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Mandeep Garg,1 Muniraju Maralakunte,1 Suruchi Garg,2 Sahajal Dhooria,3 Inderpaul Sehgal,3 Ashu Seith Bhalla,4 Rajesh Vijayvergiya,5 Sandeep Grover,6 Vikas Bhatia,1 Priya Jagia,7 Ashish Bhalla,8 Vikas Suri,8 Manoj Goyal,9 Ritesh Agarwal,3 Goverdhan Dutt Puri,10 Manavjit Singh Sandhu1 1Department of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India; 2Department of Dermatology, Aura Skin Institute, Chandigarh, India; 3Department of Pulmonary Medicine, PGIMER, Chandigarh, India; 4Department of Radiodiagnosis, AIIMS, New Delhi, India; 5Department of Cardiology, PGIMER, Chandigarh, India; 6Department of Psychiatry, PGIMER, Chandigarh, India; 7Department of Cardiovascular Imaging & Endovascular Interventions, AIIMS, New Delhi, India; 8Department of Internal Medicine, PGIMER, Chandigarh, India; 9Department of Neurology, PGIMER, Chandigarh, India; 10Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, IndiaCorrespondence: Mandeep GargDepartment of Radiodiagnosis and Imaging, PGIMER, Sector-12, Chandigarh, IndiaTel +91 9914209390Email gargmandeep@hotmail.comAbstract: COVID-19 is an ongoing pandemic with many challenges that are now extending to its intriguing long-term sequel. ‘Long-COVID-19ʹ is a term given to the lingering or protracted illness that patients of COVID-19 continue to experience even in their post-recovery phase. It is also being called ‘post-acute COVID-19ʹ, ‘ongoing symptomatic COVID-19ʹ, ‘chronic COVID-19ʹ, ‘post COVID-19 syndrome’, and ‘long-haul COVID-19ʹ. Fatigue, dyspnea, cough, headache, brain fog, anosmia, and dysgeusia are common symptoms seen in Long-COVID-19, but more varied and debilitating injuries involving pulmonary, cardiovascular, cutaneous, musculoskeletal and neuropsychiatric systems are also being reported. With the data on Long-COVID-19 still emerging, the present review aims to highlight its epidemiology, protean clinical manifestations, risk predictors, and management strategies. With the re-emergence of new waves of SARS-CoV-2 infection, Long-COVID-19 is expected to produce another public health crisis on the heels of current pandemic. Thus, it becomes imperative to emphasize this condition and disseminate its awareness to medical professionals, patients, the public, and policymakers alike to prepare and augment health care facilities for continued surveillance of these patients. Further research comprising cataloging of symptoms, longer-ranging observational studies, and clinical trials are necessary to evaluate long-term consequences of COVID-19, and it warrants setting-up of dedicated, post-COVID care, multi-disciplinary clinics, and rehabilitation centers.Keywords: ongoing symptomatic COVID-19, post-COVID-19 syndrome, chronic COVID, Long-COVID-19, post-COVID, Long-COVID

Background: Individuals with different blood groups have variable susceptibility to coronary artery disease (CAD). We studied the association between various blood group phenotypes [ABO, Rh (D) and Lewis] and coronary risk factors with angiography proven coronary artery disease patients. Materials and Methods: During the months of July-August 2005, all patients undergoing cardiac catheterization at PGIMER were enrolled in the study. They were divided in two groups: - Group 1- having coronary artery disease; Group 2:- normal coronaries. Following risk factors were analyzed: - age, gender, body mass index (BMI), waist/hip ratio, smoking, alcohol consumption, hypertension, diabetes, lipid profile [total cholesterol, HDL, LDL and triglycerides (TG)] and blood groups [ABO, Rh (D) and Lewis phenotypes]. Chi-square test or comparison of means was applied where appropriate for the univariate analysis. Odds ratio (OR) estimate for CAD were performed for the above risk factors using Mantel-Haenszel method. All the statistically significant values ( P<0.05) were analyzed using multivariate logistic regression analysis. All the analysis was carried out using SPSS-11 software. Results: Ninety three (60 Males, 33 Females) patients were enrolled in the study. Group I had 55 (45 Males, 10 Females) angiographically proven CAD patients and Group 2 had 38 (15 Males, 23 Females) normal coronary individuals. The mean age (years) was significantly higher in group 1 (55.02±8.47 vs. 42.21±12.96; P<0.0001). Males were found to be at higher risk for CAD (OR = 6.9). The CAD group patients had higher BMI (25.57±5.9 vs. 23.04±4.27; P<0.026) and waist/hip ratio (0.93±0.094 vs. 0.87±0.075; P<0.001) as compared to group 2. A higher percentage of diabetes (36.4% vs. 13.2%; P = 0.017) and history of smoking (49.1% vs. 13.2%; P<0.0001) was elicited among CAD as compared to non-CAD patients. No association was observed with CAD for ABO and Rh (D) blood group phenotypes. However, individuals with the presence of Le (ab-) phenotype on their red cells were found to be significantly associated ( P = 0.022) with CAD as compared to its absence. In lipid profile analysis, only TG levels (mg/dl) were found to be higher in CAD group as compared to non -CAD (166.45±95.61 vs. 121.23±40.53; P = 0.007). On multivariate logistic regression analysis age, sex and TG levels were found to be significantly associated with CAD. Conclusions: We observed that Le (a-b-) blood group phenotype is significantly associated with atherosclerotic CAD in north Indian population. A study with more number of patients and also in other geographical area of India is required to confirm our findings. [ABSTRACT FROM AUTHOR]

