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   Table of Contents - Current issue
January-April 2023
Volume 11 | Issue 1
Page Nos. 1-53

Online since Wednesday, April 12, 2023

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Preface to the first issue of Heart India 2023 p. 1
Alok Kumar Singh
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Echocardiographic evaluation of right heart pressure changes in healthy newborns and its follow-up till 12 weeks of life p. 3
Avishikta Das, Uttam Kumar Sarkar, Kaushik Ishore
Background: Right ventricular (RV) pressure undergoes a series of changes from foetal to neonatal period on both left and right heart. Pulmonary velocity acceleration time (PVAccT) measured by trans-thoracic echocardiography has been established as a reliable indicator of RV pressure measurement in neonates. This study aims to throw some light into the changes in the RV pressure by serial PVAccT measurements in the initial 12 weeks of life. Materials and Methods: A cross sectional study was carried out among term new-borns until 12 weeks of age and serial changes in the PVAccT values were recorded, reflecting the mean pulmonary artery pressure (MPAP), and the left ventricular internal diastolic diameter (LVIDD), left atrial diameter (LAD), right ventricular outflow tract (RVOT), right ventricular free wall thickness (RVFWT). Results: There was gradual increase in the mean value of PVAccT with age from birth i.e., 1-3 days (70.08±18.62ms) to 3 months (86.23±17.31ms) (p=<0.05). Mean value of right ventricular outflow tract proximal diameter was also seen to have an increase from day 1-3 (0.92±0.19cm) to 3 months of age (1.09±0.01cm) (p= <0.001). There was an overall decrease in the mean value of the RVFWT from day 1-3 (0.37±.07 cm) to 3 months (0.27±0.07cm) of age after an increase at 1 month (p=<0.05). Statistically significant increase in mean LAD from 1.18±0.29cm to 1.40±0.35 cm and LVIDD from 1.54±0.31cm to1.96±0.27 was seen from birth to 3 months of age. Conclusion: Changes in PVAcct and RV pressure with time from birth to 3 months of age will aid in early diagnosis of persistent pulmonary artery hypertension of new-born (PPHN) or pulmonary arterial hypertension (PAH).
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Direct innominate artery ostial cannulation using retrograde cardioplegia cannula in Type A dissection p. 8
Praveen Nayak, Archit Patel, Mausam Shah, Chirag Doshi
Objective: Axillary and innominate artery (IA) cannulation using side graft has some limitations in patients having ascending aortic dissection (AAD) with flap extending in major neck vessels. We retrospectively analyzed the outcomes of a direct under vision innominate ostial cannulation strategy for antegrade cerebral perfusion (ACP) using a retrograde balloon-tip cardioplegia cannula. Patients and Methods: This was a retrospective analysis of all patients who were operated on for AAD with a dissection flap extending into major neck vessels between November 01, 2020 and November 30, 2022. Demographic data were noted, and comorbidities were listed. The kind of surgery patients underwent was noted: three patients underwent modified Bentall's procedure, five had to ascend aortic replacement, and one patient underwent David's procedure. All patients had open distal anastomosis using moderate hypothermia with ACP by direct under vision cannulation of the true lumen of the IA using a balloon-tip retrograde cardioplegia cannula. Intraoperative parameters such as cross-clamp time, cardiopulmonary bypass time, temperature range during circulatory arrest, and total operative time were noted. The primary outcome was a comparison of the incidence of stroke, seizures, and psychosis and the secondary outcome was an analysis of end-organ malperfusion, intensive care unit (ICU) stays, total hospital stay, and 30-day mortality. Results: We retrospectively analyzed the surgical data of nine patients who were operated on between November 01, 2020 and November 20, 2022 by this technique and found that the incidence of stroke, seizures organ malperfusion, ICU stay, and hospital stay was comparable to other techniques of ACP (axillary artery/direct IA cannulation), but the operative time was a less, and local complications due to axillary cannulation such as shoulder pain and upper limb weakness and seroma were not seen. Conclusion: Direct vision cannulation of the true lumen of the IA using a retrograde balloon-tip cannula is a cost-effective and time-saving method. It evades the limitations of well-established ACP techniques such as direct IA cannulation using Seldinger's technique which is a blind procedure and also has no local complications of the cannulating right axillary artery. Our results show that this procedure is less time-consuming and is noninferior to the other two methods of ACP in patients getting operated on for AAD with open distal anastomosis under moderate hypothermia. Further studies with a larger sample size are needed to validate this preliminary study.
