Journal of Cardiovascular Medicine and Surgery

Assessment of coronary physiology in intermediate coronary lesions plays a vital role in strategic intervention. Although instantaneous free wave ratio (IFR) have been validated in coronary physiology assessment, evidence in support for novel resting full cycle ratio (RFR) is growing. In our present single center prospective study, we uniquely compared RFR with Fractional Flow Reserve (FFR) in assessment of intermediate coronary lesions and evaluated the influence of coronary hyperemia with adenosine, nitroglycerine and contrast on nonhyperemic index RFR in predicting the lesion significance. We observed RFR correlated well with FFR (agreement K:0.781) and RFR cut off of 0.89 correlated with FFR of 0.8. RFR had sensitivity of 89%, specificity of 92%, positive predictive value of 80% and negative predictive value of 96% (p<0.001, AUC 0.89) for delineating lesion severity. Effect of hyperemia in nonhyperemic indices were as follows: Hyperemic agents improve the diagnostic accuracy of nonhyperemic index RFR, contrast RFR with cut off of 0.875 correlated with an FFR of 0.8, adenosine RFR with cut off of 0.795 correlated with FFR of 0.8 in our study. Presence of diabetes and Smoking had no effect on RFR as observed in our study.

Introduction: Open heart surgery is one of the most common surgical procedures performed in developed countries; Coronary Artery Bypass Grafting (CABG), Aortic Valve Replacement (AVR), and Mitral Valve Repair (MVR) being the most common procedures. Our aim of the study is to find out the incidence of DSWI among the patients in of coronary artery bypass grafting during the hospital stay at our institute and risk factors associated with this complication and to formulate a protocol for management of this group of cardiac surgical patients and for minimizing such complications. Methods: The is aretro prospective single center observational study. The study consists of 2772 patients who underwent coronary artery bypass grafting surgery between October 2016 and September 2019 at our institute. Patients were divided in two groups based on the CABG and CABG with DSWI. In Group 1 (2706 patients), while in group 2 (66 patients). All the preoperative baseline, intraoperative and postoperative data were collected. Result: In our study we have found that Preoperative parameters PAD (p<0.0001) and Smoking (p<0.001) were significantly higher in group 2 (CABG + DSWI). Higher weight was associated with increased incidence of DSWI 42.4% of patients having BMI ≥ 30 kg/m2. (p=0.0082). Bypass Grafting with LIMA-RIMA had significantly high development rate for DSWI, LIMA-RIMA CABG performed in Group 1
in 372 (13.7%) patients and in Group 2 in 15 (22.7%) (p=0.0375). In addition, significant difference to develop DSWI is also founds in High drainage Output (≥ 1 lit), Re-exploration, Reintubation in Group 1 (Non DSWI) with 4.5% (122) patients, 3.88% (105) patients and 4.1% (112) patients while in Group 2 have only 27.2% (18), 28.7% (19) and 24.2%(16) respectively (p<0.0001). It had been seen that increase in ICU stay and increase in ventilation stay are again two chief factors to lead DSWI. Conclusion: The present study confirms that preoperative parameters like age > 60 years, uncontrolled DM II, HTN, PAD, Smoking, Obesity (BMI ≥ 30) increase the risk of deep sternal wound
infection. Intraoperative risk factors like LIMA-RIMA grafting, high rate of blood transfusion (PCV > 3 unit) have prompt to increase incidence of DSWI in postoperative period while postoperative parameters like High drainage output (≥ 1 lit), Re-exploration, Reintubation, Longer mechanical ventilation time have also predispose to develop DSWI.

Recent surgical advances have made it possible for multiple grafts without going on Cardio Pulmonary Bypass (CPB). The major Anesthetic challenge is the maintenance of hemodynamic stability during manipulation of the heart. Proven benefits of Off-pump Coronary Artery Bypass (OPCAB) include a reduction in requirement for blood and blood products and benefit to high risk patient. Good communication between surgeon and anaesthetist is vital for a successful outcome. The rationale for avoiding CPB in favour of Off pump Coronary Artery Bypass (OPCAB), has been the avoidance of the complications of CPB including systemic inflammatory response, coagulopathies, platelet dysfunction, accelerated fibrinolysis, depletion of clotting factors, neurological injury and renal impairment. With the improvement of surgical techniques and the development of cardiac stabilizing retractors, OPCAB has become an established procedure. Over the last 3 years at the Karen hospital we have done 64 OPCABG with good outcome. This technique could be a good alternative to conventional Coronary Artery Bypass Surgery (CABG), where centres with restricted surgical packages.

