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   Table of Contents - Current issue
January-April 2023
Volume 9 | Issue 1
Page Nos. 1-98

Online since Thursday, May 4, 2023

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Expert opinion on the identification and pharmacological management of worsening heart failure: A consensus statement from India p. 1
Sandeep Seth, Johann Bauersachs, Sanjay Mittal, Vishal Rastogi, Rajeev Kumar Rajput, Dheeraj Gandotra, Ripen Gupta, Manoj Sahu, SN Pathak, Mohit Bhagwati, Simmi Minocha, Pawan Sharma, Deepankar Vatsa, Raghav Aggarwal, Gyanti R B Singh, Gaurav Arora, Samir Kubba, Meera Rajeev, Pratik Jha, BS Vivek, Mohit Gupta, Rameshwar Bishnoi, Rashi Khare, Vipul Gupta, Naresh Kumar Goyal, Aseem Dhall, Amit Madan, BD Sharma, Atul D Abhyankar, Pravin Kahale, Talha Meeran, Babu Ezhumalai, BC Kalmath, VT Shah, Sandip Rungta, P Ashok Kumar, Sunil Christopher, Alok A Shah, Ramesh Dargad, Kaushik Sheth, Abhay Khode, Sunil P Mehta, Bommareddy V A Ranga Reddy, Puneet Gupta, BK Tripathi, Ritwick Raj Bhuyan
Worsening heart failure (WHF) is a distinct under-diagnosed and under-treated condition, independent of location of care. Heart failure (HF) progression is punctuated by repeated WHF events, each resulting in reduced cardiac function. One-third of the patients with HF with reduced ejection fraction experience a decompensation event. These decompensation events often result in the emergency department visits and HF hospitalization. Despite its inclusion in recent guidelines, there is no precise definition of WHF or its various forms. It is worth noting that WHF signals a need for treatment optimization as per guideline-directed medical therapy and the addition of novel drugs like a stimulator of soluble guanylate cyclase that benefit this high-risk patient population. This practical document is based on the expert opinion of cardiologists, cardiothoracic surgeons, and physicians that discussed the definition, assessment, pharmacological management, and monitoring of WHF patients in a hospitalized setting. In addition, there is also a need for an expert opinion for the management of WHF in an outpatient setting.
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Recommendations for cardiovascular disease prevention in women: An Indian perspective Highly accessed article p. 11
Zakia Khan, Sarita Rao, Ritu Bhatia, Saumitra Ray, Jamshed J Dalal
Cardiovascular disease (CVD) is one of the leading causes of death in women. On an average, coronary artery disease develops 10 years later in women than men, but they represent the majority of patients when age above 75 years is considered. Men and women share most of the classic cardiovascular risk factors, but the relative importance of each risk factor may be gender specific. This review explores the recommendations for the management of cardiovascular risk and CVD prevention in women in the Indian clinical setting based on multiple advisory board meetings conducted with cardiology experts across India. The experts concurred that women have distinct patterns of ischemic heart disease (IHD) and that the presence of traditional risk factors, female-specific risk factors, and nontraditional risk variables may add to the increasing risk of IHD. Transition to postmenopausal status is associated with a worsening coronary heart disease risk profile in women. Evidence suggests that both traditional and novel cardiovascular risk factors are often under recognized and undertreated in women. Several female-specific risk factors such as preterm delivery, preeclampsia, gestational diabetes, and polycystic ovary syndrome are not included in primary prevention nor are they routinely considered in a cardiovascular assessment at the clinical level. Understanding and good diagnostic tools are necessary to evaluate the different pathophysiological aspects and early detection of CVD in women.
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Anatomical snuffbox for interventional cardiology: Hype or hope? p. 18
E Thirumurugan
Cardiovascular catheterization has traditionally been done through transradial access. Vascular complications, primarily radial artery (RA) occlusion, continue to exist despite their rarity. In recent times, interventionalists have reported using the anatomical snuffbox (ASB) or distal transradial approach for cardiac catheterization. This distal radial approach has been promoted to lower the risk of bleeding and vascular access site complications as well as RA occlusion at the forearm. This state-of-the-art review outlines the feasibility and safety of left versus right ASB in interventional cardiology.
