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Closed mitral valvotomy (CMV) became an accepted surgical procedure to open a stenotic mitral valve (MV) about 50 years ago. CMV is performed through an incision in the left atrial appendage. Tubbs dilator is passed in to the left ventricle via the apex and then advanced retrogradely through the stenosed MV and is then opened within the orifice to split the commissures. The dilator is then removed and the orifice closed. Incisional left ventricular pseudo aneurysm has been described as a rare complication of this technique. Here we encountered a similar scenario. Percutaneous transmitral commissurotomy has virtually replaced CMV. But with the expanding use of the transapical approach to treat a variety of structural heart diseases, especially transcutaneous aortic valve replacement, one is likely to encounter similar complications in the modern era also.

Background and aims: Infection of the central nervous system is a significant cause of morbidity and mortality in children. The aim of this study was to evaluate clinical profile and outcome of children aged 1 month to 15 years admitted with acute central nervous system infection between 2008 and 2020 in the Department of Pediatrics, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, India. Materials and methods: This was a case record based retrospective study. Results: Of 62 children, 44 had meningitis and 18 had encephalitis. Most patients were in the age group 1-5 years old and males were the predominant sex (70.96%). Eighteen patients with meningitis had a clinical triad of fever, headache, and vomiting, while only three with encephalitis experienced this. Seizures and altered sensorium were seen significantly more in children with encephalitis. Cerebrospinal fluid pleocytosis was seen in significantly more patients with meningitis compared with patients with encephalitis. Aetiology for meningitis included pneumococcus, Orientia tsutsugamushi (scrub typhus), meningococcus, and Angiostrongylus cantonensis infection. Causes of encephalitis included enterovirus, mumps virus, herpes simplex virus, dengue virus, and H1N1 influenza virus infection. Paediatric intensive care unit admission was more common for patients with encephalitis. One child with pneumococcal meningitis and another with dengue encephalitis died. Seizures were the most common sequelae. Conclusion: Typical clinical features were not present in most patients with meningitis; therefore, a high index of suspicion is needed for early diagnosis. Exact aetiologies could not be identified in most of the patients. Pneumococcus, scrub typhus, and meningococcus were the aetiological agents identified for meningitis. Encephalitis was attributed to dengue virus, herpes simplex virus, enterovirus, mumps virus, and H1N1 influenza virus infection.

Introduction: Platelets play a vital role in systemic inflammation and thrombus formation in ST Elevation Myocardial Infarction (STEMI). Understanding its role has diagnostic and prognostic implications in developing therapeutic strategies. Aim: To estimate the prognostic accuracy of platelet indicesMean Platelet Volume (MPV), Platelet Distribution Width (PDW) and MPV/Platelet Count (PC) Ratio (MPV/PC ratio) on reperfusion outcome in STEMI patients. Materials and Methods: This prospective cohort study enrolled 262 subjects, who presented with acute chest pain within a window period of 12 hours, and an Electrocardiogram (ECG) suggestive of STEMI. Blood samples collected on admission were measured for MPV and PDW. The major endpoints studied were angiographic thrombus burden and in-hospital Major Adverse Cardiovascular Events (MACE). Data was summarised by Mean and SD for continuous variables, frequency and percentage for categorical variables. Results: This study demonstrated that Acute Coronary Syndrome- STEMI (ACS-STEMI) patients with larger PDW had Larger Thrombus Burden (LTB). PDW of more than 13 fL was the best cut off for predicting LTB with a sensitivity of 67.01% and a specificity of 53.23%. There was no significant difference between the means of MPV in LTB and small thrombus burden. The total in-hospital MACE at the end of one week was 20.99% (n=55/262 patients). The maximum MACE was contributed by acute heart failure (12.6%), followed by cardiac death (6.1%) and stent thrombosis (1.5%). There was a significant association between increased PDW and in-hospital MACE, mortality and acute heart failure (p-value=0.024, p-value=0.03, p-value=0.02, respectively). The best cut-off PDW value for prediction of the composite MACE endpoint was 14.7 fL with sensitivity of 75.6% and specificity of 51.4% and the area under the Receiver Operating Characteristic (ROC) curve was 0.63 (95% CI, 0.57 to 0.69). Conclusion: The study emphasises the use of platelet indices, especially PDW, as a predictor of poorer reperfusion outcomes in primary Percutaneous Coronary Intervention (PCI) as evidenced by higher MACE rates in patients with higher PDW. Hence, PDW can help in predicting the thrombus burden even before doing the angiogram and such high-risk patients could benefit from early initiation of stronger antiplatelets, Gp IIb/IIIa (Glycoprotein) antagonist drugs and thrombus aspiration techniques.

