Search

Coronary artery anatomy is the key to a successful arterial switch operation in transposition of the great arteries. We came across an unusual coronary pattern in a child with transposition in which the three major coronary arteries were seen arising from all three aortic sinuses. This coronary pattern is the first of its kind in transposition, and this case report emphasizes the difficulty in translocating such a rare coronary pattern while performing an arterial switch operation.

Objectives Growth hormone deficiency (GHD) in adults is associated with an increased risk of cardiovascular morbidity and mortality. Although children with GHD are also believed to have a similar cardiovascular disease (CVD) risk beginning at an early age, the available data in children is scarce. We aimed to determine the various CVD risk parameters in children with isolated GHD (IGHD). Methods A cross-sectional case-control study was conducted at a tertiary care centre in North India comparing various auxological, biochemical, and echocardiographic parameters between 20 IGHD children aged 5–15 years and their age and sex-matched healthy controls. Results The mean age of children with IGHD and controls was similar (10.5 ± 2.6 yr vs. 9.9 ± 2.7 yr, p=0.48). Children with IGHD had significantly higher waist-hip-ratio (p=0.01), total cholesterol (p=0.02), non-high-density lipoprotein–cholesterol (p=0.02), serum homocysteine (p Conclusions Children with IGHD showed abnormalities in several biochemical and cardiac parameters that may be associated with an increased CVD risk in later life. More extensive studies, including younger children with IGHD, are needed to determine the lower ages at which the CVD risk is detectable.

Objective Several studies have demonstrated a shift in the spectrum of infective endocarditis (IE) in the developed world. We aimed to investigate whether demographic and microbiologic characteristics of IE have changed in India. Design A retrospective analysis of patients with in north India between 2010 and 2020. Methods The clinical and laboratory profiles of 199 IE admitted to an academic hospital patients who met the modified Duke criteria for definite IE were analysed. Results The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005). Conclusion IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU.

There are no established clinical or laboratory markers of preload adequacy and fluid responsiveness in management of neonatal shock. Functional echocardiographic preload markers are evaluated in children and adults, but there is no data in neonatal septic shock. We evaluated five functional echocardiographic preload markers during intravenous volume resuscitation in neonatal septic shock.(1) To compare baseline functional echocardiographic preload markers between neonates with septic shock and their "matched" healthy controls. (2) To compare echocardiographic preload markers before and after intravenous volume resuscitation.In this cohort study, we enrolled neonates with septic shock (cases) and recorded five preload markers - inferior vena cava collapsibility index (IVC-CI), left ventricular end-diastolic (LVEDV)end-systolic volume (LVESV) and their indices (LVEDVI, LVESVI) - before initiation of intravenous fluid resuscitation (baseline evaluation). An equal number of "matched hemodynamically stable" controls were recruited, who underwent functional echocardiographic assessment once. In neonates with shock, we recorded these markers again after volume resuscitation.We analyzed 46 neonates (23 cases and 23 controls). Neonates with shock had significantly elevated baseline IVC-CI as compared to controls [53% (21, 100) vs. 20% (15, 24) respectively,Neonates with septic shock had significantly elevated IVC-CI at baseline as compared to hemodynamically stable neonates. None of the preload markers changed significantly after volume resuscitation as compared to the baseline values including IVC-CI, which was almost significant.

Interrupted inferior vena cava (IVC) with azygous continuation provides technical challenge in many percutaneous cardiac interventions. They are performed via the femoral venous access route. We describe four such cases in whom, patent ductus arteriosus (PDA) device closure was done in interrupted IVC. All the four cases were done using the femoral route. Two cases were done via retrograde approach through femoral artery access, in which one was closed with a muscular VSD device and the other with a Gianturco coil. The introduction of newer closure devices helps in the retrograde approach. Two cases were done via anterograde approach through the femoral venous route, with a loop through the azygous vein. One child had transient bradycardia due to cardiac stretch which normalized after the device deployment and introducer system removal. Thus, we describe different femoral approaches in interrupted IVC patients for PDA closure, with the difficulties faced and the complications managed.

Background and aim of the study The morphological heterogeneity of anomalous pulmonary venous drainage in mixed type total anomalous pulmonary venous connection (TAPVC) has important implications in preoperative diagnosis and surgical repair resulting in high mortality in these patients. Methods A retrospective review of 14 patients with mixed type TAPVC undergoing biventricular repair between January 2012 and December 2019 was conducted. A descriptive analysis was done, highlighting the anatomic variation, diagnostic and surgical approach, and surgical outcomes in these patients. Results The most common anatomic pattern was "3 by 1" (79%) followed by "2 by 2" (21%). The correct diagnosis by transthoracic echocardiography was made in 10 (71%) of the 14 patients. In contrast, preoperative computed tomographic (CT) angiography was performed in 10 patients and correct diagnosis was obtained in 8 (80%) of them. Pulmonary venous obstruction was seen in one patient before surgery. The in-hospital mortality was 14% (2/14). Four patients had pulmonary hypertensive crisis in the postoperative period. The average follow-up was 54 ± 27 months (range: 17-98 months) after surgical repair, and all surviving patients were asymptomatic. There was no late death. No clinically apparent sequelae were seen in six patients in whom isolated left superior pulmonary vein drainage was left uncorrected. Conclusion An accurate diagnosis of anatomic pattern in mixed type TAPVC can be difficult to establish in all the patients before surgery. Detailed intraoperative assessment, individualized surgical approach, and aggressive perioperative management may reduce surgical mortality. Operative survivors have good midterm outcome.

