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   Table of Contents - Current issue
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January-April 2022
Volume 10 | Issue 1
Page Nos. 1-59

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EDITORIAL  

Preface to the first issue of Heart India 2022 p. 1
Alok Kumar Singh
DOI:10.4103/heartindia.heartindia_25_22  
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REVIEW ARTICLE Top

Antegrade revascularization of long-segment femoropopliteal chronic total occlusion: A case report and literature review p. 3
Debasish Das, Abhinav Kumar, Dibya Sundar Mahanta, Sashikant Singh, Subhas Pramanik
DOI:10.4103/heartindia.heartindia_101_21  
Although revascularization of a femoropopliteal (CTO) always remains challenging through a retrograde or contralateral crossover approach, we report a case of successful revascularization of a long-segment femoropopliteal CTO through antegrade femoral puncture which stands as the crux of the procedure. In routine peripheral intervention, long-segment femoropopliteal occlusion is usually approached from a contralateral femoral artery or ipsilateral brachial artery, antegrade revascularization of femoropopliteal CTO is not adapted by many in routine practice. Here, we describe the technique and the tips and tricks of antegrade puncture of common femoral artery. We will also discuss the literature review of antegrade technique versus retrograde and crossover technique for revascularization of femoropopliteal CTO which may be useful for budding young interventionists. Our case carries another important learning point about management of popliteal disease where revascularization with a stent is of concern due to high knee joint mobility.
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ORIGINAL ARTICLES Top

Risk factor profile, incidence, and relevance of Mehran risk score to predict contrast-induced nephropathy in patients undergoing percutaneous coronary intervention p. 9
Shahood Ajaz Kakroo, N Rama Kumari, Manal Abdul Lateef, Remala Archana
DOI:10.4103/heartindia.heartindia_9_22  
Background: Contrast-induced nephropathy (CIN) is a grave but underdiagnosed complication of percutaneous coronary intervention (PCI) that is associated with increased in-hospital morbidity and mortality. Our aim was to study the incidence, risk factors of CIN, and applicability of Mehran risk score (MRS) in Indian population. Materials and Methods: A total number of 432 patients were enrolled in the study. Inclusion criteria were patients with acute coronary syndrome or chronic stable angina who underwent PCI. Baseline parameters of patients were noted and patients were followed for development of CIN. Results: The mean age of the study population was 57.2 + 10.43 years; males were 348 (80.6%) and females 84 (19.4%). Hypertension was present in 257 patients (59.5%), diabetes in 208 (48.1%), smoking in 208 (48.1%), anemia in 104 (24.1%), and heart failure in 95 (22%); the mean estimated glomerular filtration rate (eGFR) was 88.4 + 30.65 ml/min/1.73 m2 and the mean contrast volume usage was 122.8 + 41.9 ml. 64 patients (14.8%) developed CIN. On univariate analysis, age (P = 0.435), gender (0.125), hypertension (0.679), diabetes (0.177), and contrast volume (0.155) were not associated with the development of CIN, whereas smoking (0.021), hypotension (<0.001), heart failure (<0.001), anemia (0.001), and median eGFR (P < 0.001) were significantly associated with the development of CIN. However, on multivariate regression analysis, smoking was not associated with the development of CIN (P = 0.104). The incidence of CIN was 2.7-fold higher (odds ratio [OR]: 2.68, 95% confidence interval [CI]: 1.299–5.540, P = 0.008) in the intermediate group (MRS 6-10), 5.4-fold higher (OR: 5.403, 95% CI: 2.249–12.978, P < 0.001) in the high-risk group (MRS 11–15), and 51-fold higher (OR: 51.059, 95% CI: 18.195–143.278,P < 0.001) in the very high-risk groups (MRS >16) when compared to the low-risk group (MRS < 5). Dialysis was required only in 2 (3.1%) patients (P < 0.022). Conclusions: The overall incidence of CIN was 14.8%. The incidence of CIN in the very high-risk group (MRS >16) was substantially higher in our study (77.8%) as compared to the same group in Mehran study (57.3%).
