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   Table of Contents - Current issue
September-December 2022
Volume 10 | Issue 3
Page Nos. 111-172

Online since Wednesday, December 14, 2022

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Preface to the third issue of Heart India 2022 p. 111
Alok Kumar Singh
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The impact of administering intraoperative dexamethasone versus placebo on major complications and mortality in patients undergoing cardiac surgery: A systematic review and meta-analysis p. 113
Ashish Madkaiker, Tania Mehta, Pratik Manek, Chirag Doshi, Pratik Shah, Sanjay Patel
Background: Inflammations resulting from cardiac surgical procedures have traditionally been controlled with corticosteroids such as dexamethasone. However, the use of these medications to attenuate the inflammatory responses from cardiac surgery remains contentious. The aim of this systematic review and meta-analysis was to evaluate the effect of administering dexamethasone intraoperatively on major complications and mortality compared to placebo interventions. Study Design: This was a systematic review and meta-analysis. Methods: The research was conducted on online databases such as PubMed, Google Scholar, EMBASE, and the Cochrane Central Register of Control Trials until August 5, 2022. The studies in the online databases were written between January 1, 2000, and August 1, 2022. The studies that were selected were scanned and analyzed based on an established eligibility criteria for the study. Results: Ten randomized and controlled trials were included in this systematic review and meta-analysis. The incidence of mortality was 2.2% (154 out of 7007 patients) in the dexamethasone group and 2.3% (164 out of 7038 patients) in the placebo group (odds ratio [OR],0.94; 95% confidence interval [CI], 0.75–1.01; P = 0.73; I2 = 0%). Myocardial infarction incidence was 1.88% (88 out of 4685 patients) in the dexamethasone group and 2.12% (100 out of 4708 patients) in the placebo group (OR, 0.88; 95% CI, 0.66–1.18; P = 0.39; I2 = 9%). The incidence of stroke for the dexamethasone group was 1.56% (70 out of 4488 patients) and 1.82% (82 out of 4511 patients) in the placebo group (OR, 0.86; 95%CI, 0.62–1.18; P = 0.34; I2 = 0%). The prevalence of new onset atrial fibrillation was 32.3% (797 out of 2469 patients) for dexamethasone and 34.7% (859 out of 2478 patients) for placebo (OR, 0.90; 95%CI, 0.80–1.01; P = 0.08; I2 = 0%). The incidence of renal failure was slightly higher in the placebo group with 1.58% (108 out of 6857 patients) compared to the dexamethasone group 0.97% (66 out of 6823 patients) (OR, 0.61; 95% CI, 0.45–0.83; P = 0.002; I2 = 0%). Conclusion: According to this review, dexamethasone does not result in a significant decrease in incidences of mortality, myocardial infarction and stroke. However, the medication was associated with decreased incidences of renal failure and atrial fibrillation in a majority of the studies.
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Analytical study of angiographic profile of acute coronary syndrome and its risk factors among young individuals (≤45 years) p. 121
Thulaseedharan Sarojadevi Ashida, Senthilvelan Thenmozhi, Subramanian Girija, Jayaraman Balachander
Background: Acute coronary syndrome (ACS) in young (≤45 years) patients has devastating social and economic consequences. We present the clinical presentation, coronary angiogram (CAG) findings with particular reference to angiographic severity, treatment, and short-term follow-up. Methods: This was an ambidirectional cohort study (n = 224) conducted in the department of cardiology of a tertiary care teaching hospital in South India, catering mainly to a predominantly rural population. Patients were identified from “The CATH-lab Registry” and the data were analyzed. Results: The mean (±standard deviation) age was 39.02 ± 5.6 years, with a male predominance (79.9%). Dyslipidemia (57.6%), smoking (25.9%), and diabetes mellitus (29.9%) emerged as major risk factors. Almost equal proportion of patients presented with ST-segment elevation myocardial infarction (STEMI; 53.12%) and non-ST elevation ACS (46.88%); 30.8% of patients had left ventricular (LV) dysfunction. CAG showed involvement of left anterior descending artery in the majority (66.38%) of patients with single-vessel disease in the STEMI group. Left main coronary artery involvement was seen in 8.9% of patients. Majority (89.7%) of young ACS patients had low syntax score. Risk factors were similar among patients with obstructive and nonobstructive CAD. Almost half (47.7%) of the patients needed revascularization, with 16.9% undergoing coronary artery bypass graft surgery. Only two patients had recurrent ACS, at a mean follow-up of 12 months. Conclusions: The most important risk factors for young ACS were dyslipidemia, smoking, and diabetes mellitus. LV function was preserved in majority of young ACS patients and short-term prognosis (1 year) was favorable.
