Journal of Cardiovascular Medicine and Surgery

As cardiac surgeons (both qualified and in training), caring for post cardiac surgery patients in the ICU, we tend to focus primarily on the surgical outcomes of our surgery. Out of the many aspects of recovery, delirium is often not dealt with or understood intensively. While most of the patients recover without much short term noticeable effects, some have long lasting effects. A thorough understanding as well as early identification of this condition can improve long term outcomes as well as hospitalization costs. While there is extensive literature on this, further research is needed in predicting, identifying and treating delirium after cardiac surgery. Moreover, awareness of this situation in the early recovery phase of cardiac surgical patients can aid in the expedient recovery and hospitalization costs. 

Background: Drug-eluting stents (DES) represent a significant improvement in the treatment of coronary artery disease as they decrease restenosis rates by approximately 50% compared with bare-metal stents. The study aimed to evaluate clinical, etiological factors and angiographic characteristics associated with occurrence of In-stent restenosis in of Bare metal (BMS) vs. Drug eluting stents. Methods and Results: The study included 200 patients of percutaneous coronary angioplasty during October 2014 to June 2016.Mean age of patients was 58.06±8.79 years with 140 (70%) were males and 60 (30%) were females. BMSand DES ISR (44.1% vs 56.3%) were diabetic (DM), (61% vs 84.4%) were hypertensive, (77.9% vs 56.3%) were dyslipidemic, (46.3% vs 21.9%) were smokers consecutively. Amongst the above risk factors, Diabetes (p-value 0.01) and smoking (p-value 0.028) were the two factors which had statistically significant correlation with severity of In-stent restenosis(ISR). Patients with BMS had more Non Focal ISR 98 (79.03%) than focal ISR 38 (50%) and the difference was statistically significant (p value <0.001). There was statistically significant difference (p =<0.05) between the stent diameter and the severity of ISR with less than 2.5 mm Diameter stents associated with more Non focal ISR. Conclusion: ES appears to reduce restenosis and clinical end points and to be more cost effective than BMS. Patientrelated factors (i.e. sex, Diabetes, smoking) are important variables that affect restenosis and, hence, the appropriate selection of devices and patients is crucial.

Aims: The objective was to study the safety and efficacy of balloon mitral valvotomy in rheumatic severe mitral stenotic adult patients and to evaluate the clinical, echocardiographic and haemodynamic profile both before and immediately after the procedure. Methods: Forty adult patients aged 24yrs or older were taken for the study. All underwent balloon mitral valvotomy. We used Accura balloon in our institution. The procedure was successful in all the patients. Then clinical, echocardiographic and haemodynamic parameters were analysed before and after the procedure. Results: New York Heart Association functional class was II and III in 60% and 40% respectively. Atrial fibrillation was seen in the 25% of the patients. Mitral valve deformity as per wilkins score was 8.6 ± 0.67. Mitral valve area index by 2D echo was 0.621±0.097 cm2/m2, Mitral valve gradient 14.63±5.33 mm hg, and mean PASP was 60.10±19.32 mm of hg, after intervention the values were 1.29±0.18cm2/m2,(0.0001), 5.78±2.24 mm of hg, (p < 0.001) and 41±15.62 respectively (p = 0.0001). The mean value for left atrial pressure before 24.9±6.77mmhg and after 14.20± 4.92mmhg, significantly lower after balloon mitral valvotomy (p value 0.0001). The procedural success was 100%. Conclusion: Balloon mitral valvotomy is safe and effective in Adult rheumatic mitral stenosis and provides better immediate results.

