Prosthetic heart valve thrombosis incidence is high in developing countries and contributes to significant late mortality postvalve surgery. Many guidelines advocate surgery as the first line therapy though thrombolysis is often used in many centers. In this article, we review the newer regimens of fibrin-specific thrombolytics. Newer regimens of very low-dose, slow infusion lead to equal efficacy with lower complication in majority of patients. Patients with the New York Heart Association (NYHA) Class I–II who have low thrombus burden should receive thrombolysis with low-dose slow infusion while those with high thrombus burden should be planned for surgery. Patients presenting with NYHA Class IV should be treated with classical dose thrombolysis.

In acute stroke, rapid administration of intravenous recombinant tissue-type plasminogen activator (r-tPA) to stroke patients is the mainstay of treatment. Intravenous r-tPA improves functional outcomes when given within 4.5 h of ischemic stroke onset. Patients eligible for intravenous r-tPA should receive intravenous r-tPA even if endovascular treatments are being considered. Patients should receive endovascular therapy with a stent retriever if they meet appropriate criteria as per the American Heart Association guidelines. With the publication of results of the carotid revascularization endarterectomy versus stenting trial (CREST), there is evidence of no difference in the rate of late ipsilateral stroke after endarterectomy or stenting at 4 and 10 years. CREST provides the physician more options for the treatment of carotid stenosis and has shown that both carotid endarterectomy and carotid artery stenting are effective and safe when performed by experienced operators, and when patients are chosen appropriately.

Background: Patients with constrictive pericarditis can be treated by pericardiectomy by either left anterolateral thoracotomy or median sternotomy. The terms “radical,” “total,” “extensive,” “complete,” “subtotal,” “adequate,” “near-total,” and partial pericardiectomy have been used often without much clarity. We describe our experience with a radical pericardiectomy technique via modified left anterolateral thoracotomy and compare the same to total pericardiectomy via median sternotomy. Methods: In this study, 67 (54.9%) patients underwent radical pericardiectomy via modified left anterolateral thoracotomy (Group I), and 55 (45.1%) patients underwent total pericardiectomy via median sternotomy (Group II). Results: The operative mortalities were 2.9% and 7.2% for the radical and total pericardiectomy groups, respectively. The time taken for normalization to Class I/II in Groups I and II was 30 ± 11 and 36 ± 14 days, respectively (P = 0.009). Surgical techniques did not affect the outcome of atrial fibrillation (P = 0. 77). Reoperation was not required for any patient. The radical pericardiectomy was also associated with less postoperative low cardiac output state as compared to patients undergoing total pericardiectomy (P < 0.001). There was no difference in mean duration of hospitalization; however, the radical pericardiectomy group achieved the New York Heart Association I and II Status quicker than the total pericardiectomy group (P = 0. 009). Conclusions: We conclude that using several technical modifications of pericardial excision, it is possible to achieve radical pericardiectomy via modified left anterolateral thoracotomy, particularly removing the constricting pericardium over the anterolateral, diaphragmatic surfaces of left ventricle and the anterior and diaphragmatic surfaces of the right ventricle until the right atrioventricular groove without using cardiopulmonary bypass in the great majority of patients undergoing pericardiectomy for chronic constrictive pericarditis. Although the surgical approach for pericardiectomy is based on surgeon's preference, left anterolateral thoracotomy is the preferred and noncontroversial approach in the setting of purulent pericarditis and effusive constrictive pericarditis to prevent sternal infection. We recommend median sternotomy approach with or without cardiopulmonary bypass, in the setting of calcific pericardial patches, pericardial masses, reoperations, and calcific pericardial “cocoon” and for those with predominant right-sided and annular involvement.

Introduction: There are few data on heart failure (HF) burden and none available on the community prevalence of HF in India. We conducted a study aimed at determining the HF prevalence in a rural community as well as tertiary hospital care setting in North India. We also reviewed the existing literature regarding the estimated and projected prevalence of HF in India. Methodology: All adults (>20 years) with chronic breathlessness in six villages under a primary health care center in Northern India were identified and evaluated with standardized questionnaire and physical examination by trained health care workers. HF was diagnosed by standardized criteria and a transthoracic echocardiogram was performed in all subjects. In the hospital study, 500 consecutive patients presenting to our tertiary referral hospital were evaluated for the diagnosis of HF. For the systematic review, all published studies addressing HF or the burden of risk factors in India were identified. Projections for the absolute HF burden were made using local data and global studies of HF incidence, morbidity, and mortality. Results: Among the surveyed rural adult population of 10,163 patients, chronic breathlessness was present in 128 (1.3%). HF was present in 9% (n = 12), of which 67% (n = 8) had preserved left ventricular (LV) systolic function and 33% (n = 4) had LV systolic dysfunction. Therefore, the prevalence of HF in this general community was 1.2/1000. All patients with HF and preserved ejection fraction had poorly controlled hypertension. In the hospital study, of 500 consecutive patients, 20.4% had HF. Rheumatic heart disease (52%) was the most common cause followed by ischemic heart disease (17%). The mean age of presentation was 39 ± 16 years. The prevalence of HF in the outpatient department patients was 22.5% below 30 years and 14.9% above 50 years, reflecting the young population of HF. For the estimates concerning HF burden in India, projections were made using both age-specific extrapolations from developing countries and data regarding development of HF in the presence of risk factors. The estimated prevalence of HF is about 1% of the total population or about 8–10 million individuals. The estimated mortality attributable to HF is about 0.1–0.16 million individuals per year. Conclusions: While our hospital data are consistent with the HF burden and etiology expected in a government tertiary hospital setting, our community-based study is the first of its kind reported from India. The community study demonstrates a surprisingly low prevalence of symptomatic HF in the surveyed villages. This could be partially explained by the rural farming-based community setting but is also likely due to under-reporting of symptoms. Our review of the projected national estimates suggests an alarming burden of HF in India despite a younger population than the developed nations. A significant proportion of this burden may be preventable with better screening and early and adequate treatment of the risk factors.