Background: Mental health and physical health are essentially intertwined. People living with severe psychiatric disorders are at significant risk of suffering from many physical disorders. The prevalence of depression and anxiety in patients with cardiac disease is little understood. Aims and Objectives: The objective of this study was to assess depression and anxiety in cardiac patients and to determine relationship between them. Materials and Methods: The study sample comprised of 200 outpatients following up in the cardiology Outpatient Department (OPD) of the Mamata General Hospital, a tertiary care hospital in Khammam, Telangana, India over a period of 1 year from March 2019 to March 2020. The samples were drawn using convenience sampling method. Mini International Neuropsychiatric Interview (MINI), Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) were the scales administered. Results: Anxiety and depression were present in 51% and 30% of
the sample respectively. The mean scores of depression and anxiety were significantly high in females than males significantly. Correlation between depression and anxiety showed that depression and anxiety were positively correlated (r=0.738, P=<0.001). Conclusions: Depression and anxiety are associated with cardiac disorders. There is
a need to keep in mind anxiety and depression as comorbidities in cardiac patients for adequate intervention that can be incorporated in management plan.

Aims: This observational study was undertaken to identify the incidence of contrast induced nephropathy and the predictors for development of Contrast induced Nephropathy after Coronary Angioplasty in a tertiary
care institute.

Materials and Methods: The study consisted of 520 patients who underwent Percutaneous Coronary Angioplasty at our institute during one year duration and who satisfied the inclusion criteria were enrolled in the study. Renal parameters such as serum Creatinine and Blood Urea level was measured at baseline and at 24 hours and 48 hours post procedure. Contrast induced nephropathy was defined as an increase of >25% or >0.5 mg/dl in pre-catheterization serum creatinine at or after 48h after percutaneous coronary intervention. Standard definitions were used to define the variables.

Results: 67 patients (12.88%) developed Contrast induced Nephropathy post PCI in the study. Elderly population, presence of diabetes mellitus, hypertension, anemia were associated with the risk of developing CIN and found to be statistically significant. Increased Contrast volume and raised baseline creatinine also were also found to be associated with CIN.

Conclusions: Development of CIN is a known complication of PCI and can be mostly prevented if patients with risk factors are identified and preventive measures taken based on guideline based recommendations.

Background: The Coronary Slow Flow Phenomenon (CSFP) is sometimes seen amongst patients presenting with ACS, in particular unstable angina and rarely with Normal Epicardial Coronaries (NECA). The study attempts to identify predictors of CSFP in patients with classical angina and normal epicardial coronaries in Asian Indians. Materials and Methods: This was a prospective, open label, observational study of 3000 consecutive patients undergoing invasive coronary angiography that was carried out a tertiary level cardiac care center between August 2016 to December 2018. After identifying the prevalence of CSFP using the corrected TFC method in allcomers, equal numbers of controls were analyzed for detailed evaluation for traditional risk factors, history, clinical examination, and laboratory investigation. Results: CSFP was more prevalent in men than in women (P=0.007). Histories of smoking and hypertension were more prevalent in CSFP patients than in NECA patients statistically significant (50% vs 20%; p 0.02) and (66.7% vs 33.3%, P 0.009) with Odds Ratio (OR) of 4(95% CI 1.27 to 12.58; P 0.02) for smoking and 4(95% CI 1.37 to 11.7; P0.01) for hypertension. Presence of LV dysfunction (16.7% versus 10%, P 0.45) with OR 0.56(95% CI 0.12 to 2.57; P 0.45), high level of hemoglobin in CSFP group (14.17±1.45 vs 11.95±1.38 mg/dl; p <0.0001), high level of LDL-c (153.77±13.02 vs 92.37±11.45 mg/dl; p <0.0001) and low HDL-C (33.93±6.71 vs 55.60±5.78mg/dl; p <0.0001) were also independent predictors of CSFP. Amongst single vessel CSFP, LAD was most common vessel (40.4%). Conclusion: Prevalence of CSFP amongst Asian Indians is 1%. High LDL-c, Low HDL-c level, Smoking, elevated hemoglobin and Hypertension are independent predictors of CSFP.

Background: Recent advances in the field of nonsurgical, transcatheter interventions in pediatric cardiology, have metamorphosed the management of congenital heart disease. There is a significant change, with adoption of new techniques. Objective: To study the changing pattern of cardiac catheterization in congenital heart diseases over the last 3 decades. Materials and Results: This is a retrospective, single center study of 8,708 cases who underwent cardiac catheterization for various congenital heart diseases between April 1981 to Dec 2015. Age group ranged from 14-hour old neonate to 18 years. The study included 4,754 (54.6%) boys and 3,954 (45.4%) girls. Various clinical details were noted with particular emphasis on indication for catheterization, age, gender and details of interventions. Commonest conditions catheterized were atrial septal defects 2,015 (23.1%), ventricular septal
defects 1,653 (18.9%), patent ductus arteriosus 1,179 (13.5%), Tetralogy of Fallot 1,102 (12.7%), Pulmonary stenosis 882 (10.1%), rest were coarctation of aorta and other complex conditions. Patients were divided into three groups – Group-1(1981-1997), Group-2(1998-2006) and Group-3(2007-2015). Results showed that Group-1 mainly comprised of diagnostic catherisations. Group 2 and 3 showed both diagnostic and therapeutic indications for catheterization and the number of interventional catheterizations increased from 28%(n=652) in Group-2 to 56%(n-1439) in Group-3 (p<0.001) and number of diagnostic catheterization decreased from 98% in Group-1 to 72%(n=1677) in Group-2 to just 44%(n=1150) in Group-3(p < 0.001). Conclusions: There is significant shift from diagnostic s to therapeutic interventions in the last 3 decades. Availability of expertise and infrastructure have been mainly responsible for this trend.

