One-Year Outcomes after Myval Implantation in Patients with Bicuspid Aortic Valve Stenosis-A Multicentre Real-World Experience.

BACKGROUND: Bicuspid aortic valve (BAV) affects approximately 1.5% of the general population and is seen in nearly 50% of candidates for aortic valve replacement (AVR). Despite increasingly utilised transcatheter aortic valve implantation (TAVI) in aortic stenosis (AS) patients, its use among patients with severe bicuspid AS is limited as BAV is a heterogeneous disease associated with multiple and complex anatomical challenges. AIM: To investigate the one-year outcomes of TAVI using the balloon-expandable Myval transcatheter heart valve (THV) (Meril Life Sciences Pvt. Ltd., Vapi, India) in patients with severe bicuspid AS. METHODS AND RESULTS: We collected data from consecutive patients with bicuspid AS who underwent TAVI with the Myval THV and had at least one-year follow-up. Baseline characteristics, procedural, and 30-day echocardiographic and clinical outcomes were collected. Sixty-two patients were included in the study. The median age was 72 [66.3, 77.0] years, 45 (72.6%) were males, and the mean STS PROM score was 3.2 ± 2.2%. All TAVI procedures were performed via the transfemoral route. The median follow-up duration was 13.5 [12.2, 18.3] months; all-cause mortality was reported in 7 (11.3%) patients and cardiovascular hospitalisation in 6 (10.6%) patients. All-stroke was reported in 2 (3.2%), permanent pacemaker implantation 5 (8.3%), and myocardial infarction 1 (1.6%) patients. The echocardiographic assessment revealed a mean pressure gradient of 10 [8, 16.5] mmHg, effective orifice area 1.7 [1.4, 1.9] cm2, moderate AR in 1 (2%), mild AR in 14 (27%), and none/trace AR in 37 (71%). In total, 1 patient was diagnosed with valve thrombosis (2.1%), Stage II (moderate) haemodynamic deterioration was seen in 3 (6.4%), and stage III (severe) haemodynamic deterioration in 1 (2.1%) patient. CONCLUSIONS: TAVI with the Myval THV in selected BAV anatomy is associated with favourable one-year hemodynamic and clinical outcomes.

Safety and Efficacy of Myval Implantation in Patients with Severe Bicuspid Aortic Valve Stenosis-A Multicenter Real-World Experience.

Bicuspid aortic valve (BAV) is the most common valvular congenital anomaly and is apparent in nearly 50% of candidates for AV replacement. While transcatheter aortic valve implantation (TAVI) is a recommended treatment for patients with symptomatic severe aortic stenosis (AS) at all surgical risk levels, experience with TAVI in severe bicuspid AS is limited. TAVI in BAV is still a challenge due to its association with multiple and complex anatomical considerations. A retrospective study has been conducted to investigate TAVI's procedural and 30-day outcomes using the Myval transcatheter heart valve (THV) (Meril Life Sciences Pvt. Ltd. Vapi, Gujarat, India) in patients with severe bicuspid AS. Data were collected on 68 patients with severe bicuspid AS who underwent TAVI with the Myval THV. Baseline characteristics, procedural, 30-day echocardiographic and clinical outcomes were collected. The mean age and STS PROM score were 72.6 ± 9.4 and 3.54 ± 2.1. Procedures were performed via the transfemoral route in 98.5%. Major vascular complications (1.5%) and life-threatening bleeding (1.5%) occurred infrequently. No patient had coronary obstruction, second valve implantation or conversion to surgery. On 30-day echocardiography, the mean transvalvular gradient and effective orifice area were 9.8 ± 4.5 mmHg and 1.8 ± 0.4 cm2, respectively. None/trace aortic regurgitation occurred in 76.5%, mild AR in 20.5% and moderate AR in 3%. The permanent pacemaker implantation rate was 8.5% and 30-day all-cause death occurred in 3.0% of cases. TAVI with the Myval THV in selected BAV anatomy is associated with favorable short-term hemodynamic and clinical outcomes.

Cardiac resynchronization therapy is associated with improvement in clinical outcomes in Indian heart failure patients: Results of a large, long-term observational study.

