Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), ?-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

Bidirectional Glenn with interruption of antegrade pulmonary blood flow: Which is the preferred option: Ligation or division of the pulmonary artery.

We report a rare complication of massive aneurysm of the proximal ligated end of the main pulmonary artery which occurred in the setting of a patient with a functionally univentricular heart and increased pulmonary blood flow undergoing superior cavopulmonary connection. Awareness of this possibility may guide others to electively transect the pulmonary artery in such a clinical setting

Prevalence of carotid artery stenosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting for coronary artery disease: Role of anesthesiologist in preoperative assessment and intraoperative management.

Objective(s): This study aimed to determine the prevalence of carotid artery stenosis (CAS) due to atherosclerosis in neurologically asymptomatic patients undergoing coronary artery bypass grafting (CABG) for coronary artery disease (CAD). It contemplated a greater role for the cardiac anesthesiologist in the perioperative management of such patients with either previously undiagnosed carotid artery disease or towards re-assessment of severity of CAS. Design: Prospective, observational clinical study. Setting: Operation room of a cardiac surgery centre of a tertiary teaching hospital. Participants: A hundred adult patients with New York Heart Association (NYHA) classification I to III presenting electively for CABG. Interventions: All patients included in this study were subjected to ultrasonic examination by means of acarotid doppler scan to access for presence of CAS just prior to induction of general anesthesia. Measurements and Main Results: Based on parameters measured using carotid doppler, the presence of CAS was defined using standard criteria. The prevalence of CAS was found to be as high as 38% amongst the patients included in our study. The risk factors for CAS were identified to be advanced age, history of smoking, diabetes mellitus, dyslipidaemia and presence of a carotid bruit. Conclusion: This study points towards the relatively wide prevalence of carotid artery disease in neurologically asymptomatic patients undergoing CABG for CAD in the elective setting. It highlights the need to routinely incorporate carotid ultrasonography in the armamentarium of the cardiac anesthesiologist as standard of care for all patients presenting for CABG.

Left atrial ball thrombus with acute mesenteric ischemia: Anesthetic management and role of transesophageal echocardiography.

A 62 year old female with severe mitral stenosis, large left atrial ball thrombus and acute mesenteric ischemia emergently underwent mitral valve replacement, left atrial clot removal and emergency laparotomy for mesenteric ischemia. Peri‑operative management issues, particularly, the anesthetic challenges and the role of transesophageal echocardiography are discussed.

Non-invasive diagnosis of coronary artery disease with 16-slice computed tomography.

BACKGROUND: The gold standard for the diagnosis of coronary artery disease (CAD) is catheter angiography. However, catheter angiography is invasive and may not always be followed by interventional therapy. We report our results with the use of multislice computed tomography (MSCT) as a non-invasive diagnostic tool for CAD. METHODS: Thirty-one patients (26 with chronic stable angina, 5 with coronary anomalies) underwent 16-slice MSCT and catheter angiography. Vessels < 1.5 mm in diameter were excluded. The ability of MSCT to detect obstructive CAD (stenosis > or =50% of the diameter) was evaluated in pre-defined vessel segments. The association of calcium score with obstructive CAD, and the effect of heart rate on distal vessel visibility were also studied. RESULTS: There were 29 men and 2 women (age range: 36-80 years; mean [SD]: 53 [11] years). Of the 403 vessel segments, 391 were > 1.5 mm in diameter and 321 were interpretable on both modalities. The non-interpretability rates were 7% (26/391) for catheter angiography and 14% (54/ 391) for MSCT, with distal location (64%; 34), motion artifacts (29%; 16) and calcification (7%; 4) being chiefly responsible in case of the latter technique. The sensitivity, specificity, positive and negative predictive values of MSCT were 85% (95% confidence interval [CI]: 73-93), 94% (95% CI: 90-96), 76% (95% CI: 64-85) and 96% (95% CI: 93-98), respectively. MSCT correctly classified patients with no, single-, double- and triple-vessel disease in 87% of cases. One patient was incorrectly excluded on MSCT; catheter angiography showed 50%-70% stenosis in this case. Patients with obstructive CAD had a higher Agatston score equivalent (p=0.03). There was no significant effect of heart rate on distal segment visibility. MSCT correctly identified all coronary anomalies. CONCLUSION: MSCT has a good potential for the detection of coronary stenosis, and may be most useful for excluding CAD (due to its high negative predictive value). It accurately delineates coronary anomalies.