Transcatheter closure of ruptured sinus of Valsalva type IV with misleading severe aortic regurgitation.

We present an unusual case of ruptured sinus of Valsalva (RSOV) in the right atrium, progressive exertional dyspnea, occasional epigastric heaviness, and palpitations. The examination revealed high-pitch continuous murmur. On transthoracic echocardiography, there was a ~5-6 mm size RSOV of non-coronary sinus into right atrium, continuous turbulent flow, and unusual presentation of severe central aortic regurgitation jet with holodiastolic flow reversal seen in the descending aorta. The sinus of Valsalva aneurysm is a rare pathology, which is generally asymptomatic. In this case it manifested through a rupture into the right atrium and needed to be closed to relieve the symptoms. Transcathter closure of RSOV was done by using Amplatzer duct occluding device, there was no residual shunt, and aortic regurgitation completely disappeared. Learning objective: This is a unique case in which ruptured sinus of Valsalva flow and holodiastolic flow reversal were confused with severe aortic regurgitation. Careful and detailed transthoracic echocardiography played a key role in correct diagnosis and proper management.

Prevalence of atrial fibrillation on a 24-hour Holter in adult Indians.

OBJECTIVE: To evaluate paroxysmal atrial fibrillation (AF) prevalence in Indian adults who completed 24-Hour Holter monitoring. METHODS: A total of 23,847 patients (36.9 % women) were analyzed for AF duration using a software algorithm. RESULTS: AF was diagnosed in 4153 (17.4 %) patients with a median AF duration of 13 min and 55 s. CONCLUSION: AF prevalence was high and largely untreated. The short duration of AF episodes indicates a low likelihood of detection during clinical visits, highlighting its potential underestimation in Indian healthcare.

Complementary role of governments, non-governmental organizations, industry, and medical societies in expanding bradycardia therapy access.

As the aging population continues to grow, so has the incidence of cardiovascular diseases, including bradycardia, with much of the burden falling on low- and middle-income countries (LMICs). Pacemaker therapy remains the only guideline-recommended therapy for symptomatic bradycardia, but due to the cost and expertise required for pacemaker implants, patients in LMICs have less access to pacemaker therapies. However, with the concerted effort of organizations (governments, non-governmental organizations, industry, and medical societies) strides can continue to be made in improving access to care. Governments play a role in extending health coverage to its citizens and improving their physical and digital healthcare infrastructure. Non-governmental organizations promote access and awareness through charity and advocacy programs. Industries can continue innovating technology that is both affordable and accessible. Medical societies provide guidelines for treatment and necessary educational and networking opportunities for physicians who serve in LMICs. All of these organizations have individual responsibilities and goals in expanding access to bradycardia therapy, which can be more easily realized by their continued collaboration.

Transcatheter leadless permanent pacemaker in complex congenital heart disease with interrupted inferior vena cava: A challenging implantation.

31 years lady with complete atrioventricular canal defect, large primum atrial septal defect (ASD), inlet ventricular septal defect (VSD) and Eisenmenger syndrome, presented with atrial flutter and complete heart block. She was not suitable for corrective cardiac surgery and not yet indicated for heart-lung transplantation. She was advised single chamber permanent pacemaker and eventually Micra VR transcatheter leadless pacemaker was finalised for her. Transcatheter leadless pacemaker was deployed in her RV septum despite some unforeseen technical problems. This patient had intrahepatic interruption of IVC with Azygous continuation draining into SVC but this altered venovascular course was detected only fluoroscopically midway during the pacemaker implantation procedure and this was not detected in the preprocedural transthoracic echocardiography. This abnormal venous course was clearly demonstrated in the cardiac CT which was performed only after completion of the pacemaker implantation procedure in this patient. The technical challenges encountered mainly were mostly during the manipulation of the 27F delivery catheter of Micra through this altered cardiovascular anatomy via transfemoral approach and also due to the presence of septal defects. Thus, transcatheter leadless permanent pacemaker was implanted successfully through transfemoral access in this complex congenital heart disease with interrupted IVC and azygous continuation. Besides transthoracic echocardiography, it may be better to perform transesophageal echocardiography or even preferably radiological imaging like cardiac CT or MRI prior to transcatheter leadless pacemaker implantation in patients with complex congenital heart disease to understand the cardiovascular anatomy and plan the procedure.

