Background Clopidogrel hyporesponsiveness with decreased antiplatelet activity is prevalent in percutaneous coronary intervention (PCI) patients due to reduced function polymorphism in the CYP2C19 ...enzyme gene which results in poor conversion of this prodrug to an active metabolite. However, pharmacogenetic testing is not part of routine clinical practice in India. Methodology In this retrospective observational study, we observed the prevalence of loss of function (LOF) gene variants of CYP2C19 (*2, *3) in 60 patients undergoing PCI with complex anatomies in a tertiary healthcare hospital in North India. We do not have follow-up data for a few patients. However, the treatment regimen was recorded, and the occurrence of any clinical event was monitored for the remaining 52 patients for six months. Results The mean age of the patients was 61.76 ± 10.14 years. We found that 52% of patients carried these LOF mutations, of which 37% were intermediate metabolizers, while 15% were poor metabolizers of clopidogrel. However, out of 52 patients for whom follow-up data were available, 22 (42.3%) were intermediate metabolizers, while six (11.54%) showed genotypes associated with poor metabolism of clopidogrel. Clopidogrel (75 mg BD) was the primary replacement drug in place of ticagrelor (90 mg BD) during follow-up after four weeks (based on the clinician’s discretion). Conclusions No major ischemic event was reported during the follow-up of these 52 patients. The intermediate metabolizers’ LOF in one copy of the CYP2C19 gene seems to overcome genetic deficiency with the clopidogrel 75 mg BD regime, which is comparable to maintenance with ticagrelor 90 mg BD. This study can be extrapolated to a larger cohort to observe statistically significant differences among various groups.
On 16 Jan 2021, India launched its immunization program against COVID-19. Among the first recipients were 1.59 million Health Care Workers (HCWs) and Frontline Workers (FLWs) of the Indian Armed ...Forces, who were administered COVISHIELD (Astra Zeneca). We present an interim analysis of vaccine effectiveness (VE) estimates till 30 May 2021.
The VIN-WIN cohort study was carried out on anonymized data of HCWs and FLWs of Indian Armed Forces. The existing surveillance system, enhanced for COVID-19 monitoring, was sourced for data. The cohort transitioned from Unvaccinated (UV) to Partially Vaccinated (PV) to Fully Vaccinated (FV), serving as its own internal comparison. Outcomes studied in the three groups were breakthrough infections and COVID related deaths. Incidence Rate Ratio (IRR) was used to compare outcomes among the three groups to estimate VE.
Data of 1,595,630 individuals (mean age 27.6 years; 99% male) over 135 days was analysed. Till 30 May 21, 95.4% and 82.2% were partially and fully vaccinated. The UV, PV and FV compartments comprised 106.6, 46.7 and 58.7 million person-days respectively. The number of breakthrough cases in the UV, PV and FV groups were 10061, 1159 and 2512; while the deaths were 37, 16 and 7 respectively. Corrected VE was 91.8–94.9% against infections.
Interim results of the VIN-WIN cohort study of 1.59 million HCWs and FLWs of Indian Armed Forces showed a ∼93% reduction in COVID-19 breakthrough infections with COVISHIELD vaccination.
Transcatheter Aortic Valve Implantation (TAVI) techniques gradually evolved since 2002 and have undergone various refinements. Achieving optimal implantation depth has become crucial for good long ...term outcome. High implantation decreases the likelihood of conduction disturbances. Conventionally TAVI valve is positioned in a tricusp coplanar (CON) fluoroscopic projection however it does not ensure a optimal implantation. In an attempt to attain higher implantation(3 mm) and decrease rate of permanent pacemaker, cuspal overlap technique (COT) view has been developed. There is scarcity of Indian literature comparing TAVI deployment using coplanar and cuspal overlap techniques.
We included 111 patients who underwent TAVR with a self-expanding Core Valve Evolut R (Medtronic, Minneapolis, Minnesota), between January 2017 to September 2022 at our centre.Transcatheter Heart Valves (THV) were implanted using the traditional coplanar in 55 patients, while in 56 patients valves were implanted using the COT.