BACKGROUND: Heart failure (HF) is a common health problem in South Asia, and its incidence and prevalence are projected to rise. Cardiac resynchronization therapy (CRT) has been shown to improve mortality, reduce hospitalizations, and improve symptoms in selected patients with HF. The South Asian Systolic Heart Failure Registry (SASHFR) was designed to be a large and comprehensive registry of Indian HF patients with the purpose of enhancing the quality of care and clinical outcomes of HF patients by promoting the adoption of evidence-based, guideline-recommended therapies, in particular CRT. METHODS: Overall, 471 patients on optimized medical therapy and meeting CRT implantation guidelines were followed up in 12 Indian hospitals. During the 2-year follow-up period, clinical response in terms of clinical composite score, overall performance and changes in HF performance metrics, mortality and hospitalizations rates were evaluated. RESULTS: Of 471 patients, 116 (24.6%) accepted to be implanted with a CRT device, while 355 (75.4%) refused, financial constraints being the main reason for refusing a CRT device. The study met its primary outcome, as the number of patients associated with an improvement in clinical composite score at 24 months was significantly higher (69.1%) in the CRT group than in the no-CRT group (44.7%) [odds ratio = 2 (95% confidence interval 1.25-3.20), p = 0.004]. Also, changes in HF metrics, mortality and hospitalizations rates indicated a more favorable response among patients who underwent CRT. CONCLUSIONS: The results from the SASHFR registry show a clear superiority of CRT over optimal pharmacological therapy in terms of improvement in clinical conditions among HF patients. The low rate of CRT acceptance, in patients indicated to this therapy, highlights the need for new health-care policies to improve awareness about HF disease and its therapies and possibly to enhance financial coverage of indicated therapies.

A prospective study to evaluate the risk malignancy index and its diagnostic implication in patients with suspected ovarian mass.

BACKGROUND: There is no universal screening method for discrimination between benign and malignant adnexal masses yet. Various authors have tried tumor markers, imaging studies, cytology but no one yet is a definite method for screening of cancer ovary, for which a combined diagnostic modality has come to practice in form of RMI. With this background we conducted our study "Evaluation of risk malignancy index and its diagnostic value in patients with adnexal masses". METHODS: The aim of the study was to determine the effectiveness of risk of malignancy index (RMI-3) in preoperative discrimination between benign and malignant masses and also to reveal the most suitable cut off value. We have conducted a prospective study between November 2014 to October 2016. We included the parameters like menopausal status, ultrasound features, and serum levels of tumor marker like CA-125 for calculating RMI 3. Then RMI was compared with the histopathological report which was taken as gold standard. RESULTS: In the present study malignant tumors constitute 54.76% (69/126) & benign tumors 45.24% (57/126). Bilaterality in adnexal masses and multilocularity is higher in malignant tumors than benign tumor, but a P -value >0.005 failed to be proved significant in our study. Solid area is seen in 24.69% (20/81) of benign and 75.30% (61/81) of malignant tumor. Similarly ascites was found in 38.09% (48/126) of cases. Out of which 18.75% (9/48) cases were found to be benign and malignancy was confirmed in 81.25% (39/48) patients. There is statistically significant number of malignant ovarian cancer patients where ascites and solid area is seen in USG findings (p = 0.000). Risk of Malignancy Index compared with individual parameters of Ultrasound score, CA-125 or menopausal score and a cut-off point of 236 shows a very high sensitivity (72.5%), specificity (98.2%), positive predictive value (98.1%), negative predictive value (74.7%) and diagnostic accuracy (84.13%) for discriminating malignant and benign pelvic masses. CONCLUSION: Simplicity and applicability of the method in the primary evaluation of patients with pelvic masses makes it a good option in daily clinical practice in non-specialized gynecologic departments and also in developing countries where access to a gynaecologist oncologist is limited.

Percutaneous valvuloplasty for mitral valve restenosis: postballoon valvotomy patients fare better than postsurgical closed valvotomy patients.

AIM: To compare the results of percutaneous mitral valvuloplasty (BMV) for mitral restenosis in post-BMV versus postclosed mitral valvotomy (CMV) patients. METHODS AND RESULTS: Ninety-two patients who underwent BMV for mitral restenosis were followed up prospectively. Of these, 28 patients had undergone previous percutaneous mitral valvuloplasty (PRIOR BMV) and 64 patients had undergone previous closed mitral valvotomy (PRIOR CMV). BMV for mitral restenosis was a success in 59% patients (57.1% PRIOR BMV, 59.3% PRIOR CMV, P = 1.0). Incidence of severe mitral regurgitation was 3.25%, all in the PRIOR CMV group. In univariate analysis, the major predictor of successful BMV for mitral restenosis was Wilkins score (P = 0.004). At a follow up of 3.47 + 2.07 years, mitral valve area was similar between groups (1.45 +/- 0.22, 1.46 +/- 0.26, P = 0.35). The combined end points of mitral valve replacement (MVR), need for re-repeat BMV for mitral restenosis or death was higher in the PRIOR CMV group (31.2% PRIOR CMV, 7.1% PRIOR BMV, P = 0.027). Event-free survival at follow up was lower in the PRIOR CMV group (69% PRIOR CMV, 92.8% PRIOR BMV) mainly due to the higher need for MVR (11 vs. 0 patients, P = 0.03). CONCLUSIONS: In conclusion, following BMV for mitral restenosis, patients with PRIOR BMV are found to have lesser event rates on follow-up compared to patients with PRIOR CMV, though procedural success rates are similar.

