Preface to the third issue of Heart India 2019 Alok Kumar Singh Heart India 2019 7(3):91-92

Combined cesarean section and mitral valve replacement in severe symptomatic mitral valve disease with unfavorable valve anatomy: Experience at a tertiary referral center of North India Mandakini Pradhan, Sangeeta Yadav, Neeta Singh, Gauranga Majumdar, Surendra Kumar Agarwal Heart India 2019 7(3):93-96 Objective: To discuss the management in a subset of patients with severe mitral valve disease having calcified, nonpliable valves not suitable for percutaneous balloon mitral valvuloplasty during pregnancy, presenting with Stage III–IV of the clinical classification of New York Heart Association. Methods: Patients with nonpliable valves presenting with heart failure in pregnancy at advanced gestation were planned for simultaneous cesarean section followed by mitral valve replacement. Results: All patients underwent successful surgery with good maternal and neonatal outcome. Conclusion: Patients with severe mitral valvular disease in failure in pregnancy, who are at high risk of mortality in pregnancy or during and following delivery, benefit from combined surgery.

Biventricular dysfunction and angiographic correlates of inferior wall myocardial infarction with high degree AV blocks Tammiraju Iragavarapu, Srujanitha Tadi, K Jagadish Babu, K Prudhvi Naresh, M Sruthi, A Roopini Heart India 2019 7(3):97-104 Objectives: Inferior wall myocardial infarction (IWMI) accounts for about 50% of acute myocardial infarction (MI) which are caused predominantly by occlusion of the right coronary artery which also mostly supplies both the SinoAtrial and atrioventricular (AV) nodes. The objective of this study is to analyze the incidence of high-degree AV blocks in IWMI with respect to right ventricular (RV) MI, RV dysfunction, left ventricular (LV) dysfunction, and their angiographic correlation. Methods: This study was a hospital-based retrospective cross-sectional analytical study involving 150 patients presenting to our casualty with Acute IWMI during August 2016–February 2018. We have collected the demographic details of these patients and analyzed various complications pertaining to AV Blocks. The patients were categorized into two groups – Group 1-IWMI with high-degree AV blocks and Group 2-IWMI without AV blocks. In-depth history and other details such as electrocardiogram, ventricular dysfunction by echocardiogram and angiographic data were analyzed among these two groups. Results: Among 150 patients with acute IWMI, high-degree AV blocks were seen in 35 patients (23%). The mean age of presentation was 56–65 years (31.4%) with male preponderance (60%). Severe LV dysfunction (ejection fraction <30%) in Group 1 (60%) was statistically significant with P < 0.00001 when compared to Group 2 (17.3%). RV dysfunction (tricuspid annular plane systolic excursion <16 mm) is seen in 57.2% versus 4.3% cases in Group 1 which is statistically significant with P < 0.00001. The triple vessel disease was significant in Group 1 (57.1% vs. 17.3%) whereas single-vessel disease (8.5% vs. 43.5%) was significant in Group 2 with P < 0.00001. Reversal of AV block is seen in 94.2% of cases after recanalization of RCA. Mortality was more in Group 1 (5.8% vs. 2.6%). Conclusion: IWMI with high-degree AV block has a worse prognosis with increased incidence of RV and LV dysfunction and multivessel disease. Prompt intervention can reverse AV block in most of the cases.

Correlation between the diagnostic accuracy of the electrocardiogram and coronary angiography in localization of occluded artery in acute ST-elevation myocardial infarction: A single-center experience Denny T Dyna, Bino Benjamin, Louis Francy Heart India 2019 7(3):105-109 Background: The electrocardiogram (ECG) remains the crucial tool in the diagnosis of acute ST-elevation myocardial infarction (STEMI) other than coronary angiography (CAG). However, the specificity of the ECG in culprit vessel localization is limited due to the individual variations in coronary anatomy as well as by the presence of preexisting coronary artery disease. The current observational study was designed to establish the correlation between the diagnostic accuracy of ECG with CAG to predict the culprit artery in STEMI. Materials and Methods: A total of 140 consecutive STEMI (ST elevation of >2 mm in at least 2 contiguous leads) patients were enrolled over 1.5 years at a tertiary care center in India. Based on ECG criteria, evaluated by blinded observer, patients were categorized into anterior, inferior with or without right ventricular infarction, and posterior wall myocardial infarction. Each group was further divided based on the culprit artery. Results: A total of 96 (68.6%) were males and 109 (77.9%) were 51–70 years. ECG showed perfect agreement (κ = 0.895, 0.882, and 0.853, respectively) with CAG in the diagnosis of proximal left anterior descending (LAD), proximal right coronary artery (RCA), and mid and distal RCA. It showed just fair agreement (κ = 0.348) with CAG in the diagnosis of distal LAD. Moreover, ECG showed perfect agreement (κ = 1) with CAG in the identification of both LAD proximal to D1 and distal to S1 and left circumflex artery. Conclusion: In STEMI patients, the diagnostic accuracy of ECG exhibits good correlation and agreement with CAG to predict the culprit vessels except for distal LAD.