BACKGROUND Strain imaging by speckle tracking is a well-established method to assess left ventricular function. The objective of this study was to define the utility of strain imaging in predicting obstructive coronary artery disease (CAD) in a subset of patients who do not have regional wall motion abnormality (RWMA) on routine 2D echocardiography. METHODS This is a prospective study. Consecutive patients with no RWMA scheduled to undergo coronary angiography (CAG) for clinical indications were included in the study. Longitudinal strain imaging by speckle tracking using automated functional imaging (AFI) was done by a single investigator prior to CAG. All angiograms were reported by a second investigator who was blinded to the strain imaging findings. Obstructive CAD was defined as ≥ 70% luminal stenosis of epicardial coronary arteries and/or ≥ 50% luminal stenosis of LMCA. RESULTS 129 patients were enrolled over a 7 month period (mean age 56.07±10.7, males 69%, females 31%). For detecting obstructive CAD, strain imaging had a sensitivity of 97% for LAD, 90.69% for RCA, 91.6% for LCX, a negative predictive value of 81.81% for LAD, 91.3% for RCA, 92.3% for LCX, a specificity of 15.2% for LAD, 13.9% for RCA, 22.8% for LCX and a positive predictive value of 57.6% for LAD, 34.5% for RCA and 21.3% for LCX territories. Patients with obstructive CAD had a lower global strain value of -18.37 ± 4.13 as compared to -21.18 ± 3.81 in patients who did not have obstructive CAD (p value

Background Long-term data on outcomes of participants hospitalized with heart failure (HF) from low- and middle-income countries are limited. Methods and Results In the Trivandrum Heart Failure Registry (THFR) in 2013, 1205 participants from 18 hospitals in Trivandrum, India, were enrolled. Data were collected on demographics, clinical presentation, treatment, and outcomes. We performed survival analyses, compared groups and evaluated the association between heart failure (HF) type and mortality, adjusting for covariates that predicted mortality in a global HF risk score. The mean (standard deviation) age of participants was 61.2 (13.7) years. Ischemic heart disease was the most common cause (72%). The in-hospital mortality rate was higher for participants with HF with reduced ejection fraction (HFrEF; 9.7%) compared with those with HF with preserved ejection fraction (HFpEF; 4.8%; P = .003). After 3 years, 540 (44.8%) participants had died. The all-cause mortality rate was lower for participants with HFpEF (40.8%) compared with HFrEF (46.2%; P = .049). In multivariable models, older age (hazard ratio [HR] 1.24 per decade, 95% confidence interval [CI] 1.15-1.33), New York Heart Association functional class IV symptoms (HR 2.80, 95% CI 1.43-5.48), and higher serum creatinine (HR 1.12 per mg/dL, 95% CI 1.04-1.22) were associated with all-cause mortality. Conclusions Participants with HF in the THFR have high 3-year all-cause mortality. Targeted hospital-based quality improvement initiatives are needed to improve survival during and after hospitalization for HF.

Background There are limited data to inform policy mandating primary percutaneous coronary intervention ( PPCI ) volume benchmarks for catheterization laboratories in low‐ and middle‐income countries. Methods and Results This prospective state‐wide registry included ST‐segment–elevation myocardial infarction patients with symptoms of PPCI . From June 2013 to March 2016, we recruited 5560 consecutive patients. We categorized hospitals on the basis of annual PPCI volumes into low, medium, and high volume (PPCI volume and 1‐year mortality. Among 42 recruiting hospitals, there were 24 (57.2%) low‐volume, 8 (19%) medium‐volume, and 10 (23.8%) high‐volume hospitals. The median (25th–75th percentile) TIMI (Thrombolysis in Myocardial Infarction) ST‐segment–elevation myocardial infarction risk score was 3 (2–5). Cardiac arrest before admission occurred in 4.2%, 2.1%, and 2.9% of cases at low‐, medium‐, and high‐volume hospitals, respectively ( P =0.02). Total ischemic time differed significantly among low‐volume (median [25th–75th percentile], 3.5 [2.4–5.5] hours), medium‐volume (median, 3.8 [25th–75th percentile, 2.58–6.05] hours), and high‐volume hospitals (median, 4.16 [25th–75th percentile 2.8–6.3] hours) ( P =0.01). Vascular access was radial in 61.5%, 71.3%, and 63.2% of cases at low‐, medium‐, and high‐volume hospitals, respectively ( P =0.01). The observed 1‐year mortality rate was 6.5%, 3.4%, and 8.6% at low‐, medium‐ and high‐volume hospitals, respectively ( P CI ], 1.80 [1.12–2.90]; high versus medium: hazard ratio [95% CI ], 2.53 [1.78–3.58]) ( P Conclusions Low‐ and middle‐income countries, like India, may have a nonlinear relationship between institutional PPCI volume and outcomes, partly driven by procedural variations and inequalities in access to care.

