Effective Reversible Immobilization of Captive Himalayan Black Bears (Selenarctos thibetanus laniger) with Medetomidine-Tiletamine-Zolazepam and Atipamezole.

We used a combination of medetomidine and tiletamine-zolazepam to immobilize five Himalayan black bears (Selenarctos thibetanus laniger) in Bannerghatta Biological Park, Bangalore, India. Medetomidine and tiletamine-zolazepam were administered at 0.01 mg/kg and 0.5 mg/kg, respectively. We describe procedures and observations recorded during the immobilization.

Association of Transforming Growth Factor-ß Superfamily Genes with Non-Regression of Pulmonary Artery Hypertension Following Balloon Mitral Valvotomy: A Pilot Study.

BACKGROUND AND AIM OF THE STUDY: Pulmonary arterial hypertension (PAH) is a common accompaniment of rheumatic mitral stenosis (MS), with 70% of patients showing evidence of different grades of PAH. The latter condition is found to be a prognostic factor influencing disease outcome even after interventional or surgical therapy. The cause of the non-regression of PAH following successful balloon mitral valvotomy (BMV) is not clear. Hence, the study aim was to determine if there is an association of mutations in the genes of the TGF-ß superfamily and non-regression of PAH in patients who undergo a successful BMV. METHODS: Forty-six patients who underwent BMV and fulfilled the recruitment criteria were enrolled prospectively in this case-control study. Among the patients, 27 had non-regression of PAH while 19 had regression of PAH and served as controls. The mean age of the population was 32.63 ± 10.65 years. RESULTS: No statistically significant differences were identified in any of the baseline parameters between the two groups. None of the samples had BMPR2 or ACVRL1 mutations. Ten of the patients and four of the controls were positive for Endoglin mutation, but the inter-group difference was not statistically significant (p = 0.25) CONCLUSIONS: The present study - the first of its kind - showed that deletion-duplication mutations in the BMPR2 or ACVRL1 genes may not be associated with non-regression of PAH, even after successful BMV, or in a wider sense serve as a contributor to PAH in rheumatic MS. The association of Endoglin mutation and non-regression of PAH warrants further investigation in a larger population.

Persistent pulmonary artery hypertension in patients undergoing balloon mitral valvotomy.

Pulmonary artery pressure (PAP) is known to regress after successful balloon mitral valvotomy (BMV). Data of persistent pulmonary artery hypertension (PPAH) following BMV is scarce. We analyzed the clinical, echocardiographic, and hemodynamic data of 701 consecutive patients who have undergone successful BMV in our institute from 1997 to 2003. Data of 287 patients who had PPAH (defined by pulmonary artery systolic pressure [PASP] of ≥ 40 mmHg at one year following BMV) were compared to the data of 414 patients who did not have PPAH. Patients who had PPAH were older (39.9 ± 9.9 years vs. 29.4 ± 10.1; P < 0.001). They had higher prevalence of atrial fibrillation (AF; 21.9 vs. 12.1%, P < 0.05), moderate or severe pulmonary artery hypertension (PAH) defined as PASP more than 50 mmHg (43.5 vs. 33.8%, P = 0.00), anatomically advanced mitral valve disease as assessed by Wilkin's echocardiographic score > 8 (33.7 vs. 23.2%, P < 0.001), and coexistent aortic valve disease (45.6 vs. 37.9%, P < 0.001) at the baseline. Those patients with PPAH had comparatively lower immediate postprocedural mitral valve area (MVA). On follow-up of more than five years, the occurrence of restenosis (39.3 vs. 10.1%, P = 0.000), new onset heart failure (14% vs. 4%, P < 0.05) and need for reinterventions (9.5% vs. 2.8%, P < 0.05) were higher in the PPAH group. Patients with PPAH were older, sicker, and had advanced rheumatic mitral valve disease. They had higher incidence of restenosis, new onset heart failure, and need for reinterventions on long term follow-up. PPAH represents an advanced stage of rheumatic valve disease and indicates chronicity of the disease, which may be the reason for the poorer prognosis of these patients. Patients with PPAH requires intense and more frequent follow-up.

