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   Table of Contents - Current issue
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May-August 2020
Volume 8 | Issue 2
Page Nos. 35-118

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EDITORIAL  

Preface to the second issue of Heart India 2020 Highly accessed article p. 35
Alok Kumar Singh
DOI:10.4103/heartindia.heartindia_27_20  
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ORIGINAL ARTICLES Top

Evaluation of left ventricular function using speckle-tracking echocardiography in patients on chemotherapy and/or thoracic radiotherapy p. 38
Dinesh Kumar Singh, Ashish Jha, Bhuwan Chandra Tiwari
DOI:10.4103/heartindia.heartindia_18_20  
Background: Chemotherapy and radiotherapy in cancer patients are associated with significant cardiotoxicity. Novel technique of speckle-tracking echocardiography (STE) may help in the early detection of cardiotoxicity in these patients. Aims and Objectives: The aim and objective of this study is to evaluate the left ventricular (LV) strain by STE in newly diagnosed cancer patients at baseline and to study the impact of chemotherapy and radiotherapy on these parameters in these patients. The present study was a prospective, observational study, done at a tertiary care center in North India. Methods and Results: This study was carried out on 30 patients with newly diagnosed malignancy and 15 aged- and gender-matched healthy controls. These patients underwent two-dimensional (2D) echocardiography and STE at baseline and after the completion of their treatment. Baseline characteristics and echocardiographic parameters were similar between the cases and controls. No significant difference in left ventricular ejection fraction was seen before and after cancer therapy (64.27 ± 3.25 vs. 62.6 ± 3.12; P = 0.63), whereas global longitudinal strain reduced significantly from –21.16 ± 2.50 before cancer therapy to –19.86 ± 3.22 after it (P < 0.01). The global circumferential strain was also reduced significantly from –23.60 ± 7.36 before cancer therapy to –21.33 ± 6.97 after it. A significant reduction in segment-wise longitudinal strain rate was observed among the cases after cancer therapy in all segments. Conclusions: The present study revealed that there was a significant worsening of LV systolic function as measured by the strain parameters on STE in cancer patients on chemotherapy and/or radiotherapy which was not detected by 2D echocardiography alone. STE may thus be a valuable tool in picking up early cardiotoxic changes in cancer patients.
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Effect of nicorandil on short-term echocardiographic and acute angiographic outcomes in acute coronary syndrome patients undergoing percutaneous coronary intervention Highly accessed article p. 44
Ashish Jha, Manoj Kumar Rohit
DOI:10.4103/heartindia.heartindia_19_20  
Context: Patients with acute coronary syndrome (ACS) often have the suboptimal results of percutaneous coronary intervention (PCI) despite adequate restoration of coronary patency. Aims: This study evaluated the utility of starting nicorandil before PCI in patients with ACS, in terms of acute angiographic and short-term echocardiographic outcomes. Settings and Design: It was a prospective, randomized, blinded, single-center trial; involving stable patients with recent ACS and no prior revascularization. Subjects and Methods: Patients started on intravenous (IV) nicorandil infusion or placebo at least 2 h before PCI, continued till 48 h after PCI. Echocardiographic parameters (left ventricular ejection fraction [LVEF], Wall Motion Score Index (WMSI) score, and myocardial performance index (MPI)) were assessed at baseline and at 4 weeks post-PCI. Thrombolysis in myocardial infarction (TIMI) flow grade and corrected TIMI frame count were assessed before and after PCI. The primary endpoints were improvement in regional wall motion abnormality, MPI, LVEF, and corrected TIMI frame count. The secondary endpoints were the major adverse cardiovascular event (MACE) (cardiac death, angina, myocardial infarction [MI], or revascularization) within 30 days, no reflow, slow flow, and periprocedural MI. Results: Fifty-five patients were recruited over 1 year, of which 13 patients were excluded. There were numerically lower but statistically nonsignificant improvement in slow flow and no reflow in nicorandil arm. Significant improvement in echocardiographic parameter of MPI was seen in nicorandil group at follow-up. There was no significant improvement in other echocardiographic parameters and MACE. Conclusions: In patients with ACS and a single-vessel disease on undergoing PCI for recent ACS, the use of IV nicorandil was associated with a significant improvement in MPI at 1-month follow-up. There was no significant difference in the acute angiographic parameters, MACE, LVEF, or wall motion score index.
