Publications by authors named "Sivasubramanian Ramakrishnan"

118 Publications

Efficacy and safety of propranolol in infants with heart failure due to moderate-to-large ventricular septal defect (VSD-PHF study) - A prospective randomized trial.

Ann Pediatr Cardiol 2021 Jul-Sep;14(3):331-340. Epub 2021 Aug 11.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

Aims: The utility of beta-blocker therapy in infants with heart failure (HF) due to significant left-to-right shunt lesions is not known. The study aimed to assess the efficacy and safety of propranolol in infants with HF due to moderate-to-large ventricular septal defect (VSD).

Methods: The prospective randomized trial included 80 infants with HF and moderate-to-large VSD, randomly allocated to receive either conventional therapy alone ( = 40) or propranolol plus conventional therapy ( = 40). The primary endpoint was a composite of all-cause mortality, hospitalization for HF and/or chest infection, and referral for surgery. The secondary clinical outcomes were the individual components of the composite endpoint. In addition, the patients were followed up to detect safety outcomes, for example, bronchospasm, bradyarrhythmia, and worsening HF symptoms.

Results: The addition of propranolol therapy to the conventional medications did not result in significant improvement in the primary composite endpoint (32.50% vs. 52.50%; = 0.07). There was a trend toward improvement, but the study is underpowered for this important question. However, propranolol therapy significantly decreased the risk of hospitalization (12.50% vs. 32.50%; = 0.03) and worsening of Ross HF class (5.41% vs. 28.21%; = 0.01) as compared to conventional therapy (estimated number needed to treat = 5). Propranolol did not result in any significant safety concerns in these infants except bronchospasm in an infant.

Conclusions: Propranolol therapy in infants with significant left-to-right shunt may prevent worsening in HF symptoms and hospitalization and is well tolerated. However, it does not reduce mortality or need for surgery.
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http://dx.doi.org/10.4103/apc.APC_94_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457270PMC
August 2021

Outcome of COVID-19-positive children with heart disease and grown-ups with congenital heart disease: A multicentric study from India.

Ann Pediatr Cardiol 2021 Jul-Sep;14(3):269-277. Epub 2021 Aug 26.

Children's Heart Center, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.

Background: Outcome data of children with heart disease who acquired COVID-19 infection are limited.

Aims: We sought to analyze outcome data and identify risk factors associated with mortality in children with heart disease and grown-ups with congenital heart disease (GUCH) who had a laboratory-confirmed COVID-19 infection.

Settings And Design: This is a retrospective, multicentric, observational study.

Materials And Methods: The study included children with heart disease and GUCH population, who presented with either symptomatic or asymptomatic COVID-19 infection to any of the participating centers. COVID-19-negative patients admitted to these centers constituted the control group.

Results: From 24 pediatric cardiac centers across India, we included 94 patients with a median age of 12.5 (interquartile range 3-96) months and 49 (52.1%) patients were males. Majority (83 patients, 88.3%) were children. One-third of the patients ( = 31, 33.0%) had acyanotic congenital heart disease, and 41.5% ( = 39) were cyanotic, with > 80% of the patients being unoperated. Only 30 (31.9%) patients were symptomatic for COVID-19 infection, while the rest were incidentally detected positive on screening. A total of 13 patients died (case fatality rate: 13.8%). The in-hospital mortality rate among hospitalized patients was significantly higher among COVID-19-positive cases (13 of 48; 27.1%) as compared to COVID-negative admissions (9.2%) during the study period ( < 0.001). On multivariate analysis, the independent predictors of mortality among COVID-19-positive cases were severity of illness at admission (odds ratio [OR]: 535.7, 95% confidence interval [CI]: 6.9-41,605, = 0.005) and lower socioeconomic class (OR: 29.5, 95% CI: 1.1-814.7, = 0.046).

Conclusions: Children with heart disease are at a higher risk of death when they acquire COVID-19 infection. Systematic preventive measures and management strategies are needed for improving the outcomes.
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http://dx.doi.org/10.4103/apc.apc_134_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457291PMC
August 2021

Impact of COVID-19 pandemic on pediatric cardiac services in India.

Ann Pediatr Cardiol 2021 Jul-Sep;14(3):260-268. Epub 2021 Aug 26.

Department of Pediatrics, Division of Pediatric Cardiology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.

Background: COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India.

Aims: The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries.