Baseline characteristics including electrocardiographic findings were comparable in both groups. In all patients Evolut R or Evolut PRO valves were used. Procedure was done in conscious sedation in 90.9 % of patients in CON and 96.4 % in COT group. Predilatation and postdilatation was used in 38.8 % vs 33.9 % and 27 % vs 32 % in CON and COT groups respectively. 90 day PPI rate was less in COT group (7.3 % CON vs 3.5 % COP). Majority of patients who received permanent pacemaker implantation (PPI) had baseline ECG abnormality (RBBB in 50 %, LBBB in 16 %, Grade 1 AV block 16 %). Mean time of post procedure PPI was 5.6 days in COT group and 7.3 days in CON group. New onset LBBB was also less in COT group (21 % CON vs 12.5 % COT).There were 3.6 % intraprocedural deaths in CON group and 1.8 % in COT group. Depth of deployed valve was 4.8 ± 2.34 mm in COT and 6.6 ± 2.11 mm in CON group. Valve deployment time was more in COT group(10.40 CON vs 14.34 min COT). Average valve recapture rate was 2.58 in COP and 2.11 in CON. Stroke rate was more in COT group(3.6 % CON vs 7.14 % COT). Pericardial effusions were also more in COT group. All cause mortality at 3 months was 10.9 % in CON group and 5.3 % in COT.
In this study we achieved lower rates of PPI and new onset LBBB using COT technique in Indian patients using self-expandable prostheses. However valve deployment time, stroke rate and pericardial effusion were seen more in COT group. All cause mortality was low in cuspal overlap technique.
In this study we report our experience in implanting MICRA TPS (transcatheter pacing system) at various RV sites; observing its safety, and impact on paced QRS in Indian population.
35 patients with ...MICRA TPS deployed from March 2017 to December 2019 at Army Hospital Research and Referral, New Delhi, at RVOT, apical septum and mid septum of RV were enrolled in the study. These patents were followed up and impact of implantation site, procedure related complications, change in pacing parameters, left ventricular ejection fraction and duration of paced QRS were monitored.
Sick sinus syndrome was the commonest indication of pacing in this study (51.5%), followed by high degree AV block (34.2%). Mean follow up of 1.4 years showed no change in left ventricular ejection fraction, electrical parameters or change in pacing thresholds after implantation. Mean pQRS was broadest (166.60 ms) in apically implanted MICRA TPS and narrowest in mid septum group 139.33 ms. Among 35 cases, in our study one patient developed pericardial effusion, and other had intermittent diaphragmatic pacing.
Among these three implantation sites mid septum deployment is associated with narrowest paced QRS in Indian population.
Introduction: India is the rheumatic heart disease (RHD) capital of the world. It is home to 40% of all people of RHD. Many of these patients undergo valve replacement surgeries in our country. These ...patients present with prosthetic heart valve thrombosis (PHVT) as the international normalized ratio (INR) is not monitored due to several restraints. Many precious lives are lost due to the scarcity of cardiac surgery centers and the high mortality associated with redo procedures. Various international studies have proved the efficacy and low complication rate of slow thrombolysis with tissue plasminogen activator (tPA) compared to surgery in PHVT. Most Indian studies have used streptokinase for PHVT and data on tPA are lacking. Materials and Methods: Twenty-one patients with prosthetic mechanical mitral valve presenting with dyspnea, a high gradient across the prosthetic valve, and decreased leaflet motion were included in the study. As it is not always possible to differentiate pannus from a thrombus and association of some degree of thrombosis even in pannus, we offered thrombolysis as the first line of treatment to all patients. Slow thrombolysis with 25 mg of tPA over 6 h followed by unfractionated heparin for 18 h was given, and thereafter, patients were reassessed for thrombolytic success or complications if any. A total four sessions of thrombolysis were given, and thereafter, patients with failed thrombolysis were referred for valve replacement surgery. Results: Out of 21 patients, 67% were females. The mean age of patients was 54.33 ± 10.6 years. Fifty-seven percent of patients were in the New York Heart Association (NYHA) III/IV. Atrial fibrillation was present in 62% of patients. The mean time of interval from the time of valve surgery to the time of thrombosis was 80 ± 57 months and the mean INR was 1.43 ± 0.4. The total success rate was 71% in this study, 9% had complications, and 19% had failed thrombolysis and underwent redo mitral valve replacement. The mean dose of tPA was 56.58 mg in this study and a mortality rate of 4%. Age had no effect on the success of thrombolysis. The presence of sinus rhythm, NYHA class I/II status, EF more than 40%, and mean gradient <20 mmHg was associated with a higher likelihood of success. Conclusion: In this study of PHVT in Indian patients, slow (6 h) infusion of low-dose (25 mg) tPA proves to be associated with a low complication rate, low mortality, and a promising success rate. This regimen can be offered to PHVT patients in our peripheral centers where cardiac surgical facilities are not readily available.
