Publications by authors named "Dibbendhu Khanra"

39 Publications

Heart Failure in Tetralogy of Fallot due to Associated Hypertrophic Obstructive Cardiomyopathy: A Lesson to Learn.

J Cardiovasc Echogr 2021 Jan-Mar;31(1):35-38. Epub 2021 May 21.

Department of Endocrinology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Heart failure (HF) in a case of uncomplicated TOF is uncommon but can occur under special circumstances. TOF associated with hypertrophic obstructive cardiomyopathy (HOCM) is a very rare combination of anomalies, and very few cases have been reported in the literature. Here, we report the case of a 2-month-old male infant who presented to us with central cyanosis and features of HF. He was worked up and found to have TOF with HOCM and advised surgical correction. Hence, we propose that HOCM is also one factor which can precipitate HF in a patient of TOF along with the classical causes mentioned in the literature. Furthermore, the left ventricular outflow tract obstruction of HOCM in a patient of TOF has an inverse relation with the degree of cyanosis.
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http://dx.doi.org/10.4103/jcecho.jcecho_93_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8230164PMC
May 2021

Comparison of original and modified Q risk 2 risk score with Framingham risk score - An Indian perspective.

Indian Heart J 2021 May-Jun;73(3):353-358. Epub 2021 Jan 19.

Department of Cardiology, NRS Medical College, Kolkata, India. Electronic address:

Objective: No study among Indian population has proposed modification of existing cardiovascular disease (CVD) risk scores or novel risk scores as risk estimation using conventional risk calculators can't be generalized because of epidemiological differences.

Material And Methods: A single center observational study was performed at a tertiary care center among participants having no evidence of CVD. Prevalence of various cardiac risk factors were analysed and 10-year risk was estimated using Framingham risk score (FRS), Q risk 2 score calculator (QRISK2) and Modified Q risk 2 (mQRISK2) which included smokeless tobacco consumption. QRISK2 and mQRISK2 were compared with FRS and participant's eligibility for statin therapy as primary preventive measure was assessed.

Results: Total of 4045 participants were enrolled from August 2016 to July 2019. 3520(87%) had no history of smoking in their lifetime while smokeless tobacco consumption was seen in 1153(28.5%), diabetes in 422(10.4%), hypertension in 1096(27.1%), obesity in 2035(50.3%), and family history of CVD in 353(8.7%) participants. High risk participants were found to be 826(20.4%), 627(15.5%), and 509(12.6%) by using FRS, mQRISK2 and QRISK2, whereas those eligible for statin therapy were maximum by mQRISK2 among 1323(32.7%) participants compared to QRISK2 (n = 1191; 29.4%) and FRS (n = 826; 20.4%) model. Krippendorff's alpha for mQRISK2 was in better agreement with body mass index (BMI) and lipid FRS CVD scoring system as compared to QRISK2 risk model.

Conclusion: CVD risk stratification based on smokeless tobacco use is first of its kind from this part of world and should be part of CV risk assessment.
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http://dx.doi.org/10.1016/j.ihj.2021.01.016DOI Listing
January 2021

A Network Meta-Analysis Comparing Osteoporotic Fracture among Different Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation.

J Bone Metab 2021 May 31;28(2):139-150. Epub 2021 May 31.

Department of Cardiology, Sri Jayadeva Institute of Cardiac Sciences and Research, Bengaluru, India.

Background: There are limited studies comparing the risk of osteoporosis and fractures between different direct oral anticoagulants (DOACs) and vitamin K antagonists (VKA) in non-valvular atrial fibrillation (AF). Using a network meta-analysis (NMA), we compared osteoporotic fractures among 5 different treatment arms, viz. dabigatran, rivaroxaban, apixaban, edoxaban, and VKA.

Methods: Ten studies, including 5 randomized control trials and 5 population-based studies, with a total of 321,844 patients (148,751 and 173,093 in the VKA and DOAC group, respectively) with a median follow-up of 2 years, were included. A Bayesian random-effects NMA model comparing fractures among the treatment arms was performed using MetInsight V3. Sensitivity analysis excluded studies with the highest residual deviances from the NMA model.

Results: The mean age of the patients was 70 years. The meta-analysis favored DOACs over VKA with significantly lower osteoporotic fracture (odds ratio [OR], 0.77; 95% credible interval [CrI], 0.70-0.86). The NMA demonstrated that fractures were significantly lower with apixaban compared with dabigatran (OR, 0.64; 95% CrI, 0.44-0.95); however, fractures were statistically similar between apixaban and rivaroxaban (OR, 0.84; 95% CrI, 0.58-1.24) and dabigatran and rivaroxaban (OR, 1.32; 95% CrI, 0.90-1.87). Based on the Bayesian model of NMA, the probability of osteoporotic fracture was highest with VKA and lowest with apixaban, followed by rivaroxaban, edoxaban, and dabigatran.

Conclusions: The decision to prescribe anticoagulants in elderly patients with AF should be made not only based on thrombotic and bleeding risks but also on the risk of osteoporotic fracture; these factors should be considered and incorporated in contemporary cardiology practice.
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http://dx.doi.org/10.11005/jbm.2021.28.2.139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206613PMC
May 2021

Wild type transthyretin cardiac amyloidosis in a young individual: A case report.