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Coronary endarterectomy – A way to complete revascularization p. 128
Herin Patel, Ishan Gohil, Jignesh Kothari, Pratik Shah
Background and Aim of the Study: Coronary endarterectomy (CE) is performed adjacent to coronary artery bypass grafting (CABG) grafting to aid complete revascularization. However, the purpose of CE in surgical management of diffuse coronary artery disease (CAD) is controversial. The objective of this study was to highlight the operative outcomes, safety, and complications associated with CE. Methods: An observational, prospective research was carried out in the Department of Cardiovascular and Thoracic Surgery at our institute. All patients undergoing isolated CABG + CE from 2019 till 2021 were evaluated. Patients undergoing urgent, emergency, or elective CABG + CE off-pump/on-pump surgery were enrolled. Results: One hundred patients with CABG + CE were evaluated based on symptomatology with sequential electrocardiogram monitoring and blood samples for cardiac biomarkers. The blood samples were taken 6, 12, 24, 48, and 72 h following surgery. Eighty-five patients required single CE and 15 patients required double CE. We noticed a rising trend of cardiac markers in the first 6 h, reaching its peak level at 24 h, and downward trend following 72 h following surgery. Although patients had a tremendous rise in the cardiac biomarker values, clinically patients were stable with operative mortality of 5%. Conclusions: We believe CE helps in complete revascularization in patients with diffuse CAD. CE should be given due consideration in an era where it has been neglected due to its complexities and accompanying myths. CE is an important and integral weapon in a surgeon's armamentarium, and we should not hesitate to perform CE due to associated myths.
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Periprocedural and short-term outcomes of stenting of coarctation of the aorta in adults: A retrospective analysis from a series of seven cases p. 134
Sudarshan Kumar Vijay, Ashish Jha, Bhuwan Chandra Tiwari, Amresh Kumar Singh, Naveen Jamwal
Background: Coarctation of the aorta (CoA) is a rare congenital heart disease for which ballooning or surgery is recommended in the early stages of life, however, in adult patients, stenting has emerged as the treatment of choice. Data on various techniques and outcomes of stenting in CoA in Indian patients are scarcely available. Materials and Methods: Seven adult patients of CoA treated at our center with stenting between the years 2018 and 2022 were retrospectively studied. All patients were analyzed for their clinical presentation, coarctation segment anatomy, use of various techniques for stent deployment, perioprocedural outcomes, and 3-month echocardiography (ECHO)-based follow-up with the study of gradients and clinical features. The use of various hardware to facilitate stenting was studied, and predictors of successful stenting were also defined in the analysis. Results: The mean age of the coarctation patients was 19.1 ± 3.7 years with a male-to-female ratio of 3:4. The mean systolic blood pressure at baseline was 162.5 ± 12.6 mm of Hg and mean diastolic blood pressure of 95.7 ± 5.3 mm of Hg. The mean peak systolic gradient across the coarctation segment at baseline was 46 ± 8.2 mm of Hg. Combined antegrade and retrograde access was used for stenting of CoA in four patients (57%). Good-sized isthmus was present in only three patients (42%), and balloon predilatation was required in three patients (42%). The use of combined antegrade and retrograde route, good-sized isthmus, and adequate balloon predilatation were predictors of successful wire crossing and stent deployment across the coarctation segment. The mean ECHO-based follow-up gradient at 3 months was 9.2 ± 2.5 mm of Hg. Conclusions: Stenting for native CoA with the use of Cheatham-platinum stents in adult patients is a highly effective and safe therapy. Longer-term follow-up studies are required to show the exact incidence of stent fracture and aneurysm formation after stenting.