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Clinical characteristics, risk factors, and thyroid profile of patients admitted with acute left ventricular heart failure from a tertiary hospital in Northeast India: A single-center retrospective cohort study p. 13
Anup Kumar Boro, Prabir Kumar Gupta, Biplab Paul, Habibar Rahman, Sneha Gang, Ananya Barman
Introduction: Heart failure (HF) is a progressive chronic clinical syndrome. Thyroid dysfunction in HF patients has been reported in the literature. We aimed to explore the prevalence of thyroid dysfunction among acute left ventricular failure (LVF) patients admitted to our hospital. Materials and Methods: A retrospective study involving 78 patients diagnosed with acute LVF was conducted. Baseline information that included demographics, risk factors, clinical presentations, and biochemical data was recorded. A comparison of acute LVF patients with thyroid dysfunction to those with normal thyroid function was analyzed and documented. Results: About 29.5% (n = 23; 63.8 ± 11.4 years) of patients had normal thyroid function and 70.5% (n = 55; 65.3 ± 6 years) had thyroid dysfunction (P = 0.0003). The mean age of the cohort was 64.7 ± 12.4 years and 68% (n = 53) were men. Hypertension was the most common risk factor among both groups (56.5%, n = 13 vs. 67.3%, n = 37; P = 0.0006). Around 13% (n = 3) of patients with normal thyroid function and 20% (n = 11) of patients with thyroid dysfunction expired (P = 0.0325). The most common symptom seen in both groups was shortness of breath (28%, n = 16 vs. 72%, n = 41; P = 0009). There was a high prevalence of HF with reduced ejection fraction (60.8%, n = 14 vs. 65.5%, n = 36; P = 0.0018). Electrocardiography abnormalities were noted in 70.5% (n = 55) of patients of the cohort (65.2%, n = 15 vs. 72.7%, n = 40; P = 0.007). Irregularities in two-dimensional echocardiography and Doppler were seen in 76.5% (n = 59) of patients (69.6%, n = 16 vs. 78.2%, n = 43; P = 0.0004). Conclusions: Thyroid dysfunction can cause significant adverse effects on the heart. Early diagnosis and treatment of thyroid abnormalities can reduce and/or prevent the development of serious cardiac problems including HF.
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Hypertension clinical care in the era of coronavirus disease 2019: Practical insights from India p. 19
Mangesh Tiwaskar, Prabhakar C Koregol, Hari Hara Krishnan, Dinesh Agarwal, Omer Hasan, Mahesh Abhyankar, Santosh Revankar, Neeraj Kumar
Objective: The objective of this study was to seek the opinion of Indian health-care professionals (HCPs) about hypertension (HTN) care during coronavirus disease 2019 (COVID-19) era. Methods: HCPs' opinions (n = 2832) were recorded based on survey and round table meetings. Standard questionnaire consisting of nine questions pertaining to HTN care in COVID-19 was prepared, discussed, and evaluated by experts who treat patients with HTN during COVID-19 era. Results: Smoking/tobacco use, obesity, and comorbidities (diabetes/dyslipidemia) were ranked as the top three modifiable risk factors. A total of 37% and 33% of HCPs reported an increase in blood pressure (BP) during the lockdown period in 10%–20% and 20%–40% of hypertensive patients, respectively, who were on monotherapy. Around 35% of HCPs reported that 20%–30% of their patients with HTN showed uncontrolled BP (>150/100 mmHg). Dual-drug therapy in patients with uncontrolled BP was preferred by 56% of HCPs. Nearly 71% preferred dual combination for HTN management. In dual combination, 27% preferred angiotensin receptor blockers (ARBs) + diuretic, 26% preferred ARB + calcium channel blockers, and 18% preferred ARB + beta-blockers. The majority of HCPs (44%) consider that <30% of their patients with HTN check BP at home. A total of 47% of HCPs reported acute coronary syndrome as the most common HTN-related complication. The majority of HCPs (57%) considered that avoiding contamination during BP measurement is the challenging parameter. Around 32% considered self-BP monitoring (SBPM) as the best method to improve medication adherence. Conclusion: SBPM, combination therapies, and digital connect with patients are critical aspects of HTN management during COVID-19 pandemic.
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Double-arterial cannulation strategy in patients presenting with Type A aortic dissection: An Indian tertiary cardiac center experience p. 28
Archit Patel, Praveen Nayak, Rahul Singh, Chirag Doshi
Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality. Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality. Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes. Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs. Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.
