Antimicrobial susceptibility of Viridians Group of Streptococci isolated from infective endocarditis patients from 2018 to 2023

INTRODUCTION

Viridans Group of Streptococci (VGS) are heterogeneous alpha hemolytic Streptococci that form commensal flora in the oral cavity, upper respiratory tract, gastrointestinal tract and female genital tract and are potential pathogens that can cause serious infections like infective endocarditis and bacteremia. Penicillin or Ceftriaxone is the recommended first line agent for definitive therapy of VGS endocarditis. Alteration in penicillin binding proteins can decrease the susceptibility of VGS to penicillin and other beta-lactam agents and complicate antimicrobial therapy for serious VGS infections like Infective endocarditis. The aim of our study was to determine the antimicrobial susceptibility pattern of viridians group Streptococci isolated from blood samples of infective endocarditis patients from April 2018 to September 2023 against betalactam and other agents.

MATERIAL AND METHODS

Three sets of blood cultures with 8-10 ml per bottle were collected from suspected infective endocarditis and incubated in automated blood culture system (BACTEC from BD diagnostics). The broth from positive bottles was streaked on Blood agar, Chocolate agar and MacConkey agar plates and incubated at 37°C. Alpha hemolytic Streptococci that grew after 24-48 h were further identified and antimicrobial susceptibility determined by Vitek 2 system.

RESULTS

A total of 100 VGS was isolated from blood samples of Infective endocarditis patients. The species most commonly isolated in our study was S. sanguinis (25%) and S.mitis/oralis group (23%) followed by Non speciated Viridans Streptococci (17%). The lowest penicillin susceptibility ie. PEN MIC <0.12 μg/ml of 40% was observed in S. alactolyticus group, followed by S. mitis (52%) and S. gallolyticus (56%). S. mitis/oralis group showed the lowest susceptibilities to betalactam antibiotics among all speciated and non speciated VGS.

CONCLUSION

Infective endocarditis carries a very high mortality and morbidity and the emergence of resistance to betalactam agents like penicillin will only narrow available therapeutic options and further challenge the treatment.

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.

The Squeezed Heart-A Case Report

Pompe’s disease is an autosomal recessive disorder caused by inherited deficiency of α-1,4-glucosidase (acid maltase), a lysosomal enzyme. Patients usually die in the first year of life from cardio-respiratory failure due to massive left ventricular hypertrophy. We report a case of 3-month-old boy presented with fatal infantile onset Pompe’s disease.

The Effect of mobile application based technology use on medication compliance and modification of risk factors in Post PTCA cohort of patients

Mobile application-based technology was used to study medication compliance and influence on cardiovascular lifestyle in ischemic heart disease (IHD) patients who undergo percutaneous transluminal coronary angioplasty (PTCA). The Mobile-app was made available at Google play store; the app was downloaded and instructions to use were thought to patients by the research team during hospitalization in the study group. A total of two hundred patients with ischemic heart disease who underwent PTCA were enrolled into the study. The control group had telephonic follow up at periodic interval. Both groups had clinical follow ups at appropriate time intervals. Higher medication compliance, smaller number of adverse events and regular follow ups were significantly more in mobile-app group than in control group.

Neutralising Antibodies in Healthcare Workers after Two Doses of Covishield Vaccine at Three Months and Six Months: A Single-centre Observational Study

Introduction: The emergence of Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) as a pandemic has put the global population at risk for its infection. It has also led to an accelerated effort to develop vaccines that can mitigate progression to severe infections at a minimum. The ambiguity about existence of antibodies in the human serum poses problem in formulating public health policies like suitable interval between doses of vaccines, appropriate time for vaccinating population, post natural infection, necessity of booster doses along with single dose. Aim: To estimate neutralising antibody level following vaccination of Healthcare Workers (HCWs) after three months and six months respectively. Materials and Methods: This was a prospective observational study performed in Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India after Institutional Ethics Committee (IEC) approval from January 2021 to February 2022. The study was conducted in 304 HCWs in the institute who had received two doses of Recombinant ChAdOx1 nCoV- 19 Corona Virus Vaccine (Covishield). 41 HCWs who were naturally infected with SARS-CoV-2 either before or after vaccination were also included. These participants were then subjected to IgG neutralising antibody titer estimation at three months and six months, postvaccination. Results: The study included 304 eligible HCWs. Majority of the participants belonged to the age group of 31-40 years (35.9%). Majority of the study participants were females (51%). Of the 304 participants, 263 were uninfected and 41 participants had been infected before and after vaccination. At the six month follow-up, it was observed that all but one HCW had seroconverted with majority of the participants showing more than 60% antibody level. Participants in the age group of 31-40 years showed the highest level and this observation was found to be statistically significant. Conclusion: Neutralising antibody response in HCWs is a key indicator of the efficacy of the vaccination program for Coronavirus Disease-2019 (COVID-19) in India.