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Fetal echocardiography: A single-center tertiary care experience p. 52
Aamir Rashid, Shaheera Ajaz, Hilal Rather, Aabida Ahmed, Rabiya Khursheed, Imran Hafeez, Iqbal Dar, Naseer Choh
DOI:10.4103/heartindia.heartindia_8_20  
Background: Although fetal echocardiography is established screening tool for the detection of cardiac anomalies, its utility and awareness remains less in less-developed areas of the world. There is no data from our region about the usage and outcome of fetal echocardiography. Aims and Objectives: To study the indications, referral patterns, and outcomes of fetal echocardiography. Materials and Methods: All pregnant women referred for fetal echocardiography from January 2017 to July 2018 were included in the study. Results: A total of 600 pregnant women underwent fetal echocardiography. The mean age of patients was 28 ± 4.2 years. The mean gestational age referred for fetal echo was 26 ± 4 weeks. Four hundred and twenty (70%) patients were more than 22 weeks of gestational age. Indications included maternal indications in 385 (64.2%) patients. The various maternal indications included bad obstetrical history in 180 (30%), pregestational diabetes in 100 (16.67%), congenital heart disease (CHD) in mother in 35 (5.83%), medication use during pregnancy in 15 (2.3%), and connective tissue disorder in mother in 55 (9.16%). Other indications included abnormal/not properly visualized cardiac chambers on anomaly scan in 50 (8.3%) and previous child with heart disease in 105 (17.5%). Different abnormalities detected included ventricular septal defect, pulmonary atresia intact septum each in 3 (0.5%); tetarology of fallot (TOF), tricuspid atresia, unbalanced atrioventricular canal defect with single ventricle, corrected the great arteries, fetal cardiac tumor, Ebstein anomaly, and total anomalous pulmonary venous connection each in 1 (0.16%); double outlet right ventricle pulmonary stenosis, hypoplastic left heart syndrome, compete heart block, fetal supraventricular tachycardia, and CoA each in 2 (0.33%) patients. Twenty-four of 600 (40 per 1000) screened fetal echos were abnormal. Seventeen (70.8%) patients were referred for an unsatisfactory/abnormal anomaly scan which were low-risk pregnancies. The highest yield of CHD was in patients who had been referred for abnormal fetal anomaly scan when compared with other referral indications (17 of 50 [34%] versus 7 of 550 [1.27%] in other indications; P = 0.0001). Conclusion: The most common indication for which fetal scan was abnormal routine ultrasound which was mostly low-risk pregnancies. Dedicated cardiac screening should be part of the routine anomaly scan. Detailed fetal echo should be done in all patients who have any doubt on anomaly scan. Greater awareness in our community is needed for proper referral timings of fetal echo.