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The angiographic study of right ventricular outflow tract and pulmonary artery anatomy in tetralogy of Fallot p. 140
Anusha Buchade, Usha M K Sastry, M Jayranganath, Bharath Adaligere Parshwanath
Objective: The objective of the study is to determine various anatomic variations in the pulmonary vasculature and associated cardiac defects in patients with tetralogy of Fallot (TOF). Methods: This was a cross-sectional descriptive study conducted at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore from January 2009 to December 2017. A total of 100 patients irrespective of age and gender, who were subjected to cardiac catheterization were enrolled in the study which included all age groups. Measurement of pulmonary valve annulus, main pulmonary artery, right pulmonary artery (RPA), left pulmonary artery (LPA), and descending aorta was taken and corresponding z scores were calculated. McGoon ratio and Nakata index were also calculated. Results: The age group in our study varied from 9 months to 49 years of age. Male-to-female gender ratio was 3:2. All patients had subvalvar (infundibular) stenosis and 82% of patients had stenosis at the valvar level. Seven patients had discrete stenosis, another seven patients had disconnection of RPA or LPA and six patients had supravalvar stenosis in the form of diffuse hypoplasia of one of the pulmonary arteries (PA). Significant communicating major aortopulmonary collaterals arteries (MAPCAs) were seen in 5% of patients and 16% of the patients had a persistent patent ductus arteriosus (PDA). Persistent left superior vena cava was present in 9 patients and 13% of the patients had coronary anomalies. Conclusion: Subvalvular stenosis, confluence of PA, discrete, disconnected, and diffuse stenosis of LPA and RPA were the most common PA abnormalities found in patients with TOF. Significant-associated cardiac lesions including communicating MAPCA, PDA, and coronary anomaly were more commonly observed in these patients.
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Safety and efficacy profile of an indigenous developed CHARAK DDDR 747R dual-chamber rate-responsive pacemaker: A prospective study from a tertiary care center in North India p. 147
Yash Paul Sharma, Akash Batta, Saurabh Mehrotra, Prashant Panda, Surendra Sethi
Aim: The purpose of this study was to assess the safety and performance of the domestically manufactured Charak DDDR 747R (Pacetronix Ltd, Indore, India) pacemaker device. Materials and Methods: This was a prospective, controlled, single-center study conducted between March 2016 and August 2017. Eligible patients were implanted with a Charak DDDR 747R pacemaker with parameters set as specified on the packaging material unless otherwise advised by the physician. Patients were evaluated before discharge and at the 18-month follow-up. Data such as patient age, gender, and medical history were collected to determine patient eligibility for study participation, monitoring of study progress, and data analysis. Results: A total of 35 patients were analyzed. Males comprised 45.7% and females comprised 54.3% of patients. The average pacing threshold was threshold (atrium) was 1.05 V and the average pacing threshold (ventricle) was 1.07 V. The average impedance (atrium) was 641.09 Ω and the average impedance (ventricle) was 719.31 Ω. No serious adverse events were documented during the follow-up. One death occurred; however, this was not device-related. Conclusions: As per study findings, the Charak DDDR 747R, an indigenous pacemaker, is safe and effective in the Indian population. Durable lead parameters were obtained during the study which remained stable over time referring the same. Future larger studies are needed to confirm the preliminary data obtained from our study.