Association of Chest CT Severity Scores and Vaccination Status in COVID-19 Disease: A Cross-sectional Study

Introduction: Coronavirus Disease 2019 (COVID-19) has emerged as a pandemic with substantial morbidity and mortality. While global efforts towards mitigating the infection are focused on the vaccination of population, studies are warranted to prove the efficacy of vaccine in prevention of infection or reducing the severity of infection in affected patients. The 25-point High Resolution Computed Tomography (HRCT) severity score has proved to be an effective tool in estimating the severity of lung infection and correlates with laboratory parameters and disease outcome. The HRCT scores hence provide an objective evidence to prove the efficacy of vaccines in vaccinated individuals by assessing the extent of lung involvement. Aim: To compare the chest CT severity score in vaccinated and unvaccinated COVID-19 infected patients. Materials and Methods: This cross-sectional study was conducted in the Department of Radiology, at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Mysuru, Karnataka, India. The data of HRCT scores and vaccination status was collected during the month of April 2021 from patients who were suspected to have COVID-19 infection and underwent a chest HRCT scan. The severity of lung infection in vaccinated and unvaccinated individuals was compared based on the HRCT scores and the association between these variables were analysed. The association between the respective variables were studied using Fischer’s-exact and Kruskal-Wallis tests. Results: The study involved a total of 178 subjects (males were 98), where 127 (71.3%) were unvaccinated and 51 (28.6%) were vaccinated with one or both doses {Covaxin (Bharat Biotech) vaccine or Covishield (Oxford-AstraZeneca) vaccine approved by Emergency Use Authorisation (EUA)}. The frequency of disease was least in 14 (7.9%) among fully vaccinated subjects. Severe COVID-19 associated pneumonia with severity score of 18 or more was seen in 7% of unvaccinated individuals, while none of the partial/fully vaccinated individuals had severe disease. The median CT severity score was significantly higher among unvaccinated patients compared to partially and fully vaccinated patients (p-value=0.001). Fully vaccinated patients had almost low CT severity score indicating mild form of disease. Conclusion: To the best of authors knowledge, this study is the first to describe the chest CT severity scores of vaccinated individuals in comparison with the unvaccinated COVID-19 infected patients. The disease severity was significantly higher among unvaccinated patients compared to partially and fully vaccinated patients. The present study has provided substantial evidence of vaccine efficacy in reducing the disease severity in COVID-19 infected patients.

Incidence and predictors of chronic thromboembolic pulmonary hypertension following acute pulmonary embolism: An echocardiography guided approach

There is significant variability in the worldwide epidemiology of chronic thromboembolic pulmonary hypertension (CTEPH). We thereby aim to determine the incidence and predictors of CTEPH, following an episode of acute pulmonary embolism (PE), using non-invasive modalities. Patients with acute PE were prospectively followed-up and after receiving at least 3 months of effective anticoagulation, persistently symptomatic patients with echocardiographic evidence of persistent pulmonary hypertension, were investigated further for CTEPH. Incidence of CTEPH was 8.19%. Delayed presentation, higher pulmonary artery pressures at presentation and discharge, and greater thrombotic burden were significant predictors for the development of CTEPH following acute PE.

Significance of 'recovery ST-segment depression' in exercise stress test

Objective

To study the significance of ST-segment depression during ‘recovery’ compared to that ‘during stress’ and ‘both the phases’ in exercise stress test.

Methods

Patients with positive exercise stress test who underwent coronary angiography (CAG) from 1st January 2017 to 31st December 2018 were studied. Patients were divided into 3 groups- Group A with ST-depression restricted to recovery phase, group B with ST-depression restricted to stress phase and group C with ST-depression seen both during exercise and recovery. All patients underwent CAG. Sensitivity, specificity, and predictive values of each of these groups in diagnosis of significant coronary artery disease (CAD) were analysed and compared.

Results

Total 300 patients were studied. Mean age of the study population was 48.77 ± 7.94 years. 78.3% of patients with positive exercise stress test had significant CAD. 96% of patients in group A had significant CAD, which was higher than in group B (88.9%) & group C (70.1%). The specificity, positive predictive value and negative predictive value of ST-segment depression in group A (96.92%, 96% and 25.2% respectively) were higher than that of ST-depression in group B (89.23%, 88.89% and 24.47% respectively) and group C (13.85%, 70.05% and 7.96% respectively). Sensitivity and accuracy of ST-depression in group A were lower (20.43% and 37% respectively), compared to other 2 groups.

Conclusion

Patient with ST-depression restricted to recovery phase had highest specificity, positive predictive value, and negative predictive value. However, accuracy was highest in group with both stress phase and exercise ST-segment depression.

Feasibility and Outcomes of Left Main to Branch Vessel PCI with Novel Tapered Coronary Stent in a Tertiary Care Centre: A Real World Experience

OBJECTIVE

To assess the safety and efficacy of Novel tapered (BioMime™ Morph) sirolimus-eluting stent (SES) for left main PCI in a real-world scenario.