Transplant Renal Artery Stenosis (TRAS) is the leading vascular complication following kidney transplantation (KT), causing premature allograft loss and increased post-KT mortality. While risk factors for TRAS, such as prolonged cold ischemia time and delayed graft function, are well-documented in deceased donor-KT, the risk factors remain less clearly defined in living donor-KT. This matched case-control study, conducted at a leading national transplant center predominantly performing living donor-KT, evaluated risk factors and long-term outcomes of clinical TRAS (cTRAS). cTRAS cases diagnosed from January 2009 to December 2022 were matched with four control kidney transplant recipients (KTRs) in a study powered to assess whether ex-vivo arterial vascular reconstruction of multiple renal arteries (VR-MRA) increases the risk of cTRAS. Among 2,454 KTs, 28 KTRs (1.14%) were diagnosed with cTRAS around 3.62 ± 1.04 months post-KT, with renal allograft dysfunction (92.86%) as the most common presenting feature. Notably, 27 cTRAS cases were successfully treated with endovascular intervention, yielding favorable outcomes over a 6-180 months follow-up period. The study identified ex-vivo VR-MRA as an independent risk factor for cTRAS (P < 0.001). cTRAS cases receiving timely treatment exhibited long-term outcomes in graft and patient survival similar to control KTRs. Early screening and timely intervention for cTRAS post-KT may improve graft and patient outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Choudhary, Vijayvergiya, Kishore, Subramani, Banoth, Reddy Perugu, Mandwar, Bamaniya, Panjathia, Gupta, Patil, Sethi, Gorsi, Singh, Kenwar and Sharma.)

Objectives: The prevalence of atherosclerosis and acute coronary syndrome (ACS) is increasing in young Indians (18-50 years of age). However, the characteristics of atherosclerotic plaques in such individuals are poorly understood, presenting distinct challenges for the management of ACS. This study aims to analyze plaque characteristics in young Indian patients with ACS who underwent percutaneous coronary intervention (PCI) using optical coherence tomography (OCT) imaging., Methods: This was a prospective, multicentric, non-interventional study on patients aged 18-50 years presenting with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction, or unstable angina, and were scheduled to undergo OCT-guided PCI. Major adverse cardiac events (MACE) were assessed post-procedure and at the 6-month and 12-month follow-ups., Results: The study included 100 ACS patients (mean age = 43.6 ± 5.2 years), with 51% presenting with STEMI. Pre-PCI OCT assessment showed that fibrous plaques (75%) were most common followed by plaques containing macrophages (27%), microchannels (20%), and calcified nodules (14%). In addition, plaque rupture, plaque erosion, and lipid-rich plaques, along with red, white, and mixed thrombi, were observed in 31%, 25%, 24%, 21%, 14%, and 17% (total thrombus occurrence = 52%) of the patients, respectively. At 12 months, the MACE (coronary artery bypass graft) rate was 1%., Conclusions: Young Indian patients with ACS displayed a range of plaque morphologies identified through pre-PCI OCT. Among these, fibrous plaques were the most prominent type, followed by plaques containing macrophages. Additionally, plaque rupture, plaque erosion, and lipid-rich plaques were also observed in this population., Competing Interests: Conflict of interest All authors declare that they do not have any conflict of interest. MN is an employee of Abbott Healthcare Pvt Ltd., (Copyright © 2024 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Background: Empirical use of pharmacogenetic test(PGT) is advocated for many drugs, and resource-rich setting hospitals are using the same commonly. The clinical translation of pharmacogenetic tests in terms of cost and clinical utility is yet to be examined in hospitals of low middle income countries (LMICs)., Aim: The present study assessed the clinical utility of PGT by comparing the pharmacogenetically(PGT) guided- versus standard of care(SOC)- warfarin therapy, including the health economics of the two warfarin therapies., Methods: An open-label, randomized, controlled clinical trial recruited warfarin-receiving patients in pharmacogenetically(PGT) guided- versus standard of care(SOC)- study arms. Pharmacogenetic analysis of CYP2C9*2(rs1799853), CYP2C9*3(rs1057910) and VKORC1(rs9923231) was performed for patients recruited to the PGT-guided arm. PT(Prothrombin Time)-INR(international normalized ratio) testing and dose titrations were allowed as per routine clinical practice. The primary endpoint was the percent time spent in the therapeutic INR range(TTR) during the 90-day observation period. Secondary endpoints were time to reach therapeutic INR(TRT), the proportion of adverse events, and economic comparison between two modes of therapy in a Markov model built for the commonest warfarin indication- atrial fibrillation., Results: The study enrolled 168 patients, 84 in each arm. Per-protocol analysis showed a significantly high median time spent in therapeutic INR in the genotype-guided arm(42.85%; CI 21.4-66.75) as compared to the SOC arm(8.8%; CI 0-27.2)(p < 0.00001). The TRT was less in the PG-guided warfarin dosing group than the standard-of-care dosing warfarin group (17.85 vs. 33.92 days) (p = 0.002). Bleeding and thromboembolic events were similar in the two study groups. Lifetime expenditure was ₹1,26,830 in the PGT arm compared to ₹1,17,907 in the SOC arm. The QALY gain did not differ in the two groups(3.9 vs. 3.65). Compared to SOC, the incremental cost-utility ratio was ₹35,962 per QALY gain with PGT test opting. In deterministic and probabilistic sensitivity analysis, the base case results were found to be insensitive to the variation in model parameters. In the cost-effectiveness-acceptability curve analysis, a 90% probability of cost-effectiveness was reached at a willingness-to-pay(WTP) of ₹ 71,630 well below one time GDP threshold of WTP used., Conclusion: Clinical efficacy and the cost-effectiveness of the warfarin pharmacogenetic test suggest its routine use as a point of care investigation for patient care in LMICs., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Percutaneous coronary intervention (PCI) of calcified coronary arteries is associated with poor outcomes. Poorly modified calcified lesion hinders the stent delivery, disrupts drug-carrying polymer, impairs drug elution kinetics and results in under-expanded stent (UES). UES is the most common cause of acute stent thrombosis and in-stent restenosis after PCI of calcified lesions. Angiography has poor sensitivity for recognition and quantification of coronary calcium, thereby mandating the use of intravascular imaging. Intravascular imaging, like intravascular ultrasound and optical coherence tomography, has the potential to accurately identify and quantify the coronary calcium and to guide appropriate modification device before stent placement. Available options for the modification of calcified plaque include modified balloons (cutting balloon, scoring balloon and high-pressure balloon), atherectomy devices (rotational atherectomy and orbital atherectomy) and laser atherectomy. Coronary intravascular lithotripsy (IVL) is the newest addition to the tool box for calcified plaque modification. It produces the acoustic shockwaves, which interact with the coronary calcium to cause multiplanar fractures. These calcium fractures increase the vessel compliance and result in desirable minimum stent areas. Coronary IVL has established its safety and efficacy for calcified lesion in series of Disrupt CAD trials. Its advantages over atherectomy devices include ease of use on workhorse wire, ability to modify deep calcium, no debris embolization causing slow flow or no-flow and minimal thermal injury. It is showing promising results in modification of difficult calcified lesion subsets such as calcified nodule, calcified left main bifurcation lesions and chronic total occlusion. In this review, authors will summarize the mechanism of action for IVL, its role in contemporary practice, evidence available for its use, its advantages over atherectomy devices and its imaging insight in different calcified lesion scenarios.