Heart failure in South Asia.

South Asia (SA) is both the most populous and the most densely populated geographical region in the world. The countries in this region are undergoing epidemiological transition and are facing the double burden of infectious and non-communicable diseases. Heart failure (HF) is a major and increasing burden all over the world. In this review, we discuss the epidemiology of HF in SA today and its impact in the health system of the countries in the region. There are no reliable estimates of incidence and prevalence of HF (heart failure) from this region. The prevalence of HF which is predominantly a disease of the elderly is likely to rise in this region due to the growing age of the population. Patients admitted with HF in the SA region are relatively younger than their western counterparts. The etiology of HF in this region is also different from the western world. Untreated congenital heart disease and rheumatic heart disease still contribute significantly to the burden of HF in this region. Due to epidemiological transition, the prevalence of hypertension, diabetes mellitus, obesity and smoking is on the rise in this region. This is likely to escalate the prevalence of HF in South Asia. We also discuss potential developments in the field of HF management likely to occur in the nations in South Asia. Finally, we discuss the interventions for prevention of HF in this region.

Asymptomatic right ventricular dysfunction in surgically repaired adult tetralogy of fallot patients.

BACKGROUND: Right ventricular (RV) dysfunction after surgical repair of Tetralogy of Fallot (TOF) is often asymptomatic and may be detected by tissue Doppler imaging (TDI). The severity of RV dysfunction is more after intracardiac repair with transannular patch (TAP). METHODS: One hundred seventy-three adult patients who have undergone surgical repair for TOF were prospectively analyzed for RV function using 2D echocardiography and TDI. RV function was compared between patients who have undergone intracardiac repair with and without TAP. RESULTS: In both the patient sub-groups, TDI derived myocardial performance index (MPI) and myocardial velocities were abnormal even when 2D echocardiography derived RV functional area change was normal. TDI derived MPI was significantly higher (0.5 ± 0.1 vs. 0.4 ± 0 P < 0.001) and Systolic tricuspid annular velocity (Sa) (9.2 ± 1.3 vs. 10.8 ± 1.6 P < 0.001) was significantly lower in the TAP group. Older age at surgery and severity of pulmonary regurgitation on follow-up were among the significant predictors of TDI derived MPI. CONCLUSIONS: Asymptomatic RV dysfunction in surgically repaired adult TOF atients can be detected by TDI. Extent of RV dysfunction was significantly greater with patients requiring TAP, in those operated at older age, and in patients with severe pulmonary regurgitation.

Immediate and long-term results following balloon mitral valvotomy in patients with atrial fibrillation.

BACKGROUND: The purpose of this study was to examine the influence of atrial fibrillation (AF) on the immediate and long-term outcome of patients undergoing balloon mitral valvotomy (BMV). HYPOTHESIS: Patients with atrial fibrillation fair poorly after balloon mitral valvotomy. METHODS: There were a total of 818 consecutive patients who underwent elective BMV in this institute from 1997 to 2003, with either double-lumen or triple-lumen BMV catheters included in the study. Of them, 95 were with AF. The clinical, echocardiographic, and hemodynamic data of these patients were compared with those of 723 patients in normal sinus rhythm (NSR). Immediate procedural results and long-term events were compared between the 2 study groups. RESULTS: Patients with AF were older (39.9 ± 9.9 years vs 29.4 ± 10.1, P < 0.001) and presented more frequently with New York Heart Association (NYHA) class III-IV (53.7% vs 32.9%, P < 0.001), echocardiographic score >8 (47.4% vs 24.9%, P < 0.001), and with history of previous surgical commissurotomy (33.7% vs 11.5%, P < 0.001). In patients with AF, BMV resulted in inferior immediate and long-term outcomes, as reflected in a lesser post-BMV mitral valve area (1.3 ± 0.4 vs 1.6 ± 0.4 cm(2), P = 0.032) and higher event rate on follow-up. CONCLUSIONS: Patients with AF were older, sicker, and had advanced rheumatic mitral valve disease. They had a higher incidence of stroke, new onset heart failure, and need for reinterventions on long-term follow-up. These patients need intense and more frequent follow-up.