Heart failure (HF) has emerged as an important and increasing disease burden in India. We present the 5-year outcomes of patients hospitalized for HF in India.The Trivandrum Heart Failure Registry (THFR) recruited consecutive patients admitted for acute HF among 16 hospitals in Trivandrum, Kerala in 2013. Guideline-directed medical therapy (GDMT) was defined as the combination of beta-blockers (BB), renin angiotensin system blockers (RAS), and mineralocorticoid receptor antagonists (MRA) in patients with HF with reduced ejection fraction (HFrEF, EF 40%) at discharge. We used Cox proportional hazards models and Kaplan-Meier survival plots for analysis. The MAGGIC risk score variables were included as exposure variables.Among 1205 patients [69% male, mean (SD) age = 61.2 (13.7) years], HFrEF constituted 62% of patients and among them, 25% received GDMT. The 5-year mortality rate was 59% (n = 709 deaths), and median survival was 3.1 years. Sudden cardiac death and pump failure caused 46% and 49% of the deaths, respectively. In the multivariate Cox model, components of GDMT associated with lower 5-year mortality risks were discharge prescription of BB, RAS blocker, and MRA. Older age, lower systolic blood pressure, NYHA class III or IV, and higher serum creatinine were also associated with higher 5-year mortality.Three out of every 5 patients had died during 5-years of follow-up with a median survival of approximately 3 years. Lack of GDMT in patients with HFrEF and frequent readmissions were associated with higher 5-year mortality. Quality improvement programmes with strategies to improve adherence to GDMT and reduction in readmissions may improve HF outcomes in this region.

Objectives: To study if four cycles of remote ischemic preconditioning (RIPC) could offer protection against contrast induced nephropathy (CIN) and post procedural renal dysfunction in high risk patients undergoing percutaneous coronary intervention (PCI). Methods: This was a prospective single blind randomized sham controlled trial where patients undergoing coronary angioplasty with stage III chronic kidney disease were randomized into sham preconditioning and remote ischemic preconditioning. The primary outcome was the reduction in the incidence of CIN. The secondary outcomes were the maximum improvement in eGFR, maximum reduction in serum creatinine and composite of requirement of hemodialysis, death and rehospitalization for heart failure up to 6 weeks after PCI. Results: Eleven out of fifty patients in the study group developed CIN (22%) compared to eighteen out of the fifty control patients (36%) (p = 0.123). There was a statistically significant improvement in the post procedure creatinine values at 24 h (p = 0.013), 48 h (p = 0.015), 2 weeks (p = 0.003), 6 weeks (p = 0.003) and post procedure glomerular filtration rate (eGFR) values at 24 h (p = 0.026), 48 h (p = 0.044), 2 weeks (p = 0.015) and 6 weeks (p = 0.011) in study group compared to control group. The secondary outcome composite of requirement of hemodialysis, death and rehospitalization for heart failure was not statistically significant (p: 0.646). Conclusion: RIPC does not result in significant reduction of CIN. However RIPC helps in the prevention of post procedural worsening in eGFR and serum creatinine even up to 6 weeks. Keywords: Remote ischemic preconditioning, Contrast induced nephropathy, Percutaneous coronary intervention, Estimated glomerular filtration rate

Objective: To study the incidence and predictors of Contrast induced nephropathy (CIN) in high risk patients undergoing coronary angioplasty. To study the applicability of the Mehran Risk Score (MRS) in the prediction of CIN in our population. Methods: This was a prospective observational study where patients with an estimated glomerular filtration rate (eGFR) between 30 and 60 ml/mt undergoing elective percutaneous coronary intervention (PCI) over a period of 15 months were evaluated prospectively for the development of CIN. The patients who developed CIN were then analysed for the presence of specific risk factors. The patients were categorized into the 4 risk groups based on the MRS. Results: 100 high risk patients underwent PCI during the study period. The incidence of CIN was 29%. On multivariate analysis, the presence of anemia (p = 0.007), increased contrast volume usage (as defined by >5* B.Wt/S.cr) (p = 0.012) and usage of loop diuretics (p = 0.033) were independently found to confer a significant risk of CIN. In patients belonging to the high Mehran risk group (MRS10- 15) and very high risk group (MRS >15) the risk of CIN was 3 fold (OR: 3.055, 95% CI: 1.18–7.94, p = 0.022) and 24 fold (OR: 24, 95% CI: 2.53–228.28, p = 0.006) higher respectively when compared to intermediate and low risk patients (MRS

This report describes a very rare and life-threatening form of Stanford Type A circumferential aortic dissection causing intimo-intimal intussusception. Rapid and accurate diagnosis is possible by transesophageal echocardiography for which the features have been described in this article.