Objective: The objective of this study was to assess the effect of indapamide sustained release (SR) 1.5 mg in the treatment of hypertensive patients, untreated or uncontrolled on monotherapy with different antihypertensive agents, on blood pressure (BP) reduction and well-being. Patients and Methods: In a prospective multicenter study from 32 cities across India, 1545 patients between 40 and 70 years of age with untreated or uncontrolled hypertension (BP >140/90 mmHg) received indapamide SR 1.5 mg once daily as monotherapy, or in addition to the existing treatment for 90 days. The Nottingham general health questionnaire was used to assess the changes in well-being. Results: In 1545 hypertensive patients, with a mean (standard deviation) age of 56.86 years, 64.1% being men. Of those recruited, 29% were treatment naïve and 71% were receiving different antihypertensive medications. In terms of a sense of well-being, a lack of energy was reported in 56.6%, emotional problems in 61.6%, and disturbed sleep in 58.1% of the patients. On an intention to treat basis, 842 patients (54.5%; 95% confidence interval, 52.0–57.0) achieved BP control. The patients who achieved BP control (compared to those who did not) felt more energetic by 6.3% (8.2–4.3, P< 0.0001), emotionally better by 5% (6.3–3.6, P< 0.0001), and had improved sleep by 5.6% (7.4–4.1, P< 0.001). Conclusion: In hypertensive patients, untreated or uncontrolled on monotherapy with any of the major drug classes, the addition of indapamide SR 1.5 mg is effective in reducing BP and in improving their well-being.

A patient presented with dyspnea, chest pain, and hemoptysis. Clinical findings revealed evidence of severe pulmonary hypertension and cyanosis with clubbing and a wide split second sound. Investigations including cardiac catheterization and oxygen study were performed, and the patient was referred for surgical repair. This article discusses various aspects of history, clinical examination, and cardiac catheterization that were utilized to decide the management.

The odds ratio (OR) is a simple tool, widely utilized in clinical research. As a simple statistic, it can be hand calculated to determine the odds of a particular event or a disease, and the information provided can be useful for understanding the results of a treatment/intervention. This article discusses the application of OR with examples and shows a simple way of performing the test using an online calculator.

Cardiology developed in India in the 1950's and 1960's with the setting up of the Departments of Cardiology in Vellore, in AIIMS, and in many other colleges all over India. History teaches us many lessons and meeting some of the stalwarts who made this history inspires us to greater heights. In February 2016, AIIMS organized an alumni event in which many of the old faculty and students got together. We bring together some photographs and videos. We also invite everyone to send more photographs and thoughts to the journal for further compilation.

Hydatid disease is still prevalent in developing countries, and isolated cardiac hydatid cysts are the rarest presentation. We report a 40-year-old nondiabetic, nonhypertensive female who presented with low-grade fever for 2 months shortness of breath and orthopnea for 2 weeks. Transthoracic echocardiography revealed a large, round cystic lesion with multiple daughter cysts without any obvious intraluminal detached membranes with mass effect on the left ventricular outflow tract. After total excision, residual tissue was closed with Teflon patch. Germinative membrane and hundreds of daughter cysts were seen. Following total excision of the cyst from myocardium, myocardial cavity was washed thoroughly with 10% Betadine solution. Pathological examination confirmed the diagnosis of hydatid cyst. Preoperatively started albendazole was continued for 4 weeks even after the operation. On follow-up after 4 weeks, the patient is doing well and cardiac imaging showed normal contours of the heart.

A 64-year-old female had symptomatic severe aortic insufficiency and was taken up for aortic valve replacement. The patient was found to have a quadricuspid aortic valve and abnormally located early bifurcated left coronary ostium which were very near to the commissures. There is a risk of damaging the coronary ostia while excising the valve or the prosthetic valve can obstruct the abnormally located ostia. Intraoperative transesophageal echocardiography can help in making an accurate intraoperative diagnosis and deciding aortotomy incision and valve excision. This patient underwent successful aortic valve replacement taking great care to save the abnormally located left coronary ostium.