Background: Rheumatic heart disease/Rheumatic fever is a non - communicable disease being a major neglected health problem. Recurrent attacks of rheumatic fever can have catastrophic outcomes, therefore regular administration of antibiotics is recommended. During COVID 19 pandemic, people were afraid to approach hospitals hence the compliance and follow up of patients were affected. This study had planned to assess the treatment adherence of patients diagnosed with rheumatic fever/rheumatic heart disease during COVID 19 pandemic and to describe the socio demographic factors, clinical characteristics. This study also determines the factors associated with the treatment adherence., Methods: A cross sectional study was conducted among Rheumatic Fever/Rheumatic Heart Disease patients, attending Outpatient department at tertiary care hospital during COVID 19 pandemic. Mean score with confidence interval was calculated for quantitative data. P value less than 0.05 is significant., Results: The Mean (SD) age of the study participants was 41 ± 14.17 years. Treatment adherence was found to be 94.5 percent among Rheumatic Fever/Rheumatic Heart Disease patients during COVID 19 pandemic. 89.5% of injection benzathine penicillin users had an adherence rate above 80 percent. It was found that the presence of comorbidities (Diabetes/Hypertension/both Diabetes and Hypertension) had a statistically significant association with treatment adherence., Conclusions: Rheumatic Heart Disease is a disease of young and middle -age population affecting predominantly females. The overall adherence rate among Rheumatic Fever/Rheumatic Heart Disease patients was high. High time to maintain hospital-based registry to have follow up of patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Family Medicine and Primary Care.)

Uterine artery embolization (UAE) is a technique for management of various obstetrical and gynecological problems. Transfemoral approach (TFA) is preferred which can be unilateral or bilateral; however, unilateral puncture is preferred due to lesser chances of puncture-related complications as compared to bilateral puncture. UAE through unilateral TFA is possible with use of reverse loop catheters (Roberts uterine catheter [RUC] or Gandras catheter) to access ipsilateral uterine artery. Other way of cannulating the ipsilateral uterine artery is by maneuvering catheters to form Waltman's loop/Simmon's reverse loop. With advent of RUC, unilateral TFA became standard of care. In the recent past, RUC was retracted from Indian market and its nonavailability had mandated use of either bilateral TFA or use of catheters and techniques used in the past for unilateral TFA. Herein, we describe a technique of doing UAE by unilateral TFA using simple gentle curve catheter (Picard) by making a reverse curve loop., Competing Interests: Conflict of Interest None declared., (Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: An anomalous right coronary artery (ARCA) arising from the left sinus of Valsalva is an uncommon congenital anomaly. The unusual location, take-off and intramural courses of ARCA pose a considerable technical challenge during percutaneous coronary intervention (PCI)., Aims: We sought to report our experience of PCI of ARCA in 35 cases of atherosclerotic occlusion., Methods: The PCI database of 35 cases of ARCA was retrospectively analysed. The details about demography, clinical presentation, PCI procedure and clinical follow-up were noted., Results: The mean age was 56.7±13.5 years. The clinical presentation included stable angina in 45.7%, unstable angina in 20% and acute myocardial infarction in 34.3% of patients. Vascular access was transradial in 37.1% of cases, transfemoral in 60% of cases, and transbrachial in 1 case (2.9%). Judkins left and Amplatz left were commonly used guide catheters. Two patients with balloon-uncrossable, calcified lesions required rotablation-assisted PCI. Intravascular imaging was performed in 12 patients (34.3%). Optical coherence tomography demonstrated a proximal intramural course in 3 patients, and a slit-like orifice in 4 patients. The mean radiation dose and fluoroscopy time were 877±687.3 mGy and 18.8±11.6 minutes, respectively. Twenty-eight (80%) patients had an asymptomatic median follow-up of 49 (interquartile range: 29.0-97.5) months., Conclusions: We performed successful PCI in a cohort of 35 patients with ARCA, with favourable long-term clinical outcomes. The selection of an appropriate guide catheter and technical skills were important factors in achieving favourable results., Competing Interests: The authors have no conflicts of interest to declare relevant to the content herein.

