Background: Unprovoked venous thromboembolism is a poorly understood entity. Clinical risk factors and future outcomes are not well recognized in this subgroup of patients. Various pathogenic mechanisms like inflammation and athero-thrombosis have been put forth but remain investigative. Our study aimed to determine the clinical profile and predictors of mortality in patients with idiopathic pulmonary embolism. Methods: Our single centre observational study included 510 consecutive patients with symptomatic unprovoked venous thromboembolism. Pulmonary embolism (PE) patients were initially categorized based on the presence or absence of deep vein thrombosis (DVT). Subsequently, the patients were further sub-grouped according to mortality, and the association between clinical parameters and death was evaluated through regression analysis. Results: The in-hospital mortality of patients with unprovoked pulmonary embolism was 15.9% and 25.76% at three year follow up. Significantly higher number of patients with diabetes, hypertension, dyslipidaemia, lower TAPSE (tricuspid annular plane systolic excursion) and PASP (pulmonary arterial systolic pressure) were found in mortality patients compared to survivor patients. On regression analysis we found significant association of higher odds of age OR = 1.1 (1.05-1.23), diabetes OR = 2.47 (1.28-4.79), hypertension OR = 2.25 (1.19-4.26) and lower odds of thrombolysis OR = 0.38 (0.11-0.59) with mortality. On Kaplan Meier survival analysis, the log value of <0.05 showed significantly higher mortality in patients who were not thrombolyzed. Conclusion: Various short and long-term predictors of mortality exist for pulmonary embolism. Cardiovascular risk factors play a mediating role in venous thromboembolism and also serve as predictors for long-term mortality. Therefore, modifying these risk factors can potentially result in a reduction in long-term mortality.

In developing countries, we still come across occasional patients who have undergone classic Blalock–Taussig shunt (CBTS) previously. We present a case of 23-year-old female with tetralogy of Fallot who had undergone CBTS operation at the age of 1 year and is now presented for total correction. Takedown of CBTS during surgery has catastrophic complications during looping and ligation of shunt due to extensive collateralization. We, therefore, took a hybrid approach for the patient. The CBTS was first blocked with the balloon, followed by surgical intracardiac repair, and finally, by device closure of CBTS.

Objective: Fragmented QRS (fQRS), as defined by additional spikes in the QRS complex of a 12-lead electrocardiogram (ECG), is a marker of scarred myocardium.In patients with coronary artery disease (CAD), fQRS is a predictor of heart failure (HF) and other major adverse cardiac events (MACE).The study was aimed to evaluate the role of fQRS in prediction of HF in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).Methods: In a prospective, non-randomized, small observational study, we enrolled 188 consecutive patients with STEMI undergoing primary PCI.Patients were grouped according to the presence or absence of fQRS and their inhospital, 1 and 6-month MACE outcomes were assessed.Results: Of the 188 patients, fQRS were noted in 92 (48.94%) patients.Patients with fQRS were more likely to have Killip class II/III/IV.Patients with fQRS had a significantly higher corrected QT interval, lower left ventricular ejection fraction (LVEF), and higher N-terminal pro brain natriuretic peptide (NT-pro BNP) at 24 hours and 48 hours compared to patients without fQRS.The in-hospital (P=0.001),30-day (P=0.03) and 6-month (p=0.01)MACE were higher in patients with fQRS.On logistic multiple analysis, fQRS in anterior leads (OR=3.70,CI=1.68-10.02,p=0.001), fQRS in more than 2 leads (OR=5.20,CI=1.51-12.83,p=0.01),NT-proBNP (OR=1.05,CI=1.03-1.08,p=0.02) and Killip class II/III/IV were found to be significant predictors for HF hospitalization.Conclusion: Our findings suggest that fQRS can be a predictor for HF in patients with STEMI and provide a simple and readily available technique for predicting prognosis.Larger studies are required to validate these findings.