Blood pressure and heart rate related to sex in untreated subjects: the India ABPM study.

Women are underrepresented in groups of patients seeking hypertension care in India. The present paper reports trends in office and ambulatory blood pressure measurement (OBPM, ABPM) and 24-h heart rate (HR) with sex in 14,977 subjects untreated for hypertension (aged 47.3 ± 13.9 years, males 69.4%) visiting primary care physicians. Results showed that, for systolic blood pressure (SBP), females had lower daytime ABPM (131 ± 16 vs. 133 ± 14 mm Hg, P < .001) but higher nighttime ABPM (122 ± 18 vs. 121 ± 16 mm Hg, P < .001) than males. Females had higher HR than men at daytime (80 ± 11 vs 79 ± 11.5 bpm) and nighttime (71 ± 11 vs 69 ± 11), respectively (all P < .001). Dipping percentages for SBP (7.4 ± 7.3 vs 9.3 ± 7.4%), DBP (10.1 ± 8.6 vs. 12.3 ± 8.9%), and HR (10.7 ± 7.9 vs. 12.8 ± 9.2%) were lower (P < .001) for females than for males, respectively. Females more often had isolated nighttime hypertension as compared to males (14.9%, n = 684% vs 10.6%, n = 1105; P < .001). BP patterns and HR showed clear differences in sex, particularly at nighttime. As females were more often affected by non-dipping and elevated nighttime SBP and HR than males, they should receive ABPM, at least, as frequently as men to document higher risk necessitating treatment.

Confronting system barriers for ST- elevation MI in low and middle income countries with a focus on India.

Our previous research found seven specific factors that cause system delays in ST-elevation Myocardial infarction management in developing countries. These delays, in conjunction with a lack of organized STEMI systems of care, result in inefficient processes to treat AMI in developing countries. In our present opinion paper, we have specifically explored the three most pertinent causes that afflict the seven specific factors responsible for system delays. In doing so, we incorporated a unique strategy of global STEMI expertise. With this methodology, the recommendations were provided by expert Indian cardiologist and final guidelines were drafted after comprehensive discussions by the entire group of submitting authors. We expect these recommendations to be utilitarian in improving STEMI care in developing countries.

Profiling cardiac arrhythmia and heart failure patients in India: The Pan-arrhythmia and Heart Failure Observational Study.

BACKGROUND: The PANARrhythMia and Heart Failure Registry (PANARM HF) characterized demographic, clinical and interventional therapy indication profiles of cardiac arrhythmia (CA) and heart failure (HF) patients in India. METHODS: Consulting Physicians (CP) who medically manage CA and HF patients enrolled patients with one or more of the following: syncope, pre-syncope, dyspnea, palpitation, fatigue and LV dysfunction. The CPs were trained by interventional cardiologists (IC) to identify CA/HF patients indicated for implantable device/radiofrequency ablation (RFA). 59 CP's, 16 IC's & 2205 patients from 12 cities participated. Demographic, clinical, device/RFA indication and referral-consultation profiles were created. IC's provided device/RFA recommendations based on these profiles. RESULTS: The CA/HF distribution of patients was: HF - 58%, bradyarrhythmia - 15%, atrial fibrillation - 15%, other supraventricular tachyarrhythmia - 10% and ventricular tachycardia/fibrillation - 4.5%. 62% of the CA/HF population was male and 45% were below age 60. Coronary artery disease (52%), hypertension (44%), diabetes (30%) & myocardial infarction (20%) were prominent. 1011 (46%) of the CA/HF population were potential device/RFA candidates according to the IC's. However, only 700 (69%) of these patients were referred to the IC by the CP. Of referred patients, only 177 (25%) consulted the IC and were recommended therapy. Thus, 824 (83%) of patients indicated for interventional therapy were not advised therapy or did not opt for it. CONCLUSION: The India PANARM HF study provides new information and insights into the demographic, clinical, interventional therapy, referral and consultation pattern profiles of CA/HF patients in India.