Competing Interests: The authors have no conflicts of interest to declare.

Background: There is a dearth of evidence on the cost-effectiveness of a combination of population-based primary, secondary, and tertiary prevention and control strategies for rheumatic fever and rheumatic heart disease. The present analysis evaluated the cost-effectiveness and distributional effect of primary, secondary, and tertiary interventions and their combinations for the prevention and control of rheumatic fever and rheumatic heart disease in India., Methods: A Markov model was constructed to estimate the lifetime costs and consequences among a hypothetical cohort of 5-year-old healthy children. Both health system costs and out-of-pocket expenditure (OOPE) were included. OOPE and health-related quality-of-life were assessed by interviewing 702 patients enrolled in a population-based rheumatic fever and rheumatic heart disease registry in India. Health consequences were measured in terms of life-years and quality-adjusted life-years (QALY) gained. Furthermore, an extended cost-effectiveness analysis was undertaken to assess the costs and outcomes across different wealth quartiles. All future costs and consequences were discounted at an annual rate of 3%., Findings: A combination of secondary and tertiary prevention strategies, which had an incremental cost of ₹23 051 (US$30) per QALY gained, was the most cost-effective strategy for the prevention and control of rheumatic fever and rheumatic heart disease in India. The number of rheumatic heart disease cases prevented among the population belonging to the poorest quartile (four cases per 1000) was four times higher than the richest quartile (one per 1000). Similarly, the reduction in OOPE after the intervention was higher among the poorest income group (29·8%) than among the richest income group (27·0%)., Interpretation: The combined secondary and tertiary prevention and control strategy is the most cost-effective option for the management of rheumatic fever and rheumatic heart disease in India, and the benefits of public spending are likely to be accrued much more by those in the lowest income groups. The quantification of non-health gains provides strong evidence for informing policy decisions by efficient resource allocation on rheumatic fever and rheumatic heart disease prevention and control in India., Funding: Department of Health Research, Ministry of Health and Family Welfare, New Delhi., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Tetralogy of Fallot is a severe type of congenital heart disease (CHD) and one of the leading indirect causes of mortality & morbidity among women with CHD. We came across a rare case of an uncorrected Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries in pregnancy., Case Presentation: We are reporting the challenges in managing a pregnancy of 25-years-old G3 P0110, previous one stillbirth and who was diagnosed to have congenital heart disease during pregnancy following spontaneous abortion., Conclusions: This case report highlights the role of multidisciplinary care in managing such a high risk case. It also emphasizes the role of cardiac examination of every woman before pregnancy so that definitive treatment or optimization can be done in time for a better outcome., (© 2023. The Author(s).)

It is unusual to detect coarctation of aorta (CoA) in an adult person during their 6th decade of life. We came across a 52-year-old male who presented with left ventricular failure with low ejection fraction and atrial fibrillation, who was incidentally detected to have critical CoA. It was successfully managed with balloon angioplasty and had a favorable 6 months of clinical follow-up.

Competing Interests: The authors have no conflicts of interest to declare.

Competing Interests: The authors have no conflicts of interest to declare with regards to this article.

A 45-year-old man presented with pain in the abdomen and pulsatile abdominal swelling of 3-month duration. He had kidney transplantation for chronic kidney disease 2 years prior. After discovering a fusiform abdominal aortic aneurysm, extending from the origin of the superior mesenteric artery to the aortic bifurcation, a hybrid aortic intervention was planned. In this case, we demonstrate a favorable long-term outcome of endovascular aortic repair for juxtarenal abdominal aortic aneurysm in a post-renal transplant patient.

Background: To reduce the global burden of tobacco use, clinical guidelines support behavioral therapy and pharmacotherapy as preferred interventions for tobacco cessation. The evidence-based behavioral interventions has consistently shown to be impactful in community settings; however, its efficacy has not been established in hospital settings. The current study aims to investigate impact of trans-theoretical-based behavioral intervention package on tobacco users suffering from non-communicable diseases attending tertiary care settings of North India., Methods/design: A two-arm randomized controlled trial (RCT) in a tertiary healthcare hospital will be performed. A total of 360 tobacco users attending NCD clinics in four departments, cardiology, neurology, pulmonary medicine, and ENT (otolaryngology), will be recruited over a period of 3 months. After ascertaining the eligibility criteria, they will be followed up to 6 months (1, 3, 6) for their tobacco use status, readiness to quit, nicotine dependence, stage of behavior change, and self-reported and biochemical validation (urine cotinine) for tobacco abstinence. Assignment of intervention including allocation concealment, sequence generation, and blinding will be done as per SPIRIT guidelines for RCT protocols., Discussion: As no strong evidence exists about the effectiveness of tobacco cessation intervention in tertiary settings, the current study will build evidence about the similar interventions in such settings., Trial Registration: CTRI/2019/09/021406., (© 2022. The Author(s).)