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Transesophageal echocardiography for aortic arch atheromas in patients with cryptogenic stroke/transient ischemic attack – An underutilized entity p. 56
Raghuram Palaparti, Sudarshan Palaparthi, PS S Chowdary, Gopala Krishna Koduru, Prasad Maganti, Purnachandra Rao Kondru, Somasekhar Ghanta, Boochi Babu Mannuva, Sasidhar Yendapalli
DOI:10.4103/heartindia.heartindia_49_19  
Introduction: Large aortic arch atheromas (≥4 mm) and complex and mobile aortic atheromas have been associated with ischemic brain stroke in various previous studies. Transesophageal echocardiography (TEE) is the imaging modality of choice, however, is an underutilized investigation in routine clinical practice. We sought out to find the prevalence and severity of aortic arch atheromas in patients with cryptogenic stroke/transient ischemic attack (TIA) at a tertiary care center. Patients and Methods: One hundred and eighty-eight consecutive stroke patients were screened for stroke risk factors. Sixty-one patients were found to have stroke without obvious cause (cryptogenic), 52 patients underwent TEE, four patients were further excluded after evidence of potential cardioembolic source in TEE, and finally, data of 48 patients with cryptogenic stroke were analyzed. Results: We found that one-third of the patients (n = 16, 33.3%) had aortic atheromas and half of them (n = 8, 16.4%) had atheromas ≥4 mm. Diabetes, dyslipidemia, and smoking status were individually associated with a higher prevalence of aortic plaques in our study (P = 0.03). The frequency of aortic plaques was significantly higher in patients with ischemic brain infarction than in TIA (P = 0.01). Large atheromas (≥4 mm) were significantly associated with more severe clinical illness as assessed by the National Institute of Health Stroke Scale, longer hospital stay, and death (P < 0.001). Conclusions: In the present observational study at a tertiary care center, we found that the relevant aortic atheromas in patients with cryptogenic stroke are fairly common and are associated with adverse clinical events. The diagnosis of aortic atheromas should be sought actively by TEE in patients with cryptogenic stroke or in patients with recurrent embolic events and multiple risk factors. Antiplatelet agents and statins are the mainstay of therapy. Anticoagulation is reasonable in selected high-risk patients. Future randomized trials of direct oral anticoagulants compared to antiplatelet therapy in patients with complex aortic atheromas are anticipated to guide the clinicians.
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A study on coronary artery anomalies in adult patients undergoing coronary angiography for various indications p. 63
Avijit Moulick, Bhuban Majhi, Gouranga Sarkar
DOI:10.4103/heartindia.heartindia_20_20  
Introduction: As variations in coronary artery anatomy is very common, the term “coronary artery anomaly” (CAA) applies only to the rarer forms of anatomic aberrations seen in the general population. CAAs are usually detected incidentally during coronary angiography (CAG) or autopsy. Some hemodynamically significant anomalies cause symptoms at young age and can cause sudden death. Knowledge of CAA is necessary to suspect them in appropriate clinical setting for early diagnosis and management that may be lifesaving. Subjects and Methods: Over a period of 1 year, we studied coronary anatomy of 1000 adult patients attending a tertiary cardiac center for coronary artery disease, valvular heart disease planning valve surgery, etc., where CAG was required. The absolute prevalence of different CAAs was recorded. Results: In our study, 3.6% of the patients had CAA. Most common of them were “right coronary artery arising from the left sinus” and “separate origin of the left anterior descending artery and left circumflex artery from the left sinus.” A significant coronary artery fistula was the next common. Conclusion: Some CAAs made coronary intervention technically challenging. There were hemodynamic implications in some, namely myocardial ischemia resulting from significant myocardial bridge and “coronary steal phenomenon” related to large coronary artery fistula. A high index of suspicion is required for early diagnosis, and the management of most serious forms can abort serious consequences. Information regarding CAAs is also helpful to overcome procedural difficulty during coronary and cardiothoracic interventions and avoid complications.