Objective: To study the in-hospital outcome and short term outcomes in patients undergoing delayed total surgical correction for Tetralogy of Fallot.

Methods: A retrospective descriptive study with the above objective was conducted at our institute using data from the hospital records. Study included all the patients above the age of 13 year undergoing surgery for Tetralogy of Fallot from January 2016 to December 2017.

Results: A total of 85 patients, 56(65.9%) males and 29(34.1%) females, undergoing complete repair of TOF were identified with a mean age of 17.53±4.59 years. Two patients had undergone previous Modified Blalock- Taussig Shunt. Complications noted in the postoperative period were low cardiac output syndrome 17.64%, re intubation 2.4%, reoperation for bleeding 10.6% and free pulmonary regurgitation in 34 (40%) patients recieveing Transannular patch without
monocusp. On follow up, only 6 patients (7.1%) had significant pulmonary regurgitation. 30–day mortality was 2.35%. The postoperative outcomes depend mainly on the degree of preexisting cyanosis (p=0.048) and degree of right ventricular outflow obstruction(p=0.042).

Conclusion: Complete correction of Tetralogy of Fallot must be performed irrespective of the age at presentation. Long-term studies are required to study the late outcomes in this group of patients.

Background: The choice of valve with an Effective Orifice Area (EOA) and design material providing efficient hemodynamics is an important factor affecting the Quality of Life (QOL) in patients who are going through the aortic valve replacements. The aim of our study was to evaluate non–dyspenic life without any complications of heart failure with different types of available mechanical valve prosthesis irrespective of Body Surface Area (BSA) of patients. Materials and Methods: Our preventive strategy was to implant a larger prosthetic valve in aortic position by using suitable types of mechanical a prosthesis to avoid the patient’s severe Prosthesis Mismatch (PPM). The decision to enlarge the aortic root was taken only when 17 mm sizer could not be easily placed through the aortic root. We reviewed the clinical outcomes and complications in 21 patients who underwent aortic valve replacements
done by a single surgeon from January 2018 to May 2019. Results: The patient’s age ranged from 13–57 years with male predominance (71.42%). Majority of our patients (80.16%) had NYHA class III symptoms at initial presentation while 19.04% had class IV symptoms. The preoperative echocardiography data were in the following range:
aortic annulus diameter (17-24 mm), aortic valve areas (0.6-1.58 cm2), peak and mean gradients (72–131 mmHg, 18-64 mmHg), Left ventricle mass index (LVMI= 68-176 gm/m2). PPM was moderate in 71.425% of cases and severe in 19.04% of cases. The aortic root enlargements (Nunez Procedure) were done in 9.52% of cases. The postoperative
and follow-up echocardiography data were in the following range: peak and mean gradients (13–31 mmHg, 9–16 mmHg), EOA (1.1–3.02 cm2) Left ventricle mass index (LVMI= 26.4-114 gm/m2). Conclusion: In our study, we found that with the availability of newer generations of mechanical aortic valves having thinner sewing rings and supra-annular position with better orifice areas reduce the incidence of PPM and avoid the complications of the aortic root enlargement without compromising the Quality of Life (QOL) of patients. LV regression showed a positive correlation with the reduction of the mean aortic gradient achieved by AVR. AVR caused significant LV regression in all patients irrespective of the presence of PPM.

Background: Our aim of this study was to find the prevalence of CAD and various CAD risk factors in RHD patients < 50 years.

Materials and Method: It was a single center observational retrospective study of 6324 rheumatic heart disease patients, who underwent Coronary Angiography (CAG) prior to surgical valvular replacement from January 2011 to December 2017. Among them 3920 patients were < 50 years of age, they were included in this study. Patients with age > 50 years (2404) were excluded. Among them significant CAD group patients (stenosis ≥50% -Group A), were compared with similar age group matched patients of RHD without CAD (Group B).

Results: The overall prevalence of CAD in the patients undergoing valvular intervention was 5.68% (61.88% males, 38.12% female). The CAD incidence in patients with mitral, aortic and both valve replacement were 8.20%, 62.5%
and 29.3% respectively. The prevalence of smoking (41.7% vs. 27.48%), diabetes (18.83% vs. 3.62%), hypertension (69.05% vs. 13.52%), family history of CAD (78.02% vs. 3.8%) and aortic valve disease (62.5%) was significantly higher in group A as compared to group B.

Conclusion: Prevalence of CAD in patients with Rheumatic valvular heart disease in western population of Asian Indians with age < 50 years is 5.68%. Thus Coronary angiography should be performed in such patients only when there are associated CAD risk factors. No need of doing prophylactic angiography for those rheumatic heart disease patients who do not having any CAD risk factors in young patients age < 50 years.