BACKGROUND

Currently no data is available on clinical usefulness of tapered ultrathin stents in left main PCI.

METHODS

This was a prospective, non-randomised, single centre study carried out between February 2018 and May 2020 at a tertiary cardiac care centre in southern India. The study included patients treated with BioMime Morph tapered stent for distal de novo LMB lesion or ostial LAD/LCX lesions with significant size disparity between reference segments based on the eligibility criteria. Primary endpoint of the study was the cumulative incidence of major adverse cardiovascular events (MACE) composed of cardiac death, myocardial infraction, and clinically driven target-lesion revascularisation at follow-up.

RESULTS

A total of 41 patients (average age of 54.83±9.81 years) were included in the study. Average SS-2 score was 23.17±5.42. Majority of the lesions (n=31; 75.61%) were of medina class (0.1.0). Provisional single stent strategy was adopted for treatment of LMB lesions. TIMI flow-3 was achieved in 40 patients (97.56%). Median clinical follow-up was 20 months (range 6-34 months) There was no periprocedural complication or MACE during follow-up.

Acute decompensated heart failure (ADHF) during COVID-19 pandemic-insights from South India

AIM

This retrospective study compares admissions and outcomes due to acute decompensated heart failure (ADHF) during the COVID-19 pandemic from 25 March to 25 July 2020 with the historical patient control who were admitted during the same period in 2019.

METHODS AND RESULTS

Data of the participating hospitals was collected and analysed from the ICC NHFR (Indian College of Cardiology National Heart Failure Registry) for 2019 and 2020. Total number of ADHF admissions, demographics, aetiology, co-morbid conditions and in-hospital mortality was compared and analysed. A significant decrease in the number of hospital admissions due to ADHF from 2019 to 2020 (1056 vs. 526 respectively) was noted. Incidence of admissions with <40% ejection fraction (EF) reduced in 2020 (72.4% and 80.2% in2020 and 2019)and >40% (EF) increased (27.6% and 19.8% in 2019 and 2020 respectively, p = 0.0005). Ischemic heart disease (IHD) was the most common aetiology (78.59% in 2019 and 80.98% in 2020, p = 0.268). The in-hospital mortality was numerically higher in 2020 (10%) than in 2019 (8%), but not statistically significant (p = 0.161).

CONCLUSION

This study from the registry shows that the incidence of ADHF admissions during COVID-19 lockdown significantly reduced compared to the previous year. Demographic patterns remained similar but patients presenting with de-novo HF increased; IHD was the most common cause. The in-hospital mortality was numerically higher during the lockdown. The impact of lockdown perhaps led to fewer hospitalisations and this is to be factored in future strategies to address health care delivery during such crises.

Profile of coronary artery disease in indian rural youth (< 35 yrs)

AIMS

To study the risk factors, clinical and angiographic profile of Indian rural youth (under 35yrs) presenting with Premature Coronary Artery Disease (PCAD).

SUBJECTS

and Methods: The PCAD registry had 1628 patients who were aged below 35 years, of which 681 patients satisfied the entry criteria. The data was analysed by statistical software R version 3.5.0.

RESULTS

The study enrolled 681 patients after satisfying the entry criteria. The mean age of patients was 30.85 years. There were 405 (59.5%) aged between 30 and 35 yrs, 205 (30.1%) between 25 and 30 yrs, 64 (9.4%) between 20 and 25 yrs and 7 (1.0%) were aged less than 20 yrs. Majority of them were males, 617 (90.6%). Nearly 411 (60.4%) were smokers, 56patients (8.2%) were diabetics and 97 (14.2%) were hypertensives. Around 441 (64.8%) patients had low HDL cholesterol levels and 218 (32.0%) had elevated triglyceride levels. Abdominal obesity was seen in 443 (65.1%) patients. Most common clinical presentation was ST elevation myocardial infarction (STEMI) seen in 536 (78.7%) patients. Around 40% patients had recanalized/non obstructive/thrombotic/normal coronaries on coronary angiogram.

CONCLUSIONS

Conventional risk factors such as smoking, low HDL levels and abdominal obesity play a major role in the causation of premature coronary artery disease among the rural youth. Thrombotic milieu in the coronaries was commonly noted in coronary angiograms. Lack of awareness, combined with urbanisation of rural lifestyle could be responsible for increasing incidence of premature coronary artery disease in rural youth.

Combined cardiac anomalies in Noonan syndrome: A case report

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Noonan syndrome is the second most common syndromic cause of CHD.

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We present a rare case of Noonan syndrome having a combination of ASD, PS and HCM.

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Patient underwent balloon valvotomy for pulmonary stenosis.

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The patient is under regular follow-up and awaiting heart transplant.