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Predictors of impending cardiac arrhythmias by electrocardiographic markers in proven obstructive sleep apnea patients p. 69
AK Badrinath, KN Viswanathan, S Suresh Babu, V Yogaraja, J Karthik
DOI:10.4103/heartindia.heartindia_12_20  
Background: Obstructive sleep apnoea is proved to be one of the causes of sudden cardiac death due to undocumented transient cardiac arrhythmias.So we studied the changes in various electrocardiographic parameters (P wave duration, QRS duration and Tpeak to Tend interval) and its association with increasing severity of OSA by AHI to predict the risk of impending cardiac atrial and ventricular arrhythmias in these patients. Objective: This study compares the risk of impending cardiac arrhythmias by electrocardiographic parameters with the increasing severity of obstructive sleep apnoea by AHI (apnoea-hypopnea index) in polysomnnography. Methodology: The study was conducted in a rural based teaching tertiary care hospital in Puducherry,India. The electrocardiogram(ECG) of the 30 proven OSA patients were analysed for parameters like P wave duration, QRS duration and peak of T wave to end of T wave interval. Any deviation from the normal duration is recorded and compared with the severity of OSA by AHI to estimate the risk of arrhythmogenicity Results: Out of 30 OSA patients in the study group 7 (23.3%) were found to have mild OSA [i.e AHI= 5 TO 14 events/hr] , 6 (20%) were found to have moderate OSA [i.e AHI=15 to 29 events/hr] and 17(56.7%) were found to have severe OSA[i.e AHI=30 and above]. The p value is significant [<0.001] for electrocardiographic parameters like Tp-Te interval and P wave duration in patients with AHI more than 15 events/hr [i.e moderate and severe OSA] and p value for QRS duration is 0.162 . Conclusion: We concluded that the increase in duration of P wave, QRS duration and prolongation of Tp-Te interval in electrocardiogram is associated with increasing severity of obstructive sleep apnoea tends to possess significant risk of developing impending cardiac atrial and ventricular arrhythmias respectively which can be attributed to one of the causes of sudden cardiac death in OSA patients.
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Clinical profile of prosthetic heart valve thrombosis and outcome analysis of fibrinolytic therapy versus surgical management: A single-center experience p. 74
Zeeshan Mansuri, Vishal Sharma, Sharad Jain, Jayesh Prajapati, Sanjeev Bhatia, Krutika Patel
DOI:10.4103/heartindia.heartindia_5_20  
Context: The main aim of the study is to find out efficacy, outcomes, and complications of thrombolytic therapy and surgery for obstructive prosthetic heart valve thrombosis (PHVT). Materials and Methods: This was a prospective, observational study done on 130 patients with PHVT, from January 2016 to December 2017. Baseline details, clinical investigations, echocardiography, and fluoroscopy were done. In fibrinolytic therapy, group agents used were streptokinase and urokinase. Out of 130, 115 patients were followed for up to 6 months after the discharge. Results: Majority of the patients were females (66.9%). Sixty-five (50%) patients were in the New York Heart Association Class III, whereas 55 (42.3%) and 10 (7.7%) patients were in Class IV and II, respectively. Nearly 34.6% patients had AF, and remaining 63.1% had sinus rhythm. Out of 130 patients, 26 (20%) patients had single-leaflet valve and 103 (79.2%) patients had bileaflet valve, and only one patient had ball and cage type of the valve. Out of 130 patients, 81 (62.3%) patients received fibrinolytic therapy as the first-line therapy and 49 (37.7%) patients underwent surgery initially. In fibrinolytic therapy group, three patients underwent surgery due to failed fibrinolytic therapy. Fifty-three patients (65.5%) had complete hemodynamic and clinical success without any complications; 28 patients (34.5%) had failure. Of 130 patients, 49 patients underwent surgery as the initial treatment. In the surgical group, three patients died out of 52 patients; mortality rate was 5.80%. Conclusion: Surgery should be offered to patients with contraindications for fibrinolytic therapy as in case of recurrent PHVT surgery offers better outcome with lesser recurrences when compared with fibrinolytic therapy.