Settings And Design: This is a retrospective, multicentric, observational study.

Methods: We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019.

Results: The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 ( = 13,878) as compared to the corresponding period in 2019 ( = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%).

Conclusions: The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.
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http://dx.doi.org/10.4103/apc.apc_133_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457266PMC
August 2021

Pediatric cardiology: Is India self-reliant?

Ann Pediatr Cardiol 2021 Jul-Sep;14(3):253-259. Epub 2021 Aug 13.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/apc.apc_153_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457276PMC
August 2021

Outcomes of multisystem inflammatory syndrome in children temporally related to COVID-19: a longitudinal study.

Rheumatol Int 2021 Oct 19. Epub 2021 Oct 19.

All India Institute of Medical Sciences, New Delhi, India.

To study the clinical, laboratory characteristics and outcomes of multisystem inflammatory syndrome in children (MIS-C) temporally related to coronavirus disease 2019 (COVID-19) in a resource-limited setting. All children meeting the World Health Organization case definition of MIS-C were prospectively enrolled. Baseline clinical and laboratory parameters were compared between survivors and non-survivors. Enrolled subjects were followed up for 4-6 weeks for evaluation of cardiac outcomes using echocardiography. The statistical data were analyzed using the stata-12 software. Thirty-one children with MIS-C were enrolled in an 11-month period. Twelve children had preexisting chronic systemic comorbidity. Fever was a universal finding; gastrointestinal and respiratory manifestations were noted in 70.9% and 64.3%, respectively, while 57.1% had a skin rash. Fifty-eight percent of children presented with shock, and 22.5% required mechanical ventilation. HSP like rash, gangrene and arthritis were uncommon clinical observations.The median duration of hospital stay was 9 (6.5-18.5) days: four children with preexisting comorbidities succumbed to the illness. The serum ferritin levels (ng/ml) [median (IQR)] were significantly higher in non-survivors as compared to survivors [1061 (581, 2750) vs 309.5 (140, 720.08), p value = 0.045]. Six patients had coronary artery involvement; five recovered during follow-up, while one was still admitted. Twenty-six children received immunomodulatory drugs, and five improved without immunomodulation. The choice of immunomodulation (steroids or intravenous immunoglobulin) did not affect the outcome. Most children with MIS-C present with acute hemodynamic and respiratory symptoms.The outcome is favorable in children without preexisting comorbidities.Raised ferritin level may be a poor prognostic marker. The coronary outcomes at follow-up were reassuring.
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http://dx.doi.org/10.1007/s00296-021-05030-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524205PMC
October 2021

Anomalous subaortic course of brachiocephalic vein: Evaluation on multidetector computed tomography angiography.

J Card Surg 2021 Oct 12. Epub 2021 Oct 12.

Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India.

Aim: To evaluate the morphology and associated cardiovascular abnormalities in patients with an anomalous subaortic course of brachiocephalic vein on multidetector computed tomography (CT) angiography.

Material And Methods: A retrospective study was performed at a tertiary referral institute to identify patients with subaortic brachiocephalic vein on multidetector CT (MDCT) angiography using dual source CT scanner between January 2014 and July 2021. The morphology of the subaortic brachiocephalic vein along with the cardiovascular anatomy and associated anomalies were evaluated.

Results: Out of 4349 patients who had undergone MDCT angiography for evaluation of congenital heart diseases, we identified 126 (2.9%) patients with subaortic brachiocephalic vein. The subaortic brachiocephalic vein was left-sided in 125 patients while a right-sided subaortic brachiocephalic vein was identified in a patient with left isomerism. Common cardiovascular associations included tetralogy of Fallot (109/126; 88.1%), double outlet right ventricle (8/126; 6.3%) and common arterial trunk (5/126; 3.9%). The presence of a right aortic arch was seen in 78/126 (62%) patients. Some degree of right ventricular outflow obstruction was present in 119/126 (94.4%) patients; pulmonary stenosis was seen in 78 (62%) patients while pulmonary atresia was seen in 41 (32.5%) patients.

Conclusion: A subaortic brachiocephalic vein can coexist with various complex congenital heart diseases, most commonly tetralogy of Fallot and commonly associated with right aortic arch and pulmonary stenosis/atresia. It is important to identify this anomalous course of brachiocephalic vein before performing surgical procedures or venous catheterization to avoid potential complications.
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http://dx.doi.org/10.1111/jocs.16068DOI Listing
October 2021

Venous vascular ring: Duplicated left brachiocephalic vein with preaortic and retroesophageal course.