Medicine (Baltimore) 2021 Apr;100(17):e25462

Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Uttar Pradesh.

Rationale: Senile systemic amyloidosis, a disease of elderly is caused by amyloid deposition of wild-type transthyretin. The symptoms often overlap with other heart diseases. Hence it is either misdiagnosed or considered as a normal aging process in majority of cases.

Patient Concerns: We present a young patient of wild-type transthyretin amyloidosis, contradicting its only senile presence. The 34-year-old man presented with dyspnoea on exertion. He was suffering from hypertension for consecutive 3 years.

Diagnosis: Echocardiography demonstrated left ventricular hypertrophy with reduced global longitudinal strain and apical sparing. Congo red staining and immuno-histochemical staining of the abdominal fat biopsy confirmed transthyretin amyloid deposition. Genetic analysis revealed absence of any mutant variant/s of transthyretin gene, confirming wild-type transthyretin amyloidosis.

Intervention: A combination of amlodipine 5 mg, telmisartan 40 mg, and chlorthalidone 12.5 mg once daily was given to control the blood pressure of the patient.

Outcome: Blood pressure was controlled but he continued to have exertional dyspnoea. The patient expired in December 2019.

Lessons: A systematic diagnosis for wild type transthyretin amyloid cardiomyopathy (ATTR-CM) shall be considered in young cardiac patients suffering from cardiac distress with unknown etiology.
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http://dx.doi.org/10.1097/MD.0000000000025462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084012PMC
April 2021

Outcomes of uninterrupted vs interrupted Periprocedural direct oral Anticoagulants in atrial Fibrillation ablation: A meta-analysis.

J Arrhythm 2021 Apr 29;37(2):384-393. Epub 2021 Jan 29.

The University of Tennessee Health Science Center Memphis TN USA.

Background: Studies indicate that uninterrupted anticoagulation (UA) is superior to interrupted anticoagulation (IA) in the periprocedural period during catheter ablation of atrial fibrillation. Still IA is followed in many centers considering the bleeding risk. This meta-analysis compares interrupted and uninterrupted direct oral anticoagulation during catheter ablation of atrial fibrillation.

Methods: A systematic search into PubMed, EMBASE, and the Cochrane databases was performed and five studies were selected that directly compared IA vs UA before ablation and reported procedural outcomes, embolic, and bleeding events. The primary outcome of the study was major adverse cerebro-cardiovascular events.

Results: The meta-analysis included 840 patients with UA and 938 patients with IA. Median follow-up was 30 days. Activated clotting time (ACT) before first heparin bolus was significantly longer with UA (= .006), whereas mean ACT was similar between the two groups (= .19). Total heparin dose needed was significantly higher with IA (mean, ‒1.61; 95% CI, ‒2.67 to ‒0.55; = .003). Mean procedure time did not vary between groups (= .81). Overall complication rates were low, with similar major adverse cerebro-cardiovascular event (= .40) and total bleeding (= .55) rates between groups. Silent cerebral events (SCEs) were significantly more frequent with IA (log odds ratio, ‒0.90; 95% CI, ‒1.59 to ‒0.22; < .01; , 33%). Rates of major bleeding, minor bleeding, pericardial effusion, cardiac tamponade, and puncture complications were similar between groups.

Conclusions: UA during atrial fibrillation ablation has similar bleeding event rates, procedural times, and mean ACTs as IA, with fewer SCEs.
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http://dx.doi.org/10.1002/joa3.12507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021981PMC
April 2021

A study on normal reference values of echocardiographic chamber dimensions in young eastern Indian adults.

Indian Heart J 2021 Jan-Feb;73(1):77-84. Epub 2020 Dec 30.

Department of Cardiology, NRS Medical College, Kolkata, India. Electronic address:

Objective: Various studies have shown racial differences in adult cardiac chamber measurements by echocardiography. There is lack of any large scale data from India regarding the echocardiographic chamber measurements in cardiologically healthy individuals. In this study we present the normal reference values of echocardiographic chamber dimensions in young eastern Indian adults and compare it with the data in present guidelines and recent studies involving Indian subjects.

Methods: This study was performed on 1377 healthy adults aged 18-35 years. Standard transthoracic echocardiographies were performed to obtain basic measurements. All measurements were indexed to body surface area.

Results: The mean maximal aortic valve cusp separation (ACS) and indexed ACS were significantly more in females (p = 0.002, p = 0.03). Mean left ventricular (LV) ejection fraction (LVEF) and LV fractional shortening were marginally higher in females. Upper normal reference limit of LV end diastolic dimension (LVEdD) is slightly more for males. Comparing to ASE data, LVEdD, LV end systolic dimension, LV end diastolic volume, indexed LV end systolic volume, left atrial anteroposterior dimension, aortic root dimension and right ventricle outflow diameter were significantly lower in study population while LVEF was significantly higher (p < 0.0001).