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A narrative review on serum biomarkers of cardiac fibrosis p. 24
Santoshi Kumari, Urvashi Sharma, Deepika Jindal, Traymbak Basak
Myocardial fibrosis is the excessive deposition of extracellular matrix (ECM) proteins in the cardiac interstitium leading to pathological conditions of the heart. The objective is to understand the pathophysiology of cardiac fibrosis and the quest for serum biomarkers that will assist in early diagnosis before the occurrence of major cardiac events. There are many serum biomarkers that get elevated highlighting ECM remodeling during cardiac fibrosis. Lysyl oxidase like -2 is one such ECM protein, plays a crucial role in the up-regulation of TGF - β, the transformation of cardiac fibroblast to myoblast, the migration of collagen, and cross-linking of collagen and elastin. However, assessment of lysyl oxidase like-2 (LOXL-2) in different pathologically driven cardiac fibrosis is limited. Also, none of the serum biomarkers has proved to be the most accurate diagnostic tool for assessing fibrosis independently; hence, meticulous, less invasive, and cost-effective serum biomarkers need to be scrutinized. Hence lysyl oxidase Like-2 (LOXL-2) in combination with other serum biomarkers like PICP/PINP/TIMP-1/ST-2, or Galectin-3 can be combined to assess the presence of fibrosis in the heart. This review includes the journal, articles, and research paper on cardiac fibrosis which was published in the last 10–15 years to highlight the huge gap in the treatment of cardiac fibrosis and the need for a new combination of biomarkers with better prognostic and diagnostic value.
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Annual Report of the Heart and Lung Transplant Registry (INTRAN) of the indian society for heart and lung transplantation 2023 p. 37

This is a registry report of the Indian Society for Heart and Lung Transplantation. The data reflects thoracic transplants done in India since 1994. It is a voluntary cloud-based registry. This is the data on total number of heart and lung transplant and left ventricular assist device (LVAD) implants done till March 2023. Till date, India has done 1328 heart transplants, 475 lung transplants, 128 LVAD implants, and 61 lung transplants for COVID lung disease.
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Coronavirus disease 2019, a popup differential to the postoperative inflammatory state and its impact on outcomes after cardiac surgery – A single-center experience p. 41
KS Ram Kiran, Visharad Trivedi, Rajesh S P. Venuthurupalli, Deepika Gehlot, Sunil Ninama
Introduction: Coronavirus disease 2019 (COVID-19) affected care among surgical patients. Considering the underlying comorbidities, physical status, and intricate perioperative course, the cardiac surgery patient represents a vulnerable cohort. This study describes baseline characteristics, laboratory findings, diagnosis, postoperative course, and their correlation with immediate outcomes in patients undergoing cardiac surgery. Methodology: Patients who underwent cardiac surgery at our institute for 1 year were screened for COVID-19 with the reverse transcription-polymerase chain reaction swab test and then were posted for surgery only after corroborating negative reports, except for emergency cases. Dedicated preoperative areas and COVID-appropriate measures were taken. Data from the electronic patient records of those diagnosed with COVID-19 in the immediate postoperative period were reviewed retrospectively. Continuous normal distributed variables are presented as mean ± standard deviation, alternatively as median ± interquartile range, and categorical variables as percentages. Results: A total of 22 patients were infected in the immediate postoperative period in spite of appropriate screening and had a high mortality of 36.36% (vs. non-COVID 6.27%, P < 0.001). Days from index surgery to diagnosis were 6 (±3.75). The median stay in the intensive care unit and hospital stay was 6 (±2.75) and 10 (±3.2) days, respectively. The moderate and high-risk categories of the European System for Cardiac Operative Risk Evaluation II showed mortality of 33.3% (vs. 2.69% in non-COVID, odds ratio of 18.42) and 71.4% (vs. 11.2% in non-COVID, odds ratio of 19.65). Patients with C-reactive protein >100 mg/lit, D dimer >1000 ng/ml, and neutrophil/lymphocyte ratio >3.5 showed very high mortality. Noninvasive and invasive ventilation in 27.27% and 31.8%, respectively. Two patients acquired acute kidney injury that required hemodialysis. Conclusions: Despite requisite measures, COVID infection still remains a momentous differential to postoperative complications affecting early outcomes. Therefore, more robust preoperative protocols, better strategies for the COVID-free environment, and early clinical suspicion and workup are required to mitigate its effect on this cohort.