Pregnancy in women with hypertrophic cardiomyopathy is not well described. In this retrospective study, we analyzed data on pregnant women with hypertrophic cardiomyopathy who were under follow-up care in the cardiology department of a tertiary care hospital. We reviewed data on all women registered in the hypertrophic cardiomyopathy cohort and those who attended the cardio-obstetric clinic and delivered between January 2010 and June 2019. From these 2 groups, we identified 7 pregnant women with hypertrophic cardiomyopathy who delivered during this period. These 7 women (mean [SD] age, 25 [3.3] years) had a total of 15 pregnancies (range per woman,1-4). This was a high-risk cohort, as 7 (46.7%) pregnancies were in the modified World Health Organization class III. The mean (SD) left ventricular wall thickness was 19.71 (2.56) mm in all pregnancies. Two of the 7 women with left ventricular outflow tract obstruction developed severe symptoms in the third trimester; these improved soon after delivery. Eight pregnancies without obstruction were well tolerated. Two pregnancies occurred after successful alcohol septal ablation. Both remained asymptomatic throughout pregnancy. All women tolerated labor well. Adverse maternal outcomes, including death, were not seen in any patient. All women who became symptomatic during pregnancy had relief of symptoms after delivery. Most women remained asymptomatic or had mild symptoms during pregnancy. Of the women with left ventricular outflow tract obstruction, 28.6% had severe symptoms that improved after delivery. Pregnancy was well tolerated after successful alcohol septal ablation., (© 2022 by the Texas Heart® Institute, Houston.)

Competing Interests: The authors declare no funding or conflicts of interest.

Background: Rheumatic mitral stenosis is the common valvular heart disease seen during pregnancy. Percutaneous transvenous mitral commissurotomy is an effective, safe, and recommended treatment for critical mitral stenosis during pregnancy. We hereby report the maternal and fetal outcomes of pregnant women subjected to percutaneous trans- venous mitral commissurotomy at our institute., Methods: Seventy consecutive pregnant women with critical mitral stenosis, who under- went PTMC during the last 10 years, were retrospectively analyzed. All patients had a detailed clinical and obstetric evaluation and were optimally managed with drugs, before the intervention. A comprehensive pre- and post-percutaneous transvenous mitral commissurotomy transthoracic echocardiographic evaluation was performed. Detailed obstetric and fetal outcomes were noted at the time of delivery. Six weeks of post-partum follow-up was noted in all patients., Results: The mean gestational age at the time of percutaneous transvenous mitral com- missurotomy was 29.5 ± 6.68 weeks. Percutaneous transvenous mitral commissurotomy was successful in 97% of patients. Post-percutaneous transvenous mitral commissurot- omy New York Heart Association functional class, mitral valve area, trans-mitral pres-sure gradient, and left atrial pressure had a significant improvement (P < .001). The mean gestational age at the time of delivery was 36.92 ± 3.02 weeks. The mean birth weight of live newborn was 2.29 ± 0.55 kg. The fetal complications include growth restriction in 62.85%, preterm delivery in 34.37%, and low birth weight in 67.21%. A delayed percutane- ous transvenous mitral commissurotomy at about 30 weeks of gestation did not affect the maternal and fetal outcomes., Conclusion: Percutaneous transvenous mitral commissurotomy is safe and efficacious in managing pregnant women with critical mitral stenosis. There was a significant improve- ment in clinical symptoms and echocardiographic parameters following percutaneous transvenous mitral commissurotomy.

Optical coherence tomography (OCT) is slowly but surely gaining a foothold in the hands of interventional cardiologists. Intraluminal and transmural contents of the coronary arteries are no longer elusive to the cardiologist's probing eye. Although the graduation of an interventionalist in imaging techniques right from naked eye angiographies to ultrasound-based coronary sonographies to the modern light-based OCT has been slow, with the increasing regularity of complex coronary cases in practice, such a transition is inevitable. Although intravascular ultrasound (IVUS) due to its robust clinical data has been the preferred imaging modality in recent years, OCT provides a distinct upgrade over it in many imaging and procedural aspects. Better image resolution, accurate estimation of the calcified lesion, and better evaluation of acute and chronic stent failure are the distinct advantages of OCT over IVUS. Despite the obvious imaging advantages of OCT, its clinical impact remains subdued. However, upcoming newer trials and data have been encouraging for expanding the use of OCT to wider indications in clinical utility. During percutaneous coronary intervention (PCI), OCT provides the detailed information (dissection, tissue prolapse, thrombi, and incomplete stent apposition) required for optimal stent deployment, which is the key to successfully reducing the major adverse cardiovascular event (MACE) and stent-related morbidities. The increasing use of OCT in complex bifurcation stenting involving the left main (LM) is being studied. Also, the traditional pitfalls of OCT, such as additional contrast load for image acquisition and stenting involving the ostial and proximal LM, have also been overcome recently. In this review, we discuss the interpretation of OCT images and its clinical impact on the outcome of procedures along with current barriers to its use and newer paradigms in which OCT is starting to become a promising tool for the interventionalist and what can be expected for the immediate future in the imaging world., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Gupta, Shrivastava, Vijayvergiya, Chhikara, Datta, Aziz, Singh Meena, Nath and Kumar.)