Introduction

Noonan syndrome is the second most common syndromic cause of congenital heart disease. Most patients have an autosomal dominant inheritance, but some cases may be sporadic. Pulmonary stenosis is the most common cardiac manifestation in Noonan syndrome, associated with the atrial septal defect and hypertrophic cardiomyopathy. A combination of these three is present only in 5% of patients.

Presentation of case

We report a case of a 21-year-old female who presented to our hospital concomitant cardiac lesions associated with pulmonary stenosis, atrial septal defect, and hypertrophic cardiomyopathy. This combination of cardiac defects is an infrequent manifestation of Noonan syndrome. The patient presented with complaints of exertion syncope over the past two years. 2D-Echocardiography showed biventricular hypertrophy, dysplastic pulmonary valve, severe pulmonary stenosis, asymmetric septal hypertrophy and large atrial septal defect. The genetic analysis report showed autosomal dominant inheritance with Ras/MAPK (mitogen-activated protein kinase) Positive.

Discussion

Due to the wide spectrum of symptoms and presentations in Noonan cases, accurate clinical and genetic diagnosis, and comprehensive management of the disorder are strongly recommended.

Conclusion

We have described a case of rare combination of cardiovascular defects in Noonan Syndrome with a view to achieve better insight into the disease course and advantages of timely treatment and follow up. Our patient is currently in follow-up after treatment with percutaneous balloon pulmonary valvuloplasty, has improved symptoms, and is awaiting heart transplant.

A rare case of type X dual left anterior descending coronary artery

A dual left anterior descending (LAD) coronary artery is a rare, and benign congenital anomaly. In this anomaly, there is the presence of two LADs in the anterior inter ventricular sulcus (AIVS). One of the LADs is a short one that ends high in the AIVS. The other longer one enters the distal AIVS and feeds the apex. To date, 9 types of dual LAD variants, and one novel type X has been reported. Herein, we report a case of type X dual LAD with a literature review. <Learning objective: Dual left anterior descending coronary artery (LAD) is an important coronary anomaly to be aware of by interventional cardiologists to avoid misinterpretation of coronary angiography and surgical complications related to coronary interventions. We report a new variation of type X dual LAD with a literature review.>.

P1460Seismocardiographic measurement of systolic time intervals in left ventricular dysfunction: validation with transthoracic echo

Background

Systolic time intervals (STI) measured using Transthoracic Echo (TTE) have been shown to be sensitive indicators of contractile performance, but TTE is limited to a hospital setting. Recent advances in technology have enabled the simultaneous measurement of Electrocardiograms (ECG) and Seismocardiograms (SCG) using wearable devices. However, the use SCG to measure STIs has not been validated in a mobile setting, or on pathological subjects.

Purpose

To test the validity of an automated algorithm for measuring STIs using a wearable device recording ECG and SCG, in subjects with varying degrees of left ventricular dysfunction.

Methods

179 Patients with suspected left ventricular dysfunction were assessed using TTE performed by a Cardiologist. Patients were simultaneously fitted with a novel wearable device worn on a chest strap, recording SCG and single-lead ECG data, while the cardiologist measured the pre-ejection period (PEP) and left ventricular ejection time (LVET) with the patient in a supine position. Of these subjects 29 (16.2%) were diagnosed with Dilated cardiomyopathy (DCM), and 109 (60.8%) had Ischemic Heart disease.

The SCG and ECG data recorded on the wearable device was then analysed using a peak-detection algorithm, which detected the Q,R,S points on the ECG, and then determined the 4 most prominent peaks in the SCG signal corresponding to each R-peak. Heart rate, patient's age, gender and SCG time intervals were then used in a DecisionTree algorithm to determine the values of PEP and LVET, which were were then compared against those determined by the cardiologist using TTE.

Results

The correlation coefficient (r2) between PEP calculated using TTE, and the values obtained from the algorithm analyzing SCG data was 0.92 while the mean error was 7.47%. The r2 between the LVET calculated using the TTE and the algorithm was 0.75, while the mean error was 8.53% (p-value<0.001 for all cases).

Results All Subjects With IHD Without IHD With DCM Without DCM Number of Subjects 178 109 69 29 149 PEP (r2) 0.92 0.89 0.94 0.88 0.91 PEP (% age error) 7.47 7.50 7.42 6.99 7.56 LVET (r2) 0.75 0.81 0.66 0.55 0.83 LVET (% age error) 8.53 6.69 11.4 20.42 6.16 DCM, Dilate Cardiomyopathy; IHD, Ischemic Heart Disease.

ECG + SCG signals for a DCM patient

Conclusion

The algorithm-derived STIs measured by SCG correlate well with those measured by TTE across most patient groups, including those with Dilated Cardiomyopathy and Ischemic Heart Disease, opening prospects for continuous remote monitoring of STIs in a mobile setting.

Acknowledgement/Funding

Fourth Frontier Technologies

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.

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.