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Comparative analysis of different prognostic markers in predicting outcome in advanced heart failure p. 46
Parth Godhiwala, Sunil Kumar, Sourya Acharya, Mansi Patel
Introduction: Heart failure (HF) is a debilitating condition with an adverse outcome, especially during the advanced stage having higher morbidity and mortality rates. Various parameters have been used as prognostic markers in advanced HF. This study highlights about the comparative analysis of different prognostic markers in predicting mortality in advanced HF. Methods: This prospective observational study was conducted in patients of advanced HF admitted to the department of medicine intensive care unit in a rural tertiary care hospital from 2018 to 2020. Advanced HF was diagnosed using the updated HF Association-European Society of Cardiology criteria. The serum N-terminal pro-B-type natriuretic peptide (NT-proBNP), six-minute walk test (6MWT), left ventricular ejection fraction (LVEF), estimated glomerular filtration rate, and glycosylated hemoglobin type A1c levels were measured on admission. Receiver operating characteristic (ROC) curve was also studied for the above-mentioned variables, and the area under ROC curve (AUROC) was also determined. Results: Seventy-five patients with an average age of 60.55 ± 14.04 years were evaluated. Out of 75, 48 (64%) were male and 27 (36%) were female. There was inhospital mortality in 20 (26.67%) patients. The mean NT-proBNP levels among the mortality group was 9826.95 ± 3485.10 pg/mL, while in nonmortality group, it was 6135.40 ± 2342.77 pg/mL (P = 0.001). The cutoff range in this study for on-admission serum NT-proBNP levels was 8990 pg/mL, with AUROC of 0.81, the sensitivity of 70.0%, and specificity of 90.9%. In multiple regression analysis keeping mortality as the dependent variable, it was seen that variables NT-proBNP, 6MWT (<300 m), and LVEF were significantly associated with mortality. Conclusion: Serum NT-proBNP and 6MWT (<300 m) were important predictors of mortality in advanced HF.
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Role of yoga in prehypertension and hypertension p. 53
Anil Kumar, G Keshavamurthy, Navreet Singh, Balwinder Singh, Rajesh Vaidya, Tanmoy Roy, SP Singh, Ankush Gupta, Nitin Bajaj, Parag Barwad, Ekambir Singh
Background: The high prevalence of hypertension in India necessitates both pharmacological and nonpharmacological measures to control it. Here, we report the findings of a study to investigate the effectiveness of yoga therapy in lowering blood pressure (BP) in prehypertensive and hypertensive individuals. Methods: This was a single center, nonrandomized controlled clinical trial, of 200 hypertensives and 100 prehypertensives patients. The control group received the prescribed antihypertensive and lifestyle modification while the yoga group was additionally taught simple yogic exercise by a trained yoga teacher. This training included intensive supervised phase 2-h training sessions in Ujjayi breathing, Bhastrika Pranayama and chanting of “Om” for 10 lessons, followed by self-performed yogic exercise at home for 1 h till the end of study at 1 year. Results: The systolic BP (SBP) in the hypertensive yoga group was significantly lower (t = 3.04, P < 0.01) than the control group at 6 months, but not so at 1 year (SBP t = 0.53, P > 0.05). In the prehypertensive participants, at 6 months (t = 5.85, P = 0.00), and 1 year (t = 6.385, P < 0.05) a significant difference was observed between SBP of the two groups However, no significant difference was observed between the diastolic BP among hypertensives or prehypertensives at 6 months and 1 year. Conclusion: Our present study indicates that yoga therapy is a viable adjunct to pharmacological intervention to reduce SBP in the management of hypertension and prehypertension and that yoga should be incorporated in the treatment regime of such patients, specifically for individuals who have prehypertension.
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Immature mediastinal teratoma mimicking as pulmonary stenosis – A rare presentation p. 60
Shibsankar Sarkar, Biswajit Majumder, Debasish Mohapatra, Ratul Ghosh
Anterior mediastinal teratoma can externally compress the pulmonary artery, which can present with symptoms of pulmonary stenosis rarely. We have reported a case of a 47-year-old male with immature mediastinal teratoma presenting as pulmonary stenosis. Initial physical examination revealed an ejection systolic murmur in the pulmonary area. With suspicion of valvular heart disease, the patient was referred to our cardiology department. Chest X-ray shows mass just above the left hilar zone. Two-dimensional echocardiography shows a mediastinal mass compressing the pulmonary trunk causing an obstruction. Contrast-enhanced computed tomography of thorax and magnetic resonance study confirmed the mediastinal mass. Fine-needle aspiration cytology of the mass suggestive of immature teratoma. The patient was transferred to the cardiothoracic vascular surgery department for further management. Mediastinal mass can mimic valvular heart disease with symptoms of cardiovascular pathology. Proper investigations for diagnostic clarity and prompt management are crucial in these conditions.