Objectives Pulmonary hypertension is a common association in children with nonrestrictive ventricular septal defect. It increases perioperative mortality and morbidity. Oral sildenafil is an effective pulmonary vasodilator. In this study, we assessed effects of perioperative oral sildenafil therapy on pulmonary artery pressure and early surgical outcomes. Methods This was a single centre, prospective randomized control study. Thirty children with nonrestrictive ventricular septal defects with pulmonary hypertension were divided into two groups. In the sildenafil group (n = 15, mean age 23.3 months), oral sildenafil was administered two weeks before surgery. In the control group (n = 15, mean age 36 months), preoperative sildenafil was not given. Sildenafil was continued postoperatively in both groups, provided the postoperative pulmonary artery pressure was over 50% of systemic pressure. Results There was no perioperative mortality, pulmonary hypertensive crisis and there were no intolerable side effects related to sildenafil in either group. Mean pulmonary artery pressure showed a reduction in both groups. Sildenafil group showed statistically significant improvement in duration of cardiopulmonary bypass (100.27 ± 21.09 min vs. 125.40 ± 26.83 min, p = .008), mechanical ventilation requirement (22.79 ± 17.13 h vs. 30.53 ± 13.05 h; p = .04), epinephrine requirement (22% patients vs. 48% patients; p = .03) and hospital stay (6.13 ± 1.40 days vs. 7.53 ± 1.92 days; p = .05). Conclusion Oral Sildenafil therapy is an inexpensive and well-tolerated method for reducing pulmonary hypertension secondary to non-restrictive ventricular septal defect. It has noteworthy advantages regarding early surgical outcomes like reduced cardiopulmonary bypass time, improved mechanical ventilation time, lower inotrope requirement and shorter hospital stay if used preoperatively in select patient population.

Introduction: Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract. Methods: Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery. Results: The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR. Conclusion: The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.

Background Atrial septal defect (ASD) is one of the common congenital heart defects. Its management has transformed dramatically in the last 4 decades with the transition from surgical to percutaneous transcatheter closure for most secundum-type ASDs. Various devices are available for transcatheter closure of ASD with Amplatzer atrial septal occluder being most commonly used worldwide. Cocoon septal occlude has a nanocoating of platinum using nano-fusion technology over nitinol framework that imparts better radiopacity and excellent biocompatibility and prevents leaching of nickel into circulation, and by smoothening nitinol wire makes this device very soft and smooth. The aim of this study was to evaluate feasibility, effectiveness, safety, and long-term outcome of transcatheter closure of ASD using Cocoon septal occluder (Vascular Innovation, Thailand). Results All patients undergoing transcatheter closure of hemodynamically significant ASD between September 2012 and July 2019 in our institute were included into this single-center, prospective study. Exclusion criteria were defect > 40 mm, unsuitable anatomy, Eisenmenger syndrome, and anomalous pulmonary venous return. Three hundred and twenty patients underwent device closure, of which 238 (74%) were female. The mean age was 14.6 years (range 6–29), and the median weight was 30.2 kg (range 10–53 kg). Procedure was performed under fluoroscopy using transthoracic and transesophageal echocardiography in 298 (93.1%) and 22(6.9%) patients, respectively. Balloon-assisted technique was used, when septal defect was ≥ 34 mm, in 9 (2.8%) patients. The mean diameter of defect and device was 21.4 mm (range 12–36 mm) and 26.9 mm (range 14–40 mm), respectively. Aortic rim was absent in 11 (3.4%) patients. Primary success was achieved in 312 (97.5%) patients. Early embolization to right ventricle was noted in 2 (0.6%) patients. In both cases, 40-mm device was attempted for defect of 36 mm with inadequate aortic rim using balloon-assisted technique. One (0.3%) patient developed perforation of right atrium. All were surgically repaired. Three (0.9%) patients developed complete heart block following device deployment requiring device retrieval. Two patients had had moderate residual shunt at 6 months of follow-up. After mean follow-up of 50.92 months (range 12.5–89 months), no erosion, allergic reactions to nickel, or other major complications were reported. Conclusions Percutaneous transcatheter closure of ASD by Cocoon septal occluder (up to 36 mm) is safe and feasible with high success rate and without any significant device-related major complications over long-term follow-up. With unique device design and excellent long-term safety, it could be preferred dual-disk occluder for transcatheter closure of atrial septal defect. In most of the patients, ASD device can be safely deployed under transthoracic echocardiographic guidance.

Context: Patients with acute coronary syndrome (ACS) often have the suboptimal results of percutaneous coronary intervention (PCI) despite adequate restoration of coronary patency. Aims: This study evaluated the utility of starting nicorandil before PCI in patients with ACS, in terms of acute angiographic and short-term echocardiographic outcomes. Settings and Design: It was a prospective, randomized, blinded, single-center trial; involving stable patients with recent ACS and no prior revascularization. Subjects and Methods: Patients started on intravenous (IV) nicorandil infusion or placebo at least 2 h before PCI, continued till 48 h after PCI. Echocardiographic parameters (left ventricular ejection fraction [LVEF], Wall Motion Score Index (WMSI) score, and myocardial performance index (MPI)) were assessed at baseline and at 4 weeks post-PCI. Thrombolysis in myocardial infarction (TIMI) flow grade and corrected TIMI frame count were assessed before and after PCI. The primary endpoints were improvement in regional wall motion abnormality, MPI, LVEF, and corrected TIMI frame count. The secondary endpoints were the major adverse cardiovascular event (MACE) (cardiac death, angina, myocardial infarction [MI], or revascularization) within 30 days, no reflow, slow flow, and periprocedural MI. Results: Fifty-five patients were recruited over 1 year, of which 13 patients were excluded. There were numerically lower but statistically nonsignificant improvement in slow flow and no reflow in nicorandil arm. Significant improvement in echocardiographic parameter of MPI was seen in nicorandil group at follow-up. There was no significant improvement in other echocardiographic parameters and MACE. Conclusions: In patients with ACS and a single-vessel disease on undergoing PCI for recent ACS, the use of IV nicorandil was associated with a significant improvement in MPI at 1-month follow-up. There was no significant difference in the acute angiographic parameters, MACE, LVEF, or wall motion score index.