Background The Covid-19 pandemic has posed a challenge to organizing a safe clinical assessment for postgraduate degree candidates completing the residency programmes in various specialties. Although minimizing the risk of Covid-19 transmission is a priority, fulfilling the objectives of the assessment is equally important. Methods We conducted this study in the Department of Internal Medicine at our institute. Instead of physically examining patients, case scenarios that included history, clinical and investigational data of the cardiovascular system (CVS) were presented to the candidates. Performance was scored by both the conventional and the CVS objective-structured clinical examination (CVS-OSCE) method and compared. Results Clinical assessment examination of 27 candidates for the degree of Doctor of Medicine showed that the median cumulative score gained in narrating and analysing various differential diagnoses was lower compared to the mean cumulative score gained in arriving at a single correct diagnosis (50% [interquartile range-IQR 39%-64%] v. 79% [IQR 64%-100%], p<0.01). Most of the candidates agreed that case scenarios were good alternatives to the conventional physical examination amidst the pandemic. Conclusion CVS-OSCE-based assessment using structured case scenarios is a feasible and effective alternative for clinical skill assessment in high-stake examinations.

A cross-sectional study was conducted to predict time in therapeutic range (TTR) using clinical history, examination, and socioeconomic data. Study included warfarin-receiving patients from outpatient-clinic. In 203 patients studied, mean warfarin start-dose was 2.55 mg/day and maintenance-dose/week was 30.79 mg. Body mass index (BMI) (p = 0.03), warfarin maintenance dose/day (p = 0.02), and comorbidity presence (p = 0.04) were significantly associated with TTR. Occupation (p = 0.53), income (p = 0.83), education (p = 0.55), and socioeconomic score (p = 0.73) showed non-significant association with TTR. A TTR predicting nomogram was built from clinical history and examination findings., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Objectives: Primary hyperparathyroidism (PHPT) is associated with increased cardiovascular morbidity and mortality with inconsistent results on the reversibility of cardiovascular changes after parathyroidectomy (PTx). The present study was undertaken to evaluate both structural and functional cardiac changes and their reversal after PTx in patients with PHPT., Material and Methods: Thirty patients of symptomatic PHPT without cardiovascular risk factors were evaluated prospectively by means of 2D echocar- diography (ECHO) and Multigated Acquisition (MUGA) study before surgery and six months after curative parahyroidectomy., Results: Nine of 30 patients had hypertension which improved in two after PTx (p 0.20). Two patients had left ventricle hypertrophy on 2D ECHO pre- operatively which improved after PTx (p <0.001). Left ventricular ejection fraction (LVEF) did not show significant change before and after PTx on 2D ECHO. Nine out of 30 patients had hypertension which improved in two after PTx (p 0.20). Two patients with left ventricle hypertrophy on 2D ECHO preoperatively improved after PTx (p <0.001). Left ventricular ejection fraction (EF) did not depict significant change before and after PTx on 2D ECHO. Whereas, four out of six patients with preoperative EF <50% representing systolic dysfunction on MUGA study showed improvement after PTx. On 2D ECHO, eight patients depicted diastolic dysfunction which improved in six patients after curative surgery (p= 0.07). However, on MUGA study, 13 pa- tients presented with tTPF >180 ms indicating diastolic dysfunction, of which ten showed improvement after PTx (p= 0.007)., Conclusion: The present study analyzed preoperative and postoperative cardiac function using both 2D ECHO and MUGA study. MUGA study provided a more objective assessment of the cardiac function by determining left ventricular ejection fraction and diastolic dysfunction., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare., (Copyright © 2021, Turkish Surgical Society.)

Competing Interests: The authors have no conflicts of interest to declare.

Renal transplant remains the preferred therapy for end-stage renal disease (ESRD). Given the shortage of suitable donor kidneys, use of an expanded criteria donor (ECD) allows marginal kidneys to be transplanted; albeit at risk of increased graft failure due to lower nephron mass. To reduce the risk of graft failure, double kidney transplant (DKT) is advocated, with favorable outcomes. Transplant renal artery stenosis (TRAS) is one of the most common vascular complications following renal transplant. Unlike single kidney transplants, where TRAS usually presents with fluid overload, uncontrolled hypertension, and worsening kidney functions; it may be clinically silent in DKT patients since they have two functional transplanted kidneys. We hereby report a case of TRAS in a DKT patient who had 2 years of favorable clinical outcomes following successful endovascular stenting. He however recently died of COVID-19 associated pneumonitis., Competing Interests: Conflicts of interest: No conflicts of interest declared concerning the publication of this article., (Copyright© 2021 The authors.)

Objective: Several studies have demonstrated a shift in the spectrum of infective endocarditis (IE) in the developed world. We aimed to investigate whether demographic and microbiologic characteristics of IE have changed in India., Design: A retrospective analysis of patients with in north India between 2010 and 2020., Methods: The clinical and laboratory profiles of 199 IE admitted to an academic hospital patients who met the modified Duke criteria for definite IE were analysed., Results: The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005)., Conclusion: IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: Retroperitoneal open iliac conduits (ROIC) are used in patients with hostile iliac anatomy undergoing endovascular aortic repair (EVAR)., Objectives: We hereby report our experience of ROIC in patients subjected to EVAR., Methods: This was a retrospective evaluation of 8 patients out of a total of 75 patients (11%) who underwent EVAR in the last 10 years. Pre-procedure computed tomography angiography was used to assess the dimensions of iliac and femoral arteries. Patients who had small arterial dimensions (i.e. smaller than the recommended access size for the aortic endograft device) were subjected to ROIC., Results: The mean age of the 3 males and 5 females studied was 45.7 ± 15.2 years. The indication for ROIC was the small caliber ilio-femoral access site in 7 patients and atherosclerotic disease in 1 patient. All external grafts were anastomosed to the right common iliac artery except one which was anastomosed to the aortic bifurcation site because of a small common iliac artery. The procedural success rate was 100%. Local access site complications included infection (n=1), retroperitoneal hematoma (n=1), and need for blood transfusion (n=3). The median post-intervention hospital stay was 10 days. All patients had favorable long-term outcomes at a median follow-up of 18 months., Conclusions: Female patients require ROIC during EVAR more frequently. Adjunctive use of iliac conduit for EVAR was associated with favorable perioperative and short-term outcomes., Competing Interests: Conflicts of interest: No conflicts of interest declared concerning the publication of this article., (Copyright© 2021 The authors.)