Chronic Total Occlusion (CTO) intervention is a challenging area in interventional cardiology. Presently about 70% of CTO interventions are successful. Materials and methods: This was a single center prospective study of a cohort of all patients undergoing percutaneous coronary intervention (PCI) as elective or adhoc procedure for CTO from August 2014 to June 2015. Only antegrade CTO interventions were included. In all patients the following data were recorded. Results: A total of 210 (8.9% of total PCI (2353) during the study period) CTO patients were followed up. The mean age was 56.54 ± 8.9. In the study sixty nine patients (32.9%) presented with chronic stable angina and rest of the patients had history of acute coronary syndrome of which 22.9% (n = 48) had unstable angina (UA) or non ST elevation myocardial infarction (NSTEMI) and 44.2% (n = 93) had ST Elevation Myocardial Infarction (STEMI). In those with history of ACS, 64.78% (n = 92) had ACS during the previous year and remaining 35.22% (n = 49) had ACS prior to that. Single vessel CTO was seen in 89.5% (n = 188) and two vessel CTO in 10.5% (n = 22). LAD was involved in 36.7% (n = 77), RCA in 48.1% (n = 101), and LCX in 15.2% (n = 32). Procedural success in the first attempt was 68.1% (n = 143), which increased to 71.42% (n = 150) after the second attempt. CTO interventions were more frequently successful when the calcium was absent or minimal (p-0.05), CTO length was

Objective To evaluate the presentation, management, and outcomes of patients hospitalized for heart failure (HF) in Trivandrum, India. Methods The Trivandrum Heart Failure Registry (THFR) enrolled consecutive admissions from 13 urban and five rural hospitals in Trivandrum with a primary diagnosis of HF from January to December 2013. Clinical characteristics at presentation, treatment, in-hospital outcomes, and 90-day mortality data were collected. ‘Guideline-based’ medical treatment was defined as the combination of beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aldosterone receptor blockers in patients with left ventricular systolic dysfunction (LVSD). Results We enrolled 1205 cases (834 men, 69%) into the registry. Mean (standard deviation) age was 61.2 (13.7) years. The most common HF aetiology was ischaemic heart disease (IHD) (72%). Heart failure with preserved ejection fraction (≥45%) constituted 26% of the population. The median hospital stay was 6 days (interquartile range = 4–9 days) with an in-hospital mortality rate of 8.5% (95% confidence interval 6.9–10.0). The 90-day all-cause mortality rate was 2.43 deaths per 1000 person-days (95% confidence interval 2.11–2.78). Guideline-based medical treatment was given to 19% and 25% of patients with LVSD during hospital admission and at discharge, respectively. Older age, lower education, poor ejection fraction, higher serum creatinine, New York Heart Association functional class IV, and suboptimal medical treatment were associated with higher risk of 90-day mortality. Conclusion Patients hospitalized with HF in the THFR were younger, more likely to be men, had a higher prevalence of IHD, reported longer length of hospital stay, and higher mortality compared with published data from other registries. We also identified key areas for improving hospital-based HF medical care in Trivandrum.

Background There are sparse data on outcomes of patients with heart failure (HF) from India. The objective was to evaluate hospital readmissions and 1-year mortality outcomes of patients with HF in Kerala, India. Methods We followed 1,205 patients enrolled in the Trivandrum Heart Failure Registry for 1 year. A trained research nurse contacted each participant every 3 months using a structured questionnaire which included hospital readmission and mortality information. Results The mean (SD) age was 61.2 (13.7) years, and 31% were women. One out of 4 (26%) participants had HF with preserved ejection fraction. Only 25% of patients with HF with reduced ejection fraction received guideline-directed medical therapy at discharge. Cumulative all-cause mortality at 1 year was 30.8% (n = 371), but the greatest risk of mortality was in the first 3 months (18.1%). Most deaths (61%) occurred in patients younger than 70 years. One out of every 3 (30.2%) patients was readmitted at least once over 1 year. The hospital readmission rates were similar between HF with preserved ejection fraction and HF with reduced ejection fraction patients. New York Heart Association functional class IV status and lack of guideline-directed medical treatment after index hospitalization were associated with increased likelihood of readmission. Similarly, older age, lower education status, nonischemic etiology, history of stroke, higher serum creatinine, lack of adherence to guideline-directed medical therapy, and hospital readmissions were associated with increased 1-year mortality. Conclusions In the Trivandrum Heart Failure Registry, 1 of 3 HF patients died within 1 year of follow-up during their productive life years. Suboptimal adherence to guideline-directed treatment is associated with increased propensity of readmission and death. Quality improvement programs aiming to improve adherence to guideline-based therapy and reducing readmission may result in significant survival benefits in the relatively younger cohort of HF patients in India.

The Biomime Morph (Meril life Sciences, Gujarat, India) is a Sirolimus eluting tapered stent approved for use in India. It is available in four lengths {30 mm, 40 mm, 50 mm and 60 mm} and four diameters {2.75 mm tapering to 2.25 mm, 3 mm tapering to 2.5 mm, 3.5 mm tapering to 2.75 mm, and