Changing pattern of admissions for acute myocardial infarction in India during the COVID-19 pandemic

AIM

Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India.

METHODS & RESULTS

In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = -0·48; r2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively.

CONCLUSIONS

The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

Whole-exome sequencing and homozygosity mapping identify variants in NCOR1 and MAP2K3 associated with non-syndromic congenital heart defects

Background

Homozygosity mapping is an efficient gene mapping method applicable to recessive disorders. It can detect homozygous segments of identical haplotype structures shared at a higher frequency among ventricular septal defect (VSD) and tetralogy of Fallot (TOF) cases. This study aims to identify the recessive genes involved in congenital heart disease (CHD) cases by homozygosity mapping. A total of 36 CHD cases of Indian origin were recruited based on inclusion and exclusion criteria, disease severity, and hole size. Of these, ten prediagnosed VSD and TOF cases were selected for homozygosity mapping. For in silico validation of variations, overlapping gene variants were analyzed from 26 cases based on pathogenecity and haploinsufficiency scores.

Results

Genome-wide homozygosity mapping identified 34 homozygous regions with a maximum block length of 80 bp marked for the CHD samples under study. A total of 4863 genes were identified in these 34 homozygous regions, which were present across almost all chromosomes except chromosomes 4, 8, 12, and 13. The homozygosity region found in chromosome 17 revealed genes for CHD manifestation. This homozygous region contained VSD- and TOF-related genes—Nuclear Corepressor 1 (NCOR1) and Mitogen-Activated Protein Kinase Kinase 3 (MAP2K3). In silico validation identified damaging variants for NCOR1 and MAP2K3. Three variants, G207C, C241T, and G244A, were found on exon 2 in the transcript NM_001190438 for NCOR1. Three variants were also found for MAP2K3, namely G194T and C199T in exon 5 and C578T in exon 8 in the transcript NM_002756. All these variants were present in the protein kinase domain.

Conclusion

Presence of homozygous regions identifies recessive genes leading to disease severity. Defects in recessive genes NCOR1 and MAP2K3 are responsible for abnormal myogenesis, resulting in CHD manifestation.

Endovascular Interventions to Superficial Femoral Artery Occlusion: Different Approaches, Technique, and Follow-up

Background

Superficial femoral artery lesion is one of the main causes for intermittent claudication or critical limb ischemia. Percutaneous transluminal angioplasty is one of the approved therapies for this medical entity. Anatomical factors should be considered in choosing the right approach and puncture.The purpose of this study is to discuss the anatomical, radiological, and technical factors which determine the preference of various approaches and to determine its safety, efficacy, and mid-term clinical and radiological outcome.

Methods

Retrospectively, data were collected from patients who underwent angioplasty to superficial femoral arteries for total occlusion from January 2015 and June 2018 in our center, we performed angioplasty to 59 occluded superficial femoral artery patients at our center. The ipsilateral femoral artery, ipsilateral popliteal artery, contralateral femoral artery, or upper limb approaches were used depending on the various anatomical factors determined by radiological imaging before the procedure.

Results

Acute success rate was 91.52%. There were no significant periprocedural complications. At the latest clinical follow-up of mean 25.8 months (10-51), a restenosis rate of 16.67% in infrainguinal arteries and 5.88% in suprainguinal arteries were noted.

Conclusions

Percutaneous transluminal angioplasty of superficial femoral artery is a proven, viable, safer, and effective option, with good mid-term clinical results and patency rates. Different approaches to be chosen depends on the anatomical and technical factors to get the best possible outcome.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design

Background

COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India.

Methods

In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic.

Conclusions

This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

"Incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation at a high volume cardiac care center during percutaneous coronary intervention"

AIMS

To study the incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) at a high volume center in South-east Asia.

METHODS

Data from patients who had CAP during PCI from January 2016 to December 2019 at our center were collected. Clinical features, angiographic and procedural characteristics, their management and outcomes were analyzed retrospectively.

RESULTS

A total of 40,696 patients underwent PCI during the study period and the incidence of CAP was 0.13% (n = 51). Mean age was 60.0 ± 10.8 years and 69% were males. CAP cases involved complex type B2/C lesions in 73%, calcified lesions in 58%, and chronic total occlusions in 25%. Majority of patients presented as acute coronary syndrome (65%) and STEMI was the most frequent indication for PCI (33%). Most of the CAPs were Ellis type II (33%) and III (55%). CAP most frequently occurred during post dilation (n = 20) and wire manipulation (n = 17). Majority were treated by prolonged balloon inflation (53%) and covered stents (33%). Pericardiocentesis was required in 19 patients to alleviate tamponade. In one patient coil embolisation was done and two patients required bail-out emergency cardiac surgery. Periprocedural myocardial infarction occurred in 6% and in-hospital mortality was 10%. All-cause mortality accrued to 14% at 30 days and 16% at 6 months.

