Heart failure, the global pandemic: A call to action consensus statement from the global presidential conclave at the platinum jubilee conference of cardiological society of India 2023.

Heart failure (HF) is emerging as a major public health problem both in high- and low - income countries. The mortality and morbidity due to HF is substantially higher in low-middle income countries (LMICs). Accessibility, availability and affordability issues affect the guideline directed therapy implementation in HF care in those countries. This call to action urges all those concerned to initiate preventive strategies as early as possible, so that we can reduce HF-related morbidity and mortality. The most important step is to have better prevention and treatment strategies for diseases such as hypertension, ischemic heart disease (IHD), type-2 diabetes, and rheumatic heart disease (RHD) which predispose to the development of HF. Setting up dedicated HF-clinics manned by HF Nurses, can help in streamlining HF care. Subsidized in-patient care, financial assistance for device therapy, use of generic medicines (including polypill strategy) will be helpful, along with the use of digital technologies.

Review of current status of cardiovascular and thoracic surgery in Nepal: An analysis from collection of institutional database.

OBJECTIVE: Data collected from various institutions around the country was analyzed to assess the current status of cardiovascular and thoracic surgery in the country. METHODS: We collected data from institutions performing cardiovascular and thoracic surgery from all over the country through direct correspondence for the year 2019. Individual institution data on the number of surgeries performed for cardiac, vascular, and thoracic surgery and its outcome in terms of mortality were compiled. The data were further evaluated depending on the type of procedures performed. RESULTS: Overall, a total of 2264 cardiac surgeries were performed in the country in the year 2019. The majority of the surgeries were for valvular heart surgery accounting for 34.3%, followed by congenital surgeries (32.8%) and surgeries for coronary artery disease (25.9%). A total of 649 thoracic surgeries were documented, which is probably marginally less than the actual numbers because we were unable to include an additional few institutions performing low-volume or isolated thoracic procedures in this report. A total of 852 vascular procedures were performed in the country, which is probably underreported. The mortality rates for complex congenital procedures were higher than those reported in the literature and that of adult procedures such as valvular heart disease and coronary artery disease similar to literature. CONCLUSION: We evaluated the recent status of cardiovascular and thoracic surgery in the country with respect to the type of procedures and the postoperative outcomes.

Double Aortic Arch with Coarctation of Aorta in an Adolescent: Unraveling the Vascular Ring.

We report the case of a 12-year-old girl with balanced double aortic arch with coarctation of the aorta presenting with symptoms of respiratory and swallowing difficulty. On investigation, the patient had a double aortic arch with coarctation and clinically nonsignificant disease in the infrarenal aorta. Division of the nondominant aortic arch was done through a left thoracotomy, along with resection of the coarctation segment and placement of an interposition Dacron tube graft.

Primary surgical repair of coarctation of the aorta in adolescents and adults: intermediate results and consequences of hypertension.

OBJECTIVES: Coarctation of the aorta is known to present with hypertension in older patients; we reviewed our experience and assessed the outcome of hypertension following surgical correction. METHODS: From April 2004 to date, 43 patients above the age of 12 underwent coarctation of the aorta repair. The mean age was 20.4 + 9.7 years (maximum 56 years); 21 (48.8%) were older than 18 years and 28 (65.1%) were men. Thirty (69.8%) patients had hypertension. Fourteen (32.6%) had a bicuspid aortic valve; 11 (25.6%) had patent ductus arteriosus; 6 (14%) had myxomatous mitral valve; 4 (9.3%) had ascending aortic aneurysms; and 2 (4.7%) had descending aneurysms. RESULTS: Surgical correction included resection and interposition of a tube graft in 31 (72.1%), an end-to-end anastomosis in 6 (14%) and patch aortoplasty in 3 (7%). Three (7%) patients required an extra-anatomical bypass: 1 had a long segment coarctation of the aorta, and 2 had a Bentall procedure with an ascending-to-descending aortic bypass. Staged procedures were done for concomitant disease in 4 (9.3%). There was 1 death: a 56-year-old woman died of refractory ventricular fibrillation during surgery. Thirty (69.8%) patients were discharged with antihypertensive medication. At a follow-up of 2.8 ± 2.2 years (maximum 9.2 years), the number of hypertensive patients decreased (17/36; 47.2%) (P = 0.042). Univariable predictors for persistence of hypertension revealed the use of an interpositional tube graft for repair (odds ratio 13.855, confidence interval 0.000-0.001; P = 0.001) as an indicator, whereas there were no independent predictors for persistence of hypertension. CONCLUSIONS: Surgical intervention is warranted irrespective of age and helps correct and control hypertension better; however, significant numbers of patients still require antihypertensive medication and regular monitoring. Intervention using an interposition tube graft may affect the prevalence of hypertension.