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Safety and efficacy of transcatheter device closure of patent ductus arteriosus in pediatric patients: Long-term outcomes p. 80
Jayal Hasmukhbhai Shah, Dharmin Khimjibhai Bhalodiya, Abhishek Rawal Pravinchandra, Sanket P Saraiya
DOI:10.4103/heartindia.heartindia_6_20  
Aims: Patent ductus arteriosus (PDA) is among the most prevalent congenital heart diseases in current times. The aim of this study is to evaluate contemporarily the safety and efficacy of transcatheter device closure of PDA at long-term follow-up. Materials and Methods: Transcatheter closure of PDA was attempted in 205 children between 2008 and 2015 using the Amplatzer duct occlude (ADO). Ductal anatomy was accurately delineated on lateral and right anterior oblique view on aortic angiogram. All children underwent complete clinical evaluation, electrocardiography, chest X-rays, and echocardiography prior to discharge and at 1-month, 6-month, and annual follow-up thereafter. Results: Of a total of 205 cases, 64% were females; the mean age was 7.92 ± 3.61 years (1–17 years), while the mean weight was 16.68 ± 10.82 (5–41 kg). ADOs-I were used in all the cases. The procedure was successful in 99.03% of patients with excellent results. Two patients required surgical closure due to device-induced aortic obstruction and left pulmonary stenosis. There were no cases of procedural deaths, device embolization, device infection, and infective endocarditis. All children fared well at a median follow-up of 94 months with no complications. Conclusion: The long-term data showed that percutaneous transcatheter closure of PDA using ADO was safe and effective in pediatric population with minimal complications.
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Gender-based differences in coronary artery disease: A prospective observational study from a North Indian state p. 85
Amit Kumar Sharma, Mohd Iqbal Dar, Manazir Iqbal, Nisar A Tramboo
DOI:10.4103/heartindia.heartindia_13_20  
Introduction: Coronary artery disease (CAD) causes significant morbidity and mortality in both genders, however, the importance of CAD in females is underappreciated. Aims and Objectives: This study is aimed at investigating the gender-based differences in presentation, evaluation, and outcome of CADs in a northern state of India. Materials and Methods: This is a prospective study conducted over a period of 3 years. All the patients with CAD (acute coronary syndrome or chronic stable angina) enrolled in the study were evaluated for clinical profile, angiographic profile, and the outcome. Results: A total of 3660 patients were enrolled in this study. There were 56.2% of males and 43.8% of females. Smoking as risk factor was noted in 69.6% of males and 7.9% of females, hypertension in 52.9% of males versus 65.4% of females, diabetes in 42.5% of males versus 60.7% of females, and obesity in 46.2% of males versus 57.3% of females. Male versus female mean body mass index was 24.7 versus 27.4, low-density lipoprotein 112.8 versus 123.7, high-sensitivity C-reactive protein 1.5 versus 2.9, and Lp(a) 274.9 versus 442.1, respectively. On coronary angiographic evaluation, male versus female single-vessel involvement was seen in 54.1% versus 58.8% of patients, double-vessel disease in 31.6% versus 27.6%, left main disease in 1.7% versus 3.6%, and spontaneous coronary artery dissection in 0.9% versus 1.5% patients, respectively. The overall mortality in males was 4.03% and 5.11% in females. Conclusion: Despite its atypical presentation, CAD has the worst outcome in women than men. Greater awareness of these gender-based differences will significantly improve the management and outcome of CAD in women.