Comparative study on safety, efficacy, and midterm results of balloon mitral valvotomy performed with triple lumen and double lumen mitral valvotomy catheters.

BACKGROUND: The triple lumen Inoue balloon is routinely used for balloon mitral valvotomy (BMV) in India. Its major limitation is the high cost. The double lumen Accura balloon is less expensive, making it an attractive alternative in the developing countries. The study was meant to assess the safety, efficacy and midterm results of Accura balloon with respect to the Inoue balloon. PATIENTS AND METHODS: 816 consecutive patients, who underwent elective BMV in this Institute from 1997 to 2003, were included in the study. The data of 487 patients who underwent BMV with Accura balloon was compared with 329 patients who underwent BMV with Inoue balloon. The clinical, echocardiographic, and hemodynamic data of these patients were analyzed retrospectively to assess the safety and efficacy of Accura balloon with respect to the Inoue balloon. RESULTS: Immediate procedural success (93.9% in Inoue group and 91.6% in Accura group p. NS) and complications (6.6% in Inoue group and 5.6% in Accura group p. NS) were comparable between the study groups. The two study population had similar restenosis rate and events at 1 year after BMV. Both balloons could be reused multiple times without compromising on the safety and effectiveness. Accura balloons were less costly than Inoue balloon. The reusability with Accura was slightly more and found to be more cost-effective. CONCLUSIONS: Both Accura and Inoue balloon mitral valvotomy balloons are effective in providing relief from hemodynamically significant mitral stenosis in terms of gain in valve area and reduction in trans mitral gradient. Both groups have similar procedural success and complication rates, restenosis, and follow-up events at 1 year. Both balloons could be reused multiple times and Accura balloon is found to be more cost effective.

Esophageal small cell carcinoma with synchronous renal cell carcinoma: a case report with review of the literature.

Synchronous malignancies with an esophageal malignancy are not uncommon. However synchronous esophageal and renal cell carcinoma (RCC) is rare with only 11 cases reported in the world literature, the esophageal malignancies being adenocarcinomas or squamous cell carcinomas. Here, we report the first case of synchronous small cell carcinoma (SCC) of the esophagus with a RCC. SCC of the esophagus is an aggressive malignancy with poor prognosis constituting 0.8-2.4% of all esophageal malignancies, currently treated with induction chemotherapy followed by chemoradiotherapy. Our patient underwent chemoradiotherapy for the SCC of the esophagus followed by radical nephrectomy for the RCC. He developed metastatic disease and died 8 months after diagnosis. Larger case series are required to develop a treatment algorithm for such a rare presentation. The key points of this report are: (1) Synchronous RCC with a primary esophageal carcinoma is a rare presentation. (2) This is the first described case report of a SCC of the esophagus with a synchronous RCC. (3) Overall prognosis in a synchronous presentation is determined by the primary esophageal malignancy. (4) Esophageal carcinomas with synchronous malignancies have a poorer prognosis compared to isolated esophageal carcinoma.

Ventricular septal rupture following myocardial infarction. Long-term survival of patients who did not undergo surgery. Single-centre experience.

Long-term survival is rare in patients not undergoing surgery after post-myocardial infarction ventricular septal rupture. We report our experience of seven patients out of 27, who did not undergo surgery and were followed up for a mean period of 2.8 years. They were evaluated after a mean period of 2.2 months after infarction in our centre. The septal defects measured 9.8 mms on average and the mean left-to-right shunt ratio was 1.98: 1. The mean pulmonary artery, right atrial and left ventricular end diastolic pressures were 28.3 +/- 10.6, 4 +/- 3 and 15.8 +/- 4.8 mm Hg, respectively. Only three out of seven patients had LV aneurysm and all patients had single-vessel disease. Smaller defect size, minimal left-to-right shunt and preserved right ventricular function may be the factors responsible for long-term survival.