Congenital heart defects continue to remain a major cause of serious morbidity and mortality, especially in the developing world. This study was planned to get some insight into the role of modifiable nutritional elements in structural CHD etiology. This cross-sectional, observational study was conducted at a hospital in Northern India from January 2017 to December 2017. Infants 6 mo with structural CHD as cases and those without structural heart disease were enrolled as controls. Blood samples were collected from mother-child pairs and tested for serum folate, vitamin B12, and homocysteine. It was found that 46.7% infant-mother pairs, out of 45 in the cases group had folate deficiency, whereas in the control group, only 20% had folate deficiency, which was statistically significant (p = 0.013). Baby (0-6 mo) with congenital heart defects (CHD) and their mothers are more likely to have low folate levels compared to those not having CHD.

Background Structural congenital heart defects (CHD) take a huge toll of congenital defects in children in India. Limited information is available regarding modifiable risk factors for its causation. This study was planned with an aim to determine the prevalence of congenital rubella infection in Indian infants with structural CHD’s. Methodology This cross-sectional, observational study was conducted at a tertiary care hospital in Northern India over 1 year period (1 July 2016 to 30 June 2017). Infants Results A total of 80 infants (M : F = 56 : 24), having mean age 69.4 (±56.5) days; were enrolled. In these infants, prevalence of congenital rubella infection (either infant’s IgM rubella positive or infant’s IgG rubella titers higher than mother’s) was 8.75% (7/80). A total of 12.5% of studied mothers were seronegative for rubella IgG antibodies. Statistically significant association was found between the occurrence of congenital rubella and cataract (p = 0.0039), splenomegaly (p = 0.007) and microcephaly (p = 0.0084) in infants having structural CHD. Conclusions Congenital rubella syndrome still remains an important modifiable cause for structural CHD in India. Sincere efforts for rubella elimination via further strengthening current vaccination strategy would help in decreasing burden of structural CHD in India.

Cardiac defects presenting in childhood show significant phenotypic and genetic heterogeneity. With availability of advanced genetic technologies, these can be detected early using specialized testing. Prenatal testing is currently feasible with improved ultrasonography and fetal echocardiography. Here, we report two cases of Noonan's and cardiofaciocutaneous syndromes in patients seen in the genetic unit of a tertiary care center presenting with cardiac defect with or without developmental delay, short stature, and dysmorphism. In these conditions, there is also increased risk of malignancy such as juvenile myelomonocytic leukemia. With the advent of next-generation sequencing, definitive diagnosis and counseling is possible in this group of conditions.

BackgroundTranscatheter device closure is a safe procedure recommended in children with patent ductus arteriosus (PDA). While the standard procedure uses arterial and venous femoral access, it poses risk of vascular complications especially in young infants. Isolated venous approach has been tried in a few studies and was found to be non-inferior to the standard technique. In this prospective observational study, we have compared the two vascular approaches of PDA device closure in pediatric patients and have also studied the feasibility of this approach in young children with weight < 6 kg.ResultsPDA device occlusion was performed with either one of the approaches—venous alone (group I) or standard approach (group II) in a total of 135 children enrolled prospectively. The baseline data, procedural outcomes, vascular complications, and radiation dose were compared between the two groups.Fifty-two and 83 children were included in group I and group II, respectively. A total of 22 children (16%) (13 in group I; 9 in group II) had weight < 6 kg. In group II, 6 children (7.2%) had vascular site complications treated with heparin infusion with two children requiring thrombolysis. Another child in group II developed intravascular hemolysis following residual shunt, requiring surgical device retrieval and closure. No significant differences were observed in mean fluoroscopic time (p= 0.472) and air kerma between the two groups (p= 0.989).ConclusionTranscatheter PDA device closure without arterial access is a feasible and safe option in children including young infants. This technique avoids the risk of vascular complications although requires careful case selection.

Acute myocarditis in children is associated with high morbidity and mortality, with limited data on intravenous immunoglobulin (IVIG) treatment and outcome. Our goal was to describe clinical, treatment profile, and predictors of outcome in children with acute fulminant myocarditis (AFM) receiving intensive care. Case records of 120 children with clinical diagnosis of acute myocarditis from January 2008 to December 2018 were analyzed retrospectively. AFM was seen in 89 (74.2%) children of which nearly two-thirds (54 [60.7%]) were hypotensive at admission. The median (interquartile range [IQR]) ejection fraction on echocardiography was 25 (18.5–36%). Eighty-two children (68.3%) received IVIG. Intensive care needs were mechanical ventilation (n = 71; 59.2%) and inotrope support (n = 89; 74.2%); median inotrope score being 30 (IQR: 20–55). Twenty-one children died (17.5%). Fever (p = 0.004), arrhythmia (p = 0.03), shock (p = 0.015), higher inotrope score (p = 0.0001), need for ventilation (p = 0.025), acidosis (p = 0.013), AKI (p = 0.0001), transaminitis (p = 0.0001), and multiorgan dysfunction (p = 0.0001) were associated with mortality. The mortality was significantly less in IVIG treated group (12.1 vs. 28.9%; p = 0.02). On multiple logistic regression, MODS (p = 0.002) was independent predictor of mortality while IVIG treatment (p = 0.004) was favorably associated with survival. AFM complicated by multiorgan dysfunction carried a poor prognosis. IVIG was associated with survival benefit.