Various vascular complications following renal transplantation include renal artery and vein thrombosis, renal artery stenosis, pseudoaneurysm, and iliac artery dissection. Transplant renal artery stenosis (TRAS) is the most common, while iliac artery dissection is the rarest of these various vascular complications. We describe an elderly male, who had both external iliac artery dissection and TRAS at 2 months following renal transplantation. He underwent successful percutaneous endovascular intervention of both complications. The post-intervention course was uneventful, with improvement in graft renal functions and left lower limb perfusion., Competing Interests: Conflicts of interest: No conflicts of interest declared concerning the publication of this article., (Copyright© 2021 The authors.)

Pulmonary arterial hypertension (PAH) - a complex and progressive disease that carries significant morbidity and mortality despite optimal medical treatment. Combination therapy for PAH can be more effective than monotherapy. The present randomized trial compared the safety and efficacy of sildenafil ambrisentan combination therapy with sildenafil monotherapy. Twenty-two patients of Eisenmenger syndrome and five patients of idiopathic PAH were randomized to two arms. There was a significant improvement in NYHA functional class and mean pulmonary artery pressure, while an insignificant improving trend was observed for 6-min walk distance and oxygen saturation, following the 12 weeks of combination therapy. An upfront combination therapy was found to be safe and effective in the management of PAH patients., Competing Interests: Declaration of competing interest There is no conflict of interest on any of the authors about the present study., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Competing Interests: The authors have no conflicts of interest to declare.

With the advent of endovascular therapy, conventional angiography has replaced histology as a diagnostic gold standard for fibromuscular dysplasia (FMD). However, angiographic findings are not precisely diagnostic in isolated focal renal artery stenosis (RAS) in FMD. Optical coherence tomography (OCT) imaging by reflecting in vivo histology may improve the diagnostic accuracy in such cases. Restenosis following balloon angioplasty of RAS in FMD occurs frequently and often requires optimized reintervention. However, the role of OCT in the diagnostic evaluation of focal RAS in FMD and in optimizing the intervention is not well studied. We present a young female with resistant secondary hypertension due to bilateral focal RAS on angiography. In the absence of an angiographic string of beads appearance, the diagnoses remained uncertain. However, OCT imaging diagnosed a multifocal disease with characteristic changes of fibro-medial dysplasia, akin to its histological description in the literature. The patient underwent bilateral balloon angioplasty with good angiographic results. After one year on follow-up, relapse of uncontrolled systemic hypertension occurred due to bilateral restenosis. Despite a satisfactory repeat balloon angioplasty of the left-sided re-stenotic lesion, a significant residual pressure gradient persisted. Usage of OCT guided oversized balloon and stent safely achieved good results with complete resolution of the pressure gradient. Right renal artery stenosis required balloon angioplasty alone. She had complete resolution of hypertension without any medications at six months of follow-up. In conclusion, OCT can supplement other diagnostic modalities in providing a proper diagnosis in an angiographically ambiguous focal RAS in FMD. A persistent residual pressure gradient across the lesion despite good angiographic results may be optimized with OCT guidance during the intervention., Competing Interests: The authors report no conflicts of interest in this work., (© 2021 Otaal et al.)