Ann Thorac Surg 2021 Sep 21. Epub 2021 Sep 21.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi.

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http://dx.doi.org/10.1016/j.athoracsur.2021.08.027DOI Listing
September 2021

Mitral valvular nodules of acute rheumatic fever masquerading as intracardiac mass.

Eur Heart J 2021 Sep 16. Epub 2021 Sep 16.

Department of Cardiology, 7th Floor, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.

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http://dx.doi.org/10.1093/eurheartj/ehab638DOI Listing
September 2021

Imaging Spectrum of Valvular and Paravalvular Complications of Prosthetic Heart Valve at CT Angiography.

Radiol Cardiothorac Imaging 2021 Aug 19;3(4):e210159. Epub 2021 Aug 19.

Department of Cardiovascular Radiology & Endovascular Interventions (M.V., N.N.P., S.K.) and Department of Cardiology (S.R.), All India Institute of Medical Sciences, New Delhi 110029, India.

Prosthetic heart valve (PHV) dysfunction is an uncommon but potentially life-threatening condition. In routine practice, transthoracic echocardiography and cinefluoroscopy comprise first-line imaging for the diagnostic evaluation of PHV dysfunction. In cases in which the findings of echocardiography and cinefluoroscopy remain inconclusive or are contradictory, CT angiography can resolve these conflicts. CT angiography also provides incremental diagnostic information about patients with suspected PHV obstruction and endocarditis, in which case it can demonstrate the anatomic substrate and extent of involvement. Additionally, information regarding the coronary arteries, cardiac dimensions, and retrosternal space may be obtained in cases in which repeat surgery is planned. This imaging essay describes the imaging spectrum of valvular and paravalvular complications of PHV at CT angiography and how the knowledge regarding the spectrum of complications can be incorporated into multimodality imaging for guiding clinical management. Prosthetic Heart Valve Dysfunction, Prosthetic Heart Valve Thrombosis, Pannus, Paravalvular Leak, CT Angiography, Cardiac, Valves Supplemental material is available for this article. © RSNA, 2021.
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http://dx.doi.org/10.1148/ryct.2021210159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8415148PMC
August 2021

Regional impact of updated guidelines on prevalence and distribution of blood pressure categories for hypertension in India: Results from the National Family Health Survey 4.

Indian Heart J 2021 Jul-Aug;73(4):481-486. Epub 2021 Jun 12.

Division of Cardiovascular Disease and Comprehensive Cardiovascular Center, University of Alabama at Birmingham, AL, USA.

Introduction: In 2017, the American College of Cardiology/American Heart Association revised guidelines for diagnosis and management of hypertension in adults. The regional impact of the updated guidelines on the prevalence of hypertension in India is unknown.

Methods: Data from nationally representative Indian households were analyzed to estimate the regional prevalence of hypertension according to the old and the new guidelines in men (age 18-54 years) and women (age 18-49 years). The old guidelines defined hypertension as a systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg or treatment. The new guidelines define hypertension as a systolic blood pressure of ≥130 mmHg or diastolic blood pressure of ≥80 mmHg or treatment. We calculated the increase in the prevalence of hypertension among the states and union territories of India (hereafter "states").

Results: Among 679,712 participants (85.6% women), the median age was 31 years (interquartile range 24, 40) and was comparable among men and women (33 vs. 31 years, respectively). The overall weighted prevalence according to old and new guidelines was 18.5% (95% CI 18.2, 18.7) and 43.0% (95% CI 42.8, 43.3), respectively. There was a significant increase in hypertension prevalence, both among men and women, and across all regions. The northeast region of the country had the highest prevalence.

Conclusion: The overall prevalence of hypertension significantly increases with the new compared to the old guidelines, however, the regional heterogeneity of prevalence of hypertension is maintained.
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http://dx.doi.org/10.1016/j.ihj.2021.06.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424272PMC
June 2021

Changing pattern of admissions for acute myocardial infarction in India during the COVID-19 pandemic.

Indian Heart J 2021 Jul-Aug;73(4):413-423. Epub 2021 Jun 18.

Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India.

Aim: Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India.

Methods & Results: In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = -0·48; r = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively.