Guidance on reuse of cardio-vascular catheters and devices in India: A consensus document

Reuse of medical device is accepted worldwide. Benefits of reuse include not only cost saving but a favorable impact on environment. However, certain requirements should be met for reuse to be safe and effective. The devices, which can be reused, should be clearly defined, a meticulous process for dis-infection and sterilization followed and its functionality ascertained before use. Further, an appropriate consent should be obtained where necessary and the cost saving entailed should be directly passed on to the patient.

Aortoiliac reconstruction in the setting of in-stent restenosis

Complex iliac artery obstructions, particularly bilateral stenosis or total iliac artery occlusions, are usually treated with aortofemoral or aortobifemoral graft surgery. However, surgical treatment is associated with 3% mortality rate and significant morbidity such as intestinal ischemia, spinal cord injury, and ureteral damage. Percutaneous interventions of aortic bifurcation offer a promising alternative to surgery with potentially lower morbidity and mortality risk. We report a case of peripheral artery disease who had underwent right transfemoral iliac angioplasty with femoropopliteal bypass presented again with bilateral lower limb ischemia, who was successfully treated with stent implantation with the kissing balloon technique.

Premature coronary artery disease in India: coronary artery disease in the young (CADY) registry

BACKGROUND

Coronary artery disease (CAD) occurs at younger age in India but only a limited number of studies have evaluated risk factors and management status. This is a multisite observational registry to assess risk factors and treatment patterns in young patients presenting with acute coronary syndrome (ACS) and stable ischemic heart disease (IHD).

METHODS

We recruited 997 young patients (men <55, women <65y) presenting with ACS or stable IHD successively at 22 centers across India. Details of baseline risk factors and management status were obtained. Descriptive statistics are reported.

RESULTS

Mean age of participants was 49.1±8y, 72% were men and 68% had ACS. Family history of CAD was in 50%, diabetes 44%, hypertension 49%, history of dyslipidemia 11%, smoking/tobacco use 39%, and sedentary habits in 20%. 1.3% had "possible familial hypercholesterolemia". Metabolic risk factors (high BMI, diabetes and hypertension) were significantly greater in women (p<0.01). Women were older at diagnosis of CAD and presented more often with non-ST elevation ACS. In the study cohort antiplatelet use was in 85%, beta-blockers 38%, statins 63% and ACE inhibitors/ARBs in 41% while in ACS patients it was 80.5%, 54.6%, 80.8% and 40.8%, respectively. 35.9% patients underwent percutaneous coronary intervention while coronary bypass surgery was performed in 10.4%.

CONCLUSIONS

Conventional risk factors including family history continue to play a pivotal role in premature CAD in Indians. Women have more of metabolic risk factors, present at a later age and have non-ST elevation ACS more often. There is a need to focus on improving use of evidence-based drug therapies and interventions.

Clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis - A single centre experience

OBJECTIVE

Aim of the study was to evaluate clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis.

BACKGROUND

Takayasu's arteritis is a chronic inflammatory vasculitis affecting the aorta and its major branches. Although it is more prevalent in Asia, the distribution of the disease is worldwide with different vascular involvement patterns and clinical manifestations.

METHODS

In this prospective study a total of 50 consecutive patients who were reported as having Takayasu's arteritis between January 2010 and April 2016 were evaluated. Detailed clinical presentation and angiograms of all patients were analysed.

RESULTS

50 patients were analysed during study period. Among 50 patients, 43(86%) were female and 7 (14%) were male. Average age of presentation was 26.92years. Most common clinical presentation was claudication (74%) followed by, musculoskeletal symptoms (48%), fatigue (46%), weight loss (22%), headache (22%), visual disturbances (16%), syncope (10%), dyspnoea (20%). Most common features were absent/diminished pulses (80%), difference in blood pressure (80%), followed by bruit (70%)hypertension (64%), cerebrovascular accident (8%),heart failure (8%) and aortic regurgitation (4%). According to the new angiographic classification, angiographic type I (40%) was encountered most frequently, followed by type III (30%), type V (16%), type IIb (8%), type IIa (2%), and type IV is (4%). Angioplasty was the main stay of treatment in 66% of the patients, remaining 34% of them were treated medically either with corticosteroids or methotrexate.

CONCLUSION

Takayasu's arteritis is a rare disease, affects mainly women, manifestations range from asymptomatic disease, found as a result of impalpable pulses or bruits, to catastrophic neurological impairment. Takayasu's arteritis is the common cause of renovascular hypertension. Angiography remains the gold standard for diagnosis. Angiographic evaluation and percutaneous transluminal angioplasty with stenting is useful in selected cases.

Influence of VKORC1 and CYP2C9 Polymorphisms on Daily Acenocoumarol Dose Requirement in South Indian Patients With Mechanical Heart Valves

Background and Aim:

Chronic rheumatic heart disease (RHD) patients who undergo valve replacement with mechanical valves require lifelong anticoagulation. Acenocoumarol, a vitamin K antagonist has a narrow therapeutic range and wide inter-individual variability. Our aim was to investigate the influence of polymorphisms of VKORC1 and CYP2C9 genes on the mean daily dose requirement of acenocoumarol.