Pulmonary arterial hypertension (PAH) - a complex and progressive disease that carries significant morbidity and mortality despite optimal medical treatment. Combination therapy for PAH can be more effective than monotherapy. The present randomized trial compared the safety and efficacy of sildenafil ambrisentan combination therapy with sildenafil monotherapy. Twenty-two patients of Eisenmenger syndrome and five patients of idiopathic PAH were randomized to two arms. There was a significant improvement in NYHA functional class and mean pulmonary artery pressure, while an insignificant improving trend was observed for 6-min walk distance and oxygen saturation, following the 12 weeks of combination therapy. An upfront combination therapy was found to be safe and effective in the management of PAH patients., Graphical abstract Image 1

Background: Right ventricle outflow tract myocardium in tetralogy of Fallot reflects the effect of hemodynamic stresses on right ventricle muscle and correlates with clinical right ventricle dysfunction. It may be a useful adjunct in determining the time for intracardiac repair and predicting the clinical outcome. Methods: Septal and parietal bands of infundibular septum and obstructing muscle bands were excised in 48 patients undergoing intracardiac repair for tetralogy of Fallot. Microscopic study of histopathological changes in resected muscle bands was done. Post operative 2D echocardiography and tissue doppler imaging were done at the end of first and third month evaluating the right ventricular function. Results: Moderate myocardial fibrosis was seen in 42.9% (12/28) patients with age >5 years compared to 37.5% (6/16) patients with age between 1-5 years and 0% patients with age

Background: Secondary prevention strategies, including structured cardiac rehabilitation (CR), following myocardial infarction (MI) and coronary interventions may reduce the burden of mortality and recurrent morbidity. Objective: The objective of the study is to examine the effect of an adapted model of CR in patients who had experienced MI and had undergone percutaneous coronary intervention (PCI) in an Indian tertiary care hospital setting. Materials and Methods: A quasi-experimental design using control group and pre-test was used with patients post-MI and PCI. Fifty patients were allocated to CR intervention group for 12 weeks of intervention care compared with 51 patients in standard routine care control group. Results: After the 12-week program, participants in intervention group revealed a significant increase in coronary artery disease-related knowledge (P < 0.001), 6-minute walk test distance (P < 0.001), and high-density lipoprotein (P < 0.05). The level of physical activity was significantly higher in the intervention group in terms of mean duration of moderate or vigorous physical activity (P < 0.05) as well as mean of 10-minutes' continuous physical activity time at or above a moderate level (P < 0.01). Furthermore, depression levels (P < 0.05) and levels of glycated hemoglobin A1c significantly decreased (P < 0.05) in the intervention group. There were no changes observed in these parameters in the control group. Conclusion: CR is feasible and effective as it potentially improved health in patients who have experienced MI and had undergone PCI at a tertiary care hospital. Barriers may be recognized which might hinder participation in CR in Indian settings.

Objective: The study was conducted to assess the effectiveness of “percutaneous coronary intervention (PCI) care program” among patients undergoing PCI. Subjects and Methods: A quasi-experimental design was adopted, and purposive sampling technique was used to enroll the patients in the experimental and control groups. Different tools were used to collect the data, which include numerical pain and comfort rating scale, Barthel Index for activities of daily living, assessment for the presence of vascular complications, modified CADEQ-SV questionnaire, State-Trait Anxiety Inventory scale, self-structured satisfaction scale, and PCI manual. Results: There was a significant decrease observed in state anxiety (P < 0.001), pain level at 12 h (P = 0.03), discomfort within 12 h (P < 0.001) and 24 h (P = 0.002), improving knowledge regarding coronary artery disease (CAD) (P < 0.001), and activities of daily living as well as significant increase in satisfaction level (P < 0.001) among patients undergoing PCI in the experimental group than the control group. Conclusion: The study concluded that this program was effective in reducing anxiety, pain, and discomfort and increased satisfaction level, knowledge regarding CAD, and independence in self-care activities for PCI patients.

The pathogenesis of myocardial infarction (MI) involves environmental and genetic risk factors, with the latter putatively playing significant roles in younger patients. Genetic variability in coagulation factors comprises one such group. The coagulation factor 13 subunit A (F13A1) Val34Leu polymorphism (rs5985) has yielded variable findings in literature, with no prior South Asian data.We studied the frequency of this polymorphism using the amplification-created restriction-enzyme site (ACRES) polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) in 101 MI patients aged below 40 years and 103 controls along with plasma fibrinogen and serum homocysteine levels.The distribution of Val/Val, Val/Leu and Leu/Leu genotypes was similar among cases (72.3%, 26.7% and 1.0%) and controls (78.6%, 19.4% and 1.9%, respectively). Val and Leu allele frequencies were 85.6% and 14.4% among patients and 88.3% and 11.7% among controls, respectively (p = .416). Mean plasma fibrinogen was higher in patients vis-à-vis controls (3.1 versus 3.7 g/l; p .001) but homocysteine was elevated in both patients (52%) and controls (67%) (p = .225). Multivariate analysis revealed hypertension (p .001, OR 6.16) and smoking (p .001, OR 5.48) to impart strongest risk followed by positive family history, plasma fibrinogen levels and male gender.Despite its small sample size, this first South Asian study suggests neither protective nor deleterious effects of the F13A1 Val34Leu polymorphism on the risk of MI in young persons. The Leu allele frequency is intermediate to that reported from the West and the Far East. Traditional risk factors contribute greatly to risk even in younger MI patients in South Asia.

Stents are widely used in the management of various medical conditions including pulmonary arterial stenosis. Endovascular stenting is the treatment modality of choice for patients with branch pulmonary arterial stenosis which is unresponsive to balloon angioplasty alone. Since stents are increasingly being used in the pediatric population, stent fracture, even if uncommon, is likely to be encountered with increasing frequency during the follow-up of these patients. We hereby report a case of stent fracture in the left pulmonary artery which was treated by using a second stent.

