Search

Abstract Aims Limited data on the uptake of guideline‐directed medical therapies (GDMTs) and the mortality of acute decompensated HF (ADHF) patients are available from India. The National Heart Failure Registry (NHFR) aimed to assess clinical presentation, practice patterns, and the mortality of ADHF patients in India. Methods and results The NHFR is a facility‐based, multi‐centre clinical registry of consecutive ADHF patients with prospective follow‐up. Fifty three tertiary care hospitals in 21 states in India participated in the NHFR. All consecutive ADHF patients who satisfied the European Society of Cardiology criteria were enrolled in the registry. All‐cause mortality at 90 days was the main outcome measure. In total, 10 851 consecutive patients were recruited (mean age: 59.9 years, 31% women). Ischaemic heart disease was the predominant aetiology for HF (72%), followed by dilated cardiomyopathy (18%). Isolated right HF was noted in 62 (0.6%) participants. In eligible HF patients, 47.5% received GDMT. The 90 day mortality was 14.2% (14.9% and 13.9% in women and men, respectively) with a re‐admission rate of 8.4%. An inverse relationship between educational class based on years of education and 90 day mortality (high mortality in the lowest educational class) was observed in the study population. Patients with HF with reduced ejection fraction and HF with mildly reduced ejection fraction who did not receive GDMT experienced higher mortality (log‐rank P 120 ms, atrial fibrillation, mitral regurgitation, haemoglobin levels, serum sodium, and GDMT independently predicted 90 day mortality. Conclusion One of seven ADHF patients in the NHFR died during the first 90 days of follow‐up. One of two patients received GDMT. Adherence to GDMT improved survival in HF patients with reduced and mildly reduced ejection fractions. Our findings call for innovative quality improvement initiatives to improve the uptake of GDMT among HF patients in India.

The efficacy and safety of percutaneous transvenous mitral commissurotomy by the Inoue technique, in patients with rheumatic mitral stenosis is well known. However, presence of left atrial/appendage thrombus or difficult LV entry entails the use of ‘over the wire’(OTW)technique. Here we describe a case series highlighting the utility and modifications of OTW technique.

Aims: Sudden cardiac death (SCD) continues to be a devastating complication amongst survivors of myocardial infarction (MI). Mortality is high in the initial months after MI. The aims of the INSPIRE-ELR study were to assess the proportion of patients with significant arrhythmias early after MI and the association with mortality during 12 months of follow-up. Methods: The study included 249 patients within 14 days after MI with left ventricular ejection fraction (LVEF) ≤35% at discharge in 11 hospitals in India. Patients received a wearable external loop recorder (ELR) 5 ± 3 days after MI to monitor arrhythmias for 7 days. Results: Patients were predominantly male (86%) with a mean age of 56 ± 12 years. In 82%, reperfusion had been done and all received standard of care cardiovascular medications at discharge. LVEF was 32.2 ± 3.9%, measured 5.1 ± 3.0 days after MI. Of the 233 patients who completed monitoring (7.1 ± 1.5 days), 81 (35%) experienced significant arrhythmias, including Ventricular Tachycardia/Fibrillation (VT/VF): 10 (4.3%); frequent Premature Ventricular Contractions (PVCs): 65 (28%); Atrial Fibrillation (AF): 8 (3.4%); chronic atrial flutter: 4 (1.7%); 2nd or 3rd degree Atrioventricular (AV) block: 4 (1.7%); and symptomatic bradycardia: 8 (3.4%). In total, 26 patients died. Mortality was higher in patients with clinically significant arrhythmia (at 12 months: 23.6% vs 4.8% with 19 vs 7 deaths, hazard ratio (HR) = 5.5, 95% confidence interval (CI) 2.3 to 13.0, p

A 30-year-old lady with severe Rheumatic Mitral stenosis underwent PTMC. Despite a good result, echocardiogram on post-op day one showed a mobile mass attached to the mitral chordae causing diagnostic dilemma between a thrombus and damaged chordae, despite undergoing a cardiac MR to assess the nature of the mass. However, the mass disappeared after 4 weeks of receiving oral anticoagulation, favouring the diagnosis of a thrombus on MV apparatus.

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.

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.

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.

Coronary artery perforation (CAP) is a potentially lethal complication of percutaneous coronary intervention. The risk of coronary perforation is associated with the complexity of the lesion. Severe coronary artery perforations is a rare but potentially life threatening complication which requires immediate intervention. We report a case of severe coronary artery perforation and its management using dual guide technique or ping pong technique.

