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   Table of Contents - Current issue
January-April 2022
Volume 8 | Issue 1
Page Nos. 1-74

Online since Tuesday, April 26, 2022

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A narrative review of clinical applications of systolic time intervals Highly accessed article p. 1
Smitha Pernaje Seetharam, M S Vinutha Shankar, Niranjan Reddy
Systolic time interval (STI) estimation is an established noninvasive method for the quantifiable assessment of left ventricular (LV) performance in well-being and disease states; it stays valuable for clinical application and forms no burden to the subjects. This manuscript reviews the potential clinical applications and prognostic value of STI for the assessment of LV systolic function in cardiovascular disease (CVD). STIs could be obtained by several noninvasive imaging modalities such as transthoracic echocardiography, tissue Doppler imaging M-mode echocardiography, conventional echocardiography, and so on. In view of that, a literature review for studies reporting the clinical applications of STI in assessing LV systolic function among CVD patients was carried out using PubMed search. Accordingly, the current review describes how STI can be measured; reliability of cardiac time interval measurement in patients with CVD and its role in a clinical setting. With the advent of modern techniques, STI could be easily measured in a clinical setting. Likewise, STI parameter, particularly preejection period and LV ejection time ratio (PEP/LVET), has got the highest degree of correlation with LV ejection fraction (LVEF) in assessing LV performance. Furthermore, reproducibility of systolic ejection time (SET) achieved by the TDI M-mode method is outstanding and better when compared with the reproducibility of SET obtained by the conventional pulsed Doppler method. Furthermore, prolonged SET is independently related with enhanced outcomes among heart failure with reduced EF (HFrEF, i.e., EF ≤40%) but not HF with preserved EF (HFpEF, i.e., EF >40%) patients, indicating that stabilizing SET would be helpful in the case of systolic dysfunction. Clinically, tissue Doppler-derived time intervals could be beneficial to analyze abnormal cases in comparison with other invasive and noninvasive methods of ventricular function examination. Furthermore, phonoelectrocardiography-derived STI parameters, particularly electromechanical activation time-to-LVET ratio, may have a significant role in the diagnostic approach of heart failure (HF) in patients with undifferentiated dyspnea. In addition, in HF patients, PEP/LVET of >0.43 helps to detect LVEF <35% by pulsed Doppler echocardiography. Moreover, LVET continues to be an independent predictor of incident HF and provides incremental prognostic value on the future HF risk and death but not myocardial infarction. In conclusion, STI measurement could be useful, particularly in identifying LVEF <35% in the case of refractory HF patients. This could be beneficial in the selection of patients requiring cardiac resynchronization, specifically when accurate LVEF evaluation by echocardiography proves challenging in atrial fibrillation or if the evaluation is done by a trainee echocardiographer. Furthermore, the cardiac time intervals including SET can be acquired irrespective of rhythm. Good image quality is required for the assessment of LVEF. In contrast, evaluation of SET could be useful in the case of echocardiograms with poor quality images. As a final point, the present review suggests using an echocardiographic parameter like STIs to procure additional information regarding the risk of mortality in patients with HFrEF along with LVEF measurement.
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Genetic targets in the management of atrial fibrillation in patients with cardiomyopathy p. 9
Michaela Zigova, Eva Petrejčíková, Marta Mydlárová Blaščáková, Ján Kmec, Jarmila Bernasovská, Iveta Boroňová, Martin Kmec
Cardiomyopathies are heterogeneous health conditions with the potential for atrial fibrillation. The management of patients with cardiomyopathy accompanied by atrial fibrillation is complicated by the maintenance of sinus rhythm, toxicity, or other complications. There is a lack of information about the reasons for therapy response heterogeneity or therapy failure. Our searching strategy of scientific databases declares a potentially important role of genetics in patients' management. The promising target could be the 4q25 locus and its sequence variants. Molecular-genetic analyses may shed new light on anti-atrial fibrillation therapy in cardiomyopathy patients and help reveal the genetic subtypes of cardiomyopathy patients. In this sense, the purpose of our study is to examine the evidence for genetic variation influencing the efficacy of pharmacological or invasive therapies for atrial fibrillation, especially at the 4q25 locus, in cardiomyopathy patients and declare the importance of detected genetic markers responsible for positive or negative responses to specific anti-atrial fibrillation therapies.