Conclusions: The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.
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http://dx.doi.org/10.1016/j.ihj.2021.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424286PMC
June 2021

Non-specific aortoarteritis (NSAA) in children: a prospective observational study.

BMJ Paediatr Open 2021 9;5(1):e001106. Epub 2021 Aug 9.

Cardiology, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Objective: Prospective data on clinical profile, natural history and outcomes of NSAA (non-specific aortoarteritis) in children is limited. We initiated this prospective study to evaluate the short-term and medium-term outcomes of NSAA in children.

Design: Prospective observational study.

Setting: Tertiary care hospital in India.

Patients: We included 28 consecutive children (<15 years) with a diagnosis of NSAA.

Main Outcome Measures: Clinical profile, symptoms, left ventricular ejection fraction (LVEF), the pattern of vessel involvement, complications and markers of disease activity were assessed at the time of diagnosis. All the patients underwent treatment and interventions as per the current guidelines and were followed up for a mean duration of 13.5±6.7 months for disease activity and outcomes.

Results: The mean age of the cohort was 10±2.9 years (14 boys). Twenty (71%) patients had hypertension. Half of the children presented with acute decompensated heart failure (ADHF). Only 21 patients (75%) met Sharma modified Ishikawa criteria for the diagnosis. The children with active disease (36%) were managed with immunosuppressive drugs. Percutaneous and surgical interventions were performed in 26 (93%) children. New York Heart Association functional class, LVEF and control of hypertension improved in most children on follow-up. Four children developed vascular restenosis requiring reinterventions. There was no death during mid-term follow-up.

Conclusions: Children with NSAA, unlike adults seldom present with classical features of the disease. ADHF and ventricular dysfunction are strikingly common in children. Appropriate immunosuppressive therapy for active disease and timely intervention improves clinical outcomes over a medium term follow-up. Future studies assessing long-term outcome are needed.
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http://dx.doi.org/10.1136/bmjpo-2021-001106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354261PMC
August 2021

Clarifying the anatomy of the superior sinus venosus defect.

Heart 2021 Aug 20. Epub 2021 Aug 20.

Biosciences Institute, University of Newcastle, Newcastle-upon Tyne, UK.

Objectives: We sought to clarify the variations in the anatomy of the superior cavoatrial junction and anomalously connected pulmonary veins in patients with superior sinus venosus defects using computed tomographic (CT) angiography.

Methods: CT angiograms of 96 consecutive patients known to have superior sinus venosus defects were analysed.

Results: The median age of the patients was 34.5 years. In seven (7%) patients, the defect showed significant caudal extension, having a supero-inferior dimension greater than 25 mm. All patients had anomalous connection of the right superior pulmonary vein. The right middle and right inferior pulmonary vein were also connected anomalously in 88 (92%) and 17 (18%) patients, respectively. Anomalous connection of the right inferior pulmonary vein was more common in those with significant caudal extension of the defect (57% vs 15%, p=0.005). Among anomalously connected pulmonary veins, the right superior, middle, and inferior pulmonary veins were committed to the left atrium in 6, 17, and 11 patients, respectively. The superior caval vein over-rode the interatrial septum in 67 (70%) patients, with greater than 50% over-ride in 3 patients.

Conclusion: Anomalous connection of the right-sided pulmonary veins is universal, but is not limited to the right upper lobe. Not all individuals have over-riding of superior caval vein. In a minority of patients, the defect has significant caudal extension, and anomalously connected pulmonary veins are committed to the left atrium. These findings have significant clinical and therapeutic implications.
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http://dx.doi.org/10.1136/heartjnl-2021-319334DOI Listing
August 2021

Anomalous origin of left main coronary artery from pulmonary artery: Patient characteristics and imaging associations on multidetector computed tomography angiography.

J Card Surg 2021 Nov 19;36(11):4043-4053. Epub 2021 Aug 19.

Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India.

Aim: To evaluate the various imaging features and associations on multidetector computed tomography (CT) angiography in patients with anomalous origin of left main coronary artery (LMCA) from pulmonary artery (ALCAPA).

Materials And Methods: We retrospectively reviewed multidetector CT angiography studies done for the evaluation of congenital heart diseases at our institution through 2014 to 2021. Cases with ALCAPA were identified and relevant history and imaging findings including the origin of coronary arteries, left ventricular (LV) morphology and functions, intercoronary collaterals, and associated abnormalities were evaluated.

