Journal of Cardiovascular Medicine and Surgery

Complete heart block in children is a rare entity. A study published in 1998 calculated the mean incidence of isolated Complete Heart Block during 1970–1994 to be 1:17,000. This is a case report of a 3-year-old who presented with syncope, diagnosed with complete heart block and managed with a permanent pacemaker implantation.

Patients with symptomatic left subclavian artery stenosis (LSA), often undergo intervention. The need for intervention in incidentally detected LSA stenosis in patients undergoing coronary artery bypass grafting (CABG) is controversial. We evaluated an elderly male with triple vessel coronary artery disease and borderline stenosis in LSA. Bilateral internal thoracic artery (ITA) conduits were harvested and right ITA – left ITA ‘Y‘ grafting was done. This approach can be considered as an alternative for patients undergoing bypass surgery with asymptomatic LSA stenosis to prevent coronary subclavian steal syndrome.

Background: Thoracoplasty is the operative removal of the thoracic cage, which usually involves the subperiosteal resection of several ribs. By removing the skeletal support, the overlying chest wall will collapse to the visceral pleura, the remaining lung or mediastinum causing obliteration of pleural spaces. Thoracoplasty was originally described to treat the complications of pulmonary tuberculosis, but later it was widly applied to patients of chronic non tubercular pyothorax and bronchopleural fistulas secondary to various etiology. After the modern chemotherapy for tuberculosis, the indication for thoracoplasty drastically reduced, but its significance for the treatment of chronic non healing bronchopleural fistula has increased. Thoracoplasty is still widely performed where the burden of disease is high despite the advancement in chemotherapy for tuberculosis and incidence of post surgical bronchopleural fistula are commonly seen. Patients and Methods: patients who are treated between Jan 2015 to Dec 2018 with thoracoplasty for persistent residual space and bronchopleural fistula are included in this study. Totally 35 patients underwent thoracoplasty as a single stage procedure as a last resort after the failure of other modalities. Regular follow up of patients was done and data analysed. Result: Successful outcome is in the form of control of sepsis, closure of bronchopleural fistula, obliteration of space. The success achived in all 34 patients with obliteration of space and cure of bronchopleural fistula. An an average five to eight ribs removed in single sitting with preservation of first rib in all cases. One patient died and five patient had wound infection treated conservatively. Conclusion: Thoracoplasty is still an operation of continued relevance in Indian subcontinent and other countries where the complications of pulmonary tuberculosis is still prevalent despite the newer emergent chemotherapeutic drugs and regimens. Emergence of multidrug resistant non tubercular Pyothorax along with tubercular pyothorax causing severe debiliated and malnourished patients with the development of bronchopulmonary fistula make thoracoplasty to be performed more often.

Objective: To compare outcome in terms of recurrence and complications in children operated by classical method of herniotmy with sac ligation versus newer method of non ligation of sac. Material and method: 100 children birth to 14 years of age with inguinal hernia were included in study conducted for 1 year. Exclusion criteria were children with high chances of recurrence like comlicated hernia, incarcenated hernia. Total of 82 patients gave consent to participate in study. The total children were divided into 2 groups randomly and operated by classical and newer method of herniotomy. The children were foloowed up for a time span of 1 year for any complications. Results: There was only 3 case of recurrent hernia in the control group, and none in the study group. There was no statistically significant difference of complications in study and control group. Conclusions: This study showed that hernial sac ligation after its transection is not necessary in pediatric herniotomy. Omitting ligation did not result in any significant complications in children.

Background: Antioxidants are known to play a role in the prevention of coronary artery disease (CAD) whereas oxidative stress contributes to endothelial dysfunction and the development of atherosclerosis. Studies have reported low levels of total antioxidant capacity (TAC) in ACS patients. The objective of our study was to evaluate levels of TAC between different populations and its prognostic value. Methods and Results: A total of 163 subjects were included in the study consisting of Control (N=21), Chronic Stable Angina (CSA) (N=21), Non-ST-elevation myocardial infarction (NSTEMI) (N=57) and ST-Elevation Myocardial Infarction (STEMI) (N=64) patients between the period March 2017 to April 2018. Antioxidant levels from the plasma samples were measured by Trolox Equivalent Antioxidant Capacity (TEAC) assay. Patients were also followed up at different time intervals to identify the occurrence of major adverse cardiac events (MACE). All statistical analyses were performed using SPSS software version 16.0 (SPSS Inc., Chicago, IL). The concentration between the 3 groups varied significantly (p=0.002) with an average trolox concentration of 1.562 mM as observed in Control, 2.05 mM in CSA and 2.55 mM in ACS subjects. We also observed a negative correlation between TAC and cardiac markers, creatine phosphokinase (CPK) (r= -0.194, p=0.040) and Creatine kinase-MB (CK-MB) (r= -0.232, p=0.013). However, TAC levels did not provide any prognostic information [AUC = 0.458, p = 0.630, 95% CI (0.297-0.619)]. Conclusion: TAC levels did not provide any prognostic value. Larger sample sizes are required to assess their role.