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Clinical outcomes with the use of ticagrelor or clopidogrel after fibrinolytic therapy in patients with ST-elevation myocardial infarction – A prospective observational study p. 152
Bibek Agarwal, Sudarshan Kumar Vijay, Amresh Kumar Singh, Ashish Jha, Bhuwan Chandra Tiwari, Naveen Jamwal
Background: Thrombolytic therapy in the appropriate window period remains the most commonly used therapy in ST-elevation myocardial infarction patients, despite the advantage of primary percutaneous coronary intervention (PCI) over it. Use of newer more potent antiplatelets agents early after thrombolysis carries the chance of increasing bleeding complications, thus we planned to have a study to assess the safety and efficacy of ticagrelor as compared to clopidogrel in thrombolysed patients. Materials and Methods: This was a prospective observational study in Indian patients. A total of 142 patients were enrolled in the study with 76 in the ticagrelor group and 66 in the clopidogrel group. All patients received thrombolysis as the primary reperfusion strategy. Patients receiving either clopidogrel or ticagrelor after thrombolysis irrespective of the subsequent PCI status were followed up for any bleeding events (primary endpoints) as per thrombolysis in myocardial infarction (TIMI) definition and Bleeding Academic Research Consortium (BARC) definition. Major adverse cardiac events (MACE) including death from cardiovascular causes, myocardial infarction (MI), and stroke were also assessed as markers of efficacy and secondary endpoints. Results: Mean time from thrombolysis to study drug use was 18.9 ± 2.1 h in the ticagrelor group as compared to 14.8 ± 3.3 h in the clopidogrel group (P > 0.05). For major bleeding events (TIMI major), no statistically significant difference was observed between groups (2.6% in ticagrelor vs. 1.5% in clopidogrel) (P = 0.6). BARC 3–5 bleeding at 1-month follow-up was significantly higher in the ticagrelor group compared to the clopidogrel group (P = 0.04). At 1-month follow-up, BARC 1–2 or 3–5 bleeding events in the subjects who underwent PCI were higher in the ticagrelor group than the clopidogrel group (P = 0.03). Patients in the clopidogrel group have more major adverse cardiac events than the ticagrelor group especially driven by more fatal and nonfatal MI in the clopidogrel group (P = 0.04). Conclusions: Ticagrelor can be safely administered in postthrombolytic patients similar to clopidogrel albeit at the cost of slightly increased minor bleeding events in short-term follow-up.
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Peculiar association of a small coronary arteriovenous fistula with inferior wall myocardial infarction: A bystander or culprit? p. 160
Anurodh Dadarwal, Aditya Kapoor, Ankit Kumar Sahu
Coronary arteriovenous fistula (CVAF) is usually an asymptomatic, incidental finding observed in 0.1%–0.2% of patients undergoing coronary angiography. Myocardial infarction (MI) secondary to a CVAF has been rarely reported. We herein describe a case of a young male presenting with acute inferior wall MI without any underlying cardiovascular risk factors and normal coronaries except for the presence of a small CVAF arising from the proximal right coronary artery. This report deliberates on the possibility of this fistula being an incidental finding as a bystander or as a culprit in this special clinical scenario, after careful exclusion of other possible nonatherosclerotic etiologies.
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Fungal endocarditis: A rare presentation p. 165
Sistla Radha, Tameem Afroz, Mohammed Umar Amaan, Mallindra Swamy
Endocarditis is inflammation of the innermost lining of the heart including the valves. It can be of infective or noninfective etiology. It is a relatively rare disease with high morbidity and mortality. There are a very few cases reported from India. Infective endocarditis due to fungal organisms accounts for 2%–4% of endocarditis. We report a case of Aspergillus endocarditis in a patient with chronic rheumatic heart disease, which was incidentally diagnosed during surgery. The patient was treated with mitral valve replacement and antifungal agents. One year after surgery, the patient has a good prosthetic valve function with no evidence of vegetations.
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Giant biatrial myxomas: A rare cardiac tumor p. 168
Sanjeev Asotra, Sarita Asotra, Shivani Rao, Meena Rana
Primary cardiac tumors constitute around 10% of all tumors of the heart. Atrial myxomas are the most common tumors of the heart, constituting around 50%–70% of all tumors. Most of them arise from the left atrium but multiple-site involvement is seen in 5%. Biatrial myxomas are rare and present in around 2.5% of patients. Myxomas can have varied symptoms. We present a case of biatrial myxoma that underwent successful surgical resection.
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Hyperdominant left anterior descending artery: Anomaly or aberrancy? p. 171
Pankaj Jariwala
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