Background Sepsis-induced myocardial dysfunction has implications on outcome. For lack of echocardiography in resource-limited settings, myocardial biomarkers may be an alternative monitoring tool. Objective This study was planned to explore the longitudinal behavior of creatine phosphokinase-MB (CPK-MB) in children with sepsis with and without shock, and its correlation with clinical and echocardiographic parameters over the first 10 days. Design Prospective observational study. Setting Tertiary care hospital in a lower-middle-income economy of South Asia. Patients Children (3 months to 12 years) with nonshock sepsis (NSS) (n = 40) and septic shock survivors (SSSs) (n = 40) after optimal resuscitation. Patients with catecholamine refractory shock, preexisting heart disease, and cardiorespiratory event within the past 1 month were excluded from the study. Measurements and main results Pediatric logistic organ dysfunction (PeLOD) score, vasoactive inotrope score (VIS), CPK-MB, and echocardiographic measures of myocardial function were recorded on days 1, 3, 7, and 10. Echocardiography was repeated at 1 month. Both groups were similar at baseline. The SSSs had higher CPK-MB (180 vs 53 IU/L; p < 0.001) and PeLOD score (2 ± 0.4 vs 11.7 ± 5.1, p < 0.001) on day 1 compared to the NSS children. More than half of the SSS and none of the NSS patients had myocardial dysfunction. Reduction in CPK-MB over 10 days correlated well with improvement in PeLOD (p < 0.01), VIS (p = 0.04), and echocardiographic measures of myocardial dysfunction (p < 0.05) among SSSs. At 1 month follow-up, all had normal echocardiography. Conclusion The SSSs had markedly elevated CPK-MB, and its fall paralleled the improvement in clinical status and myocardial dysfunctions. The CPK-MB could be a potential monitoring tool for septic cardiomyopathy in resource-limited settings. How to cite this article Baranwal AK, Deepthi G, Rohit MK, Jayashree M, Angurana SK, Kumar-M P. Longitudinal Study of CPK-MB and Echocardiographic Measures of Myocardial Dysfunction in Pediatric Sepsis: Are Patients with Shock Different from Those without? Indian J Crit Care Med 2020;24(2):109–115.

Background Government of India is committed to eliminate measles and control rubella/congenital rubella syndrome (CRS) by 2020. In 2016, CRS surveillance was established in five sentinel sites. We analyzed surveillance data to describe the epidemiology of CRS in India. Methodology/Principal findings We used case definitions adapted from the WHO-recommended standards for CRS surveillance. Suspected patients underwent complete clinical examination including cardiovascular system, ophthalmic examination and assessment for hearing impairment. Sera were tested for presence of IgM and IgG antibodies against rubella. Of the 645 suspected CRS patients enrolled during two years, 137 (21.2%) were classified as laboratory confirmed CRS and 8 (1.2%) as congenital rubella infection. The median age of laboratory confirmed CRS infants was 3 months. Common clinical features among laboratory confirmed CRS patients included structural heart defects in 108 (78.8%), one or more eye signs (cataract, glaucoma, pigmentary retinopathy) in 82 (59.9%) and hearing impairment in 51. (38.6%) Thirty-three (24.1%) laboratory confirmed CRS patients died over a period of 2 years. Surveillance met the quality indicators in terms of adequacy of investigation, adequacy of sample collection for serological diagnosis as well as virological confirmation. Conclusions/Significance About one fifth suspected CRS patients were laboratory confirmed, indicating significance of rubella as a persistent public health problem in India. Continued surveillance will generate data to monitor the progress made by the rubella control program in the country., Author summary Rubella infection during the first trimester of pregnancy can affect the fetus, resulting in spontaneous abortion, stillbirth or an infant born with a combination of birth defects known as congenital rubella syndrome (CRS). Government of India is committed to eliminate measles and control rubella/CRS and has completed nationwide immunization campaigns using measles-rubella vaccine targeting children aged 9 months to 14 years. A case-based surveillance for CRS is one of the strategies for achieving elimination. The Indian Council of Medical Research and the Ministry of Health and Family Welfare initiated surveillance for CRS in five sentinel sites to estimate the disease burden. During 2016–18, the surveillance sites enrolled 645 suspected CRS patients, 137 (21.2%) were classified as laboratory confirmed CRS and 8 (1.2%) as congenital rubella infection. Common clinical features among laboratory confirmed CRS patients included structural heart defects (78.8%), one or more eye signs (cataract, glaucoma, pigmentary retinopathy (59.9%)) and hearing impairment (38.6%). Thirty-three (24.1%) laboratory confirmed CRS patients died over a period of 2 years. The surveillance data indicated significance of rubella as persistent public health problem in India.

Objective Transcatheter closure is the first-choice strategy for the management of appropriate patients with patent ductus arteriosus (PDA). The management of large PDAs is challenging due to the limited available sizes of approved devices and the inherent risks of surgical ligation, especially in adults with calcified PDAs. This study aimed to assess the outcomes of the off-label use of large occluders at a tertiary center. Methods This retrospective review included patients who underwent transcatheter PDA closure with large occluders (≥16 mm) over 16 years. The baseline patient data, procedural details, angiograms, and immediate outcomes were recorded and patients were followed up at 3, 6, 12 months after the intervention and annually thereafter. Results Of the 685 patients who underwent transcatheter PDA closure, 36 patients (mean age 16.6 ± 12.5 years) needed occluders ≥ 16 mm in size. Cocoon duct occluder, Cera duct occluder, Amplatzer atrial septal occluder (ASO), and Cera muscular ventricular septal defect occluders were used for PDA closure. There was no device embolization, one patient in whom ASO was used had residual shunt with intravascular hemolysis requiring surgery, and one patient had mild left pulmonary artery narrowing after the intervention, which was managed conservatively. No patient had residual shunt and one patient had persistent pulmonary hypertension at an intermediate duration of follow-up. Conclusion Transcatheter PDA closure with the use of large devices, which are available in Asia and Europe, is an effective and safe method, especially in adolescents and adults. However, a close follow-up of these patients is mandatory.