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Left ventricular systolic function assessment with two-dimensional strain imaging among patients with rheumatic mitral stenosis p. 93
Amresh Kumar Singh, Amit Kumar, SK Vijay, Sunitha Vishwanathan
DOI:10.4103/heartindia.heartindia_10_20  
Introduction: Two-dimensional (2D) strain is a novel technique which evaluates left ventricular (LV) systolic functions more objectively and quantitatively and does not have the limitations seen in ejection fraction (EF), tissue Doppler imaging, and Doppler strain. In this study, we aimed to evaluate the role of 2D strain in the assessment of LV systolic function and the relationship between the presence of atrial fibrillation (AF) and LV dysfunction in patients with mitral stenosis (MS). Materials and Methods: This study is a cross-sectional study. The 2D strain was obtained from LV apical LAX, 4C, and 2C view. Peak LV longitudinal systolic strain was calculated for apical LCX, 4C, and 2C view, and global LV systolic strain was calculated by averaging the three apical views. Results: A total of thirty patients were enrolled in the study. They included 24 (80%) females and 6 (20%) males. There were 11 patients (36.7%) had AF and 21 patients (63.3%) had sinus rhythm. There were mean mitral valve area 1.17 cm2 (by planimetry) and 1.19 cm2 (by pressure half-time), mean mitral valve gradient 12.0 mmHg, mean peak gradient 22 mmHg, and mean right ventricular systolic pressure (50.6 vs. 37.4 mmHg) compared to sinus group. In this study, the mean ALAX LSS (−15.12), mean A4C LSS (−14.65), mean A2C LSS (−13.89), and mean GLOBAL LSS (−14.52) were statistically significant (P < 0.001) lower than the control group. Among AF groups, there were statistically significant (P < 0.05) lower A2C LSS and GLOBAL LSS, but there was no significant difference in ALAX LSS and A4C LSS in both groups. Conclusion: Despite normal LV dimensions and EF, there was a highly significant lower (P < 0.001) global longitudinal systolic strain (GLSS) in MS patients compared to healthy controls. Patients with AF had significantly lower GLSS value (P < 0.05) than the sinus rhythm group among patients with MS.
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Heart rate in patients with or without hypertension: A retrospective study p. 98
Shankar G Vasista
DOI:10.4103/heartindia.heartindia_3_20  
Introduction: Heart rate (HR) is correlated with peripheral and central blood pressure (BP), which may be a determinant in the development of hypertension (HTN). The objective of this study was to assess the HR in patients with and without HTN and identify the determinants of HR in patients with HTN. Materials and Methods: In a retrospective analysis of patient data at a single center from central India, HR was Clinic records, with the presence assessed using an electronic pulse recorder as well as using the traditional method of counting radial pulse. A patient with HTN was identified by the presence of BP ≥140/90 mmHg or by their taking antihypertensive medications. HR was compared between patients with and without HTN. Factors associated with HR in patients with HTN were assessed. Results: In a total of 1020 patients' data included in the study, 81.5% had HTN and 18.5% were nonhypertensive. The mean HR was significantly higher in patients with HTN than in controls (78.0 ± 13.0 vs. 75.7 ± 10.3 beats per min [bpm], P = 0.033). Furthermore, the proportion of patients with HR ≥≥80 bpm was significantly higher in patients with HTN (43.9% vs. 24.4%, P = 0.017). In patients with HTN, the mean HR was significantly higher in those who had diabetes (P = 0.002). A significantly higher percentage of patients who had HR 80 bpm or more were females (P = 0.015), had diabetes (P = 0.002) and uncontrolled BP (P = 0.036), and were receiving thiazide diuretics (P = 0.001). Conclusion: HR is significantly higher in patients with HTN than nonhypertensive controls in the central Indian population. Prospective studies are necessary to assess the impact of various factors on HR and also the role of HR in the development of incident HTN and adverse cardiovascular outcomes in patients with HTN.