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Tuberculosis with new onset of diabetes and hypertension following recovery from coronavirus disease 2019 infection: A case series p. 64
Rupak Chatterjee, Aitihya Chakraborty, Kumkum Sarkar, Netai Pramanik, Shatavisa Mukherjee
The sign and symptoms of coronavirus disease 2019 (COVID-19) and infectious disease caused by severe acute respiratory syndrome coronavirus 2 are not only restricted to the respiratory system but includes a myriad of clinical manifestations involving various systems. There are various sequelae of COVID-19 reported. Here, we report a series of three cases of tuberculosis along with new onset of diabetes mellitus and hypertension in previously euglycemic, normotensive patients following recovery from COVID-19.
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LMCA aneurysm and a fistula resulting with a giant extracardiac aneurysm p. 67
Kivanc Atilgan, Burak Emre Onuk, ER Zafer Cengiz, Fahri Gurkan Yesil, Abdullah Colak, Tayfun Aybek
A 54-year-old, asymptomatic, disease-free female patient was operated for an incidentally detected left main coronary artery aneurysm (CAA) associated with fistula to a giant aneurysm associated with the right atrium (RA). The patient had an extremely rare left main CAA and a fistula connection of a giant aneurysm connecting to the RA.
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Postheart transplant prolonged hospital stay due to massive ascites p. 70
Manoj Kumar Sahu, Azaria Jayaraj Premkumar, Sarvesh Pal Singh, Ummed Singh Dhatterwal, Milind Padmakar Hote, Sandeep Seth
Heart transplantation (HTx) is a gold standard for end-stage heart failure (ESHF). Cardiomyopathies form the majority of patients who undergo HTx. Grown-up congenital heart disease, with or without prior palliative surgery, progresses to ESHF requiring HTx. They constitute the least among all heart recipients. The immediate posttransplant management may become challenging due to severe right heart failure, massive ascites, pleural effusion, and cardiac cachexia. Scarce data are available on this subset of patients. We describe one such patient's post-HTx management. A 15-year-old male with Ebstein's anomaly, restrictive cardiomyopathy, severe right ventricular (RV) dysfunction, atrial flutter, left atrial clot, postradiofrequency ablation, New York Heart Association III, and early cardiac cirrhosis underwent HTx successfully. He had significant mediastinal hemorrhage postoperatively, and managed medically; echocardiography showed a good biventricular function with mild tricuspid regurgitation (TR), and he was extubated on the 1st postoperative day. However, progressive RV function deterioration was observed over the next 72 h (tricuspid annular plane systolic excursion of 7 mm with mild TR) with massive worsening ascites and pleural effusion. He was treated with milrinone and furosemide infusion and noninvasive ventilation, but response to optimal diuretic doses was poor, and the ascites did not decrease. Hence, intermittent paracentesis was done, and 10 L of ascitic fluid was removed over 10 days. Then, he responded to diuretics; his RV function improved. His respiratory support and inotropes were discontinued. His immunosuppressants consisted of tacrolimus and prednisolone. Mycophenolate mofetil was withheld due to leukopenia. At 6-month follow-up, his cardiac functions were normal, ascites completely resolved, appetite improved, and he gained weight.
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Successful surgical extraction of an entrapped intra-aortic balloon pump p. 73
Jayarama Pai, Shivaprasad Babu Mukkannavar, Bharat Siddharth, R Geethika, D Krishna Shriram
Intra-aortic balloon pump use is an approach for the provision of mechanical support to improve cardiac output and perfusion in the perioperative period in patients undergoing coronary intervention. Despite its beneficial use, rupture of the balloon and entrapment of blood clots in the lumen may occur in very rare cases. We discuss a postoperative presentation, plan, and operative management for the removal of an entrapped balloon catheter.
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Short Chronic Total Occlusion Stump Creating an Optical Illusion of an Anomalous Coronary Artery: A Pseudo Anomaly p. 76
Ankit Kumar Sahu, Pramod Sagar, Satyendra Tewari, Aditya Kapoor
Coronary artery anomalies are often asymptomatic and detected incidentally during coronary angiography, cardiac surgery, or autopsy. However, sometimes in chronic total occlusion, the distal part of a vessel is well collateralized from the contralateral vessel that it appears almost as an anomalous coronary artery. Here, we discuss a rather interesting angiogram which at first instance, looked like a case of a dual left anterior descending (LAD) artery with anomalous origin of the LAD from the proximal right coronary artery, but after further evaluation appeared to be a case of an occluded LAD filling through Vieussens' arterial ring.