Background The spatial relationship of the coronary sinus–great cardiac vein (CS–GCV) to free posterior portion of the mitral valve annulus (MVA) and left circumflex coronary artery (LCx) has gained importance with the advent of cardiovascular interventional procedures such as percutaneous transvenous mitral annuloplasty (PTMA) and mitral isthmus (MI) ablation. Methods In 50 normal (nondilated cardiomyopathy, or non-DCM) and 20 dilated cardiomyopathy (DCM) cadaveric hearts, the diameter and distance from the MVA of CS–GCV and its spatial relationship to LCx along the free posterior portion of the MVA were studied. Results The diameter of the CS–GCV increased from the beginning to termination in both non-DCM and DCM cases. The CS–GCV was located farthest from the MVA in the vertical plane in the middle of its course and in the horizontal plane at its beginning. The LCx was located above the CS–GCV in direct contact with the epicardial aspect of MI in 12% non-DCM and 15% DCM cases and was wedged between the CS–GCV and MI in 20% non-DCM and 15% DCM cases. Conclusions Knowledge of the separation between the CS–GCV and MVA in the horizontal and vertical planes could help in selecting suitable candidates and the preprocedural prediction of success of PTMA. Awareness of the spatial relationship of LCx with CS–GCV in MI would help to reduce the risk of incomplete MI block due to a heat sink effect or damage to the LCx by direct thermal injury during MI ablation.

BACKGROUND Right ventricular (RV) function alterations are invariably present in all patients after tetralogy of Fallot (TOF) repair. Unlike the developed world where most of the patients with TOF are corrected in infancy, average age of presentation and thus surgery for these patients in the developing world may be higher. We aimed to study the correlation between RV function parameters such as tricuspid annular peak systolic excursion (TAPSE), fractional area change (FAC), and tricuspid annular peak systolic velocity (S') with early outcome variables after intracardiac repair for TOF. MATERIALS AND METHODS Fifty patients with a preoperative diagnosis of tetralogy of Fallot scheduled for corrective surgery were included in this single-center, prospective observational study. A preoperative transthoracic echocardiogram was performed to measure RV function parameters (FAC0, TAPSE0, S'0). Transthoracic echocardiography was repeated postoperatively to measure FAC1, TAPSE1, S'1 (day 1) and FAC2, TAPSE2, and S'2 (day 3). The relationship between preoperative and postoperative RV function parameters with in-hospital mortality, duration of mechanical ventilation, and intensive care unit stay was studied. RESULTS The median age of patients was 6 years (range 1-14 years). Multiple stepwise logistic regression analysis showed RV FAC as best predictor of clinical outcome. Area under the receiver operating characteristic curve for postoperative RV function parameters, that is, FAC, TAPSE, and S' to predict early or delayed recovery was 0.944, 0.875, and 0.655, respectively. CONCLUSIONS Among the RV function parameters studied, RV FAC best predicted the early outcome variables after TOF repair, followed by TAPSE while lateral tricuspid annular velocity S' being the least predictive.

Introduction: Tetralogy of Fallot (TOF) is a common cyanotic disease and the concept of ideal Cardiopulmonary Bypass (CPB) temperature is still controversial. Aim: To assess the merits and demerits in terms of short term patient outcome of normothermic CPB over hypothermic CPB during intracardiac repair of TOF amongst paediatric patients. Materials and Methods: Among 71 patients of TOF who underwent Intracardiac Repair (ICR) in the Department of Cardiovascular and Thoracic Surgery from 1st January, 2016 to 30th April, 2017, 60 patients were included in our single centre retrospective observational study. Normally distributed variables were expressed by their mean and standard deviation; non normally distributed variables were expressed by their medians and interquartile ranges; categorical variables were expressed as n (%). Statistical software Stata IC version 14, R version 3.2.1 and MedCal were used. All tests were two-tailed with level of significance as

Cardiac fibromas are rare tumours of the heart. We present a case of cardiac fibroma in a four-year-old child in view of rarity of the case and success achieved in its management. The child had presented with a history of intermittent palpitations. Electrocardiography (ECG) showed monomorphic Ventricular Tachycardia (VT). She was initially managed with intravenous Metoprolol and Amiodarone infusion but had recurrent VT. Echocardiography revealed a mass in the apical septum. A Contrast Enhanced Computed Tomography (CECT) showed a homogeneous mass involving the anterolateral and apical aspect of interventicular septum causing expansion of the septum and indentation and compression of both ventricles. The tumour was approached through median sternotomy under Cardiopulmonary Bypass (CPB). The adventitia over the exposed part of the tumour was incised and the tumour was dissected out of the interventricular septum. A bovine pericardial patch was used to close the septal defect. Most of the small tumours dispersed around Left Anterior Descending Artery (LAD) were excised. The patient was weaned off CPB easily. In the postoperative period, Amiodarone infusion was continued with no recurrence of arrhythmias. Histopathology revealed classical features of fibroma. The child is stable and is on outpatient follow-up. Our patient had a huge fibroma and we could successfully resect it avoiding need for transplant. We hereby conclude that in children with a huge intracardiac fibroma involving almost a complete cardiac chamber, success can be achieved through resection and reconstruction in selected cases and the need for transplant may be obviated.