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Prenatal echocardiographic diagnosis of congenital heart disease in high-risk antenatal mothers in a tertiary care center and their postnatal outcome: An experience from third world p. 103
Amber Bashir Mir, Kaisar Ahmed, Farhat Jabeen, Muzafar Jan, Sitaraman Radhakrishnan
DOI:10.4103/heartindia.heartindia_9_19  
Background: Congenital heart diseases (CHDs) are the most common fetal congenital defects, and until nowadays, most of them are bypassed without prenatal diagnosis. In this study, we found the incidence of fetal CHD in high-risk mothers, various indications of fetal echocardiography (FE), and their postnatal outcome in developing nation with limited resources. Materials and Methods: A total of 106 cases of antenatal mothers, who are having risk factors such as abnormal obstetric screening, diabetes mellitus, and family history, are included in the study group. The FE was done for pregnant mothers between the age groups of 20 and 40 years at different gestational ages after 20 weeks of pregnancy in the Postgraduate Department of Pediatrics, GMC, Srinagar, between January 2016 and January 2018. Results: The mean gestational age at diagnosis was 30.63 ± 4.3 weeks. The mean age of mothers at diagnosis was 29.99 ± 3.6 years. We identified indications for FE in 106 cases. The most common indication was abnormal cardiac findings in obstetrical screening sonography (30.18%). Among the 106 FE results, 80 (75.47%) were normal, eight (7.54%) were minor abnormalities, three (2.8%) were significant cardiac anomalies, eight (7.5%) were complex cardiac anomalies, and 60.7 (6.6%) were arrhythmias. The most common CHD was hypoplastic left heart syndrome (n = 4). Ninety-one neonates were examined by postnatal echo. We analyzed differences between FE and postnatal echo. There were minor differences in nine cases (9.89%) and major in only two (2.19%) cases. Transplacental fetal therapy was given in four cases. Two cases had fetal tachycardia that was reverted to sinus rhythm and two cases had complete heart block in which heart block persisted despite transplacental therapy. Conclusion: FE is a very useful tool for prenatal diagnosis of CHD. It has proven itself in the diagnosis and management of fetal arrhythmia, even in developing countries with limited resources.
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CASE REPORTS Top

Real time 3D-OCT predicts restenosis by identifying geographic miss between overlapping stents after complex multivessel percutaneous coronary intervention p. 111
Raghuram Palaparti, Gopala Krishna Koduru, Sudarshan Palaparti, PS S. Chowdary, Purnachandra Rao Kondru, Somasekhar Ghanta, Boochi Babu Mannuva, Prasad Maganti, Sasidhar Yendapalli
DOI:10.4103/heartindia.heartindia_51_19  
A 78-year-old male patient with a history of cerebrovascular accident and left hemiparesis presented with evolved inferior wall myocardial infarction and preserved left ventricle (LV) function. Coronary angiogram revealed triple-vessel disease. After heart team discussion, he was advised multivessel percutaneous coronary intervention (PCI). He underwent PCI to right coronary artery (2× sirolimus-eluting stent) in the first stage with good result. After 4 weeks, he again presented to the emergency department with acute coronary syndrome (ACS). He underwent imaging-guided left main (LM) bifurcation PCI (mini-crush technique) with 2 ×× everolimus-eluting stent (EES) across LM to left anterior descending artery (LAD) and 2 ×× EES in left circumflex artery (LCX). Real-time three-dimensional optical coherence tomography (3D-OCT) identified 1 mm geographic miss between overlapping stents in heavily calcified LAD. Cine fluoroscopy and intravascular ultrasound (IVUS) did not identify the same. In view of elderly age, already high contrast load, mild renal impairment, and low-risk OCT features, he was managed conservatively. He was doing well until 10 months after PCI, when he presented again to the emergency department with ACS and LV dysfunction. CAG showed critical in-stent restenosis (ISR) at the LAD stent overlap area. Other stents were all patent with mild ISR in LCx. He underwent PCI to LAD with 1 ×× EES. He is in follow-up for the last 1 year without any complaints and improved LV function. The availability of real-time 3D-OCT machines allowed us to easily identify “geographic miss” which is sometimes difficult to detect with cine flouroscopy or IVUS, particularly in heavily calcified vessels. This newer technology adds another dimension to intravascular imaging-guided PCI and has shown great promise particularly in complex and bifurcation PCI.
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Rheumatic valve disease in a 2-year-old child: A rare case report p. 116
Ranjit Kumar Nath, Rajeev Bharadwaj
DOI:10.4103/heartindia.heartindia_7_20  
Rheumatic fever (RF) and rheumatic heart disease (RHD) are major health hazards in developing countries. Affection with RF-RHD in preschool years is uncommon, but prognostically worse as management is technically difficult. We report a rare early presentation of rheumatic valve disease in a 2-year-old child. This is probably the youngest case of rheumatic mitral obstruction documented in literature till date. It highlights that RF-RHD is still a very prevalent disease in India yet is underdiagnosed and underreported.
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