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   Table of Contents - Current issue
May-August 2022
Volume 10 | Issue 2
Page Nos. 61-109

Online since Friday, August 12, 2022

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Preface to the second issue of Heart India 2022 p. 61
Alok Kumar Singh
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Serum lactate clearance as a predictor of outcome in infants' postcardiac surgery p. 63
Hasmukh Patel, Nirav Parikh, KS Ramkiran, Prakash Sadhwani, Ramesh Patel, Pratik Shah
Background and Aims: Prediction of postoperative outcomes by conventional hemodynamic parameters and risk scoring systems immediately after pediatric cardiac surgery has not been found to be reliable. Trends in serum lactate value over time or serum lactate clearance were found to give better estimate. The present study aimed to find out the effect of serum lactate clearance on mortality after pediatric cardiac surgery. Methods: Out of the 150 pediatric cardiac surgical procedures performed during the study period, 131 patients meeting inclusion criteria were enrolled in the present study. The study population was observed for lactate levels immediately postoperatively (T0) and then every 4 h for the first 24 h (T1-T6) and lactate clearance was calculated. Patient's outcomes in view of mortality, duration of mechanical ventilation, and length of intensive care unit (ICU) stay were observed. Results: In our study, mortality was 9.23%. Median inter quartile range with Hodges-Lehmann median difference (95% confidence interval) lactate values were higher among nonsurvivors and statistically significant at T0 = (6.14 [3.43,7.34] vs. 2.50 [1.87,3.59]; 2.53 [1.02, 4.33], P ≤ 0.0001), T1 = (3.10 [2.81, 5.16] vs. 2.30 [1.73, 3.61];0.95 [0.13, 1.73], P = 0.032), T2 = (3.49 [3.03, 5.40] vs. 2.39 [1.66, 3.38];1.32 [0.48, 2.27], P = 0.004), T3 = (3.82 [2.99, 5.54] vs. 2.20 [1.58, 3.45]; 1.46 [0.50, 2.45], P = 0.003), T4 = (4.86 [3.35, 5.44] vs. 2.09 [1.42, 3.47]; 2.02 [1.09, 3.13], P ≤ 0.0001), T5 = (4.36 [3.80, 6.27] vs. 2 [1.32, 3.26]; 2.29 [1.41, 3.25], P ≤ 0.0001), and T6 = (4.12 [3.69, 5.83] vs. 1.82 [1.31, 3.15]; 2.34 [1.15, 3.21], P ≤ 0.0001). Nonsurvivors were having decreasing trend of lactate clearance which was statistically nonsignificant. Mechanical ventilation was prolonged in nonsurvivors compared to survivor (135 [202] h vs. 30 [77] h; P = 0.002); however, there was no significant difference in ICU stay (P = 0.764). Conclusion: Poor lactate clearance and high lactate level were associated with high mortality. Serial lactate levels and decreasing trend of lactate clearance in the early postoperative period is a good predictor of postoperative outcome in pediatric cardiac surgery.
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Prospective analysis of early outcomes of off-pump coronary artery bypass in high-risk patients and role of EuroSCORE-II p. 68
Darshak Patel, Mrinal Patel, ZS Meharwal
Background: Off-pump coronary artery bypass (OPCABG) grafting has emerged as an effective alternative technique for allowing coronary revascularization without the use of cardiopulmonary bypass. OPCABG has been associated with decreased postoperative morbidity, shorter hospital stay, reduced cost, and reduced operative mortality in some studies. Materials and Methods: A total of 190 patients who underwent isolated coronary artery bypass graft surgery were evaluated with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk scoring system. Moreover, we also compared the discriminatory potentials between the EuroSCORE II with <5 and >5 scores. Results: EuroSCORE high-risk patients showed higher rates of blood transfusion (66.9%), intraaortic balloon pump insertion (12.6%), atrial fibrillation (21%), and renal failure (46.8%). There was one mortality in each EuroSCORE group. Conclusion: OPCABG can be accomplished safely in selected high-risk patients with acceptable morbidity and mortality without compromising complete revascularization. Severe renal failure needing dialysis, stroke, and deep sternal wound infection in the postoperative period carries high morbidity and mortality after OPCABG. There is no ideal risk prediction model for an individual patient but multidisciplinary approach and individual patient factors determine the operative risk.