Conclusion: The study reconfirms that Indian subjects have smaller cardiac chamber measurements compared to western population where as LVEF is higher in the Indian population and also demonstrates the wide variation of normal echocardiographic measurements within Indian subcontinent. No previous data from eastern India makes this research a singular experience.
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http://dx.doi.org/10.1016/j.ihj.2020.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961241PMC
July 2021

Non-pharmaco, non-invasive management of coronary no-reflow phenomenon.

Arch Med Sci Atheroscler Dis 2020 29;5:e271-e278. Epub 2020 Dec 29.

Department of Cardiology, Sri Aurobindo Institute of Cardiology, Indore, India.

Introduction: No-reflow is an infrequent but dreaded complication of percutaneous coronary intervention (PCI), where the culprit is obstruction of the downstream microvascular bed. The aim of this study was to evaluate the efficacy and safety of forceful injection of blood (autologous blood transfusion - ABT) in reversing no-reflow during PCI because data regarding its effectiveness is not available.

Material And Methods: 100-120 ml of blood was withdrawn through guiding catheter over 3 to 5 min using a 10 ml syringe and re-infused by forceful injection over 3 min through it, and its efficacy was assessed at 10 min using TIMI flow grade and quantitative corrected TIMI frame count.

Results: In total 93 patients received ABT following no-reflow. Their clinical presentation was ST-elevation myocardial infarction (STEMI) ( = 61; 65.6%), non-ST-elevation myocardial infarction (NSTEMI) ( = 23; 24.7%), and unstable angina ( = 9; 9.6%). It was observed among patients undergoing primary PCI ( = 18; 19.3%), pharmaco-invasive PCI ( = 27; 29%), rescue PCI ( = 11; 11.8%), and PCI for cardiogenic shock ( = 5; 5.3%). A mean volume of 108 ±4 ml blood was transfused. Commonest culprit vessel was left anterior descending artery ( = 51; 54.8%) followed by right coronary ( = 29; 31.2%), left circumflex ( = 19; 10.8%), and saphenous vein grafts ( = 3; 3.2%). Following ABT, TIMI 3 flow was successfully restored in 77 (82.7%) patients. TIMI flow grade improved from 1.02 to 2.52 and cTIMI frame count decreased from 60.6 ±12 to 16.1 ±6 ( < 0.001). ABT was well tolerated except transient hypotension ( = 17; 18.3%). Overall mortality was reported in 10 (10.7%) patients at 1 year.

Conclusions: In this largest and only study to date, ABT is a safe and highly effective approach to reverse no-reflow by raising driving pressure across the capillary bed.
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http://dx.doi.org/10.5114/amsad.2020.102424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885815PMC
December 2020

Cardiac rehabilitation: Appraisal of current evidence and utility of technology aided home-based cardiac rehabilitation.

Indian Heart J 2020 Nov-Dec;72(6):491-499. Epub 2020 Aug 26.

Department of Medicine, Krishna Hospital and Research Centre, Haldwani, Uttarakhand, India.

Cardiac rehabilitation (CR) is an evidence-based intervention that uses exercise training, health behaviour modification, medication adherence and psychological counselling to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, following coronary intervention, heart failure, or cardiac surgery. These are significantly underused, with only a minority of eligible patients participating in CR in India. Novel delivery strategies and CR endorsement by healthcare organizations are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). Differing from centre-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision. It is provided mostly or entirely outside of the traditional centre-based setting and could be facilitated by the aid of technology and web based applications. The purpose of this appraisal is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR. This appears to hold promise in expanding the use of CR to eligible patients. Additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and people in remote and rural areas. HBCR may be a reasonable option for a selected group of patients and could be a game changer in low- and middle-income countries who are eligible for CR.
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http://dx.doi.org/10.1016/j.ihj.2020.08.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772588PMC
June 2021

Meta-analysis comparing outcomes of catheter ablation for ventricular arrhythmia in ischemic versus nonischemic cardiomyopathy.

Pacing Clin Electrophysiol 2021 01 30;44(1):54-62. Epub 2020 Nov 30.

Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina.

Background: Catheter ablation is an effective treatment for ventricular arrhythmia (VA) in ischemic cardiomyopathy (ICM). However, results in non-ICM (NICM) patients are not satisfactory, and studies comparing differences between NICM and ICM are limited. We conducted a meta-analysis of procedural characteristics and long-term outcomes of catheter ablation for VA, comparing results between ICM and NICM.

Methods: Studies in the PubMed, EMBASE, and Cochrane databases were systematically reviewed. Four studies reporting comparison of catheter ablation of VA between ICM and NICM were examined. The Newcastle-Ottawa Scale was used to appraise study quality. A random-effects model with inverse variance method was used for comparisons.

Results: Epicardial approach was significantly more undertaken for the NICM group than in the ICM group (odds ratio [OR]: 0.13; 95% confidence interval [CI]: 0.09-0.18; P < .00001). Mean ablation time (P = .54), fluoroscopy time (P = .55), and procedural time (P = .18) did not differ significantly between the ICM and NICM groups. Procedural failure rates (OR: 0.46; 95% CI: 0.24-0.89; P = .02) and VA recurrence rates (risk ratio [RR]: 0.68; 95% CI: 0.46-1.01; P = .06) were significantly higher in the NICM group than in the ICM group. However, all-cause mortality (RR: 1.37; 95% CI: 0.75-2.49; P = .31) did not differ significantly between groups.