Transcatheter aortic valve implantation (TAVI) in post-MVR (mitral valve replacement) patients is a technical challenge due to the respective proximity of the aortic annulus and non-compliant ...prosthetic mitral valve ring. There are only a few case reports in literature which have reported this procedure. We herein describe a case of TAVR in rheumatic heart disease patient having prosthetic mitral valve whose distance between aortic annulus to mitral rim was only 3.8mm.
Optical coherence tomography (OCT) is slowly but surely gaining a foothold in the hands of interventional cardiologists. Intraluminal and transmural contents of the coronary arteries are no longer ...elusive to the cardiologist's probing eye. Although the graduation of an interventionalist in imaging techniques right from naked eye angiographies to ultrasound-based coronary sonographies to the modern light-based OCT has been slow, with the increasing regularity of complex coronary cases in practice, such a transition is inevitable. Although intravascular ultrasound (IVUS) due to its robust clinical data has been the preferred imaging modality in recent years, OCT provides a distinct upgrade over it in many imaging and procedural aspects. Better image resolution, accurate estimation of the calcified lesion, and better evaluation of acute and chronic stent failure are the distinct advantages of OCT over IVUS. Despite the obvious imaging advantages of OCT, its clinical impact remains subdued. However, upcoming newer trials and data have been encouraging for expanding the use of OCT to wider indications in clinical utility. During percutaneous coronary intervention (PCI), OCT provides the detailed information (dissection, tissue prolapse, thrombi, and incomplete stent apposition) required for optimal stent deployment, which is the key to successfully reducing the major adverse cardiovascular event (MACE) and stent-related morbidities. The increasing use of OCT in complex bifurcation stenting involving the left main (LM) is being studied. Also, the traditional pitfalls of OCT, such as additional contrast load for image acquisition and stenting involving the ostial and proximal LM, have also been overcome recently. In this review, we discuss the interpretation of OCT images and its clinical impact on the outcome of procedures along with current barriers to its use and newer paradigms in which OCT is starting to become a promising tool for the interventionalist and what can be expected for the immediate future in the imaging world.
RADPAD is a lead-free sterile drape that reduces scattered radiation during fluoroscopic procedures. We aimed to study the effect of using RADPAD on primary operator (PO) and secondary operator (SO) ...during coronary angiography (CAG) as well as percutaneous coronary intervention (PCI).
137 patients undergoing elective CAG and PCIwere randomized in a 1:1 pattern with or without the RADPAD. The ratio of PO received dose in mrem to total Air Kerma (AK) in mGy, Dose Area Product (DAP) in mGycm2 and Cine Adjusted Screening Time (CAST) in minute, at the end of the procedure with or without RADPAD were measured and designated as dose relative to AK, DAP and CAST. The exposure ratios were compared for both cohorts.
There was no significant difference in CAST, DAP and AK between the two patient cohorts. PO radiation dose relative to CAST was 0.15 ± 0.18 mrem/min for RADPAD cohort and 0.43 ± 0.31 mrem/min for No RADPAD cohort (p < 0.00001). PO dose relative to DAP was 0.00042 ± 0.00049 mrem/mGycm2 for RADPAD cohort and 0.0011 ± 0.0013 mrem/mGycm2 for No RADPAD cohort (p = 0.000014). PO dose relative to AK was 0.0030 ± 0.0037 mrem/mGy for RADPAD cohort and 0.0071 ± 0.0049 mrem/mGy for No RADPAD cohort (p < 0.00001). All PO doses relative to CAST, DAP and AK were significantly reduced in the RADPAD cohort compared to the No RADPAD cohort. Similar findings were observed for the SO also.
RADPAD significantly reduces radiation exposure to both PO and SO during CAG and PCI.
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