Context: Diabetes Mellitus is a proven risk factor for adverse events for coronary artery disease and its prevalence among patients continues to rise. Hemoglobin A1c (HbA1c) is an accepted marker for adequacy of glycemic control. But it is not known whether it could be used to predict outcome after off pump coronary artery bypass graft (OPCAB) surgery. Aims: To study adequacy of using baseline HbA1c levels to predict outcome after coronary artery bypass graft especially in OPCAB surgery. Settings and Design: Retrospective observational study. Methods and Material: Diabetic patients undergoing isolated OPCAB surgery from 2015 to 2018, done by a single surgical team in a tertiary care institution, were included. The cohort of 310 patients was then grouped into three groups depending upon their HbA1c levels. The patient data, operative factors and 30 day post operative outcomes were compared. Statistical analysis used: variables were compared using student’s t test and paired t test. A p value <0.05 was considered significant. Results: Of the 310 patients, there were no significant differences in the baseline and angiographic characteristics. Mortality was observed in 2 patients in group I, 3 in Group II and 4 in group
III corresponding to 3% among the groups, hence not significant. The only significant differences in morbidity were found to be higher superficial surgical site infection (p value 0.0039) and duration of post operative stay (p value 0.0032) in group III patients. Conclusions: Preoperative baseline HbA1c levels can be used to predict minor morbidity but are not suitable for predicting mortality in OPCAB surgery.

  Aortic stenosis is a common cause of valve replacement, and chronic aortic stenosis increases left ventricular wall tension with subsequent ventricular hypertrophy, dilatation, and failure. The prognosis for such patients is extremely poor if valve replacement is not performed and severe ventricular impairment is not in itself a contraindication to surgery. Early and conflicting reports have examined the peri-operative risk of patients with reduced LV systolic function undergoing aortic valve surgery. Avoiding surgical intervention has been advocated recently in such patients, however, other reports have demonstrated that aortic valve replacement in patients with aortic stenosis and reduced left ventricular function has encouraging long-term survival with improved functional class. Our study has been performed to assess the early left ventricular mass regression in patients undergoing aortic valve replacement for severe aortic stenosis with impaired LV systolic function. 

Background and Objectives: The risk of cardiovascular disease (CVD) in women has been historically underestimated due to a misperception that females are protected against CVD. There are limited studies of the risk factors and clinical characteristics of female patients presenting with myocardial infarction (MI) in India. To study clinical profile of female patient with MI in India. Methods: We enrolled a cohort of 180 female patients presenting with acute MI between June 2016 to May 2018. Results: The female MI patients were more likely to be dyslipidemic (46.11%), hypertensive (42.22%), obese (40.00%) with high mean BMI (32.05±6.42 kg/m2) and more likely to present with hest pain (83.33%) with STEMI (58.33%) compare to NSTEMI 41.66%). Conclusion: Indian female patients with acute myocardial infarction present at younger age as compared to western women, with chest pain and STEMI is more frequent  presentation. Dyslipidemia was the most common associated risk factor followed by hypertension, obesity, and diabetes. Study Design: Cohort Study. 

 Introduction: Tombstoning ST- segment elevation is a type of ST-segment elevation with a specific morphology which is observed in the early period of acute myocardial infarction (AMI). We aimed to study the clinical courseof anterior wall AMI patients with tombstoning electrocardiographic (ECG) pattern. Methodology: We investigated 46 patients with AMI for tombstoning ECG pattern. Those without tombstoning were also included and compared. Demographic, clinical, laboratory and complications were noted in both the groups of patients. Results: Out of 46 anterior wall AMI patients, typical tombstoning pattern in all the anterior wall ECG leads was seen in 19 (41%) patients. The systolic blood pressure was significantly lower in tombstoning group. CK-MB, the biochemical predictor of infarct size, was significantly higher among patients with tombstoning on ECG as compared to those without tombstoning (89.78±56.53 vs 173.01±107.57, p value < 0.001). Left ventricular ejection fractions were significantly lower in the tombstoning group (43.90±11.35) as compared to the nontombstoning group (52.29±14.01%). The incidence of pre-infarct angina was significantly lower in patients with the tombstoning ECG pattern (21%) compared with those without the pattern (52%). Cardiogenic shock (16% vs 4%), ventricular tachycardia (26% vs 4%), and ventricular fibrillation (16% vs 0%) occurred in a significantly larger percentage of patients with the tombstoning ECG pattern as compared to those without tombstoning on ECG. Conclusions: Patients with tombstoningECG patterns had a larger infarction size, lower left ventricular ejection fraction, with higher in-hospital complications. 