Conclusions: Procedural failure and VA recurrence rates were significantly higher in the NICM group, despite significantly more frequent epicardial access. These highlight the limitations of catheter ablation for VA in NICM, given our current knowledge.
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http://dx.doi.org/10.1111/pace.14129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984079PMC
January 2021

Utility of global longitudinal strain to detect significant coronary artery disease, its extent and severity in patients with stable ischemic heart disease.

Echocardiography 2020 12 25;37(12):2000-2009. Epub 2020 Oct 25.

Department of Obstetrics and Gynaecology, NRS Medical College, Kolkata, India.

Background: Early changes in cardiac function due to ischemia may be detected by global longitudinal peak systolic strain (GLS). Till date, no Indian data exist regarding role of GLS in stable ischemic heart disease (SIHD) and data showing correlation of GLS and SYNTAX score (SS) is meager in world literature. Our aim was to ascertain the role of GLS in SIHD.

Methods: One hundred and seventeen subjects with angina and normal transthoracic echocardiogram (TTE) underwent strain echocardiography and coronary angiography (CAG).

Results: There was significant correlation between GLS and SS values (R  = .686, P < .0001). The correlation was weaker yet significant in the low SS (<22) group (R  = .491, P < .0001) and high SS (≥22) group (R  = .602, P < .0001). The cutoff value of GLS to detect significant CAD was -16.5 (87.6% sensitivity, 85.7% specificity, P < .0001), to predict high SS was -13.5% (sensitivity 78.3%, specificity 87.9%, P < .0001) and to predict triple vessel disease (TVD) was -14.5 (95.7% sensitivity, 73.4% specificity, P < .0001). The agreement between GLS and CAG for detection of significant CAD was substantial (κ = 0. 676, P < .0001), similar to that between territorial strain and CAG in detecting LAD disease (κ = 0.688, P < .0001) while agreement between strain imaging and CAG for detecting number of vessels diseased was moderate (κ = 0.406, P < .0001).

Conclusion: Global longitudinal peak systolic strain must be conducted on subjects with angina and inconclusive electrocardiogram (ECG) findings to rule out significant CAD even if conventional TTE was normal. This may facilitate early diagnosis of CAD or sub-clinical left ventricular systolic dysfunction (LVSD), preventive or treatment measures, and overall cost savings.
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http://dx.doi.org/10.1111/echo.14908DOI Listing
December 2020

Association of severity of coronary artery disease by SYNTAX score (SS) and lower extremity arterial disease by duplex ultrasound (DUS) study-an Indian perspective.

Egypt Heart J 2020 Sep 7;72(1):56. Epub 2020 Sep 7.

Department of Cardiology, NRS Medical College, Kolkata, India.

Background: Coronary artery disease (CAD) and lower extremity artery disease (LEAD) often coexist. Ankle brachial index (ABI) has been shown to be an independent predictor of CAD. Studies have reported correlation of CAD and LEAD on the basis of ABI and also invasive angiography. But rigorous searching did not reveal any similar research where severity of LEAD was assessed by duplex ultrasound (DUS). In this study, we assessed the association of severity and localisation of LEAD by DUS with SYNTAX score (SS).

Results: A total of 637 subjects above 45 years of age with coronary angiographic confirmation of CAD were studied in this single centre cross-sectional, descriptive and analytical research. High SS was significantly more common in subjects with LEAD (p = 0.04). In the femoro-popliteal segment, total occlusion of arteries was found in significantly more proportion of subjects with high SS. A progressive increase in mean SS was noted across the grades of arterial disease in the femoro-popliteal segment (p = 0.007). 85.2% of the LEAD was in the femoro-popliteal segment, while below-knee arterial disease was present in 98.5% of subjects with LEAD. Hypertension, smoking, history of CVE and presentation with ACS independently increased the risk of LEAD.

Conclusion: High prevalence of asymptomatic LEAD and association of high SS with LEAD as a whole as well as femoro-popliteal involvement suggests the need for a point of care DUS study (POCUS) since treatment varies with location and extent of disease which cannot be fathomed by ABI alone. Being the largest study on association of CAD and LEAD from Indian subcontinent till date and also the first study to use non-invasive tool as DUS for LEAD assessment while studying its association with CAD makes this a landmark experience.
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http://dx.doi.org/10.1186/s43044-020-00091-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477019PMC
September 2020

Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis.

Indian Heart J 2020 Jul - Aug;72(4):225-231. Epub 2020 Jul 24.

Department of Cardiology, LPS Institution of Cardiology, Kanpur, Uttar Pradesh, India. Electronic address:

Aims: Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone.

Methods And Results: PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I = 88%).

Conclusion: PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.
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http://dx.doi.org/10.1016/j.ihj.2020.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474112PMC
March 2021

Meta-Analysis Comparing Watchman and Amplatzer Devices for Stroke Prevention in Atrial Fibrillation.

Front Cardiovasc Med 2020 22;7:89. Epub 2020 Jun 22.

Baylor College of Medicine, Houston, TX, United States.

