Clinical Outcomes of patients with coronary artery disease who underwent FFR evaluation of intermediate coronary lesionS- COFFRS study.

BACKGROUND: We undertook this study to validate the impact of FFR-guided coronary interventions among Indian patients, which is not readily available as of date. Our patients differ from their western counterparts, both in terms of risk profile (younger, more metabolic syndrome, lipid rich diet) as well as their coronary size. METHODS: We retrospectively evaluated 282 patients with intermediate stenosis in their coronary arteries, who underwent FFR to assess the functional severity of the lesion. There were 3 groups: Group 1-FFR>0.8 and kept on medical follow-up; Group 2-FFR≤0.8 and underwent revascularisation; and Group 3-FFR≤0.8 and refused to undergo revascularization. 281(99.6%) patients had regular follow-up in our clinic. RESULTS: Median age-57 years (range=28-78). Males=230, 90 patients were in Group 1, 175 in group 2 (PCI in 144 & CABG in 31) and 17 in group 3. Median follow-up of patients was 17.9 months (2 to 56 months). Three patients(3.4%) in Group 1 had MACE (1 STEMI, 2 UA); 4 patients (2.3%) in Group 2 had Non-STE-ACS; 7 patients (41%) in Group 3 had MACE (3 deaths with acute LVF, 2 NSTEMI, 2 STEMI) CONCLUSION: In our experience, MACE events were not higher in patients with FFR>0.8 and kept under medical therapy and were similarly lower in patients with FFR ≤0.8 and underwent revascularisation (p=0.73). Also MACE events were higher in patients with FFR≤0.8 and did not undergo revascularisation compared to other two appropriately treated groups (p=0.03). FFR based revascularization decision appears to be a safe strategy in Indian patients.

Flecainide challenge test: Predictors of unmasking of type 1 Brugada ECG pattern among those with non-type 1 Brugada ECG pattern.

BACKGROUND: Many subjects in community have non-type 1 Brugada pattern ECG with atypical symptoms, relevance of which is not clear. Provocative tests to unmask type 1 Brugada pattern in these patients would help in diagnosing Brugada Syndrome. However sensitivity and specificity of provocating drugs are variable. METHODS: We studied 29 patients referred to our institute with clinical presentation suggestive but not diagnostic of Brugada or with non-Type 1 Brugada pattern ECG. Flecainide Challenge Test (FCT) was done in these patients (IV Flecainide test in 4 patients and Oral Flecainide in 25 patients). Resting 12-lead ECG with standard precordial leads and ECG with precordial leads placed 1 Intercostal space above were performed after flecainide administration every 5 min for first 30 min and every 30 min thereafter until ECG became normal or upto 6 h. The positivity was defined as inducible Type 1 Brugada pattern in atleast 2 right sided leads. RESULT: Median age was 35(range = 5-65) years. In 16 (55%) patients the Type 1 Brugada pattern was unmasked. There were no episodes of major AV block, atrial or ventricular tachyarrhythmia. Three groups were considered for analysis: Group 1(n = 9) - FCT Positive among patients with non-type 1 Brugada ECG pattern, Group 2(n = 4) - FCT Negative among the patients with non-type 1 Brugada ECG pattern, and Group 3(n = 7) - FCT Positive among patients with no spontaneous Brugada ECG pattern. Binary logistic regression analysis found that family h/o SCD was predictive of FCT positivity in Group 1 (Odd's ratio 21, 95% Confidence interval 1.04 to 698.83, p = 0.004). CONCLUSION: Oral flecainide is useful and safe for unmasking of Type I Brugada pattern. In our study, among the many variables studied, family history of sudden cardiac death was the only predictor of flecainide test positivity among those with non-Type 1 Brugada pattern.

Left sympathetic cardiac denervation in managing electrical storm: acute outcome and long term follow up.

PURPOSE: Left sympathetic cardiac denervation (LSCD) may be beneficial in treating electrical storm (ES) of varied aetiologies. The present study analyse the outcome and long term follow up of LSCD in treating ES. METHODS: This is a retrospective study of patients with ES who underwent LSCD. RESULTS: Nine patients (majority males (88.89 %), median age 52 years, IQR 50.5-56.5) underwent LSCD. Coronary artery disease was the commonest substrate (7 (77.78 %)). Five patients, who had hypotension and unstable hemodynamics, underwent percutaneous stellate ganglion blockade. Three of the survivors subsequently underwent surgical sympathectomy. In the remaining four, video assisted thoracoscopy (VATS) guided sympathectomy was performed. Five (55 %) and seven (77.78 %) had a >90 and 80 % reduction in ventricular arrhythmias (VA), respectively. LSCD was ineffective in one patient, who succumbed to ES. There was no difference in outcome between patients with monomorphic versus polymorphic VA (60 vs 70 %, respectively, p = 0.82). One (11.1 %) patient had sudden death on the fifth day after LSCD. The median hospital stay was 13 days (IQR 11-16). During median 34 months of (IQR 18-46) follow up, one patient died of heart failure, and another had recurrence of ES. There was sustained reduction in VA burden in others. CONCLUSION: LSCD is effective in controlling ES and continues to reduce the incidence of VAs during long term follow up. Pharmacological LSCD needs particular emphasis, as it can be performed at bedside, and can be a bail-out procedure in centres where sophisticated procedures like VATS-guided LSCD or radiofrequency ablation are not readily available.