Submitral Aneurysm: An Unusual Aneurysm of the Left Ventricle.

We report a case of a 42-year-old man with a submitral aneurysm who presented to the emergency room in circulatory collapse, with left ventricular obstruction and severe mitral valve stenosis and regurgitation secondary to the aneurysm. Resection of the aneurysm and mitral valve replacement were performed through a median sternotomy without any complication and with good results.

Extracorporeal membrane oxygenation in aluminum phosphide poisoning in Nepal: a case report.

BACKGROUND: Aluminum phosphide is a very common suicide agent in developing countries like Nepal. Due to the unavailability of a specific antidote, mortality is very high because the phosphine molecule that is formed leads to inhibition of the cytochrome oxidase enzyme system in mitochondria. Extracorporeal membrane oxygenation provides life-saving support to the cardiovascular and respiratory systems until the deadly poison is eliminated from the body. CASE PRESENTATION: We encountered one case of 67-year-old Asian woman, a known case of major depressive disorder, who presented to our center with suicidal ingestion of aluminum phosphide with cardiovascular and respiratory dysfunction. On presentation in our emergency room, she had an ejection fraction of 20% and had to be immediately intubated for respiratory failure. Based on the evidence of almost 100% mortality with aluminum phosphide poisoning, extracorporeal membrane oxygenation was initiated in our intensive care unit. Her general condition and hemodynamics gradually improved over the course of 2 days and she was weaned from extracorporeal membrane oxygenation and ventilator by post-extracorporeal membrane oxygenation days 3 and 4, respectively. After psychiatric evaluation and establishment of normal vital parameters, she was moved out of intensive care unit on post-extracorporeal membrane oxygenation day 6 and discharged to home on post-extracorporeal membrane oxygenation day 10. CONCLUSIONS: Although this seems to be a small step in terms of global perspective, it is a giant stride for a developing country. The management of reversible but severe cardiac and respiratory failure certainly opens up newer scopes where we can ensure a quality health care service being made accessible even to the most underprivileged people.

Complex Cervical Aortic Arch With Hypoplasia: A Simple Solution to a Complex Problem.

We report a rare case of a 6-year-old boy with a complex right-sided cervical aortic arch, with retroesophageal hypoplastic transverse arch, left subclavian artery arising from the Kommerell diverticulum of the descending aorta, and a vascular ring formed by the ductus ligament. An extraanatomic ascending-to-descending aorta bypass was done through a median sternotomy along with division of the ductus ligament, without any complications and good results.

Lipoblastoma: an unusual tumour of the left ventricle.

Lipoblastoma is a rare benign tumour of infancy originating from white foetal adipose tissue. Most commonly located in the extremities, intrathoracic and mediastinal involvement of this tumour is rare, and an intracardiac location is even rarer, with only one reported case. Herein, we present a 2-month old asymptomatic boy diagnosed with an echogenic mass in the left ventricular outflow tract. The patient underwent surgical excision and histopathological evaluation revealed a lipoblastoma.

Current Experience With Acute Type B Aortic Dissection: Validity of the Complication-Specific Approach in the Present Era.