Results: Twelve patients (eight males, three adults, and nine children; age range: 2 months to 54 years) with ALCAPA were included. Gradually progressive dyspnea and failure to thrive (6/9; 66.67% each) were the most common symptoms among children, whereas adults were commonly asymptomatic (2/3; 66.67%). The LMCA was originating from pulmonary sinus, main, and right pulmonary artery in 6 (50%), 5 (41.66%), and 1 (8.3%) patients, respectively. In adult-type ALCAPA, right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCx) were dilated and tortuous, with the presence of well-developed intercoronary collaterals and preserved LV ejection fractions; these features were not seen in patients of infantile ALCAPA. LV dysfunction with global hypokinesia was the most common wall motion abnormality (7/12; 58.33%).

Conclusion: Degree of collateralization could be the key factor determining the time of presentation, clinical symptoms, and LV function, thus influencing clinical outcomes. Patients with infantile ALCAPA present with features of heart failure and have dilated and dysfunctional LV consequent to lack of collaterals, unlike adult-type ALCAPA.
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http://dx.doi.org/10.1111/jocs.15926DOI Listing
November 2021

Determinants of Waist-to-Height Ratio and Its Relation to Hypertension among School Children in India: A Multicenter Study.

Indian J Pediatr 2021 Aug 18. Epub 2021 Aug 18.

Department of Community Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

Objective: To study the factors associated with waist-to-height ratio (WHtR) among school children aged 5-15 y and its association with hypertension.

Methods: In this cross-sectional study, data on background characteristics, socioeconomic status (SES), anthropometric parameters, and blood pressure were obtained from school children from three states of India. WHtR ≥ 0.5 was defined as obesity and hypertensives were defined based on Fourth Report criteria. Descriptive statistics were applied and multiple linear regression was done to identify factors associated with WHtR. A receiver operating characteristics (ROC) analysis was used to evaluate the predictive ability of WHtR to predict hypertension RESULTS: The mean WHtR among the 12,068 students was 0.40 (± 0.05) and it showed a U-shaped distribution with age with trough at 10 y of age for both genders. Mean WHtR was higher among residents of Manipur, among boys and hypertensives. WHtR was positively associated with weight > 30 kg, male gender, schools with high SES, Manipur and Goa region, and negatively associated with age > 10 y. The area under the ROC curve of WHtR for diagnosis of hypertension was low 0.544 (95% CI 0.532, 0.556).

Conclusion: There is a nonlinear relation between age, gender, and WHtR, which varies by geographical region and HT. This would need to be kept in mind while using it to identify obesity in children, though its discriminant value for hypertension is low.
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http://dx.doi.org/10.1007/s12098-021-03879-2DOI Listing
August 2021

An extremely rare association of coarctation of aorta with double chambered right ventricle: double-trouble causing bi-ventricular failure in a child.

Cardiol Young 2021 Aug 5:1-3. Epub 2021 Aug 5.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

Double chambered right ventricle is a rare cardiac defect characterised by an obstructive hypertrophied muscle bundle in the right ventricle. The common associated lesions are ventricular septal defect followed by sub-aortic membrane. We report a child who had coarctation of aorta in association with double chambered right ventricle. This case is being reported for its rarity and challenges in management.
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http://dx.doi.org/10.1017/S1047951121003085DOI Listing
August 2021

Transcatheter closure of Abernethy malformation associated with interrupted inferior caval vein and other systemic venous anomalies.

Cardiol Young 2021 Jul 29:1-3. Epub 2021 Jul 29.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi110029, India.

Abernethy malformation is a rare entity. We report a 5-year-old boy presenting with severe pulmonary hypertension in whom Abernethy malformation and inferior caval vein interruption were diagnosed by CT angiography. In addition, the iliac veins were thrombosed with multiple venous collateral drainage. This abnormal venous anatomy caused difficulty in device closure of the Abernethy malformation, which was successfully closed using a vascular plug.
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http://dx.doi.org/10.1017/S1047951121002900DOI Listing
July 2021

Atrial septoplasty through internal jugular venous access in an infant with transposition of great arteries: technical challenges and solutions.

Cardiol Young 2021 Jul 26:1-3. Epub 2021 Jul 26.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi110029, India.