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An unusual presentation of a benign giant mature intrathoracic mediastinal teratoma with right ventricular failure and cardiac cachexia p. 79
Satyapriya Mohanty, Anindya Banerjee, Abhinav Kumar, Pranjit Deb, Shashikant Singh, Jaideep Das Gupta, Debasish Das
Mature mediastinal teratomas are infrequent, slow growing, and often asymptomatic. Traditionally, they present in the fourth decade or earlier and are found in the anterior mediastinum. These teratomas are often found incidentally on imaging, and surgical resection can be a challenge due to the size and location of the tumor; however, complete surgical excision is usually curative. Our case represents an infrequent benign giant (25 cm × 18 cm × 12 cm) mature intrathoracic mediastinal teratoma with uncommon clinical presentation of congestive heart failure and cardiac cachexia. The rare location of the tumor in the mid posterior mediastinum, very large teratoma, clinical presentation with right ventricular failure and cardiac cachexia, preoperative diagnostic dilemma, perioperative surgical challenge, and management marks this case unique.
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Hybrid approach for postclassical blalock–Taussig shunt tetralogy p. 84
Vishal Agrawal, Pankaj Garg, Pooja Vyas, Joshi Hasit, Amit Mishra
In developing countries, we still come across occasional patients who have undergone classic Blalock–Taussig shunt (CBTS) previously. We present a case of 23-year-old female with tetralogy of Fallot who had undergone CBTS operation at the age of 1 year and is now presented for total correction. Takedown of CBTS during surgery has catastrophic complications during looping and ligation of shunt due to extensive collateralization. We, therefore, took a hybrid approach for the patient. The CBTS was first blocked with the balloon, followed by surgical intracardiac repair, and finally, by device closure of CBTS.
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Coronary cameral fistula with left main coronary artery aneurysm: A challenging case p. 87
Devvrat Desai, Jignesh Kothari
Coronary fistulae with cardiac chambers (cameral fistulae) are rare congenital vascular anomalies. Here, we are reporting a case of a 25-year-old male patient who presented with a history of palpitation and chest pain. He was evaluated further and on cardiac multi-slice computed tomography, he was diagnosed to have an extremely rare coronary cameral fistula arising from the left main coronary artery, traversing tortuously between aortic roots anteriorly and left atrium posteriorly, and culminating into superior vena cava just before the cavoatrial junction. Intraoperative complexity was encountered due to the presence of a large left main coronary aneurysm and aneurysmally dilated superior vena cava. Elective surgery was performed on cardiopulmonary bypass with aortic and bicaval (high superior vena cava) cannulation. Cardioplegia delivery was challenging due to the presence of a large fistulous connection between the aortic root and superior vena cava. The patient was operated on successfully for coronary cameral fistula and symptoms resolved.
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Subacute stent thromboses in marijuana user associated with isolated protein S deficiency: Thirteenth month of the famine p. 91
Pankaj V Jariwala, Dilip Gude
We present the case of a young professional male, marijuana user who experienced subacute stent thromboses following percutaneous coronary intervention. We identified that he also had a protein S deficiency when we investigated the medical causes of procoagulant conditions. The patient was subjected to a surgical revascularization and began direct oral anticoagulant combined with antiplatelet agents to prevent recurrent thrombotic events. There is no proven way of revascularization in these cases, and antithrombotic medications are ineffective in preventing recurrent ischemia episodes, necessitating more research to determine definitive therapeutic methods for these subsets of cases.
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Concerns of non-hodgkin's lymphoma in open-heart surgery for rheumatic heart disease: A case report and review of literature p. 95
Anish Gupta, Anshuman Darbari, Uttam Kumar Nath, RS Abisho
There are concerns regarding safe conduct of open-heart surgery in a patient with hematological malignancy, both in intraoperative and postoperative management of the patient. There is a paucity of literature regarding this problem and limited data have been published regarding the conduct of coronary artery bypass surgery on pump in a patient with hematological malignancies. We describe our experience in a patient with rheumatic heart disease with non-Hodgkin's lymphoma requiring mitral valve replacement.
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