Background: Patients with non ST elevation myocardial infarction (NSTEMI) are a very heterogenous population, with varying risks of early and longterm adverse events. Early risk stratification at admission seems to be essential for planning therapeutic strategy. There are scores for this. They include the TIMI, PURSUIT and GRACE risk score. In this study we sought to compare these risk scores in a NSTEMI cohort. In the subgroup of patients with syntax score, the TIMI, PURSUIT and Grace risk scores were compared with syntax score in prognosticating patients with NSTEMI. Materials and methods: This is a prospective cohort study conducted in a tertiary care hospital catering to patients from Karnataka, Tamil Nadu and Andhra Pradesh states of India. All patients with NSTEMI admitted to the coronary care unit from 01.08.2011 to 30. 04.2013 were included in the study after informed consent. Patients were followed up for adverse cardiac events including NSTEMI, unstable angina, ST elevation myocardial infarction, congestive cardiac failure, interventions and mortality which included in hospital, 30 day and 1 yr mortality. The followup was done till 31st July 2013. Results: A total of 213 patients with NSTEMI were included in this study. The mean age of the cohort was 61 ± 12 years. 69.4% (148) were males. Univariate predictors of early mortality included low systolic (p – 0.010), low diastolic blood pressures (p – 0.048) and patient with CCS Class IV at admission (p – 0.019). Univariate predictors of longterm (1 year) mortality includes age (p -0.000), low systolic (p – 0.030) and low diastolic (p -0.001) blood pressure, low ejection fraction (p – 0.002), low hemoglobin (p - 0.004), high serum creatinine ( p – 0.009). The GRACE RS was good (AUC – 0.890 CI: 0.77 – 0.99) as compared to TIMI (Fair – AUC – 0.778) and pursuit (good – AUC – 0.865) in predicting In hospital mortality. Long-term mortality prediction was same with all risk scores (AUC – 0.7). Syntax had a better predictability for shorterm and long-term mortality when compared to the other scores. This subgroup is not a random sample and hence may not represent the cohort as a whole. Conclusion: In an Indian cohort of NSTEMI, GRACE risk score was better than TIMI and PURSUIT risk scores in discriminative and predictive accuracy for in hospital and shorterm (30 days) mortality. The three risk scores were similar in predicting long-term mortality. Low hemoglobin and diastolic blood pressure are not part of these scores but were independently associated with long term mortality in our cohort.

Objective: Benign tracheal stenosis after endotracheal intubation is a common iatrogenic problem with impactable psychological and socioeconomic burden on health care needs immediate intervention. There are no clear cut guidelines on definitive therapy for tracheal stenosis and consensus on definition of good outcome. Endoscopic dilatation is usually preferred in patients with mild stenosis of grade I or II and a stenotic segment of <1 cm. Patients with complex grade III and IV stenosis requires proper planning and evaluation before definitive surgery or palliative procedure like stenting, dilatation. But all patients with tracheal stenosis do not present to hospital in stable condition. Many patients present with acute respiratory distress with unstable general condition requires immediate intervention to tide over the crisis and buy time for stabilization and further evaluation before planned procedure. Other procedures like baloon dilatation, laser coagulation not feasible in that acute crisis situation. Gum elastic bougie dilatation is available in all establishments and can be performed with ease and cost effectively. But limited data and study literature available on the role of dilatation in complex and grade III and IV stenosis. This study is to know the role of bougie dilators in grade III and IV and complex type of benign tracheal stenosis. Patients and methods: in our institution 149 patients with complex stenosis grade III and IV Myer-Cotton classification underwent treacheal stenting with Montgomery T-tube for benign tracheal from Jan 1984 to Jan 2019. Those patients with simple stenosis and grade I and II Myer-Cotton classification were excluded from the study. Not all 149 patients were directly taken for T-Tube insertion as many of them presented in acute respiratory crisis and stridor. These were stabilised before T-tube stenting by bronchoscopic gradual dilatation with carrot type elastic bougie and followed up with bronchoscopic evaluation. Results: Totally 149 patients underwent T-tube insertion for benign tracheal stenosis 25 (17%) were prior tracheostomised and 124 (83%) complex grade III and IV stenosis. Out of 149 patients 61 (41%) were treated initially with dilatation before T-tube insertion. 5 (8%) developed Subcutaneous emphysema and 3 (5%) had pneumothorax. 40 patients 65% underwent subsequent planned procedure within 72 hours (3 days) and 21 (35%) within 48 hours (2 days). Conclusion: elastic bougie dilatation has definite role in complex tracheal grade III and IV stenotic patients who are presented with acute respiratory distress to tide over the crisis and buy time to plan and work up for definitive subsequent procedures. Gum elastic bougie dilators are simple to use and much cheaper than balloon dilators. Advantages of dilation were the provision of both visual and tactile feedback to the operating surgeon. Infrastructure facility for rigid elastic bougie is simple, easily available and easily reproducible at all centres.