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Electrocardiographic changes in pregnant women with COVID-19 p. 17
Mojtaba Yousefzadeh, Azadeh Asgarian, Roghayeh Ahangari, Mostafa Vahedian, Monireh Mirzaie
Introduction: One of the unique challenges for obstetricians in pregnancy is cardiovascular changes. This study aimed to evaluate electrocardiographic (ECG) changes in mothers with COVID-19. Materials and Methods: In a retrospective study, 89 pregnant women with positive reverse transcription-polymerase chain reaction for COVID-19, between 19 and 44 years old, were selected for the study, and 12 lead ECGs were extracted and recorded from the medical documents for all cases and all parameters analyzed. Results: Of the 89 patients that met inclusion criteria, only eight patients were admitted to intensive care unit. Of all, 64 cases (71.9%) had normal ECG, three patients showed atrioventricular (AV) block (3.4%), and three patients had first-degree AV block type (PR interval >200 ms). The mean QTC interval was 428.6 ± 37.4 ms and 15 (17%) patients had long QTC intervals (QTC ≥460 ms). There was a significant relationship between antivirus treatment (P = 0.027), as well as hydroxychloroquine (HCQ) with PR interval (P = 0.002). A significant relationship was found between corticosteroids with QTC (P = 0.019) and antibiotics with QTC (P = 0.018). Conclusion: A significant association between corticosteroids usage and QTC interval as well as antiviral and HCQ treatment with PR interval. These changes during pregnancy and COVID-19 should be interpreted with caution by physicians. Understanding changes in electrocardiography can help in better and early diagnosis and management of pregnant mothers to prevent adverse outcomes.
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Postoperative outcomes of cardio-thoracic surgery in post-COVID versus non-COVID patients - Single-center experience p. 22
Jeevesh John Thomas, Simon Philipose, Aswathy Vijayan, Yumna Pareekutty Mohammed, Murukan Padmanabhan, Antony George, Job Wilson, Grace Maria George, Jacob Abraham, GS Sunil, Bhaskar Ranganathan, Jose Chacko Periappuram
Objective: The aim of this study is to investigate the postoperative outcomes in post COVID versus non-COVID patients undergone cardiac surgery. Materials and Methods: A retrospective cohort study to analyze the impact of COVID-19 in patients undergoing elective or emergency cardiac surgeries. A total of 512 patients were included in the study over a period of 6 months. The study consists of 35 post-COVID patients and 477 non-COVID patients. All data were collected from previous medical records and hospital database. The clinical outcomes and mortality of post-COVID patients were compared with a cohort of non-COVID patients. The endpoints were compared using t-test or Chi-squared test. Results: Among the post-COVID patients, 54.3% (19) of the post-COVID patients were under COVID category A followed by category B 28.6% (10) and category C 17.1% (6). About 50% of post-COVID patients had complications, especially pneumonia and myocardial infarction following COVID-19. Around 43% of patients showed fibrotic changes in computed tomography (CT) Thorax at the time of admission for surgery. 63% showed CT score in between 1 and 5. The mean COVID antibody titer was 158 U/ml. Majority of the surgeries were coronary artery bypass graft and significant difference was observed in the requirement of intra-aortic balloon pump in post-COVID patients (P < 0.0001). No postoperative mortality reported in post-COVID patients. The postoperative outcomes and survival rates were almost similar in both groups. Conclusion: In our study, the post-COVID patients were recover in a similar way as non-COVID patients after cardiac surgery.
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The efficacy and safety of thrombolytic agents for patients with prosthetic valve thrombosis p. 30
Vinod Sharma, Brig Y K. Arora, Lokesh Chandra Gupta, Amitabh Poonia, Sukriti Raina, Uday Singh Yadav, Ruchi Sharma, S Dwivedi
Introduction: Prosthetic valve thrombosis (PVT) is a serious complication seen with mechanical prosthetic cardiac valves and is associated with high mortality. Emergency surgery (thrombectomy or valve replacement) had been the traditional treatment, but now with intravenous thrombolytic therapy as an alternative to emergency surgery in patients with PVT has shown excellent success rate and acceptable risk. This study is aimed to determine efficacy and safety of use of thrombolytic agents (tPA or STK) in patients with PVT. Materials and Methods: This was a retrospective, single-center study of patients with PVT admitted between 2004 and 2020 at a tertiary care center in North India. The diagnosis of PVT was based on a history of prosthetic heart valve replacement, clinical presentation, and by diagnostic methods. All patients received either tenecteplase or streptokinase given as a bolus dose of 2.5 lac units over ½ h, followed by 1 lac units/h for 24–48 h depending on clinical response and complication, whereas tenecteplase (1 mg/kg of body weight) was given as bolus. Results: Of 72 patients, 45 patients received t-PA as a thrombolytic drug. Complete success was obtained in 39 patients (86.66%), whereas partial success in 3 (17.77%) and failure in 3 (6.66%). Among the patients who received streptokinase (n = 27), complete success was found in 23 patients (85.19%), whereas partial success was seen in 3 (11.11%) and failure was seen in 1 patient (3.7%). Conclusion: Thrombolysis is a reasonable option in patients with PVT. Our study has reiterated that major factors for PVT are warfarin poor compliance and subtherapeutic international normalized ratio. Postclosure clinical follow-up along with patient education should be followed in patients with mechanical prosthetic valve.