For patients with atrial fibrillation who are at high risk for bleeding or who cannot tolerate oral anticoagulation, left atrial appendage (LAA) closure represents an alternative therapy for reducing risk for thromboembolic events. To compare the efficacy and safety of the Amplatzer and Watchman LAA closure devices. A meta-analysis was performed of studies comparing the safety and efficacy outcomes of the two devices. The Newcastle-Ottawa Scale was used to appraise study quality. Six studies encompassing 614 patients were included in the meta-analysis. Overall event rates were low for both devices. No significant differences between the devices were found in safety outcomes (i.e., pericardial effusion, cardiac tamponade, device embolization, air embolism, and vascular complications) or in the rates of all-cause mortality, cardiac death, stroke/transient ischemic attack, or device-related thrombosis. The total bleeding rate was significantly lower in the Watchman group (Log OR = -0.90; 95% CI = -1.76 to -0.04; = 0.04), yet no significant differences was found when the bleeding rate was categorized into major and minor bleeding. Total peridevice leakage rate and insignificant peridevice leakage rate were significantly higher in the Watchman group (Log OR = 1.32; 95% CI = 0.76 to 1.87; < 0.01 and Log OR = 1.11; 95% CI = 0.50 to 1.72; < 0.01, respectively). However, significant peridevice leakages were similar in both the devices. The LAA closure devices had low complication rates and low event rates. Efficacy and safety were similar between the systems, except for a higher percentage of insignificant peridevice leakages in the Watchman group. A randomized controlled trial comparing both devices is underway, which may provide more insight on the safety and efficacy outcomes comparison of the devices.
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http://dx.doi.org/10.3389/fcvm.2020.00089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322993PMC
June 2020

Successful occlusion of a large pulmonary arterio-venous fistula with Amplatzer septal occluder in a 16-year-old cyanotic boy.

J Cardiol Cases 2020 Jun 16;21(6):242-245. Epub 2020 Apr 16.

Department of Cardiology, LPS Institute of Cardiology, Kanpur, India.

Pulmonary arterio-venous fistula is an uncommon cause of cyanosis and should be suspected when normal cardiac examination is associated without evidence of intra-cardiac shunt. Diagnosis of extra-cardiac shunt can be suspected by contrast echocardiography using agitated saline and confirmation of pulmonary arterio-venous fistula can be made by computed tomography pulmonary angiography with information regarding the size feeding vessels necessary for the planning of intervention. With the advancement of trans-catheter devices, fistula can be occluded successfully by embolotherapy. Coils, duct occluders, and vascular plugs are some of the commonly used trans-catheter devices among the armamentarium. Each device has its own inherent advantages and limitations. However, operators' familiarity and expertise is an important parameter to choose the device to be employed in closure of fistula. The experience of Amplatzer family of devices in closure of pulmonary arterio-venous fistula is limited in the literature. We report a case of large pulmonary arterio-venous fistula successfully closed with a 20 mm Amplatzer septal occluder device in a 16-year-old cyanotic boy. Post-procedure contrast echocardiography confirmed absence of right to left shunt and computed tomography pulmonary angiography confirmed the device in situ closing the feeding vessel. Over a follow-up of six months reversal of clubbing and cyanosis was noted. <: Patients with cyanosis with normal cardiac examination without evident intra-cardiac shunt in echocardiography should be evaluated for pulmonary arterio-venous fistula. Computed tomography Pulmonary angiography is gold standard but contrast echocardiography can be valuable. Percutaneous trans-catheter closure using coils, duct occluders, or vascular plugs can be an alternative to surgery. Choice of device depends on size and tortuosity of the feeding vessel as well as operator's familiarity with the device.>.
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http://dx.doi.org/10.1016/j.jccase.2020.03.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283301PMC
June 2020

'Windsock' type atrial septal aneurysm in an adult causing paradoxical embolism.

Cardiol J 2020 ;27(2):210-211

Department of Cardiology, Nilratan Sircar Medical College and Hospital, Kolkata, West Bengal.

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http://dx.doi.org/10.5603/CJ.2020.0048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016024PMC
June 2021

Acute attack of gout precipitated by concomitant use of aspirin and diuretic in a rheumatic mitral stenosis patient.

BMJ Case Rep 2019 Sep 11;12(9). Epub 2019 Sep 11.

Cardiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.

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http://dx.doi.org/10.1136/bcr-2019-232085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738697PMC
September 2019

Giant left atrial appendage aneurysm and atrial fibrillation: chicken or the egg?

BMJ Case Rep 2019 Aug 26;12(8). Epub 2019 Aug 26.

Cardiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.

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http://dx.doi.org/10.1136/bcr-2019-231300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6720742PMC
August 2019

Systolic anterior motion: an unusual cause of late mitral valve repair failure.

BMJ Case Rep 2019 Jul 26;12(7). Epub 2019 Jul 26.

Cardiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.

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http://dx.doi.org/10.1136/bcr-2019-231301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6663304PMC
July 2019

Acute Myocardial Infarction Due to Coronary Artery Embolism in a 22-Year-Old Woman with Mitral Stenosis with Atrial Fibrillation Under Warfarinization: Successful Management with Anticoagulation.