We describe a 3-month-old infant with transposition of great arteries and restrictive foramen ovale who presented with severe cyanosis. Child had a large thrombus causing near-total occlusion of the inferior caval vein. An emergency atrial septoplasty was performed via internal jugular venous access. The case emphasises the technical challenges faced while performing this procedure through jugular approach and plausible solutions to overcome these challenges.
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http://dx.doi.org/10.1017/S1047951121002869DOI Listing
July 2021

J receptor activity in idiopathic pulmonary hypertension and its expected change in the presence of pulmonary bed vasodilators.

Respir Physiol Neurobiol 2021 Dec 21;294:103742. Epub 2021 Jul 21.

Department of Cardiology, All India Institute of Medical Sciences, Delhi, India.

Juxtapulmonary receptors (J) lying in the lung parenchyma are stimulated naturally by any condition that produces interstitial oedema, transient increases in interstitial volume and pressure or raised pulmonary capillary pressure. There is no information available about the level of their stimulation in patients with idiopathic pulmonary hypertension (IPH) who have high levels of pulmonary artery systolic pressures. The aim of the present study therefore was to find the level of these receptors activity in these patients at their prevailing pulmonary artery systolic pressures. This was done by the established method of determining the dose of i.v. lobeline that gives rise to threshold levels of sensations in the upper chest areas and accelerates respiration. In IPH patients it was found to be as high as 31.6 ± 5.6 μg/kg i.e., twice as much as that known for healthy individuals which is 15 μg/kg. This shows an enhanced stimulation of J receptors in IPH patients. Expectedly when pulmonary artery systolic pressure falls with pulmonary bed vasodilator medication given to IPH patients, a reduction in the natural stimulus of J receptors would also occur leading to a fall in their activity and hence that of the quantum of their reflexes of respiratory acceleration and inhibition of exercise. This finding provides the first insight of a neural mechanism that could be influenced to produce its effects when pulmonary artery systolic pressure falls by pulmonary vasodilator medication.
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http://dx.doi.org/10.1016/j.resp.2021.103742DOI Listing
December 2021

Dextroversion due to giant left atrium in a child.

Echocardiography 2021 08 8;38(8):1356-1358. Epub 2021 Jul 8.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

Giant left atrium is extremely rare in pediatric population. We hereby report a case of 4-year-old child with giant left atrium (LA) due to "non-rheumatic" mitral regurgitation (MR). The giant LA caused dextro-rotation of the heart, which immediately reverted to normal cardiac position after surgical repair. The case is reported for the unusual manifestation of giant LA as dextroversion.
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http://dx.doi.org/10.1111/echo.15136DOI Listing
August 2021

Delivery sheath tip invagination - An unusual cause of failure to retrieve duct occluder.

Ann Pediatr Cardiol 2021 Apr-Jun;14(2):242-243. Epub 2021 Apr 10.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

Transcatheter closure of patent ductus arteriosus is the standard of care. Retrieval of a duct occluder device is generally easy until it is detached from the delivery cable. We report two instances of failed retrieval of the device due to sheath tip invagination. The report highlights the importance of prompt identification of the mechanism of unforeseen complications in managing them effectively.
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http://dx.doi.org/10.4103/apc.APC_165_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174637PMC
April 2021

Annals of pediatric cardiology: A glorious journey and a vision for the future.

Ann Pediatr Cardiol 2021 Apr-Jun;14(2):135-138. Epub 2021 May 3.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.4103/apc.apc_54_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174636PMC
May 2021

Double trouble: A hitherto undescribed association of tricuspid atresia and common arterial trunk!

J Card Surg 2021 Aug 30;36(8):2941-2943. Epub 2021 May 30.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1111/jocs.15587DOI Listing
August 2021

Ivabradine Versus Amiodarone in the Management of Postoperative Junctional Ectopic Tachycardia: A Randomized, Open-Label, Noninferiority Study.

JACC Clin Electrophysiol 2021 08 31;7(8):1052-1060. Epub 2021 Mar 31.

Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.

Objectives: This study sought to compare the efficacy of ivabradine and amiodarone in the management of postoperative junctional ectopic tachycardia (JET) after cardiac surgery in children.

Background: JET is a serious arrhythmia occurring in children after cardiac surgery and requires aggressive management. Amiodarone has been conventionally used in its treatment. Recent studies have reported the utility of ivabradine in this regard.

Methods: In this open-label randomized controlled trial, 94 children (age ≤18 years) who developed postoperative JET were allocated to receive either amiodarone or ivabradine. The primary endpoint was restoration of normal sinus rhythm.