Methods:

205 chronic RHD patients, with mechanical heart valves and on acenocoumarol therapy, were recruited. Genotyping for VKORC1 (−1639G>A and 1173C>T) and CYP2C9 (*2 & *3 alleles) polymorphisms was done by PCR-RFLP. There was complete linkage disequilibrium between VKORC1 polymorphisms (r2 = 0.98, D′ = 1.0, LOD = 74.02). VKORC1 genotype distribution for GG/CC, GA/CT, and AA/TT were 57.6%, 36.1%, and 6.3%, respectively. CYP2C9 genotype distribution for *1/*1, *1/*3, *1/*2, *2/*2, and *2/*3 were 78.5%, 14.1%, 6.3%, 0.5%, and 0.5%, respectively. Patients with a wild type of both VKORC1 (−1639GG and 1173CC) and CYP2C9 gene variants required higher acenocoumarol dose compared to those with mutant genotype ( P = 0.023 and P = 0.008 respectively). On combined genotype analysis, patients having a combination of wild type of VKORC1 with wild type of CYP2C9 (44.4%) required higher daily dose compared to patients bearing heterozygous VKORC1 (−1639GA & 1173CT) with wild type of CYP2C9 (30.2%, P = 0.008).

Conclusion:

Presence of a mutant allele of VKORC1 (−1639A & 1173T) and CYP2C9 genes increased the odds of requiring a lower mean dosage of acenocoumarol. Studying the combination of genotypes in RHD patients could predict acenocoumarol dose requirement more accurately.

Transposition of great arteries with natural partial Senning: A rare case report

The association of transposition of the great arteries (TGA) and anomalous pulmonary venous connection is extremely rare. Children with transposition of the great arteries improved dramatically with the advent of the atrial repair. In this report, we describe a 40-day old male infant with TGA and associated anomalous pulmonary venous connection who presented with the history of cyanosis and hurried breathing. This patient underwent successful balloon atrial septostomy and discharged with uneventful recovery.

Catheter-directed thrombolysis in management of postpartum lower limb deep venous thrombosis - A case series

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in the management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all five cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.

Transcatheter closure of ruptured sinus of Valsalva: Different techniques and mid-term follow-up

OBJECTIVES

The aim of the present study was to study the feasibility and approaches to device closure of ruptured sinus of Valsalva (RSOV). We have compared the advantages and disadvantages of different devices and techniques and discussed complications which might occur during or after the procedure.

BACKGROUND

There are only a few case series of transcatheter closure of RSOV, with most cases being traditionally referred for surgery. We have employed different devices used for treatment of congenital shunt lesions to achieve closure. Reasons for failure and need for surgical referral have also been analyzed.

METHODS

Transcatheter closure was attempted in a total of 25 patients of RSOV who presented to us over a period of 4 years. Different devices were deployed using antegrade and retrograde approaches. All patients have been on regular follow-up.

RESULTS

The procedural success rate was 84%. Two patients presenting in cardiogenic shock were effectively treated by device closure. There was one case of device embolization and two patients had residual leak. Three patients were referred for surgery. There was one case of device induced severe aortic regurgitation. Ventricular septal defect and RSOV were closed simultaneously in one patient.

CONCLUSIONS

Different approaches and devices may be used for transcatheter closure of RSOV. We prefer antegrade closure using duct occluders in most cases while muscular VSD occluders may be used in select situations. ADO II devices should hardly ever be used on their own for device closure of RSOV.

Multiple intracardiac tumors secondary to non-Hodgkin lymphoma

Primary tumors of the heart are rare and are usually benign. Disseminated malignancies and lymphomas rarely involve the heart. Non-Hodgkin lymphomas (NHL) are one of the common hematological malignancies that can affect the heart usually in the form of pericardial effusion. Involvement as intracardiac masses in NHL is extremely rare and usually described in autopsy series. We report a case of NHL and massive intracardiac involvement diagnosed on echocardiographic assessment. Primary cardiac NHL is extremely rare and accounts for 1-2 % of primary cardiac tumors involving the right versus left atrium at a ratio of about 8:1 (Ceresoli et al., Cancer 80:1497-1506, 1997; Delmas-Marsalet et al., Nouv Rev Fr Hematol 37:223-230, 1995). The intracardiac secondaries in NHL are extremely rare. They are usually described in autopsy series. We report the detection of secondaries in the cardiac chambers, on interatrial septum and in atrioventricular groove, diagnosed by transthoracic echocardiography.

Predicting mortality after congenital heart surgeries: evaluation of the Aristotle and Risk Adjustement in Congenital Heart Surgery-1 risk prediction scoring systems: a retrospective single center analysis of 1150 patients

AIMS AND OBJECTIVES

To validate Aristotle basic complexity and Aristotle comprehensive complexity (ABC and ACC) and risk adjustment in congenital heart surgery-1 (RACHS-1) prediction models for in hospital mortality after surgery for congenital heart disease in a single surgical unit.