Am J Case Rep 2017 Apr 7;18:361-366. Epub 2017 Apr 7.

Department of Cardiology, LPS Institute of Cardiology, Ganesh Shankar Vidyarthi Memorial (G.S.V.M.) Medical College, Kanpur, India.

BACKGROUND Coronary artery embolization is an exceedingly rare cause of myocardial infarction, but a few cases in association with prosthetic mechanical valves have been reported. We report a case of embolic myocardial infarction caused by a thrombus in the left atrium with deranged coagulation profile in a patient with critical mitral stenosis under warfarinization. CASE REPORT A 22-year-old woman was taken to the catheterization lab for early coronary intervention in lieu of non-ST elevation myocardial infarction. Electrocardiography showed T↓ in V1 to V4, and atrial fibrillation with controlled ventricular rate. Coronary angiography showed total occlusion of the mid-left anterior descending artery with thrombus. After upstream treatment with tirofiban, the apparent thrombus was dislodged distally while passing a BMW wire. No abnormalities were seen by intravascular ultrasound study. Echocardiography revealed critical mitral stenosis, and left atrial clot with mild left ventricular dysfunction. Coagulation profile revealed sub-therapeutic international normalized ratio levels. The sequential angiographic images, normal intravascular ultrasound study, and presence of atrial fibrillation are confirmatory of coronary embolism as the cause of myocardial infarction. Anticoagulation and treatment of acute coronary syndrome were initiated and she was referred for closed mitral valvulotomy. CONCLUSIONS Coronary artery thromboembolism as a nonatherosclerotic cause of acute coronary syndrome is rare. The treatment consists of aggressive anticoagulation, antiplatelet therapy, and interventional options, including simple wiring when possible. In this context, primary prevention in the form of patient education on optimal anticoagulation with oral vitamin K antagonist and medical advice about imminent thromboembolic risks are of extreme importance.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5391154PMC
http://dx.doi.org/10.12659/ajcr.902250DOI Listing
April 2017

Fragmented QRS as a Marker of Electrical Dyssynchrony to Predict Inter-Ventricular Conduction Defect by Subsequent Echocardiographic Assessment in Symptomatic Patients of Non-Ischemic Dilated Cardiomyopathy.

Cardiol Res 2016 Aug 5;7(4):140-145. Epub 2016 Sep 5.

Department of Cardiology, LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, Uttar Pradesh 208002, India.

Background: Left ventricular (LV) dyssynchrony frequently occurs in patients with heart failure (HF). QRS ≥ 120 ms is a surrogate marker of electrical dyssynchrony, which occurs in only 30% of HF patients. In contrary, in those with normal QRS (nQRS) duration, LV dyssynchrony has been reported in 20-50%. This study was carried out to investigate the role of fragmented QRS (fQRS) on the surface electrocardiography (ECG) as a marker of electrical dyssynchrony to predict the presence of significant intraventricular dyssynchrony (IVD) by subsequent echocardiographic assessment.

Methods: A total of 226 consecutive patients with non-ischemic cardiomyopathy were assessed for fQRS on surface ECG as defined by presence of an additional R wave (R prime), notching in nadir of the S wave, notching of R wave, or the presence of more than one R prime (fragmentation) in two contiguous leads corresponding to a major myocardial segment. Tissue Doppler imaging (TDI) was performed in the apical views (four-chamber, two-chamber and long-axis) to analyze all 12 segments at both basal and middle levels. Time-to-peak myocardial sustained systolic (Ts) velocities were calculated. Significant systolic IVD was defined as Ts-SD > 32.6 ms as known as "Yu index".

Result: Of the total patients, 112 had fQRS (49.5%), while 114 had nQRS (50.5%) with male dominance (M/F = 71:29). Majority of patients were in NYHA class II (n = 122, 54%) followed by class III (n = 83; 37%), and class IV (n = 21; 9%). There were no significant differences among both groups for baseline parameters except higher QRS duration (102.42 ± 14.05 vs. 91.10 ± 13.75 ms; P = 0.001), higher Yu index (35.64 ± 12.79 vs. 20.45 ± 11.17; P = 0.01) and number of patients with positive Yu index (78.6% vs. 21.1%; P = 0.04) in group with fQRS compared with group with nQRS. fQRS complexes had 84.61% sensitivity and 80.32% specificity with positive predictive value of 78.6% and negative predictive value of 85.9% to detect IVD. On detailed segmental analysis for fQRS distribution, inferior segment had maximum (37%), followed by anterior (23%), lateral (19%), inferior and lateral (11%), anterior and inferior (8%), and anterior and lateral (2%). Among 104 patients with significant dyssynchrony, 88 patients (84.6%) had fQRS in the dyssynchronic segment.

Conclusion: Fragmentation of QRS complex is an important predictor of electro-mechanical dyssynchrony. It is also helpful in localizing the dyssynchronous segment. In future, larger studies may be carried out to investigate the role of fQRS as a predictor of response to cardiac resynchronization therapy (CRT) in this subgroup of HF patients with narrow QRS.
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http://dx.doi.org/10.14740/cr495wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5295578PMC
August 2016

Atypical Double Right Coronary Artery Presenting With Acute Coronary Syndrome, Cardiogenic Shock and Complete Heart Block.