Objective: The advent of 3D transesophageal echocardiography (TEE) was supposed to facilitate more accurate etiological diagnosis of prosthetic valve dysfunction as compared to 2D TEE; however, data to support the same is sparse especially in Asian Indians. Methods: This was a prospective, open- label study of 50 consecutive patients with prosthetic valve dysfunction who were eligible for the study. All patients underwent both 2D and 3D TEE for assessment of prosthetic valve dysfunction apart from their demographics, clinical evaluation, laboratory assessment and fluoroscopy. Results: Of 50 patients, 12 had aortic valve prosthetic dysfunction and 38 patients had mitral valve prosthesis dysfunction. Of these, 10 were male and remaining 40 were female patients. Overall, 41 (82%) patients had subtherapeutic prothrombin time at the time of presentation. Thrombus in situ was visualized in 34% of patients with 3D TEE as compared to 2D TEE (4%) (p=0.004). Pannus formation was observed in 20% of patients with 3D TEE as compared to 2D TEE, which could not identify pannus formation in any patient (p=0.03). In 34% of patients, normal motion of leaflets could be seen using 3D TEE as compared to 30% of patients by 2D TEE. Conclusion: Compared to 2D TEE, 3D TEE imaging offers superior capabilities in assessing prosthetic valve dysfunction, particularly when evaluating thrombus and pannus formation. Additionally, both modalities show nearly similar effectiveness in assessing leaflet motion.

Background Despite improvement in the surgical procedure and strictly following the guidelines for mitral valve replacement (MVR), left ventricular dysfunction still occurs. Novel echocardiographic indices can predict development of LV (left ventricle) dysfunction post MVR. LV-GLS (global longitudinal strain) derived from speckle tracking echocardiography, has been proposed as a novel measure to better depict latent LV dysfunction. Methods A total of 100 patients with severe MR (mitral regurgitation) planned for MVR were included. Speckle tracking echocardiography was performed at baseline and at follow up post MVR. ROC (Receiver operating characteristics) curve was plotted to derive the cutoff value of LV-GLS for prediction of LV dysfunction post MVR. Univariate and multi variate regression was analyzed to predict the independent predictors of LV dysfunction after MVR. Results LV-GLS was decreased from baseline data (−19.9 vs. −17.7) in patients with LVEF <50% after MVR compared to patients with LVEF≥ 50%. Baseline value of LVESD (35.36 mm vs. 28.23 mm) and LVEDD (49.33 mm vs. 45.10 mm) were significantly higher in patients with LVEF<50% compared to LVEF ≥50% at 3 months follow up. A cutoff value of GLS −19% with sensitivity of 80.3% and specificity of 75.7% was associated in patients with LV dysfunction after MVR. In multivariate regression model GLS < −19% (OR = 21.8, CI:6.61–82.4, P=<0.001) was an independent predictor of LV dysfunction post MVR. Conclusion A GLS value of less than −19% was demonstrated as an independent predictor of short term LV dysfunction after mitral valve surgery, LVESD ≥40 mm was also verified additional parameter to predict the LV dysfunction post MVR.

Context: Rheumatic heart disease (RHD) predominantly affects adults. However, in developing countries like India, it is the most common acquired heart disease in children. The prevalence of RHD also varies from the region to region in the same country due to the differences in educational, economic, and social status as well as health-care facilities of the region. Aim: The aim of the study is to establish and discuss the spectrum of RHD in children from Western India and to explore the relationship between severity of valvular lesion by the age and sex of the children with RHD. Methods: Echocardiographic findings of children (N = 820) ≤18 years with RHD seen at our institute from January 2018 to December 2018 were retrospectively analyzed. RHD was screened by echocardiography. All the echocardiogram were analyzed for the pattern and severity of various valve lesions and associated abnormalities. Results: Eight hundred and twenty children had a diagnosis of RHD. Maximum patients [476 (57.1%)] were from the age group of 13–18 years without any gender difference (418 male and 402 female). Mitral regurgitation (MR) was the most common lesion found in 81.46% children. Aortic regurgitation (AR) was seen in 29.76%, mitral stenosis (MS) was found in 20.48%, tricuspid regurgitation was seen in 66.83%, and aortic stenosis (AS) was found in 0.73% children. AR was found more common in males as compared to females (P = 0.0004). Majority of patients (69.5%) had single mitral valve involvement. Four hundred and eight patients (49.8%) had severe MR, 122 patients (14.9%) had severe MS, 62 patients (7.6%) had severe aortic regurgitation, and 2 (0.2%) patients had severe AS at the time of first presentation. Pulmonary hypertension was found in 69% of children. Children with MS and AS were older than those without MS and AS (P = 0.0001). Conclusion: Majority of children had severe valvular lesion and pulmonary hypertension at the time of first presentation. RHD is the leading cause of heart failure in children with requirement of surgical/catheter intervention and long-term medical management.