MATERIALS AND METHODS

Patients younger than 18 years, who had undergone surgery for congenital heart diseases from July 2007 to July 2013 were enrolled. Scoring for ABC and ACC scoring and assigning to RACHS-1 categories were done retrospectively from retrieved case files. Discriminative power of scoring systems was assessed with area under curve (AUC) of receiver operating curves (ROC). Calibration (test for goodness of fit of the model) was measured with Hosmer-Lemeshow modification of χ2 test. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were applied to assess reclassification.

RESULTS

A total of 1150 cases were assessed with an all-cause in-hospital mortality rate of 7.91%. When modeled for multivariate regression analysis, the ABC (χ2 = 8.24, P = 0.08), ACC (χ2 = 4.17 , P = 0.57) and RACHS-1 (χ2 = 2.13 , P = 0.14) scores showed good overall performance. The AUC was 0.677 with 95% confidence interval (CI) of 0.61-0.73 for ABC score, 0.704 (95% CI: 0.64-0.76) for ACC score and for RACHS-1 it was 0.607 (95%CI: 0.55-0.66). ACC had an improved predictability in comparison to RACHS-1 and ABC on analysis with NRI and IDI.

CONCLUSIONS

ACC predicted mortality better than ABC and RCAHS-1 models. A national database will help in developing predictive models unique to our populations, till then, ACC scoring model can be used to analyze individual performances and compare with other institutes.

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.

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.

RAPSTROM™ first-in-man study long-term results of a biodegradable polymer sustained-release sirolimus-eluting stent in de novo coronary stenoses

BACKGROUND

Durable polymers used for first-generation drug-eluting stents (DES) potentially contribute to persistent inflammation and late DES thrombosis. We report the first real-life human experience with the rapamycin-eluting biodegradable polymer-coated Rapstrom stent.

METHODS

All consecutive patients with single de novo native coronary stenosis (<30 mm and between 2.5 and 4.0 mm) were enrolled. Major adverse cardiac events (MACE) at 1 year (cardiac death, myocardial infarction [Q and non-Q], or ischemia-driven target lesion revascularization) were the primary end-point.

RESULTS

A total of 123 patients were enrolled. The stent was implanted without complications in all patients, and no MACE were recorded at 30 days. At 12-month follow-up 9 patients (7.3%) experienced a MACE and 4 (3.2%) required a target lesion revascularization, while 1 (1%) stent thrombosis was recorded. A planned angiographic follow-up (FU) was performed in 73 patients (59%) at 9.4 ± 2.6 months following the index procedure. In-stent late loss was 0.16 ± 0.09 mm, and in-segment late loss was 0.18 ± 0.8 mm.

CONCLUSION

The Rapstrom biodegradable polymer rapamycin-eluting stent appeared safe and efficacious in this first real-life human experience, due to a low late lumen loss. Larger randomized studies are required to confirm these preliminary results.

Short term efficacy and safety of low dose tolvaptan in patients with acute decompensated heart failure with hyponatremia: a prospective observational pilot study from a single center in South India

Background:

In acute decompensated heart failure (ADHF), diuretic use, the mainstay therapy for congestion, is associated with electrolyte abnormalities and worsening renal function. Vasopressin mediates fluid retention in heart failure. In contrast to diuretics, the vasopressin antagonist tolvaptan may increase net volume loss in heart failure without adversely affecting electrolytes and renal function. Hyponatremia (serum sodium concentration, <135 mEq/L) is a predictor of death among patients with heart failure.

Objective:

We prospectively observed the short term efficacy and safety of low dose (15 mg) tolvaptan in admitted patients with hyponatremia and ADHF in Indian population.

Methodology:

A total of 40 patients with ADHF along with hyponatremia (<125 mEq/L) on standard therapy were treated with 15 mg of tolvaptan at a single oral dose for 7 days.

Results:

Serum sodium concentrations increased significantly after treatment with tolvaptan from baseline (P < 0.02). There was a significant improvement in symptoms and New York Heart Association (NYHA) class after starting tolvaptan (P ≤ 0.05). Total diuretic dose and mean body weight was reduced non-significantly at 7^th day from the baseline. Side-effects associated with tolvaptan included increased thirst, dry mouth and increased urination. Few patients had worsening renal function. However, several patients developed hypernatremia.

Conclusion:

In this small observational study, tolvaptan initiation in patients with ADHF with hyponatremia in addition to standard therapy may hold promise in improvement in NYHA class and serum sodium. At the same time, we observed that serious adverse events such as renal function deterioration and hypernatremia developed after tolvaptan treatment, which needs to be addressed in future by randomized study with larger sample size.