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Bentall through a right mini-thoracotomy: A single-center experience p. 34
Pratik Manek, Mausam Shah, Ashish Madkaiker, Manish Jawarkar, Vivek Wadhawa, Chirag Doshi
Objective: The minimally invasive right thoracotomy approach is being increasingly used for aortic valve surgeries. It has several benefits in terms of decreased blood loss and length of hospital stay as compared to conventional sternotomy technique. Selected patients requiring aortic root and ascending aorta surgery can be operated on using a similar approach. In this case series, we share the outcomes of Bentall surgery done through right mini-thoracotomy. Methods: This was a single-center retrospective study of five patients who underwent elective right mini-thoracotomy modified Bentall Procedure. Instruments routinely used in minimally invasive cardiac surgery were used. The outcomes that were evaluated include cross-clamp times, cardiopulmonary bypass (CPB) times, time to extubation, total length of intensive care unit (ICU) and hospital stay, re-exploration rates, and inhospital and 30-day mortality. Results: The mean CPB times and cross-clamp times were 128 and 96 min, respectively. The total circulatory arrest was used in two patients with a mean time of 12 min. The mean time to extubation was 7 h. The mean ICU stay and the total length of hospital stay were 1.5 and 5 days, respectively. No patient required re-exploration for bleeding. We did not have any inhospital or 30-day mortality. Conclusion: The right mini-thoracotomy modified Bentall procedure is reproducible and safe in selected patients with annuloaortic ectasia.
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Clinical and demographic profile of patients of rheumatic valvular heart disease: A cross-sectional analysis of Varanasi heart valve registry p. 40
Soumik Ghosh, Rajpal Prajapati, Dheeraj Kela, Aqdas Mumtaz, OM Shankar
Background: Rheumatic heart disease (RHD) is a preventable structural heart disease involving cardiac valves affecting the young population of productive age-group having considerable morbidity and mortality due to associated complications. Aims and Objectives: To evaluate the clinic-demographical characteristics and complications of RHD patients and thus to build up a RHD valvular registry. Materials and Methods: In this study, we enrolled 570 consecutive patients diagnosed with rheumatic valvular affection as defined by echocardiographic criteria, and studied their demographic, valvular pathology, symptomatology, prophylaxis and complication profile. Results: Female patients dominated the population in number, mitral being the most affected valve, mitral stenosis the commonest lesion. Newly diagnosed patients constituting 20% of study population. One-fourth of the patients gave a proper history of acute rheumatic fever and oral prophylaxis was noted to be more compliant than parenteral. Case proportionality ratio for atrial fibrillation was highest with severe MS with AR and for pulmonary hypertension with severe MR with or without MS. Conclusion: RHD is a preventable disease and health professionals and policy making institutions at all levels should strive in unison to mitigate its incidence, disease severity and complications.
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Comparison of postoperative outcomes of milrinone versus dobutamine in tetralogy of Fallot with transannular patch p. 46
Ishan Gohil, Herin Patel, Devvrat Desai, Jignesh Kothari
Background: Since the original description of TOF, its management modalities are continuously evolving. Present modality includes complete correction of the pathology by intra-cardiac repair with or without using transannular patch. Various finer aspects of intraoperative and postoperative management of the TOF repair are still evolving. Aims and Objectives: In this single centre study we are aiming to compare short term outcomes in patients of tof operated with transannular patch repair treated postoperatively with dobutamine vs milrinone. Materials and Methods: Total 100 patients undergoing TOF repair with transannular patch were grouped with respect to the inotropes used. One group who received milrinone and other who received dobutamine. Postoperative outcomes depending upon the need of other inotropic support, duration of ventilatory support, icu stay , inotropic support , hospital stay , morbidity and mortality are compared between the groups. Observations: No significant difference was seen in both groups for mean ventilation time, duration of icu and hospital stay. Only parameter which was significant was increase in usage of adjuvant inotropic support in milrinone group which were depicted in terms of increased VIS ( Vasoactive inotrope score). Almost equal incidence of adverse events were noted in both the groups. Conclusion: Milrinone and dobutamine are fairly comparable to each other in cases of TOF repair with transannular patch. Dobutamine being a cheaper alternative have a better scope in developing countries like India.
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The aberrant continuation of the long or second left anterior descending artery from the ramus intermidius: A novel variant of the Group-I dual left anterior descending artery p. 52
Pankaj Jariwala
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