Objective: To estimate the burden of active infection and anti-SARS-CoV-2 IgG antibodies in Karnataka, India, and to assess variation across geographical regions and risk groups. Methods: A cross-sectional survey of 16,416 people covering three risk groups was conducted between 3–16 September 2020 using the state of Karnataka’s infrastructure of 290 healthcare facilities across all 30 districts. Participants were further classified into risk subgroups and sampled using stratified sampling. All participants were subjected to simultaneous detection of SARS-CoV-2 IgG using a commercial ELISA kit, SARS-CoV-2 antigen using a rapid antigen detection test (RAT) and reverse transcription-polymerase chain reaction (RT-PCR) for RNA detection. Maximum-likelihood estimation was used for joint estimation of the adjusted IgG, active and total prevalence (either IgG or active or both), while multinomial regression identified predictors. Results: The overall adjusted total prevalence of COVID-19 in Karnataka was 27.7% (95% CI 26.1–29.3), IgG 16.8% (15.5–18.1) and active infection fraction 12.6% (11.5–13.8). The case-to-infection ratio was 1:40 and the infection fatality rate was 0.05%. Influenza-like symptoms or contact with a COVID-19-positive patient were good predictors of active infection. RAT kits had higher sensitivity (68%) in symptomatic people compared with 47% in asymptomatic people. Conclusion: This sentinel-based population survey was the first comprehensive survey in India to provide accurate estimates of the COVID-19 burden. The findings provide a reasonable approximation of the population immunity threshold levels. Using existing surveillance platforms coupled with a syndromic approach and sampling framework enabled this model to be replicable.

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% (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.

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.

Atrial septal defect (ASD) is one of the most common congenital heart defects. Intracardiac repair via midline sternotomy or right thoracotomy and cardiopulmonary bypass have been considered the standard treatment for the closure of atrial septal defects, but transcatheter closure with Amplatzer septal occluder has recently become an alternative option. Transcatheter device closure of secundum ASD is a more than a decade old technology. This has become an alternative to surgical therapy, and has been regarded as generally safe and effective device closure. Device embolization is a potential complication of every attempted ASD closure, and the causative factors include undersized device, floppy rim, and operator-related technical issues, such as malposition during a “push-pull” maneuver. In this paper, we report a 32-year-old HIV positive female patient who presented with gradual onsite of dyspnea, NYHA class II, and successfully underwent a device closure of large atrial septal defect.

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. Keywords: Acute pulmonary embolism, Reteplase, Thrombolysis

Prosthetic valve dehiscence is one of the most catastrophic complications of prosthetic valves. Clinical presentation may range from mild asymptomatic regurgitation to severe paravalvular leaks causing acute heart failure, cardiogenic shock or even sudden death. Echocardiography and fluoroscopy help in early diagnosis. We report here an occurrence of late prosthetic aortic valve dehiscence (2 years post implantation) and highlight the fact that a high index of suspicion is necessary to diagnose such patients even when they present late after the index procedure. Prompt diagnosis and urgent surgical intervention can avert catastrophic consequences in such cases.

Quadricuspid aortic valve is a rare entity. Left ventricular noncompaction is an uncommon cause of cardiomyopathy. Combination of these two conditions is very rare. We report a case of quadricuspid aortic valve and moderate aortic regurgitation with left ventricular noncompaction who had presented with ventricular tachycardia.

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.

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

Percutaneous transvenous mitral commissurotomy (PTMC) using Inoue/Accura balloon is an effective procedure for management of patients with rheumatic mitral stenosis.1 Inability to cross the mitral valve is one of the pertinent reasons for procedural failure. We describe a series of three patients who were tackled with successful PTMC using a novel technique of veno-arterial looping and in the fourth patient we used double loop entry into left ventricle with veno-arterial rail and peripheral balloon dilatation for completing the PTMC. This is first such reported case series in literature to our knowledge.

Background: Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with rheumatic heart disease (RHD) being the dominant form of valvular heart disease (VHD) in developing nations. The current study was undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo). Methods: Among the 136,098 first-time Echocardiograms performed between January 2010 and December 2012, an exclusion criterion of trivial and functional regurgitant lesions yielded a total of 13,289 cases of organic valvular heart disease as the study cohort. Results: In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Isolated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS + MR > MS + AR > MR + AR > AS + AR > MR + AS > MS + AS. Overall, 9.7% of cases had organic tricuspid valve disease. Conclusion: RHD contributed most to the burden of VHD in the present study with calcific degeneration, myxomatous disease and BAV being the other major forms of VHD. Multiple valves were affected in more than a third of all cases.

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.