J Clin Med Res 2017 Mar 25;9(3):221-224. Epub 2017 Jan 25.

Department of Cardiology, LPS Institute of Cardiology, G. S. V. M. Medical College, Kanpur, Uttar Pradesh 208002, India.

Double right coronary artery (RCA) is an extremely rare coronary artery anomaly. We here report an atherosclerotic double RCA which appeared after primary percutaneous intervention performed to treat a 34-year-old male presenting with acute inferior myocardial infarction, cardiogenic shock and complete heart block. This is an unusual case as double RCA had been hidden by total atherosclerotic occlusion of the proximal part of the RCA and complete restoration of patency led complete heart block back to normal sinus rhythm.
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http://dx.doi.org/10.14740/jocmr2848wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289143PMC
March 2017

Bi-Luminal Mitral Valve: Incidence, Clinical Features, Associated Anomaly and Echocardiographic Evaluation.

J Clin Med Res 2016 Dec 26;8(12):893-898. Epub 2016 Oct 26.

Department of Cardiology, LPS Institute of Cardiology, G. S. V. M. Medical College, Kanpur, Uttar Pradesh 208002, India.

Objective: The aim of the study was to know the incidence, clinical features, associated anomaly and echocardiographic evaluation of bi-luminal mitral valve (also known as double orifice mitral valve or DOMV) in patients with suspected mitral valve disease, continous murmur or left-to-right shunt.

Methods: Twenty-eight patients with DOMV were diagnosed by transthoracic echocardiography (TTE) in a retrospective review of 52,256 echocardiographic studies in 45,898 patients performed between 2000 and 2015.

Results: The mean age was 20.1 years (15 - 34 years) with female preponderance (M/F: 1:1.8). Dyspnea and diastolic murmur were the most common symptoms found in 19 (67.8%) and 19 (67.8%) of patients, respectively. Normal sinus rhythm was the most common electrocardiographic finding. Twenty-five (89%) patients had complete bridge, while three (11%) had incomplete bridge type of DOMV. Twenty-one (75%) had severe mitral stenosis (MS) including severe tricuspid regurgitation (n = 13, 61%), ventricular septal defect (VSD, n = 3, 14%), complete endocardial cushion defect (ECD, n = 3, 14%), and mild to moderate mitral regurgitation (MR) (n = 2, 11%), moderate MS and moderate MR were found in four (16%) patients among complete bridge type of DOMV, while all patients with incomplete bridge type had severe MS and patent ductus arteriosus (PDA) as associated lesions. Overall, 24 (85%) had severe and four (15%) had moderate MS.

Conclusions: DOMV as a cause of symptomatic mitral valve disease was seen in young and middle-aged patients with estimated incidence of 0.06%. Dyspnea and diastolic murmur were the most common symptoms. Mostly, it was an isolated anomaly but in majority, associated with VSD, complete ECD and PDA. TTE examination is a reliable and sufficient means of diagnosing DOMV and determining its type.
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http://dx.doi.org/10.14740/jocmr2790wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5087630PMC
December 2016

Unusual Survival of Anomalous Left Coronary Artery From the Pulmonary Artery With Severe Rheumatic Mitral Stenosis in Septuagenarian Women: Foes Becoming Friends?

J Clin Med Res 2016 Oct 30;8(10):760-3. Epub 2016 Aug 30.

Department of Cardiology, LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur 208002, Uttar Pradesh, India.

ALCAPA syndrome (anomalous origin of the left coronary artery from the pulmonary artery) is a rare disease but lethal with clinical expression from myocardial infarction, congestive heart failure to death during early infancy and unusual survival to adulthood. We report a 73-year-old woman with ALCAPA who presented with exertional dyspnea (NYHA functional class II) over past 2 years. Physical examination revealed soft S, long mid diastolic rumbling murmur and apical pan-systolic murmur. Electrocardiography displayed biatrial enlargement and poor R progression and normal sinus rhythm. Echocardiography established calcified severe mitral stenosis (MS), presence of continuous flow entering the pulmonary trunk, turbulent continuous flow in inter-ventricular septum with left to right shunt in contrast echocardiography and normal systolic function. Coronary angiogram showed absence of left coronary artery (LCA) originating from aorta, dilated and tortuous right coronary artery (RCA) and abundant Rentrop grade 3 intercoronary collateral communicating with LCA originating from pulmonary trunk which was also confirmed on coronary CT angiogram thus establishing diagnosis of ALCAPA. It is exceedingly rare to be associated with severe MS. However, such a long survival in our patient can be explained by the severe pulmonary arterial hypertension which may be contributing to lesser coronary steal.
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http://dx.doi.org/10.14740/jocmr2674wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012248PMC
October 2016

Enteric Parasitic Infection Among Antiretroviral Therapy Naïve HIV-Seropositive People: Infection Begets Infection-Experience from Eastern India.

J Glob Infect Dis 2016 Apr-Jun;8(2):82-6

Department of General Medicine, Medical College, Kolkata, West Bengal, India.