BACKGROUND: Our group proposed in 1992 a "complication-specific approach" for the management of acute aortic dissection type B (TBAD), with uncomplicated cases being treated with medical therapy. In this study, we evaluate the efficacy of this management in in-hospital and postdischarge survival. METHODS: Between 1999 and 2014, 123 consecutive acute TBAD patients were treated at our institution. We compared complicated (rupture/impending rupture, malperfusion, expansion) vs uncomplicated TBAD, as well as TBAD with a dissection flap vs intramural hematoma/penetrating aortic ulcer. RESULTS: A total of 103 patients (84%) were strictly managed according to the complication-specific approach, with 93% in-hospital survival. Twenty deviated from complication-specific approach management (triaged to operation by complication-specific approach, but inoperable for a variety of reasons). Independent risk factors for a complicated course in the dissection flap subgroup (n = 89) were history of coronary artery disease (odds ratio. 3.139; p = 0.04) and maximum aortic diameter exceeding 5 cm (odds ratio, 4.586; p = 0.005). Uncomplicated patients were treated medically with antiimpulse therapy. Among the 103 patients treated with the complication-specific approach, long-term survival was 83%, 78%, 71% and 47% at 1, 3, 5, and 10 years, respectively. Between the uncomplicated and complicated groups, 8-year survival was 55% and 49%, respectively (log-rank p = 0.03). Uncomplicated patients showed comparable 6-year survival (log-rank p = 0.06) to matched normal population controls. CONCLUSIONS: Patients managed with the complication-specific approach showed an overall satisfactory long-term survival over 10 years. No in-hospital deaths occurred in patients with uncomplicated, medically treated acute TBAD, with comparable long-term survival to a matched normal population. These good long-term results provide counterbalancing perspective when considering routine thoracic endovascular aortic repair for all TBAD patients.

Management of Coronary Artery Disease in Patients With Descending Thoracic Aortic Aneurysms.

BACKGROUND: The combination of descending aortic aneurysm (DAA) with concomitant coronary artery disease (CAD) is associated with increased morbidity and mortality. We review the surgical management for patients with this combined disease. METHODS: From January 2000 to January 2014, we performed 268 elective surgeries on the descending or thoracoabdominal aorta. Sixty-six patients (24.7%) had significant CAD. Indications for aortic intervention included thoracoabdominal aortic aneurysm (TAAA) in 28 (42.4%), DAA in 36 (54.5%), and coarctation and ulcer in one each. Fifty-two (78.8%) patients had prior CAD, with remote coronary intervention in 32 (48.5%). RESULTS: Sixteen (24.2%) patients required coronary intervention prior to aortic surgery, percutaneous coronary intervention in three and coronary artery bypass grafting (CABG) in 13 (six off-pump). We used the right internal thoracic artery (ITA) because of vulnerability of the left ITA during DAA clamping; the left ITA as a free graft or in situ when disease was distant to the left subclavian artery; and off-pump CABG to avoid manipulation and embolization. Mean duration between coronary intervention and aortic surgery was 37.2 days. There was no mortality or major adverse cardiac events (MACE) following coronary intervention or during interim to aortic surgery. There were two (3%) cardiac mortalities following DAA/TAAA repair. CONCLUSION: CAD is common among patients with DAA/TAAA. We recommend aggressive evaluation and prior treatment of CAD to minimize perioperative MACE.

Straight deep hypothermic circulatory arrest for cerebral protection during aortic arch surgery: Safe and effective.

OBJECTIVE: To evaluate our extensive clinical experience using deep hypothermic circulatory arrest (DHCA) as a sole method of cerebral protection during aortic arch surgery, with an emphasis on determining the safe duration of DHCA. METHODS: A total of 490 consecutive patients (303 males [61.8%], mean age, 62.7 ± 13.5 years) underwent surgical interventions on the aortic arch with straight DHCA for cerebral protection. Of the procedures, 65 (13.3%) were either urgent or emergency. Aortic aneurysms (n = 417, 85.1%) and dissections (n = 71, 14.5%) were the main indications for surgery. RESULTS: The mean DHCA duration was 29.2 ± 7.9 minutes at a mean bladder temperature of 18.7°C. The overall mortality was 2.4% (12 of 490), and elective mortality was 1.4% (6 of 425). The seizure rate was 1.4% (7 of 490). Six patients (1.2%) developed renal failure that required dialysis. The postoperative stroke rate was 1.6% (8 of 490) and was 1.2% (5 of 425) for the elective cases. The overall stroke rate for patients requiring <50 minutes of DHCA was 1.3% (6 of 478), significantly different from the 16.7% (2 of 12) stroke rate for patients requiring >50 minutes of DHCA (P = .014). Multivariate analysis revealed a DHCA time >50 minutes (odds ratio, 5.11 ± 4.01, P = .038) and aortic dissection (odds ratio, 3.59 ± 1.72, P = .008) to be strong predictors of composite adverse outcomes. CONCLUSIONS: Straight DHCA is a safe and effective technique of cerebral protection for the absolute majority of interventions involving the aortic arch. At experienced centers, up to 50 minutes of DHCA can be considered safe, without significant postoperative mortality or neurologic sequelae.