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The association of serum uric acid and 1-year major adverse cardiovascular events in patients undergoing percutaneous coronary intervention p. 74
Anjum Naim, Ashish Jha, Amresh Kumar Singh, Bhuwan Chandra Tiwari, Sudarshan K Vijay, Naveen Jamwal
Context: Elevated uric acid (UA) is seen in several vascular diseases. Its significance as a prognostic marker in patients undergoing percutaneous coronary intervention (PCI) is unknown. Aims: The aim of this study was to evaluate the association between elevated UA and major adverse cardiovascular events (MACE) at 1 year in patients undergoing PCI. Settings and Design: This was a prospective, observational, single-center study. Subjects and Methods: Patients undergoing PCI were categorized into hyperuricemic (HU, UA >6.0 mg/dl in women and >7.0 mg/dl in men) and normouricemic (NU) groups and were observed for 1 year. The endpoint was difference in MACE (composite of deaths, nonfatal myocardial infarction, stroke, and target vessel revascularization) at 1 year between the two groups. The secondary endpoints were the difference in Killip class at presentation, angiographic severity of coronary artery disease (CAD), cardiac arrhythmias, and congestive heart failure (CHF) between the two groups. Results: A total of 215 patients (107 in HU arm and 108 in NU arm) were recruited. Patients in the HU arm were older, had higher frequency of multivessel CAD (93.5% vs. 79.6%, P < 0.05) and complex coronary lesions (98.1% vs. 91.7%, P < 0.05). MACE at 1 year were more frequent in the HU arm compared to the NU arm (21.5% vs. 6.5%, P < 0.05). New-onset atrial fibrillation (AF) (11.2% vs. 3.7%, P < 0.05) and CHF (13.1% vs. 4.6%, P < 0.05) were also more frequent in the HU arm versus the NU arm. Conclusions: Elevated serum UA level in patients undergoing PCI was associated with angiographically more severe and multivessel CAD, a higher frequency of MACE, CHF, new-onset AF, and a higher mortality than those having normal UA levels.
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Postoperative outcomes in patients with post infarction ventricular septal defect – Institutional experience p. 80
Deepti Kakkar, Devvrat Desai
Context: Postinfarction ventricular septal defect (VSD) is a rare but serious complication of myocardial infarction with a reported incidence of 1% to 3% in the pre thrombolytic era and <0.5% post thrombolytic therapy. Risk of death is greatest immediately after myocardial defect and then gradually declines. Early surgical treatment is recommended; however, surgical repair is associated with a high rate of mortality. Aim: To investigate the immediate survival outcome and prognostic factors associated with surgical repair of postinfarction ventricular septal rupture at our institute over a 3-year period. Materials and Methods: From April 2012 to April 2015, 32 patients underwent surgical repair of post-infarction ventricular septal rupture at our institute. Patients were identified from the electronic medical records database and preoperative, intraoperative, and postoperative variables were retrieved. Multiple perioperative variables such as anthropometric data, demography, and clinical history and preoperative details such as echocardiographic indices, coronary angiography, and intraoperative variables were analyzed. The outcomes were compared between the survivors and nonsurvivors. Results: Overall, younger patients tolerated the disease and the surgery better than the older population (59.96 ± 10.67 vs. 69.11 ± 8.11; P = 0.02). Female sex, cardiogenic shock (n = 20, 86.95% vs. n = 2, 22.22%; P = 0.001), and emergency surgery were independently associated with higher risk of postoperative mortality. History of systemic hypertension was found to be significantly associated with poor postoperative outcomes (survivors n = 9, 39.1% vs. nonsurvivors n = 8, 88.9%; P = 0.017). In our series, the overall mortality was 28.1% (n = 9). Higher NYHA class at presentation, intra-aortic balloon pump requirement and low ejection fraction are all independently associated with poor outcomes. Longer interval between the myocardial infarct and surgical repair is associated with a lower risk of operative mortality. Preoperative renal dysfunction (61.77 ± 19.04 vs. 41.36 ± 21.15; P = 0.025) and postoperative renal dysfunction (65.26 ± 28.81 vs. 27.27 ± 9.04; P = 0.001) is one of the most important predictors of postoperative outcome. The duration of aortic cross-clamp and cardiopulmonary bypass was not associated with early mortality in this study (89.17 ± 42.70 vs. 97.11 ± 76.38; P = 0.775). Conclusion: Postinfarction VSD still remains one of the most challenging conditions to treat surgically with considerable early mortality. Although percutaneous device closure and left ventricular assist devices may be used as a method to stabilize the patient preoperatively and improve the chances of survival after surgery, it is currently not advocated as a definitive treatment option. All efforts should be made to predict and prevent postoperative renal dysfunction as it is the single-most important factor affecting both short- and long-term survival outcomes.