Radial left ventricular dyssynchrony by speckle tracking in apical versus non apical right ventricular pacing- evidence of dyssynchrony on medium term follow up.

INTRODUCTION: To study effects of various sites of right ventricular pacing lead implantation on left ventricular function by 2-dimensional (2D) speckle tracking for radial strain and LV dyssynchrony. METHODS: This was retrospective prospective study. Fifteen patients each with right ventricular (RV) apical (RV apex and apical septum) and non-apical (mid septal and low right ventricular outflow tract [RVOT]) were programmed to obtain 100% ventricular pacing for evaluation by echo. Location and orientation of lead tip was noted and archived by fluoroscopy. Electrocardiography (ECG) was archived and 2D echo radial dyssynchrony was calculated. RESULTS: The baseline data was similar between two groups. Intraventricular dyssynchrony was significantly more in apical location as compared to non-apical location (radial dyssynchrony: 108.2 ± 50.2 vs. 50.5 ± 24, P < 0.001; septal to posterior wall delay [SLWD] 63.5 ± 27.5 vs. 34 ± 10.7, P < 0.001, SPWD 112.5 ± 58.1 vs. 62.7 ± 12.1, P = 0.003). The left ventricular ejection fraction was decreased more in apical location than non apical location. Interventricular dyssynchrony was more in apical group but was not statistically significant. The QRS duration, QTc and lead thresholds were higher in apical group but not statistically significant. CONCLUSION: Pacing in non apical location (RV mid septum or low RVOT) is associated with less dyssynchrony by specific measures like 2D radial strain and correlates with better ventricular function in long term.

Acute outcome of treating patients admitted with electrical storm in a tertiary care centre.

BACKGROUND: Electrical storm (ES) is a life threatening emergency. There is little data available regarding acute outcome of ES. AIMS: The study aimed to analyze the acute outcome of ES, various treatment modalities used, and the factors associated with mortality. METHODS: This is a retrospective observational study involving patients admitted with ES at our centre between 1/1/2007 and 31/12/2013. RESULTS: 41 patients (mean age 54.61 ± 12.41 years; 86.7% males; mean ejection fraction (EF) 44.51 ± 16.48%) underwent treatment for ES. Hypokalemia (14.63%) and acute coronary syndrome (ACS) (14.63%) were the commonest identifiable triggers. Only 9 (21.95%) patients already had an ICD implanted. Apart from antiarrhythmic drugs (100%), deep sedation (87.8%), mechanical ventilation (24.39%) and neuraxial modulation using left sympathetic cardiac denervation (21.95%) were the common treatment modalities used. Thirty-three (80.49%) patients could be discharged after a mean duration of 14.2 ± 2.31 days. Eight (19.5%) patients died in hospital. The mortality was significantly higher in those with EF < 35% compared to those with a higher EF (8 (42.11% vs 0 (0%), p = 0.03)). There was no significant difference in mortality between those with versus without a structural heart disease (8 (21.1% vs 0 (0%), p = 0.32)). Comparison of mortality an ACS with ES versus ES of other aetiologies (3 (50%) vs 5 (14.29) %, p = 0.076)) showed a trend towards significance. CONCLUSION: With comprehensive treatment, there is reasonable acute survival rate of ES. Hypokalemia and ACS are the commonest triggers of ES. Patients with low EF and ACS have higher mortality.

Sudden cardiac death--historical perspectives.

Sudden cardiac death (SCD) is an unexpected death due to cardiac causes that occurs in a short time period (generally within 1 h of symptom onset) in a person with known or unknown cardiac disease. It is believed to be involved in nearly a quarter of human deaths, with ventricular fibrillation being the most common mechanism. It is estimated that more than 7 million lives per year are lost to SCD worldwide. Historical perspectives of SCD are analyzed with a brief description on how the developments in the management of sudden cardiac arrest evolved over time.