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Clinical profile, microbiological spectrum, echocardiographic features, and in-hospital outcomes of patients with definite infective endocarditis: Experience and changes in patterns in two cohort of patients recorded at an interval of 10 years from a tertiary care cardiac center of South India p. 14
Chetan Bhole, Sunitha Vishwanathan, Amresh Kumar Singh, SK Vijay
DOI:10.4103/heartindia.heartindia_7_22  
Background and Objectives: Infective endocarditis (IE) remains a serious clinical problem with a persistently high morbidity and mortality, despite the availability of improved diagnostic and treatment modalities in the developing world. We examined the microbiological spectrum, clinical profile, echocardiographic features, and in-hospital outcomes of patients with definitive IE. Materials and Methods: A total of 20 consecutive cases of definitive IE, admitted between March 2017 and August 2018, at a tertiary care cardiac center (Thiruvananthapuram Medical College, India) were included in the study and followed for 6 months. We compared the clinical profile, other features and outcomes of currently enrolled patients (Group-1) with 10 years back (2007) cohort (Group-2) of IE patients (n = 25) at the same institution. Results: The mean age of the Group-1 was 44.7 (±11.6) years, whereas those in Group-2 were 48.6 ± 12.9. The overall male to female sex ratio was 2.2: 1. The rheumatic heart disease (RHD) was the most common predisposing factor accounting for nearly 40% of all cases in both groups, congenital cardiac lesions accounting for 20% in both groups. The most common significant valve lesion was mitral regurgitation (45% vs. 40% P = 0.032). Fever was the most common complaint at the time of hospital admission in both groups (80% vs. 96%). The most common complication was congestive heart failure in both groups (60% vs. 56%). Blood cultures were positive only in 35% patients from Group-1 to 48% from Group-2 (P < 0.01). The mean vegetation size in Group-1 was 7.6 mm and in Group-2 was 10.8 mm (P = 0.04). Patients with large-sized vegetation had increased incidence of heart failure, and embolic phenomena and mortality. Among Group-1, 5 (25%) patients have undergone surgery compared to Group-2, where only 4 (16%) patients have undergone surgery. The overall in hospital mortality in Group-1 was 5 (25%). Out of them, two patients expired after surgery (surgical mortality 40%). In Group-2, mortality was 7 (28%). Out of them, three patients expired after surgery (surgical mortality 42.8%). The majority (53.3%) of patients were in New York Heart Association Class II at the time of discharge. Conclusions: The average age of patients presenting with IE in India has increased, while the male predominance is maintained. RHD continues to be the most common predisposing factor. The lower culture positivity rate and lower rates of surgery are worrisome in Indian patients. Despite significant advances in medical technology over the last decade, mortality rate remains the same.
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Clinical presentation, risk factors, and coronary angiographic profile of very young adults (≤30 years) presenting with first acute myocardial infarction at a tertiary care center in Rajasthan, India p. 21
Piyush Joshi, Archit Dahiya, Manas Thakur, Ramanand Prasad Sinha, Harsh Wardhan
DOI:10.4103/heartindia.heartindia_4_22  
Introduction: Acute coronary syndrome (ACS) in very young adults with age ≤30 years is rare. In India, the prevalence of acute myocardial infarction (AMI) in this population is <2%. ACS leads to significant effects on patient's psychology, morbidity, and increased financial burden when it occurs at this young age. Young patients with ACS on coronary angiography (CAG) show a relatively increased incidence of single-vessel disease and nonobstructive stenosis. Materials and Methods: This retrospective observational study was conducted at the Department of Cardiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan. The medical records of very young adults (≤30 years of age) with first AMI between September 2019 to August 2021 were collected and analyzed. Results: Twenty-two very young adult patients aged ≤30 years were admitted with first AMI. Most of the patients were within the age group of 25–30 years. Mean patient age was 27.63 ± 2.03 years and 21 patients (95.4%) were men. Regarding the risk factors for coronary artery disease (CAD), smoking was the most common (54.5%) in young patients. Dyslipidemia and family history of premature CAD were present in 8 (36.3%) and 6 (27.2%) of patients. The most common symptom in patients was chest pain (90.9%). Obstructive CAD (vessel lumen stenosis ≥ 70%) was found in 18 (81.8%) patients. Conclusion: Very young adults presented with less extensive CAD as compared to elderly likely due to less atherosclerosis of the coronary arteries in them. The major modifiable risk factors in very young Indian population are smoking and dyslipidemia. Primary prevention by educating the public about the effects of smoking, unhealthy dietary habits, and sedentary lifestyle in early years of life may help to prevent the development of cardiac problems later in life.