Results: Sinus rhythm was achieved in 43 out of the 46 patients (93.5%) in the amiodarone group and 46 out of the 48 patients (95.8%) in the ivabradine group (mean difference of treatment effect: 2.3%; 95% confidence interval: -6.7% to 11.5%). The median (interquartile range) time taken to achieve sinus rhythm conversion was similar in both the groups: 21.5 (17-30.2) hours versus 22 (13.4-38.5) hours (p = 0.36)]. The time taken to rate control of JET was significantly less in the amiodarone group: median 7.0 (5.5-9.5) hours versus 8.0 (5.8-10.8) hours (p = 0.02)]. No drug-related adverse events were observed in the ivabradine group.

Conclusions: Oral ivabradine is not inferior to intravenous amiodarone in converting postoperative JET to sinus rhythm. There was no difference in time taken to sinus rhythm conversion between the groups, although the rate control was earlier in patients who received amiodarone. Monotherapy with ivabradine may be considered as an alternative to amiodarone in the management of postoperative JET. (Comparison of Two Drugs, Ivabradine and Amiodarone, in the Management of Junctional Ectopic Tachycardia, an Abnormality in Cardiac Rhythm in Patients Under 18 years Who Undergo Cardiac Surgery: CTRI/2018/08/015182).
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http://dx.doi.org/10.1016/j.jacep.2021.01.020DOI Listing
August 2021

Changing Pattern of Congenital Heart Disease Care During COVID-19 Pandemic.

Indian J Pediatr 2021 Sep 23;88(9):899-904. Epub 2021 Mar 23.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To study the impact of coronavirus disease 2019 (COVID-19) pandemic on the utilization of pediatric cardiac care services and to determine the role of teleconsultation services in delivering healthcare in this subset of population.

Methods: It was a retrospective, observational study. All children who attended pediatric cardiology outpatient/teleconsultation services or were admitted to pediatric cardiology ward between April 1, 2019 to July 31, 2019 and April 1, 2020 to July 31, 2020, were recruited in the study. Data for patients who underwent surgery or catheter intervention for congenital heart disease were also recorded and analyzed. Comparisons were drawn between the statistics during the two time-periods.

Results: Physical outpatient services were discontinued and were replaced by teleconsultations from April 2020. Inpatient admissions during COVID-19 pandemic (n = 66) decreased by two-thirds as compared to the admissions during similar period in 2019 (n = 189). Similarly, the percentage decrease during these 4 mo of pandemic were 84% for catheter interventions, 90% for total congenital heart disease (CHD) surgeries, and 40% for emergency CHD surgeries. The number of patients availing successful teleconsultation was 1079, which was only 15% of the total number of patients attending physical outpatient services (n = 7176) during the corresponding period in the year 2019. During the pandemic, systematic teleconsultation and local evaluation and investigations aided in better management of patients with CHD.

Conclusions: The utilization of cardiovascular services for CHD has reduced significantly during COVID-19 pandemic, for both out- and inpatient care. Teleconsultation services have streamlined the follow-up care to some extent and have helped in noncontact triaging of these patients for further care.
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http://dx.doi.org/10.1007/s12098-021-03702-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985229PMC
September 2021

An evidence-based scoring system to diagnose acute rheumatic fever with carditis in children.

Int J Cardiol 2021 06 2;333:146-151. Epub 2021 Mar 2.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

Backgound: Acute rheumatic fever (ARF) with carditis and chronic rheumatic heart disease (RHD) may be difficult to differentiate and may lead to missed diagnosis of carditis. We aimed to determine differences between these groups and to develop a new scoring system for this purpose.

Methods: Children (N = 514; mean age 11.6 ± 2.8, range 5-18 years; 65% males) enrolled in a RHD registry at a tertiary care centre were studied. Clinical, laboratory and echocardiographic features of acute rheumatic carditis group (N = 126) were compared with chronic RHD group (N = 388). We performed multiple regression analysis and then developed a new scoring system using independent predictors. Accuracy of this scoring system was assessed using receiver operating characteristic (ROC) curve analysis.