Context: Rheumatic disease is the most common cause in our country. Few data are available on post operative left ventricular function in patients with mixed stenotic and regurgitant lesions. In this study, we sought to analyze short term changes in LV function after DVR in combined rheumatic and mitral diseases. Aim: To analyze the short term changes in LV function after DVR in combined rheumatic aortic and mitral diseases. Settings and Design: Prospective analysis of all cases of DVR in combined rheumatic aortic and mitral diseases done from 1/8/2012 to 31/12/2013 in 2 surgical units at Sri Jayadeva Institute of Cardiovascular Sciences and Research and their serial clinical and 2-D Trans Thoracic Echocardiographic evaluations, post-operatively, for 1 year. Methods and Material: Serial clinical and echocardiographic evaluations were performed prospectively in patients who underwent double valve replacement for combined aortic and mitral valve diseases, immediate post-operatively, at 3 months and at 1 year. For purposes of comparison, 2 groups were made based on types of lesions, i.e. purely regurgitant lesions and combined stenotic and regurgitant lesions. Statistical analysis used: Data are presented as mean ±SD. Group comparisons made by the use of Paired t test. Significance assumed at a two-tailed value of p<0.05. Results: Left ventricular diastolic and systolic dimensions and volumes reduced significantly at 3 months in regurgitant group but not in the mixed lesions group. Conclusions: In patients with NYHA class upto III with severely dilated left ventricle and low ejection fraction, double valve replacement surgery can be done safely.

Background: Elevated blood pressure is an independent predictor of cardiovascular disease. Hypothesis: Hypertensive patients with apparently normal clinic blood pressure recordings can have abnormal Ambulatory Blood Pressure Monitoring (ABPM) profiles like nondipping and morning blood pressure surge. Abnormal ABPM profiles especially Morning blood pressure surge (MBPS) are associated with more severe hypertensive end organ damage and coronary artery disease. Methods: Fifty hypertensive patients with documented coronary artery disease and well controlled clinic blood pressure measurements who underwent successful ABPM recordings were included in the study. MBPS and dipping profiles were analyzed. The abnormal ABPM profiles were correlated with hypertensive end organ damage and coronary artery disease severity assessed by Gensini score. Results: 96% of the patients were nondippers. 62% of the patients showed morning blood pressure surge when calculated using sleep-trough morning surge. Patients with MBPS had higher LV mass and more hypertensive retinopathy. The severity and extent of coronary  artery disease by Gensini score was significantly higher in the MBPS group (59.74±31.35 vs 24.84±28.36) with a P value of 0.0002) Conclusion: A significant proportion of hypertensive patients with well controlled clinic blood pressure recordings have exaggerated MBPS and nondipping blood pressure profile identified by ABPM. MBPS is associated with more severe hypertensive target organ damage and coronary artery disease assessed by Gensini scoring system and is independent of the dipping status. In addition to anti-platelet medications, statins and lifestyle modifications, antihypertensive therapies targeting MBPS may help in preventing cardiovascular disease progression in hypertensive patients.  

Background: A successful cardiac surgery centre requires a lot of resources, skilled professionals, ancillary services and a defined patient population. Such centres are functional in super-specialty hospitals of big cities and is hard to reach for the rural poor. Hereby we are presenting the implementation process of a cardiac surgery centre in a rural tertiary care hospital and its successful service. Methods: our hospital is a 750 bedded tertiary care center with all specialties of medicine and is located in a rural area of Puducherry, India. We have cardiac cases reported from general medicine and general surgery. We built up team with a primary CT surgeon, an assistant surgeon, cardiac anesthesiologist, perfusionist, physician assistant, scrub nurses and the ICU & post operative ward nurses. Procurement of machines were made and was followed by setting up an operation theatre, ICU ward and post operative wards. Results: Our first case was an SVC type of Atrial Septal Defect, successfully operated on 21st April 2017. Till then we have completed 211 open heart procedures and our centre is getting advanced everyday. Conclusion: Establishing a cardiac surgery centre in a rural hospital setup is a challenging but feasible task. Emergence of such centers would help the rural community in terms of affordability and inconvenience in reaching super specialty centers of big cities.