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Novel oral anticoagulant in treatment of left ventricular thrombus in acute coronary syndrome – A case series p. 26
Archit Dahiya, Piyush Joshi, Ramanand Prasad Sinha, Harsh Wardhan
DOI:10.4103/heartindia.heartindia_5_22  
Introduction: Left ventricular (LV) thrombus is a known complication of myocardial infarction (MI) and it usually occurs in areas of poorly contracting LV muscle as a result of endocardial injury with associated inflammation. There is a high risk of embolization within 3 months among patients with MI complicated by mural thrombus and this risk is maximum during the first 1–2 weeks. We report a case series of five patients who presented with acute coronary syndrome with LV apical thrombus and treated with triple anti-thrombotic therapy of rivaroxaban, aspirin, and clopidogrel. Case Series: Our series involves 5 cases who developed LV apical thrombus after acute coronary syndrome. Four patients had anterior wall ST-elevation MI (STEMI) whereas 1 patient had inferior wall STEMI. One of the patients with anterior STEMI also had COVID pneumonitis. All of these patients received triple anti-thrombotic therapy consisting of tab Aspirin 75 mg OD, tab clopidogrel 75 mg OD, and tab rivaroxaban 20 mg OD for 3 months duration. Repeat ECHO after 3 months showed complete resolution of LV thrombus in all of our cases. Discussion: LV thrombus reported in STEMI patients is from 1.6% up to 39% in various studies. The incidence of LV thrombus is on decreasing trend as a result of modern revascularization strategies. The role of novel oral anticoagulants (NOACs) in treating LV thrombus is scant as compared to oral Vitamin K antagonists (VKAs) like warfarin. The current recommendation for anticoagulation in the presence of a LV thrombus after acute coronary syndrome is with VKAs for up to 6 months. Conclusion: Although there is uncertainty in decision-making regarding antithrombotic therapy, our case series demonstrate that triple antithrombotic therapy with NOACs results in resolution of LV thrombus without any additional bleeding events in patients presenting with acute coronary syndrome. NOACs have an advantage of not requiring PT/INR monitoring and have less bleeding complications. Further large-scale research or randomized controlled trials are needed to find the optimal therapies in such cases.
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Role of palliative percutaneous coronary intervention in severely symptomatic complex coronary artery disease patients who could not undergo coronary artery bypass surgery p. 30
Mukesh Tiwari, Ashish Jha, Bhuwan Chandra Tiwari, Sudarshan K Vijay, Naveen Jamwal, Amresh Kumar Singh
DOI:10.4103/heartindia.heartindia_6_22  
Context: Patients with symptomatic complex coronary artery disease (CAD) who could not undergo bypass surgery for any reason often continue to have symptoms and impaired quality of life (QoL) on optimal medical therapy (OMT) Aims: This study aimed to evaluate the role of palliative percutaneous coronary intervention (PCI) in these patients as compared to OMT alone. Settings and Design: This was a prospective, questionnaire-based, case–control, single-center study. Subjects and Methods: Patients in the case arm underwent palliative PCI of at least 1 target vessel and the control arm remained on OMT. The primary endpoint was a comparison of Seattle Angina Questionnaire (SAQ)-angina frequency (AF) and QoL scores at baseline, 3 months, and 6 months. Secondary outcomes were the difference in frequency of cardiovascular death, stroke, nonfatal myocardial infarction, and major bleeding episodes between 2 arms during the same period. Results: The study recruited 200 patients (100 in each arm). Baseline characteristics were well matched. Presenting diagnosis was stable CAD in 11% and ACS in 89%. SAQ AF and QoL scores were similar in both arms at baseline, but a significant improvement in both parameters was seen at 3 and 6 months in palliative PCI arm. Predecided cutoffs for significant improvement in SAQ-AF and SAQ-QoL were achieved in palliative PCI arm. No significant difference was seen for secondary outcome measures between the two groups. Conclusions: Palliative PCI provided a significant benefit in terms of improvement in SAQ-AF and SAQ-QoL scores, over short term (6 months), as compared to OMT alone in patients with severely symptomatic complex CAD, who could not undergo CABG.
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Cardiovascular involvement in patients with COVID-19 pneumonia: Observation from a tertiary care infectious disease Hospital p. 38
Rammohan Roy, Baisakhi Maji, Yogiraj Ray, Arijit Sinha
DOI:10.4103/heartindia.heartindia_103_21  
Background: Covid 19 pneumonia presents with various cardiovascular manifestations. The proposed mechanisms of cardiovascular involvement in COVID-19 are direct invasion of myocardial cell by the virus, hyper- inflammatory state secondary to cytokine storm, increased angiotensin II, low ACE2 levels, antiphospholipid antibodies and increased platelet reactivity which contribute significantly to thrombus formation in systemic and pulmonary vasculature. Objectives: To find out various cardiovascular manifestation of patients admitted with covid 19 pneumonia. Methodology: A retrospective observational study had been conducted in a tertiary care infectious disease hospital from July 2020 to December 2020 that included a total of 108 patients. Results: Most common risk factor were combination of hypertension and diabetes( 40.7%) followed by hypertension alone (28.7% )and diabetes in 18.5% patients. Most common presentation was asymptomatic myocarditis found in 37 patients followed by sinus tachycardia in 34, sinus bradycardia in 18, Orthostatic hypotensionin in 16, Atrial fibrillation in 14, cerebrovascular accident in 9, Acute limb ischemia in 7 , and acute coronary syndrome in 4 patients. Asymptomatic diastolic dysfunction (Grade 2 or more ) found in 17 patients without any overt features of heart failure (all have raised NTproBNP and HSTrop I along with clinical features ). A positive correlation was found between D- dimer level and severity of pneumonia by CT severity score. Conclusion: A high index of suspicion and necessary investigation may be needed for early detection of myocarditis and to prevent any complication particularly fatal arrhythmia and sudden cardiac death.
