Gender differences in genotypic distribution of endothelin-1 gene and endothelin receptor A gene in pulmonary hypertension associated with rheumatic mitral valve disease

Introduction: The female gender is a risk factor for idiopathic pulmonary arterial hypertension. However, it is unknown whether females with rheumatic mitral valve disease are more predisposed to develop pulmonary hypertension compared to males. Aim: We aimed to investigate whether there was a difference in genotypic distribution of endothelin-1 (ET-1) and endothelin receptor A (ETA) genes between female and male patients of pulmonary hypertension associated with rheumatic mitral valve disease (PH-MVD). Methods: We compared prevalence of ET-1 gene (Lys198Asn) and ETA gene (His323His) polymorphisms according to gender in 123 PH-MVD subjects and 123 healthy controls. Results: The presence of mutant Asn/Asn and either mutant Asn/Asn or heterozygous Lys/Asn genotypes of Lys198Asn polymorphism when compared to Lys/Lys in females showed significant association with higher risk (odds ratio [OR] 4.5; p ¼0.007 and OR 2.39; p ¼0.02, respectively). The presence of heterozygous C/T and either mutant T/T or heterozygous C/T genotypes of His323His polymorphism when compared to wild C/C genotype in females showed a significant association with higher risk (OR 1.96; p ¼0.047 and OR 2.26; p ¼0.01, respectively). No significant difference was seen in genotypic frequencies in males between PH-MVD subjects and controls. Logistic regression analysis showed that mutant genotype Asn/Asn (p ¼0.007) and heterozygous genotype Lys/Asn of Lys198Asn polymorphism (p ¼0.018) were independent predictors of development of PH in females.

Association of level of IL-6, IL-10, IL-18, tumour necrosis factor-?with rheumatic mitral stenosis and subsequent pulmonary hypertension

Background:Objective of the study was to provide insight on the immune response in patients of rheumatic heart disease, mitral stenosis and evaluation of various cytokines in pulmonary hypertension secondary to rheumatic heart disease.Methods:Total 163 subjects, more than 18 year of age, were enrolled in this study. 84 subjects with rheumatic mitral stenosis (group A) diagnosed on two-dimensional echocardiography (2D echo)and 79 normal healthy volunteers(group B). Patients with mitral stenosis were further divided into subgroups based on severity of mitral stenosis [mitral valve area (MVA >1 cm2 and MVA <1 cm2)(subgroup Aa and Ab)]and presence or absence of pulmonary hypertension [pulmonary arterial systolic pressure (PASP >36 mm Hg)(subgroup Ac and Ad)]. Interleukins IL-6, IL-10, IL-18, tumour necrosis factor alpha (TNF-?)andhigh-sensitivity C-reactive protein (hs-CRP)levels were assessed in both groups.Results:Mean IL-6, IL-10, IL-18, TNF-? and hs-CRP in group A and group B was 6.57�53 and 2.73�p?0.001), 8.185�8 and 3.51�86(p?0.001), 136.31�.0 and 47.96�76(p?0.001), 21.26�.59 and 5.36�57(p?0.001), 4.69�3 and 2.63�22(p?0.008) respectively. On subgroup analysis mean TNF-? in subgroup Aa was 20.71�.84, while in subgroup Ab was 7.56�93 (p?0.001). Mean IL-10 in subgroup Ac and Ad was 8.74�29 and 7.47�82, respectively. Differences in levels of other cytokines in these subgroups were not found statistically significant.Conclusions:This study finds increased IL-6, IL-10, IL-18, TNF-? and hs-CRP levels in subjects with rheumatic mitral stenosis. Subjects with severe mitral stenosis had increased TNF-? levels. Subjects of mitral stenosis having pulmonary hypertension had increased IL-10 levels.