The diagnosis of Kawasaki disease (KD), a common pediatric vasculitis, is based solely on clinical criteria. There is a need for a robust laboratory marker that can help differentiate KD from other acute, febrile, childhood illnesses and also to predict cardiac involvement. We conducted a cross-sectional study of 25 consecutive patients admitted with diagnosis of KD from January 2013 to April 2014 and compared them with age- and sex-matched febrile controls. We studied the serum pro-brain natriuretic peptide (ProBNP) [ProBNP and N-terminal pro-B-type natriuretic peptide (NT-ProBNP) levels], a marker of myocardial dysfunction, in children with KD in acute and convalescent phases of disease. These levels were also estimated in febrile controls for comparison. The ProBNP (ProBNP and NT-ProBNP) levels were much higher in the acute phase of the KD patients compared to levels in the convalescent phase of KD (p = 0.000014). Similarly, the levels in the acute phase were higher when compared to the age- and sex-matched febrile controls (p = 0.000126). The receiver operating curve (ROC) analysis for the ProBNP levels in the acute phase of KD yielded an area under the curve of 0.954 ± 0.034 (p

Objective A substantial portion of the Indian cardiac surgery population experiences rheumatic valve disease that progresses to severe pulmonary artery hypertension (PAH) in a few patients. Right ventricular (RV) function, particularly in the perioperative period, has been studied sparsely. The authors describe serial RV function and clinical variables in the perioperative period in patients with severe PAH secondary to left heart disease. Design Prospective, observational study. Setting University hospital. Participants Patients with PAH. Interventions The study comprised consecutive patients referred for open cardiac surgery from January 2012 to June 2013 who also had an estimated right ventricular systolic pressure≥50 mmHg on referral echocardiogram. Composite echocardiographic assessment of right ventricular size and linear/two-dimensional tissue Doppler systolic function and diastolic function analysis were performed at predetermined intervals. Data from right heart catheterization, inotrope use, fluid requirements, mechanical ventilation logs, and intensive care stay also were acquired. Measurements and Main Results A complete dataset was obtained in 20 of 22 patients enrolled in the study. Serial comparison of most RV echocardiographic function variables were noted to be abnormal at baseline, deteriorating further in the immediate postoperative period and trending to a partial recovery at discharge from the intensive care unit, particularly for longitudinal assessment of the RV. Fractional area change, although abnormal, was noted to be preserved. Pulmonary artery systolic pressures registered significantly declined after intervention. The clinical course was largely uneventful. Conclusion Although linear echocardiographic RV function was grossly abnormal in the perioperative period in this patient subset with PAH, there was apparent disjunction with the clinical course.

This paper presents the despeckling applications of 48 filters for B-mode echocardiographic images. The filters are grouped into eight types, namely, local statistics, fuzzy, Fourier, multiscale, nonlinear iterative, total variation, nonlocal mean, and hybrid. The thrust areas of analyses are noise suppression, edge, and structure preservation evaluated in terms of image quality metrics, visual quality assessment, and clinical validation. The comparative analysis reveals that filters based on generalized likelihood ratio, local statistics (mean and variance), detail preserving anisotropic diffusion, fast bilateral, sparse representation based beta process factor analysis, and patch-based locally optimal Wiener and probabilistic nonlocal means stand out among the techniques being considered for comparison.

Objective To develop surface landmarks for blind axillary vein puncture for pacemaker lead implantation. Methods and results Patients for routine coronary angiography were counseled for participating in our study. 20 patients who gave consent were taken up for axillary venogram after proper positioning at the time of coronary angiogram. The venograms of these 20 patients, were reviewed and the landmarks were used to develop a blind axillary puncture technique. Success rate of 100% was achieved with surface landmark guided axillary vein puncture. The implantation time while using surface landmark guided axillary puncture was not significantly longer than when venography based approach was used. Another interesting observation made from the study was that increasing BMI had a positive correlation with the time taken for venous access, the fluoroscopic time and the volume of contrast used, all the associations being statistically significant. Thus, the surface landmark guided technique is more safe and expeditious in non obese patients and probably in pediatric patients as well. Moreover, the new surface landmark guided approach is a significant safety step in terms of reducing the unwanted and avoidable radiation exposure to the hands. Conclusion The results of this study demonstrate that placement of endocardial permanent pacemaker and ICD leads via the developed surface landmarks is effective and safe and is devoid of the harmful effects of radiation and contrast exposure.

Purpose The problems of speckle noise, low contrast, and other artifacts in continuous wave Doppler (CWD) based echocardiographic images are identical to the issues prevailing in the B-mode images. The median filter and Gaussian low pass filter are more commonly used for reduction of noise in CWD images. The applications of state-of-the-art despeckling filters and their impact on delineation are not extensively analyzed using CW Doppler images.

Echocardiography is very commonly utilized in the diagnosis of cardiac abnormalities but it being an ultrasound based imaging modality, comes with inherent curse of speckle noise. It is proposed to test and analyze the effect of logarithmic based posterior sampling Bayesian estimation (PSBE) for denoising of transthoracic echocardiographic (TTE) images of aortic valve. PSBE based experimentations reveal that, the performance of technique degrades considerably, when TTE images are simulated with speckle noise and then denoised. To address this issue, a spatially adaptive Wiener filter is being embedded into logarithmic PSBE method known as hybrid PSBE. Proposed experimentations are performed using TTE images acquired in 2 windows with 5 different views, each providing different piece of information necessary for the accurate diagnosis of underlying abnormalities. The usefulness of denoising is evaluated based upon edge preservation, image quality index, and similarity index in addition to PSNR, SNR and MSE comparisons. The exhaustive visual and parametric analysis shows that the proposed hybrid techniques are more robust and effective in speckle noise reduction. The denoised images are enhanced using Butterworth low pass filter, which will assist the doctors in delineating true cardiac chamber and valvular boundaries accurately with more ease and lesser intrapersonal variations.