Recurrent myocardial infarction in a case of congenital afibrinogenemia

Afibrinogenemia is a rare autosomal recessive bleeding disorder with an estimated prevalence of 1:1,000,000. Usual presentation of this disorder is spontaneous bleeding, bleeding after minor trauma and excessive bleeding during interventional procedures. Paradoxically, few patients with afibrinogenemia may also suffer from severe thromboembolic complications. The management of these patients is particularly challenging because they are not only at risk of thrombosis but also of bleeding. We are presenting a case of 33-year-old male patient of congenital afibrinogenemia who had two episodes myocardial infarction in a span of two years. The patient was managed conservatively with antiplatelet therapy and thrombolytic therapy was not given due to high risk for bleeding.

Comparative study of high sensitivity troponin T and heart-type fatty acid-binding protein in STEMI patients

AIM AND BACKGROUND

Heart-type fatty acid-binding proteins (H-FABP) which are detected within 2-3 h of acute myocardial infarction are involved in uptake of free fatty acids in the myocardium. Our aim in the present study is to compare window periods of H-FABP to high sensitivity troponin T (hs-Trop T) in acute ST elevation myocardial infarction (STEMI).

METHODS

160 STEMI diagnosed patient's serum samples are analyzed for hs-Trop T and H-FABP. Different window periods of chest pain onset (<3 h, 3-6 h and >6 h) are compared with complications, in-hospital mortality and statistically analyzed.

RESULTS

From 160 patients, 53 (33%) cases are presented in <3 h, 75 (47%) in 3-6, and 32 (20%) after >6 h respectively. Accordingly sensitivity of hs-Trop T was 92%, 94% and 97% while H-FABP was 75%, 88% and 84%, respectively. Overall sensitivity was 94% and 82% respectively. Statistically significant difference between mean hs-Trop T values with respect to window period <3, 3-6 and >6 h was 0.21, 0.35 and 0.80 ng/ml respectively, p value < 0.0001. No significant difference in H-FABP values was observed. Hs-Trop T positively correlated with age (r = 0.153, P = 0.05), window period (r = 0.363, P < 0.0001), TIMI score (r = 0.208, P = 0.008), ejection fraction (r = 0.191, P = 0.008), serum H-FABP (r = 0.229, P = 0.004), and serum hs-CRP (r = 0.326, p < 0.001). There was a statistically significant difference of mean hs-Trop T values with or without in hospital mortality (0.35 vs. 0.85 ng/ml, respectively, p = 0.008). No significant correlation to age, TIMI score, ejection fraction and hs-CRP values for H-FABP was observed.

CONCLUSION

It appears that hs-Trop T is a more sensitive marker than H-FABP in early hours of AMI and higher hs-Trop T predicts increase in-hospital mortality.

Endovascular management of proximal lower limb deep venous thrombosis - A prospective study with six-month follow-up

BACKGROUND

Catheter-directed thrombolysis with assisted mechanical thrombolysis is the standard of medical care for proximal deep vein thrombosis. We studied the immediate and intermediate (six months) safety and effectiveness of catheter-directed thrombolysis in patients with proximal lower limb deep vein thrombosis.

METHODOLOGY

Thirty consecutive patients aged between 20 and 70 years with proximal lower limb deep vein thrombosis formed the study group. Catheter-directed thrombolysis was done with streptokinase infuse through a catheter kept in the ipsilateral popliteal vein. Unfractionated heparin was given along with streptokinase. Mechanical thromboaspiration using guiding catheter was performed in addition to thrombolytic therapy. After six months, post-thrombotic syndrome and deep venous patency were assessed by using Villalta scale and duplex ultrasound, respectively.

RESULTS

Thirty patients with proximal lower limb deep vein thrombosis were treated with catheter-directed thrombolysis. Mean age of the study patients was 41.7 ± 15 years. Mean duration of illness was 13.3 ± 12 days. The mean duration of thrombolysis was 4.5 ± 1.3 days. Grade III (complete) lysis was achieved in 10 (33%) and Grade II (50-90%) lysis in 20 (67%) of patients. Patients with significant residual lesion in Grade II lysis following catheter-directed thrombolysis underwent percutaneous transluminal angioplasty alone (12/20) or venous stenting (8/20). All patients improved clinically following catheter-directed thrombolysis or assisted catheter-directed thrombolysis. Four patients (13%) developed pulmonary embolism during course of hospital stay and among them two (6.5%) patients died. Eleven patients (37%) had minor bleeding or hematoma at local site, and seven (23%) developed anemia requiring blood transfusion and four (13%) patients had thrombocytopenia. After six months, iliofemoral patency was found in 20 (72%) and post-thrombotic syndrome was seen in six (21%) patients. Two (6.5%) patients died during follow-up due to nephrotic syndrome and carcinoma breast.

CONCLUSION

Catheter-directed thrombolysis and conventional manual aspiration thrombectomy are an effective treatment for proximal lower extremity deep vein thrombosis with good short and intermediate outcome.