Mahaim fiber accelerated automaticity and clues to a mahaim fiber being morphologically an ectopic or a split AV node.

Mahaim Fiber tachycardia characteristically causes a wide QRS tachycardia with left bundle branch morphology and left axis deviation, especially in young patients, having no structural heart disease. Mahaim fiber automaticity further cements the proposition of Mahaim fiber, due to its Atrioventricular (AV) node like property, being called as an ectopic AV node.

Electrophysiology study and radiofrequency catheter ablation of atriofascicular tracts with decremental properties (Mahaim fibre) at the tricuspid annulus.

AIMS: The aim was to study the common mapping methods for Mahaim fibre and their role in radiofrequency (RF) ablation. METHODS AND RESULTS: Fifteen patients having Mahaim fibre tachycardia underwent electrophysiological study. Mahaim fibre mapping methods like (i) Mahaim potential (M), (ii) shortest atrial stimulus-to-pre-excitation (STP), and (iii) mechanical trauma induced loss of conduction were studied. Accessory pathway mapping was performed by M potential in 10 patients (67%), shortest atrial STP in 3 patients (20%), and mechanical trauma in 2 patients (13%). Mahaim fibre was localized at right atrial freewall of tricuspid annulus (8-10 o'clock) in 13 patients (87%), at 6.30 o'clock in one patient, and at 5 o'clock in 1 patient. Fourteen patients underwent RF ablation. Thirteen patients had complete loss of conduction over accessory pathway and one had partial modification with a conduction delay. Radiofrequency ablation was not performed in one patient (shortest STP group) due to its closeness to the compact atrioventricular node. Mahaim junctional acceleration during RF ablation was observed in all patients of M potential, 1 patient of mechanical trauma, and none of the atrial STP group. One patient (M potential group) had tachycardia recurrence during follow-up. CONCLUSION: Mahaim fibre is commonly located between 8 and 10 o'clock at tricuspid annulus. M potential guides to successful RF ablation in most patients. Mahaim junctional acceleration is commonly seen during RF ablation guided by M potential map.

Subannular left ventricular pseudoaneurysm following mitral valve replacement.

Delayed development of left ventricular pseudoaneurysm is a rare late complication of mitral valve prosthesis and requires early surgical intervention. Here we describe the occurrence of such a complication diagnosed 6-months after the valve surgery in a 60-year-old lady. The anatomic delineation of subannular left ventricular pseudoaneurysm using multiple imaging modalities including CT angiography is also being discussed.

Bundle branch reentry ventricular tachycardia in arrhythmogenic right ventricular dysplasia.

A 42-year-old male had history of recurrent palpitation and was documented to have wide QRS tachycardia. Magnetic resonance imaging angiogram showed evidence of arrhythmogenic right ventricular dysplasia and severe right ventricular dysfunction. Electrophysiology study showed evidence of bundle branch reentry ventricular tachycardia. It was successfully treated by radiofrequency ablation of right bundle branch. This is probably the first case of bundle branch reentry as a mechanism for ventricular tachycardia in a case of arrhythmogenic right ventricular dysplasia.

Doppler echocardiographic assessment of TTK Chitra prosthetic heart valve in the mitral position.