Background & objectives: Adriamycin though considered as an effective anticancer drug, leads to irreversible cardiomyopathy (CMP) and congestive heart failure (CHF). The aim of this study was to determine the protective effect of carvedilol in adriamycin (ADR)-induced cardiomyopathy (CMP) in cancer patients. Methods: Patients with lymphoreticular malignancy in whom ADR therapy was planned were randomized into two groups: carvedilol and control. Twenty seven patients each were enrolled in carvedilol and control groups. In the carvedilol group, 12.5 mg once daily oral carvedilol was given during six months. The patients were evaluated by echocardiography before and after chemotherapy. Left ventricular ejection fraction (EF) and systolic and diastolic diameters were calculated. Results: At six months of follow up, six patients in the carvedilol group and five in the control group had died. The mean EF (63.19 vs. 63.88%) and fraction shortening (FS) (34 vs. 34.6) of the carvedilol group were similar at follow up, but in the control group, the mean EF (67.27 vs. 60.82%, P =0.003) and FS (38.48 vs. 34.6, P

INTRODUCTION Left ventricular ejection fraction (LVEF) is the single most important predictor of prognosis in patients with coronary artery disease (CAD) and left ventricular (LV) dysfunction. Equilibrium radionuclide ventriculography (ERNV) is considered the most reliable technique for assessing LVEF. Most of these patients undergo two dimensional (2D) echocardiography and myocardial viability study using gated myocardial perfusion imaging (MPI) or gated F-fluorodeoxyglucose (F-FDG) PET. However, the accuracy of LVEF assessed by these methods is not clear. This study has been designed to assess the correlation and agreement between the LVEF measured by 2D echocardiography, gated blood pool single photon emission computed tomography (SPECT), Tc tetrofosmin gated SPECT, and F-FDG gated PET with ERNV in CAD patients with severe LV dysfunction. PATIENTS AND METHODS Patients with CAD and severe LV dysfunction [ejection fraction (EF)

Echocardiographic images are inherent with speckle noise which makes visual reading and analysis quite difficult. The multiplicative speckle noise masks finer details, necessary for diagnosis of abnormalities. A novel speckle reduction technique based on integration of geometric, wiener, and fuzzy filters is proposed and analyzed in this paper. The denoising applications of fuzzy filters are studied and analyzed along with 26 denoising techniques. It is observed that geometric filter retains noise and, to address this issue, wiener filter is embedded into the geometric filter during iteration process. The performance of geometric-wiener filter is further enhanced using fuzzy filters and the proposed despeckling techniques are called integrated fuzzy filters. Fuzzy filters based on moving average and median value are employed in the integrated fuzzy filters. The performances of integrated fuzzy filters are tested on echocardiographic images and synthetic images in terms of image quality metrics. It is observed that the performance parameters are highest in case of integrated fuzzy filters in comparison to fuzzy and geometric-fuzzy filters. The clinical validation reveals that the output images obtained using geometric-wiener, integrated fuzzy, nonlocal means, and details preserving anisotropic diffusion filters are acceptable. The necessary finer details are retained in the denoised echocardiographic images.

Background Pulmonary vein (PV) isolation with catheter ablation in treating atrial fibrillation carries the risk of injury to phrenic nerve (PN). Left PN (LPN) stimulation continues to be one of the common complications of transvenous left ventricular lead placement during cardiac resynchronization therapy (CRT). Methods and Results In 30 formalin-fixed cadavers, spatial relationship of PNs with PV ostia, left atrial appendage (LAA), and cardiac veins was observed. Segmental location of LPN and cardiac vein crossover was also noted. Right and left PNs coursed abutting the ostium of right superior and left superior PVs in five (16.6%) and one (3.33%) cases, respectively. LPN coursed along the lateral surface of LAA in 20 (66.66%) cases and behind LAA in one (3.33%) case. Out of 18 (60%) cases having two cardiac veins draining free wall of left ventricle (LV) and suitable for CRT lead placement, both cardiac veins were crossed by LPN in two (6.66%) cases. LPN–cardiac vein crossover was located in midlateral segment in 10 (33.3%) cases; mid posterolateral segment in five (16.7%) cases; apical lateral segment and apical posterolateral segment in three (10.0%) cases each. Conclusion PN is highly susceptible to either injury during catheter ablation or stimulation with LV pacing in certain critical locations. Detailed knowledge of spatial relationship of PNs with cardiac structures could help minimize inadvertent complications during these transcatheter electrophysiological procedures.

The presence of speckle noise and artifacts make delineation of transthoracic echocardiographic (TTE) images quite difficult and challenging; the edges are to be preserved while removing noise. To address issues, a novel speckle reduction technique is being proposed and analyzed. Three fuzzy filters based on median and moving average concepts are experimented in homomorphic domain and the best one is further fine tuned for applications on TTE images. The proposed hybrid homomorphic Fuzzy (HHF) filter is the sequential integration of homomorphic fuzzy filter with anisotropic diffusion. The denoising characteristics of HHF filter are compared with ten existing techniques tested in homomorphic and other seven in non-homomorphic domain using seven different performance parameters along with visual quality assessment. Experimentations are performed on TTE images acquired in two parasternal and three apical views, since image in one view may not very precisely speak of underlying valvular abnormality. The edge preservation capability is increased by many fold (around 8 times) upon integration of homomorphic fuzzy filter with the anisotropic diffusion filtering technique. Beta metric, figure of merit and structure similarity indices are all greater than 0.97 for proposed HHF filter. The performance of proposed HHF filter is superior in comparison to seventeen state-of-art denoising techniques in terms of all seven performance parameters. Noise is reduced with the edges and structure of TTE images well preserved.

There has been a paradigm shift in the transcatheter closure of patent ductus arteriosus (PDA) over the last 45 years. With the availability of various coils, plugs and occluders, PDA of almost all shapes and sizes are amenable to transcatheter closure. However, very large PDA diagnosed late in life are being referred for surgical closure in the absence of availability of large size devices, especially in developing countries. In this case series, we have described four patients with large PDA, three of which were closed by transcatheter custom made PDA occluders. © 2013 Wiley Periodicals, Inc.

Iliac vessels are prone to injury during lumbar spine surgery due to their proximity to the lumbar spine. Arterio-venous fistula formation during lumbar spine surgery is an uncommon complication and can present as an asymptomatic incidental finding to rapidly deteriorating hemodynamics leading to cardiopulmonary collapse. We have reported three patients who had symptomatic iliac arterio-venous fistula detected soon after lumbar spine surgery. All these patients were successfully treated by endovascular transluminal stent grafting. © 2013 Wiley Periodicals, Inc.