Background: Heart failure (HF), which is an emerging public health issue, adversely affects the strained health system in India. Additionally, the adverse impact of HF on the economic well-being of affected individuals and their families has been narrated in various anecdotal reports, with affected individuals and their dependents pushed into poverty. However, there is limited research quantifying how HF impacts the economic well-being of households from low- and middle-income countries. Methods: We describe the methods of a detailed economic impact assessment of HF at the household level in India. The study will be initiated across 20 hospitals in India. The selected centres represent different regions in India stratified based on the prevailing stages of epidemiological transition levels (ETLs). We will collect data from 1800 patients with acute decompensated HF and within 6-15 months follow-up from the time of initial admission. The data that we intend to collect will consist of a) household healthcare expenditure including out-of-pocket expenditure, b) financing mechanisms used by households and (c) the impoverishing effects of health expenditures including distress financing and catastrophic health expenditure. Trained staff at each centre will collect relevant data by using a validated and structured interview schedule. The study will have 80% power to detect an 8% difference in the proportion of households experiencing catastrophic health expenditures between two ETL groups. After considering a non-response rate of 5%, the target sample size is approximately 600 patients from each group and the total sample size is 1800 patients with heart failure. Impact: The results from our study will help policy makers in understanding the micro-economic impact of HF in India and aid in allocation of appropriate resources for prevention and control of HF.

BACKGROUND:The cause-effect of conduction disturbance in chronic lesion of coronary arteries is complicated. This study was designed to evaluate coexistent CAD in patients with symptomatic bradyarrhythmia to find common anatomic basis for conduction disturbances and its relationship to conventional coronary risk factors.METHODS:In this prospective observational study, 929 patients who admitted for symptomatic bradyarrhythmia requiring permanent pacemaker implantation were included. All included patients underwent coronary angiography and were divided into groups based on angiographic findings. Association between conduction disturbances and these groups were analyzed.RESULTS:A total of 929 patients with mean age of 63.1 years were included in our study. We found age ≥50 years, male sex, presence of diabetes and hypertension as statistically significant predictors of abnormal coronary angiography. Obstructive CAD (≥50% stenosis) was found in 34.4% patients. Prevalence of single vessel disease, double vessel disease and triple vessel disease was 15.3%, 10.2% and 8.9% respectively. Severe coronary obstruction (≥90% obstruction) was found in 16.25% patients. Revascularization was advised in three fourth of cases of obstructive CAD. Approximately two third of patients didn't have significant obstruction in coronaries supplying the conduction system. Type 4 was the commonest anatomy in obstructive CAD. SA Nodal artery was found more diseased in patients of SSS with p value of 0.01.CONCLUSION:Obstructive CAD was found in one third of patients undergoing PPI. Age ≥50 years, male sex, diabetes and hypertension were found significantly correlated with presence of CAD and may act as important markers for the judgment of further coronary evaluation.

Objective: To compare the diagnostic accuracy of multi-slice computed tomography (MSCT) angiography with conventional angiography in patients undergoing major noncoronary cardiac surgeries. Materials and Methods: We studied fifty major noncoronary cardiac surgery patients scheduled for invasive coronary angiography, 29 (58%) female and 21 (42%) male. Inclusion criteria of the study were age of the patients ≥40 years, having low or intermediate probability of coronary artery disease (CAD), left ventricular ejection fraction (LVEF) >35%, and patient giving informed consent for undergoing MSCT and conventional coronary angiography. The patients with LVEF <35%, high pretest probability of CAD, and hemodynamically unstable were excluded from the study. Results: The diagnostic accuracy of CT coronary angiography was evaluated regarding true positive, true negative values. The overall sensitivity and specificity of CT angiography technique was 100% (95% confidence interval [CI]: 39.76%–100%) and 91.30% (95% CI: 79.21%–97.58%). The positive (50%; 95% CI: 15.70%–84.30%) and negative predictive values (100%; 95% CI: 91.59%–100%) of CT angiography were also fairly high in these patients. Conclusion: Our study suggests that this non-invasive technique may improve perioperative risk stratification in patients undegoing non-cardiac surgery.