Context: Parasitic opportunistic infections (POIs) frequently occur in HIV/AIDS patients and affect the quality of life.

Aims: This study assessing the standard organisms in the stool of HIV-positive patients, their comparison with HIV-negative controls, their relation with various factors, is the first of its kind in the eastern part of India.

Settings And Design: hospital-based case-control study.

Materials And Methods: A total of 194 antiretroviral therapy naïve HIV-positive patients (18-60 years) were taken as cases and 98 age- and sex-matched HIV-negative family members as controls. Demographical, clinical, biochemical, and microbiological parameters were studied.

Statistical Analysis Used: Odds ratio, 95% confidence interval, and P (< 0.05 is to be significant) were calculated using Epi Info 7 software.

Results: POI was significantly higher among HIV-seropositive cases (61.86%) (P < 0.001). Cryptosporidium was the most common POI in HIV-seropositive patients overall and without diarrhea; Entameba was the most common POI in patients with acute diarrhea, and Isospora was the most common POI in the patients having chronic diarrhea. Entameba was the most common POI in CD4 count <350 cells/μl while for CD4 count >350 cells/μl Cryptosporidium was the most common POI. Mean CD4 count was significantly (P < 0.001) lower among people having multiple infections. Male sex, hemoglobin <10 g/dl, WHO Clinical Stage 3 or 4, tuberculosis, absolute eosinophil count of more than 540/dl, CD4 count <350 cells/μl, and seroconcordance of spouses were significantly associated with HIV-seropositive cases having POI (P < 0.05).

Conclusions: Physicians should advise HIV-infected patients to undergo routine evaluation for POI, and provision of chemoprophylaxis should be made in appropriate settings.
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http://dx.doi.org/10.4103/0974-777X.182124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4879795PMC
June 2016

Clinicopathological Analysis and Multipronged Quantitative Proteomics Reveal Oxidative Stress and Cytoskeletal Proteins as Possible Markers for Severe Vivax Malaria.

Sci Rep 2016 Apr 19;6:24557. Epub 2016 Apr 19.

Department of Biosciences and Bioengineering, Indian Institute of Technology Bombay, Powai, Mumbai 400076, India.

In Plasmodium vivax malaria, mechanisms that trigger transition from uncomplicated to fatal severe infections are obscure. In this multi-disciplinary study we have performed a comprehensive analysis of clinicopathological parameters and serum proteome profiles of vivax malaria patients with different severity levels of infection to investigate pathogenesis of severe malaria and identify surrogate markers of severity. Clinicopathological analysis and proteomics profiling has provided evidences for the modulation of diverse physiological pathways including oxidative stress, cytoskeletal regulation, lipid metabolism and complement cascades in severe malaria. Strikingly, unlike severe falciparum malaria the blood coagulation cascade was not found to be affected adversely in acute P. vivax infection. To the best of our knowledge, this is the first comprehensive proteomics study, which identified some possible cues for severe P. vivax infection. Our results suggest that Superoxide dismutase, Vitronectin, Titin, Apolipoprotein E, Serum amyloid A, and Haptoglobin are potential predictive markers for malaria severity.
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http://dx.doi.org/10.1038/srep24557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4835765PMC
April 2016

Clinico-biochemical correlation to histological findings in alcoholic liver disease: a single centre study from eastern India.

J Clin Diagn Res 2014 Oct 20;8(10):MC01-5. Epub 2014 Oct 20.

Assistant Professor, Department of Pathology, Bankura Sammilani Medical College & Hospital , Bankura, India .

Background: Alcoholism is a health problem not only in developed countries but also in developing countries. Cirrhosis due to alcohol is a common cause of death among individuals abusing alcohol. A better knowledge of the spectrum of alcoholic liver diseases, its clinical, biochemical and histopathological features could result in early detection and prevention of alcoholic liver diseases before it's catastrophic and life threatening effects.

Materials And Methods: A total of 200 patients with alcoholic liver diseases were studied with respect to alcohol consumption, clinical features, biochemical and histopathological changes. The clinical features, biochemical parameters, and histopathology of liver including Ishak's modified histological activity index (HAI) were correlated with the amount and duration of alcohol consumed.

Result: Majority of the patients were in the age group of 40-49 years and all the cases were males. Majority consumed alcohol of about 75-90 grams per day for a duration of 10-12 years. Anorexia and jaundice were the most common symptom and clinical finding respectively. Hyperbilirubinemia and hypoalbuminemia were the most common abnormalities observed in liver function tests. Advanced HAI stages with features of cirrhosis were most frequent histo-pathological finding noted in this study. Clinico-biochemical profile was significantly correlated with degree of alcohol ingestion as well as with liver histopathology.

Conclusion: The wide prevalence of alcoholic liver disease including cirrhosis among Indian males was noted with significantly lower quantity and duration of alcohol ingestion. The severity of liver damage is directly proportional to the quantity and duration of alcohol consumed. Clinical features and biochemical changes may forecast the liver histopathology among the patients of alcoholic liver disease.
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http://dx.doi.org/10.7860/JCDR/2014/8763.4968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4253200PMC
October 2014
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