Results: Patients with ARF and carditis were younger, more commonly had history of fever, arthritis/arthralgias and had worse NYHA class. On echocardiography, severity of mitral regurgitation, presence of mitral leaflet nodules, mitral valve prolapse and pericardial effusion were more common in ARF group. On multiple regression analysis, following features were found to be independently predictive of ARF with carditis: age -negative association, NYHA class, severity of mitral regurgitation, mitral leaflet nodules, erythrocyte sedimentation rate and antistreptolysin titer. Based on these 6 variables, a new scoring system (0-13) was developed. A score of 5 or more was found to be best threshold for diagnosis of carditis (ROC AUC 0.87, sensitivity 76%, specificity 79%).

Conclusion: A new scoring system based on independent statistical associations appears promising for differentiating ARF with carditis from chronic RHD.
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http://dx.doi.org/10.1016/j.ijcard.2021.02.084DOI Listing
June 2021

Supravalvar aortic stenosis: Imaging characteristics and associations on multidetector computed tomography angiography.

J Card Surg 2021 Apr 15;36(4):1389-1400. Epub 2021 Feb 15.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

Aim: To evaluate the imaging features and associations in patients with supravalvar aortic stenosis on multidetector computed tomography (CT) angiography.

Materials And Methods: We retrospectively reviewed all CT angiography studies performed for evaluation of congenital heart diseases at our institution through the period from January 2014 to June 2020. Cases with supravalvar aortic stenosis were identified and classified as syndromic and nonsyndromic based on history, physical examination, and relevant investigations. The type and extent of vascular involvement and associated cardiovascular abnormalities were characterized.

Results: Supravalvar aortic stenosis was identified in 26/3926 (0.66%) patients (22 males and 4 females; Age range: 2 months to 20 years). Discrete stenosis was seen in 14/26 (53.8%) patients, while diffuse involvement of the ascending aorta to varying degrees was seen in the remaining 12 (46.2%) patients. About 15/26 (57.7%) patients had pulmonary involvement at some level, namely, infundibular, valvar, supravalvar, or peripheral pulmonic stenosis while 15/26 (57.7%) patients had coronary arterial involvement either in the form of stenosis, occlusion, or ectasia. Aortic valvular abnormality including thickening, partial fusion, and adhesion of leaflet edges to the sinutubular junction causing reduced coronary inflow was seen in 15/26 (57.7%) patients. Associated ventricular septal defect, patent ductus arteriosus, and mitral valvular prolapse were seen in four (15.4%), five (19.2%), and two (7.7%) patients respectively.

Conclusion: Supravalvar aortic stenosis is a rare abnormality showing associated pulmonary arterial involvement, coronary arterial involvement, aortic valvular abnormalities, and associated congenital cardiac defects in the majority of cases, which may influence surgical outcomes.
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http://dx.doi.org/10.1111/jocs.15415DOI Listing
April 2021

Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey.

Int J Cardiol Hypertens 2020 Dec 7;7:100055. Epub 2020 Oct 7.

Cardiology Society of India, India.

Background: The impact of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for diagnosis and management of hypertension on the prevalence of hypertension in India is unknown.

Methods: We analyzed data from the Cardiac Prevent 2015 survey to estimate the change in the prevalence of hypertension. The JNC8 guidelines defined hypertension as a systolic blood pressure of ≥140 ​mmHg or diastolic blood pressure of ≥90 ​mmHg. The 2017 ACC/AHA guidelines define hypertension as a systolic blood pressure of ≥130 ​mmHg or diastolic blood pressure of ≥80 ​mmHg. We standardized the prevalence as per the 2011 census population of India. We also calculated the prevalence as per the World Health Organization (WHO) World Standard Population (2000-2025).

Results: Among 180,335 participants (33.2% women), the mean age was 40.6 ​± ​14.9 years (41.1 ​± ​15.0 and 39.7 ​± ​14.7 years in men and women, respectively). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%) and 2,878 (1.6%) participants belonged to age group 18-19, 20-44, 45-54, 55-64, 65-74 and ​≥ ​75 years respectively. The prevalence of hypertension according to the JNC8 and 2017 ACC/AHA guidelines was 29.7% and 63.8%, respectively- an increase of 115%. With the 2011 census population of India, this suggests that currently, 486 million Indian adults have hypertension according to the 2017 ACC/AHA guidelines, an addition of 260 million as compared to the JNC8 guidelines.

Conclusion: According to the 2017 ACC/AHA guidelines, 3 in every 5 Indian adults have hypertension.
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http://dx.doi.org/10.1016/j.ijchy.2020.100055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803035PMC
December 2020
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