AIMS: TTK Chitra heart valve prosthesis (CHVP), a tilting disc mechanical heart valve of low cost and proven efficacy, has been in use for the last 15 years. Although various studies substantiating its long-term safety and efficacy are available, no study had assessed its echocardiographic characteristics. The purpose of this study was to determine the normal Doppler parameters of CHVP in the mitral position and to assess whether derivation of mitral valve area (MVA) using the continuity equation (CE) and more commonly used pressure half-time (PHT) method is comparable in the functional assessment of this tilting disc mitral prosthesis. METHODS AND RESULTS: Doppler echocardiography was performed in 40 consecutive patients with CHVP in the mitral position. All patients were clinically stable, without evidence of prosthetic valve dysfunction such as significant obstruction or regurgitation, endocarditis, left ventricular dysfunction (ejection fraction <40%), or significant aortic regurgitation. Valve sizes studied included 25, 27, and 29 mm. Mitral valve area was derived both by the PHT method and by the CE, using the stroke volume measured in the ventricular outflow tract divided by the time-velocity integral of CHVP jet. The peak Doppler gradient ranged from 5 to 21 (mean 11.0) mmHg, and the mean gradient ranged from 1.7 to 9.2 (mean 4.1) mmHg. Mean gradient negatively correlated with an increase in the actual orifice area (AOA) derived from the valve orifice diameter given by the manufacturer (r = -0.45, P = 0.004). Mitral valve area calculated by both PHT and CE increased significantly with an increase in the AOA (r = 0.42, P = 0.007 and r = 0.32, P = 0.046, respectively). Mitral valve area by the CE averaged 1.55 +/- 0.36 cm(2) (range 0.85 cm(2) for a 25 mm valve to 2.41 cm(2) for a 29 mm valve) and was smaller than by PHT (mean 2.04 +/- 0.41 cm(2), range 1.40-3.14 cm(2); P = 0.0001; t-test), irrespective of whether PHT is less than or >110 ms. CONCLUSION: The Doppler parameters obtained with CHVP in the mitral position are comparable with those obtained with the different prosthetic valves in common use. In the selected group of patients with CHVP, assessment of MVA by the PHT method is comparable with that by the CE. Areas by both methods were smaller than the AOA provided by the manufacturer, as seen in other similar design valves.

Entrapped catheter in the left ventricular posterior venous radicle of the coronary sinus in a case of hemianomalous pulmonary venous connection of left pulmonary veins to coronary sinus.

A 25-year old acyanotic lady with unclear pulmonary venous drainage and a dilated coronary sinus was catheterized. Left pulmonary veins drained into coronary sinus in a left pulmonary vein angiogram done through the coronary sinus with a National Institute of Health 7F catheter. After the angiogram, the catheter got entrapped in a coronary sinus tributary and could be removed only by surgery. The left pulmonary veins were rerouted into the left atrium by unroofing the coronary sinus. Surgery is the treatment of choice for entrapped catheters when the primary condition itself merits surgical correction.

Spontaneous automaticity of an atriofascicular accessory pathway.

In a 12-year-old girl with history of recurrent palpitation, an ambulatory 24 h Holter electrocardiogram showed a wide QRS complex rhythm with atrioventricular dissociation. During an electrophysiology study, an atriofascicular pathway was diagnosed with an inducible antidromic atrioventricular re-entrant tachycardia. At slower heart rates, the patient had a wide QRS complex escape rhythm similar to the tachycardia and the pre-excited QRS complex morphology. This indicates the presence of pacemaker-like cells in the atriofascicular accessory pathway giving rise to the wide QRS complex escape rhythm at a slower heart rate.

Right ventricular pacing via left superior vena cava.

Negotiating the pacing lead into the right ventricle via left superior vena cava, at times, can be difficult. We report two such cases in which pacing leads were introduced into the right ventricle via left superior vena cava, with the help of stylet tip shaped into a large pigtail loop.

Venogram-guided extrathoracic subclavian vein puncture.

BACKGROUND: Subclavian vein puncture is commonly performed to insert the pacing lead for permanent pacemaker implantation. Our aim was to study the safety and feasibility of venogram-guided extrathoracic subclavian vein puncture for permanent pacemaker lead insertion. METHODS AND RESULTS: Sixty patients (32 males, and 28 females) underwent permanent pacemaker lead insertion by extrathoracic subclavian vein puncture at our institute between March 2002 and December 2002. Fifteen patients underwent dual-chamber and 45 single-chamber pacemaker implantation. All the patients underwent extrathoracic subclavian vein puncture guided by venogram, except 1 who underwent dual-chamber pacemaker implantation in whom the ventricular lead insertion was via the cephalic vein on an elective basis. The procedure was successful in all the patients. Inadvertent subclavian artery puncture occurred in 2 patients without any complication. There was no incidence of pneumothorax, hemothorax or pacemaker site infection. CONCLUSIONS: Venogram-guided extrathoracic subclavian vein puncture is safe and successful. It may be adopted as one of the preferred approaches for permanent pacemaker lead insertion.