Left atrial function by two-dimensional speckle tracking echocardiography in patients with severe rheumatic mitral stenosis and pulmonary hypertension

We studied left atrial (LA) function in severe rheumatic mitral stenosis (MS) patients using twodimensional speckle tracking echocardiography (STE). Eighty patients with isolated severe MS in sinus rhythm and 40 controls underwent comprehensive echocardiography including STE derived LA strain [reservoir strain (LASr), conduit strain (LAScd) and contractile strain (LASct)]. The mean MVA was 0.93 ± 0.21 cm2 . The mean values of LASr (14.73 ± 8.59%), LAScd (±7.61 ± 4.47%) and LASct (±7.16 ± 5.15%) in patients were significantly lower (p < 0.001) vs. controls 44.11 ± 10.44%, ±32.45 ± 7.63%, -11.85 ± 6.77% respectively and showed decreasing trend with increasing MS severity and higher NYHA class. In conclusion, LA dysfunction is prevalent in severe MS irrespective of NYHA functional class.

Short- and long-term follow-up of antithrombotic management patterns in patients hospitalized with acute coronary syndrome: Indian subgroup of EPICOR Asia study

Background Acute coronary syndrome (ACS) is associated with emergency hospitalizations, and there are limited real-world data on clinical outcomes in post-ACS Asian patients. This article presents data on the Indian subgroup from the Long-term Follow-up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients in Asia (EPICOR-Asia) study. Methods EPICOR included patients with ACS [ST-segment elevation myocardial infarction (STEMI), non–ST-segment elevation myocardial infarction (NSTEMI), or unstable angina (UA)]. The study had two phases: acute phase and follow-up phase. The primary objective was to describe short- and long-term antithrombotic management patterns. Results EPICOR-India enrolled 2468 patients (STEMI-1482; NSTEMI-562; and UA-424). Cardiovascular risk factors were present in 1362 (55.2%) patients. Prehospital care was received by 879 (35.6%) patients, and the median time from the symptom onset to the first medical attention was 3 h (0.08, 100.33). The most common drug regimen prescribed during the acute phase was ≥2 antiplatelet agents + anticoagulants with no glycoprotein IIb/IIIa inhibitors and at discharge were aspirin + clopidogrel. About 78.8% of patients were discharged on dual antiplatelet therapy (DAPT) and 16%, on single antiplatelet therapy (SAPT). At 23 months after discharge, 55.6% were on DAPT, while 16.4% were on SAPT. Postdischarge outcomes at 2 years included death in 165 (6.7%) patients, composite events of death, myocardial infarction (MI), or ischemic stroke in 182 (7.4%) patients, and bleeding events in seven (0.3%) patients. Conclusion This study showed a gap between international recommendations and implementation for managing ACS in Indian patients. Most of the patients prefer to undergo invasive management instead of non-invasive therapy. At the end of the 2-year follow-up, more than half of the population was receiving DAPT, with most patients on receiving a combination of aspirin and clopidogrel. The mortality along with composite events of death, MI, or ischemic stroke was highest for patients with NSTEMI.

Neurodevelopmental Status of Children Aged 6-30 Months with Congenital Heart Disease.

Background: Children with congenital heart diseases (CHD) are considered to be at high-risk for neurodevelopmental delay, but scant Indian data are available. Objective: To evaluate the neurodevelopmental status of children with CHD. Methods: We enrolled consecutive children aged 6-30 months with echocardiographically-confirmed CHD between June 2013 and January 2014. Children with clinically recognizable genetic syndromes or disorders; visual and/or hearing deficits, and microcephaly; and post-cardiac surgery children were excluded. Development was assessed by Developmental Assessment Scale for Indian Infants (DASII) and Developmental delay defined as Development Quotient (DQ) <70 in either the mental or motor scale. Results: 75 children (53 males) with CHD were enrolled. Acyanotic CHD was seen in 51 children (VSD in 47%), and Tetralogy of Fallot was the commonest cyanotic CHD (25%). Developmental delay was seen in 25% of these children, more in the motor domain (48%) than in mental (12%). Mean motor and mental DQ in acyanotic CHD was 77 and 84, respectively; and 65 and 85, respectively in cyanotic CHD. Mean motor DQ was significantly less than mental DQ in both acyanotic and cyanotic CHD children (P=0.048). Conclusion: Children with CHD are at an increased risk for developmental delay. Periodic surveillance, screening and evaluation should be instituted in them for early identification and appropriate interventions to enhance later academic, behavioral, psycho-social and adaptive function.