Apical hypertrophic cardiomyopathy with hemodynamically unstable ventricular arrhythmia - Atypical presentation.

We present a patient with asymptomatic apical hypertrophic cardiomyopathy (AHCM) who recently developed cardiac arrhythmias, and shortly discuss the diagnostic modalities, differential diagnosis, and treatment strategy for this condition. AHCM is a rare form of hypertrophic cardiomyopathy, which usually involves the apex of the left ventricle. AHCM can occur with varied presentations such as chest pain, palpitations, dyspnea, syncope, atrial fibrillation, myocardial infarction, embolic events, ventricular fibrillation, and congestive heart failure. The most peculiar electrocardiogram findings are giant T-waves inversion in the precordial leads with left ventricular (LV) hypertrophy. A transthoracic echocardiogram is the initial diagnostic modality in the evaluation of AHCM and shows hypertrophy of the LV apex. Other diagnostic modalities, including left ventriculography, multislice spiral computed tomography, and cardiac magnetic resonance imagings, are also valuable tools. Medications used to manage include verapamil, beta-blockers, and antiarrhythmic agents. An implantable cardioverter defibrillator (ICD) is recommended for high-risk patients.

Effectiveness of Ventricular Intrinsic Preference (VIP™) and Ventricular AutoCapture (VAC) algorithms in pacemaker patients: Results of the validate study.

BACKGROUND: Several past clinical studies have demonstrated that frequent and unnecessary right ventricular pacing in patients with sick sinus syndrome and compromised atrio-ventricular conduction (AVC) produces long-term adverse effects. The safety and efficacy of two pacemaker algorithms, Ventricular Intrinsic Preference™ (VIP) and Ventricular AutoCapture (VAC), were evaluated in a multi-center study in pacemaker patients. METHODS: We evaluated 80 patients across 10 centers in India. Patients were enrolled within 15 days of dual chamber pacemaker (DDDR) implantation, and within 45 days thereafter were classified to either a compromised AVC (cAVC) arm or an intact AVC (iAVC) arm based on intrinsic paced/sensed (AV/PV) delays. In each arm, patients were then randomized (1:1) into the following groups: VIP OFF and VAC OFF (Control group; CG), or VIP ON and VAC ON (Treatment Group; TG). Subsequently, the AV/PV delays in the CG groups were mandatorily programmed at 180/150 ms, and to up to 350 ms in the TG groups. The percentage of right ventricular pacing (%RVp) evaluated at 12-month post-implantation follow-ups were compared between the two groups in each arm. Additionally, in-clinic time required for collecting device data was compared between patients programmed with the automated AutoCapture algorithm activated (VAC ON) vs. the manually programmed method (VAC OFF). RESULTS: Patients randomized to the TG with the VIP algorithm activated exhibited a significantly lower %RVp at 12 months than those in the CG in both the cAVC arm (39±41% vs. 97±3%; p=0.0004) and the iAVC arm (15±25% vs. 68±39%; p=0.0067). In-clinic time required to collect device data was less in patients with the VAC algorithm activated. No device-related adverse events were reported during the year-long study period. CONCLUSIONS: In our study cohort, the use of the VIP algorithm significantly reduced the %RVp, while the VAC algorithm reduced in-clinic time needed to collect device data.

Patient selection for ambulatory cardiac monitoring in the Indian healthcare environment.

Cardiovascular disease (CVD) in India comprises the bulk of non-communicable diseases, resulting in 2 million deaths per year. The incidence of CVD in India is estimated to be up to four times higher than in other countries. Though the quantification of the prevalence of rhythm disorders in India is not available, it can be inferred to be proportionately high. Identification and treatment of arrhythmia is limited by several socioeconomic factors including low health insurance penetration, limited reimbursement and high out-of-pocket expenditures. Thus, there exists a need in India to (1) select an appropriate tool that is both high yielding and cost effective and (2) employ a suitable patient selection method. This paper focuses on these two aspects for cardiac arrhythmia diagnosis using ambulatory monitoring technology, while keeping in mind the dynamics of the Indian healthcare setting.