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Predictors of response to cardiac resynchronization therapy: A prospective observational study p. 35
Jignesh Parikh, Rajendra Patil, Ajitkumar Krishna Jadhav
Introduction: Cardiac resynchronization therapy (CRT) has revolutionized the treatment of cardiac dyssynchrony in chronic heart failure (HF), yet, complications and failures are reported in some patients. We aim to determine the predictors of response to CRT through clinical, electrocardiographic ECG, and echocardiographic assessment of patients following CRT and recommend the best practices to achieve optimum results for patients. Methodology: We analyzed the history, clinical examination, brain natriuretic peptide (BNP) levels, ECG, and echocardiography findings of 35 patients before CRT and on day 7 and day 180 following CRT. Observations: 71.4% of patients responded to CRT and 28.6% were nonresponders. The responders had fewer hospitalizations for HF. They showed a significant improvement in the New York Heart Association (NYHA) class, mean 6 min walk distance (6MWD), BNP level, QRS duration, and echocardiographic parameters on day 7 and day 180. The duration of HF ≤3 years, NYHA class III–IV symptoms, baseline 6MWD ≥240 m, QRS duration ≥150 ms, LVEF ≥25%, septal to posterior wall motion delay ≥130 ms, and mean pulmonary arterial pressure <50 mmHg were identified as the strong predictors of response to CRT. Recommendations: Patients with symptomatic HF should undergo early CRT to reduce recurrent hospitalizations and those with NYHA Class III–IV symptoms should be offered CRT before the duration of HF exceeds 3 years. BNP levels and echocardiography are invaluable tools to assess outcomes following therapy. A multiparametric, echocardiographic approach is helpful in selecting patients likely to undergo reverse remodeling after CRT and predicting outcomes.
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Escherichia coli urosepsis leading to native valve endocarditis p. 42
Sandeep Kamat, V V. S.S. Sagar, Chitturi Venkata Sai Akhil, Sourya Acharya, Samarth Shukla, Sunil Kumar
Escherichia coli, a Gram-negative facultative anaerobe, is the common causative organism leading to urinary tract infection. However, the involvement of endocardium by E. coli has been reported to be very rare in spite of the septicemia caused by this organism. However, the mortality rate due to infective endocarditis caused by E. coli was reported to be higher than due to other organisms like HACEK group of organisms. Conventional risk factors leading to infective endocarditis include cirrhosis of the liver, prosthetic heart valves, and other sources of infection like urosepsis. Here, we report the case of a 60-year-old diabetic male who presented with obstructive uropathy-induced urinary tract infection leading to infective endocarditis.
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A rare case of premature and parallel posterior descending artery and posterior left ventricular branch with conus crossing the right ventricular outflow tract causing provocative coronary ischemia p. 45
Debasish Das, Tutan Das, Shashikant Singh, Jaideep Das Gupta, Subhas Pramanik
We report a rarely encountered case of premature and parallel posterior descending artery (PDA) and posterior left ventricular branch (PLVB) in a case of 22-year-old male with effort angina Class II for the last 6 months in whom treadmill test (TMT) was strongly positive for provocative coronary ischemia with structurally normal heart and good biventricular function. Interestingly, all the coronaries were normal without any obstructive coronary lesion. Paradoxically, those two prematurely separating branches were small making the distal right coronary artery (RCA) territory relatively ischemic attributing toward a strongly positive TMT. Small anomalous coronary is a well-known cause of demand ischemia, but our case is unique to describe small prematurely originating PDA and PLVB were the culprit behind coronary ischemia in a young male without conventional risk factors. Furthermore, much premature separation of PDA and PLVB is rarely encountered in routine clinical practice, and recognition of this anomaly is important as it should not be mistaken for duplicate RCA, dual RCA, or split RCA. Our case is also unique to illustrate the association of the premature and parallel PDA and PLVB with a conus crossing the right ventricular outflow tract without the presence of structural heart disease.