Coronary artery aneurysms following drug eluting stents implantation: A retrospective analysis from series of cases at tertiary care cardiac centre over three years Sudarshan Kumar Vijay, Dharmendra Kumar Srivastava, Bhuwan Chandra Tiwari, Mukul Misra Heart India 2019 7(3):110-117 Background: Inflammation and healing after vascular injury during the procedure and other factors may be theoretically associated with a risk of coronary artery aneurysm (CAA) formation after drug eluting stent (DES) implantation. Very few studies have provided the epidemiological features and proposed causative factors of CAAs after DES implantation. Aims and Objectives: We aim to retrospectively study the incidence, morphological features and proposed causative factors of coronary artery aneurysms noted after drug eluting stent implantation at a tertiary care cardiac centre over period of three years (2015-2018). Methods: All cases of coronary artery aneurysms occurring after drug eluting stent implantation over a period of three years (2015-2018) were studied retrospectively. Incidence, morphological and clinical features of aneurysms were retrospectively analysed from case records and angiographic analysis from computerized database at our tertiary care cardiac centre. Results: Over period of three years (2015-2018) seven cases (Incidence-0.52%) of coronary artery aneurysms were noted after DES implantation with 1340 coronary angioplasty and stenting procedures done during this period for any indication. Association of diabetes and and high pressure post dilation was seen in five (71.4%) cases. A male sex and Left anterior descending artery predilection was noted and all incriminated stents were durable polymer stents. Dissection during predilatation of the lesion was seen in two (28.5%) patients. Conclusions: Coronary artery aneurysms associated with DES implantation are rare in the current era of biodegradable polymer stents. Various procedure and stent related factors are involved in its causation.

Transaxillary decompression of thoracic outlet syndrome: A single-center study Ambrish Kumar, Vikas Singh, Monika Bhandari, Sarvesh Kumar Heart India 2019 7(3):118-122 Objective: Transaxillary approach for the surgical management of thoracic outlet syndrome (TOS) has the advantage of minimal manipulation of brachial plexus and lesser perioperative and postoperative complications. We studied the clinical presentation and transaxillary surgical excision of the first rib in TOS at our center. Materials and Methods: All patients with TOS were reviewed for their clinical presentation and outcomes of transaxillary approach for thoracic outlet decompression over a period of 10 years. We evaluated the clinical presentation, surgical details, and postoperative course of all patients who underwent surgery. Results: Sixty-three patients of TOS were studied who underwent decompression through transaxillary approach over a period of 10 years. Nearly 79.4% of the patients had neurological symptoms, whereas 20.6% had arterial symptoms. Almost all patients (98.4%) had a cervical rib. One-fourth of the study population had bilateral cervical ribs. Around 17.46% of the patients presented with acute thromboembolism of the brachial artery and were managed with emergency thromboembolectomy. Postoperative complications encountered were pleural breach (11.11%), wound infection (7.94%), and re-thrombosis (1.59%). Conclusions: Transaxillary resection of the cervical/ first rib has excellent results, with less morbidity. It is efficient in relieving symptoms and gives cosmetically acceptable scar. It is proposed that whenever any patient presents with acute upper-limb ischemia, he/she must be evaluated for cervical rib as a cause of TOS.

Spectrum of antenatally diagnosed cardiac anomalies in a tertiary referral center of North India Sangeeta Yadav, Neeta Singh, Mandakini Pradhan Heart India 2019 7(3):123-128 Background: Congenital heart disease (CHD) is the most frequent fetal anomaly seen during pregnancy. Prenatal diagnosis of CHD helps in ascertaining the prognosis of fetus and planning management. Early diagnosis and prompt intervention after delivery helps to prevent serious morbidity and mortality. Objective: To evaluate the type and pattern of fetal congenital cardiac anomalies to plan appropriate intervention. Methods: This was a retrospective study of all fetal cardiac anomalies detected on antenatal ultrasound in pregnant women at a tertiary care hospital for high-risk pregnancy in northern India. A detailed clinical evaluation and ultrasound of the fetus to look for all malformations including detailed cardiac evaluation was done in all pregnant patients. All women were thoroughly counseled regarding the malformations, possible causes, prognosis, and need for fetal karyotyping. Results: A total of 782 fetal malformations were observed during the study period, of which 211/782 (26.9%) fetuses were found to have cardiac malformation. 165/211 (78.2%) were isolated CHD and 46/211 (21.8%) had associated anomalies. The most common defect was ventricular septal defect (37/211, 17.5%) followed by fetal arrhythmias (29/211, 13.7%), hypoplastic left heart syndrome (27/211, 12.8%), tetralogy of Fallot (21/211, 9.9%), atrioventricular septal defect (18/211, 8.5%), and double outlet right ventricle (14/211, 6.6%). 96/211 (45.5%) couples opted for prenatal invasive testing, of which 14/96 (14.5%) fetuses were found to have abnormal genetic studies, most common being down syndrome. Conclusion: The problem of CHD is of profound importance, and suspected cardiac anomaly is the main reason for referral. After identification of CHD, couple should be offered genetic studies and detailed counseling, and timely cardiac intervention should be planned when indicated.