Introduction: Vasodilators are important drugs to relieve coronary spasm during coronary interventions. Use of Intracoronary (IC) Nitroglycerin (NTG) during PTCA helps to prevent or treat coronary vasospasm, augment coronary collateral flow and also helps in appropriate sizing of stents. Hemodynamic effects of NTG may preclude its use in some patients. Nicorandil (NIC) is used as a coronary vasodilator and has a favourable hemodynamic profile. Materials and Methods: 34 patients planned for elective PTCA with coronary stenosis more than 70% were included in the study. Alternate patients received intracoronary administration of 200 microgram of Nitroglycerin (NTG) or 1 mg Nicorandil (NIC). Hemodynamic parameters, TIMI flow grade and coronary diameters were analysedin both groups. Results: I.C administration of NTG resulted in significant increase in heart rate (72 ± 10.6 vs 101 ± 9.5 p<0.0001) and a reduction in Mean aortic pressure (80 ± 9.5 vs 69 ± 9.5 p<0.0001). I.C Nicorandil did not produce any significant variation in Heart rate or mean aortic pressures. Both groups showed significant increase in coronary diameters following I.C administration of NTG and Nicorandil (2.02 ± 0.12 and 2.16 ± 0.18 mm respectively). Intracoronary Nicorandil produced a greater coronary vasodilatation than NTG but the values were statistically nonsignificant (2.16 ± 0.18 mm vs 1.83 ± 0.17 mm p=0.05). Conclusion: Intracoronary Nicorandil produces a significant increase in coronary diameter following balloon dilatation without adverse effects on hemodynamic parameters compared to nitroglycerine. Nicorandil use was associated with higher TIMI 3 grades. Routine use of Nicorandil may be beneficial as a vasodilatory and cardioprotective agent during PTCA.

Introduction: Cardiac abnormalities in patients with cirrhosis includes a combination of reduced cardiac contractility with systolic and diastolic dysfunction and electrophysiological abnormalities. This study will aim to evaluate the structural and functional abnormalities of cardiac function in patients with cirrhosis of liver, correlate such abnormalities with the severity of the cirrhosis such that, in future the cardiac aspects of cirrhosis of liver can also be catered to, during the patient's treatment. Methods: This hospital based observational study was conducted for a period of one year and included 100 cases of cirrhosis of liver. A 12-lead ECG and 2D ECHO was performed in all patients. The left ventricular mass was calculated using the formula known as the 'ASE- cube formula'. Patients were classified under MELD criteria. Results: In our study, 68% patients were having MELD score between 19-24. There was significant statistical correlation of MELD with QTc, LVEDD, LV mass and E/A ratio. This study showed that QTc prolongation is a frequent finding in patients with liver disease. The LVEF was normal (≥ 55%) in all patients of the study group. The left atrial diameter and left ventricular end diastolic diameter was above normal limits in 100% and 17% of patients of the study group respectively. LV mass was more than the normal in 49% of the patients. The E/A ratio was ≤ 1.0 in 94% of the patients. Conclusion: Clinicians need to be aware of the occurrence of cardiac dysfunction in long standing patients of cirrhosis of liver, especially those who are decompensated with complications like ascites. Cardiac evaluation with non-invasive investigations like ECG and echocardiography should be included in the diagnostic algorithm of such patients to simultaneously identify cardiac compromise and to tailor therapy of such patients so as not to further worsen the cardiac overload and diastolic dysfunction.