Background: The established cardiovascular risk factors cannot explain the overall risk of coronary artery disease (CAD), especially in women. Therefore, there is a growing need for the assessment of novel biomarkers to identify women at risk. The receptor for advanced glycation end products (RAGE) and its interaction with the advanced glycation end product (AGE) ligand have been associated with atherogenesis. The soluble fraction of RAGE (sRAGE ) antagonizes RAGE signaling and exerts an antiatherogenic effect., Aim: The study aim was to explore the association between plasma levels of sRAGE and CAD in nondiabetic postmenopausal women., Methods: This case-control study included 110 nondiabetic postmenopausal women who were enrolled in two groups. Group I included 55 angiographically proven CAD subjects with > 50% stenosis in at least one of the major coronary arteries and Group II included 55 healthy control women who did not have CAD or had < 50% stenosis of the coronary arteries. Stenosis was confirmed by invasive angiography. Plasma sRAGE was determined by an enzyme-linked immunosorbent assay., Results: We observed significantly lower plasma sRAGE concentrations in subjects with CAD vs healthy controls ( P < 0.05). Univariate and multivariate logistic regression analysis also revealed a significant correlation between plasma sRAGE levels and CAD ( P = 0.01). Multivariate odds ratios for CAD revealed that subjects with sRAGE concentrations below 225 pg/mL (lowest quartile) had a 6-fold increase in CAD prevalence independent of other risk factors., Conclusion: Our findings indicated that low sRAGE levels were independently associated with CAD in nondiabetic postmenopausal women. Risk assessment of CAD in postmenopausal women can be improved by including sRAGE along with other risk factors., Competing Interests: Conflict-of-interest statement: The authors declare that they have no competing interests., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Arterial access site complications are the important predictor of successful percutaneous coronary interventions (PCI). We prospectively studied 722 consecutive PCI patients for access site complications. A total of 303 trans-femoral access (TFA) patients who had suture based vascular closure devices (VCD) were compared with 419 transradial access (TRA) patients. Incidence of hematoma was more in TFA (2.3% vs 0.23%, p 0.01). Median ambulation time (4 h vs 1 h, p < 0.01) was significantly higher in TFA. In conclusion, TRA had fewer access site complications like haematoma, compared to TFA with VCD. TRA also resulted in earlier ambulation and discharge, compared to TFA with VCD., Competing Interests: Declaration of competing interest There is no conflict of interest of any of the authors about the present study., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Objective: To study the epidemiological and clinical profile, angiographic patterns, reasons for the delay in presentation, management, and outcomes of the acute coronary syndrome (ACS) in young patients (≤40yrs) presenting to a tertiary care hospital in North India., Methods: We included a total of 182 patients aged ≤40 years and presenting with ACS to the cardiology critical care unit of our department from January 2018 to July 2019., Results: The mean age of the study population was 35.5 ± 4.7years. 96.2% were males. Risk factors prevalent were smoking (56%), hypertension (29.7%), family history of premature coronary artery disease (18.2%), and diabetes (15.9%). The median time to first medical contact and revascularization was 300 (10-43200) minutes and 2880 (75-68400) minutes, respectively. ST-elevation ACS (STE-ACS) accounted for 82% and Non-ST-elevation ACS (NSTE-ACS) accounted for 18% of cases. Thrombolysis was done in 51.7% of the cases. Coronary angiography was done in 91.7% and percutaneous coronary intervention (PCI) in 52.2% (95/182) of the total cases. Coronary artery bypass surgery (CABG) was done in 2 patients (1.1%). Among those who underwent coronary angiography, single-vessel disease (SVD) was seen in 53% of the cases. There were no deaths in hospital, and only one patient died during the 30 days follow up., Conclusions: STE-ACS was the most common presentation of ACS in the young population. Smoking was the most common risk factor. The majority of the patients had single-vessel disease, and there was a significant delay in first medical contact and revascularization., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Introduction: Sparse data and conflicting evidence exist on the prevalence and prognosis of organophosphate (OP)-related cardiac toxicity. We aimed to characterize the cardiac abnormalities of OP after an acute cholinergic crisis in adults without previous cardiovascular conditions., Patients and Methods: We did a prospective observational study in a tertiary-care hospital of north India (Postgraduate Institute of Medical Education and Research, Chandigarh) in 74 patients aged ≥ 13 years admitted with acute OP poisoning after self-ingestion. A systemic evaluation, including clinical characteristics, electrocardiography, and echocardiography, was performed to estimate the prevalence and prognosis of cardiac injury. A rate-corrected QT interval was calculated using Bazett's method, and >440 milliseconds was used to define prolongation., Results: Chlorpyrifos was the most commonly ingested OP ( n  = 29). The patients had a similar occurrence of hypotension ( n  = 10) and hypertension ( n  = 9) at admission, and electrocardiography demonstrated sinus tachycardia in 38 (51.3%) and sinus bradycardia in one case. During the hospital stay, 3 out of 74 patients had a prolonged rate-corrected QT interval (457, 468, and 461 milliseconds), and one patient developed supraventricular tachycardia. Eight (10.8%) patients developed the intermediate syndrome, and six (8.1%) died. None of the hemodynamic or electrocardiographic abnormalities was associated with in-hospital mortality or intermediate syndrome development on univariant analysis. Baseline echocardiography at hospital discharge was performed in 27 patients (admitted during 2018) and normal in all except mild tricuspid regurgitation in one. At a 6-month follow-up, 23 cases were available for cardiovascular screening (including echocardiography) and had a normal evaluation., Conclusion: Cardiac toxicity is uncommon after acute OP self-ingestion and lacks prognostic significance., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: The aim of this study is to determine the prevalence, clinical characteristics, angiographic profile and predictors of outcome for percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTO) in a tertiary referral centre of north India., Background: There is no data on the prevalence and very few reports on clinical characteristics, angiographic profile and outcome of PCI in CTO from India., Methods: Retrospective analysis was done for the data of 12,020 patients undergoing coronary angiography (CAG) between January 2018 to January 2019 at our centre. Detailed baseline clinical, angiographic and revascularization data was collected. Outcome of CTO PCI was also noted. All baseline parameters were analysed for predicting the outcome of CTO PCI., Results: CTO was identified in 16.3% (1968) patients undergoing CAG and in 24.4% of patients with hemodynamically significant CAD. CTO was predominantly found in LAD (48%) followed by RCA (42.9%) and LCx (25.3%) arterial distribution. Mean JCTO score was 1.93 ± 0.7. PCI as a management strategy was adopted in 456 of 1968 patients (23.1%) and was successful in 340 of 456 (74.6%) of patients. Almost all CTO PCI were attempted by an antegrade approach only. Increasing age, male sex, CTO in LCx arterial distribution and higher J CTO score were associated with poorer outcome in CTO PCI., Conclusions: CTO's are commonly encountered during CAG procedures. In patients undergoing CTO PCI, a fair success rate can be achieved in a high volume experienced centre., Competing Interests: Declaration of competing interest Nothing to disclose., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)