Influence of mitral valve repair versus replacement on the development of late functional tricuspid regurgitation.

OBJECTIVES: To study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation. METHODS: From January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n=683) or MVR (n=64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P<.001), atrial fibrillation (20.3% vs 8.3%, P=.002), a lower left ventricular ejection fraction (61.0% vs 65.2%, P<.003), and a higher pulmonary artery pressure (50.1 vs 41.2 mm Hg, P=.001). The patients were monitored for a mean of 6.9 years (MVr) or 7.7 years (MVR; P=.075). RESULTS: During late follow-up, no difference was found between the groups in the development of moderately severe or severe TR: 1 to 5 years (3.0% vs 3.3%, P=.91) and >5 years (6.1% vs 6.5%; P=.93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P=.011), female gender (HR, 6.86; P=.005), higher pulmonary artery pressure (HR, 1.05; P=.022), and larger left atrial size (HR, 2.11; P=.035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group. CONCLUSIONS: The risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up.

Surgical strategies for anomalous origin of coronary artery from pulmonary artery in adults.

OBJECTIVES: Limited data are available regarding the surgical strategies for an anomalous origin of the coronary artery from the pulmonary artery (ACAPA) in adulthood. We reviewed our surgical experience with ACAPA in adults. METHODS: From January 1960 to July 2011, 10 adults (30% men), aged 18 to 78 years (median, 43), underwent surgical repair of ACAPA. Anomalous left (ALCAPA) was present in 7, anomalous right (ARCAPA) in 2, and anomalous left anterior descending artery in 1. Most (90%) were symptomatic, with 7 (70%) having ischemic changes on a preoperative at rest or stress electrocardiogram. One patient had undergone previous ligation of ALCAPA in childhood. The mean left ventricular ejection fraction was 56% ± 10%, with mild dysfunction in 4. RESULTS: Of the 10 patients, 7 underwent repair by coronary artery button transfer to the aorta, with 2 requiring an interposition saphenous vein graft. In 3 patients, coronary transfer was not possible, and coronary artery bypass grafting with closure of the ACAPA was performed. The mean follow-up was 8.6 years (maximum, 37). Two late deaths occurred from noncardiac causes. One patient with ALCAPA who underwent direct reimplantation subsequently required coronary artery bypass grafting for left main stenosis, likely secondary to tension. At the last follow-up visit, all patients were in New York Heart Association class I or II. The postoperative left ventricular ejection fraction was similar at 53% ± 9%; No significant improvement was seen in those with below normal ejection fraction. CONCLUSIONS: Establishment of a dual coronary artery system with coronary transfer is preferred, even if an interposition graft is required. Coronary artery bypass grafting with closure of ACAPA should be reserved for when coronary transfer is not feasible. Surgical correction of ACAPA should be considered before the onset of left ventricular dysfunction.

Coronary artery spasm after Cryo Maze III procedure.

The Cox Maze III procedure has been simplified with the availability of tissue ablation devices; however, complications related to their use are recognized. We report a case of 45-year-old woman who underwent mitral valve repair and concomitant Cryo-Maze procedure. She had reversible right coronary artery spasm develop after the procedure demonstrated by ST-segment elevation changes and coronary angiography, which was reversed with intracoronary nitroglycerin. The region of spasm suggested it as a consequence of proximity of the right coronary artery to the right atrial ablation lines.