COVID-19 recovered patients opined by 45% of the HCPs. About, 35% HCPs reported CV complications in 10-20% of Covid-19 recovered patients and 63% HCPs reported exacerbations of CAD in 10-30% of patients. Majority of HCPs preferred to switch to dual combination therapy from monotherapy for hypertension management (52.0%) and ARBs and its combination is most preferred combination for hypertension control (60%). Majority of the HCPs suggested follow-up after 1-2 weeks (39.0%). Close monitoring on symptoms including chest pain and breathlessness (45.0%), adherence to medication and regular monitoring of lab parameters (25%) is recommended for these patients. Conclusion: Overall observations indicate an increased incidence of hypertension and CVDs post recovery from COVID-19. A dual therapy of ARBs was the preferred choice for management of hypertension. Regular follow-up and close monitoring of symptoms to prevent further CV complications in COVID-19 recovered patients is recommended.

Predictors of Left Main Coronary Artery Disease in the ISCHEMIA Trial.

BACKGROUND: Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has prognostic and therapeutic implications. Noninvasive stress imaging or an exercise tolerance test (ETT) are the most common methods to detect obstructive coronary artery disease, though stress test markers of LMD remain ill-defined. OBJECTIVES: The authors sought to identify markers of LMD as detected on coronary computed tomography angiography (CTA), using clinical and stress testing parameters. METHODS: This was a post hoc analysis of ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), including randomized and nonrandomized participants who had locally determined moderate or severe ischemia on nonimaging ETT, stress nuclear myocardial perfusion imaging, or stress echocardiography followed by CTA to exclude LMD. Stress tests were read by core laboratories. Prior coronary artery bypass grafting was an exclusion. In a stepped multivariate model, the authors identified predictors of LMD, first without and then with stress testing parameters. RESULTS: Among 5,146 participants (mean age 63 years, 74% male), 414 (8%) had LMD. Predictors of LMD were older age (P < 0.001), male sex (P < 0.01), absence of prior myocardial infarction (P < 0.009), transient ischemic dilation of the left ventricle on stress echocardiography (P = 0.05), magnitude of ST-segment depression on ETT (P = 0.004), and peak metabolic equivalents achieved on ETT (P = 0.001). The models were weakly predictive of LMD (C-index 0.643 and 0.684). CONCLUSIONS: In patients with moderate or severe ischemia, clinical and stress testing parameters were weakly predictive of LMD on CTA. For most patients with moderate or severe ischemia, anatomical imaging is needed to rule out LMD. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Congenital isolated unilateral agenesis of pulmonary arteries in adults: case series and review.

Congenital, isolated unilateral agenesis of pulmonary arteries (UAPA) has a bimodal clinical presentation. It is either diagnosed in early infancy or during adulthood. Early diagnosis and timely surgical correction at infancy prevent the development of irreversible pulmonary hypertension and enable prolonged survival. Though surgical intervention is a conclusive method of treatment, its outcome depends upon the reversibility of pulmonary hypertension and the adequacy of the pulmonary artery dimension. Adults with UAPA can be asymptomatic (diagnosed incidentally) or symptomatic. They may present clinically with myriads of symptoms like exertional dyspnea, recurrent lung infection, hemoptysis, and atypical chest pain. For cases where definitive surgical treatment is not feasible, interventional and medical management should be carried out as part of palliative therapy. A retrospective analysis of 22 cases of UAPA in adults published in the literature from the years 2017-2020 are presented here, along with our institutional case.

Prevalence and spectrum of coronary artery anomalies in 8021 patients: A single center study in South India.

OBJECTIVE: To identify the prevalence of coronary artery anomalies (CAAs) and their subtypes based on Angelini et al. classification in symptomatic yet stable population of South India using 64- slice dual source multi detector CT coronary angiography (MDCT-CA). METHODS: We retrospectively reviewed reports of 8021 symptomatic patients predominantly South Indians who were referred for CT coronary angiography (CT-CA) to our tertiary cardiac care center in Hyderabad, India from January 2011 to March 2017. RESULTS: We identified a total of 838 coronary artery anomalies in 812 patients with a prevalence of 10.09%. 96.9% of patients were older than 30 years of age with a M:F ratio of 1.39:1. Coronary artery disease (CAD) was seen in 61.5% of these patients. Among these anomalies, myocardial bridging (MB) was the most common anomaly followed by anomalous location of coronary ostium at improper sinus (ACOIS). CONCLUSION: There is no significant difference in prevalence of CAAs (including and excluding MB) in Indian and World population. CAAs were more common in males than females and most of these patients remain asymptomatic during first three decades of their life. Myocardial bridging is the most common anomaly detected by MDCT-CA followed by ACOIS. Right coronary artery (RCA) arising from left coronary sinus (LCS) is the most commonly encountered ACOIS.

Transcatheter closure of large right pulmonary artery-to-left atrial fistula.

We report the successful transcatheter closure of right pulmonary artery fistula to left atrium in a six-year-old boy, who had presented with cyanosis and shortness of breath. The two-dimensional echocardiogram with bubble contrast study demonstrated the communication between right pulmonary artery and left atrium. Computerized tomography confirmed the diagnosis and delineated the anatomy. The fistula was closed successfully by a transcatheter trans-septal approach using an 18/20 duct occluder.

Contribution of sudden cardiac death to total mortality in India - a population based study.

INTRODUCTION: Epidemiology of sudden cardiac death (SCD) in India is understudied. METHODS: We assessed proportion of SCD among total mortality in a population in Southern India using a staged, questionnaire-based kindred-wide approach. Detailed questionnaires (DQs) were completed by medical trainees from 8 medical colleges. Preliminary questionnaires evaluated total deaths in the kindred of a respondent. Deaths due to obvious non-cardiac causes were excluded. DQs were completed for the remaining deaths and categorized using a three-member adjudication system. RESULTS: A total population of 22,724 was evaluated by 478 respondents, (278 M and 200 F). Out of a total of 2185 deaths, 1691 (77.4%) were recallable. A total of 173 (10.3%; 128 M and 45 F; mean age - 60.8 ± 14 years) deaths were adjudicated as SCD. Of these, 82 (47.3%) were ≤ 60 years of age. Prior MI, LV dysfunction and prior aborted SCD were found in 33.5%, 22.5% and 5.7% respectively. Coronary artery disease (CAD) was observed in 66 (38%) and acute myocardial infarction documented in 30 (17%). At least 1 of 3 CAD risk factors - hypertension, diabetes, or smoking was observed in 80.6%. Proportion of subjects with at least one risk factor for CAD were similar in the age groups above and below 50 years (67.6% vs. 81.7%, p=0.065). CONCLUSIONS: SCD contributed to 10.3% of overall mortality in this population from Southern India. On an average, SCD cases were 5-8 years younger compared to populations reported in the western hemisphere, with a high prevalence of major risk factors for CAD.

Case report: Intra-atrial course of right coronary artery: Evaluation by dual-source CT.

We report a case of an anomalous course of the right coronary artery (RCA) through the right atrium, which was evaluated using dual-source CT angiography. There have been a few cases described previously in literature, but most of them were found either during surgery or at autopsy. Although this variant is clinically benign, it has significant consequences during interventional procedures or bypass surgery.