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Clinical significance and postoperative outcomes after pulmonary vein isolation for atrial fibrillation in mitral valve surgery p. 87
Devvrat Desai, Deepti Kakkar
Atrial fibrillation is the most common tachyarrhythmia associated with mitral valve disease, resulting in significant morbidity and mortality. Atrial fibrillation is a marker of advanced cardiovascular disease and an independent predictor of death. As a large number of patients undergoing mitral valve operations are associated with chronic atrial fibrillation, pulmonary vein isolation procedure with cut and sew method can be concomitantly performed with a mitral valve operation and it is enough to improve the quality of life after operation by eliminating the morbidity associated with chronic atrial fibrillation. The aim of this study is to find out the immediate postoperative outcomes of the patients with known mitral valve disease with atrial fibrillation who are undergoing mitral valve surgery with concomitant pulmonary vein isolation at our institution. The perioperative risk factors such as older age, duration of atrial fibrillation, the size of the left atrium, and the mitral valve pathology were evaluated for their clinical significance. Preoperative, intraoperative, and postoperative variables were retrieved and analyzed retrospectively. The outcomes were compared between these subgroups using various statistical tools. Conversion to normal sinus rhythm was more significant in the younger age group (<45 years) as compared to the older age group. Seventy-eight percent patients (n = 117) were free from atrial fibrillation at the time of discharge. The overall mortality was 4% (n = 6). There was no procedure-related death.
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Managing diffusely diseased coronary arteries – place of endarterectomy in today's scenario p. 94
Ameya Gadkari, Darshak Patel, Mrinal Patel, Kartik Patel, Chirag Doshi
Introduction: Surgical management of diffuse coronary artery disease (CAD) requires aggressive techniques for complete revascularization. Coronary endarterectomy (CE) coupled with coronary artery bypass grafting (CABG) is a valuable technique for this subset. The aim is to evaluate the perioperative and early results following CE. Materials and Methods: Three hundred and eighty patients of diffuse CAD undergoing off-pump CABG were included in the study. CE was performed in 204 patients. The mean age of the patients was 62 ± 16.32 years. The male-to-female ratio was 1.43, and the mean SYNTAX score was 33.12 ± 6.42. The mean stay in the intensive care unit was 4.94 ± 2.72 for patients undergoing CABG with CE. The perioperative mortality was 4.9%. The patients were followed up at 3 months, and graft patency was assessed with computed tomography coronary angiography. The average graft patency was 86.725% for the grafts with CE. Patients with left anterior descending (LAD) CE had higher perioperative mortality (5%), overall survival (89.79% at 3 months), and graft patency rates (87%) were favorable. The outcome following single vessel CE was better than multivessel CE. Conclusion: In patients with diffuse CAD, CE is a safe technique with comparable mortality and lesser complication rate if performed adequately. Despite perioperative difficulties, early outcomes are favorable for CE to the LAD artery grafted with the left internal thoracic artery. Single vessel CE yielded a better result as compared to multivessel CE.
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Reversible hypertension and infective arteritis p. 100
Amita Diwaker, Dhiraj Kishore, Santosh Kumar Singh, Samer Singh
Background: Idiopathic vasculitides or arteritis have very few or none treatment options. Identification of infective arteritis based on high clinical suspicion opens a window for treatment of such cases . Although these are occasional clinical scenario. Aims and Objectives: To identify the treatable cause of arteritis and starting initial treatment based on clinical suspicion. Material and Methods: Based on high clinical suspicion we aim to identify chronic infective cause of arteritis among patients of SS Hospital from 2019 to 2020 coming in EOPD. Results and Discussion: Three cases of reversible hypertension from different clinical setup relating to a common infective etiology, i.e., tuberculosis identified during the said duration, all cases presented with constitutional symptoms for 2–6 months with headache, loss of appetite, fever, and malaise. The first case presented as acute abdomen in EOPD having mesenteric ischemia and hypertension. The second case presented in antenatal care OPD with hypertension which was nonrelated to pregnancy. The third case presented in medicine OPD as a case of young hypertensive without mood changes. Partial renal artery stenosis relating to infective arteritis was a common finding in all cases. All cases responded well with the firstline antitubercular medication and became normotensive (without medication) in the follow up. Conclusion: The cause of renal artery stenosis appeared to be related to tubercular arteritis of vessel with either a past history of pulmonary TB or TB contact. Renovascular tubercular arteritis has been defined in only a few literatures and only handful of cases being reported making worth presentation.
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Recanalizing a right coronary artery chronic total occlusion with J chronic total occlusion score 3: An interesting combination of reversal of wire upgradation and miniature balloon p. 105
Debasish Das, Anindya Banerjee, Abhinav Kumar, Jogendra Singh, Tutan Das, Shashikant Singh, Jaideep Das Gupta, Subhas Pramanik, Manaranjan Dixit
We represent a case of interesting right coronary artery chronic total occlusion (CTO) revascularization where traditional wire upgradation failed to cross the CTO. Downgrading it to a Miracle 3 wire, the lesion was successfully crossed. It was further dilated with the smallest balloon (NIC Nano 0.85 mm × 6 mm), followed by serial dilation with bigger size balloons. The present manuscript conveys a message that the rule of thumb of wire upgradation during CTO revascularization does not yield in success always, it is the downgradation of the wire which can also achieve success. CTO revascularization although it has some fixed principles, sometimes, a permutation and combination even giving a fair try with wire downgradation can achieve success.
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