CONCLUSION

Although incidence of CAP in contemporary interventional practice remains low, the morbidity and mortality are considerable. Early recognition and management strategies tailored to the severity of perforation play a key role in achieving better outcomes.

Percutaneous Antegrade and Retrograde Endovascular approach to Symptomatic High-Grade Subclavian Artery Stenosis: Technique and Follow-Up

Background and Purpose:

Angioplasty and stenting of the subclavian artery have been reported with high technical and clinical success rates, low complication rates, and good midterm patency rates. Different antegrade or retrograde endovascular catheter-based approaches are used. Nowadays, endovascular therapy has taken over open surgical techniques in subclavian artery disease. The purpose of this study was to determine safety, efficacy, and midterm clinical and radiological outcome of the endovascular treatment with special focus on the different technical approaches in subclavian artery disease.

Materials and Methods:

Between 2014 and 2017, 11 patients (10 men, 1 woman) with symptomatic high-grade stenosis (90%–100%) of the subclavian artery were treated with endovascular treatment. Their mean age was 51.3 years (range, 32-61 years). Mean angiographic and clinical follow-up was 22.5 months (range, 5-44 months). Clinical follow-up was performed at hospital discharge and routine follow-up was performed at 1, 3, 12 months, and 6 monthly thereafter. In all 11 patients, a percutaneous approach was used successfully. In eight patients, the lesions were accessed retrogradely through a brachial artery puncture.

Results:

Acute success rate was 100%. There were no significant peri-procedure complications. At the latest clinical follow-up (mean of 22.5 months), all patients showed a good outcome with a restenosis rate of 18.2% including a patient with Takayasu arteritis.

Conclusion:

Percutaneous antegrade and retrograde stenting of high-grade subclavian artery stenosis is a viable less invasive alternative to open bypass surgery with good midterm clinical results and patency rates.

A review of squamous cell carcinoma arising in mature cystic teratoma of the ovary

INTRODUCTION

Germ cell tumors account for 20-25% of ovarian neoplasms. Mature cystic teratoma (MCT) is the most common ovarian germ cell tumor. Malignancy in MCT is seen in 1-2% of the cases. Squamous cell carcinoma (SCC) accounts for 80% of the cases and carries a poor prognosis.

AIM

To study the clinicopathological factors, management protocols and its outcome.

MATERIALS AND METHODS

Case records reviewed from August 2006 to August 2011 at our institute identified 10 women with SCC in ovarian MCT. Staging was done according to FIGO 2009 guidelines. Primary surgery followed by adjuvant treatment with platinum based chemotherapy was given.

RESULTS

Median age was 53.5 years. Six out of 10 patients were postmenopausal and aged above 50 years. Abdominal pain and abdominal mass were the most common presenting symptoms. According to FIGO: Two in stage 1, five in stage 2, two in stage 3 and one in stage 4. Among six optimally cytoreduced patients, five (83%) had no evidence of disease with a median follow up of 10 months. Whereas all four (100%) suboptimally cytoreduced patients had progressive disease within 3 to 4 months of primary surgery despite chemotherapy.

CONCLUSION

Squamous cell carcinoma in MCT of ovary is a rarity. It carries a poor prognosis, especially in advanced stages and suboptimally cytoreduced patients. Platinum with or without taxane based chemotherapy may be useful as adjuvant treatment. However, further studies and standardization of treatment protocols are required for any recommendations.

A retrospective clinicopathological study of 131 cases with endometrial cancers--is it possible to define the role of retroperitoneal lymphadenectomy in low-resource settings?

AIM

The study objectives were evaluation of clinicopathological characteristics, correlations between the preoperative and postoperative tumor grades, and their implications on lymph node metastasis.

MATERIALS AND METHODS

We conducted a retrospective descriptive study of 131 cases of endometrial cancer examined and treated at a tertiary regional cancer institute between the years 2003 and 2009. We reviewed the oncology database as well as the clinical records and surgico-pathological registry of all these patients. Statistical Methods Used: All the summary measure computation and Chi-square test for comparing more than one proportion was done in spreadsheet (Excel).

RESULTS

The multiparity association with endometrial cancer was commonly seen 113/131 (86.2%). Twelve (9.7%) patients preoperatively diagnosed as Grade 1 tumors upgraded to Grade 3 changes in postoperative specimens and six of these 12 patients (50%) had lymph node metastasis. A total of 14/131 (10.6%) cases had lymph nodes metastasis.

CONCLUSIONS

There is a poor correlation between the preoperative and the postoperative tumor grades. Routine pelvic lymphadenectomy may be a valuable method in low-risk cases and para-aortic lymphadenectomy may be limited to high-risk endometrial cancers.