BACKGROUND:We aimed to compare the diagnostic accuracy of four novel indexes-triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) ratio, weight height ratio (WHtR), lipid accumulation product (LAP) and visceral adiposity index (VAI) with conventional components of metabolic syndrome (MetS) in order to identify a single index for the diagnosis of MetS in Gujarati Indian population.METHODS:This observational and cross sectional study involved a total of 3329 healthy adults of 18-79 years of age. Demographic and clinical data such as body mass index, waist circumference, blood pressure were measured along with the levels of lipids and fasting blood glucose.RESULTS:The overall prevalence of MetS was 34.32%, which was almost double in older individuals (45.5% vs. 20.8%) and slightly higher in males (37% vs. 31.2%). In comparison to individual components of MetS, three novel indexes-VAI, LAP and TG/HDL-C ratio showed superior diagnostic efficacy yielding an area under curve of 0.856, 0.821 and 0.821 respectively. The optimal cut-offs for VAI, LAP and TG/HDL Ratios for male, females, young and old population are (79.71, 88.12, 75.42, 87.4), (35.62, 34.73, 35.88, 34.7) and (2.249, 3.16, 2.49, 2.79) respectively. The diagnostic effectiveness of novel markers was unaffected by the age and gender of an individual. However, the efficacy of WHtR was comparable with the other conventional markers.CONCLUSION:Three novel markers-LAP, VAI and TG/HDL-C ratio could be effectively used as a single 'Surrogate marker' for screening of asymptomatic Gujarati Asian Indians with MetS.

Introduction: The metabolic syndrome (MetS) is an epidemiological construct of different permutations of risk factors. We aimed to compare and study the overall prevalence of MetS in healthy, asymptomatic young v/s old Gujarati population. Methods: This population based- cross sectional study involved a total of 3329 healthy adults of 18-70 years of age. Clinical data such as body mass index (BMI), waist circumference (WC), blood pressure (BP) were measured along with the biochemical estimations of lipids and fasting blood glucose (FBS). The overall population was categorized in young (<40 years) and old (≥40 years) individuals. Results: The overall prevalence of MetS was 34.3% where the incidence was found to be more than double in old(45.4%) as compared to young population (20.8%, p<0.0001). The level of FBS (99.82 ± 38.49 vs 87.65 ± 19.82), HDL-C (38.94 ± 7.35 vs 37 ± 6.42) and LDL-C (129.45 ± 33.88 vs 117.39 ± 30.38) were significantly (p<0.05) higher in older population as compared to younger population. In both the age groups the prevalence of MetS was higher in males as compared to females and was majorly contributed by increased FBS level. However in old (95.6% vs 84.2) and young (84% vs 96%) females, the abnormalities of WC were significantly higher than their male counterparts. Conclusion: In summary we conclude that MetS is prevalent in Gujarati population and is subjected to age and gender. This results reinforces the need of early life style intervention and awareness programs in this ethnic group.

Introduction: In pregnant women mitral stenosis is the commonest cardiac valvular lesion. When it is present in majorly severe condition it leads to maternal and fetal morbidity and mortality. In mitral stenosis pregnancy can lead to development of heart failure. Aim: To evaluate the safety and efficacy of balloon mitral valvulotomy (BMV) in pregnant females with severe mitral stenosis. Materials and Methods: A total of 30 pregnant patients who underwent BMV were included in the study from July 2011 to November 2013. Clinical follow-up during pregnancy was done every 3 months until delivery and after delivery. The mean follow up time after BMV was 6.72±0.56 months. Results: From the 30 pregnant females 14 (46.67%) and 16 (53.3%) patients underwent BMV during the third and second trimester of pregnancy respectively. The mean mitral valve area was 0.85+0.16 cm2 before BMV that increased to 1.60+0.27 cm2 (p<0.0001) immediately after BMV. Peak and mean diastolic gradients had decreased significantly within 48 hours after the procedure (p<0.001) but remained very much unchanged at 6.72 month period of follow-up. Two patients had an increase in mitral regurgitation by 2 grades. Conclusion: During pregnancy BMV technique is safe and effective in patients with severe mitral stenosis. This results in marked symptomatic relief along with long term maternal and fetal outcomes.