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Thrombolysis in the de winter electrocardiography pattern: A therapeutic dilemma p. 48
Amit Kumar, Rajesh Chetiwal, Shweta Tanwar, Sudhish Gupta, Rohit Kumar
The de Winter's pattern is an electrocardiography (ECG) finding characterized by ST depression and tall prominent T-waves in precordial leads with ST elevation in lead aVR. It signifies the occlusion of proximal left anterior descending artery (LAD). Although it is considered a ST-elevation myocardial infarction (STEMI) equivalent, current guidelines recommend against the use of thrombolytic therapy in the absence of STEMI. As the question whether to use thrombolysis in such situations remains unanswered and controversial, we preferred to provide thrombolytic therapy with tenecteplase to our patient admitted with acute retrosternal chest pain with de Winter's ECG pattern so as to prevent myocardial damage and improve the patient outcome as the percutaneous coronary intervention facility was not immediately available. The thrombolysis was successful and the proximal LAD occlusion was confirmed later on coronary angiography which was treated with stent implantation. This case report tends to highlight the therapeutic dilemma while managing patients with de Winter's ECG pattern.
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An unusual association of left-sided inferior vena cava with slow-fast atrioventricular reentrant tachycardia p. 51
Debasish Das, Tutan Das, Subhas Pramanik
We report an extremely rare association of left-sided inferior vena cava (IVC) in a 38-year-old female presenting with recurrent palpitation for the past 2 years with typical slow-fast atrioventricular reentrant tachycardia (AVNRT). We delineated the course of the left-sided IVC with pigtail injection and catheter course to the right atrium and successfully modified the slow pathway with conventional catheters with difficulty in ablation catheter maneuvering and his catheter stability was an issue. Our case is the first description of an unusual association of isolated left-sided IVC in a patient with typical AVNRT.
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Silent rheumatic severe mitral stenosis with left ventricular noncompaction cardiomyopathy and ramifying normal coronaries: A double whammy in an octogenarian p. 55
Debasish Das, Anindya Banerjee, Abhinav Kumar, Shashikant Singh, Manaranjan Dixit
We report a unique association of rheumatic heart disease with left ventricular (LV) noncompaction cardiomyopathy in an octogenarian. He had severe mitral stenosis with severe LV systolic dysfunction secondary to noncompaction. Although the association of rheumatic heart disease with LV, noncompaction cardiomyopathy has been described sparsely in the literature, our case is a unique illustration of the presence of LV noncompaction cardiomyopathy contributing toward severe LV systolic dysfunction in rheumatic mitral stenosis in an octogenarian with no coronary artery disease.
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Anomalous left coronary artery from the right pulmonary artery with an intramural course p. 59
Krishnan Ganapathy Subramaniam, Dhruva Sharma, Vishal Vinayak Bhende, Vikram Kudumula, Shrinath N Reddy
Anomalous left coronary artery from the right pulmonary artery (RPA) is a rare congenital coronary anomaly and is one of the surgically treatable causes of ventricular dysfunction in infants. The left coronary artery when it arises from the RPA or near its base tends to follow the intramural course. Careful echocardiographic evaluation of the course of the coronary artery is necessary under sedation to avoid missing this anomaly. Unroofing of this coronary artery and closing of the pulmonary artery origin are recommended for treatment. We report a case where the intramural course was retrocommissural and unroofing would have resulted in aortic incompetence. We describe how a 90° rotation is possible by augmenting the coronary button with an anterior pericardial hood. The reconstruction of the RPA should be done with adequate mobilization and redundancy to prevent compression and bowstringing of the reimplanted coronary artery.
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Simple surgical technique for epicardial pacemaker wire preparation and insertion p. 62
Amit Mishra, Kartik Patel, Chandrasekaran Ananthanarayananh, Vivek Wadhawa, Himani Pandya
Epicardial pacing wire (EPW) insertion is an integral part of open heart surgery. However, the use of EPW insertion is also associated with complications such as bleeding, tamponade, arrhythmias, and occasionally even death of the patient. Various techniques have been described for preparing, placing, and removing EPW. We present our simple, yet effective technique of preparing, inserting, and removing EPW where the incidence of complications is nil.
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Post-COVID-19 cardiovascular syndrome: What does the evidence tell us? p. 65
Ivan David Lozada-Martinez, Geiro Alfonso Pava-Barrios, Andres Yoli-Garrido, Anderson Leal-Buitrago, Nicolas Rodriguez-Medina
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Macro T-Wave alternans in recurrent orthodromic atrioventricular reentrant tachycardia p. 68
Debasish Das, Tutan Das, Subhas Pramanik
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New year – A newer avenue for heart failure pharmacotherapy p. 70
Jes Jose, Iti Shri, Rohan Magoon, Sparsh Anil Bhalla
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Think again: The power of knowing what you don't know p. 72
Louie Galvez Giray, Mary Grace Rivas
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