Novel non-surgical method of managing cardiac perforation during percutaneous transvenous mitral commissurotomy.

We describe a new technique of sealing cardiac perforation resulting in cardiac tamponade during transvenous mitral commissurotomy by percutaneous instillation of cyanoacrylate glue at the perforation site, thus avoiding surgery.

Focal extra strength of a stent causing instent hourglass stenosis: an unusual complication.

We report an unusual complication of a 25 mm long stent, which did not expand at all for 1 mm in its proximal segment, while rest of the 24 mm length of the stent got fully expanded. Repeated attempts to expand the extremely focal unexpanded part of the stent at high pressure led to rupture of the stent balloon and its entrapment. We failed to retrieve the balloon using various techniques and the patient had to be sent for coronary artery bypass graft surgery.

Difficult percutaneous transvenous mitral commissurotomy: a new technique for left atrium to left ventricular entry.

Percutaneous transvenous mitral commissurotomy using Inoue balloon is an effective procedure for the management of patients with juvenile mitral stenosis. Inability to cross the mitral valve by the Inoue balloon catheter is one of the important reasons for failure of the procedure. We describe a new technique, facilitating left atrium to left ventricular entry using double loop of Inoue balloon catheter in a child with small left atrium.

Transcatheter closure of coronary artery fistulas.

BACKGROUND: Transcatheter closure of coronary artery fistulas has emerged as a successful alternative to surgery. We describe various techniques and short-term findings in 15 patients who were taken up for transcatheter closure of these fistulas. METHODS AND RESULTS: Fifteen patients (aged 2-55 years; 12 males) with coronary artery fistulas underwent percutaneous transcatheter closure between June 1997 and December 2002. Site of origin of these fistulas were: right coronary artery in 7, left anterior descending coronary artery in 4, left main coronary artery in 2 and left circumflex coronary artery in 2 patients. Drainage site of these fistulas were: right ventricle in 9, right atrium in 4 and pulmonary artery in 2 patients. Out of these 15 fistulas, 14 were congenital and one was iatrogenically produced following inadvertent cutting balloon angioplasty of a septal perforator in a patient with chronic total occlusion of left anterior descending coronary artery. Various occlusion devices used to close these fistulas were: conventional metallic coils in 10, floppy tips of coronary angioplasty guidewires in 2, Amplatzer duct occluder in 1 and Amplatzer septal occluder in 2 patients. One of our patients had a coronary artery fistula draining by two openings into the right atrium, both of which were successfully closed using 2 Amplatzer duct occluders. Check angiogram after the procedure revealed complete occlusion in 13 (86.6%) and small residual flow in 2 patients. Follow-up studies at 3-55 months (mean 18 months) showed complete abolition of shunt in all patients with no evidence of recanalization leading to recurrence of shunt. CONCLUSION: Transcatheter closure of coronary artery fistulas is feasible and safe in the anatomically suitable vessels. Use of floppy tips of coronary angioplasty guidewires reduces the cost of the procedure significantly. which is an important consideration in developing countries like India.

Post-stenotic dilatation: challenge in renal ostial stenting--a simple solution.

Stenting is the treatment of choice for treating stenotic renal ostial lesions. During the stenting of an ostial lesion in a renal artery with post-stenotic dilatation, we were faced with the problems of unavailability of a balloon of appropriate length and diameter, and determining the real reference vessel diameter. The problem was solved by a simple technique.

Percutaneous stenting of chronic total occlusion of unprotected left main coronary artery.

Chronic total occlusion of the left main coronary artery is very rare. We report a case in which a totally occluded, unprotected distal left main coronary artery was successfully revascularized percutaneously, establishing normal flow in the left main, left anterior descending and left circumflex coronary arteries.