CONTEXTAlthough numerous risk factors have been established to predict the development of acute coronary syndrome (ACS), the risk factor profile may be different between the younger and older individuals.AIMTo analyse the frequency and pattern of atherogenic risk factors and angiographic profiles in age-stratified Gujarati patients with ACS.MATERIALS AND METHODSACS patients undergoing coronary angiography at U.N. Mehta Institute of Cardiology and Research, Gujarat, India between January 2008 and December 2012 were classified in to two age groups with 40y as cut-off. Patients were assessed for conventional risk factors (diabetes mellitus, dyslipidaemia, hypertension, smoking, obesity), novel risk factors (high sensitivity C-reactive protein, lipoprotein (a), homocysteine), and angiographic profiles.The statistical difference between two age groups was determined by Student's t-test for continuous variables and Chi-square or Fisher's exact test for categorical variables.RESULTSA total of 200 patients, 100 patients ≤40 y of age and 100 patients >40 y of age, were evaluated. Older patients had higher frequency of hypertension (32 vs. 16%, p=0.008), while family history of coronary artery disease was more common among younger patients (19 vs. 9%, p=0.041). The incidence of diabetes, dyslipidaemia, smoking and tobacco chewing did not vary significantly between the two groups. Total cholesterol and low-density lipoprotein cholesterol levels were significantly higher in the younger group (p<0.05). Lipoprotein (a), homocysteine and high-sensitivity C reactive protein levels were comparable between two age groups. Multi-vessel coronary artery disease was more common among older group. The most commonly affected coronary artery was the left anterior descending artery among younger patients (44%) and the left circumflex artery among older patients (38.1%).CONCLUSIONYoung patients with ACS had different atherosclerotic risk profile and less extensive coronary artery disease as compared to older counterparts. Emphasis should be given on diagnosis and management of major modifiable risk factors.

Objectives: Increasing prevalence of renal artery stenosis (RAS) in coronary artery disease (CAD) patients has been reported by many.We aimed to study the incidence and risk factorsof renal artery disease in patients undergoing coronary angiography (CAG) and/or peripheral angiography (PAG). Methods: Data of 2209 consecutive patients undergoing CAG and/or PAG followed by renal angiography was collected from January-June 2013. Pervasiveness of risk factors such as hypertension, diabetes, dyslipidemia, smoking, family history and incidence of CADwerestudied. Significant difference in profiles of patients with or without compelling atherosclerotic renal artery stenosis (ARAS) was tested by chi-square and unpaired t-test. Results and conclusion: Of 2209 patients, the prevalence of RAS in the study population was 6.11%. Mean age of the RAS patient group was57.17 ± 10.82 years. Advancing age, hypertension, diabetes, smoking and dyslipidemia were found to be strongly associated with RAS. Patients with significant CAD had increased chances to develop ARAS.Ageing and presence of risk factorswere closely associated with significant ARAS and hence they could be used in effectively predicting the presence of RAS in patients undergoing routineCAG and/or PAG.

OBJECTIVES:In this study we aimed to analyse the frequency of atherosclerotic risk factors with focus to novel risk factors for coronary artery disease and angiographic profile in young (≤ 40 years) acute coronary syndrome (ACS) patient with healthy controls in Gujarat, India.METHODS:Between January 2008 and December 2012, 109 consecutive young patients aged ≤ 40 years old, diagnosed to have ACS were included in the study. All ACS patients underwent diagnostic coronary angiography. An equivalent age and sex matched population without coronary disease with similar risk factors without tobacco considered a control group. All angiographic patients were evaluated for conventional risk factors for coronary artery disease like diabetes mellitus, hypertension, smoking, obesity as well as novel atherogenic risk factors like high sensitivity C-reactive protein (Hs-CRP), Lipoprotein(a) [LP(a)], homocysteine, apolipoprotein A1 (ApoA1) and B (ApoB).RESULT:In a study group, out of 109 young patients, 90 (82.6%) patients were presented to our hospital as ST-segment elevation myocardial infarction (STEMI), 10 (9.2%) presented as known non-ST-elevation myocardial infarction (NSTEMI) and 9 (8.3%) presented as unstable angina (UA). Serum cholesterol, triglycerides, LDL, LP(a) and lipid tetrad index were significantly higher in the study group whereas the HDL levels significantly lower as compared to the control group.CONCLUSION:A quite common risk factors of premature CAD are smoking, high Hs-CRP, high LP(a), hyperhomocysteinaemia and positive family history in the young ACS. Most common presentation of ACS in young was STEMI. On angiography, single vessel involvement was the most common finding.

The novel BioMime drug-eluting stent (Meril Life Sciences Pvt. Ltd., Gujarat, India) incorporates a L605 cobalt-chromium metallic platform that combines ultra-thin struts (65μm) with hybrid cell design and a bioabsorbable co-polymer (PLLA/PLGA) formulation (2μm thickness) which carries and