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Indian Heart Journal ; 74(Supplement 1):S7, 2022.
Article in English | EMBASE | ID: covidwho-2179318


Background: Coronary re-interventions after CABG are generally preferably percutaneous, and may be related to progression of atherosclerosis due to pre-existing risk factors and may be influenced by operator experience, type of surgery-(off pump or on-pump), and conduits used. We analysed the demographics, patient and operative characteristics, clinical features of patients undergoing early re-interventions - arbitrarily defined as within 2 years of index "primary" CABG for this study (i.e. no prior percutaneous coronary interventions) to determine predictors of the same. Method(s): We collected data on 1367 patients who underwent primary CABG over a decade from Jan 1,2010 to Jan 1 2020( pre-COVID).Demographic and clinical risk factors for CAD, angiographic characteristics, pattern of CAD, electrocardiographic (ECG) changes, and prevalent LV function were evaluated at baseline, immediate post-op and on follow ups till the need of the next intervention. Patients who underwent re-intervention in the said period were compared with an age- and gender- matched population who did not undergo re interventions to determine predictors for re-intervention by both Logistic regression and Machine learning analysis using SVM, KNN and Naive Bayes Classifier Results: 160 patients ( 11.7%) patients underwent re-intervention within 2 years of the primary CABG. Multivariate backward logistic regression analysis and Machine learning analysis with three models revealed that re-intervention was performed significantly more frequent in patients with : Index admission with uncontrolled diabetes mellitus (strongest risk factor), patient age < 50 years, emergency CABG -Both as primary CABG or bail-out for PCI complications, Use of saphenous vein graft v/s total arterial revascularisation ( except RIMA usage), those undergoing off- pump CABG, failure of DAPT to continue beyond three months, CABG following recent acute coronary syndrome, CABG in Multivessel disease with Syntax score> 27 need of mechanical support following CABG ( IABP), higher ventilation requirement with delayed sternal course, patients with post-op renal insufficiency with /without undergoing assisted renal replacement, statin intolerance/ lower doses, and CABG with more than 4 grafts(all p < 0.001). Patients with carotid disease and peripheral disease were also higher in number in the re-intervened arm. Re-interventions were more common in patients with LVEF > 50% at time of need of re-intervention, but this may be attributed to selection bias due to preference for conservative management if the LVEF was too low on follow up. Conclusion(s): Predictors for early re-intervention after CABG are a pointer towards more aggressive "malignant" form of atherosclerosis. There is actually higher graft loss in younger age especially in emergency CABG, patients with uncontrolled DM, renal insufficiency and high SS, and inadequate statin usage- all of which may contribute to( or indicate towards) an inflammatory process of atherosclerosis. Knowledge of these risk factors may guide the surgeon in counselling the patient for possible graft loss as well as suitably plan the surgical course in reducing re-intervention. Copyright © 2022

Indian Heart Journal ; 73:S42-S43, 2021.
Article in English | EMBASE | ID: covidwho-1568741


Background: Nephrotic syndrome is known to be associated with hypercoagulable status. Pulmonary artery thromboembolism is one of the life- threatening complications in patients with nephrotic syndrome but rarely occurs before the diagnosis of nephrotic syndrome. Methods and Results: A 33-year-old man without any co-morbidities presented to a primary care clinic with sudden onset shortness of breath. An electrocardiogram showed sinus tachycardia with S1Q3T3. ECHO and CTPA revealed thrombi of the bilateral pulmonary arteries and he was COVID-19 negative by PCR analysis. Anticoagulant therapy was initiated immediately. Hypercoagulability workup showed normal levels of protein C, protein S, and AT III. He was ANA- and APLA negative and his homocysteine levels were normal. Lower limb Doppler showed multiple deep venous system thrombi. Three months following this episode, he presented with recurrence of acute worsening of breathlessness with pedal edema and abdominal distention. He was referred to our Cardiology emergency care. 2D Echocardiography showed classic Mc Connells sign with akinesia of RV free wall and RV systolic pressure of 60 mm Hg. CT pulmonary angiography definitively proved fresh (recurrence of) pulmonary embolism with large clots in both LPA and RPA and CXR showed classical signs of pulmonary embolism (Fig. 1). USG abdomen showed ascites, normal kidneys and no renal vein thrombosis. Laboratory examination showed he was COVID-19 negative again by PCR analysis. They also revealed low serum albumin (2.2g/dl) and nephrotic-range proteinuria (>10 gm in 24 hours) with transudative ascitic fluid. Since patient was on anticoagulation renal biopsy was deferred by the consultant nephrologist in view of possible bleeding complications. In view of possible primary membranous nephropathy, Serum Anti-Pla2r antibody was done which was strongly positive. The constellation of nephrotic-range proteinuria, pulmonary thromboembolic complications and associated serum anti-Pla2R antibody suggested primary membranous nephropathy. Immunosuppression was started as per modified Ponticelli regimen. Proteinuria resolved after three weeks and patient continues to be doing well on anticoagulation on oral VKA [Formula presented] Conclusion: Previous case reports of pulmonary artery thromboembolism associated with nephrotic syndrome are very few, particularly in adults. In the rare cases where they do occur, the patients initially present with the symptoms derived from nephrotic syndrome, unlike in our patient where the presentation was extremely rare and the investigation of the thromboembolic event led us “backwards” to the diagnosis of nephrotic syndrome. Awareness regarding the potential complications of hypercoagulable in nephrotic syndrome is thus essential.