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A study on normal reference values of echocardiographic chamber dimensions in newborn infants from Eastern India – A pilot study p. 45
Swapan Kumar Halder, Samir Kumar Roy, Anindya Mukherjee, Dibbendhu Khanra, Malyaban Das, Biaus Samanta, Soumyojit Saha, Manoranjan Mandal
DOI:10.4103/heartindia.heartindia_1_22  
Introduction: Echocardiography has been an integral part of neonatal care since the 1990s and the application of this technology is increasing ever since. It is already known that differences in weight, age, and race significantly affect the normal heart dimensions. Therefore, establishing the normative values for cardiac dimensions among Indian healthy newborn infants is of paramount importance. In this study, we report the normal reference values of echocardiographic chamber dimensions of newborn infants from Eastern India. Methodology: One hundred healthy newborn infants were included in this cross-sectional, observational, single hospital-based pilot study. A single experienced cardiologist performed the transthoracic echocardiographic studies on the participants in supine position in their respective bassinets. No sedation was used. The parameters were distributed according to body weight and in percentiles. Results: Participants were categorized according to their body weight into three groups: 2–2.4 kg, 2.5–2.9 kg, and 3–3.5 kg. Each group comprises 7, 50, and 43 newborns, respectively. The left ventricular end-diastolic dimension and left ventricular end-systolic dimension showed incremental trends across body weight. Conclusion: This study shows the difference of cardiac dimensions in Indian newborn infants from Western data. This is the first study presenting the normative reference ranges and percentiles of echocardiographic parameters in Indian newborn infants which needs confirmation with larger multicenter studies.
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Unrepaired congenital heart diseases in adults – Detection rate and diagnostic errors p. 51
Pradeep Kumar Jain, Vivek Kumar Athwani, Amit B Kinare, Shravan Kanaparthi, Vikas A Mishra, Suhel Siddiqui
DOI:10.4103/heartindia.heartindia_100_21  
Context: There are very few data about the unrepaired congenital heart disease (CHD) in adults. There are high chances of errors in diagnosis of CHD in adult population due to various reasons. If proper diagnosis is made, many of these CHDs are amenable to surgery leading to improved quality of life. Aims: Primary objective of the study was to know the detection rate of unrepaired CHD in adults. We have also reported common errors done while making the diagnosis of CHD in adults. Subjects and Methods: This was a retrospective observational study conducted from March 2020 to September 2021. Patients more than 18 years old who came for transthoracic echocardiogram (TTE) for any reason were included, and the detection rate of unrepaired CHD was calculated. Simultaneously, we have also checked for any errors in reports done outside our center and classified them based on their effect on management. Results: During the study period, 6675 TTEs were done in the study population, out of which 89 (1.33%) were detected with unrepaired CHD. Acyanotic CHD was detected in 81 (91%), whereas the rest 8 (9%) had cyanotic CHD. Forty-one patients had echocardiography report done outside, out of which 25 (61%) had discrepancies. Discrepancies were more in complex CHD. Conclusions: Cardiologists or echocardiographers should follow systematic approach and place special emphasis on identifying congenital heart diseases. Many potential lesions are amenable to surgery and near-complete correction leading to improved duration and quality of life.
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CASE REPORT Top

Incidentally detected large ventricular thrombus on echocardiography: A case series p. 56
Krishna Mala Konda Reddy Parvathareddy, Saitej Reddy Maale, Praveen Nagula, Srinivas Ravi
DOI:10.4103/heartindia.heartindia_102_21  
Ventricular thrombus is a major risk factor for systemic thromboembolism. It complicates both acute and chronic phases of ischemic heart disease (IHD) and, less frequently, non-ischemic cardiomyopathies. However, ventricular thrombus does not always manifest with thromboembolism. Advances in technology, especially the echocardiography, have improved the detection rates of intracardiac thrombi. Regarding the management, there are several uncertainties to date. We present six varied cases with incidental detection of ventricular thrombus on echocardiography with no clinically evident embolism at admission. Of the six cases, three patients had embolic complications after initiation of systemic anticoagulation.
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